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Aapro M, Fogli S, Morlion B, Danesi R. Opioid metabolism and drug-drug interaction in cancer. Oncologist 2024:oyae094. [PMID: 38780124 DOI: 10.1093/oncolo/oyae094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/11/2024] [Indexed: 05/25/2024] Open
Abstract
Concomitant use of multiple drugs in most patients with cancer may result in drug-drug interactions (DDIs), potentially causing serious adverse effects. These patients often experience unrelieved cancer-related pain (CRP) during and after cancer treatment, which can lead to a reduced quality of life. Opioids can be used as part of a multimodal pain management strategy when non-opioid analgesics are not providing adequate pain relief, not tolerated, or are contraindicated. However, due to their narrow therapeutic window, opioids are more susceptible to adverse events when a DDI occurs. Clinically relevant DDIs with opioids are usually pharmacokinetic, mainly occurring via metabolism by cytochrome P450 (CYP). This article aims to provide an overview of potential DDIs with opioids often used in the treatment of moderate-to-severe CRP and commonly used anticancer drugs such as chemotherapeutics, tyrosine kinase inhibitors (TKIs), or biologics. A DDI-checker tool was used to contextualize the tool-informed DDI assessment outcomes with clinical implications and practice. The findings were compared to observations from a literature search conducted in Embase and PubMed to identify clinical evidence for these potential DDIs. The limited results mainly included case studies and retrospective reviews. Some potential DDIs on the DDI-checker were aligned with literature findings, while others were contradictory. In conclusion, while DDI-checkers are useful tools in identifying potential DDIs, it is necessary to incorporate literature verification and comprehensive clinical assessment of the patient before implementing tool-informed decisions in clinical practice.
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Affiliation(s)
- Matti Aapro
- Genolier Cancer Centre, Clinique de Genolier, 1272 Genolier, Switzerland
| | - Stefano Fogli
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa PI, Italy
| | - Bart Morlion
- Department of Cardiovascular Sciences, Section Anesthesiology and Algology, University of Leuven, 3000 Leuven, Belgium
| | - Romano Danesi
- Department of Oncology and Hemato-Oncology, University of Milano, 20122 Milano MI, Italy
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Marinescu SC(N, Apetroaei MM, Nedea MI(I, Arsene AL, Velescu BȘ, Hîncu S, Stancu E, Pop AL, Drăgănescu D, Udeanu DI. Dietary Influence on Drug Efficacy: A Comprehensive Review of Ketogenic Diet-Pharmacotherapy Interactions. Nutrients 2024; 16:1213. [PMID: 38674903 PMCID: PMC11054576 DOI: 10.3390/nu16081213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
It is widely acknowledged that the ketogenic diet (KD) has positive physiological effects as well as therapeutic benefits, particularly in the treatment of chronic diseases. Maintaining nutritional ketosis is of utmost importance in the KD, as it provides numerous health advantages such as an enhanced lipid profile, heightened insulin sensitivity, decreased blood glucose levels, and the modulation of diverse neurotransmitters. Nevertheless, the integration of the KD with pharmacotherapeutic regimens necessitates careful consideration. Due to changes in their absorption, distribution, metabolism, or elimination, the KD can impact the pharmacokinetics of various medications, including anti-diabetic, anti-epileptic, and cardiovascular drugs. Furthermore, the KD, which is characterised by the intake of meals rich in fats, has the potential to impact the pharmacokinetics of specific medications with high lipophilicity, hence enhancing their absorption and bioavailability. However, the pharmacodynamic aspects of the KD, in conjunction with various pharmaceutical interventions, can provide either advantageous or detrimental synergistic outcomes. Therefore, it is important to consider the pharmacokinetic and pharmacodynamic interactions that may arise between the KD and various drugs. This assessment is essential not only for ensuring patients' compliance with treatment but also for optimising the overall therapeutic outcome, particularly by mitigating adverse reactions. This highlights the significance and necessity of tailoring pharmacological and dietetic therapies in order to enhance the effectiveness and safety of this comprehensive approach to managing chronic diseases.
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Affiliation(s)
- Simona Cristina (Nicolescu) Marinescu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
- Amethyst Radiotherapy Center, 42, Drumul Odăi, 075100 Otopeni, Romania
| | - Miruna-Maria Apetroaei
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Marina Ionela (Ilie) Nedea
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Andreea Letiția Arsene
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
- Marius Nasta Institute of Pneumophthiology, 90, Viilor Street, 050159 Bucharest, Romania
| | - Bruno Ștefan Velescu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Sorina Hîncu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
- Fundeni Clinical Institute, 258, Fundeni Street, 022328 Bucharest, Romania
| | - Emilia Stancu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Anca Lucia Pop
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Doina Drăgănescu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Denisa Ioana Udeanu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
- Marius Nasta Institute of Pneumophthiology, 90, Viilor Street, 050159 Bucharest, Romania
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Fürst P. The Use of Low-Dose Methadone as Add-On to Ongoing Opioid Treatment in Palliative Cancer Care—An Underrated Treatment? Life (Basel) 2022; 12:life12050679. [PMID: 35629347 PMCID: PMC9143404 DOI: 10.3390/life12050679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/16/2022] Open
Abstract
The aim of this review is to summarize the current knowledge of low-dose methadone treatment in palliative cancer care. In Sweden, methadone is quite common in specialized palliative care, where almost a tenth of patients are prescribed this drug. Negative attitudes towards methadone do not seem to prevent it from being used for pain management, and by starting with low doses and then increasing slowly and gradually, methadone can apparently be introduced safely. It is still uncertain whether methadone has a better analgesic effect than other opioids. However, for pain relief in cancer patients with severe and complex cancer-related pain, NMDA receptor inhibition with methadone may, in selected cases, be an attractive alternative, especially in the form of low-dose supplements to other ongoing opioids. Due to long half-life and complex metabolism, the use of methadone requires an experienced physician and solid follow-up. Continuous administration of opioids, including low-dose methadone, has been proven effective and safe in reducing pain in dying patients without increasing the risk of confusion, regardless of age.
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Affiliation(s)
- Per Fürst
- Department of Oncology-Pathology, Karolinska Institutet, 171 64 Stockholm, Sweden;
- Palliative Medicine, Stockholms Sjukhem Foundation, SE-112 19 Stockholm, Sweden
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Lai G, Aroke EN, Zhang SJ. Rediscovery of Methadone to Improve Outcomes in Pain Management. J Perianesth Nurs 2022; 37:425-434. [PMID: 35396188 DOI: 10.1016/j.jopan.2021.08.011] [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: 02/28/2021] [Revised: 08/09/2021] [Accepted: 08/28/2021] [Indexed: 11/29/2022]
Abstract
Clinically, methadone is most known for its use in the treatment of opioid maintenance therapy. However, methadone's pharmacological profile makes it an excellent analgesic that can enhance acute and chronic pain management. It is a potent μ-receptor agonist with a longer elimination half-life than most clinically used opioids. In addition, methadone inhibits serotonin and norepinephrine uptake, and it is an N-methyl-D-aspartate antagonist. These distinct analgesic pathways mediate hyperalgesic, allodynic, and neuropathic pain. Its unique analgesic properties provide several essential benefits in perioperative use, neuropathic pain, cancer, and noncancer pain. Despite these proven clinical utilities, methadone has not been used widely to treat acute and chronic pain in opioid naïve patients. This article describes the unique pharmacology of methadone and provides emerging evidence to support its application in acute and chronic pain management. Pain management options and guidelines for surgical patients on methadone are discussed as well.
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Affiliation(s)
- Gloria Lai
- Department of Anesthesiology, University of California San Francisco, San Francisco, CA
| | - Edwin N Aroke
- Nurse Anesthesia Program, School of Nursing, University of Alabama at Birmingham, Birmingham, AL
| | - Sarah Jingying Zhang
- Nurse Anesthesiology Program, School of Nursing, University of South Florida, Tampa, CA; Nurse Anesthesia Program, School of Nursing, Samuel Merritt University, Oakland, CA.
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A Case of a Perinatal Woman on Methadone Maintenance Who Developed Postpartum Torsades de Pointes: Importance of Perinatal Changes in Drug Metabolism. J Clin Psychopharmacol 2021; 41:484-487. [PMID: 34155161 DOI: 10.1097/jcp.0000000000001426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Terry TD. Buprenorphine Induction in Primary Care Using an In-Office Approach. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Mammana G, Bertolino M, Bruera E, Orellana F, Vega F, Peirano G, Bunge S, Armesto A, Dran G. First-line methadone for cancer pain: titration time analysis. Support Care Cancer 2021; 29:6335-6341. [PMID: 33880639 DOI: 10.1007/s00520-021-06211-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/07/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Methadone is a low-cost, strong opioid that is increasingly used as a first-line treatment for pain in palliative care (PC). Its long and unpredictable half-life and slow elimination phase can make titration challenging. Evidence for titration modalities is scarce. OBJECTIVE To describe the titration phase of the treatment with low-dose first-line methadone and the use of methadone for breakthrough pain. METHODS Prospective study with strong opioid-naïve patients with moderate to severe cancer pain followed at a tertiary PC unit in Argentina. Starting methadone dose was 2.5-5 mg/day every 8, 12, or 24 h. Titration allowed daily dose increases from day 1, and prescription of oral methadone 2.5 mg every 2 h with a maximum of 3 rescue doses/day for breakthrough pain. Pain control, methadone stabilization dose, and adverse effects, among other variables, were daily assessed over the first 7 days (T0-T7). RESULTS Sixty-two patients were included. Initial median (IQR) methadone dose was 5 (2.5) mg/day. Pain intensity decreased from a median (IQR) of 8 (2.3) at T0 to 4 (2.3) at T1 and remained ≤ 4 until T7 (all p < 0.0001 compared to T0). Similar results were obtained through the categorical and tolerability scales for pain. Fifty patients (81%) reached pain control, 66% in the first 48 h. Methadone daily doses at T2 and T7 were higher than that at T0: 7.5 (3) and 6.7 (5.5) versus 5 (2.5), respectively (all p < 0.05). The opioid escalation index at T7 was 1.7%. The median (IQR) number of rescues, stabilization dose, and time for stabilization was 0 (1), 5(4.5) mg, and 3(2) days, respectively. Two patients were discontinued due to delirium. All other side effects were mild. CONCLUSIONS First-line, low-dose methadone using rescue methadone resulted in a pronounced and rapid decrease in pain, with minimal need for titration and for breakthrough doses, and no evidence of accumulation or sedation by the end of the week.
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Affiliation(s)
- Guillermo Mammana
- Unidad de Cuidados Paliativos - Fundación FEMEBA, Hospital de Agudos Dr. E. Tornú, Buenos Aires, Argentina
| | - Mariela Bertolino
- Unidad de Cuidados Paliativos - Fundación FEMEBA, Hospital de Agudos Dr. E. Tornú, Buenos Aires, Argentina
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, & Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Fernando Orellana
- Unidad de Cuidados Paliativos - Fundación FEMEBA, Hospital de Agudos Dr. E. Tornú, Buenos Aires, Argentina
| | - Fanny Vega
- Unidad de Cuidados Paliativos - Fundación FEMEBA, Hospital de Agudos Dr. E. Tornú, Buenos Aires, Argentina
| | - Gabriela Peirano
- Unidad de Cuidados Paliativos - Fundación FEMEBA, Hospital de Agudos Dr. E. Tornú, Buenos Aires, Argentina
| | - Sofía Bunge
- Unidad de Cuidados Paliativos - Fundación FEMEBA, Hospital de Agudos Dr. E. Tornú, Buenos Aires, Argentina.,Facultad de Ciencias de la Salud, UNICEN, Buenos Aires, Argentina
| | - Arnaldo Armesto
- Cátedra de Farmacología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Graciela Dran
- Programa de Bioética, Facultad Latinoamericana de Ciencias Sociales (FLACSO), Buenos Aires, Argentina. .,Consejo Nacional de Investigación Científica y Tecnológica (CONICET), Buenos Aires, Argentina.
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Abstract
OPINION STATEMENT The opioid epidemic is one of the most important public health crises as opioid-related deaths have become a leading cause of accidental death in the USA. Various efforts have been made to understand how to safely and appropriately prescribe opioids for patients with chronic pain, including those with cancer-related pain. We find the guidelines proposed by the Expert Consensus White Paper on the use of methadone to be current, comprehensive, and practical. While methadone is a complex medication with unique pharmacokinetics and pharmacodynamics, it remains a superior choice for many patients with cancer pain given its cost and applicability in a variety of situations. Methadone should be prescribed in the context of experienced clinicians as well as an interdisciplinary team. At a critical time when preventing opioid-related deaths is a priority, we recommend implementing additional precautions for monitoring including universal screening for risk of non-medical opioid use, education on proper storage and disposal, as well as discussing a plan with patients and caregivers in the case of serious complications such as opioid overdose.
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Affiliation(s)
- Yvonne Heung
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1414, Houston, TX, 77030, USA
| | - Akhila Reddy
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1414, Houston, TX, 77030, USA.
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Abstract
Methadone has been an unique, versatile, cost effective, synthetic opioid utilized in nociceptive as well as neuropathic pain. Pain and palliative care physicians started accepting methadone in treatment of complex pain associated with advanced cancer and neuropathic pain syndromes in which conventional opioids were no longer effective. The challenge is in accepting methadone as a main stream first line opioid, from being considered as a second line replacement/substitution drug all these years. Methadone has a significant role as opioid rotation in refractory cancer pain, especially when started early leading to successful conversion. Advantages of methadone in paediatric patients with advanced cancer were its safety and efficacy as a first-choice opioid, availability as a liquid formulation and its infrequent dose requirements. Methadone is neither recommended nor justified to be used as an anti-cancer drug and its role as an anti-cancer agent is a misconception. Many guidelines were proposed after 2008 to address methadone safety. Most of them emphasized on prevention of cardiac arrhythmia and association of methadone with QTc prolongation rather than address the real issue. Methadone has been established to be safe when used in opioid naïve patients with careful titration instituted in an ambulatory setting and has equal success in opioid rotation in outpatient setup. Methadone prescription should be carried out by experienced pain and palliative care providers with careful dose titration and clinical monitoring.
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Affiliation(s)
- S Ramkiran
- Department of Anaesthesiology, Critical Care and Pain, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Vishakapatnam, Andhra Pradesh, India
| | - Raghu S Thota
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Mamat R, Nasrulddin NAA, Yusoff NAM. Continued Use of Illicit Substance among Methadone Treatment Patients in Primary Health Care Clinics in East Coast Region of Malaysia. ALCOHOLISM TREATMENT QUARTERLY 2019. [DOI: 10.1080/07347324.2019.1672600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Ruzmayuddin Mamat
- Kuantan Health District Office, Ministry of Health Malaysia, Pejabat Kesihatan Daerah, Kuantan
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Trofimovitch D, Hutchinson L, Baumrucker SJ. Preliminary Validation for the "BJR method"-A Possible New Mathematical Approach to Methadone Conversion. J Pain Palliat Care Pharmacother 2019; 33:42-48. [PMID: 31260376 DOI: 10.1080/15360288.2019.1629521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Methadone has been effectively utilized in the palliative care setting as a second-line agent for pain management in cancer patients with refractory pain, or in those who cannot tolerate other opioid medications. The lack of reliable dosing ratios, substantial interindividual variability in methadone pharmacodynamics, the potential for extensive drug interactions, and the high potency of methadone compared with other opioids all pose significant barriers to the use of this drug in routine practice. This article describes a novel approach to methadone conversion, with case studies providing preliminary validation.
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Cornett EM, Kline RJ, Robichaux SL, Green JB, Anyama BC, Gennuso SA, Okereke EC, Kaye AD. Comprehensive Perioperative Management Considerations in Patients Taking Methadone. Curr Pain Headache Rep 2019; 23:49. [PMID: 31209656 DOI: 10.1007/s11916-019-0783-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW Well-informed staff can help decrease risks and common misconceptions regarding opioid-tolerant patients, especially those taking methadone. RECENT FINDINGS In 2015, opioid pain relievers were the second most used drug at 3.8 million. Overdose death was three times greater in 2015 than in 2000. Medication-assisted treatment was sought by more than 2 million individuals with substance use disorder, one of which is methadone. Chronic pain affects millions of adults in the USA. Opioid therapy is widely used among these adults. Related to the risk of abuse and dependence, guidelines suggest that opioid therapy may not be considered first-line treatment. A multidisciplinary approach, including thorough preoperative evaluation, the utilization of multimodal pain management strategies, and opioid-sparing techniques in both the intraoperative and postoperative periods will allow for the best possible outcome.
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Affiliation(s)
- Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Ryan J Kline
- Department of Anesthesiology, LSU Health Sciences Center New Orleans, Room 659, 1542 Tulane Ave, New Orleans, LA, 70112, USA
| | - Spencer L Robichaux
- Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave, New Orleans, LA, 70112, USA
| | - Jeremy B Green
- Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave, New Orleans, LA, 70112, USA
| | - Boris C Anyama
- Saint George's University School of Medicine, University Centre Grenada, West Indies, Grenada
| | - Sonja A Gennuso
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Eva C Okereke
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Alan D Kaye
- Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave, New Orleans, LA, 70112, USA
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