Sleep Apnea and Obesity Affects on Morphine Pharmacokinetics

Study Overview
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Brief Summary
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Adenotonsillectomy (AT) is one of the most common pediatric surgeries performed, and is estimated to comprise 530,000 procedures in children under 15 years of age. Historically, the leading cause for these procedures was recurrent infections; however, more recently surgical indications include sleep disordered breathing and obstructive sleep apnea (OSAS). Pre-operative polysomnography (PSG) is recommended for all children with suspected OSAS prior to undergoing AT, although it is unclear whether sleep disordered breathing characteristics predict post-operative outcomes or complications. Obesity has become an epidemic in the pediatric population. More recently, an increased population of obese children are presenting for AT with upper airway obstruction with or without tonsillar hypertrophy, which is similar to the adult etiology of OSAS. Obesity is a multisystem disease, causing fatty liver and cardiac disease, defects in glucose metabolism, insulin resistance, leptin resistance, and creates a state of chronic inflammation. Markers for inflammation, including tumor necrosis factor (TNF)-α, C-reactive protein (CRP), leptin, interleukin (IL)-6 and IL-10, are abnormal in obese patients and have also been linked to more severe OSAS disease in children even after controlling for BMI. In pediatrics, medication dosing is based on an actual body-weight calculation, however, recent reports suggest that this dosing method is over-dosing patients with obesity. Therefore, increased respiratory complications after surgery may be related to inappropriate intra-operative opioid dosing. Specific Aim 1 (SA1): To compare morphine pharmacokinetics in normal children <=12 years of age, non-obese children with severe OSAS, and obese children with severe OSAS. The investigators hypothesize that obesity independently enhances morphine pharmacokinetics. Specific Aim 2 (SA2): To determine whether biomarkers related to obesity, chronic inflammation, and OSAS predict changes to morphine pharmacokinetics. The investigators hypothesize that inflammatory and obesity-related biomarkers are elevated in overweight children with OSAS, more so in obese children with OSA, compared to lean children with OSAS. In addition, the investigators hypothesizes that leptin independently is linked to altered morphine pharmacokinetics.

Official Title
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Effects of Obstructive Sleep Apnea Syndrome and Obesity on Morphine Pharmacokinetics in Children

Conditions
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Pediatric Sleep Apnea, Obesity, Morphine Metabolism

Intervention / Treatment
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* Other: Morphine pharmacokinetic evaluation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Child presenting for surgery that will require opioids Age between 5 -12 years of age OSAS group: Pre-operative polysomnography study conducted prior to day of surgery Obese: Body weight >95th percentile for age. Exclusion Criteria: Emergency procedures involving AT, including tonsillar bleeding Patients allergic to morphine Patients with comorbidities altering opioid metabolism (i.e. liver disease) Patients with chronic inflammatory, rheumatologic, or other confounding co-morbid diseases (i.e. Crohns disease, ulcerative colitis, sickle cell, Sjogren's, etc.)

Ages Eligible for Study
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Minimum Age: 5 Years
Maximum Age: 12 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Morphine dosing<br>Evaluating morphine pharmacokinetics (PK) in 3 groups: normal controls, children with severe OSAS, and obese children with OSAS. Morphine is dosed on ideal body weight in obese children, as recommended by manufacturer. Biomarkers were taken from patients to evaluate their relation to changes in morphine PK. | Other: Morphine pharmacokinetic evaluation<br>* Each group received morphine and blood drawn to evaluate morphine PK<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Plasma Morphine Area Under the Curve (AUC) | To determine changes in morphine AUC due to obesity and OSAS | Through study completion, up to 24 hours after study initiation | 
| Maximum Plasma Morphine Concentration (Cmax) | To determine changes in morphine Cmax due to obesity and OSAS | Through study completion, up to 24 hours after study initiation | 
| Time to Maximum Plasma Morphine Concentration (Tmax) | To determine changes in morphine Tmax due to obesity and OSAS | Through study completion, up to 24 hours after study initiation | 
| Half Life of Plasma Morphine Concentration (T1/2) | To determine changes in morphine T1/2 due to obesity and OSAS | Through study completion, up to 24 hours after study initiation | 
| Plasma Morphine Clearance (Cl) | To determine changes in morphine Cl due to obesity and OSAS | Through study completion, up to 24 hours after study initiation | 
| Plasma Morphine Volume of Distribution (Vd) | To determine changes in morphine Vd due to obesity and OSAS | Through study completion, up to 24 hours after study initiation | 
| Plasma Morphine 3-glucuronide (M3G) Maximum Plasma Concentration (Cmax) | To determine changes in M3G Cmax due to obesity and OSAS | Through study completion, up to 24 hours after study initiation | 
| Time to Maximum Morphine 3-glucuronide (M3G) Concentration (Tmax) | To determine changes in M3G Tmax due to obesity and OSAS | Through study completion, up to 24 hours after study initiation | 
| Morphine 3-glucuronide (M3G) to Morphine ratio | To determine changes in metabolism of morphine due to obesity and OSAS | Through study completion, up to 24 hours after study initiation | 
| Morphine 3-glucuronide (M3G) to Morphine 6-glucuronide (M6G) ratio | To determine changes in metabolism of morphine due to obesity and OSAS | Through study completion, up to 24 hours after study initiation | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Biomarker concentrations | To determine whether inflammatory biomarkers correlate to the severity of sleep apnea. Biomarkers that will be studied include IL 1,6,10, CRP, TNF-alpha, leptin, and insulin. | Through study completion, up to 24 hours after study initiation |