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Ekhlaspour L, Buckingham B, Bauza C, Clements M, Forlenza GP, Neyman A, Norlander L, Schamberger M, Sherr JL, Bailey R, Beck RW, Kollman C, Beasley S, Cobry E, DiMeglio LA, Paprocki E, Van Name M, Moran A. Safety and prescribing recommendations for verapamil in newly diagnosed pediatric type 1 diabetes (T1D): The CLVer experience. J Clin Transl Endocrinol 2024; 36:100352. [PMID: 38860154 PMCID: PMC11163172 DOI: 10.1016/j.jcte.2024.100352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 05/10/2024] [Accepted: 05/16/2024] [Indexed: 06/12/2024] Open
Abstract
Objectives To report the safety and side effects associated with taking verapamil for beta-cell preservation in children with newly-diagnosed T1D. Research Design and Methods Eighty-eight participants aged 8.5 to 17.9 years weighing ≥ 30 kg were randomly assigned to verapamil (N = 47) or placebo (N = 41) within 31 days of T1D diagnosis and followed for 12 months from diagnosis, main CLVer study. Drug dosing was weight-based with incremental increases to full dosage. Side effect monitoring included serial measurements of pulse, blood pressure, liver enzymes, and electrocardiograms (ECGs). At study end, participants were enrolled in an observational extension study (CLVerEx), which is ongoing. No study drug is provided during the extension, but participants may use verapamil if prescribed by their diabetes care team. Results Overall rates of adverse events were low and comparable between verapamil and placebo groups. There was no difference in the frequency of liver function abnormalities. Three CLVer participants reduced or discontinued medication due to asymptomatic ECG changes. One CLVerEx participant (18 years old), treated with placebo during CLVer, who had not had a monitoring ECG, experienced complete AV block with a severe hypotensive episode 6 weeks after reaching his maximum verapamil dose following an inadvertent double dose on the day of the event. Conclusions The use of verapamil in youth newly-diagnosed with T1D appears generally safe and well tolerated with appropriate monitoring. We strongly recommend monitoring for potential side effects including an ECG at screening and an additional ECG once full dosage is reached.ClinicalTrials.gov number: NCT04233034.
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Affiliation(s)
- Laya Ekhlaspour
- University of California, San Francisco, San Francisco, CA, USA
| | | | | | - Mark Clements
- Children’s Mercy Hospital-Kansas City, Kansas City, MO, USA
| | - Gregory P. Forlenza
- Barbara Davis Center, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - Anna Neyman
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | | | - Ryan Bailey
- Jaeb Center for Health Research, Tampa, FL, USA
| | - Roy W. Beck
- Jaeb Center for Health Research, Tampa, FL, USA
| | | | | | - Erin Cobry
- Barbara Davis Center, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | | | - Emily Paprocki
- Children’s Mercy Hospital-Kansas City, Kansas City, MO, USA
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Patten GS, Abeywardena MY, Bennett LE. Inhibition of Angiotensin Converting Enzyme, Angiotensin II Receptor Blocking, and Blood Pressure Lowering Bioactivity across Plant Families. Crit Rev Food Sci Nutr 2016; 56:181-214. [PMID: 24915402 DOI: 10.1080/10408398.2011.651176] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Hypertension is a major risk factor for coronary heart disease, kidney disease, and stroke. Interest in medicinal or nutraceutical plant bioactives to reduce hypertension has increased dramatically. The main biological regulation of mammalian blood pressure is via the renin-angiotensin-aldosterone system. The key enzyme is angiotensin converting enzyme (ACE) that converts angiotensin I into the powerful vasoconstrictor, angiotensin II. Angiotensin II binds to its receptors (AT1) on smooth muscle cells of the arteriole vasculature causing vasoconstriction and elevation of blood pressure. This review focuses on the in vitro and in vivo reports of plant-derived extracts that inhibit ACE activity, block angiotensin II receptor binding and demonstrate hypotensive activity in animal or human studies. We describe 74 families of plants that exhibited significant ACE inhibitory activity and 16 plant families with potential AT1 receptor blocking activity, according to in vitro studies. From 43 plant families including some of those with in vitro bioactivity, the extracts from 73 plant species lowered blood pressure in various normotensive or hypertensive in vivo models by the oral route. Of these, 19 species from 15 families lowered human BP when administered orally. Some of the active plant extracts, isolated bioactives and BP-lowering mechanisms are discussed.
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Affiliation(s)
- Glen S Patten
- a CSIRO Preventative Health National Research Flagship, Animal, Food and Health Sciences , Adelaide , South Australia , Australia
| | - Mahinda Y Abeywardena
- a CSIRO Preventative Health National Research Flagship, Animal, Food and Health Sciences , Adelaide , South Australia , Australia
| | - Louise E Bennett
- b CSIRO Preventative Health National Research Flagship, Animal, Food and Health Sciences, Werribee , Victoria , British Columbia , Australia
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de Andrés F, Lionetto L, Curto M, Capi M, Cipolla F, Negro A, Martelletti P. Acute, transitional and long-term cluster headache treatment: pharmacokinetic issues. Expert Opin Drug Metab Toxicol 2016; 12:1011-20. [DOI: 10.1080/17425255.2016.1201067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Fernando de Andrés
- CICAB Clinical Research Centre, Extremadura University Hospital and Medical School, Badajoz, Spain
| | - Luana Lionetto
- Advanced Molecular Diagnostics Unit, IDI-IRCCS, Rome, Italy
| | - Martina Curto
- Department of Molecular Medicine, Sant’Andrea Medical Center, Sapienza University of Rome, Rome, Italy
- Regional Referral Headache Center, Sant’Andrea Hospital, Rome, Italy
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Matilde Capi
- NESMOS Department, Sapienza University of Rome, Rome, Italy
| | | | - Andrea Negro
- Department of Molecular Medicine, Sant’Andrea Medical Center, Sapienza University of Rome, Rome, Italy
- Regional Referral Headache Center, Sant’Andrea Hospital, Rome, Italy
| | - Paolo Martelletti
- Department of Molecular Medicine, Sant’Andrea Medical Center, Sapienza University of Rome, Rome, Italy
- Regional Referral Headache Center, Sant’Andrea Hospital, Rome, Italy
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Becker WJ. Cluster headache: conventional pharmacological management. Headache 2013; 53:1191-6. [PMID: 23773141 DOI: 10.1111/head.12145] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2013] [Indexed: 11/28/2022]
Abstract
Cluster headache pain is very intense, usually increases in intensity very rapidly from onset, and attacks are often frequent. These clinical features result in significant therapeutic challenges. The most effective pharmacological treatment options for acute cluster attack include subcutaneous sumatriptan, 100% oxygen, and intranasal zolmitriptan. Subcutaneous or intramuscular dihydroergotamine and intranasal sumatriptan are additional options. Transitional therapy is applicable mainly for patients with high-frequency (>2 attacks per day) episodic cluster headache, and options include short courses of high-dose oral corticosteroids, dihydroergotamine, and occipital nerve blocks with local anesthetic and steroids. Prophylactic therapy is important both for episodic and chronic cluster headache, and the main options are verapamil and lithium. Verapamil is drug of first choice but may cause cardiac arrhythmias, and periodic electrocardiograms (EKGs) during dose escalation are important. Many other drugs are also in current use, but there is an insufficient evidence base to recommend them.
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Affiliation(s)
- Werner J Becker
- Department of Clinical Neurosciences, University of Calgary and Alberta Health Services, Calgary, AB, Canada
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Influence of CYP3A5 and MDR1 Genetic Polymorphisms on Urinary 6β-Hydroxycortisol/Cortisol Ratio After Grapefruit Juice Intake in Healthy Chinese. J Clin Pharmacol 2013; 50:775-84. [DOI: 10.1177/0091270009354997] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Bailey DG, Dresser G, Arnold JMO. Grapefruit-medication interactions: forbidden fruit or avoidable consequences? CMAJ 2012. [PMID: 23184849 DOI: 10.1503/cmaj.120951] [Citation(s) in RCA: 150] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Rodríguez-Fragoso L, Martínez-Arismendi JL, Orozco-Bustos D, Reyes-Esparza J, Torres E, Burchiel SW. Potential risks resulting from fruit/vegetable-drug interactions: effects on drug-metabolizing enzymes and drug transporters. J Food Sci 2012; 76:R112-24. [PMID: 22417366 DOI: 10.1111/j.1750-3841.2011.02155.x] [Citation(s) in RCA: 139] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
It has been well established that complex mixtures of phytochemicals in fruits and vegetables can be beneficial for human health. Moreover, it is becoming increasingly apparent that phytochemicals can influence the pharmacological activity of drugs by modifying their absorption characteristics through interactions with drug transporters as well as drug-metabolizing enzyme systems. Such effects are more likely to occur in the intestine and liver, where high concentrations of phytochemicals may occur. Alterations in cytochrome P450 and other enzyme activities may influence the fate of drugs subject to extensive first-pass metabolism. Although numerous studies of nutrient-drug interactions have been published and systematic reviews and meta-analyses of these studies are available, no generalizations on the effect of nutrient-drug interactions on drug bioavailability are currently available. Several publications have highlighted the unintended consequences of the combined use of nutrients and drugs. Many phytochemicals have been shown to have pharmacokinetic interactions with drugs. The present review is limited to commonly consumed fruits and vegetables with significant beneficial effects as nutrients and components in folk medicine. Here, we discuss the phytochemistry and pharmacokinetic interactions of the following fruit and vegetables: grapefruit, orange, tangerine, grapes, cranberry, pomegranate, mango, guava, black raspberry, black mulberry, apple, broccoli, cauliflower, watercress, spinach, tomato, carrot, and avocado. We conclude that our knowledge of the potential risk of nutrient-drug interactions is still limited. Therefore, efforts to elucidate potential risks resulting from food-drug interactions should be intensified in order to prevent undesired and harmful clinical consequences.
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Bailey DG. Fruit juice inhibition of uptake transport: a new type of food-drug interaction. Br J Clin Pharmacol 2011; 70:645-55. [PMID: 21039758 DOI: 10.1111/j.1365-2125.2010.03722.x] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A new type of interaction in which fruit juices diminish oral drug bioavailability through inhibition of uptake transport is the focus of this review. The discovery was based on an opposite to anticipated finding when assessing the possibility of grapefruit juice increasing oral fexofenadine bioavailability in humans through inhibition of intestinal MDR1-mediated efflux transport. In follow-up investigations, grapefruit or orange juice at low concentrations potentially and selectively inhibited in vitro OATP1A2-mediated uptake compared with MDR1-caused efflux substrate transport. These juices at high volume dramatically depressed oral fexofenadine bioavailability. Grapefruit was the representative juice to characterize the interaction subsequently. A volume-effect relationship study using a normal juice amount halved average fexofenadine absorption. Individual variability and reproducibility data indicated the clinical interaction involved direct inhibition of intestinal OATP1A2. Naringin was a major causal component suggesting that other flavonoids in fruits and vegetables might also produce the effect. Duration of juice clinical inhibition of fexofenadine absorption lasted more than 2 h but less than 4 h indicating the interaction was avoidable with appropriate interval of time between juice and drug consumption. Grapefruit juice lowered the oral bioavailability of several medications transported by OATP1A2 (acebutolol, celiprolol, fexofenadine, talinolol, L-thyroxine) while orange juice did the same for others (atenolol, celiprolol, ciprofloxacin, fexofenadine). Juice clinical inhibition of OATP2B1 was unresolved while that of OATP1B1 seemed unlikely. The interaction between grapefruit juice and etoposide also seemed relevant. Knowledge of both affected uptake transporter and drug hydrophilicity assisted prediction of the clinical interaction with grapefruit or orange juice.
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Affiliation(s)
- David G Bailey
- Department of Medicine and Lawson Health Research Institute, London Health Sciences Centre Department of Physiology & Pharmacology, University of Western Ontario, London, Ontario, Canada.
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Reply. J Am Coll Cardiol 2010. [DOI: 10.1016/j.jacc.2010.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Owira PM, Ojewole JA. The grapefruit: an old wine in a new glass? Metabolic and cardiovascular perspectives. Cardiovasc J Afr 2010; 21:280-5. [PMID: 20972517 PMCID: PMC3721883 DOI: 10.5830/cvja-2010-012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2009] [Accepted: 03/10/2010] [Indexed: 01/11/2023] Open
Abstract
Grapefruit is a popular, tasty and nutritive fruit enjoyed globally. Biomedical evidence in the last 10 years has, however, shown that consumption of grapefruit or its juice is associated with drug interactions, which, in some cases, have been fatal. Grapefruit-induced drug interactions are unique in that the cytochrome P450 enzyme CYP3A4, which metabolises over 60% of commonly prescribed drugs as well as other drug transporter proteins such as P-glycoprotein and organic cation transporter proteins, which are all expressed in the intestines, are involved. However, the extent to which grapefruit-drug interactions impact on clinical settings has not been fully determined, probably because many cases are not reported. It has recently emerged that grapefruit, by virtue of its rich flavonoid content, is beneficial in the management of degenerative diseases such as diabetes and cardiovascular disorders. This potentially explosive subject is reviewed here.
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Affiliation(s)
- P M Owira
- Department of Pharmacology, University of KwaZulu-Natal, Durban, South Africa.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2009. [DOI: 10.1002/pds.1652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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