• Erik Olofsen, Merel Boom, Elise Sarton, Monique van Velzen, Paul Baily, Kevin J Smith, Alexander Oksche, Albert Dahan, and Marieke Niesters.
• From the Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands (E.O., M.B., E.S., M.vV., A.D., M.N.) Mundipharma Research Limited, Cambridge, United Kingdom (P.B., K.J.S., A.O.) Rudolf-Buchheim-Institut für Pharmakologie (Rudolph-Buchheim Institute for Pharmacology), University of Giessen, Giessen, Germany (A.O.). Current affiliations: Sosei Heptares, Cambridge, United Kingdom (P.B.).
• Anesthesiology. 2019 Dec 1; 131 (6): 1327-1339.

BackgroundThere is an ongoing need for potent opioids with less adverse effects than commonly used opioids. R-dihydroetorphine is a full opioid receptor agonist with relatively high affinity at the μ-, δ- and κ-opioid receptors and low affinity at the nociception/orphanin FQ receptor. The authors quantified its antinociceptive and respiratory effects in healthy volunteers. The authors hypothesized that given its receptor profile, R-dihydroetorphine will exhibit an apparent plateau in respiratory depression, but not in antinociception.MethodsThe authors performed a population pharmacokinetic-pharmacodynamic study (Eudract registration No. 2009-010880-17). Four intravenous R-dihydroetorphine doses were studied: 12.5, 75, 125, and 150 ng/kg (infused more than 10 min) in 4 of 4, 6 of 6, 6 of 6, and 4 of 4 male subjects in pain and respiratory studies, respectively. The authors measured isohypercapnic ventilation, pain threshold, and tolerance responses to electrical noxious stimulation and arterial blood samples for pharmacokinetic analysis.ResultsR-dihydroetorphine displayed a dose-dependent increase in peak plasma concentrations at the end of the infusion. Concentration-effect relationships differed significantly between endpoints. R-dihydroetorphine produced respiratory depression best described by a sigmoid EMAX-model. A 50% reduction in ventilation in between baseline and minimum ventilation was observed at an R-dihydroetorphine concentration of 17 ± 4 pg/ml (median ± standard error of the estimate). The maximum reduction in ventilation observed was at 33% of baseline. In contrast, over the dose range studied, R-dihydroetorphine produced dose-dependent analgesia best described by a linear model. A 50% increase in stimulus intensity was observed at 34 ± 11 pg/ml.ConclusionsOver the dose range studied, R-dihydroetorphine exhibited a plateau in respiratory depression, but not in analgesia. Whether these experimental advantages extrapolate to the clinical setting and whether analgesia has no plateau at higher concentrations than investigated requires further studies.

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