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Chiclana-Rodríguez B, Garcia-Montoya E, Rouaz-El Hajoui K, Romero-Obon M, Nardi-Ricart A, Suñé-Pou M, Suñé-Negre JM, Pérez-Lozano P. Development of a Carvedilol Oral Liquid Formulation for Paediatric Use. Pharmaceutics 2023; 15:2283. [PMID: 37765252 PMCID: PMC10537783 DOI: 10.3390/pharmaceutics15092283] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/16/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023] Open
Abstract
Carvedilol (CARV) is an 'off-label' β-blocker drug to treat cardiovascular diseases in children. Since CARV is nearly insoluble in water, only CARV solid forms are commercialized. Usually, CARV tablets are manipulated to prepare an extemporaneous liquid formulation for children in hospitals. We studied CARV to improve its aqueous solubility and develop an oral solution. In this study, we assessed the solubility and preliminary stability of CARV in different pH media. Using malic acid as a solubility enhancer had satisfactory results. We studied the chemical, physical, and microbiological stability of 1 mg/mL CARV-malic acid solution. A design of experiment (DoE) was used to optimize the CARV solution's preparation parameters. A 1 mg/mL CARV solution containing malic acid was stable for up to 12 months at 25 °C and 30 °C and 6 months at 40 °C. An equation associating malic acid with CARV concentrations was obtained using DoE. Microbiological data showed that the use of methylparaben was not necessary for this period of time. We successfully developed an aqueous CARV solution suitable for paediatrics and proven to be stable over a 12-month period.
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Affiliation(s)
- Blanca Chiclana-Rodríguez
- Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, Av. Joan XXIII, 27-31, 08028 Barcelona, Spain; (B.C.-R.); (K.R.-E.H.); (A.N.-R.); (M.S.-P.); (J.M.S.-N.); (P.P.-L.)
| | - Encarnacion Garcia-Montoya
- Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, Av. Joan XXIII, 27-31, 08028 Barcelona, Spain; (B.C.-R.); (K.R.-E.H.); (A.N.-R.); (M.S.-P.); (J.M.S.-N.); (P.P.-L.)
- Pharmacotherapy, Pharmacogenetics and Pharmaceutical Technology Research Group, Bellvitge Biomedical Research Institute (IDIBELL), Av. Gran Via de l’Hospitalet, 199-203, 08090 Barcelona, Spain
| | - Khadija Rouaz-El Hajoui
- Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, Av. Joan XXIII, 27-31, 08028 Barcelona, Spain; (B.C.-R.); (K.R.-E.H.); (A.N.-R.); (M.S.-P.); (J.M.S.-N.); (P.P.-L.)
- Pharmacotherapy, Pharmacogenetics and Pharmaceutical Technology Research Group, Bellvitge Biomedical Research Institute (IDIBELL), Av. Gran Via de l’Hospitalet, 199-203, 08090 Barcelona, Spain
| | - Miquel Romero-Obon
- Quality Assurance Pharmaceutical Sites Director—Laboratorios ALMIRALL, Ctra. de Martorell, 41-61, 08740 Sant Andreu de la Barca, Spain
| | - Anna Nardi-Ricart
- Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, Av. Joan XXIII, 27-31, 08028 Barcelona, Spain; (B.C.-R.); (K.R.-E.H.); (A.N.-R.); (M.S.-P.); (J.M.S.-N.); (P.P.-L.)
| | - Marc Suñé-Pou
- Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, Av. Joan XXIII, 27-31, 08028 Barcelona, Spain; (B.C.-R.); (K.R.-E.H.); (A.N.-R.); (M.S.-P.); (J.M.S.-N.); (P.P.-L.)
- Pharmacotherapy, Pharmacogenetics and Pharmaceutical Technology Research Group, Bellvitge Biomedical Research Institute (IDIBELL), Av. Gran Via de l’Hospitalet, 199-203, 08090 Barcelona, Spain
| | - Josep M. Suñé-Negre
- Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, Av. Joan XXIII, 27-31, 08028 Barcelona, Spain; (B.C.-R.); (K.R.-E.H.); (A.N.-R.); (M.S.-P.); (J.M.S.-N.); (P.P.-L.)
- Pharmacotherapy, Pharmacogenetics and Pharmaceutical Technology Research Group, Bellvitge Biomedical Research Institute (IDIBELL), Av. Gran Via de l’Hospitalet, 199-203, 08090 Barcelona, Spain
| | - Pilar Pérez-Lozano
- Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, Av. Joan XXIII, 27-31, 08028 Barcelona, Spain; (B.C.-R.); (K.R.-E.H.); (A.N.-R.); (M.S.-P.); (J.M.S.-N.); (P.P.-L.)
- Pharmacotherapy, Pharmacogenetics and Pharmaceutical Technology Research Group, Bellvitge Biomedical Research Institute (IDIBELL), Av. Gran Via de l’Hospitalet, 199-203, 08090 Barcelona, Spain
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Wu JM, Bekfani T, Hinze A, Westphal JG, Steinacker B, Zeller M, Hartmann C, Möbius‐Winkler S, Hochhaus A, Schulze PC, Ernst T. Clonal haematopoiesis of indeterminate potential-related mutations and outcome in dilated and ischaemic cardiomyopathy. ESC Heart Fail 2022; 9:3954-3960. [PMID: 35979940 PMCID: PMC9773636 DOI: 10.1002/ehf2.14115] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/19/2022] [Accepted: 08/04/2022] [Indexed: 01/19/2023] Open
Abstract
AIMS Clonal haematopoiesis of indeterminate potential (CHIP)-associated mutation is a risk factor for the development of ischaemic cardiomyopathy (ICM), but its association with non-ischaemic dilated cardiomyopathy (DCM) remains unclear. We aimed to determine the prevalence of CHIP in patients with DCM and define its risk for disease progression. METHODS AND RESULTS Next-generation sequencing targeting 54 common CHIP-associated genes was performed in 48 ICM and 52 DCM patients. The patients were monitored for a median of 3.1 years, and a COX proportional hazards model was used to examine the association between CHIP and adverse clinical outcome with regard to all-cause death or all-cause hospitalization. Overall, the prevalence of CHIP mutations was 19% and 13% in DCM and ICM, respectively. Seventeen per cent of ICM patients over 75 years were CHIP carriers. In DCM cohort, mutation event had already been observed in the patients who were under the age of 45 (13%). Among 54 genes analysed, DNMT3A had the highest mutation frequency, followed by TET2 and CUX1. Kaplan-Meier curve over a median of 3.1 year tracking period showed a trend towards poor clinical outcome in the DCM patients who carried DNMT3A or TET2 mutation; however, such association was not statistically significant. CONCLUSIONS The prevalence of CHIP is detected at a young age in DCM, and accumulation of mutational frequency in DCM patients is independent of age. However, a larger patient cohort is required to validate the association between CHIP and clinical progression in the DCM patients.
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Affiliation(s)
- Jasmine M.F. Wu
- Department of Internal Medicine I, Division of CardiologyUniversity Hospital Jena, FSU JenaAm Klinikum 107747JenaGermany
| | - Tarek Bekfani
- Department of Internal Medicine I, Division of CardiologyUniversity Hospital Jena, FSU JenaAm Klinikum 107747JenaGermany,Clinic for Cardiology, Angiology and PneumologyUniversity Hospital Magdeburg A.ö.RMagdeburgGermany
| | - Anna Hinze
- Department of Internal Medicine II, Division of Hematology and OncologyUniversity Hospital Jena, FSU JenaJenaGermany
| | - Julian Georg Westphal
- Department of Internal Medicine I, Division of CardiologyUniversity Hospital Jena, FSU JenaAm Klinikum 107747JenaGermany
| | - Berit Steinacker
- Department of Internal Medicine I, Division of CardiologyUniversity Hospital Jena, FSU JenaAm Klinikum 107747JenaGermany
| | - Max Zeller
- Department of Internal Medicine I, Division of CardiologyUniversity Hospital Jena, FSU JenaAm Klinikum 107747JenaGermany
| | - Charlotte Hartmann
- Department of Internal Medicine I, Division of CardiologyUniversity Hospital Jena, FSU JenaAm Klinikum 107747JenaGermany
| | - Sven Möbius‐Winkler
- Department of Internal Medicine I, Division of CardiologyUniversity Hospital Jena, FSU JenaAm Klinikum 107747JenaGermany
| | - Andreas Hochhaus
- Department of Internal Medicine II, Division of Hematology and OncologyUniversity Hospital Jena, FSU JenaJenaGermany
| | - P. Christian Schulze
- Department of Internal Medicine I, Division of CardiologyUniversity Hospital Jena, FSU JenaAm Klinikum 107747JenaGermany
| | - Thomas Ernst
- Department of Internal Medicine II, Division of Hematology and OncologyUniversity Hospital Jena, FSU JenaJenaGermany
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Development of an Age-Appropriate Mini Orally Disintegrating Carvedilol Tablet with Paediatric Biopharmaceutical Considerations. Pharmaceutics 2021; 13:pharmaceutics13060831. [PMID: 34204941 PMCID: PMC8227311 DOI: 10.3390/pharmaceutics13060831] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/20/2021] [Accepted: 05/30/2021] [Indexed: 11/17/2022] Open
Abstract
Owing to considerable differences observed in anatomy and physiology between paediatric subsets, it has been well established that children respond to drugs differently compared to adults. Furthermore, from a formulation perspective, there is a distinct challenge to develop a dosage form that is capable of safely, accurately, and reliably delivering the dose across the whole paediatric population. Orally disintegrating mini-tablets (ODMT) have widely been considered as an age-appropriate formulation option that possess the ability for adequate dose flexibility, avoids swallowing difficulties, and exhibits superior stability due to its solid state. Within this study, two strengths (0.5 mg and 2 mg) of carvedilol ODMT formulations were developed using an excipient composition and load that is appropriate for paediatric use. The formulations demonstrated adequate mechanical strength (>20 N) and fast disintegration times (<30 s). Dissolution profiles observed were robust and comparable to the marketed conventional tablet formulation across various parts of the gastrointestinal (GI) tract in both the fed and fasted state, signifying appropriate efficacy, quality, and performance. As such, the formulations developed in this study show potential to address the need of an 'age-appropriate' formulation of carvedilol, as highlighted by the European Medicines Agency (EMA) Inventory of the Needs for Paediatric Medicine.
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Silvilairat S, Charoenkwan P, Saekho S, Tantiworawit A, Chattipakorn N. Carvedilol improves left ventricular diastolic dysfunction in patients with transfusion-dependent thalassemia. Ann Pediatr Cardiol 2021; 14:152-158. [PMID: 34103853 PMCID: PMC8174640 DOI: 10.4103/apc.apc_63_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 10/12/2020] [Accepted: 01/27/2021] [Indexed: 01/19/2023] Open
Abstract
Background: Iron overload cardiomyopathy is the most common cause of death in patients with transfusion-dependent thalassemia. Aim: The aim of this study was to determine the efficacy of carvedilol treatment in patients with transfusion-dependent thalassemia who had left ventricular diastolic dysfunction. Methods: Eighteen patients with transfusion-dependent thalassemia who had left ventricular diastolic dysfunction were enrolled. All patients had normal left ventricular systolic function and were given carvedilol with the target dose of 0.8 mg/kg/day. Ventricular function and the level of cardiac iron were assessed by echocardiography and magnetic resonance imaging at 0, 3, and 6 months. Results: The median age of the patients was 19 years (range 13–25 years). Four patients had severe left ventricular Grade III diastolic dysfunction and fourteen patients had Grade II diastolic dysfunction. The grade of left ventricular diastolic dysfunction was improved at 3 months after the carvedilol treatment. The Doppler parameters, including pulmonary vein atrial reversal velocity, pulmonary vein atrial reversal duration, and the difference of pulmonary vein atrial reversal and the mitral valve atrial contraction wave duration at 3 months after the carvedilol treatment, were significantly lower than these parameters before the treatment. Conclusions: Among patients with transfusion-dependent thalassemia who had left ventricular diastolic dysfunction without systolic dysfunction, treatment with carvedilol for 3 months was associated with improvement in Doppler parameters of left ventricular diastolic function. However, this finding and its clinical significance need to be confirmed in further double-blind controlled studies.
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Affiliation(s)
- Suchaya Silvilairat
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pimlak Charoenkwan
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Suwit Saekho
- Department of Radiologic Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand.,Biomedical Engineering Center, Faculty of Engineering, Chiang Mai University, Chiang Mai, Thailand
| | - Adisak Tantiworawit
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Department of Physiology, Cardiac Electrophysiology Unit, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
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Abstract
BACKGROUND Beta-blockers are an essential part of standard therapy in adult congestive heart failure and therefore, are expected to be beneficial in children. However, congestive heart failure in children differs from that in adults in terms of characteristics, aetiology, and drug clearance. Therefore, paediatric needs must be specifically investigated. This is an update of a Cochrane review previously published in 2009. OBJECTIVES To assess the effect of beta-adrenoceptor-blockers (beta-blockers) in children with congestive heart failure. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and LILACS up to November 2015. Bibliographies of identified studies were checked. No language restrictions were applied. SELECTION CRITERIA Randomised, controlled, clinical trials investigating the effect of beta-blocker therapy on paediatric congestive heart failure. DATA COLLECTION AND ANALYSIS Two review authors independently extracted and assessed data from the included trials. MAIN RESULTS We identified four new studies for the review update; the review now includes seven studies with 420 participants. Four small studies with 20 to 30 children each, and two larger studies of 80 children each, showed an improvement of congestive heart failure with beta-blocker therapy. A larger study with 161 participants showed no evidence of benefit over placebo in a composite measure of heart failure outcomes. The included studies showed no significant difference in mortality or heart transplantation rates between the beta-blocker and control groups. No significant adverse events were reported with beta-blockers, apart from one episode of complete heart block. A meta-analysis of left ventricular ejection fraction (LVEF) and fractional shortening (LVFS) data showed a very small improvement with beta-blockers. However, there were vast differences in the age, age range, and health of the participants (aetiology and severity of heart failure; heterogeneity of diagnoses and co-morbidities); there was a range of treatments across studies (choice of beta-blocker, dosing, duration of treatment); and a lack of standardised methods and outcome measures. Therefore, the primary outcomes could not be pooled in meta-analyses. AUTHORS' CONCLUSIONS There is not enough evidence to support or discourage the use of beta-blockers in children with congestive heart failure, or to propose a paediatric dosing scheme. However, the sparse data available suggested that children with congestive heart failure might benefit from beta-blocker treatment. Further investigations in clearly defined populations with standardised methodology are required to establish guidelines for therapy. Pharmacokinetic investigations of beta-blockers in children are also required to provide effective dosing in future trials.
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Affiliation(s)
- Samer Alabed
- Academic Unit of Radiology, University of Sheffield, Sheffield, UK
| | - Ammar Sabouni
- KasrAlAiny School of Medicine, Cairo University, Cairo, Egypt
| | - Suleiman Al Dakhoul
- Department of Medicine, The Wirral University Teaching Hospitals, Upton, Wirral, UK
| | - Yamama Bdaiwi
- Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
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Li T, Yuan G, Ma C, Jin P, Zhou C, Li W. Clinical efficacy of carvedilol treatment for dilated cardiomyopathy: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2019; 98:e15403. [PMID: 31045794 PMCID: PMC6504318 DOI: 10.1097/md.0000000000015403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Clinical trials examining the therapeutic benefit of carvedilol on patients with dilated cardiomyopathy have reported inconsistent results. The aim of this study was to evaluate the clinical efficacy of carvedilol on patients with dilated cardiomyopathy. METHODS PubMed, Embase, Cochrane Library, web of science, China National Knowledge Infrastructure (CNKI), Wanfang, and Chinese Scientific and Technological Journal (VIP) databases were searched for randomized controlled trials (RCTs) before March 2018. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were used to evaluate the effects of carvedilol on patients with dilated cardiomyopathy. RESULTS Twenty one studies including 1146 participants were included. There were significant improvements on heart rate (HR) (WMD = -14.18, 95% CI: -17.72 to -10.63, P < .001), LVEF (WMD = 7.28, 95% CI: 6.53-8.03, P < .001), SBP (WMD = -10.74, 95% CI: -12.78 to -8.70, P < .001), DBP (WMD = -4.61, 95% CI: -7.32 to -1.90, P = .001), LVEDD (WMD = -2.76, 95% CI: -4.89 to -0.62, P = .011), LVESD (WMD = -3.63, 95% CI: -6.55 to -0.71, P = .015), LVEDV (WMD = -9.30, 95% CI: -11.89 to -6.71, P < .001), LVESV (WMD = -12.28, 95% CI: -14.86 to -9.70, P < .001) under carvedilol treatment compared with control. CONCLUSION This meta-analysis demonstrates that carvedilol significantly improves cardiac function on patients with dilated cardiomyopathy. Further large scale, high-quality and multicenter RCTs are still required to confirm the impacts of carvedilol on patients with dilated cardiomyopathy.
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Neurohormonal targets in the treatment of pediatric heart failure. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2017.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Effect of Carvedilol on Serum Heart-type Fatty Acid-binding Protein, Brain Natriuretic Peptide, and Cardiac Function in Patients With Chronic Heart Failure. J Cardiovasc Pharmacol 2016; 65:480-4. [PMID: 25945865 DOI: 10.1097/fjc.0000000000000217] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To observe the changes of serum heart-type fatty acid-binding protein (h-FABP) and brain natriuretic peptide (BNP) in children with chronic heart failure (CHF) and evaluate the effects of carvedilol. METHODS A total of 36 patients with CHF, including 17 of endocardial fibroelastosis and 19 of dilated cardiomyopathy, were enrolled and were randomly divided into a carvedilol treatment group (group A) and a conventional treatment group (group B). Group A (n = 16) was treated with carvedilol and conventional treatment and group B (n = 20) was managed with conventional treatment only. Thirty healthy children were enrolled as controls. The concentrations of serum h-FABP and BNP were measured by enzyme-linked immunosorbent assay, and the left ventricular end-systolic diameter, left ventricular end-diastolic diameter, left ventricular ejection fraction (LVEF), left ventricular fractional shortening (LVFS), and cardiac index (CI) were measured by echocardiography. RESULTS The concentrations of serum h-FABP and BNP in patients with CHF were significantly higher than in the control group (21.7 ± 4.3 ng/mL vs. 6.3 ± 1.7 ng/mL, 582.4 ± 180.6 pg/mL vs.31.2 ± 9.8 pg/mL, all P < 0.01), positively correlated with the degree of heart failure (all P < 0.01), and were both higher in groups endocardial fibroelastosis and dilated cardiomyopathy than in the control group (all P < 0.01), but there was no statistically significant difference between the 2 groups (P > 0.05). h-FABP concentration in patients with CHF was positively correlated with BNP (r = 0.78, P < 0.01) but negatively correlated with LVEF, LVFS, and CI (r = -0.65, -0.64, and -0.71, respectively; all P < 0.01). BNP concentration was also negatively correlated with LVEF, LVFS, and CI (r = -0.75, -0.61, and -0.79, respectively; all P<0.01). After treatment with carvedilol, the serum concentrations of h-FABP and BNP in group A were lower than in group B, and the magnitude of heart rate reduction, improvement of LVEF, LVFS, and CI, and reduction of left ventricular end-systolic diameter and left ventricular end-diastolic diameter in group A were all greater than in group B (all P < 0.01). Treatment with carvedilol had no adverse events. CONCLUSIONS Serum concentrations of h-FABP and BNP can be used as biomarkers to evaluate the severity of heart failure, and carvedilol can significantly improve heart function in children with CHF.
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Tsuda E, Negishi J, Noritake K, Iwasa T, Abe T. Left ventricular reverse remodeling with infantile dilated cardiomyopathy and pitfalls of carvedilol therapy. J Cardiol 2016; 67:147-52. [DOI: 10.1016/j.jjcc.2015.08.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 08/10/2015] [Accepted: 08/27/2015] [Indexed: 10/22/2022]
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Alabed S, Sabouni A, Al Dakhoul S, Bdaiwi Y, Frobel-Mercier AK. Beta-blockers for congestive heart failure in children. Cochrane Database Syst Rev 2016:CD007037. [PMID: 26820557 DOI: 10.1002/14651858.cd007037.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Beta-blockers are an essential part of standard therapy in adult congestive heart failure and therefore, are expected to be beneficial in children. However, congestive heart failure in children differs from that in adults in terms of characteristics, aetiology, and drug clearance. Therefore, paediatric needs must be specifically investigated. This is an update of a Cochrane review previously published in 2009. OBJECTIVES To assess the effect of beta-adrenoceptor-blockers (beta-blockers) in children with congestive heart failure. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and LILACS up to November 2015. Bibliographies of identified studies were checked. No language restrictions were applied. SELECTION CRITERIA Randomised, controlled, clinical trials investigating the effect of beta-blocker therapy on paediatric congestive heart failure. DATA COLLECTION AND ANALYSIS Two review authors independently extracted and assessed data from the included trials. MAIN RESULTS We identified four new studies for the review update; the review now includes seven studies with 420 participants. Four small studies with 20 to 30 children each, and two larger studies of 80 children each, showed an improvement of congestive heart failure with beta-blocker therapy. A larger study with 161 participants showed no evidence of benefit over placebo in a composite measure of heart failure outcomes. The included studies showed no significant difference in mortality or heart transplantation rates between the beta-blocker and control groups. No significant adverse events were reported with beta-blockers, apart from one episode of complete heart block. A meta-analysis of left ventricular ejection fraction (LVEF) and fractional shortening (LVFS) data showed a very small improvement with beta-blockers.However, there were vast differences in the age, age range, and health of the participants (aetiology and severity of heart failure; heterogeneity of diagnoses and co-morbidities); there was a range of treatments across studies (choice of beta-blocker, dosing, duration of treatment); and a lack of standardised methods and outcome measures. Therefore, the primary outcomes could not be pooled in meta-analyses. AUTHORS' CONCLUSIONS There is not enough evidence to support or discourage the use of beta-blockers in children with congestive heart failure, or to propose a paediatric dosing scheme. However, the sparse data available suggested that children with congestive heart failure might benefit from beta-blocker treatment. Further investigations in clearly defined populations with standardised methodology are required to establish guidelines for therapy. Pharmacokinetic investigations of beta-blockers in children are also required to provide effective dosing in future trials.
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Affiliation(s)
- Samer Alabed
- Department of Cardiovascular Science, The University of Sheffield, Sheffield, UK
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Motoki N, Inaba Y, Matsuzaki S, Akazawa Y, Nishimura T, Fukuyama T, Koike K. Successful treatment of arrhythmia-induced cardiomyopathy in an infant with tuberous sclerosis complex. BMC Pediatr 2016; 16:16. [PMID: 26809174 PMCID: PMC4724951 DOI: 10.1186/s12887-016-0557-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 01/23/2016] [Indexed: 11/10/2022] Open
Abstract
Background Tuberous sclerosis complex (TSC) is an autosomal-dominant tumor suppressor gene syndrome that is characterized by the development of distinctive benign tumors and malformations in multiple organ systems (N Eng J Med 355:1345-1356, 2006). Cardiac rhabdomyomas are intracavitary or intramural tumors observed in 50–70 % of infants with TSC but only cause serious clinical problems in a very small fraction of these patients (N Eng J Med 355:1345-1356, 2006; Pediatrics 118:1146-1151, 2006; Eur J Pediatr 153:155-7, 1994); most individuals have no clinical symptoms and their tumors spontaneously regress. However, despite being clinically silent, these lesions can provoke arrhythmias and heart failure (Pediatrics 118:1146-1151, 2006; Eur J Pediatr 153:155-7, 1994). Case presentation We here report the clinical findings of an infant suffering from TSC complicated with dilated cardiomyopathy (DCM) after the regression of cardiac rhabdomyomas. Although his tumors improved spontaneously, tachycardia and irregular heart rate due to frequent premature ventricular and supraventricular contractions persisted from the newborn period and were refractory to several medications. His cardiomyopathy was suspected to have been induced by the tachycardia or arrhythmia. We found carvedilol therapy to be safe and highly effective in treating the cardiomyopathy. To our knowledge, this is the first case report of TSC with DCM after regression of cardiac tumors and its successful treatment. Conclusion The patient’s clinical course suggests that careful life-long disease management is important, even in TSC patients without apparent symptoms.
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Affiliation(s)
- Noriko Motoki
- Department of Pediatrics, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, 390-8621, Japan.
| | - Yuji Inaba
- Department of Pediatrics, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, 390-8621, Japan
| | - Satoshi Matsuzaki
- Department of Pediatrics, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, 390-8621, Japan
| | - Yohei Akazawa
- Department of Pediatrics, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, 390-8621, Japan
| | - Takafumi Nishimura
- Department of Pediatrics, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, 390-8621, Japan
| | - Tetsuhiro Fukuyama
- Department of Pediatrics, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, 390-8621, Japan
| | - Kenichi Koike
- Department of Pediatrics, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, 390-8621, Japan
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Moffett BS, Price JF. National Prescribing Trends for Heart Failure Medications in Children. CONGENIT HEART DIS 2014; 10:78-85. [DOI: 10.1111/chd.12183] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2014] [Indexed: 01/11/2023]
Affiliation(s)
- Brady S. Moffett
- Department of Pharmacy; Texas Children's Hospital; Houston Tex USA
- Section of Pediatric Cardiology; Department of Pediatrics; Baylor College of Medicine; Houston Tex USA
| | - Jack F. Price
- Section of Pediatric Cardiology; Department of Pediatrics; Baylor College of Medicine; Houston Tex USA
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Karabacak M, Dogan A, Tayyar S, Bas HA. Oxidative stress status increase in patients with nonischemic heart failure. Med Princ Pract 2014; 23:532-7. [PMID: 25195646 PMCID: PMC5586961 DOI: 10.1159/000365512] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 06/26/2014] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE It was the aim of this study to investigate the serum oxidative stress level in nonischemic patients with heart failure (HF). SUBJECTS AND METHODS The study included 37 patients who presented to the Department of Cardiology, Suleyman Demirel University, Isparta, Turkey, with a diagnosis of asymptomatic HF (New York Heart Association class I-II). The patients had a left ventricular (LV) ejection fraction (EF) of ≤40% and normal coronary arteries or nonsignificant stenosis (stenosis <40%). In addition, 30 age- and sex-matched normal patients were selected as the control group. Clinical and laboratory characteristics presumed to be associated with oxidative stress were evaluated. RESULTS Demographic characteristics were comparable. However, creatinine and potassium levels were higher in the HF than in the control group. Total oxidative status [2.42 μmol H2O2 Eq/l (range 0.74-5.86) vs. 1.81 μmol H2O2 Eq/l (range 0.42-3.45); p < 0.01], oxidative stress index [2.24 (range 0.63-5.33) vs. 1.53 (range 0.28-2.51); p < 0.01] and uric acid (6.1 ± 1.8 vs. 4.4 ± 1.1 mg/dl; p < 0.01) levels were significantly higher in the HF than in the control group. The total antioxidant capacity was similar in both groups [1.22 mmol Trolox Eq/l (range 0.61-1.99) vs. 1.18 mmol Trolox Eq/l (range 0.82-1.80); p = 0.77]. The γ-glutamyltransferase levels were also comparable in both groups [32 U/l (range 11-106) vs. 23 U/l (range 11-72); p = 0.10]. CONCLUSION The oxidative stress levels were higher in HF patients, and hence, oxidative stress may play an important role in poor prognosis of HF. Therefore, antioxidant treatment might be reasonable.
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Costa VM, Carvalho F, Duarte JA, Bastos MDL, Remião F. The Heart As a Target for Xenobiotic Toxicity: The Cardiac Susceptibility to Oxidative Stress. Chem Res Toxicol 2013; 26:1285-311. [PMID: 23902227 DOI: 10.1021/tx400130v] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Vera Marisa Costa
- REQUIMTE (Rede de Química e Tecnologia),
Laboratório de Toxicologia, Departamento de Ciências
Biológicas, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal
| | - Félix Carvalho
- REQUIMTE (Rede de Química e Tecnologia),
Laboratório de Toxicologia, Departamento de Ciências
Biológicas, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal
| | | | - Maria de Lourdes Bastos
- REQUIMTE (Rede de Química e Tecnologia),
Laboratório de Toxicologia, Departamento de Ciências
Biológicas, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal
| | - Fernando Remião
- REQUIMTE (Rede de Química e Tecnologia),
Laboratório de Toxicologia, Departamento de Ciências
Biológicas, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal
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Christensen AH, Fatkin D. Efficacy of carvedilol in pediatric heart failure. Future Cardiol 2013; 9:475-8. [DOI: 10.2217/fca.13.36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Evaluation of: Huang M, Zhang X, Chen S et al. The effect of carvedilol treatment on chronic heart failure in pediatric patients with dilated cardiomyopathy: a prospective, randomized-controlled study. Pediatr. Cardiol. 34, 680–685 (2013). A role for β-blockers in children with heart failure has not been established. Huang et al. conducted a randomized trial of oral carvedilol in children with dilated cardiomyopathy treated with conventional therapy for a minimum of 1 month. The primary end points were Ross score, echocardiographic parameters, brain natriuretic peptide levels and a composite clinical end point. Of the subjects assessed at 6 months, 41 had received carvedilol (up to 0.8 mg/kg/day) and 37 had not (control group). Carvedilol had favorable effects on Ross score, left ventricular function and brain natriuretic peptide levels. However, improvement was also seen in the control group, although this was not as pronounced. Composite end points were similar in the carvedilol-treated and control groups. Only one serious adverse event was observed. The results suggest a possible beneficial effect of carvedilol when added to conventional therapy, but a number of limitations of study design restrict the conclusions that can be drawn.
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Affiliation(s)
- Alex Hørby Christensen
- Molecular Cardiology Division, Victor Chang Cardiac Research Institute, 405 Liverpool Street, Darlinghurst, New South Wales 2010, Australia
| | - Diane Fatkin
- Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
- Cardiology Department, St Vincent’s Hospital, Darlinghurst, New South Wales, Australia
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Niu X, Watts VL, Cingolani OH, Sivakumaran V, Leyton-Mange JS, Ellis CL, Miller KL, Vandegaer K, Bedja D, Gabrielson KL, Paolocci N, Kass DA, Barouch LA. Cardioprotective effect of beta-3 adrenergic receptor agonism: role of neuronal nitric oxide synthase. J Am Coll Cardiol 2012; 59:1979-87. [PMID: 22624839 DOI: 10.1016/j.jacc.2011.12.046] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 11/07/2011] [Accepted: 12/01/2011] [Indexed: 01/08/2023]
Abstract
OBJECTIVES The aim of this study was to determine whether activation of β3-adrenergic receptor (AR) and downstream signaling of nitric oxide synthase (NOS) isoforms protects the heart from failure and hypertrophy induced by pressure overload. BACKGROUND β3-AR and its downstream signaling pathways are recognized as novel modulators of heart function. Unlike β1- and β2-ARs, β3-ARs are stimulated at high catecholamine concentrations and induce negative inotropic effects, serving as a "brake" to protect the heart from catecholamine overstimulation. METHODS C57BL/6J and neuronal NOS (nNOS) knockout mice were assigned to receive transverse aortic constriction (TAC), BRL37344 (β3 agonist, BRL 0.1 mg/kg/h), or both. RESULTS Three weeks of BRL treatment in wild-type mice attenuated left ventricular dilation and systolic dysfunction, and partially reduced cardiac hypertrophy induced by TAC. This effect was associated with increased nitric oxide production and superoxide suppression. TAC decreased endothelial NOS (eNOS) dimerization, indicating eNOS uncoupling, which was not reversed by BRL treatment. However, nNOS protein expression was up-regulated 2-fold by BRL, and the suppressive effect of BRL on superoxide generation was abrogated by acute nNOS inhibition. Furthermore, BRL cardioprotective effects were actually detrimental in nNOS(-/-) mice. CONCLUSIONS These results are the first to show in vivo cardioprotective effects of β3-AR-specific agonism in pressure overload hypertrophy and heart failure, and support nNOS as the primary downstream NOS isoform in maintaining NO and reactive oxygen species balance in the failing heart.
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Affiliation(s)
- Xiaolin Niu
- Department of Cardiology, Tangdu Hospital, The Fourth Military Medical University, Xinsi Road, Xi'an, China. [corrected]
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Tousoulis D, Papageorgiou N, Briasoulis A, Androulakis E, Charakida M, Tsiamis E, Stefanadis C. Conflicting effects of nitric oxide and oxidative stress in chronic heart failure: potential therapeutic strategies. Heart Fail Rev 2012; 17:65-79. [PMID: 21293971 DOI: 10.1007/s10741-011-9228-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Chronic heart failure (CHF) is characterized by decreased nitric oxide (NO) bioavailability. In addition, the beneficial NO turns to be deleterious when it reacts with superoxide anion, leading to peroxynitrite formation. Numerous experimental and clinical studies have reported increased production of reactive oxygen species (superoxide, hydrogen peroxide, hydroxyl radical) both in animals and patients with CHF. Moreover, there are indicative data suggesting mechanisms associated with endothelial dysfunction in states of CHF, mainly attributed to decreased NO bioavailability and enhanced inactivation of the latter. Thus, such molecules appear to be potential targets in patients with CHF. These patients are strong candidates to receive a variety of therapeutic agents, some of which have known antioxidant effects. Classic treatment with statins or angiotensin converting enzyme inhibitors has been found to be beneficial in restoring NO and improving myocardial function and structure. Other agents such as sildenafil and b-blockers along with novel agents such as NO synthase transcription enhancers have been proved to be also beneficial, but their use for such a purpose is still controversial. Approaches using more-effective antioxidants or targeting myocardial oxidant-producing enzymes and oxidative or nitrosative stress might be promising strategies in the future.
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Vaidyanathan B. Is there a role for carvedilol in the management of pediatric heart failure? A meta analysis and e-mail survey of expert opinion. Ann Pediatr Cardiol 2011; 2:74-8. [PMID: 20300274 PMCID: PMC2840768 DOI: 10.4103/0974-2069.52816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Balu Vaidyanathan
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, AIMS, Ponekkara P.O., Kochi, Kerala - 682 041, India
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Is medical management of paediatric heart failure evidence based? COR ET VASA 2011. [DOI: 10.33678/cor.2011.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
OBJECTIVES The objective of this study was to describe the pattern of pediatric carvedilol ingestions reported to poison centers. METHODS Cases were all carvedilol ingestions by patients aged 0 to 5 years reported to Texas poison centers during 2000 to 2008. Multiple substance ingestions and patients not followed up to a final medical outcome were excluded. The distribution of cases by selected demographic and clinical factors was determined, and the mean dose (MD) in milligrams and milligrams per kilogram calculated for those cases where the dose ingested was reported. RESULTS Of a total 111 cases, the dose in mg was reported in 67 (mean, 18.2 mg; range, 0.3-200 mg) and in mg/kg was reported in 41 (mean, 1.5 mg/kg; range, 0.1-14.8 mg/kg). Of total cases, 63.1% were males and 36.9% females. The management site was as follows: 23.4% on site (MD, 7.8 mg and 0.6 mg/kg), 37.8% already at or en route to health care facility (MD, 22.7 mg and 2.6 mg/kg), and 38.7% referred to health care facility (MD, 22.1 mg and 1.6 mg/kg). The medical outcome as follows: 97.3% no effect (MD, 18.7 mg and 1.5 mg/kg), 1.8% minor effect (MD, 3.4 mg and 0.5 mg/kg), and 0.9% moderate effect. Adverse clinical effects were reported in 4 cases (3 drowsiness and 1 hypotension). CONCLUSIONS Pediatric ingestions of as much as 200 mg (14.8 mg/kg) reported to Texas poison centers might be expected to result in at most minor effects, although ingestions involving higher doses might be referred to health care facilities.
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Abstract
Diagnostic and Therapeutic Significance of the Oxidative Stress Parameters in ChildrenPharmacotherapy of pediatric diseases represents a major challenge considering that the majority of medicines in everyday practice have not been pediatrically evaluated. The efficacy of therapy depends to a large extent on the knowledge of pathophysiological processes in the children organism at different ages. Therefore, research in that direction is of the utmost importance. An imbalance in the production of free oxygen/nitrogen species and parameters of antioxidative protection is a significant factor in many diseases (e.g. heart failure, pulmonary hypertension, asthma, neonatal sepsis, cancer etc.) in children of different age groups. Reactive oxygen/nitrogen species serve as cell signaling molecules for normal biologic processes. An increase in their generation can cause damages which can disrupt normal physiological cellular processes and eventually cause cell death. This review outlines the previous assessments of oxidative stress parameters in children of different ages for some diseases. Also, the potential diagnostic and therapeutic possibilities for the oxydative stress parameters in children have been considered.
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Chakraborty S, Shukla D, Mishra B, Singh S. Clinical updates on carvedilol: a first choice beta-blocker in the treatment of cardiovascular diseases. Expert Opin Drug Metab Toxicol 2010; 6:237-50. [PMID: 20073998 DOI: 10.1517/17425250903540220] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE OF THE FIELD Carvedilol, a non-selective beta-blocker, has recently drawn attention because of its therapeutic benefits over other prescribed analogues for the treatment of cardiovascular diseases (CVDs). AREAS COVERED IN THIS REVIEW The present review attempts to present the clinical efficacy of carvedilol in comparison to other available beta-blockers. The literature search was carried out in three electronic databases (Unbound Medline, Pubmed and Sciencedirect) and internet search engines (Scirus and Google Scholar) without time constraints to ensure maximum literature coverage. WHAT THE READER WILL GAIN A relatively large number of comparative studies have revealed that carvedilol has advantage over traditional beta-blockers with respect to hemodynamic and metabolic effects, due to its unique non-selective alpha-/beta-adrenoceptor affinity. Such results indicate its safe and effective therapeutic application particularly in patients with complicated CVDs, even in pediatric and geriatric patients. TAKE HOME MESSAGE The therapeutic profile of carvedilol indicates its suitability for treatment of complicated CVDs than other non-selective beta-blockers. However, there is a limitation in terms of its dose due to its low bioavailability (approximately 25%). Therefore, there is still need for bioavailability enhancement and dose reduction to further improve the therapeutic efficacy of the drug.
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Affiliation(s)
- Subhashis Chakraborty
- Banaras Hindu University, Institute of Technology, Department of Pharmaceutics, Varanasi-221005, India
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Patel AR, Shaddy RE. Role of β-blocker therapy in pediatric heart failure. ACTA ACUST UNITED AC 2010; 4:45-58. [PMID: 21799703 DOI: 10.2217/phe.09.65] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Heart failure is becoming an increasingly common and significant problem in the field of pediatric cardiology. The numerous types of cardiomyopathies, and more recently, long-term survival of patients with congenital heart disease, have added to a growing patient population. Over the last several decades, our knowledge base regarding mechanisms of disease and therapeutic intervention in adult patients with heart failure has drastically changed. The most recent and important breakthrough in the pharmacologic treatment of heart failure has been the particular role of β-blocker therapy. This medication has led to significant improvements in survival and symptoms in adults, with less convincing findings in limited studies in pediatrics. The ability to study the benefits of this therapy in patients has been challenging owing to the heterogeneity of the patient population and lack of large sample sizes. However, as we investigate the mechanisms behind the disease process, the differences that exist between disease conditions and ages, and the significant alterations that may exist at the molecular and genetic level, our understanding of β-blocker therapy in pediatric heart failure will improve, and ultimately may lead to patient-specific therapy.
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Affiliation(s)
- Akash R Patel
- The Children's Hospital of Philadelphia, Department of Cardiology, 34th & Civic Center Boulevard, Philadelphia, PA 19104, USA Tel.: +1 215 590 3548
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