Spironolactone diminishes urinary albumin excretion in patients with type 1 diabetes and microalbuminuria: a randomized placebo-controlled crossover study

AIMS

Adding aldosterone receptor blockade to standard renoprotective treatment may provide additional renoprotection in patients with overt nephropathy. We expected an impact of spironolactone in early diabetic nephropathy, and for this hypothesis we studied the effect on markers of glomerular and tubular damage in patients with Type 1 diabetes and persistent microalbuminuria.

METHODS

A double-blind, randomized, placebo-controlled crossover study in 21 patients with Type 1 diabetes and microalbuminuria using spironolactone 25 mg or placebo once daily, for 60 days added to standard antihypertensive treatment. After each treatment period, the primary endpoint were evaluated: urinary(u)-albumin excretion/24 hour(h) and secondary endpoints; 24 h blood pressure, glomerular filtration rate (GFR) and markers of tubular damage: urinary liver-type fatty-acid binding protein (LFABP), neutrophil gelatinase associated lipocalin (NGAL) and kidney injury molecule 1 (KIM1).

RESULTS

All patients completed the study. During spironolactone treatment, urinary albumin excretion rate was reduced by 60% (range 21-80%), from 90 mg/24 h to 35 mg/24 h (P=0.01). Blood pressure (24 h) did not change during spironolactone treatment (P>0.2 for all comparisons). The GFR (SD) decreased from 78 (6) mL/min/1.73 m(2) to 72 (6) mL/min/1.73 m(2) (P=0.003). Urinary liver-type fatty-acid binding protein, neutrophil gelatinase-associated lipocalin and kidney injury molecule 1 did not change during treatment (P>0.3 for all comparisons). Treatment was well-tolerated, but two patients had severe hyperkalaemia (plasma potassium = 5.7 mmol/l), which was sufficiently treated with diuretics and dietary intervention.

CONCLUSIONS

Spironolactone treatment in addition to standard renoprotective treatment lowers urinary albumin excretion in microalbuminuric patients with Type 1 diabetes, and thus may offer additional renoprotection independent of blood pressure.

Hemoglobin Decline in Chemotherapy Patients Prior to and after Policy Changes Affecting Use of Erythropoiesis-Stimulating Agents: 2006 – 2009

OBJECTIVE: Since 2007, the use of erythropoiesis-stimulating agents (ESAs) to treat anemia in cancer patients receiving chemotherapy has been increasingly restricted in the USA. This study assessed hemoglobin (Hb) decline over time among chemotherapy patients. METHODS: Episodes of chemotherapy care were identified in a large US-oncology electronic medical record database; weekly Hb levels were computed in the first 8 weeks. Unadjusted and adjusted proportions of patient-weeks with Hb decline > 1 g/dl (i.e. representing clinically significant decline) within 1 or 2 weeks were analyzed. RESULTS: Between 2006 and 2009, unadjusted proportions of patient-weeks with Hb decline > 1 g/dl increased (1-week, from 12.7% to 14.9%; 2-week, from 19.3% to 26.3%). Adjusted 1-week proportions in 2007 were similar to 2006, but increased in 2008 (odds ratio [OR] 1.135; 95% confidence intervals [CI] 1.067, 1.208) and in 2009 (OR 1.235; 95% CI 1.094, 1.395). Adjusted 2-week proportions had the same pattern. CONCLUSIONS: Since restrictions on ESA use were introduced in the USA, more patients have experienced a clinically significant Hb decline after chemotherapy initiation. Initiating anemia therapy at the earliest indicated opportunity may help reduce the risk of such declines.

Repeated blockade of 5-HT₇ receptors depresses glutamatergic transmission in the rat frontal cortex

The effects of the intraperitoneal administration of the 5-HT₇ receptor antagonist SB 269970 were studied in the rat frontal cortex. In ex vivo slices prepared from rats receiving 14 daily doses of the drug (1.25 mg/kg) the mean frequency and the mean amplitude of glutamate-mediated, spontaneous excitatory postsynaptic currents (sEPSCs) recorded from layer II/III pyramidal neurons, were decreased. In contrast, single administration of SB 269970 affected neither the frequency nor the amplitude of sEPSCs. Treatment with SB 269970 did not affect membrane excitability of pyramidal cells. These data indicate that repeated, but not single, treatment with SB 269970 results in an attenuation of glutamatergic transmission in the frontal cortex, most likely due to a combination of pre- and postsynaptic mechanisms.

The 5-HT(7) receptor antagonist SB 269970 counteracts restraint stress-induced attenuation of long-term potentiation in rat frontal cortex

The effects of restraint lasting for 10 min, repeated twice daily for 3 days, were studied ex vivo in rat frontal cortex slices prepared 24 h after the last stress session. In slices originating from stressed animals, the amplitude of extracellular field potentials recorded in cortical layer II/III was increased. Stress also resulted in a reduced magnitude of long-term potentiation (LTP) of field potentials. In a separate experimental group, rats were subjected to restraint lasting for 10 min, twice daily for 3 days but, additionally, animals received injections of 5-HT(7) receptor antagonist SB 269970 (1.25 mg/kg) before each restraint stress session. In this group, the amplitude of field potentials and the magnitude of LTP were not different from the control, indicating that stress-induced modifications of basal glutamatergic transmission and synaptic plasticity were prevented by the 5-HT(7) receptor antagonist.

5-HT7 receptors modulate GABAergic transmission in rat hippocampal CA1 area

The effects of the activation of serotonin-7 (5-HT(7)) receptors were investigated in the CA1 area pyramidal cells and stratum radiatum fast spiking GABAergic interneurons of rat hippocampal slices. To activate 5-HT(7) receptors, 5-carboxamidotryptamine (5-CT), a nonselective 5-HT(1A)/5-HT(7) agonist, was applied in the presence of N-[2-[4-(2-methoxyphenyl)-1piperazinyl]ethyl]-N-2-pyridinylcyclohexanecarboxamide (WAY 100635), a selective 5-HT(1A) receptor antagonist. The activation of 5-HT(7) receptors resulted in a dose-dependent increase in the mean frequency of spontaneous inhibitory postsynaptic currents (sIPSCs) recorded from pyramidal neurons while the mean amplitude of sIPSCs remained unaltered. A nonselective glutamate receptor antagonist, kynurenic acid, and voltage-gated sodium channel blocker, tetrodotoxin (TTX), attenuated but did not prevent the 5-HT(7) receptor-mediated increase of sIPSCs frequency in pyramidal cells. 5-CT application did not influence the excitability of stratum radiatum interneurons but it dose-dependently increased the mean frequency of spontaneous excitatory postsynaptic currents (sEPSCs) recorded from interneurons while the mean amplitude of sEPSCs remained unaltered. These data suggest that the activation of 5-HT(7) receptors results in an enhancement of the GABAergic transmission in the hippocampal CA1 area via two mechanisms. The first one involves an enhancement of excitatory glutamatergic input to GABAergic interneurons and is likely to be mediated by presynaptic 5-HT(7) receptors. The second effect, most likely related to the activation of 5-HT(7) receptors located on interneurons, results in an enhancement of the release of GABA.

Bortezomib retreatment in relapsed multiple myeloma - results from a retrospective multicentre survey in Germany and Switzerland

OBJECTIVES

This multicenter, retrospective survey evaluated the efficacy and safety of bortezomib retreatment in patients with relapsed multiple myeloma who had responded to initial bortezomib treatment.

METHODS

Clinical records of 94 patients receiving bortezomib retreatment in Germany and Switzerland were reviewed.

RESULTS

Sixty patients were included according to prespecified criteria. Patients had received a mean 3.7 ± 2.3 therapies prior to initial bortezomib. Overall response rate to bortezomib retreatment was 63.3%; 8 (13.3%), 3 (5.0%) and 27 (45.0%) patients achieved complete response (CR), near-CR and partial response, respectively. Response to retreatment was associated with response to initial treatment (75.0% of patients with CR to initial treatment responded to retreatment) and treatment-free interval (TFI) after initial treatment (76.9 vs. 38.1% overall response rate for patients with TFI >6 vs. ≤ 6 months). After retreatment, median time to progression was 9.3 months. Median TFI was 5.7 months; 31.7, 25.0 and 15.0% of patients experienced a TFI longer than 6, 9 and 12 months, respectively. Reported adverse drug reactions were consistent with the known safety profile of bortezomib and most resolved completely.

CONCLUSIONS

These results demonstrate that relapsed multiple myeloma patients who respond to initial bortezomib treatment have a sustained susceptibility to bortezomib and do not experience uncommon toxicity to retreatment.

Addition of rituximab to fludarabine and cyclophosphamide in patients with chronic lymphocytic leukaemia: a randomised, open-label, phase 3 trial

BACKGROUND

On the basis of promising results that were reported in several phase 2 trials, we investigated whether the addition of the monoclonal antibody rituximab to first-line chemotherapy with fludarabine and cyclophosphamide would improve the outcome of patients with chronic lymphocytic leukaemia.

METHODS

Treatment-naive, physically fit patients (aged 30-81 years) with CD20-positive chronic lymphocytic leukaemia were randomly assigned in a one-to-one ratio to receive six courses of intravenous fludarabine (25 mg/m(2) per day) and cyclophosphamide (250 mg/m(2) per day) for the first 3 days of each 28-day treatment course with or without rituximab (375 mg/m(2) on day 0 of first course, and 500 mg/m(2) on day 1 of second to sixth courses) in 190 centres in 11 countries. Investigators and patients were not masked to the computer-generated treatment assignment. The primary endpoint was progression-free survival (PFS). Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00281918.

FINDINGS

408 patients were assigned to fludarabine, cyclophosphamide, and rituximab (chemoimmunotherapy group) and 409 to fludarabine and cyclophosphamide (chemotherapy group); all patients were analysed. At 3 years after randomisation, 65% of patients in the chemoimmunotherapy group were free of progression compared with 45% in the chemotherapy group (hazard ratio 0·56 [95% CI 0·46-0·69], p<0·0001); 87% were alive versus 83%, respectively (0·67 [0·48-0·92]; p=0·01). Chemoimmunotherapy was more frequently associated with grade 3 and 4 neutropenia (136 [34%] of 404 vs 83 [21%] of 396; p<0·0001) and leucocytopenia (97 [24%] vs 48 [12%]; p<0·0001). Other side-effects, including severe infections, were not increased. There were eight (2%) treatment-related deaths in the chemoimmunotherapy group compared with ten (3%) in the chemotherapy group.

INTERPRETATION

Chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab improves progression-free survival and overall survival in patients with chronic lymphocytic leukaemia. Moreover, the results suggest that the choice of a specific first-line treatment changes the natural course of chronic lymphocytic leukaemia.

FUNDING

F Hoffmann-La Roche.

Urinary L-FABP and anaemia: distinct roles of urinary markers in type 2 diabetes

BACKGROUND

Urinary liver-type fatty acid binding protein (L-FABP) and kidney injury molecule (KIM)-1, novel urinary biomarkers of renal tubulointerstitial function, have previously been associated with acute ischaemic kidney injury. We studied the clinical significance of urinary L-FABP, KIM-1 and N-acetyl-beta-glucosaminidase (NAG) as potential markers of renal function and chronic ischaemic injury in patients with diabetic nephropathy.

MATERIAL AND METHODS

A total of 130 type 2 diabetes patients with early diabetic nephropathy and 40 healthy controls were studied. Urinary L-FABP, KIM-1, NAG, albumin excretion rate (AER) and creatinine clearance were obtained from 24-h urine samples, and correlated with measures of red blood cell count, renal function and metabolic control.

RESULTS

Urinary L-FABP was significantly increased in diabetes patients compared with healthy controls [8.1 (interquartile 0.6-11.6) vs. 2.4 (0.5-3.6) microg/g creatinine, P < 0.001] and correlated with AER (r = 0.276, P = 0.002), creatinine clearance (r = -0.189, P = 0.033) and haemoglobin levels (r = -0.190, P = 0.030). In multivariable linear regression analysis, haemoglobin (beta = -0.247, P = 0.015) and AER (beta = 0.198, P = 0.046) were significant predictors of urinary L-FABP. Prevalent anaemia was independently associated with a 6-fold risk for increased tubulointerstitial kidney damage (upper vs. lower two L-FABP tertiles: OR, 6.06; 95% CI: 1.65-22.23; P = 0.007). Urinary KIM-1 was not significantly associated with kidney function, AER, or measures of red blood cell count while urinary NAG was associated with parameters of glucose control and renal function.

CONCLUSIONS

Different urinary biomarkers may reflect distinct pathophysiological mechanisms of tubulointerstitial damage in early diabetic nephropathy: Urinary L-FABP could be a novel biomarker for chronic intrarenal ischaemia.

5-HT1A receptors mediate detrimental effects of cocaine on long-term potentiation and expression of polysialylated neural cell adhesion molecule protein in rat dentate gyrus

The present study investigated the involvement of 5-HT(1A) receptors in the inhibitory effect of single administration of cocaine (COC, 15 mg/kg i.p.) on the induction of long-term potentiation (LTP) in slices of rat dentate gyrus (DG), prepared 30 min and 2 days after COC administration. These effects of COC were blocked by an antagonist of 5-HT(1A) receptors, WAY 100635 (0.4 mg/kg i.p.), which had been administered 20 min before COC. The detrimental effect of COC on LTP in slices prepared 30 min after COC administration could be prevented by blocking glucocorticoid receptors (GRs) using mifepristone (RU 38486, 10 mg/kg s.c. given 1 h before COC), similar as in slices obtained 2 days after COC as reported previously [Maćkowiak et al. (2008) Eur J Neurosci 27:2928-2937]. After a single administration of an agonist of 5-HT(1A) receptors, 8-OH-DPAT, (0.5 mg/kg i.p.), the level of LTP in slices prepared 2 days later was significantly decreased resembling the effect of COC. This effect of 8-OH-DPAT was antagonized by WAY 100635 (0.4 mg/kg i.p.), administered 20 min before 8-OH-DPAT and by RU 38486, given 1 h before 8-OH-DPAT. COC-induced inhibition of LTP could be blocked by the inhibitor of mitogen-activated protein kinase kinase 1/2 (MEK1/2), SL 327 (50 mg/kg i.p.), administered 1 h before COC, but not by the inhibitor of phosphatidylinositol 3-kinase (PI3-kinase), LY 294002 (80 mg/kg i.p.). COC-induced reduction in the number of polysialylated neural cell adhesion molecule (PSA-NCAM)-positive neurons in rat dentate gyrus could also be prevented by WAY 100635, given 20 min before COC. These data indicate that the indirect 5-HT(1A) receptor activation by a single COC administration and subsequent stimulation of extracellular signal-regulated kinases (ERK 1/2) signaling pathway result in a decrease of the potential for long-term increase in synaptic efficacy in rat DG lasting at least two but less than 7 days, most likely via activation of the hypothalamic-pituitary-adrenal (HPA) axis.

IV immunoglobulin is associated with a reduced risk of Alzheimer disease and related disorders

OBJECTIVE

To compare the incidence of Alzheimer disease and related disorders (ADRD) in patients treated with IV immunoglobulin (IVIg) for non-Alzheimer disease (AD) indications vs untreated controls.

METHODS

This retrospective case-control analysis used medical claims for patients > or =65 years old from a national database of 20 million age-qualified patients. Cases received > or =1 IVIg administration during April 1, 2001-August 31, 2004, had claims 1 year prior to first (index) IVIg administration to confirm absence of pre-index ADRD, and had > or =3 years of continuous claims post-index. Untreated controls had their first medical claim during April 1, 2000-August 31, 2004, and otherwise met the same requirements as cases. Controls were matched 100:1 to cases on age, gender, and risk factors for ADRD. The relative incidence of ADRD post-index for the IVIg-treated cases vs untreated controls was estimated using Kaplan-Meier survival curves and a Cox proportional hazards model.

RESULTS

Treated patients in the Kaplan-Meier analysis had lower ADRD incidence (p = 0.02) with an estimated 2.6% of the 847 IVIg-treated vs 4.6% of 84,700 controls diagnosed with ADRD at 60 months after index date. Treated patients in the Cox proportional hazard model had a 42% lower risk of being diagnosed with ADRD (hazard ratio, 0.577; 95% confidence interval, 0.359 to 0.930; p = 0.024) with an estimated 2.8% of treated vs 4.8% of controls diagnosed with ADRD at 60 months after index date.

CONCLUSIONS

Previous treatment with IV immunoglobulin was associated with a reduced risk of developing Alzheimer disease and related disorders (ADRD) in this study. Evidence from additional studies is needed to evaluate the relationship between IVIg exposure and ADRD diagnosis.

Imipramine counteracts corticosterone-induced alterations in the effects of the activation of 5-HT(7) receptors in rat hippocampus

Using extracellular recording we studied changes in the reactivity of rat hippocampal slices to an agonist of the 5-HT(7) receptor, 5-carboxamidotryptamine (5-CT; 0.025-1 microM), induced by an earlier treatment of animals with corticosterone. Spontaneous bursting activity was recorded in ex vivo slices incubated in the presence of 2-[4-(2-methoxyphenyl)-1piperazinyl]ethyl]-N-2-pyridinylcyclohexanecarboxamide (WAY 100635; 2 microM), an antagonist of the 5-HT(1A) receptor, in the medium devoid of Mg2+ ions. Saturation binding assays were performed using [(3)H]-(2R)-1-[(3-hydroxyphenyl)sulfonyl]-2-[2-(4-methyl-1-piperidinyl)ethyl]pyrrolidine hydrochloride (SB 269970), a specific antagonist of the 5-HT(7) receptor. Repetitive, but not single, corticosterone administration lasting 7 and 21 days, resulted in an enhancement of the effect related to the 5-HT(7) receptor activation without changes in its binding properties. In a separate set of experiments rats were treated with corticosterone for 3 weeks and additionally with imipramine, beginning on the eighth day of corticosterone administration. In the corticosterone plus imipramine group the excitatory effect of 5-CT was weaker than in the corticosterone group, indicating that corticosterone-induced functional modifications in the reactivity of the 5-HT(7) receptor were reversed and further weakened by imipramine treatment. This effect was accompanied by a reduction in the density of [3H]-SB 269970 binding sites. Thus, imipramine treatment counteracts the corticosterone-induced increase in the reactivity of the hippocampal circuitry to the activation of the 5-HT(7) receptor.

A retrospective study evaluating treatment patterns and outcomes in patients receiving trastuzumab for treatment of first-line and second-line metastatic breast cancer (mBC)

e12008

Background: Practice patterns for patients with MBC following 1st line therapy have often continued trastuzumab treatments while changing other chemotherapeutic agents in the regimen. We described treatment patterns, switching patterns and progression in mBC patients treated with a trastuzumab containing regimen for 1st and second line mBC. Methods: A retrospective, longitudinal, observational study of patients with mBC during 1/1/2003 up to 6/30/2008. The dataset comprised 304,654 cancer patients from 91practice sites across 23 states using Varian or Impac electronic medical records (EMRs). The start and end of a line of therapy was defined by a regimen change or a > 42 day gap in the regimen. In addition to the database analyses, a manual chart review was also conducted for 20% of the study sample to validate the source data and results. Patients were required to be observed for ≥ 9 months from index. Mean, median, standard deviation, and standard error for the duration in days by line and regimen was calculated as well as an overall weighted mean by line. Results: The study sample of 239 patients post-mBC was treated with the following regimens in the Table. Conclusion: Trastuzumab is most frequently given with taxanes in the first and second line settings. In the second line trastuzumab monotherapy, vinorelbine and gemcitabine were also frequently used. First line therapy may influence the selection of second line therapy. As EMRs often reflect care primarily at the practice site, prescribing of oral agents should be further researched.

[Table: see text]

[Table: see text]

Erythropoiesis stimulating agent (ESA) administration at Hb <10 g/dL for chemotherapy-induced anemia (CIA) following the National Coverage Decision (NCD)

e20627

Background: Medicare coverage of ESA treatment for CIA was changed in 7/07 to a hemoglobin (Hb) < 10 g/dL prior to administration. We describe the proportion of ESA administrations at Hb < 10 g/dL over four quarters following the NCD. Methods: A retrospective analysis of ESA administrations from 7/07 - 6/08 using Varian and Impac electronic medical records for 304,654 cancer patients from 91 practice sites across 19 states. Episodes of ESA treatment were identified within chemotherapy episodes. A > 42 day gap in ESA use identified a completed ESA episode and a > 90 day gap in chemotherapy identified a chemotherapy episode. Hb ≤ 7 days prior to ESA administration date was identified for each ESA episode. The percent of ESA administrations at Hb < 10 g/dL was measured from Q3 07 to Q2 08 for darbepoetin alfa (DA) and epoetin alfa (EA) stratified by age. Results: For patients age ≥ 65, the percent of ESAs administered at Hb < 10 g/dL increased from Q3 07 to Q2 08 for initial and maintenance administrations. A less pronounced trend was observed in patients age < 65. Maintenance administrations at Hb < 10 g/dL in patients age < 65 were significantly lower for EA vs. DA. Conclusions: ESA administrations have been increasingly administered at Hb < 10 g/dL. A higher proportion of Medicare-eligible patients received maintenance ESA administrations at Hb < 10 g/dL.

[Table: see text]

[Table: see text]

The addition of rituximab to front-line therapy with CHOP (R-CHOP) results in a higher response rate and longer time to treatment failure in patients with lymphoplasmacytic lymphoma: results of a randomized trial of the German Low-Grade Lymphoma Study Group (GLSG)

Lymphoplasmacytic lymphoma (LPL) is an indolent lymphoma with moderate sensitivity to conventional chemotherapy. This study investigated whether the addition of rituximab to standard chemotherapy improves treatment outcome in LPL and the subgroup of LPL patients fulfilling the criteria of Waldenstroem's macroglobulinemia (WM). A total of 69 patients with previously untreated LPL were enrolled into the trial; 64 patients were evaluable for treatment outcome. In all, 48 of the 64 LPL patients fulfilled the criteria of WM. Patients were randomly assigned to R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone, n=34) or CHOP (n=30). R-CHOP resulted in significantly higher overall response (OR) rate (94 vs 67%, P=0.0085) in the LPL patients and in the WM subgroup (91 vs 60%, P=0.0188). With a median observation time of 42 months, R-CHOP induced a significantly longer time to treatment failure (TTF) with a median of 63 months for R-CHOP vs 22 months in the CHOP arm in the LPL patients (P=0.0033) and in the WM subgroup (P=0.0241). There was no major difference of treatment-associated toxicity between both treatment groups. These data indicate that the addition of rituximab to front-line chemotherapy improves treatment outcome in patients with LPL or WM.

Peripheral administration of group III mGlu receptor agonist ACPT-I exerts potential antipsychotic effects in rodents

Several lines of evidence implicate dysfunction of glutamatergic neurotransmission in the pathophysiology of schizophrenia. Previous behavioral studies have indicated that metabotropic glutamate (mGlu) receptors may be useful targets for the treatment of psychosis. It has been shown that agonists and positive allosteric modulators of group II mGlu receptors produce potential antipsychotic effects in behavioral models of schizophrenia in rodents. Group III mGlu receptors seem to be also promising targets for a variety of neuropsychiatric and neurodegenerative disorders. However, despite encouraging data in animal models, most ligands of group III mGlu receptors still suffer from weak affinities, incapacity to cross the blood-brain barrier or absence of full pharmacological characterization. These limitations slow down the validation process of group III mGlu receptors as therapeutic targets. In this work, we choose to study an agonist of group III mGlu receptors (1S,3R,4S)-1-aminocyclo-pentane-1,3,4-tricarboxylic acid (ACPT-I) using intraperitoneal administration in three animal behavioral models predictive of psychosis or hallucinations. The results of the present study show that ACPT-I, given at doses of 10 or 30mg/kg, decreased MK-801-induced hyperlocomotion and at a dose of 100mg/kg decreased amphetamine-induced hyperlocomotion in rats. Furthermore, ACPT-I dose-dependently decreased DOI-induced head twitches in mice and suppresses DOI-induced frequency and amplitude of spontaneous EPSPs in slices from mouse brain frontal cortices. These data demonstrate that ACPT-I is a brain-penetrating compound and illustrates its promising therapeutic role for the treatment of schizophrenia.