Reversal of Opioid-induced Respiratory Depression With Opioid Antagonists (ROAR)

Reversal of Opioid-induced Respiratory Depression With Opioid Antagonists - a Study in Opioid naïve Individuals and Chronic Opioid Users Under Real-life Conditions

In this pharmacokinetic/pharmacodynamic modelling study we will determine the ability of intranasal and intramuscular naloxone to reverse opioid (fentanyl and sufentanil)- induced respiratory depression in healthy volunteers and chronic opioid users to develop dosing recommendations in case of opioid-induced respiratory depression from an opioid overdose in clinical practice and in the out-of-hospital overdose.

Study Overview

• Status: Recruiting
• Conditions: Chronic Opioid Use; Opioid Induced Respiratory Depression
• Intervention / Treatment: Drug: Narcan 40 MG/ML Nasal Spray; Drug: Naloxone Hydrochloride

Detailed Description

Primary objective:

To describe the pharmacokinetics and pharmacodynamics of intravenous fentanyl and sufentanil on ventilation and intranasal and intramuscular naloxone in its ability to reverse respiratory depression (important model parameters include C50, a measure of potency and t½ke0). The results of these studies will allow us to perform simulation studies aimed at optimizing dosing regimens for intranasal and intramuscular naloxone in individuals that overdosed on potent opioids, with respiratory depression ranging from moderate to severe.

Secondary objectives:

To describe the pharmacokinetics and pharmacodynamics of intravenous fentanyl and sufentanil on pupil diameter and intranasal and intramuscular naloxone in its ability to reverse miosis (important model parameters include C50, a measure of potency and t½ke0). The results of these studies will allow us to compare the ventilatory and pupil effects of the opioids and of naloxone.

Study design:

This is an open-label, randomized (IM versus IN naloxone), crossover study in a mixed population.

Study population:

We will study 12 healthy individuals of either sex aged 18-55 years and 12 individuals that are chronic opioids users (> 60 daily oral morphine equivalents; 18-55 years).

Intervention:

Study 1: Infusion of low-dose fentanyl and sufentanil whilst measuring minute ventilation and pupil diameter. When ventilation has dropped by 40-60% (Saturation > 85%), intranasal naloxone (IN, 4 mg) will be administered at 30 min intervals. At the end of each experiment 0.4 mg naloxone will be administered intravenously to determine its effect on ventilation and to allow calculation of naloxone intranasal bioavailability.

Study 2: Infusion of low-dose fentanyl and sufentanil whilst measuring minute ventilation and pupil diameter. When ventilation has dropped by 40-60% (Saturation > 85%), intramuscular (IM, 2 mg) will be administered at 30 min intervals. At the end of each experiment 0.4 mg naloxone will be administered intravenously to determine its effect on ventilation and to allow calculation of naloxone intramuscular bioavailability. At regular intervals blood will be drawn for measurement of drug concentration; at regular intervals pupil diameter will be measured.

Main study parameters:

The main study measurement is minute ventilation. Together with the plasma concentration of the opioid and naloxone), ventilation is inputted in the PKPD model to get meaningful model parameters such as C50 and t½ke0, measures of potency and the speed of onset/offset of effect, respectively. See Data analysis below.

The secondary study measurement is pupil diameter. Together with the plasma concentration of the opioid and naloxone), the pupil diameter is inputted in the PKPD model to get meaningful model parameters such as C50 and t½ke0, measures of potency and the speed of onset/offset of effect, respectively. See Data analysis below. Nature and extent of the burden and risks associated with participation, benefit and group relatedness:

In this pharmacokinetic-pharmacodynamic modeling study, the effect of intramuscular and intranasal naloxone is studied during infusion of two opioids, fentanyl and sufentanil, in mixed population of healthy volunteers and chronic opioid users. The PK/PD analysis will yield important information regarding dosing regimens of IM and IN naloxone at fentanyl and sufentanil doses much higher than we will administer here, but that may represent doses in case of an overdose both in clinical patients and opioid abusers. Side effects related to the medication will be mild to moderate with most common side effects: nausea, vomiting, dizziness, somnolence, dry mouth and respiratory depression (from the opioids), and possibly mild withdrawal symptoms from naloxone. Side effects will dissipate over time while severe occurrences of nausea and vomiting will be treated with an antiemetic; severe occurrence of withdrawal symptoms will be treated with clonidine.

Respiratory depression is the topic of the current study; severe occurrences may be treated with intravenous naloxone. The participants will have no benefit from this trial in terms of disease burden reduction or disease alleviation. The gained knowledge from the study is large as this is the first study to systematically study IM and IN naloxone dosing in chronic opioid users.

• Study Type: Interventional
• Enrollment (Anticipated): 24
• Phase: Phase 1

Contacts and Locations

• Study Contact: Name: Albert Dahan, MD PhD; Phone Number: +31 (0)71 5299780; Email: a.dahan@lumc.nl

Study Locations

• Netherlands
  • ZH
    • Leiden, ZH, Netherlands, 2333 ZA
      • Recruiting
      • Leiden University Medical Center
      • Contact: Albert Dahan, MD PhD; Phone Number: +31715262301; Email: a.dahan@lumc.nl
      • Principal Investigator: Albert Dahan, MD PhD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 70 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

Healthy volunteers

1. Signed the informed consent form (ICF) and able to comply with the study requirements and restrictions listed therein;
2. Male and female subjects, age 18 to 70 years, inclusive;
3. Women of childbearing potential (defined as all women who are not surgically sterile or postmenopausal for at least 1 year prior to informed consent) must have a negative serum pregnancy test prior to enrolment and must agree to use a medically acceptable means of contraception from screening through at least 1 month after the last dose of study drug;
4. Body Mass Index (BMI) 18 to 30 kg/m2, inclusive;
5. Healthy as defined by the Investigator, based on a medical evaluation that includes the subject's medical and surgical history, physical examination, vital signs, lab chemistry: estimated glomerular filtration rate >60 mL/min as estimated by the CKD-EPI equation, and AST or ALT levels < 3.0 times the upper limit of normal at screening, and negative serology tests for HIV, acute hepatitis B, or acute hepatitis C;
6. No history of substance use disorder;

Chronic opioid users

1. Signed the consent form and able to comply with the requirements and restrictions listed therein;
2. Males or females age 18 to 70 years, inclusive;
3. Women of childbearing potential (defined as all women who are not surgically sterile or postmenopausal for at least 1 year prior to informed consent) must have a negative serum pregnancy test prior to enrolment and must agree to use a medically acceptable means of contraception from screening through at least 1 3 month after the last dose of study drug.
4. BMI 18 to 32 kg/m2, inclusive;
5. Opioid tolerant patients administered prescription opioids at daily doses ≥ 60 mg oral morphine equivalents (See Table 3);
6. Stable as defined by the Investigator, based on a medical evaluation that includes the subject's medical and surgical history, physical examination, vital signs, 12-lead ECG, hematology, and blood chemistry;

Exclusion Criteria:

Healthy volunteers

1. Currently meet the criteria for diagnosis of substance use disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 criteria on any substance;
2. Any other active medical condition, organ disease or concurrent medication or treatment that may either compromise subject safety or interfere with study endpoints;
3. Consume, on average, >27 20 units/week of alcohol in men and > 20 13 units/week of alcohol in women (1 unit = 1 glass (250 mL) beer, 125 mL glass of wine or 25 mL of 40% spirit);
4. Previous or current treatment with opioid agonist, partial agonist, or antagonist treatment within 30 days prior to the first study drug administration;
5. Significant traumatic injury, major surgery, or open biopsy within the prior 4 weeks of informed consent;
6. History of suicidal ideation within 30 days prior to informed consent or history of a suicide attempt in the 6 months prior to informed consent;
7. Measured systolic blood pressure greater than 160 or less than 95 mmHg or diastolic pressure greater than 95 mmHg at screening;
8. History or presence of allergic response to fentanyl, sufentanil or naloxone;
9. Subjects who have demonstrated allergic reactions (e.g., food, drug, atopic reactions or asthmatic episodes) which, in the opinion of the Investigator and sponsor, interfere with their ability to participate in the trial;
10. Treatment with another investigational drug within 3 months prior to dosing or having participated in more than 4 investigational drug studies within 1 year prior to screening;
11. Site staff or subjects affiliated with, or a family member of, site staff directly involved in the study;

Chronic opioid users

1. Currently meet the criteria for diagnosis of moderate or severe substance use disorder according to the DSM-5 criteria on any substances other than opioids, caffeine, or nicotine;
2. Any active medical condition, organ disease or concurrent medication or treatment that may either compromise subject safety or interfere with study endpoints;
3. Consume, on average, >27 units/week of alcohol in men and >20 units/week of alcohol in women (1 unit = 1 glass (250 mL) beer, 125 mL glass of wine or 25 mL of 40% spirit);
4. Currently receiving medication-assisted treatment for the treatment of opioid-use disorder;
5. Significant traumatic injury, major surgery, or open biopsy within the prior 4 weeks of informed consent;
6. History of suicidal ideation within 30 days prior to informed consent or history of a suicide attempt in the 6 months prior to informed consent;
7. Measured systolic blood pressure greater than 160 or less than 95 mmHg or diastolic pressure greater than 95 mmHg at screening;
8. History or presence of allergic response to study medication;
9. Opioid tolerant patients who have demonstrated allergic reactions (e.g., food, drug, atopic reactions or asthmatic episodes) which, in the opinion of the Investigator and sponsor, interfere with their ability to participate in the trial.
10. Estimated glomerular filtration rate <60 mL/min as estimated by the CKD-EPI equation;
11. Anemia at screening or donation of > 250 mL of blood or plasma within the last 3 months;
12. Positive serology tests for HIV, acute hepatitis B, or acute hepatitis C (OT patients with asymptomatic hepatitis B or C infection may be enrolled);
13. AST or ALT levels >3.0 times the upper limit of normal at screening;
14. Treatment with another investigational drug within 3 months prior to dosing or having participated in more than 4 investigational drug studies within 1 year prior to screening;
15. Site staff or subjects affiliated with, or a family member of, site staff directly involved in the study.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Non-Randomized
• Interventional Model: Crossover Assignment
• Masking: None (Open Label)

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Intravenous fentanyl year 1; continuous intravenous infusion of fentanyl to induce 40-60% respiratory depression.	Drug: Narcan 40 MG/ML Nasal Spray; naloxone 4mg/0.1 mL intranasal spray, up to 4 doses intranasally, followed by 1ml 0.4 mg/ml naloxone hydrochloride intravenously; Other Names: Intranasal naloxone
Experimental: Intravenous sufentanil year 1; continuous intravenous infusion of sufentanil to induce 40-60% respiratory depression.	Drug: Narcan 40 MG/ML Nasal Spray; naloxone 4mg/0.1 mL intranasal spray, up to 4 doses intranasally, followed by 1ml 0.4 mg/ml naloxone hydrochloride intravenously; Other Names: Intranasal naloxone
Experimental: Intravenous sufentanil year 2; continuous intravenous infusion of sufentanil to induce 40-60% respiratory depression.	Drug: Naloxone Hydrochloride; naloxone 0.4mg/ml, up to 4 doses 2mg intramuscularly, followed by 1ml 0.4 mg/ml naloxone hydrochloride intravenously; Other Names: Intramuscular naloxone
Experimental: Intravenous fentanyl year 2; continuous intravenous infusion of fentanyl to induce 40-60% respiratory depression.	Drug: Naloxone Hydrochloride; naloxone 0.4mg/ml, up to 4 doses 2mg intramuscularly, followed by 1ml 0.4 mg/ml naloxone hydrochloride intravenously; Other Names: Intramuscular naloxone

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Minute ventilation	Minute ventilation (liters/minute)	Minute ventilation will be measured for up to 180 minutes following the start of opioid infusion
Plasma concentration sufentanil/fentanyl	50 samples of 2ml arterial blood	at 2,5,10,15,20 and 30 minutes following opioid infusion and following every administration of intranasal/intramuscular/intravenous naloxone
Plasma concentration naloxone	50 samples of 2ml arterial blood	at 2,5,10,15,20 and 30 minutes following opioid infusion and following every administration of intranasal/intramuscular/intravenous naloxone

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pupil diameter	Pupil diameter in millimeters	at 2,5,10,15,20 and 30 minutes following opioid infusion and following every administration of intranasal/intramuscular/intravenous naloxone. After discontinuation of infusion every 20 min. up to 6 hrs. following the start of opioid infusion

Collaborators and Investigators

• Sponsor: Leiden University Medical Center
• Collaborators: U.S. Food and Drug Administration (FDA)
• Investigators: Principal Investigator: Rutger van der Schrier, MD, LUMC

Publications and helpful links

General Publications

• Algera MH, Kamp J, van der Schrier R, van Velzen M, Niesters M, Aarts L, Dahan A, Olofsen E. Opioid-induced respiratory depression in humans: a review of pharmacokinetic-pharmacodynamic modelling of reversal. Br J Anaesth. 2019 Jun;122(6):e168-e179. doi: 10.1016/j.bja.2018.12.023. Epub 2019 Feb 1.
• Algera MH, Olofsen E, Moss L, Dobbins RL, Niesters M, van Velzen M, Groeneveld GJ, Heuberger J, Laffont CM, Dahan A. Tolerance to Opioid-Induced Respiratory Depression in Chronic High-Dose Opioid Users: A Model-Based Comparison With Opioid-Naive Individuals. Clin Pharmacol Ther. 2021 Mar;109(3):637-645. doi: 10.1002/cpt.2027. Epub 2020 Oct 5.
• Dahan A, Aarts L, Smith TW. Incidence, Reversal, and Prevention of Opioid-induced Respiratory Depression. Anesthesiology. 2010 Jan;112(1):226-38. doi: 10.1097/ALN.0b013e3181c38c25.
• Olofsen E, van Dorp E, Teppema L, Aarts L, Smith TW, Dahan A, Sarton E. Naloxone reversal of morphine- and morphine-6-glucuronide-induced respiratory depression in healthy volunteers: a mechanism-based pharmacokinetic-pharmacodynamic modeling study. Anesthesiology. 2010 Jun;112(6):1417-27. doi: 10.1097/ALN.0b013e3181d5e29d.
• Olofsen E, Boom M, Nieuwenhuijs D, Sarton E, Teppema L, Aarts L, Dahan A. Modeling the non-steady state respiratory effects of remifentanil in awake and propofol-sedated healthy volunteers. Anesthesiology. 2010 Jun;112(6):1382-95. doi: 10.1097/ALN.0b013e3181d69087.
• van Dorp E, Yassen A, Dahan A. Naloxone treatment in opioid addiction: the risks and benefits. Expert Opin Drug Saf. 2007 Mar;6(2):125-32. doi: 10.1517/14740338.6.2.125.
• Yassen A, Olofsen E, van Dorp E, Sarton E, Teppema L, Danhof M, Dahan A. Mechanism-based pharmacokinetic-pharmacodynamic modelling of the reversal of buprenorphine-induced respiratory depression by naloxone : a study in healthy volunteers. Clin Pharmacokinet. 2007;46(11):965-80. doi: 10.2165/00003088-200746110-00004.
• Gepts E, Shafer SL, Camu F, Stanski DR, Woestenborghs R, Van Peer A, Heykants JJ. Linearity of pharmacokinetics and model estimation of sufentanil. Anesthesiology. 1995 Dec;83(6):1194-204. doi: 10.1097/00000542-199512000-00010.

Study record dates

Study Major Dates

• Study Start (Actual): June 24, 2022
• Primary Completion (Anticipated): May 1, 2024
• Study Completion (Anticipated): May 30, 2024

Study Registration Dates

• First Submitted: April 14, 2022
• First Submitted That Met QC Criteria: April 14, 2022
• First Posted (Actual): April 21, 2022

Study Record Updates

• Last Update Posted (Estimate): January 13, 2023
• Last Update Submitted That Met QC Criteria: January 12, 2023
• Last Verified: January 1, 2023

More Information

Terms related to this study

• Keywords: Reversal of opioid induced respiratory depression; Intranasal naloxone
• Additional Relevant MeSH Terms: Behavioral Symptoms; Mental Disorders; Respiratory Tract Diseases; Mood Disorders; Respiration Disorders; Depression; Depressive Disorder; Respiratory Insufficiency; Physiological Effects of Drugs; Peripheral Nervous System Agents; Sensory System Agents; Narcotic Antagonists; Naloxone
• Other Study ID Numbers: P21.112

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Yes
• IPD Plan Description: Individual participant data that underlie the results reported in this article, after deidentification (texts, tables, figures and appendices)
• IPD Sharing Time Frame: Immediately following publication. No end date
• IPD Sharing Access Criteria: Researchers who provide a methodologically sound proposal to achieve aims in the approved proposal. Proposals should be directed at. A.Dahan@lumc.nl
• IPD Sharing Supporting Information Type: Study Protocol; Statistical Analysis Plan (SAP); Analytic Code

Drug and device information, study documents

• 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.: Yes