1
|
Flores A, Nguyen NM, Pendyala G. Developmental outcomes with perinatal exposure (DOPE) to prescription opioids. NEUROIMMUNE PHARMACOLOGY AND THERAPEUTICS 2023; 2:339-351. [PMID: 38058996 PMCID: PMC10696573 DOI: 10.1515/nipt-2023-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/07/2023] [Indexed: 12/08/2023]
Abstract
Researchers have found considerable evidence in the past 20 years that perinatal opioid exposure leads to an increased risk of developmental disorders in offspring that persist into adulthood. The use of opioids to treat pain concerning pregnancy, delivery, and postpartum complications has been rising. As a result, communities have reported a 300-400 % increase in Neonatal Opioid Withdrawal Syndrome (NOWS). NOWS represents the initial stage of several behavioral, phenotypic, and synaptic deficits. This review article summarizes the Developmental Outcomes of Perinatal Exposure (DOPE) to prescription opioids. Moreover, we also seek to connect these findings to clinical research that describes DOPE at multiple stages of life. Since specific mechanisms that underlie DOPE remain unclear, this article aims to provide a framework for conceptualizing across all ages and highlight the implications they may have for longevity.
Collapse
Affiliation(s)
- Adrian Flores
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE, USA
- Department of Cellular and Integrative Physiology, UNMC, Omaha, NE, USA
| | - Nghi M. Nguyen
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE, USA
- Department of Genetics, Cell Biology and Anatomy, UNMC, Omaha, NE, USA
| | - Gurudutt Pendyala
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE, USA
- Department of Genetics, Cell Biology and Anatomy, UNMC, Omaha, NE, USA
- Child Health Research Institute, Omaha, NE, USA
- National Strategic Research Institute, UNMC, Omaha, NE, USA
| |
Collapse
|
2
|
de Moura RS, Bittar IP, Gomes JH, de Oliveira YVR, de Sousa Filho GD, de Faria Soares GCF, Lima EM, Franco LG. Plasma concentration, cardiorespiratory and analgesic effects of ketamine-fentanyl infusion in dogs submitted to mastectomy. BMC Vet Res 2022; 18:225. [PMID: 35701767 PMCID: PMC9199142 DOI: 10.1186/s12917-022-03244-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 02/28/2022] [Indexed: 01/12/2023] Open
Abstract
Background The analgesic and cardiorespiratory effects of ketamine, fentanyl, or ketamine-fentanyl constant rate infusion (CRI) in dogs undergoing mastectomy were evaluated. Seventeen female dogs received CRI of ketamine (GK [n = 6]: bolus 0.5 mg/kg; CRI 20 µg/kg/min in intra- and postoperative periods], fentanyl (GF [n = 5]: bolus 20 µg/kg; intraoperative CRI 5 20 µg/kg/hour and postoperative CRI 2 20 µg/kg/hour), or combination of ketamine-fentanyl (GKF [n = 6]: aforementioned doses) for 8 h. Cardiorespiratory, blood gas analyses, plasma drug concentrations, sedation score (SS), Pain Scores were evaluated. Results The heart rate decreased in the GF and GKF (p < 0.04); the mean arterial pressure was lower in the GKF than in the GK at 35 min (p < 0.001). Maximum plasma concentrations were observed 5 min after bolus in the GK (2847.06 ± 2903.03 ng/mL) and GKF (2811.20 ± 1931.76 ng/mL). Plasma concentration in intraoperative period of ketamine was of > 100 ng/mL in 5/5 and 2/5 animals in the GKF and GK, respectively; and > 1.1 ng/mL of fentanyl in 4/5 and 3/5 in GKF and GF, respectively. Conclusion Ketamine with/without fentanyl provided analgesia without significant cardiorespiratory and guaranteed the minimal plasma levels with analgesic potential during the 8 h.
Collapse
Affiliation(s)
- Rauane Sousa de Moura
- Department of Veterinary Medicine, Federal University of Goiás, 74.690-900, Goiânia, GO, Brazil
| | - Isabela Plazza Bittar
- Department of Veterinary Medicine, Federal University of Goiás, 74.690-900, Goiânia, GO, Brazil
| | - Janainne Hilbig Gomes
- Department of Veterinary Medicine, Federal University of Goiás, 74.690-900, Goiânia, GO, Brazil
| | | | | | | | - Eliana Martins Lima
- Development and Technological Innovation in Drugs - FarmaTec, Research Center, Universidade Federal de Goiás, Goiânia, GO, Brazil
| | - Leandro Guimarães Franco
- Department of Veterinary Medicine, Federal University of Goiás, 74.690-900, Goiânia, GO, Brazil.
| |
Collapse
|
3
|
Preoperative Risk Stratification: Identifying Modifiable Risks for Optimization. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00519-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
4
|
CYP 450 enzymes influence (R,S)-ketamine brain delivery and its antidepressant activity. Neuropharmacology 2021; 206:108936. [PMID: 34965407 DOI: 10.1016/j.neuropharm.2021.108936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 12/07/2021] [Accepted: 12/21/2021] [Indexed: 11/23/2022]
Abstract
Esketamine, the S-stereoisomer of (R,S)-ketamine was recently approved by drug agencies (FDA, EMA), as an antidepressant drug with a new mechanism of action. (R,S)-ketamine is a N-methyl-d-aspartate receptor (NMDA-R) antagonist putatively acting on GABAergic inhibitory synapses to increase excitatory synaptic glutamatergic neurotransmission. Unlike monoamine-based antidepressants, (R,S)-ketamine exhibits rapid and persistent antidepressant activity at subanesthetic doses in preclinical rodent models and in treatment-resistant depressed patients. Its major brain metabolite, (2R,6R)-hydroxynorketamine (HNK) is formed following (R,S)-ketamine metabolism by various cytochrome P450 enzymes (CYP) mainly activated in the liver depending on routes of administration [e.g., intravenous (largely used for a better bioavailability), intranasal spray, intracerebral, subcutaneous, intramuscular or oral]. Experimental or clinical studies suggest that (2R,6R)-HNK could be an antidepressant drug candidate. However, questions still remain regarding its molecular and cellular targets in the brain and its role in (R,S)-ketamine's fast-acting antidepressant effects. The purpose of the present review is: 1) to review (R,S)-ketamine pharmacokinetic properties in humans and rodents and its metabolism by CYP enzymes to form norketamine and HNK metabolites; 2) to provide a summary of preclinical strategies challenging the role of these metabolites by modifying (R,S)-ketamine metabolism, e.g., by administering a pre-treatment CYP inducers or inhibitors; 3) to analyze the influence of sex and age on CYP expression and (R,S)-ketamine metabolism. Importantly, this review describes (R,S)-ketamine pharmacodynamics and pharmacokinetics to alert clinicians about possible drug-drug interactions during a concomitant administration of (R,S)-ketamine and CYP inducers/inhibitors that could enhance or blunt, respectively, (R,S)-ketamine's therapeutic antidepressant efficacy in patients.
Collapse
|
5
|
Kaye AD, Edinoff AN, Babin KC, Hebert CM, Hardin JL, Cornett EM, Kaye AJ, Kaye AM, Urman RD. Pharmacological Advances in Opioid Therapy: A Review of the Role of Oliceridine in Pain Management. Pain Ther 2021; 10:1003-1012. [PMID: 34480744 PMCID: PMC8586099 DOI: 10.1007/s40122-021-00313-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/23/2021] [Indexed: 12/12/2022] Open
Abstract
Problems with the treatment of acute pain may arise when a patient is opioid-tolerant, such as those on chronic therapy with opioids or opiate replacement therapy, those who misuse opioids, and those who are in recovery. While some of the adverse effects of opioid medications are well known, it is also important to recognize the roles of tolerance and hyperalgesia. Oliceridine can target and modulate a novel μ-receptor pathway. The G protein-biased agonism of oliceridine allows for effective re-sensitization and desensitization of the mu-opioid receptor, which decreases the formation of opioid tolerance in patients. Oliceridine has been demonstrated to be an effective and relatively safe intravenous analgesic for the treatment of postoperative pain and is generally well tolerated with a favorable side effect profile when compared to morphine. As the prevalence of pain increases, it is becoming increasingly important to find safe and effective analgesics.
Collapse
Affiliation(s)
- Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Amber N Edinoff
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Science Center Shreveport, 1501 Kings Hwy, Shreveport, LA, 71103, USA.
| | - Katherine C Babin
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Chance M Hebert
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Justin L Hardin
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Aaron J Kaye
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Adam M Kaye
- Thomas J. Long School of Pharmacy and Health Sciences, Department of Pharmacy Practice, University of the Pacific, Stockton, CA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
6
|
Pharmacogenomic Testing and Patient Perception Inform Pain Pharmacotherapy. J Pers Med 2021; 11:jpm11111112. [PMID: 34834463 PMCID: PMC8621784 DOI: 10.3390/jpm11111112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/19/2021] [Accepted: 10/26/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Chronic pain is one of the most common reasons for individuals to seek medications. Historically, opioids have been the mainstay of chronic pain management. However, in some patient populations, opioids fail to demonstrate therapeutic efficacy, whereas in other populations, opioids may cause toxic effects, even at lower doses. Response to pain medication is affected by many factors, including an individual's genetic variations. Pharmacogenomic testing has been designed to help achieve optimal treatment outcomes. This study aimed at assessing the impact of CYP2D6 pharmacogenomic testing on physicians' choice in prescribing chronic pain medications and patient pain control. (2) Methods: This retrospective study reviewed 107 patient charts from a single site pain management center. All 107 patients received pharmacogenomic testing. The outcomes of interest were confirmation that the optimal pain medication is being administered or a change in the chronic pain medication is warranted as a result of the pharmacogenomic testing. The main independent variable was the pharmacogenomic test result. Other independent variables included patient gender, race, and comorbidities. The retrospective study was reviewed and approved by the Touro College and University System IRB, HSIRB1653E. (3) Results: Patients self-reported pain intensity on a scale of 1-10 before and after pharmacogenomic testing. Then, 100% of patients in the retrospective study were tested for their pain pharmacogenomic profile. Of the 107 patients participating in the study, more than 50% had their medications altered as a result of the pharmacogenomic testing. The percentage of patients with intense pain were decreased post-pharmacogenomic testing (5.6%) as compared to pre-pharmacogenomic testing (10.5%). Patients with intense, moderate, and mild pain categories were more likely to receive changes in pain medications. In contrast, patients with severe pain were less likely to receive a change in pain medication. Hispanic ethnicity was associated with a statistically significantly decrease in a pain scale category. Illegal drug abuse was associated with a decrease in pain scale category. Change in medication dose was associated with a decrease in pain scale category. (4) Conclusion: In this retrospective study, implementation of pharmacogenomic testing demonstrated significant benefits to patients with intense pain undergoing treatment.
Collapse
|
7
|
Batistaki C, Chrona E, Kostroglou A, Kostopanagiotou G, Gazouli M. CYP2D6 Basic Genotyping of Patients with Chronic Pain Receiving Tramadol or Codeine. A Study in a Greek Cohort. PAIN MEDICINE 2021; 21:3199-3204. [PMID: 32443139 DOI: 10.1093/pm/pnaa122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To assess CYP2D6 genotype prevalence in chronic pain patients treated with tramadol or codeine. DESIGN Prospective cohort study. SETTING General hospital, pain management unit. SUBJECTS Patients with chronic pain, treated with codeine or tramadol. METHODS Patients' pain was assessed at baseline (numeric rating scale [NRS]; 0-10). Prescription of codeine or tramadol was selected randomly. The assessment of patients' response to the drug in terms of pain relief and adverse effects was performed after 24 hours. Reduction of pain intensity of >50% or an NRS <4 was considered a positive response. Patients' blood samples were collected during the first visit. Genotyping for the common variants CYP2D6 *2, *3, *4, *5, *6, *9, *10, *14, and *17 was performed, and alleles not carrying any polymorphic allele were classified as CYP2D6*1 (wild-type [wt]). RESULTS Seventy-six consecutive patients were studied (20 males, 56 females), aged 21-85 years. Thirty-four received tramadol and 42 codeine. The main genotypes of CYP2D6 identified were the wt/wt (35.5%), the *4/wt (17.1%), and the *6/wt (10.5%). Adverse effects were common, especially in carriers of *9/*9, *5/*5, *5/*4, and *10/*10, as well as in variants including the 4 allele (*4/*1 [38.4%] and *4/*4 [42.8%]). CONCLUSIONS Genotyping can facilitate personalized pain management with opioids, as specific alleles are related to decreased efficacy and adverse effects.
Collapse
Affiliation(s)
- Chrysanthi Batistaki
- 2nd Department of Anaesthesiology, Faculty of Medicine, National, Kapodistrian University of Athens, Pain Management Unit, "Attikon" Hospital, Athens, Greece
| | - Eleni Chrona
- Department of Anaesthesiology, General Hospital of Nikea, "Ag. Panteleimon," Piraeus, Greece
| | - Andreas Kostroglou
- 2nd Department of Anaesthesiology, Faculty of Medicine, National, Kapodistrian University of Athens, Pain Management Unit, "Attikon" Hospital, Athens, Greece
| | - Georgia Kostopanagiotou
- 2nd Department of Anaesthesiology, Faculty of Medicine, National, Kapodistrian University of Athens, Pain Management Unit, "Attikon" Hospital, Athens, Greece
| | - Maria Gazouli
- Laboratory of Biology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
8
|
Primorac D, Molnar V, Matišić V, Hudetz D, Jeleč Ž, Rod E, Čukelj F, Vidović D, Vrdoljak T, Dobričić B, Antičević D, Smolić M, Miškulin M, Ćaćić D, Borić I. Comprehensive Review of Knee Osteoarthritis Pharmacological Treatment and the Latest Professional Societies' Guidelines. Pharmaceuticals (Basel) 2021; 14:ph14030205. [PMID: 33801304 PMCID: PMC8001498 DOI: 10.3390/ph14030205] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 02/06/2023] Open
Abstract
Osteoarthritis is the most common musculoskeletal progressive disease, with the knee as the most commonly affected joint in the human body. While several new medications are still under research, many symptomatic therapy options, such as analgesics (opioid and non-opioid), nonsteroid anti-inflammatory drugs, symptomatic slow-acting drugs in osteoarthritis, and preparations for topical administration, are being used, with a diverse clinical response and inconsistent conclusions across various professional societies guidelines. The concept of pharmacogenomic-guided therapy, which lies on principles of the right medication for the right patient in the right dose at the right time, can significantly increase the patient’s response to symptom relief therapy in knee osteoarthritis. Corticosteroid intra-articular injections and hyaluronic acid injections provoke numerous discussions and disagreements among different guidelines, even though they are currently used in daily clinical practice. Biological options, such as platelet-rich plasma and mesenchymal stem cell injections, have shown good results in the treatment of osteoarthritis symptoms, greatly increasing the patient’s quality of life, especially when combined with other therapeutic options. Non-inclusion of the latter therapies in the guidelines, and their inconsistent stance on numerous therapy options, requires larger and well-designed studies to examine the true effects of these therapies and update the existing guidelines.
Collapse
Affiliation(s)
- Dragan Primorac
- St. Catherine Specialty Hospital, 49210 Zabok/10000 Zagreb, Croatia; (V.M.); (V.M.); (D.H.); (Ž.J.); (E.R.); (F.Č.); (D.V.); (T.V.); (B.D.); (D.A.); (I.B.)
- Eberly College of Science, The Pennsylvania State University, University Park, State College, PA 16802, USA
- The Henry C. Lee College of Criminal Justice and Forensic Sciences, University of New Haven, West Haven, CT 06516, USA
- Medical School, University of Split, 21000 Split, Croatia;
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia;
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Medical School, University of Rijeka, 51000 Rijeka, Croatia
- Medical School REGIOMED, 96450 Coburg, Germany
- Medical School, University of Mostar, 88000 Mostar, Bosnia and Herzegovina
- Correspondence: ; Tel.: +385-98-470-710
| | - Vilim Molnar
- St. Catherine Specialty Hospital, 49210 Zabok/10000 Zagreb, Croatia; (V.M.); (V.M.); (D.H.); (Ž.J.); (E.R.); (F.Č.); (D.V.); (T.V.); (B.D.); (D.A.); (I.B.)
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
| | - Vid Matišić
- St. Catherine Specialty Hospital, 49210 Zabok/10000 Zagreb, Croatia; (V.M.); (V.M.); (D.H.); (Ž.J.); (E.R.); (F.Č.); (D.V.); (T.V.); (B.D.); (D.A.); (I.B.)
| | - Damir Hudetz
- St. Catherine Specialty Hospital, 49210 Zabok/10000 Zagreb, Croatia; (V.M.); (V.M.); (D.H.); (Ž.J.); (E.R.); (F.Č.); (D.V.); (T.V.); (B.D.); (D.A.); (I.B.)
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Clinical Hospital “Sveti Duh”, 10000 Zagreb, Croatia
| | - Željko Jeleč
- St. Catherine Specialty Hospital, 49210 Zabok/10000 Zagreb, Croatia; (V.M.); (V.M.); (D.H.); (Ž.J.); (E.R.); (F.Č.); (D.V.); (T.V.); (B.D.); (D.A.); (I.B.)
- Department of Nursing, University North, 48000 Varaždin, Croatia
| | - Eduard Rod
- St. Catherine Specialty Hospital, 49210 Zabok/10000 Zagreb, Croatia; (V.M.); (V.M.); (D.H.); (Ž.J.); (E.R.); (F.Č.); (D.V.); (T.V.); (B.D.); (D.A.); (I.B.)
| | - Fabijan Čukelj
- St. Catherine Specialty Hospital, 49210 Zabok/10000 Zagreb, Croatia; (V.M.); (V.M.); (D.H.); (Ž.J.); (E.R.); (F.Č.); (D.V.); (T.V.); (B.D.); (D.A.); (I.B.)
- Medical School, University of Split, 21000 Split, Croatia;
- Department of Health Studies, University of Split, 21000 Split, Croatia
- Clinic for Traumatology, University Hospital “Sisters of Mercy”, 10000 Zagreb, Croatia
| | - Dinko Vidović
- St. Catherine Specialty Hospital, 49210 Zabok/10000 Zagreb, Croatia; (V.M.); (V.M.); (D.H.); (Ž.J.); (E.R.); (F.Č.); (D.V.); (T.V.); (B.D.); (D.A.); (I.B.)
- Clinic for Traumatology, University Hospital “Sisters of Mercy”, 10000 Zagreb, Croatia
| | - Trpimir Vrdoljak
- St. Catherine Specialty Hospital, 49210 Zabok/10000 Zagreb, Croatia; (V.M.); (V.M.); (D.H.); (Ž.J.); (E.R.); (F.Č.); (D.V.); (T.V.); (B.D.); (D.A.); (I.B.)
- Clinical Hospital “Sveti Duh”, 10000 Zagreb, Croatia
| | - Borut Dobričić
- St. Catherine Specialty Hospital, 49210 Zabok/10000 Zagreb, Croatia; (V.M.); (V.M.); (D.H.); (Ž.J.); (E.R.); (F.Č.); (D.V.); (T.V.); (B.D.); (D.A.); (I.B.)
- Department of Orthopaedics and Traumatology, University Hospital Dubrava, 10000 Zagreb, Croatia
| | - Darko Antičević
- St. Catherine Specialty Hospital, 49210 Zabok/10000 Zagreb, Croatia; (V.M.); (V.M.); (D.H.); (Ž.J.); (E.R.); (F.Č.); (D.V.); (T.V.); (B.D.); (D.A.); (I.B.)
| | - Martina Smolić
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia;
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
| | - Mladen Miškulin
- Medical School, University of Split, 21000 Split, Croatia;
- Aksis Specialty Hospital, 10000 Zagreb, Croatia
| | - Damir Ćaćić
- General Hospital Karlovac, 47000 Karlovac, Croatia;
| | - Igor Borić
- St. Catherine Specialty Hospital, 49210 Zabok/10000 Zagreb, Croatia; (V.M.); (V.M.); (D.H.); (Ž.J.); (E.R.); (F.Č.); (D.V.); (T.V.); (B.D.); (D.A.); (I.B.)
- Medical School, University of Split, 21000 Split, Croatia;
- Medical School, University of Rijeka, 51000 Rijeka, Croatia
- Medical School, University of Mostar, 88000 Mostar, Bosnia and Herzegovina
- Department of Health Studies, University of Split, 21000 Split, Croatia
| |
Collapse
|
9
|
Rollason V, Lloret-Linares C, Lorenzini KI, Daali Y, Gex-Fabry M, Piguet V, Besson M, Samer C, Desmeules J. Evaluation of Phenotypic and Genotypic Variations of Drug Metabolising Enzymes and Transporters in Chronic Pain Patients Facing Adverse Drug Reactions or Non-Response to Analgesics: A Retrospective Study. J Pers Med 2020; 10:E198. [PMID: 33121061 PMCID: PMC7711785 DOI: 10.3390/jpm10040198] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/22/2020] [Accepted: 10/24/2020] [Indexed: 12/11/2022] Open
Abstract
This retrospective study evaluates the link between an adverse drug reaction (ADR) or a non-response to treatment and cytochromes P450 (CYP), P-glycoprotein (P-gp) or catechol-O-methyltransferase (COMT) activity in patients taking analgesic drugs for chronic pain. Patients referred to a pain center for an ADR or a non-response to an analgesic drug between January 2005 and November 2014 were included. The genotype and/or phenotype was obtained for assessment of the CYPs, P-gp or COMT activities. The relation between the event and the result of the genotype and/or phenotype was evaluated using a semi-quantitative scale. Our analysis included 243 individual genotypic and/or phenotypic explorations. Genotypes/phenotypes were mainly assessed because of an ADR (n = 145, 59.7%), and the majority of clinical situations were observed with prodrug opioids (n = 148, 60.9%). The probability of a link between an ADR or a non-response and the genotypic/phenotypic status of the patient was evaluated as intermediate to high in 40% and 28.2% of all cases, respectively. The drugs in which the probability of an association was the strongest were the prodrug opioids, with an intermediate to high link in 45.6% of the cases for occurrence of ADRs and 36.0% of the cases for non-response. This study shows that the genotypic and phenotypic approach is useful to understand ADRs or therapeutic resistance to a usual therapeutic dosage, and can be part of the evaluation of chronic pain patients.
Collapse
Affiliation(s)
- Victoria Rollason
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive Care, Geneva University Hospitals, 1205 Geneva, Switzerland; (K.I.L.); (Y.D.); (V.P.); (M.B.); (C.S.); (J.D.)
- Faculty of Medicine, Geneva University, 1206 Geneva, Switzerland
| | - Célia Lloret-Linares
- Ramsay Générale de Santé, Hôpital Privé Pays de Savoie, Maladies Nutritionnelles et Métaboliques, 74000 Annemasse, France;
| | - Kuntheavy Ing Lorenzini
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive Care, Geneva University Hospitals, 1205 Geneva, Switzerland; (K.I.L.); (Y.D.); (V.P.); (M.B.); (C.S.); (J.D.)
- Faculty of Medicine, Geneva University, 1206 Geneva, Switzerland
| | - Youssef Daali
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive Care, Geneva University Hospitals, 1205 Geneva, Switzerland; (K.I.L.); (Y.D.); (V.P.); (M.B.); (C.S.); (J.D.)
- Faculty of Medicine, Geneva University, 1206 Geneva, Switzerland
| | - Marianne Gex-Fabry
- Division of Psychiatric Specialties, Department of Psychiatry and Mental Health, Geneva University Hospitals, 1226 Thônex, Switzerland;
| | - Valérie Piguet
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive Care, Geneva University Hospitals, 1205 Geneva, Switzerland; (K.I.L.); (Y.D.); (V.P.); (M.B.); (C.S.); (J.D.)
| | - Marie Besson
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive Care, Geneva University Hospitals, 1205 Geneva, Switzerland; (K.I.L.); (Y.D.); (V.P.); (M.B.); (C.S.); (J.D.)
- Faculty of Medicine, Geneva University, 1206 Geneva, Switzerland
| | - Caroline Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive Care, Geneva University Hospitals, 1205 Geneva, Switzerland; (K.I.L.); (Y.D.); (V.P.); (M.B.); (C.S.); (J.D.)
- Faculty of Medicine, Geneva University, 1206 Geneva, Switzerland
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive Care, Geneva University Hospitals, 1205 Geneva, Switzerland; (K.I.L.); (Y.D.); (V.P.); (M.B.); (C.S.); (J.D.)
- Faculty of Medicine, Geneva University, 1206 Geneva, Switzerland
| |
Collapse
|
10
|
Kaye AD, Koress CM, Novitch MB, Jung JW, Urits I, Viswanath O, Renschler JS, Alpaugh ES, Cornett EM. Pharmacogenomics, concepts for the future of perioperative medicine and pain management: A review. Best Pract Res Clin Anaesthesiol 2020; 34:651-662. [PMID: 33004174 DOI: 10.1016/j.bpa.2020.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 02/07/2023]
Abstract
Pharmacogenomics is the study of how genetic differences between individuals affect pharmacokinetics and pharmacodynamics. These differences are apparent to clinicians when taking into account the wide range of responses to medications given in clinical practice. A review of literature involving pharmacogenomics and pain management was performed. The implementation of preoperative pharmacogenomics will allow us to better care for our patients by delivering personalized, safer medicine. This review describes the current state of pharmacogenomics as it relates to many aspects of clinical practice and how clinicians can use these tools to improve patient outcomes.
Collapse
Affiliation(s)
- Alan D Kaye
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA.
| | - Cody M Koress
- Tulane University School of Medicine, Department of Internal Medicine, New Orleans, LA, USA.
| | - Matthew B Novitch
- University of Washington, Department of Anesthesiology, Seattle, WA, USA; Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL, USA.
| | - Jai Won Jung
- Georgetown University School of Medicine, Washington, DC, USA.
| | - Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Omar Viswanath
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ, USA; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, USA; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology Phoenix, AZ, USA.
| | | | - Edward S Alpaugh
- Louisiana State University Health Sciences Center, Department of Anesthesiology, Orleans, LA, USA.
| | - Elyse M Cornett
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA.
| |
Collapse
|
11
|
Cornett EM, Carroll Turpin MA, Pinner A, Thakur P, Sekaran TSG, Siddaiah H, Rivas J, Yates A, Huang GJ, Senthil A, Khurmi N, Miller JL, Stark CW, Urman RD, Kaye AD. Pharmacogenomics of Pain Management: The Impact of Specific Biological Polymorphisms on Drugs and Metabolism. Curr Oncol Rep 2020; 22:18. [PMID: 32030524 DOI: 10.1007/s11912-020-0865-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Pain is multifactorial and complex, often with a genetic component. Pharmacogenomics is a relative new field, which allows for the development of a truly unique and personalized therapeutic approach in the treatment of pain. RECENT FINDINGS Until recently, drug mechanisms in humans were determined by testing that drug in a population and calculating response averages. However, some patients will inevitably fall outside of those averages, and it is nearly impossible to predict who those outliers might be. Pharmacogenetics considers a patient's unique genetic information and allows for anticipation of that individual's response to medication. Pharmacogenomic testing is steadily making progress in the management of pain by being able to identify individual differences in the perception of pain and susceptibility and sensitivity to drugs based on genetic markers. This has a huge potential to increase efficacy and reduce the incidence of iatrogenic drug dependence and addiction. The streamlining of relevant polymorphisms of genes encoding receptors, transporters, and drug-metabolizing enzymes influencing the pain phenotype can be an important guide to develop safe new strategies and approaches to personalized pain management. Additionally, some challenges still prevail and preclude adoption of pharmacogenomic testing universally. These include lack of knowledge about pharmacogenomic testing, inadequate standardization of the process of data handling, questionable benefits about the clinical and financial aspects of pharmacogenomic testing-guided therapy, discrepancies in clinical evidence supporting these tests, and doubtful reimbursement of the tests by health insurance agencies.
Collapse
Affiliation(s)
- Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Michelle A Carroll Turpin
- Department of Biomedical Sciences, College of Medicine, University of Houston, Health 2 Building, Room 8037, Houston, TX, USA
| | - Allison Pinner
- Ochsner LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Pankaj Thakur
- Department of Anesthesiology, Ochsner LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | | | - Harish Siddaiah
- Department of Anesthesiology, Ochsner LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Jasmine Rivas
- Department of Family Medicine, ECU Vidant Medical Center, 101 Heart Drive, Greenville, NC, 27834, USA
| | - Anna Yates
- LSU Health Shreveport School of Medicine, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - G Jason Huang
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Anitha Senthil
- Department of Anesthesiology, Lahey Hospital & Medical Center, 41Mall Road, Burlington, MA, 01805, USA
| | - Narjeet Khurmi
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Jenna L Miller
- LSU Health Sciences Center New Orleans, 1901 Perdido Street, New Orleans, LA, 70112, USA
| | - Cain W Stark
- Medical College of Wisconsin, 8701 West Watertown Plank Road, Wauwatosa, WI, 53226, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Alan David Kaye
- Department of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University School of Medicine, 1501 Kings Hwy, Shreveport, LA, 71103, USA
| |
Collapse
|
12
|
Gabriel RA, Burton BN, Urman RD, Waterman RS. Genomics Testing and Personalized Medicine in the Preoperative Setting. Surg Oncol Clin N Am 2020; 29:73-86. [DOI: 10.1016/j.soc.2019.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
13
|
Corli O, Damia G, Galli F, Verrastro C, Broggini M. Lack of Efficacy: When Opioids Do Not Achieve Analgesia from the Beginning of Treatment in Cancer Patients. Cancer Manag Res 2019; 11:10337-10344. [PMID: 31849523 PMCID: PMC6911322 DOI: 10.2147/cmar.s211818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 10/22/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Opioids are often used to relieve moderate to severe pain, but their analgesic response may vary. We focused on the absolute lack of analgesic response immediately after beginning opioid treatment, quantifying the proportion of patients with unchanged or worse pain on day 3 (defined as early non-responders (ENRs)) and day 7. Methods This is a post-hoc analysis from a randomized controlled trial involving 498 cancer patients with pain, starting to receive WHO step III opioids. On days 1, 3 and 7 pain intensity (PI) was measured. Results On day 3, 68 (13.7%) patients were ENRs, 53 no change and 15 greater PI compared to baseline. The relationships between pain and clinical characteristics showed no significant differences between ENRs and Early responders (ERs), except for PI at baseline, which was significantly lower in ENRs. ENRs on day 3 were re-assessed on day 7 to explore the patterns of analgesic response: 31.7% of patients remained NRs, 48.3% had become responders, and 20.0% were poor responders. Adverse drug reactions were similar in ERs and ENRs at each visit. Discussion The complete lack of early response to opioids in cancer patients is clinically important and more frequent than expected. Better definition of the mechanism will allow better pain management in cancer and non-cancer patients.
Collapse
Affiliation(s)
- Oscar Corli
- Unit of Pain and Palliative Care Research, Laboratory of Methodology for Clinical Research, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Giovanna Damia
- Laboratory of Molecular Pharmacology, Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Francesca Galli
- Laboratory of Methodology for Clinical Research, Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Carmen Verrastro
- Day Hospital of Rheumatology, ASST Gaetano Pini CTO, Milan, Italy
| | - Massimo Broggini
- Laboratory of Molecular Pharmacology, Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| |
Collapse
|
14
|
Awad H, Ahmed A, Urman RD, Stoicea N, Bergese SD. Potential role of pharmacogenomics testing in the setting of enhanced recovery pathways after surgery. Pharmgenomics Pers Med 2019; 12:145-154. [PMID: 31440074 PMCID: PMC6666379 DOI: 10.2147/pgpm.s198224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 07/10/2019] [Indexed: 11/23/2022] Open
Abstract
In 2001, a group of European academic surgeons created the Enhanced Recovery After Surgery (ERAS) study group and established the first official ERAS protocol. One of the most significant challenges during ERAS implementation is variability of drugs used throughout the perioperative period. Pharmacogenomic testing (blood or saliva) results (obtained within approximately 48 hrs) provide guidelines on how to prescribe the optimal drug with the optimal dosage to each patient based on an individual's unique genetic profile. Pharmacogenomic testing of various methods of multimodal analgesia is an essential element of ERAS protocols spanning the entire perioperative period to ultimately optimize postoperative pain control. The key goal for anesthetic management in ERAS protocols is to facilitate rapid emergence by using the shortest acting agents available, thus accelerating recovery and reducing length of stay, hospital expenses, and postoperative complications. Postoperative nausea and vomiting (PONV) is an additional challenge that should be overcome to ensure an enhanced recovery and shorter length of stay with the use of antiemetics. Postoperative ileus (POI) can result in longer hospital stay with increasing susceptibility to associated morbidities along with an increase in associated hospitalization costs. Genetics-guided pharmacotherapy and its impact on clinical outcomes should be thoroughly studied for better understanding and managing drug administration in the settings of ERAS.
Collapse
Affiliation(s)
- Hamdy Awad
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ahmed Ahmed
- Department of Anesthesiology, The University of Texas, Houston, TX, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicoleta Stoicea
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sergio D Bergese
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| |
Collapse
|
15
|
Kaye AD, Garcia AJ, Hall OM, Jeha GM, Cramer KD, Granier AL, Kallurkar A, Cornett EM, Urman RD. Update on the pharmacogenomics of pain management. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2019; 12:125-143. [PMID: 31308726 PMCID: PMC6613192 DOI: 10.2147/pgpm.s179152] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 05/09/2019] [Indexed: 12/30/2022]
Abstract
Pharmacogenomics is the study of genetic variants that impact drug effects through changes in a drug’s pharmacokinetics and pharmacodynamics. Pharmacogenomics is being integrated into clinical pain management practice because variants in individual genes can be predictive of how a patient may respond to a drug treatment. Pain is subjective and is considered challenging to treat. Furthermore, pain patients do not respond to treatments in the same way, which makes it hard to issue a consistent treatment regimen for all pain conditions. Pharmacogenomics would bring consistency to the subjective nature of pain and could revolutionize the field of pain management by providing personalized medical care tailored to each patient based on their gene variants. Additionally, pharmacogenomics offers a solution to the opioid crisis by identifying potentially opioid-vulnerable patients who could be recommended a nonopioid treatment for their pain condition. The integration of pharmacogenomics into clinical practice creates better and safer healthcare practices for patients. In this article, we provide a comprehensive history of pharmacogenomics and pain management, and focus on up to date information on the pharmacogenomics of pain management, describing genes involved in pain, genes that may reduce or guard against pain and discuss specific pain management drugs and their genetic correlations.
Collapse
Affiliation(s)
- Alan David Kaye
- Department of Anesthesiology, LSU Health Sciences Center, New Orleans, LA, USA
| | - Andrew Jesse Garcia
- Department of Anesthesiology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - O Morgan Hall
- Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - George M Jeha
- Department of Anesthesiology, LSU Health Sciences Center New Orleans, New Orleans, LA, USA
| | - Kelsey D Cramer
- Department of Anesthesiology, LSU Health Sciences Center New Orleans, New Orleans, LA, USA
| | - Amanda L Granier
- Department of Anesthesiology, LSU Health Sciences Center New Orleans, New Orleans, LA, USA
| | - Anusha Kallurkar
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
16
|
Abstract
Pharmacogenomics (PGx) is the study of how individuals' personal genotypes may affect their responses to various pharmacologic agents. The application of PGx principles in perioperative medicine is fairly novel. Challenges in executing PGx programs into health care systems include physician buy-in and integration into usual clinical workflow, including the electronic health record. This article discusses the current evidence highlighting the potential of PGx with various drug categories (including opioids, nonopioid analgesics, sedatives, β-blockers, antiemetics, and anticoagulants) used in the perioperative process and the challenges of integrating PGx into a health care system and relevant workflows.
Collapse
|
17
|
Kaye AD, Mahakian T, Kaye AJ, Pham AA, Hart BM, Gennuso S, Cornett EM, Gabriel RA, Urman RD. Pharmacogenomics, precision medicine, and implications for anesthesia care. Best Pract Res Clin Anaesthesiol 2018; 32:61-81. [DOI: 10.1016/j.bpa.2018.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/30/2018] [Indexed: 01/28/2023]
|
18
|
Stone AB, Urman RD, Kaye AD, Grant MC. Labeling Morphine Milligram Equivalents on Opioid Packaging: a Potential Patient Safety Intervention. Curr Pain Headache Rep 2018; 22:46. [PMID: 29855852 DOI: 10.1007/s11916-018-0695-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
PURPOSE OF REVIEW Given that the primary cause of overdose death in the USA is related to prescribed opioids, one potential strategy to improve awareness and decrease morbidity and/or mortality could include improved labeling. Specific patient populations which significantly struggle with adverse outcomes related to opioid abuse are seen in palliative care, chronic pain, and acute pain treatment settings. RECENT FINDINGS An unexplored option for improving the healthcare quality and safety for patients currently prescribed opioids would be to require pharmaceutical companies to provide a morphine milligram equivalent (MME) on opioid packaging. Some limitations to MME conversions include equianalgesic conversions being estimates at best and may not account for variations in genetics and pharmacokinetics. Changing opioid labeling requirements is feasible as it falls under the purview of the US Food and Drug Administration (FDA), which has been mandated to provide mechanisms to reduce or to minimize overdoses related to opioid prescriptions. Labeling opioid packaging with MME per dose will promote clearer communication about opioid strength between patients and physicians. Labeling MME on packaging could help prevent prescriber errors.
Collapse
Affiliation(s)
- Alexander B Stone
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University, New Orleans, LA, USA
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
| |
Collapse
|
19
|
Gabriel RA, Ehrenfeld JM, Urman RD. Preoperative Genetic Testing and Personalized Medicine: Changing the Care Paradigm. J Med Syst 2017; 41:185. [PMID: 29039620 DOI: 10.1007/s10916-017-0835-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA.,Department of Biomedical Informatics, University of California, San Diego, San Diego, CA, USA
| | | | - Richard D Urman
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, 02115, USA.
| |
Collapse
|
20
|
Sekhri NK, Cooney MF. Opioid Metabolism and Pharmacogenetics: Clinical Implications. J Perianesth Nurs 2017; 32:497-505. [PMID: 28938988 DOI: 10.1016/j.jopan.2017.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 11/30/2022]
|