Evaluation of histamine elimination curves in plasma and whole blood of several circulatory regions: a method for studying kinetics of histamine release in the whole animal

Markers of mast cell degranulation

Mast cells are the primary effector cells of immediate hypersensitivity reactions in humans. Upon mast cell activation both preformed and newly synthesized mediators are secreted. Histamine can be measured by fluorometric assays, radioenzymatic assays, and immunoassays. These methods have been applied to plasma and urine to detect histamine that had been released in vivo and to release histamine in vitro from basophils and mast cells. Another mast cell constituent is tryptase, which is a more selective marker of mast cells, because negligible amounts are found in basophils. beta-Tryptase is stored in secretory granules and is actively released when mast cells degranulate. alpha-Protryptase remains in the proenzyme form and is constitutively released from mast cells, and consequently its level in serum reflects total numbers of mast cells. alpha-Protryptase levels are elevated in serum at baseline in subjects with systemic mastocytosis, whereas beta-tryptase is elevated in serum from subjects with systemic anaphylaxis. These markers serve as precise clinical indicators of the involvement of mast cells in human disease.

Mucosal histamine elimination and its effect on acid secretion in rabbit gastric mucosa

BACKGROUND

Rapid elimination of histamine near the oxyntic cells is important in the termination of the secretory response when the signal for histamine release is discontinued. The mechanism of this local process is still unclear.

METHOD

Gastric mucosal histamine elimination was, therefore, examined in fundic mucosa mounted in flux chambers and in dispersed mucosal cells.

RESULTS

[3H]histamine placed into the serosal chamber medium was transported across the mucosal tissue into the lumen, but a greater quantity was methylated to an inactive metabolite, Nt-methylhistamine, and preferentially released to the serosal chamber, the interstitial medium. Both processes were enhanced by increased substrate concentration. They were reduced by lowering the temperature and by sodium replacement. Inhibition of histamine methyltransferase suppressed histamine uptake and methylation and significantly increased histamine-stimulated acid secretion in the tissue preparation and in dispersed mucosal cells. The augmentation was reduced by an H2-receptor blocker.

CONCLUSION

Mucosal histamine methylation and the secretion of histamine into the gastric lumen removes histamine from the extracellular space effectively, reducing the histamine concentration near the oxyntic cell surface.

Perioperative nonspecific histamine release: a new classification by aetiological mechanisms and evaluation of their clinical relevance

As a consequence of the performance of a randomized controlled clinical trial on perioperative histamine release and cardiovascular and respiratory disturbances, several types of increases in plasma histamine had to be distinguished instead of only two which existed at the beginning of the study: drug-induced allergic and pseudoallergic reactions. First of all, the new classification by aetiology (clinical epidemiology) was derived from a meta-analysis (secondary analysis) of the most recent literature. According to that histamine release in the perioperative period has several, different causes and is involved in several, different disease manifestations. A clear distinction (classification), however, is necessary if histamine release as an unwanted (adverse) effect has to be recognized, value judged according to its clinical relevance and therefore also prevented by histamine antagonists. Histamine release by neuro-endocrine and neuro-inflammatory mechanisms, cytotoxic histamine release and local, cytokine induced histamine release have been distinguished from pseudoallergic histamine release, but its functions are not yet clear. It has been analysed in prospective trials which used special clinical situations as models: patients on a normal ward or before and during upper GI endoscopy without premedication, but also in specific phases of laparoscopic cholecystectomy (trocar phase and dissection phase). Their existence in the clinical reality is now very likely, but new trials must investigate the pathophysiological effects such as in metabolism, coagulation, pulmonary haemodynamics (shunt volume) and gastric acid secretion. Histamine release by pseudoallergic mechanisms, however, was identified in the very vulnerable post-induction phase of anaesthesia up to skin incision. Its incidence was much higher than ever expected and its clinical relevance was demonstrated by the severity of reactions and the intervention strategies of the anaesthetists who were blinded concerning the type of the plasma substitute given and the prophylaxis with antihistamines. Pseudoallergic histamine release was clearly unwanted (adverse). Its occurrence in the other phases of anaesthesia has to be further evaluated in the tedious procedure of data analysis of the Mainz-Marburg-trial. The overall incidence of histamine release in the trial was so incredible high (72% of all patients, some of them with up to 4 episodes of histamine release) that a distinction between pseudoallergic (unwanted) and other types of histamine release (possibly less unwanted or even beneficial) is urgently needed. In the phase of steady state (maintenance) of anaesthesia the H1-(+)H2-prophylaxis was highly effective. Further analysis must show whether this is also the case during the phases of induction of anesthesia.(ABSTRACT TRUNCATED AT 400 WORDS)

Determination of histamine in human plasma: the European external quality control study 1988

There is an increasing interest in measuring human plasma histamine levels in various clinical conditions. A variety of 'old' and newly developed techniques are applied to meet this demand. However, the discrepancy between reported reference values for histamine in human plasma measured using this variety of techniques, suggests the existence of a certain degree of inaccuracy and imprecision. We therefore organized an external quality control study on the reliability of current histamine determinations in European laboratories. Three lyophilized plasma quality control samples, in duplicate, covering the normal and pathological range of histamine concentrations (0-45 nmol/l), two different aqueous histamine standard samples and one solvent sample were sent to 10 laboratories for the analysis of their histamine content. The following methods were used: gas chromatography-mass spectrometry (n = 2), enzymatic single isotopic assay (n = 1), fluorometric-fluoroenzymatic assay (n = 3), radioimmunoassay (n = 3) and high performance liquid chromatography (n = 2). The study was performed and evaluated according to the approved recommendations (1983) of the International Federation of Clinical Chemistry (IFCC). The target values +/- s.d. of the three plasma samples were: 39.5 +/- 4.6 nmol/l (CV = 11.6%), 2.3 +/- 2.2 nmol/l (CV = 96%) and 8.9 +/- 1.5 nmol/l (CV = 17%), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Inhibition of histamine-N-methyltransferase activity by neuromuscular blocking drugs

On the basis of previous findings that histamine-N-methyltransferase (HMT) activity can be significantly enhanced or inhibited by a number of analogues of histamine and drugs containing dialkylaminoalkyl moieties, we investigated whether the neuromuscular blocking drugs alcuronium, d-tubocurarine, decamethonium, succinylcholine, gallamine and pancuronium each of which contain quaternary ammonium groups, influence the activity of HMT. Our findings showed that all six drugs significantly inhibited HMT activity in the concentration range 10(-7)-10(-3) M with alcuronium being the most potent inhibitor (I.D.50 = 2 X 10(-6) M). Activities at these concentrations reveals that alcuronium, pancuronium, d-tubocurarine and gallamine are more potent inhibitors than two of the most potent histamine analogue inhibitors, N tau-methylhistamine and 2-methylhistamine. Alcuronium proved to be of similar potency to the dimaprit analogue, SKF 91488 regarded as one of the most potent HMT inhibitors known. The structurally similar and chemically least complex straight chain neuromuscular blocking compounds, succinylcholine and decamethonium proved to be the least potent inhibitors.

Inhibition of human and canine diamine oxidase by drugs used in an intensive care unit: relevance for clinical side effects?

Three hundred and forty-one drugs, commonly used in intensive care units (ICU), were chosen for an investigation of possible activation or inhibition of the histamine metabolizing enzyme diamine oxidase (DAO). After examination of 164 substances, using both canine and human DAO in an in vitro screening test, 61 agents inhibited DAO activity to various degrees. Of these, 44 inhibited the enzyme from both species, 4 inhibited the canine enzyme only and 13 the human DAO only. No compound tested was able to enhance the enzyme activity. The inhibiting agents included representatives of all major therapeutic groups. A particularly strong inhibition was observed with the neuromuscular blocking drugs d-tubocurarine, pancuronium and alcuronium, however, the other commonly used neuromuscular blocking drug, suxamethonium, was without effect. Similarly with the cephalosporines, cefotiame and cefuroxime caused a marked inhibition of the human DAO activity, whereas another regularly-used substance of this class, cefotaxime, inhibited neither the human nor the canine enzyme in concentrations up to 10(-3) M. The observation that within a given therapeutic group some members inhibit and others do not, could be useful in choosing a therapy concept which minimizes the risk of a more severe 'histamine' reaction in seriously ill patients.

Plasma histamine and hemodynamic responses following administration of nalbuphine and morphine

A comparative study of plasma histamine levels following administration or morphine and nalbuphine in pentobarbital anesthetized dogs was performed. Two concentrations, 3 mg/kg and 0.3 mg/kg of these drugs were investigated. High dose morphine caused an immediate marked increase in plasma histamine from 5.0 +/- 0.4 to 340 +/- 72 ng/ml. Simultaneous with this increase in plasma histamine was a marked decrease in mean arterial blood pressure within the first minute. In contrast significant alterations in plasma histamine levels were not observed with high or low doses of nalbuphine. A low dose of morphine (0.3 mg/kg) did not increase plasma histamine levels. Heart rate was not changed by any drug treatment. The use of compound 48/80 a specific mast cell degranulating agent allowed for the identification of a specific pool of mast cells capable of responding to morphine. In vitro exposure of purified dog leukocytes to high doses of morphine did not result in histamine release. These results indicate that nalbuphine does not increase plasma histamine, while morphine does, and that the source of the increase in plasma histamine is from tissue mast cells.

Binding of histamine by glass surfaces

Tritiated histamine (Hm) is significantly bound by glass surfaces. Many of the characteristics of the Hm binding suggest a specific process. Binding reaches equilibrium in 40 minutes and can be prevented by unlabeled Hm. Scatchard analysis reveals two Hm binding sites with dissociation constants of 0.051 microM and 14.4 microM. Histamine is 78.9% bound to the glass surface after 40 minutes when the concentration of Hm is 4ng/ml. Hm binding to glass can be prevented by potassium phosphate buffers, EDTA, and 0.1 M HCl and reduced by albumin, formic acid, and ethanol. Binding does not occur with quartz and is minimal with polystyrene tubes.

Epidemiology of adverse reactions in anaesthesia in Germany and the Netherlands

We consider 292 anaphylactoid reactions from the own material (1964-1980) out of two different Departments of anesthesiology to attempt to review the continental epidemiology of this life-threatening adverse drug reaction. We conclude the following: The specialty of this type of adverse reaction is likely to prove a special separating name i.e. "anaphylactoid reaction". The overall frequency can be estimated for 1 : 400-600 in anesthesiology, a preponderance of females may be possible. There is no predictability of the reaction, not even by sophisticated history. But it is possible to avoid the development of severe shock by early diagnosis and immediate full causative therapy. With growing experience in diagnosis and therapy the mortality of anaphylactoid reaction should be irrelevant in the near future.

Prophylaxis of anaphylactoid reactions to a polypeptidal plasma substitute by H1- plus H2-receptor antagonists: synopsis of three randomized controlled trials

To demonstrate the efficacy of a premedication with H1- + H2-receptor antagonists against histamine-release responses in anaesthesia and surgery 3 randomized controlled trials were conducted in patients, volunteers and experimental animals (dogs). Cutaneous anaphylactoid reactions following infusion of polygeline (Haemaccel) in orthopedic patients were successfully abolished by premedication with 0.1 mg/kg dimethpyrindene (Fenistil) and 5 mg/kg cimetidine (Tagamet). Chlorpheniramine (Piriton) was also useful, but dimethpyrindene was more effective in the doses recommended and used. Side-effects of the premedication were not observed when the 2 drugs were slowly administered (2 min each). Systemic anaphylactoid reactions following infusion of polygeline were completely prevented in volunteers by the same premedication (0.1 mg/kg dimethpyrindene and 10 mg/kg cimetidine). Life-threatening reactions could not be tested in human subjects, but were elicited in experimental animals (dogs). In this species which resembles man in its sensitivity against histamine, in plasma histamine levels and in response to polygeline life-threatening reactions were prevented or in especially severe cases diminished to such an extent by the premedication with H1- + H2-blockers that this premedication was finally judged to be very effective against histamine-release responses of any grade of severity. To confirm this clinically very important hypothesis more clinical trials in patients at risk for anaphylactoid reactions to drugs are urgently needed.

Histamine release and hypotensive reactions in dogs by solubilizing agents and fatty acids: analysis of various components in cremophor El and development of a compound with reduced toxicity

Anaphylactoid reactions in man following administration of drugs solubilized with cremophor El (polyethylenglycolglycerol riconoleate) are a considerable clinical problem. Since these reactions occur in dogs on first exposure and in pigs on second exposure, the 'dog model' was used in this communication to analyse components and chemical modifications of cremophor El and its components for their clinical effects, their hypotensive actions and their histamine-releasing capacity. Two series of experiments in 1978 and 1980 were performed in 144 adult mongrel dogs of both sexes. In these studies histamine release was not related to the effect of the solubilizing agents as tensides and was elicited by rather low doses (about 10--100 mg/kg i.v.). The effect of these substances on blood pressure and on blood histamine levels was connected with distinct chemical features: the most potent compounds were oxethylated and additionally esterified unsaturated or hydroxylated fatty acids. Several phases in hypotensive reactions were observed, including an immediate response, a delayed blood pressure response and a late response about 15--20 min after injection. Only the delayed response was associated with histamine release. The combination of cardiovascular effects and histamine release was fatal on some occasions indicating that histamine release can be dangerous. Compared to cremophor El, the tenside effect was equal, but the toxicity was reduced in oxethylated 12-hydroxystearic acid. It is recommended that this solubilizer should be used in further extended studies in animals and - if these are successful - in clinical trials.

[Plasma histamine assay in anaphylactoid reactions of the anesthetized subject. Effects of collection methods and plasma preparation on measured histamine]

Plasma histamine assay in man is indicated for the diagnosis of histamine release, as well as the elucidation of the mechanisms of adverse drug reactions, and the identification of clinical situations in anaesthesia and surgery where a pathological plasma histamine level may occur. Normal and pathological plasma histamine levels vary considerably in the literature. Data from various studies, especially one involving 300 patients in Heidelberg (G.F.R.), allow us to define the normal range for human plasma histamine as 0-1.0 ng . ml-1 . Values greater than 1 ng . ml-1 have to be considered as pathological. The problems related to blood collection and plasma preparation are considered here. Any judgement concerning the method described in the test must take into consideration our long experience of 15 years with it, its reliability in clinical conditions, its practicability, its relatively low cost, and finally, the absence of radioisotopes.

H1 + H2-receptor antagonists for premedication in anaesthesia and surgery: a critical view based on randomized clinical trials with Haemaccel and various antiallergic drugs

Histamine release by drugs used in anaesthesia and surgery has been often demonstrated in human volunteers, but only occassionally in patients. Three questions arose from these studies. (1) Is the incidence of histamine release high in patients during routine anaesthesia and surgery? (2) Can the clinical effects of histamine release in man be prevented by H1 + H2-receptor antagonists? (3) Are there any side-effects of such a premedication? These problems were investigated in patients and volunteers by randomized controlled clinical trials using only one of the histamine-liberating drugs in man, the plasma substitute Haemaccel. This drug was chosen because it causes a reproducible histamine release in man and because its mechanism of action in man is largely known. (1) Out of 600 orthopaedic patients 30 (5%) showed anaphylactoid reactions following Haemaccel infusion. 26 of these had a histamine release of more than 1 ng histamine/ml plasma. Using predictive values this gives an efficiency of the test by nearly 98%. (2) In volunteers the combination of an H1-plus H2-receptor antagonist (dimethypyrindene and cimetidine) completely prevented the clinical effects of histamine release by Haemaccel (9 allergoid and anaphylactoid reactions in the control group, none in the H1 + H2-group). The incidence of histamine release, however, remained unchanged. (3) The premedication was found to release histamine itself. Cimetidine was effective when given alone but especially in combination with chlorpheniramine (4 events out of 7 applications). The clinical side-effects of these premedication were mild since apparently the free histamine was largely blocked at the receptor sites. It is concluded that premedication with a combination of H1- and H2-receptor antagonists is indicated due to the high incidence of histamine release during anaesthesia and surgery induced by various drugs and treatments. Such premedication is effective but associated with mild side-effects. For this reason more extended clinical trials with dimethpyrindene plus cimetidine in patients are necessary before this premedication can be generally recommended.

[Studies on the pre- and posthepatic plasma histamine concentrations and their possible pathophysiological effects in liver cirrhosis (author's transl)]

Fluorometric estimations of plasma histamine in the peripheral venous blood were performed in a control group of 16 subjects with normal liver values and normal liver biopsy specimen. Two further groups with liver changes were studied: Ten patients with fatty liver (stage I-II) and 22 cases suffering from liver cirrhosis, including 7 patients with portocaval shunt. Additionally, plasma histamine concentrations were determined in the blood of the portal vein, hepatic vein, cubital vein and in the femoral artery of another 11 normal subjects and 8 cirrhotic patients, some of them with portocaval shunt. The elimination of histamine by the liver was calculated. In healthy humans about two thirds (67.8 plus or minus 11.4 per cent; n=11) of the histamine content in the portal vein is eliminated by liver passage. This is due mainly to liver uptake and catabolism of histamine. It could be shown, that the elimination rate (41.0 plus or minus 15.1 per cent, n=8) is diminished in cirrhotic livers. Therefore, the plasma histamine content measured in the peripheral venous blood is significantly higher (p less than 0.001) in cirrhotic patients (1.2 +/- 0.3 ng/ml; n=22) than in healthy subjects (0.7 +/0 0.2 ng/ml; n=16). The expected pathophysiological effects of the elevated plasma histamine levels in liver cirrhosis are discussed with respect to circulatory changes ("hyperdynamic circulation") and their possible role in the development of "hepatogenic" ulcers of the stomach.

Blood and urine histamine levels in normal and pathological states as measured by a radiochemical assay

The utility of the enzymatic radiochemical assay of histamine in diagnosing diseases with known abnormalities in histamine production was investigated. Whole blood histamine levels were abnormal only in patients with basophilia, i.e. chronic myelocytic leukemia or polycythemia vera. Histamine was not detectable (less than 1 ng/ml) in normal plasma but was detected in plasma of some patients witheither mastocytosis or chronic myelocytic leukemia. These patients also had symptoms which could be attributed to histamine release as, for example, hyperchlorhydria and hypotension. Urinary histamine excretion was also abnormally high in these diseases compared to normal subjects (range less than 5-42 microgram/24 h, n = 31). Patients with systemic mastocytosis had higher urine values (greater than 150 microgram/24 h) than those with cutaneous mastocytosis (39-88 microgram/24 h), and the urinary histamine excretion appeared to be an index of the severity of the diseases. Studies with L-histidine loading suggest that the kidney is one possible source of urinary histamine.

Histamine release in dogs by Cremophor E1 and its derivatives: oxethylated oleic acid is the most effective constituent

Several preparations of Cremophor E1, several of other non-ionic detergents and several components of Cremophor E1 were tested for their histamine-releasing capacity in dogs. Lutensol AP 10 and a derivative of 1,2-propylenglycol were ineffective, but showed excellent properties as detergents. Thus the histamine-releasing capacity was not necessarily combined with the tenside effect of the surfactants. Oleic acid found in Tween 80 as well as in Cremophor E1 seems to be the most effective constituent, but the alcohol seems also to be important for the histamine-releasing capacity. The development of a non-toxic solubilizer for lipophilic drugs seems of considerable clinical interest.

Diamine oxidase activity and histamine release in dogs following acute mesenteric artery occlusion

Following superior mesenteric artery occlusion and revascularization in dogs all animals died in a circulatory collapse state. However, pretreatment by aminoguanidine, the strong and specific inhibitor of diamine oxidase, accelerated the circulatory break-down significantly and increased the venous plasma histamine concentrattions up to levels which also in normal dogs are effective in the circulatory system. Furthermore, the haematocrit increased significantly more in the aminoguanidine-treated animals than in the dogs treated by saline. No changes in plasma diamine oxidase activity were observed in saline-treated animals during intestinal ischemia and following revascularization. In aminoguanidine-treated animals no enzymic activity could be measured. The results were interpreted by a protective role of intestinal diamine oxidase in intestinal ischemia. Enhancement of the enzymic activity in patients, for instance by heparin, may be helpful in mesenteric infarction disease.

Influence of H1- and H2-receptor antagonists on the circulatory system and on the endogenous plasma histamine concentrations in dogs

The effects of the H1-receptor antagonist dimethpyrindene and the H2-receptor antagonist burimamide on circulatory and respiratory parameters and on plasma histamine levels were tested in 21 mongrel dogs. Both drugs released histamine. The incidence for this effect was 10/11 in the case of dimethpyrindene and 5/10 in the case of burimamide. Following dimethpyrindene all animals showed arterial hypotension, pulmonal hypertension, decrease in peripheral resistance and hyperventilation. The portal venous pressure was increased in dogs reacting by a histamine release. Following burimamide both an initial arterial hypertension and a subsequent hypotension were observed the latter being more pronounced in the group with histamine release. In this group the portal venous pressure raised considerably. In the non-reacting animals cardiac output was elevated, probably due to a release of catecholamines. It seemed remarkable that the effect of exogenous histamine on portal venous pressure was completely blocked by dimethpyrindene, but not the action of histamine released by the drug itself. It is concluded that the effects of anti-histaminic drugs on possibly histamine-induced physiological and pathophysiological processes should be interpreted very carefully as far as their specificity is concerned.

Marburg experiment on surgical research: a five-years' experience on the cooperation between clinical and theoretical surgeons

The organisation of surgical research in Marburg is an experiment which has run for five-years and war carried out in attempt to establish a cooperation between clinical and theoretical surgeons (scientists in basic research). The experiment was started 1970 by creating a Division of Experimental Surgery and Pathological Biochemistry at the Surgery Clinic of the University. Structures and functions in this experiment were 6 small working teams, special services for the teams and for the whole Department of Surgery as well as a training programme in surgical research for theoretical surgeons. Success and failure in the experiment were evaluated by criteria testing three principal functions of surgical research: Training of clinical and theoretical surgeons in methods and techniques of surgical research, performance of controlled clinical trials and basic research in surgery. The early results of the Marburg experiment seem to be promising.

Histamine and peptic ulcer: a prospective study of mucosal histamine concentration in duodenal ulcer patients and in control subjects suffering from various gastrointestinal diseases

In a prospective study the histamine content of the mucosa of the body of the stomach was measured in 100 patients consisting of control subjects, patients with duodenal ulcer and patients suffering from various gastrointestinal diseases. The histamine content was found to be 43 mug/g in male control subjects (median) while in duodenal ulcer patients levels attained were significantly lower by about 30 per cent. In all the other groups of patients histamine concentrations in gastric mucosa were found to be "normal". Since in most species it is extremely diffcult to alter the mucosal histamine concentration by any form of treatment, the diminished histamine content of the gastric mucosa in patients with duodenal ulcer seems remarkable. Among several possible explanations offered for this finding we think the most likely is that histamine release is increased in duodenal ulcer disease.

Effect of amodiaquine on gastric histamine methyltransferase and on histamine-stimulated gastric secretion

1 Amodiaquine was found to be a potent inhibitor in vitro of gastric histamine methyltransferase from human and canine corpus and from pig antrum. The ID50 for the enzyme, purified from pig antrum mucosa by ultracentrifugation and chromatography on DEAE-cellulose, was 2.5 muM. 2 In six dogs with Heidenhanin pouches the maximum secretory response to histamine (40 mug/kg i.m.) was augmented by i.m. injection of amodiaquine. The augmentation depended on the dose of amodiaquine, the optimum effect (40% increase in volume of gastric juice, 80% in acid output) being achieved with 2 mg/kg. The maximum secretory response to betazole was also enhanced by amodiaquine. 3 It was suggested that amodiaquine may enhance the histamine and betazole stimulated gastric secretion by an inhibition of gastric histamine methyltransferase in vivo.