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Methadone Pharmacokinetics and Cardiac Effects in Newborns

This study has been completed.
Sponsor:
Collaborators:
Case Western Reserve University
Children's Mercy Hospital Kansas City
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
Information provided by (Responsible Party):
Robert Ward, University of Utah
ClinicalTrials.gov Identifier:
NCT00715988
First received: July 10, 2008
Last updated: April 8, 2017
Last verified: April 2017
  Purpose

The Primary objectives of this proposal are to determine the population kinetics for methadone and its enantiomers in preterm newborns and infants at 29 weeks to 48 weeks post menstrual age (PMA) who are 1 week old and older and establish any correlations of the kinetics with PMA to determine the bioavailability for enterally administered methadone in these newborns and young infants.

The secondary objectives of this proposal are to explore possible genotypic changes in CYP3A4-3A7-3A5, CYP2B6, CYP2C8, CYP2C19, and CYP2D6 and PGO on the kinetics of methadone in neonates and young infants and to test the safety of methadone in this population by correlating the plasma concentrations of the methadone enantiomers, S-methadone and R-methadone, with changes in cardiac repolarization by measurement of corrected QT, heart rate, and blood pressure.


Condition Intervention Phase
Pain Drug: Methadone HCl Inject 10 mg/ml (will require dilution) Drug: Methadone Phase 1

Study Type: Interventional
Study Design: Allocation: Non-Randomized
Intervention Model: Single Group Assignment
Masking: No masking
Primary Purpose: Supportive Care
Official Title: Safety and Single Dose Population Pharmacokinetics and Bioavailability of Methadone and Its Enantiomers in Newborns and Young Infants At 29-48 Weeks Post Menstrual Age

Resource links provided by NLM:


Further study details as provided by Robert Ward, University of Utah:

Primary Outcome Measures:
  • Find the population kinetics for methadone and its enantiomers in preterm newborns and infants at 29 weeks to 48 wks PMA who are 1 week old and older [ Time Frame: 48 hours ]

Secondary Outcome Measures:
  • Measure the effects of R and S enantiomers of methadone on QT interval in newborns [ Time Frame: 48 hours ]

Enrollment: 7
Study Start Date: October 2007
Study Completion Date: February 10, 2017
Primary Completion Date: September 2012 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: Scheme 1
Patients who are feeding or not feeding and mechanically ventilated, >/=3 d of age and 29 0/7wks-48 6/7 wks PMA, treated with i.v. bolus doses or infusion of fentanyl, morphine or methadone for clinical indications, with arterial/venous line in place & expected treatment for at least 1-2 more days. Pk sampling = 0.5 ml blood samples x6/infant. ECG monitoring. Three patients will be enrolled in 5 PMA groups. Should apnea or hypotension occur, dosages for Treatment Scheme 2 will be reduced (50%); more patients will be studied in Treatment Scheme 1 to insure that the lower dose is well tolerated & effective.
Drug: Methadone
Methadone HCl oral solution 5 mg/ml Methadone HCl inject 10 ml/ml (will require dilution) Single dose
Other Name: Dolophine, Methadose, Methadose Oral
Experimental: Scheme 2
Patients defined in Scheme 1, tolerating feeds for >/= 3 days will be studied twice, after i.v. methadone and after enteral methadone after the end of sampling after the first dose. 4-5 samples will be obtained after dose 1 and after dose 2 depending on PMA and weight. Patients will be divided into groups based on PMA..
Drug: Methadone HCl Inject 10 mg/ml (will require dilution)
Methadone HCl oral solution 5 mg/ml Methadone HCl inject 10 mg/ml (will require dilution)
Other Name: Dolophine, Methadose, Methadose Oral

Detailed Description:

Painful procedures are frequent during the NICU care of sick newborns. Newborns are capable of perceiving pain by the time in fetal development when they reach our current limits of viability around 23-24 weeks post menstrual age.1 Painful procedures include suctioning during mechanical ventilation, thoracostomy tube placement, heel lance and venipuncture for blood sampling, and care following surgical procedures such as PDA ligation and bowel resection. Simons et al recently reported on the number of painful procedures in a large NICU in Rotterdam and provided a review of the frequency of such procedures from other NICU's.2 This review shows that before discharge from the NICU, newborns may experience as many as 376 painful procedures and as many as 61 painful procedures in a single day (or more if all procedures were not observed or reported). The most frequent procedures were heel lance and suctioning, both associated with the need for mechanical ventilation. Topical treatment of pain from heel lance has not been successful with EMLA3 or tetracaine.4

During initial NICU care for infants supported with mechanical ventilation, systemic analgesia is usually provided with parenteral treatment with fentanyl or morphine. Most neonates are extubated soon after birth, and continued systemic treatment with analgesics is not needed. Other neonates have problems associated with chronic pain or continued painful procedures, such as surgical problems, chronic lung disease, airway anomalies, pulmonary hypoplasia and pulmonary hypertension following ECMO and congenital diaphragmatic hernia repair. These patients often require mechanical ventilation for weeks and sometimes months. During that prolonged care, systemic analgesia is changed to enteral dosing to reduce risks of infection associated with central catheters and to reduce the number of intravenous catheter insertions.

Morphine and fentanyl administered enterally do not provide reliable systemic concentrations and effects due to first-pass metabolism. Fentanyl undergoes first-pass metabolism by CYP3A4 during passage through the intestines and liver. Morphine undergoes first pass hepatic metabolism primarily by UGT2B7. In addition for morphine, one of its major metabolites, the 3-glucuronide, is anti-analgesic and can cause dysphoria. An effective and well-characterized systemic analgesic that can be administered enterally is needed for the care of infants who require prolonged analgesic treatment and methadone can meet those needs.

Methadone treatment in adults provides effective systemic analgesia after enteral administration through binding to the mu opioid receptor with a wide range of reported half-lives of 5 to 130 hrs,5 2 to 50 hrs,6 and 33 to 46 hrs; 7 and bioavailability ranging from 41 to 95%.8, 9

Recently, methadone was reported to prolong QTc in adults receiving large doses of methadone during chronic treatment, often with additional predisposing factors for QT prolongation. Methadone is dispensed in a racemic mixture whose enantiomers have different potency for analgesia and for binding to the myocardium to potentially prolong QT. In addition the different enantiomers exhibit complex kinetics in adults as they undergo metabolism, primarily by CYP3A4, CYP2B6, and CYP2C19. This study will evaluate kinetics and bioavailability of methadone enantiomers and its effects on QT of neonates and young infants.

  Eligibility

Ages Eligible for Study:   29 Weeks to 48 Weeks   (Child)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

INCLUSION CRITERIA

  1. Patients must be in the NICU or PICU with continuous cardiorespiratory monitoring
  2. PMA between 29 0/7 to 48 6/7 weeks (EGA at birth (wks) + postnatal age wks) at the start of study
  3. Weight >1499 gm at the time of enrollment
  4. Postnatal age of 3 days or more
  5. Arterial or venous catheter suitable for blood sampling with a separate i.v. infusion site is preferred, but not essential
  6. Currently being treated with methadone bolus doses or fentanyl or morphine in bolus doses or by infusion for clinical indications and expected to be treated for at least 1-2 more days with opioids for study of single dose pharmacokinetics and to be treated for 3-5 days more during the study of bioavailability
  7. Hematocrit ≥35%
  8. Parental permission
  9. Approval by the patient's attending physician

    Treatment Scheme 1, studied for 48 hr after a single i.v. dose of methadone

  10. Feeding or not feeding
  11. Mechanically ventilated

    Treatment Scheme 2 studied for 24 to 48 hr after a single i.v. dose of methadone AND again after a single enteral dose of methadone after the end of sampling after the first dose; order of doses is randomized. If the caregiver feels the patient is too sedated at the end of pK sampling after Dose, 1, then Dose 2 will be delayed until patient is judged to need analgesic treatment.

  12. Tolerating enteral feeding for 3 consecutive days before study

EXCLUSION CRITERIA

  1. Clinically diagnosed liver dysfunction
  2. Clinically diagnosed kidney dysfunction with urine output <1.0 ml/kg/hr
  3. Gastrointestinal malformation or dysfunction that might interfere with enteral drug absorption
  4. Congenital anomalies or other conditions thought to be incompatible with life
  5. History of arrhythmias, excluding bradycardia associated with apnea
  6. Unstable cardiorespiratory status
  7. Serum K+ <3.0 mEq/L
  8. QTc[H] >0.449 ms using Hodges correction =QT + 1.75(rate - 60).
  9. Family history of unexplained early cardiac deaths, syncope, or long QT syndrome in primary relatives: siblings, parents, grandparents, or aunts/uncles.
  10. Treatment with inhibitors and inducers of CYP3A4, CYP2B6, CYP2D6 and PGP including:

amiodarone, carbamazepine, ciprofloxacin, clarithromycin, clotrimazole, dexamethasone, erythromycin, ethosuximide, fluconazole, fluoxetine, fluvoxamine, grapefruit juice, indinavir, itraconazole, ketoconazole, metronidazole, miconazole, nelfinavir, paroxetine, phenobarbital, phenytoin, quercetin, quinidine, rifabutin, rifampin, ritonavir, saquinavir, sulfadimidine, sulfinpyrazone, troleandomycin

  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT00715988

Locations
United States, Utah
University of Utah
Salt Lake City, Utah, United States, 84108
Primary Children's Medical Center
Salt Lake City, Utah, United States, 84113
Sponsors and Collaborators
University of Utah
Case Western Reserve University
Children's Mercy Hospital Kansas City
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
Investigators
Principal Investigator: Robert Ward, M.D. University of Utah
  More Information

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
Responsible Party: Robert Ward, Professor, Pediatrics; Adjunct Professor, Pharmacology/Toxicology, University of Utah
ClinicalTrials.gov Identifier: NCT00715988     History of Changes
Other Study ID Numbers: 24569
1U10HD045986-01 ( U.S. NIH Grant/Contract )
Study First Received: July 10, 2008
Last Updated: April 8, 2017
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Yes
Plan Description: Data shared with other investigators leading to publication of the pediatric population pharmacokinetics of methadone

Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No
Product Manufactured in and Exported from the U.S.: No

Keywords provided by Robert Ward, University of Utah:
Methadone
analgesia
newborns
QT prolongation
Young Infants

Additional relevant MeSH terms:
Methadone
Analgesics, Opioid
Narcotics
Central Nervous System Depressants
Physiological Effects of Drugs
Analgesics
Sensory System Agents
Peripheral Nervous System Agents
Antitussive Agents
Respiratory System Agents

ClinicalTrials.gov processed this record on July 21, 2017