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Bickel J, Aboutara N, Jungen H, Szewczyk A, Müller A, Ondruschka B, Iwersen-Bergmann S. Morphine concentrations in fatalities after palliative treatment of acute burn injury. Int J Legal Med 2024; 138:839-847. [PMID: 38231204 PMCID: PMC11004028 DOI: 10.1007/s00414-024-03164-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/08/2024] [Indexed: 01/18/2024]
Abstract
The evaluation of a morphine concentration in postmortem blood is routine for a forensic toxicologist. We here report three fatal cases where we found high morphine concentrations with 7.96, 4.30, and 5.82 mg/l in femoral blood that have to be estimated as unusually high. All these individuals died due to severe burn injuries and obtained morphine in the context of their palliative care in the last hours of their lives. According to the autopsy results, the cause of death in case 1 was burn disease with burns of about 90% of the body surface area (BSA), case 2 burn trauma, and case 3 burn shock. Besides morphine, propofol, fentanyl, sufentanil, midazolam, diazepam, lorazepam, cefazolin, and rocuronium were detected in femoral blood. The findings fitted well with the detailed clinical documentation. Further evidence of therapeutic concentrations of quetiapine, duloxetine, and melperone could be matched to preexisting medication of the individuals. Physiologically based pharmacokinetic modelling (PBPK) was applied, developed for the intravenous administration of morphine, to find an explanation for the high morphine concentrations in femoral blood. Quantification of morphine in body fluids and tissue was performed to calculate morphine tissue concentration ratios to the morphine concentration in femoral blood. The presented cases show that pharmacokinetic simulations can reflect decreased renal clearance and decreased hepatic metabolism in general. However, this prediction is not sufficient to explain the high morphine concentrations in femoral blood measured here. It can be assumed that burn shock in particular leads to altered pharmacokinetics, namely decreased distribution of morphine.
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Affiliation(s)
- Julian Bickel
- Department of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Nadine Aboutara
- Research Centre Borstel Leibniz Lung Centre, Borstel, Germany
| | - Hilke Jungen
- Department of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Szewczyk
- Department of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander Müller
- Department of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Ondruschka
- Department of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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2
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Chen YL, Lai YH, Huang EYK, Wang HJ, Hung HY. Nalbuphine-6-glucuronide is a potent analgesic with superior safety profiles by altering binding affinity and selectivity for mu-/kappa-opioid receptors. Life Sci 2024; 340:122441. [PMID: 38253309 DOI: 10.1016/j.lfs.2024.122441] [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: 09/28/2023] [Revised: 01/05/2024] [Accepted: 01/14/2024] [Indexed: 01/24/2024]
Abstract
Although nalbuphine, a semi-synthetic analgesic compound, is less potent than morphine in terms of alleviating severe pain, our recent findings have revealed that nalbuphine-6-glucuronide (N6G), one of the glucuronide metabolites of nalbuphine, promotes a significantly more robust analgesic effect than its parent drug. Nevertheless, despite these promising observations, the precise mechanisms underlying the analgesic effects of nalbuphine glucuronides have yet to be determined. In this study, we aim to elucidate the mechanisms associated with the analgesic effects of nalbuphine glucuronides. Pharmacokinetic and pharmacodynamic studies were conducted to investigate the relationship between the central and peripheral compartments of nalbuphine and its derivatives. The analgesic responses of these compounds were evaluated based on multiple behavioral tests involving thermal and mechanical stimuli. Radioligand binding assays were also performed to determine the binding affinity and selectivity of these compounds for different opioid receptors. The results of these tests consistently confirmed that the heightened analgesic effects of N6G are mediated through its enhanced binding affinity for both mu- and kappa-opioid receptors, even comparable to those of morphine. Notably, N6G exhibited fewer side effects and did not induce sudden death, thereby highlighting its superior safety profile. Additionally, pharmacokinetic studies indicated that N6G could cross the blood-brain barrier when administered peripherally, offering pain relief. Overall, N6G provides great analgesic efficacy and enhanced safety. These findings highlight the potential value of nalbuphine glucuronides, particularly N6G, as promising candidates for the development of novel analgesic drugs.
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Affiliation(s)
- Yen-Lun Chen
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Yen-Hsun Lai
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Eagle Yi-Kung Huang
- Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Hong-Jaan Wang
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan, Republic of China; School of Pharmacy, National Defense Medical Center, Taipei, Taiwan, Republic of China.
| | - Hao-Yuan Hung
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan, Republic of China; Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan, Republic of China; Department of Pharmacy Practice, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China.
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3
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Casamento A, Ghosh A, Neto AS, Young M, Lawrence M, Taplin C, Eastwood GM, Bellomo R. The effect of age on clinical dose equivalency of fentanyl and morphine analgosedation in mechanically ventilated patients: Findings from the ANALGESIC trial. Aust Crit Care 2024; 37:236-243. [PMID: 37574387 DOI: 10.1016/j.aucc.2023.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 06/18/2023] [Accepted: 07/06/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND The dose equivalency of fentanyl vs. morphine is widely considered to be approximately 1:100. However, little is known about the effect of age on this ratio when these agents are used as infusions for analgosedation. OBJECTIVES To assess the impact of age on the clinical dose equivalency of fentanyl and morphine when used as infusions for analgosedation in mechanically ventilated intensive care unit patients. METHODS We performed a post hoc analysis of the Assessment of Opioid Administration to Lead to Analgesic Effects and Sedation in Intensive Care (ANALGESIC) cluster randomised crossover trial of fentanyl and morphine infusions for analgosedation. Dose and analgosedative clinical equivalency of fentanyl and morphine were assessed by age and by using different body-size descriptors. RESULTS We studied 663 patients (338 fentanyl, 325 morphine). Median (interquartile range) hourly dose of fentanyl and morphine were 58.1 (40.0-89.2) mcg and 3400 (2200-5000) mcg, respectively. The ratio of total dose of fentanyl:morphine was 1:93 in the 18- to 29-year-old group and 1:25 in the ≥80-year-old group (p = 0.015), respectively, with fentanyl becoming relatively less clinically effective as age increased. This effect was also seen when comparing dosing by different body-size descriptors with the strongest age-related change when using body surface area as body-size descriptor (p = 0.009). CONCLUSION The analgosedative clinical dose equivalency of fentanyl vs. morphine is heterogeneous when used as infusions for analgosedation, with fentanyl becoming relatively less clinically effective as age increases. This information can help guide prescription of these agents during transition from one agent to the other in critically ill patients.
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Affiliation(s)
- Andrew Casamento
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Intensive Care, Northern Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia.
| | - Angajendra Ghosh
- Department of Intensive Care, Northern Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Department of Medical Education, University of Melbourne, Melbourne, Australia
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Data Analytics Research & Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Marcus Young
- Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mervin Lawrence
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
| | - Christina Taplin
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Data Analytics Research & Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia
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4
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Tueshaus T, McKemie DS, Kanarr K, Kass PH, Knych HK. Pharmacokinetics and effects of codeine in combination with acetaminophen on thermal nociception in horses. J Vet Pharmacol Ther 2023; 46:311-325. [PMID: 37021661 DOI: 10.1111/jvp.13126] [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: 11/14/2022] [Revised: 02/22/2023] [Accepted: 03/21/2023] [Indexed: 04/07/2023]
Abstract
Codeine and acetaminophen in combination have proven to be an effective analgesic treatment for moderate-to-severe and postoperative pain in humans. Studies have demonstrated that codeine and acetaminophen, when administered as sole agents, are well tolerated by horses. In the current study, we hypothesized that administration of the combination of codeine and acetaminophen would result in a significant thermal antinociceptive effect compared with administration of either alone. Six horses were administered oral doses of codeine (1.2 mg/kg), acetaminophen (20 mg/kg), and codeine plus acetaminophen (1.2 mg/kg codeine and 6-6.4 mg/kg acetaminophen) in a three-way balanced crossover design. Plasma samples were collected, concentrations of drug and metabolites determined via liquid chromatography-mass spectrometry, and pharmacokinetic analyses were performed. Pharmacodynamic outcomes, including effect on thermal thresholds, were assessed. Codeine Cmax and AUC were significantly different between the codeine and combination group. There was considerable inter-individual variation in the pharmacokinetic parameters for codeine, acetaminophen, and their metabolites in horses. All treatments were well tolerated with minimal significant adverse effects. An increase in the thermal threshold was noted at 1.5 and 2 h, from 15 min through 6 h and 0.5, 1, 1.5, and 3 h in the codeine, acetaminophen, and combination groups, respectively.
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Affiliation(s)
- Tisa Tueshaus
- K.L Maddy Equine Analytical Pharmacology Laboratory, University of California Davis, School of Veterinary Medicine, Davis, California, USA
| | - Daniel S McKemie
- K.L Maddy Equine Analytical Pharmacology Laboratory, University of California Davis, School of Veterinary Medicine, Davis, California, USA
| | - Kirsten Kanarr
- K.L Maddy Equine Analytical Pharmacology Laboratory, University of California Davis, School of Veterinary Medicine, Davis, California, USA
| | - Philip H Kass
- Department of Medicine and Epidemiology, University of California Davis, School of Veterinary Medicine, Davis, California, USA
| | - Heather K Knych
- K.L Maddy Equine Analytical Pharmacology Laboratory, University of California Davis, School of Veterinary Medicine, Davis, California, USA
- Department of Molecular Biosciences, University of California Davis, School of Veterinary Medicine, Davis, California, USA
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5
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Poth MKM, McKemie DS, Traynham M, Kass PH, Knych HK. Concentrations, pharmacokinetics and selected pharmacodynamics of morphine and its active metabolites following oral administration to horses. J Vet Pharmacol Ther 2023. [PMID: 36883679 DOI: 10.1111/jvp.13122] [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: 10/15/2022] [Revised: 01/25/2023] [Accepted: 02/18/2023] [Indexed: 03/09/2023]
Abstract
The metabolism and pharmacokinetics of intravenous (i.v.) morphine in the horse have been described; however, administration of therapeutic doses has also been associated with neuroexcitation and adverse gastrointestinal effects. In this study, we hypothesized that oral administration would lead to comparable concentrations of morphine and its presumed active metabolite, morphine 6-glucuronide (M6G) without the adverse effects associated with i.v. administration. Eight horses were administered a single i.v. dose of 0.2 mg/kg morphine and oral doses of 0.2, 0.6, and 0.8 mg/kg of morphine in a four-way balanced crossover design, with a 2-week washout period between doses. Concentrations of morphine and metabolites were determined, and pharmacokinetic parameters determined. Physiologic and behavioral outcomes including the number of steps taken, changes in heart rate, and gastrointestinal borborygmi were assessed. Oral administration of morphine resulted in higher concentrations of morphine metabolites, including M6G (Cmax : 11.6-37.8 ng/mL (0.6 mg/kg); 15.8-42.6 ng/mL (0.8 mg/kg)), compared with i.v. Bioavailability was 36.5%, 27.6% and 28.0% for 0.2, 0.6 and 0.8 mg/kg, respectively. Behavioral and physiologic changes were noted in all groups but were less prominent with oral compared with i.v. administration. Results of the current study are encouraging for further study, specifically anti-nociceptive effects of morphine following oral administration.
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Affiliation(s)
- Meghan K M Poth
- K.L. Maddy Equine Analytical Pharmacology Laboratory, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Daniel S McKemie
- K.L. Maddy Equine Analytical Pharmacology Laboratory, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Megan Traynham
- K.L. Maddy Equine Analytical Pharmacology Laboratory, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Philip H Kass
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Heather K Knych
- K.L. Maddy Equine Analytical Pharmacology Laboratory, School of Veterinary Medicine, University of California, Davis, Davis, California, USA.,Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
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6
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Qiu Q, Chew JCJ, Irwin MG. Opioid MOP receptor agonists in late-stage development for the treatment of postoperative pain. Expert Opin Pharmacother 2022; 23:1831-1843. [DOI: 10.1080/14656566.2022.2141566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Qiu Qiu
- Department of Anaesthesiology, Queen Mary Hospital, Hong Kong, Special Administrative Region, China
| | - Joshua CJ Chew
- Department of Anaesthesiology, Queen Mary Hospital, Hong Kong, Special Administrative Region, China
- Department of Anaesthesiology, The University of Hong Kong, Special Administrative Region, China
| | - Michael G Irwin
- Department of Anaesthesiology, The University of Hong Kong, Special Administrative Region, China
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7
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Morphine Accumulates in the Retina Following Chronic Systemic Administration. Pharmaceuticals (Basel) 2022; 15:ph15050527. [PMID: 35631353 PMCID: PMC9146690 DOI: 10.3390/ph15050527] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
Opioid transport into the central nervous system is crucial for the analgesic efficacy of opioid drugs. Thus, the pharmacokinetics of opioid analgesics such as morphine have been extensively studied in systemic circulation and the brain. While opioid metabolites are routinely detected in the vitreous fluid of the eye during postmortem toxicological analyses, the pharmacokinetics of morphine within the retina of the eye remains largely unexplored. In this study, we measured morphine in mouse retina following systemic exposure. We showed that morphine deposits and persists in the retina long after levels have dropped in the serum. Moreover, we found that morphine concentrations (ng/mg tissue) in the retina exceeded brain morphine concentrations at all time points tested. Perhaps most intriguingly, these data indicate that following chronic systemic exposure, morphine accumulates in the retina, but not in the brain or serum. These results suggest that morphine can accumulate in the retina following chronic use, which could contribute to the deleterious effects of chronic opioid use on both image-forming and non-image-forming visual functions.
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8
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Casamento AJ, Serpa Neto A, Young M, Lawrence M, Taplin C, Eastwood GM, Ghosh A, Bellomo R. A Phase II Cluster-Crossover Randomized Trial of Fentanyl versus Morphine for Analgosedation in Mechanically Ventilated Patients. Am J Respir Crit Care Med 2021; 204:1286-1294. [PMID: 34543581 DOI: 10.1164/rccm.202106-1515oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: The continuous infusion of fentanyl or morphine is often prescribed to assist with analgesia and sedation (analgosedation) during mechanical ventilation. Objectives: To compare the effect of fentanyl versus morphine on patient-centered outcomes in ventilated patients. Methods: We conducted a cluster-randomized, cluster-crossover trial between July 2019 and August 2020 in two adult ICUs. We compared two continuous infusion regimens (fentanyl versus morphine). One ICU was randomized to the fentanyl-morphine sequence and the other to the morphine-fentanyl sequence. The primary outcome was the number of ventilator-free days at Day 28. Secondary outcomes included, among others, duration of mechanical ventilation in survivors and ICU-free days at Day 28. Measurements and Main Results: Via cluster allocation, we randomized 737 patients. Of these, 56 were excluded because of the opt-out consent process, leaving 681 (344 to fentanyl and 337 to morphine) for primary analysis (median [interquartile range] age, 59 [44-69] years). Median ventilator-free days at Day 28 were 26.1 (20.7-27.3) in the fentanyl versus 25.3 (19.1-27.2) in the morphine group (median difference, 0.79 [95% confidence interval, 0.31 to 1.28], P = 0.001). ICU-free days were greater (P < 0.001) and length of stay in the ICU for survivors shorter (P < 0.001) in the fentanyl group. All other secondary outcomes were not statistically different by treatment group. Conclusions: Among adult patients requiring mechanical ventilation, compared with morphine, fentanyl infusion significantly increased the median number of ventilator-free days at Day 28. The choice of opioid infusion agent may affect clinical outcomes and requires further investigation.
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Affiliation(s)
- Andrew J Casamento
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Intensive Care, Northern Hospital, Melbourne, Australia.,Department of Critical Care and
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Critical Care and.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Data Analytics Research and Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; and.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Marcus Young
- Department of Critical Care and.,Data Analytics Research and Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; and
| | - Mervin Lawrence
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
| | - Christina Taplin
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Critical Care and
| | - Angajendra Ghosh
- Department of Intensive Care, Northern Hospital, Melbourne, Australia.,Department of Medical Education, University of Melbourne, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Critical Care and.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Data Analytics Research and Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; and
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9
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Tadjalli A, Seven YB, Sharma A, McCurdy CR, Bolser DC, Levitt ES, Mitchell GS. Acute morphine blocks spinal respiratory motor plasticity via long-latency mechanisms that require toll-like receptor 4 signalling. J Physiol 2021; 599:3771-3797. [PMID: 34142718 DOI: 10.1113/jp281362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 06/15/2021] [Indexed: 12/22/2022] Open
Abstract
KEY POINTS While respiratory complications following opioid use are mainly mediated via activation of mu opioid receptors, long-latency off-target signalling via innate immune toll-like receptor 4 (TLR4) may impair other essential elements of breathing control such as respiratory motor plasticity. In adult rats, pre-treatment with a single dose of morphine blocked long-term facilitation (LTF) of phrenic motor output via a long-latency TLR4-dependent mechanism. In the phrenic motor nucleus, morphine triggered TLR4-dependent activation of microglial p38 MAPK - a key enzyme that orchestrates inflammatory signalling and is known to undermine phrenic LTF. Morphine-induced LTF loss may destabilize breathing, potentially contributing to respiratory side effects. Therefore, we suggest minimizing TLR-4 signalling may improve breathing stability during opioid therapy. ABSTRACT Opioid-induced respiratory dysfunction is a significant public health burden. While respiratory effects are mediated via mu opioid receptors, long-latency off-target opioid signalling through innate immune toll-like receptor 4 (TLR4) may modulate essential elements of breathing control, particularly respiratory motor plasticity. Plasticity in respiratory motor circuits contributes to the preservation of breathing in the face of destabilizing influences. For example, respiratory long-term facilitation (LTF), a well-studied model of respiratory motor plasticity triggered by acute intermittent hypoxia, promotes breathing stability by increasing respiratory motor drive to breathing muscles. Some forms of respiratory LTF are exquisitely sensitive to inflammation and are abolished by even a mild inflammation triggered by TLR4 activation (e.g. via systemic lipopolysaccharides). Since opioids induce inflammation and TLR4 activation, we hypothesized that opioids would abolish LTF through a TLR4-dependent mechanism. In adult Sprague Dawley rats, pre-treatment with a single systemic injection of the prototypical opioid agonist morphine blocks LTF expression several hours later in the phrenic motor system - the motor pool driving diaphragm muscle contractions. Morphine blocked phrenic LTF via TLR4-dependent mechanisms because pre-treatment with (+)-naloxone - the opioid inactive stereoisomer and novel small molecule TLR4 inhibitor - prevented impairment of phrenic LTF in morphine-treated rats. Morphine triggered TLR4-dependent activation of microglial p38 MAPK within the phrenic motor system - a key enzyme that orchestrates inflammatory signalling and undermines phrenic LTF. Morphine-induced LTF loss may destabilize breathing, potentially contributing to respiratory side effects. We suggest minimizing TLR-4 signalling may improve breathing stability during opioid therapy by restoring endogenous mechanisms of plasticity within respiratory motor circuits.
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Affiliation(s)
- Arash Tadjalli
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA.,Department of Physical Therapy, University of Florida, Gainesville, FL, USA
| | - Yasin B Seven
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA.,Department of Physical Therapy, University of Florida, Gainesville, FL, USA
| | - Abhisheak Sharma
- Department of Pharmaceutics, University of Florida, Gainesville, FL, USA
| | | | - Donald C Bolser
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA.,Department of Physiological Sciences, University of Florida, Gainesville, FL, USA
| | - Erica S Levitt
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA.,Department of Pharmacology and Therapeutics, University of Florida, Gainesville, FL, USA
| | - Gordon S Mitchell
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA.,Department of Physical Therapy, University of Florida, Gainesville, FL, USA
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10
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Lefrancois E, Reymond N, Thomas A, Lardi C, Fracasso T, Augsburger M. Summary statistics for drugs and alcohol concentration recovered in post-mortem femoral blood in Western Switzerland. Forensic Sci Int 2021; 325:110883. [PMID: 34229141 DOI: 10.1016/j.forsciint.2021.110883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/15/2021] [Accepted: 06/17/2021] [Indexed: 10/21/2022]
Abstract
In post-mortem investigations of fatal intoxication, it is challenging to determine which drug(s) were responsible for the death, and which drugs did not. This study aims to provide post-mortem femoral blood drug levels in lethal intoxication and in post-mortem control cases, where the cause of death was other than intoxication. The reference values could assist in the interpretation of toxicological results in the routine casework. To this end, all post-mortem toxicological results in femoral blood from 2011 to 2017 in Western Switzerland were considered. A full autopsy with systematic toxicological analysis (STA) was conducted in all cases. Results take into account the cause of death classified into one of four categories (as published by Druid and colleagues): I) certified intoxication by one substance alone, IIa) certified intoxication by more than one substance, IIb) certified other causes of death with incapacitation due to drugs, and III) certified other causes of death without incapacitation due to drugs. This study includes 1 990 post-mortem cases where femoral blood was analysed. The material comprised 619 women (31%) and 1 371 men (69%) with a median age of 50 years. The concentrations of the 32 most frequently recorded substances as well as alcohol are discussed. These include 6 opioids and opiates, 3 antidepressants, 6 neuroleptics and hypnotics, 1 barbiturate, 11 benzodiazepines (and related drugs), 2 amphetamine-type stimulants, cocaine, paracetamol, and tetrahydrocannabinol (THC). The most common substances that caused intoxication alone were morphine, methadone, ethanol, tramadol, and cocaine. The post-mortem concentration ranges for all substance are categorized as I, IIa, IIb, or III. Statistical post-mortem reference concentrations for drugs are discussed and compared with previously published concentrations. This study shows that recording and classifying cases is time-consuming, but it is rewarding in a long-term perspective to achieve a more reliable information about fatal and non-fatal blood concentrations.
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Affiliation(s)
- Elodie Lefrancois
- School of criminal justice, Faculty of Law, Criminal Justice and Public Administration, University of Lausanne, Switzerland; University Centre of Legal Medicine (CURML), Lausanne, Geneva, Switzerland
| | - Naomi Reymond
- School of criminal justice, Faculty of Law, Criminal Justice and Public Administration, University of Lausanne, Switzerland
| | - Aurélien Thomas
- University Centre of Legal Medicine (CURML), Lausanne, Geneva, Switzerland
| | - Christelle Lardi
- University Centre of Legal Medicine (CURML), Lausanne, Geneva, Switzerland
| | - Tony Fracasso
- University Centre of Legal Medicine (CURML), Lausanne, Geneva, Switzerland
| | - Marc Augsburger
- University Centre of Legal Medicine (CURML), Lausanne, Geneva, Switzerland
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11
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Park SK, Kim H, Yoo S, Kim WH, Lim YJ, Kim JT. Predicted Versus Non-Predicted Opioid Administration Using Preoperative Pain Sensitivity in Patients Undergoing Gynecological Surgery: A Randomized-Controlled Trial. J Clin Med 2021; 10:jcm10040585. [PMID: 33557259 PMCID: PMC7914520 DOI: 10.3390/jcm10040585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 01/27/2021] [Accepted: 02/01/2021] [Indexed: 12/03/2022] Open
Abstract
Individualized administration of opioids based on preoperative pain sensitivity may improve postoperative pain profiles. This study aimed to examine whether a predicted administration of opioids could reduce opioid-related adverse effects after gynecological surgery. Patients were randomized to the predicted group or control group. Participants received a preoperative sensory test to measure pressure pain thresholds. Patients were treated with a higher or lower (15 or 10 μg/mL) dose of fentanyl via intravenous patient-controlled analgesia. The opioid dose was determined according to pain sensitivity in the predicted group, while it was determined regardless of pain sensitivity in the control group. The primary outcome was the incidence of nausea over the first 48 h postoperative period. Secondary outcomes included postoperative pain scores and opioid requirements. There was no difference in the incidence of nausea (40.0% vs. 52.5% in predicted and control groups, respectively; p = 0.191) and postoperative pain scores (3.3 vs. 3.5 in predicted and control groups, respectively; p = 0.691). However, opioid consumptions were lower in the predicted group compared to the control group (median 406.0 vs. 526.5 μg; p = 0.042). This study showed that offering a predicted dose of opioids according to pain sensitivity did not affect the incidence of nausea and pain scores.
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Mazák K, Noszál B, Hosztafi S. Advances in the Physicochemical Profiling of Opioid Compounds of Therapeutic Interest. ChemistryOpen 2019; 8:879-887. [PMID: 31312587 PMCID: PMC6610444 DOI: 10.1002/open.201900115] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/24/2019] [Indexed: 01/27/2023] Open
Abstract
This review focuses on recent developments in the physicochemical profiling of morphine and other opioids. The acid-base properties and lipophilicity of these compounds is discussed at the microscopic, species-specific level. Examples are provided where this type of information can reveal the mechanism of pharmacokinetic processes at the submolecular level. The role of lipophilicity in quantitative structure-activity relationship (QSAR) studies of opioids is reviewed. The physicochemical properties and pharmacology of the main metabolites of morphine are also discussed. Recent studies indicate that the active metabolite morphine-6-glucuronide (M6G) can contribute to the analgesic activity of systemically administered morphine. The unexpectedly high lipophilicity of M6G partly accounts for its analgesic activity. When administered parenterally, another suspected minor metabolite, morphine-6-sulfate (M6S) has superior antinociceptive effects to those of morphine. However, because sulfate esters of morphine derivatives cannot cross the blood-brain barrier these esters may be good candidates to develop peripheral analgesic drugs.
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Affiliation(s)
- Károly Mazák
- Semmelweis University Department of Pharmaceutical Chemistry, Research Group of Drugs of Abuse and Doping Agents, Hungarian Academy of Sciences Hőgyes E. u. 9. H-1092 Budapest Hungary
| | - Béla Noszál
- Semmelweis University Department of Pharmaceutical Chemistry, Research Group of Drugs of Abuse and Doping Agents, Hungarian Academy of Sciences Hőgyes E. u. 9. H-1092 Budapest Hungary
| | - Sándor Hosztafi
- Semmelweis University Department of Pharmaceutical Chemistry, Research Group of Drugs of Abuse and Doping Agents, Hungarian Academy of Sciences Hőgyes E. u. 9. H-1092 Budapest Hungary
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Practicalities of Total Intravenous Anesthesia and Target-controlled Infusion in Children. Anesthesiology 2019; 131:164-185. [DOI: 10.1097/aln.0000000000002657] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Abstract
Propofol administered in conjunction with an opioid such as remifentanil is used to provide total intravenous anesthesia for children. Drugs can be given as infusion controlled manually by the physician or as automated target-controlled infusion that targets plasma or effect site. Smart pumps programmed with pharmacokinetic parameter estimates administer drugs to a preset plasma concentration. A linking rate constant parameter (keo) allows estimation of effect site concentration. There are two parameter sets, named after the first author describing them, that are commonly used in pediatric target-controlled infusion for propofol (Absalom and Kataria) and one for remifentanil (Minto). Propofol validation studies suggest that these parameter estimates are satisfactory for the majority of children. Recommended target concentrations for both propofol and remifentanil depend on the type of surgery, the degree of surgical stimulation, the use of local anesthetic blocks, and the ventilatory status of the patient. The use of processed electroencephalographic monitoring is helpful in pediatric total intravenous anesthesia and target-controlled infusion anesthesia, particularly in the presence of neuromuscular blockade.
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Hannam JA, Anderson BJ. Contribution of Morphine and Morphine-6-Glucuronide to Respiratory Depression in a Child. Anaesth Intensive Care 2019; 40:867-70. [DOI: 10.1177/0310057x1204000516] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- J. A. Hannam
- Department of Anaesthesiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - B. J. Anderson
- Department of Anaesthesiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Palmer GM, Anderson BJ, Linscott DK, Paech MJ, Allegaert K. Tramadol, breast feeding and safety in the newborn. Arch Dis Child 2018; 103:1110-1113. [PMID: 29599166 DOI: 10.1136/archdischild-2017-313786] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 02/26/2018] [Accepted: 02/27/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Greta M Palmer
- Department of Paediatric Anaesthesia and Pain Management, Royal Children's Hospital; University of Melbourne and Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Brian J Anderson
- Department of Anaesthesiology, Faculty of Medicine and Health Science, University of Auckland, Auckland, New Zealand
| | - David K Linscott
- Department of Anaesthesia, Christchurch Hospital; University of Otago, Christchurch, New Zealand
| | - Michael J Paech
- The University of Western Australia, Perth, Western Australia, Australia.,Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery and Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Pope JE, Deer TR, Amirdelfan K, McRoberts WP, Azeem N. The Pharmacology of Spinal Opioids and Ziconotide for the Treatment of Non-Cancer Pain. Curr Neuropharmacol 2017; 15:206-216. [PMID: 26861471 PMCID: PMC5412702 DOI: 10.2174/1570159x14666160210142339] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 04/01/2015] [Accepted: 02/05/2016] [Indexed: 12/29/2022] Open
Abstract
Background Intrathecal drug delivery has undergone a revitalization following a better understanding of this delivery route and its pharmacokinetics. Driven by patient safety and outcomes, clinicians are motivated to rethink the traditional spinal infusion pump patient selection criteria and indications. We review the current understanding of the pharmacology of commonly employed intrathecal agents and the clinical relevance. Methods Search strategies for data acquisition included Medline database, PubMed, Google scholar, along with international and national professional meeting content, with key words including pharmacology of opioids, intrathecal therapy, ziconotide, pharmacokinetics, and intrathecal drug delivery. The search results were limited to the English language. Results Over 300 papers were identified. The literature was condensed and digested to evaluate the most commonly used medications in practice, sto serve as a foundation for review. We review on-label medications: ziconotide and morphine, and off label medications including fentanyl, sufentail, and hydromorphine. Conclusion Intrathecal therapy has level-one evidence for use for malignant pain and nonmalignant pain, with continued cost savings and improved safety. To most effectively serve our patients, a clear appreciation for the pharmacology of these commonly employed medication is paramount..
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Affiliation(s)
- J E Pope
- Center for Pain Relief, Charleston, WV, USA. United States
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Dawes JM, Cooke EM, Hannam JA, Brand KA, Winton P, Jimenez-Mendez R, Aleksa K, Lauder GR, Carleton BC, Koren G, Rieder MJ, Anderson BJ, Montgomery CJ. Oral morphine dosing predictions based on single dose in healthy children undergoing surgery. Paediatr Anaesth 2017; 27:28-36. [PMID: 27779356 DOI: 10.1111/pan.13020] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2016] [Indexed: 01/20/2023]
Abstract
BACKGROUND Oral morphine has been proposed as an effective and safe alternative to codeine for after-discharge pain in children following surgery but there are few data guiding an optimum safe oral dose. AIMS The aim of this study was to characterize the absorption pharmacokinetics of enteral morphine in order to simulate time-concentration profiles in children given common oral morphine dose regimens. METHODS Children (2-6 years, n = 34) undergoing elective surgery and requiring opioid analgesia were randomized to receive preoperative oral morphine (100 mcg·kg-1 , 200 mcg·kg-1 , 300 mcg·kg-1 ). Blood sampling for morphine assay was performed at 30, 60, 90, 120, 180, and 240 min. Morphine serum concentrations were determined by liquid chromatography-mass spectroscopy and pharmacokinetic parameters were calculated using nonlinear mixed effects models. Current data were pooled with published time-concentration profiles from children (n = 1059, age 23 weeks postmenstrual age - 3 years) administered intravenous morphine, to determine oral bioavailability (F), absorption lag time (TLAG ), and absorption half-time (TABS ). These parameter estimates were used to predict concentrations in children given oral morphine (100, 200, 300, 400, 500 mcg·kg-1 ) at different dosing intervals (3, 4, 5, 6, 8, 12 h). RESULTS The oral morphine formulation had F 0.298 (CV 36.5%), TLAG 0.45 (CV 63.6%) h and TABS 0.71 (CV 55%) h. A single-dose morphine 100 mcg·kg-1 achieved a mean CMAX 10 mcg·l-1 . Repeat 4-hourly dosing achieved mean steady-state concentration 13-18 mcg·l-1 ; concentrations associated with good analgesia after intravenous administration. Serum concentration variability was large ranging from 5 to 55 mcg·l-1 at steady state. CONCLUSIONS Oral morphine 200 mcg·kg-1 then 100 mcg·kg-1 4 h or 150 mcg·kg-1 6 h achieves mean concentrations associated with analgesia. There was high serum concentration variability suggesting that respiration may be compromised in some children given these doses.
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Affiliation(s)
- Joy M Dawes
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | - Erin M Cooke
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Jacqueline A Hannam
- Department of Anaesthesiology, School of Medicine, University of Auckland, Auckland, New Zealand
| | - Katherine A Brand
- Department of Anaesthesia, Evelina London Children's Hospital and St Thomas' Hospital, London, UK
| | - Pamela Winton
- Department of Anaesthesia, Royal Hospital for Sick Children, Edinburgh, UK
| | - Ricardo Jimenez-Mendez
- Department of Paediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Katarina Aleksa
- Division of Clinical Pharmacology/Toxicology, Hospital for Sick Children, Toronto, ON, Canada
| | - Gillian R Lauder
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Bruce C Carleton
- Department of Paediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Gideon Koren
- Division of Clinical Pharmacology/Toxicology, Hospital for Sick Children, Toronto, ON, Canada
| | - Michael J Rieder
- Departments of Paediatrics, University of Western Ontario, London, ON, Canada
| | - Brian J Anderson
- Department of Anaesthesiology, School of Medicine, University of Auckland, Auckland, New Zealand
| | - Carolyne J Montgomery
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
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Yang ZZ, Li L, Wang L, Xu MC, An S, Jiang C, Gu JK, Wang ZJJ, Yu LS, Zeng S. siRNA capsulated brain-targeted nanoparticles specifically knock down OATP2B1 in mice: a mechanism for acute morphine tolerance suppression. Sci Rep 2016; 6:33338. [PMID: 27629937 PMCID: PMC5024137 DOI: 10.1038/srep33338] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/24/2016] [Indexed: 12/18/2022] Open
Abstract
Regulating main brain-uptake transporter of morphine may restrict its tolerance generation, then modify its antinociception. In this study, more than 2 fold higher intracellular uptake concentrations for morphine and morphine-6-glucuronide (M6G) were observed in stable expression cells, HEK293-hOATP2B1 than HEK293-MOCK. Specifically, the Km value of morphine to OATP2B1 (57.58 ± 8.90 μM) is 1.4-time more than that of M6G (80.31 ± 21.75 μM); Cyclosporine A (CsA), an inhibitor of OATP2B1, can inhibit their intracellular accumulations with IC50 = 3.90 ± 0.50 μM for morphine and IC50 = 6.04 ± 0.86 μM for M6G, respectively. To further investigate the role of OATP2B1 in morphine brain transport and tolerance, the novel nanoparticles of DGL-PEG/dermorphin capsulated siRNA (OATP2B1) were applied to deliver siRNA into mouse brain. Along with OATP2B1 depressed, a main reduction was found for each of morphine or M6G in cerebrums or epencephalons of acute morphine tolerance mice. Furthermore, calcium/calmodulin-dependent protein kinase IIα (CaMKIIα) in mouse prefrontal cortex (mPFC) underwent dephosphorylation at Thr286. In conclusion, OATP2B1 downregulation in mouse brain can suppress tolerance via blocking morphine and M6G brain transport. These findings might help to improve the pharmacological effects of morphine.
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Affiliation(s)
- Zi-Zhao Yang
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Li Li
- Zhejiang Provincial Key Laboratory of Geriatrics &Geriatrics Institute of Zhejiang Province, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, Zhejiang Province 310013, China
| | - Lu Wang
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Ming-Cheng Xu
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Sai An
- Key Laboratory of Smart Drug Delivery, Ministry of Education, Department of Pharmaceutics, School of Pharmacy, Fudan University, 826 Zhangheng Road, Shanghai 201203, China; State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai 200032, China
| | - Chen Jiang
- Key Laboratory of Smart Drug Delivery, Ministry of Education, Department of Pharmaceutics, School of Pharmacy, Fudan University, 826 Zhangheng Road, Shanghai 201203, China; State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai 200032, China
| | - Jing-Kai Gu
- School of Life Sciences, Jilin Univeristy, Changchun, 130012, China
| | - Zai-Jie Jim Wang
- Department of Biopharmaceutical Sciences, University of Illinois, 833 S. Wood Street, Chicago, IL 60612, USA
| | - Lu-Shan Yu
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China
| | - Su Zeng
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, China
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Roy DN, Goswami R. Drugs of abuse and addiction: A slippery slope toward liver injury. Chem Biol Interact 2015; 255:92-105. [PMID: 26409324 DOI: 10.1016/j.cbi.2015.09.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/14/2015] [Accepted: 09/18/2015] [Indexed: 02/08/2023]
Abstract
Substances of abuse induce alteration in neurobehavioral symptoms, which can lead to simultaneous exacerbation of liver injury. The biochemical changes of liver are significantly observed in the abused group of people using illicit drugs or drugs that are abused. A huge amount of work has been carried out by scientists for validation experiments using animal models to assess hepatotoxicity in cases of drugs of abuse. The risk of hepatotoxicity from these psychostimulants has been determined by different research groups. Hepatotoxicity of these drugs has been recently highlighted and isolated case reports always have been documented in relation to misuse of the drugs. These drugs induce liver toxicity on acute or chronic dose dependent process, which ultimately lead to liver damage, acute fatty infiltration, cholestatic jaundice, liver granulomas, hepatitis, liver cirrhosis etc. Considering the importance of drug-induced hepatotoxicity as a major cause of liver damage, this review emphasizes on various drugs of abuse and addiction which induce hepatotoxicity along with their mechanism of liver damage in clinical aspect as well as in vitro and in vivo approach. However, the mechanisms of drug-induced hepatotoxicity is dependent on reactive metabolite formation via metabolism, modification of covalent bonding between cellular components with drug and its metabolites, reactive oxygen species generation inside and outside of hepatocytes, activation of signal transduction pathways that alter cell death or survival mechanism, and cellular mitochondrial damage, which leads to alteration in ATP generation have been notified here. Moreover, how the cytokines are modulated by these drugs has been mentioned here.
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Affiliation(s)
- Dijendra Nath Roy
- Department of Bio Engineering, National Institute of Technology (NIT)-Agartala, West Tripura, Tripura 799046, India.
| | - Ritobrata Goswami
- Institute of Life Sciences, Ahmedabad University, Ahmedabad 380009, Gujarat, India
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20
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Ickert I, Herten M, Vogl M, Ziskoven C, Zilkens C, Krauspe R, Kircher J. Opioids as an alternative to amide-type local anaesthetics for intra-articular application. Knee Surg Sports Traumatol Arthrosc 2015; 23:2674-81. [PMID: 24792069 DOI: 10.1007/s00167-014-2989-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 04/03/2014] [Indexed: 01/09/2023]
Abstract
PURPOSE Recently, the safety profile of local anaesthetics in intra-articular use became into focus of investigation. Opioid drugs have a different mode of action and may be a safe and potent alternative for intra-articular application. The purpose of this in vitro study is to provide evidence for significant chondrotoxicity of amide-type local anaesthetics even after short-term application on human chondrocytes and to demonstrate the absence of such negative effects for opioids [morphine, morphine-6-glucuronide (M6G)]. METHOD Visually intact cartilage explants of human, mainly osteoarthritic joints (n = 9), were harvested and cultivated in monolayer for expansion and transferred into alginate bead. The beads were incubated for increasing incubation times (15 min, 1 and 4 h) in decreasing concentrations (full, ½, ¼ for 15 min) of bupivacaine, ropivacaine, morphine, M6G or saline control. Adenosine triphosphate content of 798 beads was measured 3 days post-incubation to assess cell viability. RESULTS A clear ranking of cytotoxic potency: bupivacaine > ropivacaine > morphine = M6G = saline was observed. Results reveal a dose- and time-dependent manner of cytotoxic effects on human chondrocytes for bupivacaine and ropivacaine but not for opioids. Cell viability after exposure to morphine and M6G was comparable to exposure to saline. CONCLUSION The results confirm dose- and time-dependent cytotoxic effects on human chondrocytes for amide-type local anaesthetics. This study confirms the safety of morphine and M6G in terms of an absence of cytotoxic effects after intra-articular application, making them safe potential alternatives in clinical practice.
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Affiliation(s)
- Irina Ickert
- Department of Orthopedics, University Hospital, Heinrich-Heine-University, Duesseldorf, Germany
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Shabani F, Farrier AJ, Krishnaiyan R, Hunt C, Uzoigwe CE, Venkatesan M. Common contra-indications and interactions of drugs in orthopaedic practice. Bone Joint J 2015; 97-B:434-41. [PMID: 25820879 DOI: 10.1302/0301-620x.97b4.35230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Drug therapy forms an integral part of the management of many orthopaedic conditions. However, many medicines can produce serious adverse reactions if prescribed inappropriately, either alone or in combination with other drugs. Often these hazards are not appreciated. In response to this, the European Union recently issued legislation regarding safety measures which member states must adopt to minimise the risk of errors of medication. In March 2014 the Medicines and Healthcare products Regulatory Agency and NHS England released a Patient Safety Alert initiative focussed on errors of medication. There have been similar initiatives in the United States under the auspices of The National Coordinating Council for Medication Error and The Joint Commission on the Accreditation of Healthcare Organizations. These initiatives have highlighted the importance of informing and educating clinicians. Here, we discuss common drug interactions and contra-indications in orthopaedic practice. This is germane to safe and effective clinical care.
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Affiliation(s)
- F Shabani
- Princess Alexandra Hospital, Hamstel Road, Harlow, Essex CM20 1QX, UK
| | - A J Farrier
- University Hospitals of North Tees, Hardwick Road, Stockton-on-Tees, Cleveland TS19 8PE, UK
| | - R Krishnaiyan
- University Hospitals of Leicester, Infirmary Square, Leicester, LE1 5WW, UK
| | - C Hunt
- University Hospitals of North Tees, Hardwick Road, Stockton-on-Tees, Cleveland TS19 8PE, UK
| | - C E Uzoigwe
- Harcourt Building, 8 Harcourt Crescent, Sheffield, UK
| | - M Venkatesan
- University Hospitals of Leicester, Infirmary Square, Leicester, LE1 5WW, UK
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Klimas R, Mikus G. Morphine-6-glucuronide is responsible for the analgesic effect after morphine administration: a quantitative review of morphine, morphine-6-glucuronide, and morphine-3-glucuronide. Br J Anaesth 2014; 113:935-44. [DOI: 10.1093/bja/aeu186] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ballas SK. Pathophysiology and principles of management of the many faces of the acute vaso-occlusive crisis in patients with sickle cell disease. Eur J Haematol 2014; 95:113-23. [PMID: 25288149 DOI: 10.1111/ejh.12460] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2014] [Indexed: 12/11/2022]
Abstract
Effective management of sickle cell pain entails a thorough understanding of its pathophysiology and the pharmacogenomics of the opioids used to manage it. In recent years, there has been significant progress along these two lines. At the pathophysiologic level, there is evidence that the severity and frequency of painful stimuli modulate their transmission at the level of the dorsal horn of the spinal cord. This modulation is achieved via two channels: the α-Amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) and NMDA receptors. Initially, the AMPA channel controls the transmission of stimuli of mild-moderate severity. Once the AMPA channel reaches its limit of membrane depolarization, the NMDA channel is activated and facilitates the transmission of painful stimuli in a progressive fashion leading to central sensitization and glial activation. At the level of pharmacogenomics, the metabolism of each opioid is patient-specific. Glucuronidation is unique for the metabolism of morphine, hydromorphone, and oxymorphone. The metabolism of all other opioids requires specific Cytochrome P450 (CYP) isoenzymes. The activity of each isoenzyme and the activity of the metabolites of each opioid vary among patients depending on their genetic makeup and coexistent environmental factors such as the use of other medications that may enhance or inhibit the CYP isoenzyme activity.
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Affiliation(s)
- Samir K Ballas
- Cardeza Foundation for Hematologic Research, Department of Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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Gender-related difference in postoperative pain after laparoscopic Roux-En-Y gastric bypass in morbidly obese patients. Obes Surg 2014; 23:1880-4. [PMID: 23695438 DOI: 10.1007/s11695-013-0996-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Some evidence exist to suggest that women experience more pain and require more medication than men to achieve a similar state of analgesia. However, this was not studied in morbidly obese patients. The study evaluates the effect of gender on postoperative pain and analgesic consumption in the first 24 h in morbidly obese patients who undergo laparoscopic Roux-En-Y gastric bypass surgery (RYNGPB). One hundred thirty obese adult patients who underwent elective RYNGPB were included in the study. Postoperative pain scores were compared using a numeric rating scale, at intervals (0, 15, 30, 45, 60, 90, and 120 min), and following discharge from the postanesthesia care unit (PACU) at 6, 12, and 24 h. Titrated morphine dose during the 2-h PACU stay and pethidine consumption in the subsequent 24 h were measured. One hundred fourteen patients completed the study (59 females and 55 males). Female patients had higher initial pain scores and higher morphine consumption (10.1 ± 3.1 mg) than male patients (7.2 ± 4.5 mg), P = 0.0001. Following PACU discharge, there was no gender difference in pain scores or analgesic consumption. Pethidine consumption in male patients during the first day was 97.8 ± 35.1 versus 98.1 ± 61.6 mg among female patients, P = 0.9729. Female patients had higher initial pain score and morphine consumption than men in the immediate postoperative period, but that difference disappeared after discharge from PACU.
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Campos J, Lobo C, Queiroz AMM, do Nascimento EM, Lima CB, Cardoso G, Ballas SK. Treatment of the acute sickle cell vaso-occlusive crisis in the Emergency Department: a Brazilian method of switching from intravenous to oral morphine. Eur J Haematol 2014; 93:34-40. [PMID: 24571671 DOI: 10.1111/ejh.12293] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Describe the treatment of patients with vaso-occlusive crises (VOC) in a Brazilian emergency department (ED) and the successful switch from intravenous to oral morphine. PATIENTS AND METHODS We analyzed records of 315 patients with sickle cell disease using two different protocols for pain: one in March 2010 prescribing intravenous morphine every 4 h throughout their stay, and another in March 2011 and 2012 prescribing one initial dose of intravenous morphine followed by equianalgesic doses of oral morphine every 4 h. Patients were triaged into three groups: mild, moderate, and severe VOC. The mild group was treated within 1 h after triage, the moderate within 30 min and the severe was treated immediately. Patients whose pain was not relieved within 6 h after the first dose of morphine were transferred into a different holding area of the ED where they continued to receive the same treatment for 48 h after which they were hospitalized if still in pain. RESULTS The number of patients who stayed <24 h in the ED increased significantly from 63 in 2010 to 87 in 2012, and the number of admissions decreased from 26 in 2010 to 10 in 2012. The incidence of acute chest syndrome decreased from 8.5% in 2010 to 1.9% in 2012. CONCLUSION Patients treated with oral morphine stayed a shorter time in the ED, had more pain relief, were admitted less frequently, and had less acute chest syndrome. These differences may be due to environmental, cultural, psychological, and pharmacogenetic factors.
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Affiliation(s)
- Jessica Campos
- Clinical Hematology Division, Instituto de Hematologia Arthur de Siqueira Cavalcanti - HEMORIO, Rio de Janeiro, Brazil
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Togna AR, Antonilli L, Dovizio M, Salemme A, De Carolis L, Togna GI, Patrignani P, Nencini P. In vitro morphine metabolism by rat microglia. Neuropharmacology 2013; 75:391-8. [PMID: 23988259 DOI: 10.1016/j.neuropharm.2013.08.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 08/07/2013] [Accepted: 08/15/2013] [Indexed: 10/26/2022]
Abstract
Morphine is mainly transformed to morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) in the liver. Glucuronidation is also performed by rat brain homogenates and UDP-glucuronosyltransferases (UGTs) are present in the brain. Here we investigated the possibility that microglia transforms morphine into its metabolites M3G and M6G. Primary cultures of neonatal rat microglia were incubated for different intervals of time in basal conditions or with different concentrations of morphine. The following measures were performed on these cultures and/or in the medium: (i) morphine as well as M3G and M6G concentrations; (ii) levels of mRNA coding for UGT1A1, UGT1A6, UGT1A7, and UGT2B1 as well as their protein levels; (iii) released prostaglandin (PG)E2 and nitrite concentrations. Results show that in basal conditions morphine and M3G are produced by microglia; accordingly, these cells expressed UGT1A1, UGT1A6 and UGT1A7, but not UGT2B1. When cultures were exposed to different concentrations of exogenous morphine, M6G was also synthesized. This shift in the glucuronidation was associated with variations in the expression of UGT isozymes. In particular, UGT1A7 expression was rapidly upregulated and this event was translated into enhanced protein levels of UGT1A7; lesser effects were exerted on UGT1A1 and UGT1A6. Upon prolonged exposure to morphine, microglial cell UGT expression returned to baseline conditions or even to reduced levels of expression. Morphine exposure did not affect the synthesis of both PGE2 and nitrites, ruling out a generalized priming of microglia by morphine. In conclusion, this study suggests that morphine glucuronides found in the cerebrospinal liquor upon peripheral morphine administration may at least in part be brain-born, reconciling the conceptual gap between the high hydrophilic features of morphine glucuronides and their presence beyond the blood-brain barrier.
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Affiliation(s)
- Anna Rita Togna
- Department of Physiology and Pharmacology "Vittorio Erspamer", Sapienza University of Rome, P.le A. Moro 5, 00185 Rome, Italy
| | - Letizia Antonilli
- Department of Physiology and Pharmacology "Vittorio Erspamer", Sapienza University of Rome, P.le A. Moro 5, 00185 Rome, Italy
| | - Melania Dovizio
- Department of Neuroscience and Imaging, "G. d'Annunzio" University, Via dei Vestini 31, 66100 Chieti, Italy; Center of Excellence on Aging (CeSI), "Gabriele d'Annunzio" University Foundation, Via dei Vestini 31, 66100 Chieti, Italy
| | - Adele Salemme
- Department of Physiology and Pharmacology "Vittorio Erspamer", Sapienza University of Rome, P.le A. Moro 5, 00185 Rome, Italy
| | - Lorenza De Carolis
- Department of Physiology and Pharmacology "Vittorio Erspamer", Sapienza University of Rome, P.le A. Moro 5, 00185 Rome, Italy
| | - Giuseppina I Togna
- Department of Physiology and Pharmacology "Vittorio Erspamer", Sapienza University of Rome, P.le A. Moro 5, 00185 Rome, Italy
| | - Paola Patrignani
- Department of Neuroscience and Imaging, "G. d'Annunzio" University, Via dei Vestini 31, 66100 Chieti, Italy; Center of Excellence on Aging (CeSI), "Gabriele d'Annunzio" University Foundation, Via dei Vestini 31, 66100 Chieti, Italy
| | - Paolo Nencini
- Department of Physiology and Pharmacology "Vittorio Erspamer", Sapienza University of Rome, P.le A. Moro 5, 00185 Rome, Italy.
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Pawlowska M, Chu R, Fedejko-Kap B, Augustin E, Mazerska Z, Radominska-Pandya A, Chambers TC. Metabolic transformation of antitumor acridinone C-1305 but not C-1311 via selective cellular expression of UGT1A10 increases cytotoxic response: implications for clinical use. Drug Metab Dispos 2012; 41:414-21. [PMID: 23160818 DOI: 10.1124/dmd.112.047811] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The acridinone derivates 5-dimethylaminopropylamino-8-hydroxytriazoloacridinone (C-1305) and 5-diethylaminoethylamino-8-hydroxyimidazoacridinone (C-1311) are promising antitumor agents with high activity against several experimental cellular and tumor models and are under evaluation in preclinical and early phase clinical trials. Recent evidence from our laboratories has indicated that both compounds were conjugated by several uridine diphosphate-glucuronyltransferase (UGT) isoforms, the most active being extrahepatic UGT1A10. The present studies were designed to test the ability and selectivity of UGT1A10 in the glucuronidation of acridinone antitumor agents in a cellular context. We show that in KB-3 cells, a HeLa subline lacking expression of any UGT isoforms, both C-1305 and C-1311 undergo metabolic transformation to the glucuronidated forms on overexpression of UGT1A10. Furthermore, UGT1A10 overexpression significantly increased the cytotoxicity of C-1305, but not C-1311, suggesting that the glucuronide was more potent than the C-1305 parent compound. These responses were selective for UGT1A10 because documented overexpression of UGT2B4 failed to produce glucuronide products and failed to alter the cytotoxicity for both compounds. These findings contribute to our understanding of the mechanisms of action of these agents and are of particular significance because data for C-1305 contradict the dogma that glucuronidation typically plays a role in detoxification or deactivation. In summary, these studies suggest that extrahepatic UGT1A10 plays an important role in the metabolism and the bioactivation of C-1305 and constitutes the basis for further mechanistic studies on the mode of action of this drug, as well as translational studies on the role of this enzyme in regulation of C-1305 toxicity in cancer.
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Affiliation(s)
- Monika Pawlowska
- Department of Pharmaceutical Technology and Biochemistry, Chemical Faculty, Gdańsk University of Technology, Gdańsk, Poland
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Due MR, Piekarz AD, Wilson N, Feldman P, Ripsch MS, Chavez S, Yin H, Khanna R, White FA. Neuroexcitatory effects of morphine-3-glucuronide are dependent on Toll-like receptor 4 signaling. J Neuroinflammation 2012; 9:200. [PMID: 22898544 PMCID: PMC3519737 DOI: 10.1186/1742-2094-9-200] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 07/31/2012] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Multiple adverse events are associated with the use of morphine for the treatment of chronic non-cancer pain, including opioid-induced hyperalgesia (OIH). Mechanisms of OIH are independent of opioid tolerance and may involve the morphine metabolite morphine-3-glucuronide (M3G). M3G exhibits limited affinity for opioid receptors and no analgesic effect. Previous reports suggest that M3G can act via the Toll-like receptor 4 (TLR4)/myeloid differentiation protein-2 (MD-2) heterodimer in the central nervous system to elicit pain. METHODS Immunoblot and immunocytochemistry methods were used to characterize the protein expression of TLR4 present in lumbar dorsal root ganglion (DRG). Using in vitro intracellular calcium and current clamp techniques, we determined whether TLR4 activation as elicited by the prototypical agonists of TLR4, lipopolysaccharide (LPS) and M3G, contributed to changes in intracellular calcium and increased excitation. Rodents were also injected with M3G to determine the degree to which M3G-induced tactile hyperalgesia could be diminished using either a small molecule inhibitor of the MD-2/TLR4 complex in rats or TLR4 knockout mice. Whole cell voltage-clamp recordings were made from small- and medium-diameter DRG neurons (25 μm < DRG diameter <45 μm) for both control and M3G-treated neurons to determine the potential influence on voltage-gated sodium channels (NaVs). RESULTS We observed that TLR4 immunoreactivity was present in peptidergic and non-peptidergic sensory neurons in the DRG. Non-neuronal cells in the DRG lacked evidence of TLR4 expression. Approximately 15% of assayed small- and medium-diameter sensory neurons exhibited a change in intracellular calcium following LPS administration. Both nociceptive and non-nociceptive neurons were observed to respond, and approximately 40% of these cells were capsaicin-insensitive. Increased excitability observed in sensory neurons following LPS or M3G could be eliminated using Compound 15, a small molecule inhibitor of the TLR4/MD-2 complex. Likewise, systemic injection of M3G induced rapid tactile, but not thermal, nociceptive behavioral changes in the rat, which were prevented by pre-treating animals with Compound 15. Unlike TLR4 wild-type mice, TLR4 knockout mice did not exhibit M3G-induced hyperalgesia. As abnormal pain sensitivity is often associated with NaVs, we predicted that M3G acting via the MD-2/TLR4 complex may affect the density and gating of NaVs in sensory neurons. We show that M3G increases tetrodotoxin-sensitive and tetrodotoxin-resistant (NaV1.9) current densities. CONCLUSIONS These outcomes provide evidence that M3G may play a role in OIH via the TLR4/MD-2 heterodimer complex and biophysical properties of tetrodotoxin-sensitive and tetrodotoxin-resistant NaV currents.
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Affiliation(s)
- Michael R Due
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Shimizu A, Ohe T, Chiba M. A novel method for the determination of the site of glucuronidation by ion mobility spectrometry-mass spectrometry. Drug Metab Dispos 2012; 40:1456-9. [PMID: 22611068 DOI: 10.1124/dmd.112.045435] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Glucuronidation not only plays a detoxifying role in living body, but it also can complicate pharmacological and toxicological profiles of new drug candidates by forming active and reactive conjugated metabolites. The opportunity to elucidate structure of conjugated metabolites has increased in drug metabolism studies at the early development stage. General methodologies for the structure elucidation of glucuronide conjugate(s) include liquid chromatography-tandem mass spectrometry (LC-MS/MS) and NMR spectroscopy. In many cases, LC-MS/MS alone cannot unequivocally identify the site(s) of conjugation in isomeric glucuronidations. In the present study, we established a new strategy for the structure elucidation of glucuronide conjugates using ion mobility spectrometry (IMS)-mass spectrometry. Linear correlation between calculated collision cross-sections (CCS) and actual drift times from IMS was found for each set of parent compound (raloxifene, losartan, telmisartan, and estradiol) and the corresponding MS/MS product ions. Thus, obtained regression lines accurately and selectively projected the actual drift times of authentic standards of glucuronide conjugate based on the theoretical CCS values. The established method was used for the accurate assignment of predominant formation of phenolic glucuronide conjugate (SCH 60663) in the isomeric (phenolic and benzylic) glucuronidations of ezetimibe in the incubated sample with cryopreserved human hepatocytes. This application demonstrates the potential to facilitate the structure identification of glucuronide conjugates at the early development stage of new drug candidates.
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Affiliation(s)
- Atsushi Shimizu
- Discovery Drug Metabolism & Pharmacokinetics, Tsukuba Research Center, Taiho Pharmaceutical Co., Ltd., 3 Okubo, Tsukuba, Ibaraki 300-2611, Japan.
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Abstract
The involvement of reactive oxygen species (ROS) in morphine-induced analgesia and tolerance has been suggested, yet how and where ROS take part in these processes remains largely unknown. Here, we report a novel role for the superoxide-generating enzyme NOX1/NADPH oxidase in the regulation of analgesia and acute analgesic tolerance. In mice lacking Nox1 (Nox1(-/Y)), the magnitude of the analgesia induced by morphine was significantly augmented. More importantly, analgesic tolerance induced by repeated administration of morphine was significantly suppressed compared with that in the littermates, wild-type Nox1(+/Y). In a membrane fraction obtained from the dorsal spinal cord, no difference was observed in morphine-induced [(35)S]GTPγS-binding between the genotypes, whereas morphine-stimulated GTPase activity was significantly attenuated in Nox1(-/Y). At 2 h after morphine administration, a significant decline in [(35)S]GTPγS-binding was observed in Nox1(+/Y) but not in Nox1(-/Y). No difference in the maximal binding and affinity of [(3)H]DAMGO was observed between the genotypes, but the translocation of protein kinase C isoforms to the membrane fraction following morphine administration was almost completely abolished in Nox1(-/Y). Finally, the phosphorylation of RGS9-2 and formation of a complex by Gαi2/RGS9-2 with 14-3-3 found in morphine-treated Nox1(+/Y) were significantly suppressed in Nox1(-/Y). Together, these results suggest that NOX1/NADPH oxidase attenuates the pharmacological effects of opioids by regulating GTPase activity and the phosphorylation of RGS9-2 by protein kinase C. NOX1/NADPH oxidase may thus be a novel target for the development of adjuvant therapy to retain the beneficial effects of morphine.
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Aubrun F, Mazoit JX, Riou B. Postoperative intravenous morphine titration. Br J Anaesth 2012; 108:193-201. [DOI: 10.1093/bja/aer458] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Smith T, Binning AR, Dahan A. Efficacy and safety of morphine-6-glucuronide (M6G) for postoperative pain relief: A randomized, double-blind study. Eur J Pain 2012; 13:293-9. [DOI: 10.1016/j.ejpain.2008.04.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2008] [Revised: 04/10/2008] [Accepted: 04/27/2008] [Indexed: 10/22/2022]
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Clavijo CF, Hoffman KL, Thomas JJ, Carvalho B, Chu LF, Drover DR, Hammer GB, Christians U, Galinkin JL. A sensitive assay for the quantification of morphine and its active metabolites in human plasma and dried blood spots using high-performance liquid chromatography-tandem mass spectrometry. Anal Bioanal Chem 2011; 400:715-28. [PMID: 21400080 DOI: 10.1007/s00216-011-4775-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Revised: 01/28/2011] [Accepted: 02/04/2011] [Indexed: 10/18/2022]
Abstract
Opioids such as morphine are the cornerstone of pain treatment. The challenge of measuring the concentrations of morphine and its active metabolites in order to assess human pharmacokinetics and monitor therapeutic drugs in children requires assays with high sensitivity in small blood volumes. We developed and validated a semi-automated LC-MS/MS assay for the simultaneous quantification of morphine and its active metabolites morphine 3β-glucuronide (M3G) and morphine 6β-glucuronide (M6G) in human plasma and in dried blood spots (DBS). Reconstitution in water (DBS only) and addition of a protein precipitation solution containing the internal standards were the only manual steps. Morphine and its metabolites were separated on a Kinetex 2.6-μm PFP analytical column using an acetonitrile/0.1% formic acid gradient. The analytes were detected in the positive multiple reaction mode. In plasma, the assay had the following performance characteristics: range of reliable response of 0.25-1000 ng/mL (r(2) > 0.99) for morphine, 1-1,000 ng/mL (r(2) > 0.99) for M3G, and 2.5-1,000 ng/mL for M6G. In DBS, the assay had a range of reliable response of 1-1,000 ng/mL (r(2) > 0.99) for morphine and M3G, and of 2.5-1,000 ng/mL for M6G. For inter-day accuracy and precision for morphine, M3G and M6G were within 15% of the nominal values in both plasma and DBS. There was no carryover, ion suppression, or matrix interferences. The assay fulfilled all predefined acceptance criteria, and its sensitivity using DBS samples was adequate for the measurement of pediatric pharmacokinetic samples using a small blood of only 20-50 μL.
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Affiliation(s)
- Claudia F Clavijo
- iC42 Clinical Research & Development, Department of Anesthesiology, University of Colorado Denver, Aurora, 80045-7503, USA
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Abstract
Pharmacokinetic (PK) and pharmacodynamic (PD) modeling has elucidated aspects of developmental pharmacology of value to the anesthetic community. The increasing sophistication of modeling techniques is associated with pitfalls that may not be readily apparent to readers or investigators. While size and age are considered primary covariates for PK models, the impact of birth on clearance maturation is poorly documented, dose in obese children is poorly investigated, pharmacologic implications of physiologic changes poorly portrayed, disease progression on drug response poorly depicted and the impact of metabolites on effect poorly illustrated. This review identifies some of these pitfalls and suggests ideas to circumvent or investigate these hazards.
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Affiliation(s)
- Brian J Anderson
- Department of Anaesthesiology, University of Auckland School of Medicine, Auckland, New Zealand.
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Holtman JR, Crooks PA, Johnson-Hardy J, Wala EP. Antinociceptive effects and toxicity of morphine-6-O-sulfate sodium salt in rat models of pain. Eur J Pharmacol 2010; 648:87-94. [DOI: 10.1016/j.ejphar.2010.08.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 07/22/2010] [Accepted: 08/25/2010] [Indexed: 11/25/2022]
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Lloret Linares C, Declèves X, Oppert JM, Basdevant A, Clement K, Bardin C, Scherrmann JM, Lepine JP, Bergmann JF, Mouly S. Pharmacology of morphine in obese patients: clinical implications. Clin Pharmacokinet 2009; 48:635-51. [PMID: 19743886 DOI: 10.2165/11317150-000000000-00000] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Morphine is an analgesic drug used to treat acute and chronic pain. Obesity is frequently associated with pain of various origins (e.g. arthritis, fibromyalgia, cancer), which increases the need for analgesic drugs. Obesity changes drug pharmacokinetics, and for certain drugs, specific modalities of prescription have been proposed for obese patients. However, scant data are available regarding the pharmacokinetics and pharmacodynamics of morphine in obesity. Prescription of morphine depends on pain relief but the occurrence of respiratory adverse effects correlates with obesity, and is not currently taken into account. Variations in the volume of distribution, elimination half-life and oral clearance of morphine, as well as recent advances in the respective roles of drug-metabolizing enzymes, catechol-O-methyltransferase and the mu opioid receptor in morphine pharmacokinetics and pharmacodynamics, may contribute to differences between obese and non-obese patients. In addition, drug-drug interactions may alter the disposition of morphine and its glucuronide metabolites, which may either increase the risk of adverse effects or reduce drug efficacy.
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Affiliation(s)
- Célia Lloret Linares
- Unit of Therapeutic Research, Department of Internal Medicine, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
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Mashayekhi SO, Ghandforoush-Sattari M, Routledge PA, Hain RDW. Pharmacokinetic and pharmacodynamic study of morphine and morphine 6-glucuronide after oral and intravenous administration of morphine in children with cancer. Biopharm Drug Dispos 2009; 30:99-106. [PMID: 19260034 DOI: 10.1002/bdd.649] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The aim of this study was to characterize the pharmacokinetics and pharmacodynamics of morphine and morphine 6-glucuronide (M6G) in children with cancer. Serum concentrations of morphine and M6G in children who received single oral or short term continuous intravenous morphine were determined by HPLC and ELISA assays, respectively. The serum C(max) of morphine and M6G after i.v. morphine administration was 560.5 and 309.0 nM and the T(max) was 61 and 65 min, respectively. The elimination half-life was 140.0 and 328.7 min, respectively. After oral administration of morphine, the serum C(max) of morphine and M6G was 408.34 and 256.3 nM and the T(max) was 40.0 and 60 min, respectively. The half-life was 131.0 and 325.8 min, respectively. The side effects were: drowsiness (100%), nausea and/or vomiting (57%), pruritus (28%) and urinary retention (14%). There were no reports of respiratory complications. This study showed that pharmacokinetics factors of morphine and M6G in children were significantly different from adults. Therefore the required dose for children should be different from that of adults and should be based on studies performed on children rather than on studies on adults. Some adverse effects, particularly nausea and pruritus, may be commoner than is usually thought, while others, particularly respiratory problems did not occur.
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Affiliation(s)
- Simin O Mashayekhi
- Faculty of Pharmacy, NPMC and Haematology and Oncology Research Centre, Tabriz University (Medical Sciences), Tabriz, Iran
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van Dorp ELA, Morariu A, Dahan A. Morphine-6-glucuronide: potency and safety compared with morphine. Expert Opin Pharmacother 2008; 9:1955-61. [PMID: 18627332 DOI: 10.1517/14656566.9.11.1955] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In contemporary medicine, morphine remains the drug of choice in the treatment of severe postoperative pain. Nevertheless, morphine has several side effects, which can seriously compromise its analgesic effectiveness and the patient safety/compliance. The search for opioid analgesics with a better side-effect profile than morphine has led to a morphine metabolites, morphine-6-glucuronide (M6G). OBJECTIVE The objectives of the current paper are to give an overview of the analgesic properties of M6G, assess the dose range at which it produces equianalgesia to morphine and explore its side-effect profile. METHODS A review of published clinical studies (Phase II - III) on M6G in the treatment of experimental and clinical pain is given. RESULTS/CONCLUSIONS M6G > 0.2 mg/kg is an effective analgesic with a slower onset but longer duration of action (> 12 h) compared with morphine. Side effects, most importantly postoperative nausea and vomiting, occur less frequent after M6G treatment. M6G is an attractive alternative to morphine in the treatment of severe postoperative pain.
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Affiliation(s)
- Eveline L A van Dorp
- Leiden University Medical Centre, Department of Anesthesiology, P5-Q, PO Box 9600, 2300 RC Leiden, The Netherlands
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Muller A, Glattard E, Taleb O, Kemmel V, Laux A, Miehe M, Delalande F, Roussel G, Van Dorsselaer A, Metz-Boutigue MH, Aunis D, Goumon Y. Endogenous morphine in SH-SY5Y cells and the mouse cerebellum. PLoS One 2008; 3:e1641. [PMID: 18327293 PMCID: PMC2265639 DOI: 10.1371/journal.pone.0001641] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Accepted: 01/23/2008] [Indexed: 11/18/2022] Open
Abstract
Background Morphine, the principal active agent in opium, is not restricted to plants, but is also present in different animal tissues and cell types, including the mammalian brain. In fact, its biosynthetic pathway has been elucidated in a human neural cell line. These data suggest a role for morphine in brain physiology (e.g., neurotransmission), but this hypothesis remains a matter of debate. Recently, using the adrenal neuroendocrine chromaffin cell model, we have shown the presence of morphine-6-glucuronide (M6G) in secretory granules and their secretion products, leading us to propose that these endogenous alkaloids might represent new neuroendocrine factors. Here, we investigate the potential function of endogenous alkaloids in the central nervous system. Methodology and Principal Findings Microscopy, molecular biology, electrophysiology, and proteomic tools were applied to human neuroblastoma SH-SY5Y cells (i) to characterize morphine and M6G, and (ii) to demonstrate the presence of the UDP-glucuronyltransferase 2B7 enzyme, which is responsible for the formation of M6G from morphine. We show that morphine is secreted in response to nicotine stimulation via a Ca2+-dependent mechanism involving specific storage and release mechanisms. We also show that morphine and M6G at concentrations as low as 10−10 M are able to evoke specific naloxone-reversible membrane currents, indicating possible autocrine/paracrine regulation in SH-SY5Y cells. Microscopy and proteomic approaches were employed to detect and quantify endogenous morphine in the mouse brain. Morphine is present in the hippocampus, cortex, olfactory bulb, and cerebellum at concentration ranging from 1.45 to 7.5 pmol/g. In the cerebellum, morphine immunoreactivity is localized to GABA basket cells and their termini, which form close contacts on Purkinje cell bodies. Conclusions/Significance The presence of morphine in the brain and its localization in particular areas lead us to conclude that it has a specific function in neuromodulation and/or neurotransmission. Furthermore, its presence in cerebellar basket cell termini suggests that morphine has signaling functions in Purkinje cells that remain to be discovered.
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Affiliation(s)
- Arnaud Muller
- Inserm, U575, Physiopathologie du Système Nerveux, Strasbourg, France
| | - Elise Glattard
- Inserm, U575, Physiopathologie du Système Nerveux, Strasbourg, France
| | - Omar Taleb
- Inserm, U575, Physiopathologie du Système Nerveux, Strasbourg, France
| | - Véronique Kemmel
- Inserm, U575, Physiopathologie du Système Nerveux, Strasbourg, France
- Faculty of Medicine, Institut de Chimie Biologique, Strasbourg, France
| | - Alexis Laux
- Inserm, U575, Physiopathologie du Système Nerveux, Strasbourg, France
| | - Monique Miehe
- Inserm, U575, Physiopathologie du Système Nerveux, Strasbourg, France
| | | | - Guy Roussel
- Inserm, U575, Physiopathologie du Système Nerveux, Strasbourg, France
- Faculty of Medicine, Institut de Chimie Biologique, Strasbourg, France
| | - Alain Van Dorsselaer
- Centre National de la Recherche Scientifique (CNRS), Laboratoire de Spectrométrie de Masse Bio-Organique, The European School of Chemistry, Polymers and Materials (ECPM), Université Louis Pasteur, LC4-UMR7178, Strasbourg, France
| | | | - Dominique Aunis
- Inserm, U575, Physiopathologie du Système Nerveux, Strasbourg, France
| | - Yannick Goumon
- Inserm, U575, Physiopathologie du Système Nerveux, Strasbourg, France
- *E-mail:
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Dahan A, van Dorp E, Smith T, Yassen A. Morphine-6-glucuronide (M6G) for postoperative pain relief. Eur J Pain 2007; 12:403-11. [PMID: 17869146 DOI: 10.1016/j.ejpain.2007.07.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2007] [Revised: 07/17/2007] [Accepted: 07/31/2007] [Indexed: 01/06/2023]
Abstract
Morphine-6-glucuronide (M6G) is morphine's active metabolite acting at the mu-opioid receptor. Recent experimental human studies and 5 of 6 randomized clinical trials indicate that M6G causes adequate and long lasting pain relief comparable to morphine. There are various observations that M6G is associated with a reduction in the severity of side effects normally associated with opioid use, such as reduced postoperative nausea and vomiting (PONV) and reduced respiratory depression. The present drug profile provides a review of the pharmacological properties of M6G, the clinical evidence relating to its efficacy and safety, and discusses its future role in the treatment of postoperative pain.
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Affiliation(s)
- Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, P5-Q, P.O. Box 9600, 2300 RC Leiden, The Netherlands.
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Romberg R, van Dorp E, Hollander J, Kruit M, Binning A, Smith T, Dahan A. A Randomized, Double-blind, Placebo-controlled Pilot Study of IV Morphine-6-Glucuronide for Postoperative Pain Relief After Knee Replacement Surgery. Clin J Pain 2007; 23:197-203. [PMID: 17314577 DOI: 10.1097/ajp.0b013e31802b4f6a] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the dose-response effect of intravenous morphine-6-glucuronide (M6G) on acute postoperative pain. METHODS Patients undergoing knee replacement surgery under spinal anesthesia were randomly assigned to 1 of 4 single intravenous M6G doses, 0 (placebo), 10, 20, or 30 mg/70 kg, administered 150 minutes after the spinal anesthetic was given. Analgesic effects were evaluated by determining the cumulative patient controlled analgesia (PCA) morphine dose, consumed over a 12 and 24 hours period, after the initial dose of M6G. For pain assessments, a 10 cm visual analog scale was used. RESULTS Data from 41 patients were evaluated (n=10, 10, 10, and 11 in the 0, 10, 20, and 30 mg M6G groups). Only at the highest M6G dose (30 mg/70 kg), morphine PCA consumption was significantly less compared with placebo: over the first 12 postoperative hours mean PCA morphine consumption was 3.0+/-2.0 mg/h after placebo and 1.4+/-0.5 mg/h after 30 mg M6G (P=0.03); over the first 24 h mean PCA morphine consumption was 2.5+/-2.1 mg after placebo and 1.0+/-0.4 mg after 30 mg M6G (P=0.04) (mean+/-SD). Visual analog scale values were similar across all groups during these time periods. DISCUSSION The analgesic effect of M6G in postoperative pain was demonstrated with 30 mg/70 kg M6G superior to placebo. At this dose, M6G has a long duration of action as determined by a reduction in the use of morphine PCA over 12 and 24 hours.
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Affiliation(s)
- Raymonda Romberg
- Department of Anesthesiology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
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Villesen HH, Foster DJR, Upton RN, Christrup LL, Somogyi AA, Martinez A, Grant C. Blood-brain distribution of morphine-6-glucuronide in sheep. Br J Pharmacol 2006; 149:754-60. [PMID: 17016501 PMCID: PMC2014650 DOI: 10.1038/sj.bjp.0706916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND AND PURPOSE At present there are few data regarding the rate and extent of brain-blood partitioning of the opioid active metabolite of morphine, morphine-6-glucuronide (M6G). In this study the cerebral kinetics of M6G were determined, after a short-term intravenous infusion, in chronically instrumented conscious sheep. EXPERIMENTAL APPROACH Five sheep received an intravenous infusion of M6G 2.2 mg kg(-1) over a four-minute period. Non-linear mixed-effects analysis, with hybrid physiologically based kinetic models, was used to estimate cerebral kinetics from the arterio-sagittal sinus concentration gradients and cerebral blood flow measurements. KEY RESULTS A membrane limited model was selected as the final model. The blood-brain equilibration of M6G was relatively slow (time to reach 50% equilibration of the deep compartment 5.8 min), with low membrane permeability (PS, population mean, 2.5 ml min(-1)) from the initial compartment (V1, 13.7 ml) to a small deep distribution volume (V2) of 18.4 ml. There was some between-animal variability (%CV) in the initial distribution volume (29%), but this was not identified for PS or V2. CONCLUSION AND IMPLICATIONS Pharmacokinetic modelling of M6G showed a delayed equilibration between brain and blood of a nature that is primarily limited by permeability across the blood-brain-barrier, in accordance with its physico-chemical properties.
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Affiliation(s)
- H H Villesen
- Department of Pharmacology and Pharmacotherapy, The Danish University of Pharmaceutical Sciences, Copenhagen, Denmark.
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