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Bouchard J, Shepherd G, Hoffman RS, Gosselin S, Roberts DM, Li Y, Nolin TD, Lavergne V, Ghannoum M. Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup. Crit Care 2021; 25:201. [PMID: 34112223 PMCID: PMC8194226 DOI: 10.1186/s13054-021-03585-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/26/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND β-adrenergic antagonists (BAAs) are used to treat cardiovascular disease such as ischemic heart disease, congestive heart failure, dysrhythmias, and hypertension. Poisoning from BAAs can lead to severe morbidity and mortality. We aimed to determine the utility of extracorporeal treatments (ECTRs) in BAAs poisoning. METHODS We conducted systematic reviews of the literature, screened studies, extracted data, and summarized findings following published EXTRIP methods. RESULTS A total of 76 studies (4 in vitro and 2 animal experiments, 1 pharmacokinetic simulation study, 37 pharmacokinetic studies on patients with end-stage kidney disease, and 32 case reports or case series) met inclusion criteria. Toxicokinetic or pharmacokinetic data were available on 334 patients (including 73 for atenolol, 54 for propranolol, and 17 for sotalol). For intermittent hemodialysis, atenolol, nadolol, practolol, and sotalol were assessed as dialyzable; acebutolol, bisoprolol, and metipranolol were assessed as moderately dialyzable; metoprolol and talinolol were considered slightly dialyzable; and betaxolol, carvedilol, labetalol, mepindolol, propranolol, and timolol were considered not dialyzable. Data were available for clinical analysis on 37 BAA poisoned patients (including 9 patients for atenolol, 9 for propranolol, and 9 for sotalol), and no reliable comparison between the ECTR cohort and historical controls treated with standard care alone could be performed. The EXTRIP workgroup recommends against using ECTR for patients severely poisoned with propranolol (strong recommendation, very low quality evidence). The workgroup offered no recommendation for ECTR in patients severely poisoned with atenolol or sotalol because of apparent balance of risks and benefits, except for impaired kidney function in which ECTR is suggested (weak recommendation, very low quality of evidence). Indications for ECTR in patients with impaired kidney function include refractory bradycardia and hypotension for atenolol or sotalol poisoning, and recurrent torsade de pointes for sotalol. Although other BAAs were considered dialyzable, clinical data were too limited to develop recommendations. CONCLUSIONS BAAs have different properties affecting their removal by ECTR. The EXTRIP workgroup assessed propranolol as non-dialyzable. Atenolol and sotalol were assessed as dialyzable in patients with kidney impairment, and the workgroup suggests ECTR in patients severely poisoned with these drugs when aforementioned indications are present.
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Affiliation(s)
- Josée Bouchard
- Research Center, CIUSSS du Nord-de-L'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada
| | - Greene Shepherd
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Sophie Gosselin
- Centre Intégré de Santé et de Services Sociaux (CISSS) Montérégie-Centre Emergency Department, Hôpital Charles-Lemoyne, Greenfield Park, QC, Canada
- Department of Emergency Medicine, McGill University, Montreal, QC, Canada
- Centre Antipoison du Québec, Quebec, QC, Canada
| | - Darren M Roberts
- Departments of Renal Medicine and Transplantation and Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Yi Li
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, and Department of Medicine Renal-Electrolyte Division, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA, USA
| | - Valéry Lavergne
- Research Center, CIUSSS du Nord-de-L'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada
| | - Marc Ghannoum
- Research Center, CIUSSS du Nord-de-L'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada.
- Verdun Hospital, 4000 Lasalle Boulevard, Verdun, Montreal, QC, H4G 2A3, Canada.
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Hermida RC, Hermida-Ayala RG, Smolensky MH, Mojón A, Fernández JR. Ingestion-time – relative to circadian rhythms – differences in the pharmacokinetics and pharmacodynamics of hypertension medications. Expert Opin Drug Metab Toxicol 2020; 16:1159-1173. [DOI: 10.1080/17425255.2020.1825681] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Ramón C. Hermida
- Bioengineering & Chronobiology Laboratories, Atlantic Research Center for Information and Communication Technologies (Atlanttic), University of Vigo, Vigo, Spain
- Department of Biomedical Engineering, Cockrell School of Engineering, the University of Texas at Austin, Austin, TX, USA
| | | | - Michael H. Smolensky
- Department of Biomedical Engineering, Cockrell School of Engineering, the University of Texas at Austin, Austin, TX, USA
| | - Artemio Mojón
- Bioengineering & Chronobiology Laboratories, Atlantic Research Center for Information and Communication Technologies (Atlanttic), University of Vigo, Vigo, Spain
| | - José R. Fernández
- Bioengineering & Chronobiology Laboratories, Atlantic Research Center for Information and Communication Technologies (Atlanttic), University of Vigo, Vigo, Spain
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Advani P, Joseph B, Ambre P, Pissurlenkar R, Khedkar V, Iyer K, Gabhe S, Iyer RP, Coutinho E. In silico optimization of pharmacokinetic properties and receptor binding affinity simultaneously: a 'parallel progression approach to drug design' applied to β-blockers. J Biomol Struct Dyn 2015; 34:384-98. [PMID: 25854164 DOI: 10.1080/07391102.2015.1033646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The present work exploits the potential of in silico approaches for minimizing attrition of leads in the later stages of drug development. We propose a theoretical approach, wherein 'parallel' information is generated to simultaneously optimize the pharmacokinetics (PK) and pharmacodynamics (PD) of lead candidates. β-blockers, though in use for many years, have suboptimal PKs; hence are an ideal test series for the 'parallel progression approach'. This approach utilizes molecular modeling tools viz. hologram quantitative structure activity relationships, homology modeling, docking, predictive metabolism, and toxicity models. Validated models have been developed for PK parameters such as volume of distribution (log Vd) and clearance (log Cl), which together influence the half-life (t1/2) of a drug. Simultaneously, models for PD in terms of inhibition constant pKi have been developed. Thus, PK and PD properties of β-blockers were concurrently analyzed and after iterative cycling, modifications were proposed that lead to compounds with optimized PK and PD. We report some of the resultant re-engineered β-blockers with improved half-lives and pKi values comparable with marketed β-blockers. These were further analyzed by the docking studies to evaluate their binding poses. Finally, metabolic and toxicological assessment of these molecules was done through in silico methods. The strategy proposed herein has potential universal applicability, and can be used in any drug discovery scenario; provided that the data used is consistent in terms of experimental conditions, endpoints, and methods employed. Thus the 'parallel progression approach' helps to simultaneously fine-tune various properties of the drug and would be an invaluable tool during the drug development process.
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Affiliation(s)
- Poonam Advani
- a Department of Pharmaceutical Chemistry , C.U. Shah College of Pharmacy, S.N.D.T. Women's University , Mumbai , Maharashtra , India.,e Mumbai Educational Trust , Institute of Pharmacy , Bandra Reclamation, Bandra (W), Mumbai , India
| | - Blessy Joseph
- b Department of Pharmaceutical Chemistry , Bombay College of Pharmacy , Mumbai , Maharashtra , India
| | - Premlata Ambre
- b Department of Pharmaceutical Chemistry , Bombay College of Pharmacy , Mumbai , Maharashtra , India
| | - Raghuvir Pissurlenkar
- b Department of Pharmaceutical Chemistry , Bombay College of Pharmacy , Mumbai , Maharashtra , India
| | - Vijay Khedkar
- b Department of Pharmaceutical Chemistry , Bombay College of Pharmacy , Mumbai , Maharashtra , India
| | - Krishna Iyer
- b Department of Pharmaceutical Chemistry , Bombay College of Pharmacy , Mumbai , Maharashtra , India
| | - Satish Gabhe
- c Department of Pharmaceutical Chemistry , Poona College of Pharmacy, Bharati Vidyapeeth Deemed University , Pune , India
| | | | - Evans Coutinho
- b Department of Pharmaceutical Chemistry , Bombay College of Pharmacy , Mumbai , Maharashtra , India
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Portaluppi F, Lemmer B. Chronobiology and chronotherapy of ischemic heart disease. Adv Drug Deliv Rev 2007; 59:952-65. [PMID: 17675179 DOI: 10.1016/j.addr.2006.07.029] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2006] [Accepted: 07/07/2006] [Indexed: 11/16/2022]
Abstract
The occurrence of the clinical manifestations of ischemic heart disease (IHD)--myocardial ischemia and angina pectoris, acute myocardial infarction, and sudden cardiac death--is unevenly distributed during the 24 h with greater than expected events during the initial hours of the daily activity span and in the late afternoon or early evening. Such temporal patterns result from circadian rhythms in pathophysiological mechanisms plus cyclic environmental stressors that trigger ischemic events. Both the pharmacokinetics (PK) and pharmacodynamics (PD) of many, though not all, anti-ischemic oral nitrate, calcium channel blocker, and beta-adrenoceptor antagonist medications have been shown to be influenced by the circadian time of their administration. The requirement for preventive and therapeutic interventions varies predictably during the 24 h, and thus therapeutic strategies should also be tailored accordingly to optimize outcomes. During the past decade, two first generation calcium channel blocker chronotherapies have been developed, trialed, and marketed in North America for the improved treatment of IHD. Nonetheless, there has been relatively little investigation of the administration-time (circadian rhythm) dependencies of the PK and PD of conventional anti-ischemic medications, and there has been little progress in the development of new generation IHD chronotherapies. Available epidemiologic, pharmacologic, and clinico-therapeutic evidence demonstrates how the chronobiologic approach to IHD can contribute new insight and opportunities to improve drug design and drug delivery to enhance therapeutic outcomes.
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Affiliation(s)
- Francesco Portaluppi
- Hypertension Center, Department of Clinical and Experimental Medicine, University of Ferrara, via Savonarola 9, I-44100 Ferrara, Italy.
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Lemmer B. Chronopharmacology of cardiovascular medications. BIOL RHYTHM RES 2007. [DOI: 10.1080/09291010600906216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Affiliation(s)
- B Lemmer
- Institute of Pharmacology and Toxicology, Faculty of Clinical Medicine, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
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Panton LB, Guillen GJ, Williams L, Graves JE, Vivas C, Cediel M, Pollock ML, Garzarella L, Krumerman J, Derendorf H. The lack of effect of aerobic exercise training on propranolol pharmacokinetics in young and elderly adults. J Clin Pharmacol 1995; 35:885-94. [PMID: 8786248 DOI: 10.1002/j.1552-4604.1995.tb04133.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The effects of exercise training on the pharmacokinetics of orally administered propranolol were studied in young and elderly healthy volunteers. Twenty-three young (30 +/- 5 years of age) and 20 elderly (67 +/- 5 years of age) adults were randomly assigned to endurance training (N = 12 young subjects, 10 elderly subjects) or nonexercising control (N = 11 young subjects, 10 elderly subjects) groups. Training consisted of treadmill walking, stair climbing, or both three times per week for 40 minutes at 70-85% of maximal heart rate reserve for 16 weeks. Resting plasma propranolol concentrations after a single dose of 80 mg of oral propranolol were measured by high performance liquid chromatography with fluorescence detection, and estimated hepatic blood flow measured was measured using indocyanine green during supine test. Aerobic training increased maximal oxygen uptake (VO2 max) by 13% and 14% in the exercising young and elderly groups, respectively. There was no change in VO2 max in either control group. Adjusted mean estimated hepatic blood flow after exercise corrected for body weight for the young subjects who did not exercise (15.6 mL/min/Kg) and those who did (18.2 mL/min/Kg) groups were of borderline significance. No statistical differences were detected in the experimental propranolol pharmacokinetic parameters (maximal concentration, time of maximal concentration, terminal half-life, area under the curve, and protein binding) or derived pharmacokinetic parameters (intrinsic clearance, bioavailability, clearance, and volume of distribution). These results provide evidence that changes in aerobic fitness do not produce corresponding changes in propranolol pharmacokinetics in young or elderly adults.
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Affiliation(s)
- L B Panton
- Department of Medicine, University of Florida, Gainesville, USA
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