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Lu HR, Damiano BP, Kreir M, Rohrbacher J, van der Linde H, Saidov T, Teisman A, Gallacher DJ. The Potential Mechanisms behind Loperamide-Induced Cardiac Arrhythmias Associated with Human Abuse and Extreme Overdose. Biomolecules 2023; 13:1355. [PMID: 37759755 PMCID: PMC10527387 DOI: 10.3390/biom13091355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/01/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023] Open
Abstract
Loperamide has been a safe and effective treatment for diarrhea for many years. However, many cases of cardiotoxicity with intentional abuse of loperamide ingestion have recently been reported. We evaluated loperamide in in vitro and in vivo cardiac safety models to understand the mechanisms for this cardiotoxicity. Loperamide slowed conduction (QRS-duration) starting at 0.3 µM [~1200-fold (×) its human Free Therapeutic Plasma Concentration; FTPC] and reduced the QT-interval and caused cardiac arrhythmias starting at 3 µM (~12,000× FTPC) in an isolated rabbit ventricular-wedge model. Loperamide also slowed conduction and elicited Type II/III A-V block in anesthetized guinea pigs at overdose exposures of 879× and 3802× FTPC. In ion-channel studies, loperamide inhibited hERG (IKr), INa, and ICa currents with IC50 values of 0.390 µM, 0.526 µM, and 4.091 µM, respectively (i.e., >1560× FTPC). Additionally, in silico trials in human ventricular action potential models based on these IC50s confirmed that loperamide has large safety margins at therapeutic exposures (≤600× FTPC) and confirmed repolarization abnormalities in the case of extreme doses of loperamide. The studies confirmed the large safety margin for the therapeutic use of loperamide but revealed that at the extreme exposure levels observed in human overdose, loperamide can cause a combination of conduction slowing and alterations in repolarization time, resulting in cardiac proarrhythmia. Loperamide's inhibition of the INa channel and hERG-mediated IKr are the most likely basis for this cardiac electrophysiological toxicity at overdose exposures. The cardiac toxic effects of loperamide at the overdoses could be aggravated by co-medication with other drug(s) causing ion channel inhibition.
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Affiliation(s)
- Hua Rong Lu
- Global Safety Pharmacology, Janssen Research and Development, Turnhoutseweg 30, 2340 Beerse, Belgium; (B.P.D.); (J.R.); (H.v.d.L.); (T.S.); (A.T.); (D.J.G.)
| | | | - Mohamed Kreir
- Global Safety Pharmacology, Janssen Research and Development, Turnhoutseweg 30, 2340 Beerse, Belgium; (B.P.D.); (J.R.); (H.v.d.L.); (T.S.); (A.T.); (D.J.G.)
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BARTAKOVA A, NOVAKOVA M, STRACINA T. Anesthetized guinea pig as a model for drug testing. Physiol Res 2022; 71:S211-S218. [PMID: 36647909 PMCID: PMC9906665 DOI: 10.33549/physiolres.934994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Based on the World Health Organization statistics, cardiovascular diseases represent the major cause of death worldwide. Although a wide range of treatment approaches and pharmaceuticals is available, the therapy is often not effective enough and therefore health risks for the patient persist. Thus, it is still essential to test new drug candidates for the treatment of various pathophysiological conditions related to cardiovascular system. In vivo models represent indispensable part of preclinical testing of such substances. Anesthetized guinea pig as a whole-body model allows to evaluate complex reactions of cardiovascular system to tested substance. Moreover, action potential of guinea pig cardiomyocyte is quite comparable to that of human. Hence, the results from this model are then quite well translatable to clinical medicine. Aim of this paper was to summarize the methodology of this model, including its advantages and/or limitations and risks, based on the effects of two substances with adrenergic activity on the ECG parameters. The model of anesthetized guinea pig proved to be valuable and suitable for testing of drugs with cardiovascular effects.
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Affiliation(s)
- Anna BARTAKOVA
- Department of Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Marie NOVAKOVA
- Department of Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tibor STRACINA
- Department of Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Izumi-Nakaseko H, Nakamura Y, Cao X, Wada T, Ando K, Sugiyama A. Assessment of Safety Margin of an Antipsychotic Drug Haloperidol for Torsade de Pointes Using the Chronic Atrioventricular Block Dogs. Cardiovasc Toxicol 2016; 17:319-325. [DOI: 10.1007/s12012-016-9388-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Morissette P, Regan HK, Fitzgerald K, Bernasconi S, Gerenser P, Travis J, Fanelli P, Sannajust F, Regan CP. QT interval correction assessment in the anesthetized guinea pig. J Pharmacol Toxicol Methods 2015; 75:52-61. [DOI: 10.1016/j.vascn.2015.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 04/10/2015] [Accepted: 05/13/2015] [Indexed: 01/08/2023]
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Stracina T, Slaninova I, Polanska H, Axmanova M, Olejnickova V, Konecny P, Masarik M, Krizanova O, Novakova M. Long-Term Haloperidol Treatment Prolongs QT Interval and Increases Expression of Sigma 1 and IP3 Receptors in Guinea Pig Hearts. TOHOKU J EXP MED 2015; 236:199-207. [PMID: 26094568 DOI: 10.1620/tjem.236.199] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2023]
Abstract
Haloperidol is a neuroleptic drug used for a medication of various psychoses and deliria. Its administration is frequently accompanied by cardiovascular side effects, expressed as QT interval prolongation and occurrence of even lethal arrhythmias. Despite these side effects, haloperidol is still prescribed in Europe in clinical practice. Haloperidol binds to sigma receptors that are coupled with inositol 1,4,5-trisphosphate (IP3) receptors. Sigma receptors are expressed in various tissues, including heart muscle, and they modulate potassium channels. Together with IP3 receptors, sigma receptors are also involved in calcium handling in various tissues. Therefore, the present work aimed to study the effects of long-term haloperidol administration on the cardiac function. Haloperidol (2 mg/kg once a day) or vehiculum was administered by intraperitoneal injection to guinea pigs for 21 consecutive days. We measured the responsiveness of the hearts isolated from the haloperidol-treated animals to additional application of haloperidol. Expression of the sigma 1 receptor and IP3 receptors was studied by real time-PCR and immunohistochemical analyses. Haloperidol treatment caused the significant decrease in the relative heart rate and the prolongation of QT interval of the isolated hearts from the haloperidol-treated animals, compared to the hearts isolated from control animals. The expression of sigma 1 and IP3 type 1 and type 2 receptors was increased in both atria of the haloperidol-treated animals but not in ventricles. The modulation of sigma 1 and IP3 receptors may lead to altered calcium handling in cardiomyocytes and thus contribute to changed sensitivity of cardiac cells to arrhythmias.
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Affiliation(s)
- Tibor Stracina
- Department of Physiology, Faculty of Medicine, Masaryk University
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LIU BAOXIN, LI SHUANG, SU YANG, XIONG MENGTING, XU YAWEI. Comparative study of the protective effects of terfenadine and amiodarone on barium chloride/aconitine-induced ventricular arrhythmias in rats: A potential role of terfenadine. Mol Med Rep 2014; 10:3217-26. [DOI: 10.3892/mmr.2014.2640] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Accepted: 07/22/2014] [Indexed: 11/06/2022] Open
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Holzgrefe H, Ferber G, Champeroux P, Gill M, Honda M, Greiter-Wilke A, Baird T, Meyer O, Saulnier M. Preclinical QT safety assessment: Cross-species comparisons and human translation from an industry consortium. J Pharmacol Toxicol Methods 2014; 69:61-101. [DOI: 10.1016/j.vascn.2013.05.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Revised: 05/08/2013] [Accepted: 05/09/2013] [Indexed: 01/10/2023]
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Morissette P, Nishida M, Trepakova E, Imredy J, Lagrutta A, Chaves A, Hoagland K, Hoe CML, Zrada MM, Travis JJ, Zingaro GJ, Gerenser P, Friedrichs G, Salata JJ. The anesthetized guinea pig: An effective early cardiovascular derisking and lead optimization model. J Pharmacol Toxicol Methods 2013; 68:137-49. [DOI: 10.1016/j.vascn.2013.04.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 04/19/2013] [Accepted: 04/27/2013] [Indexed: 10/26/2022]
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Marks L, Borland S, Philp K, Ewart L, Lainée P, Skinner M, Kirk S, Valentin JP. The role of the anaesthetised guinea-pig in the preclinical cardiac safety evaluation of drug candidate compounds. Toxicol Appl Pharmacol 2012; 263:171-83. [DOI: 10.1016/j.taap.2012.06.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 06/07/2012] [Accepted: 06/11/2012] [Indexed: 11/30/2022]
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Testai L, Cecchetti V, Sabatini S, Martelli A, Breschi MC, Calderone V. Effects of KATPopeners on the QT prolongation induced by HERG-blocking drugs in guinea-pigs. J Pharm Pharmacol 2010. [DOI: 10.1211/jpp.62.07.0014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Fialova K, Krizanova O, Jarkovsky J, Novakova M. Apparent desensitization of the effects of sigma receptor ligand haloperidol in isolated rat and guinea pig hearts after chronic treatment. Can J Physiol Pharmacol 2010; 87:1019-27. [PMID: 20029538 DOI: 10.1139/y09-066] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The supposed role of cardiac sigma receptors is fine tuning of contractility. Sigma receptors affect several ionic channels and hence their signaling is reflected by the electrophysiological properties of the heart. Numerous ligands of sigma receptors are known to prolong the QT interval and therefore cause a variety of arrhythmias, including severe ones. The effects of the prototypical sigma ligand haloperidol have been studied extensively in humans as well as in various animal models, primarily after acute administration. We examined the incidence of arrhythmias, changes in heart rate, and prolongation of QT interval in isolated Langendorff-perfused rat and guinea pig hearts after they were exposed to nanomolar concentrations of haloperidol. Hearts from both untreated (acute) and pretreated (chronic) animals were investigated. While QT prolongation and arrhythmias due to haloperidol administration were observed in untreated rat and guinea pig hearts, arrhythmias were completely prevented in both species of chronically treated animals. In treated guinea pigs, the results were generally less convincing. Since the hearts were exposed to nanomolar concentration of haloperidol, we conclude that our data may be explained by desensitization of sigma receptors.
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Affiliation(s)
- Katerina Fialova
- Department of Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Kettenhofen R, Bohlen H. Preclinical assessment of cardiac toxicity. Drug Discov Today 2008; 13:702-7. [PMID: 18602016 DOI: 10.1016/j.drudis.2008.06.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Revised: 06/02/2008] [Accepted: 06/04/2008] [Indexed: 10/21/2022]
Abstract
The exact prediction of the clinical behavior of drugs represents one of the most difficult duties in preclinical drug development. The use of cell-based assay systems underpins the development of many drug candidates, but owing to the artificial character of many of these systems, cell response and physiological behavior seem to be mutually exclusive. Embryonic stem cell-derived cells represent a system that may address the disconnect between the behavior of cultured cells and cells in situ. While undifferentiated ES cells allow standardization, expansion and genetic manipulation, the differentiated cells provide a reflection of the normal physiological image of their primary counterpart. We compare common models to detect cardiac toxicity with an assay system comprising in vitro differentiated pure cardiomyocytes.
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