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Lu M, Baima YJ, Ni Z, Yang L, Zhang SS, Zhang YT. Advances in the potential of nebulized inhalation for the treatment of pulmonary arterial hypertension. Curr Probl Cardiol 2024; 49:102752. [PMID: 39059783 DOI: 10.1016/j.cpcardiol.2024.102752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Accepted: 07/23/2024] [Indexed: 07/28/2024]
Abstract
Pulmonary hypertension is a pathophysiologic manifestation of a heterogeneous group of diseases, with the main pathophysiologic mechanisms being persistent pulmonary vasoconstriction and irreversible vascular remodeling. The impact significantly affects the prognosis of patients with pulmonary hypertension. If it is not treated and intervened in time, it may lead to right ventricular failure and further endanger the patient's life. Within the past decade or so, nebulized inhalation therapy is considered to have advantages in the treatment of pulmonary hypertension as a safe, limited, and rapid therapy, for example, inhaled vasodilators (prostate analogs, nitroglycerin, carbon monoxide analogs sildenafil, and nitroprusside), inhaled anti-inflammatory and antiproliferative agents (simvastatin, and selatinib), and inhaled peroxides (levocetirizine) have been recognized as emerging therapeutic approaches in the treatment of pulmonary hypertension as emerging therapeutic approaches. Therefore, this article provides a brief review of recent advances in the potential of nebulized inhaled vasodilators, anti-inflammatory and antiproliferative agents, and anti-peroxides for the treatment of pulmonary hypertension, with the aim of providing different therapeutic options for the treatment of pulmonary hypertension, enhancing the quality of survival, alleviating symptoms, and improving the prognosis of patients with this condition.
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Affiliation(s)
- Miao Lu
- Tibet University Medical College, Lhasa, Tibet Autonomous Region 850000, China; Department of Pulmonary Medicine, Lhasa People's Hospital, Lhasa, Tibet Autonomous Region 850013, China
| | - Yang-Jin Baima
- Department of Pulmonary Medicine, Lhasa People's Hospital, Lhasa, Tibet Autonomous Region 850013, China
| | - Zhu Ni
- Department of Pulmonary Medicine, Lhasa People's Hospital, Lhasa, Tibet Autonomous Region 850013, China
| | - Li Yang
- Department of Pulmonary Medicine, Lhasa People's Hospital, Lhasa, Tibet Autonomous Region 850013, China
| | - Song-Shan Zhang
- Tibet University Medical College, Lhasa, Tibet Autonomous Region 850000, China; Department of External Medicine, Tibet Autonomous Region People's Hospital, Lhasa, Tibet Autonomous Region 850000, China
| | - Yun-Tao Zhang
- Department of Pulmonary Medicine, Lhasa People's Hospital, Lhasa, Tibet Autonomous Region 850013, China.
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Polzin A, Curtis ED, Rupe E, Sang HI. Inhaled Nitroglycerin for Pulmonary Edema in Air Medical Services: A Retrospective Pilot Study. Air Med J 2024; 43:151-156. [PMID: 38490779 DOI: 10.1016/j.amj.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/13/2023] [Accepted: 11/12/2023] [Indexed: 03/17/2024]
Abstract
OBJECTIVE The use of traditional inhaled pulmonary vasodilators, such as nitric oxide, to treat symptomatic pulmonary edema is not practical in the air medical or prehospital environment because of difficulty with administration. A hospital-based critical care air medical transport service initiated a pilot study to investigate the use of inhaled nitroglycerin (iNTG) as an alternative pulmonary vasodilator. METHODS For this pilot study, iNTG was administered using a jet nebulizer setup and concentrated nitroglycerin, both of which are widely available in acute care settings. In conjunction with medical oversight, transport personnel identified patients with respiratory distress secondary to pulmonary edema. Twenty-two months after initiating the protocol, a retrospective chart review was conducted. Data for patients receiving iNTG were retrospectively abstracted through a medical record search and manual chart review. RESULTS Twelve patients received iNTG during the pilot study. Basic demographics, medical comorbidities, concurrent medications, laboratory values, and radiographic studies were collected for each patient. Basic statistics were performed to identify any potential trends. CONCLUSION The administration of iNTG is feasible in an air medical transport setting and may provide a useful adjunct to treating patients with pulmonary edema and respiratory distress. Because iNTG delivery targets the pulmonary vasculature, this may be of particular benefit in patients with a poor hemodynamic profile. Larger randomized controlled or cohort studies are needed to specifically analyze and compare hemodynamics, diagnostics, and patient outcomes.
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Affiliation(s)
| | | | - Eric Rupe
- University of South Dakota Sanford School of Medicine, Vermillion, SD
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Nitroglycerin inhalation for acute treatment of pulmonary arterial hypertension in children with congenital heart disease. Cardiol Young 2021; 31:1381-1385. [PMID: 34082850 DOI: 10.1017/s1047951121002092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Acute pulmonary hypertension and pulmonary hypertensive crisis may result in adverse clinical outcomes if unsuccessfully treated. Inhaled nitric oxide has long been considered as the standard pharmacotherapy for acute pulmonary hypertension, but lack of feasibility in some settings and evidences challenging its benefits lead to the use of alternative treatment, amongst which is nitroglycerin inhalation. The purpose of this review article is to discuss available data on the use of nitroglycerin inhalation for acute treatment of pulmonary hypertension in children with CHD and its potential benefit in post-operative setting. DATA SOURCES Literatures included in this review were acquired by searching in PubMed online database. Keywords used were "Pulmonary Hypertension", "Congenital heart defects", "Pediatrics", "Inhaled nitroglycerin", and its synonyms. STUDY SELECTION Title and abstract were screened to select relevant literatures including the three paediatric clinical trials on nitroglycerin inhalation. Critical appraisal of the clinical trials was then done using the University of Oxford Centre of Evidence-Based Medicine Critical Appraisal Tools. CONCLUSIONS Paediatric studies showed the benefit of nitroglycerin inhalation in uncorrected cases of CHD during catheterisation procedures. Until recently, there have been no studies conducted in paediatric post-operative CHD cases. Further study is required to provide evidence for inhaled nitroglycerin use in this setting including the appropriate dosing and potential side effects with repeated administration.
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Daxon BT, Lark E, Matzek LJ, Fields AR, Haselton KJ. Nebulized Nitroglycerin for Coronavirus Disease 2019-Associated Acute Respiratory Distress Syndrome: A Case Report. A A Pract 2021; 15:e01376. [PMID: 33560642 PMCID: PMC7908862 DOI: 10.1213/xaa.0000000000001376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 11/17/2022]
Abstract
We present a case where nitroglycerin tablets dissolved in saline and intravenous nitroglycerin solution were nebulized as surrogates for inhaled nitric oxide (iNO) after our iNO supply was depleted during the coronavirus disease 2019 (COVID-19) surge in New York. We gave this treatment to a COVID-19 patient with severe acute respiratory distress syndrome (ARDS) and hypercarbia. In response, the patient had immediate and clinically meaningful improvement in multiple organ systems despite no other interventions or ventilator changes.
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Affiliation(s)
- Benjamin T. Daxon
- From the Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Erin Lark
- Department of Emergency Medicine, Henry Ford Wyandotte Hospital, Wyandotte, Michigan
| | - Luke J. Matzek
- From the Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Amanda R. Fields
- From the Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kyle J. Haselton
- From the Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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Lo CCW, Moosavi SM, Bubb KJ. The Regulation of Pulmonary Vascular Tone by Neuropeptides and the Implications for Pulmonary Hypertension. Front Physiol 2018; 9:1167. [PMID: 30190678 PMCID: PMC6116211 DOI: 10.3389/fphys.2018.01167] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/03/2018] [Indexed: 12/20/2022] Open
Abstract
Pulmonary hypertension (PH) is an incurable, chronic disease of small pulmonary vessels. Progressive remodeling of the pulmonary vasculature results in increased pulmonary vascular resistance (PVR). This causes secondary right heart failure. PVR is tightly regulated by a range of pulmonary vasodilators and constrictors. Endothelium-derived substances form the basis of most current PH treatments. This is particularly the case for pulmonary arterial hypertension. The major limitation of current treatments is their inability to reverse morphological changes. Thus, there is an unmet need for novel therapies to reduce the morbidity and mortality in PH. Microvessels in the lungs are highly innervated by sensory C fibers. Substance P and calcitonin gene-related peptide (CGRP) are released from C-fiber nerve endings. These neuropeptides can directly regulate vascular tone. Substance P tends to act as a vasoconstrictor in the pulmonary circulation and it increases in the lungs during experimental PH. The receptor for substance P, neurokinin 1 (NK1R), mediates increased pulmonary pressure. Deactivation of NK1R with antagonists, or depletion of substance P prevents PH development. CGRP is a potent pulmonary vasodilator. CGRP receptor antagonists cause elevated pulmonary pressure. Thus, the balance of these peptides is crucial within the pulmonary circulation (Graphical Abstract). Limited progress has been made in understanding their impact on pulmonary pathophysiology. This is an intriguing area of investigation to pursue. It may lead to promising new candidate therapies to combat this fatal disease. This review provides a summary of the current knowledge in this area. It also explores possible future directions for neuropeptides in PH.
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Affiliation(s)
- Charmaine C. W. Lo
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW, Australia
| | - Seyed M. Moosavi
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW, Australia
- School of Life Sciences, University of Technology Sydney, Ultimo, NSW, Australia
| | - Kristen J. Bubb
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW, Australia
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Gu Z, Xin L, Wang Z, Wang J. Intravenous anesthesia with nitroglycerin inhalation for surgical abortion in a patient with severe congenital heart disease and low oxygen saturation: A case report. Medicine (Baltimore) 2018; 97:e11108. [PMID: 29924007 PMCID: PMC6023693 DOI: 10.1097/md.0000000000011108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Congenital heart disease and pulmonary arterial hypertension are perilous to a gravida for the high morbidity and mortality. CASE PRESENTATION We report an extremely rare case of a 27-year-old gravida with congenital heart disease and severe pulmonary arterial hypertension of 115 mmHg. Arterial blood gas analysis revealed her oxygen saturation (SpO2) of 67.8% and oxygen partial pressure of 40.0 mmHg, which were severely low. The patient was diagnosed as having gestation combined with congenital heart disease, severe pulmonary arterial hypertension, and hypoxemia. INTERVENTIONS The patient was treated with surgical abortion. The patient was monitored with invasive blood pressure (BP), electrocardiogram (ECG), heart rate, SpO2, and arterial gas analysis as from entry into the operation suite. We performed total intravenous anesthesia with nitroglycerin inhalation. She was returned to the ward at the end of surgery. CONCLUSION To our knowledge, this is the first reported case in a gravida with severe heart disease and very low SpO2. Nitroglycerin inhalation may provide dilation of the pulmonary artery, reduction of pulmonary artery pressure, and improvement of oxygenation. Our case report may provide alternative regimen to anesthesia practitioners in similar circumstances.
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Thunberg CA, Morozowich ST, Ramakrishna H. Inhaled therapy for the management of perioperative pulmonary hypertension. Ann Card Anaesth 2016; 18:394-402. [PMID: 26139748 PMCID: PMC4881725 DOI: 10.4103/0971-9784.159811] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Patients with pulmonary hypertension (PH) are at high risk for complications in the perioperative setting and often receive vasodilators to control elevated pulmonary artery pressure (PAP). Administration of vasodilators via inhalation is an effective strategy for reducing PAP while avoiding systemic side effects, chiefly hypotension. The prototypical inhaled pulmonary-specific vasodilator, nitric oxide (NO), has a proven track record but is expensive and cumbersome to implement. Alternatives to NO, including prostanoids (such as epoprostenol, iloprost, and treprostinil), NO-donating drugs (sodium nitroprusside, nitroglycerin, and nitrite), and phosphodiesterase inhibitors (milrinone, sildenafil) may be given via inhalation for the purpose of treating elevated PAP. This review will focus on the perioperative therapy of PH using inhaled vasodilators.
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Affiliation(s)
| | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Phoenix, Arizona, USA
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Kraemer U, Cochius-den Otter S, Snoek KG, Tibboel D. Pharmacodynamic considerations in the treatment of pulmonary hypertension in infants: challenges and future perspectives. Expert Opin Drug Metab Toxicol 2015; 12:1-19. [DOI: 10.1517/17425255.2016.1116520] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
Perioperative pulmonary hypertension can originate from an established disease or acutely develop within the surgical setting. Patients with increased pulmonary vascular resistance are consequently at greater risk for complications. Despite the various specific therapies available, the ideal therapeutic approach in this patient population is not currently clear. This article describes the basic principles of perioperative pulmonary hypertension and reviews the different classes of agents used to promote pulmonary vasodilation in the surgical setting.
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Evlakhov VI, Poyasov IZ. Changes in pulmonary hemodynamics induced by experimental myocardial ischemia in nitroglycerin- or acetylcholine-treated rabbits. Bull Exp Biol Med 2014; 157:443-6. [PMID: 25110079 DOI: 10.1007/s10517-014-2586-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Indexed: 10/24/2022]
Abstract
The responses of cardiovascular parameters to left-ventricular myocardial ischemia induced under control conditions and after administration of nitroglycerin or acetylcholine were examined in rabbits. In nitroglycerine-treated rabbits, experimental myocardial ischemia produced less pronounced depressor BP shifts in the pulmonary artery than those produced by ischemia in controls (prior to pharmacological treatment) or by experimental ischemia provoked after acetylcholine infusion. Control and experimental ischemia (provoked after nitroglycerin or acetylcholine administration) induced the same drop in pulmonary blood fl ow accompanied with insignificant changes in vascular pulmonary resistance. Experimental ischemia produced smaller pressure increase in left atrium of nitroglycerine-treated rabbits (evidencing a smaller drop in left ventricular contractility) than the control ischemia performed prior to pharmacological treatment, or the experimental ischemia in acetylcholine-treated rabbits, which attested to protective effect of nitroglycerin against ischemia.
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Affiliation(s)
- V I Evlakhov
- Department of Physiology of Visceral Systems, Research Institute of Experimental Medicine, Northwestern Division of the Russian Academy of Medical Sciences, St. Petersburg, Russia
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11
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Tonelli AR, Minai OA. Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Perioperative management in patients with pulmonary hypertension. Ann Thorac Med 2014; 9:S98-S107. [PMID: 25077004 PMCID: PMC4114269 DOI: 10.4103/1817-1737.134048] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 04/05/2014] [Indexed: 01/30/2023] Open
Abstract
Patients with pulmonary hypertension (PH) are being encountered more commonly in the perioperative period and this trend is likely to increase as improvements in the recognition, management, and treatment of the disease continue to occur. Management of these patients is challenging due to their tenuous hemodynamic status. Recent advances in the understanding of the patho-physiology, risk factors, monitoring, and treatment of the disease provide an opportunity to reduce the morbidity and mortality associated with PH in the peri-operative period. Management of these patients requires a multi-disciplinary approach and meticulous care that is best provided in centers with vast experience in PH. In this review, we provide a detailed discussion about oerioperative strategies in PH patients, and give evidence-based recommendations, when applicable.
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Affiliation(s)
- Adriano R Tonelli
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Ohio, USA
| | - Omar A Minai
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Ohio, USA
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12
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Wang QQ, Cheng N, Yi WB, Peng SM, Zou XQ. Synthesis, nitric oxide release, and α-glucosidase inhibition of nitric oxide donating apigenin and chrysin derivatives. Bioorg Med Chem 2014; 22:1515-21. [PMID: 24508143 DOI: 10.1016/j.bmc.2014.01.038] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 01/20/2014] [Accepted: 01/22/2014] [Indexed: 10/25/2022]
Abstract
α-Glucosidase (AG) play crucial roles in the digestion of carbohydrates. Inhibitors of α-glucosidase (AGIs) are promising candidates for the development of anti-diabetic drugs. Here, five series of apigenin and chrysin nitric oxide (NO)-donating derivatives were synthesised and evaluated for their AG inhibitory activity and NO releasing capacity in vitro. Except for 9a-c, twelve compounds showed remarkable inhibitory activity against α-glucosidase, with potency being better than that of acarbose and 1-deoxynojirimycin. All organic nitrate derivatives released low concentrations of NO in the presence of l-cysteine. Structure activity relationship studies indicated that 5-OH, hydrophobic coupling chain, and carbonyl groups of the coupling chain could enhance the inhibitory activity. Apigenin and chrysin derivatives therefore represents a new class of promising compounds that can inhibit α-glucosidase activity and supply moderate NO for preventing the development of diabetic complications.
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Affiliation(s)
- Qi-Qin Wang
- Key Laboratory of Environmentally Friendly Chemistry and Applications of Ministry of Education, College of Chemistry, Xiangtan University, Xiangtan 411105, China; Department of Pharmacy and Guangdong Province Key Laboratory of Pharmacodynamic Constituents of Traditional Chinese Medicine & New Drug Research, Jinan University, Guangzhou 510632, China
| | - Ning Cheng
- Key Laboratory of Environmentally Friendly Chemistry and Applications of Ministry of Education, College of Chemistry, Xiangtan University, Xiangtan 411105, China
| | - Wen-Bing Yi
- Key Laboratory of Environmentally Friendly Chemistry and Applications of Ministry of Education, College of Chemistry, Xiangtan University, Xiangtan 411105, China
| | - Sheng-Ming Peng
- Key Laboratory of Environmentally Friendly Chemistry and Applications of Ministry of Education, College of Chemistry, Xiangtan University, Xiangtan 411105, China; Postdoctoral Programme of Chemical Engineering & Technology, Xiangtan University, Xiangtan 411105, China.
| | - Xiao-Qing Zou
- Key Laboratory of Environmentally Friendly Chemistry and Applications of Ministry of Education, College of Chemistry, Xiangtan University, Xiangtan 411105, China
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Thunberg CA, Gaitan BD, Grewal A, Ramakrishna H, Stansbury LG, Grigore AM. Pulmonary Hypertension in Patients Undergoing Cardiac Surgery: Pathophysiology, Perioperative Management, and Outcomes. J Cardiothorac Vasc Anesth 2013; 27:551-72. [DOI: 10.1053/j.jvca.2012.07.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Indexed: 11/11/2022]
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Raffay TM, Martin RJ, Reynolds JD. Can nitric oxide-based therapy prevent bronchopulmonary dysplasia? Clin Perinatol 2012; 39:613-38. [PMID: 22954273 PMCID: PMC3437658 DOI: 10.1016/j.clp.2012.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A growing understanding of endogenous nitric oxide (NO) biology is helping to explain how and when exogenous NO may confer benefit or harm; this knowledge is also helping to identify new better-targeted NO-based therapies. In this review, results of the bronchopulmonary dysplasia clinical trials that used inhaled NO in the preterm population are placed in context, the biologic basis for novel NO therapeutics is considered, and possible future directions for NO-focused clinical and basic research in developmental lung disease are identified.
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Affiliation(s)
- Thomas M. Raffay
- Division of Neonatology, Department of Pediatrics Rainbow Babies & Children’s Hospital, Case Medical Center/University Hospitals, Cleveland, Ohio
| | - Richard J. Martin
- Division of Neonatology, Department of Pediatrics Rainbow Babies & Children’s Hospital, Case Medical Center/University Hospitals, Cleveland, Ohio
| | - James D. Reynolds
- Department of Anesthesia and Perioperative Medicine, Case Medical Center/University Hospitals, Cleveland, Ohio
,Institute for Transformative Molecular Medicine, Case Medical Center/University Hospitals, Cleveland, Ohio
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França-Silva MS, Luciano MN, Ribeiro TP, Silva JS, Santos AF, França KC, Nakao LS, Athayde-Filho PF, Braga VA, Medeiros IA. The 2-nitrate-1,3-dibuthoxypropan, a new nitric oxide donor, induces vasorelaxation in mesenteric arteries of the rat. Eur J Pharmacol 2012; 690:170-5. [DOI: 10.1016/j.ejphar.2012.06.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 06/19/2012] [Accepted: 06/20/2012] [Indexed: 11/26/2022]
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Omar SA, Artime E, Webb AJ. A comparison of organic and inorganic nitrates/nitrites. Nitric Oxide 2012; 26:229-40. [PMID: 22491087 DOI: 10.1016/j.niox.2012.03.008] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 02/15/2012] [Accepted: 03/22/2012] [Indexed: 11/19/2022]
Abstract
Although both organic and inorganic nitrates/nitrites mediate their principal effects via nitric oxide, there are many important differences. Inorganic nitrate and nitrite have simple ionic structures and are produced endogenously and are present in the diet, whereas their organic counterparts are far more complex, and, with the exception of ethyl nitrite, are all medicinally synthesised products. These chemical differences underlie the differences in pharmacokinetic properties allowing for different modalities of administration, particularly of organic nitrates, due to the differences in their bioavailability and metabolic profiles. Whilst the enterosalivary circulation is a key pathway for orally ingested inorganic nitrate, preventing an abrupt effect or toxic levels of nitrite and prolonging the effects, this is not used by organic nitrates. The pharmacodynamic differences are even greater; while organic nitrates have potent acute effects causing vasodilation, inorganic nitrite's effects are more subtle and dependent on certain conditions. However, in chronic use, organic nitrates are considerably limited by the development of tolerance and endothelial dysfunction, whereas inorganic nitrate/nitrite may compensate for diminished endothelial function, and tolerance has not been reported. Also, while inorganic nitrate/nitrite has important cytoprotective effects against ischaemia-reperfusion injury, continuous use of organic nitrates may increase injury. While there are concerns that inorganic nitrate/nitrite may induce carcinogenesis, direct evidence of this in humans is lacking. While organic nitrates may continue to dominate the therapeutic arena, this may well change with the increasing recognition of their limitations, and ongoing discovery of beneficial effects and specific advantages of inorganic nitrate/nitrite.
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Affiliation(s)
- Sami A Omar
- King's College London British Heart Foundation Centre, Cardiovascular Division, Department of Clinical Pharmacology, London, UK
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Strumpher J, Jacobsohn E. Pulmonary Hypertension and Right Ventricular Dysfunction: Physiology and Perioperative Management. J Cardiothorac Vasc Anesth 2011; 25:687-704. [DOI: 10.1053/j.jvca.2011.02.022] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Indexed: 11/11/2022]
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18
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Baliga RS, MacAllister RJ, Hobbs AJ. New perspectives for the treatment of pulmonary hypertension. Br J Pharmacol 2011; 163:125-40. [PMID: 21175577 PMCID: PMC3085874 DOI: 10.1111/j.1476-5381.2010.01164.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Revised: 11/12/2010] [Accepted: 11/16/2010] [Indexed: 11/30/2022] Open
Abstract
Pulmonary hypertension (PH) is a debilitating disease with a poor prognosis. Therapeutic options remain limited despite the introduction of prostacyclin analogues, endothelin receptor antagonists and phosphodiesterase 5 inhibitors within the last 15 years; these interventions address predominantly the endothelial and vascular dysfunctionS associated with the condition, but simply delay progression of the disease rather than offer a cure. In an attempt to improve efficacy, emerging approaches have focused on targeting the pro-proliferative phenotype that underpins the pulmonary vascular remodelling in the lung and contributes to the impaired circulation and right heart failure. Many novel targets have been investigated and validated in animal models of PH, including modulation of guanylate cyclases, phosphodiesterases, tyrosine kinases, Rho kinase, bone morphogenetic proteins signalling, 5-HT, peroxisome proliferator activator receptors and ion channels. In addition, there is hope that combinations of such treatments, harnessing and optimizing vasodilator and anti-proliferative properties, will provide a further, possibly synergistic, increase in efficacy; therapies directed at the right heart may also offer an additional benefit. This overview highlights current therapeutic options, promising new therapies, and provides the rationale for a combination approach to treat the disease.
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Singh R, Choudhury M, Saxena A, Kapoor PM, Juneja R, Kiran U. Inhaled Nitroglycerin Versus Inhaled Milrinone in Children with Congenital Heart Disease Suffering from Pulmonary Artery Hypertension. J Cardiothorac Vasc Anesth 2010; 24:797-801. [DOI: 10.1053/j.jvca.2009.10.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2009] [Indexed: 11/11/2022]
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20
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Zhou YP, Guo Q, Chen XK, Huang G. Is nitroglycerin effective in treatment of haemoptysis? Br J Clin Pharmacol 2010; 69:311-3. [DOI: 10.1111/j.1365-2125.2009.03592.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Intraoperative management of pulmonary hypertension and associated right heart failure. Curr Opin Anaesthesiol 2010; 23:49-56. [DOI: 10.1097/aco.0b013e3283346c51] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Suesaowalak M, Cleary JP, Chang AC. Advances in diagnosis and treatment of pulmonary arterial hypertension in neonates and children with congenital heart disease. World J Pediatr 2010; 6:13-31. [PMID: 20143207 DOI: 10.1007/s12519-010-0002-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Accepted: 04/08/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND This article aims to review recent advances in the diagnosis and treatment of pulmonary arterial hypertension in neonates and children with congenital heart disease. DATA SOURCES Articles on pulmonary arterial hypertension in congenital heart disease were retrieved from PubMed and MEDLINE published after 1958. RESULTS A diagnosis of primary (or idiopathic) pulmonary arterial hypertension is made when no known risk factor is identified. Pulmonary arterial hypertension associated with congenital heart disease constitutes a heterogenous group of conditions and has been characterized by congenital systemic-to-pulmonary shunts. Despite the similarities in histologic appearance of pulmonary vascular disease, there are differences between pulmonary arterial hypertension secondary to congenital systemic-to-pulmonary shunts and those with other conditions with respect to pathophysiology, therapeutic strategies, and prognosis. Revision and subclassification within the category of secondary pulmonary arterial hypertension based on pathophysiology were conducted to improve specific treatments. The timing of surgical repair is crucial to prevent and minimize risk of postoperative pulmonary arterial hypertension. Drug therapies including prostacyclin, endothelin-receptor antagonist, phosphodiesterase inhibitor, and nitric oxide have been evolved with promising results in neonates and children. CONCLUSIONS Among the different forms of congenital heart diseases, an early correction generally prevents subsequent development of pulmonary arterial hypertension. Emerging therapies for treatment of patients with idiopathic pulmonary arterial hypertension also improve quality of life and survival in neonates and children with congenital heart disease associated with pulmonary arterial hypertension. Heart and lung transplantation or lung transplantation in combination with repair of the underlying cardiac defect is a therapeutic option in a minority of patients. Partial repair options are also beneficial in some selected cases. Randomized controlled trials are needed to evaluate the safety and efficacy of these therapies including survival and long-term outcome.
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Friedman A, Friedman J. New biomaterials for the sustained release of nitric oxide: past, present and future. Expert Opin Drug Deliv 2009; 6:1113-22. [PMID: 19663720 DOI: 10.1517/17425240903196743] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Nitric oxide (NO), the 1992 'Molecule of the Year', is the focus of immense medical and scientific exploration. Interest in NO has grown exponentially since the initial and relatively recent discovery that NO is the long sought after endothelial relaxing factor. There is intense research that is continuing to expose the extensive physiologic impact of NO in virtually all organ and tissue systems under both normal and pathological conditions. Both the rate of delivery and the amount of site-specific generated NO modulate a balance between cytoregulatory and cytotoxic activities. This balancing act and the very short lifetime of NO under physiological conditions pose an extreme challenge with respect to harnessing the exceptional therapeutic potential of this molecule. Over the past two decades, the race to translate the therapeutic potential of NO to the bedside has been overwhelmingly through the development of numerous NO delivery devices/vehicles. So far no one product has emerged as a clearcut winner. This review: discusses and evaluates NO-donating platforms that are available at present; attempts to enhance delivery and efficacy through encapsulation in silane-based hydrogel matrices; and discusses and evaluates the future direction of these advances.
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Affiliation(s)
- Adam Friedman
- Department of Medicine, Albert Einstein of Medicine, Bronx, NY 10467, USA.
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Winterhalter M, Simon A, Fischer S, Rahe-Meyer N, Chamtzidou N, Hecker H, Zuk J, Piepenbrock S, Strüber M. Comparison of Inhaled Iloprost and Nitric Oxide in Patients With Pulmonary Hypertension During Weaning From Cardiopulmonary Bypass in Cardiac Surgery: A Prospective Randomized Trial. J Cardiothorac Vasc Anesth 2008; 22:406-13. [PMID: 18503929 DOI: 10.1053/j.jvca.2007.10.015] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Indexed: 02/02/2023]
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Miller MR, Megson IL. Recent developments in nitric oxide donor drugs. Br J Pharmacol 2007; 151:305-21. [PMID: 17401442 PMCID: PMC2013979 DOI: 10.1038/sj.bjp.0707224] [Citation(s) in RCA: 431] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Revised: 02/05/2007] [Accepted: 02/12/2007] [Indexed: 12/16/2022] Open
Abstract
During the 1980s, the free radical, nitric oxide (NO), was discovered to be a crucial signalling molecule, with wide-ranging functions in the cardiovascular, nervous and immune systems. Aside from providing a credible explanation for the actions of organic nitrates and sodium nitroprusside that have long been used in the treatment of angina and hypertensive crises respectively, the discovery generated great hopes for new NO-based treatments for a wide variety of ailments. Decades later, however, we are still awaiting novel licensed agents in this arena, despite an enormous research effort to this end. This review explores some of the most promising recent advances in NO donor drug development and addresses the challenges associated with NO as a therapeutic agent.
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Affiliation(s)
- M R Miller
- Centre for Cardiovascular Science, University of Edinburgh, Queen's Medical Research Institute Edinburgh, UK
| | - I L Megson
- Free Radical Research Facility, Department of Diabetes, UHI Millennium Institute Inverness, UK
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