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Lappe A, Luelf UJ, Keilhammer M, Bokel A, Urlacher VB. Bacterial cytochrome P450 enzymes: Semi-rational design and screening of mutant libraries in recombinant Escherichia coli cells. Methods Enzymol 2023; 693:133-170. [PMID: 37977729 DOI: 10.1016/bs.mie.2023.09.011] [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] [Indexed: 11/19/2023]
Abstract
Bacterial cytochromes P450 (P450s) have been recognized as attractive targets for biocatalysis and protein engineering. They are soluble cytosolic enzymes that demonstrate higher stability and activity than their membrane-associated eukaryotic counterparts. Many bacterial P450s possess broad substrate spectra and can be produced in well-known expression hosts like Escherichia coli at high levels, which enables quick and convenient mutant libraries construction. However, the majority of bacterial P450s interacts with two auxiliary redox partner proteins, which significantly increase screening efforts. We have established recombinant E. coli cells for screening of P450 variants that rely on two separate redox partners. In this chapter, a case study on construction of a selective P450 to synthesize a precursor of several chemotherapeutics, (-)-podophyllotoxin, is described. The procedure includes co-expression of P450 and redox partner genes in E. coli with subsequent whole-cell conversion of the substrate (-)-deoxypodophyllotoxin in 96-deep-well plates. By omitting the chromatographic separation while measuring mass-to-charge ratios specific for the substrate and product via MS in so-called multiple injections in a single experimental run (MISER) LC/MS, the analysis time could be drastically reduced to roughly 1 min per sample. Screening results were verified by using isolated P450 variants and purified redox partners.
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Affiliation(s)
- Alessa Lappe
- Institute of Biochemistry, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - U Joost Luelf
- Institute of Biochemistry, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Mirco Keilhammer
- Institute of Biochemistry, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ansgar Bokel
- Institute of Biochemistry, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Vlada B Urlacher
- Institute of Biochemistry, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
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2
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Bicalutamide Exhibits Potential to Damage Kidney via Destroying Complex I and Affecting Mitochondrial Dynamics. J Clin Med 2021; 11:jcm11010135. [PMID: 35011880 PMCID: PMC8745250 DOI: 10.3390/jcm11010135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022] Open
Abstract
Bicalutamide (Bic) is an androgen deprivation therapy (ADT) for treating prostate cancer, while ADT is potentially associated with acute kidney injury. Previously, we recognized Bic induced renal mitochondria dysfunction in vitro and in vivo via the ROS -HIF1α pathway. Whether OXPHOS complex, as well as mitochondrial dynamics, can be influenced by Bic via modulation of peroxisome proliferator-activated receptor coactivator 1α (PGC1α), NADPH oxidase 4 (Nox4), mitofusins 1/2 (MFN 1/2), optic atrophy 1 (OPA1), and sirtuins (SIRTs) has not been documented. Renal mesangial cell line was treated with Bic (30~60 μM) for the indicated time. SIRTs, complex I, mitochondrial dynamics- and oxidative stress-related proteins were analyzed. Bic dose-dependently reduced mitochondrial potential, but dose- and time-dependently suppressed translocase of the outer mitochondrial membrane member 20 (Tomm 20), complex I activity. Nox4 and glutathione lead to decreased NAD+/NADH ratio, with upregulated superoxide dismutase 2. SIRT1 was initially stimulated and then suppressed, while SIRT3 was time- and dose-dependently downregulated. PGC1α, MFN2, and OPA1 were all upregulated, with MFN1 and pro-fission dynamin-related protein I downregulated. Bic exhibits potential to damage mitochondria via destroying complex I, complex I activity, and mitochondrial dynamics. Long-term treatment with Bic should be carefully followed up.
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Swarm RA, Paice JA, Anghelescu DL, Are M, Bruce JY, Buga S, Chwistek M, Cleeland C, Craig D, Gafford E, Greenlee H, Hansen E, Kamal AH, Kamdar MM, LeGrand S, Mackey S, McDowell MR, Moryl N, Nabell LM, Nesbit S, O'Connor N, Rabow MW, Rickerson E, Shatsky R, Sindt J, Urba SG, Youngwerth JM, Hammond LJ, Gurski LA. Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2019; 17:977-1007. [PMID: 31390582 DOI: 10.6004/jnccn.2019.0038] [Citation(s) in RCA: 258] [Impact Index Per Article: 51.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In recent years, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain have undergone substantial revisions focusing on the appropriate and safe prescription of opioid analgesics, optimization of nonopioid analgesics and adjuvant medications, and integration of nonpharmacologic methods of cancer pain management. This selection highlights some of these changes, covering topics on management of adult cancer pain including pharmacologic interventions, nonpharmacologic interventions, and treatment of specific cancer pain syndromes. The complete version of the NCCN Guidelines for Adult Cancer Pain addresses additional aspects of this topic, including pathophysiologic classification of cancer pain syndromes, comprehensive pain assessment, management of pain crisis, ongoing care for cancer pain, pain in cancer survivors, and specialty consultations.
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Affiliation(s)
- Robert A Swarm
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Judith A Paice
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | - Doralina L Anghelescu
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | | | | | | | | | - Ellin Gafford
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Heather Greenlee
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | | | - Susan LeGrand
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
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- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Nina O'Connor
- Abramson Cancer Center at the University of Pennsylvania
| | | | | | | | - Jill Sindt
- Huntsman Cancer Institute at the University of Utah
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Riechelmann RP, Krzyzanowska MK. Drug interactions and oncological outcomes: a hidden adversary. Ecancermedicalscience 2019; 13:ed88. [PMID: 31123502 PMCID: PMC6467454 DOI: 10.3332/ecancer.2019.ed88] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Indexed: 12/16/2022] Open
Abstract
Patients with cancer are at particularly high risk of drug-drug interactions, with approximately 30% of them being exposed to potentially dangerous drug-drug combinations. Yet the real impact of such interactions on oncology practice remains mostly unknown, partly because of the challenges associated with disentangling the effects of harmful interactions from expected side effects of therapy or disease-related symptoms. Recently, some studies have looked at how oncologic outcomes are influenced by drug-drug interactions. In this editorial, we discuss the drug combinations that should be avoided, such as, for example, capecitabine and proton-pump inhibitors, and how research should be conducted in this neglected but clinically relevant topic.
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Affiliation(s)
| | - Monika K Krzyzanowska
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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Houlind MB, Petersen KK, Palm H, Jørgensen LM, Aakjær M, Christrup LL, Petersen J, Andersen O, Treldal C. Creatinine-Based Renal Function Estimates and Dosage of Postoperative Pain Management for Elderly Acute Hip Fracture Patients. Pharmaceuticals (Basel) 2018; 11:E88. [PMID: 30231578 PMCID: PMC6160960 DOI: 10.3390/ph11030088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 09/13/2018] [Accepted: 09/14/2018] [Indexed: 12/12/2022] Open
Abstract
Many analgesics and their metabolites are renally excreted. The widely used Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)-estimated glomerular filtration rate (eGFR) equations are not developed for use in the elderly, while the recent Berlin Initiative Study (BIS), Full Age Spectrum (FAS), and Lund-Malmö revised (LMR) equations are. This observational study investigated differences between creatinine-based eGFR equations and how the choice of equation influences dosage of analgesics in elderly (≥70 years) patients admitted with acute hip fracture. eGFR was calculated by the CKD-EPI, BIS, Cockcroft-Gault (CG), FAS, LMR, and Modification of Diet in Renal Disease (MDRD) equations. Standard daily dose for postoperative pain medications ibuprofen, morphine and gabapentin was simulated for each equation according to dosage recommendations in Renbase®. For 118 patients, mean eGFR from the CKD-EPI, BIS, CG, FAS, LMR, and MDRD equations was 67.3 mL/min/1.73 m², 59.1 mL/min/1.73 m², 56.9 mL/min/1.73 m², 60.3 mL/min/1.73 m², 58.9 mL/min/1.73 m², and 79.1 mL/min/1.73 m², respectively (p < 0.0001). Mean difference to CKD-EPI was -10.4 mL/min/1.73 m² to 11.8 mL/min/1.73 m². Choice of eGFR equation significantly influenced the recommended dose (p < 0.0001). Shifting to BIS, FAS, or LMR equations led to a lower recommended dose in 20% to 31% of patients. Choice of eGFR equation significantly influenced dosing of ibuprofen, morphine, and gabapentin.
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Affiliation(s)
- Morten Baltzer Houlind
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
- The Capital Region Pharmacy, Marielundvej 25, 2730 Herlev, Denmark.
- Section of Pharmacotherapy, Department of Drug Design and Pharmacology, University of Copenhagen, Universitetsparken 2, 2100 København Ø, Denmark.
| | - Kristian Kjær Petersen
- Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Fredrik Bajers Vej 7, building A2-206, 9220 Aalborg Ø, Denmark.
| | - Henrik Palm
- Orthopedic Department, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400 København, Denmark.
| | - Lillian Mørch Jørgensen
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
| | - Mia Aakjær
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
- The Capital Region Pharmacy, Marielundvej 25, 2730 Herlev, Denmark.
- Section of Pharmacotherapy, Department of Drug Design and Pharmacology, University of Copenhagen, Universitetsparken 2, 2100 København Ø, Denmark.
| | - Lona Louring Christrup
- Section of Pharmacotherapy, Department of Drug Design and Pharmacology, University of Copenhagen, Universitetsparken 2, 2100 København Ø, Denmark.
| | - Janne Petersen
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Enterance B, 2nd floor, 1014 København, Denmark.
| | - Ove Andersen
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
- Emergency Department, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 436, 2650 Hvidovre, Denmark.
| | - Charlotte Treldal
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
- The Capital Region Pharmacy, Marielundvej 25, 2730 Herlev, Denmark.
- Section of Pharmacotherapy, Department of Drug Design and Pharmacology, University of Copenhagen, Universitetsparken 2, 2100 København Ø, Denmark.
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Bail JR, Traeger L, Pirl WF, Bakitas MA. Psychological Symptoms in Advanced Cancer. Semin Oncol Nurs 2018; 34:241-251. [DOI: 10.1016/j.soncn.2018.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Matsusue A, Ikeda T, Tani N, Waters B, Hara K, Kashiwagi M, Takayama M, Ikematsu N, Kubo SI, Ishikawa T. Association between cytochrome P450 2D6 polymorphisms and body fluid methamphetamine concentrations in Japanese forensic autopsy cases. Forensic Sci Int 2018; 289:33-39. [PMID: 29843110 DOI: 10.1016/j.forsciint.2018.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/03/2018] [Accepted: 05/10/2018] [Indexed: 12/14/2022]
Abstract
Methamphetamine (MA) is an illicit stimulant that affects the central nervous system. Cytochrome P450 2D6 (CYP2D6) plays an important role in MA metabolism. Numerous allelic variants confer substantial variation in CYP2D6 activity among individuals. In the present study, we examined the frequencies of CYP2D6 alleles, including CYP2D6*1, *2, *4, *5, *10, *14A, *14B, *18, and *36, and multiplication, in 82 forensic autopsy cases of MA abusers and 567 autopsy cases in which MA was not detected (controls). Ultrarapid metabolizer (UM), extensive metabolizer (EM), intermediate metabolizer (IM), and poor metabolizer (PM) phenotypes were predicted from CYP2D6 genotypes. Of MA abusers, 64 subjects were predicted to be EM, 17 were IM, and 1 was UM. No MA abuser had the predicted PM phenotype. No significant differences in CYP2D6 phenotype frequencies were found between MA abusers and controls. MA and amphetamine (AMP) concentrations were measured in the right heart blood, left heart blood, peripheral external iliac blood, urine, pericardial fluid, and bone marrow of MA abusers. MA concentrations in urine and bone marrow were significantly higher in IM than in EM. AMP concentration was not associated with CYP2D6 phenotype in any body fluid. These results suggest that the MA concentration in body fluids is influenced by CYP2D6 phenotypes in the Japanese population.
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Affiliation(s)
- Aya Matsusue
- Department of Forensic Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan.
| | - Tomoya Ikeda
- Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, Osaka 545-8585, Japan
| | - Naoto Tani
- Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, Osaka 545-8585, Japan
| | - Brian Waters
- Department of Forensic Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan
| | - Kenji Hara
- Department of Forensic Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan
| | - Masayuki Kashiwagi
- Department of Forensic Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan
| | - Mio Takayama
- Department of Forensic Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan
| | - Natsuki Ikematsu
- Department of Forensic Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan
| | - Shin-Ichi Kubo
- Department of Forensic Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan
| | - Takaki Ishikawa
- Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, Osaka 545-8585, Japan
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Pierson RC, Gufford BT, Desta Z, Eadon MT. Clinical and educational impact of pharmacogenomics testing: a case series from the INGENIOUS trial. Pharmacogenomics 2017; 18:835-841. [PMID: 28594278 DOI: 10.2217/pgs-2017-0042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Pharmacogenomic testing has become increasingly widespread. However, there remains a need to bridge the gap between test results and providers lacking the expertise required to interpret these results. The Indiana Genomics Implementation trial is underway at our institution to examine total healthcare cost and patient outcomes after genotyping in a safety-net healthcare system. As part of the study, trial investigators and clinical pharmacology fellows interpret genotype results, review patient histories and medication lists and evaluate potential drug-drug interactions. We present a case series of patients in whom pharmacogenomic consultations aided providers in appropriately applying pharmacogenomic results within the clinical context. Formal consultations not only provide valuable patient care information but educational opportunities for the fellows to cement pharmacogenomic concepts.
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Affiliation(s)
- Rebecca C Pierson
- Department of Obstetrics, Gynecology & Women's Health, University of Louisville, KY 40202, USA
| | - Brandon T Gufford
- Department of Medicine, Division of Clinical Pharmacology, Indiana University, IN 46202, USA
| | - Zeruesenay Desta
- Department of Medicine, Division of Clinical Pharmacology, Indiana University, IN 46202, USA
| | - Michael T Eadon
- Department of Medicine, Division of Clinical Pharmacology, Indiana University, IN 46202, USA.,Department of Medicine, Division of Nephrology, Indiana University, IN 46202, USA
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9
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Mercadante S. Opioid metabolism and clinical aspects. Eur J Pharmacol 2015; 769:71-8. [DOI: 10.1016/j.ejphar.2015.10.049] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 10/14/2015] [Accepted: 10/27/2015] [Indexed: 12/16/2022]
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Kotlinska-Lemieszek A, Paulsen O, Kaasa S, Klepstad P. Polypharmacy in patients with advanced cancer and pain: a European cross-sectional study of 2282 patients. J Pain Symptom Manage 2014; 48:1145-59. [PMID: 24780183 DOI: 10.1016/j.jpainsymman.2014.03.008] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 02/24/2014] [Accepted: 04/02/2014] [Indexed: 11/17/2022]
Abstract
CONTEXT Patients with advanced cancer need multiple drugs to control symptoms and to treat cancer and concomitant diseases. At the same time, the goal of treatment changes as life expectancy becomes limited. This results in a risk for polypharmacy, maintained use of unneeded drugs, and drug-drug interactions (DDIs). OBJECTIVES The aim of the study was to analyze the use of medications and to identify unneeded drugs, and drugs and drug combinations with a risk for DDIs in a cohort of advanced cancer pain patients, defined by a need for a World Health Organization analgesic ladder Step III opioid. METHODS All drugs taken within a study day by cancer patients receiving opioids for moderate or severe pain (Step III opioids) were analyzed. Nonopioids and adjuvants were analyzed for their use across countries. Unneeded medications and drugs and drug combinations with a risk for pharmacodynamic and pharmacokinetic DDIs were identified on the basis of published literature and electronic resources. RESULTS In total, 2282 patients from 17 centers in 11 European countries were included. They received a mean of 7.8 drugs (range 1-20). Over one-quarter used 10 or more medications. The drugs and drug classes most frequently coadministered with opioids were proton pump inhibitors, laxatives, corticosteroids, paracetamol (acetaminophen), nonsteroidal anti-inflammatory drugs, metoclopramide, benzodiazepines, anticoagulants, antibiotics, anticonvulsants, diuretics, and antidepressants. The use of nonopioids and essential adjuvants varied across countries. Approximately 45% of patients received unnecessary or potentially unnecessary drugs, and about 7% were given duplicate or antagonizing agents. Exposures to DDIs were frequent and increased the risk of sedation, gastric ulcerations, bleedings, and neuropsychiatric and cardiac complications. Many patients were exposed to pharmacokinetic DDIs involving cytochrome P450, including about 58% who used a Step III opioid CYP3A4 (izoenzyme of cytochrome P450) substrate, and more than 10% who were given major CYP3A4 inhibitors or inducers. CONCLUSION Patients with cancer treated with a World Health Organization Step III opioid use a high number of drugs. Nonopioid analgesics and corticosteroids are frequently used, but different patterns of use between countries were found. Many patients receive unneeded drugs and are at risk of serious DDIs. These findings demonstrate that drug therapy in these patients needs to be evaluated continuously.
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Affiliation(s)
- Aleksandra Kotlinska-Lemieszek
- Department of Palliative Medicine Karol Marcinkowski University of Medical Sciences, Poznan, Poland; Hospice Palium, University Hospital of the Lord's Transfiguration, Poznan, Poland.
| | - Ornulf Paulsen
- Palliative Care Unit, Department of Medicine, Telemark Hospital Trust, Skien, Norway; European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Anaesthesiology and Intensive Care Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Does pharmacogenomics account for variability in control of acute chemotherapy-induced nausea and vomiting with 5-hydroxytryptamine type 3 receptor antagonists? Curr Oncol Rep 2013; 15:276-85. [PMID: 23512709 DOI: 10.1007/s11912-013-0312-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Chemotherapy-induced nausea and vomiting is one of the most concerning adverse drug effects from cytotoxic chemotherapy. Despite appropriate use of antiemetic guidelines, 20-30 % of patients experience breakthrough nausea and vomiting secondary to chemotherapy. To assess the variability of 5-hydroxytryptamine type 3 receptor antagonist efficacy caused by genetic variation, a review of the available literature was conducted. From the literature, three sources of pharmacogenomic variability were identified: polymorphisms associated with 5-hydroxytryptamine type 3 receptor subunits, drug metabolism via cytochromes P450, and drug transport in the body. Testing for receptor subunit polymorphisms is not applicable to a clinical setting at this time; however, cytochrome P450 2D6 testing is FDA-approved and widely accessible. Cytochrome P450 2D6 ultrarapid metabolizers and poor metabolizers displayed altered antiemetic efficacy when compared with intermediate metabolizers and extensive metabolizers. We postulate that testing for cytochrome P450 2D6 phenotypes may be the most accessible way to provide individualized antiemetic therapy in the future.
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12
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Billio A, Morello E, Clarke MJ. WITHDRAWN: Serotonin receptor antagonists for highly emetogenic chemotherapy in adults. Cochrane Database Syst Rev 2013; 2013:CD006272. [PMID: 24323437 PMCID: PMC10654806 DOI: 10.1002/14651858.cd006272.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This review is now out of date although it is correct as of the date of publication. The latest version of this review (available in ‘Other versions’ tab on The Cochrane Library) may still be useful to readers. The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Atto Billio
- Central Hospital S, MaurizioDepartment of Haematology and Bone Marrow TransplantationBolzanoItaly39100
| | - Enrico Morello
- Spedali Civili di BresciaHaematology DepartmentBresciaItaly25100
| | - Mike J Clarke
- Queen's University BelfastCentre for Public HealthInstitute of Clinical Sciences, Block B, Royal Victoria HospitalGrosvenor RoadBelfastNorthern IrelandUKBT12 6BJ
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14
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Xie G, Zhou D, Cheng KW, Wong CC, Rigas B. Comparative in vitro metabolism of phospho-tyrosol-indomethacin by mice, rats and humans. Biochem Pharmacol 2013; 85:1195-202. [PMID: 23399640 DOI: 10.1016/j.bcp.2013.01.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 01/28/2013] [Accepted: 01/30/2013] [Indexed: 02/09/2023]
Abstract
Phospho-tyrosol-indomethacin (PTI; MPI 621), a novel anti-cancer agent, is more potent and safer than conventional indomethacin. Here, we show that PTI was extensively metabolized in vitro and in vivo. PTI was rapidly hydrolyzed by carboxylesterases to generate indomethacin as its major metabolite in the liver microsomes and rats. PTI additionally undergoes cytochromes P450 (CYP)-mediated hydroxylation at its tyrosol moiety and O-demethylation at its indomethacin moiety. Of the five major human CYPs, CYP3A4 and CYP2D6 catalyze the hydroxylation and O-demethylation reactions of PTI, respectively; whereas CYP1A2, 2C9 and 2C19 are inactive towards PTI. In contrast to PTI, indomethacin is primarily O-demethylated by CYP2C9, which prefers acidic substrates. The hydrolyzed and O-demethylated metabolites of PTI are further glucuronidated and sulfated, facilitating drug elimination and detoxification. We observed substantial inter-species differences in the metabolic rates of PTI. Among the liver microsomes from various species, PTI was the most rapidly hydrolyzed, hydroxylated and O-demethylated in mouse, human and rat liver microsomes, respectively. These results reflect the differential expression patterns of carboxylesterase and CYP isoforms among these species. Of the human microsomes from various tissues, PTI underwent more rapid carboxylesterase- and CYP-catalyzed reactions in liver and intestine microsomes than in kidney and lung microsomes. Together, our results establish the metabolic pathways of PTI, reveal significant inter-species differences in its metabolism, and provide insights into the underlying biochemical mechanisms.
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Affiliation(s)
- Gang Xie
- Division of Cancer Prevention, Department of Medicine, Stony Brook University, HSC, T17-080, Stony Brook, NY 11794, USA.
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15
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Leppert W. CYP2D6 in the Metabolism of Opioids for Mild to Moderate Pain. Pharmacology 2011; 87:274-85. [DOI: 10.1159/000326085] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 02/14/2011] [Indexed: 11/19/2022]
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Andreassen TN, Klepstad P, Davies A, Bjordal K, Lundström S, Kaasa S, Dale O. Influences on the pharmacokinetics of oxycodone: a multicentre cross-sectional study in 439 adult cancer patients. Eur J Clin Pharmacol 2010; 67:493-506. [PMID: 21140139 PMCID: PMC3076582 DOI: 10.1007/s00228-010-0948-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Accepted: 10/27/2010] [Indexed: 12/16/2022]
Abstract
Objective Oxycodone is widely used for the treatment of cancer pain, but little is known of its pharmacokinetics in cancer pain patients. The aim of this study was to explore the relationships between ordinary patient characteristics and serum concentrations of oxycodone and the ratios noroxycodone or oxymorphone/oxycodone in cancer patients. Methods Four hundred and thirty-nine patients using oral oxycodone for cancer pain were included. The patients’ characteristics (sex, age, body mass index [BMI], Karnofsky performance status, “time since starting opioids”, “oxycodone total daily dose”, “time from last oxycodone dose”, use of CYP3A4 inducer/inhibitor, “use of systemic steroids”, “number of medications taken in the last 24 h”, glomerular filtration rate (GFR) and albumin serum concentrations) influence on oxycodone serum concentrations or metabolite/oxycodone ratios were explored by multiple regression analyses. Results Sex, CYP3A4 inducers/inhibitors, total daily dose, and “time from last oxycodone dose” predicted oxycodone concentrations. CYP3A4 inducers, total daily dose, and “number of medications taken in the last 24 h” predicted the oxymorphone/oxycodone ratio. Total daily dose, “time from last dose to blood sample”, albumin, sex, CYP3A4 inducers/inhibitors, steroids, BMI and GFR predicted the noroxycodone/oxycodone ratio. Conclusion Women had lower oxycodone serum concentrations than men. CYP3A4 inducers/inhibitors should be used with caution as these are predicted to have a significant impact on oxycodone pharmacokinetics. Other characteristics explained only minor parts of the variability of the outcomes.
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Affiliation(s)
- Trine Naalsund Andreassen
- Pain and Palliation Research Group, Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
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Pergolizzi Jr. JV, Labhsetwar SA, Puenpatom RA, Joo S, Ben-Joseph RH, Summers KH. Prevalence of Exposure to Potential CYP450 Pharmacokinetic Drug-Drug Interactions among Patients with Chronic Low Back Pain Taking Opioids. Pain Pract 2010; 11:230-9. [DOI: 10.1111/j.1533-2500.2010.00413.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Billio A, Morello E, Clarke MJ. Serotonin receptor antagonists for highly emetogenic chemotherapy in adults. Cochrane Database Syst Rev 2010:CD006272. [PMID: 20091591 DOI: 10.1002/14651858.cd006272.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Serotonin receptor antagonists (5-HT(3) RAs) are used to control chemotherapy-induced emesis. Although they have the same general mechanism of action (blockade of serotonin receptors), they have different chemical structures and may have different effects. OBJECTIVES To compare efficacy of different serotonin receptor antagonists (5-HT(3) RAs) in the control of acute and delayed emesis induced by highly emetogenic chemotherapy. SEARCH STRATEGY We searched CENTRAL, the Specialised Register of the Cochrane PaPaS Group, PubMed, EMBASE, and LILACS databases. Our most recent search was in March 2009. SELECTION CRITERIA Randomised trials comparing 5-HT(3) RAs in an adult cancer population. DATA COLLECTION AND ANALYSIS We extracted information from the included studies on the control of acute and delayed nausea and vomiting, either as a single or a combined outcome. Where appropriate, we combined the results of similar trials. We carried out sensitivity and subgroup analyses to test the robustness of our findings. MAIN RESULTS We included 16 randomised trials (7808 participants). Nine of the trials compared granisetron versus ondansetron. No other drug comparison was studied in more than one trial. The meta-analyses of the granisetron versus ondansetron trials found similar results for the two drugs on acute vomiting (eight trials, 4256 participants, odds ratio (OR) 0.89; 95% CI 0.78 to 1.02), acute nausea (seven trials, 4160 participants, OR 0.97; 95% CI 0.85 to 1.10), delayed vomiting (three trials, 1119 participants, OR 1.00; 95% CI 0.74 to 1.34) and delayed nausea (two trials, 1024 participants, OR 0.96; 95% CI 0.75 to 1.24). Granisetron and ondansetron showed similar effects on headache and diarrhoea, with the possible exception of less constipation associated with ondansetron.One study of 1114 participants comparing palonosetron plus dexamethasone versus granisetron plus dexamethasone showed superiority of palonosetron in controlling delayed vomiting (OR 1.45; 95% CI 1.14 to 1.85) and delayed nausea (OR 1.63; 95% CI 1.27 to 2.10). Complete response for delayed nausea and vomiting was also in favour of the combination palonosetron and dexamethasone (OR 1.63; 95% CI 1.29 to 2.07). AUTHORS' CONCLUSIONS Ondansetron and granisetron appear to be equivalent drugs for the prevention of acute and delayed emesis following the use of highly emetogenic chemotherapy.According to one single trial the combination of palonosetron and dexamethasone was superior to granisetron and dexamethasone in controlling delayed emesis. However, more evidence is needed before palonosetron could become the candidate 5-HT(3) RA for the control of delayed emesis induced by highly emetogenic chemotherapy.
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Affiliation(s)
- Atto Billio
- Department of Haematology and Bone Marrow Transplantation, Central Hospital S, Maurizio, Bolzano, Italy, 39100
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Dreiseitel A, Schreier P, Oehme A, Locher S, Hajak G, Sand PG. Anthocyanins and their metabolites are weak inhibitors of cytochrome P450 3A4. Mol Nutr Food Res 2009; 52:1428-33. [PMID: 18727015 DOI: 10.1002/mnfr.200800043] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The cytochrome P450 enzyme cytochrome P450 3A4 (CYP3A4) controls the metabolism of about 60% of all drugs, and its inhibition may dramatically affect drug safety. Modulation of cytochrome P450 activity has been observed by constituents of fruit extracts including several flavonoids. The present investigation addresses CYP3A4 inhibition by anthocyanins, their aglycons, proanthocyanidins, and phenolic metabolites using a chemiluminescent assay. Test compounds inhibited CYP3A4 activity in a concentration-dependent manner featuring IC(50) values from 12.2 up to 7,842 microM. In the order of decreasing effect size, anthocyanidins were followed by anthocyanins, proanthocyanidins, and phenolic acids. When compared to earlier data on furanocoumarins from grapefruit extract, the inhibitory activity of tested anthocyanins, and anthocyanidins was shown to be about 10,000-fold weaker, and was negligible for phenolic acids (>100 000-fold weaker). Future studies are invited to address effects of the above flavonoids on other CYP isoforms for more detailed toxicity profiles.
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Affiliation(s)
- Andrea Dreiseitel
- Department of Psychiatry, University of Regensburg, Regensburg, Germany.
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21
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Skorpen F, Laugsand EA, Klepstad P, Kaasa S. Variable response to opioid treatment: any genetic predictors within sight? Palliat Med 2008; 22:310-27. [PMID: 18541635 DOI: 10.1177/0269216308089302] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this literature review is to summarize and discuss the available evidence for a relationship between polymorphisms in human genes and variability in opioid analgesia and side effects among patients treated for moderate or severe pain. The evidence supporting a role of certain alleles, genotypes or haplotypes in modulation of opioid analgesia is derived from a limited number of studies, a limited number of genes and a limited number of opioids. Although several interesting candidates have emerged as potentially relevant factors, only for one polymorphism, the prevalent 118A>G of the micro-opioid receptor, the accumulated evidence is sufficient to suggest a clinically relevant effect for an opioid used for moderate or severe pain. Still the data are valid only at the group level and cannot be used to predict treatment outcome in individual patients. Only a few of the symptoms often seen as opioid adverse effects in palliative care, such as nausea, vomiting, constipation and sedation, have been associated with genetic variants in various genes, but the results have been based on case reports, healthy volunteers or post-operative patients. So far, there is no clear evidence that genetic markers can be used to predict opioid efficacy or adverse effects in palliative care patients. This reflects the general lack of studies performed in the context of palliative care, the lack of sufficiently scaled studies and the lack of international standards for the assessment of subjective symptoms.
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Affiliation(s)
- F Skorpen
- Department of Laboratory Medicine, Children's and Women's Health, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
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Georgy A, Neceskas J, Goodin S. Antiemetic care for patients with breast cancer: focus on drug interactions and safety concerns. Am J Health Syst Pharm 2007; 64:2227-36. [PMID: 17959573 DOI: 10.2146/ajhp060609] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The drug interactions and adverse events that should be considered when individualizing antiemetic therapy for patients undergoing treatment for breast cancer are reviewed. SUMMARY A variety of antiemetic agents are available, including antihistamines, dopamine-receptor antagonists, serotonin-receptor antagonists, and neurokinin-receptor antagonists. To ensure optimal symptom control for each patient without unnecessarily prolonging treatment, patient- and treatment-specific risk factors must be considered. Neurokinin-receptor antagonists, the newest class of antiemetics, are effective in preventing acute and delayed chemotherapy-induced nausea and vomiting but must be used in combination with a serotonin-receptor antagonist and a corticosteroid. The serotonin-receptor antagonists have become the mainstay of antiemetic therapy, but current guidelines do not distinguish among the different agents in this class. However, there are distinct pharmacologic differences that may affect the potential for drug interactions and, ultimately, patient outcomes and the occurrence of adverse events. Therefore, the potential for drug interactions must be considered when selecting an antiemetic, particularly for patients who are taking multiple concomitant medications. Further, because a number of breast cancer therapies and some antiemetic agents carry cardiovascular warnings or precautions and since breast cancer patients may already be suffering from cardiovascular complications, the possible cardiotoxic effects of the antiemetic or chemotherapy agents or the combinations of these agents should be considered. CONCLUSION Antiemetic treatment is essential for patients with breast cancer who are undergoing moderately to highly emetogenic cytotoxic treatment. When selecting an antiemetic, clinicians must select an agent that provides optimal protection against nausea and vomiting while avoiding drug-drug interactions and additional adverse events.
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Affiliation(s)
- Angela Georgy
- Pharmaceutical Industry Fellowship Institute, School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
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23
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Ryu KH. Anesthetic Drug Interactions. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.53.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Keon Hee Ryu
- Department of Anesthesiology and Pain Medicine, School of Medicine, The Catholic University of Korea, Seoul, Korea
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Bernard S, Neville KA, Nguyen AT, Flockhart DA. Interethnic differences in genetic polymorphisms of CYP2D6 in the U.S. population: clinical implications. Oncologist 2006; 11:126-35. [PMID: 16476833 DOI: 10.1634/theoncologist.11-2-126] [Citation(s) in RCA: 218] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
DNA polymorphisms have been identified in the genes encoding a number of the cytochrome P450 (CYP) enzymes, leading to wide interindividual variation in drug clearance. CYP2D6 metabolizes a significant number of clinically used medications, and genetic variants of the CYP2D6 isozyme that result in varying levels of metabolic activity are of clinical importance in some settings. The exact nature of the clinical effect caused by polymorphisms of the gene depends on the drug in question and the specific variant alleles expressed, as individual variants result in differing phenotypes with a range of levels of enzymatic activity. Compromised drug efficacy due to CYP2D6 variation has been documented with a variety of agents, and this review considers a number of examples, including the 5-HT(3)-receptor antagonists, which are used in oncology supportive care for the prophylaxis of nausea and vomiting. CYP2D6 is involved in the metabolism of all of the most commonly available agents, except granisetron, and their efficacy and side effects may therefore be affected by the CYP2D6 polymorphism. Significant interethnic differences in CYP2D6 allele frequencies have been demonstrated from studies across many countries. However, incidences of polymorphisms in the U.S. population have been challenging to characterize because of the country's wide ethnic diversity. The CYP2D6 polymorphism may become more important as robust clinical tests become widely available and as the use of multiple medications and the attendant risk for drug-drug interactions increases.
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Affiliation(s)
- Stephen Bernard
- Division of Hematology and Medical Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina 27599-7305, USA.
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van Waterschoot RAB, Keizers PHJ, de Graaf C, Vermeulen NPE, Tschirret-Guth RA. Topological role of cytochrome P450 2D6 active site residues. Arch Biochem Biophys 2006; 447:53-8. [PMID: 16466686 DOI: 10.1016/j.abb.2006.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2005] [Revised: 01/04/2006] [Accepted: 01/05/2006] [Indexed: 10/25/2022]
Abstract
Recent reports have identified Phe120, Asp301, Thr309, and Glu216 as important residues in cytochrome P450 2D6 (CYP2D6) substrate binding and catalysis. Complementary homology models have located these amino acids within the binding pocket of CYP2D6 and in the present study we have used aryldiazenes to test these models and gain further insight in the role these amino acids have in maintaining the integrity of the active site cavity. When Phe120 was replaced to alanine, there was a significant increase in probe migration to pyrrole nitrogens C and D, in agreement with homology models which have located the phenyl side-chain of Phe120 above these two pyrrole rings. No changes in topology were observed with the D301Q mutant, supporting claims that in this mutant the electrostatic interactions with the B/C-loop are largely maintained and the loop retains its native orientation. The T309V mutation resulted in significant topological alteration suggesting that, in addition to its potential role in dioxygen activation, Thr309 plays an important structural role within the active site crevice. Replacement of Ile106 with Glu, engineered to cause electrostatic repulsion with Glu216, had a profound topological effect in the higher region within the active site cavity and impaired the catalytic activity towards CYP2D6 probe substrates.
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Affiliation(s)
- Robert A B van Waterschoot
- LACDR/Division of Molecular Toxicology, Department of Pharmacochemistry, Vrije Universiteit, De Boelelaan 1083, 1081 HV Amsterdam, The Netherlands
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Kuebler KK. Palliative care. Clin J Oncol Nurs 2005; 9:617-20. [PMID: 16235589 DOI: 10.1188/05.cjon.617-620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Horiot JC. Antiemetic therapy in cancer: an update. Expert Opin Pharmacother 2005; 6:1713-23. [PMID: 16086657 DOI: 10.1517/14656566.6.10.1713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Although nausea and vomiting are widely recognised as two of the most distressing symptoms of cytotoxic therapy, there is still concern over the adequate control of these symptoms in the cancer population. Recently updated Antiemetic Consensus Guidelines recommend the prophylactic treatment of all patients at moderate-to-high risk of experiencing nausea and vomiting following chemotherapy and radiotherapy. It is important that these guidelines are fully adhered to; however, when considering which antiemetic regimen is most appropriate in an individual patient, it is also important to consider individual patient-related factors. In addition, certain patient groups, such as the young or the elderly, may be in need of specific consideration due to age-related factors that may influence treatment decisions.
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Affiliation(s)
- Jean-Claude Horiot
- Centre de Lutte contre le Cancer GF Leclerc, 1 rue Marion, BP 77980, Dijon, 21079, France.
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Aapro M, Blower P. 5-hydroxytryptamine type-3 receptor antagonists for chemotherapy-induced and radiotherapy-induced nausea and emesis: can we safely reduce the dose of administered agents? Cancer 2005; 104:1-18. [PMID: 15929119 DOI: 10.1002/cncr.21141] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Nausea and emesis as a consequence of chemotherapy or radiotherapy can have an adverse effect on patients' quality of life during cancer treatment and may last for > 5 days after administration. Guidelines suggest that, used at appropriate doses, the 5-hydroxytryptamine type-3 (5-HT3) receptor antagonists--which are considered the antiemetic "gold standard" when they are administered in combination with corticosteroids--demonstrate equivalent efficacy and safety. However, due to financial considerations, these agents often are used at lower doses than recommended. METHODS A literature review of relevant publications pertaining to the control of chemotherapy-induced nausea and emesis and dosing issues of the 5-HT3 receptor antagonists was undertaken to provide a comprehensive review of dosing issues relevant to the 5-HT3 receptor antagonists. RESULTS The issue of "down dosing" was particularly pertinent because of the nature of the 5-HT3 receptor antagonist dose-response curve: A steep dose-response profile within a narrow dose range suggests that antiemetic control will be lost suddenly after dose deescalation. However, the array of predisposing and confounding patient factors indicates that it is unlikely that a loss of antiemetic control will be apparent across a population; rather, individuals will experience loss of control as the dose is reduced below threshold. Of the 4 5-HT3 receptor antagonists currently licensed in the United States (granisetron, ondansetron, dolasetron, and palonosetron), ondansetron is used sometimes at lower than optimal doses, and there is evidence to suggest that even the approved oral dose of dolasetron may be suboptimal. CONCLUSIONS Suboptimal dosing not only will be detrimental to patients' quality of life but, ultimately, will prove counterproductive in terms of hospital resources, and it will add to the already significant socioeconomic burden associated with cancer therapy. Therefore, the dose of antiemetic agent administered should be sufficiently high to ensure good emesis control across the whole patient population.
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Affiliation(s)
- Matti Aapro
- Clinique de Genolier, Genolier, Switzerland.
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Blower P, de Wit R, Goodin S, Aapro M. Drug–drug interactions in oncology: Why are they important and can they be minimized? Crit Rev Oncol Hematol 2005; 55:117-42. [PMID: 15890526 DOI: 10.1016/j.critrevonc.2005.03.007] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2004] [Revised: 02/28/2005] [Accepted: 03/11/2005] [Indexed: 12/22/2022] Open
Abstract
Adverse drug-drug interactions are a major cause of morbidity and mortality. Cancer patients are at particularly high risk of such interactions because they commonly receive multiple medications, including cytotoxic chemotherapy, hormonal agents and supportive care drugs. In addition, the majority of cancer patients are elderly, and so require medications for co-morbid conditions such as cardiovascular, gastrointestinal, and rheumatological diseases. Furthermore, the age-related decline in hepatic and renal function reduces their ability to metabolize and clear drugs and so increases the potential for toxicity. Not all drug-drug interactions can be predicted, and those that are predictable are not always avoidable. However, increased awareness of the potential for these interactions will allow healthcare providers to minimize the risk by choosing appropriate drugs and also by monitoring for signs of interaction. This review considers the basic principles of drug-drug interactions, and presents specific examples that are relevant to oncology.
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Affiliation(s)
- Peter Blower
- Biophar Consulting, Poole House, Great Yeldham, Halstead, Essex CO9 4HP, UK.
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30
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Feyer P, Seegenschmiedt MH, Steingraeber M. Granisetron in the control of radiotherapy-induced nausea and vomiting: a comparison with other antiemetic therapies. Support Care Cancer 2005; 13:671-8. [PMID: 16044252 DOI: 10.1007/s00520-004-0766-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2004] [Accepted: 12/07/2004] [Indexed: 11/28/2022]
Abstract
Radiotherapy-induced nausea and vomiting (RINV) can be one of the most distressing symptoms of radiotherapy treatment, which if incompletely controlled may last for several weeks with fractionated radiotherapy and prevent completion of the planned treatment course. Current treatment guidelines recommend the use of 5-HT(3) receptor antagonists with or without corticosteroids for highly and moderately emetogenic radiotherapy, though only granisetron and ondansetron are currently indicated for RINV in most countries. Granisetron is a potent and highly selective 5-HT(3) receptor antagonist, with demonstrated efficacy in RINV in both placebo-controlled and comparative studies. In this paper the clinical experience with granisetron in RINV is reviewed, and its efficacy and safety compared with other antiemetic therapies.
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Affiliation(s)
- Petra Feyer
- Clinic of Radiooncology and Nuclear Medicine, Vivantes Clinics Neukoelln, 12351 Berlin, Germany.
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Abstract
BACKGROUND Management of chemotherapy- or radiotherapy-induced emesis has improved significantly following the introduction of the 5-HT3-receptor antagonists. Prophylactic use of these agents is recommended for the prevention of both chemotherapy- and radiotherapy-induced nausea and vomiting, given with a corticosteroid. Despite these advances, nausea and vomiting remain among the most feared and debilitating adverse effects of cytotoxic therapy. The shift towards a more elderly population of patients with cancer presents additional considerations for supportive care, with an emphasis on achieving control of nausea and vomiting, whilst minimising toxicity and avoiding drug-drug interactions. This review presents some of the key issues for consideration in optimising antiemetic therapy. The PubMed search engine was used to search for relevant literature (up to December 2004) and relevant international congress materials collected during 2003 and 2004. SCOPE While the early stages of nausea and vomiting are 5-HT-mediated, identification of a role for substance P in late emesis has led to the development of the NK1-receptor antagonist, aprepitant. As a new agent, the clinical profile of aprepitant is still being explored, including its interaction with concomitant medications. Patients who achieve good control of acute and late-acute nausea and vomiting have a reduced risk of experiencing delayed onset symptoms, emphasising the importance of prophylactic management with effective agents. Although the 5-HT3-receptor antagonists are widely considered to have equivalent efficacy, they vary in half-life and the nature of antagonism at receptors. Their metabolic profiles also differ, with cytochrome P450 (CYP) metabolism affecting their propensity for drug-drug interactions. Several sets of guidelines are available that outline recommendations for selection and use of antiemetic therapy. However, under-use of 5-HT3 receptor antagonists has been reported in both the radiotherapy and chemotherapy settings, and some commonly used doses may be suboptimal. CONCLUSION In optimising antiemetic therapy, wider implementation of guidelines is desirable, as is consideration of each patient's individual needs. Safety and tolerability of supportive care medications should be a key consideration, and cardiovascular warnings and the possibility of drug-drug interactions should be given sufficient consideration, particularly in view of the older age of the population with cancer.
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Affiliation(s)
- Matti Aapro
- Clinique de Genolier, 1272, Genolier, Switzerland.
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de Wit R, Aapro M, Blower PR. Is there a pharmacological basis for differences in 5-HT3-receptor antagonist efficacy in refractory patients? Cancer Chemother Pharmacol 2005; 56:231-8. [PMID: 15838653 DOI: 10.1007/s00280-005-1033-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2004] [Accepted: 11/25/2004] [Indexed: 12/29/2022]
Abstract
5-HT3-receptor antagonists are the current antiemetic 'gold standard' for chemotherapy- and radiotherapy-induced nausea and vomiting. Interestingly, studies have shown that patients experiencing poor control of acute chemotherapy-induced nausea and vomiting with one antiemetic therapy may respond well to another agent, including a drug of the same class. This review examines pharmacological differences between the 5-HT3-receptor antagonists in order to determine potential reasons for their differing efficacy, particularly in relation to refractory emesis. Differences in drug metabolism by the cytochrome P450 system, inadequate dosing of the respective agents, differences in onset and duration of action, and effects on serotonin release and reuptake are discussed.
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Affiliation(s)
- Ronald de Wit
- Rotterdam Cancer Institute, Groene Hilledijk 301, 3075, Rotterdam, The Netherlands.
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Horiot JC, Aapro M. Treatment implications for radiation-induced nausea and vomiting in specific patient groups. Eur J Cancer 2004; 40:979-87. [PMID: 15093572 DOI: 10.1016/j.ejca.2003.12.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2003] [Accepted: 12/30/2003] [Indexed: 11/29/2022]
Abstract
Radiation-induced nausea and vomiting (RINV) affect the management and quality of life of cancer patients. Current guidelines for RINV prevention recommend prophylaxis with a 5-hydroxytryptamine (5-HT(3))-receptor antagonist for patients receiving moderately or highly emetogenic radiotherapy regimens. Randomised trials have compared such antagonists with conventional antiemetics, and have demonstrated their efficacy and safety. Special consideration is needed for antiemetic treatment in certain patient groups, particularly the elderly and those with renal or hepatic impairment. Radiation oncologists should be aware of the effect on antiemetic treatment of factors such as comorbid conditions (particularly cardiovascular disease), polypharmacy and drug-drug interactions, and choose the agent with the lowest potential for additional complications. The most appropriate antiemetic treatment to improve patient compliance and quality of life should ideally combine proven efficacy with uncomplicated administration and convenient dosing regimens.
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Affiliation(s)
- J-C Horiot
- Centre de Lutte contre le Cancer G.F. Leclerc, 1 Rue Marion, BP 77980, Dijon 21079, France.
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Abstract
The prevalence of pain increases with each decade of life. Pain in the elderly is distinctly different from pain experienced by younger individuals. Cancer is a leading cause of pain; however, other conditions that cause pain such as facet joint arthritis (causing low back pain), polymyalgia rheumatica, Paget's disease, neuropathies, peripheral vascular disease and coronary disease most commonly occur in patients over the age of 50 years. Poorly controlled pain in the elderly leads to cognitive failure, depression and mood disturbance and reduces activities of daily living. Barriers to pain management include a sense of fatalism, denial, the desire to be 'the good patient', geographical barriers and financial limitations. Aging causes physiological changes that alter the pharmacokinetics and pharmacodynamics of analgesics, narrowing their therapeutic index and increasing the risk of toxicity and drug-drug interactions. CNS changes lead to an increased risk of delirium. Assessment among the verbal but cognitively impaired elderly is satisfactorily accomplished with the help of unidimensional and multidimensional pain scales. A comprehensive physical examination and pain history is essential, as well as a review of cognitive function and activities of daily living. The goal of pain management among the elderly is improvement in pain and optimisation of activities of daily living, not complete eradication of pain nor the lowest possible drug dosages. Most successful management strategies combine pharmacological and nonpharmacological (home remedies, massage, topical agents, heat and cold packs and informal cognitive strategies) therapies. A basic principle of the pharmacological approach in the elderly is to start analgesics at low dosages and titrate slowly. The WHO's three-step guideline to pain management should guide prescribing. Opioid choices necessitate an understanding of pharmacology to ensure safe administration in end-organ failure and avoidance of drug interactions. Adjuvant analgesics are used to reduce opioid adverse effects or improve poorly controlled pain. Adjuvant analgesics (NSAIDs, tricyclic antidepressants and antiepileptic drugs) are initiated prior to opioids for nociceptive and neuropathic pain. Preferred adjuvants for nociceptive pain are short-acting paracetamol (acetaminophen), NSAIDs, cyclo-oxygenase-2 inhibitors and corticosteroids (short-term). Preferred drugs for neuropathic pain include desipramine, nortriptyline, gabapentin and valproic acid. Drugs to avoid are pentazocine, pethidine (meperidine), dextropropoxyphene and opioids that are both an agonist and antagonist, ketorolac, indomethacin, piroxicam, mefenamic acid, amitriptyline and doxepin. The type of pain, and renal and hepatic function, alter the preferred adjuvant and opioid choices. Selection of the appropriate analgesics is also influenced by versatility, polypharmacy, severity and type of pain, drug availability, associated symptoms and cost.
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Affiliation(s)
- Mellar P Davis
- Harry R Horvitz Center for Palliative Medicine, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Goodin S, Cunningham R. 5-HT(3)-receptor antagonists for the treatment of nausea and vomiting: a reappraisal of their side-effect profile. Oncologist 2003; 7:424-36. [PMID: 12401905 DOI: 10.1634/theoncologist.7-5-424] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Nausea and vomiting can cause considerable distress and discomfort to patients undergoing chemotherapy, radiotherapy, or surgery. Several classes of antiemetic agents exist to combat these side effects, though the 5-HT(3)-receptor antagonists have become the first-line treatment choice for many cancer patients and are considered the "gold standard" in antiemetic therapy. Compared with the older generation antiemetic drugs, 5-HT(3)-receptor antagonists are effective, well tolerated, and associated with few side effects. However, emerging differences among these agents suggest that the incidence and/or intensity of adverse events should not be regarded as a class effect. The side-effect profile of any supportive care therapy is particularly important in certain subgroups of patients, including pediatric patients and the elderly, as well as those suffering comorbid conditions, such as cardiovascular disease and renal or hepatic impairment. Indeed, dolasetron is associated with cardiovascular effects, and thus, should be used with extreme caution in patients who suffer from or may develop prolongation of cardiac conduction intervals. Ondansetron, on the other hand, is associated with a greater incidence of central nervous system side effects than either dolasetron or ondansetron, and pharmacokinetic parameters are affected in patients with hepatic impairment, thereby requiring dose adjustments. Clinicians are encouraged to evaluate patients on an individual basis when choosing which 5-HT(3)-receptor antagonist to prescribe.
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Affiliation(s)
- Susan Goodin
- The Cancer Institute of New Jersey, New Brunswick 08903, USA.
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Abstract
Recent discoveries in opioid pharmacology help explain the enormous variability in clinical responses to these powerful analgesics. Although there is only one m opioid receptor gene, splice variants of that gene's expression result in a panoply of different functioning receptors. Other sources of variable response include polymorphisms in the m opioid receptor regulatory region, and pharmacokinetic differences because of cytochrome P-450 mono-oxygenase heterogeneity. Analgesic tolerance is likely the key phenomenon limiting the benefit of opioids. A plethora of intracellular pathways affects this. Among them are the N-methyl-D-aspartate receptor, protein kinase C gamma activity, nitric oxide synthase, and GM1 ganglioside content of the neuronal membrane. Clinical studies undercut the routine use of meperidine in most settings. Other studies have shown better ways to diminish opioid side effects.
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MESH Headings
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/therapeutic use
- Animals
- Clinical Trials as Topic
- Drug Tolerance
- Humans
- Pain/drug therapy
- Pain/physiopathology
- Receptors, Opioid/drug effects
- Receptors, Opioid/genetics
- Receptors, Opioid/physiology
- Receptors, Opioid, mu/drug effects
- Receptors, Opioid, mu/genetics
- Receptors, Opioid, mu/physiology
- Trans-Activators/genetics
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Affiliation(s)
- Eric Chevlen
- Cancer Care Center, St. Elizabeth Hospital, 1044 Belmont Avenue, Youngstown, OH 44501, USA.
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38
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Kuebler K. Analgesic prescribing. Am J Nurs 2003; 103:16; author reply 16. [PMID: 12549473 DOI: 10.1097/00000446-200301000-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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39
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Abstract
Many patients with cancer receive multiple chemotherapy agents as well as other medications for coexisting medical conditions. Despite the introduction of 5-HT3 receptor antagonists, the management of nausea and vomiting following cancer treatment and after cancer surgery remains complex, particularly when patients are receiving multiple prescription medications. As a drug class, the 5-HT3 receptor antagonists have good antiemetic efficacy and an improved safety profile over conventional antiemetics. Nevertheless, pharmacologic differences exist between these agents, such as their interaction with the metabolic cytochrome P450 system. This review examines the major metabolic differences between the most frequently prescribed 5-HT3 receptor antagonists, dolasetron, granisetron, ondansetron, and tropisetron. The potential drug interactions that these differences may precipitate and key genetic interindividual variations in drug metabolism are also considered. To avoid or minimize potential drug interactions, the 5-HT3 receptor antagonist with the lowest risk of these interactions should be considered as first choice.
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40
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Davis MP, Khawam E, Pozuelo L, Lagman R. Management of symptoms associated with advanced cancer: olanzapine and mirtazapine. A World Health Organization project. Expert Rev Anticancer Ther 2002; 2:365-76. [PMID: 12647979 DOI: 10.1586/14737140.2.4.365] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Advanced cancer patients are polysymptomatic and often receive multiple medications for symptom relief. Common symptoms include anorexia, weight loss, delirium and depression. Olanzapine and mirtazapine may have several advantages over older agents despite increased acquisition costs. Both medications can treat several symptoms with a low risk for drug-drug interactions and with only once- or twice-daily dosing. Drug side effects are low, compared with more conventionally used agents. The pharmacokinetics and pharmacodynamics of both agents are unique and explain many of the benefits. More research and clinical experience will be necessary to define their role in the palliation of advanced cancer.
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Affiliation(s)
- Mellar P Davis
- Harry R Horvtiz Center for Palliative Medicine, Cleveland Clinic Foundation, OH 44195, USA.
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