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Hostrup M, Jacobson GA, Eibye K, Narkowicz CK, Nichols DS, Jessen S. Beta 2-adrenergic agonist salbutamol exhibits enantioselective disposition in skeletal muscle of lean young men following oral administration. Drug Test Anal 2024. [PMID: 39148405 DOI: 10.1002/dta.3787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 07/19/2024] [Accepted: 08/01/2024] [Indexed: 08/17/2024]
Abstract
Salbutamol is a common short-acting beta2-adrenergic agonist used in treatment of asthma and exercise-induced bronchoconstriction but also possesses anabolic and metabolic actions in skeletal muscle. As a chiral compound, salbutamol is a racemic 1:1 mixture of two enantiomers, (R)-salbutamol and (S)-salbutamol, which exhibit divergent pharmacokinetic and pharmacodynamic actions. Despite salbutamol being available for decades, information on the enantioselective disposition of salbutamol enantiomers in human skeletal muscle is absent. In this study, we determined concentrations of (R)-salbutamol and (S)-salbutamol by UHPLC-MS/MS in arterial plasma and vastus lateralis muscle samples from 12 lean young men 2½ and 7 h following ingestion of 24 mg oral salbutamol. Mean (range) arterial plasma concentrations were 10-fold higher (p < 0.001) for (S)-salbutamol than (R)-salbutamol, being 33(9-62) and 49(30-84) ng·mL-1 for (S)-salbutamol and 4 (1-6) and 4 (2-5) ng·mL-1 for (R)-salbutamol 2½ and 7 h following administration, respectively, reflecting faster elimination of the (R)-enantiomer. Mean (range) muscle concentrations were higher (p < 0.001) for (S)-salbutamol than (R)-salbutamol 2½ h (0.17 [0.1-0.26] vs. 0.04 [0.02-0.06]) and 7 h (0.31 [0.21-0.46] vs. 0.06 [0.04-0.12] ng·mgd.w. -1) after administration. However, muscle:plasma partition coefficient was two-fold higher (p < 0.001) for (R)-salbutamol than (S)-salbutamol 7 h following administration. These observations demonstrate that oral salbutamol exhibits enantioselective disposition in systemic circulation and muscle favoring the (S)-enantiomer but with higher relative partitioning of the (R)-enantiomer in skeletal muscle. Furthermore, the concentration-time profiles of salbutamol enantiomers are different in skeletal muscle and systemic circulation following oral ingestion. These findings have implications for the application of chiral switch (R)-salbutamol in doping control.
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Affiliation(s)
- Morten Hostrup
- August Krogh Section for Human Physiology, Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Glenn A Jacobson
- School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Hobart, Australia
| | - Kasper Eibye
- August Krogh Section for Human Physiology, Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Christian K Narkowicz
- School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Hobart, Australia
| | - David S Nichols
- Central Science Laboratory, University of Tasmania, Hobart, Australia
| | - Søren Jessen
- August Krogh Section for Human Physiology, Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
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2
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Mozo Vives B, Mainguy‐Seers S, Lavoie J. Comparative study of the bronchodilator efficacy and adverse effects of salbutamol and hyoscine butylbromide in horses with severe asthma. J Vet Intern Med 2024; 38:1835-1841. [PMID: 38609079 PMCID: PMC11099713 DOI: 10.1111/jvim.17057] [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: 11/03/2023] [Accepted: 03/20/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Salbutamol and hyoscine butylbromide (HBB) are commonly used bronchodilators in horses with severe asthma (SA). OBJECTIVE To compare the bronchodilation potency, duration, and adverse effects of salbutamol and HBB in SA. ANIMALS Six horses in exacerbation of SA. METHODS The effects of inhaled salbutamol (1000 μg) and HBB (150 mg, IV) were compared in a randomized, blinded, crossover experiment. Lung function, intestinal borborygmi and heart rate were assessed before and sequentially until 180 minutes after drug administration, and analyzed with 2-way repeated-measures ANOVA and Dunnett's multiple comparison tests. RESULTS Both treatments caused a similar improvement in lung function. Pulmonary resistance and reactance returned to baseline values within 30 minutes after HBB administration, whereas salbutamol improved reactance until 180 minutes (mean improvement at 180 minutes of 0.040 Kpa/L/s, 95% CI = 0.004 to 0.076; P = .02 for salbutamol and of 0.009 Kpa/L/s, 95% CI = -0.028 to 0.045; P = .98 for HBB for the resistance at 3 Hz and of 0.040 Kpa/L/s, 95% CI = 0.007 to 0.074; P = .01 for salbutamol and of 0.009 Kpa/L/s, 95% CI = -0.024 to 0.042; P = .97 for HBB for the reactance at 7 Hz). From 5 to 30 minutes after HBB administration, the heart rate accelerated (mean increase of 3.3 beats per minute, 95% CI = -6.6 to 13.1; P = .92 for salbutamol, and of 13.0 beats per minute, 95% CI = 3.6 to 22.4; P = .002 for HBB at 30 minutes) and the gut sounds decreased (mean reduction of 1.3, 95% CI = -0.1 to 2.8; P = .09 for salbutamol and of 2.8 for the gastrointestinal auscultation score, 95% CI = 1.4 to 4.3; P < .0001 for HBB at 30 minutes). CONCLUSIONS AND CLINICAL IMPORTANCE Both drugs have a similar bronchodilator potency but with a longer duration for salbutamol. Gastrointestinal and cardiovascular effects were noted only with HBB, suggesting the preferential use of salbutamol to relieve bronchoconstriction in horses with asthma.
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Affiliation(s)
- Berta Mozo Vives
- Faculty of Veterinary Medicine, Department of Clinical SciencesUniversity of MontrealSt‐HyacintheQuebecCanada
| | - Sophie Mainguy‐Seers
- Faculty of Veterinary Medicine, Department of Clinical SciencesUniversity of MontrealSt‐HyacintheQuebecCanada
| | - Jean‐Pierre Lavoie
- Faculty of Veterinary Medicine, Department of Clinical SciencesUniversity of MontrealSt‐HyacintheQuebecCanada
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Harps LC, Jendretzki AL, Wolf CA, Girreser U, Wolber G, Parr MK. Development of an HPLC-MS/MS Method for Chiral Separation and Quantitation of ( R)- and ( S)-Salbutamol and Their Sulfoconjugated Metabolites in Urine to Investigate Stereoselective Sulfonation. Molecules 2023; 28:7206. [PMID: 37894685 PMCID: PMC10609612 DOI: 10.3390/molecules28207206] [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: 08/31/2023] [Revised: 10/09/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
The aim of this study was to develop and optimize a chiral HPLC-MS/MS method for quantitative analysis of (R)-/(S)-salbutamol and (R)-/(S)-salbutamol-4'-O-sulfate in human urine to allow for bioanalytical quantitation of the targeted analytes and investigations of stereoselectivity in the sulfonation pathway of human phase Ⅱ metabolism. For analytical method development, a systematic screening of columns and mobile phases to develop a separation via enantiomerically selective high performance liquid chromatography was performed. Electrospray ionization settings were optimized via multiple-step screening and a full factorial design-of-experiment. Both approaches were performed matrix-assisted and the predicted values were compared. The full factorial design was superior in terms of prediction power and knowledge generation. Performing a longitudinal excretion study in one healthy volunteer allowed for the calculation of excretion rates for all four targeted analytes. For this proof-of-concept, either racemic salbutamol or enantiopure levosalbutamol was administered perorally or via inhalation, respectively. A strong preference for sulfonation of (R)-salbutamol for inhalation and peroral application was found in in vivo experiments. In previous studies phenol sulfotransferase 1A3 was described to be mainly responsible for salbutamol sulfonation in humans. Thus, in vitro and in silico investigations of the stereoselectivity of sulfotransferase 1A3 complemented the study and confirmed these findings.
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Affiliation(s)
- Lukas Corbinian Harps
- Pharmaceutical Analysis, Institute of Pharmacy, Freie Universität Berlin, Königin-Luise-Straße 2+4, 14195 Berlin, Germany; (L.C.H.); (A.L.J.)
| | - Annika Lisa Jendretzki
- Pharmaceutical Analysis, Institute of Pharmacy, Freie Universität Berlin, Königin-Luise-Straße 2+4, 14195 Berlin, Germany; (L.C.H.); (A.L.J.)
| | - Clemens Alexander Wolf
- Pharmaceutical and Medicinal Chemistry (Computer-Aided Drug Design), Institute of Pharmacy, Freie Universität Berlin, Königin-Luise-Straße 2+4, 14195 Berlin, Germany; (C.A.W.); (G.W.)
| | - Ulrich Girreser
- Institute of Pharmacy, Christian-Albrechts University Kiel, Gutenbergstr. 76, 24118 Kiel, Germany;
| | - Gerhard Wolber
- Pharmaceutical and Medicinal Chemistry (Computer-Aided Drug Design), Institute of Pharmacy, Freie Universität Berlin, Königin-Luise-Straße 2+4, 14195 Berlin, Germany; (C.A.W.); (G.W.)
| | - Maria Kristina Parr
- Pharmaceutical Analysis, Institute of Pharmacy, Freie Universität Berlin, Königin-Luise-Straße 2+4, 14195 Berlin, Germany; (L.C.H.); (A.L.J.)
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4
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Zhang M, Zhang F, Qiu J, Shu X, Zhou T, Liu S, Wang Y, Liu R, Zheng X, He L. Stereoselective Pharmacokinetics and Residue Depletion of Praziquantel and Its Metabolites, 4-Hydroxypraziquantel Enantiomers, in Swine. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2023; 71:12061-12069. [PMID: 37524372 DOI: 10.1021/acs.jafc.3c03546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
Praziquantel (PZQ) is administered as a racemic mixture during swine production to treat parasitic diseases. Despite its widespread application, the pharmacokinetics, residue depletion, bioactivity, and toxicity of PZQ enantiomers in swine remain largely unknown. In this study, a systematic investigation of the pharmacokinetics, tissue distribution, and residue depletion of PZQ, its major metabolites (trans- and cis-4-OH-PZQ), and their enantiomers was conducted in swine. The findings indicated that PZQ was absorbed and metabolized rapidly. In swine plasma, the concentrations of S-PZQ, S-trans-4-OH-PZQ, and R-cis-4-OH-PZQ were higher than those of their respective enantiomers. The three analytes exhibited significant tissue distribution and stereoselectivity in 10 swine tissues. Notably, the two enantiomers of PZQ demonstrated comparable tissue concentrations except in the liver and lung. Moreover, the concentrations of S-trans-4-OH-PZQ and R-cis-4-OH-PZQ were higher than those of their respective enantiomers in the 10 tissues. This study has significant implications for the development of rational dosing strategies, reducing drug usage, and minimizing side effects, as well as accurately assessing the risks associated with PZQ administration and, by extension, other chiral drugs. Furthermore, it lays a theoretical foundation for the future use of the active enantiomer, R-PZQ.
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Affiliation(s)
- Meiyu Zhang
- National Reference Laboratory of Veterinary Drug Residues, College of Veterinary Medicine, South China Agricultural University, Guangzhou 510642, China
- College of Animal Science and Technology, Guangdong Polytechnic of Science and Trade, Guangzhou 510430, China
| | - Fangyu Zhang
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou 510642, China
- National Reference Laboratory of Veterinary Drug Residues, College of Veterinary Medicine, South China Agricultural University, Guangzhou 510642, China
- Quality Supervision, Inspection and Testing Center for Domestic Animal Products (Guangzhou), Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, South China Agricultural University, Guangzhou 510642, China
| | - Jingli Qiu
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou 510642, China
- National Reference Laboratory of Veterinary Drug Residues, College of Veterinary Medicine, South China Agricultural University, Guangzhou 510642, China
| | - Xiaogui Shu
- National Reference Laboratory of Veterinary Drug Residues, College of Veterinary Medicine, South China Agricultural University, Guangzhou 510642, China
- Quality Supervision, Inspection and Testing Center for Domestic Animal Products (Guangzhou), Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, South China Agricultural University, Guangzhou 510642, China
| | - Tong Zhou
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou 510642, China
- National Reference Laboratory of Veterinary Drug Residues, College of Veterinary Medicine, South China Agricultural University, Guangzhou 510642, China
- Quality Supervision, Inspection and Testing Center for Domestic Animal Products (Guangzhou), Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, South China Agricultural University, Guangzhou 510642, China
| | - Sijia Liu
- College of Animal Science and Technology, Guangdong Polytechnic of Science and Trade, Guangzhou 510430, China
| | - Yaxin Wang
- College of Animal Science and Technology, Guangdong Polytechnic of Science and Trade, Guangzhou 510430, China
| | - Rong Liu
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou 510642, China
- Quality Supervision, Inspection and Testing Center for Domestic Animal Products (Guangzhou), Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, South China Agricultural University, Guangzhou 510642, China
| | - Xiantong Zheng
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou 510642, China
| | - Limin He
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou 510642, China
- National Reference Laboratory of Veterinary Drug Residues, College of Veterinary Medicine, South China Agricultural University, Guangzhou 510642, China
- Quality Supervision, Inspection and Testing Center for Domestic Animal Products (Guangzhou), Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, South China Agricultural University, Guangzhou 510642, China
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5
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Saleh B, Jiang S, Li J, Du X, Wang Y, He L. Analytical methods for determination of closantel enantiomers by HPLC and their residual elimination profiles in ten tissues of black goats. Microchem J 2023. [DOI: 10.1016/j.microc.2023.108672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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Tverdislov VA, Sidorova AE, Bagrova OE, Belova EV, Bystrov VS, Levashova NT, Lutsenko AO, Semenova EV, Shpigun DK. Chirality As a Symmetric Basis of Self-Organization of Biomacromolecules. Biophysics (Nagoya-shi) 2022. [DOI: 10.1134/s0006350922050190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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7
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Peluso P, Chankvetadze B. Recognition in the Domain of Molecular Chirality: From Noncovalent Interactions to Separation of Enantiomers. Chem Rev 2022; 122:13235-13400. [PMID: 35917234 DOI: 10.1021/acs.chemrev.1c00846] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
It is not a coincidence that both chirality and noncovalent interactions are ubiquitous in nature and synthetic molecular systems. Noncovalent interactivity between chiral molecules underlies enantioselective recognition as a fundamental phenomenon regulating life and human activities. Thus, noncovalent interactions represent the narrative thread of a fascinating story which goes across several disciplines of medical, chemical, physical, biological, and other natural sciences. This review has been conceived with the awareness that a modern attitude toward molecular chirality and its consequences needs to be founded on multidisciplinary approaches to disclose the molecular basis of essential enantioselective phenomena in the domain of chemical, physical, and life sciences. With the primary aim of discussing this topic in an integrated way, a comprehensive pool of rational and systematic multidisciplinary information is provided, which concerns the fundamentals of chirality, a description of noncovalent interactions, and their implications in enantioselective processes occurring in different contexts. A specific focus is devoted to enantioselection in chromatography and electromigration techniques because of their unique feature as "multistep" processes. A second motivation for writing this review is to make a clear statement about the state of the art, the tools we have at our disposal, and what is still missing to fully understand the mechanisms underlying enantioselective recognition.
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Affiliation(s)
- Paola Peluso
- Istituto di Chimica Biomolecolare ICB, CNR, Sede secondaria di Sassari, Traversa La Crucca 3, Regione Baldinca, Li Punti, I-07100 Sassari, Italy
| | - Bezhan Chankvetadze
- Institute of Physical and Analytical Chemistry, School of Exact and Natural Sciences, Tbilisi State University, Chavchavadze Avenue 3, 0179 Tbilisi, Georgia
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8
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Belova EV, Semenova EV, Tverdislov VA. On the Chirality of Drugs and the Structures of Biomacromolecules. Biophysics (Nagoya-shi) 2022. [DOI: 10.1134/s0006350922030034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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9
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Chen ZY, Lin YM, Wu JH, Zhang XQ, Zhang Y, Xie WX, Chu SQ, Li Y. Effect of doxofylline on pulmonary inflammatory response and oxidative stress during mechanical ventilation in rats with COPD. BMC Pulm Med 2022; 22:66. [PMID: 35177065 PMCID: PMC8851859 DOI: 10.1186/s12890-022-01859-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/01/2022] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To evaluate the effects of doxofylline on inflammatory responses and oxidative stress during mechanical ventilation in rats with chronic obstructive pulmonary disease (COPD). METHODS Eight-week-old male Sprague Dawley rats were selected, and the COPD rat model was constructed. The rats were randomly divided into a model group (group M), a model + normal saline group (group N), a doxofylline group (group D), and a control group fed with conventional chow and given normal oxygen supply (group C) (n = 12 in each group). Tracheal intubation and mechanical ventilation were conducted in the rats in each group after anesthesia. A real-time intravenous infusion with 50 mg/kg of doxofylline was conducted in group D, and there was no drug intervention in groups C, N and M. Pathological manifestations of the pulmonary tissues were observed and compared among the groups. And some indicators were evaluated. RESULTS (1) The pulmonary tissues of the rats in groups M, N, and D exhibited typical pathological histological changes of COPD. (2) Groups M, N, and D showed increased Ppeak, PaCO2, total white blood cell count in BALF, and IL-8, TNF-α, and MDA levels in the pulmonary tissue and BALF, and decreased PaO2 and IL-10 and SOD levels, compared with group C. (3). Group D showed decreased Ppeak, PaCO2, total white blood cell count in BALF, and IL-8, TNF-α, and MDA levels in the pulmonary tissue, and increased PaO2 and IL-10 and SOD levels, compared with group N or M. CONCLUSION Doxofylline was shown to improve ventilation and air exchange during mechanical ventilation in rats with COPD, reduce the inflammatory response and oxidative stress, and mitigate the degree of pulmonary tissue injury.
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Affiliation(s)
- Zhi-Yuan Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, No. 950 of Donghai Street, Fengze District, Quanzhou, 362000, China
| | - Yu-Mei Lin
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, No. 950 of Donghai Street, Fengze District, Quanzhou, 362000, China
| | - Jian-Hua Wu
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, No. 950 of Donghai Street, Fengze District, Quanzhou, 362000, China
| | - Xiao-Qi Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, No. 950 of Donghai Street, Fengze District, Quanzhou, 362000, China
| | - Yi Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, No. 950 of Donghai Street, Fengze District, Quanzhou, 362000, China
| | - Wen-Xi Xie
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, No. 950 of Donghai Street, Fengze District, Quanzhou, 362000, China.
| | - Shu-Qiang Chu
- Department of Pathology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, 362000, China
| | - Yan Li
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, No. 950 of Donghai Street, Fengze District, Quanzhou, 362000, China.
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Ružena Č, Jindra V, Renáta H. Chirality of β2-agonists. An overview of pharmacological activity, stereoselective analysis, and synthesis. OPEN CHEM 2020. [DOI: 10.1515/chem-2020-0056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Abstractβ2-Agonists (β2-adrenergic agonists, bronchodilatants, and sympathomimetic drugs) are a group of drugs that are mainly used in asthma and obstructive pulmonary diseases. In practice, the substances used to contain one or more stereogenic centers in their structure and their enantiomers exhibit different pharmacological properties. In terms of bronchodilatory activity, (R)-enantiomers showed higher activity. The investigation of stereoselectivity in action and disposition of chiral drugs together with the preparation of pure enantiomer drugs calls for efficient stereoselective analytical methods. The overview focuses on the stereoselectivity in pharmacodynamics and pharmacokinetics of β2-agonists and summarizes the stereoselective analytical methods for the enantioseparation of racemic beta-agonists (HPLC, LC-MS, GC, TLC, CE). Some methods of the stereoselective synthesis for β2-agonists preparation are also presented.
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Affiliation(s)
- Čižmáriková Ružena
- Department of Chemical Theory of Drugs, Faculty of Pharmacy, Comenius University in Bratislava, Odbojárov 10, 832 32 Bratislava, Slovakia
| | - Valentová Jindra
- Department of Chemical Theory of Drugs, Faculty of Pharmacy, Comenius University in Bratislava, Odbojárov 10, 832 32 Bratislava, Slovakia
| | - Horáková Renáta
- Department of Chemical Theory of Drugs, Faculty of Pharmacy, Comenius University in Bratislava, Odbojárov 10, 832 32 Bratislava, Slovakia
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Jiang Z, Huang Y, Jiang H, Wang P, Zhang L, Ren L, Han P. Albuterol combined with tiotropium bromide to improve the conditions and pulmonary functions of patients with acute exacerbation of chronic obstructive pulmonary disease. ALL LIFE 2020. [DOI: 10.1080/26895293.2020.1846084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Zhendong Jiang
- Department of Respiratory Medicine, Wuhu First People’s Hospital, Wuhu, People’s Republic of China
| | - Youming Huang
- Department of Respiratory Medicine, the Second Affiliated Hospital of Wannan Medical College, Wuhu, People’s Republic of China
| | - Hui Jiang
- the Sencond Department of Respiratory Medicine, General Hospital of Wanbei Coal and Power Group, Suzhou, People’s Republic of China
| | - Ping Wang
- Department of Respiratory Medicine, Wuhu First People’s Hospital, Wuhu, People’s Republic of China
| | - Lei Zhang
- Department of Respiratory Medicine, Wuhu First People’s Hospital, Wuhu, People’s Republic of China
| | - Li Ren
- Wuhu First People’s Hospital, Wuhu, People’s Republic of China
| | - Ping Han
- Department of Respiratory and Critical Medicine, Linyi People’s Hospital, Linyi, People’s Republic of China
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12
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Della Bella A, Müller M, Danani A, Soldati L, Bettini R. Effect of Lactose Pseudopolymorphic Transition on the Aerosolization Performance of Drug/Carrier Mixtures. Pharmaceutics 2019; 11:pharmaceutics11110576. [PMID: 31689975 PMCID: PMC6920796 DOI: 10.3390/pharmaceutics11110576] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/18/2019] [Accepted: 11/01/2019] [Indexed: 02/04/2023] Open
Abstract
Physico-chemical properties of lactose are key factors in adhesive mixtures used as dry powder inhaler (DPI). Despite the abundant literature on this topic, the effect of the polymorphism and pseudo-polymorphism of lactose has been seldom investigated and discussed although often lactose used in DPI is subjected to unit operations, which may alter its solid-state properties. Here, we studied the aerosolization performance of salbutamol sulphate (SS) or budesonide (BUD) formulations by investigating the effect of lactose pseudopolymorphism in ternary (coarse lactose/fine lactose/drug) and binary (coarse lactose/drug) mixtures. An improvement of the aerosolization performance of SS formulations with the increase of the amount of fine micronized lactose up to 30% (fine particle fraction (FPF) = 57%) was observed. Micronized lactose contained hygroscopic anhydrous α-lactose, which converted to α-lactose monohydrate at ambient conditions. This implied that the positive effect of fines on the aerosolization performance decreased and eventually disappeared with the formulation aging. Positive effect on SS deposition was observed also with binary mixtures with anhydrous lactose, whereas the opposite occurred with budesonide-containing formulations. The collected data demonstrated the crucial role of the carrier crystal form on the positive effect of fines on the deposition.
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Affiliation(s)
| | - Michele Müller
- Micro-Sphere S.A., Ponte Cremenaga, 6996 Monteggio, Switzerland.
| | - Andrea Danani
- Istituto Delle Molle di Studi Sull'Intelligenza Artificiale, Scuola Universitaria Professionale Della Svizzera Italiana, 6928 Manno, Switzerland.
| | - Luciano Soldati
- Micro-Sphere S.A., Ponte Cremenaga, 6996 Monteggio, Switzerland.
| | - Ruggero Bettini
- Food and Drug Department, University of Parma, 43124 Parma, Italy.
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13
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Jacobson GA, Hostrup M, Narkowicz CK, Nichols DS, Walters EH. Enantioselective disposition of (R,R)-formoterol, (S,S)-formoterol and their respective glucuronides in urine following single inhaled dosing and application to doping control. Drug Test Anal 2019; 11:950-956. [PMID: 30865387 DOI: 10.1002/dta.2587] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 12/17/2022]
Abstract
Formoterol is a long-acting beta2-adrenoceptor agonist (LABA) used for the treatment of asthma and exercise-induced bronchoconstriction. Formoterol is usually administered as a racemic (rac-) mixture of (R,R)- and (S,S)-enantiomers. While formoterol is restricted by the World Anti-Doping Agency (WADA), inhalation of formoterol is permitted to a predetermined dose (54 μg/24 hours) and a urine threshold of 40 ng/mL. However, chiral switch enantiopure (R,R)-formoterol is available, effectively doubling the therapeutic advantage for the same threshold. The aim of this study was to investigate whether formoterol exhibits enantioselective urinary pharmacokinetics following inhalation. Six healthy volunteers were administered a 12 μg inhaled dose of rac-formoterol. Urine was collected over 24 hours and analyzed by enantioselective ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) assay. Total (free drug plus conjugated metabolite) median (min-max) rac-formoterol urine levels following inhalation were 1.96 (1.05-13.4) ng/mL, 1.67 (0.16-9.67) ng/mL, 0.45 (0.16-1.51) ng/mL, 0.61 (0.33-0.78) ng/mL, and 0.17 (0.08-1.06) ng/mL at 2, 4, 8, 12, and 24 hours, respectively, well below the 2019 urine threshold. The proportion of conjugation differed between enantiomers with glucuronide conjugation much greater for (R,R)-formoterol (around 30%-60% of total) compared to (S,S)-formoterol (0%-30%). There was clear evidence of inter-individual enantioselectivity observed in the ratios of (R,R):(S,S)-formoterol, where (S,S)- was predominant in free formoterol, and (R,R)- predominant in the conjugated metabolite. In conclusion, rac-formoterol delivered by inhalation exhibits enantioselective elimination in urine following single-dose administration. Enantioselective assays should be employed in doping control to screen for banned beta2-agonist chiral switch products such as (R,R)-formoterol, and total hydrolyzed rac-formoterol is warranted to account for inter-individual differences in enantioselective glucuronidation.
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Affiliation(s)
| | - Morten Hostrup
- Section of Integrative Physiology, Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark.,Department of Respiratory Medicine, Bispebjerg University Hospital, Denmark
| | | | - David S Nichols
- Central Science Laboratory, University of Tasmania, Hobart, Australia
| | - E Haydn Walters
- School of Medicine, University of Tasmania, Hobart, Australia
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14
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Boger E, Fridén M. Physiologically Based Pharmacokinetic/Pharmacodynamic Modeling Accurately Predicts the Better Bronchodilatory Effect of Inhaled Versus Oral Salbutamol Dosage Forms. J Aerosol Med Pulm Drug Deliv 2019; 32:1-12. [DOI: 10.1089/jamp.2017.1436] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Elin Boger
- Department of Drug Metabolism and Pharmacokinetics, Respiratory, Inflammation, and Autoimmunity IMED Biotech Unit, AstraZeneca R&D, Gothenburg, Sweden
| | - Markus Fridén
- Department of Drug Metabolism and Pharmacokinetics, Respiratory, Inflammation, and Autoimmunity IMED Biotech Unit, AstraZeneca R&D, Gothenburg, Sweden
- Translational PKPD, Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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15
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Zhu Y, Liu W, Qi S, Wang H, Wang Y, Deng G, Zhang Y, Li S, Ma C, Wang Y, Cheng X, Wang C. Stereoselective glucuronidation metabolism, pharmacokinetics, anti-amnesic pharmacodynamics, and toxic properties of vasicine enantiomers in vitro and in vivo. Eur J Pharm Sci 2018; 123:459-474. [PMID: 30077712 DOI: 10.1016/j.ejps.2018.07.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 07/24/2018] [Accepted: 07/30/2018] [Indexed: 01/05/2023]
Abstract
Vasicine (VAS) is a potential natural cholinesterase inhibitor for treatment of Alzheimer's disease. Due to one chiral centre (C-3) presenting in molecule, VAS has two enantiomers, d-vasicine (d-VAS) and l-vasicine (l-VAS). The study was undertaken to investigate the stereoselective glucuronidation metabolism, pharmacokinetics, anti-amnesic effect and acute toxicity of VAS enantiomers. In results, the glucuronidation metabolic rate of l-VAS was faster than d-VAS in human liver microsomes and isoenzymes tests, and it was proved that the UDP-glucuronosyltransferase (UGT) 1A9 and UGT2B15 were the major metabolic enzymes for glucuronidation of l-VAS, while only UGT1A9 for d-VAS, which take responsibility of the significantly less metabolic affinity of d-VAS than l-VAS in HLM and rhUGT1A9. The plasma exposure of d-VAS in rats was 1.3-fold and 1.6-fold higher than that of l-VAS after intravenous and oral administration of d-VAS and l-VAS, respectively. And the plasma exposure of the major glucuronidation metabolite d-VASG was one of tenth of l-VASG or more less, no matter by intravenous or oral administration. Both d-VAS and l-VAS were exhibited promising acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) inhibitory activities, and the BChE inhibitory activity of d-VAS with IC50 of 0.03 ± 0.001 μM was significantly stronger than that of l-VAS with IC50 of 0.98 ± 0.19 μM. The molecular docking results indicated that d-VAS and l-VAS could bind to the catalytic active site (CAS position) either of human AChE and BChE, and the BChE combing ability of d-VAS (the score of GBI/WAS dG -7.398) was stronger than that of l-VAS (the score of GBI/WAS dG -7.135). Both d-VAS and l-VAS could improving the learning and memory on scopolamine-induced memory deficits in mice. The content of acetylcholine (ACh) after oral administration d-VAS increased more than that of l-VAS in mice cortex, through inhibiting cholinesterase (ChE) and increasing choline acetyltransferase (ChAT). In addition, the LD50 value of d-VAS (282.51 mg·kg-1) was slight lower than l-VAS (319.75 mg·kg-1). These results indicated that VAS enantiomers displayed significantly stereoselective metabolic, pharmacokinetics, anti-amnesic effect and toxic properties in vitro and in vivo. The d-VAS might be the dominant configuration for treating Alzheimer's disease.
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Affiliation(s)
- Yudan Zhu
- Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, The MOE Key Laboratory for Standardization of Chinese Medicines, The SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, 1200 Cailun Road, Shanghai 201203, China
| | - Wei Liu
- Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, The MOE Key Laboratory for Standardization of Chinese Medicines, The SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, 1200 Cailun Road, Shanghai 201203, China
| | - Shenglan Qi
- Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, The MOE Key Laboratory for Standardization of Chinese Medicines, The SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, 1200 Cailun Road, Shanghai 201203, China
| | - Hanxue Wang
- Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, The MOE Key Laboratory for Standardization of Chinese Medicines, The SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, 1200 Cailun Road, Shanghai 201203, China
| | - Yuwen Wang
- Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, The MOE Key Laboratory for Standardization of Chinese Medicines, The SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, 1200 Cailun Road, Shanghai 201203, China
| | - Gang Deng
- Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, The MOE Key Laboratory for Standardization of Chinese Medicines, The SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, 1200 Cailun Road, Shanghai 201203, China
| | - Yunpeng Zhang
- Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, The MOE Key Laboratory for Standardization of Chinese Medicines, The SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, 1200 Cailun Road, Shanghai 201203, China
| | - Shuping Li
- Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, The MOE Key Laboratory for Standardization of Chinese Medicines, The SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, 1200 Cailun Road, Shanghai 201203, China
| | - Chao Ma
- Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, The MOE Key Laboratory for Standardization of Chinese Medicines, The SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, 1200 Cailun Road, Shanghai 201203, China
| | - Yongli Wang
- Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, The MOE Key Laboratory for Standardization of Chinese Medicines, The SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, 1200 Cailun Road, Shanghai 201203, China; Shanghai R&D Centre for Standardization of Chinese Medicines, 1200 Cailun Road, Shanghai 201203, China
| | - Xuemei Cheng
- Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, The MOE Key Laboratory for Standardization of Chinese Medicines, The SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, 1200 Cailun Road, Shanghai 201203, China; Shanghai R&D Centre for Standardization of Chinese Medicines, 1200 Cailun Road, Shanghai 201203, China
| | - Changhong Wang
- Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, The MOE Key Laboratory for Standardization of Chinese Medicines, The SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, 1200 Cailun Road, Shanghai 201203, China; Shanghai R&D Centre for Standardization of Chinese Medicines, 1200 Cailun Road, Shanghai 201203, China.
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16
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Jacobson GA, Raidal S, Robson K, Narkowicz CK, Nichols DS, Walters EH. Salmeterol undergoes enantioselective bronchopulmonary distribution with receptor localisation a likely determinant of duration of action. J Pharm Biomed Anal 2018; 154:102-107. [PMID: 29544104 DOI: 10.1016/j.jpba.2018.02.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 02/20/2018] [Accepted: 02/21/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Salmeterol (a long acting beta2-agonist) is a chiral molecule. (RR)-salmeterol is responsible for pharmacological effect, but basic knowledge of enantioselective pulmonary pharmacodynamics and pharmacokinetics of salmeterol remains unknown. There are safety concerns with (S)-enantiomers of beta2-agonists, with suggestions that these enantiomers may increase bronchial hyperresponsivneness in asthma patients. METHODOLOGY Horses (n = 12) received racemic (rac-) salmeterol 250 μg via inhalation. Enantioselective UPLC-MS/MS was used to determine (R)- and (S)-salmeterol concentrations in pulmonary epithelial lining fluid (PELF) sampled 2, 5, 10 and 15 min after administration, in central lung (endoscopic bronchial biopsy) and peripheral lung (percutaneous pulmonary biopsy) tissues (at 20 and 25 min respectively), and in plasma samples. RESULTS Physiologically relevant tissue concentrations were found for both enantiomers, with median levels greater in central than peripheral lung (equivalent to 32 and 5 mM (R)-salmeterol for central and peripheral lung respectively). Levels in PELF decreased around 50% over 15 min and enantioselective distribution was observed in the central lung with levels of (R)-salmeterol around 30% higher than (S)-salmeterol. CONCLUSION Salmeterol distribution is enantioselective in the central lung. This suggests duration of action is more likely associated with specific B2ADR localisation effects rather than non-specific physiochemical factors which would not be enantioselective.
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Affiliation(s)
- Glenn A Jacobson
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia.
| | - Sharanne Raidal
- School of Animal and Veterinary Sciences, Charles Sturt University, Wagga Wagga, New South Wales, Australia
| | - Kate Robson
- School of Animal and Veterinary Sciences, Charles Sturt University, Wagga Wagga, New South Wales, Australia
| | | | - David S Nichols
- Central Science Laboratory, University of Tasmania, Hobart, Tasmania, Australia
| | - E Haydn Walters
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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17
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Guillon A, Sécher T, Dailey LA, Vecellio L, de Monte M, Si-Tahar M, Diot P, Page CP, Heuzé-Vourc'h N. Insights on animal models to investigate inhalation therapy: Relevance for biotherapeutics. Int J Pharm 2017; 536:116-126. [PMID: 29180257 DOI: 10.1016/j.ijpharm.2017.11.049] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 11/20/2017] [Accepted: 11/21/2017] [Indexed: 12/20/2022]
Abstract
Acute and chronic respiratory diseases account for major causes of illness and deaths worldwide. Recent developments of biotherapeutics opened a new era in the treatment and management of patients with respiratory diseases. When considering the delivery of therapeutics, the inhaled route offers great promises with a direct, non-invasive access to the diseased organ and has already proven efficient for several molecules. To assist in the future development of inhaled biotherapeutics, experimental models are crucial to assess lung deposition, pharmacokinetics, pharmacodynamics and safety. This review describes the animal models used in pulmonary research for aerosol drug delivery, highlighting their advantages and limitations for inhaled biologics. Overall, non-clinical species must be selected with relevant scientific arguments while taking into account their complexities and interspecies differences, to help in the development of inhaled medicines and ensure their successful transposition in the clinics.
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Affiliation(s)
- A Guillon
- INSERM, Centre d'Etude des Pathologies Respiratoires, U1100, F-37032, Tours, France; Université François Rabelais de Tours, F-37032, Tours, France; CHRU de Tours, Service de Médecine Intensive - Réanimation, F-37000, Tours, France
| | - T Sécher
- INSERM, Centre d'Etude des Pathologies Respiratoires, U1100, F-37032, Tours, France; Université François Rabelais de Tours, F-37032, Tours, France
| | - L A Dailey
- Institute of Pharmacy, Martin-Luther-University Halle-Wittenberg, Wolfgang-Langenbeck Str. 4, 06122, Halle (Saale), Germany
| | - L Vecellio
- INSERM, Centre d'Etude des Pathologies Respiratoires, U1100, F-37032, Tours, France; Aerodrug, Université François Rabelais - Faculté de Médecine, Tours, France
| | - M de Monte
- Plateforme Scientifique et Technique (PST) Animaleries, Université F. Rabelais, F-37000, Tours, France
| | - M Si-Tahar
- INSERM, Centre d'Etude des Pathologies Respiratoires, U1100, F-37032, Tours, France; Université François Rabelais de Tours, F-37032, Tours, France
| | - P Diot
- INSERM, Centre d'Etude des Pathologies Respiratoires, U1100, F-37032, Tours, France; Université François Rabelais de Tours, F-37032, Tours, France; CHRU de Tours, Service de Pneumologie, F-37000, Tours, France
| | - C P Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, 150 Stamford Street, London, SE1 9NH, UK
| | - N Heuzé-Vourc'h
- INSERM, Centre d'Etude des Pathologies Respiratoires, U1100, F-37032, Tours, France; Université François Rabelais de Tours, F-37032, Tours, France.
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18
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Jacobson GA, Raidal S, Robson K, Narkowicz CK, Nichols DS, Haydn Walters E. Bronchopulmonary pharmacokinetics of (R)-salbutamol and (S)-salbutamol enantiomers in pulmonary epithelial lining fluid and lung tissue of horses. Br J Clin Pharmacol 2017; 83:1436-1445. [PMID: 28061018 DOI: 10.1111/bcp.13228] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 10/20/2016] [Accepted: 12/21/2016] [Indexed: 01/11/2023] Open
Abstract
AIMS Salbutamol is usually administered as a racemic mixture but little is known about the enantioselectivity of salbutamol pharmacokinetics in the lung. This study was designed to investigate enantiomer concentrations in lung tissue after inhaled dosing. METHODS Horses (n = 12) received racemic salbutamol 1000 μg via inhalation. Enantioselective ultra performance liquid chromatography-tandem mass spectrometry was used to determine salbutamol concentrations in pulmonary epithelial lining fluid (PELF) sampled 2, 5, 10 and 15 min after administration, in central lung (endoscopic bronchial biopsy) and peripheral lung (percutaneous pulmonary biopsy) tissues (at 20 and 25 min respectively), and in plasma samples. RESULTS Mean ± 95% confidence interval (CI) yield of PELF was 57 ± 10 mg. Initial mean ± 95%CI (R)- and (S)-salbutamol PELF concentrations were 389 ± 189 ng g-1 and 378 ± 177 ng g-1 respectively, and both reduced approximately 50% by 15 min. Mean ± 95%CI central lung levels of drug were higher than peripheral lung tissue for both (R)-salbutamol (875 ± 945 vs. 49.5 ± 12 ng g-1 ) and (S)-salbutamol (877 ± 955 vs. 50.9 ± 12 ng g-1 ) respectively. There was no evidence of enantioselectivity in PELF or central lung but minor (~2%) enantioselectivity was observed in the peripheral lung. Enantioselectivity was clearly evident in plasma with (S):(R) ratio of 1.25 and 1.14 for both area under the concentration-time curve (0-25 min) and Cmax respectively. CONCLUSIONS PELF sampling in horses offers sufficient yield allowing direct detection of drug and, combined with tissue sampling, is a valuable model to investigate bronchopulmonary pharmacokinetics. Salbutamol did not demonstrate enantioselectivity in PELF or central lung tissue uptake following acute dosing, however, enantioselective plasma concentrations were demonstrated, with minor enantioselectivity in the peripheral lung.
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Affiliation(s)
- Glenn A Jacobson
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Sharanne Raidal
- School of Animal and Veterinary Sciences, Charles Sturt University, Wagga Wagga, New South Wales, Australia
| | - Kate Robson
- School of Animal and Veterinary Sciences, Charles Sturt University, Wagga Wagga, New South Wales, Australia
| | | | - David S Nichols
- Central Science Laboratory, University of Tasmania, Hobart, Tasmania, Australia
| | - E Haydn Walters
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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