1
|
Sneyd JR. Why sedative hypnotics often fail in development. Curr Opin Anaesthesiol 2024; 37:391-397. [PMID: 38841982 DOI: 10.1097/aco.0000000000001381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW Drug development to support anaesthesia and sedation has been slow with few candidates emerging from preclinical discovery and limited innovation beyond attempted reformulation of existing compounds. RECENT FINDINGS The market is well supported by low-cost generic products and development compounds have not been shown to improve patient outcomes or possess other distinctive characteristics to justify the cost of development. SUMMARY To make progress in a large-volume, low margin and highly competitive environment requires meaningful advances in relevant basic science. Opportunities exist, but probably require bolder initiatives than further attempts at reformulation or fiddling with the structure of propofol. Extending development ambitions to include nonanaesthesiologist providers challenges professional boundaries but may facilitate cost-effective changes in patterns of care.
Collapse
Affiliation(s)
- J Robert Sneyd
- Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, UK
| |
Collapse
|
2
|
Abstract
PURPOSE OF REVIEW Steadily mounting evidence of anesthesia-induced developmental neurotoxicity has been a challenge in pediatric anesthesiology. Considering that presently used anesthetics have, in different animal models, been shown to cause lasting behavioral impairments when administered at the peak of brain development, the nagging question, 'Is it time for the development of a new anesthetic' must be pondered. RECENT FINDINGS The emerging 'soft analogs' of intravenous anesthetics aim to overcome the shortcomings of currently available clinical drugs. Remimazolam, a novel ester-analog of midazolam, is a well tolerated intravenous drug with beneficial pharmacological properties. Two novel etomidate analogs currently in development are causing less adrenocortical suppression while maintaining equally favorable hemodynamic stability and rapid metabolism. Quaternary lidocaine derivatives are explored as more potent and longer lasting alternatives to currently available local anesthetics. Xenon, a noble gas with anesthetic properties, is being considered as an anesthetic-sparing adjuvant in pediatric population. Finally, alphaxalone is being reevaluated in a new drug formulation because of its favorable pharmacological properties. SUMMARY Although a number of exciting anesthetic drugs are under development, there is currently no clear evidence to suggest their lack of neurotoxic properties in young brain. Well designed preclinical studies are needed to evaluate their neurotoxic potential.
Collapse
Affiliation(s)
- Nemanja Useinovic
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Vesna Jevtovic-Todorovic
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Pharmacology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| |
Collapse
|
3
|
Deng C, Liu J, Zhang W. Structural Modification in Anesthetic Drug Development for Prodrugs and Soft Drugs. Front Pharmacol 2022; 13:923353. [PMID: 35847008 PMCID: PMC9283706 DOI: 10.3389/fphar.2022.923353] [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: 04/19/2022] [Accepted: 06/01/2022] [Indexed: 11/18/2022] Open
Abstract
Among the advancements in drug structural modifications, the increased focus on drug metabolic and pharmacokinetic properties in the anesthetic drug design process has led to significant developments. Drug metabolism also plays a key role in optimizing the pharmacokinetics, pharmacodynamics, and safety of drug molecules. Thus, in the field of anesthesiology, the applications of pharmacokinetic strategies are discussed in the context of sedatives, analgesics, and muscle relaxants. In this review, we summarize two approaches for structural optimization to develop anesthetic drugs, by designing prodrugs and soft drugs. Drugs that both failed and succeeded during the developmental stage are highlighted to illustrate how drug metabolism and pharmacokinetic optimization strategies may help improve their physical and chemical properties.
Collapse
Affiliation(s)
- Chaoyi Deng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Wensheng Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wensheng Zhang,
| |
Collapse
|
4
|
Vellinga R, Valk BI, Absalom AR, Struys MMRF, Barends CRM. What's New in Intravenous Anaesthesia? New Hypnotics, New Models and New Applications. J Clin Med 2022; 11:jcm11123493. [PMID: 35743563 PMCID: PMC9224877 DOI: 10.3390/jcm11123493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/10/2022] [Accepted: 06/14/2022] [Indexed: 02/01/2023] Open
Abstract
New anaesthetic drugs and new methods to administer anaesthetic drugs are continually becoming available, and the development of new PK-PD models furthers the possibilities of using arget controlled infusion (TCI) for anaesthesia. Additionally, new applications of existing anaesthetic drugs are being investigated. This review describes the current situation of anaesthetic drug development and methods of administration, and what can be expected in the near future.
Collapse
Affiliation(s)
- Remco Vellinga
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (B.I.V.); (A.R.A.); (M.M.R.F.S.); (C.R.M.B.)
- Correspondence:
| | - Beatrijs I. Valk
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (B.I.V.); (A.R.A.); (M.M.R.F.S.); (C.R.M.B.)
- Department of Anesthesiology, University Medical Center Göttingen, 37075 Göttingen, Germany
| | - Anthony R. Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (B.I.V.); (A.R.A.); (M.M.R.F.S.); (C.R.M.B.)
| | - Michel M. R. F. Struys
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (B.I.V.); (A.R.A.); (M.M.R.F.S.); (C.R.M.B.)
- Department of Basic and Applied Medical Sciences, Ghent University, 9041 Ghent, Belgium
| | - Clemens R. M. Barends
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (B.I.V.); (A.R.A.); (M.M.R.F.S.); (C.R.M.B.)
| |
Collapse
|
5
|
Valk BI, Struys MMRF. Etomidate and its Analogs: A Review of Pharmacokinetics and Pharmacodynamics. Clin Pharmacokinet 2021; 60:1253-1269. [PMID: 34060021 PMCID: PMC8505283 DOI: 10.1007/s40262-021-01038-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2021] [Indexed: 01/09/2023]
Abstract
Etomidate is a hypnotic agent that is used for the induction of anesthesia. It produces its effect by acting as a positive allosteric modulator on the γ-aminobutyric acid type A receptor and thus enhancing the effect of the inhibitory neurotransmitter γ-aminobutyric acid. Etomidate stands out among other anesthetic agents by having a remarkably stable cardiorespiratory profile, producing no cardiovascular or respiratory depression. However, etomidate suppresses the adrenocortical axis by the inhibition of the enzyme 11β-hydroxylase. This makes the drug unsuitable for administration by a prolonged infusion. It also makes the drug unsuitable for administration to critically ill patients. Etomidate has relatively large volumes of distributions and is rapidly metabolized by hepatic esterases into an inactive carboxylic acid through hydrolyzation. Because of the decrease in popularity of etomidate, few modern extensive pharmacokinetic or pharmacodynamic studies exist. Over the last decade, several analogs of etomidate have been developed, with the aim of retaining its stable cardiorespiratory profile, whilst eliminating its suppressive effect on the adrenocortical axis. One of these molecules, ABP-700, was studied in extensive phase I clinical trials. These found that ABP-700 is characterized by small volumes of distribution and rapid clearance. ABP-700 is metabolized similarly to etomidate, by hydrolyzation into an inactive carboxylic acid. Furthermore, ABP-700 showed a rapid onset and offset of clinical effect. One side effect observed with both etomidate and ABP-700 is the occurrence of involuntary muscle movements. The origin of these movements is unclear and warrants further research.
Collapse
Affiliation(s)
- Beatrijs I Valk
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Michel M R F Struys
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
- Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium.
| |
Collapse
|
6
|
Modeling the Effect of Excitation on Depth of Anesthesia Monitoring in γ-Aminobutyric Acid Type A Receptor Agonist ABP-700. Anesthesiology 2021; 134:35-51. [PMID: 33064833 DOI: 10.1097/aln.0000000000003590] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND γ-Aminobutyric acid type A (GABAA) receptor agonists are known to cause involuntary muscle movements. The mechanism of these movements is not known, and its relationship to depth of anesthesia monitoring is unclear. We have explored the effect of involuntary muscle movement on the pharmacokinetic-pharmacodynamic model for the GABAA receptor agonist ABP-700 and its effects on the Bispectral Index (BIS) as well as the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scores. METHODS Observations from 350 individuals (220 men, 130 women) were analyzed, comprising 6,312 ABP-700 concentrations, 5,658 ABP-700 metabolite (CPM-acid) concentrations, 25,745 filtered BIS values, and 6,249 MOAA/S scores, and a recirculatory model developed. Various subject covariates and pretreatment with an opioid or a benzodiazepine were explored as covariates. Relationships between BIS and MOAA/S models and involuntary muscle movements were examined. RESULTS The final model shows that the pharmacokinetics of ABP-700 are characterized by small compartmental volumes and rapid clearance. The BIS model incorporates an effect-site for BIS suppression and a secondary excitatory/disinhibitory effect-site associated with a risk of involuntary muscle movements. The secondary effect-site has a threshold that decreases with age. The MOAA/S model did not show excitatory effects. CONCLUSIONS The GABAA receptor agonist ABP-700 shows the expected suppressive effects for BIS and MOAA/S, but also disinhibitory effects for BIS associated with involuntary muscle movements and reduced by pretreatment. Our model provides information about involuntary muscle movements that may be useful to improve depth of anesthesia monitoring for GABAA receptor agonists. EDITOR’S PERSPECTIVE
Collapse
|
7
|
Dalia AA, Raines DE. Etomidate and Adrenocortical Suppression: Should We Take the Concerns to Heart? J Cardiothorac Vasc Anesth 2021; 35:1086-1088. [PMID: 33579572 DOI: 10.1053/j.jvca.2021.01.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Adam A Dalia
- Division of Cardiac Anesthesiology, Department of Critical Care, Anesthesia, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Critical Care, Anesthesia, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Douglas E Raines
- Department of Critical Care, Anesthesia, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
8
|
Deng C, Gong D, Yang J, Ke B, Kang Y, Liu J, Zhang W. New insights for screening etomidate analogues in the human H295R cell model. Toxicol In Vitro 2020; 68:104934. [PMID: 32653408 DOI: 10.1016/j.tiv.2020.104934] [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: 12/18/2019] [Revised: 06/27/2020] [Accepted: 07/06/2020] [Indexed: 02/05/2023]
Abstract
Etomidate is a sedative-hypnotic with excellent pharmacological effects, including rapid onset and hemodynamic stability. However, etomidate causes adrenocortical toxicity via binding to 11β-hydroxylase. Therefore, developing an approach to screen new etomidate analogues without endocrine-disrupting effects is urgently warranted. In this study, we employed the adrenocortical tumour cell line, NCI-H295R, as an in vitro system for etomidate analogues screening and detected the hormone levels in these cells using a high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) method. After obtaining the concentration-response curves of hormone release, the "Adrenocortical Inhibitory Index" was used to evaluate the adrenocortical inhibitory potency of each compound. In summary, we demonstrate the benefits of our methods for screening of etomidate analogues that lack adrenocortical suppression, especially when this in vitro system is combined with in vivo testing.
Collapse
Affiliation(s)
- Chaoyi Deng
- Laboratory of Anesthesia and Critical Care Medicine, Department of Anesthesiology, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China; West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu 610041, Sichuan, China; National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Deying Gong
- Laboratory of Anesthesia and Critical Care Medicine, Department of Anesthesiology, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China; National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Jun Yang
- Laboratory of Anesthesia and Critical Care Medicine, Department of Anesthesiology, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China; West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu 610041, Sichuan, China; National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Bowen Ke
- Laboratory of Anesthesia and Critical Care Medicine, Department of Anesthesiology, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China; West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu 610041, Sichuan, China; National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Yi Kang
- Laboratory of Anesthesia and Critical Care Medicine, Department of Anesthesiology, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China; National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Jin Liu
- Laboratory of Anesthesia and Critical Care Medicine, Department of Anesthesiology, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China; West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu 610041, Sichuan, China; National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Wensheng Zhang
- Laboratory of Anesthesia and Critical Care Medicine, Department of Anesthesiology, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China; West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu 610041, Sichuan, China; National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
| |
Collapse
|
9
|
Soft drugs in anesthesia: remifentanil as prototype to modern anesthetic drug development. Curr Opin Anaesthesiol 2020; 33:499-505. [PMID: 32530892 DOI: 10.1097/aco.0000000000000879] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW The unique demands of modern anesthesia practice require that medications be effective, well tolerated, and efficient. These attributes are increasingly achieved with the soft drug approach, wherein novel active compounds are specifically designed to be susceptible to rapid biotransformation to inactive metabolites. The present review summarizes the historical background and recent trends in soft drug development in anesthesiology. RECENT FINDINGS Soft drug development programs for propranadid, etomidate, and benzodiazepine analogues have been undertaken in recent years. Although all three drugs advanced into human trials, neuro-excitatory adverse effects hampered the propranadid and etomidate analogue projects. Remimazolam, the soft benzodiazepine analogue, is at an advanced stage of development, having already received regulatory approval or review in several countries. SUMMARY With succinylcholine as the historical forerunner and remifentanil as the modern prototype, the soft drug paradigm continues to hold promise for the future of anesthesia drug development.
Collapse
|
10
|
Toxicologic and Inhibitory Receptor Actions of the Etomidate Analog ABP-700 and Its Metabolite CPM-Acid. Anesthesiology 2019; 131:287-304. [DOI: 10.1097/aln.0000000000002758] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
The etomidate analog ABP-700 produces involuntary muscle movements that could be manifestations of seizures. To define the relationship (if any) between involuntary muscle movements and seizures, electroencephalographic studies were performed in Beagle dogs receiving supra-therapeutic (~10× clinical) ABP-700 doses. γ-aminobutyric acid type A (GABAA) and glycine receptor studies were undertaken to test receptor inhibition as the potential mechanism for ABP-700 seizures.
Methods
ABP-700 was administered to 14 dogs (6 mg/kg bolus followed by a 2-h infusion at 1 mg · kg-1 · min-1, 1.5 mg · kg-1 · min-1, or 2.3 mg · kg-1 · min-1). Involuntary muscle movements were documented, electroencephalograph was recorded, and plasma ABP-700 and CPM-acid concentrations were measured during and after ABP-700 administration. The concentration-dependent modulatory actions of ABP-700 and CPM-acid were defined in oocyte-expressed α1β3γ2L GABAA and α1β glycine receptors (n = 5 oocytes/concentration) using electrophysiologic techniques.
Results
ABP-700 produced both involuntary muscle movements (14 of 14 dogs) and seizures (5 of 14 dogs). However, these phenomena were temporally and electroencephalographically distinct. Mean peak plasma concentrations were (from lowest to highest dosed groups) 35 μM, 45 μM, and 102 μM (ABP-700) and 282 μM, 478 μM, and 1,110 μM (CPM-acid). ABP-700 and CPM-acid concentration–GABAA receptor response curves defined using 6 μM γ-aminobutyric acid exhibited potentiation at low and/or intermediate concentrations and inhibition at high ones. The half-maximal inhibitory concentrations of ABP-700 and CPM-acid defined using 1 mM γ-aminobutyric acid were 770 μM (95% CI, 590 to 1,010 μM) and 1,450 μM (95% CI, 1,340 to 1,560 μM), respectively. CPM-acid similarly inhibited glycine receptors activated by 1 mM glycine with a half-maximal inhibitory concentration of 1,290 μM (95% CI, 1,240 to 1,330 μM).
Conclusions
High dose ABP-700 infusions produce involuntary muscle movements and seizures in Beagle dogs via distinct mechanisms. CPM-acid inhibits both GABAA and glycine receptors at the high (~100× clinical) plasma concentrations achieved during the dog studies, providing a plausible mechanism for the seizures.
Collapse
|
11
|
Antkowiak B, Rammes G. GABA(A) receptor-targeted drug development -New perspectives in perioperative anesthesia. Expert Opin Drug Discov 2019; 14:683-699. [DOI: 10.1080/17460441.2019.1599356] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Bernd Antkowiak
- Department of Anesthesiology and Intensive Care, Experimental Anesthesiology Section, Eberhard-Karls-University,
Tübingen, Germany
- Department of Anaesthesiology and Intensive Care, Experimental Anaesthesiology Section, Werner Reichardt Center for Integrative Neuroscience, Tübingen,
Germany
| | - Gerhard Rammes
- University Hospital rechts der Isar, Department of Anesthesiology, München,
Germany
| |
Collapse
|
12
|
Mason KP, Seth N. Future of paediatric sedation: towards a unified goal of improving practice. Br J Anaesth 2019; 122:652-661. [PMID: 30916013 DOI: 10.1016/j.bja.2019.01.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/10/2019] [Accepted: 01/14/2019] [Indexed: 12/11/2022] Open
Abstract
This review offers a perspective on the future of paediatric sedation. This future will require continued evaluation of adverse events, their risk factors, and predictors. As the introduction of new sedatives with paediatric applications will remain limited, the potential role of mainstay sedatives administered by new routes, for new indications, and with new delivery techniques, should be considered. The role of non-pharmacological strategies for anxiolysis, along with the application of non-mainstay physiologic monitoring, may aid in the improvement of targeted sedation delivery. Understanding the mechanism and location of action of the different sedatives will remain an important focus. Important developments in paediatric sedation will require that large scale studies with global data contribution be conducted in order to support changes in sedation practice, improve the patient experience, and make sedation safer.
Collapse
Affiliation(s)
- Keira P Mason
- Harvard Medical School, Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, MA, USA.
| | - Neena Seth
- Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
13
|
|
14
|
Abstract
The pharmacological and historical knowledge about the currently available intravenous induction hypnotics form the basis for the daily work of anesthetists. Side effects of using hypnotic induction agents must be anticipated and adequately treated. Decades of experience with using intravenous induction hypnotics have led to theoretical requirements for an ideal narcotic agent with a best possible side effect profile. In the absence of this optimal hypnotic induction agent, a careful selection of one or a combination of narcotic drugs is necessary to meet the needs of the respective risk constellation of the patient. While propofol enjoyed increasing frequency of use over the last three decades and is currently regarded as the gold standard in numerous clinics, thiopental is a noteworthy alternative apart from its elimination kinetics. Furthermore, substances with favorable hemodynamic profiles are available with etomidate and ketamine. Midazolam as a short-acting benzodiazepine rounds off the spectrum.
Collapse
Affiliation(s)
- C Dumps
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Augsburg, Stenglinstr. 2, 85156, Augsburg, Deutschland.
| | - D Bolkenius
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Augsburg, Stenglinstr. 2, 85156, Augsburg, Deutschland
| | - E Halbeck
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Augsburg, Stenglinstr. 2, 85156, Augsburg, Deutschland
| |
Collapse
|
15
|
|
16
|
Valk B, Absalom A, Meyer P, Meier S, den Daas I, van Amsterdam K, Campagna J, Sweeney S, Struys M. Safety and clinical effect of i.v. infusion of cyclopropyl-methoxycarbonyl etomidate (ABP-700), a soft analogue of etomidate, in healthy subjects. Br J Anaesth 2018; 120:1401-1411. [DOI: 10.1016/j.bja.2018.01.038] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 01/15/2018] [Accepted: 02/19/2018] [Indexed: 11/25/2022] Open
|
17
|
Affiliation(s)
- Simon Hendel
- From the Department of Anaesthesia and Perioperative Medicine, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Anesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| |
Collapse
|
18
|
McGrath M, Raines DE. Anesthetic Drug Discovery and Development: A Case Study of Novel Etomidate Analogs. Methods Enzymol 2018; 603:153-169. [PMID: 29673523 DOI: 10.1016/bs.mie.2018.01.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
All currently available general anesthetic agents possess potentially lethal side effects requiring their administration by highly trained clinicians. Among these agents is etomidate, a highly potent imidazole-based intravenous sedative-hypnotic that deleteriously suppresses the synthesis of adrenocortical steroids in a manner that is both potent and persistent. We developed two distinct strategies to design etomidate analogs that retain etomidate's potent hypnotic activity, but produce less adrenocortical suppression than etomidate. One strategy seeks to reduce binding to 11β-hydroxylase, a critical enzyme in the steroid biosynthetic pathway, which is potently inhibited by etomidate. The other strategy seeks to reduce the duration of adrenocortical suppression after etomidate administration by modifying the drug's structure to render it susceptible to rapid metabolism by esterases. In this chapter, we describe the methods used to evaluate the hypnotic and adrenocortical inhibitory potencies of two lead compounds designed using the aforementioned strategies. Our purpose is to provide a case study for the development of novel analogs of existing drugs with reduced side effects.
Collapse
Affiliation(s)
- Megan McGrath
- Massachusetts General Hospital, Boston, MA, United States
| | | |
Collapse
|
19
|
Sneyd J. Thiopental to desflurane - an anaesthetic journey. Where are we going next? Br J Anaesth 2017; 119:i44-i52. [DOI: 10.1093/bja/aex328] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2017] [Indexed: 01/06/2023] Open
|
20
|
Abstract
GABA (γ-aminobutyric acid) receptors, of which there are two types, are involved in inhibitory synapses within the central nervous system. The GABAA receptor (GABAAR) has a central role in modern anesthesia and sedation practice, which is evident from the high proportion of agents that target the GABAAR. Many GABAAR agonists are used in anesthesia practice and sedation, including propofol, etomidate, methohexital, thiopental, isoflurane, sevoflurane, and desflurane. There are advantages and disadvantages to each GABAAR agonist currently in clinical use. With increasing knowledge regarding the pharmacology of GABAAR agonists, however, newer sedative agents have been developed which employ 'soft pharmacology', a term used to describe the pharmacology of agents whereby their chemical configuration allows rapid metabolism into inactive metabolites after the desired therapeutic effect(s) has occurred. These newer 'soft' GABAAR agonists may well approach ideal sedative agents, as they can offer well-controlled, titratable activity and ultrashort action. This review provides an overview of the role that GABAAR agonists currently play in sedation and anesthesia, in addition to discussing the future role of novel GABAAR agonists in anesthesia and sedation.
Collapse
|