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Locatelli F, Paoletti E, Del Vecchio L. Cardiovascular safety of current and emerging drugs to treat anaemia in chronic kidney disease: a safety review. Expert Opin Drug Saf 2023; 22:1179-1191. [PMID: 38111209 DOI: 10.1080/14740338.2023.2285889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 11/16/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Erythropoiesis-stimulating agents (ESAs) are the standard of treatment for anemia in chronic kidney disease. Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHI) are small molecules that stimulate endogenous erythropoietin synthesis. AREAS COVERED The cardiovascular safety of ESAs and HIF-PHIs. We performed a PubMed search using several key words, including anemia, chronic kidney disease, safety, erythropoiesis stimulating agents, HIF-PH inhibitors. EXPERT OPINION ESAs are well-tolerated drugs with a long history of use; there are safety concerns, especially when targeting high hemoglobin levels. HIF-PHIs have comparable efficacy to ESAs in correcting anemia. Contrary to expectations, randomized phase 3 clinical trials have shown that overall HIF-PHIs were non-inferior to ESA or placebo with respect to the risk of cardiovascular endpoints. In addition, some phase 3 trials raised potential safety concerns regarding cardiovascular and thrombotic events, particularly in non-dialysis patients.Today, HIF-PHIs represent an additional treatment option for anemia in patients with chronic kidney disease. This has made the management of anemia in CKD more complex and heterogeneous. A better understanding of the mechanisms causing hypo-responsiveness to ESAs, combined with an individualized approach that balances ESAs, HIF-PHIs and iron doses, could increase the benefits while reducing the risks.
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Affiliation(s)
| | - Ernesto Paoletti
- Department of Nephrology, Dialysis and Renal Transplant, San Martino Hospital, Largo Rosanna Benzi, Genoa, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, Como, Italy
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2
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Haber M, Amyot F, Lynch CE, Sandsmark DK, Kenney K, Werner JK, Moore C, Flesher K, Woodson S, Silverman E, Chou Y, Pham D, Diaz-Arrastia R. Imaging biomarkers of vascular and axonal injury are spatially distinct in chronic traumatic brain injury. J Cereb Blood Flow Metab 2021; 41:1924-1938. [PMID: 33444092 PMCID: PMC8327117 DOI: 10.1177/0271678x20985156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/07/2020] [Accepted: 12/06/2020] [Indexed: 11/17/2022]
Abstract
Traumatic Brain Injury (TBI) is associated with both diffuse axonal injury (DAI) and diffuse vascular injury (DVI), which result from inertial shearing forces. These terms are often used interchangeably, but the spatial relationships between DAI and DVI have not been carefully studied. Multimodal magnetic resonance imaging (MRI) can help distinguish these injury mechanisms: diffusion tensor imaging (DTI) provides information about axonal integrity, while arterial spin labeling (ASL) can be used to measure cerebral blood flow (CBF), and the reactivity of the Blood Oxygen Level Dependent (BOLD) signal to a hypercapnia challenge reflects cerebrovascular reactivity (CVR). Subjects with chronic TBI (n = 27) and healthy controls (n = 14) were studied with multimodal MRI. Mean values of mean diffusivity (MD), fractional anisotropy (FA), CBF, and CVR were extracted for pre-determined regions of interest (ROIs). Normalized z-score maps were generated from the pool of healthy controls. Abnormal ROIs in one modality were not predictive of abnormalities in another. Approximately 9-10% of abnormal voxels for CVR and CBF also showed an abnormal voxel value for MD, while only 1% of abnormal CVR and CBF voxels show a concomitant abnormal FA value. These data indicate that DAI and DVI represent two distinct TBI endophenotypes that are spatially independent.
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Affiliation(s)
- Margalit Haber
- Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Franck Amyot
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Cillian E Lynch
- Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Danielle K Sandsmark
- Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Kimbra Kenney
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - John K Werner
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Carol Moore
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Kelley Flesher
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Sarah Woodson
- Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Erika Silverman
- Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Yiyu Chou
- Center for Neuroscience and Regenerative Medicine, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Dzung Pham
- Center for Neuroscience and Regenerative Medicine, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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DuPont T, Chalak L. Future alternative therapies in the pipeline for mild neonatal encephalopathy: Review of evidence of neuroprotection with erythropoiesis stimulating agents. Early Hum Dev 2018; 120:95-98. [PMID: 29471979 DOI: 10.1016/j.earlhumdev.2018.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Tara DuPont
- Department of Pediatrics, Division of Neonatology, University of New Mexico School of Medicine, Albuquerque, NM, United States.
| | - Lina Chalak
- Department of Pediatrics, Division of Neonatology, University of New Mexico School of Medicine, Albuquerque, NM, United States
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Main BS, Villapol S, Sloley SS, Barton DJ, Parsadanian M, Agbaegbu C, Stefos K, McCann MS, Washington PM, Rodriguez OC, Burns MP. Apolipoprotein E4 impairs spontaneous blood brain barrier repair following traumatic brain injury. Mol Neurodegener 2018; 13:17. [PMID: 29618365 PMCID: PMC5885297 DOI: 10.1186/s13024-018-0249-5] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 03/21/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Traumatic Brain Injury (TBI) is a major cause of disability and mortality, to which there is currently no comprehensive treatment. Blood Brain Barrier (BBB) dysfunction is well documented in human TBI patients, yet the molecular mechanisms that underlie this neurovascular unit (NVU) pathology remains unclear. The apolipoprotein-E (apoE) protein has been implicated in controlling BBB integrity in an isoform dependent manner, via suppression of Cyclophilin A (CypA)-Matrix metallopeptidase-9 (MMP-9) signaling cascades, however the contribution of this pathway in TBI-induced BBB permeability is not fully investigated. METHODS We exposed C57Bl/6 mice to controlled cortical impact and assessed NVU and BBB permeability responses up to 21 days post-injury. We pharmacologically probed the role of the CypA-MMP-9 pathway in BBB permeability after TBI using Cyclosporin A (CsA, 20 mg/kg). Finally, as the apoE4 protein is known to be functionally deficient compared to the apoE3 protein, we used humanized APOE mice as a clinically relevant model to study the role of apoE on BBB injury and repair after TBI. RESULTS In C57Bl/6 mice there was an inverse relationship between soluble apoE and BBB permeability, such that damaged BBB stabilizes as apoE levels increase in the days following TBI. TBI mice displayed acute pericyte loss, increased MMP-9 production and activity, and reduced tight-junction expression. Treatment with the CypA antagonist CsA in C57Bl/6 mice attenuates MMP-9 responses and enhances BBB repair after injury, demonstrating that MMP-9 plays an important role in the timing of spontaneous BBB repair after TBI. We also show that apoe mRNA is present in both astrocytes and pericytes after TBI. We report that APOE3 and APOE4 mice have similar acute BBB responses to TBI, but APOE3 mice display faster spontaneous BBB repair than APOE4 mice. Isolated microvessel analysis reveals delayed pericyte repopulation, augmented and sustained MMP-9 expression at the NVU, and impaired stabilization of Zonula Occludens-1, Occludin and Claudin-5 expression at tight junctions in APOE4 mice after TBI compared to APOE3 mice. CONCLUSIONS These data confirm apoE as an important modulator of spontaneous BBB stabilization following TBI, and highlights the APOE4 allele as a risk factor for poor outcome after TBI.
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Affiliation(s)
- Bevan S Main
- Laboratory for Brain Injury and Dementia, Department of Neuroscience, Georgetown University Medical Center, Washington, DC, 20057, USA
| | - Sonia Villapol
- Laboratory for Brain Injury and Dementia, Department of Neuroscience, Georgetown University Medical Center, Washington, DC, 20057, USA
| | - Stephanie S Sloley
- Laboratory for Brain Injury and Dementia, Department of Neuroscience, Georgetown University Medical Center, Washington, DC, 20057, USA
| | - David J Barton
- Laboratory for Brain Injury and Dementia, Department of Neuroscience, Georgetown University Medical Center, Washington, DC, 20057, USA
| | - Maia Parsadanian
- Laboratory for Brain Injury and Dementia, Department of Neuroscience, Georgetown University Medical Center, Washington, DC, 20057, USA
| | - Chinyere Agbaegbu
- Laboratory for Brain Injury and Dementia, Department of Neuroscience, Georgetown University Medical Center, Washington, DC, 20057, USA
| | - Kathryn Stefos
- Laboratory for Brain Injury and Dementia, Department of Neuroscience, Georgetown University Medical Center, Washington, DC, 20057, USA
| | - Mondona S McCann
- Laboratory for Brain Injury and Dementia, Department of Neuroscience, Georgetown University Medical Center, Washington, DC, 20057, USA
| | - Patricia M Washington
- Laboratory for Brain Injury and Dementia, Department of Neuroscience, Georgetown University Medical Center, Washington, DC, 20057, USA
| | - Olga C Rodriguez
- Lombardi Comprehensive Cancer Center, Department of Oncology, Georgetown University Medical Center, Washington, DC, 20057, USA
| | - Mark P Burns
- Laboratory for Brain Injury and Dementia, Department of Neuroscience, Georgetown University Medical Center, Washington, DC, 20057, USA. .,Department of Neuroscience, Georgetown University Medical Center, New Research Building-EG11, 3970 Reservoir Rd, NW, Washington, D.C, 20057, USA.
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Blixt J, Gunnarson E, Wanecek M. Erythropoietin Attenuates the Brain Edema Response after Experimental Traumatic Brain Injury. J Neurotrauma 2018; 35:671-680. [PMID: 29179621 PMCID: PMC5806078 DOI: 10.1089/neu.2017.5015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Erythropoietin (EPO) has neuroprotective effects in multiple central nervous system (CNS) injury models; however EPO's effects on traumatic brain edema are elusive. To explore EPO as an intervention in traumatic brain edema, male Sprague–Dawley (SD) rats were subjected to blunt, controlled traumatic brain injury (TBI). Animals were randomized to EPO 5000 IU/kg or saline (control group) intraperitoneally within 30 min after trauma and once daily for 4 consecutive days. Brain MRI, immunohistofluorescence, immunohistochemistry, and quantitative protein analysis were performed at days 1 and 4 post- trauma. EPO significantly prevented the loss of the tight junction protein zona occludens 1 (ZO-1) observed in control animals after trauma. The decrease of ZO-1 in the control group was associated with an immunoglobulin (Ig)G increase in the perilesional parenchyma, indicating blood–brain barrier (BBB) dysfunction and increased permeability. EPO treatment attenuated decrease in apparent diffusion coefficient (ADC) after trauma, suggesting a reduction of cytotoxic edema, and reduced the IgG leakage, indicating that EPO contributed to preserve BBB integrity and attenuated vasogenic edema. Animals treated with EPO demonstrated conserved levels of aquaporin 4 (AQP4) protein expression in the perilesional area, whereas control animals showed a reduction of AQP4. We show that post TBI administration of EPO decreases early cytotoxic brain edema and preserves structural and functional properties of the BBB, leading to attenuation of the vasogenic edema response. The data support that the mechanisms involve preservation of the tight junction protein ZO-1 and the water channel AQP4, and indicate that treatment with EPO may have beneficial effects on the brain edema response following TBI.
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Affiliation(s)
- Jonas Blixt
- 1 Perioperative Medicine and Intensive Care, Karolinska University Hospital, Karolinska Institutet , Stockholm, Sweden .,2 Department of Physiology and Pharmacology, Karolinska University Hospital, Karolinska Institutet , Stockholm, Sweden
| | - Eli Gunnarson
- 3 Department of Women's and Children's Health Karolinska University Hospital, Karolinska Institutet , Stockholm, Sweden
| | - Michael Wanecek
- 2 Department of Physiology and Pharmacology, Karolinska University Hospital, Karolinska Institutet , Stockholm, Sweden
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Roberts JK, Stockmann C, Ward RM, Beachy J, Baserga MC, Spigarelli MG, Sherwin CMT. Population Pharmacokinetics of Darbepoetin Alfa in Conjunction with Hypothermia for the Treatment of Neonatal Hypoxic-Ischemic Encephalopathy. Clin Pharmacokinet 2016; 54:1237-44. [PMID: 25989868 DOI: 10.1007/s40262-015-0286-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AIM The aim of this study was to determine the population pharmacokinetics of darbepoetin alfa in hypothermic neonates with hypoxic-ischemic encephalopathy treated with hypothermia. METHODS Neonates ≥36 weeks gestation and <12 h postpartum with moderate to severe hypoxic-ischemic encephalopathy who were undergoing hypothermia treatment were recruited in this randomized, multicenter, investigational, new drug pharmacokinetic study. Two intravenous darbepoetin alfa treatment groups were evaluated: 2 and 10 µg/kg. Serum erythropoietin concentrations were measured using an enzyme-linked immunosorbent assay. Monolix 4.3.1 was used to estimate darbepoetin alfa clearance and volume of distribution. Covariates tested included: birthweight, gestational age, postnatal age, postmenstrual age, sex, Sarnat score, and study site. RESULTS Darbepoetin alfa pharmacokinetics were well described by a one-compartment model with exponential error. Clearance and the volume of distribution were scaled by birthweight (centered on the mean) a priori. Additionally, gestational age (also centered on the mean) significantly affected darbepoetin alfa clearance. Clearance and volume of distribution were estimated as 0.0465 L/h (95% confidence interval 0.0392-0.0537) and 1.58 L (95% confidence interval 1.29-1.87), respectively. CONCLUSIONS A one-compartment model successfully described the pharmacokinetics of darbepoetin alfa among hypothermic neonates treated for hypoxic-ischemic encephalopathy. Clearance decreased with increasing gestational age.
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Affiliation(s)
- Jessica K Roberts
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Chris Stockmann
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA.,Department of Pharmacology and Toxicology, College of Pharmacy, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Robert M Ward
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA.,Department of Pharmacology and Toxicology, College of Pharmacy, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA.,Division of Neonatology, Department of Pediatrics, School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Joanna Beachy
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Mariana C Baserga
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Michael G Spigarelli
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA.,Department of Pharmacology and Toxicology, College of Pharmacy, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Catherine M T Sherwin
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA.
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Kenney K, Amyot F, Haber M, Pronger A, Bogoslovsky T, Moore C, Diaz-Arrastia R. Cerebral Vascular Injury in Traumatic Brain Injury. Exp Neurol 2016; 275 Pt 3:353-366. [DOI: 10.1016/j.expneurol.2015.05.019] [Citation(s) in RCA: 155] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 05/19/2015] [Accepted: 05/26/2015] [Indexed: 12/14/2022]
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Grasso G, Tomasello G, Noto M, Alafaci C, Cappello F. Erythropoietin for the Treatment of Subarachnoid Hemorrhage: A Feasible Ingredient for a Successful Medical Recipe. Mol Med 2015; 21:979-987. [PMID: 26581085 DOI: 10.2119/molmed.2015.00177] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 11/16/2015] [Indexed: 11/06/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) following aneurysm bleeding accounts for 6% to 8% of all cerebrovascular accidents. Although an aneurysm can be effectively managed by surgery or endovascular therapy, delayed cerebral ischemia is diagnosed in a high percentage of patients resulting in significant morbidity and mortality. Cerebral vasospasm occurs in more than half of all patients after aneurysm rupture and is recognized as the leading cause of delayed cerebral ischemia after SAH. Hemodynamic strategies and endovascular procedures may be considered for the treatment of cerebral vasospasm. In recent years, the mechanisms contributing to the development of vasospasm, abnormal reactivity of cerebral arteries and cerebral ischemia following SAH, have been investigated intensively. A number of pathological processes have been identified in the pathogenesis of vasospasm, including endothelial injury, smooth muscle cell contraction from spasmogenic substances produced by the subarachnoid blood clots, changes in vascular responsiveness and inflammatory response of the vascular endothelium. To date, the current therapeutic interventions remain ineffective as they are limited to the manipulation of systemic blood pressure, variation of blood volume and viscosity and control of arterial carbon dioxide tension. In this scenario, the hormone erythropoietin (EPO) has been found to exert neuroprotective action during experimental SAH when its recombinant form (rHuEPO) is administered systemically. However, recent translation of experimental data into clinical trials has suggested an unclear role of recombinant human EPO in the setting of SAH. In this context, the aim of the current review is to present current evidence on the potential role of EPO in cerebrovascular dysfunction following aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- Giovanni Grasso
- Neurosurgical Clinic, Department of Experimental Biomedicine and Clinical Neurosciences, Euro-Mediterranean Institute of Science and Technology (IEMEST), Palermo, Italy
| | - Giovanni Tomasello
- Section of Anatomy, Department of Experimental Biomedicine and Clinical Neurosciences, and Euro-Mediterranean Institute of Science and Technology (IEMEST), Palermo, Italy
| | | | - Concetta Alafaci
- Department of Neurosurgery, University of Messina, Messina, Italy
| | - Francesco Cappello
- Section of Anatomy, Department of Experimental Biomedicine and Clinical Neurosciences, and Euro-Mediterranean Institute of Science and Technology (IEMEST), Palermo, Italy
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9
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Baserga MC, Beachy JC, Roberts JK, Ward RM, DiGeronimo RJ, Walsh WF, Ohls RK, Anderson J, Mayock DE, Juul SE, Christensen RD, Loertscher MC, Stockmann C, Sherwin CM, Spigarelli MG, Yoder BA. Darbepoetin administration to neonates undergoing cooling for encephalopathy: a safety and pharmacokinetic trial. Pediatr Res 2015; 78:315-22. [PMID: 25996892 PMCID: PMC5564328 DOI: 10.1038/pr.2015.101] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 02/23/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Despite therapeutic hypothermia, neonates with encephalopathy (NE) have high rates of death or disability. Darbepoetin alfa (Darbe) has comparable biological activity to erythropoietin, but has extended circulating half-life (t(1/2)). Our aim was to determine Darbe safety and pharmacokinetics as adjunctive therapy to hypothermia. STUDY DESIGN Thirty infants (n = 10/arm) ≥36 wk gestation undergoing therapeutic hypothermia for NE were randomized to receive placebo, Darbe low dose (2 μg/kg), or high dose (10 μg/kg) given intravenously within 12 h of birth (first dose/hypothermia condition) and at 7 d (second dose/normothermia condition). Adverse events were documented for 1 mo. Serum samples were obtained to characterize Darbe pharmacokinetics. RESULTS Adverse events (hypotension, altered liver and renal function, seizures, and death) were similar to placebo and historical controls. Following the first Darbe dose at 2 and 10 μg/kg, t(1/2) was 24 and 32 h, and the area under the curve (AUC(inf)) was 26,555 and 180,886 h*mU/ml*, respectively. In addition, clearance was not significantly different between the doses (0.05 and 0.04 l/h). At 7 d, t(1/2) was 26 and 35 h, and AUC(inf) was 10,790 and 56,233 h*mU/ml*, respectively (*P < 0.01). CONCLUSION Darbe combined with hypothermia has similar safety profile to placebo with pharmacokinetics sufficient for weekly administration.
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Affiliation(s)
- Mariana C. Baserga
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Joanna C. Beachy
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Jessica K. Roberts
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Robert M. Ward
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah,Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Robert J. DiGeronimo
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - William F. Walsh
- Division of Neonatology, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
| | - Robin K. Ohls
- Division of Neonatology, Department of Pediatrics, University of New Mexico, Albuquerque, New Mexico
| | - Jennifer Anderson
- Division of Neonatology, Department of Pediatrics, University of New Mexico, Albuquerque, New Mexico
| | - Dennis E. Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Sandra E. Juul
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, Washington
| | | | - Manndi C. Loertscher
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Chris Stockmann
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Catherine M.T. Sherwin
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Michael G. Spigarelli
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Bradley A. Yoder
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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Wu YW, Gonzalez FF. Erythropoietin: a novel therapy for hypoxic-ischaemic encephalopathy? Dev Med Child Neurol 2015; 57 Suppl 3:34-9. [PMID: 25800490 DOI: 10.1111/dmcn.12730] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2014] [Indexed: 11/27/2022]
Abstract
Perinatal hypoxic-ischaemic encephalopathy (HIE) occurs in 1 to 3 per 1000 term births. HIE is not preventable in most cases, and therapies are limited. Hypothermia improves outcomes and is the current standard of care. Yet, clinical trials suggest that 44-53% of infants who receive hypothermia will die or suffer moderate to severe neurological disability. In this article, we review the preclinical and clinical evidence for erythropoietin (EPO) as a potential novel neuroprotective agent for the treatment of HIE. EPO is a novel neuroprotective agent, with remarkable neuroprotective and neuroregenerative effects in animals. Rodent and primate models of neonatal brain injury support the safety and efficacy of multiple EPO doses for improving histological and functional outcomes after hypoxia-ischaemia. Small clinical trials of EPO in neonates with HIE have also provided evidence supporting safety and preliminary efficacy in humans. There is currently insufficient evidence to support the use of high-dose EPO in newborns with HIE. However, several on-going trials will provide much needed data regarding the safety and efficacy of this potential new therapy when given in conjunction with hypothermia for HIE. Novel neuroprotective therapies are needed to further reduce the rate and severity of neurodevelopmental disabilities resulting from HIE. High-dose EPO is a promising therapy that can be administered in conjunction with hypothermia. However, additional data are needed to determine the safety and efficacy of this adjuvant therapy for HIE.
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Affiliation(s)
- Yvonne W Wu
- Department of Neurology, University of California, San Francisco, CA, USA; Department of Pediatrics, University of California, San Francisco, CA, USA
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11
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Hralová M, Plaňanská E, Angerová Y, Jadwiszczoková A, Bortelová J, Lippertová-Grünerová M, Marešová D. Effects of a Single Dose of Erythropoietin on Motor Function and Cognition after Focal Brain Ischemia in Adult Rats. Prague Med Rep 2014; 115:5-15. [DOI: 10.14712/23362936.2014.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
We tested the influence of erythropoietin (EPO), a basic cytokine in erythropoiesis regulation, on the process of motor function and cognition after focal brain ischemia induced by a local application of endothelin. Endothelin-1 (ET-1) induced short lasting strong vasoconstriction, with described impact on the structure and on the function of neuronal cells. Neurological description of motor function and Morris water maze test (the swimming test is one of most widely used methods for studying cognitive functions in rodents) were used to study the process of learning and memory in three-month-old male albino Wistar rats (n=52). Both tests were performed one week before, and three weeks after ischemia induction (endothelin application on the cortex in the area of a. cerebri media dx.). Experimental group received i.p. injection of EPO (5,000 IU/kg body weight, 10 min before endothelin application). Control group of animals received one i.p. injection of saline at the dose of 1 ml/kg body weight at the same time. Only sham surgery was performed in the third group of animals. Rats with EPO pretreatment before the experimental lesion exhibited significantly better motor and cognitive function then those with saline injection. No significant changes in the motor and cognitive function were found in the third group of rats (sham operated controls).
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12
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Cruz Navarro J, Pillai S, Ponce LL, Van M, Goodman JC, Robertson CS. Endothelial nitric oxide synthase mediates the cerebrovascular effects of erythropoietin in traumatic brain injury. Front Immunol 2014; 5:494. [PMID: 25346735 PMCID: PMC4191322 DOI: 10.3389/fimmu.2014.00494] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 09/23/2014] [Indexed: 11/23/2022] Open
Abstract
Background: Erythropoietin (Epo) improves post-traumatic cerebral blood flow (CBF), pressure autoregulation, and vascular reactivity to l-arginine. This study examines the dependence of these cerebral hemodynamic effects of Epo on nitric oxide generated by endothelial nitric oxide synthase (eNOS). Methods: Using laser Doppler flow imaging, CBF was monitored in wild-type (WT) and eNOS-deficient mice undergoing controlled cortical impact followed by administration of Epo (5000 U/kg) or normal saline. Results: Cerebral blood flow decreased in all groups post-injury with the greatest reductions occurring at the impact site. Epo administration resulted in significantly higher CBF in the peri-contusional sites in the WT mice [70.2 ± 3.35% in Epo-treated compared to 53 ± 3.3% of baseline in saline-treated mice (p < 0.0001)], but no effect was seen in the eNOS-deficient mice. No CBF differences were found at the core impact site where CBF dropped to 20–25% of baseline in all groups. Conclusion: These differences between eNOS-deficient and WT mice indicate that the Epo mediated improvement in CBF in traumatic brain injury is eNOS dependent.
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Affiliation(s)
| | - Shibu Pillai
- Department of Neurosurgery, Baylor College of Medicine , Houston, TX , USA
| | - Lucido L Ponce
- Department of Neurosurgery, Baylor College of Medicine , Houston, TX , USA
| | - Mai Van
- Department of Neurosurgery, Baylor College of Medicine , Houston, TX , USA
| | - Jerry Clay Goodman
- Department of Pathology and Immunology, Baylor College of Medicine , Houston, TX , USA ; Department of Neurology, Baylor College of Medicine , Houston, TX , USA
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13
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Diaz-Arrastia R, Kochanek PM, Bergold P, Kenney K, Marx CE, Grimes CJB, Loh LTCY, Adam LTCGE, Oskvig D, Curley KC, Salzer W. Pharmacotherapy of traumatic brain injury: state of the science and the road forward: report of the Department of Defense Neurotrauma Pharmacology Workgroup. J Neurotrauma 2014; 31:135-58. [PMID: 23968241 DOI: 10.1089/neu.2013.3019] [Citation(s) in RCA: 190] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Despite substantial investments by government, philanthropic, and commercial sources over the past several decades, traumatic brain injury (TBI) remains an unmet medical need and a major source of disability and mortality in both developed and developing societies. The U.S. Department of Defense neurotrauma research portfolio contains more than 500 research projects funded at more than $700 million and is aimed at developing interventions that mitigate the effects of trauma to the nervous system and lead to improved quality of life outcomes. A key area of this portfolio focuses on the need for effective pharmacological approaches for treating patients with TBI and its associated symptoms. The Neurotrauma Pharmacology Workgroup was established by the U.S. Army Medical Research and Materiel Command (USAMRMC) with the overarching goal of providing a strategic research plan for developing pharmacological treatments that improve clinical outcomes after TBI. To inform this plan, the Workgroup (a) assessed the current state of the science and ongoing research and (b) identified research gaps to inform future development of research priorities for the neurotrauma research portfolio. The Workgroup identified the six most critical research priority areas in the field of pharmacological treatment for persons with TBI. The priority areas represent parallel efforts needed to advance clinical care; each requires independent effort and sufficient investment. These priority areas will help the USAMRMC and other funding agencies strategically guide their research portfolios to ensure the development of effective pharmacological approaches for treating patients with TBI.
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Affiliation(s)
- Ramon Diaz-Arrastia
- 1 Department of Neurology, Uniformed Services University of the Health Sciences , Bethesda, Maryland
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14
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Hralová M, Angerová Y, Gueye T, Bortelová J, Svestková O, Zima T, Lippertová-Grünerová M. Long-term results of enriched environment and erythropoietin after hypobaric hypoxia in rats. Physiol Res 2013; 62:463-70. [PMID: 23590602 DOI: 10.33549/physiolres.932354] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
After global cerebral hypoxia, many patients are severely disabled even after intensive neurorehabilitation. Secondary mechanisms of brain injury as a result of biochemical and physiological events occur within a period of hours to months, and provide a window of opportunity for therapeutic intervention. Erythropoietin (EPO) has been shown to be neuroprotective in the brain subjected to a variety of injuries. Fifty-nine 3-month-old male Wistar rats were randomly distributed to experimental groups with respect to the housing (enriched environment - EE, standard housing - SH), to hypoxia exposure, and to EPO treatment. An acute mountain sickness model was used as a hypobaric hypoxia simulating an altitude of 8000 m. One half of the animals received erythropoietin injections, while the others were injected saline. Spatial memory was tested in a Morris water maze (MWM). The escape latency and the path length were measured. Better spatial learning in MWM was only seen in the group that received erythropoietin together with enriched environment. EPO administration itself had no influence on spatial memory. The results were very similar for both latencies and path lengths. These results support the idea that after brain injuries, the recovery can be potentiated by EPO administration combined with neurorehabilitation.
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Affiliation(s)
- M Hralová
- Department of Rehabilitation Medicine, General Teaching Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
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15
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Gaddam SK, Cruz J, Robertson C. Erythropoietin and cytoprotective cytokines in experimental traumatic brain injury. Methods Mol Biol 2013; 982:141-62. [PMID: 23456867 DOI: 10.1007/978-1-62703-308-4_9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The various biochemical cascades that follow primary brain injury result in secondary brain injury which can adversely affect the clinical outcome. Over the last few years it has been well established that molecules like erythropoietin (Epo) have a neuroprotective role in experimental traumatic brain injury (TBI). Epo is shown to produce this effect by modulating multiple cellular processes, including apoptosis, inflammation, and regulation of cerebral blood flow. Derivatives of Epo, including asialo Epo and carbamylated Epo, have been developed to separate the neuroprotective properties from the erythropoiesis-stimulating activities of Epo which may have adverse effects in clinical situations. Peptides that mimic a portion of the Epo molecule, including Helix B surface peptide and Epotris, have also been developed to isolate the neuroprotective activities. The TBI model in rodents most commonly used to study the effect of Epo and these derivatives in TBI is controlled cortical impact injury, which is a model of focal contusion following a high velocity impact to the parietal cortex. Following TBI, rodents are given Epo or an Epo derivative vs. placebo and the outcome is evaluated in terms of physiological parameters (cerebral blood flow, intracranial pressure, cerebral perfusion pressure), behavioral parameters (motor and memory), and histological parameters (contusion volumes, hippocampus cell counts).
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16
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Del Vecchio L, Locatelli F. Safety issues related to erythropoiesis-stimulating agents used to treat anemia in patients with chronic kidney disease. Expert Opin Drug Saf 2012; 11:923-31. [DOI: 10.1517/14740338.2012.712680] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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