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Chen YH, Xenitidis A, Hoffmann P, Matthews L, Padmanabhan SG, Aravindan L, Ressler R, Sivam I, Sivam S, Gillispie CF, Sadhasivam S. Opioid use disorder in pediatric populations: considerations for perioperative pain management and precision opioid analgesia. Expert Rev Clin Pharmacol 2024; 17:455-465. [PMID: 38626303 PMCID: PMC11116045 DOI: 10.1080/17512433.2024.2343915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 04/12/2024] [Indexed: 04/18/2024]
Abstract
INTRODUCTION Opioids are commonly used for perioperative analgesia, yet children still suffer high rates of severe post-surgical pain and opioid-related adverse effects. Persistent and severe acute surgical pain greatly increases the child's chances of chronic surgical pain, long-term opioid use, and opioid use disorder. AREAS COVERED Enhanced recovery after surgery (ERAS) protocols are often inadequate in treating a child's severe surgical pain. Research suggests that 'older' and longer-acting opioids such as methadone are providing better methods to treat acute post-surgical pain. Studies indicate that lower repetitive methadone doses can decrease the incidence of chronic persistent surgical pain (CPSP). Ongoing research explores genetic components influencing severe surgical pain, inadequate opioid analgesia, and opioid use disorder. This new genetic research coupled with better utilization of opioids in the perioperative setting provides hope in personalizing surgical pain management, reducing pain, opioid use, adverse effects, and helping the fight against the opioid pandemic. EXPERT OPINION The opioid and analgesic pharmacogenomics approach can proactively 'tailor' a perioperative analgesic plan to each patient based on underlying polygenic risks. This transition from population-based knowledge of pain medicine to individual patient knowledge can transform acute pain medicine and greatly reduce the opioid epidemic's socioeconomic, personal, and psychological strains globally.
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Affiliation(s)
- Yun Han Chen
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Paul Hoffmann
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Leslie Matthews
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | - Ruth Ressler
- Department of Biochemistry and Molecular Biology, The College of Wooster, Wooster, Ohio, USA
| | - Inesh Sivam
- North Allegheny High School, Pittsburgh, Pennsylvania, USA
| | - Sahana Sivam
- North Allegheny High School, Pittsburgh, Pennsylvania, USA
| | - Chase F. Gillispie
- Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia 25701
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Ferreira do Couto ML, Fonseca S, Pozza DH. Pharmacogenetic Approaches in Personalized Medicine for Postoperative Pain Management. Biomedicines 2024; 12:729. [PMID: 38672085 PMCID: PMC11048650 DOI: 10.3390/biomedicines12040729] [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: 01/31/2024] [Revised: 03/08/2024] [Accepted: 03/19/2024] [Indexed: 04/28/2024] Open
Abstract
Despite technical and pharmacological advancements in recent years, including optimized therapies and personalized medicine, postoperative pain management remains challenging and sometimes undertreated. This review aims to summarize and update how genotype-guided therapeutics within personalized medicine can enhance postoperative pain management. Several studies in the area have demonstrated that genotype-guided therapy has the ability to lower opioid consumption and improve postoperative pain. Gene mutations, primarily OPRM1, CYP2D6, CYP2C9, COMT and ABCB1, have been shown to exert nuanced influences on analgesic response and related pharmacological outcomes. This review underscores the integration of pharmacogenetic-guided personalized medicine into perioperative care, particularly when there is uncertainty regarding opioid prescriptions. This approach leads to superior outcomes in terms of postoperative pain relief and reduced morbidity for numerous patients.
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Affiliation(s)
- Maria Leonor Ferreira do Couto
- Experimental Biology Unit, Department of Biomedicine, Faculty of Medicine of Porto, University of Porto, 4200-319 Porto, Portugal;
| | - Sara Fonseca
- Anesthesiology Department, São João University Hospital Centre, 4200-135 Porto, Portugal;
| | - Daniel Humberto Pozza
- Experimental Biology Unit, Department of Biomedicine, Faculty of Medicine of Porto, University of Porto, 4200-319 Porto, Portugal;
- Institute for Research and Innovation in Health and IBMC (i3S), University of Porto, 4200-135 Porto, Portugal
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3
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Yang J, Sun YZ, Li QF, Fu Z, Guan YY, Song C, Zheng L. Study on the association between adverse drug reactions to opioids and gene polymorphisms: a case-case-control study. BMC Pharmacol Toxicol 2023; 24:64. [PMID: 37990344 PMCID: PMC10662635 DOI: 10.1186/s40360-023-00708-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 11/15/2023] [Indexed: 11/23/2023] Open
Abstract
OBJECTIVE Adverse drug reactions (ADRs) caused by opioid drugs show individual differences. Our objective was to explore the association between gene polymorphism and ADRs induced by opioid drugs. METHODS Evidence-based medical data analysis was conducted for genes related to ADRs induced by opioid drugs to select target genes. Sixty patients with cancer pain who had ADRs after taking opioid drugs (morphine, codeine, oxycodone) and 60 patients without ADRs after taking opioid drugs were used as the experimental group and control group, respectively. Then, we used polymerase chain reaction (PCR) or in situ hybridization to detect target genes. By combining with clinical data such as age, sex, dosage and duration of medication, the effect of gene polymorphism on the ADR of patients after taking opioid drugs was statistically analysed. RESULTS Based on a database search and evidence-based medical data, we identified CYP2D6*10, CYP3A5*3, ABCB1, and OPRM1 as target genes for detection. The results of statistical analysis showed no significant difference in genotype distribution between the experimental group and the control group (p > 0.05). However, if 32 patients with ADRs after taking oxycodone and 32 controls were selected for comparison, the SPSS22.0 and SNPStats genetic models showed that the ABCB1 (062rs1045642) CT and TT genotypes correlated with the occurrence of ADRs (p < 0.05): the total number of CT + TT genotypes in the experimental group was 29 (90.62%), with 11 (34.37%) CT + TT genotypes types in the control group. CONCLUSION Polymorphism of ABCB1 (062rs1045642) is related to ADRs caused by oxycodone, and the incidence of ADRs is higher with the allele T. Polymorphism of ABCB1 is expected to become a clinical predictor of ADRs to oxycodone, and attention should be given to the occurrence of serious ADRs in patients with ABCB1 (062rs1045642) CT and TT genotypes.
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Affiliation(s)
- Jing Yang
- School of Medicine and Pharmacy, Ocean University of China, Qingdao, China
- Department of Pharmacy, Shandong Medical College, Jinan, China
- Department of Pharmacy, Shandong Provincial Third Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ying-Zi Sun
- Department of Pharmacy, Shandong Provincial Third Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qun-Fang Li
- Department of Pharmacy, Shandong Medical College, Jinan, China
| | - Zheng Fu
- Department of Pharmacy, Shandong Medical College, Jinan, China
| | - Yu-Yao Guan
- Department of Pharmacy, Shandong Provincial Third Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chao Song
- Department of Pharmacy, Shandong Provincial Third Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
| | - Lei Zheng
- Department of Pharmacy, Shandong Provincial Third Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
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Dzierba AL, Stollings JL, Devlin JW. A pharmacogenetic precision medicine approach to analgesia and sedation optimization in critically ill adults. Pharmacotherapy 2023; 43:1154-1165. [PMID: 36680385 DOI: 10.1002/phar.2768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/17/2022] [Accepted: 12/21/2022] [Indexed: 01/22/2023]
Abstract
Precision medicine is a growing field in critical care. Research increasingly demonstrated pharmacogenomic variability to be an important determinant of analgesic and sedative drug response in the intensive care unit (ICU). Genome-wide association and candidate gene finding studies suggest analgesic and sedatives tailored to an individual's genetic makeup, environmental adaptations, in addition to several other patient- and drug-related factors, will maximize effectiveness and help mitigate harm. However, the number of pharmacogenetic studies in ICU patients remains small and no prospective studies have been published using pharmacogenomic data to optimize analgesic or sedative therapy in critically ill patients. Current recommendations for treating ICU pain and agitation are based on controlled studies having low external validity, including the failure to consider pharmacogenomic factors affecting response. Use of a precision medicine approach to individualize pharmacotherapy focused on optimizing ICU patient comfort and safety may improve the outcomes of critically ill adults. Additionally, benefits and risks of analgesic and/or sedative therapy in an individual may be informed with large, standardized datasets. The purpose of this review was to describe a precision medicine approach focused on optimizing analgesic and sedative therapy in individual ICU patients to optimize clinical outcomes and reduce safety concerns.
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Affiliation(s)
- Amy L Dzierba
- Department of Pharmacy, New York-Presbyterian Hospital, New York, New York, USA
- Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, New York, USA
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee, USA
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, Massachusetts, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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5
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McDonnell JM, Rigney B, Storme J, Ahern DP, Cunniffe G, Butler JS. Pharmacogenetic profiling and individualised therapy in the treatment of degenerative spinal conditions. Ir J Med Sci 2022:10.1007/s11845-022-03112-9. [PMID: 35962253 DOI: 10.1007/s11845-022-03112-9] [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: 06/11/2022] [Accepted: 07/20/2022] [Indexed: 10/15/2022]
Abstract
Patients presenting with degenerative spinal changes are often poor surgical candidates due to associated co-morbidities, frailty, or sarcopenia. Additionally, surgeries of a degenerative spine can prove difficult due to the distortion of normal surgical anatomy. Therefore, many patients are managed conservatively with a variety of modalities, including over-the-counter and prescription medications. Nevertheless, several patients do not experience adequate relief from pain with analgesic medications, precipitating multiple hospital visits, and usage of resources. As a result, back pain is regarded as a major economic burden, with total costs of associated treatment exceeding $100 billion annually. Pharmacogenetics is a relatively novel method of evaluating an individual's response to analgesic medications, through analysis of germline polymorphisms. It entails obtaining a genetic sample, often via buccal swab or peripheral blood sample, and genetic analysis achieved through either polymerase chain reaction +/- Sanger sequencing, microassays, restriction length fragment polymorphism analysis, or genetic library preparation and next generation sequencing. The potential efficacy of pharmacogenetic analysis has been highlighted across several specialities to date. However, a paucity of evidence exists regarding spine surgery populations. Nevertheless, regular prospective pharmacogenetic analysis may ultimately prove beneficial when concerning degenerative spinal cohorts due to aforementioned surgical and economic considerations. The purpose of this narrative review is to outline how metaboliser profile variants affect the pharmacokinetics of specific analgesia used to treat back pain, and to discuss the current potential and limitations of employing regular pharmacogenetic analysis for spine surgery populations with degenerative conditions.
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Affiliation(s)
- Jake M McDonnell
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Eccles St., Dublin, D07 R2WY, Ireland.
| | - Brian Rigney
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Eccles St., Dublin, D07 R2WY, Ireland
| | - James Storme
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Eccles St., Dublin, D07 R2WY, Ireland
| | - Daniel P Ahern
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Eccles St., Dublin, D07 R2WY, Ireland.,School of Medicine, Trinity College, Dublin, Ireland
| | - Gráinne Cunniffe
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Eccles St., Dublin, D07 R2WY, Ireland
| | - Joseph S Butler
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Eccles St., Dublin, D07 R2WY, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
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6
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Role of Drug Transporters in Elucidating Inter-Individual Variability in Pediatric Chemotherapy-Related Toxicities and Response. Pharmaceuticals (Basel) 2022; 15:ph15080990. [PMID: 36015138 PMCID: PMC9415926 DOI: 10.3390/ph15080990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 11/16/2022] Open
Abstract
Pediatric cancer treatment has evolved significantly in recent decades. The implementation of risk stratification strategies and the selection of evidence-based chemotherapy combinations have improved survival outcomes. However, there is large interindividual variability in terms of chemotherapy-related toxicities and, sometimes, the response among this population. This variability is partly attributed to the functional variability of drug-metabolizing enzymes (DME) and drug transporters (DTS) involved in the process of absorption, distribution, metabolism and excretion (ADME). The DTS, being ubiquitous, affects drug disposition across membranes and has relevance in determining chemotherapy response in pediatric cancer patients. Among the factors affecting DTS function, ontogeny or maturation is important in the pediatric population. In this narrative review, we describe the role of drug uptake/efflux transporters in defining pediatric chemotherapy-treatment-related toxicities and responses. Developmental differences in DTS and the consequent implications are also briefly discussed for the most commonly used chemotherapeutic drugs in the pediatric population.
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Zhao J, Cai S, Zhang L, Rao Y, Kang X, Feng Z. Progress, Challenges, and Prospects of Research on the Effect of Gene Polymorphisms on Adverse Reactions to Opioids. Pain Ther 2022; 11:395-409. [PMID: 35429333 PMCID: PMC9098754 DOI: 10.1007/s40122-022-00374-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 03/07/2022] [Indexed: 11/28/2022] Open
Abstract
The abuse of opioids has become one of the most serious concerns in the world. Opioid use can cause serious adverse reactions, including respiratory depression, postoperative nausea and vomiting, itching, and even death. These adverse reactions are also important complications of clinical application of opioid drugs that may affect patient safety and recovery. Due to the fear of adverse reactions of opioids, clinicians often do not dare to use opioids in an adequate or appropriate amount, thus affecting the clinical medication strategy and the quality of treatment for patients. The prediction of adverse reactions to opioids is one of the most concerned problems in clinical practice. At present, the correlation between gene polymorphism and the efficacy of opiates has been widely studied and preliminarily confirmed, but the research on the effect of gene polymorphism on the adverse reactions of opiates is relatively limited. Existing studies have made encouraging progress in predicting the incidence and severity of adverse opioid reactions and clinical management by using genetic testing, but most of these studies are single-center, small-sample clinical studies or animal experiments, which have strong limitations. When the same receptor or enzyme is studied by different experimental methods, different or even opposite conclusions can be drawn. These phenomena indicate that the correlation between gene polymorphism and adverse opioid reaction still needs further research and demonstration. At present, it is still too early to use genetic testing to predict opioid adverse reactions in clinic. In this paper, the correlation between gene polymorphism and adverse opioid reactions and a small number of clinical applications were reviewed in terms of pharmacokinetics and pharmacodynamics, in order to provide some suggestions for future research and clinical drug decision making.
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8
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Chi M, Xi Q, Su D, Li H, Wei N, Shi X, Wang S, Zuo Y, Yang L. Characterized the diversity of ABCB1 subtypes in immunogenomic landscape for predicting the drug response in breast cancer. Methods 2022; 204:223-233. [PMID: 34999214 DOI: 10.1016/j.ymeth.2022.01.003] [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: 12/10/2021] [Revised: 12/30/2021] [Accepted: 01/03/2022] [Indexed: 12/24/2022] Open
Abstract
ABCB1 is an important gene that closely related to analgesic tolerance to opioids, and plays an important role in their postoperative treatment. Recent studies have demonstrated that ABCB1 genotype is significantly associated with the chemico-resistance and chemical sensitivity in breast cancer patients. So, it is become very important to investigate the important role of ABCB1 for predicting drug response in breast cancer patients. In this study, by conducting the Cox proportional hazards regression analysis in breast cancer patients, significant differences were found in prognosis between the ABCB1 high- and low-expression subtypes. Meanwhile, by using immune infiltration profiles as well as transcriptomics datasets, the ABCB1 high subtype was found to be significantly enriched in many immune-related KEGG pathways and biological processes, and was characterized by the high infiltration levels of immune cell types. Furthermore, bioinformatics inference revealed that the ABCB1 subtypes were associated with the therapeutic effect of immunotherapy, which would be important for patient prognosis. In conclusion, these findings may provide useful help for recognizing the diversity between ABCB1 subtypes in tumor immune microenvironment, and may unravel prognosis outcomes and immunotherapy utility for ABCB1 in breast cancer.
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Affiliation(s)
- Meng Chi
- Department of Anesthesiology, Harbin Medical University Cancer Hospital, Harbin 150081, China
| | - Qilemuge Xi
- The State Key Laboratory of Reproductive Regulation and Breeding of Grassland Livestock, College of Life Sciences, Inner Mongolia University, Hohhot 010070, China
| | - Dongqing Su
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin 150081, China
| | - Hanshuang Li
- The State Key Laboratory of Reproductive Regulation and Breeding of Grassland Livestock, College of Life Sciences, Inner Mongolia University, Hohhot 010070, China
| | - Na Wei
- Department of Anesthesiology, Harbin Medical University Cancer Hospital, Harbin 150081, China
| | - Xiaoding Shi
- Department of Anesthesiology, Harbin Medical University Cancer Hospital, Harbin 150081, China
| | - Shiyuan Wang
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin 150081, China
| | - Yongchun Zuo
- The State Key Laboratory of Reproductive Regulation and Breeding of Grassland Livestock, College of Life Sciences, Inner Mongolia University, Hohhot 010070, China; Digital College, Inner Mongolia Intelligent Union Big Data Academy, Inner Mingolia Wesure Date Technology Co., Ltd., Hohhot 010010, China.
| | - Lei Yang
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin 150081, China.
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9
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van Hoogdalem MW, Wexelblatt SL, Akinbi HT, Vinks AA, Mizuno T. A review of pregnancy-induced changes in opioid pharmacokinetics, placental transfer, and fetal exposure: Towards fetomaternal physiologically-based pharmacokinetic modeling to improve the treatment of neonatal opioid withdrawal syndrome. Pharmacol Ther 2021; 234:108045. [PMID: 34813863 DOI: 10.1016/j.pharmthera.2021.108045] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/29/2021] [Accepted: 11/15/2021] [Indexed: 02/07/2023]
Abstract
Physiologically-based pharmacokinetic (PBPK) modeling has emerged as a useful tool to study pharmacokinetics (PK) in special populations, such as pregnant women, fetuses, and newborns, where practical hurdles severely limit the study of drug behavior. PK in pregnant women is variable and everchanging, differing greatly from that in their nonpregnant female and male counterparts typically enrolled in clinical trials. PBPK models can accommodate pregnancy-induced physiological and metabolic changes, thereby providing mechanistic insights into maternal drug disposition and fetal exposure. Fueled by the soaring opioid epidemic in the United States, opioid use during pregnancy continues to rise, leading to an increased incidence of neonatal opioid withdrawal syndrome (NOWS). The severity of NOWS is influenced by a complex interplay of extrinsic and intrinsic factors, and varies substantially between newborns, but the extent of prenatal opioid exposure is likely the primary driver. Fetomaternal PBPK modeling is an attractive approach to predict in utero opioid exposure. To facilitate the development of fetomaternal PBPK models of opioids, this review provides a detailed overview of pregnancy-induced changes affecting the PK of commonly used opioids during gestation. Moreover, the placental transfer of these opioids is described, along with their disposition in the fetus. Lastly, the implementation of these factors into PBPK models is discussed. Fetomaternal PBPK modeling of opioids is expected to provide improved insights in fetal opioid exposure, which allows for prediction of postnatal NOWS severity, thereby opening the way for precision postnatal treatment of these vulnerable infants.
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Affiliation(s)
- Matthijs W van Hoogdalem
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA
| | - Scott L Wexelblatt
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Center for Addiction Research, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Henry T Akinbi
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Center for Addiction Research, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Center for Addiction Research, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.
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10
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Packiasabapathy S, Aruldhas BW, Zhang P, Overholser BR, Quinney SK, Sadhasivam S. Novel associations between CYP2B6 polymorphisms, perioperative methadone metabolism and clinical outcomes in children. Pharmacogenomics 2021; 22:591-602. [PMID: 34100292 PMCID: PMC8238023 DOI: 10.2217/pgs-2021-0039] [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] [Indexed: 11/21/2022] Open
Abstract
Aim: Methadone exhibits significant variability in clinical response. This study explores the genetic influence of variable methadone pharmacokinetics. Methods: This is a prospective study of methadone in children undergoing major surgery. CYP2B6 genotyping, plasma methadone and metabolite levels were obtained. Clinical outcomes include pain scores and postoperative nausea and vomiting (PONV). Results: CYP2B6 poor metabolizers (*6/*6) had >twofold lower methadone metabolism compared with normal/rapid metabolizers. The incidence of PONV was 4.7× greater with CYP2B6 rs1038376 variant. AG/GG variants of rs2279343 SNP had 2.86-fold higher incidence of PONV compared with the wild variant (AA). Nominal associations between rs10500282, rs11882424, rs4803419 and pain scores were observed. Conclusion: We have described novel associations between CYP2B6 genetic variants and perioperative methadone metabolism, and associations with pain scores and PONV.
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Affiliation(s)
- Senthil Packiasabapathy
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Blessed W Aruldhas
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, 632 004, India
| | - Pengyue Zhang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Brian R Overholser
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Pharmacy Practice, Purdue University College of Pharmacy, Indianapolis, IN 46202, USA
| | - Sara K Quinney
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Obstetrics & Gynecology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Center for Computational Biology & Bioinformatics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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11
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Zhao C, Zhang N, Shrestha N, Liu H, Ge M, Luo F. Dexamethasone as a ropivacaine adjuvant to pre-emptive incision-site infiltration analgesia in pediatric craniotomy patients: A prospective, multicenter, randomized, double-blind, controlled trial. Paediatr Anaesth 2021; 31:665-675. [PMID: 33713371 DOI: 10.1111/pan.14178] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/13/2021] [Accepted: 03/03/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Dexamethasone added to incision-site infiltration has been routinely used to reduce pain after tonsillectomy in children. However, this has not been studied in pediatric craniotomy patients yet. We hypothesized that incision-site infiltration with a combination of ropivacaine and dexamethasone might provide superior analgesia to ropivacaine alone in pediatric craniotomy patients. METHODS In this multicenter, double-blind, randomized, controlled trial, children aged 2-12 years, scheduled for craniotomy, were prospectively enrolled at two study centers, from September 2, 2019, to July 5, 2020. Eighty children were randomly assigned (1:1) to either ropivacaine plus dexamethasone group who received pre-emptive incision-site infiltration with 0.2% ropivacaine plus 0.025% dexamethasone, or ropivacaine group who received 0.2% ropivacaine alone. Primary outcome was the modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) at 24 h postoperatively. Primary analysis was performed using the modified intention-to-treat principle. RESULTS Pre-emptive incision-site infiltration with ropivacaine plus dexamethasone had a reduced pain score of 2.0, compared with the pain score of 2.9 in the ropivacaine group, at 24 h postoperatively (mean difference -0.9, 95% confidence interval [CI], -1.7 to -0.2; p = .019). Estimated median of the time of first rescue analgesic demand was 24 h in the ropivacaine plus dexamethasone group and 8.5 h in the ropivacaine group [hazard ratio 0.43, 95% CI 0.24 to 0.08; Log-rank p = .0025]. No adverse events related to incision-site infiltration with dexamethasone were observed in this study. DISCUSSION Dexamethsone reduces the local production of pro-inflammatory factors after tissue damage and as a ropivacaine adjuvant for incision-site infiltration reduced the pain scores by 31% at 24 h postoperatively. The results were similar to several prior studies on to tonsillectomy patients. However, this changes on pain scores might has limited clinical significance. CONCLUSIONS The addition of dexamethasone to ropivacaine for preoperative incision-site infiltration has better postoperative analgesic effect than ropivacaine alone in pediatric craniotomy patients.
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Affiliation(s)
- Chunmei Zhao
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Nijia Zhang
- Department of Pediatric Neurosurgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Niti Shrestha
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongbing Liu
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Ge
- Department of Pediatric Neurosurgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Fang Luo
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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12
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A functional polymorphism in the ATP-Binding Cassette B1 transporter predicts pharmacologic response to combination of nortriptyline and morphine in neuropathic pain patients. Pain 2021; 161:619-629. [PMID: 31738228 DOI: 10.1097/j.pain.0000000000001750] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Many genetic markers have been associated with variations in treatment response to analgesics, but none have been assessed in the context of combination therapies. In this study, the treatment effects of nortriptyline and morphine were tested for an association with genetic markers relevant to pain pathways. Treatment effects were determined for single and combination therapies. A total of 24 functional single nucleotide polymorphisms were tested within the gene loci of mu-opioid receptor (OPRM1) gene locus, ATP-Binding Cassette B1 Transporter (ABCB1), Cytochrome P450 gene family (CYP2C19 and CYP2D6), catecholamine inactivator Catechol-O-Methyl Transferase (COMT), and serotonin receptor 2A (HTR2A). Genotyping was performed in a population of neuropathic pain patients who previously participated in a clinical trial. For monotherapy, neither nortriptyline nor morphine responses were associated with single nucleotide polymorphisms. However, for nortriptyline + morphine combination therapy, the single nucleotide polymorphism rs1045642 within the drug efflux pump ABCB1 transporter significantly predicted analgesic response. The presence of the C allele accounted for 51% of pain variance in this subgroup in response to combination treatment. The T-allele homozygotes demonstrated only 20% improvement in pain scores, whereas the C-allele homozygotes 88%. There was no significant contribution of rs1045642 to the medication side effects under all treatment conditions. The UK Biobank data set was then used to validate this genetic association. Here, patients receiving similar combination therapy (opioid + tricyclic antidepressant) carrying the C allele of rs1045642 displayed 33% fewer body pain sites than patients without that allele, suggesting better pain control. In all, our results show a robust effect of the rs1045642 polymorphism in response to chronic pain treatment with a nortriptyline + morphine combination.
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13
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Bruckmueller H, Cascorbi I. ABCB1, ABCG2, ABCC1, ABCC2, and ABCC3 drug transporter polymorphisms and their impact on drug bioavailability: what is our current understanding? Expert Opin Drug Metab Toxicol 2021; 17:369-396. [PMID: 33459081 DOI: 10.1080/17425255.2021.1876661] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Interindividual differences in drug response are a frequent clinical challenge partly due to variation in pharmacokinetics. ATP-binding cassette (ABC) transporters are crucial determinants of drug disposition. They are subject of gene regulation and drug-interaction; however, it is still under debate to which extend genetic variants in these transporters contribute to interindividual variability of a wide range of drugs. AREAS COVERED This review discusses the current literature on the impact of genetic variants in ABCB1, ABCG2 as well as ABCC1, ABCC2, and ABCC3 on pharmacokinetics and drug response. The aim was to evaluate if results from recent studies would increase the evidence for potential clinically relevant pharmacogenetic effects. EXPERT OPINION Although enormous efforts have been made to investigate effects of ABC transporter genotypes on drug pharmacokinetics and response, the majority of studies showed only weak if any associations. Despite few unique results, studies mostly failed to confirm earlier findings or still remained inconsistent. The impact of genetic variants on drug bioavailability is only minor and other factors regulating the transporter expression and function seem to be more critical. In our opinion, the findings on the so far investigated genetic variants in ABC efflux transporters are not suitable as predictive biomarkers.
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Affiliation(s)
- Henrike Bruckmueller
- Institute of Experimental and Clinical Pharmacology, University Hospital Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany
| | - Ingolf Cascorbi
- Institute of Experimental and Clinical Pharmacology, University Hospital Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany
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14
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Abstract
Genome-wide association studies and candidate gene findings suggest that genetic approaches may help in choosing the most appropriate drug and dosage, while preventing adverse drug reactions. This is the field that addresses precision medicine: to evaluate variations in the DNA sequence that could be responsible for different individual analgesic response. We review potential gene biomarkers with best overall convergent functional evidence, for opioid use, in pain management. Polymorphisms can modify pharmacodynamics (i.e., mu opioid receptor, OPRM1) and pharmacokinetics (i.e., CYP2D6 phenotypes) pathways altering opioid effectiveness, consumption, side effects or additionally, prescription opioid use dependence vulnerability. This review provides a summary of these candidate variants for the translation of genotype into clinically useful information in pain medicine.
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Affiliation(s)
- Mongi Benjeddou
- Department of Biotechnology, University of The Western Cape, Robert Sobukwe Road, Bellville 7535, Cape Town, Western Cape, South Africa
| | - Ana M Peiró
- Neuropharmacology on Pain & Functional Diversity (NED), Alicante Institute for Health & Biomedical Research (ISABIAL), Alicante, Spain
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15
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Packiasabapathy S, Rangasamy V, Horn N, Hendrickson M, Renschler J, Sadhasivam S. Personalized pediatric anesthesia and pain management: problem-based review. Pharmacogenomics 2020; 21:55-73. [PMID: 31849281 DOI: 10.2217/pgs-2019-0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Pharmacogenetics, the genetic influence on the interpersonal variability in drug response, has enabled tailored pharmacotherapy and emerging 'personalized medicine.' Although oncology spearheaded the clinical implementation of personalized medicine, other specialties are rapidly catching up. In anesthesia, classical examples of genetically mediated idiosyncratic reactions have been long known (e.g., malignant hyperthermia and prolonged apnea after succinylcholine). The last two decades have witnessed an expanding body of pharmacogenetic evidence in anesthesia. This review highlights some of the prominent pharmacogenetic associations studied in anesthesia and pain management, with special focus on pediatric anesthesia.
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Affiliation(s)
- Senthil Packiasabapathy
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Valluvan Rangasamy
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Nicole Horn
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Michele Hendrickson
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Janelle Renschler
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
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16
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Chaturvedi R, Alexander B, A'Court AM, Waterman RS, Burton BN, Urman RD, Gabriel RA. Genomics testing and personalized medicine in the preoperative setting: Can it change outcomes in postoperative pain management? Best Pract Res Clin Anaesthesiol 2020; 34:283-295. [PMID: 32711834 DOI: 10.1016/j.bpa.2020.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 10/24/2022]
Abstract
Postoperative pain and opioid use are major challenges in perioperative medicine. Pain perception and its response to opioid use are multi-faceted and include pharmacological, psychological, and genetic components. Precision medicine is a unique approach to individualized health care in which decisions in management are based on genetics, lifestyle, and environment of each person. Genetic variations can have an impact on the perception of pain and response to treatment. This can have an effect on pain management in both acute and chronic settings. Although there is currently not enough evidence for making recommendations about genetic testing to guide pain management in the acute care setting, there are some known polymorphisms that play a role in surgical pain and opioid-related postoperative adverse outcomes. In this review, we describe the potential use of pharmacogenomics (PGx) for improving perioperative pain management. We first review a number of genotypes that have shown correlations with pain and opioid use and then describe the importance of PGx-guided analgesic protocols and implementation of screening in a preoperative evaluation clinical setting.
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Affiliation(s)
- Rahul Chaturvedi
- School of Medicine, University of California, San Diego, La Jolla, CA, USA.
| | - Brenton Alexander
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA.
| | - Alison M A'Court
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA.
| | - Ruth S Waterman
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA.
| | - Brittany N Burton
- Department of Anesthesiology, University of California, Los Angeles, Los Angeles, CA, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School/Brigham and Women's Hospital, Boston, MA, USA.
| | - Rodney A Gabriel
- Department of Anesthesiology and Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA, USA.
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17
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Kaye AD, Koress CM, Novitch MB, Jung JW, Urits I, Viswanath O, Renschler JS, Alpaugh ES, Cornett EM. Pharmacogenomics, concepts for the future of perioperative medicine and pain management: A review. Best Pract Res Clin Anaesthesiol 2020; 34:651-662. [PMID: 33004174 DOI: 10.1016/j.bpa.2020.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 02/07/2023]
Abstract
Pharmacogenomics is the study of how genetic differences between individuals affect pharmacokinetics and pharmacodynamics. These differences are apparent to clinicians when taking into account the wide range of responses to medications given in clinical practice. A review of literature involving pharmacogenomics and pain management was performed. The implementation of preoperative pharmacogenomics will allow us to better care for our patients by delivering personalized, safer medicine. This review describes the current state of pharmacogenomics as it relates to many aspects of clinical practice and how clinicians can use these tools to improve patient outcomes.
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Affiliation(s)
- Alan D Kaye
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA.
| | - Cody M Koress
- Tulane University School of Medicine, Department of Internal Medicine, New Orleans, LA, USA.
| | - Matthew B Novitch
- University of Washington, Department of Anesthesiology, Seattle, WA, USA; Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL, USA.
| | - Jai Won Jung
- Georgetown University School of Medicine, Washington, DC, USA.
| | - Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Omar Viswanath
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ, USA; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, USA; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology Phoenix, AZ, USA.
| | | | - Edward S Alpaugh
- Louisiana State University Health Sciences Center, Department of Anesthesiology, Orleans, LA, USA.
| | - Elyse M Cornett
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA.
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18
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You D, Richardson JR, Aleksunes LM. Epigenetic Regulation of Multidrug Resistance Protein 1 and Breast Cancer Resistance Protein Transporters by Histone Deacetylase Inhibition. Drug Metab Dispos 2020; 48:459-480. [PMID: 32193359 DOI: 10.1124/dmd.119.089953] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 02/13/2020] [Indexed: 02/06/2023] Open
Abstract
Multidrug resistance protein 1 (MDR1, ABCB1, P-glycoprotein) and breast cancer resistance protein (BCRP, ABCG2) are key efflux transporters that mediate the extrusion of drugs and toxicants in cancer cells and healthy tissues, including the liver, kidneys, and the brain. Altering the expression and activity of MDR1 and BCRP influences the disposition, pharmacodynamics, and toxicity of chemicals, including a number of commonly prescribed medications. Histone acetylation is an epigenetic modification that can regulate gene expression by changing the accessibility of the genome to transcriptional regulators and transcriptional machinery. Recently, studies have suggested that pharmacological inhibition of histone deacetylases (HDACs) modulates the expression and function of MDR1 and BCRP transporters as a result of enhanced histone acetylation. This review addresses the ability of HDAC inhibitors to modulate the expression and the function of MDR1 and BCRP transporters and explores the molecular mechanisms by which HDAC inhibition regulates these transporters. While the majority of studies have focused on histone regulation of MDR1 and BCRP in drug-resistant and drug-sensitive cancer cells, emerging data point to similar responses in nonmalignant cells and tissues. Elucidating epigenetic mechanisms regulating MDR1 and BCRP is important to expand our understanding of the basic biology of these two key transporters and subsequent consequences on chemoresistance as well as tissue exposure and responses to drugs and toxicants. SIGNIFICANCE STATEMENT: Histone deacetylase inhibitors alter the expression of key efflux transporters multidrug resistance protein 1 and breast cancer resistance protein in healthy and malignant cells.
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Affiliation(s)
- Dahea You
- Joint Graduate Program in Toxicology, Rutgers, The State University of New Jersey, Piscataway, New Jersey (D.Y.); Department of Environmental Health Sciences, Robert Stempel School of Public Health and Social Work, Florida International University, Miami, Florida (J.R.R.); Environmental and Occupational Health Sciences Institute, Piscataway, New Jersey (J.R.R., L.M.A.); and Department of Pharmacology and Toxicology, Rutgers, The State University of New Jersey, Ernest Mario School of Pharmacy, Piscataway, New Jersey (L.M.A.)
| | - Jason R Richardson
- Joint Graduate Program in Toxicology, Rutgers, The State University of New Jersey, Piscataway, New Jersey (D.Y.); Department of Environmental Health Sciences, Robert Stempel School of Public Health and Social Work, Florida International University, Miami, Florida (J.R.R.); Environmental and Occupational Health Sciences Institute, Piscataway, New Jersey (J.R.R., L.M.A.); and Department of Pharmacology and Toxicology, Rutgers, The State University of New Jersey, Ernest Mario School of Pharmacy, Piscataway, New Jersey (L.M.A.)
| | - Lauren M Aleksunes
- Joint Graduate Program in Toxicology, Rutgers, The State University of New Jersey, Piscataway, New Jersey (D.Y.); Department of Environmental Health Sciences, Robert Stempel School of Public Health and Social Work, Florida International University, Miami, Florida (J.R.R.); Environmental and Occupational Health Sciences Institute, Piscataway, New Jersey (J.R.R., L.M.A.); and Department of Pharmacology and Toxicology, Rutgers, The State University of New Jersey, Ernest Mario School of Pharmacy, Piscataway, New Jersey (L.M.A.)
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19
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Cornett EM, Carroll Turpin MA, Pinner A, Thakur P, Sekaran TSG, Siddaiah H, Rivas J, Yates A, Huang GJ, Senthil A, Khurmi N, Miller JL, Stark CW, Urman RD, Kaye AD. Pharmacogenomics of Pain Management: The Impact of Specific Biological Polymorphisms on Drugs and Metabolism. Curr Oncol Rep 2020; 22:18. [PMID: 32030524 DOI: 10.1007/s11912-020-0865-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Pain is multifactorial and complex, often with a genetic component. Pharmacogenomics is a relative new field, which allows for the development of a truly unique and personalized therapeutic approach in the treatment of pain. RECENT FINDINGS Until recently, drug mechanisms in humans were determined by testing that drug in a population and calculating response averages. However, some patients will inevitably fall outside of those averages, and it is nearly impossible to predict who those outliers might be. Pharmacogenetics considers a patient's unique genetic information and allows for anticipation of that individual's response to medication. Pharmacogenomic testing is steadily making progress in the management of pain by being able to identify individual differences in the perception of pain and susceptibility and sensitivity to drugs based on genetic markers. This has a huge potential to increase efficacy and reduce the incidence of iatrogenic drug dependence and addiction. The streamlining of relevant polymorphisms of genes encoding receptors, transporters, and drug-metabolizing enzymes influencing the pain phenotype can be an important guide to develop safe new strategies and approaches to personalized pain management. Additionally, some challenges still prevail and preclude adoption of pharmacogenomic testing universally. These include lack of knowledge about pharmacogenomic testing, inadequate standardization of the process of data handling, questionable benefits about the clinical and financial aspects of pharmacogenomic testing-guided therapy, discrepancies in clinical evidence supporting these tests, and doubtful reimbursement of the tests by health insurance agencies.
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Affiliation(s)
- Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Michelle A Carroll Turpin
- Department of Biomedical Sciences, College of Medicine, University of Houston, Health 2 Building, Room 8037, Houston, TX, USA
| | - Allison Pinner
- Ochsner LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Pankaj Thakur
- Department of Anesthesiology, Ochsner LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | | | - Harish Siddaiah
- Department of Anesthesiology, Ochsner LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Jasmine Rivas
- Department of Family Medicine, ECU Vidant Medical Center, 101 Heart Drive, Greenville, NC, 27834, USA
| | - Anna Yates
- LSU Health Shreveport School of Medicine, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - G Jason Huang
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Anitha Senthil
- Department of Anesthesiology, Lahey Hospital & Medical Center, 41Mall Road, Burlington, MA, 01805, USA
| | - Narjeet Khurmi
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Jenna L Miller
- LSU Health Sciences Center New Orleans, 1901 Perdido Street, New Orleans, LA, 70112, USA
| | - Cain W Stark
- Medical College of Wisconsin, 8701 West Watertown Plank Road, Wauwatosa, WI, 53226, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Alan David Kaye
- Department of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University School of Medicine, 1501 Kings Hwy, Shreveport, LA, 71103, USA
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20
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Gabriel RA, Burton BN, Urman RD, Waterman RS. Genomics Testing and Personalized Medicine in the Preoperative Setting. Surg Oncol Clin N Am 2020; 29:73-86. [DOI: 10.1016/j.soc.2019.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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21
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Ding X, Yang Q, Su L, Huang X, Zhou Z. Correlation Between C3435T Locus of ABCB1 Gene and Poststroke Depression in China. DNA Cell Biol 2019; 38:808-813. [PMID: 31335167 DOI: 10.1089/dna.2018.4565] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Xianhui Ding
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, P.R. China
| | - Qian Yang
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, P.R. China
| | - Liwei Su
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, P.R. China
| | - Xianjun Huang
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, P.R. China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, P.R. China
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22
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Kaye AD, Garcia AJ, Hall OM, Jeha GM, Cramer KD, Granier AL, Kallurkar A, Cornett EM, Urman RD. Update on the pharmacogenomics of pain management. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2019; 12:125-143. [PMID: 31308726 PMCID: PMC6613192 DOI: 10.2147/pgpm.s179152] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 05/09/2019] [Indexed: 12/30/2022]
Abstract
Pharmacogenomics is the study of genetic variants that impact drug effects through changes in a drug’s pharmacokinetics and pharmacodynamics. Pharmacogenomics is being integrated into clinical pain management practice because variants in individual genes can be predictive of how a patient may respond to a drug treatment. Pain is subjective and is considered challenging to treat. Furthermore, pain patients do not respond to treatments in the same way, which makes it hard to issue a consistent treatment regimen for all pain conditions. Pharmacogenomics would bring consistency to the subjective nature of pain and could revolutionize the field of pain management by providing personalized medical care tailored to each patient based on their gene variants. Additionally, pharmacogenomics offers a solution to the opioid crisis by identifying potentially opioid-vulnerable patients who could be recommended a nonopioid treatment for their pain condition. The integration of pharmacogenomics into clinical practice creates better and safer healthcare practices for patients. In this article, we provide a comprehensive history of pharmacogenomics and pain management, and focus on up to date information on the pharmacogenomics of pain management, describing genes involved in pain, genes that may reduce or guard against pain and discuss specific pain management drugs and their genetic correlations.
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Affiliation(s)
- Alan David Kaye
- Department of Anesthesiology, LSU Health Sciences Center, New Orleans, LA, USA
| | - Andrew Jesse Garcia
- Department of Anesthesiology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - O Morgan Hall
- Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - George M Jeha
- Department of Anesthesiology, LSU Health Sciences Center New Orleans, New Orleans, LA, USA
| | - Kelsey D Cramer
- Department of Anesthesiology, LSU Health Sciences Center New Orleans, New Orleans, LA, USA
| | - Amanda L Granier
- Department of Anesthesiology, LSU Health Sciences Center New Orleans, New Orleans, LA, USA
| | - Anusha Kallurkar
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
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23
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Zhao C, Jia Y, Jia Z, Xiao X, Luo F. Pre-emptive scalp infiltration with ropivacaine plus methylprednisolone versus ropivacaine alone for relief of postoperative pain after craniotomy in children (RP/MP vs RP): a study protocol for a randomised controlled trial. BMJ Open 2019; 9:e027864. [PMID: 31230016 PMCID: PMC6596953 DOI: 10.1136/bmjopen-2018-027864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Pre-emptive scalp infiltration with local anaesthetics is the simplest and most effective method to prevent postoperative incisional pain. However, local infiltration of an anaesthetic only provides relatively short-term pain relief. Methylprednisolone (MP) treatment, administered as an adjuvant at the wound site, has been shown to provide satisfactory pain management after lumbar laminectomy. However, there is no evidence regarding the efficacy of MP infiltration for the relief of postoperative pain after craniotomy. Currently, postoperative pain after craniotomy in children is undertreated. Therefore, we aim to investigate whether pre-emptive scalp infiltration with ropivacaine (RP) plus MP is superior to RP alone to improve postoperative pain after craniotomy in children. METHODS AND ANALYSIS The RP/MP versus RP trial is a prospective, single-centre, randomised, parallel-group study of 100 children aged 8-18 years undergoing intracranial surgery. Participants will be randomly allocated to receive pre-emptive scalp infiltration with either RP plus MP or RP alone. The primary outcome will be the cumulative fentanyl dose administered by patient-controlled intravenous analgesia within 24 hours postoperatively. The secondary outcomes will include postoperative Numerical Rating Scale scores, pain control satisfaction scores, length of stay and adverse events. Data will be analysed by the intention-to-treat principle. ETHICAL APPROVAL AND DISSEMINATION The study protocol has been approved by the Institutional Review Board of Beijing Tiantan Hospital Affiliated to Capital Medical University (Approval Number: KY 2018-066-02). The results will be disseminated in international academic meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03636165; Pre-results.
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Affiliation(s)
- Chunmei Zhao
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yitong Jia
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zipu Jia
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiong Xiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fang Luo
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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24
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Awad ME, Padela MT, Sayeed Z, El-Othmani MM, Zekaj M, Darwiche HF, Saleh KJ. Pharmacogenomic Testing for Postoperative Pain Optimization Before Total Joint Arthroplasty: A Focus on Drug-Drug-Gene Interaction with Commonly Prescribed Drugs and Prior Opioid Use. JBJS Rev 2019; 7:e2. [PMID: 31094889 DOI: 10.2106/jbjs.rvw.18.00058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mohamed E Awad
- Resident Research Partnership, Detroit, Michigan.,FAJR Scientific, Detroit, Michigan.,Michigan State University College of Osteopathic Medicine, Detroit, Michigan.,John D. Dingell VA Medical Center, Detroit, Michigan
| | - Muhammad Talha Padela
- Resident Research Partnership, Detroit, Michigan.,FAJR Scientific, Detroit, Michigan.,John D. Dingell VA Medical Center, Detroit, Michigan.,Department of Orthopaedic Surgery and Sports Medicine, Detroit Medical Center, Detroit, Michigan.,Department of Orthopaedic Surgery, Chicago Medical School, Rosalind Franklin University, North Chicago, Illinois
| | - Zain Sayeed
- Resident Research Partnership, Detroit, Michigan.,John D. Dingell VA Medical Center, Detroit, Michigan.,Department of Orthopaedic Surgery and Sports Medicine, Detroit Medical Center, Detroit, Michigan.,Department of Orthopaedic Surgery, Chicago Medical School, Rosalind Franklin University, North Chicago, Illinois
| | - Mouhanad M El-Othmani
- Department of Orthopaedic Surgery and Sports Medicine, Detroit Medical Center, Detroit, Michigan
| | - Mark Zekaj
- Department of Orthopaedic Surgery and Sports Medicine, Detroit Medical Center, Detroit, Michigan
| | - Hussein F Darwiche
- Department of Orthopaedic Surgery and Sports Medicine, Detroit Medical Center, Detroit, Michigan
| | - Khaled J Saleh
- FAJR Scientific, Detroit, Michigan.,Michigan State University College of Osteopathic Medicine, Detroit, Michigan.,John D. Dingell VA Medical Center, Detroit, Michigan
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25
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Increased MDR1 Transporter Expression in Human Brain Endothelial Cells Through Enhanced Histone Acetylation and Activation of Aryl Hydrocarbon Receptor Signaling. Mol Neurobiol 2019; 56:6986-7002. [PMID: 30963442 DOI: 10.1007/s12035-019-1565-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 03/13/2019] [Indexed: 12/21/2022]
Abstract
Multidrug resistance protein 1 (MDR1, ABCB1, P-glycoprotein) is a critical efflux transporter that extrudes chemicals from the blood-brain barrier (BBB) and limits neuronal exposure to xenobiotics. Prior studies in malignant cells demonstrated that MDR1 expression can be altered by inhibition of histone deacetylases (HDAC), enzymes that modify histone structure and influence transcription factor binding to DNA. Here, we sought to identify the mechanisms responsible for the up-regulation of MDR1 by HDAC inhibitors in human BBB cells. Immortalized human brain capillary endothelial (hCMEC/D3) cells were treated with HDAC inhibitors and assessed for MDR1 expression and function. Of the HDAC inhibitors profiled, valproic acid (VPA), apicidin, and suberoylanilide hydroxamic acid (SAHA) increased MDR1 mRNA and protein levels by 30-200%, which corresponded with reduced intracellular accumulation of the MDR1 substrate rhodamine 123. Interestingly, induction of MDR1 mRNA by HDAC inhibitors mirrored increases in the expression of the aryl hydrocarbon receptor (AHR) and its target gene cytochrome P450 1A1. To explore the role of AHR in HDAC inhibitor-mediated regulation of MDR1, a pharmacological activator (β-naphthoflavone, βNF) and inhibitor (CH-223191, CH) of AHR were tested. The induction of MDR1 in cells treated with SAHA was amplified by βNF and attenuated by CH. Furthermore, SAHA increased the binding of acetylated histone H3K9/K14 and AHR proteins to regions of the MDR1 promoter that contain AHR response elements. In conclusion, HDAC inhibitors up-regulate the expression and activity of the MDR1 transporter in human brain endothelial cells by increasing histone acetylation and facilitating AHR binding at the MDR1 promoter.
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Candidate gene analyses for acute pain and morphine analgesia after pediatric day surgery: African American versus European Caucasian ancestry and dose prediction limits. THE PHARMACOGENOMICS JOURNAL 2019; 19:570-581. [PMID: 30760877 PMCID: PMC6693985 DOI: 10.1038/s41397-019-0074-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 10/30/2018] [Accepted: 12/21/2018] [Indexed: 12/17/2022]
Abstract
Acute pain and opioid analgesia demonstrate inter-individual variability and polygenic influence. In 241 children of African American and 277 of European Caucasian ancestry, we sought to replicate select candidate gene associations with morphine dose and postoperative pain and then to estimate dose prediction limits. Twenty-seven single-nucleotide polymorphisms (SNPs) from nine genes (ABCB1, ARRB2, COMT, DRD2, KCNJ6, MC1R, OPRD1, OPRM1, and UGT2B7) met selection criteria and were analyzed along with TAOK3. Few associations replicated: morphine dose (mcg/kg) in African American children and ABCB1 rs1045642 (A allele, β = -9.30, 95% CI: -17.25 to -1.35, p = 0.02) and OPRM1 rs1799971 (G allele, β = 23.19, 95% CI: 3.27-43.11, p = 0.02); KCNJ6 rs2211843 and high pain in African American subjects (T allele, OR 2.08, 95% CI: 1.17-3.71, p = 0.01) and in congruent European Caucasian pain phenotypes; and COMT rs740603 for high pain in European Caucasian subjects (A allele, OR: 0.69, 95% CI: 0.48-0.99, p = 0.046). With age, body mass index, and physical status as covariates, simple top SNP candidate gene models could explain theoretical maximums of 24.2% (European Caucasian) and 14.6% (African American) of morphine dose variances.
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Abstract
PURPOSE OF REVIEW The current review will discuss the current literature on genetics of pain and analgesia, with special emphasis on perioperative setting. We will also discuss pharmacogenetics-based management guidelines, current clinical status and future perspectives. RECENT FINDINGS Recent literature suggests that the interindividual variability in pain and postoperative analgesic response is at least in part because of one's genetic make-up. Some of the well characterized polymorphisms that are associated with surgical pain and opioid-related postoperative adverse outcomes are described in catechol-O-methyl transferase, CYP2D6 and μ-opioid receptor (OPRM1), ATP-binding cassette subfamily B member 1, ABCC3, organic cation transporter 1 genes. Clinical Pharmacogenetics Implementation Consortium has put forth recommendations on CYP2D6 genotype-based opioid selection and dosing. The list of drug-gene pairs studied continue to expand. SUMMARY Pharmacogenetic approach marks the dawn of personalized pain medicine both in perioperative and chronic pain settings.
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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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Lam YWF. Principles of Pharmacogenomics. Pharmacogenomics 2019. [DOI: 10.1016/b978-0-12-812626-4.00001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Zhou S, Skaar DJ, Jacobson PA, Huang RS. Pharmacogenomics of Medications Commonly Used in the Intensive Care Unit. Front Pharmacol 2018; 9:1436. [PMID: 30564130 PMCID: PMC6289166 DOI: 10.3389/fphar.2018.01436] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/20/2018] [Indexed: 12/11/2022] Open
Abstract
In the intensive care unit (ICU) setting, where highly variable and insufficient drug efficacies, as well as frequent and unpredictable adverse drug reactions (ADRs) occur, pharmacogenomics (PGx) offers an opportunity to improve health outcomes. However, PGx has not been fully evaluated in the ICU, partly due to lack of knowledge of how genetic markers may affect drug therapy. To fill in this gap, we conducted a review to summarize the PGx information for the medications commonly encountered in the ICU.
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Affiliation(s)
- Shuqin Zhou
- Department of Emergency and Critical Care Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China.,Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Debra J Skaar
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - R Stephanie Huang
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
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Packiasabapathy S, Sadhasivam S. Gender, genetics, and analgesia: understanding the differences in response to pain relief. J Pain Res 2018; 11:2729-2739. [PMID: 30519077 PMCID: PMC6235329 DOI: 10.2147/jpr.s94650] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Genetic variations and gender contribute significantly to the large interpatient variations in opioid-related serious adverse effects and differences in pain relief with other analgesics. Opioids are the most commonly used analgesics to relieve moderate-to-severe postoperative pain. Narrow therapeutic index and unexplained large interpatient variations in opioid-related serious adverse effects and analgesia negatively affect optimal perioperative outcomes. In surgical, experimental, chronic, and neuropathic pain models, females have been reported to have more pain than males. This review focuses on literature evidence of differences in pain relief due to multiple genetic variations and gender of the patient.
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Affiliation(s)
- Senthil Packiasabapathy
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA,
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA,
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Abstract
Pharmacogenomics (PGx) is the study of how individuals' personal genotypes may affect their responses to various pharmacologic agents. The application of PGx principles in perioperative medicine is fairly novel. Challenges in executing PGx programs into health care systems include physician buy-in and integration into usual clinical workflow, including the electronic health record. This article discusses the current evidence highlighting the potential of PGx with various drug categories (including opioids, nonopioid analgesics, sedatives, β-blockers, antiemetics, and anticoagulants) used in the perioperative process and the challenges of integrating PGx into a health care system and relevant workflows.
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Effects of Single Nucleotide Polymorphisms on Surgical and Postsurgical Opioid Requirements: A Systematic Review and Meta-Analysis. Clin J Pain 2018; 33:1117-1130. [PMID: 28379874 DOI: 10.1097/ajp.0000000000000498] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES There is great heterogeneity in the way individuals respond to medications. Inherited differences, such as single nucleotide polymorphisms (SNP), can influence the efficacy and toxicity of drugs. This meta-analysis aims to collate data from studies investigating the effect of SNPs on postoperative and/or intraoperative opioid requirements. MATERIALS AND METHODS A meta-analysis was conducted following PRISMA guidelines. Eligibility criteria for studies included were reporting amount of postoperative and/or intraoperative opioid used as the primary outcome and genotyping patients for SNPs in one of the following genes; OPRM1, CYP2D6, CYP3A4, CYP3A5, COMT, UGT2B7, or ABCB1. A comprehensive systematic search for articles using keywords "opioid-sensitivity," "polymorphisms," "post-operative opioid," "post-surgical opioid," "post-operative pain," and "post-surgical pain" was performed. RESULTS Fifty-one studies were included. Individuals homozygous for AA at the OPRMI (rs1799971) polymorphisms required less postsurgical opioid compared with those homozygous for GG (Hedges g, -0.270; 95% confidence interval, -0.433 to -0.108; P=0.001). Polymorphisms in CYP2D6, CYP3A4, CYP3A5, COMT, UGT2B7, and ABCB1 did not affect opioid requirements. DISCUSSION Investigation of single changes in 1 gene can only yield limited information regarding genetic effects on opioid requirements. Rapid development of whole genome sequencing enables information on all genetic modifications that may affect analgesic response to be collected. The information collected must include data on the individual's metabolic enzymes, as well as information on drug receptors and enzymes responsible for drug degradation, so that a personal profile can be built up which will predict individual response to drugs, and guide clinicians on the type and dosage of drug to use.
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Kaye AD, Mahakian T, Kaye AJ, Pham AA, Hart BM, Gennuso S, Cornett EM, Gabriel RA, Urman RD. Pharmacogenomics, precision medicine, and implications for anesthesia care. Best Pract Res Clin Anaesthesiol 2018; 32:61-81. [DOI: 10.1016/j.bpa.2018.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/30/2018] [Indexed: 01/28/2023]
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Abstract
Pain is an unpleasant feeling usually resulting from tissue damage that can persist along weeks, months, or even years after the injury, turning into pathological chronic pain, the leading cause of disability. Currently, pharmacology interventions are usually the first-line therapy but there is a highly variable analgesic drug response. Pharmacogenetics (PGx) offers a means to identify genetic biomarkers that can predict individual analgesic response opening doors to precision medicine. PGx analyze the way in which the presence of variations in the DNA sequence (single-nucleotide polymorphisms, SNPs) could be responsible for portions of the population reaching different levels of pain relief (phenotype) due to gene interference in the drug mechanism of action (pharmacodynamics) and/or its concentration at the place of action (pharmacokinetics). SNPs in the cytochrome P450 enzymes genes (CYP2D6) influence metabolism of codeine, tramadol, hydrocodone, oxycodone, and tricyclic antidepressants. Blood concentrations of some NSAIDs depend on CYP2C9 and/or CYP2C8 activity. Additional candidate genes encode for opioid receptors, transporters, and other molecules important for pharmacotherapy in pain management. However, PGx studies are often contradictory, slowing the uptake of this information. This is likely due, in large part, to a lack of robust evidence demonstrating clinical utility and to its polygenic response modulated by other exogenous or epigenetics factors. Novel therapies, including targeting of epigenetic changes and gene therapy-based approaches, broaden future options to improve understanding of pain and the treatment of people who suffer it.
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Affiliation(s)
- Ana M Peiró
- Clinical Pharmacology Unit, Department of Health of Alicante-General Hospital, Alicante, Spain; Neuropharmacology on Pain (NED), Alicante Institute for Health and Biomedical Research (ISABIAL-FISABIO Foundation), Alicante, Spain.
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Knutsen HK, Alexander J, Barregård L, Bignami M, Brüschweiler B, Ceccatelli S, Cottrill B, Dinovi M, Edler L, Grasl-Kraupp B, Hogstrand C, Hoogenboom LR, Nebbia CS, Oswald IP, Petersen A, Rose M, Roudot AC, Schwerdtle T, Vollmer G, Wallace H, Benford D, Calò G, Dahan A, Dusemund B, Mulder P, Németh-Zámboriné É, Arcella D, Baert K, Cascio C, Levorato S, Schutte M, Vleminckx C. Update of the Scientific Opinion on opium alkaloids in poppy seeds. EFSA J 2018; 16:e05243. [PMID: 32625895 PMCID: PMC7009406 DOI: 10.2903/j.efsa.2018.5243] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Poppy seeds are obtained from the opium poppy (Papaver somniferum L.). They are used as food and to produce edible oil. The opium poppy plant contains narcotic alkaloids such as morphine and codeine. Poppy seeds do not contain the opium alkaloids, but can become contaminated with alkaloids as a result of pest damage and during harvesting. The European Commission asked EFSA to provide an update of the Scientific Opinion on opium alkaloids in poppy seeds. The assessment is based on data on morphine, codeine, thebaine, oripavine, noscapine and papaverine in poppy seed samples. The CONTAM Panel confirms the acute reference dose (ARfD) of 10 μg morphine/kg body weight (bw) and concluded that the concentration of codeine in the poppy seed samples should be taken into account by converting codeine to morphine equivalents, using a factor of 0.2. The ARfD is therefore a group ARfD for morphine and codeine, expressed in morphine equivalents. Mean and high levels of dietary exposure to morphine equivalents from poppy seeds considered to have high levels of opium alkaloids (i.e. poppy seeds from varieties primarily grown for pharmaceutical use) exceed the ARfD in most age groups. For poppy seeds considered to have relatively low concentrations of opium alkaloids (i.e. primarily varieties for food use), some exceedance of the ARfD is also seen at high levels of dietary exposure in most surveys. For noscapine and papaverine, the available data do not allow making a hazard characterisation. However, comparison of the dietary exposure to the recommended therapeutical doses does not suggest a health concern for these alkaloids. For thebaine and oripavine, no risk characterisation was done due to insufficient data. However, for thebaine, limited evidence indicates a higher acute lethality than for morphine and the estimated exposure could present a health risk.
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Xie S, Ma W, Guo Q, Liu J, Li W, McLeod HL, He Y. The pharmacogenetics of medications used in general anesthesia. Pharmacogenomics 2018; 19:285-298. [PMID: 29318929 DOI: 10.2217/pgs-2017-0168] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
General anesthesia is a state of unconsciousness, amnesia, analgesia and akinesia induced by drugs including opioids, hypnotic-sedative agents, muscle relaxants and antiemetics. Clinical and genetic factors are reported to influence the efficacy and side effects of these agents. Based on the evidence, clinical action is needed to improve clinical outcomes. This review summarizes the latest knowledge with regards to the pharmacogenetics of anesthetics and general anesthesia related complications.
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Affiliation(s)
- Shangchen Xie
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, Hunan, P.R. China
| | - Wenjuan Ma
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Qulian Guo
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Jie Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, Hunan, P.R. China
| | - Wei Li
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, Hunan, P.R. China
| | - Howard L McLeod
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, Hunan, P.R. China
- Moffitt Cancer Center, DeBartolo Family Personalized Medicine Institute, Tampa, FL 33601, USA
| | - Yijing He
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, Hunan, P.R. China
- Moffitt Cancer Center, DeBartolo Family Personalized Medicine Institute, Tampa, FL 33601, USA
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Lingren T, Sadhasivam S, Zhang X, Marsolo K. Electronic medical records as a replacement for prospective research data collection in postoperative pain and opioid response studies. Int J Med Inform 2017; 111:45-50. [PMID: 29425633 DOI: 10.1016/j.ijmedinf.2017.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 09/21/2017] [Accepted: 12/16/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM Many clinical research studies claim to collect data that are also captured in the electronic medical record (EMR). We evaluate the potential for EMR data to replace prospective research data collection. METHODS Using a dataset of 358 surgical patients enrolled in a prospective study, we examined the completeness and agreement of EMR and study entries for several variables, including the patient's stay in the post-operative care unit (PACU), surgical pain relief and pain medication side effects. RESULTS For all variables with a completeness percentage, values were greater than 96%. For the adverse event variables, we found slight to substantial agreement (Cohen's kappa), ranging from 0.19 (nausea) to 0.48 (respiratory depression) to 0.73 (emesis). CONCLUSION The potential to use EMR data as a replacement for prospective research data collection shows promise, but for now, should be evaluated on a variable-by-variable basis.
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Affiliation(s)
- Todd Lingren
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | | | - Xue Zhang
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Keith Marsolo
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.
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Zhang Y, Li Y, Wang H, Cai F, Shen S, Luo X. Correlation of MDR1 gene polymorphism with propofol combined with remifentanil anesthesia in pediatric tonsillectomy. Oncotarget 2017; 9:20294-20303. [PMID: 29755652 PMCID: PMC5945500 DOI: 10.18632/oncotarget.23168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 10/29/2017] [Indexed: 02/01/2023] Open
Abstract
The motive of this study was to investigate the interaction between polymorphisms in the MDR1 gene and anesthetic effects following pediatric tonsillectomy. In total, 240 children undergoing tonsillectomy with preoperative propofol-remifentanil anesthesia were selected. Genomic DNA was extracted from the peripheral blood of children after operation, and the MDR1 gene polymorphisms of 2677 G>T/A, 1236 C>T and 3435 C>T were detected by direct sequencing. We tested mean arterial pressure, diastolic blood pressure, systolic blood pressure, and heart rate at several time-points: T0 (5 mins after the repose), T1 (0 min after tracheal intubation), T2 (5 mins after the tracheal intubation), T3 (0 min after the tonsillectomy), T4 (0 min after removal of the mouth-gag) and T5 (5 min after the extubation). The visual analog scale, the face, legs, activity, cry, and consolability pain assessment, and the Ramsay sedation score were recorded after the patients regained consciousness. Adverse reactions were also recorded. The time of induction, respiration recovery, eye-opening, and extubation of children with the CC genotype were found to be shorter compared to the CT + TT genotype of MDR1 1236C > T (all P <.05). The mean arterial pressure, diastolic blood pressure, systolic blood pressure, and heart rate were significantly reduced at T5 in children with the CC genotype (all P <.05). The visual analog scale at 1, 2, 4, and 8 hours post-operation, and the Ramsay sedation score at 5, 10, and 30 min after the extubation were decreased, while the face, legs, activity, cry, and consolability pain assessment score increased (all P <0.05). There was no statistically significant difference in the adverse reaction of MDR1 mutations (P> 0.05). It could be concluded that anesthetic effect following pediatric tonsillectomy in patients with the MDR1 1236C > T CC genotype was stronger than in those carrying the CT + TT genotype.
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Affiliation(s)
- YunLong Zhang
- Department of Anesthesiology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yongpei Li
- Hangzhou Women's Hospital, Hangzhou Maternity and Child Health Care Hospital, Hangzhou, Zhejiang, China
| | - Hongfa Wang
- Department of Anesthesiology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Fang Cai
- Department of Anesthesiology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Sheliang Shen
- Department of Anesthesiology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xiaopan Luo
- Department of Anesthesiology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China
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Ethnicity-dependent influence of innate immune genetic markers on morphine PCA requirements and adverse effects in postoperative pain. Pain 2017; 157:2458-2466. [PMID: 27649267 DOI: 10.1097/j.pain.0000000000000661] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Although several genetic factors have been associated with postsurgical morphine requirements, those involving the innate immune system and cytokines have not been well investigated. The aim of this study was to investigate the contribution of genetic variability in innate immune signalling pathways to variability in morphine dosage after elective caesarean section under spinal anaesthesia in 133 Indian, 230 Malay, and 598 Han Chinese women previously studied. Twenty single nucleotide polymorphisms in 14 genes involved in glial activation (TLR2, TLR4, MYD88, MD2), inflammatory signalling (IL2, IL6, IL10, IL1B, IL6R, TNFA, TGFB1, CRP, CASP1), and neuronal regulation (BDNF) were newly investigated, in addition to OPRM1, COMT, and ABCB1 genetic variability identified previously. Postsurgical patient-controlled analgesia morphine use (mg/24 hours) was binned into 6 normally distributed groups and scored 0 to 5 to facilitate step-down multiple linear regression analysis of genetic predictors, controlling for ethnicity and nongenetic variables. Ethnicity, OPRM1 rs1799971 (increased), TLR2 rs3804100 (decreased), and an interaction between ethnicity and IL1B rs1143634 (increased), predicted 9.8% of variability in morphine use scores in the entire cohort. In the Indian cohort, 14.5% of the variance in morphine use score was explained by IL1B rs1143634 (increased) and TGFB1 rs1800469 (decreased). In Chinese patients, the incidence of postsurgical pain was significantly higher in variant COMT rs4680 genotypes (P = 0.0007) but not in the Malay or Indian cohorts. Innate immune genetics may contribute to variability in postsurgical opioid requirements in an ethnicity-dependent manner.
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Money S. Patient Safety and Risk Management in the Treatment of Pain. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2017. [DOI: 10.1007/s40138-017-0143-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Individual variability in clinical effect and tolerability of opioid analgesics – Importance of drug interactions and pharmacogenetics. Scand J Pain 2017; 17:193-200. [DOI: 10.1016/j.sjpain.2017.09.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 09/11/2017] [Accepted: 09/12/2017] [Indexed: 11/23/2022]
Abstract
Abstract
Background
As pain is often a comorbid condition, many patients use opioid analgesics in combination with several other drugs. This implies a generally increased risk of drug interactions, which along with inherent pharmacogenetic variability and other factors may cause differences in therapeutic response of opioids.
Aim
To provide an overview of interactions and pharmacogenetic variability of relevance for individual differences in effect and tolerability of opioid analgesics, which physicians and other healthcare professionals should be aware of in clinical practice.
Methods
The article was based on unsystematic searches in PubMed to identify literature highlighting the clinical impact of drug interactions and pharmacogenetics as sources of variable response of opioid analgesics.
Results
Cytochrome P450 (CYP)-mediated metabolism is an important process for both clinically relevant interactions and pharmacogenetic variability of several opioids. Concomitant use of CYP inhibitors (e.g. paroxetine, fluoxetine and bupropion) or inducers (e.g. carbamazepine, phenobarbital and phenytoin) could counteract the clinical effect or trigger side effects of analgesics in the same manner as genetically determined differences in CYP2D6-mediated metabolism of many opioids. Moreover, combination treatment with drugs that inhibit or induce P-glycoprotein (ABCB1), a blood-brain barrier efflux transporter, may alter the amount (‘dose’) of opioids distributed to the brain. At the pharmacodynamic level, it is crucial to be aware of the potential risk of interaction causing serotonergic syndrome when combining opioids and serotonergic drugs, in particular antidepressants inhibiting serotonin reuptake (SSRIs and SNRIs). Regarding pharmacogenetics at the receptor level of pain treatment, the knowledge is currently scarce, but an allelic variant of the μ1 opioid receptor (OPRM1) gene has been associated with higher dosage requirement to achieve analgesia.
Conclusions and implications
Drug interactions and pharmacogenetic differences may lead to therapeutic failure or serious side effects of opioid analgesics. Many interactions involve combinations with antidepressants and antiepileptics, which are highly relevant drugs in patients suffering from pain. To prevent unfavourable drug interactions it is important that clinicians pay close attention and use electronic drug interaction checkers when treatments are initiated or discontinued. For the management of issues related to pharmacogenetic differences, blood-based CYP genotyping is available as routine test at many laboratories, and provide a valuable tool for proper choice of drugs and doses for treatment of pain and other diseases.
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Owusu Obeng A, Hamadeh I, Smith M. Review of Opioid Pharmacogenetics and Considerations for Pain Management. Pharmacotherapy 2017; 37:1105-1121. [DOI: 10.1002/phar.1986] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Aniwaa Owusu Obeng
- The Charles Bronfman Institute for Personalized Medicine; Icahn School of Medicine at Mount Sinai; New York NY
- Pharmacy Department; The Mount Sinai Hospital; New York New York
- Division of General Internal Medicine; Department of Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | | | - Michael Smith
- University of Michigan College of Pharmacy; Ann Arbor Michigan
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Myers MF, Zhang X, McLaughlin B, Kissell D, Perry CL, Veerkamp M, Zhang K, Holm IA, Prows CA. Prior opioid exposure influences parents' sharing of their children's CYP2D6 research results. Pharmacogenomics 2017; 18:1199-1213. [PMID: 28745549 DOI: 10.2217/pgs-2017-0091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
AIM To determine parents' use of their children's CYP2D6 research result. We hypothesized that perceived utility, likelihood of sharing and actual sharing of results would differ between parents with children previously exposed (cases) or unexposed (controls) to opioids. METHODS We returned results by phone (baseline). We surveyed parents about perceived utility and likelihood of sharing their child's research result at baseline, and actual sharing at 3 and 12 months. RESULTS Cases were more likely than controls to agree that they (p = 0.022) and the doctors (p = 0.041) could use the results to care for their child, to report higher likelihood of sharing (p = 0.042) and to actually share results with the child's doctor (p = 0.026). CONCLUSION Prior opioid exposure influenced perceived clinical utility and sharing behaviors.
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Affiliation(s)
- Melanie F Myers
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,College of Medicine, Department of Pediatrics, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Xue Zhang
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Brooke McLaughlin
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,College of Medicine, Department of Pediatrics, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Diane Kissell
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Cassandra L Perry
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA 02115, USA
| | - Matthew Veerkamp
- Center for Autoimmune Genomics & Etiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Kejian Zhang
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Ingrid A Holm
- Division of Genetics & Genomics & The Manton Center for Orphan Disease Research, Department of Medicine, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Cynthia A Prows
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Division of Patient Services, Department of Clinical Shared Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
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An observational study examining the effects of a surgically induced inflammatory response on the distribution of morphine and its metabolites into cerebrospinal fluid. Can J Anaesth 2017; 64:1009-1022. [PMID: 28710563 DOI: 10.1007/s12630-017-0933-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 05/25/2017] [Accepted: 07/05/2017] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Morphine is administered intravenously for pain management in the perioperative period. The effect of the inflammatory response to surgery on morphine distribution across the blood-brain barrier (BBB) in humans was investigated. We hypothesized that a graded surgically induced, systemic inflammatory response alters cerebrospinal fluid (CSF) levels of morphine, morphine-3-glucuronide (M3G), and morphine-6-glucuronide (M6G) through a temporary reduction in BBB drug efflux transporter function. METHODS We conducted a prospective pharmacokinetic study of the plasma and CSF distribution of the P-glycoprotein (PGP) substrate morphine in 33 patients undergoing open thoracic (n = 18) or endovascular (n = 15) aortic aneurysm repair. Morphine was administered with induction of anesthesia and in the intensive care unit. Plasma and CSF concentrations of interleukin (IL)-6, morphine, M3G, M6G, and albumin were measured prior to surgery (baseline), during surgery, and postoperatively every six hours until removal of the CSF drain. The area under the curve (AUC) was determined for plasma and CSF IL-6, morphine, M3G, and M6G concentrations vs time. The primary endpoint measures were the correlations between the morphine, M6G, and M3G AUC CSF/plasma ratios and systemic inflammation as quantified by the time-normalized IL-6 exposure, which was calculated for each individual by dividing the total exposure (AUC) by time (t). A Bonferroni corrected P < 0.017 indicated a significant correlation. RESULTS Plasma and CSF IL-6 concentrations increased postoperatively. The median [interquartile range] IL-6 exposures were significantly higher in the open vs endovascular surgical group for plasma (105 [40-256] pg·mL-1 vs 29 [16-70] pg·mL-1, respectively; P = 0.013) and CSF (79 [26-133] pg·mL-1 vs 16 [9-80] pg·mL-1, respectively; P = 0.013). For the primary endpoint, the plasma IL-6 AUC/t did not correlate with the CSF accumulation of morphine (r = -0.009; P = 0.96) or M3G (r = 0.37; P = 0.04) when corrected for surgical procedure, age, and sex. There were insufficient data on CSF concentration to complete the primary analysis for M6G. CONCLUSION Morphine distribution into the CSF was not significantly altered in patients undergoing thoracic aortic aneurysm repair. This suggests that BBB PGP function may not be affected by the perioperative inflammatory response. TRIAL REGISTRATION www.clinicaltrials.gov , NCT 00878371. Registered 7 April 2009.
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Matic M, de Wildt SN, Tibboel D, van Schaik RHN. Analgesia and Opioids: A Pharmacogenetics Shortlist for Implementation in Clinical Practice. Clin Chem 2017. [DOI: 10.1373/clinchem.2016.264986] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
The use of opioids to alleviate pain is complicated by the risk of severe adverse events and the large variability in dose requirements. Pharmacogenetics (PGx) could possibly be used to tailor pain medication based on an individual's genetic background. Many potential genetic markers have been described, and the importance of genetic predisposition in opioid efficacy and toxicity has been demonstrated in knockout mouse models and human twin studies. Such predictors are especially of value for neonates and young children, in whom the assessment of efficacy or side effects is complicated by the inability of the patient to communicate this properly. The current problem is determining which of the many potential candidates to focus on for clinical implementation.
CONTENT
We systematically searched publications on PGx for opioids in 5 databases, aiming to identify PGx markers with sufficient robust data and high enough occurrence for potential clinical application. The initial search yielded 4257 unique citations, eventually resulting in 852 relevant articles covering 24 genes. From these genes, we evaluated the evidence and selected the most promising 10 markers: cytochrome P450 family 2 subfamily D member 6 (CYP2D6), cytochrome P450 family 3 subfamily A member 4 (CYP3A4), cytochrome P450 family 3 subfamily A member 5 (CYP3A5), UDP glucuronosyltransferase family 2 member B7 (UGT2B7), ATP binding cassette subfamily B member 1 (ABCB1), ATP binding cassette subfamily C member 3 (ABCC3), solute carrier family 22 member 1 (SLC22A1), opioid receptor kappa 1 (OPRM1), catechol-O-methyltransferase (COMT), and potassium voltage-gated channel subfamily J member 6 (KCNJ6). Treatment guidelines based on genotype are already available only for CYP2D6.
SUMMARY
The application of PGx in the management of pain with opioids has the potential to improve therapy. We provide a shortlist of 10 genes that are the most promising markers for clinical use in this context.
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Affiliation(s)
- Maja Matic
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center–Sophia Children Hospital, Rotterdam, the Netherlands
| | - Saskia N de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center–Sophia Children Hospital, Rotterdam, the Netherlands
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center–Sophia Children Hospital, Rotterdam, the Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands
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ABCB1 genotype is associated with fentanyl requirements in critically ill children. Pediatr Res 2017; 82:29-35. [PMID: 28388599 PMCID: PMC5509475 DOI: 10.1038/pr.2017.103] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/30/2017] [Indexed: 01/28/2023]
Abstract
BackgroundThe gene ABCB1 encodes p-glycoprotein, a xenobiotic efflux pump capable of transporting certain opioids, including fentanyl. ABCB1 genotype has been previously associated with patient opioid requirements and may influence fentanyl dosing requirements in critically ill children.MethodsA diagnostically diverse cohort of 61 children who received a fentanyl infusion while admitted to the pediatric intensive care unit (PICU) were included in this study. We examined associations between fentanyl requirements, pain and sedation scores, serum fentanyl levels, and ABCB1 genotype.ResultsPatients with the AA allele at ABCB1 locus rs1045642 received less fentanyl compared with patients with the AG or GG allele. A multivariable model demonstrated that patients with the AA allele received 18.6 mcg/kg/day less fentanyl than patients with either the AG or GG allele (95% confidence interval -33.4 to -3.8 mcg/kg/day; P=0.014). Incorporating race in this model demonstrated a similar association, but did not reach the threshold for multiple testing.ConclusionABCB1 genotype rs1045642 AA is associated with fentanyl administration in this cohort of children admitted to the PICU, likely because of decreased expression and activity of p-glycoprotein. Prospective evaluation of the influence of ABCB1 in sedative-analgesia administration in critically ill children is warranted.
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Abstract
A significant number of commonly administered medications in anesthesia show wide clinical interpatient variability. Some of these include neuromuscular blockers, opioids, local anesthetics, and inhalation anesthetics. Individual genetic makeup may account for and predict cardiovascular outcomes after cardiac surgery. These interactions can manifest at any point in the perioperative period and may also only affect a specific system. A better understanding of pharmacogenomics will allow for more individually tailored anesthetics and may ultimately lead to better outcomes, decreased hospital stays, and improved patient satisfaction.
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Affiliation(s)
- Ramsey Saba
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Alan D Kaye
- Department of Anesthesiology and Pain Medicine, LSU Health Science Center, Louisiana State University School of Medicine, 1542 Tulane Avenue, Room 659, New Orleans, LA 70112, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Shi NJ, Zhang WX, Zhang N, Zhong LN, Wang LP. Correlation of MDR1 gene polymorphisms with anesthetic effect of sevoflurane-remifentanil following pediatric tonsillectomy. Medicine (Baltimore) 2017; 96:e7002. [PMID: 28614221 PMCID: PMC5478306 DOI: 10.1097/md.0000000000007002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The motive of this study was to investigate the collaboration between MDR1 gene polymorphisms and anesthetic effects following pediatric tonsillectomy. METHODS All together 178 children undergoing tonsillectomy with preoperative sevoflurane-remifentanil anesthesia were selected. In order to determine MDR1 gene polymorphisms of 3435C > T, 1236C > T, and 2677G > T/A, polymerase chain reaction-restriction fragment length polymorphism was used. Mean arterial pressure (MAP), diastolic blood pressure (DBP), systolic blood pressure (SBP), and heart rate (HR) at T0 (5 mins after the repose), T1 (0 min after tracheal intubation), T2 (5 mins after the tracheal intubation), T3 (0 min after the tonsillectomy), T4 (0 min after removal of the mouth-gag) and T5 (5 min after the extubation) were observed. The visual analog scale (VAS), the face, legs, activity, cry, and consolability (FLACC) pain assessment, and Ramsay sedation score were recorded after the patients gained consciousness. The adverse reactions were also observed. RESULTS As compared to the CT + TT genotype of MDR1 1236C > T, the time of induction, respiration recovery, eye-opening, and extubation of children with the CC genotype was found to be shorter (all P <.05); the MAP, SBP, DBP, and HR were significantly reduced at T5 in children that possessed the CC genotype (all P <.05), the VAS at postoperative 1, 2, 4, and 8 hours and Ramsay sedation score were decreased, while the FLACC score increased (all P <.05). It was found that the adverse reaction rate was lower in children bearing the CC genotype (P <.05). CONCLUSION It could be concluded that anesthetic effect in patients with the MDR1 1236C > T CC genotype was found to be superior to those carrying the CT + TT genotype.
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Abstract
There is interpatient variability to analgesic administration. Much can be traced to pharmacogenomics variations between individuals. Certain ethnicities are more prone to reduced function of CYP2D6. Weak opioids are subject to interpatient variation based on their CYP2D6 type. Strong opioids have variations based on their transport and individual metabolism. Several cytochrome enzymes have been found to be involved with ketamine but there is no strong evidence of individual polymorphisms manifesting in clinical outcomes. Nonsteroidal anti-inflammatory drugs have adverse outcomes that certain CYP variants are more prone toward. There are now recommendations for dosing based on specific genomic makeup.
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Affiliation(s)
- Ramsey Saba
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Alan D Kaye
- Department of Anesthesiology and Pain Medicine, Louisiana State University School of Medicine, LSU Health Science Center, 1542 Tulane Avenue, Room 659, New Orleans, LA 70112, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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