Oral bioavailability and intravenous pharmacokinetics of amrinone in humans

Fourteen healthy males received two 75-mg doses of amrinone as a single capsule and as an intravenous solution in a single-dose crossover study. The mean (+/-SD) bioavailability, based on the area under the plasma concentration versus time curves, was 0.93 +/- 0.12. The plasma data for these subjects during the intravenous phase was described by an open two-compartment body model with a mean (+/-SD) apparent first-order terminal elimination rate constant, beta, of 0.19 +/- 0.06 hr-1, which corresponds to a half-life of 3.6 hr.

Side effects of amrinone therapy

We gave intravenous amrinone to 40 patients in heart failure, and oral amrinone to 18 patients. Acute intravenous administration caused a significant reduction in mean blood pressure and this was severe enough to require correction by plasma infusion in five patients. Oral amrinone was accompanied by thrombocytopenia in 10 patients but no complications were associated with the low platelet count. Other potentially serious adverse effects were: abdominal pain (two patients), nausea and vomiting (three patients), jaundice (one patient), myositis (one patient), pulmonary infiltrates (two patients), and polyserositis (one patient). Less serious adverse effects observed were: splenomegaly, eosinophilia, fever, headache, reduced tear secretion, dry skin, and nail discoloration. The potentially severe adverse reactions with amrinone need to be weighed carefully against its benefits in the treatment of heart failure.

Acute pharmacodynamics and pharmacokinetics of oral amrinone

Amrinone was administered orally as a single 100-mg dose to six male patients with moderate-severe congestive heart failure to determine the acute pharmacodynamic effects and pharmacokinetics of the drug. Following right heart catherization and amrinone administration, measurements of hemodynamic parameters including cardiac index (Cl), right atrial pressure (RA), pulmonary capillary wedge pressure (PCW), and serum amrinone concentrations (SAC) were made at hourly intervals for up to 8 hours. Cl increased (29.0 per cent) significantly (P less than 0.05) at 3 hours after dose. PCW declined quickly after dose and was significantly (P less than 0.05) lower (-31.3 per cent) than control at 3 hours. RA declined gradually, and a significant (P less than 0.05) reduction (-25.2 per cent) was achieved 5 hours after the dose. Amrinone was absorbed quickly (tmax = 1.4 hour), and the disappearance of amrinone from serum was log-linear (t1/2 = 5.1 hours). The time courses of per cent change in Cl and SAC were similar, and the correlation between the average per cent change in Cl and average SAC was linear and significant (r = 0.80; P less than 0.05).

Clinical experience with amrinone in patients with advanced congestive heart failure

To examine the efficacy of chronic amrinone therapy, the drug was administered to 12 patients with advanced congestive heart failure on average for 27.9 days. The majority of patients had a persistent increase in cardiac index and a persistent decrease in systemic vascular resistance. A decrease in pulmonary arterial diastolic pressure was observed after oral amrinone administration in three patients. However, changes in pulmonary arterial pressure were not consistent in response to intravenous administration of the drug. Thrombocytopenia occurred in four patients, hypogeusia was noted by three patients, and dysosmia developed in two patients. The cumulative survival of the amrinone patients was significantly poorer than that of a second group of patients with congestive heart failure having similar symptoms. These findings indicate that there is a subset of patients with congestive heart failure who do not benefit from chronic amrinone administration and that in such patients its use (especially when given concomitantly with potentially toxic and hypotensive drugs) should be extremely guarded.

Metabolism of amrinone in animals

The biotransformation of 14C-amrinone was studied in rats, dogs, and monkeys by automated gradient high-performance liquid chromatography. The major pathways of metabolism elucidated are: A) glucuronidation at the primary amino nitrogen atom and/or the enolized oxygen atom of the pyridone ring; B) addition of glutathione at the pyridone 2-position and ultimate hydrolysis of this compound to the 2-S-cysteinyl metabolite; C) formation of the primary amino N-acetyl derivative and subsequent oxidation of this to the corresponding N-glycolate. In each species studied, urine was the primary route of elimination and unchanged amrinone was the major urinary excretion product, the other known pathways being: rat, A and C; dog, A and B; monkey, A.

Long-term amrinone therapy in patients with severe heart failure: drug-dependent hemodynamic benefits despite progression of disease

Six patients with severe congestive heart failure refractory to conventional therapy, including vasodilators, were treated with oral amrinone for a mean duration of 41 weeks (range 20 to 72 weeks). At initiation of therapy, the cardiac index increased from 1.74 +/- 0.31 to 2.62 +/- 0.52 (mean +/- SD) liters/min/m2 (p less than 0.01) and pulmonary capillary wedge pressure decreased from 26.5 +/- 3.5 to 19.5 +/- 5.4 mm Hg (p less than 0.05). Symptoms were alleviated and exercise capacity increased from 5.9 +/- 2.9 to 11.5 +/- 4.5 minutes (p less than 0.05). During long-term therapy, exercise capacity remained constants in three patients whereas it decreased in three others. All patients demonstrated an increase in heart size. Withdrawal of amrinone therapy precipitated severe symptoms at rest and hemodynamic deterioration in all patients. The cardiac index decreased from 1.87 +/- 0.49 to 1.32 +/- 0.30 liter/min/m2 (p less than 0.05) and pulmonary capillary wedge pressure rose from 20.6 +/- 2.9 to 28.8 +/- 5.6 mm Hg (p less than 0.05). These changes were reversed by reinstitution of therapy. Thus, amrinone-dependent hemodynamic benefits were demonstrated during long-term therapy without tachyphylaxis. In addition, progression of the underlying cardiac disease was observed in every patient.

Amrinone--a new inotropic agent in chronic resistant congestive cardiac failure

A patient with severe cardiac failure due to idiopathic congestive cardiomyopathy resistant to conventional therapy, responded to amrinone, a new non-glycosidic non-catecholamine positive inotropic agent. Amrinone produced significant haemodynamic improvement during both intravenous and oral administration. Thrombocytopaenia, however, was induced, necessitating cessation of the drug. Amrinone is a promising, orally effective inotropic agent for patients with refractory congestive cardiac failure, but is limited to its tendency to cause thrombocytopaenia.

Behavioral and cardiorespiratory responses to 4-aminopyridine in healthy awake horses

4-Aminopyridine was administered in incremental IV doses to healthy horses to evaluate cardiorespiratory and behavioral effects. Doses of 100 micrograms/kg produced apparent sensory discomfort, manifested by wiggling or curling of the lips and tongue, arching or stretching the neck, snorting, squealing, and coughing. At cumulative dosages of 300 to 500 micrograms/kg, muscle tremors, a stilted gait, and signs of excitement occurred. Once signs of excitement occurred, additional administration of 4-aminopyridine resulted in prolonged excitement consisting of severe muscle tremors and exaggerated responses to external stimuli. Heavy sedation with xylazine provided nearly complete relief from these effects. 4-Aminopyridine could be a useful adjunct to treatment of botulism in horses; however, administration of doses in excess of 300 to 500 micrograms/kg may cause severe CNS excitatory effects.

Hemodynamic comparison of intravenous amrinone and dobutamine in patients with chronic congestive heart failure

Amrinone, a new inotropic agent, has been shown to be beneficial in patients with congestive heart failure. However, its hemodynamic effects have not been compared with those those of currently useful catecholamines. In this study, the effects of intravenously administered dobutamine and amrinone were compared in eight patients with severe chronic congestive heart failure. Dobutamine was infused with a maximal increase in cardiac index was reached for undesirable effects were produced. This dose was then continued for 8 hours. After a return of hemodynamic values to baseline level, amrinone was infused at a rate of 40 microgram/kg per min for 1 hour and then 10 microgram/kg per min for 24 hours. Both drugs significantly improved cardiac index while simultaneously decreasing systemic vascular resistance and right atrial and pulmonary wedge pressures (p less than 0.05). Initially no differences could be found between the drugs. However, with prolonged infusion amrinone produced a sustained improvement whereas dobutamine had a decreased effectiveness. Thus, amrinone is comparable in effect with the optimal dose of dobutamine and would appear to be an extremely promising drug in the acute treatment of severe congestive heart failure.

[Pymadine, a new type of non-depolarizing muscle-relaxant antagonist]

The paper presents the author's experience in post-anesthetic decurarization with a new antagonist of competitive curare. Presented for the first time in 1970, 4-amino-pyridine was found o tbe a substance with a different mode of action than that of reversible inhibitors of cholinesterase, without parasympaticomimetic effects, and without untoward effects on the cardio-circulatory function. It also has a central analeptic effect. This is why the authors consider the new drug as a powerful means for reversing the competitive neuromuscular blockage.

Treatment with oral 4-aminopyridine in disorders of neuromuscular transmission

Four patients with Eaton-Lambert syndrome, four patients with congenital myasthenia, and one patient with myasthenia gravis were treated with oral 4-aminopyridine for periods of up to 10 months, doses varying from 40 to 200 mg per day. Clinical and electrophysiologic assessment confirmed the effectiveness of the drug when given alone or in conjunction with anticholinesterases. At therapeutically effective doses, central side effects were frequent and unpredictable. Three patients had a generalized fit and one patient developed a confusional state. Adverse side effects must severely limit the place of 4-aminopyridine in the treatment of patients with these conditions.

Oral amrinone in refractory congestive heart failure

The acute effects of an oral preparation of amrinone, a recently synthesized cardiotonic agent, were assessed noninvasively in nine patients who had advanced heart failure that persisted despite treatment with digitalis, diuretic drugs and afterload-reducing agents. All patients demonstrated an improvement in left ventricular ejection fraction determined by radionuclide ventriculography (20.3 +/- 2.8 to 30.8 +/- 4.8 percent [mean +/- standard error of the mean], p less than 0.005) after a single dose of amrinone. Initial effects were seen within 1 hour, with the peak effect occurring at 1 to 3 hours; persistent effects were demonstrable at 4 to 6 hours. No change in blood pressure, heart rate or rhythm was observed, and there was no clinical evidence of myocardial ischemia. Continued benefit was demonstrated by radionuclide ventriculography in two patients treated for 1 and 6 weeks, respectively, although two other patients experienced major side effects with the chronic administration of amrinone. Although orally administered amrinone shows promise as a potentially useful agent in the treatment of advanced heart failure, the safety of this drug remains to be established.

Facilitatory effects of 4-aminopyridine on normal neuromuscular transmission

The effects of 4-aminopyridine (4-AP) on neuromuscular transmission were studied in vitro in the rat flexor digitorum longus muscles. 4-AP produced dose-dependent increases in endplate potential (EPP) amplitude, in rise time to peak, and in the average number of acetylcholine quanta released by presynaptic nerve impulses. The neuromuscular blocking effects of d-tubocurarine or low Ca2+/high Mg2+ concentrations could be completely reversed by 4-AP, and EPPs developed into muscle action potentials (APs). The drug had minimal effects on the amplitude or frequency of spontaneous miniature endplate potentials, but increased the duration of indirectly elicited muscle APs. The action of 4-AP required the presence of extracellular Ca2+; thus, its effect may be to promote Ca2+ entry into the motor nerve terminal, and thereby increase the neurally evoked transmitter release. 4-AP is effective in overcoming both presynaptic and postsynaptic blockade of neuromuscular transmission, suggesting a potential role for this drug in the treatment of neuromuscular diseases.

Convulsive effects of 3-aminopyridine on cortical neurones

The authors examined the effects of 3-aminopyridine (3-AP) on pyramidal tract neurones in the motor cortex of anesthetised cats. 3-AP proved to be a strong convulsive agent. Local application of 3-AP in concentrations of 15-20 mM resulted in typical paroxysmal alterations of neuronal activity: (a) enhancement of background firing, (b) augmentation of EPSPs, (c) depression of IPSPs and (d) single and serial paroxysmal depolarization shifts (PDSs). Serial PDSs were reflected by large synchronous waves in the surface ECoG.

[Hemodynamic effects of various doses of a new inotropic: amrinoma]

The hemodinamic effects of Amrinone, bipiridine derivate with positive inotropic effects in animals, were studied on eight patients under right and left heart catheterization. The cardiac index, stroke volume, dP/dt and stroke work index were increased; the pulmonary pressure and the left ventricle end diastolic pressure were decreased all with statistical significant values. There were no changes in mean aortic pressure. These effects are mainly due to an increase in contractility and, partially, to vasodilation and tachycardia. The intrinsic mechanism of action of this compound is not known. Its place in cardiac therapy must be established with additional clinical investigations.

4-Aminopyridine potentiates neostigmine and pyridostigmine in man

To elucidate the interaction of 4-aminopyridine with neostigmine and pyridostigmine, the authors studied 57 anesthetized surgical patients using a technique of constant infusion of pancuronium to quantitate antagonist activity. 4-Aminopyridine, 0.15 or 0.35 mg/kg, produced no antagonism, while 0.5 mg/kg produced a mean 24 +/- 6 per cent (peak) antagonism. The dose that produced 50 per cent antagonism (ED50) of neostigmine alone was 22 micrograms/kg; with 0.35 mg/kg 4-aminopyridine, it was 7 micrograms/kg. The ED50 of pyridostigmine alone was 110 micrograms/kg; with 0.35 mg/kg 4-aminopyridine, it was 27 micrograms/kg. 4-Aminopyridine prolonged the onset times of both neostigmine and pyridostigmine, but prolonged the duration of action of neostigmine only. At a given level of antagonism of pancuronium, adding 4-aminopyridine 0.35 mg/kg, to neostigmine and to pyridostigmine decreased the amounts of atropine needed to prevent a change in heart rate by 68 and 70 per cent, respectively. The authors conclude that 4-aminopyridine potentiates antagonism of a pancuronium-induced neuromuscular blockade by neostigmine or pyridostigmine. Also, less atropine is needed to prevent cardiac muscarinic stimulation when 4-aminopyridine is used with either neostigmine or pyridostigmine.

Antagonism of polymyxin B-induced neuromuscular and cardiovascular depression by 4-aminopyridine in the anesthetized cat

In an attempt to find a better antidote to polymyxin B-induced neuromuscular blockade, the authors tested 4-aminopyridine, 0.4--1 mg/kg, in ten anesthetized cats. The sciatic--tibialis anterior nerve--muscle preparation was used. The neuromuscular blockade was successfully reversed in all cats. Rapidity of reversal depended on the dose of 4-aminopyridine administered. At 0.6--1 mg/kg, reversal of the twitch response from 20 per cent of control to 80 per cent of control required 2.4 (SE, 0.5) min; to 100 per cent, 14.4 (SE, 3.7) min. An overshoot of the recovery of neuromuscular blockade of 6--10 hours' duration followed the reversal. The mechanical twitch response reached a peak of approximately 140 per cent of control at 2 hours. At a lower dosage, 0.4 mg/kg, two of three cats took more than an hour for complete recovery of the twitch response, and the overshoot was approximately 10 per cent of control. The hypotensive effect of polymyxin B was partially reversed, but the bradycardia was not. It is concluded that 4-aminopyridine is an effective antidote to polymyxin B-induced neuromuscular blockade in the cat.