Pholcodine

Abstract: Background: Neuromuscular blocking agents (NMBAs) can cause anaphylaxis through immunoglobulin E (IgE) antibodies that bind quaternary ammonium ion epitopes. These epitopes are present in numerous common chemicals and drugs, exposure to which, theoretically, could be of importance in the development and maintenance of the IgE sensitization promoting allergic reactions. Pholcodine is one such drug, which in a recent pilot study was shown to induce a remarkable increase in serum IgE levels in two IgE-sensitized individuals. The present study explores the effect of pholcodine exposure on IgE in a population with previously diagnosed IgE-mediated anaphylaxis towards NMBAs. Methods: Seventeen patients were randomized to 1 week’s exposure with cough syrup containing either pholcodine or guaifenesin. The primary variables serum IgE and IgE antibodies towards pholcodine, morphine and suxamethonium were measured before and 4 and 8 weeks after start of exposure. Results: Patients exposed to pholcodine had a sharp rise in levels of IgE antibodies towards pholcodine, morphine and suxamethonium, the median proportional increases 4 weeks after exposure reaching 39.0, 38.6 and 93.0 times that of the base levels respectively. Median proportional increase of IgE was 19.0. No changes were observed in the guaifenesin group. Conclusion: Serum levels of IgE antibodies associated with allergy towards NMBAs increase significantly in sensitized patients after exposure to cough syrup containing pholcodine. Availability of pholcodine should be restricted by medical authorities because of the potential risk of future allergic reactions to muscle relaxants.

Abstract: Background: Immunoglubulin E antibody-mediated allergic reactions to opioids are rare and difficult to document correctly Objective: Assessment of the basophil activation test in the diagnosis of IgE-mediated allergy to the antitussive pholcodine and associated sensitizations to neuromuscular blocking agents (NMBA) Methods: Three patients with a suspected IgE-mediated allergy to pholcodine were investigated using skin tests, quantification of specific IgE, and flow cytometric activation of basophils Results and conclusion: Flow cytometric activation of basophils, with simultaneous analysis of CD63 appearance and median histamine content per cell, is the only technique capable to correctly document pholcodine allergy The negative predictive value of basophil activation tests might help to elucidate on the controversial putative cross-reactivity between pholcodine and NMBA V C 2013 International Clinical Cytometry Society

Abstract: Pholcodine (3-O-(2'-morpholinoethyl)-morphine) is used in many countries as an antitussive without analgesic or addictive properties. It is of forensic relevance that pholcodine interferes with opiate immunoassays. In this paper a gas chromatographic-mass spectrometric (GC-MS) procedure for the precise and sensitive detection of pholcodine and its metabolites in urine and hair, after acid hydrolysis, extraction and acetylation, is presented. Furthermore, detection of pholcodine using radio immunoassay (RIA), fluorescence polarisation immunoassay (FPIA) and enzyme immunoassay (EIA) for opiates is described. Using GC-MS, unmodified pholcodine could be detected in urine samples 4-7 weeks after ingestion of a single therapeutic dose of 50mg of pholcodine, the desmorpholinohydroxy metabolite for 1-2 weeks and the other metabolites (nor-, nordesmorpholinohydroxy-, hydroxy-, oxo- and noroxo-pholcodine) only during the first few hours. Morphine could also be detected in urine samples for the first few days. It was however mainly formed artificially during acid hydrolysis and only in trace amounts by metabolism. All the immunoassays tested gave positive results in urine samples during the first week taking the cut-off values recommended by the manufacturer into consideration. If values between the cut-off and the detection limit were taken into consideration, RIA and FPIA gave positive results for 2-4 weeks and EIA up to 2 weeks. Pholcodine could also be detected by RIA and GC-MS in samples of head hair clipped 10 weeks after ingestion of 50mg and in daily shaved samples of beard hair over a period of three weeks after ingestion of three doses of 60mg. It can be concluded that the widely used immunoassays for opiates show positive results in urine and hair samples for a long time after ingestion of the non-opioid pholcodine and that these results can be confirmed by the GC-MS procedure described in this paper.