PT - JOURNAL ARTICLE AU - Jessica I. Griffith AU - Minjee Kim AU - Daniel J. Bruce AU - Cristina D. Peterson AU - Kelley F. Kitto AU - Afroz S. Mohammad AU - Sneha Rathi AU - Carolyn A. Fairbanks AU - George L. Wilcox AU - William F. Elmquist TI - Central Nervous System Distribution of an Opioid Agonist Combination with Synergistic Activity AID - 10.1124/jpet.121.000821 DP - 2022 Jan 01 TA - Journal of Pharmacology and Experimental Therapeutics PG - 34--46 VI - 380 IP - 1 4099 - http://jpet.aspetjournals.org/content/380/1/34.short 4100 - http://jpet.aspetjournals.org/content/380/1/34.full SO - J Pharmacol Exp Ther2022 Jan 01; 380 AB - Novel combinations of specific opioid agonists like loperamide and oxymorphindole targeting the µ- and δ-opioid receptors, respectively, have shown increased potency with minimized opioid-associated risks. However, whether their interaction is pharmacokinetic or pharmacodynamic in nature has not been determined. This study quantitatively determined whether these drugs have a pharmacokinetic interaction that alters systemic disposition or central nervous system (CNS) distribution. We performed intravenous and oral in vivo pharmacokinetic assessments of both drugs after discrete dosing and administration in combination to determine whether the combination had any effect on systemic pharmacokinetic parameters or CNS exposure. Drugs were administered at 5 or 10 mg/kg i.v. or 30 mg/kg orally to institute for cancer research (ICR) mice and 5 mg/kg i.v. to Friend leukemia virus strain B mice of the following genotypes: wild-type, breast cancer resistance protein (Bcrp–/–) (Bcrp knockout), Mdr1a/b–/– [P-glycoprotein (P-gp) knockout], and Bcrp–/– Mdr1a/b–/–(triple knockout). In the combination, clearance of oxymorphindole (OMI) was reduced by approximately half, and the plasma area under the concentration-time curve (AUC) increased. Consequently, brain and spinal cord AUCs for OMI in the combination also increased proportionately. Both loperamide and OMI are P-gp substrates, but administration of the two drugs in combination does not alter efflux transport at the CNS barriers. Because OMI alone shows appreciable brain penetration but little therapeutic efficacy on its own, and because loperamide’s CNS distribution is unchanged in the combination, the mechanism of action for the increased potency of the combination is most likely pharmacodynamic and most likely occurs at receptors in the peripheral nervous system. This combination has favorable characteristics for future development.SIGNIFICANCE STATEMENT Opioids have yet to be replaced as the most effective treatments for moderate-to-severe pain and chronic pain, but their side effects are dangerous. Combinations of opioids with peripheral activity, such as loperamide and oxymorphindole, would be valuable in that they are effective at much lower doses and have reduced risks for dangerous side effects because the µ-opioid receptor agonist is largely excluded from the CNS.