Opioid analgesics-related pharmacokinetic drug interactions: from the perspectives of evidence based on randomized controlled trials and clinical risk management

Abstract

Background

Multimorbidity results in complex polypharmacy which may bear a risk of drug interactions. A better understanding of opioid analgesics combination therapy used for pain management could help warrant medication safety, efficacy, and economic relevance. Until now there has been no review summarizing the opioid analgesics-related pharmacokinetic drug interactions from the perspective of evidence based on randomized controlled trials (RCTs).

Method

A literature search was performed using PubMed, MEDLINE, and the Cochrane Library, using a PRISMA flowchart.

Results

Fifty-two RCTs were included for data interpretation. Forty-two RCTs (80.8%) were conducted in healthy volunteers, whereas 10 RCTs (19.2%) enrolled true patients. None of the opioid–drug/herb pairs was listed as contraindications of opioids involved in this review. Circumstances in which opioid is comedicated as a precipitant drug include morphine–P2Y12 inhibitors, morphine–gabapentin, and methadone–zidovudine. Circumstances in which opioid is comedicated as an object drug include rifampin–opioids (morphine, tramadol, oxycodone, methadone), quinidine–opioids (morphine, fentanyl, oxycodone, codeine, dihydrocodeine, methadone), antimycotics–opioids (buprenorphine, fentanyl, morphine, oxycodone, methadone, tilidine, tramadol), protease inhibitors–opioids (ritonavir, ritonavir/lopinavir–oxycodone, ritonavir–fentanyl, ritonavir–tilidine), grapefruit juice–opioids (oxycodone, fentanyl, methadone), antidepressants–opioids (paroxetine–tramadol, paroxetine–hydrocodone, paroxetine–oxycodone, escitalopram–tramadol), metoclopramide–morphine, amantadine–morphine, sumatriptan–butorphanol nasal sprays, ticlopidine–tramadol, St John’s wort–oxycodone, macrolides/ketolides–oxycodone, and levomepromazine–codeine. RCTs investigating the same combination, almost unanimously, drew consistent conclusions, except two RCTs on amantadine–intravenous morphine combination where a different amantadine dose was used and two RCTs on morphine–ticagrelor combination where healthy volunteers and true patients were enrolled, respectively. RCTs investigating in true patients may reflect a realistic clinical scenario and overcome the limitation of RCTs performed in healthy volunteers under standardized conditions. Further research opportunities are also presented in this review.

Conclusion

Effective and safe combination therapy of opioids can be achieved by promoting the awareness of potential changes in therapeutic efficacy and toxicities, prescribing alternatives or changing administration strategy, tailoring dose, reviewing the appropriateness of orders, and paying attention to medication monitoring.

Keywords:

• adverse drug reaction
• clinical efficacy
• combination therapy
• drug-drug interactions
• drug metabolism
• drug transporter
• pain management
• pharmacokinetics
• polypharmacy

Acknowledgments

This work was supported by the Zhejiang Provincial Bureau of Education (grant N20140209). The authors would also like to thank Professor Yong-bin Zhu (vice dean of Division of Medical Administration), Mr Guang-wu Li (inpatient pharmacy supervisor), and Ye-zhen Lu (clinical coordinator) for their kind help in medication management and use of opioid analgesics.

Disclosure

The authors report no conflicts of interest in this work.