Elevation of serum lipid peroxide level associated with doxorubicin toxicity and its amelioration by [dl]-alpha-tocopheryl acetate or coenzyme Q10 in mouse (doxorubicin, toxicity, lipid peroxide, tocopherol, coenzyme Q10)

Toxic Mechanisms of the Heart: A Review*

Toxic injury is one of the many ways by which the functional integrity of the heart may become compromised. Any of the subcellular elements may be the target of toxic injury, including all of the various membranes and organelles. Understanding the mechanisms underlying cardiotoxicity may lead to treatment of the toxicity or to its prevention. Doxorubicin and its analogs are very important cancer chemotherapeutic agents that can cause cardiotoxicity. Other agents which are cardiotoxic and which have profound public health implications include the alkaloid emetine in ipecac syrup, cocaine, and ethyl alcohol. The most important cardiotoxic mechanisms proposed for doxorubicin include oxidative stress with its resultant damage to myocardial elements, changes in calcium homeostasis, decreased ability to produce ATP, and systemic release of cardiotoxic humoral mediators from tissue mast cells. Each of the first 3 mechanisms can lead to each of the other 2, and the causal relationships between all of these mechanisms are not clear. New evidence suggests that doxorubicinol, one of the metabolites of doxorubicin may be the moiety responsible for cardiotoxicity. Several other potential mechanisms also have been proposed for doxorubicin. Emetine in ipecac syrup is the first aid treatment of choice for many acute toxic oral ingestions and the alkaloid, itself, is used to treat amebiasis. Cardiotoxicity occurs following chronic exposure, such as occurs therapeutically in amebiasis and with ipecac abuse by bulemics. A number of mechanisms are proposed for emetine cardiotoxicity, but the current mechanistic literature is quite scarce. Cocaine abuse recently has caught the public interest, in particular because of the drug-related sudden deaths of certain athletes. Cocaine can cause hypertension, arrhythmias, and reduced coronary blood flow, each of which can contribute to its lethality. However, it may be possible that cocaine sudden death episodes are more related to hyperthermia and convulsive seizures, rather than to cardiovascular toxicity. Chronic alcohol use leads to dilated cardiomyopathy and failure as part of the general physical degeneration that occurs with alcoholism. Several mechanisms are proposed for the cardiomyopathy, but only 2 things seem clear. The cardiotoxicity is due to an intrinsic effect of alcohol, rather than to malnutrition or co-toxicity, and abstinence is the only effective treatment for the cardiomyopathy. Recent articles indicate that very moderate use of alcohol may be beneficial and protect against cardiovascular-related morbidity. One explanation for these findings seems to be that the non-drinking groups, against whom the moderate drinking comparisons were made, were enriched in former drinkers with significant alcohol-related cardiovascular pathology.

Coenzyme Q10 for Prevention of Anthracycline-Induced Cardiotoxicity

Preclinical and clinical studies suggest that anthracycline-induced cardiotoxicity can be prevented by administering coenzyme Q10 during cancer chemotherapy that includes drugs such as doxorubicin and daunorubicin. Studies further suggest that coenzyme Q10 does not interfere with the antineoplastic action of anthracyclines and might even enhance their anticancer effects. Preventing cardiotoxicity might allow for escalation of the anthracycline dose, which would further enhance the anticancer effects. Based on clinical investigation, although limited, a cumulative dose of doxorubicin of up to 900 mg/m2, and possibly higher, can be administered safely during chemotherapy as long as coenzyme Q10 is administered concurrently. The etiology of the dose-limiting cardiomyopathy that is induced by anthracyclines can be explained by irreversible damage to heart cell mitochondria, which differ from mitochondria of other cells in that they possess a unique enzyme on the inner mitochondrial membrane. This enzyme reduces anthracyclines to their semiquinones, resulting in severe oxidative stress, disruption of mitochondrial energetics, and irreversible damage to mitochondrial DNA. Damage to mitochondrial DNA blocks the regenerative capability of the organelle and ultimately leads to apoptosis or necrosis of myocytes. Coenzyme Q10, an essential component of the electron transport system and a potent intracellular antioxidant, appears to prevent damage to the mitochondria of the heart, thus preventing the development of anthracycline-induced cardiomyopathy.

The restoration of kidney mitochondria function by inhibition of angiotensin-II production in rats with acute adriamycin-induced nephrotoxicity

Adriamycin (ADR) is commonly used for many solid tumor treatments. Its clinical utility is, however, largely limited by the adverse reactions, are known to be nephrotoxic. The mechanism by which it induces kidney damage is still not completely understood, but its nephrotoxicity might relate to increase reactive oxidant status (ROS), mitochondrial dysfunction. Until now, neurohormonal activation of it is unclear. ADR might activate the renin angiotensin system. Angiotensin-II also induced ROS and mitochondrial dysfunction. The aim of this study was to investigate whether angiotensin-II production inhibition has the protective effect on attenuation of mitochondrial function in rats with acute ADR-nephrotoxicity or not. Rats were divided into five groups as a control, ADR, co-treated ADR with captopril (CAP), co-treated ADR with Aliskren, co-treated ADR with both CAP and Aliskren groups. Creatinine kinase (CK) levels were measured at the end of treatment period. The kidneys were homogenized and biochemical measurements were made in mitochondria, cytosol. Mitochondria membrane potential (MMP) and ATP levels were determined. ADR increased CK levels and oxidative stress in mitochondria too (p<0.05). ADR significantly decreased MMP and ATP level in kidney mitochondria (p<0.05). Co-administration with ADR and Aliskren and CAP improved the dissipation of MMP (p<0.05). The decrease in ATP level was restored by treatment with inhibitors of ACE and renin. We concluded that inhibitors of angiotensin-II are effective against acute ADR induced nephrotoxicity via the restoration of MMP and ATP production and prevention of mitochondrial damage in vivo.

Multi drug resistance-dependent “vacuum cleaner” functionality potentially driven by the interactions between endocytosis, drug size and Pgp-like transporters surface density

In cells, multi drug resistance (MDR) is associated with Pgp-like transporters expression extruding drugs from cellular membranes. MDR is efficiently generated with a relatively small fraction of membrane transporters. As the insertion of drugs into cellular membranes is widespread, there are no reasons why a drug should incorporate the membrane in the vicinity of a transporter. As a result a further elusive hypothesis is usually invoked: these transporters act like "vacuum cleaners" of drugs embedded in the membrane. Nonetheless, how these transporters attract drugs remains obscure. To clarify the "vacuum cleaner" notion, we suggest that during its residency time in cellular membranes, the lateral movement of drugs from their point of insertion to transporters is governed by Brownian's diffusion, which allows the drugs/transporters interaction. Taking into account the functionality of Pgp-like transporters, namely the extrusion of drugs from the plasma membrane inner leaflet, we characterize how the state of drug resistance is triggered involving: membrane endocytosis, drug physico-chemical properties and the surface density of Pgp-like transporters. In addition, the theory developed provides for the first time a theoretical proof of Lipinski's second rule with regard to drugs' size (or MW) selectivity on their permeation across cellular membranes.

Dietary antioxidants during cancer chemotherapy: impact on chemotherapeutic effectiveness and development of side effects

Several studies suggest that dietary supplementation with antioxidants can influence the response to chemotherapy as well as the development of adverse side effects that results from treatment with antineoplastic agents. Administration of antineoplastic agents results in oxidative stress, i.e., the production of free radicals and other reactive oxygen species (ROS). Oxidative stress reduces the rate of cell proliferation, and that occurring during chemotherapy may interfere with the cytotoxic effects of antineoplastic drugs, which depend on rapid proliferation of cancer cells for optimal activity. Antioxidants detoxify ROS and may enhance the anticancer effects of chemotherapy. For some supplements, activities beyond their antioxidant properties, such as inhibition of topoisomerase II or protein tyrosine kinases, may also contribute. ROS cause or contribute to certain side effects that are common to many anticancer drugs, such as gastrointestinal toxicity and mutagenesis. ROS also contribute to side effects that occur only with individual agents, such as doxorubicin-induced cardiotoxicity, cisplatin-induced nephrotoxicity, and bleomycin-induced pulmonary fibrosis. Antioxidants can reduce or prevent many of these side effects, and for some supplements the protective effect results from activities other than their antioxidant properties. Certain side effects, however, such as alopecia and myelosuppression, are not prevented by antioxidants, and agents that interfere with these side effects may also interfere with the anticancer effects of chemotherapy.

A recombinant human interleukin-1 beta protects adriamycin-induced toxicity. Adriamycin cardiotoxicity and interleukin-1

Pretreatment with recombinant human interleukin-1 beta (IL-1) protected normal BALB/c mice from the lethal effect adriamycin (ADM) of related to dose and frequency of administration. Posttreatment with IL-1 failed to protect. Neutrophil and platelet counts after the administration of ADM (16 mg/kg) did not differ between the group with and that without IL-1 pretreatment, whereas lipid peroxide levels in the heart were reduced in the group pretreated with IL-1. It appears that the chemoprotection mechanism of IL-1 lies in the prevention of cardiotoxicity due to ADM-induced free radicals.

The protective activity of ICRF-187 against doxorubicin-induced cardiotoxicity in the rat

The protective activity of the bisdioxopiperazine ICRF-187 against the cardiotoxicity of doxorubicin was evaluated in the rat using both functional and histological assays. Animals that had received a single i.v. dose of doxorubicin (4 mg/kg) alone were compared with those that had been pretreated with a single i.v. injection of saline or ICRF-187 (40 or 60 mg/kg). All rats showed a transient reduction in body weight during the first 3 weeks after drug administration. The greatest reduction (approximately 16%) was observed in animals that had received a combination of ICRF-187 (40 or 60 mg/kg) and doxorubicin. Deaths related to cardiotoxicity were observed only in rats that had received doxorubicin alone and in those treated with saline; most of the deaths occurred at between 8 and 13 weeks after drug administration. Sequential assessments of heart function showed a persistent depression of cardiac output in animals that had received doxorubicin, with or without pretreatment with ICRF-187. The reduction in cardiac output observed in rats that had been pretreated with ICRF-187 (40 or 60 mg/kg) amounted to approximately 15% and approximately 30% after 12 and 20 weeks, respectively, indicating that cardioprotection was only partial. Nevertheless, this represented a marked improvement as compared with the approximately 35% reduction in cardiac output measured at 12 weeks in animals that had received doxorubicin but without pretreatment with ICRF-187. Histological examination of animals that had died during the course of the study and had received doxorubicin after pretreatment with saline revealed severe myocardial lesions typical of doxorubicin-induced damage. In contrast, animals that had been pretreated with ICRF-187 and survived for up to 20 weeks after treatment showed a marked amelioration of these lesions. The present findings may be interpreted as a true cardioprotection or a delay in the onset of the cardiotoxicity of doxorubicin resulting from pretreatment with the bisdioxopiperazine ICRF-187. Although prior and ongoing clinical trials clearly indicate that ICRF-187 protects patients well against doxorubicin-induced heart damage, further investigations are required before high doses of ICRF-187 can be used as a means of increasing the protective activity of this drug against doxorubicin-induced cardiotoxicity.

Free radical formation by antitumor quinones

Quinones are among the most frequently used drugs to treat human cancer. All of the antitumor quinones can undergo reversible enzymatic reduction and oxidation, and form semiquinone and oxygen radicals. For several antitumor quinones enzymatic reduction also leads to formation of alkylating species but whether this involves reduction to the semiquinone or the hydroquinone is not always clear. The antitumor activity of quinones is frequently linked to DNA damage caused by alkylating species or oxygen radicals. Some other effects of the antitumor quinones, such as cardiotoxicity and skin toxicity, may also be related to oxygen radical formation. The evidence for a relationship between radical formation and the biological activity of the antitumor quinones is evaluated.

Lipid peroxidation and mechanisms of toxicity

Aerobic organisms by definition require oxygen, and the importance of iron in aerobic respiration has long been recognized, but despite their beneficial roles, these elements can pose a real threat to the organism. During oxygen reduction, reactive species such as O2-. and H2O2 are formed readily. Iron can combine with these species, or with molecular oxygen itself, to generate free radicals which will attack the polyunsaturated fatty acids of membrane lipids. This oxidative deterioration of membrane lipids is known as lipid peroxidation. To protect itself against this form of attack, the organism possesses several types of defense mechanisms. Under normal conditions, these defenses appear to offer adequate protection for cell membranes, but the possibility exists that certain foreign compounds may interfere with or even overwhelm these defenses, and herein could lie a general mechanism of toxicity. This possible cause of toxicity is discussed in relation to other suggested causes.

Hyperlipidemic effects of adriamycin in rats

Adriamycin, an anticancer drug, caused dramatic increases in the serum lipid levels of rats fed a high-cholesterol diet. Male Lewis inbred rats were fed a basal or 1.5% cholesterol diet containing 0.5% cholic acid for 8 weeks. The rats were injected with adriamycin in doses of 1.5 mg/kg body weight, twice a week, and 6.0 mg/kg body weight, every other week. The serum lipid peroxide level gradually rose in adriamycin-treated rats, reaching a four-fold level at the end of the experiment. Cholesterol feeding, however, had a lowering effect on the lipid peroxide level. Adriamycin treatment or cholesterol feeding moderately elevated serum lipid levels, but their combination exerted a synergistic effect. In rats injected with a large dose of adriamycin and fed a high-cholesterol diet, the serum cholesterol, triglyceride and phospholipid levels strikingly increased by approx. 2000, 1500 and 1300 mg/100 ml, respectively. However, the ester ratio of cholesterol remained almost constant. Furthermore, serum GOT, GPT and ALP activities were only slightly different from the control values. Adriamycin treatment produced severe hypoalbuminemia. Ascites was also observed in rats given a large dose of adriamycin. The present findings indicate that the hyperlipidemia we observed may basically result from adriamycin-induced nephrosis and can be markedly enhanced when rats are fed a high-cholesterol diet. In spite of remarkably high levels of serum lipids and lipid peroxides, the aortic cholesterol level increased only slightly.

Effects of an antimitotic agent (cyclophosphamide) on plasma lipoproteins

A cyclophosphamide injection to male New Zealand white rabbits induced a pronounced hypertriglyceridemia and a hypercholesterolemia whose concentration was maximal at 16 hr. Different doses were studied. In this hyperlipemia significant changes in plasma lipoprotein fractions appeared: the very low density lipoproteins increased and the high density lipoproteins decreased. Lipid composition showed that HDL cholesterol was very low comparatively to a high VLDL cholesterol. The apoprotein composition of VLDL from treated rabbits was studied and compared to that of normal rabbits. After electrophoresis in urea/polyacrylamide gels, two new apoproteins which resembled those observed in irradiated rabbits appeared. The molecular weight of these proteins was about 10,000, and they focused into three bands with isoelectric points of 6.72, 6.42 and 6.10. Total lipoprotein lipase activity in treated rabbits decreased; it was very low with 32.5 mg/kg. This lipolytic activity remains to be studied after separation of hepatic triacylglycerol lipase and lipoprotein lipase activities by chromatography.

Enhancement of adriamycin toxicity by carboxymethylcellulose in mice

Carboxymethylcellulose (CMC) (1% in 0.9% NaCl, 0.2 ml/10 g ip) a common suspending agent, enhanced adriamycin (ADR) (15 mg/kg ip) toxicity when administered to mice 5 hr before the antibiotic. Compared with ADR alone, this combination treatment produced, after 7 days, an increase in lethality from 15 to 80%. The pathologic analysis of hearts, livers, kidneys, and small bowels was performed, revealing an increase in the incidence and severity of hepatic damage in mice receiving ADR + CMC. Furthermore, reduced glutathione (GSH) was measured in livers of all mice; the animals treated with CMC and ADR + CMC showed a significant (p less than 0.01) reduction of hepatic GSH in comparison with controls and ADR-alone-treated animals. These data further confirm a crucial protective role for GSH in ADR toxicity and prove that CMC exerts an important biochemical effect on hepatic GSH.

Hepatic redox homeostasis following acute adriamycin intoxication in rats

Adriamycin toxicity is postulated to result from cytochrome P-450 reductase-catalyzed univalent reduction of the quinone to the semiquinone free radical intermediate. Oxygen radicals generated during the nonenzymatic reoxidation of the semiquinone have been implicated in the deleterious modification of a variety of tissue macromolecules. Detoxification of reactive products, such as hydroperoxides, is proposed to involve the consumption of vital cellular reducing equivalents which may, in itself, represent the primary causative event in toxic tissue damage. The present investigation demonstrates that hepatic tissue has sufficient glutathione (GSH) reductase to prevent a decrease in GSH following acute adriamycin administration to rats. Similarly, except for a transient decrease in NAD, adriamycin intoxication caused minimal changes in the hepatic pyridine nucleotide content in vivo. It is concluded that species- and tissue-specific differences in the distribution of antioxidant defense mechanisms may be primary determinants of the relative insensitivity of liver and, in contrast, the rather selective cardiomyopathy resulting from adriamycin administration in vivo.

Elevation of lipid peroxide in children treated with a combination of chemotherapeutic agents including doxorubicin

The fluorometric method of Yagi was used to determine serum lipid peroxide levels in children with various types of malignancies, treated with or without doxorubicin. It was found that patients on regimens of intermittent combination chemotherapies including doxorubicin had higher levels of serum lipid peroxide and were all apparently free from cardiotoxicity. Doxorubicin was the only determinant in affecting the serum lipid peroxide value. Coenzyme Q10 given concurrently failed to reduce the elevated levels to normal.

Toxic effects of free and DNA-linked daunorubicin on isolated rat cardiac myocytes

Isolated cardiac myocytes from adult rats were used as a model to study the cardiotoxicity of free and DNA-linked daunorubicin. The toxic effects on the myocytes were evaluated by studying morphological changes, trypan blue exclusion and cell membrane permeability to NADH, as determined by LDH-activity. At a concentration of 100 microM daunorubicin caused an increased plasma membrane permeability within 30 min. Using light microscopy, the myocytic injury induced by daunorubicin could be distinguished from that induced by anoxia or elevated pH. In contrast to the effect of the free drug, no toxic effects could be demonstrated after incubation with DNA-linked daunorubicin (100 microM) for 5 hours. The higher toxicity of the free drug was related to a much higher intracellular accumulation of daunorubicin. No fluorescent metabolites of daunorubicin could be detected in the myocardial cells. Daunorubicin did not induce lipid peroxidation, as judged by the absence of malondialdehyde production and evolution of ethane. It is concluded that daunorubicin exerts toxic effects on rat cardiac myocytes by mechanisms that do not involve lipid peroxidation. Isolated cardiac cells from adult rats seem to be a useful model for the further study of such mechanisms.

Covalent protein binding of reactive adriamycin metabolites in rat liver and rat heart microsomes

Covalent binding of 3H-labeled adriamycin metabolites to bovine serum albumin and microsomal protein is demonstrated in an aerobic incubation system with rat liver and rat heart microsomes, respectively, using exhaustive organic solvent extraction and gel chromatography. Covalent protein binding was dependent on active microsomes, NADPH, and oxygen and was inhibited by reduced glutathione and other sulfhydryl compounds. The anthracycline moiety was spectrophotometrically evidenced in the adriamycin metabolite(s) covalently bound to protein. Thus, enzymatic activation of adriamycin in the heart with consecutive covalent protein binding of reactive adriamycin semiquinone radicals may contribute to adriamycin cardiotoxicity.

Histological evaluation of radiochemotherapy for prostatic cancer: early results of a pilot study

Antiandrogen therapy has been widely used for prostatic cancer, yet many authors have reported on the limited efficacy of hormonal therapy for this disease. The present report is based on an histological evaluation of chemotherapy and radiotherapy in combination for prostatic cancer. To determine the usefulness of this combined therapy, 15 prostatic cancer patients were treated with a combination of Bleomycin and Adriamycin (BA therapy), or with only Adriamycin. Radiotherapy was administered to all cases. Twelve of the 15 patients were evaluable histologically with effects ranging from Grade I to Grade IV in Shimosato's classification. We conclude that further investigation, including a randomized study of hormonal therapy, is necessary.