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Escher M, Cullati S, Hudelson P, Nendaz M, Ricou B, Perneger T, Dayer P. Admission to intensive care: A qualitative study of triage and its determinants. Health Serv Res 2018; 54:474-483. [PMID: 30362106 DOI: 10.1111/1475-6773.13076] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine physicians' decision making and its determinants about admission to intensive care. DATA SOURCES/STUDY SETTING ICU physicians (n = 12) and internists (n = 12) working in a Swiss tertiary care hospital. STUDY DESIGN We conducted in-depth interviews. DATA COLLECTION/EXTRACTION METHODS Interviews were analyzed using an inductive thematic approach. PRINCIPAL FINDINGS Admission decisions regarding seriously ill or elderly patients with comorbidities are complex. Nonmedical factors such as ICU beds availability, health care resources on the ward, information about patient preferences, and family behavior determine the decision. Code status and the quality of interaction between physicians are key determinants. The absence of code status or poor documentation of code status discussions makes decisions more difficult and laden emotionally, as physicians feel they are making a life-death decision. Mutual respect and collaborative decision making facilitate the decision. Tensions arise due to ICU physicians' postponing the decision because of lack of beds, ICU physicians' dismissive attitudes, perceived shortcomings in the other physician's completion of expected tasks, and preconceptions about the other physician. CONCLUSIONS Systematic documentation of code status, and fostering collaboration between ICU physicians and internists would facilitate ICU admission decisions in complex clinical situations.
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Affiliation(s)
- Monica Escher
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland.,Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Stéphane Cullati
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| | - Patricia Hudelson
- Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Mathieu Nendaz
- Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Bara Ricou
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Perneger
- Division of Clinical Epidemiology, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Dayer
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
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Daouk S, Chèvre N, Vernaz N, Bonnabry P, Dayer P, Daali Y, Fleury-Souverain S. Prioritization methodology for the monitoring of active pharmaceutical ingredients in hospital effluents. J Environ Manage 2015; 160:324-332. [PMID: 26144564 DOI: 10.1016/j.jenvman.2015.06.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 04/24/2015] [Accepted: 06/19/2015] [Indexed: 06/04/2023]
Abstract
The important number of active pharmaceutical ingredients (API) available on the market along with their potential adverse effects in the aquatic ecosystems, lead to the development of prioritization methods, which allow choosing priority molecules to monitor based on a set of selected criteria. Due to the large volumes of API used in hospitals, an increasing attention has been recently paid to their effluents as a source of environmental pollution. Based on the consumption data of a Swiss university hospital, about hundred of API has been prioritized following an OPBT approach (Occurrence, Persistence, Bioaccumulation and Toxicity). In addition, an Environmental Risk Assessment (ERA) allowed prioritizing API based on predicted concentrations and environmental toxicity data found in the literature for 71 compounds. Both prioritization approaches were compared. OPBT prioritization results highlight the high concern of some non steroidal anti-inflammatory drugs and antiviral drugs, whereas antibiotics are revealed by ERA as potentially problematic to the aquatic ecosystems. Nevertheless, according to the predicted risk quotient, only the hospital fraction of ciprofloxacin represents a risk to the aquatic organisms. Some compounds were highlighted as high-priority with both methods: ibuprofen, trimethoprim, sulfamethoxazole, ritonavir, gabapentin, amoxicillin, ciprofloxacin, raltegravir, propofol, etc. Analyzing consumption data and building prioritization lists helped choosing about 15 API to be monitored in hospital wastewaters. The API ranking approach adopted in this study can be easily transposed to any other hospitals, which have the will to look at the contamination of their effluents.
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Affiliation(s)
- Silwan Daouk
- Geneva University Hospitals (HUG), Pharmacy, Geneva, Switzerland.
| | - Nathalie Chèvre
- University of Lausanne (UNIL), Institute of Earth Surface Dynamics, Lausanne, Switzerland
| | - Nathalie Vernaz
- Geneva University Hospitals (HUG), Pharmacy, Geneva, Switzerland
| | - Pascal Bonnabry
- Geneva University Hospitals (HUG), Pharmacy, Geneva, Switzerland; University of Geneva, University of Lausanne, School of Pharmaceutical Sciences, Geneva, Switzerland
| | - Pierre Dayer
- Geneva University Hospitals (HUG), Clinical Pharmacology and Toxicology, Geneva, Switzerland
| | - Youssef Daali
- Geneva University Hospitals (HUG), Clinical Pharmacology and Toxicology, Geneva, Switzerland
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Guignard B, Bonnabry P, Perrier A, Dayer P, Desmeules J, Samer CF. Drug-related problems identification in general internal medicine: The impact and role of the clinical pharmacist and pharmacologist. Eur J Intern Med 2015; 26:399-406. [PMID: 26066400 DOI: 10.1016/j.ejim.2015.05.012] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 05/18/2015] [Accepted: 05/19/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patients admitted to general internal medicine wards might receive a large number of drugs and be at risk for drug-related problems (DRPs) associated with increased morbidity and mortality. This study aimed to detect suboptimal drug use in internal medicine by a pharmacotherapy evaluation, to suggest treatment optimizations and to assess the acceptance and satisfaction of the prescribers. METHODS This was a 6-month prospective study conducted in two internal medicine wards. Physician rounds were attended by a pharmacist and a pharmacologist. An assessment grid was used to detect the DRPs in electronic prescriptions 24h in advance. One of the following interventions was selected, depending on the relevance and complexity of the DRPs: no intervention, verbal advice of treatment optimization, or written consultation. The acceptance rate and satisfaction of prescribers were measured. RESULTS In total, 145 patients were included, and 383 DRPs were identified (mean: 2.6 DRPs per patient). The most frequent DRPs were drug interactions (21%), untreated indications (18%), overdosages (16%) and drugs used without a valid indication (10%). The drugs or drug classes most frequently involved were tramadol, antidepressants, acenocoumarol, calcium-vitamin D, statins, aspirin, proton pump inhibitors and paracetamol. The following interventions were selected: no intervention (51%), verbal advice of treatment optimization (42%), and written consultation (7%). The acceptance rate of prescribers was 84% and their satisfaction was high. CONCLUSION Pharmacotherapy expertise during medical rounds was useful and well accepted by prescribers. Because of the modest allocation of pharmacists and pharmacologists in Swiss hospitals, complementary strategies would be required.
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Affiliation(s)
- Bertrand Guignard
- Pharmacy, Geneva University Hospitals, Geneva, Switzerland; Service of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland.
| | - Pascal Bonnabry
- Pharmacy, Geneva University Hospitals, Geneva, Switzerland; School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Arnaud Perrier
- Service of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Dayer
- Service of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland; School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Jules Desmeules
- Service of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland; School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Caroline Flora Samer
- Service of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland; Swiss Centre for Applied Human Toxicology, University of Geneva, Geneva, Switzerland
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Besson M, Samer C, Rollason V, Dayer P, Desmeules J. Providing Quality Therapeutics in Switzerland: Role of the Stakeholders and Recent Incentives for Further Improvements. Clin Ther 2015; 37:1588-92. [PMID: 26049714 DOI: 10.1016/j.clinthera.2015.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/18/2015] [Accepted: 05/06/2015] [Indexed: 11/26/2022]
Abstract
Quality therapeutics play an important role in Switzerland's health care and economy. Switzerland holds a key position in the world of research and development, as well as in drug production. Recently, new emphasis has been placed on promoting clinical research and maintaining Switzerland's position as a center of excellence in the field. Recent revisions to the law regarding medical trials in human research allow for better allocation of regulatory resources and simplified procedures for drugs already authorized in Switzerland. The country has its own regulatory agency, the Swiss Agency for Therapeutic Products (Swissmedic), which is a public institution of the Swiss government. Swissmedic is responsible for ensuring safety in medicines, particularly regarding authorizations and market surveillance in the sector of medicinal products and medical devices. Although the centralized authorization procedure of the European Union for medicines does not apply to Switzerland, there are mutual recognition mechanisms between the Swiss medicine regulatory authority and the European Medicines Agency. Swissmedic is also in charge of postmarketing safety and oversees the national pharmacovigilance center, which collaborates closely with the World Health Organization center in Uppsala. In addition, university hospital-based clinical pharmacologists, who are involved in basic science and clinical research, regulatory affairs, ethics committees, and pharmacovigilance, promote quality therapeutics. This article discusses the role of the various stakeholders and the recent efforts made to provide a better allocation of resources aimed at further improving quality therapeutics in Switzerland.
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Affiliation(s)
- Marie Besson
- Psychopharmacology Unit, Division of Clinical Pharmacology and Toxicology, University Hospital of Geneva, Geneva, Switzerland.
| | - Caroline Samer
- Division of Clinical Pharmacology and Toxicology, University Hospital of Geneva, Geneva, Switzerland
| | - Victoria Rollason
- Division of Clinical Pharmacology and Toxicology, University Hospital of Geneva, Geneva, Switzerland; Clinical Research Center, University Hospital and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - Pierre Dayer
- Division of Clinical Pharmacology and Toxicology, University Hospital of Geneva, Geneva, Switzerland; Medical Direction, University Hospital of Geneva, Geneva, Switzerland
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology, University Hospital of Geneva, Geneva, Switzerland; Clinical Research Center, University Hospital and Faculty of Medicine of Geneva, Geneva, Switzerland
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Ing Lorenzini K, Broers B, Lalive PH, Dayer P, Desmeules J, Piguet V. [Clinical pharmacology of medical cannabinoids in chronic pain]. Rev Med Suisse 2015; 11:1390-1394. [PMID: 26267945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
In Switzerland, medical cannabinoids can be prescribed under compassionate use after special authorization in justified indications such as refractory pain. Evidence of efficacy in pain is limited and the clinical benefit seems to be modest. Their drug-drug interactions (DDI) profile is poorly documented. Cytochromes P450 (CYP) 2C9 and 3A4 are involved in the metabolism of tetrahydrocannabinol and cannabidiol, which implies possible DDI with CYP450 inhibitor and inducer, such as anticonvulsivants and HIV protease inhibitors, which may be prescribed in patients with neuropathic pain.
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Escher M, Perrier A, Rudaz S, Dayer P, Perneger TV. Doctors' decisions when faced with contradictory patient advance directives and health care proxy opinion: a randomized vignette-based study. J Pain Symptom Manage 2015; 49:637-45. [PMID: 25131892 DOI: 10.1016/j.jpainsymman.2014.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 06/27/2014] [Accepted: 07/06/2014] [Indexed: 11/18/2022]
Abstract
CONTEXT Sometimes a written advance directive contradicts the opinion of a health care proxy. How this affects doctors' decision making is unknown. OBJECTIVES To quantify the influence of contradictory instructions on doctors' decisions. METHODS All the generalists and internists in French-speaking Switzerland were mailed the questionnaire. Respondents (43.5%) evaluated three vignettes that described medical decisions for incapacitated patients. Each vignette was produced in four versions: one with an advance directive, one with a proxy opinion, one with both, and one with neither (control). In the first vignette, the directive and proxy agreed on the recommendation to forgo a medical intervention; in the second, the advance directive opposed, but the proxy favored the intervention; and in the third, the roles were reversed. Each doctor received one version of each vignette, attributed at random. The outcome variables were the doctor's decision to forgo the medical intervention and the rating of the decision as difficult. RESULTS Written advance directives and proxy opinions significantly influenced doctors' decision making. When both were available and concordant, they reinforced each other (odds ratio [OR] of forgoing intervention 35.7, P < 0.001 compared with no instruction). When the directive and proxy disagreed, the resulting effect was to forgo the intervention (ORs 2.1 and 2.2 for the two discordant vignettes, both P < 0.001). Discordance between instructions was associated with increased odds of doctors rating the decision as difficult (both ORs 2.0, P ≤ 0.001). CONCLUSION Contradictions between advance directives and proxy opinions result in a weak preference for abstention from treatment and increase the difficulty of the decision.
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Affiliation(s)
- Monica Escher
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland.
| | - Arnaud Perrier
- Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Sandrine Rudaz
- Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Pierre Dayer
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland
| | - Thomas V Perneger
- Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
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Gschwind L, Rollason V, Boehlen F, Rebsamen M, Combescure C, Matthey A, Bonnabry P, Dayer P, Desmeules JA. P-glycoprotein: a clue to vitamin K antagonist stabilization. Pharmacogenomics 2015; 16:129-36. [PMID: 25616099 DOI: 10.2217/pgs.14.164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Acenocoumarol is a vitamin K antagonist used in some European countries. As warfarin, this drug is characterized by a narrow therapeutic index and a large interindividual variability. AIM The objective of this study was to assess the involvement of ABCB1 polymorphisms on acenocoumarol treatment. MATERIALS & METHODS An observational cohort study was conducted to assess whether there is an association between the presence of the allelic variants of the ABCB1 gene coding for P-glycoprotein and acenocoumarol stabilization and daily doses during the first 35 days of treatment. RESULTS One hundred and fifteen patients met the inclusion criteria. The results of the clinical study showed that carriers of ABCB1 c.3435TT were more rapidly stabilized than wild-type patients (HR: 2.97, 95% CI: 1.23-7.18; p = 0.02). The same tendency was observed for the ABCB1 c.2677GT and 2677TT genotypes compared with ABCB1 c.2677GG. The ABCB1 c.2677TT genotype was also associated with a significant increase in doses of acenocoumarol (p = 0.03), the same tendency was observed with the ABCB1 c.3435TT genotype compared with the wild-type patients. CONCLUSION These data suggest that ABCB1 polymorphisms could be involved in the response to acenocoumarol treatment.
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Affiliation(s)
- Liliane Gschwind
- Division of Clinical Pharmacology & Toxicology, University Hospitals of Geneva, Switzerland
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Bosilkovska M, Clément M, Dayer P, Desmeules J, Daali Y. Incorporation of Flurbiprofen in a 4-Drug Cytochrome P450 Phenotyping Cocktail. Basic Clin Pharmacol Toxicol 2014; 115:465-6. [DOI: 10.1111/bcpt.12231] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 02/28/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Marija Bosilkovska
- Division of Clinical Pharmacology and Toxicology; Geneva University Hospitals; Geneva Switzerland
| | - Mallorie Clément
- Division of Clinical Pharmacology and Toxicology; Geneva University Hospitals; Geneva Switzerland
| | - Pierre Dayer
- Division of Clinical Pharmacology and Toxicology; Geneva University Hospitals; Geneva Switzerland
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology; Geneva University Hospitals; Geneva Switzerland
| | - Youssef Daali
- Division of Clinical Pharmacology and Toxicology; Geneva University Hospitals; Geneva Switzerland
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Gschwind L, Rollason V, Boehlen F, Rebsamen M, Combescure C, Grünenwald M, Matthey A, Bonnabry P, Dayer P, Desmeules JA. Impact of CYP2C9 polymorphisms on the vulnerability to pharmacokinetic drug-drug interactions during acenocoumarol treatment. Pharmacogenomics 2014; 14:745-53. [PMID: 23651023 DOI: 10.2217/pgs.13.55] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
AIM The objective of this study was to investigate the impact of CYP2C9 polymorphisms and drug-drug interactions on the risk of overanticoagulation in patients treated with acenocoumarol, a vitamin K antagonist. MATERIALS & METHODS A prospective observational study was performed on patients starting acenocoumarol (n = 115). CYP2C9 genotypes were assessed. Data on International Normalized Ratio, comedications and doses of acenocoumarol were collected during the first 35 days of therapy. Overanticoagulation was defined as the occurrence of at least one International Normalized Ratio ≥4. RESULTS The presence of a CYP2C9 inhibitor or a CYP2C9 polymorphisms statistically increased the risk of overanticoagulation (hazard ratio [HR]: 2.8, p < 0.001 and HR: 1.7, p = 0.04, respectively). The presence of CYP2C9 polymorphisms almost tripled the risk of overanticoagulation (HR: 2.91, p = 0.01) in the presence of a clinically significant drug-drug interaction. CONCLUSION These findings support the fact that CYP2C9 genotyping could be useful to identify patients requiring closer monitoring, especially when a drug-drug interaction is expected.
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Affiliation(s)
- Liliane Gschwind
- Division of Clinical Pharmacology & Toxicology, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland
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Desmeules J, Chabert J, Rebsamen M, Rapiti E, Piguet V, Besson M, Dayer P, Cedraschi C. Central Pain Sensitization, COMT Val158Met Polymorphism, and Emotional Factors in Fibromyalgia. The Journal of Pain 2014; 15:129-35. [DOI: 10.1016/j.jpain.2013.10.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 09/12/2013] [Accepted: 10/16/2013] [Indexed: 01/26/2023]
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Abstract
Pain is one of the most debilitating symptoms that presents with neuropathy. Neuropathic pain syndrome is a challenge to treat and, even with appropriate evidence-based treatment, only a 40% reduction of symptoms can be achieved in approximately half of patients. Furthermore, efficient doses are often difficult to obtain because of adverse effects. These observations underline that the treatment of neuropathic pain is still an unmet medical need. New approaches to the pharmacotherapy of neuropathy embrace different lines of work, including a fundamental mechanism-based approach, a clinical mechanism-based approach and an evidence-based approach. Moreover, interindividual variability in drug response, and genetic polymorphism in particular, is an emerging aspect to consider. Together with reviewing recent evidence-based guidelines as well as briefly discussing genetic polymorphisms that may influence the individual responses to treatments, this article will focus on what a mechanism-based approach is bringing to the clinical setting, on the perspective in fundamental research and on the difficulty of bridging the gap between fundamental notions and positive clinical outcomes.
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Affiliation(s)
- Marie Besson
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospital, Rue Micheli du Crest 24, 1211 Geneva 14, Switzerland.
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12
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Escher M, Perneger TV, Rudaz S, Dayer P, Perrier A. Impact of advance directives and a health care proxy on doctors' decisions: a randomized trial. J Pain Symptom Manage 2014; 47:1-11. [PMID: 23742734 DOI: 10.1016/j.jpainsymman.2013.03.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 03/02/2013] [Accepted: 03/19/2013] [Indexed: 10/26/2022]
Abstract
CONTEXT Advance directives or proxy designations are widely recommended, but how they affect doctors' decision making is not well known. OBJECTIVES The aim of this study was to quantify the influence of advance directives and proxy opinions on doctors' decisions. METHODS We mailed to all the generalists and internists in French-speaking Switzerland (N = 1962) three vignettes describing difficult decisions involving incapacitated patients. In each case, the advance directive requested that further care be withheld. One vignette tested the impact of a written advance directive vs. a proxy. Another compared the impact of a handwritten directive vs. a formalized document. The third vignette compared the impact of a family member vs. a doctor as a proxy. Each vignette was prepared in three or four versions, including a control version in which no directive or proxy was present. Vignettes were randomly allocated to respondents. We used logistic regression to predict the decision to forgo a medical intervention. RESULTS Compared with the control condition, the odds of forgoing a medical intervention were increased by the written advance directive (odds ratio [OR] 7.3; P < 0.001), the proxy (OR 7.9; P < 0.001), and the combination of the two (OR 35.7; P < 0.001). The handwritten directive had the same impact (OR 13.3) as the formalized directive (OR 13.8). The effect of proxy opinion was slightly stronger when provided by a doctor (OR 11.3) rather than by family (OR 7.8). CONCLUSION Advance directives and proxy opinions are equally effective in influencing doctors' decisions, but having both has the strongest effect. The format of the advance directive and the identity of the proxy have little influence on decisions.
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Affiliation(s)
- Monica Escher
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland.
| | - Thomas V Perneger
- Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Sandrine Rudaz
- Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Pierre Dayer
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland
| | - Arnaud Perrier
- Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
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Girardin FR, Gex-Fabry M, Berney P, Shah D, Gaspoz JM, Dayer P. Drug-induced long QT in adult psychiatric inpatients: the 5-year cross-sectional ECG Screening Outcome in Psychiatry study. Am J Psychiatry 2013; 170:1468-76. [PMID: 24306340 DOI: 10.1176/appi.ajp.2013.12060860] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The authors aimed to determine the prevalence of drug-induced long QT at admission to a public psychiatric hospital and to document the associated factors using a cross-sectional approach. METHOD All ECG recordings over a 5-year period were reviewed for drug-induced long QT (heart-rate corrected QT ≥500 ms and certain or probable drug imputability) and associated conditions. Patients with drug-induced long QT (N=62) were compared with a sample of patients with normal ECG (N=143). RESULTS Among 6,790 inpatients, 27.3% had abnormal ECG, 1.6% had long QT, and 0.9% qualified as drug-induced long QT case subjects. Sudden cardiac death was recorded in five patients, and torsade de pointes was recorded in seven other patients. Relative to comparison subjects, patients with drug-induced long QT had significantly higher frequencies of hypokalemia, hepatitis C virus (HCV) infection, HIV infection, and abnormal T wave morphology. Haloperidol, sertindole, clotiapine, phenothiazines, fluoxetine, citalopram (including escitalopram), and methadone were significantly more frequent in patients with drug-induced long QT. After adjustment for hypokalemia, HCV infection, HIV infection, and abnormal T wave morphology, the effects of haloperidol, clotiapine, phenothiazines, and citalopram (including escitalopram) remained statistically significant. Receiver operating characteristic curve analysis based on the number of endorsed factors per patient indicated that 85.5% of drug-induced long QT patients had two or more factors, whereas 81.1% of patients with normal ECG had fewer than two factors. CONCLUSIONS Drug-induced long QT and arrhythmia propensity substantially increase when specific psychotropic drugs are administered to patients with hypokalemia, abnormal T wave morphology, HCV infection, and HIV infection.
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Matthey A, Cedraschi C, Piguet V, Besson M, Chabert J, Daali Y, Courvoisier D, Montagne A, Dayer P, Desmeules JA. Dual reuptake inhibitor milnacipran and spinal pain pathways in fibromyalgia patients: a randomized, double-blind, placebo-controlled trial. Pain Physician 2013; 16:E553-E562. [PMID: 24077206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Investigations based on quantitative sensory testing have consistently shown evidence of allodynia in fibromyalgia syndrome (FMS) patients involving both the spinal and supraspinal pain regulatory systems. Functional imaging studies have demonstrated enhanced neural activities in pain-related brain areas as well as impairment of pain inhibition in the descending nociceptive regulatory system. A higher state of excitability of spinal nociceptive neurons as evidenced by lowered nociceptive flexion reflex R-III (NFR) threshold was reported for FMS patients. The NFR procedure has been shown to be a valuable tool to evaluate pharmacologically active therapeutic agents at the spinal level. OBJECTIVE Serotonin-noradrenaline reuptake inhibitors have been shown to reduce pain in FMS patients possibly through descending monoaminergic pain pathways modulation. This randomized double-blind placebo-controlled trial assessed the pharmacodynamic activity of the dual-reuptake inhibitor milnacipran (MLN) at the spinal level by means of the objective spinal NFR. STUDY DESIGN Randomized, double-blind, placebo-controlled trial. SETTING A single academic medical center, outpatient setting. METHODS Seven-week exposure (100, 150, 200mg/day) in women fibromyalgia patients. Evaluation consisted of extensive quantitative sensory testing including determination of the NFR threshold, self-reported standard questionnaires investigating pain, visual analog scales, fibromyalgia impact, health-related quality of life, depression and anxiety questionnaires, as well as the Patient's Global Impression of Change (PGIC). Analysis of covariance adjusted for baseline value was used for all endpoints. RESULTS Seventy-seven (39 placebo, 38 milnacipran all doses) out of 80 randomized patients were available for analysis. The absence of influence of MLN (any dose) on the NFR surprisingly contrasted with the dose-dependent analgesic effect observed in MLN-treated patients with an adjusted change difference of -18.4mm (-30.9; -5.8) in pain reduction between placebo and the maximum dosage (200 mg) MLN groups (P = 0.02). Unchanged depression and anxiety scores confirmed the predominant selectivity of the analgesic effect of MLN on nociceptive pain pathway. Self-reported questionnaires consistently reflected the positive effects of MLN on quality of life and psychological well-being. Odds ratio 5.1 for PGIC responders (i.e. much/very much improved) was significantly in favor of MLN (P = 0.04). CONCLUSION Milnacipran has a predominantly supraspinal analgesic effect as evidenced by the significant clinical benefits and the absence of changes in the nociceptive spinal reflex threshold. Higher dose was associated with higher pain reduction. Reported analgesia was independent of patients' emotional status.
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Affiliation(s)
- Alain Matthey
- Division of Clinical Pharmacology & Toxicology, Multidisciplinary Pain Centre, Geneva University Hospitals, Switzerland;Division of General Medical Rehabilitation, Geneva University Hospitals, Switzerland; University of Geneva, Switzerland; Division of Cl
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Matthey A, Cedraschi C, Piguet V, Besson M, Chabert J, Daali Y, Courvoisier D, Montagne A, Dayer P, Desmeules J. Oc027—Dual Reuptake Inhibitor Milnacipran And Spinal Pain Pathways In Fibromyalgia Patients: A Randomized Double-Blind Placebo-Controlled Trial. Clin Ther 2013. [DOI: 10.1016/j.clinthera.2013.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Besson M, Matthey A, Youssef D, Vuillemier P, Curatolo M, Dayer P, Zeilhofer H, Desmeules J. PP273—Effect of the gabaa ligands clobazam and clonazepam on the modulation of pain transmission in humans: A pk-pd study. Clin Ther 2013. [DOI: 10.1016/j.clinthera.2013.07.301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Marsousi N, Daali Y, Humphries H, Almond L, Dayer P, Desmeules J, Samer C. PP189—A Physiologically-Based Mechanistic Pharmacokinetic Model to Assess the Metabolism of Oxycodone in Healthy Volunteers: Interplay Between CYP3A and 2D6 Inhibition. Clin Ther 2013. [DOI: 10.1016/j.clinthera.2013.07.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Daali Y, Millet P, Dayer P, Pastor C. PP175—Evidence of Drug–Drug Interactions Through Uptake and Efflux Transport Systems in Rat Hepatocytes: Implications For Cellular Concentrations Of Competing Drugs. Clin Ther 2013. [DOI: 10.1016/j.clinthera.2013.07.211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Ing Lorenzini K, Samer C, Pugin J, Harbarth S, Bonnabry P, Fathi M, Dayer P, Desmeules J. PP197—Therapeutic Drug Monitoring of Vancomycin and Aminoglycosides in an Intensive Care Unit, a Retrospective Study. Clin Ther 2013. [DOI: 10.1016/j.clinthera.2013.07.227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Guignard B, Samer C, Perrier A, Bonnabry P, Dayer P, Desmeules J. PP008—Drug-related problems in a general internal medicine service. Clin Ther 2013. [DOI: 10.1016/j.clinthera.2013.07.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vernaz N, Haller G, Girardin F, Huttner B, Combescure C, Dayer P, Muscionico D, Salomon JL, Bonnabry P. PP060—Patented drug extension strategies and hospital restrictive drug formulary: A cost-evaluation analysis. Clin Ther 2013. [DOI: 10.1016/j.clinthera.2013.07.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Samer C, Doffey-Lazeyras F, Sorg O, Saurat JH, Dayer P, Daali Y, Desmeules J. PP233—CYP1A activity after chronic exposure to dioxins from a waste incinerator. Clin Ther 2013. [DOI: 10.1016/j.clinthera.2013.07.273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Uppugunduri C, Ansari M, Théorêt Y, Déglon J, Versace F, Gumy-Pause F, Dayer P, Desmeules J, Daali Y. Oc013 — A Simplified Method For Busulfan Therapeutic Drug Monitoring Using Dried Blood Spot Sampling In Pediatric Patient Undergoing Stem Cell Transplantation. Clin Ther 2013. [DOI: 10.1016/j.clinthera.2013.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Girardin F, Poncet A, Blondon M, Rollason V, Vernaz N, Dayer P, Combescure C. PP064—Agranulocytosis detection outcome by clozapine treatment (ADOC study) in psychiatry: A cost-effectiveness study. Clin Ther 2013. [DOI: 10.1016/j.clinthera.2013.07.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Bosilkovska M, Deglon J, Samer C, Walder B, Dayer P, Desmeules J, Staub C, Daali Y. PP193—Simultaneous LC-MS/MS Quantification of P-Glycoprotein and Cytochrome P450 Probe Substrates and Their Metabolites In Dried Blood Spots. Clin Ther 2013. [DOI: 10.1016/j.clinthera.2013.07.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Rollason V, Gschwind L, Boehlen F, Rebsamen M, Combescure C, Grünenwald M, Matthey A, Bonnabry P, Dayer P, Desmeules J. OC036—Impact Of Cyp2c9 Polymorphisms On The Vulnerability To Pharmacokinetic Drug–Drug Interactions During Acenocoumarol Treatment. Clin Ther 2013. [DOI: 10.1016/j.clinthera.2013.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Girardin F, Gex-Fabry M, Berney P, Shah D, Gaspoz JM, Dayer P. PP268—Drug-induced long QT in adult psychiatric inpatients: The 5-year cross-sectional ESOP study. Clin Ther 2013. [DOI: 10.1016/j.clinthera.2013.07.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Gschwind L, Rollason V, Daali Y, Bonnabry P, Dayer P, Desmeules JA. Role of P-glycoprotein in the Uptake/Efflux Transport of Oral Vitamin K Antagonists and Rivaroxaban through the Caco-2 Cell Model. Basic Clin Pharmacol Toxicol 2013; 113:259-65. [DOI: 10.1111/bcpt.12084] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 05/02/2013] [Indexed: 11/28/2022]
Affiliation(s)
| | - Victoria Rollason
- Division of Clinical Pharmacology and Toxicology; University Hospitals of Geneva; Geneva; Switzerland
| | - Youssef Daali
- Division of Clinical Pharmacology and Toxicology; University Hospitals of Geneva; Geneva; Switzerland
| | | | - Pierre Dayer
- Division of Clinical Pharmacology and Toxicology; University Hospitals of Geneva; Geneva; Switzerland
| | - Jules Alexandre Desmeules
- Division of Clinical Pharmacology and Toxicology; University Hospitals of Geneva; Geneva; Switzerland
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Daali Y, Millet P, Dayer P, Pastor CM. Evidence of Drug-Drug Interactions through Uptake and Efflux Transport Systems in Rat Hepatocytes: Implications for Cellular Concentrations of Competing Drugs. Drug Metab Dispos 2013; 41:1548-56. [DOI: 10.1124/dmd.113.051870] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Uppugunduri CRS, Daali Y, Desmeules J, Dayer P, Krajinovic M, Ansari M. Transcriptional regulation of CYP2C19 and its role in altered enzyme activity. Curr Drug Metab 2013; 13:1196-204. [PMID: 22804232 DOI: 10.2174/138920012802850146] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2012] [Revised: 07/02/2012] [Accepted: 07/07/2012] [Indexed: 11/22/2022]
Abstract
Cytochrome P450 2C19 (CYP2C19) is involved in the metabolism of several drugs that are currently in clinical use. The gene encoding CYP2C19 is polymorphic with the existence of different alleles resulting in altered enzyme activity. In addition, CYP2C19 activity is also dependent on its basal expression levels determined by the transcriptional regulation. Genetic variations located in the CYP2C19 promoter region may alter the interaction of promoter with transcription factors causing variable transcription. Genetic variants may also influence the induction, inhibition of CYP2C19 and may as well affect drug-drug interactions involving CYP2C19 substrates. The role of various transcription factors and genetic variants in the promoter region of CYP2C19 regulating its expression are discussed in this review. Furthermore, induction and inhibition of CYP2C19 by various drugs in clinically meaningful drug interactions are also discussed.
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Schenkel F, Csajka C, Baglivo E, Kondo-Oestreicher M, Dayer P, Gex-Fabry M, Daali Y. Intraocular penetration of penciclovir after oral administration of famciclovir: a population pharmacokinetic model. J Antimicrob Chemother 2013; 68:1635-41. [PMID: 23539240 DOI: 10.1093/jac/dkt064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES We developed a population model that describes the ocular penetration and pharmacokinetics of penciclovir in human aqueous humour and plasma after oral administration of famciclovir. METHODS Fifty-three patients undergoing cataract surgery received a single oral dose of 500 mg of famciclovir prior to surgery. Concentrations of penciclovir in both plasma and aqueous humour were measured by HPLC with fluorescence detection. Concentrations in plasma and aqueous humour were fitted using a two-compartment model (NONMEM software). Inter-individual and intra-individual variabilities were quantified and the influence of demographics and physiopathological and environmental variables on penciclovir pharmacokinetics was explored. RESULTS Drug concentrations were fitted using a two-compartment, open model with first-order transfer rates between plasma and aqueous humour compartments. Among tested covariates, creatinine clearance, co-intake of angiotensin-converting enzyme inhibitors and body weight significantly influenced penciclovir pharmacokinetics. Plasma clearance was 22.8±9.1 L/h and clearance from the aqueous humour was 8.2×10(-5) L/h. AUCs were 25.4±10.2 and 6.6±1.8 μg·h/mL in plasma and aqueous humour, respectively, yielding a penetration ratio of 0.28±0.06. Simulated concentrations in the aqueous humour after administration of 500 mg of famciclovir three times daily were in the range of values required for 50% growth inhibition of non-resistant strains of the herpes zoster virus family. CONCLUSIONS Plasma and aqueous penciclovir concentrations showed significant variability that could only be partially explained by renal function, body weight and comedication. Concentrations in the aqueous humour were much lower than in plasma, suggesting that factors in the blood-aqueous humour barrier might prevent its ocular penetration or that redistribution occurs in other ocular compartments.
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Affiliation(s)
- Fanny Schenkel
- Clinical Pharmacology and Toxicology Service, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
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Ehret GB, Daali Y, Chabert J, Rebsamen M, Wolff A, Forster A, Moursli F, Fritschy D, Rossier MF, Piguet V, Dayer P, Gex-Fabry M, Desmeules JA. Influence of CYP2D6 activity on pre-emptive analgesia by the N-methyl-D-aspartate antagonist dextromethorphan in a randomized controlled trial of acute pain. Pain Physician 2013; 16:45-56. [PMID: 23340533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND There is some evidence that dextromethorphan (DM) is effective as a pre-emptive analgesic agent. DM is mainly metabolized to dextrorphan (DOR) by CYP2D6 whose activity can be inhibited by pharmacologic intervention. OBJECTIVES To investigate the efficacy of DM as a pre-emptive analgesic agent and describe the population pharmacokinetics in the presence of normal and poor CYP2D6 metabolism in acute post-operative pain. STUDY DESIGN Double blind, randomized, placebo-controlled trial SETTING Post-surgical analgesic consumption after knee ligament surgery, a setting of acute pain. METHODS Forty patients were randomized to a single oral dose of 50 mg quinidine or placebo, administered 12 hours before 50 mg DM. Patients were genotyped for the major CYP2D6 and ABCB1 variants and phenotyped for CYP2D6 using urine DM/DOR metabolic ratios and blood samples for population pharmacokinetic modeling. RESULTS Quinidine was effective in inhibiting CYP2D6 activity, with 2-fold reduction of DM to DOR biotransformation clearance, prolonged DM half-life, and increased DM systemic availability. Patients in the quinidine group required significantly less often NSAIDs than patients in the placebo group (35.3% vs. 75.0%, P = 0.022). The odds ratio for NSAID consumption in the placebo vs. quinidine group was 5.5 (95% confidence interval (CI) 1.3 - 22.7) at 48 hours after surgery. LIMITATIONS While this study shows an impact of DM on pre-emptive analgesia and is mechanistically interesting, the findings need to be confirmed in larger trials. CONCLUSION CYP2D6 inhibition by quinidine influenced the pre-emptive analgesic effectiveness of DM confirming that CYP2D6 phenotypic switch increases the neuromodulatory effect of oral dextromethorphan.
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Affiliation(s)
- Georg B Ehret
- Division of Clinical Pharmacology and Toxicology & Multidisciplinary Pain Center, Geneva University Hospital, Geneva, Switzerland
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Vernaz N, Haller G, Girardin F, Huttner B, Combescure C, Dayer P, Muscionico D, Salomon JL, Bonnabry P. Patented drug extension strategies on healthcare spending: a cost-evaluation analysis. PLoS Med 2013; 10:e1001460. [PMID: 23750120 PMCID: PMC3672218 DOI: 10.1371/journal.pmed.1001460] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2012] [Accepted: 04/24/2013] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Drug manufacturers have developed "evergreening" strategies to compete with generic medication after patent termination. These include marketing of slightly modified follow-on drugs. We aimed to estimate the financial impact of these drugs on overall healthcare costs and also to examine the impact of listing these drugs in hospital restrictive drug formularies (RDFs) on the healthcare system as a whole ("spillover effect"). METHODS AND FINDINGS We used hospital and community pharmacy invoice office data in the Swiss canton of Geneva to calculate utilisation of eight follow-on drugs in defined daily doses between 2000 and 2008. "Extra costs" were calculated for three different scenarios assuming replacement with the corresponding generic equivalent for prescriptions of (1) all brand (i.e., initially patented) drugs, (2) all follow-on drugs, or (3) brand and follow-on drugs. To examine the financial spillover effect we calculated a monthly follow-on drug market share in defined daily doses for medications prescribed by hospital physicians but dispensed in community pharmacies, in comparison to drugs prescribed by non-hospital physicians in the community. Estimated "extra costs" over the study period were €15.9 (95% CI 15.5; 16.2) million for scenario 1, €14.4 (95% CI 14.1; 14.7) million for scenario 2, and €30.3 (95% CI 29.8; 30.8) million for scenario 3. The impact of strictly switching all patients using proton-pump inhibitors to esomeprazole at admission resulted in a spillover "extra cost" of €330,300 (95% CI 276,100; 383,800), whereas strictly switching to generic cetirizine resulted in savings of €7,700 (95% CI 4,100; 11,100). Overall we estimated that the RDF resulted in "extra costs" of €503,600 (95% CI 444,500; 563,100). CONCLUSIONS Evergreening strategies have been successful in maintaining market share in Geneva, offsetting competition by generics and cost containment policies. Hospitals may be contributing to increased overall healthcare costs by listing follow-on drugs in their RDF. Therefore, healthcare providers and policy makers should be aware of the impact of evergreening strategies.
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Ancrenaz V, Desmeules J, James R, Fontana P, Reny JL, Dayer P, Daali Y. The paraoxonase-1 pathway is not a major bioactivation pathway of clopidogrel in vitro. Br J Pharmacol 2012; 166:2362-70. [PMID: 22428615 DOI: 10.1111/j.1476-5381.2012.01946.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND PURPOSE Clopidogrel is a prodrug bioactivated by cytochrome P450s (CYPs). More recently, paraoxonase-1 (PON1) has been proposed as a major contributor to clopidogrel metabolism. The purpose of this study was to assess the relative contribution of CYPs and PON1 to clopidogrel metabolism in vitro. EXPERIMENTAL APPROACH Clopidogrel metabolism was studied in human serum, recombinant PON1 enzyme (rePON1), pooled human liver microsomes (HLMs), HLMs with the CYP2C19*1/*1 genotype and HLMs with the CYP2C19*2/*2 genotype. Inhibition studies were also performed using specific CYP inhibitors and antibodies. Clopidogrel and its metabolites were measured using LC/MS/MS method. KEY RESULTS PON1 activity was highest in the human serum and there was no difference in PON1 activity between any of the HLM groups. The production of clopidogrel's active metabolite (clopidogrel-AM) from 2-oxo-clopidogrel in pooled HLMs was approximately 500 times that in serum. When 2-oxo-clopidogrel was incubated with rePON1, clopidogrel-AM was not detected. Clopidogrel-AM production from 2-oxo-clopidogrel was lower in CYP2C19*2/*2 HLMs compared with CYP2C19*1/*1 HLMs, while PON1 activity in HLMs with both genotypes was similar. Moreover, incubation with inhibitors of CYP3A, CYP2B6 and CYP2C19 significantly reduced clopidogrel bioactivation while a PON1 inhibitor, EDTA, had only a weak inhibitory effect. CONCLUSION AND IMPLICATIONS This in vitro study shows that the contribution of PON1 to clopidogrel metabolism is limited at clinically relevant concentrations. Moreover, CYP2C19, CYP2B6 and CYP3A play important roles in the bioactivation of clopidogrel.
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Affiliation(s)
- V Ancrenaz
- Clinical Pharmacology and Toxicology Service, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Besson M, Daali Y, Di Lio A, Dayer P, Zeilhofer HU, Desmeules J. Antihyperalgesic effect of the GABA(A) ligand clobazam in a neuropathic pain model in mice: a pharmacokinetic-pharmacodynamic study. Basic Clin Pharmacol Toxicol 2012; 112:192-7. [PMID: 23006671 DOI: 10.1111/bcpt.12017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Accepted: 09/10/2012] [Indexed: 11/30/2022]
Abstract
Facilitation of spinal GABAergic inhibition with benzodiazepines (BZDs) reverses pain sensitization in animals; however, the use of BZDs in man is limited by their sedative effect. The antihyperalgesic effects of GABA(A) agonists are mediated by GABA(A) receptors containing α2 subunits, whereas sedation is linked to α1 subunit-containing receptors. α2 and α3 selective GABA(A) receptor modulators have been tested in animals but are not yet available for use in human beings. Clobazam is a 1,5-BZD, which exhibits less cognitive side effects than other benzodiazepines. Here, we studied its antihyperalgesic effects in a mouse model of neuropathic pain. Clobazam showed a dose-dependent antihyperalgesic effect in the chronic constriction injury (CCI) model of neuropathic pain, peaking at 1 hr after administration and lasting for 4 hr with no relevant sedation at a dose of 3 mg/kg. At higher doses, the antihyperalgesic effect was stronger, but sedation became significant. The blood and brain kinetics of clobazam were linear over the range of doses tested with a short half-life of the parent compound and a ready penetration of the blood-brain barrier. Clobazam blood concentrations decreased rapidly, falling below the limit of detection at 120 min. after drug application. Its main metabolite, N-desmethyl-clobazam, showed more delayed and prolonged pharmacokinetics, partly explaining why antihyperalgesia persisted when clobazam was no longer detectable in the blood. Considering its therapeutic margin and its pharmacokinetic properties, clobazam would be a valuable compound to assess the role of the GABAergic pathway in pain transmission in human beings.
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Affiliation(s)
- Marie Besson
- Multidisciplinary Pain Center, Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland.
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Ancrenaz V, Déglon J, Samer C, Staub C, Dayer P, Daali Y, Desmeules J. Pharmacokinetic interaction between prasugrel and ritonavir in healthy volunteers. Basic Clin Pharmacol Toxicol 2012; 112:132-7. [PMID: 22900583 PMCID: PMC3561686 DOI: 10.1111/j.1742-7843.2012.00932.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 08/09/2012] [Indexed: 12/22/2022]
Abstract
The new anti-aggregating agent prasugrel is bioactivated by cytochromes P450 (CYP) 3A and 2B6. Ritonavir is a potent CYP3A inhibitor and was shown in vitro as a CYP2B6 inhibitor. The aim of this open-label cross-over study was to assess the effect of ritonavir on prasugrel active metabolite (prasugrel AM) pharmacokinetics in healthy volunteers. Ten healthy male volunteers received 10 mg prasugrel. After at least a week washout, they received 100 mg ritonavir, followed by 10 mg prasugrel 2 hr later. We used dried blood spot sampling method to monitor prasugrel AM pharmacokinetics (Cmax, t1/2, tmax, AUC0–6 hr) at 0, 0.25, 0.5, 1, 1.5, 2, 4 and 6 hr after prasugrel administration. A ‘cocktail’ approach was used to measure CYP2B6, 2C9, 2C19 and 3A activities. In the presence of ritonavir, prasugrel AM Cmax and AUC were decreased by 45% (mean ratio: 0.55, CI 90%: 0.40–0.7, p = 0.007) and 38% (mean ratio: 0.62, CI 90%: 0.54–0.7, p = 0.005), respectively, while t1/2 and tmax were not affected. Midazolam metabolic ratio (MR) dramatically decreased in presence of ritonavir (6.7 ± 2.6 versus 0.13 ± 0.07) reflecting an almost complete inhibition of CYP3A4, whereas omeprazole, flurbiprofen and bupropion MR were not affected. These data demonstrate that ritonavir is able to block prasugrel CYP3A4 bioactivation. This CYP-mediated drug–drug interaction might lead to a significant reduction of prasugrel efficacy in HIV-infected patients with acute coronary syndrome.
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Affiliation(s)
- Virginie Ancrenaz
- Clinical Pharmacology and Toxicology Service, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Gschwind L, Rollason V, Lovis C, Boehlen F, Bonnabry P, Dayer P, Desmeules JA. Identification and weighting of the most critical "real-life" drug-drug interactions with acenocoumarol in a tertiary care hospital. Eur J Clin Pharmacol 2012; 69:617-27. [PMID: 22903542 DOI: 10.1007/s00228-012-1358-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 07/11/2012] [Indexed: 01/30/2023]
Abstract
PURPOSE The objective of this study was to identify the most clinically relevant drug-drug interactions (DDIs) at risk of affecting acenocoumarol safety in our tertiary care university hospital, a 2,000 bed institution. METHODS We identified DDIs occurring with acenocoumarol by combining two different sources of information: a 1-year retrospective analysis of acenocoumarol prescriptions and comedications from our Computerized Physician Order Entry (CPOE) system (n = 2,439 hospitalizations) and a retrospective study of clinical pharmacology consultations involving acenocoumarol over the past 14 years (1994-2007) (n = 407). We classified these DDIs using an original risk-analysis method. A criticality index was calculated for each associated drug by multiplying three scores based on mechanism of interaction, involvement in a supratherapeutic international normalized ratio (INR) (≥ 6) and involvement in a severe bleeding. RESULTS One hundred and twenty-six DDIs were identified and weighted. Twenty-eight drugs had a criticality index ≥ 20 and were therefore considered at high risk for interacting with acenocoumarol by increasing its effect: 75% of these drugs involved a pharmacokinetic mechanism and 14 % a pharmacodynamic mechanism. An unknown mechanism of interaction was involved in 11 % of drugs. CONCLUSION Twenty-eight specific drugs were identified as being at high risk for interacting with acenocoumarol in our hospital using an original risk-analysis method. Most analyzed drugs interact with acenocoumarol via a pharmacokinetic mechanism. Actions such as the implementation of alerts in our CPOE system should be specifically developed for these drugs.
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Affiliation(s)
- L Gschwind
- Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland.
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Ansari M, Uppugunduri CRS, Déglon J, Théorêt Y, Versace F, Gumy-Pause F, Ozsahin H, Dayer P, Desmules J, Daali Y. A simplified method for busulfan monitoring using dried blood spot in combination with liquid chromatography/tandem mass spectrometry. Rapid Commun Mass Spectrom 2012; 26:1437-1446. [PMID: 22592987 DOI: 10.1002/rcm.6241] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
RATIONALE Busulfan (Bu) is an important component of the myeloablative conditioning regimen prior to hematopoietic stem cell transplantation (HSCT) especially in children. Intravenously administered Bu exhibits a therapeutic window phenomenon requiring therapeutic drug monitoring. Analytical methods developed for Bu routine monitoring were aimed at using low volumes of biological fluids and development of simple procedures to facilitate the dosage adjustment. In this report, we describe a simple, rapid method for Bu measurement using dried blood spots (DBS) from only 5 μL of whole blood. METHODS Bu extracted from DBS with methanol was measured by high-performance liquid chromatography with electrospray ionization and tandem mass spectrometry in multiple reaction monitoring mode using D8-Bu as an internal standard. The method was in-house validated evaluating trueness, repeatability, within-laboratory reproducibility, specificity and the lower limit of quantification (LLOQ). RESULTS The method was linear in the calibration range of 100-2000 ng mL(-1) (r(2)>0.99) encompassing the therapeutic concentrations of Bu. A good trueness (<14%), precision (<10%), and recovery (100%) were observed during validation of the method with quality controls of 300, 600 and 1400 ng mL(-1). The LLOQ was determined as 50 ng mL(-1) and no matrix or carryover effects were observed. The validated method was applied to measure Bu levels in four children receiving infusion of Bu prior to HSCT. A good correlation was observed between the Bu levels measured by DBS and dried plasma spot (DPS) (r(2) =0.96) and between DPS and the GC/MS method (r(2) =0.92). Bu was found to be stable in DBS up to 6 h at room temperature and for 24 h at 4 °C. CONCLUSIONS The new DBS method facilitates earlier dosage adjustment during Bu therapy by its specific and simple procedure using 5 μL of whole blood.
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Affiliation(s)
- Marc Ansari
- Department of Pediatrics, Onco-hematology Unit, Geneva University Hospitals, Geneva, Switzerland
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Ing Lorenzinit K, Meier R, Suva D, Dayer P, Desmeules J, Peter R. [Atypical femoral fracture associated with the use of bisphosphonates, an adverse drug reaction not to be missed]. Rev Med Suisse 2012; 8:1238-1242. [PMID: 22730621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Atypical femur fractures represent a new disease entity associated with the use of oral bisphosphonates. This review summarizes the current understanding of this phenomenon. These fractures are usually transverse, affecting the proximal third of the femoral shaft. They occur after minor or no trauma, include a thickening of the lateral femoral cortex, a delayed consolidation time and prodromal symptoms. In this context, the risk/benefit ratio of bisphosphonates remains favorable if the indication is adequate. In case of fracture, indication to treatment should be reevaluated. Pain or discomfort in the thigh in a patient receiving bisphosphonate should lead to radiological investigations in order to detect the possible occurrence of a stress fracture.
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Affiliation(s)
- Kuntheavy Ing Lorenzinit
- Service de pharmacologie et toxicologie cliniques, Centre régional de pharmacovigilance, HUG et Faculté de médecine, Genève
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Lorenzini KI, Besson M, Daali Y, Salomon D, Dayer P, Desmeules J. Validation of the Simplified UVB Model to Assess the Pharmacodynamics of Analgesics in Healthy Human Volunteers. Chimia (Aarau) 2012; 66:296-9. [DOI: 10.2533/chimia.2012.296] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Desmeules J, Piguet V, Besson M, Chabert J, Rapiti E, Rebsamen M, Rossier MF, Curtin F, Dayer P, Cedraschi C. Psychological distress in fibromyalgia patients: A role for catechol-O-methyl-transferase Val158met polymorphism. Health Psychol 2012; 31:242-249. [DOI: 10.1037/a0025223] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Daali Y, Samer C, Déglon J, Thomas A, Chabert J, Rebsamen M, Staub C, Dayer P, Desmeules J. Oral flurbiprofen metabolic ratio assessment using a single-point dried blood spot. Clin Pharmacol Ther 2012; 91:489-96. [PMID: 22237256 DOI: 10.1038/clpt.2011.247] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We investigated whether a single blood measurement using the minimally invasive technique of a finger prick to draw a blood sample of 5 µl (to yield a dried blood spot (DBS)) is suitable for the assessment of flurbiprofen (FLB) metabolic ratio (MR). Ten healthy volunteers who had been genotyped for CYP2C9 were recruited as subjects. They received FLB alone in session 1 and FLB with fluconazole in session 2. In session 3, the subjects were pretreated for 4 days with rifampicin and received FLB with the last dose of rifampicin on day 5. Plasma and DBS samples were obtained between 0 and 8 h after FLB administration, and urine was collected during the 8 h after administration. The pharmacokinetic profiles of the drugs were comparable in DBS and plasma. FLB's apparent clearance values decreased by 35% in plasma and DBS during session 2 and increased by 75% in plasma and by 30% in DBS during session 3. Good correlations were observed between MRs calculated from urine, plasma, and DBS samples.
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Affiliation(s)
- Y Daali
- Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland.
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Ing Lorenzini K, Daali Y, Dayer P, Desmeules J. Pharmacokinetic-Pharmacodynamic Modelling of Opioids in Healthy Human Volunteers. A MiniReview. Basic Clin Pharmacol Toxicol 2011; 110:219-26. [DOI: 10.1111/j.1742-7843.2011.00814.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Daali Y, Ancrenaz V, Bosilkovska M, Dayer P, Desmeules J. Ritonavir inhibits the two main prasugrel bioactivation pathways in vitro: a potential drug-drug interaction in HIV patients. Metabolism 2011; 60:1584-9. [PMID: 21550074 DOI: 10.1016/j.metabol.2011.03.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 03/17/2011] [Accepted: 03/22/2011] [Indexed: 11/24/2022]
Abstract
Prasugrel is an antiplatelet prodrug used in patients with acute coronary syndrome. Prasugrel is mainly bioactivated by cytochromes P450 3A4/5 and CYP2B6. HIV patients are at risk of cardiovascular disease, and the protease inhibitor ritonavir is a potent inhibitor of these 2 CYPs. The aim of this in vitro study was to determine the impact of ritonavir in prasugrel metabolism. Human liver microsomes (HLMs) and recombinant microsomes were used to identify the enzymes responsible for the bioactivation of prasugrel. Prasugrel concentrations of 5 to 200 μM were used for Km determination. Inhibition by ritonavir was characterized using HLMs at concentrations of 0.1 to 30 μM. Prasugrel active metabolite determination was performed with a validated liquid chromatography-mass spectrometry method. Using recombinant microsomes, prasugrel biotransformation was mainly performed by CYP2B6, CYP2D6, CYP2C19, CYP3A4, and CYP3A5. With specific inhibitors of CYP3A, CYP2B6, CYP2D6, CYP2C9, and CYP2C19, active metabolite production was decreased by 38% ± 15% with 4-(4-chlorobenzyl)pyridine (CYP2B6 inhibitor) and by 45 ± 16% with ketoconazole (CYP3A inhibitor). The Km value for prasugrel metabolism in HLMs was determined to be 92.5 μM. Ritonavir at 0.1 to 30 μM was shown to be a potent dose-dependent inhibitor of prasugrel. In this in-vitro study, we found a potent inhibition of prasugrel bioactivation by ritonavir compared to the specific inhibitors of CYP3A and CYP2B6 due to the simultaneous inhibition of CYP2B6 and CYP3A by ritonavir. This finding suggests a potential significant drug-drug interaction between these two drugs.
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Affiliation(s)
- Youssef Daali
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland.
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L'Huillier AG, Ing Lorenzini K, Crisinel PA, Rebsamen MC, Fluss J, Korff CM, Barbe RP, Siegrist CA, Dayer P, Posfay-Barbe KM, Desmeules JA. ABCB1 polymorphisms and neuropsychiatric adverse events in oseltamivir-treated children during influenza H1N1/09 pandemia. Pharmacogenomics 2011; 12:1493-501. [PMID: 21902503 DOI: 10.2217/pgs.11.91] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
AIMS To examine the safety profile of oseltamivir in children and evaluate the impact of P-glycoprotein polymorphisms on the incidence of neuropsychiatric adverse events (NPAE) in oseltamivir-treated children. SUBJECTS & METHODS This prospective cohort study was conducted in our tertiary care pediatric hospital (University Hospitals of Geneva, Switzerland) during the H1N1 pandemia, between 1 October 2009 and 31 January 2010. All newborn to 18 year-old patients presenting at the emergency department with a flu-like illness were eligible for inclusion. Adverse events were systematically recorded by pediatricians and/or by parents at home using a diary card, with a 30-day follow-up period. The causality assessment of oseltamivir in NPAE was performed by two clinical pharmacologists. After informed consent, enrolled patients were also genotyped for ABCB1 3435C>T (rs1045642) and 2677G>T/A (rs2032582) polymorphisms. RESULTS Among the 42 H1N1-infected, oseltamivir-treated children who were genotyped for ABCB1 3435C>T and 2677G>T/A variants, 36% presented NPAE. When examining the association between the diplotype and the development of NPAE, we observed that the frequency of NPAE displayed a 'genotype-trend effect' with the variant and the wild-type subgroups at the two far ends. A total of 11% of the 2677GG-3435CC individuals (wild-type homozygous) presented NPAE, compared with 39% of the individuals being heterozygous for at least one variant allele and 67% of the 2677TT-3435TT individuals (homozygous variants) (p = 0.149, nonsignificant). CONCLUSION These observations suggest a potential influence of ABCB1 polymorphisms in oseltamivir-related NPAE, maybe as a result of an enhanced permeability of the blood-brain barrier to oseltamivir
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Affiliation(s)
- Arnaud G L'Huillier
- Geneva Medical Faculty & University Hospitals of Geneva, Department of Pediatrics, Geneva, Switzerland
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Ing Lorenzini K, Besson M, Daali Y, Salomon D, Dayer P, Desmeules J. A randomized, controlled trial validates a peripheral supra-additive antihyperalgesic effect of a paracetamol-ketorolac combination. Basic Clin Pharmacol Toxicol 2011; 109:357-64. [PMID: 21615691 DOI: 10.1111/j.1742-7843.2011.00733.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The combination of paracetamol with non-steroidal anti-inflammatory drugs (NSAIDs) is widely used; however, the nature and mechanism of their interaction are still debated. A double-blind, pharmacokinetic/pharmacodynamic, randomized, cross-over, placebo-controlled study was carried out in human healthy volunteers. The aim was to explore the existence of a positive interaction between paracetamol 1 g and ketorolac 20 mg administered intravenously on experimental pain models in human beings. The effects of the paracetamol-ketotolac combination were compared with similar doses of respective single analgesic and to placebo on the sunburn model (UVB-induced inflammation), cold pain tolerance and the nociceptive flexion reflex. The kinetics of the plasma concentrations of paracetamol and ketorolac were measured using 2D-liquid chromatography-mass spectrometry. Thirteen volunteers were screened, and 11 completed the study. Ketorolac significantly decreased primary hyperalgesia to heat stimuli compared with paracetamol (p < 0.014). The combination performed better than paracetamol (p < 0.001) and placebo (p < 0.042), increasing heat pain threshold by 1.5°C. The combination radically reduced primary hyperalgesia to mechanical stimulation (39%) compared with placebo (p < 0.002) and single agents (paracetamol p < 0.024 and ketorolac p < 0.032). The combination also reduced, slightly although significantly, the intensity of pain (10%) for the cold pressor test (versus placebo: p < 0.012, paracetamol: p < 0.019 and ketorolac p < 0.004). None of the treatments significantly affected the central models of pain at this dosage level. No pharmacokinetic interactions were observed. These results suggest a supra-additive pharmacodynamic interaction between paracetamol and ketorolac in an inflammatory pain model. The mechanism of this interaction could mainly rely on a peripheral contribution of paracetamol to the effect of NSAIDs.
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Affiliation(s)
- Kuntheavy Ing Lorenzini
- Division of Clinical Pharmacology and Toxicology, Multidisciplinary Pain Centre, University Hospitals of Geneva, Geneva, Switzerland
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Samer CF, Dayer P, Desmeules JA. How close are we to individual analgesic adjustment according to a patient’s genotype? Per Med 2011; 8:289-292. [DOI: 10.2217/pme.11.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Caroline Flora Samer
- Clinical Pharmacology & Toxicology, Geneva University Hospitals, Switzerland and Swiss Center for Applied Human Toxicology, University of Geneva, Switzerland
| | - Pierre Dayer
- Clinical Pharmacology & Toxicology, Geneva University Hospitals, Switzerland
| | - Jules Alexandre Desmeules
- Clinical Pharmacology & Toxicology Geneva University Hospitals Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland and Swiss Center for Applied Human Toxicology, University of Geneva, Switzerland
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Samer CF, Daali Y, Wagner M, Hopfgartner G, Eap CB, Rebsamen MC, Rossier MF, Hochstrasser D, Dayer P, Desmeules JA. Genetic polymorphisms and drug interactions modulating CYP2D6 and CYP3A activities have a major effect on oxycodone analgesic efficacy and safety. Br J Pharmacol 2010; 160:919-30. [PMID: 20590588 DOI: 10.1111/j.1476-5381.2010.00709.x] [Citation(s) in RCA: 143] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE The major drug-metabolizing enzymes for the oxidation of oxycodone are CYP2D6 and CYP3A. A high interindividual variability in the activity of these enzymes because of genetic polymorphisms and/or drug-drug interactions is well established. The possible role of an active metabolite in the pharmacodynamics of oxycodone has been questioned and the importance of CYP3A-mediated effects on the pharmacokinetics and pharmacodynamics of oxycodone has been poorly explored. EXPERIMENTAL APPROACH We conducted a randomized crossover (five arms) double-blind placebo-controlled study in 10 healthy volunteers genotyped for CYP2D6. Oral oxycodone (0.2 mg x kg(-1)) was given alone or after inhibition of CYP2D6 (with quinidine) and/or of CYP3A (with ketoconazole). Experimental pain (cold pressor test, electrical stimulation, thermode), pupil size, psychomotor effects and toxicity were assessed. KEY RESULTS CYP2D6 activity was correlated with oxycodone experimental pain assessment. CYP2D6 ultra-rapid metabolizers experienced increased pharmacodynamic effects, whereas cold pressor test and pupil size were unchanged in CYP2D6 poor metabolizers, relative to extensive metabolizers. CYP2D6 blockade reduced subjective pain threshold (SPT) for oxycodone by 30% and the response was similar to placebo. CYP3A4 blockade had a major effect on all pharmacodynamic assessments and SPT increased by 15%. Oxymorphone C(max) was correlated with SPT assessment (rho(S)= 0.7) and the only independent positive predictor of SPT. Side-effects were observed after CYP3A4 blockade and/or in CYP2D6 ultra-rapid metabolizers. CONCLUSIONS AND IMPLICATIONS The modulation of CYP2D6 and CYP3A activities had clear effects on oxycodone pharmacodynamics and these effects were dependent on CYP2D6 genetic polymorphism.
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Affiliation(s)
- C F Samer
- Clinical Pharmacology and Toxicology and Multidisciplinary Pain Centre, Department of Anaesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland.
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Samer CF, Daali Y, Wagner M, Hopfgartner G, Eap CB, Rebsamen MC, Rossier MF, Hochstrasser D, Dayer P, Desmeules JA. The effects of CYP2D6 and CYP3A activities on the pharmacokinetics of immediate release oxycodone. Br J Pharmacol 2010; 160:907-18. [PMID: 20590587 DOI: 10.1111/j.1476-5381.2010.00673.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE There is high interindividual variability in the activity of drug-metabolizing enzymes catalysing the oxidation of oxycodone [cytochrome P450 (CYP) 2D6 and 3A], due to genetic polymorphisms and/or drug-drug interactions. The effects of CYP2D6 and/or CYP3A activity modulation on the pharmacokinetics of oxycodone remains poorly explored. EXPERIMENTAL APPROACH A randomized crossover double-blind placebo-controlled study was performed with 10 healthy volunteers genotyped for CYP2D6 [six extensive (EM), two deficient (PM/IM) and two ultrarapid metabolizers (UM)]. The volunteers randomly received on five different occasions: oxycodone 0.2 mg x kg(-1) and placebo; oxycodone and quinidine (CYP2D6 inhibitor); oxycodone and ketoconazole (CYP3A inhibitor); oxycodone and quinidine+ketoconazole; placebo. Blood samples for plasma concentrations of oxycodone and metabolites (oxymorphone, noroxycodone and noroxymorphone) were collected for 24 h after dosing. Phenotyping for CYP2D6 (with dextromethorphan) and CYP3A (with midazolam) were assessed at each session. KEY RESULTS CYP2D6 activity was correlated with oxymorphone and noroxymorphone AUCs and C(max) (-0.71 < Spearman correlation coefficient rhos < -0.92). Oxymorphone C(max) was 62% and 75% lower in PM than EM and UM. Noroxymorphone C(max) reduction was even more pronounced (90%). In UM, oxymorphone and noroxymorphone concentrations increased whereas noroxycodone exposure was halved. Blocking CYP2D6 (with quinidine) reduced oxymorphone and noroxymorphone C(max) by 40% and 80%, and increased noroxycodone AUC(infinity) by 70%. Blocking CYP3A4 (with ketoconazole) tripled oxymorphone AUC(infinity) and reduced noroxycodone and noroxymorphone AUCs by 80%. Shunting to CYP2D6 pathway was observed after CYP3A4 inhibition. CONCLUSIONS AND IMPLICATIONS Drug-drug interactions via CYP2D6 and CYP3A affected oxycodone pharmacokinetics and its magnitude depended on CYP2D6 genotype.
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Affiliation(s)
- C F Samer
- Clinical Pharmacology and Toxicology and Multidisciplinary Pain Centre, Department of Anaesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Switzerland.
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Ancrenaz V, Daali Y, Fontana P, Besson M, Samer C, Dayer P, Desmeules J. Impact of Genetic Polymorphisms and Drug – Drug Interactions on Clopidogrel and Prasugrel Response Variability. Curr Drug Metab 2010; 11:667-77. [DOI: 10.2174/138920010794233521] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 09/30/2010] [Indexed: 11/22/2022]
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