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Kipka H, Liebchen U, Hübner M, Höfner G, Frey O, Wanner KT, Kilger E, Hagl C, Tomasi R, Mannell H. Serum concentrations of levosimendan and its metabolites OR-1855 and OR-1896 in cardiac surgery patients with cardiopulmonary bypass. Front Cardiovasc Med 2024; 11:1406338. [PMID: 39175630 PMCID: PMC11338783 DOI: 10.3389/fcvm.2024.1406338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 04/19/2024] [Indexed: 08/24/2024] Open
Abstract
Background The inotropic drug levosimendan is often used as an individualized therapeutic approach perioperatively in cardiac surgery patients with cardiopulmonary bypass (CPB). Data regarding serum concentrations of levosimendan and its metabolites within this context is lacking. Methods In this retrospective descriptive proof-of-concept study, total serum concentrations (TSC) and unbound fractions (UF) of levosimendan and its metabolites OR-1896 and OR-1855 in cardiac surgery patients with CPB were measured using LC-ESI-MS/MS. Simulation of expected levosimendan TSC was performed using Pharkin 4.0. Serum NT-proBNP was assessed with ELISA. Results After levosimendan infusion (1.25 mg or 2.5 mg, respectively) after anaesthesia induction, a median TSC of 1.9 ng/ml and 10.4 ng/ml was determined in samples taken directly after surgery (T1). Median TSC of 7.6 ng/ml and 22.0 ng/ml, respectively, were simulated at T1. Whereas 1.1 ng/ml and 1.6 ng/ml TSC of OR-1896, respectively, was quantified the day after surgery (T2), TSC of the intermediate metabolite OR-1855 was mostly below the lower limit of quantification (LLOQ). The UF was 0.5% and 1.1% for levosimendan and 64.1% and 52.1% for OR-1896, respectively, with over half the samples being below LLOQ. NT-proBNP concentrations before surgery and T2 did not differ. Discussion The low TSC, UF and unchanged NT-proBNP levels in combination with high variation of serum levels between patients suggest a need for optimized dosing regimen of levosimendan combined with therapeutic drug monitoring for such an individualized approach. In addition, the differences between the measured and estimated concentrations may suggest a possible influence of CPB on levosimendan serum concentrations.
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Affiliation(s)
- Hannah Kipka
- Doctoral Program Clinical Pharmacy, LMU University Hospital, LMU Munich, Germany
- Institute of Cardiovascular Physiology and Pathophysiology, Biomedical Center, LMU Munich, Planegg, Germany
| | - Uwe Liebchen
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Max Hübner
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
- Walter Brendel Center of Experimental Medicine, LMU Munich, LMU University Hospital, Munich, Germany
| | - Georg Höfner
- Department of Pharmacy, Center for Drug Research, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Otto Frey
- Department of Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Klaus T. Wanner
- Department of Pharmacy, Center for Drug Research, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Erich Kilger
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Germany
- DZHK (German Centre of Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Roland Tomasi
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Hanna Mannell
- Doctoral Program Clinical Pharmacy, LMU University Hospital, LMU Munich, Germany
- Institute of Cardiovascular Physiology and Pathophysiology, Biomedical Center, LMU Munich, Planegg, Germany
- Physiology, Institute for Theoretical Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
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2
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Rayo-Abella LM, Grundig P, Bernhardt MN, Hofmann B, Neumann J, Gergs U. OR-1896 increases force of contraction in the isolated human atrium. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2023; 396:3823-3833. [PMID: 37354216 PMCID: PMC10643428 DOI: 10.1007/s00210-023-02592-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/19/2023] [Indexed: 06/26/2023]
Abstract
OR-1896 ((R)-N-(4-(4-methyl-6-oxo-1,4,5,6-tetrahydropyridazin-3-yl)phenyl)acetamide) is the main active metabolite of levosimendan. However, nobody has reported a positive inotropic effect of OR-1896 in isolated human cardiac preparations. The mechanism of action of OR-1896 remains controversial. Hence, we wanted to know whether OR-1896 exerts a positive inotropic effect in humans and what might be the underlying mechanism. Therefore, we measured the contractile effects of OR-1896 (0.01-10 µM cumulatively applied) in isolated electrically stimulated (1 Hz) human right atrial preparations (HAP) obtained during cardiac surgery. OR-1896, given alone, exerted time- and concentration-dependent positive inotropic effects; 1-µM OR-1896 increased force by 72 ± 14.7% (p < 0.05, n = 6) and shortened the time of relaxation by 10.6 ± 3.6% (p < 0.05, n = 11) in HAP started at 0.1 µM, plateaued at 1-µM OR-1896, and was antagonized by 1-µM propranolol. The maximum positive inotropic effect of OR-1896 in human right atrial preparations was less than that of 10-µM isoprenaline. EMD 57033 (10 µM), a calcium sensitizer, enhanced the force of contraction further in the additional presence of 1-µM OR-1896 by 109 ± 19% (p < 0.05, n = 4). Cilostamide (10 µM), an inhibitor of phosphodiesterase III given before OR-1896 (1 µM), blocked the positive inotropic effect of OR-1896 in HAP. Our data suggest that OR-1896 is, indeed, a positive inotropic agent in the human heart. OR-1896 acts as a PDE III inhibitor. OR-1896 is unlikely to act as a calcium sensitizer in the human heart.
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Affiliation(s)
- Lina M Rayo-Abella
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Magdeburger Straße 4, 06097, Halle, Germany
| | - Peter Grundig
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Magdeburger Straße 4, 06097, Halle, Germany
| | - Max N Bernhardt
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Magdeburger Straße 4, 06097, Halle, Germany
| | - Britt Hofmann
- Herzchirurgie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Ernst Grube Straße 40, 06097, Halle, Germany
| | - Joachim Neumann
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Magdeburger Straße 4, 06097, Halle, Germany.
| | - Ulrich Gergs
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Magdeburger Straße 4, 06097, Halle, Germany
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3
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Schiefenhövel F, Berger C, Penkova L, Grubitzsch H, Haller B, Meyer A, Heringlake M, Sander M, Erb JM, Balzer F, Treskatsch S. Influence of timing of Levosimendan administration on outcomes in cardiac surgery. Front Cardiovasc Med 2023; 10:1213696. [PMID: 37564910 PMCID: PMC10410848 DOI: 10.3389/fcvm.2023.1213696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/06/2023] [Indexed: 08/12/2023] Open
Abstract
Purpose Though a subgroup analysis has shown improved survival for patients suffering severely reduced ventricular function undergoing coronary artery bypass grafting, RCTs were not able to demonstrate overall beneficial effects of perioperative Levosimendan in cardiac surgery. This might be due to Levosimendan's pharmacokinetics reaching a steady-state concentration only 4-8 h after administration. Thus, this study now analysed the influence of timing of Levosimendan administration on perioperative outcome in cardiac surgery patients preoperatively presenting with severely reduced ventricular function and therefore considered at high-risk for intra- or postoperative low cardiac output syndrome. We hypothesized that prolonged preoperative Levosimendan administration ("preconditioning") would reduce mortality. Methods All adult patients undergoing cardiac surgery between 2006 and 2018 perioperatively receiving Levosimendan were included in this retrospective, observational cohort study (n = 498). Patients were stratified into 3 groups: Levosimendan started on the day prior to surgery ("preop"), Levosimendan started on the day of surgery ("intraop") or post ICU admission ("postop"). After propensity score matching (PSM) was performed, outcomes defined according to proposed standard definitions for perioperative outcome research were compared between groups. Results After PSM, there were no significant differences in patients' characteristics, comorbidities and type/priority of surgery between groups. Compared to intraop or postop Levosimendan treatment, preop treated patients had significantly lower in-hospital-mortality (preop vs. intraop. vs. postop = 16,7% vs. 33,3% vs. 42,3%), duration of mechanical ventilation and rate of continuous renal replacement therapy. Conclusions Prolonged preoperative treatment with Levosimendan of cardiac surgery patients preoperatively presenting with severely reduced left ventricular function might be beneficial in terms of postoperative outcome. Our results are in line with recent experts' recommendations concerning the prolonged perioperative use of Levosimendan. We strongly recommend that future randomized trials include this "preconditioning" treatment as an experimental arm.
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Affiliation(s)
- Fridtjof Schiefenhövel
- Department of Anaesthesiology and Intensive Care (AINS), Medical Center Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- Institute for Artificial Intelligence and Informatics in Medicine (AIIM), Chair of Medical Informatics, Medical Center Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Medical Informatics, Berlin, Germany
| | - Christian Berger
- Department of Anaesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Berlin, Germany
| | - Liubov Penkova
- Department of Anaesthesiology and Intensive Care Medicine, Charité Campus Mitte and Charité Campus Virchow, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Berlin, Germany
| | - Herko Grubitzsch
- Klinik für Kardiovaskuläre Chirurgie, Campus Virchow Klinikum, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Berlin, Germany
| | - Bernhard Haller
- Institute for Artificial Intelligence and Informatics in Medicine (AIIM), Chair of Medical Informatics, Medical Center Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Alexander Meyer
- Klinik für Kardiovaskuläre Chirurgie, Campus Virchow Klinikum, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Berlin, Germany
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Matthias Heringlake
- Department of Anaesthesia, Heart and Diabetes Center, Klinikum Karlsburg, Karlsburg, Germany
| | - Michael Sander
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Gießen UKGM, Justus-Liebig University Gießen, Gießen, Germany
| | - Joachim M. Erb
- Clinic for Anaesthesiology, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Felix Balzer
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Medical Informatics, Berlin, Germany
| | - Sascha Treskatsch
- Department of Anaesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Berlin, Germany
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Lim S, Shin S, Sung Y, Lee HE, Kim KH, Song JY, Lee GH, Aziz H, Lukianenko N, Kang DM, Boesen N, Jeong H, Abdildinova A, Lee J, Yu BY, Lim SM, Lee JS, Ryu H, Pae AN, Kim YK. Levosimendan inhibits disulfide tau oligomerization and ameliorates tau pathology in Tau P301L-BiFC mice. Exp Mol Med 2023; 55:612-627. [PMID: 36914856 PMCID: PMC10073126 DOI: 10.1038/s12276-023-00959-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 12/26/2022] [Accepted: 01/01/2023] [Indexed: 03/14/2023] Open
Abstract
Tau oligomers play critical roles in tau pathology and are responsible for neuronal cell death and transmitting the disease in the brain. Accordingly, preventing tau oligomerization has become an important therapeutic strategy to treat tauopathies, including Alzheimer's disease. However, progress has been slow because detecting tau oligomers in the cellular context is difficult. Working toward tau-targeted drug discovery, our group has developed a tau-BiFC platform to monitor and quantify tau oligomerization. By using the tau-BiFC platform, we screened libraries with FDA-approved and passed phase I drugs and identified levosimendan as a potent anti-tau agent that inhibits tau oligomerization. 14C-isotope labeling of levosimendan revealed that levosimendan covalently bound to tau cysteines, directly inhibiting disulfide-linked tau oligomerization. In addition, levosimendan disassembles tau oligomers into monomers, rescuing neurons from aggregation states. In comparison, the well-known anti-tau agents methylene blue and LMTM failed to protect neurons from tau-mediated toxicity, generating high-molecular-weight tau oligomers. Levosimendan displayed robust potency against tau oligomerization and rescued cognitive declines induced by tauopathy in the TauP301L-BiFC mouse model. Our data present the potential of levosimendan as a disease-modifying drug for tauopathies.
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Affiliation(s)
- Sungsu Lim
- Center for Brain Disorders, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea
| | - Seulgi Shin
- Center for Brain Disorders, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea
| | - Yoonsik Sung
- Center for Brain Disorders, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea.,Division of Bio-Medical Science & Technology, KIST School, Korea University of Science and Technology (UST), Seoul, 02792, Republic of Korea
| | - Ha Eun Lee
- Center for Brain Disorders, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea
| | - Kyu Hyeon Kim
- Center for Brain Disorders, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea.,Division of Bio-Medical Science & Technology, KIST School, Korea University of Science and Technology (UST), Seoul, 02792, Republic of Korea
| | - Ji Yeon Song
- Center for Brain Disorders, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea
| | - Gwan-Ho Lee
- Advanced Analysis Center, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea
| | - Hira Aziz
- Center for Brain Disorders, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea.,Division of Bio-Medical Science & Technology, KIST School, Korea University of Science and Technology (UST), Seoul, 02792, Republic of Korea
| | - Nataliia Lukianenko
- Center for Brain Disorders, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea.,Division of Bio-Medical Science & Technology, KIST School, Korea University of Science and Technology (UST), Seoul, 02792, Republic of Korea
| | - Dong Min Kang
- Center for Brain Disorders, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea.,Department of Life Sciences, Korea University, Seoul, 02841, Korea
| | - Nicolette Boesen
- Center for Brain Disorders, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea.,Division of Bio-Medical Science & Technology, KIST School, Korea University of Science and Technology (UST), Seoul, 02792, Republic of Korea
| | - Hyeanjeong Jeong
- Center for Brain Disorders, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea
| | - Aizhan Abdildinova
- Center for Brain Disorders, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea
| | - Junghee Lee
- Boston University Alzheimer's disease Research Center and VA Boston Health care System, Boston, MA, 02130, USA
| | - Byung-Yong Yu
- Advanced Analysis Center, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea
| | - Sang Min Lim
- Center for Brain Disorders, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea
| | - Jun-Seok Lee
- Department of Pharmacology, Korea University College of Medicine, Seoul, 02792, Republic of Korea
| | - Hoon Ryu
- Center for Brain Disorders, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea.,Boston University Alzheimer's disease Research Center and Department of Neurology, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Ae Nim Pae
- Center for Brain Disorders, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea.
| | - Yun Kyung Kim
- Center for Brain Disorders, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea. .,Division of Bio-Medical Science & Technology, KIST School, Korea University of Science and Technology (UST), Seoul, 02792, Republic of Korea.
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5
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Bourgoin P, Lecomte J, Oualha M, Berthomieu L, Pereira T, Davril E, Lamoureux F, Joram N, Chenouard A, Duflot T. Population Pharmacokinetics of Levosimendan and its Metabolites in Critically Ill Neonates and Children Supported or Not by Extracorporeal Membrane Oxygenation. Clin Pharmacokinet 2023; 62:335-348. [PMID: 36631687 DOI: 10.1007/s40262-022-01199-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Levosimendan (LVSMD) is a calcium-sensitizer inotropic and vasodilator agent whose use might have a beneficial effect on the weaning of venoarterial extracorporeal membrane oxygenation (VA-ECMO). In light of LVSMD pharmacological characteristics, we hypothesized that ECMO may induce major pharmacokinetic (PK) modifications for LVSMD and its metabolites. OBJECTIVE The aim of this study was to investigate the PK of LVSMD and its metabolites, and to assess the effects of ECMO on PK parameters. METHODS We conducted a multicentric, prospective study (NCT03681379). Twenty-seven infusions of LVSMD were performed, allowing for the collection of 255 blood samples. Non-linear mixed-effects modeling software (MONOLIX®) was used to develop a parent-metabolite PK model of LVSMD and its metabolites. RESULTS Most patients received a 0.2 µg/kg/min infusion of LVSMD over 24 h. After elimination of non-reliable samples or concentrations below the limit of quantification, 166, 101 and 85 samples were considered for LVSMD, OR-1855 and OR-1896, respectively, of which 81, 53 and 41, respectively, were drawn under ECMO conditions. Parent-metabolite PK modeling revealed that a two-compartment model with first-order elimination best described LVSMD PK. Use of a transit compartment allowed for an explanation of the delayed appearance of circulating OR-1855 and OR-1896, with the latter following a first-order elimination. Patient weight influenced the central volume of distribution and elimination of LVSMD. ECMO support increased the elimination rate of LVSMD by 78%, and ECMO also slowed down the metabolite formation rate by 85% for OR-1855, which in turn is converted to the active metabolite OR-1896, 14% slower than without ECMO. Simulated data revealed that standard dosing may not be appropriate for patients under ECMO, with a decrease in the steady-state concentration of LVSMD and lower exposure to the active metabolite OR-1896. CONCLUSIONS ECMO altered PK parameters for LVSMD and its metabolites. An infusion of LVSMD over 48 h, instead of 24 h, with a slightly higher dose may promote synthesis of the active metabolite OR-1896, which is responsible for the long-term efficacy of LVSMD. Further trials evaluating ECMO effects using a PK/pharmacodynamic approach may be of interest. REGISTRATION ClinicalTrials.gov identifier number NCT03681379.
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Affiliation(s)
- Pierre Bourgoin
- Pediatric Intensive Care Unit, CHU Nantes, 44093, Nantes, France. .,Department of Anesthesiology, CHU Nantes, 44093, Nantes, France.
| | - Jules Lecomte
- Department of Anesthesiology, CHU Nantes, 44093, Nantes, France
| | - Mehdi Oualha
- Pediatric Intensive Care Unit, CHU Necker Enfants Malades, 75015, Paris, France
| | - Lionel Berthomieu
- Pediatric Intensive Care Unit, CHU Toulouse, 31059, Toulouse, France
| | - Tony Pereira
- INSERM U1096, UNIROUEN, Normandie University, 76000, Rouen, France
| | - Emeline Davril
- INSERM U1096, UNIROUEN, Normandie University, 76000, Rouen, France
| | - Fabien Lamoureux
- INSERM U1096, UNIROUEN, Normandie University, 76000, Rouen, France.,Department of Pharmacology, CHU Rouen, 76000, Rouen, France
| | - Nicolas Joram
- Pediatric Intensive Care Unit, CHU Nantes, 44093, Nantes, France
| | - Alexis Chenouard
- Pediatric Intensive Care Unit, CHU Nantes, 44093, Nantes, France
| | - Thomas Duflot
- INSERM U1096, UNIROUEN, Normandie University, 76000, Rouen, France.,Department of Pharmacology, CHU Rouen, 76000, Rouen, France.,CHU Rouen, CIC-CRB U1404, 76000, Rouen, France
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Akhtar MS, Hassan MQ, Siddiqui A, Alavudeen SS, Afzal O, Altamimi ASA, Rahman SO, Khurana M, Ahsan MJ, Sharma AK, Tabassum F. Levosimendan: mechanistic insight and its diverse future aspects in cardiac care. Acta Cardiol 2022; 78:170-187. [PMID: 36222590 DOI: 10.1080/00015385.2022.2115761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Inotropic agents are generally recommended to use in patients with acute decompensated heart failure (HF) with reduced ejection fraction (HFrEF) concurrent to end-organ dysfunction. However, due to certain pharmacological limitations like developing life threatening arrhythmia and tolerance, cannot be employed as much as needed. Meanwhile, Calcium ion (Ca2+) sensitisers exhibits their inotropic action by increasing the sensitivity of the cardiomyocyte to intracellular Ca2+ ion and have been reported as emerging therapeutic alternative in HF cases. Levosimendan (LEVO) is an inodilator and with its unique pharmacology justifying its use in a wide range of cardiac alterations in HF particularly in undergoing cardiac surgery. It is also reported to be better than classical inotropes in maintaining cardiac mechanical efficacy and reducing congestion in acute HF with hypotension. This review paper was designed to compile various evidence about basic pharmacology and potential clinical aspects of LEVO in cardiac surgery and other HF associated alterations. This will benefit directly to the researcher in initiating research and to fill the gaps in the area of thrust.
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Affiliation(s)
| | - Md Quamrul Hassan
- Department of Pharmacology, SNS College of Pharmacy, Motihari, India
| | - Aisha Siddiqui
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Selangor, Malaysia
| | | | - Obaid Afzal
- Department of Pharmaceutical Chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Abdulmalik S A Altamimi
- Department of Pharmaceutical Chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Syed Obaidur Rahman
- Department of Pharmacology, School of Pharmaceutical Education and Research, New Delhi, India
| | - Mallika Khurana
- Department of Pharmacology, School of Pharmaceutical Education and Research, New Delhi, India
| | - Mohamed Jawed Ahsan
- Department of Pharmaceutical Chemistry, Maharishi Arvind College of Pharmacy, Jaipur, India
| | - Arun Kumar Sharma
- Department of Pharmacology, Amity Institute of Pharmacy, Noida, India
| | - Fauzia Tabassum
- Department of Pharmacology, College of Dentistry and Pharmacy, Buraydah, Saudi Arabia
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7
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The importance of pharmacokinetics, pharmacodynamic and repetitive use of levosimendan. Biomed Pharmacother 2022; 153:113391. [DOI: 10.1016/j.biopha.2022.113391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 12/15/2022] Open
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8
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Kipka H, Tomasi R, Hübner M, Liebchen U, Hagl C, Wanner KT, Mannell H, Höfner G. Simultaneous LC-ESI-MS/MS Quantification of Levosimendan and Its Metabolites for Therapeutic Drug Monitoring of Cardiac Surgery Patients. Pharmaceutics 2022; 14:pharmaceutics14071454. [PMID: 35890349 PMCID: PMC9319272 DOI: 10.3390/pharmaceutics14071454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
Levosimendan is used in severe chronic cardiac insufficiency, also within the peri-operative setting. Real-life pharmacokinetic data in surgical patients is lacking, making therapeutic drug monitoring (TDM) of levosimendan, its pharmacologically active metabolite OR-1896, and its intermediate OR-1855 important. A simultaneous highly sensitive quantification of levosimendan and its metabolites in small-volume samples has not yet been described. Here, levosimendan (LLOQ 0.450 nM), OR-1896, and OR-1855 (LLOQ both 1.0 nM) were successfully quantified by LC-ESI-MS/MS after liquid-liquid extraction in 300 µL of blood. A short C8 column under reversed-phase conditions enabled simultaneous and fast quantification of levosimendan in the negative and the metabolites in the positive ionization mode in a single run within 2 min. Interestingly and unexpectedly, constitutional isomers of levosimendan metabolites with identical mass transitions and similar retention times were observed in surgical patients’ samples, which we identified as the metamizole metabolites 4-aminoantipyrine and 4-acetamidoantipyrine. A longer C8 column and a modified mobile phase enabled selective quantification of all analytes in a single run within 7 min. We developed, validated, and applied highly sensitive LC-ESI-MS/MS methods for simultaneous quantification of levosimendan and its metabolites, enabling efficient TDM of cardiac surgery patients even with additional metamizole administration.
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Affiliation(s)
- Hannah Kipka
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, 81377 Munich, Germany;
- Institute of Cardiovascular Physiology and Pathophysiology, Biomedical Center, LMU Munich, 82152 Planegg, Germany
- Correspondence:
| | - Roland Tomasi
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (R.T.); (M.H.); (U.L.)
| | - Max Hübner
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (R.T.); (M.H.); (U.L.)
- Walter Brendel Center of Experimental Medicine, LMU Munich, 81377 Munich, Germany
| | - Uwe Liebchen
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (R.T.); (M.H.); (U.L.)
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany;
- DZHK (German Centre of Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Klaus T. Wanner
- Department of Pharmacy, Center for Drug Research, Ludwig-Maximilians-Universität, 81377 Munich, Germany; (K.T.W.); (G.H.)
| | - Hanna Mannell
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, 81377 Munich, Germany;
- Institute of Cardiovascular Physiology and Pathophysiology, Biomedical Center, LMU Munich, 82152 Planegg, Germany
| | - Georg Höfner
- Department of Pharmacy, Center for Drug Research, Ludwig-Maximilians-Universität, 81377 Munich, Germany; (K.T.W.); (G.H.)
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9
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Nandkeolyar S, Ryu R, Mohammad A, Cordero-Caban K, Abramov D, Tran H, Hauschild C, Stoletniy L, Hilliard A, Sakr A. A Review of Inotropes and Inopressors for Effective Utilization in Patients With Acute Decompensated Heart Failure. J Cardiovasc Pharmacol 2021; 78:336-345. [PMID: 34117179 DOI: 10.1097/fjc.0000000000001078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/19/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Inotropes and inopressors are often first-line treatment in patients with cardiogenic shock. We summarize the pharmacology, indications, and contraindications of dobutamine, milrinone, dopamine, norepinephrine, epinephrine, and levosimendan. We also review the data on the use of these medications for acute decompensated heart failure and cardiogenic shock in this article.
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Affiliation(s)
- Shuktika Nandkeolyar
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda CA; and
| | | | - Adeba Mohammad
- Medicine, Loma Linda University Medical Center, Loma Linda CA
| | | | - Dmitry Abramov
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda CA; and
| | | | | | - Liset Stoletniy
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda CA; and
| | - Anthony Hilliard
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda CA; and
| | - Antoine Sakr
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda CA; and
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10
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Xie Y, Hu F, Xiang D, Lu H, Li W, Zhao A, Huang L, Wang R. The metabolic effect of gut microbiota on drugs. Drug Metab Rev 2020; 52:139-156. [PMID: 32116054 DOI: 10.1080/03602532.2020.1718691] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Yuan Xie
- School of Pharmacy, Lanzhou University, Lanzhou, China
- Key Laboratory of the Plateau Medicial, The 940 Hospital of Joint Logistics Support, PLA, Lanzhou, China
| | - Fangdi Hu
- School of Pharmacy, Lanzhou University, Lanzhou, China
| | - Dawei Xiang
- Key Laboratory of the Plateau Medicial, The 940 Hospital of Joint Logistics Support, PLA, Lanzhou, China
| | - Hui Lu
- Key Laboratory of the Plateau Medicial, The 940 Hospital of Joint Logistics Support, PLA, Lanzhou, China
| | - Wenbin Li
- Key Laboratory of the Plateau Medicial, The 940 Hospital of Joint Logistics Support, PLA, Lanzhou, China
| | - Anpeng Zhao
- Key Laboratory of the Plateau Medicial, The 940 Hospital of Joint Logistics Support, PLA, Lanzhou, China
| | - Longji Huang
- School of Pharmacy, Lanzhou University, Lanzhou, China
- Key Laboratory of the Plateau Medicial, The 940 Hospital of Joint Logistics Support, PLA, Lanzhou, China
| | - Rong Wang
- School of Pharmacy, Lanzhou University, Lanzhou, China
- Key Laboratory of the Plateau Medicial, The 940 Hospital of Joint Logistics Support, PLA, Lanzhou, China
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11
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Wang A, Cui C, Fan Y, Zi J, Zhang J, Wang G, Wang F, Wang J, Tan Q. Prophylactic use of levosimendan in pediatric patients undergoing cardiac surgery: a prospective randomized controlled trial. Crit Care 2019; 23:428. [PMID: 31888711 PMCID: PMC6937718 DOI: 10.1186/s13054-019-2704-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 12/13/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The administration of levosimendan prophylactically to patients undergoing cardiac surgery remains a controversial practice, and few studies have specifically assessed the value of this approach in pediatric patients. This study therefore sought to explore the safety and efficacy of prophylactic levosimendan administration to pediatric patients as a means of preventing low cardiac output syndrome (LCOS) based upon hemodynamic, biomarker, and pharmacokinetic readouts. METHODS This was a single-center, double-blind, randomized, placebo-controlled trial. Patients ≤ 48 months old were enrolled between July 2018 and April 2019 and were randomly assigned to groups that received either placebo or levosimendan infusions for 48 h post-surgery, along with all other standard methods of care. LCOS incidence was the primary outcome of this study. RESULTS A total of 187 patients were enrolled, of whom 94 and 93 received levosimendan and placebo, respectively. LCOS incidence did not differ significantly between the levosimendan and placebo groups (10 [10.6%] versus 18 [19.4%] patients, respectively; 95% confidence interval [CI] 0.19-1.13; p = 0.090) nor did 90-day mortality (3 [3.2%] versus 4 [4.3%] patients, CI 0.14-3.69, p = 0.693), duration of mechanical ventilation (median, 47.5 h and 39.5 h, respectively; p = 0.532), ICU stay (median, 114.5 h and 118 h, respectively; p = 0.442), and hospital stay (median, 20 days and 20 days, respectively; p = 0.806). The incidence of hypotension and cardiac arrhythmia did not differ significantly between the groups. Levels of levosimendan fell rapidly without any plateau in plasma concentrations during infusion. A multiple logistic regression indicated that randomization to the levosimendan group was a predictor of LCOS. CONCLUSIONS Prophylactic levosimendan administration was safe in pediatric patients and had some benefit to postoperative hemodynamic parameters, but failed to provide significant benefit with respect to LCOS or 90-day mortality relative to placebo. TRIAL REGISTRATION Name of the registry: Safety evaluation and therapeutic effect of levosimendan on the low cardiac output syndrome in patients after cardiopulmonary bypass. TRIAL REGISTRATION NUMBER ChiCTR1800016594. Date of registration: 11 June 2018. URL of trial registry record: http://www.chictr.org.cn/index.aspx.
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Affiliation(s)
- Anbiao Wang
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Chaomei Cui
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Yiou Fan
- Department of Toxicological and Functional Test, Centers for Disease Control and Prevention of Shandong, Jinan, 250014 China
| | - Jie Zi
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Jie Zhang
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Guanglai Wang
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Fang Wang
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Jun Wang
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, 250021 China
| | - Qi Tan
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021 China
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12
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Faisal SA, Apatov DA, Ramakrishna H, Weiner MM. Levosimendan in Cardiac Surgery: Evaluating the Evidence. J Cardiothorac Vasc Anesth 2019; 33:1146-1158. [DOI: 10.1053/j.jvca.2018.05.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Indexed: 11/11/2022]
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13
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Desai PM, Sarkar MS, Umbarkar SR. Prophylactic preoperative levosimendan for off-pump coronary artery bypass grafting in patients with left ventricular dysfunction: Single-centered randomized prospective study. Ann Card Anaesth 2018; 21:123-128. [PMID: 29652271 PMCID: PMC5914210 DOI: 10.4103/aca.aca_178_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Off-pump coronary artery bypass surgery (OPCAB) is often complicated by hemodynamic instability, especially in patients with prior left ventricular (LV) dysfunction and appropriate choice of inotrope plays a vital role in perioperative management of these patients. Aim and Objective: To study hemodynamic effects and immediate outcome of prophylactic infusion of levosimendan in patients with the LV dysfunction undergoing OPCAB surgery and whether this strategy helps in successful conduct of OPCAB surgery. Materials and Methods: After Institutional Ethics Committee approval, 60 patients posted for elective OPCAB surgery were randomly divided into two groups (n = 30 each). Patients with the LV ejection fraction <30% were included. Study group was started on injection levosimendan (@ 0.1 μg/kg/min) in the previous night before surgery and continued for 24 h including intraoperative period. Hemodynamic monitoring included heart rate, invasive blood pressure, cardiac index (CI), pulmonary capillary wedge pressure (PCWP), pulse oximetry, and arterial blood gases with serum lactates at as T0 (baseline), T1 (15 min after obtuse marginal and/or PDA anastomoses), T2 (at end of surgery), T3 (6 h after surgery in Intensive Care Unit [ICU]), T4 (12 h after surgery), and T5 (24 h after surgery in ICU). Vasopressor was added to maintain mean arterial pressure >60 mmHg. Chi-square/Fisher's exact/Mid P exact test and Student's t-tests were applied for categorical and continuous data. Results: CI was greater and PCWP reduced significantly in Group L during intraoperative and early postoperative period. Serum lactate concentration was lower in patients pretreated with levosimendan. Incidence of postoperative atrial fibrillation (POAF) (36.6 vs. 6.6%; P = 0.01), low cardiac output syndrome (LCOS) (30% vs. 6%; P = 0.02), and acute kidney injury (23.3% vs. 6.7%; P = 0.04) was less in Group L. Three patients (10%) in control group required conversion to cardiopulmonary bypass (CPB) as compared to none in the study group. There was no difference regarding ICU or hospital stay and mortality in both groups. Conclusion: Preoperative levosimendan helps in successful conduct of OPCAB and reduces the incidence of LCOS, POAF, conversion to CPB, and requirement of intra-aortic balloon pump.
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Affiliation(s)
- Pushkar Mahendra Desai
- Department of Anesthesiology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Manjula S Sarkar
- Department of Anesthesiology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Sanjeeta R Umbarkar
- Department of Anesthesiology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
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14
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Goyer I, Brossier D, Toledano B. Hemodynamic support of a 15-year-old waiting for a heart transplant: Is there a role for levosimendan in pediatric heart failure? Arch Pediatr 2018; 25:132-135. [PMID: 29395891 DOI: 10.1016/j.arcped.2017.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/17/2017] [Accepted: 12/10/2017] [Indexed: 11/25/2022]
Abstract
Decompensated heart failure in children requires rapid and aggressive support. In refractory cases, invasive supportive care is essential to ensure cardiac output. This results in lengthy pediatric intensive care unit (PICU) stays, secondary morbidity, and high cost. Levosimendan may help palliate the pitfalls encountered with the usual treatment. It has been shown to improve hemodynamics and decrease morbidity and mortality from heart failure in adult trials and pediatric cohorts. We report the case of a 15-year-old boy with dilated cardiomyopathy and refractory ventricular dysfunction who was weaned from continuous inotropes and discharged from the PICU with levosimendan while waiting for heart transplantation.
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Affiliation(s)
- I Goyer
- Department of pharmacy, CHU Sainte-Justine, 3175 Côte-Ste-Catherine, H3T1C5 Montreal, QC, Canada.
| | - D Brossier
- Department of pediatric intensive care unit, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen, France
| | - B Toledano
- Department of pediatrics, university of Montreal, CHU Sainte-Justine, 3175 Côte-Ste-Catherine, H3T1C5 Montreal, QC, Canada
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15
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Putzu A, Clivio S, Belletti A, Cassina T. Perioperative levosimendan in cardiac surgery: A systematic review with meta-analysis and trial sequential analysis. Int J Cardiol 2017; 251:22-31. [PMID: 29126653 DOI: 10.1016/j.ijcard.2017.10.077] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/24/2017] [Accepted: 10/17/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Several studies suggested beneficial effects of perioperative levosimendan on postoperative outcome after cardiac surgery. However, three large randomized controlled trials (RCTs) have been recently published and presented neutral results. We performed a systematic review with meta-analysis and trial sequential analysis (TSA) to assess benefits and harms of perioperative levosimendan therapy in cardiac surgery. METHODS Electronic databases were searched up to September 2017 for RCTs on preoperative levosimendan versus any type of control. The Cochrane methodology was employed. We calculated odds ratio (OR) or Risk Ratio (OR) and 95% confidence interval (CI) using fixed-effects meta-analyses and we further performed TSA. RESULTS We included data from 40 RCTs and 4246 patients. Pooled analysis of 5 low risk of bias trials (1910 patients) showed no association between levosimendan and mortality (OR 0.86 [95% CI, 0.62, 1.18], p=0.34, TSA inconclusive), acute kidney injury, need of renal replacement therapy, myocardial infarction, ventricular arrhythmias, and serious adverse events, but an association with higher incidence of supraventricular arrhythmias (RR 1.11 [95% CI, 1.00, 1.24], p=0.05, TSA inconclusive) and hypotension (RR 1.15 [95% CI, 1.01, 1.30], p=0.04, TSA inconclusive). Analysis including all 40 trials found that levosimendan was associated with lower postoperative mortality (OR 0.56 [95% CI, 0.44, 0.71], p<0.00001, TSA conclusive), acute kidney injury, and renal replacement therapy, and higher incidence of hypotension. CONCLUSIONS There is not enough high-quality evidence to neither support nor discourage the systematic use of levosimendan in cardiac surgery.
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Affiliation(s)
- Alessandro Putzu
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland.
| | - Sara Clivio
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland.
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Tiziano Cassina
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland.
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16
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Wilson ID, Nicholson JK. Gut microbiome interactions with drug metabolism, efficacy, and toxicity. Transl Res 2017; 179:204-222. [PMID: 27591027 PMCID: PMC5718288 DOI: 10.1016/j.trsl.2016.08.002] [Citation(s) in RCA: 367] [Impact Index Per Article: 52.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 07/21/2016] [Accepted: 08/05/2016] [Indexed: 12/21/2022]
Abstract
The gut microbiota has both direct and indirect effects on drug and xenobiotic metabolisms, and this can have consequences for both efficacy and toxicity. Indeed, microbiome-driven drug metabolism is essential for the activation of certain prodrugs, for example, azo drugs such as prontosil and neoprontosil resulting in the release of sulfanilamide. In addition to providing a major source of reductive metabolizing capability, the gut microbiota provides a suite of additional reactions including acetylation, deacylation, decarboxylation, dehydroxylation, demethylation, dehalogenation, and importantly, in the context of certain types of drug-related toxicity, conjugates hydrolysis reactions. In addition to direct effects, the gut microbiota can affect drug metabolism and toxicity indirectly via, for example, the modulation of host drug metabolism and disposition and competition of bacterial-derived metabolites for xenobiotic metabolism pathways. Also, of course, the therapeutic drugs themselves can have effects, both intended and unwanted, which can impact the health and composition of the gut microbiota with unforeseen consequences.
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Affiliation(s)
- Ian D Wilson
- Biomolecular Medicine, Division of Computational and Systems Medicine, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, UK.
| | - Jeremy K Nicholson
- Biomolecular Medicine, Division of Computational and Systems Medicine, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, UK
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17
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Séguéla PE, Tafer N, Thambo JB, Mauriat P. [Use of levosimendan in children]. Arch Pediatr 2016; 23:848-56. [PMID: 27369103 DOI: 10.1016/j.arcped.2016.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 03/09/2016] [Accepted: 05/10/2016] [Indexed: 11/17/2022]
Abstract
Levosimendan is a calcium-sensitizing drug with positive inotropic properties. As an inodilator, this molecule also has a vasodilation effect. While its efficacy has been demonstrated in the adult in the context of cardiac surgery, its pediatric use is still not widespread. Many studies have shown its safety of use in children, including in the newborn. Across the world, a growing number of teams use levosimendan to treat both acute and chronic heart failure. Through a review of the literature, we describe its pharmacodynamic effects, its current applications, and its perspectives of use in children.
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Affiliation(s)
- P-E Séguéla
- Service de cardiologie pédiatrique et congénitale, hôpital Haut-Lévèque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac cedex, France; Service de réanimation chirurgicale des cardiopathies congénitales, hôpital Haut-Lévèque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac, France.
| | - N Tafer
- Service de réanimation chirurgicale des cardiopathies congénitales, hôpital Haut-Lévèque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac, France
| | - J-B Thambo
- Service de cardiologie pédiatrique et congénitale, hôpital Haut-Lévèque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac cedex, France
| | - P Mauriat
- Service de réanimation chirurgicale des cardiopathies congénitales, hôpital Haut-Lévèque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac, France
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18
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Kivikko M, Kuoppamäki M, Soinne L, Sundberg S, Pohjanjousi P, Ellmen J, Roine RO. Oral Levosimendan Increases Cerebral Blood Flow Velocities in Patients with a History of Stroke or Transient Ischemic Attack: A Pilot Safety Study. CURRENT THERAPEUTIC RESEARCH 2015; 77:46-51. [PMID: 26082815 PMCID: PMC4461857 DOI: 10.1016/j.curtheres.2015.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/16/2015] [Indexed: 11/18/2022]
Abstract
Background Intravenous levosimendan is indicated for acute heart failure. The compound has shown promising beneficial effects in ischemic stroke models. Objective We evaluated the efficacy and safety of oral levosimendan in patients with a history of cerebral ischemia. Methods In a randomized, double-blind, placebo-controlled, parallel-group study, 16 patients with a history of ischemic stroke/transient ischemic attack received oral levosimendan in 5 escalating doses from 0.125 to 2.0 mg daily for 18-day intervals of each dose; 5 patients received placebo. Twenty-four-hour ambulatory ECG and cerebral blood flow velocities using transcranial Doppler ultrasound were recorded at baseline and at the end of each dosing period. Vasomotor reactivity was assessed via the breath holding index. In addition, plasma levels of N-terminal-pro-B-type natriuretic peptide (NT-pro-BNP) and the metabolites of levosimendan were determined. Results Levosimendan induced an increase in cerebral blood flow velocities and a decrease in NT-pro-BNP compared with placebo. There was no significant effect on breath holding index. Doses ≥0.5 mg increased heart rate by 5 to 9 beats/min. The dose level of 2.0 mg exceeded the preset safety margin of ventricular extrasystoles per hour (ie, upper 90% CI of the ratio of levosimendan to placebo above 2) with an estimate of 3.10 (90% CI, 0.95–10.07). Conclusions Oral levosimendan increases cerebral blood flow velocities and diminishes NT-pro-BNP levels in patients with earlier ischemic cerebrovascular event. Daily doses up to 1.0 mg were well tolerated, whereas the 2.0 mg dose level induced an increase in ventricular extrasystoles. ClinicalTrials.gov identifier: NCT00698763.
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Affiliation(s)
- Matti Kivikko
- Department of Cardiology, Helsinki University Central Hospital, Helsinki, Finland ; Orion Pharma, Espoo, Finland
| | | | - Lauri Soinne
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Stig Sundberg
- Department of Biosciences, Division of Physiology and Neurosciences, University of Helsinki, Helsinki Finland
| | | | | | - Risto O Roine
- Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland
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Lymperopoulos A, Garcia D, Walklett K. Pharmacogenetics of cardiac inotropy. Pharmacogenomics 2014; 15:1807-1821. [PMID: 25493572 DOI: 10.2217/pgs.14.120] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The ability to stimulate cardiac contractility is known as positive inotropy. Endogenous hormones, such as adrenaline and several natural or synthetic compounds possess this biological property, which is invaluable in the modern cardiovascular therapy setting, especially in acute heart failure or in cardiogenic shock. A number of proteins inside the cardiac myocyte participate in the molecular pathways that translate the initial stimulus, that is, the hormone or drug, into the effect of increased contractility (positive inotropy). Genetic variations (polymorphisms) in several genes encoding these proteins have been identified and characterized in humans with potentially significant consequences on cardiac inotropic function. The present review discusses these polymorphisms and their effects on cardiac inotropy, along with the individual pharmacogenomics of the most important positive inotropic agents in clinical use today. Important areas for future investigations in the field are also highlighted.
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Affiliation(s)
- Anastasios Lymperopoulos
- From the Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, 3200 S. University Drive, HPD (Terry) Bldg/Room 1338, Ft. Lauderdale, FL 33328-2018, USA
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20
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Shah B, Sharma P, Brahmbhatt A, Shah R, Rathod B, Shastri N, Patel J, Malhotra A. Study of levosimendan during off-pump coronary artery bypass grafting in patients with LV dysfunction: a double-blind randomized study. Indian J Pharmacol 2014; 46:29-34. [PMID: 24550581 PMCID: PMC3912803 DOI: 10.4103/0253-7613.125161] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 08/05/2013] [Accepted: 10/06/2013] [Indexed: 12/03/2022] Open
Abstract
Objectives: Levosimendan is a calcium sensitizer drug which has been used in cardiac surgery for the prevention of postoperative low cardiac output syndrome (LCOS) and in difficult weaning from cardiopulmonary bypass (CPB). This study aims to evaluate perioperative hemodynamic effects of levosimendan pretreatment in patients for off-pump coronary artery bypass graft (OPCABG) surgery with low left ventricular ejection fractions (LVEF < 30%). Materials and Methods: Fifty patients undergoing OPCABG surgery with low LVEF (<30%) were enrolled in the study. Patients were randomly divided in two groups: Levosimendan pretreatment (Group L) and placebo pretreatment (Group C) of 25 each. Group L, patients received levosimendan infusion 200 μg/kg over 24 h and in Group C Patients received placebo. The clinical parameters measured before and after the drug administration up to 48 h were heart rate (HR; for the hour after drug infusion), cardiac index (CI), and pulmonary capillary wedge pressure (PCWP). The requirement of inotropes, intraaortic balloon pump (IABP), CPB, intensive care unit (ICU) stay, and hospital stay were also measured. Results: The patients in group L exhibited higher CI and PCWP during operative in early postoperative period as compared to control group C. Group L also had a less requirement for inotropes, CPB support and IABP with shorter ICU stay as well as hospital stay. Conclusion: Levosimendan pretreatment (24 h infusion) in patient for OPCABG with poor LVEF shows better outcomes and hemodynamics in terms of inotropes, CPB and IABP requirements. It also reduces ICU stay.
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Affiliation(s)
- B Shah
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - P Sharma
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - A Brahmbhatt
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - R Shah
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - B Rathod
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - Naman Shastri
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - J Patel
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - A Malhotra
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
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22
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Pierrakos C, Velissaris D, Franchi F, Muzzi L, Karanikolas M, Scolletta S. Levosimendan in critical illness: a literature review. J Clin Med Res 2014; 6:75-85. [PMID: 24578748 PMCID: PMC3935527 DOI: 10.14740/jocmr1702w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2013] [Indexed: 01/30/2023] Open
Abstract
Levosimendan, the active enantiomer of simendan, is a calcium sensitizer developed for treatment of decompensated heart failure, exerts its effects independently of the beta adrenergic receptor and seems beneficial in cases of severe, intractable heart failure. Levosimendan is usually administered as 24-h infusion, with or without a loading dose, but dosing needs adjustment in patients with severe liver or renal dysfunction. Despite several promising reports, the role of levosimendan in critical illness has not been thoroughly evaluated. Available evidence suggests that levosimendan is a safe treatment option in critically ill patients and may reduce mortality from cardiac failure. However, data from well-designed randomized controlled trials in critically ill patients are needed to validate or refute these preliminary conclusions. This literature review is an attempt to synthesize available evidence on the role and possible benefits of levosimendan in critically ill patients with severe heart failure.
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Affiliation(s)
- Charalampos Pierrakos
- Department of Intensive Care, Universite Catholique de Louvain, Mont-Godinne University Hospital, Yvoir 5530, Belgium
| | - Dimitrios Velissaris
- Department of Internal Medicine, University of Patras School of Medicine, Patras, Greece
| | - Federico Franchi
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Luigi Muzzi
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Menelaos Karanikolas
- Department of Anesthesiology, Washington University School of Medicine, Campus Box 8054, 660 S. Euclid Avenue, St. Louis, MO, USA
| | - Sabino Scolletta
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
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Plaschke K, Bent F, Wagner S, Zorn M, Kopitz J. In contrast to its anti-inflammatory and anti-apoptotic peripheral effect, levosimendan failed to induce a long-term neuroprotective effect in a rat model of mild septic encephalopathy: a pilot study. Neurosci Lett 2013; 560:117-21. [PMID: 24361133 DOI: 10.1016/j.neulet.2013.12.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 11/13/2013] [Accepted: 12/10/2013] [Indexed: 11/25/2022]
Abstract
Levosimendan shows protective myocardial characteristics and is administered to enhance cardiac contractility in patients. However, currently little is known about levosimendan's effect on brain. The aim of this pilot study was to investigate the long-term effect of levosimendan on brain and during mild rat sepsis in comparison to its peripheral mode of action. Adult rats (n=40) were divided into four groups with n=10 per group: (I) sham, (II) levosimendan (283 μg/kg body weight i.v.), (III) lipopolysaccharide (LPS, 8 mg/kg body weight i.p.), and (IV) LPS+levosimendan. Levosimendan was given 24h after injecting LPS. Psychometric investigations were conducted using a Morris water maze (MWM) and a holeboard test. In cerebral and splenic tissue, IL-1β, Il-6, TNFalpha levels, and apoptosis were determined; cerebral tissue corticosterone concentration was measured 6 days after injecting LPS. Blood cytokine concentrations were determined 1 day and 6 days after injecting LPS. Rats that received an LPS injection spent more time in the outer zone of the MWM according to increased cerebral corticosterone levels, and showed decreased cognitive abilities. LPS induced a reduction in body weight, increased splenic apoptosis and blood cytokine level. Levosimendan showed anti-inflammatory and anti-apoptotic properties in spleen but failed to show a long-term neuroprotective effect.
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Affiliation(s)
- Konstanze Plaschke
- Department of Anesthesiology, Medical Faculty, University of Heidelberg, Im Neuenheimer Feld 110, D-69120 Heidelberg, Germany.
| | - Franziska Bent
- Department of Anesthesiology, Medical Faculty, University of Heidelberg, Im Neuenheimer Feld 110, D-69120 Heidelberg, Germany
| | - Sören Wagner
- Department of Anesthesiology, Medical Faculty, University of Heidelberg, Im Neuenheimer Feld 110, D-69120 Heidelberg, Germany
| | - Markus Zorn
- Department of Internal Medicine, Laboratory Medicine, University of Heidelberg, Im Neuenheimer Feld 671, D-69120 Heidelberg, Germany
| | - Jürgen Kopitz
- Department of Pathology, Medical Faculty, University of Heidelberg, Im Neuenheimer Feld 224, D-69120 Heidelberg, Germany
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Pathak A, Lebrin M, Vaccaro A, Senard JM, Despas F. Pharmacology of levosimendan: inotropic, vasodilatory and cardioprotective effects. J Clin Pharm Ther 2013; 38:341-9. [PMID: 23594161 DOI: 10.1111/jcpt.12067] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 03/20/2013] [Indexed: 01/15/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Positive inotropic agents are frequently used in acute decompensated heart failure (ADHF) due to left ventricular systolic dysfunction. These agents are known to improve cardiac performance and peripheral perfusion in the short-term treatment. However, several preclinical and clinical studies emphasized detrimental effects of these drugs on myocardial oxygen demand and on sympathetic tone entailing arrhythmogenesis. Levosimendan is an inotropic agent with an original mechanism of action. This review focuses on major data available for levosimendan. METHODS A literature search was conducted in the PubMed database by including studies published in English using combinations of the following key words, levosimendan, inotropic drugs and acute heart failure. Furthermore, bibliographies of selected references were also evaluated for relevant articles. The collection for this review was limited to the most recently available human and animal data. RESULTS AND DISCUSSION Levosimendan's vasodilatory and cardioprotective effects are mediated by calcium sensitization of contractile proteins and opening of adenosine triphosphate (ATP)-dependent K+ channels in vascular smooth muscle cells and on mitochondrial ATP-sensitive potassium [mito.K(ATP)] channels. This inotropic agent has mild PDE inhibitory action. Unlike other inotropic agents, levosimendan improves cardiac performance without activating the sympathetic nervous system. Moreover, there are evidences that levosimendan has additional anti-inflammatory and anti-apoptotic properties that prevent cardiac toxicity and contributes to positive hemodynamic response of the drug. Four randomized trials evaluated the effects of levosimendan on mortality in patients with acute decompensated chronic heart failure; nevertheless, a clear benefit has not been demonstrated so far. Although levosimendan is indicated for the treatment of ADHF (class of recommendation IIa, level of evidence B), it is has not been approved in all countries. WHAT IS NEW AND CONCLUSION This review summarizes the characteristics and the current knowledge of the literature on levosimendan and its active metabolite OR-1896.
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Affiliation(s)
- A Pathak
- Institut National de Sante et de Recherche Médicale (INSERM), UMR-1048, Institut des maladies métaboliques et cardiovasculaires I2MC, Toulouse, France
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Puttonen J, Kantele S, Ruck A, Ramela M, Häkkinen S, Kivikko M, Pentikäinen PJ. Pharmacokinetics of Intravenous Levosimendan and Its Metabolites in Subjects With Hepatic Impairment. J Clin Pharmacol 2013; 48:445-54. [DOI: 10.1177/0091270007313390] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Obach RS. Pharmacologically active drug metabolites: impact on drug discovery and pharmacotherapy. Pharmacol Rev 2013; 65:578-640. [PMID: 23406671 DOI: 10.1124/pr.111.005439] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Metabolism represents the most prevalent mechanism for drug clearance. Many drugs are converted to metabolites that can retain the intrinsic affinity of the parent drug for the pharmacological target. Drug metabolism redox reactions such as heteroatom dealkylations, hydroxylations, heteroatom oxygenations, reductions, and dehydrogenations can yield active metabolites, and in rare cases even conjugation reactions can yield an active metabolite. To understand the contribution of an active metabolite to efficacy relative to the contribution of the parent drug, the target affinity, functional activity, plasma protein binding, membrane permeability, and pharmacokinetics of the active metabolite and parent drug must be known. Underlying pharmacokinetic principles and clearance concepts are used to describe the dispositional behavior of metabolites in vivo. A method to rapidly identify active metabolites in drug research is described. Finally, over 100 examples of drugs with active metabolites are discussed with regard to the importance of the metabolite(s) in efficacy and safety.
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Affiliation(s)
- R Scott Obach
- Pfizer Inc., Eastern Point Rd., Groton, CT 06340, USA.
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Abstract
Although studies have evaluated the efficacy of levosimendan in heart failure during sepsis, it still is a subject of controversy whether levosimendan produces an effect on platelets. In this study, the short- and long-term effects of levosimendan on platelet aggregation were investigated in untreated animals and in a rat model of sepsis. Therefore, adult rats (n = 40) were randomly divided into four groups with n = 10 per group: (I) sham, (II) levosimendan (bolus 53 µg/kg + 285 µg/kg/hour, intravenously (i.v.) injected), (III) LPS (lipopolysaccharide, 8 mg/kg body weight intraperitoneally injected), and (IV) LPS + levosimendan. Levosimendan was given 24 hours after LPS injections. The number of platelets was determined. Platelet aggregation was measured using venous blood from rats 10 minutes and 5 days after levosimendan application with Dynabyte Multiplate system. Aggregation responses were evaluated with adenosine diphosphate (10 µM) and collagen (5 µg/ml). In addition to clinical dosage, the in vitro effect of high-dosage levosimendan on platelet function was investigated. The results clearly showed that LPS significantly reduced the platelet aggregation 1 day after injection compared to controls; 6 days after LPS, a marked increase (p < 0.01) was noted. This result is associated with numbers of platelets. Levosimendan (bolus 53 µg/kg + 285 µg/kg/hour i.v.) had no significant effect on the platelets of rats in contrast to the high-dosage in vitro findings. Thus, the in vivo use of levosimendan does not affect blood coagulation significantly in this rat model. This also applies under the conditions of decreased and increased numbers of platelets during mild sepsis.
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Affiliation(s)
- Franziska Bent
- Department of Anesthesiology, University of Heidelberg, Im Neuenheimer Feld 110, D-69120 Heidelberg, Germany.
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Masutani S, Cheng HJ, Tachibana H, Little WC, Cheng CP. Levosimendan restores the positive force-frequency relation in heart failure. Am J Physiol Heart Circ Physiol 2011; 301:H488-96. [PMID: 21572004 PMCID: PMC3154658 DOI: 10.1152/ajpheart.01116.2010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 05/10/2011] [Indexed: 11/22/2022]
Abstract
Frequency potentiation of contractile function is a major mechanism of the increase in myocardial performance during exercise. In heart failure (HF), this positive force-frequency relation is impaired, and the abnormal left ventricular (LV)-arterial coupling is exacerbated by tachycardia. A myofilament Ca(2+) sensitizer, levosimendan, has been shown to improve exercise tolerance in HF. This may be due to its beneficial actions on the force-frequency relation and LV-arterial coupling (end-systolic elastance/arterial elastance, E(ES)/E(A)). We assessed the effects of therapeutic doses of levosimendan on the force-frequency relation and E(ES)/E(A) in nine conscious dogs after pacing-induced HF using pressure-volume analysis. Before HF, pacing tachycardia increased E(ES), shortened τ, and did not impair E(ES)/E(A) and mechanical efficiency (stroke work/pressure-volume area, SW/PVA). In contrast, after HF, pacing at 140, 160, 180, and 200 beat/min (bpm) produced smaller a increase of E(ES) or less shortening of τ, whereas E(ES)/E(A) (from 0.56 at baseline to 0.42 at 200 bpm) and SW/PVA (from 0.52 at baseline to 0.43 at 200 bpm) progressively decreased. With levosimendan, basal E(ES) increased 27% (6.2 mmHg/ml), τ decreased 11% (40.8 ms), E(ES)/E(A) increased 34% (0.75), and SW/PVA improved by 15% (0.60). During tachycardia, E(ES) further increased by 23%, 37%, 68%, and 89%; τ decreased by 9%, 12%, 15%, and 17%; and E(ES)/E(A) was augmented by 11%, 16%, 31%, and 33%, incrementally, with pacing rate. SW/PVA was improved (0.61 to 0.64). In conclusion, in HF, treatment with levosimendan restores the normal positive LV systolic and diastolic force-frequency relation and prevents tachycardia-induced adverse effect on LV-arterial coupling and mechanical efficiency.
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Affiliation(s)
- Satoshi Masutani
- Cardiology Section, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Deng Y, Rogers M, Sychterz C, Talley K, Qian Y, Bershas D, Ho M, Shi W, Chen EP, Serabjit-Singh C, Gorycki PD. Investigations of Hydrazine Cleavage of Eltrombopag in Humans. Drug Metab Dispos 2011; 39:1747-54. [DOI: 10.1124/dmd.111.040188] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Kivikko M, Sundberg S, Karlsson MO, Pohjanjousi P, Colucci WS. Acetylation status does not affect levosimendan's hemodynamic effects in heart failure patients. SCAND CARDIOVASC J 2010; 45:86-90. [DOI: 10.3109/14017431.2010.540762] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Khelil M, Zenati A, Makrelouf M, Otmane A, Tayebi B. Polymorphisms in NAT2 gene and atherosclerosis in an Algerian population. Arch Med Res 2010; 41:215-20. [PMID: 20682180 DOI: 10.1016/j.arcmed.2010.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2009] [Accepted: 03/19/2010] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND AIMS The etiology of atherosclerosis is multifactorial. Genetic and environmental factors are involved in the development of atherosclerosis. Human arylamine N-acetyltransferase 2 (NAT2) is an important metabolizing enzyme that exhibits genetic polymorphisms and modifies individual response and/or toxicity to many xenobiotics. We undertook this study to investigate the NAT2 polymorphisms in patients with atherosclerosis. METHODS Genotyping for NAT2 alleles was performed using polymerase chain reaction-restriction fragment-length polymorphism (PCR-RFLP) in 285 Algerian patients with atherosclerosis and 286 controls. RESULTS There was no association between NAT2 polymorphisms and atherosclerosis risk. However, the haplotype NAT2(*)5F decreased susceptibility to the disease (p = 0.005, OR = 0.55, 95% CI = 0.37-0.84). The frequency of the slow acetylator phenotype was approximately 50% in both cases and controls. CONCLUSIONS These results suggest that NAT2 polymorphisms may not be involved in the pathogenesis of atherosclerosis.
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Affiliation(s)
- Malika Khelil
- Département de Biologie Cellulaire et Moléculaire, Faculté des Sciences Biologiques, Université des Sciences et de la Technologie Houari, Boumediène, Alger, Algérie.
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Kaptan K, Beyan C, Ifran A. Do levosimendan have an adverse effect on platelet function? Int J Cardiol 2010; 144:414-5. [PMID: 19327852 DOI: 10.1016/j.ijcard.2009.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2009] [Accepted: 03/04/2009] [Indexed: 10/21/2022]
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Kaptan K, Beyan C. Levosimendan and platelet function. J Cardiothorac Vasc Anesth 2009; 24:532. [PMID: 19632863 DOI: 10.1053/j.jvca.2009.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Indexed: 11/11/2022]
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Mebazaa A, Nieminen MS, Filippatos GS, Cleland JG, Salon JE, Thakkar R, Padley RJ, Huang B, Cohen-Solal A. Levosimendan vs. dobutamine: outcomes for acute heart failure patients on beta-blockers in SURVIVE. Eur J Heart Fail 2009; 11:304-11. [PMID: 19158152 PMCID: PMC2645051 DOI: 10.1093/eurjhf/hfn045] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Revised: 10/09/2008] [Accepted: 12/15/2008] [Indexed: 12/24/2022] Open
Abstract
AIMS Many chronic heart failure (CHF) patients take beta-blockers. When such patients are hospitalized for decompensation, it remains unclear how ongoing beta-blocker treatment will affect outcomes of acute inotrope therapy. We aimed to assess outcomes of SURVIVE patients who were on beta-blocker therapy before receiving a single intravenous infusion of levosimendan or dobutamine. METHODS AND RESULTS Cox proportional hazard regression revealed all-cause mortality benefits of levosimendan treatment over dobutamine when the SURVIVE population was stratified according to baseline presence/absence of CHF history and use/non-use of beta-blocker treatment at baseline. All-cause mortality was lower in the CHF/levosimendan group than in the CHF/dobutamine group, showing treatment differences by hazard ratio (HR) at days 5 (3.4 vs. 5.8%; HR, 0.58, CI 0.33-1.01, P = 0.05) and 14 (7.0 vs. 10.3%; HR, 0.67, CI 0.45-0.99, P = 0.045). For patients who used beta-blockers (n = 669), mortality was significantly lower for levosimendan than dobutamine at day 5 (1.5 vs. 5.1% deaths; HR, 0.29; CI 0.11-0.78, P = 0.01). CONCLUSION Levosimendan may be better than dobutamine for treating patients with a history of CHF or those on beta-blocker therapy when they are hospitalized with acute decompensations. These findings are preliminary but important for planning future studies.
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Affiliation(s)
- Alexandre Mebazaa
- Department of Anaesthesiology and Critical Care Medicine, Hôpital Lariboisière, APHP; Université Paris 7 Paris Diderot; U 942 INSERM, 2 rue Ambroise-Paré, Paris Cedex 10 75475, France.
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Parissis JT, Rafouli-Stergiou P, Paraskevaidis I, Mebazaa A. Levosimendan: from basic science to clinical practice. Heart Fail Rev 2008; 14:265-75. [DOI: 10.1007/s10741-008-9128-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Accepted: 11/28/2008] [Indexed: 12/01/2022]
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Kota B, Prasad AS, Economides C, Singh BN. Levosimendan and Calcium Sensitization of the Contractile Proteins in Cardiac Muscle: Impact on Heart Failure. J Cardiovasc Pharmacol Ther 2008; 13:269-78. [PMID: 19087950 DOI: 10.1177/1074248408324550] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Levosimendan increases the sensitivity of the cardiac fibrils to calcium, favorably affects hemodynamics in patients with heart failure. It is a positive inotrope and a peripheral vasodilator. The elimination half-life of the compound is about 1 hour. The drug decreases pulmonary capillary wedge pressure, increases cardiac output with the improvement in left ventricular ejection fraction leading to symptomatic improvement which includes decreased dyspnea and fatigue. Levosimendan can be used safely with diuretics, nitrates, beta-blockers, digoxin, and angiotensin-converting enzyme inhibitors. The most common adverse effects of levosimendan are headache and hypotension. Prolongation of the QTc interval does not appear to increase the incidence of arrhythmias, including ventricular tachycardia, ventricular fibrillation, and torsades de pointes. Levosimendan is a novel agent in the treatment of decompensated heart failure, representing a newer class of medications aimed at increasing calcium sensitivity. Its properties holds promise for the treatment of heart failure but further large-scale studies will be needed to determine its precise efficacy, safety, as well as the compound's long-term impact on mortality.
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Affiliation(s)
| | | | | | - Bramah N. Singh
- West LA VA Medical Center, Division of Cardiology, David Geffen School of Medicine, UCLA
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Masutani S, Cheng HJ, Hyttilä-Hopponen M, Levijoki J, Heikkilä A, Vuorela A, Little WC, Cheng CP. Orally Available Levosimendan Dose-Related Positive Inotropic and Lusitropic Effect in Conscious Chronically Instrumented Normal and Heart Failure Dogs. J Pharmacol Exp Ther 2008; 325:236-47. [DOI: 10.1124/jpet.107.134940] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Segreti JA, Marsh KC, Polakowski JS, Fryer RM. Evoked Changes in Cardiovascular Function in Rats by Infusion of Levosimendan, OR-1896 [(R)-N-(4-(4-Methyl-6-oxo-1,4,5,6-tetrahydropyridazin-3-yl)phenyl)acetamide], OR-1855 [(R)-6-(4-Aminophenyl)-5-methyl-4,5-dihydropyridazin-3(2H)-one], Dobutamine, and Milrinone: Comparative Effects on Peripheral Resistance, Cardiac Output, dP/dt, Pulse Rate, and Blood Pressure. J Pharmacol Exp Ther 2008; 325:331-40. [DOI: 10.1124/jpet.107.132530] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Banfor PN, Preusser LC, Campbell TJ, Marsh KC, Polakowski JS, Reinhart GA, Cox BF, Fryer RM. Comparative effects of levosimendan, OR-1896, OR-1855, dobutamine, and milrinone on vascular resistance, indexes of cardiac function, and O2consumption in dogs. Am J Physiol Heart Circ Physiol 2008; 294:H238-48. [DOI: 10.1152/ajpheart.01181.2007] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Levosimendan enhances cardiac contractility via Ca2+sensitization and induces vasodilation through the activation of ATP-dependent K+and large-conductance Ca2+-dependent K+channels. However, the hemodynamic effects of levosimendan, as well as its metabolites, OR-1896 and OR-1855, relative to plasma concentrations achieved, are not well defined. Thus levosimendan, OR-1896, OR-1855, or vehicle was infused at 0.01, 0.03, 0.1, and 0.3 μmol·kg−1·30 min−1, targeting therapeutic to supratherapeutic concentrations of total levosimendan (62.6 ng/ml). Results were compared with those of the β1-agonist dobutamine and the phosphodiesterase 3 inhibitor milrinone. Peak concentrations of levosimendan, OR-1896, and OR-1855 were 455 ± 21, 126 ± 6, and 136 ± 6 ng/ml, respectively. Levosimendan and OR-1896 produced dose-dependent reductions in mean arterial pressure (−31 ± 2 and −42 ± 3 mmHg, respectively) and systemic resistance without affecting pulse pressure, effects paralleled by increases in heart rate; OR-1855 produced no effect at any dose tested. Dobutamine, but not milrinone, increased mean arterial pressure and pulse pressure (17 ± 2 and 23 ± 2 mmHg, respectively). Regarding potency to elicit reductions in time to peak pressure and time to systolic pressure recovery: OR-1896 > levosimendan > milrinone > dobutamine. Levosimendan and OR-1896 elicited dose-dependent increases in change in pressure over time (118 ± 10 and 133 ± 13%, respectively), concomitant with reductions in left ventricular end-diastolic pressure and ejection time. However, neither levosimendan nor OR-1896 produced increases in myocardial oxygen consumption at inotropic and vasodilatory concentrations, whereas dobutamine increased myocardial oxygen consumption (79% above baseline). Effects of the levosimendan and OR-1896 were limited to the systemic circulation; neither compound produced changes in pulmonary pressure, whereas dobutamine produced profound increases (74 ± 13%). Thus levosimendan and OR-1896 are hemodynamically active in the anesthetized dog at concentrations observed clinically and elicit cardiovascular effects consistent with activation of both K+channels and Ca2+sensitization, whereas OR-1855 is inactive on endpoints measured in this study.
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Puttonen J, Laine T, Ramela M, Häkkinen S, Zhang W, Pradhan R, Pentikäinen P, Koskinen M. Pharmacokinetics and excretion balance of OR-1896, a pharmacologically active metabolite of levosimendan, in healthy men. Eur J Pharm Sci 2007; 32:271-7. [PMID: 17888637 DOI: 10.1016/j.ejps.2007.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Revised: 08/03/2007] [Accepted: 08/04/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate the pharmacokinetics and excretion balance of [(14)C]-OR-1896, a pharmacologically active metabolite of levosimendan, in six healthy male subjects. In addition, pharmacokinetic parameters of total radiocarbon and the deacetylated congener, OR-1855, were determined. METHODS OR-1896 was administered as a single intravenous infusion of 200 microg of [(14)C]-OR-1896 (specific activity 8.6 MBq/mg) over 10 min. The pharmacokinetic parameters were calculated by three-compartmental methods. RESULTS During the 14-day collection of urine and faeces, excretion (+/-S.D.) averaged 94.2+/-1.4% of the [(14)C]-OR-1896 dose. Mean recovery of radiocarbon in urine was 86.8+/-1.9% and in faeces 7.4+/-1.5%. Mean terminal elimination half-life of OR-1896 (t(1/2)) was 70.0+/-44.9 h. Maximum concentrations of OR-1855 were approximately 30% to that of OR-1896. Total clearance and the volume of distribution of OR-1896 were 2.0+/-0.4 l/h and 175.6+/-74.5l, respectively. Renal clearances of OR-1896 and OR-1855 were 0.9+/-0.4 l/h and (5.4+/-2.3)x10(-4) l/h, respectively. CONCLUSIONS This study provides data to demonstrate that nearly one half of OR-1896 is eliminated unchanged into urine and that the active metabolites metabolite of levosimendan remain in the body longer than levosimendan. The remaining half of OR-1896 dose is eliminated through other metabolic routes, partially through interconversion back to OR-1855 with further metabolism of OR-1855. Given the fact that the pharmacological activity and potency of OR-1896 is similar to levosimendan, these results emphasize the clinical significance of OR-1896 and its contribution to the long-lasting effects of levosimendan.
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Affiliation(s)
- Jaakko Puttonen
- Research and Development, Orion Pharma, P.O. Box 1780, FIN-70701 Kuopio, Finland.
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Abstract
Levosimendan has been developed for the treatment of decompensated heart failure and is used intravenously when patients with heart failure require immediate initiation of drug therapy. It increases cardiac contractility and induces vasodilatation. The pharmacokinetics of levosimendan are linear at the therapeutic dose range of 0.05-0.2 microg/kg/minute. The short half-life (about 1 hour) of the parent drug, levosimendan, enables fast onset of drug action, although the effects are long-lasting due to the active metabolite OR-1896, which has an elimination half-life of 70-80 hours in patients with heart failure (New York Heart Association functional class III-IV). Although levosimendan is administered intravenously, it is excreted into the small intestine and reduced by intestinal bacteria to an amino phenolpyridazinone metabolite (OR-1855). This metabolite is further metabolised by acetylation to N-acetylated conjugate (OR-1896). The circulating metabolites OR-1855 and OR-1896 are formed slowly, and their maximum concentrations are seen on average 2 days after stopping a 24-hour infusion. The haemodynamic effects after levosimendan seem to be similar between fast and slow acetylators despite the fact that the enzyme N-acetyltransferase-2, which is responsible for the metabolism of OR-1855 to OR-1896, is polymorphically distributed in the population. Levosimendan reduces peripheral vascular resistance and has direct contractility-enhancing effects on the failing left ventricle. It also improves indices of diastolic function and seems to improve the function of stunned myocardium. Despite an improvement in ventricular function, levosimendan does not increase myocardial oxygen uptake significantly. An increase in coronary blood flow and a reduction in coronary vascular resistance have been observed. Levosimendan reduces plasma brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) levels substantially, and a decrease in plasma endothelin-1 has been observed. Levosimendan also exerts beneficial effects on proinflammatory cytokines and apoptosis mediators. The effects of a 24-hour levosimendan infusion on filling pressure, ventricular function and BNP, as well as NT-proBNP, last for at least 7 days.
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Affiliation(s)
- Saila Antila
- National Agency for Medicines, Helsinki, Finland.
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Puttonen J, Kantele S, Kivikko M, Häkkinen S, Harjola VP, Koskinen P, Pentikäinen PJ. Effect of severe renal failure and haemodialysis on the pharmacokinetics of levosimendan and its metabolites. Clin Pharmacokinet 2007; 46:235-46. [PMID: 17328582 DOI: 10.2165/00003088-200746030-00004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVES Levosimendan is a calcium sensitiser developed for the treatment of congestive heart failure. It increases myocardial contractility, reduces the filling pressure and dilates both the peripheral and coronary vessels. The circulating metabolites of levosimendan, OR-1855 and OR-1896, are formed and eliminated slowly after intravenous administration of levosimendan. The aim of this study was to investigate the effect of impaired renal function and haemodialysis on the pharmacokinetics of levosimendan, OR-1855 and OR-1896. STUDY DESIGN This study was an open-label, nonrandomised, phase I pharmacokinetic study. Levosimendan was administered as a single-dose infusion of 0.1 microg/kg/minute for 24 hours. The follow-up period lasted 3 weeks. STUDY SETTING Twenty-fivepatients were included:12 patients with severe chronic renal failure (CRF) with creatinine clearance of < 30 mL/minute/1.73 m(2) and 13 patients with end-stage renal disease (ESRD) undergoing haemodialysis. A group of 12 healthy subjects served as controls. RESULTS Levosimendan, the parent drug, was eliminated rapidly from the plasma after discontinuation of its infusion, with an elimination half-life (t(1/2)) [mean +/- standard error of mean] of 1.5 +/- 0.09 hours in ESRD patients undergoing haemodialysis, 1.0 +/- 0.2 hours in patients with severe CRF and 0.91 +/- 0.03 hours in healthy subjects. The t(1/2) of levosimendan was significantly longer (p < 0.001) in ESRD patients undergoing haemodialysis than in healthy subjects. The t(1/2) of OR-1855 and OR-1896 were 94.0 +/- 20.4 hours and 96.5 +/- 19.5 hours, respectively, in ESRD patients undergoing haemodialysis compared with 60.8 +/- 5.2 and 61.6 +/- 5.2 hours, respectively, in healthy subjects (p = not significant). The t(1/2) of OR-1855 was significantly longer (85.0 +/- 13.6 hours) in patients with severe CRF than in healthy subjects (60.8 +/- 5.2 hours, p < 0.05). The area under the plasma concentration-time curve (AUC) and the peak plasma concentration (C(max)) of the metabolites were approximately 2-fold in patients with ESRD undergoing haemodialysis and patients with severe CRF compared with healthy subjects. The mean unbound fraction (f(u)) of levosimendan in plasma was approximately 2% in each study group, whereas the f(u) of the metabolites was considerably higher (63-70%). In contrast to levosimendan, the metabolites were dialysable, with dialysis clearance of approximately 100 mL/minute. The haemodynamic responses and adverse event profiles were similar in the study groups, with headache, palpitations and dizziness being the most frequently recorded adverse events. CONCLUSION The t(1/2) of the levosimendan metabolites was prolonged 1.5-fold and their AUC and C(max) were 2-fold in patients with severe CRF and ESRD patients undergoing haemodialysis as compared with healthy subjects. These results suggest that the dose should be reduced when levosimendan is used for the treatment of congestive heart failure in patients with severe renal insufficiency.
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Missant C, Rex S, Segers P, Wouters PF. Levosimendan improves right ventriculovascular coupling in a porcine model of right ventricular dysfunction*. Crit Care Med 2007; 35:707-15. [PMID: 17255859 DOI: 10.1097/01.ccm.0000257326.96342.57] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Experimental data suggest that levosimendan has pulmonary vasodilatory properties which, in combination with its positive inotropic effects, would render it particularly attractive for the treatment of right ventricular dysfunction. To test this hypothesis, we developed an experimental model of right ventricular failure and analyzed the effects of levosimendan on ventriculovascular coupling between the right ventricle and pulmonary artery (PA). DESIGN Prospective, randomized, placebo-controlled animal study. SETTING University hospital laboratory. SUBJECTS Fourteen pigs (mean weight 36 +/- 1 kg). INTERVENTIONS Pigs were instrumented with biventricular conductance catheters, a PA and right coronary artery flow probe, and a high-fidelity pulmonary pressure catheter. Right ventricular dysfunction was induced by repetitive episodes of ischemia/reperfusion in the presence of temporary PA constriction. Pigs were randomly assigned to receive levosimendan (120 mg/kg/hr [corrected] for 10 mins followed by continuous infusion of 60 mg/kg/hr [corrected] for 45 mins) or the placebo (control). MEASUREMENTS AND MAIN RESULTS Induction of right ventricular dysfunction resulted in a 42% decrease in contractility (reduction in slope of preload recruitable stroke work [Mw] from 2.5 +/- 0.4 to 1.8 +/- 0.5 mW x sec x mL(-1); p = .02) and a 60% increase in right ventricular afterload (effective pulmonary arterial elastance [PA-Ea] from 0.6 +/- 0.1 to 1.0 +/- 0.3 mm Hg x mL(-1); p < .01). Right ventriculovascular coupling, as assessed by the quotient of right ventricular end-systolic elastance (E(max)) over PA-Ea, decreased from 1.23 +/- 0.38 to 0.64 +/- 0.21 (p = .03). Treatment with levosimendan improved right ventricular contractility (Mw from 1.9 +/- 0.4 to 2.9 +/- 0.5 mW x sec x mL(-1); p < .01), lowered right ventricular afterload (PA-Ea from 1.1 +/- 0.3 to 0.8 +/- 0.3 mm Hg x mL(-1); p = .02), and restored right ventriculovascular coupling to normal values (E(max)/PA-Ea = 1.54 +/- 0.51). Levosimendan also significantly increased coronary blood flow and left ventricular contractility (Mw from 7.2 +/- 3.3 to 9.5 +/- 2.9 mW x sec x mL(-1); p = .01) but did not affect biventricular diastolic function. CONCLUSIONS In an experimental model of acute right ventricular dysfunction, levosimendan improved global hemodynamics and optimized right ventriculovascular coupling via a moderate increase in right ventricular contractility and a mild reduction of right ventricular afterload.
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Affiliation(s)
- Carlo Missant
- Center for Experimental Anesthesiology, Emergency and Intensive Care Medicine, Department of Acute Medical Sciences, Katholieke Universiteit Leuven, Belgium
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Abstract
Calcium sensitizers are a new group of inotropic drugs. Levosimendan is the only calcium sensitizer in clinical use in Europe. Its mechanism of action includes both calcium sensitization of contractile proteins and the opening of adenosine triphosphate (ATP)-dependent potassium channels as mechanism of vasodilation. The combination of K-channel opening with positive inotropy offers potential benefits in comparison to currently available intravenous inotropes, since K-channel opening protects myocardium during ischemia. Due to the calcium-dependent binding of levosimendan to troponin C, the drug increases contractility without negative lusitropic effects. In patients with heart failure levosimendan dose-dependently increases cardiac output and reduces pulmonary capillary wedge pressure. Since levosimendan has an active metabolite OR-1896 with a half-life of some 80 hours, the duration of the hemodynamic effects significantly exceeds the 1-hour half-life of the parent compound. The hemodynamic effects of the levosimendan support its use in acute and postoperative heart failure. Several moderate-size trials (LIDO, RUSSLAN, CASINO) have previously suggested that the drug might even improve the prognosis of patients with decompensated heart failure. These trials were carried out in patients with high filling pressures. Recently two larger trials (SURVIVE and REVIVE) in patients who were hospitalized because of worsening heart failure have been finalized. These trials did not require filling pressures to be measured. The two trials showed that levosimendan improves the symptoms of heart failure, but does not improve survival. The results raise the question whether a 24-hour levosimendan infusion can be used without invasive hemodynamic monitoring.
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Affiliation(s)
- Lasse Lehtonen
- Department of Clinical Pharmacology, Helsinki University Central Hospital, Helsinki, Finland.
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Lechner E, Moosbauer W, Pinter M, Mair R, Tulzer G. Use of levosimendan, a new inodilator, for postoperative myocardial stunning in a premature neonate. Pediatr Crit Care Med 2007; 8:61-3. [PMID: 17149153 DOI: 10.1097/01.pcc.0000253026.67341.5d] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To first report the successful use of the new inodilator levosimendan in a premature infant with congestive heart failure (CHF) following cardiac surgery. Although the calcium sensitizer levosimendan improves hemodynamics in adults with CHF, no data are available on the use of levosimendan in premature infants with CHF. DESIGN Single case report. SETTING Twenty-bed postoperative adult and pediatric cardiac intensive care unit. PATIENT A 32 wks gestational age, 1525-g premature male twin with transposition of the great arteries. INTERVENTIONS The patient underwent arterial switch operation. MEASUREMENTS AND MAIN RESULTS Immediately after operation, the patient developed signs of low cardiac output syndrome. Mixed venous saturation was 56%, serum lactate increased to 14.8 mmol/L, systolic arterial pressure was 40 mm Hg, left atrial pressure was 24 mm Hg, and echocardiography showed reduced left ventricular function with a fractional shortening of 10%. There were no signs of reduced coronary perfusion. Milrinone, dobutamine, and epinephrine did not improve hemodynamics. Levosimendan was initiated at a dose of 0.05 mug.kg.min, increased to 0.1 mug.kg.min, and continuously infused for 24 hrs. Within 6 hrs after starting the levosimendan infusion, left atrial pressure decreased to 7 mm Hg and systolic arterial pressure increased to 60 mm Hg; within 24 hrs after initiation serum lactate level normalized to 1.7 mmol/L and mixed venous saturation increased to 81%. Echocardiography revealed improvement of left ventricular function with a fractional shortening of 25%. No side effects were recognized during administration of levosimendan. CONCLUSIONS In this premature neonate with postoperative low cardiac output syndrome due to failing myocardial function, levosimendan was a potent inotropic agent.
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Affiliation(s)
- Evelyn Lechner
- Department of Pediatric Cardiology, Children's Heart Center Linz, Linz, Austria
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Trikas A, Antoniades C, Latsios G, Vasiliadou K, Karamitros I, Tousoulis D, Tentolouris C, Stefanadis C. Long-term effects of levosimendan infusion on inflammatory processes and sFas in patients with severe heart failure. Eur J Heart Fail 2006; 8:804-9. [PMID: 16713737 DOI: 10.1016/j.ejheart.2006.03.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2005] [Revised: 02/02/2006] [Accepted: 03/08/2006] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND The calcium sensitizer levosimendan improves myocardial contractility in patients with heart failure, although its effects on inflammation and apoptosis are unknown. AIM To examine the effects of levosimendan on markers of inflammation and apoptosis, over a period of 30 d following a 24 h infusion, in patients with heart failure. METHODS Thirty four patients with severe heart failure were randomised to receive a 24 h infusion of levosimendan or placebo, in a double-blind trial. Haemodynamic evaluation and blood sampling were performed at baseline, 24 h, 30 h, 48 h, 7 d and 30 d after the end of the infusion. RESULTS Seven patients (1 levosimendan, 6 placebo), were excluded during follow-up. In the remaining 27 patients, levosimendan decreased serum IL-6 and sFAS, 24 h after the infusion (p<0.01 and p<0.05 vs baseline), an effect sustained for 7-30 d. Serum TNF-alpha and sTNF-R1 were decreased between 48 h (p<0.01 vs baseline for both) and 7 d (p<0.05 vs baseline for sTNF-R1) after infusion. Serum sTNF-R2 was decreased at 24 h (p<0.05 vs baseline) and remained lower than baseline for at least 7 d (p<0.05). CONCLUSIONS These findings indicate that levosimendan decreases the expression of proinflammatory cytokines, TNF-alpha receptors and sFAS, immediately after infusion, an effect which persists for 7-30 d.
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Affiliation(s)
- Athanasios Trikas
- Athens University Medical School, A' Cardiology Department, Athens, Greece.
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Holley AD, Ziegenfuss M. Levosimendan: a new option in acute cardiac failure. Emerg Med Australas 2006; 18:505-9. [PMID: 17083641 DOI: 10.1111/j.1742-6723.2006.00871.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Anthony David Holley
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia.
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Papp Z, Csapó K, Pollesello P, Haikala H, Edes I. Pharmacological Mechanisms Contributing to the Clinical Efficacy of Levosimendan. ACTA ACUST UNITED AC 2006; 23:71-98. [PMID: 15867949 DOI: 10.1111/j.1527-3466.2005.tb00158.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Acute decompensation of chronic heart failure is a direct life-threatening situation with short-term mortality approaching 30%. A number of maladaptive changes are amplified within the cardiovascular system during the progression of chronic heart failure that makes the decompensation phase difficult to handle. Levosimendan is a new Ca2+-sensitizer for the treatment of acutely decompensated heart failure that has proved to be effective during the decompensation of chronic heart failure and acute myocardial infarction. Levosimendan differs from other cardiotonic agents that are used for acute heart failure in that it utilizes a unique dual mechanism of action: Ca2+-sensitization through binding to troponin C in the myocardium, and the opening of ATP-sensitive K+ channels in vascular smooth muscle. In general, these mechanisms evoke positive inotropy and vasodilation. Clinical studies suggested long-term benefits on mortality following short-term administration. It may, therefore, be inferred that levosimendan has additional effects on the cardiovascular system that are responsible for the prolongation of survival. Results of preclinical and clinical investigations suggest that the combination of levosimendan-induced cardiac and vascular changes has favorable effects on the coronary, pulmonary and peripheral circulations. Redistribution of the circulating blood offers an improved hemodynamic context for the development of a positive inotropic effect through Ca2+-sensitization of the contractile filaments, without a proportionate increase in myocardial oxygen consumption or the development of arrhythmias. Activation of ATP-sensitive K+ channels, both on sarcolemma and mitochondria, may protect against myocardial ischemia, and decreased levels of cytokines may prevent the development of further myocardial remodeling. Collectively, these effects of levosimendan shift the disturbed cardiovascular parameters towards normalization, thereby halting the perpetuation of the vicious cycle of heart failure progression. This may contribute to stabilization of the circulation and improved life expectancy of patients with chronic heart failure.
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Affiliation(s)
- Zoltán Papp
- Division of Clinical Physiology, Institute of Cardiology, University of Debrecen, Medical and Health Science Center, Medical School, P.O. BOX 1, H-4004 Debrecen, Hungary.
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Earl GL, Fitzpatrick JT. Levosimendan: a novel inotropic agent for treatment of acute, decompensated heart failure. Ann Pharmacother 2005; 39:1888-96. [PMID: 16219899 DOI: 10.1345/aph.1g128] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the literature on a novel calcium sensitizer, levosimendan. DATA SOURCES Articles were identified through searches of MEDLINE (1966-June 2005), International Pharmaceutical Abstracts (1970-June 2005), and EMBASE (1992-June 2005) using the key words levosimendan, simendan, calcium sensitizer, calcium sensitiser, and congestive heart failure. STUDY SELECTION AND DATA EXTRACTION Clinical trials and pharmacokinetic studies evaluating the safety and efficacy of levosimendan were selected. DATA SYNTHESIS Levosimendan 6-24 mug/kg intravenous bolus followed by a 24-hour continuous infusion of 0.05-0.2 microg/kg/min improved cardiac output and reduced pulmonary capillary wedge pressure in a dose-dependent manner. Dose-ranging and randomized clinical trials have demonstrated improvement in symptoms and hemodynamics and short-term survival outcomes in the treatment of acute, decompensated heart failure. Clinical trials evaluating retrospective mortality data and combined endpoints (mortality, rehospitalization) have demonstrated better outcomes with levosimendan compared with dobutamine. The incidence of hypotension with levosimendan is not significantly different than with dobutamine, but there is a dose-related increase in heart rate. CONCLUSIONS Levosimendan is useful in moderate to severe low-output heart failure in patients who have failed to respond to diuretics and vasodilators. Based on current studies, levosimendan appears to be a safe alternative to dobutamine for treatment of acute, decompensated heart failure. Prospective clinical trials are needed to confirm the effect of levosimendan on long-term survival and its role in heart failure in the setting of myocardial infarction.
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Affiliation(s)
- Grace L Earl
- Department of Pharmacy Practice and Administration, University of the Sciences in Philadelphia, Philadelphia, PA 19104, USA.
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Abstract
Current therapies for acute heart failure syndromes (AHFS) target hemodynamics by decreasing congestion or increasing myocardial contraction. Several new agents for AHFS use novel mechanisms of action that focus on new treatment targets, such as those providing anti-ischemic and anti-stunning effects, blocking vasopressin receptors, or blocking endothelin-1 receptors. For example, levosimendan acts as a calcium sensitizer and adenosine triphosphate-dependent potassium (K(ATP)) channel opener that increases contraction, causes vasodilation, and provides cardioprotective effects. This is accomplished by its dual mechanism of action. Levosimendan binds to cardiac troponin C, thereby enhancing calcium myofilament responsiveness and increasing myocardial contraction without increasing intracellular calcium levels. Thus, contraction is increased with no significant increase in myocardial oxygen consumption. The opening of K(ATP) channels by levosimendan causes vasodilation and exerts anti-ischemic and anti-stunning effects on the myocardium. Other new agents target neurohormonal pathways. Tezosentan is an antagonist of endothelin-1 receptors A and B. By inhibiting endothelin-1 receptors, tezosentan may counteract the activities of endothelin-1, which include vasoconstriction, proarrhythmic activities, potentiation of other neurohormones, and mediation of increased vascular permeability. Tolvaptan is a vasopressin V2-receptor antagonist that functions as an aquaretic (ie, it increases urine volume and serum sodium with little or no sodium loss). Therefore, by using novel mechanisms of action, these agents may provide new opportunities for helping patients with AHFS.
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Affiliation(s)
- Mihai Gheorghiade
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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