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Sheibani M, Zamani N, Gerami AH, Akhondi H, Hassanian-Moghaddam H. Clinical, Laboratory, and Electrocardiographic Findings in Colchicine Toxicity: 10 Years of Experience. Front Med (Lausanne) 2022; 9:872528. [PMID: 35665351 PMCID: PMC9160711 DOI: 10.3389/fmed.2022.872528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
Background: We aimed to investigate the clinical, laboratory, and electrocardiographic (ECG) findings of colchicine poisoning and to evaluate if there is a correlation between them and the two major outcomes of this toxicity which are respiratory/cardiovascular failure and death. Materials and Methods Medical records of 34 colchicine-intoxicated patients that were treated in our center during the past 10 years were retrospectively evaluated. The patient's clinical presentation, vital signs, laboratory tests, ECGs, and outcomes were reviewed. Results Abdominal pain, and hypotension at presentation had significant correlation with mortality (p = 0.003, OR: 2.2 [4.1, 7.9], p = 0.029, OR: 13.0 [1.5, 111.8]). Mortality significantly occurred in those with sinus tachycardia, hypokalemia, metabolic acidosis, and impaired liver and kidney function tests (p-values = 0.025, 0.007, 0.04, and 0.008, respectively). All the patients had some ECG abnormalities. Most frequent ECG abnormalities were pathologic ST segment elevation and depression (70%), left atrial enlargement (48%), and sinus tachycardia (37%), PR elevation in aVR lead (37%), and T wave inversion (37%). Conclusions Colchicine toxicity is a dangerous entity regarding the cardiovascular events and requires close general and cardiac monitoring.
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Affiliation(s)
- Mehdi Sheibani
- Cardiovascular Research Center, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Nasim Zamani
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Hushang Gerami
- School of Medicine, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Hossein Akhondi
- Department of Internal Medicine, University of Central Florida and Florida State University, Orlando, FL, United States
| | - Hossein Hassanian-Moghaddam
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- *Correspondence: Hossein Hassanian-Moghaddam
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Parashar P, Mazhar I, Kanoujia J, Yadav A, Kumar P, Saraf SA, Saha S. Appraisal of anti-gout potential of colchicine-loaded chitosan nanoparticle gel in uric acid-induced gout animal model. Arch Physiol Biochem 2022; 128:547-557. [PMID: 31852265 DOI: 10.1080/13813455.2019.1702702] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Present study is aimed at transdermal delivery of colchicine-loaded chitosan nanoparticles. The nanoformulations were prepared utilising spontaneous emulsification method and optimised through 23 factorial designs. The optimised formulation (CHNP-OPT) displayed an average particle size of 294 ± 3.75 nm, entrapment efficiency 92.89 ± 1.1% and drug content 83.45 ± 2.5%, respectively. In vitro release study demonstrated 89.34 ± 2.90% release over a period of 24 h. Further, CHNP-OPT incorporated into HPMC-E4M (hydroxypropyl methylcellulose) to form transdermal gel. CHNPgel displayed 74.65 ± 1.90% permeation and stability over a period of 90 days. The anti-gout potential of CHNPgel formulation was evaluated in vivo against monosodium urate (MSU) crystal-induced gout in animal model. There was significant reduction in uric acid level, during MSU administration, when compared with the conventional gel of colchicine. The enhanced therapeutic potential was witnessed through X-ray. The study revealed that colchicine-loaded CHNPgel proved their supremacy over plain colchicine and can be an efficient delivery system for gout treatment.
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Affiliation(s)
- Poonam Parashar
- Department of Pharmaceutical Sciences, Babasaheb Bhimrao Ambedkar University, Lucknow, India
| | - Ifrah Mazhar
- Department of Pharmaceutical Sciences, Babasaheb Bhimrao Ambedkar University, Lucknow, India
| | - Jovita Kanoujia
- Department of Pharmaceutical Sciences, Babasaheb Bhimrao Ambedkar University, Lucknow, India
| | - Abhishek Yadav
- Department of Pharmaceutical Sciences, Babasaheb Bhimrao Ambedkar University, Lucknow, India
| | - Pranesh Kumar
- Department of Pharmaceutical Sciences, Babasaheb Bhimrao Ambedkar University, Lucknow, India
| | - Shubhini A Saraf
- Department of Pharmaceutical Sciences, Babasaheb Bhimrao Ambedkar University, Lucknow, India
| | - Sudipta Saha
- Department of Pharmaceutical Sciences, Babasaheb Bhimrao Ambedkar University, Lucknow, India
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3
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Pisaniello HL, Fisher MC, Farquhar H, Vargas-Santos AB, Hill CL, Stamp LK, Gaffo AL. Efficacy and safety of gout flare prophylaxis and therapy use in people with chronic kidney disease: a Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN)-initiated literature review. Arthritis Res Ther 2021; 23:130. [PMID: 33910619 PMCID: PMC8080370 DOI: 10.1186/s13075-021-02416-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 01/04/2021] [Indexed: 12/27/2022] Open
Abstract
Gout flare prophylaxis and therapy use in people with underlying chronic kidney disease (CKD) is challenging, given limited treatment options and risk of worsening renal function with inappropriate treatment dosing. This literature review aimed to describe the current literature on the efficacy and safety of gout flare prophylaxis and therapy use in people with CKD stages 3-5. A literature search via PubMed, the Cochrane Library, and EMBASE was performed from 1 January 1959 to 31 January 2018. Inclusion criteria were studies with people with gout and renal impairment (i.e. estimated glomerular filtration rate (eGFR) or creatinine clearance (CrCl) < 60 ml/min/1.73 m2), and with exposure to colchicine, interleukin-1 inhibitors, non-steroidal anti-inflammatory drugs (NSAIDs), and glucocorticoids. All study designs were included. A total of 33 studies with efficacy and/or safety analysis stratified by renal function were reviewed-colchicine (n = 20), anakinra (n = 7), canakinumab (n = 1), NSAIDs (n = 3), and glucocorticoids (n = 2). A total of 58 studies reported these primary outcomes without renal function stratification-colchicine (n = 29), anakinra (n = 10), canakinumab (n = 6), rilonacept (n = 2), NSAIDs (n = 1), and glucocorticoids (n = 10). Most clinical trials excluded study participants with severe CKD (i.e. eGFR or CrCl of < 30 mL/min/1.73 m2). Information on the efficacy and safety outcomes of gout flare prophylaxis and therapy use stratified by renal function is lacking. Clinical trial results cannot be extrapolated for those with advanced CKD. Where possible, current and future gout flare studies should include patients with CKD and with study outcomes reported based on renal function and using standardised gout flare definition.
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Affiliation(s)
- Huai Leng Pisaniello
- Discipline of Medicine, Faculty of Health and Medical Sciences, the University of Adelaide, Adelaide, South Australia, Australia
| | - Mark C Fisher
- Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA.,Prima CARE, Fall River, MA, USA
| | - Hamish Farquhar
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | | | - Catherine L Hill
- Discipline of Medicine, Faculty of Health and Medical Sciences, the University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Angelo L Gaffo
- Division of Rheumatology and Clinical Immunology, University of Alabama, 1720 2nd Avenue South, Birmingham, AL, 35294, USA. .,Birmingham VA Medical Center, Birmingham, USA.
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4
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McEwan T, Robinson PC. A systematic review of the infectious complications of colchicine and the use of colchicine to treat infections. Semin Arthritis Rheum 2020; 51:101-112. [PMID: 33360321 PMCID: PMC7832726 DOI: 10.1016/j.semarthrit.2020.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/23/2020] [Accepted: 11/02/2020] [Indexed: 02/06/2023]
Abstract
Objective Colchicine has been used historically as an anti-inflammatory agent for a wide range of diseases. Little is known regarding the relationship between colchicine use and infectious disease outcomes. The objective of this study was to systematically examine infectious adverse events associated with colchicine usage and the clinical use of colchicine for infectious diseases. Methods A systematic review was conducted in accordance with PRISMA methodology. PubMed, EMBASE, Scopus and Cochrane Library databases were searched (up to 12th October, 2020) for interventional and observational studies that included colchicine usage associated with infectious adverse events or infectious disease outcomes. Results A total of 9,237 studies were initially identified and after exclusions, 36 articles comprising 21 interventional studies and 15 observational studies were included in this systematic review. There were 19 studies that reported infectious adverse events and 17 studies that examined the efficacy of colchicine in treating infectious disease. Only two out of six studies reported a significant benefit using colchicine in the management of viral liver disease. There was some evidence colchicine is beneficial in managing COVID-19 by reducing time to deterioration, length of stay in hospital and mortality. Colchicine had some benefit in managing malaria, condyloma accuminata and verruca vulgaris, viral myocarditis and erythema nodosum leprosum based on case-series or small, pilot clinical studies. Two of the clinical trials and five of the observational studies reported significant associations between infections adverse events and colchicine usage. Risk of pneumonia was found in three studies and post-operative infections were reported in two studies. Risks of urinary tract infections, H. pylori and C.difficile were only reported by one study each. Conclusion There is a current lack of clinical evidence that colchicine has a role in treating or managing infectious diseases. Preliminary studies have demonstrated a possible role in the management of COVID-19 but results from more clinical trials are needed. There is inconclusive evidence that suggests colchicine is associated with increased risk of infections, particularly pneumonia.
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Affiliation(s)
- Timothy McEwan
- University of Queensland School of Clinical Medicine, Queensland, Australia
| | - Philip C Robinson
- University of Queensland School of Clinical Medicine, Queensland, Australia.
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5
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Safety and efficacy of intravenous Colchicine in children with Familial Mediterranean Fever. Rheumatol Int 2019; 40:121-128. [PMID: 31230112 DOI: 10.1007/s00296-019-04348-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/13/2019] [Indexed: 01/04/2023]
Abstract
Familial Mediterranean Fever (FMF), the most common monogenic inflammatory disease, is mainly treated by oral Colchicine. However, 5% of patients are considered non-responders and, therefore, candidates for biologic therapy. Intravenous (IV) Colchicine treatment has been shown to be effective and safe in adult patients. The objective of this study was to evaluate the safety of IV Colchicine for pediatric FMF patients in our hospital, refractory to oral Colchicine, by reviewing their medical records. Inclusion criteria were all patients with FMF who commenced treatment with IV Colchicine before the age of 18 years, and received at least 6 months of IV therapy. The patients completed questionnaires to assess the efficacy of the treatment. Between 2004 and 2017, 7 pediatric FMF patients receiving maximal oral Colchicine doses and deemed non-responders were treated with weekly IV Colchicine, including 38 cumulative patient years of follow-up data (a full blood count, renal and liver function tests). All patients were homozygous for the M694V genotype. Long-term follow-up showed normal laboratory results with no Colchicine-related hospital admissions or toxicity. Global health assessment and the number of disease-free days have significantly improved (P < 0.05). Prolonged IV Colchicine use is described in pediatric FMF patients for the first time, with an excellent safety profile in our population, and decrease in intensity and frequency of attacks. In the biological era, IV Colchicine, although not leading to complete remission, may be considered a second-line option in countries where anti-interleukin 1 blockers are not available, or as a third-line option in case of failure to respond to biologics.
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6
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El-Feky GS, El-Naa MM, Mahmoud AA. Flexible nano-sized lipid vesicles for the transdermal delivery of colchicine; in vitro/in vivo investigation. J Drug Deliv Sci Technol 2019. [DOI: 10.1016/j.jddst.2018.10.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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7
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Grossman C, Farberov I, Feld O, Livneh A, Ben-Zvi I. Efficacy and safety of long-term treatment with intravenous colchicine for familial Mediterranean fever (FMF) refractory to oral colchicine. Rheumatol Int 2019; 39:517-523. [PMID: 30604205 DOI: 10.1007/s00296-018-04237-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 12/27/2018] [Indexed: 10/27/2022]
Abstract
Colchicine is the mainstay of treatment for familial Mediterranean fever (FMF). Intravenous (IV) colchicine, administered over several months, has been shown to be effective for FMF patients unresponsive to oral colchicine. The objective of this study was to evaluate the efficacy and safety of long-term IV colchicine treatment in oral colchicine-resistant FMF. We analyzed data of 15 patients with frequent FMF attacks, despite a maximal tolerated dose of oral colchicine (2-3 mg/day), who were treated with weekly IV injections of 1 mg of colchicine for at least 12 months. Treatment efficacy was determined by changes in frequency, duration and severity of FMF attacks. Safety was assessed according to adverse events. The mean duration of IV colchicine treatment was 5.16 ± 2.85 years. Decreases were observed from pre-treatment period in the monthly mean rates of abdominal attacks (from 5.6 ± 3.7 to 1.9 ± 3.3, p = 0.0009), joint attacks (from 6.5 ± 5.1 to 1.6 ± 1.6, p = 0.01) and overall attacks (from 22.3 ± 16.2 to 7.4 ± 5.7, p = 0.002) as well as in the mean duration (from 3.8 ± 1.5 to 2.4 ± 1.1 days per attack, p = 0.008) and severity of attacks (from 9.9 ± 0.3 to 5.7 ± 2.6, on a scale of 0-10, p < 0.05). The rate of adverse events was low, and they were mainly gastrointestinal. No severe or serious adverse events were recorded. Long-term treatment with IV colchicine in patients unresponsive to oral colchicine therapy is effective and safe.
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Affiliation(s)
- Chagai Grossman
- Department of Internal Medicine F, The Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel.,Rheumatology Unit, The Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Itzhak Farberov
- Department of Internal Medicine F, The Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel
| | - Olga Feld
- Department of Internal Medicine F, The Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel
| | - Avi Livneh
- Department of Internal Medicine F, The Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel.,Rheumatology Unit, The Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel.,Heller Institute of Medical Research, The Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ilan Ben-Zvi
- Department of Internal Medicine F, The Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel. .,Rheumatology Unit, The Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel. .,Heller Institute of Medical Research, The Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel. .,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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8
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Affiliation(s)
- Naomi Schlesinger
- Department of Medicine Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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9
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Gasparyan AY, Ayvazyan L, Yessirkepov M, Kitas GD. Colchicine as an anti-inflammatory and cardioprotective agent. Expert Opin Drug Metab Toxicol 2015; 11:1781-94. [PMID: 26239119 DOI: 10.1517/17425255.2015.1076391] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Colchicine has been successfully used for the treatment of neutrophilic disorders such as familial Mediterranean fever (FMF), Behçet disease (BD) and gout. There is a growing interest in its cardiovascular effects. AREAS COVERED A MEDLINE/PubMed search for English articles published from January 1972 to June 2015 was completed using the following terms: therapy, pharmacokinetics, efficiency, side effects, toxicity, heart, colchicine, inflammation, FMF, amyloidosis, BD, gout, cardiovascular disorders, pericarditis, arrhythmias, inflammation, neutrophils, platelets. EXPERT OPINION By targeting neutrophils, endothelial cells and platelets, inhibiting mitosis, vascular hyperplasia and fibrosis, colchicine improves outcomes of pericarditis, myocardial ischemia and coronary interventions. Studies in neutrophilic rheumatic diseases and cardiovascular disorders demonstrated that oral colchicine at doses of 0.5 - 2.5 mg/daily is useful for treating pericarditis, myocardial ischemia and coronary occlusion. In rheumatic and cardiovascular disorders, therapeutic doses of the drug reduce C-reactive protein to levels below 2 mg/L, prevent myocardial damage and preserve normal values of atrial and ventricular impulse generation. One of the drug's frequent side effects is diarrhea, which is treated by diet modification or temporary discontinuation of the therapy. Certain drugs (macrolides, statins), comorbidities and certain genetic factors increase risk of colchicine toxicity.
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Affiliation(s)
- Armen Yuri Gasparyan
- a 1 Dudley Group NHS Foundation Trust (Teaching Trust of University of Birmingham), Russells Hall Hospital, Departments of Rheumatology and Research & Development , DY1 2HQ, Dudley, UK +44 138 424 4842 ; +44 138 424 4808 ;
| | - Lilit Ayvazyan
- b 2 Yerevan State Medical University, Department of Medical Chemistry , Yerevan, Armenia
| | - Marlen Yessirkepov
- c 3 South Kazakhstan State Pharmaceutical Academy, Department of Biochemistry, Biology and Microbiology , Shymkent, Kazakhstan
| | - George D Kitas
- a 1 Dudley Group NHS Foundation Trust (Teaching Trust of University of Birmingham), Russells Hall Hospital, Departments of Rheumatology and Research & Development , DY1 2HQ, Dudley, UK +44 138 424 4842 ; +44 138 424 4808 ; .,d 4 University of Manchester, Arthritis Research UK Epidemiology Unit , Manchester, UK
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10
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Solomon LR. Thrombocytopenia due to low-dose colchicine therapy: A possible drug interaction with nivolumab and implications for supportive care. Acta Oncol 2015; 54:1235-7. [PMID: 25608826 DOI: 10.3109/0284186x.2014.1002572] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Lawrence R Solomon
- a Section of Palliative Care, Department of Medicine , Yale University School of Medicine and Smilow Cancer Hospital , New Haven , CT , USA
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11
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Sun Y, Liang Y, Hu J, Wang J, Wang D, Li X, Yan L. Reduction of intraarticular adhesion by topical application of colchicine following knee surgery in rabbits. Sci Rep 2014; 4:6405. [PMID: 25245566 PMCID: PMC4171695 DOI: 10.1038/srep06405] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 08/21/2014] [Indexed: 12/23/2022] Open
Abstract
The aim of this study was to investigate the efficacy of topical application of colchicine in reducing intraarticular adhesion in rabbits. Thirty-six rabbits were randomly and equally divided into three groups. An approximately 10 × 10 mm2 area of cortical bone was removed from both sides of the left femoral condyle, and the cancellous bone underneath was exposed. Cotton pads soaked with different concentrations of colchicine or saline were applied to the decorticated areas for 10 minutes. The surgical limb was fixed in a flexed position for 4 weeks postoperatively. To evaluate knee intraarticular adhesion, we performed macroscopic evaluation, histological and collagen density analyses, hydroxyproline content determination, fibroblast counting and densitometric analyses. The results showed that loose collagen tissues with little or no adhesion were present around the decorticated areas in the group treated with 0.5 mg/ml colchicine. The intraarticular adhesion score, hydroxyproline content, number of fibroblasts and densitometric value in this group were also significantly lower than those in the other groups. There was moderate intraarticular adhesion in the group treated with 0.1 mg/ml colchicine. However, dense scar tissue with dense adhesions was found in the control group. In conclusion, topical application of 0.5 mg/ml colchicine may reduce knee intraarticular adhesion.
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Affiliation(s)
- Yu Sun
- 1] Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou 225001, China [2]
| | - Yuan Liang
- 1] Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou 225001, China [2]
| | - Jinlong Hu
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou 225001, China
| | - Jingcheng Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou 225001, China
| | - Daxin Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou 225001, China
| | - Xiaolei Li
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou 225001, China
| | - Lianqi Yan
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou 225001, China
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12
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Amanova A, Kendi Celebi Z, Bakar F, Caglayan MG, Keven K. Colchicine levels in chronic kidney diseases and kidney transplant recipients using tacrolimus. Clin Transplant 2014; 28:1177-83. [DOI: 10.1111/ctr.12448] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2014] [Indexed: 01/07/2023]
Affiliation(s)
- Anara Amanova
- Department of Internal Medicine; Ankara University School of Medicine; Ankara Turkey
| | - Zeynep Kendi Celebi
- Department of Nephrology; Ankara University School of Medicine; Ankara Turkey
| | - Filiz Bakar
- Department of Biochemistry; Ankara University School of Pharmacy; Ankara Turkey
| | - Mehmet G. Caglayan
- Department of Analytical Chemistry; Ankara University School of Pharmacy; Ankara Turkey
| | - Kenan Keven
- Department of Nephrology; Ankara University School of Medicine; Ankara Turkey
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13
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Dalbeth N, Lauterio TJ, Wolfe HR. Mechanism of action of colchicine in the treatment of gout. Clin Ther 2014; 36:1465-79. [PMID: 25151572 DOI: 10.1016/j.clinthera.2014.07.017] [Citation(s) in RCA: 233] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 07/07/2014] [Accepted: 07/22/2014] [Indexed: 12/25/2022]
Abstract
PURPOSE The aims of this article were to systematically review the literature about the mechanism of action of colchicine in the multimodal pathology of acute inflammation associated with gout and to consider the clinical utility of colchicine in other chronic inflammatory diseases. METHODS The English-language literature on PubMed was searched for articles published between 1990 and October 2013, with a cross-reference to citations across all years. Relevant articles pertaining to the mechanism of action of colchicine and the clinical applications of colchicine in gout and other inflammatory conditions were identified and reviewed. FINDINGS The molecular pathology of acute inflammation associated with gouty arthritis involves several concurrent pathways triggered by a variety of interactions between monosodium urate crystals and the surface of cells. Colchicine modulates multiple pro- and antiinflammatory pathways associated with gouty arthritis. Colchicine prevents microtubule assembly and thereby disrupts inflammasome activation, microtubule-based inflammatory cell chemotaxis, generation of leukotrienes and cytokines, and phagocytosis. Many of these cellular processes can be found in other diseases involving chronic inflammation. The multimodal mechanism of action of colchicine suggests potential efficacy of colchicine in other comorbid conditions associated with gout, such as osteoarthritis and cardiovascular disease. IMPLICATIONS Colchicine has multiple mechanisms of action that affect inflammatory processes and result in its utility for treating and preventing acute gout flare. Other chronic inflammatory diseases that invoke these molecular pathways may represent new therapeutic applications for colchicine.
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Affiliation(s)
- Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand.
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14
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Wang Y, Wang L, Li E, Li Y, Wang Z, Sun X, Yu X, Ma L, Wang Y, Wang Y. Chuanhu anti-gout mixture versus colchicine for acute gouty arthritis: a randomized, double-blind, double-dummy, non-inferiority trial. Int J Med Sci 2014; 11:880-5. [PMID: 25013367 PMCID: PMC4081309 DOI: 10.7150/ijms.9165] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 06/01/2014] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The Chuanhu anti-gout mixture has been used for many years in the treatment of gout in Chinese Traditional Medicine, and current methods for treatments for acute gouty arthritis have been either less effective or have had serious side effects. METHODS In this 12-week, double-blind, double-dummy, non-inferiority study, outpatient individuals with newly diagnosed acute gouty arthritis were randomly assigned to receive Chuanhu anti-gout mixture or colchicine. Both the study investigators and the participants were masked to the treatment assignments. The primary outcome was the recurrence rate of acute gouty arthritis, and the secondary outcomes were changes in white blood cells (WHC) and C-reactive protein (CRP). This trial is registered at ISRCTN.org as trial ISRCTN65219941. RESULTS A total of 176 patients were randomly assigned to receive either the Chuanhu anti-gout mixture or Colchicine. The overall recurrence rates in the Chuanhu anti-gout mixture group (CH group) and the Colchicine group (Col group) were 12.50% vs 14.77% (difference -2.22%, 95% confidence interval (95% CI): -10.78%~6.23%), meeting the predefined non-inferiority criterion of 15%, as did the data for WHC and CRP. The incidence of adverse events (mainly diarrhea) was less in the Col group than in the CH group (2.27% vs 28.41%, 95% CI 0.01~0.26). In addition, changes in blood uric acid, alanine aminotransferase, aspartate aminotransferase and creatinine in the CH group were significantly larger compared to those in the Col group (P<0.05). CONCLUSIONS The Chuanhu anti-gout mixture was non-inferior to colchicine for the treatment of acute gouty arthritis. The study suggested that the Chuanhu anti-gout mixture can be considered an alternative choice for the treatment of acute gouty arthritis because of its lower incidence of adverse events and its protection of kidney and renal function.
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Affiliation(s)
- YanGang Wang
- 1. Department of endocrinology, The Affiliated Hospital of Medical College Qingdao University, 16 Jiangsu Road, Qingdao, 266003, China
| | - Luan Wang
- 1. Department of endocrinology, The Affiliated Hospital of Medical College Qingdao University, 16 Jiangsu Road, Qingdao, 266003, China
| | - EnZe Li
- 2. Department of pharmacy, The Affiliated Hospital of Medical College Qingdao University, 16 Jiangsu Road, Qingdao, 266003, China
| | - Yang Li
- 1. Department of endocrinology, The Affiliated Hospital of Medical College Qingdao University, 16 Jiangsu Road, Qingdao, 266003, China
| | - ZhongChao Wang
- 1. Department of endocrinology, The Affiliated Hospital of Medical College Qingdao University, 16 Jiangsu Road, Qingdao, 266003, China
| | - XiaoFang Sun
- 1. Department of endocrinology, The Affiliated Hospital of Medical College Qingdao University, 16 Jiangsu Road, Qingdao, 266003, China
| | - XiaoLong Yu
- 1. Department of endocrinology, The Affiliated Hospital of Medical College Qingdao University, 16 Jiangsu Road, Qingdao, 266003, China
| | - Lin Ma
- 2. Department of pharmacy, The Affiliated Hospital of Medical College Qingdao University, 16 Jiangsu Road, Qingdao, 266003, China
| | - YunLong Wang
- 3. Gout laboratory, The Affiliated Hospital of Medical College Qingdao University, Shandong Provincial Key Laboratory of Metabolic Diseases, Qingdao, 266003, China
| | - YouXin Wang
- 4. Beijing Municipal Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing 100069, China
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Ozdemir O, Calisaneller T, Sonmez E, Kiyici H, Caner H, Altinors N. Topical use of colchicine to prevent spinal epidural fibrosis in rats. Neurol Res 2013; 32:1117-20. [DOI: 10.1179/016164110x12681290831487] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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16
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Zarowitz BJ, O'Shea TE. Demographic and Clinical Profile of Nursing Facility Residents with Gout. ACTA ACUST UNITED AC 2013; 28:370-82. [DOI: 10.4140/tcp.n.2013.370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Long-term outcome after suicidal colchicine intoxication in a 14-year-old girl: case report and review of literature. Pediatr Emerg Care 2013; 29:89-92. [PMID: 23283275 DOI: 10.1097/pec.0b013e31827b5747] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Colchicine is used as an anti-inflammatory drug in the treatment of gout, familial Mediterranean fever, and Behçet disease. However, because of its potent inhibition of mitosis, adverse effects and symptoms of intoxication are frequent. Clinical manifestations of colchicine intoxication include abdominal cramps, diarrhea, and multiorgan failure including cardiovascular collapse with fatal outcome. OBJECTIVE We report here the case of a 14-year-old girl who ingested 12.5 mg (0.23 mg/kg body weight) colchicine in a suicide attempt. CASE REPORT Major complaints of this fully conscious patient at the time of presentation ∼2 hours after ingestion of colchicine were nausea and impaired vision. Apart from a colchicine serum concentration of 16.2 ng/mL, no abnormalities were seen in the physical examination and blood tests. Gastrointestinal decontamination by activated charcoal, repeated administrations of sodium sulfate (Glauber salt) and substitution of volume and electrolytes led to complete recovery.
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Todd BA, Billups SJ, Delate T, Canty KE, Kauffman AB, Rawlings JE, Wagner TM. Assessment of the association between colchicine therapy and serious adverse events. Pharmacotherapy 2012; 32:974-80. [PMID: 23019065 DOI: 10.1002/phar.1125] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY OBJECTIVE As data that prompted a 2009 labeling change detailing contraindications, precautions, and dosing recommendations for the first branded colchicine product were limited to case reports of myotoxicity and blood dyscrasias ascribed to the drug, we sought to quantify the association of colchicine therapy with serious adverse outcomes in a cohort of insured patients. DESIGN Case-control study. DATA SOURCE Kaiser Permanente Colorado electronic data warehouses and electronic medical records. PATIENTS Cases were patients with a creatine kinase (CK) level of at least 2000 U/L or who developed a clinically significant non-cancer-related blood dyscrasia (thrombocytopenia, neutropenia, leukopenia, aplastic anemia, or pancytopenia) between January 1, 2006, and June 30, 2009 (954 cases). Each case was matched to up to 10 controls by age, sex, and index date (date of the increased CK level or blood dyscrasia-supporting laboratory value). Controls were patients without elevated CK levels or blood dyscrasias who had a routine health maintenance examination during the same time period (index date was the date of their health maintenance examination [9007 controls]). MEASUREMENTS AND MAIN RESULTS The primary study outcome was colchicine exposure, defined as a colchicine prescription purchase in the 100 days before the index date. The likelihood of colchicine exposure was examined with conditional logistic regression. Cases experienced a higher rate of previous colchicine exposure compared with controls (0.6% vs 0.2%, odds ratio 3.9, 95% confidence interval 1.4-10.7). In addition, cases had higher hospitalization rates (14.9% vs 5.0%, p<0.001), higher mean chronic disease scores (2.5 vs 0.0, p<0.001), and were more likely to have been exposed to drugs that may increase the risk of adverse events due to an interaction with a CYP3A4 inhibitor drug (6.9% vs 2.3%, p<0.001). CONCLUSION Patients with confirmed elevations in CK level and/or blood dyscrasias had a higher rate of previous colchicine exposure, although low overall, and greater hospitalization rates and exposure to drugs that may increase the risk of adverse events compared with controls. These findings support the 2009 United States Food and Drug Administration labeling for the first branded colchicine product, cautioning use in patients with liver impairment or renal dysfunction and/or those receiving concurrent drugs that may increase risk of adverse events.
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Diagnosis and management of familial Mediterranean fever: Integrating medical genetics in a dedicated interdisciplinary clinic. Genet Med 2011; 13:263-9. [PMID: 21317656 DOI: 10.1097/gim.0b013e31820e27b1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Wang F, Zhou J, Liu Y, Wu S, Song G, Ye B. Electrochemical oxidation behavior of colchicine on a graphene oxide-Nafion composite film modified glassy carbon electrode. Analyst 2011; 136:3943-9. [DOI: 10.1039/c1an15372b] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Finkelstein Y, Aks SE, Hutson JR, Juurlink DN, Nguyen P, Dubnov-Raz G, Pollak U, Koren G, Bentur Y. Colchicine poisoning: the dark side of an ancient drug. Clin Toxicol (Phila) 2010; 48:407-14. [PMID: 20586571 DOI: 10.3109/15563650.2010.495348] [Citation(s) in RCA: 346] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Colchicine is used mainly for the treatment and prevention of gout and for familial Mediterranean fever (FMF). It has a narrow therapeutic index, with no clear-cut distinction between nontoxic, toxic, and lethal doses, causing substantial confusion among clinicians. Although colchicine poisoning is sometimes intentional, unintentional toxicity is common and often associated with a poor outcome. METHODS We performed a systematic review by searching OVID MEDLINE between 1966 and January 2010. The search strategy included "colchicine" and "poisoning" or "overdose" or "toxicity" or "intoxication." TOXICOKINETICS Colchicine is readily absorbed after oral administration, but undergoes extensive first-pass metabolism. It is widely distributed and binds to intracellular elements. Colchicine is primarily metabolized by the liver, undergoes significant enterohepatic re-circulation, and is also excreted by the kidneys. THERAPEUTIC AND TOXIC DOSES: The usual adult oral doses for FMF is 1.2-2.4 mg/day; in acute gout 1.2 mg/day and for gout prophylaxis 0.5-0.6 mg/day three to four times a week. High fatality rate was reported after acute ingestions exceeding 0.5 mg/kg. The lowest reported lethal doses of oral colchicine are 7-26 mg. DRUG INTERACTIONS CYP 3A4 and P-glycoprotein inhibitors, such as clarithromycin, erythromycin, ketoconazole, ciclosporin, and natural grapefruit juice can increase colchicine concentrations. Co-administration with statins may increase the risk of myopathy. MECHANISMS OF TOXICITY Colchicine's toxicity is an extension of its mechanism of action - binding to tubulin and disrupting the microtubular network. As a result, affected cells experience impaired protein assembly, decreased endocytosis and exocytosis, altered cell morphology, decreased cellular motility, arrest of mitosis, and interrupted cardiac myocyte conduction and contractility. The culmination of these mechanisms leads to multi-organ dysfunction and failure. REPRODUCTIVE TOXICOLOGY AND LACTATION: Colchicine was not shown to adversely affect reproductive potential in males or females. It crosses the placenta but there is no evidence of fetal toxicity. Colchicine is excreted into breast milk and considered compatible with lactation. CLINICAL FEATURES Colchicine poisoning presents in three sequential and usually overlapping phases: 1) 10-24 h after ingestion - gastrointestinal phase mimicking gastroenteritis may be absent after intravenous administration; 2) 24 h to 7 days after ingestion - multi-organ dysfunction. Death results from rapidly progressive multi-organ failure and sepsis. Delayed presentation, pre-existing renal or liver impairment are associated with poor prognosis. 3) Recovery typically occurs within a few weeks of ingestion, and is generally a complete recovery barring complications of the acute illness. DIAGNOSIS History of ingestion of tablets, parenteral administration, or consumption of colchicine-containing plants suggest the diagnosis. Colchicine poisoning should be suspected in patients with access to the drug and the typical toxidrome (gastroenteritis, hypotension, lactic acidosis, and prerenal azotemia). MANAGEMENT Timely gastrointestinal decontamination should be considered with activated charcoal, and very large, recent (<60 min) ingestions may warrant gastric lavage. Supportive treatments including administration of granulocyte colony-stimulating factor are the mainstay of treatment. Although a specific experimental treatment (Fab fragment antibodies) for colchicine poisoning has been used, it is not commercially available. CONCLUSION Although colchicine poisoning is relatively uncommon, it is imperative to recognize its features as it is associated with a high mortality rate when missed.
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Affiliation(s)
- Yaron Finkelstein
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
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Abstract
Purified from a Mediterranean plant nearly two centuries ago, colchicine has been discovered to inhibit many steps in the inflammatory process. The drug has good oral bioavailability and some enterohepatic recirculation, requiring dose adjustments for kidney disease and avoidance in liver disease. Toxicities are primarily gastrointestinal, hepatic, and hematologic. Colchicine is approved by the U.S. Federal Drug Administration for the treatment and prophylaxis of gout flares but has also been tried with varying success in the treatment of familial Mediterranean fever, primary biliary cirrhosis, psoriasis, Behçet's disease, aphthous stomatitis, linear IgA dermatosis, relapsing polychondritis, Sweet's syndrome, scleroderma, amyloidosis, leukocytoclastic vasculitis, epidermolysis bullosa, and dermatomyositis.
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Affiliation(s)
- Anupama Bhat
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, California 95616, USA
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24
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Wall GC, Cooper SA. Gout and Hyperuricemia: New Guidelines and Treatments. J Pharm Pract 2009. [DOI: 10.1177/0897190008322243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Gout is the most common inflammatory arthritis in western countries and the incidence is increasing. Additionally, evidence now exists that cases of severe, refractory gout seem to be increasing. The management of gout and hyperuricemia has remained largely unchanged for decades and includes antiinflammatories used initially for acute attacks and primarily allopurinol to prevent future attacks. Evidence-based guidance for the management of gout and hyperuricemia has been plagued by a lack of randomized, controlled studies and the lack of new medications. Recently evidence-based guidelines by the European League Against Rheumatism were published; one of the first attempts by a major medical body to assess the state of gout and hyperuricemia treatment. Additionally, several new compounds seem poised to be released for hyperuricemia treatment. This review details the important aspects of the gout guidelines relating to pharmacotherapy and critically examines the data surrounding new modalities to decrease serum uric acid.
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Affiliation(s)
- Geoffrey C. Wall
- Iowa Methodist Medical Center, Des Moines, College of Pharmacy and Health Sciences, Drake University, Des Moines, Iowa,
| | - Sarah A. Cooper
- College of Pharmacy and Health Sciences, Drake University, Des Moines, Iowa
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Gaffo AL, Saag KG. Management of hyperuricemia and gout in CKD. Am J Kidney Dis 2008; 52:994-1009. [PMID: 18971014 DOI: 10.1053/j.ajkd.2008.07.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2008] [Accepted: 07/21/2008] [Indexed: 02/07/2023]
Affiliation(s)
- Angelo L Gaffo
- Birmingham VA Medical Center, University of Alabama at Birmingham, AL, USA
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Nuki G. Colchicine: its mechanism of action and efficacy in crystal-induced inflammation. Curr Rheumatol Rep 2008; 10:218-27. [PMID: 18638431 DOI: 10.1007/s11926-008-0036-3] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
New light has been shed on the mechanisms of action of colchicine in crystal-associated arthropathies. Colchicine, long used to treat gout, arrests microtubule assembly and inhibits many cellular functions. At micromolar concentrations, it suppresses monosodium urate crystal-induced NACHT-LRR-PYD-containing protein-3 (NALP3) inflammasome-driven caspase-1 activation, IL-1beta processing and release, and L-selectin expression on neutrophils. At nanomolar concentrations, colchicine blocks the release of a crystal-derived chemotactic factor from neutrophil lysosomes, blocks neutrophil adhesion to endothelium by modulating the distribution of adhesion molecules on the endothelial cells, and inhibits monosodium urate crystal-induced production of superoxide anions from neutrophils. Cyto-chrome P450 3A4, the multidrug transporter P-glycoprotein, and the drugs that bind these proteins influence its pharmacokinetics and pharmacodynamics. Trial evidence supports its efficacy in acute gout and in preventing gout flares, but it has narrow therapeutic index, and overdosage is associated with gastrointestinal, hepatic, renal, neuromuscular, and cerebral toxicity; bone marrow damage; and high mortality.
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Affiliation(s)
- George Nuki
- University of Edinburgh, Osteoarticular Research Group, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, Scotland, United Kingdom.
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27
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Abstract
OBJECTIVES Colchicine is a relatively uncommon toxin, but is known to precipitate severe multiorgan failure in overdose. Little is known about exposure patterns and outcomes in cases of colchicine ingestion. Our goal was to add to toxicologic knowledge through a database review and descriptive study of colchicine exposures. METHODS Texas Poison Center Network Data was reviewed for the years 2000 to 2005, and all reports of colchicine exposures were reviewed. RESULTS A total of 79 cases were found in the time period studied. The most common exposure reasons were unintentional-therapeutic error (33%), unintentional-general (28%), and intentional-suspected suicide (18%). Medical outcomes included no effect (24%), minor effect (20%), moderate effect (15%), and major effect (3%). The most common clinical findings included vomiting (20%), diarrhea (17%), and abdominal pain (7%). The most commonly employed therapies were dilution (28%), single-dose activated charcoal (26%), cathartics (16%), and gastrointestinal lavage (15%). CONCLUSION The majority of cases of exposure produced no significant effects, and fatality was uncommon in this sample. Colchicine is a relatively uncommon toxin among therapeutic drugs, and though capable of it, is rarely responsible for significant morbidity or mortality. Meticulous exposure record keeping at poison centers is a key to the study of patterns of toxicity with uncommon toxins such as colchicine.
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29
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Abstract
Since the original recognition of these conditions in 1961, a great deal has been learned about the pathogenesis, clinical manifestations, and appropriate treatment of gout and pseudogout, and the role of crystals in osteoarthritis has been further defined. The variable manifestations of crystal-induced arthritis in elderly populations has led to a greater need for proper diagnosis and treatment strategies for these increasingly common forms of arthritis.
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Affiliation(s)
- Christopher M Wise
- Internal Medicine, Division of Rheumatology, Allergy, and Immunology, Medical College of Virginia, Virginia Commonwealth University Health System, 417 North 11th Street, Box 980647, Richmond, VA 23298, USA.
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30
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Edwards NL. Case 6: maintenance therapy for simple intermittent gout. Am J Med 2006; 119:S20-2. [PMID: 17059908 DOI: 10.1016/j.amjmed.2006.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- N Lawrence Edwards
- Department of Medicine, University of Florida, Gainesville, Florida, USA.
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31
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Croft JD. Discussion following cases 4 and 5. Am J Med 2006; 119:S16-9. [PMID: 17059906 DOI: 10.1016/j.amjmed.2006.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Joseph D Croft
- Georgetown University Medical School, Washington, District of Columbia, USA.
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32
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Zhang W, Doherty M, Bardin T, Pascual E, Barskova V, Conaghan P, Gerster J, Jacobs J, Leeb B, Lioté F, McCarthy G, Netter P, Nuki G, Perez-Ruiz F, Pignone A, Pimentão J, Punzi L, Roddy E, Uhlig T, Zimmermann-Gòrska I. EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 2006; 65:1312-24. [PMID: 16707532 PMCID: PMC1798308 DOI: 10.1136/ard.2006.055269] [Citation(s) in RCA: 755] [Impact Index Per Article: 41.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2006] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To develop evidence based recommendations for the management of gout. METHODS The multidisciplinary guideline development group comprised 19 rheumatologists and one evidence based medicine expert representing 13 European countries. Key propositions on management were generated using a Delphi consensus approach. Research evidence was searched systematically for each proposition. Where possible, effect size (ES), number needed to treat, relative risk, odds ratio, and incremental cost-effectiveness ratio were calculated. The quality of evidence was categorised according to the level of evidence. The strength of recommendation (SOR) was assessed using the EULAR visual analogue and ordinal scales. RESULTS 12 key propositions were generated after three Delphi rounds. Propositions included both non-pharmacological and pharmacological treatments and addressed symptomatic control of acute gout, urate lowering therapy (ULT), and prophylaxis of acute attacks. The importance of patient education, modification of adverse lifestyle (weight loss if obese; reduced alcohol consumption; low animal purine diet) and treatment of associated comorbidity and risk factors were emphasised. Recommended drugs for acute attacks were oral non-steroidal anti-inflammatory drugs (NSAIDs), oral colchicine (ES = 0.87 (95% confidence interval, 0.25 to 1.50)), or joint aspiration and injection of corticosteroid. ULT is indicated in patients with recurrent acute attacks, arthropathy, tophi, or radiographic changes of gout. Allopurinol was confirmed as effective long term ULT (ES = 1.39 (0.78 to 2.01)). If allopurinol toxicity occurs, options include other xanthine oxidase inhibitors, allopurinol desensitisation, or a uricosuric. The uricosuric benzbromarone is more effective than allopurinol (ES = 1.50 (0.76 to 2.24)) and can be used in patients with mild to moderate renal insufficiency but may be hepatotoxic. When gout is associated with the use of diuretics, the diuretic should be stopped if possible. For prophylaxis against acute attacks, either colchicine 0.5-1 mg daily or an NSAID (with gastroprotection if indicated) are recommended. CONCLUSIONS 12 key recommendations for management of gout were developed, using a combination of research based evidence and expert consensus. The evidence was evaluated and the SOR provided for each proposition.
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Affiliation(s)
- W Zhang
- Academic Rheumatology, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK.
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Abstract
The history of gout and the many distinguished historical figures who have suffered the agonies of this crystal deposition disorder have claimed the attention of medical historians like no other disease. Its treatment with uric acid lowering drugs became a twentieth century paradigm for the successful management and prevention of a chronic rheumatic disease, but the colorful history of the treatment of gout and crystal deposition disorders stretches back over 4,000 years.
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Affiliation(s)
- George Nuki
- Queen's Medical Research Institute, University of Edinburgh, Scotland, UK.
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Abstract
Gouty arthritis is a characteristically intense acute inflammatory reaction that erupts in response to articular deposits of monosodium urate (MSU) crystals. Important recent molecular biologic advances in this field have given us a clear picture of the mechanistic basis of gouty inflammation. The innate immune inflammatory response is critically involved in the pathology of gout. Specifically, MSU crystals promote inflammation directly by stimulating cells via Toll-like receptor signaling and by providing a surface for cleavage of C5 and formation of complement membrane attack complex (C5b-9), culminating in secretion of cytokines, chemokines, and other inflammatory mediators with a dramatic influx of neutrophils into the joint. Despite the detailed mechanistic picture for gouty inflammation, there are no placebo-controlled, randomized clinical studies for any of the therapies commonly used, although comparative studies have demonstrated that many nonsteroidal anti-inflammatory drugs are equivalent to indomethacin with respect to controlling acute gouty attacks. In general, the first line of anti-inflammatory therapy for acute gout is nonsteroidal anti-inflammatory drugs, and the selective cyclo-oxygenase-2 inhibitor celecoxib can be used where appropriate. The second line of treatment is glucocorticosteroids, given systemically (oral, intravenous, or intramuscular) or intra-articularly. Alternatively, synthetic adrenocorticotropic hormone is effective, partly via induction of adrenal glucocorticosteroids and partly via rapid peripheral suppression of leukocyte activation by melatonin receptor 3 signaling. The third line of treatment is oral colchicine, which is highly effective when given early in an acute gouty attack, but it is poorly tolerated because of predictable gastrointestinal side effects.
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Affiliation(s)
- Bruce N Cronstein
- Department of Medicine and Division of Clinical Pharmacology, New York University School of Medicine, New York, New York, USA.
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Abstract
Gout is a common form of inflammatory arthritis that has been managed primarily in general medical practices for centuries. It appears that there has been an increasing prevalence of gout over the past decades, implying a growing public health burden. Accurate diagnosis and recognition of the various stages and manifestations of gout enable realistic goal setting for management. Recent evidence suggests new risk factors and potentially refutes others. Management of gout requires characterising and modifying risk factors and associated disorders, and commonly initiating drug therapy. Pharmacotherapy of gout includes the management of acute flares with anti-inflammatory agents such as NSAIDs and glucocorticoids and long-term treatment with urate-lowering drugs. Although pharmacotherapy is generally safe and effective, there are caveats and limitations to all gout therapies. Patient non-adherence and errors with the use of drugs for gout treatment are important factors leading to medical failures. With early intervention, careful monitoring and patient education, gout is a condition that can be managed very effectively. The advent of new drugs (such as febuxostat and urate oxidase [uricase]) and enhanced understanding of the pathogenesis of gout continue to improve our therapeutic options, particularly in a subset of patients with refractory disease and those who are intolerant to currently available medications.
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Affiliation(s)
- Gim Gee Teng
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama 35294-3296, USA
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Choy G. An update on the treatment options for gout and calcium pyrophosphate deposition. Expert Opin Pharmacother 2005; 6:2443-53. [PMID: 16259576 DOI: 10.1517/14656566.6.14.2443] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gout and calcium pyrophosphate deposition disease are two common causes of inflammatory joint disease. Despite differences underlying their pathogenesis, their clinical presentation and treatment share some common features. Optimal treatment for both requires prompt resolution of acute synovitis, reduction of chronic joint damage and management of associated conditions. Available therapeutic interventions and future strategies are reviewed in this article.
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Affiliation(s)
- Gregory Choy
- Division of Rheumatology, University of Toronto, Sunnybrook and Women's College Health Science Centre, M1-401, Toronto, ON, M4N 3M5, Canada
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Hung IFN, Wu AKL, Cheng VCC, Tang BSF, To KW, Yeung CK, Woo PCY, Lau SKP, Cheung BMY, Yuen KY. Fatal Interaction between Clarithromycin and Colchicine in Patients with Renal Insufficiency: A Retrospective Study. Clin Infect Dis 2005; 41:291-300. [PMID: 16007523 DOI: 10.1086/431592] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2005] [Accepted: 03/16/2005] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Clarithromycin is frequently used to treat community-acquired pneumonia in elderly persons. Like erythromycin, it may interact with other drugs by interfering with metabolism by cytochrome P450 enzymes and with the P-glycoprotein transporter system. Colchicine, used for treatment of acute gout and for prophylaxis, may cause bone marrow toxicity. It is metabolized by CYP3A4 and is transported by P-glycoprotein. Initial case reports suggested potentially fatal interactions between clarithromycin and colchicine. METHODS A retrospective study was conducted with 116 patients who were prescribed clarithromycin and colchicine during the same clinical admission. Case-control comparisons were made between patients who received concomitant therapy with the 2 drugs and patients who received sequential therapy. We assessed the clinical presentations and outcomes of the 2 patient groups and analyzed the risk factors associated with fatal outcomes. RESULTS Nine (10.2%) of the 88 patients who received the 2 drugs concomitantly died. Only 1 (3.6%) of the 28 patients who received the drugs sequentially died. Multivariate analysis of the 88 patients who received concomitant therapy showed that longer overlapped therapy (relative risk [RR], 2.16; 95% confidence interval [CI], 1.41-3.31; P< or =.01), the presence of baseline renal impairment (RR, 9.1; 95% CI, 1.75-47.06; P<.001), and the development of pancytopenia (RR, 23.4; 95% CI, 4.48-122.7; P<.001) were independently associated with death. CONCLUSIONS Clarithromycin increases the risk of fatal colchicine toxicity, especially for patients with renal insufficiency. Since there are other drugs for treatment of pneumonia and gout, these 2 drugs should not be coprescribed, because of the risk of fatality.
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Affiliation(s)
- I F N Hung
- Research Center of Infection and Immunology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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38
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Abstract
Since the original descriptions of the involvement of crystals in arthritis, our understanding of the clinical syndromes of gout and pseudogout, and the role of basic calcium crystals in arthritis has increased. Gout is usually considered an affliction confined to middle-aged men, but has an increasing prevalence in older populations, with unique and often atypical features. Calcium pyrophosphate dihydrate crystal deposition disease is common in elderly patients. The diagnosis of both of these common forms of arthritis and the need to individualize therapy in patients with other medical problems remain important clinical challenges to the practicing physician.
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Affiliation(s)
- Christopher M Wise
- Internal Medicine Division of Rheumatology, Allergy, and Immunology, Medical College of Virginia, Virginia Commonwealth University Health System, Richmond, VA 23298, USA.
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Tortorici MA, Skledar S, Barnes B, Wasko MCM. Hazards of colchicine. Am J Health Syst Pharm 2005. [DOI: 10.2146/050057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Michael A. Tortorici
- Department of Pharmaceutical Sciences School of Pharmacy University of Pittsburgh Pittsburgh, PA 15261
| | - Sue Skledar
- Drug Use and Disease State Management University of Pittsburgh Medical Center Pittsburgh, PA 15261
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40
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Abstract
This review provides current information on the use of antigen-binding fragments (Fab) from cleaved antibodies to treat poisoning with digoxin and other potent, low formula mass poisons, such as colchicine and tricyclic antidepressants. Anti-digoxin Fab fragments have been used successfully for many years in the management of severe poisoning with digoxin, digitoxin, and a range of other structurally related compounds, including cardiotoxins from Nerium and Thevetia sp. (oleander) and Bufo sp. (toads). However, their main use remains treating digoxin poisoning. Equimolar doses of anti-digoxin Fab fragments completely bind digoxin in vivo. The approximate dose of Fab fragments (mg) is 80 times the digoxin body burden (mg). If neither the dose ingested nor the plasma digoxin/digitoxin concentration is known, in an adult 380 mg of anti-digoxin Fab fragments should be given. The dose for elderly patients or those with renal impairment should be similar to that for those with normal renal function. Fab fragments have a plasma half-life of 12-20 hours, but this can be prolonged in patients with renal impairment. Analysis of serum ultrafiltrate using an immunoassay shown not to have matrix bias remains the most accurate approach to measuring free digoxin in the presence of anti-digoxin Fab fragments. The antibody fragments are given intravenously over 15-30 minutes after dilution to at least 250 mL with plasma protein solution, 0.9% (w/v) sodium chloride, or deionised water, except in infants where the volume infused can be reduced. Factors limiting the efficacy of Fab fragments are the dose, the duration of the infusion and any delay in administration. Guidelines for Fab fragment administration in children include (i) dilution to a final Fab concentration of 10 g/L in either 5% (w/v) dextrose or 0.9% (w/v) sodium chloride; (ii) infusion through a 0.22 microm filter; (iii) administration of the total dose over a minimum of 30 minutes; and (iv) avoiding coadministration of other drugs and/or electrolyte solutions. Fab fragments are generally well tolerated. Adverse effects attributable to Fab treatment include hypokalaemia and exacerbation of congestive cardiac failure; renal function could be impaired in some patients. Fab fragment preparations for treating acute colchicine and tricyclic antidepressant poisoning have been developed, but are not available commercially. Colchicine poisoning is rare in Western countries, and pharmacological management together with supportive care is usually effective even in severe tricyclic antidepressant overdosage. Attempts have been made to produce anti-paraquat antibodies capable of enhancing paraquat elimination from the lung, but thus far all such attempts have proved unsuccessful.
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Affiliation(s)
- Robert J Flanagan
- Medical Toxicology Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK.
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López Jiméneza M, García Puigb J. Cartas al Editor. Med Clin (Barc) 2004. [DOI: 10.1016/s0025-7753(04)74672-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Deveaux M, Hubert N, Demarly C. Colchicine poisoning: case report of two suicides. Forensic Sci Int 2004; 143:219-22. [PMID: 15240048 DOI: 10.1016/j.forsciint.2004.02.040] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2003] [Accepted: 02/13/2004] [Indexed: 10/26/2022]
Abstract
Colchicine overdose is uncommon but potentially life threatening because of the high toxicity of the drug. Poisoning by colchicine may occur following ingestion of medication used in acute attacks of gout and inflammatory diseases. We describe two cases involving suicide by the ingestion of medications marketed in France. In case 1, only heart blood was taken after body external examination. In case 2 an autopsy was performed and heart blood, urine, gastric contents and bile were taken for toxicological analysis. Colchicine was assayed in biological specimens by an HPLC-DAD method, after extraction by dichloromethane at pH 8, adding prazepam as internal standard (IS). Analyses were performed on a Symetry C-8 column. Mobile phase was a gradient of acetonitrile/pH 3.8 phosphate buffer. Colchicine is eluted at 13.1 min and the method is linear for blood, urine and bile over the range 4-1000 ng/mL. LOQ is 4 ng/mL. The concentrations of colchicine detected are: case 1: heart blood 13 ng/mL; case 2: heart blood 66 ng/mL, urine 500 ng/mL, gastric content 12 ng/mL, bile 5632 ng/mL. Our findings are in the range of lethal concentrations previously described, but there is no correlation with the amount of ingested drug. Even after massive overdose, it could be impossible to detect colchicine in blood, and as there is a widespread enterohepatic recirculation before excretion in bile and feces, bile is the target sample to analyse. We conclude in both cases that the cause of death was suicide with colchicine. It appears very important to perform an autopsy in order to obtain bile, urine, heart blood and femoral blood.
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Affiliation(s)
- Marc Deveaux
- Institut de Médecine Légale, Faculté de Médecine, Université de Lille II, Rue André Verhaeghe, F-59045, France.
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Affiliation(s)
- Seza Ozen
- Department of Pediatrics, Hacettepe University, Ankara, Turkey.
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Affiliation(s)
- Robert A Terkeltaub
- Rheumatology Section, Department of Medicine, San Diego Veterans Affairs Medical Center and the University of California San Diego School of Medicine, San Diego, CA 92161, USA
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Kristensen BW, Noer H, Gramsbergen JB, Zimmer J, Noraberg J. Colchicine induces apoptosis in organotypic hippocampal slice cultures. Brain Res 2003; 964:264-78. [PMID: 12576187 DOI: 10.1016/s0006-8993(02)04080-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The microtubule-disrupting agent colchicine is known to be particular toxic for certain types of neurons, including the granule cells of the dentate gyrus. In this study we investigated whether colchicine could induce such neuron-specific degeneration in developing (1 week in vitro) and mature (3 weeks in vitro) organotypic hippocampal slice cultures and whether the induced cell death was apoptotic and/or necrotic. When applied to 1-week-old cultures for 48 h, colchicine induced primarily apoptotic, but also a minor degree of necrotic cell death in the dentate granule cells, as investigated by cellular uptake of the fluorescent dye propidium iodide (PI), immunostaining for active caspase 3 and c-Jun/AP-1 (N) and fragmentation of nuclei as seen in Hoechst 33342 staining. All four markers appeared after 12 h of colchicine exposure. Two of them, active caspase 3 and c-Jun/AP-1 (N) displayed a similar time course and reached a maximum after 24 h of exposure, 24 h ahead of both PI uptake and Hoechst 33342 staining, which together displayed similar time profiles and a close correlation. In 3-week-old cultures, colchicine did not induce apoptotic or necrotic cell death. Attempts to interfere with the colchicine-induced apoptosis in 1-week-old cultures showed that colchicine-induced PI uptake and formation of apoptotic nuclei were temporarily prevented by coapplication of the protein synthesis inhibitor cycloheximide. Application of the pancaspase inhibitor z-VAD-fmk almost completely abolished the formation of active caspase 3 protein and apoptotic nuclei induced by colchicine, but the formation of necrotic nuclei increased correspondingly and the PI uptake was unaffected. We conclude that colchicine induces caspase 3-dependent apoptotic cell death of dentate granule cells in hippocampal brain slice cultures, but the apoptotic cell death is highly dependent on the developmental stage of the cultures.
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Affiliation(s)
- Bjarne W Kristensen
- Department of Anatomy and Neurobiology, Institute of Medical Biology, University of Southern Denmark, Winsløwparken 21, DK-5000 C, Odense, Denmark.
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Abstract
The Food and Drug Administration (FDA) is responsible not only for approving drugs but also for monitoring their safety after they reach the market. The complete adverse event profile of a drug is not known at the time of approval because of the small sample size, short duration, and limited generalizability of pre-approval clinical trials. This report describes the FDA's postmarketing surveillance system, to which many clinicians submit reports of adverse drug events encountered while treating their patients. Despite its limitations, the spontaneous reporting system is an extremely valuable mechanism by which hazards with drugs that were not observed or recognized at the time of approval are identified. Physicians are strongly encouraged to submit reports of adverse outcomes with suspect drugs to the FDA, and their reports make a difference. The FDA is strengthening its postmarketing surveillance with access to new data sources that have the potential to further improve the identification, quantification, and subsequent management of drug risk.
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Affiliation(s)
- Syed Rizwanuddin Ahmad
- Division of Drug Risk Evaluation, Office of Drug Safety, Food and Drug Administration, Center for Drug Evaluation and Research, Rockville, Md 20857, USA.
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2003; 12:73-88. [PMID: 12616852 DOI: 10.1002/pds.787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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