Description of the Patient Case
The patient was a 30-year-old white woman who had delivered a child via cesarean section. She had no chronic conditions or previous surgeries and no severe diseases in her patient history. The patient was prescribed codeine for managing post-cesarean pain; the dosage was adjusted for the woman’s age and weight, and she took no more than the prescribed dose. Nevertheless, while on codeine, the patient experienced the adverse effects of dizziness and nausea.
The woman also saw that her breastfed baby was lethargic and showed a lack of appetite. The patient shared her observations of these adverse effects with her physician, who recommended the discontinuation of codeine. When the medicine was discontinued, both the patient and her infant returned to their normal condition and demonstrated no above-mentioned symptoms.
Factors Influencing Pharmacokinetics and Pharmacodynamics
The patient’s response to codeine can be explained by several individual variations. The first factor is genetic variants that change the person’s drug metabolism, which are the most prevalent genetic mechanism modifying drug responses (Rosenthal & Burchum, 2017).
Codeine refers to opioids, and its effect is exerted through opioid receptors located throughout the body (Dean, 2017). However, since this medicine is a prodrug, its effect is highly dependent on metabolism, which converts it into morphine that possesses stronger analgesic properties (Dean, 2017). This conversion requires the liver enzyme CYP2D6, which metabolizes codeine into morphine via the process called O- demethylation (Dean, 2017). Usually, only 5-10% of codeine is converted into morphine, with 80% of the administered dose being transformed into inactive metabolites (Dean, 2017). Yet, this conversion rate may be different in some patients because of the varied activity of the CYP2D6 enzyme.
The activity of the CYP2D6 enzyme depends on the individual’s genotype. Patients with low enzyme activity are called “poor metabolizers” because they receive little morphine from codeine, while those with higher activity of this enzyme are “ultrarapid metabolizers” (Kwon & Flood, 2020). Given that the dose administrated to the patient in the described case was normal for her age and weight but resulted in the symptoms of intoxication, it may be concluded that the patient was an ultrarapid metabolizer.
The second factor that may have influenced the patient’s response to codeine is physiologic alterations due to pregnancy. Research indicates that the activity level of the CYP2D6 enzyme usually rises in pregnancy (Dean, 2017). Since the patient in the case gave birth shortly before codeine administration, it may be assumed that the elevated enzyme activity level was still present. This would result in greater conversion of codeine into morphine than expected, causing dizziness and nausea in the mother and lethargy in the breastfed infant.
Finally, the patient’s response to the drug may be explained by a lack of dose adjustment to the patient’s race. Studies show that Caucasians require a lower dose of codeine than Asians (Baber et al., 2015). The patient belonged to the Caucasian race, meaning that her appropriate dose of codeine should have been lower than that of an Asian patient of a similar age and weight.
Details of the Personalized Care Plan
Individual factors should be considered when prescribing drugs to avoid adverse effects or inadequate drug response. One way to account for individual variations is laboratory testing (Rosenthal & Burchum, 2017). In the given case, genetic testing for determining the patient’s CYP2D6 genotype would be beneficial as it has been proven effective for predicting patients’ responses to opioid drugs and adjusting doses accordingly (Ribeiro et al., 2019).
It is necessary to consider that the patient is a breastfeeding mother, and in this patient group, opioid-sparing analgesia is preferred, including such medicines as NSAIDs, acetaminophen, dexamethasone, gabapentin, and ketamine (Chidambaran et al., 2017). If the patient has moderate to severe pain, oral opioids may be administered, but codeine is not recommended because of high metabolic variability (Chidambaran et al., 2017). Finally, a prescription should not contain confusing abbreviations and symbols, such as µg instead of mcg or.5 mg instead of 0.5 mg (ISMP, 2021). This is necessary to avoid medical errors in drug prescriptions.
References
Baber, M., Chaudhry, S., Kelly, L., Ross, C., Carleton, B., Berger, H., & Koren, G. (2015). The pharmacogenetics of codeine pain relief in the postpartum period. The Pharmacogenomics Journal, 15, 430-435.
Chidambaran, V., Sadhasivam, S., & Mahmoud, M. (2017). Codeine and opioid metabolism: Implications and alternatives for pediatric pain management. Current opinion in anaesthesiology, 30(3), 349-356. Web.
Dean, L. (2017). Codeine therapy and CYP2D6 genotype. Medical Genetics Summaries. Web.
Institute for Safe Medication Practices [ISMP]. (2021). List of error-prone abbreviations. Web.
Kwon, A. H., & Flood, P. (2020). Genetics and gender in acute pain and perioperative opioid analgesia. Anesthesiology Clinics, 38(2), 341-355. Web.
Ribeiro, C., Quinta, R., Raposo, A., Valentim, A., Albuquerque, J., & Grazina, M. (2019). CYP2D6 pharmacogenetics testing and post-cesarean section pain scores—A preliminary study. Pain Medicine, 20(2), 359-368. Web.
Rosenthal, L., & Burchum, J. (2017). Lehne’s pharmacotherapeutics for nurse practitioners and physician assistants. Elsevier.