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Jansson-Rehnberg AS, Drewes AM, Sponheim J, Borgfelt C, Münch A, Graf W, Simrén M, Lindberg G, Hellström PM. Diarrhoea of unknown cause: medical treatment in a stepwise manner Management of Idiopathic Diarrhoea Based on Experience of Step-Up Medical Treatment. Scand J Gastroenterol 2024; 59:543-546. [PMID: 38343268 DOI: 10.1080/00365521.2024.2313061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/25/2024] [Indexed: 04/26/2024]
Abstract
The basic principle for the treatment of idiopathic diarrhoea (functional diarrhoea K59.1) is to delay transit through the gut in order to promote the absorption of electrolytes and water. Under mild conditions, bulking agents may suffice. With increasing severity, antidiarrhoeal pharmaceuticals may be added in a stepwise manner. In diarrhoea of unknown aetiology, peripherally-acting opioid receptor agonists, such as loperamide, are first-line treatment and forms the pharmaceutical basis of antidiarrheal treatment. As second-line treatment opium drops have an approved indication for severe diarrhoea when other treatment options fail. Beyond this, various treatment options are built on experience with more advanced treatments using clonidine, octreotide, as well as GLP-1 and GLP-2 analogs which require specialist knowledge the field.
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Affiliation(s)
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Jon Sponheim
- Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Christer Borgfelt
- Department of obstetrics and gynaecology, Skåne University Hospital, Lund, Sweden
| | - Andreas Münch
- Department of Gastrointestinal Medicine, University Hospital, Linköping, Sweden
| | - Wilhelm Graf
- Department of Surgical Sciences, University of Uppsala, Sweden
| | - Magnus Simrén
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Greger Lindberg
- Department of Medicine, Karolinska University Hospital, Huddinge, Sweden
| | - Per M Hellström
- Department of Medical Sciences, University of Uppsala, Sweden
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2
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Jia Z, Wei X, Chen N, Xu X, Zhao G, Fu X, Wang H, Goldring MB, Goldring SR, Wang D. Thermoresponsive Polymeric Hydromorphone Prodrug Provides Sustained Local Analgesia without Apparent Adverse Effects. Mol Pharm 2024; 21:1838-1847. [PMID: 38413029 DOI: 10.1021/acs.molpharmaceut.3c01133] [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: 02/29/2024]
Abstract
The extensive use of opioids for chronic pain management has contributed significantly to the current opioid epidemic. While many alternative nonopioid analgesics are available, opioids remain the most potent analgesics for moderate to severe pain management. In addition to the implementation of multimodal analgesia, there is a pressing need for the development of more effective and safer opioids. In this study, we developed a thermoresponsive N-(2-hydroxypropyl) methacrylamide (HPMA) copolymer-based hydromorphone (HMP) prodrug (ProGel-HMP, HMP content = 16.2 wt %, in base form). The aqueous solution of ProGel-HMP was free-flowing at 4 °C but became a hydrogel when the temperature was raised to ≥37 °C, allowing sustained local retention when administered in vivo. When tested in the destabilization of the medial meniscus (DMM) mouse model of osteoarthritis (OA), ProGel-HMP was retained after intra-articular injection in the OA knee joint for at least 2 weeks postinjection, with low extra-articular distribution. ProGel-HMP was not detected in the central nervous system (CNS). A single dose of ProGel-HMP produced rapid and sustained joint pain resolution for greater than 14 days when compared to saline and dose-equivalent HMP controls, likely mediated through peripheral μ-opioid receptors in the knee joint. Systemic analgesia effect was absent in the DMM mice treated with ProGel-HMP, as evident in the lack of difference in tail flick response between the ProGel-HMP-treated mice and the controls (i.e., Healthy, Saline, and Sham). Repeated dosing of ProGel-HMP did not induce tolerance. Collectively, these data support the further development of ProGel-HMP as a potent, safe, long-acting and nonaddictive analgesic for better clinical pain management.
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Affiliation(s)
- Zhenshan Jia
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| | - Xin Wei
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| | - Ningrong Chen
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| | - Xiaoke Xu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| | - Gang Zhao
- Ensign Pharmaceutical, Omaha, Nebraska 68106, United States
| | - Xin Fu
- Ensign Pharmaceutical, Omaha, Nebraska 68106, United States
| | - Hanjun Wang
- Department of Anesthesiology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198-4455, United States
| | - Mary B Goldring
- Hospital for Special Surgery, New York, New York 10021, United States
| | - Steven R Goldring
- Ensign Pharmaceutical, Omaha, Nebraska 68106, United States
- Hospital for Special Surgery, New York, New York 10021, United States
| | - Dong Wang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
- Ensign Pharmaceutical, Omaha, Nebraska 68106, United States
- Department of Orthopaedic and Rehabilitation, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198-5640, United States
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3
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Fu Q, Han N, Li N, Gui L, Shi C, Rong P, Zeng F, Rao H, Chen Y. Guidelines for Rational Clinical Use of Fentanyl Transdermal Patch. Drug Des Devel Ther 2024; 18:233-255. [PMID: 38362136 PMCID: PMC10869233 DOI: 10.2147/dddt.s414318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 01/11/2024] [Indexed: 02/17/2024] Open
Abstract
Pain is one of the most common clinical symptoms of cancer patients, seriously affecting the quality of life of patients and bringing heavy mental and economic burden to families and society. The treatment of cancer pain in China is facing numerous challenges, one of which includes the irrational usage of analgesic drugs in clinical practice. As a strong opioid analgesic, transdermal fentanyl patch has been widely used due to its convenient clinical application and obvious therapeutic effect. Several basic-level hospitals and even general hospitals in China fail to appropriate the application of drugs in clinical application due to the lack of understanding of the pharmacological characteristics and clinical application of fentanyl transdermal patch by medical staff, seriously affecting the treatment quality. Therefore, it is imperative to strengthen the rational use and management of fentanyl transdermal patches. Accordingly, the initiation by the Cancer Rehabilitation and Palliative Treatment Professional Committee of the Hubei Anti-cancer Association launched the compilation of the "Guidelines for Rational Clinical Use of Fentanyl Transdermal Patch" (from now on referred to as the "Guidelines") in Hubei Province, China. The experts in the preparation group are experts in many disciplines, such as medicine, pharmacy, and nursing. The expert group determines the outline, prepares the required regulations, and revises it repeatedly. Moreover, these experts put forward suggestions for revision to strictly control the accuracy and scientific authenticity of the contents of the "Guide". Finally, all experts of the preparation team certify and finalize the draft. This "Guide" prepared by experts of the Cancer Rehabilitation and Palliative Treatment Professional Committee of the Hubei Anti-cancer Association and the expert advisory group with joint efforts, aims to play a positive role in promoting the rational clinical use of fentanyl transdermal patch, reducing the mental and economic burden of patients, and ensuring medical quality and medical safety.
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Affiliation(s)
- Qiang Fu
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
| | - Na Han
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
| | - Na Li
- Cancer Center, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, People’s Republic of China
| | - Ling Gui
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
| | - Chen Shi
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China
| | - Peipei Rong
- Department of Pharmacy, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, People’s Republic of China
| | - Fan Zeng
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
| | - He Rao
- Department of Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, 430071, People’s Republic of China
| | - Yuan Chen
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
| | - On behalf of Cancer Rehabilitation and Palliative Treatment Professional Committee of Hubei Anti Cancer Association
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
- Cancer Center, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, People’s Republic of China
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China
- Department of Pharmacy, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, People’s Republic of China
- Department of Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, 430071, People’s Republic of China
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4
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Zhao Y, Luo H, Ren X, Jia B, Li J, Wang L, Li J. The P2Y 1 receptor in the colonic myenteric plexus of rats and its correlation with opioid-induced constipation. BMC Gastroenterol 2024; 24:23. [PMID: 38191294 PMCID: PMC10773096 DOI: 10.1186/s12876-024-03119-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 01/01/2024] [Indexed: 01/10/2024] Open
Abstract
This study was designed to explore the expression changes of P2Y1 receptors in the distal colonic myenteric layer of rats. An opioid induced constipation(OIC) rat model was generated by intraperitoneal (i.p) injection of loperamide. At 7 days post-treatment, the model rats were assessed by calculating the fecal water content and the gastrointestinal transit ratio. The immunofluorescence (IF)-based histochemical study was used to observe the distribution of P2Y1 receptors in the distal colonic myenteric plexus. Western blotting (WB) was performed to evaluate the expression changes of P2Y1 proteins in the myenteric layer, and the electrophysiological approaches were carried out to determine the regulatory roles of P2Y1 receptors on distal colonic motor function. IF showed that P2Y1 receptors are co-expressed MOR in the enteric nerve cells of the distal colonic myenteric plexus. Moreover, the WB revealed that the protein levels of P2Y1 were significantly decreased in the distal colonic myenteric layer of OIC rats. In vitro tension experiments exhibited that the P2Y1 receptor antagonist MRS2500 enhanced the spontaneous contraction amplitude, adding EM2 and β-FNA did not have any effect on MRS2500. Therefore, P2Y1 receptor expression could be associated with the occurrence of OIC in this rat model and the regulation of colonic motility by MOR may be related to the release of purine neurotransmitters such as ATP in the colonic nervous system.
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Affiliation(s)
- Yuqiong Zhao
- Department of Human Anatomy and Histoembryology, College of Basic Medical Sciences, Ningxia Medical University, 1160 Shengli Street, 750001, Yinchuan, Ningxia Hui Autonomous Region, P.R. China
| | - Huijuan Luo
- Department of Human Anatomy and Histoembryology, College of Basic Medical Sciences, Ningxia Medical University, 1160 Shengli Street, 750001, Yinchuan, Ningxia Hui Autonomous Region, P.R. China
| | - Xiaojie Ren
- Department of Human Anatomy and Histoembryology, College of Basic Medical Sciences, Ningxia Medical University, 1160 Shengli Street, 750001, Yinchuan, Ningxia Hui Autonomous Region, P.R. China
| | - Binghan Jia
- Department of Human Anatomy and Histoembryology, College of Basic Medical Sciences, Ningxia Medical University, 1160 Shengli Street, 750001, Yinchuan, Ningxia Hui Autonomous Region, P.R. China
| | - Jinzhao Li
- Department of Human Anatomy and Histoembryology, College of Basic Medical Sciences, Ningxia Medical University, 1160 Shengli Street, 750001, Yinchuan, Ningxia Hui Autonomous Region, P.R. China
| | - Lixin Wang
- The Medical Laboratory Center of General Hospital of Ningxia Medical University, 804 Shengli Street, 750001, Yinchuan, Ningxia Hui Autonomous Region, P.R. China.
| | - Junping Li
- Department of Human Anatomy and Histoembryology, College of Basic Medical Sciences, Ningxia Medical University, 1160 Shengli Street, 750001, Yinchuan, Ningxia Hui Autonomous Region, P.R. China.
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5
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Monroe SC, Radke AK. Opioid withdrawal: role in addiction and neural mechanisms. Psychopharmacology (Berl) 2023; 240:1417-1433. [PMID: 37162529 DOI: 10.1007/s00213-023-06370-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/19/2023] [Indexed: 05/11/2023]
Abstract
Withdrawal from opioids involves a negative affective state that promotes maintenance of drug-seeking behavior and relapse. As such, understanding the neurobiological mechanisms underlying withdrawal from opioid drugs is critical as scientists and clinicians seek to develop new treatments and therapies. In this review, we focus on the neural systems known to mediate the affective and somatic signs and symptoms of opioid withdrawal, including the mesolimbic dopaminergic system, basolateral amygdala, extended amygdala, and brain and hormonal stress systems. Evidence from preclinical studies suggests that these systems are altered following opioid exposure and that these changes mediate behavioral signs of negative affect such as aversion and anxiety during withdrawal. Adaptations in these systems also parallel the behavioral and psychological features of opioid use disorder (OUD), highlighting the important role of withdrawal in the development of addictive behavior. Implications for relapse and treatment are discussed as well as promising avenues for future research, with the hope of promoting continued progress toward characterizing neural contributors to opioid withdrawal and compulsive opioid use.
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Affiliation(s)
- Sean C Monroe
- Department of Psychology and Center for Neuroscience and Behavior, Miami University, 90 N Patterson Ave, Oxford, OH, USA
| | - Anna K Radke
- Department of Psychology and Center for Neuroscience and Behavior, Miami University, 90 N Patterson Ave, Oxford, OH, USA.
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6
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Lin D, Ou Y, Li L, Wu K, Zhang Q, Yan J, Kuang K, Peng D. Acupuncture for postoperative gastrointestinal dysfunction in cancer: a systematic review and meta-analysis. Front Oncol 2023; 13:1184228. [PMID: 37361600 PMCID: PMC10289226 DOI: 10.3389/fonc.2023.1184228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/26/2023] [Indexed: 06/28/2023] Open
Abstract
Background Postoperative gastrointestinal dysfunction (PGD) in cancer is the commonest and most severe postoperative complication in patients with cancer. Acupuncture has been widely used for PGD in cancer. This study aimed to evaluate the efficacy and safety of acupuncture for PGD in cancer. Methods We comprehensively searched eight randomised controlled trials (RCTs) of acupuncture for PGD in cancer published until November 2022. Time to first flatus (TFF) and time to first defecation (TFD) were the primary outcomes, and time to bowel sound recovery (TBSR) and the length of hospital stay (LOS) were the secondary outcomes. The Cochrane Collaboration Risk of Bias Tool was used to assess the quality of the RCTs, and the Grading of Recommendations Assessment, Development, and Evaluations (GRADE) system was used to evaluate the certainty of the evidence. The meta-analysis was performed using RevMan 5.4, and a publication bias test was performed using Stata 15.1. Results Sixteen RCTs involving 877 participants were included in this study. The meta-analysis indicated that acupuncture could effectively reduce the TFF, TFD, and TBSR compared with routine treatment (RT), sham acupuncture, and enhanced recovery after surgery (ERAS). However, acupuncture did not shorten the LOS compared with RT and ERAS. The subgroup analysis revealed that acupuncture could significantly reduce the TFF and TFD. Acupuncture effectively reduced the TFF and TFD in all cancer types included in this review. Besides, local acupoints in combination with distal acupoints could reduce the TFF and TFD, and distal-proximal acupoints could significantly reduce the TFD. No trial reported adverse events of acupuncture. Conclusions Acupuncture is an effective and relatively safe modality for treating PGD in cancer. We anticipate that there will be more high-quality RCTs involving more acupuncture techniques and cancer types, focusing on combining acupoints for PGD in cancer, further determining the effectiveness and safety of acupuncture for PGD in patients with cancer outside China. Systematic review registration https://www.crd.york.ac.uk/prospero, identifier CRD42022371219.
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7
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Wang L, Gharibani P, Yang Y, Guo Y, Yin J. Regulation of enteric nervous system via sacral nerve stimulation in opioid-induced constipated rats. Front Neurosci 2023; 17:1146883. [PMID: 37332864 PMCID: PMC10272359 DOI: 10.3389/fnins.2023.1146883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/16/2023] [Indexed: 06/20/2023] Open
Abstract
Objectives Sacral nerve stimulation (SNS) has been employed for treating constipation. However, its mechanisms involving enteric nervous system (ENS) and motility are largely unknown. In this study, we investigated the possible ENS involvement of SNS in treating Loperamide-induced constipation in rats. Methods Experiment-1 was designed to study the effects of acute SNS on whole colon transit time (CTT). In experiment-2, we induced constipation by Loperamide and then applied daily SNS or sham-SNS for 1 week. Choline acetyltransferase (ChAT), nitric oxide synthase (nNOS), and PGP9.5 in colon tissue were examined at the end of the study. Moreover, survival factors such as phosphorylated AKT (p-AKT) and Glial cell-derived neurotrophic factor (GDNF) were measures by immunohistochemistry (IHC) and western blot (WB). Key results (1) SNS with one set of parameters shortened CTT starting at 90 min after phenol red administration (p < 0.05). (2) While Loperamide induced slow transit constipation with a significant reduction in fecal pellet number and feces wet weight, daily SNS for a week resolved constipation. (3) Moreover, SNS was able to shorten whole gut transit time comparing to sham-SNS (p = 0.01). (4) Loperamide reduced the number of PGP9.5 and ChAT positive cells, and downregulated ChAT protein expression and upregulated nNOS protein expression, whereas these detrimental effects were significantly reversed by SNS. (5) Furthermore, SNS increased expressions of both GDNF and p-AKT in colon tissue. (6) Vagal activity was reduced following Loperamide (p < 0.01); yet SNS normalized vagal activity. Conclusion SNS with appropriate parameters improves opioid-induced constipation and reversed the detrimental effects of Loperamide on enteric neurons possibly via the GDNF-PI3K/Akt pathway.GRAPHICAL ABSTRACT.
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Affiliation(s)
- Liyun Wang
- Department of Gastroenterology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Payam Gharibani
- Division of Neuroimmunology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Yi Yang
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yu Guo
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jieyun Yin
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Amend N, Thiermann H, Worek F, Wille T. A pharmacologically pre-contracted smooth muscle bowel model for the study of highly-potent opioid receptor agonists and antagonists. Toxicol Lett 2023:S0378-4274(23)00187-X. [PMID: 37245850 DOI: 10.1016/j.toxlet.2023.05.010] [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: 07/18/2022] [Revised: 02/24/2023] [Accepted: 05/22/2023] [Indexed: 05/30/2023]
Abstract
Isolated organ models are a versatile tool for pharmacological and toxicological research. Small bowel has been used to assess the inhibition of smooth muscle contraction by opioids. In the present study, we set out to establish a pharmacologically stimulated rat bowel model. The effects of carfentanil, remifentanil and the new synthetic opioid U-48800 and their respective antagonists naloxone, nalmefene and naltrexone were studied in a small bowel model in rats. The IC50 values of the tested opioids were as follows: carfentanil (IC50 = 0.02 µmol/L, CI 0.02-0.03 µmol/L) ≫ remifentanil (IC50 = 0.51 µmol/L, CI 0.40-0.66 µmol/L) ≫ U-48800 (IC50 = 1.36 µmol/L, CI 1.20-1.54 µmol/L). The administration of the opioid receptor antagonists naloxone, naltrexone and nalmefene led to progressive, parallel rightward shifts of the dose-response curves. Naltrexone was most potent in antagonizing the effects of U-48800, whereas naltrexone and nalmefene were most effective in antagonizing the effects of carfentanil. In summary, the current model seems to be a robust tool to study opioid effects in a small bowel model without the necessity of using electrical stimulation.
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Affiliation(s)
- Niko Amend
- Bundeswehr Institute of Pharmacology and Toxicology, Neuherbergstr. 11, 80937 Munich, Germany.
| | - Horst Thiermann
- Bundeswehr Institute of Pharmacology and Toxicology, Neuherbergstr. 11, 80937 Munich, Germany
| | - Franz Worek
- Bundeswehr Institute of Pharmacology and Toxicology, Neuherbergstr. 11, 80937 Munich, Germany
| | - Timo Wille
- Bundeswehr Institute of Pharmacology and Toxicology, Neuherbergstr. 11, 80937 Munich, Germany
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Mazzeo F, Meccariello R, Guatteo E. Molecular and Epigenetic Aspects of Opioid Receptors in Drug Addiction and Pain Management in Sport. Int J Mol Sci 2023; 24:ijms24097831. [PMID: 37175536 PMCID: PMC10178540 DOI: 10.3390/ijms24097831] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/14/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
Opioids are substances derived from opium (natural opioids). In its raw state, opium is a gummy latex extracted from Papaver somniferum. The use of opioids and their negative health consequences among people who use drugs have been studied. Today, opioids are still the most commonly used and effective analgesic treatments for severe pain, but their use and abuse causes detrimental side effects for health, including addiction, thus impacting the user's quality of life and causing overdose. The mesocorticolimbic dopaminergic circuitry represents the brain circuit mediating both natural rewards and the rewarding aspects of nearly all drugs of abuse, including opioids. Hence, understanding how opioids affect the function of dopaminergic circuitry may be useful for better knowledge of the process and to develop effective therapeutic strategies in addiction. The aim of this review was to summarize the main features of opioids and opioid receptors and focus on the molecular and upcoming epigenetic mechanisms leading to opioid addiction. Since synthetic opioids can be effective for pain management, their ability to induce addiction in athletes, with the risk of incurring doping, is also discussed.
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Affiliation(s)
- Filomena Mazzeo
- Department of Economics, Law, Cybersecurity and Sports Sciences, University of Naples "Parthenope", 80133 Naples, Italy
- Department of Movement Sciences and Wellbeing, University of Naples "Parthenope", 80133 Naples, Italy
| | - Rosaria Meccariello
- Department of Movement Sciences and Wellbeing, University of Naples "Parthenope", 80133 Naples, Italy
| | - Ezia Guatteo
- Department of Movement Sciences and Wellbeing, University of Naples "Parthenope", 80133 Naples, Italy
- IRCCS Santa Lucia Foundation, Via del Fosso di Fiorano 64, 00143 Rome, Italy
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Graven-Nielsen CS, Knoph CS, Okdahl T, Høyer KL, Krogh K, Hellström PM, Drewes AM. Opioids in the Treatment of Chronic Idiopathic Diarrhea in Humans—A Systematic Review and Treatment Guideline. J Clin Med 2023; 12:jcm12072488. [PMID: 37048572 PMCID: PMC10094889 DOI: 10.3390/jcm12072488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023] Open
Abstract
In patients with chronic idiopathic diarrhea resistant to standard treatment, opioids are often used as rescue therapy. This systematic review investigated opioid effects on gut function in chronic diarrhea. PubMed and Embase were searched regarding effects of opioid agonists on the gastrointestinal tract in humans with chronic or experimentally induced diarrhea. A total of 1472 relevant articles were identified and, after thorough evaluation, 11 clinical trials were included. Generally, studies reported a reduction in stool frequency and an increase in transit time during treatment with the opioid receptor agonists loperamide, asimadoline, casokefamide, and codeine compared with placebo. Loperamide and diphenoxylate significantly improved stool consistency compared with placebo, whereas asimadoline showed no such effects. Compared with placebo, loperamide treatment caused less abdominal pain and urgency. Asimadoline showed no significant subjective improvements, but fedotozine was superior to placebo in reducing abdominal pain and bloating in selected patients. Only two relevant studies were published within the last 20 years, and standardized endpoint measures are lacking. Most trials included few participants, and further evidence is needed from larger, prospective studies. Likewise, consensus is needed to standardize endpoints for stool frequency, transit time, and consistency to conduct future meta-analyses on opioids in management of chronic idiopathic diarrhea.
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11
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Shah ED, Chamberlain BH, Rhiner M, Slatkin NE, Stambler N, Israel RJ. Subcutaneous Methylnaltrexone as Treatment for Opioid-Induced Constipation in Patients with Advanced Cancer and Noncancer Illnesses: A Post Hoc Analysis of Two Clinical Trials. J Pain Res 2023; 16:395-406. [PMID: 36798078 PMCID: PMC9926929 DOI: 10.2147/jpr.s366460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 01/22/2023] [Indexed: 02/11/2023] Open
Abstract
Purpose To evaluate the efficacy and safety of subcutaneous (SC) methylnaltrexone for opioid-induced constipation (OIC) in patients with and without active cancer. Patients and Methods We analyzed two randomized, double-blind, placebo-controlled, Phase 3/4 trials (NCT00402038, NCT00672477). Patients received SC methylnaltrexone (study 302, 0.15 mg/kg; study 4000, 8 mg or 12 mg based on body weight) or placebo every other day for 2 weeks. Patients were stratified by cancer status. Primary efficacy endpoints included proportion of patients achieving rescue-free laxation (RFL); secondary endpoints included time to RFL, pain intensity scores, and safety/tolerability. Trial results were evaluated separately. Results The safety population (patients receiving ≥1 study drug dose) included 364 patients (study 302, n=134; study 4000, n=230). Study 302 had 78 patients with active cancer (methylnaltrexone, n=37; placebo, n=41) and 56 without cancer (methylnaltrexone, n=26; placebo, n=30); study 4000 had 152 patients with active cancer (methylnaltrexone, n=79; placebo, n=73) and 78 without cancer (methylnaltrexone, n=37; placebo, n=41). A significantly greater proportion of patients treated with methylnaltrexone achieved a laxation response within 4 hours after at least 2 of the first 4 doses versus placebo, dosed by body weight (cancer, 54.1% [methylnaltrexone] vs 7.3% [placebo], P<0.0001; noncancer, 48.0% vs 10.0%; P<0.005) or given as a weight-adjusted fixed dose (cancer, 59.5% vs 6.8%; noncancer, 70.3% vs 14.6%; P<0.0001 each). With fixed-dose methylnaltrexone, average time to RFL for patients with and without cancer was <1 hour of the first dose; with methylnaltrexone dosed by body weight, the first RFL occurred in <4 and <7 hours of treatment in patients with and without cancer, respectively. No significant differences were found in pain scores. SC methylnaltrexone was well tolerated at all doses in all patient cohorts. Conclusion SC methylnaltrexone was efficacious in inducing rapid RFL and safe among patients with and without active cancer suffering from OIC.
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Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Correspondence: Eric D Shah, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03766, USA, Tel +1 603-650-5261, Email
| | | | - Michelle Rhiner
- Department of Family Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Neil E Slatkin
- School of Medicine, University of California Riverside, Riverside, CA, USA,Medical Affairs, Salix Pharmaceuticals, Bridgewater, NJ, USA
| | - Nancy Stambler
- Clinical Research, Progenics Pharmaceuticals, Inc., A Subsidiary of Lantheus Holdings, Inc, New York, NY, USA
| | - Robert J Israel
- Clinical and Medical Affairs, Bausch Health US, LLC, Bridgewater, NJ, USA
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12
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Zhao Y, Ren X, Li F, Jia B, Wang D, Jia H, Jiao X, Wang L, Li J. P2Y1 receptor in the colonic submucosa of rats and its association with opioid‑induced constipation. Exp Ther Med 2022; 25:67. [PMID: 36605532 PMCID: PMC9798462 DOI: 10.3892/etm.2022.11766] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 11/03/2022] [Indexed: 12/15/2022] Open
Abstract
The aim of the present study was to explore the expression changes of P2Y purinergic receptor 1 (P2Y1) in the distal colonic submucosa of opioid-induced constipation (OIC) rats and its association with the occurrence of OIC, an OIC rat model was generated by intraperitoneal injection of loperamide hydrochloride, a selective agonist of µ-opioid receptors (MORs). At 7 days post-treatment, the model was assessed by analyzing stool scores and calculating the gastrointestinal (GI) transit ratio of rats. The distribution of P2Y1-expressing neurons in the colonic submucosal plexus was demonstrated by immunofluorescence (IF). Western blotting was performed to evaluate the expression changes of MOR, P2Y1 and ATP synthase subunit β (ATPB) proteins in the colonic submucosa, while reverse transcription-quantitative PCR (RT-qPCR) analysis was performed to determine the relative mRNA expression of MOR and P2Y1. After 7 days, the feces of OIC rats exhibited an appearance of sausage-shaped pieces and both the stool weight and GI transit ratio of OIC rats were significantly decreased. IF revealed co-expression of P2Y1 and calbindin and MOR and ATPB in the nerve cells of the distal colonic submucosal plexus. Moreover, RT-qPCR analysis showed that the MOR mRNA levels were significantly increased in the distal colonic submucosa of OIC rats, while mRNA levels of P2Y1 were decreased. WB showed that in the distal colonic submucosa of OIC rats, MOR protein expression was increased, whereas that of P2Y1 was significantly decreased. GI transit ratio analysis suggested that the P2Y agonist ATP significantly relieved constipation symptoms in rats, while the P2Y inhibitor MRS2179 aggravated these symptoms. Finally, P2Y1 expression change was shown to be associated with the occurrence of OIC, while expression of MOR and P2Y1 was associated with OIC development in rats.
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Affiliation(s)
- Yuqiong Zhao
- Department of Human Anatomy and Histoembryology, College of Basic Medical Sciences, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750001, P.R. China
| | - Xiaojie Ren
- Department of Human Anatomy and Histoembryology, College of Basic Medical Sciences, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750001, P.R. China
| | - Fan Li
- Department of Gastrointestinal Surgery, Xiantao First People's Hospital Affiliated to Yangtze University, Xiantao, Hubei 433000, P.R. China
| | - Binghan Jia
- Department of Human Anatomy and Histoembryology, College of Basic Medical Sciences, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750001, P.R. China
| | - Dengke Wang
- Department of Human Anatomy and Histoembryology, College of Basic Medical Sciences, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750001, P.R. China
| | - Hua Jia
- Department of Human Anatomy and Histoembryology, College of Basic Medical Sciences, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750001, P.R. China
| | - Xuwen Jiao
- Department of Human Anatomy and Histoembryology, College of Basic Medical Sciences, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750001, P.R. China
| | - Lixin Wang
- The Medical Laboratory Center of General Hospital of Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750001, P.R. China,Correspondence to: Dr Junping Li, Department of Human Anatomy and Histoembryology, College of Basic Medical Sciences, Ningxia Medical University, 1160 Shengli Street, Yinchuan, Ningxia Hui Autonomous Region 750001, P.R. China
| | - Junping Li
- Department of Human Anatomy and Histoembryology, College of Basic Medical Sciences, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750001, P.R. China,Correspondence to: Dr Junping Li, Department of Human Anatomy and Histoembryology, College of Basic Medical Sciences, Ningxia Medical University, 1160 Shengli Street, Yinchuan, Ningxia Hui Autonomous Region 750001, P.R. China
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13
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Bougie O, Blom J, Zhou G, Murji A, Thurston J. Use and misuse of opioid after gynecologic surgery. Best Pract Res Clin Obstet Gynaecol 2022; 85:23-34. [PMID: 35973919 DOI: 10.1016/j.bpobgyn.2022.07.005] [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: 04/30/2022] [Revised: 05/25/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
Postoperative opioid use following gynecologic surgery may be necessary for effective treatment of pain; however, it can result in significant side effects, adverse reactions, and negative health consequences, including prolonged problematic use. Surgeons and healthcare providers of patients recovering from gynecologic procedures should be aware of effective strategies that can decrease the need for opioid use, while providing high-quality pain management. These include adherence to Enhanced Recovery After Surgery Protocols, particularly the use of multimodal analgesia management. When prescribing opioids, providers should adhere to responsible prescribing practices to minimize the risk of inappropriate and/or long-term opioid use.
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Affiliation(s)
- Olga Bougie
- Department of Obstetrics & Gynecology, Queen's University, Kingston Health Sciences Centre, Kingston, ON, USA.
| | - Jessica Blom
- Department of Obstetrics & Gynecology, Queen's University, Kingston Health Sciences Centre, Kingston, ON, USA
| | - Grace Zhou
- Department of Obstetrics & Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, ON, USA
| | - Ally Murji
- Department of Obstetrics & Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, ON, USA
| | - Jackie Thurston
- Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, USA
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14
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The role of kappa opioid receptors in immune system - An overview. Eur J Pharmacol 2022; 933:175214. [PMID: 36007608 DOI: 10.1016/j.ejphar.2022.175214] [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: 11/09/2021] [Revised: 08/05/2022] [Accepted: 08/12/2022] [Indexed: 11/20/2022]
Abstract
Opioids are one of the most effective anti-nociceptive agents used in patients with cancer pain or after serious surgery in most countries. The endogenous opioid system participates in pain perception, but recently its role in inflammation was determined. κ-opioid receptors (KOP receptors), a member of the opioid receptor family, are expressed in the central and peripheral nervous system as well as on the surface of different types of immune cells, e.g. T cells, B cells and monocytes. In this review, we focused on the involvement of KOP receptors in the inflammatory process and described their function in a number of conditions in which the immune system plays a key role (e.g. inflammatory bowel disease, arthritis, subarachnoid hemorrhage, vascular dysfunction) and inflammatory pain. We summed up the application of known KOP ligands in pathophysiology and we aimed to shed new light on KOP receptors as important elements during inflammation.
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15
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Babaie S, Taghvimi A, Hong JH, Hamishehkar H, An S, Kim KH. Recent advances in pain management based on nanoparticle technologies. J Nanobiotechnology 2022; 20:290. [PMID: 35717383 PMCID: PMC9206757 DOI: 10.1186/s12951-022-01473-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 05/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain is a vital sense that indicates the risk of injury at a particular body part. Successful control of pain is the principal aspect in medical treatment. In recent years, the advances of nanotechnology in pain management have been remarkable. In this review, we focus on literature and published data that reveal various applications of nanotechnology in acute and chronic pain management. METHODS The presented content is based on information collected through pain management publications (227 articles up to April 2021) provided by Web of Science, PubMed, Scopus and Google Scholar services. RESULTS A comprehensive study of the articles revealed that nanotechnology-based drug delivery has provided acceptable results in pain control, limiting the side effects and increasing the efficacy of analgesic drugs. Besides the ability of nanotechnology to deliver drugs, sophisticated nanosystems have been designed to enhance imaging and diagnostics, which help in rapid diagnosis of diseases and have a significant impact on controlling pain. Furthermore, with the development of various tools, nanotechnology can accurately measure pain and use these measurements to display the efficiency of different interventions. CONCLUSIONS Nanotechnology has started a new era in the pain management and many promising results have been achieved in this regard. Nevertheless, there is still no substantial and adequate act of nanotechnology in this field. Therefore, efforts should be directed to broad investigations.
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Affiliation(s)
- Soraya Babaie
- Physical Medicine and Rehabilitation Research Center and Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Arezou Taghvimi
- Biotechnology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Joo-Hyun Hong
- School of Pharmacy, Sungkyunkwan University (SKKU), Suwon, 16419, Republic of Korea
| | - Hamed Hamishehkar
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Seongpil An
- SKKU Advanced Institute of Nanotechnology (SAINT) and Department of Nano Engineering, Sungkyunkwan University (SKKU), Suwon, 16419, Republic of Korea.
| | - Ki Hyun Kim
- School of Pharmacy, Sungkyunkwan University (SKKU), Suwon, 16419, Republic of Korea.
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16
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Simpson S, Mclellan R, Wellmeyer E, Matalon F, George O. Drugs and Bugs: The Gut-Brain Axis and Substance Use Disorders. J Neuroimmune Pharmacol 2022; 17:33-61. [PMID: 34694571 PMCID: PMC9074906 DOI: 10.1007/s11481-021-10022-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/06/2021] [Indexed: 02/07/2023]
Abstract
Substance use disorders (SUDs) represent a significant public health crisis. Worldwide, 5.4% of the global disease burden is attributed to SUDs and alcohol use, and many more use psychoactive substances recreationally. Often associated with comorbidities, SUDs result in changes to both brain function and physiological responses. Mounting evidence calls for a precision approach for the treatment and diagnosis of SUDs, and the gut microbiome is emerging as a contributor to such disorders. Over the last few centuries, modern lifestyles, diets, and medical care have altered the health of the microbes that live in and on our bodies; as we develop, our diets and lifestyle dictate which microbes flourish and which microbes vanish. An increase in antibiotic treatments, with many antibiotic interventions occurring early in life during the microbiome's normal development, transforms developing microbial communities. Links have been made between the microbiome and SUDs, and the microbiome and conditions that are often comorbid with SUDs such as anxiety, depression, pain, and stress. A better understanding of the mechanisms influencing behavioral changes and drug use is critical in developing novel treatments for SUDSs. Targeting the microbiome as a therapeutic and diagnostic tool is a promising avenue of exploration. This review will provide an overview of the role of the gut-brain axis in a wide range of SUDs, discuss host and microbe pathways that mediate changes in the brain's response to drugs, and the microbes and related metabolites that impact behavior and health within the gut-brain axis.
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Affiliation(s)
- Sierra Simpson
- Department of Psychiatry, University of California San Diego, La Jolla, San Diego, CA, 92093, US.
| | - Rio Mclellan
- Department of Psychiatry, University of California San Diego, La Jolla, San Diego, CA, 92093, US
| | - Emma Wellmeyer
- Department of Psychiatry, University of California San Diego, La Jolla, San Diego, CA, 92093, US
| | - Frederic Matalon
- Department of Psychiatry, University of California San Diego, La Jolla, San Diego, CA, 92093, US
| | - Olivier George
- Department of Psychiatry, University of California San Diego, La Jolla, San Diego, CA, 92093, US
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17
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BouSaba J, Sannaa W, Camilleri M. Update on the role of naldemedine in opioid-induced constipation in patients with chronic noncancer pain. Therap Adv Gastroenterol 2022; 15:17562848221078638. [PMID: 35509419 PMCID: PMC9058332 DOI: 10.1177/17562848221078638] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/17/2022] [Indexed: 02/04/2023] Open
Abstract
Chronic noncancer pain (CNCP) affects up to 20% of adults and can interfere with activities of daily living. Up to 4% of adults in the United States receive chronic opioid therapy and up to 57% of patients on long-term opioids for CNCP report opioid-induced constipation (OIC). OIC is essentially constipation occurring after starting opioid treatment. While laxatives are traditionally the first-line therapy for OIC, 81% of patients taking daily laxatives and opioids still reported OIC and considered that it negatively affected their quality of life. Naldemedine is a peripherally acting µ-opioid receptor antagonists (PAMORA) approved for the treatment of OIC in patients with CNCP. This article reviews the mechanism of action, efficacy, and safety of naldemedine in CNCP patients. Naldemedine improves OIC in patients with CNCP by acting as an opioid receptor antagonist in the gastrointestinal tract. It does not interfere with the analgesic properties of opioids or cause withdrawal symptoms since these effects are centrally mediated, and naldemedine does not cross the blood brain barrier. Naldemedine showed significant and sustained improvement in frequency of bowel movements, quality of life, and constipation-related symptoms. It is generally well tolerated with a higher incidence of gastrointestinal adverse events of mild or moderate severity such as diarrhea, abdominal pain, or vomiting compared to placebo. While there are no randomized, controlled trials that compare head-to-head pharmacological therapies used for treatment of OIC, network meta-analysis shows that naldemedine has an overall good benefit-risk profile compared to the other approved medications.
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18
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Jaramillo-Polanco J, Lopez-Lopez C, Yu Y, Neary E, Hegron A, Canals M, Bunnett NW, Reed DE, Lomax AE, Vanner SJ. Opioid-Induced Pronociceptive Signaling in the Gastrointestinal Tract Is Mediated by Delta-Opioid Receptor Signaling. J Neurosci 2022; 42:3316-3328. [PMID: 35256532 PMCID: PMC9034783 DOI: 10.1523/jneurosci.2098-21.2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 11/21/2022] Open
Abstract
Opioid tolerance (OT) leads to dose escalation and serious side effects, including opioid-induced hyperalgesia (OIH). We sought to better understand the mechanisms underlying this event in the gastrointestinal tract. Chronic in vivo administration of morphine by intraperitoneal injection in male C57BL/6 mice evoked tolerance and evidence of OIH in an assay of colonic afferent nerve mechanosensitivity; this was inhibited by the δ-opioid receptor (DOPr) antagonist naltrindole when intraperitoneally injected in previous morphine administration. Patch-clamp studies of DRG neurons following overnight incubation with high concentrations of morphine, the µ-opioid receptors (MOPr) agonist [D-Ala2, N-Me-Phe4, Gly5-ol]-Enkephalin (DAMGO) or the DOPr agonist [D-Ala2, D-Leu5]-Enkephalin evoked hyperexcitability. The pronociceptive actions of these opioids were blocked by the DOPr antagonist SDM25N but not the MOPr antagonist D-Pen-Cys-Tyr-D-Trp-Orn-Thr-Pen-Thr-NH2 The hyperexcitability induced by DAMGO was reversed after a 1 h washout, but reapplication of low concentrations of DAMGO or [D-Ala2, D-Leu5]-Enkephalin restored the hyperexcitability, an effect mediated by protein kinase C. DOPr-dependent DRG neuron hyperexcitability was blocked by the endocytosis inhibitor Pitstop 2, and the weakly internalizing DOPr agonist ARM390 did not cause hyperexcitability. Bioluminescence resonance energy transfer studies in HEK cells showed no evidence of switching of G-protein signaling from Gi to a Gs pathway in response to either high concentrations or overnight incubation of opioids. Thus, chronic high-dose opioid exposure leads to opioid tolerance and features of OIH in the colon. This action is mediated by DOPr signaling and is dependent on receptor endocytosis and downstream protein kinase C signaling.SIGNIFICANCE STATEMENT Opioids are effective in the treatment of abdominal pain, but escalating doses can lead to opioid tolerance and potentially opioid-induced hyperalgesia. We found that δ-opioid receptor (DOPr) plays a central role in the development of opioid tolerance and opioid-induced hyperalgesia in colonic afferent nociceptors following prolonged exposure to high concentrations of MOPr or DOPr agonists. Furthermore, the role of DOPr was dependent on OPr internalization and activation of a protein kinase C signaling pathway. Thus, targeting DOPr or key components of the downstream signaling pathway could mitigate adverse side effects by opioids.
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Affiliation(s)
- Josue Jaramillo-Polanco
- Gastrointestinal Diseases Research Unit, Kingston General Hospital, Queen's University, Kingston, Ontario K7L 2V7, Canada
| | - Cintya Lopez-Lopez
- Gastrointestinal Diseases Research Unit, Kingston General Hospital, Queen's University, Kingston, Ontario K7L 2V7, Canada
| | - Yang Yu
- Gastrointestinal Diseases Research Unit, Kingston General Hospital, Queen's University, Kingston, Ontario K7L 2V7, Canada
| | - Emma Neary
- Gastrointestinal Diseases Research Unit, Kingston General Hospital, Queen's University, Kingston, Ontario K7L 2V7, Canada
| | - Alan Hegron
- Department of Molecular Pathobiology, Department of Neuroscience and Physiology, Neuroscience Institute, New York University, New York, New York 10010
| | - Meritxell Canals
- Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, United Kingdom
- Centre of Membrane Protein and Receptors, Universities of Birmingham and Nottingham, Nottingham, NG7 2UH, United Kingdom
| | - Nigel W Bunnett
- Department of Molecular Pathobiology, Department of Neuroscience and Physiology, Neuroscience Institute, New York University, New York, New York 10010
| | - David E Reed
- Gastrointestinal Diseases Research Unit, Kingston General Hospital, Queen's University, Kingston, Ontario K7L 2V7, Canada
| | - Alan E Lomax
- Gastrointestinal Diseases Research Unit, Kingston General Hospital, Queen's University, Kingston, Ontario K7L 2V7, Canada
| | - Stephen J Vanner
- Gastrointestinal Diseases Research Unit, Kingston General Hospital, Queen's University, Kingston, Ontario K7L 2V7, Canada
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19
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Baker Rogers J, Higa GM. Spoken and Unspoken Matters Regarding the Use of Opioids in Cancer. J Pain Res 2022; 15:909-924. [PMID: 35411188 PMCID: PMC8994621 DOI: 10.2147/jpr.s349107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/24/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Janna Baker Rogers
- Sections of Geriatrics, Palliative Medicine and Hospice, Department of Medicine, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Gerald M Higa
- Departments of Clinical Pharmacy and Medicine, Schools of Pharmacy and Medicine, West Virginia University, Morgantown, WV, USA
- Correspondence: Gerald M Higa, Departments of Clinical Pharmacy and Medicine, Schools of Pharmacy and Medicine, West Virginia University, Morgantown, WV, USA, 26506, Email
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20
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Mark EB, Nedergaard RB, Hansen TM, Nissen TD, Frøkjaer JB, Scott SM, Krogh K, Drewes AM. Tapentadol results in less deterioration of gastrointestinal function and symptoms than standard opioid therapy in healthy male volunteers. Neurogastroenterol Motil 2021; 33:e14131. [PMID: 34051122 DOI: 10.1111/nmo.14131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/17/2021] [Accepted: 03/09/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Tapentadol is a combined opioid agonist and norepinephrine reuptake inhibitor with fewer gastrointestinal side effects at equianalgesic doses compared with classical strong opioids. Previous studies on tapentadol have included multi-morbid patients in whom confounders exclude detailed assessment of the mechanistic effects and strict comparison with other opioids or placebo. This study aimed at investigating the effects of tapentadol and oxycodone on gastrointestinal motility and gastrointestinal side effects. METHODS 21 healthy males participated in a randomized, double-blind, placebo-controlled, crossover study. Tapentadol (50 mg twice daily), oxycodone (10 mg twice daily), or placebo tablets were administered for 14 days. Segmental gastrointestinal transit times and colonic motility parameters were measured with electromagnetic capsules. Gastrointestinal side effects were assessed using questionnaires. KEY RESULTS During dosing with tapentadol, gastrointestinal side effects and motility parameters were on placebo level. Compared with tapentadol, oxycodone increased whole gut transit time by 17.9 hours (p = .015) and rectosigmoid transit time by 6.5 hours (p = .005). Compared with tapentadol, oxycodone also reduced long, fast antegrade colonic movements (p = .001). In comparison with placebo, oxycodone prolonged whole gut transit time by 31.6 hours, (p < .001). Moreover, less long, fast antegrade colonic movements (p = .002) were observed during oxycodone. For oxycodone only, slow colonic movements were associated with gastrointestinal side effects. CONCLUSIONS & INFERENCES In this mechanistic study, tapentadol caused significantly less colonic dysmotility and gastrointestinal side effects as compared with oxycodone in equianalgesic doses.
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Affiliation(s)
- Esben Bolvig Mark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Rasmus Bach Nedergaard
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Tine Maria Hansen
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Thomas Dahl Nissen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Jens Brøndum Frøkjaer
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - S Mark Scott
- Neurogastroenterology Group (GI Physiology Unit), Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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21
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Yan Y, Chen Y, Zhang X. The effect of opioids on gastrointestinal function in the ICU. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:370. [PMID: 34689805 PMCID: PMC8543814 DOI: 10.1186/s13054-021-03793-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/12/2021] [Indexed: 12/31/2022]
Abstract
Gastrointestinal (GI) dysfunction is common in the critical care setting and is highly associated with clinical outcomes. Opioids increase the risk for GI dysfunction and are frequently prescribed to reduce pain in critically ill patients. However, the role of opioids in GI function remains uncertain in the ICU. This review aims to describe the effect of opioids on GI motility, their potential risk of increasing infection and the treatment of GI dysmotility with opioid antagonists in the ICU setting.
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Affiliation(s)
- Yun Yan
- Department of Anaesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.,Department of Critical Care Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yu Chen
- Department of Anaesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China. .,Department of Critical Care Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.
| | - Xijing Zhang
- Department of Anaesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China. .,Department of Critical Care Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.
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D'Arcy Y, Mantyh P, Yaksh T, Donevan S, Hall J, Sadrarhami M, Viktrup L. Treating osteoarthritis pain: mechanisms of action of acetaminophen, nonsteroidal anti-inflammatory drugs, opioids, and nerve growth factor antibodies. Postgrad Med 2021; 133:879-894. [PMID: 34252357 DOI: 10.1080/00325481.2021.1949199] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Osteoarthritis (OA) is a common difficult-to-treat condition where the goal, in the absence of disease-modifying treatments, is to alleviate symptoms such as pain and loss of function. Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids are common pharmacologic treatments for OA. Antibodies directed against nerve growth factor (NGF-Abs) are a new class of agents under clinical investigation for the treatment of OA. This narrative review describes (and uses schematics to visualize) nociceptive signaling, chronification of pain, and the mechanisms of action (MOAs) of these different analgesics in the context of OA-related pain pathophysiology. Further, the varying levels of efficacy and safety of these agents observed in patients with OA is examined, based on an overview of published clinical data and/or treatment guidelines (when available), in the context of differences in their MOAs.
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Affiliation(s)
- Yvonne D'Arcy
- Independent Nurse Practitioner, Ponte Vedra Beach, FL, USA
| | - Patrick Mantyh
- Department of Pharmacology and Cancer Center, University of Arizona, Tucson, AZ, USA
| | - Tony Yaksh
- Department of Anesthesiology and Pharmacology, University of California at San Diego, San Diego, CA, USA
| | | | - Jerry Hall
- Lilly Biomedicines, US/Global Medical Affairs, Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Lars Viktrup
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
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23
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De Giorgio R, Zucco FM, Chiarioni G, Mercadante S, Corazziari ES, Caraceni A, Odetti P, Giusti R, Marinangeli F, Pinto C. Management of Opioid-Induced Constipation and Bowel Dysfunction: Expert Opinion of an Italian Multidisciplinary Panel. Adv Ther 2021; 38:3589-3621. [PMID: 34086265 PMCID: PMC8279968 DOI: 10.1007/s12325-021-01766-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 04/28/2021] [Indexed: 12/14/2022]
Abstract
The prescribing and use of opioid analgesics is increasing in Italy owing to a profusion in the number and types of opioid analgesic products available, and the increasing prevalence of conditions associated with severe pain, the latter being related to population aging. Herein we provide the expert opinion of an Italian multidisciplinary panel on the management of opioid-induced constipation (OIC) and bowel dysfunction. OIC and opioid-induced bowel dysfunction are well-recognised unwanted effects of treatment with opioid analgesics that can profoundly affect quality of life. OIC can be due to additional factors such as reduced mobility, a low-fibre diet, comorbidities, and concomitant medications. Fixed-dose combinations of opioids with mu (μ) opioid receptor antagonists, such as oxycodone/naloxone, have become available, but have limited utility in clinical practice because the individual components cannot be independently titrated, creating a risk of breakthrough pain as the dose is increased. A comprehensive prevention and management strategy for OIC should include interventions that aim to improve fibre and fluid intake, increase mobility or exercise, and restore bowel function without compromising pain control. Recommended first-line pharmacological treatment of OIC is with an osmotic laxative (preferably polyethylene glycol [macrogol]), or a stimulant laxative such as an anthraquinone. A second laxative with a complementary mechanism of action should be added in the event of an inadequate response. Second-line treatment with a peripherally acting μ opioid receptor antagonist (PAMORA), such as methylnaltrexone, naloxegol or naldemedine, should be considered in patients with OIC that has not responded to combination laxative treatment. Prokinetics or intestinal secretagogues, such as lubiprostone, may be appropriate in the third-line setting, but their use in OIC is off-label in Italy, and should therefore be restricted to settings such as specialist centres and clinical trials.
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Rekatsina M, Paladini A, Drewes AM, Ayob F, Viswanath O, Urits I, Corli O, Pergolizzi J, Varrassi G. Efficacy and Safety of Peripherally Acting μ-Opioid Receptor Antagonist (PAMORAs) for the Management of Patients With Opioid-Induced Constipation: A Systematic Review. Cureus 2021; 13:e16201. [PMID: 34367804 PMCID: PMC8339109 DOI: 10.7759/cureus.16201] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/05/2021] [Indexed: 12/13/2022] Open
Abstract
In treating chronic and acute pain, opioids are widely used. Although they do provide analgesia, their usage does come with adverse events (AEs). One of the most burdensome is opioid-induced bowel dysfunction, and more specifically opioid-induced constipation (OIC). The pathogenesis of these AEs is well known as the consequence of the action of opioids on m-receptors in the enteric nervous system. In recent years, medicines counteracting this specific action at the receptors have been registered for clinical use: the peripherally acting μ-opioid receptor antagonists (PAMORAs). The knowledge of their comparative efficacy and tolerability is very important for physicians and patients in opioid therapy. This systematic review of the existing literature on PAMORAs aimed to study the relative clinical advantages and disadvantages. The most important data banks, including "PubMed," "Embase," "CT.gov," "ICTRP" and "CINAHL" were used to find the published material on PAMORAs. The selected publications were examined to systematically analyze the efficacy and safety of the four existing PAMORAs. All of the medications are superior to placebo in reducing OIC. There are few published data on alvimopan used to treat OIC, and it is only indicated for the treatment of post-abdominal surgery ileus. Methylnaltrexone is studied mainly in its subcutaneous (SC) formulation. When used in its oral formulation, it seems more rapid than naloxegol and placebo in the reduction of OIC. Naldemedine is able to produce more spontaneous bowel movements (SBMs) when compared to alvimopan and naloxegol. Tolerability was found to be similar for all of them. In particular, they affect the gastrointestinal tract (GI), with flatulence and diarrhea, especially at high dosages. For some of them, nasopharyngitis and abdominal pain were observed as treatment adverse effects (TEAs). Several cardiovascular TEAs were reported after methylnaltrexone use, but it is not clear whether they were consequences of the drug or related to the general conditions of the patients. Considering the existing data, naloxegol and naldemedine seem to be the best choices, with a higher number of spontaneous bowel movements following naldemedine administration.
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Affiliation(s)
- Martina Rekatsina
- Pain Management, Whipps Cross Hospital Barts Health NHS, London, GBR
| | - Antonella Paladini
- Department of Clinical Medicine, Public Health and Life Science (MESVA), University of L'Aquila, L'Aquila, ITA
| | - Asbjørn M Drewes
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, DNK
| | | | - Omar Viswanath
- Pain Management, Valley Pain Consultants - Envision Physician Services, Phoenix, USA
| | - Ivan Urits
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Oscar Corli
- Pain and Palliative Care Research Unit, Mario Negri Institute IRCCS, Milano, ITA
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25
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Ahmadimoghaddam D, Zarei M, Mohammadi S, Izadidastenaei Z, Salehi I. Bupleurum falcatum L. alleviates nociceptive and neuropathic pain: Potential mechanisms of action. JOURNAL OF ETHNOPHARMACOLOGY 2021; 273:113990. [PMID: 33689798 DOI: 10.1016/j.jep.2021.113990] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/26/2021] [Accepted: 02/28/2021] [Indexed: 06/12/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE In Iranian folkloric medicine, Bupleurum falcatum L. (Chinese Thoroughwax) has been used as a selective analgesic remedy for several centuries. OBJECTIVE The current research was conducted to explore the anti-nociceptive and anti-allodynic action of Bupleurum falcatum L. roots essential oil (BFEO) in Swiss mice. MATERIALS AND METHODS Formalin-induced paw licking (FIPL) model was applied for exploring of BFEO antinociceptive effects (neurogenic or inflammatory pain). The involvements of L-arginine-NO-cGMP-KATP channel pathway and several receptors such as opioid, peroxisome proliferator-activated (PPA), cannabinoid, transient receptor potential vanilloid, and adrenergic receptors were assesses to detect the anti-nociceptive activity of BFEO. Cervical spinal cord contusion (CSC) paradigm was employed for induction of neuropathic pain. RESULTS BFEO (100 mg/kg), in the FIPL model, produced significant antinociception compared to the control mice (p < 0.01). Furthermore, L-arginine, methylene blue, glibenclamide, naloxonazine, GW9662, and SR141716A pre-treatments restored the BFEO anti-nociceptive effects (p < 0.05) in the FIPL (second phase) test (p < 0.05). Intraperitoneal administration of saikosaponin A (one of the main constituents of BFEO) partially alleviated (p < 0.05) pain in FIPL test. Likewise, in CSC mice, the von Frey assay exhibited that BFEO could alter mechanical allodynia. CONCLUSION Finally, it seems that, in male mice, BFEO has both anti-allodynic and anti-nociceptive effects. The present data also suggest activating the L-arginine-NO-cGMP-KATP channel pathway as well as interaction of opioid, PPA, and cannabinoid receptors in the BFEO anti-nociceptive activities. These results also propose that BFEO could effectively attenuate allodynia in CSC mice.
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Affiliation(s)
- Davoud Ahmadimoghaddam
- Department of Pharmacology and Toxicology, School of Pharmacy, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Mohammad Zarei
- Department of Physiology, School of Medicine, Neurophysiology Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Saeed Mohammadi
- Department of Physiology, School of Medicine, Neurophysiology Research Center, Hamadan University of Medical Sciences, Hamadan, Iran.
| | - Zohreh Izadidastenaei
- Department of Physiology, School of Medicine, Neurophysiology Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Iraj Salehi
- Department of Physiology, School of Medicine, Neurophysiology Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
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Lin YM, Tang Y, Fu Y, Hegde S, Shi DW, Huang LYM, Shi XZ. An opioid receptor-independent mechanism underlies motility dysfunction and visceral hyperalgesia in opioid-induced bowel dysfunction. Am J Physiol Gastrointest Liver Physiol 2021; 320:G1093-G1104. [PMID: 33908261 PMCID: PMC8285582 DOI: 10.1152/ajpgi.00400.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Constipation and abdominal pain are commonly encountered in opioid-induced bowel dysfunction (OBD). The underlying mechanisms are incompletely understood, and treatments are not satisfactory. As patients with OBD often have fecal retention, we aimed to determine whether fecal retention plays a pathogenic role in the development of constipation and abdominal pain in OBD, and if so to investigate the mechanisms. A rodent model of OBD was established by daily morphine treatment at 10 mg/kg for 7 days. Bowel movements, colonic muscle contractility, visceromotor response to colorectal distention, and cell excitability of colon-projecting dorsal root ganglion neurons were determined in rats fed with normal pellet food, or with clear liquid diet. Morphine treatment (Mor) reduced fecal outputs starting on day 1, and caused fecal retention afterward. Compared with controls, Mor rats demonstrated suppressed muscle contractility, increased neuronal excitability, and visceral hypersensitivity. Expression of cyclooxygenase-2 (COX-2) and nerve growth factor (NGF) was upregulated in the smooth muscle of the distended colon in Mor rats. However, prevention of fecal retention by feeding rats with clear liquid diet blocked upregulation of COX-2 and NGF, restored muscle contractility, and attenuated visceral hypersensitivity in Mor rats. Moreover, inhibition of COX-2 improved smooth muscle function and fecal outputs, whereas anti-NGF antibody administration attenuated visceral hypersensitivity in Mor rats. Morphine-induced fecal retention is an independent pathogenic factor for motility dysfunction and visceral hypersensitivity in rats with OBD. Liquid diet may have therapeutic potential for OBD by preventing fecal retention-induced mechanotranscription of COX-2 and NGF.NEW & NOTEWORTHY Our preclinical study shows that fecal retention is a pathogenic factor in opioid-induced bowel dysfunction, as prevention of fecal retention with liquid diet improved motility and attenuated visceral hyperalgesia in morphine-treated animals by blocking expression of cyclooxygenase-2 and nerve growth factor in the colon.
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Affiliation(s)
- You-Min Lin
- 1Department of Internal Medicine, The University of Texas
Medical Branch, Galveston, Texas
| | - Yanbo Tang
- 1Department of Internal Medicine, The University of Texas
Medical Branch, Galveston, Texas,2Department of Gastroenterology, The First Affiliated Hospital, Guangxi University of Science and Technology, Guangxi, China
| | - Yu Fu
- 1Department of Internal Medicine, The University of Texas
Medical Branch, Galveston, Texas
| | - Shrilakshmi Hegde
- 1Department of Internal Medicine, The University of Texas
Medical Branch, Galveston, Texas
| | - Daniel W. Shi
- 1Department of Internal Medicine, The University of Texas
Medical Branch, Galveston, Texas,3College of Science, Texas A&M University, College Station, Texas
| | - Li-Yen M. Huang
- 4Department of Neuroscience and Cell Biology, The University of Texas Medical Branch, Galveston, Texas
| | - Xuan-Zheng Shi
- 1Department of Internal Medicine, The University of Texas
Medical Branch, Galveston, Texas
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Bonifazi A, Battiti FO, Sanchez J, Zaidi SA, Bow E, Makarova M, Cao J, Shaik AB, Sulima A, Rice KC, Katritch V, Canals M, Lane JR, Newman AH. Novel Dual-Target μ-Opioid Receptor and Dopamine D 3 Receptor Ligands as Potential Nonaddictive Pharmacotherapeutics for Pain Management. J Med Chem 2021; 64:7778-7808. [PMID: 34011153 DOI: 10.1021/acs.jmedchem.1c00611] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The need for safer pain-management therapies with decreased abuse liability inspired a novel drug design that retains μ-opioid receptor (MOR)-mediated analgesia, while minimizing addictive liability. We recently demonstrated that targeting the dopamine D3 receptor (D3R) with highly selective antagonists/partial agonists can reduce opioid self-administration and reinstatement to drug seeking in rodent models without diminishing antinociceptive effects. The identification of the D3R as a target for the treatment of opioid use disorders prompted the idea of generating a class of ligands presenting bitopic or bivalent structures, allowing the dual-target binding of the MOR and D3R. Structure-activity relationship studies using computationally aided drug design and in vitro binding assays led to the identification of potent dual-target leads (23, 28, and 40), based on different structural templates and scaffolds, with moderate (sub-micromolar) to high (low nanomolar/sub-nanomolar) binding affinities. Bioluminescence resonance energy transfer-based functional studies revealed MOR agonist-D3R antagonist/partial agonist efficacies that suggest potential for maintaining analgesia with reduced opioid-abuse liability.
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Affiliation(s)
- Alessandro Bonifazi
- Medicinal Chemistry Section, Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse-Intramural Research Program, National Institutes of Health, 333 Cassell Drive, Baltimore, Maryland 21224, United States
| | - Francisco O Battiti
- Medicinal Chemistry Section, Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse-Intramural Research Program, National Institutes of Health, 333 Cassell Drive, Baltimore, Maryland 21224, United States
| | - Julie Sanchez
- Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UH, U.K.,Centre of Membrane Protein and Receptors, Universities of Birmingham and Nottingham, Midlands NG2 7AG, U.K
| | - Saheem A Zaidi
- Bridge Institute, Michelson Center for Convergent Bioscience, Department of Chemistry, Department of Biological Sciences, University of Southern California, Los Angeles, California 90089, United States
| | - Eric Bow
- Drug Design and Synthesis Section, Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse-Intramural Research Program, National Institutes of Health, 9800 Medical Center Drive, Bethesda, Maryland 20892, United States
| | - Mariia Makarova
- Drug Design and Synthesis Section, Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse-Intramural Research Program, National Institutes of Health, 9800 Medical Center Drive, Bethesda, Maryland 20892, United States
| | - Jianjing Cao
- Medicinal Chemistry Section, Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse-Intramural Research Program, National Institutes of Health, 333 Cassell Drive, Baltimore, Maryland 21224, United States
| | - Anver Basha Shaik
- Medicinal Chemistry Section, Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse-Intramural Research Program, National Institutes of Health, 333 Cassell Drive, Baltimore, Maryland 21224, United States
| | - Agnieszka Sulima
- Drug Design and Synthesis Section, Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse-Intramural Research Program, National Institutes of Health, 9800 Medical Center Drive, Bethesda, Maryland 20892, United States
| | - Kenner C Rice
- Drug Design and Synthesis Section, Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse-Intramural Research Program, National Institutes of Health, 9800 Medical Center Drive, Bethesda, Maryland 20892, United States
| | - Vsevolod Katritch
- Bridge Institute, Michelson Center for Convergent Bioscience, Department of Chemistry, Department of Biological Sciences, University of Southern California, Los Angeles, California 90089, United States
| | - Meritxell Canals
- Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UH, U.K.,Centre of Membrane Protein and Receptors, Universities of Birmingham and Nottingham, Midlands NG2 7AG, U.K
| | - J Robert Lane
- Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UH, U.K.,Centre of Membrane Protein and Receptors, Universities of Birmingham and Nottingham, Midlands NG2 7AG, U.K
| | - Amy Hauck Newman
- Medicinal Chemistry Section, Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse-Intramural Research Program, National Institutes of Health, 333 Cassell Drive, Baltimore, Maryland 21224, United States
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28
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Ueda H. Review of Kyotorphin Research: A Mysterious Opioid Analgesic Dipeptide and Its Molecular, Physiological, and Pharmacological Characteristics. FRONTIERS IN MEDICAL TECHNOLOGY 2021; 3:662697. [PMID: 35047919 PMCID: PMC8757751 DOI: 10.3389/fmedt.2021.662697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/10/2021] [Indexed: 11/25/2022] Open
Abstract
Tyrosine-arginine (kyotorphin), an opioid analgesic dipeptide, was discovered more than 40 years ago in 1979. The evidence accumulated during this period has established the physiological significance of kyotorphin as a neuromodulating peptide, and pharmacological applications. Some of the following important findings have been discussed in this review: (1) kyotorphin is unevenly distributed in the brain; it is found in high concentrations in the pain pathway, which involves the regions associated with morphine analgesia; (2) kyotorphin is subcellularly localized in the synaptosome fraction or nerve-ending particles; (3) a specific synthetase generates kyotorphin from tyrosine and arginine; (4) kyotorphin may be also processed from calpastatin by a novel calcium-activated neutral protease or calpain; (5) kyotorphin preloaded into the synaptosome is released by high K+ depolarization in a Ca2+-dependent manner; (6) kyotorphin has a specific G protein coupled receptor, which mediates the activation of phospholipase C (PLC) and inhibition of adenylyl cyclase through Gi; (7) leucine-arginine works as a specific kyotorphin receptor antagonist; 8) membrane-bound aminopeptidase or excretion through a peptide transporter, PEPT2, may contribute to the inactivation of kyotorphin; and (9) kyotorphin causes increased Met-enkephalin release from brain and spinal slices. It is also known that the opening of plasma membrane Ca2+ channels through a conformational coupling of the InsP3 receptor with the transient receptor potential C1, which is downstream of the kyotorphin receptor-mediated activation of Gi and PLC, could be a potential underlying mechanism of Met-enkephalin release. Considering these findings, translational research is an exciting domain that can be explored in the future. As kyotorphin is a small molecule, we could design function-added kyotorphin derivatives. These studies would include not only the brain-permeable kyotorphin derivatives but also hybrid kyotorphin derivatives conjugated with small compounds that have additional pharmacological actions. Further, since there are reports of kyotorphin being involved in either the etiology or treatment of Alzheimer's disease, epilepsy, inflammation, and chronic pain, studies on the beneficial effects of kyotorphin derivatives should also be expected in the future.
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Affiliation(s)
- Hiroshi Ueda
- Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto, Japan
- Institute of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
- Research Institute for Production Development, Kyoto, Japan
- *Correspondence: Hiroshi Ueda
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29
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Zarei M, Ahmadimoghaddam D, Mohammadi S. Artemisia biennis Willd.: Anti-Nociceptive effects and possible mechanisms of action. JOURNAL OF ETHNOPHARMACOLOGY 2021; 268:113604. [PMID: 33232780 DOI: 10.1016/j.jep.2020.113604] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/10/2020] [Accepted: 11/18/2020] [Indexed: 06/11/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Artemisia biennis Willd. (Dermane in Persian) has been used as an antinociceptive remedy in Iranian folkloric medicine. OBJECTIVE The aim of the present study was to evaluate the anti-nociceptive effects of Artemisia biennis Willd. aerial part essential oil (ABAEO) on male Swiss mice. MATERIALS AND METHODS Nociceptive pain techniques including acetic acid-induced writhing (AAIW), formalin-induced paw licking (FPL), glutamate-induced paw licking (GPL), and tail-flick (TF) models were applied. We assessed opioid and L-arginine-NO-cGMP-KATP pathways to detect the possible anti-nociceptive properties of ABAEO. In addition, neuropathic pain was induced by the cervical spinal cord contusion model. RESULTS ABAEO (120 mg/kg) had a significant anti-nociceptive activities in comparison to the control animals (p < 0.05) in the AAIW, TF, GPL, and FPL assays. The selective opioid antagonist (naloxonazine) administration in the AAIW test alleviated the anti-nociceptive effect of ABAEO (p < 0.05). L-arginine, methylene blue, and glibenclamide treatment prevented the ABAEO anti-nociceptive effects (p < 0.05); however, sodium nitroprusside could profoundly potentiate the ABAEO-associated antinociception in the FPL (phase II) test (p < 0.05). In nociceptive pain models, Cr (one of the main constituents of ABAEO) showed significant anti-nociceptive effects (p < 0.05). Moreover, the von Frey results indicated that ABAEO could attenuate mechanical allodynia in mice. CONCLUSION Our observation revealed the anti-nociceptive effects of ABAEO in male mice. These effects could include, at least in part, modulating glutamatergic mechanisms via opioid systems. Our data output also indicates activating the L-arginine-NO-cGMP-KATP system in ABAEO anti-nociceptive activities.
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Affiliation(s)
- Mohammad Zarei
- Department of Physiology, School of Medicine, Neurophysiology Research Center, Hamadan University of Medical Sciences, Hamadan, Iran.
| | - Davoud Ahmadimoghaddam
- Department of Pharmacology and Toxicology, School of Pharmacy, Hamadan University of Medical Sciences, Hamadan, Iran.
| | - Saeed Mohammadi
- Department of Physiology, School of Medicine, Neurophysiology Research Center, Hamadan University of Medical Sciences, Hamadan, Iran.
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30
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Abstract
Opioids such as morphine and oxycodone are analgesics frequently prescribed for the treatment of moderate or severe pain. Unfortunately, these medications are associated with exceptionally high abuse potentials and often cause fatal side effects, mainly through the μ-opioid receptor (MOR). Efforts to discover novel, safer, and more efficacious analgesics targeting MOR have encountered challenges. In this review, we summarize alternative strategies and targets that could be used to develop safer nonopioid analgesics. A molecular understanding of G protein-coupled receptor activation and signaling has illuminated not only the complexities of receptor pharmacology but also the potential for pathway-selective agonists and allosteric modulators as safer medications. The availability of structures of pain-related receptors, in combination with high-throughput computational tools, has accelerated the discovery of multitarget ligands with promising pharmacological profiles. Emerging clinical evidence also supports the notion that drugs targeting peripheral opioid receptors have potential as improved analgesic agents.
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Affiliation(s)
- Tao Che
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri 63110, USA; .,Center for Clinical Pharmacology, University of Health Sciences and Pharmacy and Washington University School of Medicine, St. Louis, Missouri 63110, USA
| | - Bryan L Roth
- Department of Pharmacology, University of North Carolina School of Medicine, Chapel Hill, North Carolina 27599, USA;
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31
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Pineyro G, Nagi K. Signaling diversity of mu- and delta- opioid receptor ligands: Re-evaluating the benefits of β-arrestin/G protein signaling bias. Cell Signal 2020; 80:109906. [PMID: 33383156 DOI: 10.1016/j.cellsig.2020.109906] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/24/2020] [Accepted: 12/27/2020] [Indexed: 01/02/2023]
Abstract
Opioid analgesics are elective for treating moderate to severe pain but their use is restricted by severe side effects. Signaling bias has been proposed as a viable means for improving this situation. To exploit this opportunity, continuous efforts are devoted to understand how ligand-specific modulations of receptor functions could mediate the different in vivo effects of opioids. Advances in the field have led to the development of biased agonists based on hypotheses that allocated desired and undesired effects to specific signaling pathways. However, the prevalent hypothesis associating β-arrestin to opioid side effects was recently challenged and multiple of the newly developed biased drugs may not display the superior side effects profile that was sought. Moreover, biased agonism at opioid receptors is now known to be time- and cell-dependent, which adds a new layer of complexity for bias estimation. Here, we first review the signaling mechanisms underlying desired and undesired effects of opioids. We then describe biased agonism at opioid receptors and discuss the different perspectives that support the desired and undesired effects of opioids in view of exploiting biased signaling for therapeutic purposes. Finally, we explore how signaling kinetics and cellular background can influence the magnitude and directionality of bias at those receptors.
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Affiliation(s)
- Graciela Pineyro
- Department of Pharmacology and Physiology, Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada; CHU Sainte-Justine research center, Montreal, QC H3T 1C5, Canada
| | - Karim Nagi
- College of Medicine, QU Health, Qatar University, Doha, Qatar.
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32
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Ahmadimoghaddam D, Sadeghian R, Ranjbar A, Izadidastenaei Z, Mohammadi S. Antinociceptive activity of Cnicus benedictus L. leaf extract: a mechanistic evaluation. Res Pharm Sci 2020; 15:463-472. [PMID: 33628288 PMCID: PMC7879793 DOI: 10.4103/1735-5362.297849] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 05/04/2020] [Accepted: 09/27/2020] [Indexed: 12/17/2022] Open
Abstract
Background and purpose: Cnicus benedictus, a medicinal herb, traditionally had been used for the treatment of stomachache pain. In this study, the possible efficacy of Cnicus benedictus leaf methanolic extract (CBHE) and also cnicin, one of its major constituents, was measured on pain. Experimental approach: In this study, pain assessment tests include writhing, tail-flick (TF), and formalin- induced paw licking test (FIPLT) were used. To understand the possible mediated anti-nociceptive mechanism of CBHE, the opioid mechanism(s), and involvement of the L-arginine/ nitric oxide/cGMP/ATP-sensitive potassium channel pathway (LNCaP) were scrutinized. Findings/Results: In TF and writhing tests, CBHE (150 and 300 mg/kg, i.p) remarkably exhibited an anti-nociceptive effect compared to that of the control. Furthermore, CBHE (150 and 300 mg/kg, i.p) in comparison with the control showed a noteworthy anti-nociceptive effect (P < 0.01) in the tonic phase of FIPLT. In the writhing test, administration of selective opioid antagonist (naltrindole, nor-binaltorphimine, and naloxonazine) attenuated the anti-nociceptive effect of CBHE (300 mg/kg) in comparison with control. Moreover, pre-treatment with Nω-nitro-L-arginine methyl ester hydrochloride, L-arginine hydrochloride, and glibenclamide significantly blocked the CBHE (300 mg/kg) anti-nociception (P < 0.05) while administration of sodium nitroprusside remarkably potentiated (P < 0.05) the antinociception induced by CBHE in the tonic phase of the FIPLT. Besides, cnicin (30 mg/kg) showed noteworthy anti-nociceptive effects in writhing, TF, and FIPLT paradigms. Conclusion and implications: Taken together, we elucidate that both CBHE and cnicin demonstrated antinociceptive effects in behavioral tests. The possible mechanisms of CBHE antinociception may involve in various neural signaling and modulatory pathways including LNCaP and opioidergic mechanisms.
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Affiliation(s)
- Davoud Ahmadimoghaddam
- Department of Pharmacology and Toxicology, School of Pharmacy, Hamadan University of Medical Sciences, Hamadan, I.R. Iran.,Medicinal Plants and Natural Products Research Center, Hamadan University of Medical Sciences, Hamadan, I.R. Iran
| | - Reihaneh Sadeghian
- Student Research Committee, Hamadan University of Medical Sciences, Hamadan, I.R. Iran.,Medical Plants Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord, I.R. Iran
| | - Akram Ranjbar
- Department of Pharmacology and Toxicology, School of Pharmacy, Hamadan University of Medical Sciences, Hamadan, I.R. Iran.,Medicinal Plants and Natural Products Research Center, Hamadan University of Medical Sciences, Hamadan, I.R. Iran
| | - Zohreh Izadidastenaei
- Neurophysiology Research Center, Hamadan University of Medical Sciences, Hamadan, I.R. Iran
| | - Saeed Mohammadi
- Neurophysiology Research Center, Hamadan University of Medical Sciences, Hamadan, I.R. Iran.,Department of Biology, Science and Research Branch, Islamic Azad University, Tehran, I.R. Iran
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μ-Opioid Receptors on Distinct Neuronal Populations Mediate Different Aspects of Opioid Reward-Related Behaviors. eNeuro 2020; 7:ENEURO.0146-20.2020. [PMID: 32859725 PMCID: PMC7508564 DOI: 10.1523/eneuro.0146-20.2020] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 02/01/2023] Open
Abstract
μ-Opioid receptors (MORs) are densely expressed in different brain regions known to mediate reward. One such region is the striatum where MORs are densely expressed, yet the role of these MOR populations in modulating reward is relatively unknown. We have begun to address this question by using a series of genetically engineered mice based on the Cre recombinase/loxP system to selectively delete MORs from specific neurons enriched in the striatum: dopamine 1 (D1) receptors, D2 receptors, adenosine 2a (A2a) receptors, and choline acetyltransferase (ChAT). We first determined the effects of each deletion on opioid-induced locomotion, a striatal and dopamine-dependent behavior. We show that MOR deletion from D1 neurons reduced opioid (morphine and oxycodone)-induced hyperlocomotion, whereas deleting MORs from A2a neurons resulted in enhanced opioid-induced locomotion, and deleting MORs from D2 or ChAT neurons had no effect. We also present the effect of each deletion on opioid intravenous self-administration. We first assessed the acquisition of this behavior using remifentanil as the reinforcing opioid and found no effect of genotype. Mice were then transitioned to oxycodone as the reinforcer and maintained here for 9 d. Again, no genotype effect was found. However, when mice underwent 3 d of extinction training, during which the drug was not delivered, but all cues remained as during the maintenance phase, drug-seeking behavior was enhanced when MORs were deleted from A2a or ChAT neurons. These findings show that these selective MOR populations play specific roles in reward-associated behaviors.
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Berry JAD, Ogunlade J, Kashyap S, Berry DK, Wacker M, Miulli DE, Saini H. Clinical Efficacy of Mesenteric Lift to Relieve Constipation in Traumatic Brain Injury Patients. J Osteopath Med 2020; 120:2765207. [PMID: 32750717 DOI: 10.7556/jaoa.2020.094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
CONTEXT Patients with severe traumatic brain injury (TBI) often have multiple autonomic disturbances that interfere with normal gastrointestinal motility. Many of the pharmacologic agents used in the intensive care unit (ICU) also adversely affect gastrointestinal motility. The body is further subjected to excessive levels of sympathetic discharge in states of traumatic injury and extreme stress, which can interfere with the proper absorption of fluids and nutrients. OBJECTIVE To determine whether mesenteric lift, an osteopathic manipulative treatment technique, is effective in relieving constipation in patients with TBI who are intubated in the ICU. METHODS This retrospective medical record review examined the effect of mesenteric lift on intubated patients with significant TBI who were unable to have a bowel movement within 72 hours of admission. The primary endpoint was the return of normal bowel function within 24 hours. A control group consisted of intubated patients with TBI during the same period who did not receive mesenteric lift. RESULTS Of patients who received mesenteric lift, 77% experienced bowel movements (n=27 of 35), compared with 36% (n=16 of 44) in the control group (P=.01). CONCLUSION The application of mesenteric lift to intubated patients with severe TBI in the intensive care unit significantly increased patients' ability to resume normal bowel function and expel waste.
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Abstract
PURPOSE OF REVIEW Opioids have been shown to be associated with an increased risk of fracture. The purpose of this paper is to review recent research into the effects of opioids on bone formation and bone healing in animal models and in human studies. RECENT FINDINGS Most opioids, such as morphine and fentanyl, negatively affected bone remodeling and bone healing in animal models. Conversely, remifentanil has been recently shown to promote in vitro osteoblast differentiation and to inhibit differentiation and maturation of osteoclasts, therefore reducing bone resorption. According to the possible negative role of opioids in bone healing, opioid antagonists have been shown to enhance bone mineralization, suggesting a possible therapeutic role in the future for osteoporosis. Other neuropeptides, such as the vasoactive intestinal peptide (VIP) and the neuropeptide Y (NPY), have been proved to promote osteogenesis. The increased risk of fractures among opioid users may be related to their central nervous system side effects or to the reduced bone density, partly due to their endocrine effects, and partly to their direct activity on bone cells. Clinical data strongly suggested a potential negative effect of opioids in bone healing. The risk of nonunion fracture is significantly increased in opioid users, and bone mass density was reduced in patients under long-term opioid treatment. The direct effects of opioids on bone remodeling appears evident from these reports. Not all opioids have the same potential for negatively impacting bone healing. Opioid antagonists may increase bone density and could represent a possible future treatment for low bone mass density pathologies. However, further trials are warranted to clarify the clinical relevance of these emerging findings from animal studies.
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Affiliation(s)
- Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, Corso della Repubblica 79, 04100, Latina, Italy.
- Unit of Anaesthesia, Intensive Care Medicine and Pain Therapy, AUSL Latina c/o ICOT, Latina, Italy.
| | - Maria Sole Scerpa
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, Corso della Repubblica 79, 04100, Latina, Italy
- Unit of Anaesthesia, Intensive Care Medicine and Pain Therapy, AUSL Latina c/o ICOT, Latina, Italy
| | - Marco Centanni
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, Corso della Repubblica 79, 04100, Latina, Italy
- Endocrinology Unit, Santa Maria Goretti Hospital, AUSL Latina, Latina, Italy
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Gillis A, Gondin AB, Kliewer A, Sanchez J, Lim HD, Alamein C, Manandhar P, Santiago M, Fritzwanker S, Schmiedel F, Katte TA, Reekie T, Grimsey NL, Kassiou M, Kellam B, Krasel C, Halls ML, Connor M, Lane JR, Schulz S, Christie MJ, Canals M. Low intrinsic efficacy for G protein activation can explain the improved side effect profiles of new opioid agonists. Sci Signal 2020; 13:13/625/eaaz3140. [PMID: 32234959 DOI: 10.1126/scisignal.aaz3140] [Citation(s) in RCA: 190] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Biased agonism at G protein-coupled receptors describes the phenomenon whereby some drugs can activate some downstream signaling activities to the relative exclusion of others. Descriptions of biased agonism focusing on the differential engagement of G proteins versus β-arrestins are commonly limited by the small response windows obtained in pathways that are not amplified or are less effectively coupled to receptor engagement, such as β-arrestin recruitment. At the μ-opioid receptor (MOR), G protein-biased ligands have been proposed to induce less constipation and respiratory depressant side effects than opioids commonly used to treat pain. However, it is unclear whether these improved safety profiles are due to a reduction in β-arrestin-mediated signaling or, alternatively, to their low intrinsic efficacy in all signaling pathways. Here, we systematically evaluated the most recent and promising MOR-biased ligands and assessed their pharmacological profile against existing opioid analgesics in assays not confounded by limited signal windows. We found that oliceridine, PZM21, and SR-17018 had low intrinsic efficacy. We also demonstrated a strong correlation between measures of efficacy for receptor activation, G protein coupling, and β-arrestin recruitment for all tested ligands. By measuring the antinociceptive and respiratory depressant effects of these ligands, we showed that the low intrinsic efficacy of opioid ligands can explain an improved side effect profile. Our results suggest a possible alternative mechanism underlying the improved therapeutic windows described for new opioid ligands, which should be taken into account for future descriptions of ligand action at this important therapeutic target.
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Affiliation(s)
- Alexander Gillis
- Discipline of Pharmacology, School of Medical Sciences, University of Sydney, NSW 2006, Australia
| | - Arisbel B Gondin
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, VIC 3052, Australia
| | - Andrea Kliewer
- Institute of Pharmacology and Toxicology, Jena University Hospital, Friedrich-Schiller-University, 07747 Jena, Germany
| | - Julie Sanchez
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, VIC 3052, Australia.,Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, UK.,Centre of Membrane Proteins and Receptors, Universities of Birmingham and Nottingham, Midlands, UK
| | - Herman D Lim
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, VIC 3052, Australia
| | - Claudia Alamein
- Discipline of Pharmacology, School of Medical Sciences, University of Sydney, NSW 2006, Australia
| | - Preeti Manandhar
- Department of Biomedical Sciences, Macquarie University, NSW 2109, Australia
| | - Marina Santiago
- Department of Biomedical Sciences, Macquarie University, NSW 2109, Australia
| | - Sebastian Fritzwanker
- Institute of Pharmacology and Toxicology, Jena University Hospital, Friedrich-Schiller-University, 07747 Jena, Germany
| | - Frank Schmiedel
- Institute of Pharmacology and Toxicology, Jena University Hospital, Friedrich-Schiller-University, 07747 Jena, Germany
| | - Timothy A Katte
- School of Chemistry, University of Sydney, NSW 2006, Australia
| | - Tristan Reekie
- School of Chemistry, University of Sydney, NSW 2006, Australia
| | - Natasha L Grimsey
- Department of Pharmacology and Clinical Pharmacology, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Michael Kassiou
- School of Chemistry, University of Sydney, NSW 2006, Australia
| | - Barrie Kellam
- School of Pharmacy, Centre for Biomolecular Sciences, University of Nottingham, Nottingham NG7 2RD, UK
| | - Cornelius Krasel
- Department of Pharmacology and Toxicology, Philipps-University Marburg, D-35043 Marburg, Germany
| | - Michelle L Halls
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, VIC 3052, Australia
| | - Mark Connor
- Department of Biomedical Sciences, Macquarie University, NSW 2109, Australia
| | - J Robert Lane
- Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, UK.,Centre of Membrane Proteins and Receptors, Universities of Birmingham and Nottingham, Midlands, UK
| | - Stefan Schulz
- Institute of Pharmacology and Toxicology, Jena University Hospital, Friedrich-Schiller-University, 07747 Jena, Germany
| | - Macdonald J Christie
- Discipline of Pharmacology, School of Medical Sciences, University of Sydney, NSW 2006, Australia.
| | - Meritxell Canals
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, VIC 3052, Australia. .,Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, UK.,Centre of Membrane Proteins and Receptors, Universities of Birmingham and Nottingham, Midlands, UK
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Kibaly C, Xu C, Cahill CM, Evans CJ, Law PY. Non-nociceptive roles of opioids in the CNS: opioids' effects on neurogenesis, learning, memory and affect. Nat Rev Neurosci 2019; 20:5-18. [PMID: 30518959 DOI: 10.1038/s41583-018-0092-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Mortality due to opioid use has grown to the point where, for the first time in history, opioid-related deaths exceed those caused by car accidents in many states in the United States. Changes in the prescribing of opioids for pain and the illicit use of fentanyl (and derivatives) have contributed to the current epidemic. Less known is the impact of opioids on hippocampal neurogenesis, the functional manipulation of which may improve the deleterious effects of opioid use. We provide new insights into how the dysregulation of neurogenesis by opioids can modify learning and affect, mood and emotions, processes that have been well accepted to motivate addictive behaviours.
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Affiliation(s)
- Cherkaouia Kibaly
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, Shirley and Stefan Hatos Center for Neuropharmacology, University of California, Los Angeles, CA, USA.
| | - Chi Xu
- State Key Laboratory of Natural Medicines, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Catherine M Cahill
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, Shirley and Stefan Hatos Center for Neuropharmacology, University of California, Los Angeles, CA, USA
| | - Christopher J Evans
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, Shirley and Stefan Hatos Center for Neuropharmacology, University of California, Los Angeles, CA, USA
| | - Ping-Yee Law
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, Shirley and Stefan Hatos Center for Neuropharmacology, University of California, Los Angeles, CA, USA
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Abstract
The impact of opioid use on the lower gastrointestinal tract is well described, but recent opioid crisis has caused increased awareness of the detrimental effects of these drugs on esophageal and gastroduodenal motility. Opioid use has been associated with increased incidence of spastic esophageal motility disorders and gastroduodenal dysfunction. Opioid receptors are present with high abundance in the myenteric and submucosal plexus of the enteric nervous system. Activation of these receptors leads to suppressed excitability of the inhibitory musculomotor neurons and unchecked tonic contraction of the autogenic musculature (such as the lower esophageal sphincter and the pylorus).
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DiCello JJ, Rajasekhar P, Eriksson EM, Saito A, Gondin AB, Veldhuis NA, Canals M, Carbone SE, Poole DP. Clathrin and GRK2/3 inhibitors block δ-opioid receptor internalization in myenteric neurons and inhibit neuromuscular transmission in the mouse colon. Am J Physiol Gastrointest Liver Physiol 2019; 317:G79-G89. [PMID: 31091149 DOI: 10.1152/ajpgi.00085.2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Endocytosis is a major mechanism through which cellular signaling by G protein-coupled receptors (GPCRs) is terminated. However, recent studies demonstrate that GPCRs are internalized in an active state and continue to signal from within endosomes, resulting in effects on cellular function that are distinct to those arising at the cell surface. Endocytosis inhibitors are commonly used to define the importance of GPCR internalization for physiological and pathophysiological processes. Here, we provide the first detailed examination of the effects of these inhibitors on neurogenic contractions of gastrointestinal smooth muscle, a key preliminary step to evaluate the importance of GPCR endocytosis for gut function. Inhibitors of clathrin-mediated endocytosis (Pitstop2, PS2) or G protein-coupled receptor kinase-2/3-dependent phosphorylation (Takeda compound 101, Cmpd101), significantly reduced GPCR internalization. However, they also attenuated cholinergic contractions through different mechanisms. PS2 abolished contractile responses by colonic muscle to SNC80 and morphine, which strongly and weakly internalize δ-opioid and μ-opioid receptors, respectively. PS2 did not affect the increased myogenic contractile activity following removal of an inhibitory neural influence (tetrodotoxin) but suppressed electrically evoked neurogenic contractions. Ca2+ signaling by myenteric neurons in response to exogenous ATP was unaffected by PS2, suggesting inhibitory actions on neurotransmitter release rather than neurotransmission. In contrast, Cmpd101 attenuated contractions to the cholinergic agonist carbachol, indicating direct effects on smooth muscle. We conclude that, although PS2 and Cmpd101 are effective blockers of GPCR endocytosis in enteric neurons, these inhibitors are unsuitable for the study of neurally mediated gut function due to their inhibitory effects on neuromuscular transmission and smooth muscle contractility.NEW & NOTEWORTHY Internalization of activated G protein-coupled receptors is a major determinant of the type and duration of subsequent downstream signaling events. Inhibitors of endocytosis effectively block opioid receptor internalization in enteric neurons. The clathrin-dependent endocytosis inhibitor Pitstop2 blocks effects of opioids on neurogenic contractions of the colon in an internalization-independent manner. These inhibitors also significantly impact cholinergic neuromuscular transmission. We conclude that these tools are unsuitable for examination of the contribution of neuronal G protein-coupled receptor endocytosis to gastrointestinal motility.
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Affiliation(s)
- Jesse J DiCello
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Parkville, Victoria, Australia
| | - Pradeep Rajasekhar
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Emily M Eriksson
- Divisions of Population Health & Immunity and Infection and Immunity, The Walter and Eliza Hall Institute, Parkville, Victoria, Australia.,Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia
| | - Ayame Saito
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Parkville, Victoria, Australia
| | - Arisbel B Gondin
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Parkville, Victoria, Australia
| | - Nicholas A Veldhuis
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Parkville, Victoria, Australia
| | - Meritxell Canals
- Centre for Membrane Proteins and Receptors, School of Life Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Simona E Carbone
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Parkville, Victoria, Australia
| | - Daniel P Poole
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, Parkville, Victoria, Australia.,Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, Victoria, Australia
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40
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Thapa N, Kappus M, Hurt R, Diamond S. Implications of the Opioid Epidemic for the Clinical Gastroenterology Practice. Curr Gastroenterol Rep 2019; 21:44. [PMID: 31346779 DOI: 10.1007/s11894-019-0712-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW The opioid epidemic in the USA has led to a rise in opioid-related gastrointestinal (GI) side effects that are often difficult to diagnose and treat. The aim of this report is to discuss opioid pathophysiology, opioid-related GI side effects, clinical presentation, and diagnostic criteria and to review the current pharmacotherapy available. RECENT FINDINGS Opioid-related GI disorders are increasingly recognized and include, but are not limited to, opioid-induced esophageal dysfunction (OIED), gastroparesis, opioid-induced constipation (OIC), narcotic bowel syndrome (NBS), acute post-operative ileus, and anal sphincter dysfunction. Treatment of these conditions is challenging. OIC has the most available pharmacotherapy for treatment, including classical laxatives, peripherally acting μ-receptor antagonists (PAMORAs), novel therapies (lubiprostone, prucalopride- 5-HT agonist), and preventative therapies (PR oxycodone/naloxone). The gastrointestinal effects of opioid therapy are variable and often debilitating. While medical management for some opioid-related GI side effects exists, limiting or completely avoiding opioid use for chronic non-cancer pain will mitigate these effects most effectively.
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Affiliation(s)
- Namisha Thapa
- Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Matthew Kappus
- Department of Medicine, Duke University, Durham, NC, USA
| | - Ryan Hurt
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sarah Diamond
- Department of Medicine, Division of Gastroenterology and Hepatology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, L-461, Portland, OR, 97239, USA.
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Carbone SE, Veldhuis NA, Gondin AB, Poole DP. G protein-coupled receptor trafficking and signaling: new insights into the enteric nervous system. Am J Physiol Gastrointest Liver Physiol 2019; 316:G446-G452. [PMID: 30702900 DOI: 10.1152/ajpgi.00406.2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
G protein-coupled receptors (GPCRs) are essential for the neurogenic control of gastrointestinal (GI) function and are important and emerging therapeutic targets in the gut. Detailed knowledge of both the distribution and functional expression of GPCRs in the enteric nervous system (ENS) is critical toward advancing our understanding of how these receptors contribute to GI function during physiological and pathophysiological states. Equally important, but less well defined, is the complex relationship between receptor expression, ligand binding, signaling, and trafficking within enteric neurons. Neuronal GPCRs are internalized following exposure to agonists and under pathological conditions, such as intestinal inflammation. However, the relationship between the intracellular distribution of GPCRs and their signaling outputs in this setting remains a "black box". This review will briefly summarize current knowledge of agonist-evoked GPCR trafficking and location-specific signaling in the ENS and identifies key areas where future research could be focused. Greater understanding of the cellular and molecular mechanisms involved in regulating GPCR signaling in the ENS will provide new insights into GI function and may open novel avenues for therapeutic targeting of GPCRs for the treatment of digestive disorders.
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Affiliation(s)
- Simona E Carbone
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences and Australian Research Council Centre of Excellence in Convergent Bio-Nano Science and Technology, Monash University , Parkville, Victoria , Australia
| | - Nicholas A Veldhuis
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences and Australian Research Council Centre of Excellence in Convergent Bio-Nano Science and Technology, Monash University , Parkville, Victoria , Australia
| | - Arisbel B Gondin
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences and Australian Research Council Centre of Excellence in Convergent Bio-Nano Science and Technology, Monash University , Parkville, Victoria , Australia
| | - Daniel P Poole
- Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences and Australian Research Council Centre of Excellence in Convergent Bio-Nano Science and Technology, Monash University , Parkville, Victoria , Australia.,Anatomy and Neuroscience, The University of Melbourne , Parkville, Victoria , Australia
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42
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Raffa RB, Taylor R, Pergolizzi JV. Treating opioid‐induced constipation in patients taking other medications: Avoiding CYP450 drug interactions. J Clin Pharm Ther 2019; 44:361-371. [DOI: 10.1111/jcpt.12812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/15/2019] [Accepted: 01/18/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Robert B. Raffa
- University of Arizona College of Pharmacy Tucson Arizona
- Temple University School of Pharmacy Philadelphia Pennsylvania
- Neumentum Inc Palo Alto California
- The NEMA Research Group Naples Florida
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43
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Viscusi ER. Clinical Overview and Considerations for the Management of Opioid-induced Constipation in Patients With Chronic Noncancer Pain. Clin J Pain 2019; 35:174-188. [PMID: 30289777 PMCID: PMC6343957 DOI: 10.1097/ajp.0000000000000662] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 09/04/2018] [Accepted: 09/15/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Opioid analgesics may be associated with chronic adverse effects, such as opioid-induced constipation (OIC). Available and emerging prescription medications for OIC in patients with chronic noncancer pain are described, including concerns and challenges associated with OIC management. METHODS Narrative review. RESULTS OIC is characterized by a change in bowel habits and defecation patterns that occurs when initiating opioid therapy and is associated with reduced bowel frequency, straining, sensation of incomplete evacuation, and/or patient distress related to bowel habits. Prescription medications are indicated when OIC persists despite conservative approaches (eg, increased fiber and fluid intake, exercise, over-the-counter laxatives and stool softeners). Phase 3 studies have demonstrated the efficacy of peripherally acting µ-opioid receptor antagonists (PAMORA; methylnaltrexone, naloxegol, naldemedine), and a chloride channel activator (lubiprostone) for improving OIC in patients with chronic noncancer pain. Although head-to-head studies are lacking, a meta-analysis demonstrated that μ-opioid receptor antagonists were more effective than placebo for the treatment of OIC. The most common adverse effects associated with prescription medications for OIC are gastrointestinal related (eg, nausea, diarrhea, abdominal pain, or distention), with most being mild or moderate in severity. Therapy currently in development for OIC includes the PAMORA axelopran. DISCUSSION Health care providers should be aware of this complication in patients receiving opioids and should monitor and address constipation-related symptoms to optimize pain management and improve patient quality of life.
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Affiliation(s)
- Eugene R Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
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Farmer AD, Drewes AM, Chiarioni G, De Giorgio R, O'Brien T, Morlion B, Tack J. Pathophysiology and management of opioid-induced constipation: European expert consensus statement. United European Gastroenterol J 2019; 7:7-20. [PMID: 30788113 PMCID: PMC6374852 DOI: 10.1177/2050640618818305] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/18/2018] [Indexed: 12/31/2022] Open
Abstract
Background Opioid-induced bowel dysfunction is a complication of opioid therapy, in which constipation is the most common and problematic symptom. However, it is frequently under-recognised and thus effective management is often not instituted despite a number of treatment options. Objective The central objective of this study is to provide a summary of the pathophysiology and clinical evaluation of opioid-induced constipation and to provide a pragmatic management algorithm for day-to-day clinical practice. Methods This summary and the treatment algorithm is based on the opinion of a European expert panel evaluating current evidence in the literature. Results The pathophysiology of opioid-induced constipation is multi-faceted. The key aspect of managing opioid-induced constipation is early recognition. Specific management includes increasing fluid intake, exercise and standard laxatives as well as addressing exacerbating factors. The Bowel Function Index is a useful way of objectively evaluating severity of opioid-induced constipation and monitoring response. Second-line treatments can be considered in those with recalcitrant symptoms, which include gut-restricted or peripherally acting mu-opioid receptor antagonists. However, a combination of interventions may be needed. Conclusion Opioid-induced constipation is a common, yet under-recognised and undertreated, complication of opioid therapy. We provide a pragmatic step-wise approach to opioid-induced constipation, which should simplify management for clinicians.
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Affiliation(s)
- Adam D Farmer
- Institute of Applied Clinical Science, Keele University, Keele, UK
- Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
- Centre for Trauma and Neuroscience, Queen Mary University of London, London, UK
| | - Asbjørn M Drewes
- Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Giuseppe Chiarioni
- Division of Gastroenterology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | | | - Tony O'Brien
- Marymount University Hospital and Hospice, Curraheen, Ireland
- Cork University Hospital, Wilton, Ireland
| | - Bart Morlion
- Leuven Centre for Algology and Pain Management, University of Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
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Abstract
The clinical setting in which women's health physicians practice, whether as generalist, obstetricians and gynecologists, or subspecialists, dictates our frequent clinical interaction with "pain." Opioid-containing medications are frequently prescribed within our specialty as a means of immediate pain relief. Opioid-containing medication causes a deep physiological alteration of several systems resulting in potential harm to acute and chronic opioid users. This article includes a thorough system-based review of opioid-containing medications on physiological systems. Women's health providers should have an in-depth understanding of such reverberations on patients' wellbeing to maintain the safest level of care. A solid grasp of physiological repercussions of opioid use would encourage physicians to seek alternative treatment options. Such practice is essential in curbing the opioid epidemic our patients are facing.
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Mark EB, Bødker MB, Grønlund D, Østergaard LR, Frøkjaer JB, Drewes AM. MRI analysis of fecal volume and dryness: Validation study using an experimental oxycodone-induced constipation model. J Magn Reson Imaging 2019; 50:733-745. [PMID: 30609164 DOI: 10.1002/jmri.26628] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/12/2018] [Accepted: 12/12/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Opioids are known to affect gastrointestinal motility, but their effect on fluid absorption and secretion is poorly understood in humans. PURPOSE To investigate the effect of oxycodone on colonic fecal volume and stool dryness by using a novel MRI-based technique. STUDY TYPE Prospective, randomized, double-blinded, crossover study. SUBJECTS Twenty-five healthy male volunteers (median age: 24 years [range: 21-56]; mean body mass index [BMI]: 23.9 kg/m2 [range: 22.9-25.0]) without known gastrointestinal disease. FIELD STRENGTH/SEQUENCE T2 -weighted and two-point Dixon MRI scans of the abdomen at 1.5 T. ASSESSMENT Subjects were treated for 5 days with prolonged-release oxycodone or a placebo. Imaging was performed on the first and last study day in each period. Images of the colon were analyzed with semiautomatic k-means-based segmentation software. Regional colonic fecal volumes were quantified excluding gas volume and colon wall. Two-point Dixon and T2 -weighted MRI signal intensity were assessed as a proxy of colonic stool dryness. Data were obtained in a previously reported study. STATISTICAL TESTS Intraclass correlation coefficients were used to test the reliability of measurements between days, while repeated measures mixed models were applied to test treatment effects. RESULTS After oxycodone treatment, total colonic fecal volume was significantly increased compared with placebo (mean change 100 mL vs. -13 mL; P = 0.001), with the largest increase (24%) observed in the ascending colon/cecum (P = 0.001). Dixon signal increased (less water in colon content) after oxycodone treatment compared with placebo (mean 0.09 vs. -0.02; P < 0.001). T2 -weighted signal decreased (less water in colon content) after oxycodone treatment compared with placebo (mean -0.03 vs. 0.03; P = 0.002). DATA CONCLUSION The 5-day oxycodone treatment increased colonic fecal volume and increased stool dryness compared with placebo. This imaging-based method for noninvasive analysis of colon content has the potential to characterize gastrointestinal symptoms in general, such as in constipation. LEVEL OF EVIDENCE 2 Technical Efficacy Stage: 1 J. Magn. Reson. Imaging 2019;50:733-745.
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Affiliation(s)
- Esben B Mark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Mark B Bødker
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Debbie Grønlund
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Lasse R Østergaard
- Department of Health Science and Technology, Aalborg University, Aalborg Øst, Denmark
| | - Jens B Frøkjaer
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Asbjørn M Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Streicher JM, Bilsky EJ. Peripherally Acting μ-Opioid Receptor Antagonists for the Treatment of Opioid-Related Side Effects: Mechanism of Action and Clinical Implications. J Pharm Pract 2018; 31:658-669. [PMID: 28946783 PMCID: PMC6291905 DOI: 10.1177/0897190017732263] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Opioid receptors are distributed throughout the central and peripheral nervous systems and on many nonneuronal cells. Therefore, opioid administration induces effects beyond analgesia. In the enteric nervous system (ENS), stimulation of µ-opioid receptors triggers several inhibitory responses that can culminate in opioid-induced bowel dysfunction (OBD) and its most common side effect, opioid-induced constipation (OIC). OIC negatively affects patients' quality of life (QOL), ability to work, and pain management. Although laxatives are a common first-line OIC therapy, most have limited efficacy and do not directly antagonize opioid effects on the ENS. Peripherally acting µ-opioid receptor antagonists (PAMORAs) with limited ability to cross the blood-brain barrier have been developed. The PAMORAs approved by the U S Food and Drug Administration for OIC are subcutaneous and oral methylnaltrexone, oral naloxegol, and oral naldemedine. Although questions of cost-effectiveness and relative efficacy versus laxatives remain, PAMORAs can mitigate OIC and improve patient QOL. PAMORAS may also have applications beyond OIC, including reducing the increased cardiac risk or potential tumorigenic effects of opioids. This review discusses the burden of OIC and OBD, reviews the mechanism of action of new OIC therapies, and highlights other potential opioid-related side effects mediated by peripheral opioid receptors in the context of new OIC therapies.
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Affiliation(s)
- John M Streicher
- Department of Pharmacology, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Edward J Bilsky
- Pacific Northwest University of Health Sciences, Yakima, WA, USA
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Machelska H, Celik MÖ. Advances in Achieving Opioid Analgesia Without Side Effects. Front Pharmacol 2018; 9:1388. [PMID: 30555325 PMCID: PMC6282113 DOI: 10.3389/fphar.2018.01388] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 11/12/2018] [Indexed: 12/12/2022] Open
Abstract
Opioids are the most effective drugs for the treatment of severe pain, but they also cause addiction and overdose deaths, which have led to a worldwide opioid crisis. Therefore, the development of safer opioids is urgently needed. In this article, we provide a critical overview of emerging opioid-based strategies aimed at effective pain relief and improved side effect profiles. These approaches comprise biased agonism, the targeting of (i) opioid receptors in peripheral inflamed tissue (by reducing agonist access to the brain, the use of nanocarriers, or low pH-sensitive agonists); (ii) heteromers or multiple receptors (by monovalent, bivalent, and multifunctional ligands); (iii) receptor splice variants; and (iv) endogenous opioid peptides (by preventing their degradation or enhancing their production by gene transfer). Substantial advancements are underscored by pharmaceutical development of new opioids such as peripheral κ-receptor agonists, and by treatments augmenting the action of endogenous opioids, which have entered clinical trials. Additionally, there are several promising novel opioids comprehensively examined in preclinical studies, but also strategies such as biased agonism, which might require careful rethinking.
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Affiliation(s)
- Halina Machelska
- Department of Experimental Anesthesiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Melih Ö Celik
- Department of Experimental Anesthesiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Camilleri M, Chedid V, Ford AC, Haruma K, Horowitz M, Jones KL, Low PA, Park SY, Parkman HP, Stanghellini V. Gastroparesis. Nat Rev Dis Primers 2018; 4:41. [PMID: 30385743 DOI: 10.1038/s41572-018-0038-z] [Citation(s) in RCA: 186] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Gastroparesis is a disorder characterized by delayed gastric emptying of solid food in the absence of a mechanical obstruction of the stomach, resulting in the cardinal symptoms of early satiety, postprandial fullness, nausea, vomiting, belching and bloating. Gastroparesis is now recognized as part of a broader spectrum of gastric neuromuscular dysfunction that includes impaired gastric accommodation. The overlap between upper gastrointestinal symptoms makes the distinction between gastroparesis and other disorders, such as functional dyspepsia, challenging. Thus, a confirmed diagnosis of gastroparesis requires measurement of delayed gastric emptying via an appropriate test, such as gastric scintigraphy or breath testing. Gastroparesis can have idiopathic, diabetic, iatrogenic, post-surgical or post-viral aetiologies. The management of gastroparesis involves: correcting fluid, electrolyte and nutritional deficiencies; identifying and treating the cause of delayed gastric emptying (for example, diabetes mellitus); and suppressing or eliminating symptoms with pharmacological agents as first-line therapies. Several novel pharmacologic agents and interventions are currently in the pipeline and show promise to help tailor individualized therapy for patients with gastroparesis.
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Affiliation(s)
- Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| | - Victor Chedid
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Alexander C Ford
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Ken Haruma
- Department of Internal Medicine 2, General Medical Center, Kawasaki Medical School, Okayama, Japan
| | - Michael Horowitz
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Karen L Jones
- National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
| | - Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Seon-Young Park
- Division of Gastroenterology, Chonnam National University School of Medicine, Gwangju, Republic of Korea
| | - Henry P Parkman
- GI Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Vincenzo Stanghellini
- Department of Digestive Diseases, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
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Webster LR, Israel RJ. Oral methylnaltrexone is efficacious and well tolerated for the treatment of opioid-induced constipation in patients with chronic noncancer pain receiving concomitant methadone. J Pain Res 2018; 11:2509-2516. [PMID: 30425563 PMCID: PMC6205130 DOI: 10.2147/jpr.s160625] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Purpose To evaluate the safety and efficacy of oral methylnaltrexone for opioid-induced constipation (OIC). Patients and methods This was a post hoc analysis of patients receiving methadone in a randomized, double-blind, placebo-controlled, Phase 3 trial. The trial included adults with chronic noncancer pain for ≥2 months receiving opioid doses ≥50 mg/day of oral morphine equivalents for ≥14 days and with a history of OIC. Patients were assigned to oral methylnaltrexone (150, 300, or 450 mg) or placebo once daily (QD) for 4 weeks followed by 8 weeks as needed. Percentage of dosing days that resulted in a rescue-free bowel movement (RFBM) within 4 hours of dosing was assessed during QD dosing (primary efficacy endpoint). Other endpoints included percentage of responders (ie, ≥3 RFBMs/week, with an increase of ≥1 RFBM/week from baseline for ≥3 of the 4 weeks) during QD dosing and change in weekly number of RFBMs. Adverse events were assessed. Results Concomitant methadone was reported in 120 patients (oral methylnaltrexone: 150 mg [n=33], 300 mg [n=30], and 450 mg [n=31]; placebo [n=26]). Oral methylnaltrexone-treated patients had significant increases in mean percentage of dosing days with RFBMs within 4 hours of dosing during weeks 1–4 with 300 mg (33.6%; P<0.01) and 450 mg (38.2%; P<0.001) vs placebo; improvements with 150 mg (20.0%) vs placebo (15.1%) did not reach statistical significance. The percentage of responders was greater vs placebo, but not significant, for the higher doses during the QD period (150 mg [39.4%], 300 mg [60.0%], 450 mg [67.7%], and placebo [38.5%]). Change from baseline in the mean number of weekly RFBMs (weeks 1–4) was significantly greater with oral methylnaltrexone 450 mg vs placebo (least-squares mean difference vs placebo, 1.2; P=0.04); no significant differences were found for 300 or 150 mg. Oral methylnaltrexone was well tolerated at all doses; few patients discontinued treatment. Conclusion Oral methylnaltrexone, particularly 450 mg, was efficacious and safe for treating OIC in these patients.
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Affiliation(s)
- Lynn R Webster
- Scientific Affairs, PRA Health Sciences, Salt Lake City, UT, USA
| | - Robert J Israel
- Clinical and Medical Affairs, Salix Pharmaceuticals, Bridgewater, NJ, USA,
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