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Popescu R, Dinu-Pîrvu CE, Ghica MV, Anuța V, Popa L. Physico-Chemical Characterization and Initial Evaluation of Carboxymethyl Chitosan-Hyaluronan Hydrocolloid Systems with Insulin Intended for Intranasal Administration. Int J Mol Sci 2024; 25:10452. [PMID: 39408782 PMCID: PMC11476560 DOI: 10.3390/ijms251910452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2024] [Revised: 09/19/2024] [Accepted: 09/25/2024] [Indexed: 10/20/2024] Open
Abstract
The nasal route of administration can bypass the blood-brain barrier in order to obtain a higher concentration in the brain, thus offering a feasible alternative route of administration for diseases associated with the central nervous system. The advantages of the intranasal administration and the potential favorable therapeutic effects of intranasally administered insulin led to the formulation of carboxymethyl chitosan (CMC) and sodium hyaluronate (NaHA) hydrocolloidal systems with insulin for nasal administration, targeting nose-to-brain delivery and the initial assessment of these systems. The influence of the formulation variables on the response parameters defined as surface properties, rheology, and in vitro release of insulin were analyzed using experimental design and statistical programs (Modde and Minitab software). The systems recorded good wetting and adhesion capacity, allowing the spread of the hydrocolloidal systems on the nasal mucosa. The samples had a pseudoplastic flow and the rapid release of the insulin was according to our objective. According to the physico-chemical characterization and preliminary assessment, these formulations are appropriate for administration on the nasal mucosa, but further studies are necessary to demonstrate the beneficial therapeutic actions and the safety of using intranasal insulin.
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Affiliation(s)
- Roxana Popescu
- Department of Physical and Colloidal Chemistry, Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Str., 020950 Bucharest, Romania; (R.P.); (C.-E.D.-P.); (V.A.); (L.P.)
| | - Cristina-Elena Dinu-Pîrvu
- Department of Physical and Colloidal Chemistry, Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Str., 020950 Bucharest, Romania; (R.P.); (C.-E.D.-P.); (V.A.); (L.P.)
- Innovative Therapeutic Structures Research and Development Centre (InnoTher), “Carol Davila” University of Medicine and Pharmacy, 020956 Bucharest, Romania
| | - Mihaela Violeta Ghica
- Department of Physical and Colloidal Chemistry, Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Str., 020950 Bucharest, Romania; (R.P.); (C.-E.D.-P.); (V.A.); (L.P.)
- Innovative Therapeutic Structures Research and Development Centre (InnoTher), “Carol Davila” University of Medicine and Pharmacy, 020956 Bucharest, Romania
| | - Valentina Anuța
- Department of Physical and Colloidal Chemistry, Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Str., 020950 Bucharest, Romania; (R.P.); (C.-E.D.-P.); (V.A.); (L.P.)
- Innovative Therapeutic Structures Research and Development Centre (InnoTher), “Carol Davila” University of Medicine and Pharmacy, 020956 Bucharest, Romania
| | - Lăcrămioara Popa
- Department of Physical and Colloidal Chemistry, Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Str., 020950 Bucharest, Romania; (R.P.); (C.-E.D.-P.); (V.A.); (L.P.)
- Innovative Therapeutic Structures Research and Development Centre (InnoTher), “Carol Davila” University of Medicine and Pharmacy, 020956 Bucharest, Romania
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Wang X, Chen Y, Dong J, Ge J, Liu X, Liu J. Neurobiology of Stress-Induced Nicotine Relapse. Int J Mol Sci 2024; 25:1482. [PMID: 38338760 PMCID: PMC10855331 DOI: 10.3390/ijms25031482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/15/2024] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
Tobacco smoking is the leading cause of preventable death and disease. Although there are some FAD-approved medicines for controlling smoking, the relapse rate remains very high. Among the factors that could induce nicotine relapse, stress might be the most important one. In the last decades, preclinical studies have generated many new findings that lead to a better understanding of stress-induced relapse of nicotine-seeking. Several molecules such as α3β4 nicotinic acetylcholine receptor, α2-adrenergic receptors, cannabinoid receptor 1, trace amine-associated receptor 1, and neuropeptide systems (corticotropin-releasing factor and its receptors, dynorphine and kappa opioid receptor) have been linked to stress-induced nicotine relapse. In this review, we discuss recent advances in the neurobiology, treatment targets, and potential therapeutics of stress-induced nicotine relapse. We also discuss some factors that may influence stress-induced nicotine relapse and that should be considered in future studies. In the final section, a perspective on some research directions is provided. Further investigation on the neurobiology of stress-induced nicotine relapse will shed light on the development of new medicines for controlling smoking and will help us understand the interactions between the stress and reward systems in the brain.
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Affiliation(s)
| | | | | | | | | | - Jianfeng Liu
- Institute of Brain Science and Advanced Technology, Hubei Province Key Laboratory of Occupational Hazard Identification and Control, School of Medicine, Wuhan University of Science and Technology, Wuhan 430065, China (Y.C.); (J.D.)
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Fihurka O, Wang Y, Hong Y, Lin X, Shen N, Yang H, Brown B, Mommer M, Zieneldien T, Li Y, Kim J, Li M, Cai J, Zhou Q, Cao C. Multi-Targeting Intranasal Nanoformulation as a Therapeutic for Alzheimer's Disease. Biomolecules 2023; 13:232. [PMID: 36830601 PMCID: PMC9953380 DOI: 10.3390/biom13020232] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/05/2023] [Accepted: 01/20/2023] [Indexed: 01/26/2023] Open
Abstract
Melatonin, insulin, and Δ9-tetrahydrocannabinol (THC) have been shown to reverse cognitive deficits and attenuate neuropathologies in transgenic mouse models of Alzheimer's disease (AD) when used individually. Here, we evaluated the therapeutic properties of long-term intranasal treatment with a novel nanoformulation containing melatonin, insulin, and THC in aged APPswe/PS1ΔE9 (APP/PS1) mice, a transgenic model of AD. Transgenic mice at the age of 12 months were intranasally administered with a new nanoformulation containing melatonin, insulin, and THC at doses of 0.04, 0.008, and 0.02 mg/kg, respectively, once daily for 3 months. The spatial memory of the mice was assessed using the radial arm water maze (RAWM) test before and after drug treatment. Brain tissues were collected at the end of the treatment period for the assessment of Aβ load, tauopathy state, and markers of mitochondrial function. The RAWM test revealed that the treatment with the melatonin-insulin-THC (MIT) nasal spray improved the spatial learning memory of APP/PS1 mice significantly. Results of protein analyses of brain homogenates indicated that MIT treatment significantly decreased the tau phosphorylation implicated in tau toxicity (p < 0.05) and the expression of CKMT1 associated with mitochondrial dysfunction. Moreover, MIT significantly decreased the expression of two mitochondrial fusion-related proteins, Mfn2 and Opa1 (p < 0.01 for both), while increasing the expression of a mitophagy regulator, Parkin, suggesting a compensatory enhancement of mitophagy due to MIT-promoted mitochondrial fusion. In conclusion, this study was the first to demonstrate the ability of an MIT nanoformulation to improve spatial memory in AD mice through its multi-targeting effects on Aβ production, tau phosphorylation, and mitochondrial dynamics. Thus, MIT may be a safe and effective therapeutic for AD.
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Affiliation(s)
- Oksana Fihurka
- Department of Pharmaceutical Sciences, Taneja College of Pharmacy, University of South Florida, Tampa, FL 33612, USA
- Department of Neurology, College of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - Yanhong Wang
- Department of Pharmaceutical Sciences, Taneja College of Pharmacy, University of South Florida, Tampa, FL 33612, USA
| | - Yuzhu Hong
- Department of Pharmaceutical Sciences, Taneja College of Pharmacy, University of South Florida, Tampa, FL 33612, USA
| | - Xiaoyang Lin
- Department of Pharmaceutical Sciences, Taneja College of Pharmacy, University of South Florida, Tampa, FL 33612, USA
| | - Ning Shen
- Department of Pharmaceutical Sciences, Taneja College of Pharmacy, University of South Florida, Tampa, FL 33612, USA
| | - Haiqiang Yang
- Department of Pharmaceutical Sciences, Taneja College of Pharmacy, University of South Florida, Tampa, FL 33612, USA
| | - Breanna Brown
- Department of Pharmaceutical Sciences, Taneja College of Pharmacy, University of South Florida, Tampa, FL 33612, USA
| | - Marcus Mommer
- Department of Pharmaceutical Sciences, Taneja College of Pharmacy, University of South Florida, Tampa, FL 33612, USA
| | - Tarek Zieneldien
- Department of Pharmaceutical Sciences, Taneja College of Pharmacy, University of South Florida, Tampa, FL 33612, USA
| | - Yitong Li
- Department of Pharmaceutical Sciences, Taneja College of Pharmacy, University of South Florida, Tampa, FL 33612, USA
| | - Janice Kim
- Department of Pharmaceutical Sciences, Taneja College of Pharmacy, University of South Florida, Tampa, FL 33612, USA
| | - Minghua Li
- Department of Pharmaceutical Sciences, Taneja College of Pharmacy, University of South Florida, Tampa, FL 33612, USA
| | - Jianfeng Cai
- Department of Chemistry, College of Arts & Sciences, University of South Florida, Tampa, FL 33612, USA
| | - Qingyu Zhou
- Department of Pharmaceutical Sciences, Taneja College of Pharmacy, University of South Florida, Tampa, FL 33612, USA
| | - Chuanhai Cao
- Department of Pharmaceutical Sciences, Taneja College of Pharmacy, University of South Florida, Tampa, FL 33612, USA
- Department of Neurology, College of Medicine, University of South Florida, Tampa, FL 33612, USA
- Department of Chemistry, College of Arts & Sciences, University of South Florida, Tampa, FL 33612, USA
- USF-health Byrd Alzheimer Institute, Tampa, FL 33612, USA
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Wetzel L, Pourbaix M, Riegler A, Pfeifer AM, Reinhard I, Hoffmann S, Vollstädt-Klein S, Kiefer F, Sommer W, Bumb JM, Bach P, Koopmann A. G-CuP: the effect of a forced oral glucose intake on alcohol craving and mesolimbic cue reactivity in alcohol dependence-study protocol of a randomized, double-blind, placebo-controlled crossover study. Trials 2022; 23:693. [PMID: 35986409 PMCID: PMC9389768 DOI: 10.1186/s13063-022-06626-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multiple studies indicate that a lower plasma level of the acetylated form of the appetite-regulating hormone ghrelin and higher plasma levels of insulin lead to a reduction in subjective alcohol craving and a reduced mesolimbic cue reactivity in functional magnetic resonance imaging (fMRI) when being exposed to alcohol-associated stimuli. The ghrelin level can physiologically be reduced by the induction of stomach distension and the ingestion of glucose or lipids. METHODS A total of 108 alcohol-dependent patients aged between 18 and 65 years are examined in the randomized, double-blind, placebo-controlled crossover study. After collecting demographic and psychometric data, participants take part in an alcohol exposure session. Afterwards, the participants go through the intervention condition (oral glucose intake) and the control condition (placebo intake) in a randomized order on two examination days. Blood samples are taken repeatedly (every 10 min) during the study course on both measuring days to determine changes in acetylated and total ghrelin and insulin plasma levels. In parallel, subjective alcohol craving after the glucose or placebo intake as the primary outcome is assessed using the Alcohol Urge Questionnaire (AUQ) and a visual analog scale (VAS). To examine the mesolimbic cue reactivity as the secondary outcome, a fMRI measurement is conducted while being exposed to alcohol-related stimuli. Appropriate statistical analysis will be used for the evaluation of the outcomes. DISCUSSION If successful, the results of this study could offer alcohol-dependent patients a new potential option for acute short-term reduction of alcohol craving and thus prevent relapses and prolong periods of abstinence in the long term. TRIAL REGISTRATION German Clinical Trials Register DRKS00022419 (UTN: U1111-1278-9428). Retrospectively registered on September 15, 2020.
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Affiliation(s)
- Lea Wetzel
- Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany.
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim/ Heidelberg University, Mannheim, Germany.
| | - Madeleine Pourbaix
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim/ Heidelberg University, Mannheim, Germany
| | - Alisa Riegler
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim/ Heidelberg University, Mannheim, Germany
- Feuerlein Centre on Translational Addiction Medicine (FCTS), University of Heidelberg, Heidelberg, Germany
| | - Anna-Maria Pfeifer
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim/ Heidelberg University, Mannheim, Germany
| | - Iris Reinhard
- Department of Biostatistics, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Sabine Hoffmann
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim/ Heidelberg University, Mannheim, Germany
- Department of Biostatistics, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Sabine Vollstädt-Klein
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim/ Heidelberg University, Mannheim, Germany
| | - Falk Kiefer
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim/ Heidelberg University, Mannheim, Germany
- Feuerlein Centre on Translational Addiction Medicine (FCTS), University of Heidelberg, Heidelberg, Germany
| | - Wolfgang Sommer
- Institute of Psychopharmacology, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Jan Malte Bumb
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim/ Heidelberg University, Mannheim, Germany
| | - Patrick Bach
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim/ Heidelberg University, Mannheim, Germany
- Feuerlein Centre on Translational Addiction Medicine (FCTS), University of Heidelberg, Heidelberg, Germany
| | - Anne Koopmann
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim/ Heidelberg University, Mannheim, Germany
- Feuerlein Centre on Translational Addiction Medicine (FCTS), University of Heidelberg, Heidelberg, Germany
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Intranasal calcitonin gene-related peptide administration impairs fear memory retention in mice through the PKD/p-HDAC5/Npas4 pathway. Sci Rep 2022; 12:1450. [PMID: 35087146 PMCID: PMC8795377 DOI: 10.1038/s41598-022-05518-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/13/2022] [Indexed: 12/15/2022] Open
Abstract
The calcitonin gene-related peptide (CGRP) suppresses fear memory retention in mice. Although intracerebroventricular administration of CGRP alters the fear memory processes, making it a promising therapeutic strategy for post-traumatic stress disorder (PTSD), direct brain injection into patients is not practical. Therefore, we propose that intranasal application may be an effective way to deliver CGRP to the brain. This study tested whether CGRP nasal administration exerts the same effect as intracerebroventricular administration using C57BL6J mice. The amount of CGRP in the cerebrospinal fluid and hippocampus 30 min after nasal administration of CGRP was significantly higher when compared with saline. Intranasal CGRP also elicited photophobic behaviors similar to intracerebroventricular injection. Moreover, intranasal CGRP decreased fear memory retention but did not affect reactivation and extinction of fear memory. We found intranasal CGRP significantly increased the expression of protein kinase D (PKD), phosphorylated histone deacetylase 5 (p-HDAC5) and neuronal PAS domain protein 4 (Npas4) in the hippocampus. CGRP-mediated impairment of fear memory and Npas4 expression increases were attenuated significantly by the CGRP receptor antagonist BIBN4096. Together, our data demonstrate that intranasal CGRP delivery activates the PKD/p-HDAC5/Npas4 pathway, decreases fear memory retention.
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Ou G, Li Q, Zhu L, Zhang Y, Liu Y, Li X, Du L, Jin Y. Intranasal Hydrogel of Armodafinil Hydroxypropyl-β-Cyclodextrin Inclusion Complex for the Treatment of Post-Traumatic Stress Disorder. Saudi Pharm J 2022; 30:265-282. [PMID: 35498223 PMCID: PMC9051980 DOI: 10.1016/j.jsps.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 01/12/2022] [Indexed: 11/30/2022] Open
Abstract
Armodafinil inclusion complex (AIC) hydrogel was prepared and evaluated for its therapeutic effect on Post-traumatic Stress Disorder (PTSD). After computer simulation and physicochemical property investigation, the AIC was formed by lyophilization of armodafinil with ethanol as solvent and hydroxypropyl-beta-cyclodextrin (HP-β-CD) aqueous solution, in which the molar ratio of armodafinil and HP-β-CD was 1–1. The AIC encapsulation efficiency (EE) was (90.98 ± 3.72)% and loading efficiency (LE) was (13.95 ± 0.47)% and it increased the solubility of armodafinil in aqueous solution to 21 times. AIC hydrogel was prepared by adding AIC to methylcellulose (MC) hydrogels (3.33% w/v), and its higher drug release amount and slower release rate were testified by the in-vitro release assay and the rheological test. The mucosa irritation of AIC hydrogel was also evaluated. Healthy group, Model group, Sertraline group with 30 mg/kg sertraline gavage, AIC Hydrogel group with 20 mg/kg AIC hydrogel intranasal administration and AIC Aqueous Solution group with 20 mg/kg AIC aqueous solution gavage were set up for the treatment of mice with PTSD generated from foot shock method. Based on freezing response test in fear-conditioning box and open field test, compared with other groups, PTSD mice in AIC Hydrogel group showed significant improvement in behavioral parameters after 11 days of continuous drug administration and 5 days of drug withdrawal. After sacrifice, the plasma CORT level of PTSD mice in AIC Hydrogel group was elevated compared to Model group. Besides, the western blot (WB) of hippocampal brain-derived neurotrophic factor (BDNF) and amygdala dopamine transporter (DAT) immunohistochemistry sections indicated that AIC hydrogel had a protective effect on the brain tissue of PTSD mice. The brain targeting of intranasal administration was evaluated by fluorescence imaging characteristics of Cy7 hydrogel in the nasal route of drug administration, pharmacokinetics and in-vivo distribution of armodafinil. In short, AIC hydrogel is a promising formulation for the treatment of PTSD based on its high brain delivery and anti-PTSD effect.
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Affiliation(s)
- Ge Ou
- Medical School of Chinese PLA, Beijing 100853, China
- Pharmacy Department, Chinese PLA General Hospital, Beijing 100853, China
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Qian Li
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, Beijing 100850, China
- School of Medicine, Shandong University of Traditional Chinese Medicine, Jinan 250355, China
| | - Lin Zhu
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Yuanyuan Zhang
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, Beijing 100850, China
- School of Medicine, Shandong University of Traditional Chinese Medicine, Jinan 250355, China
| | - Yijing Liu
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, Beijing 100850, China
- School of Medicine, Shandong University of Traditional Chinese Medicine, Jinan 250355, China
| | - Xin Li
- Pharmacy Department, Chinese PLA General Hospital, Beijing 100853, China
- Corresponding authors at: Pharmacy Department, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing 100853, China (X. Li). Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, 27 Taiping Road, Haidian District, Beijing 100850, China (L. Du).
| | - Lina Du
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, Beijing 100850, China
- School of Medicine, Shandong University of Traditional Chinese Medicine, Jinan 250355, China
- Corresponding authors at: Pharmacy Department, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing 100853, China (X. Li). Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, 27 Taiping Road, Haidian District, Beijing 100850, China (L. Du).
| | - Yiguang Jin
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, Beijing 100850, China
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Goel H, Kalra V, Verma SK, Dubey SK, Tiwary AK. Convolutions in the rendition of nose to brain therapeutics from bench to bedside: Feats & fallacies. J Control Release 2021; 341:782-811. [PMID: 34906605 DOI: 10.1016/j.jconrel.2021.12.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 12/24/2022]
Abstract
Brain, a subtle organ of multifarious nature presents plethora of physiological, metabolic and bio-chemical convolutions that impede the delivery of biomolecules and thereby resulting in truncated therapeutic outcome in pathological conditions of central nervous system (CNS). The absolute bottleneck in the therapeutic management of such devastating CNS ailments is the BBB. Another pitfall is the lack of efficient technological platforms (due to high cost and low approval rates) as well as limited clinical trials (due to failures of neuro‑leads in late-stage pipelines) for CNS disorders which has become a literal brain drain with poorest success rates compared to other therapeutic areas, owing to time consuming processes, tremendous convolutions and conceivable adverse effects. With the advent of intranasal delivery (via direct N2B or indirect nose to blood to brain), several novel drug delivery carriers viz. unmodified or surface modified nanoparticle based carriers, lipid based colloidal nanocarriers and drysolid/liquid/semisolid nanoformulations or delivery platforms have been designed as a means to deliver therapeutic agents (small and large molecules, peptides and proteins, genes) to brain, bypassing BBB for disorders such as Alzheimer's disease (AD), Parkinson's disease (PD), epilepsy, schizophrenia and CNS malignancies primarily glioblastomas. Intranasal application offers drug delivery through both direct and indirect pathways for the peripherally administered psychopharmacological agents to CNS. This route could also be exploited for the repurposing of conventional drugs for new therapeutic uses. The limited clinical translation of intranasal formulations has been primarily due to existence of barriers of mucociliary clearance in the nasal cavity, enzyme degradation and low permeability of the nasal epithelium. The present review literature aims to decipher the new paradigms of nano therapeutic systems employed for specific N2B drug delivery of CNS drugs through in silico complexation studies using rationally chosen mucoadhesive polymers (exhibiting unique physicochemical properties of nanocarrier's i.e. surface modification, prolonging retention time in the nasal cavity, improving penetration ability, and promoting brain specific delivery with biorecognitive ligands) via molecular docking simulations. Further, the review intends to delineate the feats and fallacies associated with N2B delivery approaches by understanding the physiological/anatomical considerations via decoding the intranasal drug delivery pathways or critical factors such as rationale and mechanism of excipients, affecting the permeability of CNS drugs through nasal mucosa as well as better efficacy in terms of brain targeting, brain bioavailability and time to reach the brain. Additionally, extensive emphasis has also been laid on the innovative formulations under preclinical investigation along with their assessment by means of in vitro /ex vivo/in vivo N2B models and current characterization techniques predisposing an efficient intranasal delivery of therapeutics. A critical appraisal of novel technologies, intranasal products or medical devices available commercially has also been presented. Finally, it could be warranted that more reminiscent pharmacokinetic/pharmacodynamic relationships or validated computational models are mandated to obtain effective screening of molecular architecture of drug-polymer-mucin complexes for clinical translation of N2B therapeutic systems from bench to bedside.
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Affiliation(s)
- Honey Goel
- Department of Pharmaceutics, University Institute of Pharmaceutical Sciences and Research, Baba Farid University of Health Sciences, Faridkot, Punjab, India.
| | - Vinni Kalra
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab, India
| | - Sant Kumar Verma
- Department of Pharmaceutical Chemistry, Indo-Soviet Friendship College of Pharmacy, Moga, Punjab, India
| | | | - Ashok Kumar Tiwary
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab, India.
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Abstract
The intranasal (IN) route enables the delivery of insulin to the central nervous system in the relative absence of systemic uptake and related peripheral side effects. Intranasally administered insulin is assumed to travel along olfactory and adjacent pathways and has been shown to rapidly accumulate in cerebrospinal fluid, indicating efficient transport to the brain. Two decades of studies in healthy humans and patients have demonstrated that IN insulin exerts functional effects on metabolism, such as reductions in food intake and body weight and improvements of glucose homeostasis, as well as cognition, ie, enhancements of memory performance both in healthy individuals and patients with mild cognitive impairment or Alzheimer's disease; these studies moreover indicate a favourable safety profile of the acute and repeated use of IN insulin. Emerging findings suggest that IN insulin also modulates neuroendocrine activity, sleep-related mechanisms, sensory perception and mood. Some, but not all studies point to sex differences in the response to IN insulin that need to be further investigated along with the impact of age. "Brain insulin resistance" is an evolving concept that posits impairments in central nervous insulin signalling as a pathophysiological factor in metabolic and cognitive disorders such as obesity, type 2 diabetes and Alzheimer's disease, and, notably, a target of interventions that rely on IN insulin. Still, the negative outcomes of longer-term IN insulin trials in individuals with obesity or Alzheimer's disease highlight the need for conceptual as well as methodological advances to translate the promising results of proof-of-concept experiments and pilot clinical trials into the successful clinical application of IN insulin.
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Affiliation(s)
- Manfred Hallschmid
- Institute of Medical Psychology and Behavioural Neurobiology, University of Tübingen, Tübingen, Germany
- German Centre for Diabetes Research (DZD), Tübingen, Germany
- Institute for Diabetes Research and Metabolic Diseases, Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany
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9
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Elman I, Howard M, Borodovsky JT, Mysels D, Rott D, Borsook D, Albanese M. Metabolic and Addiction Indices in Patients on Opioid Agonist Medication-Assisted Treatment: A Comparison of Buprenorphine and Methadone. Sci Rep 2020; 10:5617. [PMID: 32221389 PMCID: PMC7101411 DOI: 10.1038/s41598-020-62556-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 03/03/2020] [Indexed: 12/18/2022] Open
Abstract
Metabolic hormones stabilize brain reward and motivational circuits, whereas excessive opioid consumption counteracts this effect and may impair metabolic function. Here we addressed the role of metabolic processes in the course of the agonist medication-assisted treatment for opioid use disorder (OUD) with buprenorphine or methadone. Plasma lipids, hemoglobin A1C, body composition, the oral glucose tolerance test (oGTT) and the Sweet Taste Test (STT) were measured in buprenorphine- (n = 26) or methadone (n = 32)- treated subjects with OUD. On the whole, the subjects in both groups were overweight or obese and insulin resistant; they displayed similar oGTT and STT performance. As compared to methadone-treated subjects, those on buprenorphine had significantly lower rates of metabolic syndrome (MetS) along with better values of the high-density lipoproteins (HDL). Subjects with- vs. without MetS tended to have greater addiction severity. Correlative analyses revealed that more buprenorphine exposure duration was associated with better HDL and opioid craving values. In contrast, more methadone exposure duration was associated with worse triglycerides-, HDL-, blood pressure-, fasting glucose- and hemoglobin A1C values. Buprenorphine appears to produce beneficial HDL- and craving effects and, contrary to methadone, its role in the metabolic derangements is not obvious. Our data call for further research aimed at understanding the distinctive features of buprenorphine metabolic effects vis-à-vis those of methadone and their potential role in these drugs' unique therapeutic profiles.
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Affiliation(s)
- Igor Elman
- Center for Pain and the Brain, Department of Anesthesia, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.
| | - Margaret Howard
- Rhode Island Department of Behavioral Healthcare, Cranston, RI, USA
| | - Jacob T Borodovsky
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - David Mysels
- Department of Psychiatry, Alpert Medical School of Brown University, Providence, RI, USA
| | - David Rott
- Department of Cardiology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - David Borsook
- Center for Pain and the Brain, Department of Anesthesia, Critical Care and Pain Medicine, Boston Children's Hospital, Massachusetts General Hospital and McLean Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark Albanese
- Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA
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Abstract
Addiction to substances such as alcohol, cocaine, opioids, and methamphetamine poses a continuing clinical and public challenge globally. Despite progress in understanding substance use disorders, challenges remain in their treatment. Some of these challenges include limited ability of therapeutics to reach the brain (blood-brain barrier), adverse systemic side effects of current medications, and importantly key aspects of addiction not addressed by currently available treatments (such as cognitive impairment). Inability to sustain abstinence or seek treatment due to cognitive deficits such as poor decision-making and impulsivity is known to cause poor treatment outcomes. In this review, we provide an evidenced-based rationale for intranasal drug delivery as a viable and safe treatment modality to bypass the blood-brain barrier and target insulin to the brain to improve the treatment of addiction. Intranasal insulin with improvement of brain cell energy and glucose metabolism, stress hormone reduction, and improved monoamine transmission may be an ideal approach for treating multiple domains of addiction including memory and impulsivity. This may provide additional benefits to enhance current treatment approaches.
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Affiliation(s)
- Bhavani Kashyap
- HealthPartners Neuroscience Center, 295 Phalen Blvd, St Paul, Minnesota, 55130, USA.
- HealthPartners Institute, Bloomington, Minnesota, USA.
| | - Leah R Hanson
- HealthPartners Neuroscience Center, 295 Phalen Blvd, St Paul, Minnesota, 55130, USA
- HealthPartners Institute, Bloomington, Minnesota, USA
| | - William H Frey Ii
- HealthPartners Neuroscience Center, 295 Phalen Blvd, St Paul, Minnesota, 55130, USA
- HealthPartners Institute, Bloomington, Minnesota, USA
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11
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Wang Z, Xiong G, Tsang WC, Schätzlein AG, Uchegbu IF. Nose-to-Brain Delivery. J Pharmacol Exp Ther 2019; 370:593-601. [PMID: 31126978 DOI: 10.1124/jpet.119.258152] [Citation(s) in RCA: 121] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 05/21/2019] [Indexed: 01/08/2023] Open
Abstract
The global prevalence of neurologic disorders is rising, and yet we are still unable to deliver most drug molecules, in therapeutic quantities, to the brain. The blood brain barrier consists of a tight layer of endothelial cells surrounded by astrocyte foot processes, and these anatomic features constitute a significant barrier to drug transport from the blood to the brain. One way to bypass the blood brain barrier and thus treat diseases of the brain is to use the nasal route of administration and deposit drugs at the olfactory region of the nares, from where they travel to the brain via mechanisms that are still not clearly understood, with travel across nerve fibers and travel via a perivascular pathway both being hypothesized. The nose-to-brain route has been demonstrated repeatedly in preclinical models, with both solution and particulate formulations. The nose-to-brain route has also been demonstrated in human studies with solution and particle formulations. The entry of device manufacturers into the arena will enable the benefits of this delivery route to become translated into approved products. The key factors that determine the efficacy of delivery via this route include the following: delivery to the olfactory area of the nares as opposed to the respiratory region, a longer retention time at the nasal mucosal surface, penetration enhancement of the active through the nasal epithelia, and a reduction in drug metabolism in the nasal cavity. Indications where nose-to-brain products are likely to emerge first include the following: neurodegeneration, post-traumatic stress disorder, pain, and glioblastoma.
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Affiliation(s)
- Zian Wang
- UCL School of Pharmacy, London, United Kingdom (Z.-a.W., G.X., W.C.T., A.G.S., I.F.U.); and Nanomerics, London, United Kingdom (A.G.S., I.F.U.)
| | - Guojun Xiong
- UCL School of Pharmacy, London, United Kingdom (Z.-a.W., G.X., W.C.T., A.G.S., I.F.U.); and Nanomerics, London, United Kingdom (A.G.S., I.F.U.)
| | - Wai Chun Tsang
- UCL School of Pharmacy, London, United Kingdom (Z.-a.W., G.X., W.C.T., A.G.S., I.F.U.); and Nanomerics, London, United Kingdom (A.G.S., I.F.U.)
| | - Andreas G Schätzlein
- UCL School of Pharmacy, London, United Kingdom (Z.-a.W., G.X., W.C.T., A.G.S., I.F.U.); and Nanomerics, London, United Kingdom (A.G.S., I.F.U.)
| | - Ijeoma F Uchegbu
- UCL School of Pharmacy, London, United Kingdom (Z.-a.W., G.X., W.C.T., A.G.S., I.F.U.); and Nanomerics, London, United Kingdom (A.G.S., I.F.U.)
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12
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Naef L, Seabrook L, Hsiao J, Li C, Borgland SL. Insulin in the ventral tegmental area reduces cocaine-evoked dopamine in the nucleus accumbens in vivo. Eur J Neurosci 2018; 50:2146-2155. [PMID: 30471157 DOI: 10.1111/ejn.14291] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 11/08/2018] [Accepted: 11/13/2018] [Indexed: 02/06/2023]
Abstract
Mesolimbic dopamine circuits, implicated in incentive motivation, are sensitive to changes in metabolic state such as weight loss and diet-induced obesity. These neurons are important targets for metabolic hormones such as leptin, glucagon-like peptide-1, ghrelin and insulin. Insulin receptors are located on dopamine neurons in the ventral tegmental area (VTA) and we have previously demonstrated that insulin induces long-term depression of excitatory synapses onto VTA dopamine neurons. While insulin can decrease dopamine concentration in somatodendritic regions, it can increase dopamine in striatal slices. Whether insulin directly targets the VTA to alter dopamine release in projection areas, such as the nucleus accumbens (NAc), remains unknown. The main goal of the present experiments was to examine NAc dopamine concentration following VTA administration of insulin. Using in vivo FSCV to detect rapid fluctuations in dopamine concentration, we showed that intra-VTA insulin via action at insulin receptors reduced pedunculopontine nucleus-evoked dopamine release in the NAc. Furthermore, intra-VTA insulin reduced cocaine-potentiated NAc dopamine. Finally, intra-VTA or intranasal insulin decreased locomotor responses to cocaine, an effect blocked by an intra-VTA administered insulin receptor antagonist. Together, these data demonstrate that mesolimbic dopaminergic projections are important targets of the metabolic hormone, insulin.
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Affiliation(s)
- Lindsay Naef
- Department of Physiology & Pharmacology, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, T2N 4N1, Canada
| | - Lauren Seabrook
- Department of Physiology & Pharmacology, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, T2N 4N1, Canada
| | - Jeff Hsiao
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Calvin Li
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephanie L Borgland
- Department of Physiology & Pharmacology, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, T2N 4N1, Canada
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13
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Schmid V, Kullmann S, Gfrörer W, Hund V, Hallschmid M, Lipp HP, Häring HU, Preissl H, Fritsche A, Heni M. Safety of intranasal human insulin: A review. Diabetes Obes Metab 2018; 20:1563-1577. [PMID: 29508509 DOI: 10.1111/dom.13279] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 02/26/2018] [Accepted: 02/28/2018] [Indexed: 12/12/2022]
Abstract
AIMS To conduct a review in order to assess the safety of intranasal human insulin in clinical studies as well as the temporal stability of nasal insulin sprays. MATERIAL AND METHODS An electronic search was performed using MEDLINE. We selected original research on intranasal human insulin without further additives in humans. The studies included could be of any design as long as they used human intranasal insulin as their study product. All outcomes and adverse side effects were extracted. RESULTS A total of 38 studies in 1092 individuals receiving acute human intranasal insulin treatment and 18 studies in 832 individuals receiving human intranasal insulin treatment lasting between 21 days and 9.7 years were identified. No cases of symptomatic hypoglycaemia or severe adverse events (AEs) were reported. Transient local side effects in the nasal area were frequently experienced after intranasal insulin and placebo spray, while other AEs were less commonly reported. There were no reports of participants being excluded as a result of AEs. No instances of temporal stability of nasal insulin were reported in the literature. Tests on insulin that had been repacked into spray flasks showed that it had a chemical stability of up to 57 days. CONCLUSIONS Our retrospective review of published studies on intranasal insulin did not reveal any safety concerns; however, there were insufficient data to ensure the long-term safety of this method of chronic insulin administration. Improved insulin preparations that cause less nasal irritation would be desirable for future treatment.
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MESH Headings
- Administration, Intranasal
- Aerosols
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/drug therapy
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/drug therapy
- Drug Compounding
- Drug Stability
- Humans
- Hyperglycemia/prevention & control
- Hypoglycemia/chemically induced
- Hypoglycemia/prevention & control
- Hypoglycemic Agents/administration & dosage
- Hypoglycemic Agents/adverse effects
- Hypoglycemic Agents/chemistry
- Hypoglycemic Agents/therapeutic use
- Insulin, Regular, Human/administration & dosage
- Insulin, Regular, Human/adverse effects
- Insulin, Regular, Human/chemistry
- Insulin, Regular, Human/therapeutic use
- Protein Stability
- Recombinant Proteins/administration & dosage
- Recombinant Proteins/adverse effects
- Recombinant Proteins/chemistry
- Recombinant Proteins/therapeutic use
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Affiliation(s)
- Vera Schmid
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center, Munich, at the University of Tübingen, Tübingen, Germany
- German Centre for Diabetes Research (DZD e.V.), Tübingen, Germany
- Department of Internal Medicine, Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Stephanie Kullmann
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center, Munich, at the University of Tübingen, Tübingen, Germany
- German Centre for Diabetes Research (DZD e.V.), Tübingen, Germany
| | | | - Verena Hund
- University Pharmacy, University Hospital, Tübingen, Germany
| | - Manfred Hallschmid
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center, Munich, at the University of Tübingen, Tübingen, Germany
- German Centre for Diabetes Research (DZD e.V.), Tübingen, Germany
- Institute of Medical Psychology and Behavioral Neurobiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | | | - Hans-Ulrich Häring
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center, Munich, at the University of Tübingen, Tübingen, Germany
- German Centre for Diabetes Research (DZD e.V.), Tübingen, Germany
- Department of Internal Medicine, Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Hubert Preissl
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center, Munich, at the University of Tübingen, Tübingen, Germany
- German Centre for Diabetes Research (DZD e.V.), Tübingen, Germany
- Department of Internal Medicine, Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry, Eberhard Karls University Tübingen, Tübingen, Germany
- Institute for Diabetes and Obesity, Helmholtz Diabetes Centre at Helmholtz Zentrum München, German Research Centre for Environmental Health (GmbH), Neuherberg, Germany
- Institute of Pharmaceutical Sciences, Department of Pharmacy and Biochemistry, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Andreas Fritsche
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center, Munich, at the University of Tübingen, Tübingen, Germany
- German Centre for Diabetes Research (DZD e.V.), Tübingen, Germany
- Department of Internal Medicine, Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Martin Heni
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center, Munich, at the University of Tübingen, Tübingen, Germany
- German Centre for Diabetes Research (DZD e.V.), Tübingen, Germany
- Department of Internal Medicine, Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry, Eberhard Karls University Tübingen, Tübingen, Germany
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14
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Hamidovic A, Candelaria L, Rodriguez I, Yamada M, Nawarskas J, Burge MR. Learning and memory performance following acute intranasal insulin administration in abstinent smokers. Hum Psychopharmacol 2018; 33:e2649. [PMID: 29363182 PMCID: PMC6005370 DOI: 10.1002/hup.2649] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 11/03/2017] [Accepted: 12/08/2017] [Indexed: 11/06/2022]
Abstract
The highest incidence of relapse to smoking occurs within the first 2 weeks of a cessation attempt. In addition to enhanced nicotine craving, this phase of smoking cessation is also marked by learning and memory dysfunction. Many smokers are not able to overcome these symptoms, and they relapse to smoking shortly after trying to quit. In two clinical studies, we evaluated intranasal insulin for efficacy in improving learning and memory function during nicotine withdrawal. Our first study was a crossover evaluation (N = 19) following 20 hr of smoking abstinence. Study 2 was a parallel design study (N = 50) following 16 hr of abstinence. Intranasal insulin (60 IU) dose was administered in both studies and cognitive function was measured using California Verbal Learning Test-II. Intranasal insulin did not improve learning over the 5 verbal learning trials. In addition, intranasal insulin did not improve either short- or long-delay recall in either study. In summary, the one-time administration of intranasal insulin does not improve verbal learning and memory in smokers. Whether longer administration schedules may be of benefit should be evaluated in future studies.
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Affiliation(s)
- Ajna Hamidovic
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | | | | | - Mikiko Yamada
- University of New Mexico, Albuquerque, New Mexico, USA
| | | | - Mark R Burge
- University of New Mexico, Albuquerque, New Mexico, USA
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15
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Hamidovic A. Targeting Mediators of Smoking Persistence with Intranasal Insulin. Front Pharmacol 2017; 8:706. [PMID: 29085297 PMCID: PMC5649209 DOI: 10.3389/fphar.2017.00706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 09/21/2017] [Indexed: 12/23/2022] Open
Abstract
Rapid-acting, non-irritating nasal treatment options for smoking cessation pharmacotherapy are lacking. The halt in development is due, in part, to difficulty in delivering compounds across the blood brain barrier. Recently, in both human and animal models, insulin was shown to be capable of being transported to the cerebrospinal fluid and various brain regions via the “nose-to-brain” pathway, which bypasses the blood brain barrier, but is not free of its own unique, though different from blood brain barrier, challenges. This review will first evaluate and critique pharmacokinetic and pharmacodynamic evidence of intranasal insulin (i.e., nose-to-brain) delivery. As intranasal insulin has been shown in clinical trials to be effective in reducing nicotine cravings, in the remainder of the review, hypothesis-generating literature for additional mediators (i.e., other than the already shown nicotine craving) of smoking persistence will be reviewed. In particular, weight gain, impulsive behavior, and anhedonia have been shown to contribute to the inability to quit smoking. For each of these, after reviewing how the mediator promotes smoking, intranasal insulin literature from animal and clinical models will be critiqued in assessing whether a hypothesis may be generated that intranasal insulin may alleviate it, thereby potentially contributing to a successful smoking cessation outcome.
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Affiliation(s)
- Ajna Hamidovic
- Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, United States
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