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Yang W, Ouyang Q, Zhu Z, Wu Y, Fan M, Liao Y, Guo X, Xu Z, Zhang X, Zhang Y, Hu N, Zhang D. A biosensing system employing nonlinear dynamic analysis-assisted neural network for drug-induced cardiotoxicity assessment. Biosens Bioelectron 2023; 222:114923. [PMID: 36455375 DOI: 10.1016/j.bios.2022.114923] [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: 07/07/2022] [Accepted: 11/16/2022] [Indexed: 11/18/2022]
Abstract
Preclinical investigation of drug-induced cardiotoxicity is of importance for drug development. To evaluate such cardiotoxicity, in vitro high-throughput interdigitated electrode-based recording of cardiomyocytes mechanical beating is widely used. To automatically analyze the features from the beating signals for drug-induced cardiotoxicity assessment, artificial neural network analysis is conventionally employed and signals are segmented into cycles and feature points are located in the cycles. However, signal segmentation and location of feature points for different signal shapes require design of specific algorithms. Consequently, this may lower the efficiency of research and the applications of such algorithms in signals with different morphologies are limited. Here, we present a biosensing system that employs nonlinear dynamic analysis-assisted neural network (NDANN) to avoid the signal segmentation process and directly extract features from beating signal time series. By processing beating time series with fixed time duration to avoid the signal segmentation process, this NDANN-based biosensing system can identify drug-induced cardiotoxicity with accuracy over 0.99. The individual drugs were classified with high accuracies over 0.94 and drug-induced cardiotoxicity levels were accurately predicted. We also evaluated the generalization performance of the NDANN-based biosensing system in assessing drug-induced cardiotoxicity through an independent dataset. This system achieved accuracy of 0.85-0.95 for different drug concentrations in identification of drug-induced cardiotoxicity. This result demonstrates that our NDANN-based biosensing system has the capacity of screening newly developed drugs, which is crucial in practical applications. This NDANN-based biosensing system can work as a new screening platform for drug-induced cardiotoxicity and improve the efficiency of bio-signal processing.
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Affiliation(s)
- Wenjian Yang
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China
| | - Qiangqiang Ouyang
- First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510006, China
| | - Zhijing Zhu
- Key Laboratory of Novel Target and Drug Study for Neural Repair of Zhejiang Province, School of Medicine, School of Computer & Computing Science, Zhejiang University City College, Hangzhou, 310015, China; School of Brain Science and Brain Medicine, Zhejiang University, Hangzhou, 310058, China
| | - Yue Wu
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China.
| | - Minzhi Fan
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China
| | - Yuheng Liao
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China
| | - Xinyu Guo
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China
| | - Zhongyuan Xu
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China
| | - Xiaoyu Zhang
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China
| | - Yunshan Zhang
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China
| | - Ning Hu
- ZJU-Hangzhou Global Scientific and Technological Innovation Center, Hangzhou, 311200, China; Stoddart Institute of Molecular Science, Department of Chemistry, Zhejiang University, Hangzhou, 310058, China
| | - Diming Zhang
- Research Center for Intelligent Sensing Systems, Zhejiang Laboratory, Hangzhou, 311100, China.
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Mamoshina P, Rodriguez B, Bueno-Orovio A. Toward a broader view of mechanisms of drug cardiotoxicity. CELL REPORTS MEDICINE 2021; 2:100216. [PMID: 33763655 PMCID: PMC7974548 DOI: 10.1016/j.xcrm.2021.100216] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cardiotoxicity, defined as toxicity that affects the heart, is one of the most common adverse drug effects. Numerous drugs have been shown to have the potential to induce lethal arrhythmias by affecting cardiac electrophysiology, which is the focus of current preclinical testing. However, a substantial number of drugs can also affect cardiac function beyond electrophysiology. Within this broader sense of cardiotoxicity, this review discusses the key drug-protein interactions known to be involved in cardiotoxic drug response. We cover adverse effects of anticancer, central nervous system, genitourinary system, gastrointestinal, antihistaminic, anti-inflammatory, and anti-infective agents, illustrating that many share mechanisms of cardiotoxicity, including contractility, mitochondrial function, and cellular signaling.
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Affiliation(s)
| | - Blanca Rodriguez
- Department of Computer Science, BHF Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Alfonso Bueno-Orovio
- Department of Computer Science, BHF Centre of Research Excellence, University of Oxford, Oxford, UK
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Skardal A, Aleman J, Forsythe S, Rajan S, Murphy S, Devarasetty M, Pourhabibi Zarandi N, Nzou G, Wicks R, Sadri-Ardekani H, Bishop C, Soker S, Hall A, Shupe T, Atala A. Drug compound screening in single and integrated multi-organoid body-on-a-chip systems. Biofabrication 2020; 12:025017. [PMID: 32101533 DOI: 10.1088/1758-5090/ab6d36] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Current practices in drug development have led to therapeutic compounds being approved for widespread use in humans, only to be later withdrawn due to unanticipated toxicity. These occurrences are largely the result of erroneous data generated by in vivo and in vitro preclinical models that do not accurately recapitulate human physiology. Herein, a human primary cell- and stem cell-derived 3D organoid technology is employed to screen a panel of drugs that were recalled from market by the FDA. The platform is comprised of multiple tissue organoid types that remain viable for at least 28 days, in vitro. For many of these compounds, the 3D organoid system was able to demonstrate toxicity. Furthermore, organoids exposed to non-toxic compounds remained viable at clinically relevant doses. Additional experiments were performed on integrated multi-organoid systems containing liver, cardiac, lung, vascular, testis, colon, and brain. These integrated systems proved to maintain viability and expressed functional biomarkers, long-term. Examples are provided that demonstrate how multi-organoid 'body-on-a-chip' systems may be used to model the interdependent metabolism and downstream effects of drugs across multiple tissues in a single platform. Such 3D in vitro systems represent a more physiologically relevant model for drug screening and will likely reduce the cost and failure rate associated with the approval of new drugs.
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Affiliation(s)
- Aleksander Skardal
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27101, United States of America. Department of Biomedical Engineering, The Ohio State University, 1080 Carmack Road, Columbus, OH, 43210, United States of America
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Rosa GM, Baccino D, Valbusa A, Scala C, Barra F, Brunelli C, Ferrero S. Cardiovascular effects of antimuscarinic agents and beta3-adrenergic receptor agonist for the treatment of overactive bladder. Expert Opin Drug Saf 2018. [PMID: 29542337 DOI: 10.1080/14740338.2018.1453496] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Overactive bladder (OAB) syndrome is common in the general population, particularly in elderly patients. Antimuscarinic drugs (AMs) are considered the mainstay pharmaceutical treatment of OAB whereas β3-adrenoceptor agonists, such as mirabegron, represent a good alternative. Owing to the important role of muscarinic and β3 receptors in cardiovascular (CV) tissue and to the fact that OAB patients often have CV comorbidities, the safety-profile of these drugs constitute an important challenge. AREAS COVERED The aim of this review is to evaluate the CV effects of AMs and mirabegron in OAB. A systematic literature search from inception until December 2017 was performed on PubMed and Medline. EXPERT OPINION AMs are generally considered to have good CV safety profile but, however, they may cause undesirable adverse events, such as dry mouth, constipation. CV AEs are rare but noteworthy, the most common CV consequences related to the use of these drugs are constituted by an increase in HR and QT interval. Mirabegron has similar efficacy and tolerability to AMs but causes less adverse events, with either modest hypertension and modest increase in HR (<5 bpm) being the most commonly reported.
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Affiliation(s)
- Gian Marco Rosa
- a Department of Internal Medicine, Cardiology , Ospedale Policlinico San Martino , Genoa , Italy
| | - Danilo Baccino
- a Department of Internal Medicine, Cardiology , Ospedale Policlinico San Martino , Genoa , Italy
| | - Alberto Valbusa
- a Department of Internal Medicine, Cardiology , Ospedale Policlinico San Martino , Genoa , Italy
| | - Carolina Scala
- b Academic Unit of Obstetrics and Gynecology , Ospedale Policlinico San Martino , Genoa , Italy.,c Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
| | - Fabio Barra
- b Academic Unit of Obstetrics and Gynecology , Ospedale Policlinico San Martino , Genoa , Italy.,c Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
| | - Claudio Brunelli
- a Department of Internal Medicine, Cardiology , Ospedale Policlinico San Martino , Genoa , Italy
| | - Simone Ferrero
- b Academic Unit of Obstetrics and Gynecology , Ospedale Policlinico San Martino , Genoa , Italy.,c Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
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Qu Y, Page G, Abi-Gerges N, Miller PE, Ghetti A, Vargas HM. Action Potential Recording and Pro-arrhythmia Risk Analysis in Human Ventricular Trabeculae. Front Physiol 2018; 8:1109. [PMID: 29354071 PMCID: PMC5760531 DOI: 10.3389/fphys.2017.01109] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/14/2017] [Indexed: 01/20/2023] Open
Abstract
To assess drug-induced pro-arrhythmic risk, especially Torsades de Pointe (TdP), new models have been proposed, such as in-silico modeling of ventricular action potential (AP) and stem cell-derived cardiomyocytes (SC-CMs). Previously we evaluated the electrophysiological profile of 15 reference drugs in hESC-CMs and hiPSC-CMs for their effects on intracellular AP and extracellular field potential, respectively. Our findings indicated that SC-CMs exhibited immature phenotype and had the propensity to generate false positives in predicting TdP risk. To expand our knowledge with mature human cardiac tissues for drug-induced pro-arrhythmic risk assessment, human ventricular trabeculae (hVT) from ethically consented organ donors were used to evaluate the effects of the same 15 drugs (8 torsadogenic, 5 non-torsadogenic, and 2 discovery molecules) on AP parameters at 1 and 2 Hz. Each drug was tested blindly with 4 concentrations in duplicate trabeculae from 2 hearts. To identify the pro-arrhythmic risk of each drug, a pro-arrhythmic score was calculated as the weighted sum of percent drug-induced changes compared to baseline in various AP parameters, including AP duration and recognized pro-arrhythmia predictors such as triangulation, beat-to-beat variability and incidence of early-afterdepolarizations, at each concentration. In addition, to understand the translation of this preclinical hVT AP-based model to clinical studies, a ratio that relates each testing concentration to the human therapeutic unbound Cmax (Cmax) was calculated. At a ratio of 10, for the 8 torsadogenic drugs, 7 were correctly identified by the pro-arrhythmic score; 1 was mislabeled. For the 5 non-torsadogenic drugs, 4 were correctly identified as safe; 1 was mislabeled. Calculation of sensitivity, specificity, positive predictive value, and negative predictive value indicated excellent performance. For example, at a ratio of 10, scores for sensitivity, specificity, positive predictive value and negative predictive values were 0.88, 0.8, 0.88 and 0.8, respectively. Thus, the hVT AP-based model combined with the integrated analysis of pro-arrhythmic score can differentiate between torsadogenic and non-torsadogenic drugs, and has a greater predictive performance when compared to human SC-CM models.
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Affiliation(s)
- Yusheng Qu
- Integrated Discovery and Safety Pharmacology, Amgen Inc., Thousand Oaks, CA, United States
| | - Guy Page
- AnaBios Corporation, San Diego, CA, United States
| | | | | | - Andre Ghetti
- AnaBios Corporation, San Diego, CA, United States
| | - Hugo M. Vargas
- Integrated Discovery and Safety Pharmacology, Amgen Inc., Thousand Oaks, CA, United States
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Cardiotoxicity screening: a review of rapid-throughput in vitro approaches. Arch Toxicol 2015; 90:1803-16. [PMID: 26676948 DOI: 10.1007/s00204-015-1651-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 11/18/2015] [Indexed: 01/07/2023]
Abstract
Cardiac toxicity represents one of the leading causes of drug failure along different stages of drug development. Multiple very successful pharmaceuticals had to be pulled from the market or labeled with strict usage warnings due to adverse cardiac effects. In order to protect clinical trial participants and patients, the International Conference on Harmonization published guidelines to recommend that all new drugs to be tested preclinically for hERG (Kv11.1) channel sensitivity before submitting for regulatory reviews. However, extensive studies have demonstrated that measurement of hERG activity has limitations due to the multiple molecular targets of drug compound through which it may mitigate or abolish a potential arrhythmia, and therefore, a model measuring multiple ion channel effects is likely to be more predictive. Several phenotypic rapid-throughput methods have been developed to predict the potential cardiac toxic compounds in the early stages of drug development using embryonic stem cells- or human induced pluripotent stem cell-derived cardiomyocytes. These rapid-throughput methods include microelectrode array-based field potential assay, impedance-based or Ca(2+) dynamics-based cardiomyocytes contractility assays. This review aims to discuss advantages and limitations of these phenotypic assays for cardiac toxicity assessment.
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Serra DB, Affrime MB, Bedigian MP, Greig G, Milosavljev S, Skerjanec A, Wang Y. QT and QTc Interval With Standard and Supratherapeutic Doses of Darifenacin, a Muscarinic M3Selective Receptor Antagonist for the Treatment of Overactive Bladder. J Clin Pharmacol 2013; 45:1038-47. [PMID: 16100298 DOI: 10.1177/0091270005279010] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Prolongation of QT interval on an electrocardiogram is a valuable predictor of a drug's ability to cause potentially fatal ventricular tachyarrhythmia (torsades de pointes). Darifenacin is a muscarinic M3 selective receptor antagonist developed for the treatment of overactive bladder, a debilitating condition that is particularly prevalent in the older population. This 7-day, randomized, parallel-group study (n=188) measured QT/QTc interval in healthy volunteers receiving once-daily darifenacin at steady-state therapeutic (15 mg) and supratherapeutic (75 mg) doses, alongside controls receiving placebo or moxifloxacin (positive control, 400 mg) once daily. There was no significant increase in QTcF interval with darifenacin treatment compared with placebo. Mean changes from baseline at pharmacokinetic Tmax versus placebo were -0.4 and -2.2 milliseconds in the darifenacin 15 mg and 75 mg groups, respectively, compared with +11.6 milliseconds in the moxifloxacin group (P<.01). This study demonstrates that darifenacin does not prolong QT/QTc interval.
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Affiliation(s)
- Denise B Serra
- Exploratory Clinical Development, Novartis Pharmaceuticals Corporation, 435/1159, One Health Plaza, East Hanover, NJ 07936-1080, USA
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Zhang W, Roederer MW, Chen WQ, Fan L, Zhou HH. Pharmacogenetics of drugs withdrawn from the market. Pharmacogenomics 2012; 13:223-31. [PMID: 22256871 DOI: 10.2217/pgs.11.137] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The safety and efficacy of candidate compounds are critical factors during the development of drugs, and most drugs have been withdrawn from the market owing to severe adverse reactions. Individuals/populations with different genetic backgrounds may show significant differences in drug metabolism and efficacy, which can sometimes manifest as severe adverse drug reactions. With an emphasis on the mechanisms underlying abnormal drug effects caused by genetic mutations, pharmacogenetic studies may enhance the safety and effectiveness of drug use, provide more comprehensive delineations of the scope of usage, and change the fates of drugs withdrawn from the market.
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Affiliation(s)
- Wei Zhang
- Pharmacogenetics Research Institute, Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha, Hunan 410078, China
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9
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Abstract
The myocardium is the target of toxicity for a number of drugs. Based on pharmacological evidence, cellular targets for drugs that produce adverse reactions can be categorized into a number of sites that include the cell membrane-bound receptors, the second messenger system, ionic channels, ionic pumps, and intracellular organelles. Additionally, interference with the neuronal input to the heart can also present a global site where adverse drug effects can manifest themselves. Simply, a drug can interfere with the normal cardiac action by modifying an ion channel function at the plasma membrane level leading to abnormal repolarization and/or depolarization of the heart cells thus precipitating a disruption in the rhythm and causing dysfunction in contractions and/or relaxations of myocytes. It is now recognized that toxic actions of drugs against the myocardium are not exclusive to the antitumor or the so-called cardiac drugs, and many other drugs with diverse chemical structures, such as antimicrobial, antimalarial, antihistamines, psychiatric, and gastrointestinal medications, seem to be capable of severely compromising myocardium function. At present, great emphasis in terms of drug safety is being placed on the interaction of many classes of drugs with the hERG potassium channel in cardiac tissue. The interest in the latter channel stems from the simplified view that drugs that block the hERG potassium channel cause prolongation of the QT interval, and this can cause life-threatening cardiac arrhythmias. Based on the evidence in the current literature, this concept does not seem to always hold true.
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Affiliation(s)
- Reza Tabrizchi
- Division of BioMedical Sciences, Memorial University of Newfoundland, Health Sciences Centre, St. John's, NL, A1B 3V6, Canada.
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Drake MJ. Emerging drugs for treatment of overactive bladder and detrusor overactivity. Expert Opin Emerg Drugs 2008; 13:431-46. [PMID: 18764721 DOI: 10.1517/14728214.13.3.431] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Overactive bladder (OAB) signifies the presence of urinary urgency and can have major effects on quality of life and social functioning. Standard antimuscarinic drugs have good initial response rates but substantial adverse effects and long-term compliance problems. OBJECTIVES To review the complexities of the mechanisms underlying OAB and the current drugs available for treating its symptoms. METHODS The literature was reviewed to define current therapies and drugs in clinical trials. Articles were identified by means of a computerised PubMed and Cochrane Library search (using the following keywords: overactive bladder, detrusor overactivity, urgency and bladder), supported by a search of the PharmaProjects database. CONCLUSIONS New drug classes, such as beta-3 adrenergic agonists, may work by reducing contractility or excitability of bladder muscle. Moderation of afferent activity may allow improved OAB symptoms, with lower risk of affecting voiding function. Agents acting on the CNS could influence OAB favourably, but target selection and adverse effects are an issue. The recognition of the functional contribution of the urothelium and the diversity of nerve transmitters has sparked interest in both peripheral and central modulation of OAB pathophysiology.
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Affiliation(s)
- Marcus J Drake
- Bristol Urological Institute, Southmead Hospital, Bristol, BS10 5NB, UK.
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Christ T, Wettwer E, Wuest M, Braeter M, Donath F, Champeroux P, Richard S, Ravens U. Electrophysiological profile of propiverine--relationship to cardiac risk. Naunyn Schmiedebergs Arch Pharmacol 2007; 376:431-40. [PMID: 18092154 DOI: 10.1007/s00210-007-0231-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Accepted: 11/22/2007] [Indexed: 10/22/2022]
Abstract
Drugs that prolong the QT interval by blocking human ether-a-go-go (HERG) channels may enhance the risk of ventricular arrhythmia. The spasmolytic drug propiverine is widely used for the therapy of overactive bladder (OAB). Here, we have investigated the effects of propiverine on cardiac ion channels and action potentials as well as on contractile properties of cardiac tissue, in order to estimate its cardiac safety profile, because other drugs used in this indication had to be withdrawn due to safety reasons. Whole-cell patch clamp technique was used to record the following cardiac ion currents: rapidly and slowly activating delayed rectifier K+ current (I(Kr), I(Ks)), ultra rapidly activating delayed rectifier K+ current (I(Kur)), inwardly rectifying K+ current I(K1), transient outward K+ current (I(to)), and L-type Ca2+ current (I(Ca,L)). Action potentials in cardiac tissue biopsies were recorded with conventional microelectrodes. The torsade de pointes screening assay (TDPScreen) was used for drug scoring. Propiverine blocked in a concentration-dependent manner HERG channels expressed in HEK293 cells, as well as native I(Kr) current in ventricular myocytes of guinea pig (IC50 values: 10 microM and 1.8 microM respectively). At high concentrations (100 microM), propiverine suppressed I(Ks). I(K1) and the transient outward current I(to) and I(Kur) were not affected. In guinea-pig ventricular and human atrial myocytes, propiverine also blocked I(Ca,L) (IC50 values: 34.7 microM and 41.7 microM, respectively) and reduced force of contraction. Despite block of I(Kr), action potential duration was not prolonged in guinea-pig and human ventricular tissue, but decreased progressively until excitation failed altogether. Similar effects were observed in dog Purkinje fibers. Propiverine obtained a low score in the TDPScreen. In conclusion, in vitro and in vivo studies of propiverine do not provide evidence for an enhanced cardiovascular safety risk. We propose that lack of torsadogenic risk of propiverine is related to enhancement of repolarization reserve by block of I(Ca,L).
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Affiliation(s)
- Torsten Christ
- Department of Pharmacology and Toxicology, Medical Faculty, Dresden University of Technology, Fetscherstrasse 74, 01307 Dresden, Germany
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Martin RL, Su Z, Limberis JT, Palmatier JD, Cowart MD, Cox BF, Gintant GA. In Vitro Preclinical Cardiac Assessment of Tolterodine and Terodiline: Multiple Factors Predict the Clinical Experience. J Cardiovasc Pharmacol 2006; 48:199-206. [PMID: 17110801 DOI: 10.1097/01.fjc.0000246853.15926.d4] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Terodiline and tolterodine are drugs used to treat urinary incontinence. Terodiline was removed from the market in 1991 for proarrhythmia, whereas tolterodine has a generally benign clinical cardiac profile. To assess differences in the electrophysiologic actions of these drugs, we evaluated their effects on hERG current (HEK cells) and cardiac Purkinje fiber repolarization. The IC50 for hERG block (37 degrees C) by tolterodine was 9.6 nM and by terodiline was 375 nM, values near or below clinical concentrations. Tolterodine elicited concentration-dependent prolongation of the action potential duration (APD90). In contrast, terodiline depressed the action potential plateau and induced triangulation without affecting APD90. The triangulation ratios (normalized ratio of APD50 over APD90) for terodiline were 0.94 and 0.59 for 1.0 and 10 microM and for tolterodine, were 0.99 and 0.97 at 7 and 70 nM. In summary, tolterodine, a potent hERG blocker, has a benign clinical cardiac profile at therapeutic concentrations that may be due to its lack of triangulation, as well as extensive plasma protein binding. However, at supratherapeutic concentrations, preclinical data predict risk of QT prolongation. These data suggest that hERG block and triangulation are among multiple factors that must be considered in preclinical cardiac safety assessments.
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Affiliation(s)
- Ruth L Martin
- Department of Integrative Pharmacology, Abbott, Abbott Park, Illinois 60064-6119, USA.
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Dmochowski R, Staskin DR. The Q-T interval and antimuscarinic drugs. CURRENT BLADDER DYSFUNCTION REPORTS 2006. [DOI: 10.1007/s11884-006-0001-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Antimuscarinic drugs form the mainstay of pharmacotherapy for the treatment of overactive bladder. The primary sites of activity of the agents for the desired therapeutic effect are the M3 and M2 receptors of the bladder. Drug interaction with other non-vesical muscarinic receptors produces a range of undesired adverse events. In general, certain adverse effects associated with antimuscarinic agents such as dry mouth (salivary) and constipation (colon) may be considered only bothersome, and somnolence and confusion (central nervous system) may be considered more serious in nature. However, effects on the myocardium are considered to be more significant safety issues and increased awareness and understanding of the effect of drugs on the myocardium, including the additional effects of drug-drug interaction, has increased a need for the evaluation of new drugs for cardiac safety. The role of genetics (and the identification of populations at risk) in the causation of congenital dysrhythmias has received specific attention in this area. New drugs now must undergo more intense scrutiny and cardiac testing to evaluate their effects on cardiac rate and rhythm, especially the QT interval. The recently approved agents (trospium, solifenacin, darifenacin) used for the treatment of overactive bladder have been rigorously evaluated for these effects.
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Affiliation(s)
- Roger Dmochowski
- Vanderbilt Continence Center, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN 37232-2765, USA.
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Kang J, Chen XL, Wang H, Ji J, Reynolds W, Lim S, Hendrix J, Rampe D. Cardiac Ion Channel Effects of Tolterodine. J Pharmacol Exp Ther 2004; 308:935-40. [PMID: 14711935 DOI: 10.1124/jpet.103.062182] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Tolterodine is a muscarinic antagonist widely used in the treatment of urinary incontinence. Although tolterodine has not been reported to alter cardiac repolarization, it is chemically related to other muscarinic antagonists known to prolong cardiac repolarization. For this reason, we studied the effects of tolterodine on cardiac ion channels and action potential recordings. Using patch-clamp electrophysiology, we found that tolterodine was a potent antagonist of the human ether-a-go-go-related gene (HERG) K(+) channel, displaying an IC(50) value of 17 nM. This potency was similar to that observed for the antiarrhythmic drug dofetilide (IC(50) of 11 nM). Tolterodine block of HERG displayed a positive voltage dependence, suggesting an interaction with an activated state. Tolterodine had little effect on the human cardiac Na(+) channel at concentrations of up to 1 microM. Inhibition of L-type Ca(2+) currents by tolterodine was frequency-dependent with IC(50) values measuring 143 and 1084 nM at 1 and 0.1 Hz, respectively. Both tolterodine and dofetilide prolonged action potential duration in single guinea pig myocytes over the concentration range of 3 to 100 nM. However, prolongation was significantly larger for dofetilide compared with tolterodine. Tolterodine seems to be an unusual drug in that it blocks HERG with high affinity, but produces little QT prolongation clinically. Low plasma levels after therapeutic doses combined with mixed ion channel effects, most notably Ca(2+) channel blockade, may serve to attenuate the QT prolonging effects of this potent HERG channel antagonist.
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Affiliation(s)
- Jiesheng Kang
- Department of Drug Safety Evaluation, Bridgewater, NJ, USA
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16
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Drug Therapy of Urinary Urge Incontinence. Obstet Gynecol 2002. [DOI: 10.1097/00006250-200211000-00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fossa AA, DePasquale MJ, Raunig DL, Avery MJ, Leishman DJ. The relationship of clinical QT prolongation to outcome in the conscious dog using a beat-to-beat QT-RR interval assessment. J Pharmacol Exp Ther 2002; 302:828-33. [PMID: 12130750 DOI: 10.1124/jpet.102.035220] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
QT interval prolongation of the electrocardiogram has been associated with the occurrence of life-threatening fatal ventricular arrhythmias. To understand the relationship between preclinical cardiac conduction assessment to clinical outcome, comparisons of free (unbound)-plasma drug concentrations and their associated effects in the conscious mongrel dog were made to the free plasma concentrations in humans reported to produce QT prolongation. E-4031 (an experimental class III antiarrhythmic), cisapride, terfenadine, terodiline, and verapamil all affect cardiac repolarization and can produce QT prolongation in humans. In the conscious dog, the QT interval was assessed on a beat-to-beat basis in relation to each preceding RR interval at concentrations approximating the same unbound human concentrations. E-4031, cisapride and terodiline statistically increased the QT(RR1000) interval [the QT interval at a 60 beats/min (bpm) heart rate] 23, 8, and 9 ms, respectively, at concentrations 0.3 to 15.8 times their relevant clinical level. Increases were not observed for terfenadine or verapamil (p > 0.05 at all doses). Inspection of individual dog QT versus RR interval relationships showed clear QT interval responses specific to each treatment but not readily apparent when data are averaged at a heart rate of 60 bpm. For specific rectifier K(+) current (IKr) blockers, robust effects on mean QT prolongation can be detected. However, for drugs that affect repolarization through multiple channels, the effect on the mean QT interval may be more difficult to detect. Inspection of the beat-to-beat QT-RR interval relationship in an individual animal can increase the sensitivity for more accurate clinical prediction.
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Affiliation(s)
- Anthony A Fossa
- Pfizer Global Research and Development, Eastern Point Road, Building 118, MS 4036, Groton, CT 06340, USA.
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18
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Wang PS, Levin R, Zhao SZ, Avorn J. Urinary antispasmodic use and the risks of ventricular arrhythmia and sudden death in older patients. J Am Geriatr Soc 2002; 50:117-24. [PMID: 12028256 DOI: 10.1046/j.1532-5415.2002.50017.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The introduction of new medications to treat overactive bladder has resulted in a significant increase in the number of individuals with this condition who use medications for symptoms. Formal epidemiological studies of the safety of these medications in typical patient populations are lacking, particularly studies of serious events. We sought to determine whether the use of urinary antispasmodics increases the risk of ventricular arrhythmias or sudden death. DESIGN Retrospective cohort study. SETTING Retrospective analysis of data of participants in community, hospital or nursing home setting. PARTICIPANTS Fourteen thousand six hundred thirty-eight subjects with a diagnosis of urinary incontinence made between January 1, 1991, and June 30, 1995; all were aged 65 and older and enrolled in Medicare and Medicaid or the Pharmacy Assistance for the Aged and Disabled programs of New Jersey. MEASUREMENTS Filled prescriptions for oxybutynin (Ditropan), flavoxate (Urispas), hyoscyamine (Cystospas), and hyoscyamine sulfate (Cystospas-M) were used to define days of exposure to these drugs. We also identified all use of nonsedating antihistamines and cytochrome P450 3A4 inhibitors, and their concurrent use, to serve as a positive control exposure. Two outcomes were then defined: a new diagnosis of ventricular arrhythmia combined with initiation of an antiarrhythmic medication and sudden death. Other covariates, including clinical, demographic, medication use, and healthcare utilization variables, were also assessed. Adjusted risk ratios of ventricular arrhythmia and sudden death were derived from multivariable Cox proportional hazards models. RESULTS There was no significant association between periods of use of urinary antispasmodics and the development of ventricular arrhythmias (adjusted risk ratio (RR) = 1.23, 95 confidence interval (CI) = 0.87-1.75) or sudden death (adjusted RR = 0.70, 95% CI = 0.28-1.74). A significantly increased risk of ventricular arrhythmia was observed for the positive control regimen, concurrent use of nonsedating antihistamines and cytochrome P450 3A4 inhibitors (adjusted RR = 5.47; 95% CI = 1.34-22.26), but not for use of either drug group alone. Concurrent use of nonsedating antihistamines and cytochrome P450 3A4 inhibitors was also associated with a significant increase in the risk of sudden death (adjusted RR = 21.50, 95% CI = 5.23-88.37). Other variables significantly associated with ventricular arrhythmia included ischemic heart disease and congestive heart failure, whereas nursing home use before the index date was associated with a decreased likelihood of receiving a diagnosis of and treatment for ventricular arrhythmia. Other variables significantly associated with sudden death included male gender, black race, and congestive heart failure. CONCLUSIONS Antimuscarinic urinary antispasmodics available before 1996 were not associated with an increased risk of ventricular arrhythmias and sudden death. Additional study will be required to confirm these results, exclude the possibility of unmeasured confounders contributing to any lack of an observed relationship, and extend these findings to newer agents such as tolterodine.
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Affiliation(s)
- Philip S Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Srinivas NR, Barbhaiya RH, Midha KK. Enantiomeric drug development: issues, considerations, and regulatory requirements. J Pharm Sci 2001; 90:1205-15. [PMID: 11745774 DOI: 10.1002/jps.1074] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- N R Srinivas
- Metabolism and Pharmacokinetics, Bristol-Myers Squibb Pharmaceutical Research Institute, Princeton, NJ 08543, USA
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20
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Witchel HJ, Hancox JC. Familial and acquired long qt syndrome and the cardiac rapid delayed rectifier potassium current. Clin Exp Pharmacol Physiol 2000; 27:753-66. [PMID: 11022966 DOI: 10.1046/j.1440-1681.2000.03337.x] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
1. Long QT syndrome (LQTS) is a cardiac disorder characterized by syncope, seizures and sudden death; it can be congenital, idiopathic, or iatrogenic. 2. Long QT syndrome is so-named because of the connection observed between the distinctive polymorphic ventricular tachycardia torsade de pointes and prolongation of the QT interval of the electrocardiogram, reflecting abnormally slowed ventricular action potential (AP) repolarization. Acquired LQTS has many similar clinical features to congenital LQTS, but typically affects older individuals and is often associated with specific pharmacological agents. 3. A growing number of drugs associated with QT prolongation and its concomitant risks of arrhythmia and sudden death have been shown to block the 'rapid' cardiac delayed rectifier potassium current (IKr) or cloned channels encoded by the human ether-a-go-go-related gene (HERG; the gene believed to encode native IKr). Because IKr plays an important role in ventricular AP repolarization, its inhibition would be expected to result in prolongation of both the AP and QT interval of the electrocardiogram. 4. The drugs that produce acquired LQTS are structurally heterogeneous, including anti-arrhythmics, such as quinidine, non-sedating antihistamines, such as terfenadine, and psychiatric drugs, such as haloperidol. In addition to heterogeneity in their structure, the electrophysiological characteristics of HERG/IKr inhibition differ between agents. 5. Here, clinical observations are associated with cellular data to correlate acquired LQTS with the IKr/HERG potassium (K+) channel. One strategy for developing improved compounds in those drug classes that are currently associated with LQTS could be to design drug structures that preserve clinical efficacy but are modified to avoid pharmacological interactions with IKr. Until such time, awareness of the QT-prolongation risk of particular agents is important for the clinician.
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Affiliation(s)
- H J Witchel
- Department of Physiology and Cardiovascular Research Laboratories, School of Medical Sciences, University of Bristol, United Kingdom.
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Jones SE, Shuba LM, Zhabyeyev P, McCullough JR, McDonald TF. Differences in the effects of urinary incontinence agents S-oxybutynin and terodiline on cardiac K(+) currents and action potentials. Br J Pharmacol 2000; 131:245-54. [PMID: 10991917 PMCID: PMC1572333 DOI: 10.1038/sj.bjp.0703595] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
1. The cardiac electrophysiological effects of S-oxybutynin, a single-enantiomer drug under evaluation for the management of urinary incontinence, have been investigated and compared with those of terodiline, an incontinence agent withdrawn following reports of QT lengthening and ventricular tachyarrhythmia. Membrane currents were recorded from whole-cell configured guinea-pig and rabbit ventricular myocytes, and action potentials were recorded from guinea-pig and rabbit papillary muscles. 2. L-type Ca(2+) current (I:(Ca,L)), rapidly-activating K(+) current (I:(Kr)) and slowly-activating K(+) current (I:(Ks)) were unaffected by submicromolar S-oxybutynin and inhibited by higher concentrations; IC(50) values were 17.8 microM for I:(Ca,L), 12 microM for I:(Kr), and 41 microM for I:(Ks). Terodiline IC(50) values were somewhat lower for I:(Ca,L) (15.2 microM) and I:(Ks) (30 microM), but 24 fold lower in the case of I:(Kr) (0.5 microM). 3. The durations of action potentials in guinea-pig and rabbit papillary muscles driven at 1 Hz were unaffected or moderately shortened by 0.1 - 100 microM S-oxybutynin, but lengthened by terodiline. Terodiline (< or =10 microM) also depressed maximal upstroke velocity. 4. The action potential plateau shortened by an average of 23% when control rabbit papillary muscles were driven at 0.4 Hz instead of 1 Hz. Plateau shortening was significantly smaller in the presence of drugs (30 microM S-oxybutynin, 3 and 30 microM terodiline), suggesting that they suppress the transient outward current (I:(to)) involved in rate-dependent shortening. In experiments on rabbit ventricular myocytes, 3 and 30 microM S-oxybutynin inhibited I:(to) by 9+/-2% and 35+/-3%, respectively, whereas 3 and 30 microM terodiline inhibited the current by 31+/-3% and 87+/-3%, respectively. 5. The results indicate that S-oxybutynin has relatively weak non-specific effects on cardiac ion channels, and that clinically relevant submicromolar concentrations are unlikely to have terodiline-like proarrhythmic actions on the myocardium.
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Affiliation(s)
- Stephen E Jones
- Department of Physiology and Biophysics, Dalhousie University Halifax, Nova Scotia, B3H 4H7 Canada
| | - Lesya M Shuba
- Department of Physiology and Biophysics, Dalhousie University Halifax, Nova Scotia, B3H 4H7 Canada
| | - Pavel Zhabyeyev
- Department of Physiology and Biophysics, Dalhousie University Halifax, Nova Scotia, B3H 4H7 Canada
| | - John R McCullough
- Sepracor Inc., 111 Locke Avenue, Marlborough, Massachusetts, MA 01752, U.S.A
| | - Terence F McDonald
- Department of Physiology and Biophysics, Dalhousie University Halifax, Nova Scotia, B3H 4H7 Canada
- Author for correspondence:
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Ford GA, Wood SM, Daly AK. CYP2D6 and CYP2C19 genotypes of patients with terodiline cardiotoxicity identified through the yellow card system. Br J Clin Pharmacol 2000; 50:77-80. [PMID: 10886124 PMCID: PMC2014965 DOI: 10.1046/j.1365-2125.2000.00230.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AIMS Terodiline has concentration dependent QT prolonging effects and thus the potential for cardiotoxicity. Pharmacogenetic variation in terodiline metabolism could be responsible for cardiotoxicity. We sought to determine whether CYP2D6 (debrisoquine hydroxylase) or CYP2C19 (S-mephenytoin hydroxylase) status is a risk factor for terodiline cardiotoxicity. METHODS Using the UK Yellow Card scheme to identify patients, blood samples were obtained from eight patients who survived ventricular tachycardia or torsades de pointes suspected to be due to terodiline, for determination of CYP2D6 and CYP2C19 genotypes. Genotype prevalence was compared with that in published general population groups. RESULTS One patient was a CYP2D6 poor metaboliser (CYP2D6*4 homozygous) and a second was heterozygous for CYP2D6*4, a slightly lower frequency for these genotypes compared with the general population (P = 0.31). In the case of CYP2C19, one patient was a poor metaboliser and four were heterozygous for the variant CYP2C19*2 allele, compared with general population frequencies of 2% and 23%, respectively (P = 0.035). CONCLUSIONS These findings suggest that debrisoquine poor metaboliser status is not primarily responsible for terodiline cardiotoxicity. However, possession of the CYP2C19*2 allele appears to contribute to adverse cardiac reactions to terodiline. The present study demonstrates the feasibility of using spontaneous adverse drug reaction reporting schemes to determine the contribution of genotype for metabolizing enzymes to uncommon adverse drug reactions.
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Affiliation(s)
- G A Ford
- Department of Pharmacological Sciences, University of Newcastle upon Tyne, UK.
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23
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Ogura T, Jones S, Shuba LM, McCullough JR, McDonald TF. Block and modified gating of cardiac calcium channel currents by terodiline. Br J Pharmacol 1999; 127:1837-45. [PMID: 10482914 PMCID: PMC1566165 DOI: 10.1038/sj.bjp.0702713] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
1. Terodiline, an anticholinergic/antispasmodic drug effective in the treatment of urinary incontinence, is presently restricted due to adverse side effects on cardiac function. To characterize its effects on cardiac L-type Ca2+-channel current carried by Ca2+ (ICa, L) and Ba2+ (IBa,L), concentrations ranging from 0.1 to 100 microM were applied to whole-cell-configured guinea-pig ventricular myocytes. 2. Although sub-micromolar concentrations of terodiline had no effect on ICa,L at 0 mV, 100 microM drug reduced its amplitude to ca. 10% of pre-drug control. The estimated IC50 (15.2 microM in K+-dialysed cells, 12.2 microM in Cs+-dialysed cells; 0.1 Hz pulsing rate) is eight times higher than reported for ICa,L in bladder smooth muscle myocytes. 3. Terodiline affected ICa,L in a use-dependent manner; block increased when the pulsing rate was increased from 0.1 to 2 - 3 Hz, and when holding potential was lowered from -43 mV. The drug accelerated the decay of ICa,L at 0 mV in a concentration-dependent manner, and slowed the recovery of channels from inactivation. 4. Terodiline reduced peak IBa,L more effectively than peak ICa,L, and markedly accelerated the rate of inactivation of the current. 5. The results are discussed in terms of mechanisms of Ca2+ channel block and relation to the therapeutic and cardiotoxic effects of the drug.
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Affiliation(s)
- T Ogura
- Department of Physiology and Biophysics, Dalhousie University, Halifax, Nova Scotia, Canada B3H 4H7
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Jones SE, Kasamaki Y, Ogura T, Shuba LM, McCullough JR, McDonald TF. Inhibition of cardiac inward-rectifier K+ current by terodiline. Eur J Pharmacol 1999; 370:319-27. [PMID: 10334509 DOI: 10.1016/s0014-2999(99)00130-2] [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: 11/27/2022]
Abstract
The antispasmodic agent terodiline has cardiotoxic effects that include QT lengthening. To determine whether inhibition of inwardly-rectifying K+ current (I(K1)) might be a factor in the cardiotoxicity, we measured I(K1) in guinea pig ventricular myocytes. Terodiline reduced outward I(K1) with an IC50 of 7 microM; maximal reduction was 60% with 100-300 microM concentration. Inhibition was independent of current direction, and persisted after removal of the drug. Terodiline (3-5 microM) lengthened action potentials in guinea pig papillary muscles by ca. 10%, primarily by slowing phase 3 repolarization; higher concentrations abbreviated the plateau and markedly slowed late repolarization. Terodiline washout provoked an extra lengthening, consistent with persistent inhibition of I(K1) and rapid recovery of net inward plateau current. The results suggest that inhibition of I(K1) is a likely factor in the cardiotoxicity of the drug.
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Affiliation(s)
- S E Jones
- Department of Physiology and Biophysics, Dalhousie University, Halifax, Nova Scotia, Canada
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25
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Proceedings of the British Toxicology Society Autumn Meeting University of York 20-22 September 1998. Hum Exp Toxicol 1999. [DOI: 10.1177/096032719901800107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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26
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Wagg A, Malone-Lee J. The management of urinary incontinence in the elderly. BRITISH JOURNAL OF UROLOGY 1998; 82 Suppl 1:11-7. [PMID: 9883257 DOI: 10.1046/j.1464-410x.1998.0820s1011.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- A Wagg
- Department of Medicine, University College London Medical School, St Pancras Hospital, UK
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27
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Jones SE, Ogura T, Shuba LM, McDonald TF. Inhibition of the rapid component of the delayed-rectifier K+ current by therapeutic concentrations of the antispasmodic agent terodiline. Br J Pharmacol 1998; 125:1138-43. [PMID: 9863639 PMCID: PMC1565686 DOI: 10.1038/sj.bjp.0702173] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Prolongation of the QT interval and malignant ventricular arrhythmia have been observed in patients administered terodiline for urinary incontinence. Since this adverse reaction might be caused by inhibition of delayed-rectifier K+ current (IK), we investigated whether clinically relevant (< or = 10 microM) concentrations of the drug modify IK in guinea-pig ventricular myocytes. Myocytes superfused with normal Tyrode's solution were pulsed from -40 mV to more positive test potentials (V) for 0.2 - 1 s to elicit tail IK on repolarization and measure tail IK-V relationships. IKr was distinguished from IKs by its sensitivity to the selective blocker E4031. Inhibition of IKr by 5 microM E4031 was completely occluded by pretreatment with 3 microM terodiline. In addition, action potential lengthening by E4031 in guinea-pig papillary muscles (29+/-3%) was abolished (3+/-2%) (P<0.001) by terodiline pretreatment. Inhibition of IKr by terodiline appeared to be voltage-independent, and the parameters of the Hill equation describing the inhibition were IC50 = 0.7 microM and nH = 1.6. High concentrations of the drug also affect IKs; in experiments with K+-free Tyrode's, 10 microM terodiline inhibited tail IKs by 27+/-3% (n=5) (P< 0.001). These data suggest that QT lengthening at therapeutic concentrations of the drug (approximately equal to 1.5 microM) is primarily due to inhibition of IKr. Inhibition of other K+ currents such as IKs is likely to be important at higher concentrations.
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Affiliation(s)
- S E Jones
- Department of Physiology and Biophysics, Dalhousie University, Halifax, Nova Scotia, Canada
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Natsukawa T, Matsuzaki T, Hayashi S, Ukai Y, Yoshikuni Y, Kimura K. Comparison of the effects of NS-21 and terodiline on the QTc interval in dogs. GENERAL PHARMACOLOGY 1998; 30:137-42. [PMID: 9457495 DOI: 10.1016/s0306-3623(97)00025-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
1. NS-21 [(+/-)-4-diethylamino-1,1-dimethylbut-2-yn-1-yl 2-cyclohexyl-2-hydroxy-2-phenylacetate monohydrochloride monohydrate], its active metabolite, RCC-36, and terodiline, are mixed anticholinergic-Ca2+ antagonistic drugs. Among them, terodiline has been shown to cause torsade de pointes, a serious polymorphic ventricular tachycardia. It remains unknown, however, whether NS-21 or its active metabolite, RCC-36, produces torsade de pointes. 2. In anesthetized dogs, terodiline (10 mg/kg i.v.) significantly prolonged the QTc interval by 6-8%, an effect thought to be associated with torsade de pointes. In contrast, neither NS-21 nor RCC-36 (10 mg/kg i.v.) prolonged the QTc interval; therefore NS-21 is unlikely to cause ventricular tachyarrhythmias, such as those associated with terodiline. 3. The effects of NS-21, RCC-36 and terodiline on the action potential were investigated in guinea pig papillary muscle. However, none of these drugs prolonged the duration of the action potential, although only terodiline caused the muscle preparation to lose its excitability.
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Affiliation(s)
- T Natsukawa
- Research Laboratories, Nippon Shinyaku Co., Ltd., Kyoto, Japan
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Abstract
Drugs can cause cardiac arrhythmias in a number of clinical situations, and many of the implicated agents are used to treat non-cardiac conditions. These adverse effects are frequently idiosyncratic, but are often mediated via triggered activity causing torsade de pointes. Drugs being used for treatment of cardiac conditions may promote arrhythmias by re-entrant mechanisms or via triggered activity. Many drugs may cause cardiac arrhythmic complications when taken in excessive amounts. Keys to reducing the incidence of drug-induced cardiac arrhythmias include increased awareness among the medical, pharmaceutical and nursing professions of the potential problems in using certain agents, especially in specific situations. Appropriate monitoring when such treatment is essential and, after diagnosis, prompt withdrawal of the offending agent and treatment for the arrhythmia should be initiated.
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Affiliation(s)
- J C Doig
- Cardiology Department, North Tyneside General Hospital, North Shields, England
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Hartigan-Go K, Bateman DN, Nyberg G, Mårtensson E, Thomas SH. Concentration-related pharmacodynamic effects of thioridazine and its metabolites in humans. Clin Pharmacol Ther 1996; 60:543-53. [PMID: 8941027 DOI: 10.1016/s0009-9236(96)90150-2] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To measure cardiac and other effects of thioridazine and relate these to the plasma concentration of the parent drug and its principal metabolites. METHODS A double-blind, randomized-order crossover study involving nine healthy male subjects compared the effects of single doses of thioridazine (10 mg and 50 mg) with placebo. Plasma concentrations of thioridazine and its ring sulfoxide, side-chain sulfoxide, and side-chain sulfone metabolites were measured, together with effects on the ECG, blood pressure, salivary flow, and a batch of psychomotor tests for 72 hours after administration. RESULTS Thioridazine, 50 mg, reduced standing systolic blood pressure (mean peak changes from baseline [95% CI] -32 mm Hg [-55, 10 mm Hg]; p < 0.01 versus placebo) and diastolic blood pressure (-14 mm Hg [-26, -2 mm Hg]; p < 0.05), increased standing heart rate (7 beats/min [-1, 16 beats/min]; p < 0.05), impaired psychomotor function, and prolonged the JT (20 ms1/2 [7, 34 ms1/2]; p < 0.05), QTa (22 ms1/2 [8, 36 ms1/2]; p < 0.05), and QTc (22 ms1/2 [11, 33 ms1/2]; p < 0.01) intervals, but had no effect on QT dispersion (-12 ms1/2 [-31, 6 ms1/2]). Thioridazine, 1.0 mg, also significantly increased QTc, but the effect was less marked (9 ms1/2 [-1, 19 ms1/2]; p < 0.05). Plasma thioridazine and metabolite concentrations did not correlate significantly with these effects. Maximum effects on QTc occurred after peak concentrations of thioridazine but before peak concentrations of the ring sulfoxide and side-chain sulfone metabolites. CONCLUSIONS These data suggest that thioridazine has dose-related effects on ventricular repolarization and that the parent drug causes an important proportion of these effects, although its metabolites may also contribute.
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Affiliation(s)
- K Hartigan-Go
- Wolfson Department of Clinical Pharmacology, University of Newcastle, Newcastle-upon-Tyne, England
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Hartigan-Go K, Bateman DN, Daly AK, Thomas SH. Stereoselective cardiotoxic effects of terodiline. Clin Pharmacol Ther 1996; 60:89-98. [PMID: 8689817 DOI: 10.1016/s0009-9236(96)90171-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To study the cardiovascular and electrocardiographic (ECG) effects of the R(+)- and S(-)- enantiomers of terodiline. The racemic drug was previously used to treat detrusor instability but was withdrawn after it caused serious ventricular arrhythmias associated with prolongation of the QT interval. METHODS A double-blind, placebo-controlled, randomized crossover study was performed that involved nine healthy volunteers who were given single oral doses of racemic terodiline hydrochloride (200 mg), R(+)-terodiline hydrochloride (100 mg), S(-)-terodiline tartrate (100 mg), or placebo. Plasma concentrations of each enantiomer and cardiovascular and ECG effects, including QT intervals and QT dispersion, were measured over 14 days after each treatment. RESULTS Both racemic and R(+)-terodiline significantly increased QT interval, corrected QT interval (QTc), and QRS duration (all p < 0.05), without affecting QT dispersion. S(-)-Terodiline tartrate (100 mg) did not affect QTc. Peak effects occurred 8 hours after dosing when increases in QTc from baseline (95% confidence intervals) were -3 (-20, 13) for placebo, 23 (8, 37) for racemic terodiline, 19 (6, 33) for R(+)-terodiline, and 0 (-10, 9) ms1/2 for S(-)-terodiline. Although differences were observed between the pharmacokinetics of the two enantiomers, these were not sufficient to account for the differences in ECG effects, and elimination half-lives were similar. Elimination of terodiline enantiomers was not significantly delayed in two genotypic poor metabolizers of debrisoquin (CYP2D6). CONCLUSIONS QT prolongation associated with racemic terodiline is caused exclusively by the R(+)-enantiomer, which therefore appears to be responsible for the ventricular arrhythmias caused by the drug.
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Affiliation(s)
- K Hartigan-Go
- Wolfson Department of Clinical Pharmacology, University of Newcastle, Claremont Place, Newcastle-upon-Tyne, England
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Hussain RM, Hartigan-Go K, Thomas SH, Ford GA. Effect of oxybutynin on the QTc interval in elderly patients with urinary incontinence. Br J Clin Pharmacol 1996; 41:73-5. [PMID: 8824696 DOI: 10.1111/j.1365-2125.1996.tb00161.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
1. Terodiline, an anticholinergic drug with calcium antagonist properties, is associated with QT prolongation and ventricular arrhythmias. It is not known if oxybutynin, a drug with a similar pharmacological profile, causes QT prolongation. ECGs were obtained before and at least 4 weeks after commencement of oxybutynin (mean daily dose 7.6, range 2.5-10 mg), in 21 elderly (mean age 75, range 58-88 years) patients treated for urinary incontinence. Heart rate, (mean +/- s.d.) 74 +/- 11 vs 69 +/- 11 beats min-1, -6 (-13,2), before vs during oxybutynin therapy, mean difference (95% confidence intervals); PR interval, 168 +/- 27 vs 156 +/- 27 ms, -11 (-26,3); QTc 454 +/- 27 vs 447 +/- 31 ms1/2, -9 (-23,5), and QTc dispersion, QTc max-QTc min, 68 +/- 24 vs 63 +/- 26 ms1/2, -1 (-15,14) were all unaltered by oxybutynin therapy. The lack of an effect on resting heart rate suggests that oxybutynin has little anticholinergic action at cardiac M2 receptors at usually administered doses. Oxybutynin therapy is not associated with QTc interval prolongation and is unlikely to produce ventricular arrhythmias.
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Affiliation(s)
- R M Hussain
- Department of Medicine (Geriatrics), University of Newcastle upon Tyne, UK
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