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Mu RJ, Liu TL, Liu XD, Liu L. PBPK-PD model for predicting morphine pharmacokinetics, CNS effects and naloxone antagonism in humans. Acta Pharmacol Sin 2024:10.1038/s41401-024-01255-2. [PMID: 38570601 DOI: 10.1038/s41401-024-01255-2] [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: 12/21/2023] [Accepted: 02/27/2024] [Indexed: 04/05/2024] Open
Abstract
Morphine and morphine-6-glucuronide (M6G) produce central nervous system (CNS) effects by activating mu-opioid receptors, while naloxone is used mainly for the reversal of opioid overdose, specifically for the fatal complication of respiratory depression, but also for alleviating opioid-induced side effects. In this study we developed a physiologically-based pharmacokinetic-pharmacodynamic (PBPK-PD) model to simultaneously predict pharmacokinetics and CNS effects (miosis, respiratory depression and analgesia) of morphine as well as antagonistic effects of naloxone against morphine. The pharmacokinetic and pharmacodynamic parameters were obtained from in vitro data, in silico, or animals. Pharmacokinetic and pharmacodynamic simulations were conducted using 39 and 36 clinical reports, respectively. The pharmacokinetics of morphine and M6G following oral or intravenous administration were simulated, and the PBPK-PD model was validated using clinical observations. The Emax model correlated CNS effects with free concentrations of morphine and M6G in brain parenchyma. The predicted CNS effects were compared with observations. Most clinical observations fell within the 5th-95th percentiles of simulations based on 1000 virtual individuals. Most of the simulated area under the concentration-time curve or peak concentrations also fell within 0.5-2-fold of observations. The contribution of morphine to CNS effects following intravenous or oral administration was larger than that of M6G. Pharmacokinetics and antagonistic effects of naloxone on CNS effects were also successfully predicted using the developed PBPK-PD model. In conclusion, the pharmacokinetics and pharmacodynamics of morphine and M6G, antagonistic effects of naloxone against morphine-induced CNS effects may be successfully predicted using the developed PBPK-PD model based on the parameters derived from in vitro, in silico, or animal studies.
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Affiliation(s)
- Rui-Jing Mu
- Department of Pharmacology, College of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Tian-Lei Liu
- Department of Pharmacology, College of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Xiao-Dong Liu
- Department of Pharmacology, College of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China.
| | - Li Liu
- Department of Pharmacology, College of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China.
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The Use of Caffeine Citrate for Respiratory Stimulation in Acquired Central Hypoventilation Syndrome: A Case Series. J Crit Care Med (Targu Mures) 2023; 9:49-54. [PMID: 36890973 PMCID: PMC9987273 DOI: 10.2478/jccm-2023-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 12/27/2022] [Indexed: 02/11/2023] Open
Abstract
Introductions Caffeine is commonly used as a respiratory stimulant for the treatment of apnea of prematurity in neonates. However, there are no reports to date of caffeine used to improve respiratory drive in adult patients with acquired central hypoventilation syndrome (ACHS). Presentation of case series We report two cases of ACHS who were successfully liberated from mechanical ventilation after caffeine use, without side effects. The first case was a 41-year-old ethnic Chinese male, diagnosed with high-grade astrocytoma in the right hemi-pons, intubated and admitted to the intensive care unit (ICU) in view of central hypercapnia with intermittent apneic episodes. Oral caffeine citrate (1600mg loading followed by 800mg once daily) was initiated. His ventilator support was weaned successfully after 12 days. The second case was a 65-year-old ethnic Indian female, diagnosed with posterior circulation stroke. She underwent posterior fossa decompressive craniectomy and insertion of an extra-ventricular drain. Post-operatively, she was admitted to the ICU and absence of spontaneous breath was observed for 24 hours. Oral caffeine citrate (300mg twice daily) was initiated and she regained spontaneous breath after 2 days of treatment. She was extubated and discharged from the ICU. Conclusion Oral caffeine was an effective respiratory stimulant in the above patients with ACHS. Larger randomized controlled studies are needed to determine its efficacy in the treatment of ACHS in adult patients.
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Abstract
The ventilatory control system is highly vulnerable to exogenous administered opioid analgesics. Particularly respiratory depression is a potentially lethal complication that may occur when opioids are overdosed or consumed in combination with other depressants such as sleep medication or alcohol. Fatalities occur in acute and chronic pain patients on opioid therapy and individuals that abuse prescription or illicit opioids for their hedonistic pleasure. One important strategy to mitigate opioid-induced respiratory depression is cotreatment with nonopioid respiratory stimulants. Effective stimulants prevent respiratory depression without affecting the analgesic opioid response. Several pharmaceutical classes of nonopioid respiratory stimulants are currently under investigation. The majority acts at sites within the brainstem respiratory network including drugs that act at α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors (ampakines), 5-hydroxytryptamine receptor agonists, phospodiesterase-4 inhibitors, D1-dopamine receptor agonists, the endogenous peptide glycyl-glutamine, and thyrotropin-releasing hormone. Others act peripherally at potassium channels expressed on oxygen-sensing cells of the carotid bodies, such as doxapram and GAL021 (Galleon Pharmaceuticals Corp., USA). In this review we critically appraise the efficacy of these agents. We conclude that none of the experimental drugs are adequate for therapeutic use in opioid-induced respiratory depression and all need further study of efficacy and toxicity. All discussed drugs, however, do highlight potential mechanisms of action and possible templates for further study and development.
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Roozekrans M, Olofsen E, van der Schrier R, Boom M, Mooren R, Dahan A. Doxapram-mediated Increase in Cardiac Output Reduces Opioid Plasma Concentrations: A Pharmacokinetic/Pharmacodynamic-Pharmacokinetic/Pharmacodynamic Modeling Study in Healthy Volunteers. Clin Pharmacol Ther 2017; 102:115-122. [DOI: 10.1002/cpt.601] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 12/05/2016] [Accepted: 12/08/2016] [Indexed: 11/09/2022]
Affiliation(s)
- M Roozekrans
- Department of Anesthesiology; Leiden University Medical Center; Leiden The Netherlands
| | - E Olofsen
- Department of Anesthesiology; Leiden University Medical Center; Leiden The Netherlands
| | - R van der Schrier
- Department of Anesthesiology; Leiden University Medical Center; Leiden The Netherlands
| | - M Boom
- Department of Anesthesiology; Leiden University Medical Center; Leiden The Netherlands
| | - R Mooren
- Department of Anesthesiology; Leiden University Medical Center; Leiden The Netherlands
| | - A Dahan
- Department of Anesthesiology; Leiden University Medical Center; Leiden The Netherlands
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Richards JR, Davis MT, Curry MR, Tsushima JH, McKinney HE. Doxapram reversal of suspected gamma-hydroxybutyrate-induced coma. Am J Emerg Med 2016; 35:517.e1-517.e3. [PMID: 27641247 DOI: 10.1016/j.ajem.2016.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 09/06/2016] [Indexed: 11/16/2022] Open
Affiliation(s)
- John R Richards
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA.
| | - M Thais Davis
- Department of Emergency Medicine, Division of Toxicology, University of California Davis Medical Center, Sacramento, CA
| | - Mark R Curry
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA
| | - John H Tsushima
- Department of Pathology and Laboratory Medicine, University of California Davis Medical Center, Sacramento, CA
| | - Howard E McKinney
- Department of Pharmacy, University of California Davis Medical Center, Sacramento, CA
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Haji A, Kimura S, Ohi Y. Reversal of morphine-induced respiratory depression by doxapram in anesthetized rats. Eur J Pharmacol 2016; 780:209-15. [DOI: 10.1016/j.ejphar.2016.03.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 03/23/2016] [Accepted: 03/29/2016] [Indexed: 10/22/2022]
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Kimura S, Haji A. Pharmacological strategy for overcoming opioid-induced ventilatory disturbances. Eur J Pharmacol 2014; 725:87-90. [DOI: 10.1016/j.ejphar.2013.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 08/21/2013] [Indexed: 01/17/2023]
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Kao JH, Chen SL, Ma HI, Law PY, Tao PL, Loh HH. Intrathecal delivery of a mutant micro-opioid receptor activated by naloxone as a possible antinociceptive paradigm. J Pharmacol Exp Ther 2010; 334:739-45. [PMID: 20554907 DOI: 10.1124/jpet.109.165399] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Direct injection of double-stranded adeno-associated virus type 2 (dsAAV2) with a mu-opioid receptor (MOR) mutant [S4.45(196)A], and a reporter protein (enhanced green fluorescent protein) into the spinal cord (S2/S3) dorsal horn region of ICR mice resulted in antinociceptive responses to systemic injection of opioid antagonist naloxone without altering the acute agonist morphine responses and no measurable tolerance or dependence development during subchronic naloxone treatment. To develop further such mutant MORs into a therapeutic agent in pain management, a less invasive method for virus delivery is needed. Thus, in current studies, the dsAAV2 was locally injected into the subarachnoid space of the spinal cord by intrathecal administration. Instead of using the MORS196A mutant, we constructed the dsAAV2 vector with the MORS196ACSTA mutant, a receptor mutant in which naloxone has been shown to exhibit full agonistic properties in vitro. After 2 weeks of virus injection, naloxone (10 mg/kg s.c.) elicited antinociceptive effect (determined by tail-flick test) without tolerance (10 mg/kg s.c., b.i.d. for 6 days) and significant withdrawal symptoms. On the other hand, subchronic treatment with morphine (10 mg/kg s.c., b.i.d.) for 6 days induced significant tolerance (4.8-fold) and withdrawal symptoms. Furthermore, we found that morphine, but not naloxone, induced the rewarding effects (determined by conditioned place preference test). These data suggest that local expression of MORS196ACSTA in spinal cord and systemic administration of naloxone has the potential to be developed into a new strategy in the management of pain without addiction liability.
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Affiliation(s)
- J H Kao
- Graduate Institute of Life Science, National Defense Medical Center, Taipei, Taiwan, Republic of China
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Deibert P, Xander C, Blum HE, Becker G. Methylnaltrexone: the evidence for its use in the management of opioid-induced constipation. CORE EVIDENCE 2010; 4:247-58. [PMID: 20694079 PMCID: PMC2899781 DOI: 10.2147/ce.s8556] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Indexed: 12/26/2022]
Abstract
Introduction: Constipation is a distressing side effect of opioid treatment, being so irksome in some cases that patients would rather suffer the pain than the side effect of opioid analgesics. Stool softeners or stimulating laxatives are often ineffective or even aggravate the situation. A new efficacious and safe drug is needed to limit the frequently observed side effects induced by effective opioid-based analgesic therapy and to improve the quality of life for patients, most of whom are impaired by a severe disease. Aims: The purpose of this article is to assess current evidence supporting the use of the peripherally acting μ-opioid receptor antagonist, methylnaltrexone, to restrict passage across the blood–brain barrier in patients with opioid-induced bowel dysfunction. Evidence review: There are now convincing data from phase II and multicenter phase III randomized, double-blind, placebo-controlled trials that methylnaltrexone induces laxation in patients with long-term opioid use without affecting central analgesia or precipitation of opioid withdrawal. Onset of the effect is rapid and improvement is maintained for at least 3 months during the drug treatment. The action of methylnaltrexone is dose dependent. Weight-related dosing appeared to be effective. There were no severe side effects or signs of opioid withdrawal. Adverse events, most frequently abdominal cramping or nausea, were usually mild to moderate. Methylnaltrexone is contraindicated in patients with known or suspected mechanical intestinal stenosis. Patients receiving methylnaltrexone must be monitored. Place in therapy: Methylnaltrexone applied subcutaneously every other day may be given to patients suffering from chronic constipation due to opioid therapy for whom laxatives do not provide adequate relief of their symptoms.
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Affiliation(s)
- Peter Deibert
- Department of Rehabilitative and Preventive Sports Medicine
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Tao PL, Law PY, Loh HH. Search for the "ideal analgesic" in pain treatment by engineering the mu-opioid receptor. IUBMB Life 2010; 62:103-11. [PMID: 20039371 DOI: 10.1002/iub.292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The myriad of side effects that associate with morphine has been problematic in the clinical use to manage moderate to severe pain. It has been the holy grail of the pharmacologists to develop a compound, or treatment paradigm that could retain the analgesic effect of the drug as eliminating or reducing the side effects, mainly the tolerance and addiction development associates with chronic usage of the drug. In our earlier receptor structure/activities studies, we discovered an unique mutation of a conserved Ser in the fourth transmembrane domain of the opioid receptor that the alkaloid antagonist could activate the receptor. On the basis of this initial finding, we decide to explore the possibility of using virus to deliver the mutant mu-opioid receptor at the various sites of the nociceptive pathway and induce the antinociceptive responses with the systemic administration of opioid antagonists. In this article, we will summarize the progress of such approach and the probable advantages over the conventional approach of drug development in the treatment of chronic pain.
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Affiliation(s)
- Pao-Luh Tao
- Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan, Republic of China
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Pharmacology of stimulants prohibited by the World Anti-Doping Agency (WADA). Br J Pharmacol 2008; 154:606-22. [PMID: 18500382 DOI: 10.1038/bjp.2008.124] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
This review examines the pharmacology of stimulants prohibited by the World Anti-Doping Agency (WADA). Stimulants that increase alertness/reduce fatigue or activate the cardiovascular system can include drugs like ephedrine available in many over-the-counter medicines. Others such as amphetamines, cocaine and hallucinogenic drugs, available on prescription or illegally, can modify mood. A total of 62 stimulants (61 chemical entities) are listed in the WADA List, prohibited in competition. Athletes may have stimulants in their body for one of three main reasons: inadvertent consumption in a propriety medicine; deliberate consumption for misuse as a recreational drug and deliberate consumption to enhance performance. The majority of stimulants on the list act on the monoaminergic systems: adrenergic (sympathetic, transmitter noradrenaline), dopaminergic (transmitter dopamine) and serotonergic (transmitter serotonin, 5-HT). Sympathomimetic describes agents, which mimic sympathetic responses, and dopaminomimetic and serotoninomimetic can be used to describe actions on the dopamine and serotonin systems. However, many agents act to mimic more than one of these monoamines, so that a collective term of monoaminomimetic may be useful. Monoaminomimietic actions of stimulants can include blockade of re-uptake of neurotransmitter, indirect release of neurotransmitter, direct activation of monoaminergic receptors. Many of the stimulants are amphetamines or amphetamine derivatives, including agents with abuse potential as recreational drugs. A number of agents are metabolized to amphetamine or metamphetamine. In addition to the monoaminomimetic agents, a small number of agents with different modes of action are on the list. A number of commonly used stimulants are not considered as Prohibited Substances.
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Leri F. Co-administration of opioid agonists and antagonists in addiction and pain medicine. Expert Opin Pharmacother 2008; 9:1387-96. [DOI: 10.1517/14656566.9.8.1387] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Lee JH, Kim AR, Kim YH, Yoon SH. Effect of daxapram on recovery following total intravenous anesthesia with propofol and remifentanil. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.55.5.585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jun Hwa Lee
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - A Reum Kim
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Yoon Hee Kim
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Seok Hwa Yoon
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
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Abstract
UNLABELLED Opioid medication is the mainstay of therapy for severe acute and chronic pain. Unfortunately, the side effects of these medications can affect patient comfort and safety, thus limiting their proven therapeutic potential. Whereas the main analgesic effects of opioids are centrally mediated, many of the common side effects are mediated via peripheral receptors. Novel peripheral opioid antagonists have been recently introduced that can block the peripheral actions of opioids without affecting centrally mediated analgesia. We review the clinical and experimental evidence of their efficacy in ameliorating opioid side effects and consider what further information might be useful in defining their role. IMPLICATIONS The major analgesic effects of opioid medication are mediated within the brain and spinal cord. Many of the side effects of opioids are caused by activation of receptors outside these areas. Recently developed peripherally restricted opioid antagonists have the ability to block many opioid side effects without affecting analgesia.
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Affiliation(s)
- John J Bates
- *Department of Anaesthesia and Intensive Care Medicine, Cork University Hospital, Ireland; and †Clinical Research, Adolor Inc, Exton, Pennsylvania
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Clyburn PA, Rosen M. Patient-controlled analgesia with a mixture of pethidine and doxapram hydrochloride. A comparison of the incidence of respiratory dysrhythmias with pethidine alone. Anaesthesia 1988; 43:190-3. [PMID: 3129954 DOI: 10.1111/j.1365-2044.1988.tb05537.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Twenty-four patients who underwent elective cholecystectomy received double-blind increments of either pethidine 30 mg or a mixture of pethidine 30 mg and doxapram 45 mg delivered on a patient-controlled basis. A loading dose of doxapram 100 mg or saline was administered. There was no difference in respiratory depression as indicated by respiratory frequency and end tidal carbon dioxide concentration. The incidence of respiratory apnoea was similar in the two groups but apnoea was of shorter duration in patients who received doxapram, although the difference was not significant. Patients who received doxapram assessed overall pain as worse on a linear analogue scale (p less than 0.05) but demanded similar amounts of pethidine. There was no difference in pain on movement.
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Affiliation(s)
- P A Clyburn
- Department of Anaesthetics, University Hospital of Wales, Heath Park, Cardiff
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Year 1980 clinical trial publications. Clin Trials 1986. [DOI: 10.1093/acprof:oso/9780195035681.005.0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Meinert CL, Tonascia S, Higgins K. Content of reports on clinical trials: a critical review. CONTROLLED CLINICAL TRIALS 1984; 5:328-47. [PMID: 6394208 DOI: 10.1016/s0197-2456(84)80013-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
A 10% sample of English language papers, published in 1980, listed in Index Medicus, and classified under the heading, Clinical Trials, was used to assess the state of trials and reports from them. Tabulations are presented concerning the design of the trials represented by the papers in the sample. The manuscript concludes with a discussion of reporting responsibilities for investigators involved in trials and of methods for meeting those responsibilities.
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