Calcium in suramin-induced rat sensory neuron toxicity in vitro

Rational treatment of chemotherapy-induced peripheral neuropathy with capsaicin 8% patch: from pain relief towards disease modification

Purpose

Chemotherapy-induced peripheral neuropathy (CIPN) with associated chronic pain is a common and disabling condition. Current treatments for neuropathic pain in CIPN are largely ineffective, with unfavorable side-effects. The capsaicin 8% patch (capsaicin 179 mg patch) is approved for the treatment of neuropathic pain: a single topical cutaneous application can produce effective pain relief for up to 12 weeks. We assessed the therapeutic potential of capsaicin 8% patch in patients with painful CIPN, and its mechanism of action.

Patients and methods

16 patients with chronic painful CIPN (mean duration 2.5 years), in remission for cancer and not receiving chemotherapy, were treated with 30 min application of capsaicin 8% patch to the feet. Symptoms were monitored using the 11-point numerical pain rating scale (NPRS), and questionnaires. Investigations were performed at baseline and three months after patch application, including skin biopsies with a range of markers, and quantitative sensory testing (QST).

Results

Patients reported significant reduction in spontaneous pain (mean NPRS: −1.27; 95% CI 0.2409 to 2.301; p=0.02), touch-evoked pain (−1.823; p=0.03) and cold-evoked pain (−1.456; p=0.03). Short-Form McGill questionnaire showed a reduction in neuropathic (p=0.0007), continuous (p=0.01) and overall pain (p=0.004); Patient Global Impression of Change showed improvement (p=0.001). Baseline skin biopsies showed loss of intra-epidermal nerve fibers (IENF), and also of sub-epidermal nerve fibers quantified by image analysis. Post-patch application skin biopsies showed a significant increase towards normalization of intra-epidermal and sub-epidermal nerve fibers (for IENF: structural marker PGP9.5, p=0.009; heat receptor TRPV1, p=0.027; regenerating nerve marker GAP43, p=0.04). Epidermal levels of Nerve Growth Factor (NGF), Neurotrophin-3 (NT-3), and Langerhans cells were also normalized. QST remained unchanged and there were no systemic side-effects, as in previous studies.

Conclusion

Capsaicin 8% patch provides significant pain relief in CIPN, and may lead to regeneration and restoration of sensory nerve fibers ie, disease modification.

Suramin-Induced Neurotoxicity: Preclinical Models and Neuroprotective Strategies

Suramin is a trypan blue analogon originally developed to treat protozoan infections, which was found to have diverse antitumor effects. One of the most severe side effects in clinical trials was the development of a peripheral sensory-motor polyneuropathy. In this study, we aimed to investigate suramin-induced neuropathy with a focus on calcium (Ca²⁺) homeostasis as a potential pathomechanism. Adult C57Bl/6 mice treated with a single injection of 250 mg/kg bodyweight suramin developed locomotor and sensory deficits, which were confirmed by electrophysiological measurements showing a predominantly sensory axonal-demyelinating polyneuropathy. In a next step, we used cultured dorsal root ganglia neurons (DRGN) as an in vitro cell model to further investigate underlying pathomechanisms. Cell viability of DRGN was significantly decreased after 24-hour suramin treatment with a calculated IC₅₀ of 283 µM. We detected a suramin-induced Ca²⁺ influx into DRGN from the extracellular space, which could be reduced with the voltage-gated calcium channel (VGCC) inhibitor nimodipine. Co-incubation of suramin and nimodipine partially improved cell viability of DRGN after suramin exposure. In summary, we describe suramin-induced neurotoxic effects on DRGN as well as potentially neuroprotective agents targeting intracellular Ca²⁺ dyshomeostasis.

Developing and applying the adverse outcome pathway concept for understanding and predicting neurotoxicity

The Adverse Outcome Pathway (AOP) concept has recently been proposed to support a paradigm shift in regulatory toxicology testing and risk assessment. This concept is similar to the Mode of Action (MOA), in that it describes a sequence of measurable key events triggered by a molecular initiating event in which a stressor interacts with a biological target. The resulting cascade of key events includes molecular, cellular, structural and functional changes in biological systems, resulting in a measurable adverse outcome. Thereby, an AOP ideally provides information relevant to chemical structure-activity relationships as a basis for predicting effects of structurally similar compounds. AOPs could potentially also form the basis for qualitative and quantitative predictive modeling of the human adverse outcome resulting from molecular initiating or other key events for which higher-throughput testing methods are available or can be developed. A variety of cellular and molecular processes are known to be critical for normal function of the central (CNS) and peripheral nervous systems (PNS). Because of the biological and functional complexity of the CNS and PNS, it has been challenging to establish causative links and quantitative relationships between key events that comprise the pathways leading from chemical exposure to an adverse outcome in the nervous system. Following introduction of the principles of MOA and AOPs, examples of potential or putative adverse outcome pathways specific for developmental or adult neurotoxicity are summarized and aspects of their assessment considered. Their possible application in developing mechanistically informed Integrated Approaches to Testing and Assessment (IATA) is also discussed.

Basic science and clinical management of painful and non-painful chemotherapy-related neuropathy

Chemotherapy-induced peripheral neuropathy (CIPN) is a dose-limiting toxicity of several chemotherapeutics used in the treatment of all the most common malignancies. There are several defined mechanisms of nerve damage that take place along different areas of the peripheral and the central nervous system. Treatment is based on symptom management and there are several classes of medications found to be efficacious in the treatment of neuropathic pain. Neuropathic pain that persists despite appropriate pharmacotherapy may respond to interventional procedures that span a range of invasiveness. The purpose of this review article is to examine the basic science of neuropathy and currently available treatment options in the context of chemotherapy induced peripheral neuropathy.

Mechanisms in cancer-chemotherapeutic drugs-induced peripheral neuropathy

Anti-cancer drugs such as vincristine, paclitaxel, oxaliplatin, cisplatin and bortezomib are well reported to exert direct and indirect effects on sensory nerves to alter the amplitude of action potential, conduction velocity and induce pain. It results in patient suffering and also limits the treatment with potentially useful anticancer drugs. The different scientists have worked in this area to explore the mechanisms responsible for its pathogenesis. Anti-cancer agents activate plasma membrane localized ion channels on dorsal root ganglia and dorsal horn neurons including sodium, calcium, potassium, glutamate activated NMDA receptors to alter cytosolic ionic mileu particularly intracellular calcium that trigger secondary changes to induce neuropathic pain. These may include opening of mPTP pore on mitochondria to induce intracellular calcium release; activation of protein kinase C; phosphorylation of TRPV; activation of calpases/calpains; generation of nitric oxide and free radicals to induce cytotoxicity to axons and neuronal cell bodies. Furthermore, the inflammatory process initiated in glial cells and macrophages also trigger changes in the sensory neurons to alter nociceptive processing. The present review elaborates the role of all these individual targets in the pathogenesis of anticancer agents-induced neuropathic pain to develop effective therapeutic modalities for pain management.

Chemotherapy-induced neuropathy

Neurotoxic side effects of cancer therapy are second in frequency to hematological toxicity. Unlike hematological side effects that can be treated with hematopoietic growth factors, neuropathies cannot be treated and protective treatment strategies have not been effective. For the neurologist, the diagnosis of a toxic neuropathy is primarily based on the case history, the clinical and electrophysiological findings, and knowledge of the pattern of neuropathy associated with specific agents. In most cases, toxic neuropathies are length-dependent, sensory, or sensorimotor neuropathies often associated with pain. The platinum compounds are unique in producing a sensory ganglionopathy. Neurotoxicity is usually dependent on cumulative dose. Severity of neuropathy increases with duration of treatment and progression stops once drug treatment is completed. The platinum compounds are an exception where sensory loss may progress for several months after cessation of treatment ("coasting"). As more effective multiple drug combinations are used, patients will be treated with several neurotoxic drugs. Synergistic neurotoxicity has not been extensively investigated. Pre-existent neuropathy may influence the development of a toxic neuropathy. Underlying inherited or inflammatory neuropathies may predispose patients to developing very severe toxic neuropathies. Other factors such as focal radiotherapy or intrathecal administration may enhance neurotoxicity. The neurologist managing the cancer patient who develops neuropathy must answer a series of important questions as follows: (1) Are the symptoms due to peripheral neuropathy? (2) Is the neuropathy due to the underlying disease or the treatment? (3) Should treatment be modified or stopped because of the neuropathy? (4) What is the best supportive care in terms of pain management or physical therapy for each patient? Prevention of toxic neuropathies is most important. In patients with neuropathy, restorative approaches have not been well established. Symptomatic and other management are necessary to maintain and improve quality of life.

Chemotherapy-induced peripheral neurotoxicity

Chemotherapy-induced peripheral neurotoxicity (CIPN) is a major clinical problem because it represents the dose-limiting side effects of a significant number of antineoplastic drugs. The incidence of CIPN varies depending on the drugs and schedules used, and this can be quite high, particularly when neurophysiological methods are used to make a diagnosis. However, even when CIPN is not a dose-limiting side effect, its onset may severely affect the quality of life of cancer patients and cause chronic discomfort. In this review the features of CIPN due to the administration of the most widely used drugs, such as platinum drugs, taxanes and vinca alkaloids, and of two old drugs with new clinical applications, suramin and thalidomide, will be discussed. Moreover, the earliest data regarding the neurotoxicity of some new classes of very promising antineoplastic agents, such as epothilones and proteasome inhibitors, will be discussed. Finally, the data available on neuroprotectants, evaluated in the attempt to prevent CIPN, will be summarised.

Nitric oxide acts as a slow-down and search signal in developing neurites

Nitric oxide (NO) has been demonstrated to act as a signaling molecule during neuronal development, but its precise function is unclear. Here we investigate whether NO might function at the neuronal growth cone to affect growth cone motility. We have previously demonstrated that growth cones of identified neurons from the snail Helisoma trivolvis show a rapid and transient increase in filopodial length in response to NO, which was regulated by soluble guanylyl cyclase (sGC) [S. Van Wagenen and V. Rehder (1999) J. Neurobiol., 39, 168-185]. Because in vivo studies have demonstrated that growth cones have longer filopodia and advance more slowly in regions where pathfinding decisions are being made, this study aimed to establish whether NO could function as a combined 'slow-down and search signal' for growth cones by decreasing neurite outgrowth. In the presence of the NO donor NOC-7, neurites of B5 neurons showed a concentration-dependent effect on neurite outgrowth, ranging from slowing at low, stopping at intermediate and collapsing at high concentrations. The effects of the NO donor were mimicked by directly activating sGC with YC-1, or by increasing its product with 8-bromo-cGMP. In addition, blocking sGC in the presence of NO with NS2028 blocked the effect of NO, suggesting that NO affected outgrowth via sGC. Ca2+ imaging of growth cones with Fura-2 indicated that [Ca2+]i increased transiently in the presence of NOC-7. These results support the hypothesis that NO can function as a potent slow/stop signal for developing neurites. When coupled with transient filopodia elongation, this phenomenon emulates growth cone searching behavior.

Suramin-induced neuropathy in an animal model

Suramin is being used either alone, or in combination with other chemotherapeutic agents, in the treatment of hormone-refractory or metastatic prostate cancer. Use of this potentially valuable chemotherapy is limited by a dose-dependent polyneuropathy. It has been difficult in human studies to characterize peripheral suramin toxicity separately from cancer-related neuropathy. To characterize suramin-induced neuropathy in a rat model, adult rats were given either a single dose of 500 mg/kg (high dose) or 50 mg/kg (low dose) weekly suramin for 2 months. Electrophysiology and peroneal/sural nerve morphometry were performed. In high dose animals, neuropathy developed within 2 weeks, most severe in the digital sensory responses (DSR) (p<0.05) and tail and hind limb compound muscle action potential (p<0.001). Histologically, there was evidence of axonal degeneration and axon atrophy. With low dose suramin, the DSR (p<0.05) and tail distal sensory and motor responses (p<0.01) were most severely affected at 2 months. Axonal degeneration was seen in teased fibers from most animals. With TEM, there were abundant characteristic lysosomal inclusion bodies in DRG and Schwann cells. Electrophysiological and histological evidence of peripheral demyelination was rare, being observed in only one animal. Suramin induced a length, dose and time-dependent axonal sensorimotor polyneuropathy associated with axonal degeneration, atrophy, and accumulation of glycolipid lysosomal inclusions.

Pathogenesis of axonal degeneration: parallels between Wallerian degeneration and vincristine neuropathy

Peripheral neuropathies and Wallerian degeneration share a number of pathological features; the most prominent of which is axonal degeneration. We asked whether common pathophysiologic mechanisms are involved in these 2 disorders by directly comparing in vitro models of axonal degeneration after axotomy or exposure to the neurotoxin vincristine. Embryonic rat dorsal root ganglia (DRG) were allowed to extend neurites for 5 days in culture, and then were either axotomized or exposed to 0.01 microM vincristine. Neurites universally degenerated by 3 days after axotomy or after 6 days of vincristine exposure. The neuroprotective effects of a low calcium environment or pharmacologic inhibition of the cysteine protease calpain were compared in these 2 models of axonal degeneration. Addition of EGTA or growth in zero-calcium media provided significant protection against axonal degeneration after either axotomy or vincristine exposure. Treatment with the experimental calpain inhibitor AK295 was equally protective in both models. Chronic exposure to AK295 was not toxic to the cultures. These data suggest that common mechanisms involving calcium and calpains are involved in both axotomy-induced and vincristine-induced axonal degeneration. In addition, calpain inhibition may provide a strategy for preventing axonal degeneration and preserving neurologic function in a variety of PNS and CNS disorders.

Calmidazolium-induced rises in cytosolic calcium concentrations in Madin Darby canine kidney cells

The effect of calmidazolium on Ca(2+) signaling in Madin Darby canine kidney (MDCK) cells was investigated using fura-2 as a Ca(2+) probe. Calmidazolium at 2-5 microM increased [Ca(2+)](i) concentration dependently. The [Ca(2+)](i) rise induced by 2-5 microM calmidazolium comprised an immediate rise and a slow decay. External Ca(2+) removal partly inhibited the Ca(2+) signals, suggesting that calmidazolium activated external Ca(2+) influx and internal Ca(2+) release. In Ca(2+)-free medium, pretreatment with 3 microM calmidazolium abolished the Ca(2+) release induced by 1 microM thapsigargin, an endoplasmic reticulum Ca(2+) pump inhibitor, and, vice versa, pretreatment with thapsigargin inhibited calmidazolium-induced Ca(2+) release. This indicates that thapsigargin-sensitive Ca(2+) store was the source of calmidazolium-induced Ca(2+) release. Calmidazolium (3 microM) induced Mn(2+) quench of fura-2 fluorescence at 360 nm excitation wavelength, which was suppressed by 0.1 mM La(3+). Addition of 3 mM Ca(2+) increased [Ca(2+)](i) after pretreatment with 3-5 microM calmidazolium in Ca(2+)-free medium. This implies that calmidazolium activated concentration-dependent capacitative Ca(2+) entry. Calmidazolium (3 microM) augmented the capacitative Ca(2+) entry induced by 1 microM thapsigargin or 0.1 mM ATP by 38%. Calmidazolium (3 microM)-induced Ca(2+) release was blocked by pretreatment with 40 microM aristolochic acid and 2 microM U73122 (2 microM) to inhibit phospholipase A(2) and phospholipase, respectively, but pretreatment with 0.1 mM propranolol to inhibit phospholipase D had no effect. This suggests that calmidazolium induced internal Ca(2+) release in a manner dependent on phospholipases C- and A(2)-coupled events.

Possible mechanism for the decrease of mitochondrial aspartate aminotransferase activity in ischemic and hypoxic rat retinas

Glutamate is believed to be an excitatory amino acid neurotransmitter in the retina. Enzymes for glutamate metabolism, such as glutamate dehydrogenase, ornithine aminotransferase, glutaminase, and aspartate aminotransferase (AAT), exist mainly in the mitochondria. The abnormal increase of intracellular calcium ions in ischemic retinal cells may cause an influx of calcium ions into the mitochondria, subsequently affecting various mitochondrial enzyme activities through the activity of mitochondrial calpain. As AAT has the highest level of activity among enzymes involved in glutamate metabolism, we investigated the change of AAT activity in ischemic and hypoxic rat retinas and the protection against such activity by calpain inhibitors. We used normal RCS (rdy+/rdy+) rats. For the in vivo studies, we clamped the optic nerve of anesthetized rats to induce ischemia. In the in vitro studies, the eye cups were incubated with Locke's solution saturated with 95% N2/5% CO2. The activity of cytosolic AAT (cAAT) was about 20% of total activity, whereas mitochondrial AAT (mAAT) was about 75% in rat retina. Ninety minutes of ischemia or hypoxia caused a 20% decrease in mAAT activity, whereas cAAT activity remained unchanged. To examine the contribution of intracellular calcium ions to the degradation of mAAT, we used Ca2+-free Locke's solution containing 1 mM EGTA, ryanodine (Ca2+ channel blocker), and thapsigargin (Ca2+-ATPase inhibitor). In the present study, thapsigargin in Ca2+-free Locke's solution, but not ryanodine in this solution, was found to prevent AAT degradation. AAT degradation was also prevented by calpain inhibitors (Ca2+-dependent protease inhibitor) such as calpeptin at 1 nM, 10 nM, 0.1 microM, 1 microM and 10 microM, and by calpain inhibitor peptide, but not by other protease inhibitors (10 microM leupeptin, pepstatin, chymostatin). Additionally, we determined the subcellular localization of calpain activity and examined the change of calpain activity in ischemic rat retinas. Our results suggest that decreased activity of mAAT in ischemic and hypoxic rat retinas might be evoked by the degradation by calpain-catalyzed proteolysis in mitochondria.

m-Calpain (calcium-activated neutral proteinase) in Alzheimer's disease brains

An antibody specific for the calpain isoform m-calpain was used to resolve conflicting results from several studies on the possible role of m-calpain in the pathogenesis of Alzheimer's disease (AD). Levels of the enzyme in both cytosolic and membranous fractions of brain tissue were determined by Western blot analysis. We also demonstrated changes in m-calpain molecules in AD brains using high-resolution 2D gel electrophoresis (2DE). The levels of the m-calpain isoform detected in the cytosolic fraction were significantly increased in AD brains when compared with the levels in controls. On 2DE, m-calpain molecules resolved into eight main spots. These spots were detected in AD brains as well as in control brains, suggesting that the calpain molecule was not qualitatively changed in AD. Quantitative analysis of the m-calpain spots on 2DE, on the other hand, indicated that the ratio of the intensity of four protein spots in the acidic region to that of the total spots was increased in AD brains.