1
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Wong AK, Klepstad P, Somogyi AA, Vogrin S, Rubio J, Le B, Philip J. Influence of COMT (rs4680) and OPRM1 (rs1799971) on Cancer Pain, Opioid Dose, and Adverse Effects. J Palliat Med 2024. [PMID: 39253879 DOI: 10.1089/jpm.2024.0112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024] Open
Abstract
Background: The influence of pharmacogenomics on opioid response, particularly with COMT (rs4680) and OPRM1 (rs1799971) variants, has been studied individually and in combination. However, most studies are in a noncancer context and not all their possible variant combinations have been examined. Objectives: This study examined COMT (rs4680) and OPRM1 (rs1799971), and their allele combinations, in advanced cancer to examine associations with pain scores, opioid dose, and adverse effects. Setting/Subjects: This multicenter prospective cohort study recruited patients receiving opioids for advanced cancer pain in Melbourne, Australia. Clinical data (demographics, opioids), validated instruments (pain and adverse effects), and blood (DNA) were collected. Descriptive analyses were used. Univariate and multivariate logistic regression analyses were used to evaluate associations between clinical outcomes (opioid dose, pain, adverse effects) and genotypes of interest. Results: Fifty-four participants were recruited to the study. Those with COMT A allele required lower opioid doses [130 mg (interquartile range [IQR] 67.5,230) versus 180 mg (IQR 55,322.5), p = 0.047] and experienced greater adverse effects [sickness response aOR (adjusted odds ratio) 7.1 (95% CI 1.51,33.41), p = 0.01]. Those with the COMT GG/OPRM1 G allele combination required higher opioid doses [322.5 mg (IQR 264,360) versus 125 mg (65,225), (p = 0.04)]. Those with COMT AG/OPRM1 AA experienced higher average pain [aOR 1.55 (95% CI 1.03, 2.33), p = 0.04] and moderate-severe nausea [aOR 5.47 (95% CI 1.35, 22.21), p = 0.02] but reduced drowsiness [aOR 0.25 (95% CI 0.06, 1.02), p = 0.05]. Conclusions: Patients with cancer with the COMT alternate (A) allele have greater sickness response adverse effects, which may be responsible for the lower opioid doses observed. Significant results of two new COMT/OPRM1 genotype combinations are presented that have not previously been studied, with plausible phenotype descriptions suggested.
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Affiliation(s)
- Aaron K Wong
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Australia
| | - Pal Klepstad
- Department Intensive Care Medicine, St. Olavs University Hospital, Trondheim, Norway
| | - Andrew A Somogyi
- Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent's Hospital Melbourne, University of Melbourne, Melbourne, Australia
| | - Justin Rubio
- Florey Institute of Neuroscience & Mental Health, Victoria, Australia
| | - Brian Le
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- The Royal Melbourne Hospital, Parkville, Australia
| | - Jennifer Philip
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Australia
- St Vincent's Hospital, Palliative Care Service, Fitzroy, Australia
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2
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Miller JS, Bada HS, Westgate PM, Sithisarn T, Leggas M. Neonatal Abstinence Signs during Treatment: Trajectory, Resurgence and Heterogeneity. CHILDREN (BASEL, SWITZERLAND) 2024; 11:203. [PMID: 38397314 PMCID: PMC10887053 DOI: 10.3390/children11020203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 01/28/2024] [Accepted: 01/28/2024] [Indexed: 02/25/2024]
Abstract
Neonatal abstinence syndrome (NAS) presents with a varying severity of withdrawal signs and length of treatment (LOT). We examined the course and relevance of each of the NAS withdrawal signs during treatment in a sample of 182 infants with any prenatal opioid exposure, gestational age ≥ 35 weeks, without other medical conditions, and meeting the criteria for pharmacological treatment. Infants were monitored using the Finnegan Neonatal Abstinence Scoring Tool. Daily mean Finnegan scores were estimated using linear mixed models with random subject effects to account for repeated withdrawal scores from the same subject. Daily item prevalence was estimated using generalized estimating equations with a within-subject exchangeable correlation structure. The median LOT was 12.86 days. The prevalence of withdrawal signs decreased from day one to day three of treatment. However, certain central nervous system (CNS) and gastrointestinal (GI) signs showed sporadic increases in prevalence notable around two weeks of treatment, accounting for increases in Finnegan scores that guided pharmacotherapy. We question whether the resurgence of signs with a prolonged LOT is mainly a consequence of opioid tolerance or withdrawal. Monitoring CNS and GI signs throughout treatment is crucial. Future studies directed to better understand this clinical phenomenon may lead to the refining of NAS pharmacotherapy and perhaps the discovery of treatment alternatives.
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Affiliation(s)
- Jennifer S. Miller
- College of Nursing, University of Tennessee, Knoxville, TN 37996, USA;
- College of Medicine, University of Kentucky, Lexington, KY 40536, USA;
| | - Henrietta S. Bada
- College of Medicine, University of Kentucky, Lexington, KY 40536, USA;
| | - Philip M. Westgate
- College of Public Health, University of Kentucky, Lexington, KY 40536, USA;
| | | | - Markos Leggas
- Division of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA;
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3
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Yalçin N, Flint RB, van Schaik RHN, Simons SHP, Allegaert K. The Impact of Pharmacogenetics on Pharmacokinetics and Pharmacodynamics in Neonates and Infants: A Systematic Review. Pharmgenomics Pers Med 2022; 15:675-696. [PMID: 35795337 PMCID: PMC9252316 DOI: 10.2147/pgpm.s350205] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/14/2022] [Indexed: 12/22/2022] Open
Abstract
In neonates, pharmacogenetics has an additional layer of complexity. This is because in addition to genetic variability in genes that code for proteins relevant to clinical pharmacology, there are rapidly maturational changes in these proteins. Consequently, pharmacotherapy in neonates has unique challenges. To provide a contemporary overview on pharmacogenetics in neonates, we conducted a systematic review to identify, describe and quantify the impact of pharmacogenetics on pharmacokinetics and -dynamics in neonates and infants (PROSPERO, CRD42022302029). The search was performed in Medline, Embase, Web of Science and Cochrane, and was extended by a PubMed search on the ‘top 100 Medicines’ (medicine + newborn/infant + pharmacogen*) prescribed to neonates. Following study selection (including data in infants, PGx related) and quality assessment (Newcastle–Ottawa scale, Joanna Briggs Institute tool), 55/789 records were retained. Retained records relate to metabolizing enzymes involved in phase I [cytochrome P450 (CYP1A2, CYP2A6, CYP2B6, CYP2C8/C9/C18, CYP2C19, CYP2D6, CYP3A5, CYP2E1)], phase II [glutathione-S-transferases, N-acetyl transferases, UDP-glucuronosyl-transferase], transporters [ATP-binding cassette transporters, organic cation transporters], or receptor/post-receptor mechanisms [opioid related receptor and post-receptor mechanisms, tumor necrosis factor, mitogen-activated protein kinase 8, vitamin binding protein diplotypes, corticotrophin-releasing hormone receptor-1, nuclear receptor subfamily-1, vitamin K epoxide reductase complex-1, and angiotensin converting enzyme variants]. Based on the available overview, we conclude that the majority of reported pharmacogenetic studies explore and extrapolate observations already described in older populations. Researchers commonly try to quantify the impact of these polymorphisms in small datasets of neonates or infants. In a next step, pharmacogenetic studies in neonatal life should go beyond confirmation of these associations and explore the impact of pharmacogenetics as a covariate limited to maturation of neonatal life (ie, fetal malformations, breastfeeding or clinical syndromes). The challenge is to identify the specific factors, genetic and non-genetic, that contribute to the best benefit/risk balance.
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Affiliation(s)
- Nadir Yalçin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands
| | - Robert B Flint
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands
- Division of Neonatology, Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands
| | - Ron H N van Schaik
- Division of Neonatology, Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands
- Department of Clinical Chemistry, Erasmus MC, Rotterdam, the Netherlands
| | - Sinno H P Simons
- Division of Neonatology, Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Child and Youth Institute, KU Leuven, Leuven, Belgium
- Correspondence: Karel Allegaert, Neonatal Intensive Care Unit, UZ Leuven, Herestraat 49, Leuven, 3000, Belgium, Tel +32-016-342020, Fax +32-016-343209, Email
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4
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Abstract
Chronic pain and agitation in neonatal life impact the developing brain. Oral sweet-tasting solutions should be used judiciously to mitigate behavioral responses to mild painful procedures, keeping in mind that the long-term impact is unknown. Rapidly acting opioids should be used as part of premedication cocktails for nonemergent endotracheal intubations. Continuous low-dose morphine or dexmedetomidine may be considered for preterm or term neonates exhibiting signs of stress during mechanical ventilation and therapeutic hypothermia, respectively. Further research is required regarding the pharmacokinetics, pharmacodynamics, safety, and efficacy of pharmacologic agents used to mitigate mild, moderate, and chronic pain and stress in neonates.
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Affiliation(s)
- Christopher McPherson
- Department of Pharmacy, St. Louis Children's Hospital, 1 Children's Place, St. Louis, MO 63110, USA; Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
| | - Ruth E Grunau
- Department of Pediatrics, University of British Columbia, F605B, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver BC V5Z 4H4, Canada
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5
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Matic M, de Hoogd S, de Wildt SN, Tibboel D, Knibbe CA, van Schaik RH. OPRM1 and COMT polymorphisms: implications on postoperative acute, chronic and experimental pain after cardiac surgery. Pharmacogenomics 2021; 21:181-193. [PMID: 31967515 DOI: 10.2217/pgs-2019-0141] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Aim: Investigate the potential role of OPRM1 (mu-opioid receptor) and COMT (catechol-O-methyltransferase enzyme) polymorphisms in postoperative acute, chronic and experimental thermal pain. Methods: A secondary analysis of 125 adult cardiac surgery patients that were randomized between fentanyl and remifentanil during surgery and genotyped. Results: Patients in the fentanyl group with the COMT high-pain sensitivity haplotype required less postoperative morphine compared with the average-pain sensitivity haplotype (19.4 [16.5; 23.0] vs 34.6 [26.2; 41.4]; p = 0.00768), but not to the low-pain sensitivity group (30.1 [19.1; 37.7]; p = 0.13). No association was found between COMT haplotype and other pain outcomes or OPRM1 polymorphisms and the different pain modalities. Conclusion: COMT haplotype appears to explain part of the variability in acute postoperative pain in adult cardiac surgery patients.
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Affiliation(s)
- Maja Matic
- Department of Clinical Chemistry, Erasmus MC - University Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands.,Intensive Care & Department of Paediatric Surgery, Erasmus MC - University Medical Center Rotterdam, Sophia Children's Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Sjoerd de Hoogd
- Department of Clinical Pharmacy, St Antonius Hospital, Koekoeklaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Saskia N de Wildt
- Intensive Care & Department of Paediatric Surgery, Erasmus MC - University Medical Center Rotterdam, Sophia Children's Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands.,Department of Pharmacology & Toxicology, Radboud University, Nijmegen, The Netherlands
| | - Dick Tibboel
- Intensive Care & Department of Paediatric Surgery, Erasmus MC - University Medical Center Rotterdam, Sophia Children's Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Catherijne Aj Knibbe
- Department of Clinical Pharmacy, St Antonius Hospital, Koekoeklaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Ron Hn van Schaik
- Department of Clinical Chemistry, Erasmus MC - University Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
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6
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Packiasabapathy S, Rangasamy V, Horn N, Hendrickson M, Renschler J, Sadhasivam S. Personalized pediatric anesthesia and pain management: problem-based review. Pharmacogenomics 2020; 21:55-73. [PMID: 31849281 DOI: 10.2217/pgs-2019-0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Pharmacogenetics, the genetic influence on the interpersonal variability in drug response, has enabled tailored pharmacotherapy and emerging 'personalized medicine.' Although oncology spearheaded the clinical implementation of personalized medicine, other specialties are rapidly catching up. In anesthesia, classical examples of genetically mediated idiosyncratic reactions have been long known (e.g., malignant hyperthermia and prolonged apnea after succinylcholine). The last two decades have witnessed an expanding body of pharmacogenetic evidence in anesthesia. This review highlights some of the prominent pharmacogenetic associations studied in anesthesia and pain management, with special focus on pediatric anesthesia.
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Affiliation(s)
- Senthil Packiasabapathy
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Valluvan Rangasamy
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Nicole Horn
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Michele Hendrickson
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Janelle Renschler
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
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7
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Donato J, Rao K, Lewis T. Pharmacology of Common Analgesic and Sedative Drugs Used in the Neonatal Intensive Care Unit. Clin Perinatol 2019; 46:673-692. [PMID: 31653302 DOI: 10.1016/j.clp.2019.08.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In this review of analgesic and sedation medication in neonates, important classes of old and newer medications commonly used in the neonatal intensive care unit setting are discussed. In addition to drug metabolism, efficacy, and safety for individual drugs, new insights into multimodal analgesic approaches suggest ways in which multiple analgesic drug classes can be combined to maximize efficacy and minimize toxicity. Opiate pharmacogenetics and the potential for a precision therapeutics approach is explored, with a final description of gaps in knowledge and a call for future research of pain and sedation control in the neonatal population.
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Affiliation(s)
- Jamesia Donato
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Karishma Rao
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Tamorah Lewis
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA; Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Department of Pediatrics, Division of Pediatric Clinical Pharmacology, UMKC School of Medicine, Children's Mercy Hospital, Kansas City, MO, USA.
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8
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Gender based differences, pharmacogenetics and adverse events in chronic pain management. THE PHARMACOGENOMICS JOURNAL 2019; 20:320-328. [PMID: 31745220 DOI: 10.1038/s41397-019-0118-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/08/2019] [Accepted: 11/06/2019] [Indexed: 12/28/2022]
Abstract
Safety data in chronic non-cancer pain (CNCP) with long-term opioid therapy has been poorly studied and can be differently influenced by gender. Furthermore, pharmacogenetics (PGx) could possibly be used to tailor pain medication based on the individual's genetic background. The aim was to assess whether PGx applied to a pharmacovigilance system could help to improve a patient's security profile. A pharmacovigilance data recording system was conducted over 24 months, including genotyping of OPRM1 variants (opioid receptor, A118G) and COMT (enzyme that degrades catecholamines such as norepinephrine, G1947A). Pain intensity (visual analogue scale, VAS), morphine equivalent daily dose (MEDD), adverse events (AEs) and suspected adverse drug reactions (ADRs) were recorded and analysed by gender. The Ethics Committee approved the study and data were analysed with R 3.6.0 software. A total of 748 patients were recruited in the study (67% female, VAS 62 ± 29 mm, MEDD 119 ± 114 mg/day) reporting a median of 6 (3.5-9) AEs/patient. Women presented more nausea, headaches, insomnia, loss of appetite, weight change, depression and dizziness than men. Analysis by genotype demonstrated that PGx influenced the prevalence of vomiting and depression in men, dizziness in women and sexual dysfunction in both. Physicians notified 150 ADRs mostly in females (79%) related to nervous system disorders. PGx applied to a pharmacovigilance recording system provides important information to achieve a better knowledge about AEs in CNCP pharmacological therapy. OPRM1 and COMT polymorphisms were associated with AEs in CNCP patients that differed according to gender.
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9
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Lucenteforte E, Vannacci A, Crescioli G, Lombardi N, Vagnoli L, Giunti L, Cetica V, Coniglio ML, Pugi A, Bonaiuti R, Aricò M, Giglio S, Messeri A, Barale R, Giovannelli L, Mugelli A, Maggini V. Opioid response in paediatric cancer patients and the Val158Met polymorphism of the human catechol-O-methyltransferase (COMT) gene: an Italian study on 87 cancer children and a systematic review. BMC Cancer 2019; 19:113. [PMID: 30704436 PMCID: PMC6357360 DOI: 10.1186/s12885-019-5310-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/21/2019] [Indexed: 01/08/2023] Open
Abstract
Background Genetic polymorphisms in genes involved in pain modulation have been reported to be associated to opioid efficacy and safety in different clinical settings. Methods The association between COMT Val158Met polymorphism (rs4680) and the inter-individual differences in the response to opioid analgesic therapy was investigated in a cohort of 87 Italian paediatric patients receiving opioids for cancer pain (STOP Pain study). Furthermore, a systematic review of the association between opioid response in cancer patients and the COMT polymorphism was performed in accordance with the Cochrane Handbook and the Prisma Statement. Results In the 87 paediatric patients, pain intensity (total time needed to reach the lowest possible level) was significantly higher for G/G than A/G and A/A carriers (p-value = 0.042). In the 60 patients treated only with morphine, the mean of total dose to reach the same pain intensity was significantly higher for G/G than A/G and A/A carriers (p-value = 0.010). Systematic review identified five studies on adults, reporting that opioid dose (mg after 24 h of treatment from the first pain measurement) was higher for G/G compared to A/G and A/A carriers. Conclusions Present research suggests that the A allele in COMT polymorphism could be a marker of opioid sensitivity in paediatric cancer patients (STOP Pain), as well as in adults (Systematic Review), indicating that the polymorphism impact could be not age-dependent in the cancer pain context. Trial registration Registration number: CRD42017057831. Electronic supplementary material The online version of this article (10.1186/s12885-019-5310-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ersilia Lucenteforte
- Department of Clinical and Experimental Medicine University of Pisa, Pisa, Italy
| | - Alfredo Vannacci
- Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - Giada Crescioli
- Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - Niccolò Lombardi
- Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - Laura Vagnoli
- Pain and Palliative Care Unit, Meyer Children's University Hospital, Florence, Italy
| | - Laura Giunti
- Medical Genetics Unit, Meyer Children's University Hospital, Florence, Italy
| | - Valentina Cetica
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department, Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Maria Luisa Coniglio
- Department of Paediatric Oncohematology, Meyer Children's University Hospital, Florence, Italy
| | - Alessandra Pugi
- Clinical Trial Office, Meyer Children's University Hospital, Florence, Italy
| | - Roberto Bonaiuti
- Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - Maurizio Aricò
- Direzione Generale, Azienda Sanitaria Provinciale, Ragusa, Italy
| | - Sabrina Giglio
- Medical Genetics Unit, Meyer Children's University Hospital, Florence, Italy.,Medical Genetics Unit, Department of Clinical and Experimental Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Andrea Messeri
- Pain and Palliative Care Unit, Meyer Children's University Hospital, Florence, Italy
| | | | - Lisa Giovannelli
- Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - Alessandro Mugelli
- Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - Valentina Maggini
- Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy. .,Center for Integrative Medicine, Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, Largo Brambilla, 3 -, 50134, Florence, Italy.
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10
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Chau CMY, Ross CJD, Chau V, Synnes AR, Miller SP, Carleton B, Grunau RE. Morphine biotransformation genes and neonatal clinical factors predicted behaviour problems in very preterm children at 18 months. EBioMedicine 2019; 40:655-662. [PMID: 30709768 PMCID: PMC6413679 DOI: 10.1016/j.ebiom.2019.01.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 01/18/2023] Open
Abstract
Background Behaviour problems are prevalent among children born very preterm (≤ 32 weeks gestation), and have been associated with morphine exposure. Morphine accumulation in the brain is determined by genetic variations related to morphine biotransformation. The objective of the study was to investigate whether morphine-biotransformation genotypes contribute to individual differences in long-term effects of morphine on behaviour at 18 months corrected age (CA). Methods 198 children born very preterm (24–32 weeks gestation) were followed from birth and seen at 18 months CA. Relationships between child behavior (Internalizing, Externalizing on the Child Behavior Checklist), morphine exposure, neonatal clinical variables, and morphine biotransformation gene variants in ABCB1, UGT1A9, UGT 2B7*2, ABCC2, ABCC3, SLCO1B1, CYP3A4, COMT were examined. Findings Neonatal clinical predictors and genotypes accounted for 39% of the overall variance in behaviour. In children with the minor allele of UGT1A9 rs17863783 (marker of UGT1A6*4, UDP-glucuronosyltransferase), greater morphine exposure (p = ·0011) was associated with more Internalizing behaviour. More Externalizing behaviour was predicted by greater morphine exposure in children with the COMT rs4680 Met/Met genotype (p = ·0006). Interpretation Genetic variations that affect relative accumulation of morphine in the brain, together with neonatal clinical factors, are differentially related to anxiety and depressive symptoms (internalizing) and to acting out (externalizing) behaviours at 18 months CA in children born very preterm. Fund NIH/NICHD HD039783 (REG); CIHR MOP86489 (REG), MOP68898 (SPM), MOP79262 (SPM, REG).
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Affiliation(s)
- Cecil M Y Chau
- BC Children's Hospital Research Institute, Vancouver, Canada; Pediatrics, University of British Columbia, Vancouver, Canada
| | - Colin J D Ross
- BC Children's Hospital Research Institute, Vancouver, Canada; Pediatrics, University of British Columbia, Vancouver, Canada
| | - Vann Chau
- Neurology, The Hospital for Sick Children, Toronto, Canada; Paediatrics, University of Toronto, Toronto, Canada
| | - Anne R Synnes
- BC Children's Hospital Research Institute, Vancouver, Canada; Pediatrics, University of British Columbia, Vancouver, Canada
| | - Steven P Miller
- Neurology, The Hospital for Sick Children, Toronto, Canada; Paediatrics, University of Toronto, Toronto, Canada
| | - Bruce Carleton
- BC Children's Hospital Research Institute, Vancouver, Canada; Pediatrics, University of British Columbia, Vancouver, Canada
| | - Ruth E Grunau
- BC Children's Hospital Research Institute, Vancouver, Canada; Pediatrics, University of British Columbia, Vancouver, Canada.
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11
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Lewis T, Leeder JS. Pharmacogenomics and implementation of precision therapeutics in the neonatal ICU: a new frontier? Pharmacogenomics 2018; 19:1231-1233. [PMID: 30334480 DOI: 10.2217/pgs-2018-0132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Tamorah Lewis
- Department of Pediatrics, Division of Neonatology, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, Kansas City, MO 64152, USA.,Department of Pediatrics, Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, Kansas City, MO 64152, USA
| | - J Steven Leeder
- Department of Pediatrics, Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, Kansas City, MO 64152, USA
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12
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Euteneuer JC, Kamatkar S, Fukuda T, Vinks AA, Akinbi HT. Suggestions for Model-Informed Precision Dosing to Optimize Neonatal Drug Therapy. J Clin Pharmacol 2018; 59:168-176. [PMID: 30204236 DOI: 10.1002/jcph.1315] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/17/2018] [Indexed: 12/19/2022]
Abstract
Evidence for dosing, efficacy, and safety of most medications used to treat neonates is sparse. Thus, dosing is usually derived by extrapolation from adult and pediatric pharmacologic data with scaling by body weight or body surface area. This may lead to drug dosing that is unsafe or ineffective. However, new strategies are being developed and studied to dose medications in critically ill neonates. Mass spectroscopy technology capable of quickly analyzing drug levels is readily available. Software that integrates population pharmacokinetics and pharmacodynamics with data from sparse samples from neonates allows for timely adjustments of dosing to achieve the desired effect while minimizing adverse outcomes. Some genetic polymorphisms that affect drug response in neonates have also been reported. This review highlights aspects of drug response and how it is impacted by prematurity, assesses pharmacogenomic studies in neonates, and offers suggestions for innovative pharmacokinetic/pharmacodynamic model-based approaches that combine population- or physiology-based pharmacology data, Bayesian analysis, and electronic decision support tools for precision dosing in neonates while illustrating examples where this approach can be used to optimize medical therapy in neonates. Barriers to implementing precision dosing in neonates and how to overcome them are also discussed.
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Affiliation(s)
- Joshua C Euteneuer
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA.,Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Suyog Kamatkar
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Henry T Akinbi
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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13
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Abstract
Pain is an unpleasant feeling usually resulting from tissue damage that can persist along weeks, months, or even years after the injury, turning into pathological chronic pain, the leading cause of disability. Currently, pharmacology interventions are usually the first-line therapy but there is a highly variable analgesic drug response. Pharmacogenetics (PGx) offers a means to identify genetic biomarkers that can predict individual analgesic response opening doors to precision medicine. PGx analyze the way in which the presence of variations in the DNA sequence (single-nucleotide polymorphisms, SNPs) could be responsible for portions of the population reaching different levels of pain relief (phenotype) due to gene interference in the drug mechanism of action (pharmacodynamics) and/or its concentration at the place of action (pharmacokinetics). SNPs in the cytochrome P450 enzymes genes (CYP2D6) influence metabolism of codeine, tramadol, hydrocodone, oxycodone, and tricyclic antidepressants. Blood concentrations of some NSAIDs depend on CYP2C9 and/or CYP2C8 activity. Additional candidate genes encode for opioid receptors, transporters, and other molecules important for pharmacotherapy in pain management. However, PGx studies are often contradictory, slowing the uptake of this information. This is likely due, in large part, to a lack of robust evidence demonstrating clinical utility and to its polygenic response modulated by other exogenous or epigenetics factors. Novel therapies, including targeting of epigenetic changes and gene therapy-based approaches, broaden future options to improve understanding of pain and the treatment of people who suffer it.
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Affiliation(s)
- Ana M Peiró
- Clinical Pharmacology Unit, Department of Health of Alicante-General Hospital, Alicante, Spain; Neuropharmacology on Pain (NED), Alicante Institute for Health and Biomedical Research (ISABIAL-FISABIO Foundation), Alicante, Spain.
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14
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Precision therapeutics in the NICU: why are we missing the mark? J Perinatol 2018; 38:444-446. [PMID: 29379159 DOI: 10.1038/s41372-018-0052-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 12/01/2017] [Indexed: 11/09/2022]
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15
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Zeilmaker GA, Pokorna P, Mian P, Wildschut ED, Knibbe CAJ, Krekels EHJ, Allegaert K, Tibboel D. Pharmacokinetic considerations for pediatric patients receiving analgesia in the intensive care unit; targeting postoperative, ECMO and hypothermia patients. Expert Opin Drug Metab Toxicol 2018; 14:417-428. [PMID: 29623729 DOI: 10.1080/17425255.2018.1461836] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Adequate postoperative analgesia in pediatric patients in the intensive care unit (ICU) matters, since untreated pain is associated with negative outcomes. Compared to routine postoperative patients, children undergoing hypothermia (HT) or extracorporeal membrane oxygenation (ECMO), or recovering after cardiac surgery likely display non-maturational differences in pharmacokinetics (PK) and pharmacodynamics (PD). These differences warrant additional dosing recommendations to optimize pain treatment. Areas covered: Specific populations within the ICU will be discussed with respect to expected variations in PK and PD for various analgesics. We hereby move beyond maturational changes and focus on why PK/PD may be different in children undergoing HT, ECMO or cardiac surgery. We provide a stepwise manner to develop PK-based dosing regimens using population PK approaches in these populations. Expert opinion: A one-dose to size-fits-all for analgesia is suboptimal, but for several commonly used analgesics the impact of HT, ECMO or cardiac surgery on average PK parameters in children is not yet sufficiently known. Parameters considering both maturational and non-maturational covariates are important to develop population PK-based dosing advices as part of a strategy to optimize pain treatment.
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Affiliation(s)
- Gerdien A Zeilmaker
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Paula Pokorna
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,b Department of Pediatrics, General Faculty Hospital Prague, First Faculty of Medicine , Charles University and General University Hospital in Prague , Prague , Czech Republic.,c Institute of Pharmacology, First Faculty of Medicine , Charles University and General University Hospital in Prague , Prague , Czech Republic
| | - Paola Mian
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Enno D Wildschut
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Catherijne A J Knibbe
- d Division of Pharmacology , LACDR, Leiden University , Leiden , The Netherlands.,e Department of Clinical Pharmacy , St. Antonius Hospital , Nieuwegein , The Netherlands
| | - Elke H J Krekels
- d Division of Pharmacology , LACDR, Leiden University , Leiden , The Netherlands
| | - Karel Allegaert
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,f Department of Development and Regeneration , KU Leuven , Leuven , Belgium
| | - Dick Tibboel
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
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16
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Xie S, Ma W, Guo Q, Liu J, Li W, McLeod HL, He Y. The pharmacogenetics of medications used in general anesthesia. Pharmacogenomics 2018; 19:285-298. [PMID: 29318929 DOI: 10.2217/pgs-2017-0168] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
General anesthesia is a state of unconsciousness, amnesia, analgesia and akinesia induced by drugs including opioids, hypnotic-sedative agents, muscle relaxants and antiemetics. Clinical and genetic factors are reported to influence the efficacy and side effects of these agents. Based on the evidence, clinical action is needed to improve clinical outcomes. This review summarizes the latest knowledge with regards to the pharmacogenetics of anesthetics and general anesthesia related complications.
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Affiliation(s)
- Shangchen Xie
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, Hunan, P.R. China
| | - Wenjuan Ma
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Qulian Guo
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Jie Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, Hunan, P.R. China
| | - Wei Li
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, Hunan, P.R. China
| | - Howard L McLeod
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, Hunan, P.R. China
- Moffitt Cancer Center, DeBartolo Family Personalized Medicine Institute, Tampa, FL 33601, USA
| | - Yijing He
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, Hunan, P.R. China
- Moffitt Cancer Center, DeBartolo Family Personalized Medicine Institute, Tampa, FL 33601, USA
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17
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Van Donge T, Mian P, Tibboel D, Van Den Anker J, Allegaert K. Drug metabolism in early infancy: opioids as an illustration. Expert Opin Drug Metab Toxicol 2018; 14:287-301. [PMID: 29363349 DOI: 10.1080/17425255.2018.1432595] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Drug dosing in infants frequently depends on body weight as a crude indicator for maturation. Fentanyl (metabolized by Cytochrome P450 3A4) and morphine (glucuronidated by UDP-glucuronosyltransferase-2B7) served as model drugs to provide insight in maturation patterns of these enzymes and provide understanding of the impact of non-maturational factors to optimize dosing in infants. Areas covered: Systematic searches on metabolism and population pharmacokinetic (Pop-PK) models for fentanyl and morphine were performed. Pre- and post-model selection criteria were applied to assess and evaluate the validity of these models. It was observed that maturational changes have been rather well investigated, be it with variability in the maturational function estimates. The same holds true for Pop-PK models, where non-maturational covariates have also been reported (pharmacogenetics, disease state or external influences), although less incorporated in the PK models and with limited knowledge on mechanisms involved. Expert opinion: PK models for fentanyl and morphine are currently available. Consequently, we suggest that researchers should not continue to develop new models, but should investigate whether collected data fit in already existing models and provide additional value concerning the impact of (non)-maturational factors like drug-drug interactions or pharmacogenetics.
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Affiliation(s)
- Tamara Van Donge
- a Intensive Care and Department of Paediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,b Systems Biomedicine and Pharmacology , LACDR, Leiden University , Leiden , The Netherlands
| | - Paola Mian
- a Intensive Care and Department of Paediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Dick Tibboel
- a Intensive Care and Department of Paediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - John Van Den Anker
- a Intensive Care and Department of Paediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,c Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland.,d Division of Clinical Pharmacology , Children's National Health System , Washington , DC , USA
| | - Karel Allegaert
- a Intensive Care and Department of Paediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,e Department of Development and Regeneration , KU Leuven , Leuven , Belgium
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18
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Peiró AM, Planelles B, Juhasz G, Bagdy G, Libert F, Eschalier A, Busserolles J, Sperlagh B, Llerena A. Pharmacogenomics in pain treatment. Drug Metab Pers Ther 2017; 31:131-42. [PMID: 27662648 DOI: 10.1515/dmpt-2016-0005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/08/2016] [Indexed: 11/15/2022]
Abstract
The experience of chronic pain is one of the commonest reasons for seeking medical attention, being a major issue in clinical practice. While pain is a universal experience, only a small proportion of people who felt pain develop pain syndromes. In addition, painkillers are associated with wide inter-individual variability in the analgesic response. This may be partly explained by the presence of single nucleotide polymorphisms in genes encoding molecular entities involved in pharmacodynamics and pharmacokinetics. However, uptake of this information has been slow due in large part to the lack of robust evidences demonstrating clinical utility. Furthermore, novel therapies, including targeting of epigenetic changes and gene therapy-based approaches are further broadening future options for the treatment of chronic pain. The aim of this article is to review the evidences behind pharmacogenetics (PGx) to individualize therapy (boosting the efficacy and minimizing potential toxicity) and genes implicated in pain medicine, in two parts: (i) genetic variability with pain sensitivity and analgesic response; and (ii) pharmacological concepts applied on PGx.
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19
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Abstract
Pain sensitivity is an inherited factor that varies strongly between individuals. We investigated whether genetic polymorphisms in the candidate genes COMT, OPRM1, OPRD1, TAOK3, TRPA1, TRPV1, and SCN9A are contributing to experimental pain variability between children. Our study included 136 children and adolescents (8-18 years). Cold and heat pain thresholds were determined with a Thermal Sensory Analyzer. Women and young children were significantly more sensitive to pain (P < 0.05). After correction for age, gender, reaction time, and correction for multiple testing, OPRM1 118A>G G-allele carriers (AG and GG) rated the hot stimulus as significantly less painful than did OPRM1 118A>G AA genotyped individuals (2[1-5] vs 7 [3-9], respectively; P = 0.00005). Additionally, OPRM1 118G allele carriers reached more frequently the minimum temperature limit (44% vs 17%, respectively; P = 0.003) and maximum temperature limit (52% vs 24%, respectively; P = 0.0052), indicative for lower pain sensitivity. The combined genotype, based on expected pain sensitivity, OPRM1 118AA/COMT 472 GA or AA genotyped children, was associated with lower pain thresholds (ie, higher pain sensitivity) than were the OPRM1 118GA or GG/COMT 472GG genotyped children. This is the first study reporting on genetic variants and experimental thermal pain in children and adolescents. OPRM1 rs1799971 and the combined OPRM1/COMT genotype could serve as biomarkers for pain sensitivity.
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20
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Owusu Obeng A, Hamadeh I, Smith M. Review of Opioid Pharmacogenetics and Considerations for Pain Management. Pharmacotherapy 2017; 37:1105-1121. [DOI: 10.1002/phar.1986] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Aniwaa Owusu Obeng
- The Charles Bronfman Institute for Personalized Medicine; Icahn School of Medicine at Mount Sinai; New York NY
- Pharmacy Department; The Mount Sinai Hospital; New York New York
- Division of General Internal Medicine; Department of Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | | | - Michael Smith
- University of Michigan College of Pharmacy; Ann Arbor Michigan
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21
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Matic M, Jongen JL, Elens L, de Wildt SN, Tibboel D, Sillevis Smitt PA, van Schaik RH. Advanced cancer pain: the search for genetic factors correlated with interindividual variability in opioid requirement. Pharmacogenomics 2017; 18:1133-1142. [PMID: 28745577 DOI: 10.2217/pgs-2017-0060] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To assess association between genetic variants and opioid requirement in cancer patients. MATERIALS & METHODS A prospective observational trial of 243 advanced cancer patients with inadequate analgesia treated by the palliative care team was analyzed for ABCB1, ARRB2, COMT, GCH1, IL1RN, KCNJ6, OPRM1, RHBDF2, SCN9A and Stat6 polymorphisms. RESULTS For patients carrying OPRM1 118AG/GG and COMT 472GG (Val158Val) or these genotypes alone, a significant higher median percentage dose increase was observed (95.2% [32.8-345]) compared with OPRM1 118AA and COMT 472GA/AA (158Met allele carriers; 48.5% [0-98.8]; p = 0.0016). No associations were found with morphine equivalent dose after consultation palliative care team or ketamine use. CONCLUSION Patients with the combined OPRM1 118AG/GG and COMT 472GG genotype required 50% higher dose increase for sufficient analgesia.
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Affiliation(s)
- Maja Matic
- Department of Clinical Chemistry, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Pediatric Surgery, Erasmus MC - University Medical Center Rotterdam, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Joost Lm Jongen
- Department of Neurology, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Laure Elens
- Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium.,Louvain Centre for Toxicology & Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et clinique (IREC), Université catholique de Louvain, Brussels, Belgium
| | - Saskia N de Wildt
- Department of Pediatric Surgery, Erasmus MC - University Medical Center Rotterdam, Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pharmacology & Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery, Erasmus MC - University Medical Center Rotterdam, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Peter Ae Sillevis Smitt
- Department of Neurology, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ron Hn van Schaik
- Department of Clinical Chemistry, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
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22
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Matic M, de Wildt SN, Tibboel D, van Schaik RHN. Analgesia and Opioids: A Pharmacogenetics Shortlist for Implementation in Clinical Practice. Clin Chem 2017. [DOI: 10.1373/clinchem.2016.264986] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
The use of opioids to alleviate pain is complicated by the risk of severe adverse events and the large variability in dose requirements. Pharmacogenetics (PGx) could possibly be used to tailor pain medication based on an individual's genetic background. Many potential genetic markers have been described, and the importance of genetic predisposition in opioid efficacy and toxicity has been demonstrated in knockout mouse models and human twin studies. Such predictors are especially of value for neonates and young children, in whom the assessment of efficacy or side effects is complicated by the inability of the patient to communicate this properly. The current problem is determining which of the many potential candidates to focus on for clinical implementation.
CONTENT
We systematically searched publications on PGx for opioids in 5 databases, aiming to identify PGx markers with sufficient robust data and high enough occurrence for potential clinical application. The initial search yielded 4257 unique citations, eventually resulting in 852 relevant articles covering 24 genes. From these genes, we evaluated the evidence and selected the most promising 10 markers: cytochrome P450 family 2 subfamily D member 6 (CYP2D6), cytochrome P450 family 3 subfamily A member 4 (CYP3A4), cytochrome P450 family 3 subfamily A member 5 (CYP3A5), UDP glucuronosyltransferase family 2 member B7 (UGT2B7), ATP binding cassette subfamily B member 1 (ABCB1), ATP binding cassette subfamily C member 3 (ABCC3), solute carrier family 22 member 1 (SLC22A1), opioid receptor kappa 1 (OPRM1), catechol-O-methyltransferase (COMT), and potassium voltage-gated channel subfamily J member 6 (KCNJ6). Treatment guidelines based on genotype are already available only for CYP2D6.
SUMMARY
The application of PGx in the management of pain with opioids has the potential to improve therapy. We provide a shortlist of 10 genes that are the most promising markers for clinical use in this context.
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Affiliation(s)
- Maja Matic
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center–Sophia Children Hospital, Rotterdam, the Netherlands
| | - Saskia N de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center–Sophia Children Hospital, Rotterdam, the Netherlands
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center–Sophia Children Hospital, Rotterdam, the Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands
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23
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Allegaert K, Simons SHP, Tibboel D, Krekels EH, Knibbe CA, van den Anker JN. Non-maturational covariates for dynamic systems pharmacology models in neonates, infants, and children: Filling the gaps beyond developmental pharmacology. Eur J Pharm Sci 2017; 109S:S27-S31. [PMID: 28506866 DOI: 10.1016/j.ejps.2017.05.023] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 05/11/2017] [Indexed: 02/07/2023]
Abstract
Pharmacokinetics and -dynamics show important changes throughout childhood. Studies on the different maturational processes that influence developmental pharmacology have been used to create population PK/PD models that can yield individualized pediatric drug dosages. These models were subsequently translated to semi-physiologically or physiology-based PK (PBPK) models that support predictions in pediatric patient cohorts and other special populations. Although these translational efforts are crucial, these models should be further improved towards individual patient predictions by including knowledge on non-maturational covariates. These efforts are needed to ultimately get to systems pharmacology models for children. These models take developmental changes relating to the pediatric dynamical system into account but also other aspects that may be of importance such as abnormal body composition, pharmacogenetics, critical illness and inflammatory status.
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Affiliation(s)
- Karel Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Development and Regeneration KU Leuven, Leuven, Belgium
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Elke H Krekels
- Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden, the Netherlands
| | - Catherijne A Knibbe
- Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden, the Netherlands; Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - John N van den Anker
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands; Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA; Division of Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
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24
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Baarslag MA, Allegaert K, Van Den Anker JN, Knibbe CAJ, Van Dijk M, Simons SHP, Tibboel D. Paracetamol and morphine for infant and neonatal pain; still a long way to go? Expert Rev Clin Pharmacol 2016; 10:111-126. [PMID: 27785937 DOI: 10.1080/17512433.2017.1254040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Pharmacologic pain management in newborns and infants is often based on limited scientific data. To close the knowledge gap, drug-related research in this population is increasingly supported by the authorities, but remains very challenging. This review summarizes the challenges of analgesic studies in newborns and infants on morphine and paracetamol (acetaminophen). Areas covered: Aspects such as the definition and multimodal character of pain are reflected to newborn infants. Specific problems addressed include defining pharmacodynamic endpoints, performing clinical trials in this population and assessing developmental changes in both pharmacokinetics and pharmacodynamics. Expert commentary: Neonatal and infant pain management research faces two major challenges: lack of clear biomarkers and very heterogeneous pharmacokinetics and pharmacodynamics of analgesics. There is a clear call for integral research addressing the multimodality of pain in this population and further developing population pharmacokinetic models towards physiology-based models.
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Affiliation(s)
- Manuel A Baarslag
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Karel Allegaert
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands.,b Department of development and regeneration , KU Leuven , Leuven , Belgium
| | - John N Van Den Anker
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands.,c Division of Clinical Pharmacology , Children's National Health System , Washington , DC , USA.,d Division of Pediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland
| | - Catherijne A J Knibbe
- e Department of Clinical Pharmacy , St. Antonius Hospital , Nieuwegein , The Netherlands.,f Division of Pharmacology, Leiden Academic Center for Drug Research , Leiden University , Leiden , the Netherlands
| | - Monique Van Dijk
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands.,g Department of Pediatrics, division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Sinno H P Simons
- g Department of Pediatrics, division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Dick Tibboel
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
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25
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Neonatal pain management: still in search for the Holy Grail. Int J Clin Pharmacol Ther 2016; 54:514-23. [PMID: 27087155 PMCID: PMC5012190 DOI: 10.5414/cp202561] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2016] [Indexed: 12/31/2022] Open
Abstract
Inadequate pain management but also inappropriate use of analgesics in early infancy has negative effects on neurodevelopmental outcome. As a consequence, neonatal pain management is still in search for the Holy Grail. At best, effective pain management is based on prevention, assessment, and treatment followed by a re-assessment of the pain to determine if additional treatment is still necessary. Unfortunately, epidemiological observations suggest that neonates are undergoing painful procedures very frequently, unveiling the need for effective preventive, non-pharmacological strategies. In addition, assessment is still based on validated, multimodal, but subjective pain assessment tools. Finally, in neonatal intensive care units, there is a shift in clinical practices (e.g., shorter intubation and ventilation), and this necessitates the development and validation of new pharmacological treatment modalities. To illustrate this, a shift in the use of opioids to paracetamol has occurred and short-acting agents (remifentanil, propofol) are more commonly administered to neonates. In addition to these new modalities and as part of a more advanced approach of the developmental pharmacology of analgesics, pharmacogenetics also emerged as a tool for precision medicine in neonates. To assure further improvement of neonatal pain management the integration of pharmacogenetics with the usual covariates like weight, age and/or disease characteristics is needed.
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26
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Smits A, van den Anker JN, Allegaert K. Clinical pharmacology of analgosedatives in neonates: ways to improve their safe and effective use. ACTA ACUST UNITED AC 2016; 69:350-360. [PMID: 27364566 DOI: 10.1111/jphp.12599] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 06/11/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To propose approaches tailored to the specific needs of neonates, such as structured product development programmes, with the ultimate goal to improve the safe and effective use of analgosedatives in these fragile patients. KEY FINDINGS The feasibility and relevance of a structured product development programme in neonates (optimal study design based on preliminary data; model development; internal, external and prospective evaluation; an individualized dosing regimen; long-term safety; pharmacogenetics) are illustrated for the use of morphine. Based on changes in clinical practices, similar development plans are in progress for short-acting analgosedatives such as propofol, but are in need of tailored pharmacodynamic tools to assess and quantify effects. Furthermore, for drugs like paracetamol where there is already sufficient clinical pharmacology knowledge, attention needs to be given to long-term safety aspects. Finally, new covariates such as pharmacogenetics might further improve neonatal pain management, but clearly need to be integrated with other well-established covariates like age or weight. SUMMARY Product development programmes for analgosedatives in neonates are needed. These programmes should be tailored to their specific needs (short-acting sedation, pain relief), should include long-term safety and should incorporate the exploration of newer covariates like pharmacogenetics.
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Affiliation(s)
- Anne Smits
- Neonatal Intensive Care Unit, VU Medical Center, Amsterdam, The Netherlands.,Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - John N van den Anker
- Intensive Care and Department of Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Division of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Basel, Switzerland.,Division of Pediatric Clinical Pharmacology, Children's National Medical Center, Washington, DC, USA.,Departments of Pediatrics, Integrative Systems Biology, Pharmacology & Physiology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Karel Allegaert
- Intensive Care and Department of Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Pharmacogenomic incidental findings in 308 families: The NIH Undiagnosed Diseases Program experience. Genet Med 2016; 18:1303-1307. [PMID: 27253732 PMCID: PMC5133159 DOI: 10.1038/gim.2016.47] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 03/08/2016] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Using SNP chip and exome sequence data from individuals participating in the NIH Undiagnosed Diseases Program (UDP), we evaluated the number and therapeutic informativeness of incidental pharmacogenetic variants. METHODS Pharmacogenomics Knowledgebase (PharmGKB) annotated sequence variants were identified in 1,101 individuals. Medication records of participants were used to identify individuals prescribed medications for which a genetic variant might alter efficacy. RESULTS 395 sequence variants, including 19 PharmGKB 1A and 1B variants, were identified in SNP chip sequence data and 388 variants, including 21 PharmGKB 1A and 1B variants, were identified in the exome sequence data. Nine participants had incidental pharmacogenetic variants associated with altered efficacy of a prescribed medication. CONCLUSIONS Despite the small size of the NIH UDP patient cohort, we identified pharmacogenetic incidental findings potentially useful for guiding therapy. Consequently, groups conducting clinical genomic studies might consider reporting of pharmacogenetic incidental findings.
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Abstract
This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants). This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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Matic M, Norman E, Rane A, Beck O, Andersson M, Elens L, Tibboel D, Fellman V, van Schaik RHN. Effect of UGT2B7 -900G>A (-842G>A; rs7438135) on morphine glucuronidation in preterm newborns: results from a pilot cohort. Pharmacogenomics 2015; 15:1589-97. [PMID: 25340733 DOI: 10.2217/pgs.14.115] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
AIM Assess association between UGT2B7 polymorphism -900G>A (rs7438135, also known as -842G>A) with morphine kinetics in preterm newborns undergoing mechanical ventilation. MATERIALS & METHODS Thirty-four infants were enrolled in a randomized clinical trial and allocated to rapid sequence intubation with remifentanil (1 µg/kg) or morphine (0.3 mg/kg). The latter group was included in our study. RESULTS Morphine plasma concentrations at 20 min post intubation were associated with postnatal age (p=0.017) and UGT2B7 -900G>A (p=0.036). UGT2B7 -900A allele carriers (n=13) had lower morphine levels compared with UGT2B7 -900G/G patients (n=2). Morphine-3-glucuronide and morphine-6-glucuronide plasma concentrations were only found to be associated with gestational and postnatal age. However, -900A allele carriers had a higher morphine-3-glucuronide:morphine metabolic ratio compared with patients genotyped as -900G/G (p=0.005), as determined by linear regression. CONCLUSION Our small pilot study illustrates that in addition to gestational and postnatal age, the UGT2B7 -900G>A polymorphism significantly alters morphine pharmacokinetics in preterm infants.
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Affiliation(s)
- Maja Matic
- Department Clinical Chemistry, Erasmus MC - University Medical Center Rotterdam, The Netherlands
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