Ototoxicity: Of Mice and Men

Self-Protection against Aminoglycoside Ototoxicity in Guinea Pigs

BACKGROUND: Amikacin is a semisynthetic aminoglycoside. It acts against most of the microbial species. Amikacin limitation of the therapeutic application is the ototoxicity which promotes permanent lesions in the cochlear system. Aminoglycoside antibiotics have ototoxic potential. The target cells are preferentially the outer hair cells in the cochlear basal turns. Amynoglicoside antibiotics can quelate iron forming a complex with oxidate properties and promotes the formation of free radicals. Responsible for production of lesions in the hair cells.

OBJECTIVE: The objective of the present investigation was to determine whether the use of the aminoglycoside amikacin at small doses may lead to the occurrence of some types of resistance to or protection against ototoxicity of the drug by analyzing lesions to the organ of Corti by scanning electron microscopy.

METHODS: The study was conducted on 31 guinea pigs that were divided into 4 groups, amikacin was administered intramuscularly. The groups consisted of: group A = control group: 5 animals (10 cochleae); group B = 5 animals (10 cochleae), amikacin 20 mg/kg/day for 30 days; group c = 7 animals (13 cochleae), amikacin 400 mg/kg/day for 12 days; group d = 14 animals (26 cochleae) amikacin 20 mg/kg/day for 30 days, followed by 400 mg/kg/day for 12 days. Histological studies were performed by scanning electron microscopy. Three cochleae were excluded.

RESULTS: In groups A and B, the cells were normal in all cochleae, in group C there were extensive lesions of the 2 more basal turns, and in group D there was a significant reduction of lesions in the 2 more basal turns compared with group C, which had received the ototoxic dose of amikacin alone.

CONCLUSION: We conclude that the non-ototoxic dose of amikacin administered before the ototoxic dose of the same antibiotic had a statistically significant protective effect on the 2 more basal turns of the guinea pig cochlea.

Dissociation of antibacterial activity and aminoglycoside ototoxicity in the 4-monosubstituted 2-deoxystreptamine apramycin

Aminoglycosides are potent antibacterials, but therapy is compromised by substantial toxicity causing, in particular, irreversible hearing loss. Aminoglycoside ototoxicity occurs both in a sporadic dose-dependent and in a genetically predisposed fashion. We recently have developed a mechanistic concept that postulates a key role for the mitochondrial ribosome (mitoribosome) in aminoglycoside ototoxicity. We now report on the surprising finding that apramycin, a structurally unique aminoglycoside licensed for veterinary use, shows little activity toward eukaryotic ribosomes, including hybrid ribosomes which were genetically engineered to carry the mitoribosomal aminoglycoside-susceptibility A1555G allele. In ex vivo cultures of cochlear explants and in the in vivo guinea pig model of chronic ototoxicity, apramycin causes only little hair cell damage and hearing loss but it is a potent antibacterial with good activity against a range of clinical pathogens, including multidrug-resistant Mycobacterium tuberculosis. These data provide proof of concept that antibacterial activity can be dissected from aminoglycoside ototoxicity. Together with 3D structures of apramycin-ribosome complexes at 3.5-Å resolution, our results provide a conceptual framework for further development of less toxic aminoglycosides by hypothesis-driven chemical synthesis.

In vitro and in vivo models of drug ototoxicity: studying the mechanisms of a clinical problem

INTRODUCTION

Drug ototoxicity represents one of the main preventable causes of deafness. Ototoxicity is a trait shared by aminoglycoside and macrolide antibiotics, antimalarial medications, loop diuretics, platinum-based chemotherapeutic agents, some NSAIDs and most recently described, acetaminophen when abused with narcotic medication. These medications are prescribed despite their side effects, which includes inner ear toxicity, because they are life-saving drugs or there is a lack of better treatment.

AREAS COVERED

This review will discuss in vitro and in vivo models of ototoxicity highlighting recently published ototoxicity research. The reader will learn the strengths and limitations of different ototoxicity models and what molecular insights have been gained from their application. A better understanding of the cellular mechanisms of these ototoxins will help in the discovery of ways to prevent and treat hearing loss associated with ototoxic medications.

EXPERT OPINION

There are benefits to both in vitro and in vivo models of ototoxicity. Research of a particular medication and its ototoxic mechanisms should draw from several models, enabling a better answer to the clinical question of prevention and treatment of inner ear drug toxicity.

Understanding drug ototoxicity: molecular insights for prevention and clinical management

Ototoxicity is a trait shared by aminoglycoside and macrolide antibiotics, loop diuretics, platinum-based chemotherapeutic agents, some NSAIDs and antimalarial medications. Because their benefits in combating certain life-threatening diseases often outweigh the risks, the use of these ototoxic drugs cannot simply be avoided. In this review, the authors discuss some of the most frequently used ototoxic drugs and what is currently known about the cell and molecular mechanisms underlying their noxious effects. The authors also provide suggestions for the clinical management of ototoxic medications, including ototoxic detection and drug monitoring. Understanding the mechanisms of drug ototoxicity may lead to new strategies for preventing and curing drug-induced hearing loss, as well as developing new pharmacological drugs with less toxic side effects.

The aminoglycoside antibiotic dihydrostreptomycin rapidly enters mouse outer hair cells through the mechano-electrical transducer channels

The most serious side-effect of the widely used aminoglycoside antibiotics is irreversible intracellular damage to the auditory and vestibular hair cells of the inner ear. The mechanism of entry into the hair cells has not been unequivocally resolved. Here we report that extracellular dihydrostreptomycin not only blocks the mechano-electrical transducer channels of mouse outer hair cells at negative membrane potentials, as previously shown, but also enters the cells through these channels, which are located in the cells' mechanosensory hair bundles. The voltage-dependent blocking kinetics indicate an open-channel block mechanism, which can be well described by a two barrier-one binding site model, quantifying the antibiotic's block of the channel as well as its permeation in terms of the associated rate constants. The results identify the open transducer channels as the main route for aminoglycoside entry. Intracellularly applied dihydrostreptomycin also blocks the transducer channels, but at positive membrane potentials. However, the potency of the block was two orders of magnitude lower than that due to extracellular dihydrostreptomycin. Extracellular Ca2+ increases the free energy of the barrier nearest the extracellular side and of the binding site for dihydrostreptomycin. This reduces both the entry of dihydrostreptomycin into the channel and the channel's affinity for the drug. In vivo, where the extracellular Ca2+ concentration in the endolymph surrounding the hair bundles is < 100 microM, we predict that some 9000 dihydrostreptomycin molecules per second enter each hair cell at therapeutic drug concentrations.

Otoproteção das células ciliadas auditivas contra a ototoxicidade da amicacina

Objetivo: Este estudo teve por objetivo verificar a ocorrência de otoproteção contra a ototoxicidade da amicacina em cobaias. Forma de estudo: experimental. Material e método: Foram estudadas as células ciliadas externas do órgão de Corti de 31 animais por meio de microscopia eletrônica de varredura (JEOL-JMS 5200). Foram estudados 4 grupos: A, controle; B, amicacina 20 mg/kg/dia por 30 dias; C, amicacina 400 mg/Kg/ dia 12 dias; grupo D, amicacina 20 mg/kg/dia por 30 dias seguido de 400 mg/kg/dia por 12 dias. Resultados: Nos grupos A e B, as células estavam normais em todas as cócleas; no grupo C houve lesões extensas nas duas espiras mais basais; no grupo D houve redução significante das lesões nas duas mais basais em comparação com o grupo C que recebeu a dose ototóxica de amicacina isoladamente. Conclusão: Conclui-se que a dose não ototóxica de amicacina administrada previamente à dose ototóxica do mesmo antibiótico tem efeito protetor, estatisticamente significante, nas duas espiras mais basais das cócleas de cobaias.

Salicylate protects hearing and kidney function from cisplatin toxicity without compromising its oncolytic action

Salicylate has recently been demonstrated to protect against the auditory and vestibular side effects of aminoglycoside antibiotics. Similarities in the toxic mechanisms suggest salicylate as a treatment strategy to prevent the ototoxic side effects of cisplatin (CDDP). We first tested protection of the inner ear in Wistar rats receiving a single infusion of 16 mg CDDP/kg body weight with or without treatment with 100 mg/kg salicylate (bid) for 5 days beginning one day before the CDDP infusion. Cisplatin induced a threshold shift of more than 30 dB (at 14 kHz; measured by auditory evoked brain stem response) that was significantly reduced by salicylate. We then examined the protective potential of salicylate on the cochlea, peripheral nerves, and kidney in a rat model of breast cancer--Fisher344 rats implanted with highly metastatic MTLn3 breast cancer cells. Animals received 3 x 5 mg CDDP/kg (given every third day), and salicylate was administered at 100 mg/kg (bid) from 2 days before to 3 days after CDDP treatment. Salicylate significantly attenuated the CDDP-induced threshold shift from approximately 20 dB (at 16 and 24 kHz) to approximately 5 dB, and drastically reduced the loss of cochlear outer hair cells. Likewise, salicylate protected kidney function (measured as plasma blood urea nitrogen and creatinine levels) from CDDP toxicity. Protection of nerve conduction velocities of both sensory and motor nerves was minimal. The chemotherapeutic efficacy of CDDP on suppression of tumor mass and cancer cell metastasis remained unaffected by salicylate. The results suggest that administration of salicylate may become the basis of an effective therapeutic intervention against the ototoxic and nephrotoxic side effects associated with CDDP chemotherapy.

Temporal, spatial, and morphologic features of hair cell regeneration in the avian basilar papilla

Hair cell-selective antibodies were used in combination with the nucleotide bromode-oxyuridine (BrdU) to examine the temporal, spatial, and morphologic progression of auditory hair cell regeneration in chicks after a single gentamicin injection. New hair cells are first identifiable with an antibody to class III beta (beta) tubulin (TuJ1) by 14 hours after BrdU incorporation, but progenitor cells in S phase and M phase are TuJ1-negative. TuJ1 labeling reveals that new hair cells are first detected at 3 days after gentamicin, in the base, and the emergence and maturation of regenerating hair cells spreads apically over time. Differentiation of regenerating hair cells consists of a progressive series of morphologic changes. During early differentiation (14 hours to 1 day after BrdU), regenerating hair cells are round or fusiform and remain near the lumen, where they are generated. During intermediate differentiation (2-4 days after BrdU), regenerating hair cells resemble support cells; their somata are elongated, their nuclei are in the support cell layer, and they appear to contact both the lumenal surface and the basal lamina. The 275-kDa hair cell antigen is first expressed in regenerating hair cells during this period. During late differentiation (7 days after BrdU and later), TuJ1-positive cells acquire the globose shape of mature hair cells. Labeling with antibodies to hair cell antigen, calmodulin, and ribosomal RNA confirms this morphologic progression. Examination of sister cells born at 3 days post-gentamicin reveals that there is equal likelihood that they will assume the hair cell or support cell fate (i.e., both asymmetric and symmetric differentiation occur).

Effects of salicylates on evoked otoacoustic emissions and remote masking in humans

The aim of this study was to evaluate, in young volunteer subjects, the effects of salicylates on evoked otoacoustic emissions (EOAEs), which presumably reflect an active mechanical process in the cochlea due to outer hair cell (OHC) activity, and on remote masking (RM), which has been proposed as a useful tool in the study of the non-linear cochlear distortion products generated by high-frequency maskers. Data from the present research are consistent with the literature showing a reversible effect of salicylate leading to elevated hearing thresholds and reduced EOAE amplitudes. From the point of view of new findings, the results demonstrate a reversible effect of salicylates on RM magnitude, which decreases as serum salicylate concentration increases. As described previously by other authors, salicylate selectivity inhibits OHC motility and, in consequence, reduces the amplitude of the motion of the basilar membrane. According to these data it is very likely that the observed reduction in RM magnitude after salicylate administration is also the result of the decreased ability of the OHCs to contract and of the reduced basilar membrane motion. The results are consistent with the conclusion that the OHC system function plays a role in producing RM.

Iron chelators protect from aminoglycoside-induced cochleo- and vestibulo-toxicity

The attenuation of gentamicin-induced hearing loss by iron chelators and radical scavengers has recently been demonstrated in guinea pig in vivo. The present study investigated whether this protective treatment is effective against hearing loss and vestibular damage caused by other aminoglycosides. In a direct comparison, dihydroxybenzoate was chosen over deferoxamine because of its more effective action against gentamicin-induced hearing loss. Guinea pigs received daily injections of kanamycin (250 mg/kg/d) or streptomycin (300 mg/kg/d) for 23 d to induce severe cochlear or vestibular toxicity, respectively. Kanamycin injections resulted in a progressive threshold shift of 60 to 80 dB at 18 kHz, while streptomycin injections induced only a small threshold shift. In contrast, streptomycin abolished almost all vestibular responses. Coinjection of aminoglycosides with a mixture of dihydroxybenzoate (100 mg/kg/d) and mannitol (30 mg/kg/d) significantly attenuated kanamycin-induced hearing loss and protected against streptomycin-induced vestibulotoxicity. DHB/mannitol did not affect serum levels or the antibacterial efficacy of either aminoglycoside. This study supports the idea that iron and free radicals play a critical role in the toxic side effects of aminoglycoside antibiotics. Furthermore, the previously proposed therapeutic protection is not limited to gentamicin but applicable to other aminoglycosides as well.

Aminoglycoside ototoxicity: prevention in sight?

Despite the development of new antibiotics, the aminoglycosides are still indispensable in the treatment of life-threatening diseases. Worldwide they are the most commonly used antibiotics, and their use is expected to increase in the wake of the rising incidence of tuberculosis. The most prominent side effects of aminoglycoside treatment--cochlear, vestibular, and renal impairment--are a limiting factor in the utility of these drugs. A novel mechanism of gentamicin ototoxicity is based on observations of iron chelation and free radical formation. Predictions from this mechanism have led to successful therapeutic prevention of ototoxicity by use of iron chelators and radical scavengers in guinea pigs. The drugs used for this interventive treatment affect neither serum levels of gentamicin nor its antibacterial efficacy. Because these drugs are in clinical use, the suggested protective treatment should lend itself to clinical trials.