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Bouchard J, Shepherd G, Hoffman RS, Gosselin S, Roberts DM, Li Y, Nolin TD, Lavergne V, Ghannoum M. Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup. Crit Care 2021; 25:201. [PMID: 34112223 PMCID: PMC8194226 DOI: 10.1186/s13054-021-03585-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/26/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND β-adrenergic antagonists (BAAs) are used to treat cardiovascular disease such as ischemic heart disease, congestive heart failure, dysrhythmias, and hypertension. Poisoning from BAAs can lead to severe morbidity and mortality. We aimed to determine the utility of extracorporeal treatments (ECTRs) in BAAs poisoning. METHODS We conducted systematic reviews of the literature, screened studies, extracted data, and summarized findings following published EXTRIP methods. RESULTS A total of 76 studies (4 in vitro and 2 animal experiments, 1 pharmacokinetic simulation study, 37 pharmacokinetic studies on patients with end-stage kidney disease, and 32 case reports or case series) met inclusion criteria. Toxicokinetic or pharmacokinetic data were available on 334 patients (including 73 for atenolol, 54 for propranolol, and 17 for sotalol). For intermittent hemodialysis, atenolol, nadolol, practolol, and sotalol were assessed as dialyzable; acebutolol, bisoprolol, and metipranolol were assessed as moderately dialyzable; metoprolol and talinolol were considered slightly dialyzable; and betaxolol, carvedilol, labetalol, mepindolol, propranolol, and timolol were considered not dialyzable. Data were available for clinical analysis on 37 BAA poisoned patients (including 9 patients for atenolol, 9 for propranolol, and 9 for sotalol), and no reliable comparison between the ECTR cohort and historical controls treated with standard care alone could be performed. The EXTRIP workgroup recommends against using ECTR for patients severely poisoned with propranolol (strong recommendation, very low quality evidence). The workgroup offered no recommendation for ECTR in patients severely poisoned with atenolol or sotalol because of apparent balance of risks and benefits, except for impaired kidney function in which ECTR is suggested (weak recommendation, very low quality of evidence). Indications for ECTR in patients with impaired kidney function include refractory bradycardia and hypotension for atenolol or sotalol poisoning, and recurrent torsade de pointes for sotalol. Although other BAAs were considered dialyzable, clinical data were too limited to develop recommendations. CONCLUSIONS BAAs have different properties affecting their removal by ECTR. The EXTRIP workgroup assessed propranolol as non-dialyzable. Atenolol and sotalol were assessed as dialyzable in patients with kidney impairment, and the workgroup suggests ECTR in patients severely poisoned with these drugs when aforementioned indications are present.
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Affiliation(s)
- Josée Bouchard
- Research Center, CIUSSS du Nord-de-L'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada
| | - Greene Shepherd
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Sophie Gosselin
- Centre Intégré de Santé et de Services Sociaux (CISSS) Montérégie-Centre Emergency Department, Hôpital Charles-Lemoyne, Greenfield Park, QC, Canada
- Department of Emergency Medicine, McGill University, Montreal, QC, Canada
- Centre Antipoison du Québec, Quebec, QC, Canada
| | - Darren M Roberts
- Departments of Renal Medicine and Transplantation and Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Yi Li
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, and Department of Medicine Renal-Electrolyte Division, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA, USA
| | - Valéry Lavergne
- Research Center, CIUSSS du Nord-de-L'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada
| | - Marc Ghannoum
- Research Center, CIUSSS du Nord-de-L'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada.
- Verdun Hospital, 4000 Lasalle Boulevard, Verdun, Montreal, QC, H4G 2A3, Canada.
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2
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Hosohata Y, Sasaki K, Suzuki M, Karakisawa Y, Maruyama K, Tsuchihashi H, Nagatomo T. Alpha-1 and beta-adrenergic receptor blocking potencies of bopindolol and its two metabolites (18-502 and 20-785) as assessed by radioligand binding assay methods. GENERAL PHARMACOLOGY 1995; 26:743-7. [PMID: 7635249 DOI: 10.1016/0306-3623(94)00255-l] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
1. The pKi value of bopindolol for alpha 1High-subtypes in canine aorta, rat hearts and rat brain was 5.71, 5.52 and 6.56, respectively. In addition, the pKi values of these drugs in canine aorta, rat hearts and rat brain for the alpha 1Low-subtype was very low. 2. The phenylephrine induced-contractions of aortae of guinea pigs and rats were not inhibited by these agents. 3. Both bovine hearts and tracheal smooth muscles indicated that 18-502 had the highest pKi value to beta 1- and beta 2-adrenoceptor subtypes and the rank order of these beta-blocking potencies were 18-502 > bopindolol > 20-785.
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Affiliation(s)
- Y Hosohata
- Department of Pharmacology, Niigata College of Pharmacy, Japan
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3
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Holmes D, Nuesch E, Houle JM, Rosenthaler J. Steady state pharmacokinetics of hydrolysed bopindolol in young and elderly men. Eur J Clin Pharmacol 1991; 41:175-8. [PMID: 1683836 DOI: 10.1007/bf00265913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Steady-state pharmacokinetic parameters of the new, long-acting beta-adrenoceptor blocker bopindolol have been measured in 17 young and 20 elderly healthy men. The t 1/2 beta and the AUC(0----24 h) of hydrolysed bopindolol (the active metabolite) were both increased (40% and 26%, respectively) in the elderly subjects but tmax, Cmax and CL/f were not altered. However, after adjusting the parameters to allow for the different average body weights of the two groups, Cmax and CL/f became significantly different (+29% and -30%, respectively). AUC(0----24 h) was increased by 41%. The changes of up to 41% in pharmacokinetic parameters were smaller than the alterations of 50-100% usually seen when titrating doses of antihypertensive drugs. The clinical relevance of the effects was not examined, but similar changes have been reported for other beta-blockers which did not appear to be clinically relevant and did not affect the dosage required to treat hypertension.
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Affiliation(s)
- D Holmes
- Clinical Research Department, Sandoz Pharma Ltd., Basel, Switzerland
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4
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MacDonald NJ, Grant AC, Rodger RS, Meredith PA, Elliott HL. The effect of renal impairment on the pharmacokinetics and metabolism of bopindolol. Br J Clin Pharmacol 1991; 31:697-700. [PMID: 1678272 PMCID: PMC1368583 DOI: 10.1111/j.1365-2125.1991.tb05596.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The pharmacokinetics of the non-selective beta-adrenoceptor antagonist, bopindolol, have been studied in 18 hypertensive patients with varying degrees of renal impairment following single and multiple oral dosing. Bopindolol, which undergoes extensive hepatic metabolism, was found to accumulate in patients with chronic renal failure but the disposition in patients on regular haemodialysis did not differ significantly from patients with normal renal function. The mechanism underlying these changes in pharmacokinetics is not clear but suggests the presence of metabolic inhibitors in uraemic plasma which are removed by regular haemodialysis.
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Affiliation(s)
- N J MacDonald
- University Department of Medicine and Therapeutics, Stobhill General Hospital, Glasgow
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5
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Abstract
A sensitive and reproducible radioreceptor assay (RRA) is described for the determination of low picogram levels of timolol in plasma. The plasma or serum samples (1 mL) are prepared by selectively extracting timolol with lipophilic solvents or, alternatively, only plasma (serum) proteins are precipitated prior to binding assay. The recovery of timolol is at least 90% during the sample preparation. In the radioligand binding assay, timolol and the nonselective beta-antagonist [3H](-)-CGP-12177 compete for the binding sites present in the rat reticulocyte membranes. The detection limit for timolol (30 pg/mL) exceeds 50 times the sensitivity of the GC-MS techniques for timolol. The RRA results and GC results obtained from the same clinical samples correlate excellently (r = 0.99). There was no evidence for interference caused by timolol metabolites in the RRA. Timolol concentrations in plasma following its oral and even ocular administration were possible to monitor using the RRA. The method can be modified to also measure several other beta-antagonist drugs in picogram per milliliter quantities.
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Affiliation(s)
- T Kaila
- Department of Clinical Pharmacology, University of Turku, Finland
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6
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Harron DW, Goa KL, Langtry HD. Bopindolol. A review of its pharmacodynamic and pharmacokinetic properties and therapeutic efficacy. Drugs 1991; 41:130-49. [PMID: 1706984 DOI: 10.2165/00003495-199141010-00010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Bopindolol is a nonselective beta-adrenoceptor antagonist [corrected] with partial agonist activity which is used in the treatment of hypertension. The drug is rapidly metabolised to an active hydrolysed form. The antihypertensive effects of bopindolol 0.5 to 4 mg are sustained for more than 24 hours after once daily dosing, and the drug appears similar in efficacy to propranolol, metoprolol, atenolol, pindolol and slow release nifedipine in the treatment of mild to moderate forms of this disease. In limited trials bopindolol has also successfully reduced symptoms in patients with angina pectoris, anxiety and essential tremor. Thus, bopindolol is an effective and well-tolerated beta-adrenoceptor antagonist.
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Affiliation(s)
- D W Harron
- Queen's University, Belfast, Northern Ireland
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7
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Wensing G, Branch RA, Humbert H, Ohnhaus EE, Kirch W. Pharmacokinetics after a single oral dose of bopindolol in patients with cirrhosis. Eur J Clin Pharmacol 1990; 39:569-72. [PMID: 1982762 DOI: 10.1007/bf00316097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The plasma concentration-time curve of the hydrolysis product of bopindolol has been investigated in 14 patients with cirrhosis and in 15 healthy volunteers given a single oral dose of 2 mg bopindolol. Cirrhosis was confirmed by history and clinical examination or liver biopsy. The time to maximum concentration, maximum concentration and AUC of hydrolyzed bopindolol were similar in the patients and controls. However, the elimination half-life was 6.0 h in controls and 9.5 h in cirrhotics. Antipyrine clearance was markedly decreased in patients with cirrhosis, but no correlation was found with the pharmacokinetic parameters of hydrolysed bopindolol. Although the AUC was not significantly altered in patients with cirrhosis, the longer half-life of hydrolysed bopindolol suggests impairment of its disposition in liver disease, which could lead to significant accumulation of drug during chronic dosing.
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Affiliation(s)
- G Wensing
- I. Medizinische Klinik, Christian-Albrechts-Universität, Kiel, FRG
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8
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Davies CL. Chromatography of beta-adrenergic blocking agents. JOURNAL OF CHROMATOGRAPHY 1990; 531:131-80. [PMID: 1979561 DOI: 10.1016/s0378-4347(00)82283-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The determination of beta-blockers has posed pharmaceutical analysts with a variety of problems arising from the essential characteristics of these compounds as bases and the variability of physicochemical properties of individual drugs. Liquid chromatography has become the favoured method of analysis and to a certain extent there is a standardised approach to analysis based on either solvent or solid-phase extraction and reversed-phase high-performance liquid chromatography coupled to fluorescence detection. The analyst must be aware of interactions occurring during extraction stages. All manipulations should be fully evaluated for individual drugs and metabolites prior to use. Other analytical options are chosen for specific or more demanding applications. The use of unmodified silicas for the liquid chromatography of beta-blockers (and other basic drugs) is an example of a potential alternative mode of chromatography. The stereoselectivity of the pharmacology of beta-blockers has spawned a great deal of literature describing the resolution of enantiomers by chromatographic methods. It is envisaged that this area will achieve greater prominence in the future as drug development pursues optical purity. The demand for the availability of enantiomerically pure pharmaceutical preparations will certainly see developments for preparative-scale separations as well as analytical methods and will surely promote developments in new and established methods of chromatography.
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Affiliation(s)
- C L Davies
- Public Health Laboratory Service, Centre for Applied Microbiology and Research, Porton Down, Salisbury, U.K
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9
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Virgolini I, Fitscha P, Rauscha F, Sinzinger H. Effects of bopindolol on platelet function in hypertension at rest and during exercise. Prostaglandins Leukot Essent Fatty Acids 1990; 40:125-30. [PMID: 2143586 DOI: 10.1016/0952-3278(90)90154-d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The effects of bopindolol, a new nonselective beta-blocking agent, on platelet function have been studied in 10 male hypertensive patients given the drug (1 mg/day) in turn for eight weeks. Bopindolol significantly (p less than 0.01) decreased the bicycle exercise- (1.5 W/kg body weight for 6 minutes) induced increase in platelet aggregation. During bopindolol-treatment both the slope and the height of the platelet aggregation response curve were moderately decreased at rest before exercise and significantly (p less than 0.05) decreased at rest after exercise. During exercise the slope amounted to 75.4 +/- 44 degrees before and to 70.8 +/- 5.3 degrees after therapy (p less than 0.01), the height to 64.0 +/- 11.9% before and to 58.1 +/- 14.7% (p less than 0.05) after therapy. Furthermore, bopindolol significantly increased the exercise-induced decrease in platelet sensitivity to PGI2 (p less than 0.05; IC-50-value: 2.10 +/- 0.47 vs 1.88 +/- 0.31 ng/ml) and PGD2 (p less than 0.05; IC-50-value: (19.88 +/- 2.10 vs 18.57 +/- 1.63 ng/ml). Bopindolol also significantly (p less than 0.05) decreased the exercise-induced elevation in serum-TXB2 (244.9 +/- 35.2 vs 237.3 +/- 27.2 ng/ml) and plasma-TXB2 (15.7 +/- 6.3 vs 13.1 +/- 3.7 pg/ml). The platelet count, the plasma levels of 6-oxo-PGF1 alpha, beta-thromboglobulin (beta-TG) and platelet factor 4 (PF4) were not affected by bopindolol. It is concluded that bopindolol favourably affects platelet function, in that it lowers exercise-induced platelet aggregation and TXB2-formation in therapeutical doses and increases platelet sensitivity to antiaggregatory prostaglandins.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- I Virgolini
- Atherosclerosis Research Group (ASF) Vienna, University of Vienna, Austria
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10
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Fitscha P, Meisner W, Tiso B. Comparison of the acute haemodynamic effects of bopindolol and propranolol at rest and during supine exercise. Eur J Clin Pharmacol 1988; 34:359-62. [PMID: 2900143 DOI: 10.1007/bf00542436] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The acute cardiovascular effects of two beta-adrenoceptor blocking agents, bopindolol and propranolol, were compared in a randomized study in 16 male patients with coronary heart disease. All patients had had an uncomplicated acute myocardial infarction at least 8 weeks earlier. The two drugs reduced the arterial blood pressure to the same extent, both at rest and during exercise. As heart rate and stroke volume were also decreased, cardiac output was reduced, whereas systemic vascular resistance was increased at rest and during exercise. Left ventricular filling pressure was increased. No statistically significant differences in these variables were seen between the two groups.
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Affiliation(s)
- P Fitscha
- 2nd Department of Internal Medicine, Policlinic, Vienna, Austria
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12
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Humbert H, Denouel J, Keller HP. Column liquid chromatographic determination of hydrolysed bopindolol, in the picogram per millilitre range in plasma, using cartridge extraction and dual electrochemical detection. JOURNAL OF CHROMATOGRAPHY 1987; 422:205-15. [PMID: 2893803 DOI: 10.1016/0378-4347(87)80453-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A highly sensitive and specific column liquid chromatographic assay with electrochemical detection was developed for hydrolysed bopindolol, an active metabolite of bopindolol (Sandonorm) in human plasma. The pre-chromatographic sample preparation involved Extrelut column clean-up followed by liquid extraction of the organic extract into dilute acetic acid. Separation was on a Nucleosil ODS 3-microns column at 40 degrees C, with a phosphate buffer-methanol mobile phase. Detection was performed at +450 mV with an ESA electrochemical detector. Mepindolol was used as internal standard and quantitation was based on peak-area ratios. Total analysis time was 14 min per sample. The recovery rate of the assay was at least 70% for both compounds. A detection limit as low as 25 pg/ml, starting with 1 ml of plasma, was achieved. The day-to-day reproducibility and accuracy, checked with quality-control samples, demonstrated the reliability of this assay used by different analysts, on different chromatographic systems and over a long period of time.
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Affiliation(s)
- H Humbert
- Sandoz Laboratories, Pharmaceutical Research Centre, Rueil-Malmaison, France
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