Comparative inhibition of voltage-gated cation channels by local anesthetics

Membrane-Mediated Activity of Local Anesthetics

The activity of local anesthetics (LAs) has been attributed to the inhibition of ion channels, causing anesthesia. However, there is a growing body of research showing that LAs act on a wide range of receptors and channel proteins far beyond simple analgesia. The current concept of ligand recognition may no longer explain the multitude of protein targets influenced by LAs. We hypothesize that LAs can cause anesthesia without directly binding to the receptor proteins just by changing the physical properties of the lipid bilayer surrounding these proteins and ion channels based on LAs' amphiphilicity. It is possible that LAs act in one of the following ways: They 1) dissolve raft-like membrane microdomains, 2) impede nerve impulse propagation by lowering the lipid phase transition temperature, or 3) modulate the lateral pressure profile of the lipid bilayer. This could also explain the numerous additional effects of LAs besides anesthesia. Furthermore, the concepts of membrane-mediated activity and binding to ion channels do not have to exclude each other. If we were to consider LA as the middle part of a continuum between unspecific membrane-mediated activity on one end and highly specific ligand binding on the other end, we could describe LA as the link between the unspecific action of general anesthetics and toxins with their highly specific receptor binding. This comprehensive membrane-mediated model offers a fresh perspective to clinical and pharmaceutical research and therapeutic applications of local anesthetics. SIGNIFICANCE STATEMENT: Local anesthetics, according to the World Health Organization, belong to the most important drugs available to mankind. Their rediscovery as therapeutics and not only anesthetics marks a milestone in global pain therapy. The membrane-mediated mechanism of action proposed in this review can explain their puzzling variety of target proteins and their thus far inexplicable therapeutic effects. The new concept presented here places LAs on a continuum of structures and molecular mechanisms in between small general anesthetics and the more complex molecular toxins.

Mechanisms underlying odorant-induced and spontaneous calcium signals in olfactory receptor neurons of spiny lobsters, Panulirus argus

We determined if a newly developed antennule slice preparation allows studying chemosensory properties of spiny lobster olfactory receptor neurons under in situ conditions with Ca(2+) imaging. We show that chemical stimuli reach the dendrites of olfactory receptor neurons but not their somata, and that odorant-induced Ca(2+) signals in the somata are sufficiently stable over time to allow stimulation with a substantial number of odorants. Pharmacological manipulations served to elucidate the source of odorant-induced Ca(2+) transients and spontaneous Ca(2+) oscillations in the somata of olfactory receptor neurons. Both Ca(2+) signals are primarily mediated by an influx of extracellular Ca(2+) through voltage-activated Ca(2+) channels that can be blocked by CoCl2 and the L-type Ca(2+) channel blocker verapamil. Intracellular Ca(2+) stores contribute little to odorant-induced Ca(2+) transients and spontaneous Ca(2+) oscillations. The odorant-induced Ca(2+) transients as well as the spontaneous Ca(2+) oscillations depend on action potentials mediated by Na(+) channels that are largely TTX-insensitive but blocked by the local anesthetics tetracaine and lidocaine. Collectively, these results corroborate the conclusion that odorant-induced Ca(2+) transients and spontaneous Ca(2+) oscillations in the somata of olfactory receptor neurons closely reflect action potential activity associated with odorant-induced phasic-tonic responses and spontaneous bursting, respectively. Therefore, both types of Ca(2+) signals represent experimentally accessible proxies of spiking.

New formulations of local anaesthetics-part I

Part 1 comments on the types of local anaesthetics (LAs); it provides a better understanding of the mechanisms of action of LAs, and their pharmacokinetics and toxicity. It reviews the newer LAs such as levobupivacaine, ropivacaine, and articaine, and examines the newer structurally different LAs. The addition of adjuvants such as adrenaline, bicarbonate, clonidine, and corticosteroids is explored. Comment is made on the delivery of topical LAs via bioadhesive plasters and gels and controlled-release local anaesthetic matrices. Encapulation matrices such as liposomes, microemulsions, microspheres and nanospheres, hydrogels and liquid polymers are discussed as well. New innovations pertaining to LA formulations have indeed led to prolonged action and to novel delivery approaches.

Pharmacological modulation of brain Nav1.2 and cardiac Nav1.5 subtypes by the local anesthetic ropivacaine

OBJECTIVE

The present study was aimed to investigate the pharmacological modulatory effects of ropivacaine, an amide-type local anesthetic, on rat Nav1.2 (rNav1.2) and rNav1.5, the two Na(+) channel isoforms heterologously expressed in Xenopus oocytes and in HEK293t cell line, respectively.

METHODS

Two-electrode voltage-clamp (TEVC) and whole-cell patch-clamp recordings were employed to record the whole-cell currents.

RESULTS

Ropivacaine induced tonic inhibition of peak Na(+) currents of both subtypes in a dose- and frequency-dependent manner. rNav1.5 appeared to be more sensitive to ropivacaine. In addition, for both Na(+) channel subtypes, the steady-state inactivation curves, but not the activation curves, were significantly shifted to the hyperpolarizing direction by ropivacaine. Use-dependent blockade of both rNav1.2 and rNav1.5 channels was induced by ropivacaine through a high frequency of depolarization, suggesting that ropivacaine could preferentially bind to the 2 inactivated Na(+) channel isoforms.

CONCLUSION

The results will be helpful in understanding the pharmacological modulation by ropivacaine on Nav1.2 subtype in the central nervous system, and on Nav1.5 subtype abundantly expressed in the heart.

Novel ideas of local anaesthetic actions on various ion channels to ameliorate postoperative pain

This review considers the ion channels that underlie transduction of nociceptive energies in the periphery, that are involved in impulse initiation and propagation in peripheral sensory neurones, and that participate in pre- and post-synaptic actions in the spinal cord dorsal horn, in light of their susceptibility to local anaesthetics. Although there are results from experiments on isolated cells and tissues ex vivo that support the hypothesized actions, their extrapolation to actions in vivo and the consequences for peri- and postoperative pain control are largely speculative.

Tetracaine-membrane interactions: effects of lipid composition and phase on drug partitioning, location, and ionization

Interactions of the local anesthetic tetracaine with unilamellar vesicles made of dimyristoyl or dipalmitoyl phosphatidylcholine (DMPC or DPPC), the latter without or with cholesterol, were examined by following changes in the drug's fluorescent properties. Tetracaine's location within the membrane (as indicated by the equivalent dielectric constant around the aromatic fluorophore), its membrane:buffer partition coefficients for protonated and base forms, and its apparent pK(a) when adsorbed to the membrane were determined by measuring, respectively, the saturating blue shifts of fluorescence emission at high lipid:tetracaine, the corresponding increases in fluorescence intensity at this lower wavelength with increasing lipid, and the dependence of fluorescence intensity of membrane-bound tetracaine (TTC) on solution pH. Results show that partition coefficients were greater for liquid-crystalline than solid-gel phase membranes, whether the phase was set by temperature or lipid composition, and were decreased by cholesterol; neutral TTC partitioned into membranes more strongly than the protonated species (TTCH(+)). Tetracaine's location in the membrane placed the drug's tertiary amine near the phosphate of the headgroup, its ester bond in the region of the lipids' ester bonds, and associated dipole field and the aromatic moiety near fatty acyl carbons 2-5; importantly, this location was unaffected by cholesterol and was the same for neutral and protonated tetracaine, showing that the dipole-dipole and hydrophobic interactions are the critical determinants of tetracaine's location. Tetracaine's effective pK(a) was reduced by 0.3-0.4 pH units from the solution pK(a) upon adsorption to these neutral bilayers, regardless of physical state or composition. We propose that the partitioning of tetracaine into solid-gel membranes is determined primarily by its steric accommodation between lipids, whereas in the liquid-crystalline membrane, in which the distance between lipid molecules is larger and steric hindrance is less important, hydrophobic and ionic interactions between tetracaine and lipid molecules predominate.

Local anesthetics

Local anesthetics are used broadly to prevent or reverse acute pain and treat symptoms of chronic pain. This chapter, on the analgesic aspects of local anesthetics, reviews their broad actions that affect many different molecular targets and disrupt their functions in pain processing. Application of local anesthetics to peripheral nerve primarily results in the blockade of propagating action potentials, through their inhibition of voltage-gated sodium channels. Such inhibition results from drug binding at a site in the channel's inner pore, accessible from the cytoplasmic opening. Binding of drug molecules to these channels depends on their conformation, with the drugs generally having a higher affinity for the open and inactivated channel states that are induced by membrane depolarization. As a result, the effective potency of these drugs for blocking impulses increases during high-frequency repetitive firing and also under slow depolarization, such as occurs at a region of nerve injury, which is often the locus for generation of abnormal, pain-related ectopic impulses. At distal and central terminals the inhibition of voltage-gated calcium channels by local anesthetics will suppress neurogenic inflammation and the release of neurotransmitters. Actions on receptors that contribute to nociceptive transduction, such as TRPV1 and the bradykinin B2 receptor, provide an independent mode of analgesia. In the spinal cord, where local anesthetics are present during epidural or intrathecal anesthesia, inhibition of inotropic receptors, such as those for glutamate, by local anesthetics further interferes with neuronal transmission. Activation of spinal cord mitogen-activated protein (MAP) kinases, which are essential for the hyperalgesia following injury or incision and occur in both neurons and glia, is inhibited by spinal local anesthetics. Many G protein-coupled receptors are susceptible to local anesthetics, with particular sensitivity of those coupled via the Gq alpha-subunit. Local anesthetics are also infused intravenously to yield plasma concentrations far below those that block normal action potentials, yet that are frequently effective at reversing neuropathic pain. Thus, local anesthetics modify a variety of neuronal membrane channels and receptors, leading to what is probably a synergistic mixture of analgesic mechanisms to achieve effective clinical analgesia.

Local anesthetic effects of cocaethylene and isopropylcocaine on rat peripheral nerves

Cocaethylene is a naturally occurring cocaine derivative that has been used as a tool in both clinical studies of cocaine reward and as a potential model compound for agonist substitution therapy in cocaine dependence. It is equipotent to cocaine at inhibiting dopamine uptake in-vitro and in-vivo. Because it has been reported that local anesthetic properties may influence the reinforcing effects of dopamine uptake inhibitors, we investigated the local anesthetic properties of cocaethylene as well as isopropylcocaine, another potential pharmacological tool in studies of cocaine reward and agonist substitution therapy. We compared the efficacy of nerve impulse blockade by lidocaine, cocaine, cocaethylene and isopropylcocaine using rat sciatic nerves and dorsal roots (DRs). Nerves were placed in a modified sucrose gap chamber and repetitively stimulated at high frequency. The amplitude of compound action potentials (CAPs) at the beginning and end of each stimulus train was measured before and after exposure to each compound. All compounds produced concentration-dependent and use-dependent decrements in CAP amplitude, but cocaethylene and isopropylcocaine at medium to high concentration (0.375-1.875 mM) showed a more prolonged block after washout relative to cocaine or lidocaine. Patch clamp studies on dorsal root ganglion (DRG) neurons indicated a use-dependent blockade of sodium channels. These studies provide a more complete understanding of the pharmaocology of potential agonist treatment candidates, and suggest a mechanism whereby cocaethylene produces a decreased euphoria in humans compared to cocaine.

Antinociceptive interaction between spinal clonidine and lidocaine in the rat formalin test: an isobolographic analysis

Clinical and basic science studies suggest that spinal alpha-2-adrenergic receptor agonists and local anesthetics produce analgesia, but interaction between alpha-2-adrenergic receptor agonists and local anesthetics in the persistent pain model has not been examined. In the present study, using isobolographic analysis, we investigated the antinociceptive interaction of intrathecal clonidine and lidocaine in the rat formalin test. Sprague-Dawley rats were implanted with chronic lumbar intrathecal catheters, and were tested for paw flinch by formalin injection. Biphasic painful behavior was counted. Intrathecal clonidine (3-12 nmol) was administered 15 min before formalin, and intrathecal lidocaine (375-1850 nmol) was administered 5 min before formalin. To examine the interaction of intrathecal clonidine and lidocaine, an isobolographic design was used. Spinal administration of clonidine produced dose-dependent suppression of the biphasic responses in the formalin test. Spinal lidocaine resulted in dose-dependent transient motor dysfunction and the motor dysfunction recovered to normal at 10-15 min after administration. Spinal lidocaine produced dose-dependent suppression of phase-2 activity in the formalin test. Isobolographic analysis showed that the combination of intrathecal clonidine and lidocaine synergistically reduced Phase-2 activity. We conclude that intrathecal clonidine synergistically interacts with lidocaine in reducing the nociceptive response in the formalin test.

IMPLICATIONS

Preformalin administration of intrathecal clonidine and lidocaine dose-dependently produced antinociception in the formalin test. The combination of clonidine and lidocaine, synergistically produced suppression of nociceptive response in the persistent pain model.

The effects of ropivacaine on sodium currents in dorsal horn neurons of neonatal rats

We used a whole cell patch clamp technique to study the effects of ropivacaine on rat dorsal horn neurons. Under voltage clamp, ropivacaine (10-400 microM) produced a dose-dependent inhibition of sodium current. From a holding potential (V(h)) of -80 mV, sodium currents evoked by test pulses to 0 mV were inhibited by ropivacaine with a mean drug concentration required to produce 50% current inhibition (IC(50)) value of 117.3 microM, which was more than the value of the bupivacaine (IC(50) 53.7 microM). The inhibition effect of ropivacaine was also voltage-dependent. Current evoked from a V(h) of -60 mV was inhibited by ropivacaine with a mean IC(50) value of 74.3 microM, which was less than that obtained at the V(h) of -80 mV. The inhibition effect of ropivacaine on sodium current was use dependent. Repeated activation by a train of depolarizing pulses (5 Hz, 20 ms) increased the inhibitory effects of ropivacaine. The ratio amplitudes of the 20th to the first pulse were 91.2% and 71.1%, respectively, in the absence and presence of ropivacaine (50 microM). Ropivacaine also produced a significant hyperpolarizing shift of 11 mV in the steady-state inactivation curve of sodium current. The inhibition of ropivacaine on the sodium channel may contribute to the mechanism of action of local anesthetics during epidural and spinal anesthesia.

Comparisons of the anesthetic potency and intracellular concentrations of S(-) and R() bupivacaine and ropivacaine in crayfish giant axon in vitro

Levobupivacaine and ropivacaine are both single S(-) enantiomers that have less severe cardiotoxic and convulsant effects than racemic bupivacaine. We compared the anesthetic actions of S(-) bupivacaine, R(+) bupivacaine, and ropivacaine in vitro by studying their effects on action potential amplitude and the maximal rate of rise of action potential in crayfish giant axon. To clarify the difference of intracellular anesthetic concentration, the intracellular ionized anesthetic concentration was measured. Desheathed crayfish axons were stimulated at a frequency of either 0. 1 or 5 Hz and perfused with 1 mM of each anesthetic at pH 7.0. Intracellular anesthetic concentration was measured by us- ing local anesthetic-sensitive glass microelectrodes. At 0.1-Hz stimulation, no differences were observed in their potency. At 5-Hz stimulation, the order of magnitude of the mean percentage decrease in maximal rate of rise of action potential was S(-) bupivacaine > R(+) bupivacaine > ropivacaine. Intracellular local anesthetic concentration did not differ among the three anesthetics at 0.1 Hz and 5 Hz. We conclude that, compared with ropivacaine, S(-) bupivacaine has a more potent phasic blocking effect in crayfish giant axon. The intracellular local anesthetic concentrations of S(-), R(+) bupivacaine and ropivacaine were not significantly different, regardless of differences in blocking effect and stimulation frequency.

IMPLICATIONS

S(-) bupivacaine has a more potent phasic blocking effect than ropivacaine or R(+) bupivacaine in crayfish giant axons in vitro. An equivalent intracellular local anesthetic concentration for the three anesthetics was found, suggesting that the intracellular cationic local anesthetic concentration is not directly correlated with the intensity of block.

Isobolographic analysis of interaction between spinal endomorphin-1, a newly isolated endogenous opioid peptide, and lidocaine in the rat formalin test

Endomorphin-1, a newly isolated endogenous opioid ligand, has a potential affinity with mu-opioid receptor. We investigated antinociception of intrathecal endomorphin-1 and lidocaine in the rat formalin test and examined the interaction between the two agents using isobolographic analysis. Intrathecal endomorphin-1 caused dose-dependent suppression of the formalin-induced biphasic behavioral response. Intrathecal lidocaine produced dose-dependent inhibition of phase-2 behavioral response. Isobolographic analysis confirmed that combination of intrathecal endomorphin-1 and lidocaine, given at a fixed dose ratio, produced synergistic suppression of phase-2 behavioral response. These data demonstrate that spinal endomorphin-1 synergistically interacts with local anesthetic lidocaine in producing antinociception in the formalin test.

Inhibition by local anesthetics of Ca2+ channels in rat anterior pituitary cells

The characteristics of local anesthetic inhibition of voltage-dependent Ca2+ channels in a rat pituitary clonal cell line were investigated by whole-cell voltage clamp and compared with inhibition by the dihydropyridine Ca2+ channel antagonist, nicardipine. With extracellular Ba2+ (10 mM) as the current carrier, depolarization above -40 mV evoked a slowly inactivating I(Ba). Extracellularly applied lidocaine inhibited I(Ba) without changing the activation threshold, the voltage of peak current, or the reversal potential. Inhibition was greater at a holding potential of -60 mV (IC50 = 1.2 mM) than at -80 mV (IC50 = 2.6 mM). This depolarization-induced potentiation in I(Ba) inhibition developed over 0.1-10 s after membrane depolarization began. Nicardipine also dose-dependently inhibited I(Ba) with an IC50 = 90 nM (at a holding potential = -80 mV). Both lidocaine and nicardipine shifted the I(Ba) steady-state inactivation (availability) curves to the left. Double-pulse protocols revealed that lidocaine (1 mM) accelerated the depolarization-induced inhibition (inactivation) of I(Ba) over the rate in drug-free solutions, but had no effect on the hyperpolarization-induced removal of channel inactivation. Nicardipine also accelerated the depolarization-induced inactivation of I(Ba) but, in addition, it slowed the hyperpolarization-induced inactivation removal. The relative inhibitory action of lidocaine in suppressing I(Ba) was unchanged in the presence of nicardipine. These results suggest that lidocaine has a direct action on membrane Ca2+ channels, similar to the voltage-dependent action of dihydropyridine, but acting at a separate and independent site.

Molecular and kinetic determinants of local anaesthetic action on sodium channels

(1) Local anaesthetics (LA) rely for their clinical actions on state-dependent inhibition of voltage-dependent sodium channels. (2) Single, batrachoxin-modified sodium channels in planar lipid bilayers allow direct observation of drug-channel interactions. Two modes of inhibition of single-channel current are observed: fast block of the open channels and prolongation of a long-lived closed state, some of whose properties resemble those of the inactivated state of unmodified channels. (3) Analogues of different parts of the LA molecule separately mimic each blocking mode: amines--fast block, and water-soluble aromatics--closed state prolongation. (4) Interaction between a mu-conotoxin derivative and diethylammonium indicate an intrapore site of fast, open-state block. (5) Site-directed mutagenesis studies suggest that hydrophobic residues in transmembrane segment 6 of repeat domain 4 of sodium channels are critical for both LA binding and stabilization of the inactivated state.

Graded, irreversible changes in crayfish giant axon as manifestations of lidocaine neurotoxicity in vitro

High concentrations of lidocaine induce irreversible conduction block with little effect on resting membrane potential (Em). We assumed the mechanism of persistent neurologic deficit caused by local anesthetics may result from neural death, as represented by the loss of Em. We investigated the effects of lidocaine on Em and action potential (AP) in single crayfish giant axons in vitro. Axons were perfused with two doses of lidocaine for either 15 or 30 min, and they were continuously washed. No axons exposed to 80 mM lidocaine for 30 min showed recovery of AP and Em. Those exposed to 40 mM for 30 min and 80 mM for 15 min showed a return to baseline for Em, but no recovery of AP. Those exposed to 40 mM lidocaine for 15 min showed full recovery of Em and AP immediately after washing. The membrane depolarization was significantly greater during exposure to 80 mM lidocaine for 30 min than in other groups. We conclude that lidocaine has a direct neurotoxic effect on crayfish giant axons and that the generation of AP is more vulnerable than the maintenance of Em. The irreversibility of AP and Em is dose- and time-dependent.

IMPLICATIONS

Highly concentrated lidocaine induced an irreversible conduction block and a complete loss of resting membrane potential in crayfish giant axons in vitro. Our results may represent a possible explanation for various grades of local anesthetic-induced neurotoxicity in clinical cases if the same toxicity occurs in mammalian nerves in vivo.

Molecular determinants of stereoselective bupivacaine block of hKv1.5 channels

Enantiomers of local anesthetics are useful probes of ion channel structure that can reveal three-dimensional relations for drug binding in the channel pore and may have important clinical consequences. Bupivacaine block of open hKv1.5 channels is stereoselective, with the R(+)-enantiomer being 7-fold more potent than the S(-)-enantiomer (Kd = 4.1 mumol/L versus 27.3 mumol/L). Using whole-cell voltage clamp of hKv1.5 channels and site-directed mutants stably expressed in Ltk- cells, we have identified a set of amino acids that determine the stereoselectivity of bupivacaine block. Replacement of threonine 505 by hydrophobic amino acids (isoleucine, valine, or alanine) abolished stereoselective block, whereas a serine substitution preserved it [Kd = 60 mumol/L and 7.4 mumol/L for S(-)- and R(+)-bupivacaine, respectively]. A similar substitution at the internal tetraethylammonium binding site (T477S) reduced the affinity for both enantiomers similarly, thus preserving the stereoselectivity [Kd = 45.5 mumol/L and 7.8 mumol/L for S(-)- and R(+)-bupivacaine, respectively]. Replacement of L508 or V512 by a methionine (L508M and V512M) abolished stereoselective block, whereas substitution of V512 by an alanine (V512A) preserved it. Block of Kv2.1 channels, which carry valine, leucine, and isoleucine residues at T505, L508, and V512 equivalent sites, respectively, was not stereoselective [Kd = 8.3 mumol/L and 13 mumol/L for S(-)- and R(+)-bupivacaine, respectively]. These results suggest that (1) the bupivacaine binding site is located in the inner mouth of the pore, (2) stereoselective block displays subfamily selectivity, and (3) a polar interaction with T505 combined with hydrophobic interactions with L508 and V512 are required for stereoselective block.

The action of local anesthetics on myelin structure and nerve conduction in toad sciatic nerve

X-ray scattering and electrophysiological experiments were performed on toad sciatic nerves in the presence of local anesthetics. In vitro experiments were performed on dissected nerves superfused with Ringer's solutions containing procaine, lidocaine, tetracaine, or dibucaine. In vivo experiments were performed on nerves dissected from animals anesthesized by targeted injections of tetracaine-containing solutions. In all cases the anesthetics were found to have the same effects on the x-ray scattering spectra: the intensity ratio of the even-order to the odd-order reflections increases and the lattice parameter increases. These changes are reversible upon removal of the anesthetic. The magnitude of the structural changes varies with the duration of the superfusion and with the nature and concentration of the anesthetic molecule. A striking quantitative correlation was observed between the structural effects and the potency of the anesthetic. Electron density profiles, which hardly showed any structural alteration of the unit membrane, clearly indicated that the anesthetics have the effect of moving the pairs of membranes apart by increasing the thickness of the cytoplasmic space. Electrophysiological measurements performed on the very samples used in the x-ray scattering experiments showed that the amplitude of the compound action potential is affected earlier than the structure of myelin (as revealed by the x-ray scattering experiments), whereas conduction velocity closely follows the structural alterations.

[Alkalinization of local anesthetics: theoretically justified but clinically useless]

PURPOSE

In vitro studies have demonstrated the potential advantages of alkalinization on anaesthetic activity, by decreasing the ratio of ionized to nonionized molecules, there by permitting more rapid penetration of local anaesthetic through biological membranes, thus decreasing the onset time. The proportion of each form depends on the pKa of the agent and the ultimate pH of the solution. When NaHCO3 is mixed with local anaesthetics, CO2 is produced. Carbon dioxide has been reported to enhance local anaesthetic action by diffusion trapping of the cationic form in pH gradient combined with a direct depressant action of CO2. The purpose of this study was to examine if clinical studies confirmed the in vitro action of alkalinisation.

SOURCE

The literature pertinent to alkalinization of local anaesthetics published in the major anaesthesia and pharmacology journals of North America and Europe.

PRINCIPAL FINDINGS

While in vitro studies have demonstrated potential advantages for alkalinization on anaesthetic activity, clinical studies have shown that alkalinization of local anaesthetics produces inconsistent results. For bupivacaine and etidocaine, alkalinization of local anaesthetic solution can produce precipitation, thus limiting the feasibility of increasing the pH.

CONCLUSIONS

On the basis of this review, routine alkalinization of local anaesthetics is not recommended.

Stereoselective block of cardiac sodium channels by bupivacaine in guinea pig ventricular myocytes

BACKGROUND

Bupivacaine is a potent local anesthetic widely used for prolonged local and regional anesthesia. However, accidental intravascular injection of bupivacaine can produce severe arrhythmias and cardiac depression. Although used clinically as a racemic mixture, S(-)-bupivacaine appears less toxic than the R(+)-enantiomer despite at least equal potency for local anesthesia. If the R(+)-enantiomer is more potent in blocking cardiac sodium channels, then the S(-)-enantiomer could be used with less chance of cardiovascular toxicity. Therefore, we tested whether such stereoselectivity existed in the bupivacaine affinity for the cardiac sodium channel.

METHODS AND RESULTS

The inhibitory effects on the cardiac sodium current (INa) of 10 mumol/L R(+)- and S(-)-bupivacaine were investigated by use of the whole-cell voltage clamp technique in isolated guinea pig ventricular myocytes. Both enantiomers produced similar but limited levels of tonic block (6% and 8%). During long depolarizations (5 seconds at 0 mV), R(+)-bupivacaine induced a significantly larger inhibition of INa: 72 +/- 2% versus 58 +/- 3% for the S(-)-enantiomer (P < .01). Development of block was slow, but its rate was faster for R(+)-bupivacaine [time constant, 1.84 +/- 0.16 versus 2.56 +/- 0.26 seconds for the S(-)-enantiomer, P < .05]. The voltage dependence of the availability of the Na+ current was shifted to more hyperpolarizing potentials compared with the control; R(+)-bupivacaine induced a larger shift than S(-)-bupivacaine (37 +/- 2 versus 30 +/- 2 mV, P < .05). These data indicate stereoselective interactions with the inactivated state. In addition, both enantiomers induced substantial use-dependent block during 2.5-Hz pulse trains with medium (100-ms) and short (10-ms) depolarizations but without stereoselective difference. A stepwise approach was used to model these experimental results and to derive apparent affinities and rate constants. We initially assumed that bupivacaine interacted only with the rested and inactivated states of the Na+ channel. The apparent affinities of the inactivated state for S(-)- and R(+)-bupivacaine were 4.8 and 2.9 mumol/L, respectively. With the derived binding and unbinding rate constants, this model reproduced the stereoselective block during long depolarizations but failed to predict the use-dependent block induced by trains of short (10-ms) depolarizations. To account for the observed use-dependent interactions, it was necessary to include interactions with the activated state, which resulted in adequate reproduction of the experimental results. The apparent affinities of the activated or open state for S(-)- and R(+)-bupivacaine were 4.3 and 3.3 mumol/L, respectively.

CONCLUSIONS

Both the large level of pulse-dependent block and the failure of the pure inactivated-state block model indicate that bupivacaine interacts with the activated (or open) state of the cardiac sodium channel in addition to its block of the inactivated state. The bupivacaine-induced block of the inactivated state of the Na+ channel displayed stereoselectivity, with R(+)-bupivacaine interacting faster and more potently. Both enantiomers also bind with high affinity to the activated or open state of the channel, but this interaction did not display stereoselectivity, although the binding to the activated or open state was faster for S(-)- than for R(+)-bupivacaine. The higher potency of R(+)-bupivacaine to block the inactivated state of the cardiac Na+ channel may explain its higher toxicity because of the large contribution of the inactivated-state block during the plateau phase of the cardiac action potential. These results would support the use of the S(-)-enantiomer to reduce cardiac toxicity.

Local anesthetics potently block a potential insensitive potassium channel in myelinated nerve

Effects of some local anesthetics were studied in patch clamp experiments on enzymatically demyelinated peripheral amphibian nerve fibers. Micromolar concentrations of external bupivacaine depolarized the excised membrane considerably. The flicker K+ channel was found to be the most sensitive ion channel to local anesthetics in this preparation. Half-maximum inhibiting concentrations (IC50) for extracellular application of bupivacaine, ropivacaine, etidocaine, mepivacaine, lidocaine, and QX-314 were 0.21, 4.2, 8.6, 56, 220, and > 10,000 microM, respectively. The corresponding concentration-effect curves could be fitted under the assumption of a 1:1 reaction. Application from the axoplasmic side resulted in clearly lower potencies with IC50 values of 2.1, 6.6, 16, 300, 1,200, and 1,250 microM, respectively. The log(IC50)-values of the local anesthetics linearly depended on the logarithm of their octanol:buffer distribution coefficients with two regression lines for the piperidine derivatives and the standard amino-amides indicating an inherently higher potency of the cyclic piperidine series. Amide-linked local anesthetics did not impair the amplitude of the single-channel current but prolonged the time of the channel to be in the closed state derived as time constants tau c from closed-time histograms. With etidocaine and lidocaine tau c was 133 and 7.2 ms, and proved to be independent of concentration. With the most potent bupivacaine time constants of wash in and wash out were 1.8 and 5.2 s for 600 nM bupivacaine. After lowering the extracellular pH from 7.4 to 6.6, externally applied bupivacaine showed a reduced potency, whereas at higher pH of 8.2 the block was slightly enhanced. Intracellular pH of 6.4, 7.2, 8.0 had almost no effect on internal bupivacaine block. It is concluded that local anesthetics block the flicker K+ channel by impeding its gating but not its conductance. The slow blocker bupivacaine and the fast blocker lidocaine compete for the same receptor. Lipophilic interactions are of importance for blockade but besides a hydrophobic pathway, there exists also a hydrophilic pathway to the binding site which could only be reached from the cytoplasmic side of the membrane. Under physiological conditions, blockade of the flicker K+ channel which is more sensitive to bupivacaine than the Na+ channel might lead via membrane depolarization and the resulting sodium channel inactivation to a pronounced block of conduction in thin fibers.

Quantitative sensory examination of epidural anaesthesia and analgesia in man: combination of morphine and bupivacaine

The effect of epidural administration of a combination of low-dose morphine (2 mg) and bupivacaine (25 mg) on somatosensory and motor functions was examined in 13 healthy volunteers. The study design was a double-blind 4-way cross-over in which combined treatment was compared with either drug used alone or placebo. Every 2nd hour for 10 h effects on nociceptive and non-nociceptive somatosensory functions were quantified with 12 psychophysical measures. In addition knee extension strength, reaction time and skin temperature were examined. Epidural bupivacaine had hypoalgesic effect in all nociceptive tests, whereas epidural morphine only demonstrated hypoalgesic properties in nociceptive test with prolonged stimuli. In comparison with bupivacaine alone the combination treatment had a lesser peak effect but a more prolonged hypoalgesic action. In comparison with morphine alone the combination treatment induced a faster onset and demonstrated a modest increase in hypoalgesic effect in a subset of the test, even beyond the duration of bupivacaine when administered alone. Motor function was not attenuated by any of the treatments. Mechanisms of interaction between morphine and bupivacaine as well as their possible clinical implications are discussed.