Methadone maintenance therapy is used to treat opiate addiction and effectively prevents opiate withdrawal, diminishes illicit drug use, and reduces human immunodeficiency virus/acquired immune deficiency syndrome and other infectious diseases.1 Methadone is also used to treat acute, chronic, and cancer pain.2–4 Nevertheless, the clinical use of methadone is challenging. There is considerable and unpredictable interindividual and intraindividual variability in methadone pharmacokinetics and pharmacodynamics, including metabolism and clearance, as well as susceptibility to drug interactions.5,6 This variability confers risks of drug accumulation and toxicity, or opiate withdrawal or inadequate analgesia, which can confound methadone use. This is particularly acute during the first few weeks of use. While there was a 13-fold increase in methadone prescriptions between 1997 and 2006,7 there was also an exponential increase in methadone toxicity, including a nearly 1800% increase in adverse events and a 390% increase in fatalities,8,9 which persist today.10
It is well recognized that the first 1 to 2 weeks of methadone treatment for pain therapy constitute the highest risk period for adverse events, most often relative overdose.11–13 Mortality rates in the first 1 to 2 weeks are 10-fold to 100-fold greater than in the period thereafter.11–13 This constitutes a major challenge, whether initiating pain therapy with methadone, using it as a second-line drug, or in an opioid rotation scheme.14 Contributing to the problem of interindividual variability in methadone disposition are the changes in methadone clearance during the initiation of therapy. Elimination of both IV and oral methadone undergoes time-dependent autoinduction (methadone induced increases in methadone elimination) with repeated dosing.15–17 After at least 1 week, plasma concentrations decreased 25% to 40%,18 and elimination half-life was reduced by half.17 Autoinduction is highly variable. Reductions in plasma methadone concentrations after 8 days averaged 25% to 40%, but were as much as 60% in some patients.17,18 Methadone autoinduction also occurs in rodents, along with induction of hepatic microsomal enzymes and methadone N-demethylation.19–21
Methadone in humans is cleared primarily by hepatic cytochrome P450 (CYP)-catalyzed metabolism, with some urinary excretion of unchanged drug. The most abundant metabolite is 2-ethyl-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), which is pharmacologically inactive. Methadone clearance and N-demethylation are stereoselective. After considerable research, a consensus has emerged that methadone N-demethylation in vitro, both by human liver microsomes and expressed CYPs, is catalyzed most efficiently by CYP2B6 and CYP3A4 (while CYP3A5 is comparatively inactive), and only CYP2B6 N-demethylates methadone stereoselectively.22–26 In contrast, the relative importance of CYPs 2B6 and 3A4 in clinical methadone clearance remains unclear, and the identity of the CYP isoform responsible for methadone clearance remains controversial. Based on extrapolation of early in vitro studies of CYP3A4, methadone metabolism and clearance in vivo were attributed to CYP3A4.6,27–30 Conversely, several subsequent clinical investigations showed minimal or no role for CYP3A in single-dose methadone clearance.23,31–33 Moreover, several studies are consonant with CYP2B6, rather than CYP3A4, mediating clinical methadone metabolism and clearance.23,25,28,29,31,34–36
Autoinduction of methadone elimination in humans has been ascribed to increased clearance and metabolism,16 and speculatively to hepatic CYP3A4 induction.37,38 Nevertheless, it appears from the above that CYP3A4 induction may not be the mechanism. Methadone autoinduction remains poorly understood, and yet clinically significant. A previous investigation in human hepatocytes showed that methadone-induced CYP2B6 and CYP3A4 messenger RNA (mRNA) and protein expression, which were attributed to pregnane X receptor (PXR) and constitutive androstane receptor (CAR) activation.39 That investigation did not measure CYP enzymatic activity, did not evaluate methadone enantiomer effects on enzyme induction, and used Western blot analysis to measure CYP expression. Western blot analysis, however, particularly of CYP2B6, has been reported to be only semiquantitative due to issues such as antibody affinity and specificity,40 and Western blot analysis of hepatocyte CYP2B6 protein was reported to underestimate the degree of induction, compared with that of mRNA and enzyme activity.41 Recently, tandem mass spectrometry–based CYP protein quantification methods have been developed, which also allow the simultaneous absolute quantification of multiple CYP isoforms.42 Therefore, the purpose of this investigation was to use primary human hepatocytes to test the hypothesis that autoinduction of human methadone clearance can result from increased methadone N-demethylation, in turn caused by induction of CYP2B6 and/or CYP3A4 mRNA, protein, and catalytic activity.
Chemicals and Reagents
Alfentanil and methadone were obtained from the National Institutes of Drug Abuse through the Research Triangle Institute (Research Triangle, NC). Williams E Media was obtained from Lonza Walkersville (Walkersville, MD). Hepatocyte Supplement was obtained from Life Technologies (Durham, NC). Dimethyl sulfoxide (DMSO), rifampin, phenobarbital, and bupropion hydrochloride were obtained from Sigma (St. Louis, MO). Formic acid was obtained from Fisher Scientific (Pittsburg, PA) and acetonitrile from Sigma, and both were high-performance liquid chromatography (HPLC) grade. Noralfentanil, EDDP, and hydroxybupropion were obtained from Cerilliant (Round Rock, TX).
Fresh plated human hepatocytes from 4 donor livers were generously provided by Life Technologies. Donor descriptions are provided in Table 1. Hepatocytes were isolated from 4 donor livers, plated, and overlaid with Matrigel before shipping. Cells were plated at a density of 0.5 × 106 cells/well and microscopically examined for proper morphology and confluency before shipment. The shipping media (HypoThermosol FRS, Biolife Solutions, Bothell, WA) was removed and changed to supplemented Williams E Media on arrival and the cells allowed to equilibrate for 24 hours at 37°C/5% CO2/95% humidity. A 1000 times DMSO stock methadone was made for each concentration tested (0.1, 1, and 10 µM) and indicated concentrations were achieved by diluting the DMSO stock into supplemented Williams E Media. Phenobarbital test solution was made by solubilizing compound directly into media and adding sufficient DMSO to equal 0.1%. Cells were incubated in drug-containing media (or vehicle control, 0.1% DMSO) for 72 hours, with media/drug changed each day, using recommended assay conditions.43 Cell morphology and confluency were examined microscopically each day and the plate discarded if any changes were observed.
After the 72-hour induction period, hepatocytes were incubated with drug-free media for 1 hour at 37°C in a shaker incubator (approximately 60 rpm). Media was then changed to media that contained 500 µM bupropion and incubated for 40 minutes at 37°C. Media was sampled for analysis, and replaced with drug-free media for 1 hour. The wash media was then exchanged and the sequence of 40-minute incubation, followed by a 1-hour washout period was performed for both 500 µM methadone and then 200 µM alfentanil. Racemic methadone N-demethylation was determined from the formation of racemic EDDP.23,44 CYP2B6 activity was determined by the standard probe racemic bupropion hydroxylation, assessed by the formation of racemic hydroxybupropion, and CYP3A4/5 activity was determined by alfentanil N-dealkylation, measured by the formation of noralfentanil.45 At the end of each experiment, hepatocytes were frozen for later quantification of mRNA and CYP protein. Fold induction was calculated for each substrate by comparing the metabolic activity after methadone or phenobarbital treatment with that after the treatment with 0.1% DMSO.
Metabolite analysis was performed on an API 3200 triple-quadrupole mass spectrometer (EDDP and noralfentanil) and API 4000 QTRAP mass spectrometer (hydroxybupropion), each equipped with a Turbo Ion Spray ionization source (Applied Biosystems/MDS Sciex, Foster City, CA). Structurally comparable deuterated analogs were used as internal standards for each analyte. The HPLC system for the API 3200 mass spectrometer was a Shimadzu LC-20AC HPLC system (Shimadzu, Columbia, MD) whereas an Agilent 1100 series HPLC system was used for the API 4000 mass spectrometer (Agilent, Wilmington, DE). The chromatographic separation was performed on a T3 column (50 × 2.1 mm, 3.5 μm; Waters Corp, Milford, MA). The injection volume was 20 μL, and the oven temperature was 25°C. HPLC mobile phase was (A) 0.1% formic acid and (B) 0.1% formic acid in methanol using a flow rate of 0.3 mL/min. The gradient program for EDDP was 35% B for 0 minutes, linear gradient to 60% B between 0 and 1.0 minutes, held at 60% until 2 minutes, linear gradient to 100% until 3 minutes, held at 100% B until 4 minutes, then re-equilibrated to initial conditions between 4.01 and 5.0 minutes; for noralfentanil, it was 35% B for 0 minutes, linear gradient to 40% B between 0 and 0.5 minutes, held at 40% until 2.5 minutes, linear gradient to 100% until 3 minutes, held at 100% B until 4 minutes, then re-equilibrated to initial conditions between 4.0 and 5.5 minutes, and for hydroxybupropion it was 10% B for 0 minutes, linear gradient to 30% B between 0 and 1.0 minutes, held at 30% until 1.5 minutes, linear gradient to 100% until 2 minutes, held at 100% B until 2.5 minutes, then re-equilibrated to initial conditions between 2.5 and 6.0 minutes. Under these conditions, retention times for EDDP, noralfentanil, and hydroxybupropion were 2.7, 2.9, and 1.5 minutes, respectively. Both Q1 and Q3 quadrupoles were optimized to unit mass resolution, and the mass spectrometer conditions were optimized for each analyte. The instrument was operated in positive-ion mode with an ion spray voltage of 5500 V. The curtain gas was set at 20, ion source gas 1 at 30, ion source gas 2 at 30, and the collision gas was set at 5. Analytes were monitored using multiple reaction monitoring. Transitions for each analyte and internal standard were m/z 278.2→234.2 and m/z 281.2→234.2 for EDDP and EDDP d3; m/z 277.0→128.0 and m/z 282.0→128.0 for noralfentanil and noralfentanil d5; and m/z 256.1→238.1 and m/z 262.2→167.2 for hydroxybupropion and hydroxybupropion d6. Metabolites were quantified using area ratios and standard curves prepared using calibration standards in blank media.
Quantification of CYP Proteins by HPLC-MS/MS
CYP protein quantification by HPLC-tandem mass spectrometry (HPLC-MS/MS) was performed as described previously,42 with slight modification. Each sample (100 µL) was precipitated with 600 µL of acetone (−80°C) and centrifuged at 14,000 rpm for 15 minutes. The supernatant was discarded and the protein precipitate dried under vacuum for 30 minutes. Twenty microliters of 100 mM Tris (pH 8) was added to each sample along with 2 µL of 10% octyl β-D-glucopyranoside. Two microliters of 100 mM Tris (2-carboxyethyl) phosphine was then added and incubated at 60°C for 1 hour. Five microliters of 0.1 M methyl methanethiosulfonate was added and incubated at room temperature for 10 minutes. The mixture was then tryptically digested by first adding another 20 µL of the TRIS solution followed by 25 µg of trypsin, and the resultant solution was digested 4 hours at 37°C. Finally, 2 pmol of each isotopically enriched synthetic peptide was added to the digest and analyzed by HPLC-MS/MS. HPLC-MS/MS was performed using a Shimadzu 30AD HPLC system (Shimadzu) coupled to an Acquity UPLC BEH C18 (2.1 × 100 mm) column (Waters Corp). The peptides were separated with a linear gradient of 5% to 30% B over 8 minutes. Mobile phase A consisted of 2% acetonitrile, 0.1% formic acid and mobile phase B consisted of 90% acetonitrile, 10% water, 0.1% formic acid. The HPLC flow rate was 700 µL/min. MS detection was performed on a 5500 QTRAP system (AB SCIEX, Framingham, MA) using a Turbo V source and Analyst software 1.5.1 (AB SCIEX). The scheduled multiple reaction monitoring algorithm was used to maximize dwell time on each transition.
Quantitative Polymerase Chain Reaction
After the metabolic activity assays were performed, mRNA was isolated using an RNeasy kit (QIAGEN, Valencia, CA) following the manufacturer’s protocol. mRNA was then converted to complementary DNA (cDNA) using Superscript VILO (Invitrogen, Carlsbad, CA) and quantified using a Synergy Mx plate reader (BioTEK, Winooski, VT). cDNA samples were then analyzed using Taqman Gene Expression Assay kits (Applied Biosystems, Carlsbad, CA) labeled with either FAM (CYP2B6 Hs03044635_g1, CYP3A4 Hs00604506_m1, or CYP3A5 Hs00241417_m1) or VIC (glyceraldehyde 3-phosphate dehydrogenase [GAPDH], Hs02758991_g1) and were used according to the manufacturer’s protocol. Briefly, 75 ng of total cDNA was added to the premixed Taqman kit for each analyte and amplified using a 7500 FAST PCR instrument (Applied Biosystems, Carlsbad, CA) for 55 cycles. Each multiplexed reaction contained probes for both a CYP and GAPDH and the amplification of each monitored by separate channels of the instrument. Data from each quantitative polymerase chain reaction run were analyzed with SDS software (v.1.3.1, Applied Biosystems, Foster City, CA) and the cDNA copy number for each sample was calculated using the formula below, where CT is the crossing threshold as determined by the instrument software. Fold induction was then calculated comparing the drug-treated sample with the vehicle control.
Pregnane X Receptor Reporter Gene Assay
The PXR reporter gene assay was performed by Puracyp, Inc (Carlsbad, CA) using their proprietary method. Briefly, HepG2 cells transfected with both a PXR response element and the luciferase gene were exposed to either, 0.1% DMSO, 10 µM rifampin or methadone. After 24-hour incubation, both cell viability and luciferase activity were examined and fold induction calculated. The relative light unit values for each well was corrected for number of viable cells in that well and normalized assuming the amount of luminescence detected in response to treatment with 0.1% DMSO to be uninduced.
Constitutive Androstane Receptor Reporter Gene Assay
The ability of methadone to act as an agonist for human CAR isoform 3 (CAR) was assessed using the CAR Reporter Assay System from Indigo Biosystems, Inc (State College, PA) and using the manufacturer’s protocol. Briefly, Chinese hamster ovary cells transfected with both the CAR response element and a luciferase gene, were thawed, plated, and incubated overnight (37°/5% CO2/95% humidity) with either positive control (6-(4-Chlorophenyl)imidazole[2,1-b][1,3]thiazole-5-carbaldehyde O-(3,4-dichlorobenzyl)oxime, CITCO) or methadone. Eight concentrations of both were analyzed, and a vehicle control was included as a 0 nM treatment. After an overnight incubation, the incubation media was removed and the provided Luciferase Detection Reagent was added to each well. The plate was then incubated at room temperature for 20 minutes and luminescence intensity quantified using a BioTEK, Synergy Mx plate reader (Winooski, VT) and reported in terms of relative light units. Percent activity was calculated such that the highest and lowest relative light unit values represent 0% and 100%, respectively. Curve fitting and 50% effective dose calculations (ED50) were performed using SigmaPlot 12.3 (Systat Software, San Jose, CA) using the embedded functions. Each point represents the mean and standard deviation of 3 independent determinations.
Hepatocyte induction incubations were performed in triplicate from each liver, using cells from 4 liver donors. Triplicate observations from each liver were averaged to obtain the result for that liver. For most experiments, results for 3 livers (n = 3) were then reported as the arithmetic mean ± SD. Data were analyzed according to standard approaches.43,46 The primary criterion for determination of induction was an increase in enzyme activity of at least 2-fold. A positive result in at least 1 of the donor hepatocytes was considered an indication of induction.
Induction was measured in hepatocytes from 4 human livers after 72-hour incubation with 0.1 to 10 µM methadone, with daily change of media and replenishment of methadone. Cells were washed to remove residual methadone before assessing catalytic activities. Formation of racemic EDDP from racemic methadone was increased 2-fold after incubation with 10 µM methadone, whereas lower concentrations had lesser or no inductive effect (Fig. 1). Phenobarbital (1 mM) and rifampin (10 µM) were used as standard positive controls for hepatocyte induction. Induction of methadone N-demethylation was approximately half that observed for phenobarbital and rifampin (approximately 4-fold for both). An enantioselective assay for EDDP was also used to analyze the stereoselectivity of induction of R-EDDP and S-EDDP formation from racemic methadone.24 No differences in R-EDDP versus S-EDDP formation rates from methadone were observed after induction by 10 µM methadone, or by phenobarbital or rifampin, compared with controls (data not shown).
In vitro activities of CYP2B6 and CYP3A4/5 were measured by metabolism of bupropion to hydroxybupropion, and N-dealkylation of alfentanil to noralfentanil, respectively. Both CYP2B6 and CYP3A4/5 activities were induced approximately 2-fold by 10 µM methadone compared with vehicle control (Fig. 1). Lower methadone concentrations (0.1 and 1 µM) did not increase CYP2B6 or CYP3A activities. Both phenobarbital and rifampin increased CYP3A4/5 activity 12-fold, and increased CYP2B6 activity 10-fold and 4-fold, respectively. The extent of both CYP2B6 and CYP3A4/5 induction by 10 µM methadone was approximately 20% of that by phenobarbital.
Stereoselectivity of methadone enantiomer induction of hepatocyte CYP2B6 and CYP3A4/5 activities, and of methadone N-demethylation was also evaluated. There were no differences in the effects of R-methadone versus S-methadone, at any concentration, on methadone metabolism or CYP2B6 and CYP3A4/5 activities (Fig. 2).
To explore whether the changes in hepatocyte CYP catalytic activity were due to increased synthesis of new protein, CYP2B6, CYP3A4, and CYP3A5 contents were quantified by HPLC-MS/MS. The multiplex assay also quantified CYP1A2. CYP2B6 and CYP3A4 protein contents were both increased approximately 2-fold after incubation with 10 µM methadone, compared with DMSO control (Fig. 3). The extent of induction by 10 µM methadone was approximately 20% of that by phenobarbital. Neither CYP1A2 nor CYP3A5 protein levels increased more than the 2-fold cutoff generally used as the criterion for induction. When compared with the 0.1% DMSO control, lesser content of each CYP isoform was detected after incubation with 1 µM methadone.
After incubation with methadone, phenobarbital, rifampin or 0.1% DMSO, mRNA transcripts for CYP2B6, CYP3A4, and CYP3A5 were quantified (Fig. 4). As with metabolic activity and protein contents, 10 µM methadone but not lower concentrations increased mRNA levels >2-fold. Both the CYP2B6 and CYP3A4 transcripts increased approximately 3-fold compared with control. Assuming that 1 mM phenobarbital represents maximal induction,43 10 µM methadone increased CYP2B6 transcripts to 36% of that for phenobarbital, and to 59% of that for rifampin. CYP3A4 transcript levels were approximately 19% of those for both phenobarbital and rifampin. Lower methadone concentrations had no effect on CYP2B6 or CYP3A4 mRNA expression, and CYP3A5 mRNA transcript levels were unchanged at all methadone concentrations.
To assess the ability of methadone to function as either a PXR or CAR agonist, reporter gene assays were conducted for both nuclear receptors (Figs. 5 and 6). Three methadone concentrations (1–100 µM) and a positive control (rifampin) were incubated with HepG2 cells transfected with both a PXR response element and the luciferase gene and the resulting luciferase activity used as an indication of the ability of the test compound to induce the transcription of genes under the PXR response element (Fig. 5). At clinically relevant methadone concentrations (1 or 10 µM) induction was approximately 2-fold, and at 100 µM methadone induction was 13-fold. The positive control rifampin induced PXR-related luminescence >16-fold. This result demonstrated that methadone is a PXR agonist.
For the CAR assay (Fig. 6), the relative light unit values for each sample were normalized such that the lowest and highest values were defined as 0% and 100%, respectively. For the methadone-treated samples, no increase in luminescence was detected over the entire concentration range tested (10.2 nM–250 µM), whereas the positive control (CITCO) gave a very robust signal (approximately 200-fold higher than that observed for methadone) with an 50% effective concentration value (224 nM) comparable with that provided by the manufacturer (220 nM). This result demonstrated that methadone is not a CAR agonist.
Mortality rates related to accidental methadone overdose in the first 1 to 2 weeks of dosing are 10-fold to 100-fold greater than in the period thereafter.11–13 Previous in vivo and in vitro studies have shown that with repeated dosing over approximately 2 weeks, methadone clearance increased 2-fold to 3-fold.19 The half-life of this autoinduction was estimated to be 94 hours.37,38 The autoinduction of methadone clearance has been attributed to induction of methadone N-demethylation, as urinary EDDP/methadone concentration ratios were increased 3-fold at steady state.16 Initial methadone dosing paradigms that are incorrectly based on steady-state clearance values, rather than on initial-dose clearance values, will result in plasma concentrations that are 2-fold to 3-fold greater than anticipated, and may result in unintended toxicity or even overdose. Thus, although autoinduction actually increases methadone clearance over time, it may be paradoxically contributing indirectly to untoward clinical outcomes, and accidental overdose, at initial dosing. Although the clinical phenomenon of autoinduction of methadone clearance has been well described,15–17,37,47 the mechanism of methadone autoinduction is incompletely understood.
Fresh human hepatocytes cultured between a sandwich of rat tail collagen are considered the “gold standard” for evaluating in vitro induction of CYP enzymes, because the cells retain “liver-like” morphology and expression of liver-specific proteins.43 Therefore, this investigation used primary human hepatocytes to evaluate the mechanism of methadone autoinduction, testing the hypothesis that methadone N-demethylation undergoes upregulation.
The primary result was that methadone-induced methadone N-demethylation in human hepatocytes, and at clinically relevant concentrations. This is the first report of such an effect. EDDP formation was upregulated 2-fold by 10 µM racemic methadone, but not by 1 µM methadone. Thus, methadone clearly causes hepatic autoinduction. Actual clinical hepatic methadone concentrations are unknown, but maximal hepatic concentrations can be predicted using standard approaches,48 which predict 3 to 21 µM RS-methadone after 10 to 100 mg oral methadone. Therefore, methadone N-demethylation was induced by hepatic (portal) methadone concentrations, which would be achieved after oral dosing. In contrast, the hepatic methadone concentrations occurring at systemic steady-state (<2–3 µM) methadone concentrations might not be expected to cause autoinduction. There was no difference in the effects of R-methadone versus S-methadone on induction of CYP activity or methadone N-demethylation. The clinical implication is that autoinduction is unlikely to differ between the 2 marketed forms of methadone, racemic and single (R-) enantiomer. The 2-fold induction of hepatocyte methadone N-demethylation is similar to the 2-fold to 3-fold increase in methadone clearance and N-demethylation found clinically after several weeks of oral methadone.16,17 It is interesting to note that in rats, autoinduction was observed with oral, but not subcutaneous or intraperitoneal methadone, further suggesting route and concentration dependence of autoinduction.19,21
Autoinduction of methadone N-demethylation was associated with upregulation of both CYP2B6 and CYP3A4 catalytic activities, an observation also not previously reported. Catalytic activity of both CYPs was induced approximately 2-fold, as were protein and mRNA expression. CYP3A5 protein expression was also somewhat increased, but this could not contribute to autoinduction of methadone N-demethylation because CYP3A5 is comparatively inactive toward methadone.23,26 Both CYP2B6 and CYP3A4 are the major isoforms catalyzing methadone metabolism in vitro;22–26 however, there is a lack of agreement as to their relative contributions to metabolism and clearance clinically,6,22,23,28,31–33,35,36,49 and there is no information on their relative contribution to clinical methadone autoinduction. The relative contribution of CYP2B6 and CYP3A4 to autoinduction of methadone N-demethylation in hepatocytes is similarly unknown, and the present data do not inform any relative attributions. CYP2B6-mediated methadone N-demethylation is stereoselective, whereas that by CYP3A4 is not.22–26 Previous studies predicted,24,25 and later validated,25 that clinical CYP3A4 induction would minimally affect the plasma R/S-methadone concentration ratio, whereas CYP2B6 induction would increase the ratio. That hepatocyte methadone autoinduction and induction by rifampin and phenobarbital in the present investigation did not alter the R/S-EDDP ratio, suggests that the relative contribution of CYPs 2B6 and 3A4 to methadone N-demethylation remained unchanged, regardless of the inducer. The finding that protein expression of all 4 CYP isoforms decreased with 1 µM methadone appears to be an assay artifact, and not supported by either a decrease in methadone metabolism or decreased mRNA levels.
Reporter gene assays were used to identify the role of the human xenobiotic receptors PXR and CAR in the methadone-mediated transcriptional upregulation of CYP2B6 and CYP3A4. Human PXR and CAR are both members of the nuclear receptor 1I subfamily that include mediators of vitamin D signaling, and xenobiotic sensors.50 While CAR is the closest mammalian relative of PXR, and is activated by some of the same ligands, it is less promiscuous than PXR and displays fundamental differences from PXR with regard to cellular regulation and ligand interaction.50 The PXR reporter gene assay showed a strong response to methadone. However, the human CAR reporter gene assay did not show any activation, up to 250 µM methadone. This suggests that methadone upregulation of CYP2B6 and CYP3A5 is mediated by PXR but not CAR. The observation that CYP2B6 and CYP3A4 activity, protein, and mRNA were similarly induced by methadone, and that methadone activated PXR but not CAR, is similar to the previous finding of upregulation of both CYP2B6 and CYP3A4 by the PXR ligand rifampicin, but preferential upregulation of CYP2B6 over CYP3A4 by a CAR-specific ligand.51
Results of this investigation show some similarities and differences compared with a previous report.39 Methadone was reported to induce the expression of CYP2B6 and CYP3A4 mRNA and expression, although effects on CYP activity and on methadone N-demethylation, as well as the enantioselectivity of these effects, were not evaluated.39 Thus, both studies showed that methadone upregulated CYP2B6 and CYP3A4 mRNA. Transcript levels were higher in the previous study; however, differences may be due to the shorter incubation time (24 hours) than the current investigation (72 hours). Zhang et al.41 showed that CYP2B6 mRNA peaked after 6 to 24 hours of phenobarbital or rifampin exposure and decreased to 90% of peak expression by 72 hours. CYP3A4 mRNA peaked after 48 hours and decreased 25% by 72 hours. CYP protein expression and activity, however, were greatest after 72 hours.41 In the present investigation, a 72-hour time point was selected based on enzymatic activity as the primary end point, with protein and mRNA quantification as confirmatory, and consistency with Food and Drug Administration guidance for in vitro induction studies.43a After 72 hours, there was approximately 2-fold induction of CYP2B6 and CYP3A4 protein expression by 10 µM methadone and smaller increases in CYP1A2 and CYP3A5 protein expression, using HPLC-MS/MS. In contrast, the previous study, using Western blot analysis, found that CYP2B6 protein level did not increase when incubated with up to 50 µM methadone, and CYP3A4 protein was either unchanged or increased in 2 different hepatocyte preparations.39 In preliminary experiments using Western blot, we found that CYP3A4 protein was increased by methadone, phenobarbital, and rifampin, but CYP2B6 protein expression could not be reliably quantified, despite using several different antibodies as well as a novel Taqman chemistry-based protein expression assay (results not shown). Others also found that analysis of hepatocyte CYP2B6 expression by Western blot was not sensitive or quantitative, and underestimated induction compared with mRNA and enzyme activity.41 The use of mass spectrometry for CYP quantification eliminates many of the selectivity and specificity issues often associated with Western blot analysis. Other factors, including hepatocyte donors and the longer incubation times used herein, may explain differences between the present and previous investigations.39 The last difference was the apparent mechanism of CYP2B6 and CYP3A4 induction. The present investigation found evidence for methadone activation of human PXR but not CAR. In contrast, Tolson et al.39 reported methadone activation of both PXR and CAR. Nevertheless, CAR activation occurred only at concentrations exceeding 25 µM methadone, and the response was weak compared with a standard positive control. Differences between the present and previous CAR assays include the cell line and vector used, and, given also the complexity of CAR-mediated gene regulation, the primary conclusion of both investigations is that methadone autoinduction is primarily PXR-mediated.
In addition to autoinduction of methadone metabolism and clearance, other factors may also contribute to interindividual and/or intraindividual variability in methadone disposition. These may include genetic variability in CYP expression and activity (particularly CYP2B6)52 and drug interactions. These require further elucidation.
In conclusion, these in vitro studies demonstrate that methadone causes autoinduction of methadone N-demethylation in human hepatocytes, in turn related to induction of CYP2B6 and CYP3A4 catalytic activity, protein expression, and mRNA expression, in turn mediated by PXR activation. These in vitro findings parallel previous clinical evidence of autoinduction of methadone metabolism and clearance during the first 2 weeks of therapy, and provide insights into the mechanism by which this occurs.
Name: Scott D. Campbell, PhD.
Contribution: This author helped in the study design, conduct of the study, data collection, data analysis, and manuscript preparation.
Attestation: Scott D. Campbell, PhD, reviewed the original study data and data analysis, attests to the integrity of the original data and the analysis reported in this manuscript, approved the final manuscript, and is the archival author.
Name: Amanda Crafford, BS.
Contribution: This author helped in the conduct of the study, data collection, and data analysis.
Attestation: Amanda Crafford, BS, approved the final manuscript.
Name: Brian L. Williamson, PhD.
Contribution: This author helped in the conduct of the study, data collection, and data analysis.
Attestation: Brian L. Williamson, PhD, approved the final manuscript.
Name: Evan D. Kharasch, MD, PhD.
Contribution: This author helped in the study design and manuscript preparation.
Attestation: Evan D. Kharasch, MD, PhD, reviewed the original study data and data analysis, attests to the integrity of the original data and the analysis reported in this manuscript, and approved the final manuscript.
This manuscript was handled by: Marcel E. Durieux, MD, PhD.
We thank Puracyp Inc. for performing the PXR assay described in this article, Life Technologies for their generous gift of human hepatocytes, and Thomas Kim for excellent technical assistance.
a U.S. Food and Drug Administration. Guidances (Drugs). Available at: http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/default.htm.
1. Lobmaier P, Gossop M, Waal H, Bramness J. The pharmacological treatment of opioid addiction–a clinical perspective. Eur J Clin Pharmacol. 2010;66:537–45
2. Nicholson AB. Methadone for cancer pain. Cochrane Database Syst Rev. 2007:CD003971
3. Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, Donovan MI, Fishbain DA, Foley KM, Fudin J, Gilson AM, Kelter A, Mauskop A, O’Connor PG, Passik SD, Pasternak GW, Portenoy RK, Rich BA, Roberts RG, Todd KH, Miaskowski CAmerican Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. . Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113–30
4. Kharasch ED. Intraoperative methadone: rediscovery, reappraisal, and reinvigoration? Anesth Analg. 2011;112:13–6
5. Ferrari A, Coccia CP, Bertolini A, Sternieri E. Methadone–metabolism, pharmacokinetics and interactions. Pharmacol Res. 2004;50:551–9
6. Saber-Tehrani AS, Bruce RD, Altice FL. Pharmacokinetic drug interactions and adverse consequences between psychotropic medications and pharmacotherapy for the treatment of opioid dependence. Am J Drug Alcohol Abuse. 2011;37:1–11
7. Governale L. Methadone utilization in the US 2002–2006: FDA Center for Drug Evaluation and Research. 2007 Available at: http://ww.slidefinder.net/m/methdone_utilization_u_s/2002_2006/finalmethadonegovernalesamhsa7-20-07/1166138
. Accessed April 30, 2013
8. Sims SA, Snow LA, Porucznik CA. Surveillance of methadone-related adverse drug events using multiple public health data sources. J Biomed Inform. 2007;40:382–9
9. Government Accountability Office. . Methadone-associated overdose deaths: Factors contributing to increased deaths and efforts to prevent them. United States Government Accountability Office Report GAO-09-341. 2009. Available at: http://www.gao.gov/new.items/d09341.pdf
. Accessed February 17, 2013
10. Madden ME, Shapiro SL. The methadone epidemic: methadone-related deaths on the rise in Vermont. Am J Forensic Med Pathol. 2011;32:131–5
11. Zador DA, Sunjic SD. Deaths in methadone maintenance treatment in New South Wales, Australia 1990–1995. Addiction. 2000;95:77–84
12. Buster MC, van Brussel GH, van den Brink W. An increase in overdose mortality during the first 2 weeks after entering or re-entering methadone treatment in Amsterdam. Addiction. 2002;97:993–1001
13. Gibson AE, Degenhardt LJ. Mortality related to pharmacotherapies for opioid dependence: a comparative analysis of coronial records. Drug Alcohol Rev. 2007;26:405–10
14. Ripamonti C, Bianchi M. The use of methadone for cancer pain. Hematol Oncol Clin North Am. 2002;16:543–55
15. Anggård E, Gunne LM, Homstrand J, McMahon RE, Sandberg CG, Sullivan HR. Disposition of methadone in methadone maintenance. Clin Pharmacol Ther. 1975;17:258–66
16. Verebely K, Volavka J, Mulé S, Resnick R. Methadone in man: pharmacokinetic and excretion studies in acute and chronic treatment. Clin Pharmacol Ther. 1975;18:180–90
17. Anggård E, Nilsson MI, Holmstrand J, Gunne LM. Pharmacokinetics of methadone during maintenance therapy: pulse labeling with deuterated methadone in the steady state. Eur J Clin Pharmacol. 1979;16:53–7
18. Holmstrand J, Anggård E, Gunne LM. Methadone maintenance: plasma levels and therapeutic outcome. Clin Pharmacol Ther. 1978;23:175–80
19. Misra AL, Mulé SJ, Bloch R, Vadlamani NL. Physiological disposition and metabolism of levo-methadone-1-3 H in nontolerant and tolerant rats. J Pharmacol Exp Ther. 1973;185:287–99
20. Masten LW, Peterson GR, Burkhalter A, Way EL. Effect of oral administration of methadone on hepatic microsomal mixed function oxidase activity in mice. Life Sci. 1974;14:1635–40
21. Kapeghian JC, Burdock GA, Masten LW. Effect of the route of administration on microsomal enzyme induction following repeated administration of methadone in the mouse. Biochem Pharmacol. 1979;28:3021–5
22. Gerber JG, Rhodes RJ, Gal J. Stereoselective metabolism of methadone N-demethylation by cytochrome P4502B6 and 2C19. Chirality. 2004;16:36–44
23. Kharasch ED, Hoffer C, Whittington D, Sheffels P. Role of hepatic and intestinal cytochrome P450 3A and 2B6 in the metabolism, disposition, and miotic effects of methadone. Clin Pharmacol Ther. 2004;76:250–69
24. Totah RA, Allen KE, Sheffels P, Whittington D, Kharasch ED. Enantiomeric metabolic interactions and stereoselective human methadone metabolism. J Pharmacol Exp Ther. 2007;321:389–99
25. Totah RA, Sheffels P, Roberts T, Whittington D, Thummel K, Kharasch ED. Role of CYP2B6 in stereoselective human methadone metabolism. Anesthesiology. 2008;108:363–74
26. Chang Y, Fang WB, Lin SN, Moody DE. Stereo-selective metabolism of methadone by human liver microsomes and cDNA-expressed cytochrome P450s: a reconciliation. Basic Clin Pharmacol Toxicol. 2011;108:55–62
27. Eap CB, Buclin T, Baumann P. Interindividual variability of the clinical pharmacokinetics of methadone: implications for the treatment of opioid dependence. Clin Pharmacokinet. 2002;41:1153–93
28. Crettol S, Déglon JJ, Besson J, Croquette-Krokkar M, Gothuey I, Hämmig R, Monnat M, Hüttemann H, Baumann P, Eap CB. Methadone enantiomer plasma levels, CYP2B6, CYP2C19, and CYP2C9 genotypes, and response to treatment. Clin Pharmacol Ther. 2005;78:593–604
29. Crettol S, Déglon JJ, Besson J, Croquette-Krokar M, Hämmig R, Gothuey I, Monnat M, Eap CB. ABCB1 and cytochrome P450 genotypes and phenotypes: influence on methadone plasma levels and response to treatment. Clin Pharmacol Ther. 2006;80:668–81
30. Gruber VA, McCance-Katz EF. Methadone, buprenorphine, and street drug interactions with antiretroviral medications. Curr HIV/AIDS Rep. 2010;7:152–60
31. Kharasch ED, Bedynek PS, Park S, Whittington D, Walker A, Hoffer C. Mechanism of ritonavir changes in methadone pharmacokinetics and pharmacodynamics: I. Evidence against CYP3A mediation of methadone clearance. Clin Pharmacol Ther. 2008;84:497–505
32. Kharasch ED, Hoffer C, Whittington D, Walker A, Bedynek PS. Methadone pharmacokinetics are independent of cytochrome P4503A (CYP3A) activity and gastrointestinal drug transport: insights from methadone interactions with ritonavir/indinavir. Anesthesiology. 2009;110:660–72
33. Kharasch ED, Walker A, Whittington D, Hoffer C, Bedynek PS. Methadone metabolism and clearance are induced by nelfinavir despite inhibition of cytochrome P4503A (CYP3A) activity. Drug Alcohol Depend. 2009;101:158–68
34. Bunten H, Liang WJ, Pounder D, Seneviratne C, Osselton MD. CYP2B6 and OPRM1 gene variations predict methadone-related deaths. Addict Biol. 2011;16:142–4
35. Kharasch ED, Whittington D, Ensign D, Hoffer C, Bedynek PS, Campbell S, Stubbert K, Crafford A, London A, Kim T. Mechanism of efavirenz influence on methadone pharmacokinetics and pharmacodynamics. Clin Pharmacol Ther. 2012;91:673–84
36. Kharasch ED, Bedynek PS, Hoffer C, Walker A, Whittington D. Lack of indinavir effects on methadone disposition despite inhibition of hepatic and intestinal cytochrome P4503A (CYP3A). Anesthesiology. 2012;116:432–47
37. Rostami-Hodjegan A, Wolff K, Hay AW, Raistrick D, Calvert R, Tucker GT. Population pharmacokinetics of methadone in opiate users: characterization of time-dependent changes. Br J Clin Pharmacol. 1999;48:43–52
38. Wolff K, Rostami-Hodjegan A, Hay AW, Raistrick D, Tucker G. Population-based pharmacokinetic approach for methadone monitoring of opiate addicts: potential clinical utility. Addiction. 2000;95:1771–83
39. Tolson AH, Li H, Eddington ND, Wang H. Methadone induces the expression of hepatic drug-metabolizing enzymes through the activation of pregnane X receptor and constitutive androstane receptor. Drug Metab Dispos. 2009;37:1887–94
40. Rodríguez-Antona C, Donato MT, Pareja E, Gómez-Lechón MJ, Castell JV. Cytochrome P-450 mRNA expression in human liver and its relationship with enzyme activity. Arch Biochem Biophys. 2001;393:308–15
41. Zhang JG, Ho T, Callendrello AL, Crespi CL, Stresser DM. A multi-endpoint evaluation of cytochrome P450 1A2, 2B6 and 3A4 induction response in human hepatocyte cultures after treatment with β-naphthoflavone, phenobarbital and rifampicin. Drug Metab Lett. 2010;4:185–94
42. Williamson BL, Purkayastha S, Hunter CL, Nuwaysir L, Hill J, Easterwood L, Hill J. Quantitative protein determination for CYP induction via LC-MS/MS. Proteomics. 2011;11:33–41
43. Chu V, Einolf HJ, Evers R, Kumar G, Moore D, Ripp S, Silva J, Sinha V, Sinz M, Skerjanec A. In vitro and in vivo induction of cytochrome p450: a survey of the current practices and recommendations: a pharmaceutical research and manufacturers of america perspective. Drug Metab Dispos. 2009;37:1339–54
44. Faucette SR, Hawke RL, Lecluyse EL, Shord SS, Yan B, Laethem RM, Lindley CM. Validation of bupropion hydroxylation as a selective marker of human cytochrome P450 2B6 catalytic activity. Drug Metab Dispos. 2000;28:1222–30
45. Klees TM, Sheffels P, Dale O, Kharasch ED. Metabolism of alfentanil by cytochrome p4503a (cyp3a) enzymes. Drug Metab Dispos. 2005;33:303–11
46. Fahmi OA, Kish M, Boldt S, Obach RS. Cytochrome P450 3A4 mRNA is a more reliable marker than CYP3A4 activity for detecting pregnane X receptor-activated induction of drug-metabolizing enzymes. Drug Metab Dispos. 2010;38:1605–11
47. Nilsson MI, Anggård E, Holmstrand J, Gunne LM. Pharmacokinetics of methadone during maintenance treatment: adaptive changes during the induction phase. Eur J Clin Pharmacol. 1982;22:343–9
48. Ito K, Iwatsubo T, Kanamitsu S, Ueda K, Suzuki H, Sugiyama Y. Prediction of pharmacokinetic alterations caused by drug-drug interactions: metabolic interaction in the liver. Pharmacol Rev. 1998;50:387–412
49. McCance-Katz EF, Sullivan LE, Nallani S. Drug interactions of clinical importance among the opioids, methadone and buprenorphine, and other frequently prescribed medications: a review. Am J Addict. 2010;19:4–16
50. Moore LB, Parks DJ, Jones SA, Bledsoe RK, Consler TG, Stimmel JB, Goodwin B, Liddle C, Blanchard SG, Willson TM, Collins JL, Kliewer SA. Orphan nuclear receptors constitutive androstane receptor and pregnane X receptor share xenobiotic and steroid ligands. J Biol Chem. 2000;275:15122–7
51. Faucette SR, Zhang TC, Moore R, Sueyoshi T, Omiecinski CJ, LeCluyse EL, Negishi M, Wang H. Relative activation of human pregnane X receptor versus constitutive androstane receptor defines distinct classes of CYP2B6 and CYP3A4 inducers. J Pharmacol Exp Ther. 2007;320:72–80
52. Gadel S, Crafford A, Regina K, Kharasch ED. Methadone N-Demethylation by the Common CYP2B6 Allelic Variant CYP2B6.6. Drug Metab Dispos. 2013;41:709–13