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Shang E, Tan H. Comparison of Drug Therapy Efficacy in Patients With Hypertrophic Cardiomyopathy: A Network Meta-Analysis. Am J Cardiol 2024; 226:97-107. [PMID: 39019204 DOI: 10.1016/j.amjcard.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 07/02/2024] [Accepted: 07/09/2024] [Indexed: 07/19/2024]
Abstract
The aim of this network meta-analysis was to compare the efficacy of various commonly used drugs in treating patients with hypertrophic cardiomyopathy (HCM). Randomized controlled trials on drugs for HCM treatment were retrieved from PubMed, Embase, Cochrane Library, and Web of Science (search cutoff: January 10, 2024). Quality assessment was performed using the risk of bias tool, and data analysis used R software. Seventeen studies (1,133 patients with HCM) were included. The network meta-analysis indicated that mavacamten and perhexiline improved peak oxygen consumption compared with placebo. Mavacamten reduced N-terminal pro-B-type natriuretic peptide, left ventricular mass index, left atrial volume index, and septal E/e' ratio. Losartan decreased systolic blood pressure, whereas candesartan, mavacamten, and valsartan reduced maximum wall thickness. Perhexiline had better efficacy in increasing peak oxygen consumption, and candesartan in reducing maximum wall thickness. No drug significantly improved left ventricular ejection fraction compared with placebo. In conclusion, on the basis of current studies, commonly used drugs may effectively improve some of the outcome measures in patients with HCM, whereas the novel drug mavacamten showed significant therapeutic effects in most of the remaining outcome measures except for left ventricular ejection fraction.
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Affiliation(s)
- Erhan Shang
- School of Medicine, Shenzhen Campus of Sun Yat-Sen University, Shenzhen, Guangdong, China.
| | - Hongmei Tan
- School of Medicine, Shenzhen Campus of Sun Yat-Sen University, Shenzhen, Guangdong, China.
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Dhakal B, Tomita Y, Drew P, Price T, Maddern G, Smith E, Fenix K. Perhexiline: Old Drug, New Tricks? A Summary of Its Anti-Cancer Effects. Molecules 2023; 28:molecules28083624. [PMID: 37110858 PMCID: PMC10145508 DOI: 10.3390/molecules28083624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
Cancer metabolic plasticity, including changes in fatty acid metabolism utilisation, is now widely appreciated as a key driver for cancer cell growth, survival and malignancy. Hence, cancer metabolic pathways have been the focus of much recent drug development. Perhexiline is a prophylactic antianginal drug known to act by inhibiting carnitine palmitoyltransferase 1 (CPT1) and 2 (CPT2), mitochondrial enzymes critical for fatty acid metabolism. In this review, we discuss the growing evidence that perhexiline has potent anti-cancer properties when tested as a monotherapy or in combination with traditional chemotherapeutics. We review the CPT1/2 dependent and independent mechanisms of its anti-cancer activities. Finally, we speculate on the clinical feasibility and utility of repurposing perhexiline as an anti-cancer agent, its limitations including known side effects and its potential added benefit of limiting cardiotoxicity induced by other chemotherapeutics.
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Affiliation(s)
- Bimala Dhakal
- Discipline of Surgery, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, SA 5011, Australia
| | - Yoko Tomita
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, SA 5011, Australia
- Medical Oncology, The Queen Elizabeth Hospital, Adelaide, SA 5011, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Paul Drew
- Discipline of Surgery, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, SA 5011, Australia
| | - Timothy Price
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, SA 5011, Australia
- Medical Oncology, The Queen Elizabeth Hospital, Adelaide, SA 5011, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Guy Maddern
- Discipline of Surgery, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, SA 5011, Australia
| | - Eric Smith
- Discipline of Surgery, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, SA 5011, Australia
- Medical Oncology, The Queen Elizabeth Hospital, Adelaide, SA 5011, Australia
| | - Kevin Fenix
- Discipline of Surgery, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, SA 5011, Australia
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Perhexiline Therapy in Patients with Type 2 Diabetes: Incremental Insulin Resistance despite Potentiation of Nitric Oxide Signaling. Biomedicines 2022; 10:biomedicines10102381. [PMID: 36289640 PMCID: PMC9598312 DOI: 10.3390/biomedicines10102381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/16/2022] [Accepted: 09/17/2022] [Indexed: 11/21/2022] Open
Abstract
Perhexiline (Px) inhibits carnitine palmitoyltransferase 1 (CPT1), which controls uptake of long chain fatty acids into mitochondria. However, occasional cases of hypoglycaemia have been reported in Px-treated patients, raising the possibility that Px may also increase sensitivity to insulin. Furthermore, Px increases anti-aggregatory responses to nitric oxide (NO), an effect which may theoretically parallel insulin sensitization. We therefore sought to examine these relationships in patients with stable Type 2 diabetes (T2D) and cardiovascular disease (n = 30). Px was initiated, and dosage was titrated, to reach the therapeutic range and thus prevent toxicity. Investigations were performed before and after 2 weeks, to examine changes in insulin sensitivity and, utilizing aggregometry in whole blood, platelet responsiveness to the anti-aggregatory effects of the NO donor sodium nitroprusside (SNP). Other parameters that affect may affect NO signalling were also evaluated. Px substantially potentiated inhibition of platelet aggregation by SNP (from 16.7 ± 3.0 to 27.3 ± 3.7%; p = 0.005). Px did not change fasting blood glucose concentrations but reduced insulin sensitivity (HOMA-IR score increased from median of 4.47 to 6.08; p = 0.028), and increased fasting plasma insulin concentrations (median 16.5 to 19.0 mU/L; p = 0.014). Increases in SNP responses tended (r = −0.30; p = 0.11) to be reciprocally related to increases in HOMA-IR, and increases in HOMA-IR were greater (p = 0.002) in patients without NO-sensitizing effects. No patient developed symptomatic hypoglycaemia, nor was there any other short-term toxicity of Px. Thus, in patients with stable T2D and cardiovascular disease, Px increases anti-aggregatory responsiveness to NO, but is not an insulin sensitizer, and does not induce hypoglycaemia. Absence of NO-sensitizing effect occurs in approximately 30% of Px-treated patients with T2D, and is associated with induction of insulin resistance in these patients.
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Sreenivasan J, Hooda U, Aronow WS. What is the current value of beta-adrenoreceptor antagonists for angina? Expert Opin Pharmacother 2021; 23:413-416. [PMID: 34789060 DOI: 10.1080/14656566.2021.2006181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Jayakumar Sreenivasan
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Urvashi Hooda
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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Ananthakrishna R, Lee SL, Foote J, Sallustio BC, Binda G, Mangoni AA, Woodman R, Semsarian C, Horowitz JD, Selvanayagam JB. Randomized controlled trial of perhexiline on regression of left ventricular hypertrophy in patients with symptomatic hypertrophic cardiomyopathy (RESOLVE-HCM trial). Am Heart J 2021; 240:101-113. [PMID: 34175315 DOI: 10.1016/j.ahj.2021.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 06/20/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The presence and extent of left ventricular hypertrophy (LVH) is a major determinant of symptoms in patients with hypertrophic cardiomyopathy (HCM). There is increasing evidence to suggest that myocardial energetic impairment represents a central mechanism leading to LVH in HCM. There is currently a significant unmet need for disease-modifying therapy that regresses LVH in HCM patients. Perhexiline, a potent carnitine palmitoyl transferase-1 (CPT-1) inhibitor, improves myocardial energetics in HCM, and has the potential to reduce LVH in HCM. OBJECTIVE The primary objective is to evaluate the effects of perhexiline treatment on the extent of LVH, in symptomatic HCM patients with at least moderate LVH. METHODS/DESIGN RESOLVE-HCM is a prospective, multicenter double-blind placebo-controlled randomized trial enrolling symptomatic HCM patients with at least moderate LVH. Sixty patients will be randomized to receive either perhexiline or matching placebo. The primary endpoint is change in LVH, assessed utilizing cardiovascular magnetic resonance (CMR) imaging, after 12-months treatment with perhexiline. SUMMARY RESOLVE-HCM will provide novel information on the utility of perhexiline in regression of LVH in symptomatic HCM patients. A positive result would lead to the design of a Phase 3 clinical trial addressing long-term effects of perhexiline on risk of heart failure and mortality in HCM patients.
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Affiliation(s)
- Rajiv Ananthakrishna
- College of Medicine and Public Health, Flinders University, Adelaide, Australia; South Australian Health and Medical Research Institute, Adelaide, Australia; Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Sau L Lee
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Jonathon Foote
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Benedetta C Sallustio
- Department of Clinical Pharmacology, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, Australia; Discipline of Pharmacology, Adelaide Medical School, University of Adelaide, Australia
| | - Giulia Binda
- South Australian Health and Medical Research Institute, Adelaide, Australia; Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Arduino A Mangoni
- Department of Clinical Pharmacology, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide, Australia
| | - Richard Woodman
- Flinders Centre for Epidemiology and Biostatistics, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute and Sydney Medical School, University of Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - John D Horowitz
- The Queen Elizabeth Hospital, Basil Hetzel Institute for Translational Research, University of Adelaide, Adelaide, Australia
| | - Joseph B Selvanayagam
- College of Medicine and Public Health, Flinders University, Adelaide, Australia; South Australian Health and Medical Research Institute, Adelaide, Australia; Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia.
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Shatoor AS, Al Humayed S, Almohiy HM. Short-term administration of C. aronia stimulates insulin signaling, suppresses fatty acids metabolism, and increases glucose uptake and utilization in the hearts of healthy rats. Saudi J Biol Sci 2021; 28:1966-1977. [PMID: 33732083 PMCID: PMC7938129 DOI: 10.1016/j.sjbs.2020.12.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/24/2020] [Accepted: 12/29/2020] [Indexed: 11/03/2022] Open
Abstract
This study evaluated the effect of Crataegus aronia (C. aronia) aqueous extract on cardiac substrate utilization and insulin signaling in adult male healthy Wistar rats. Rats (n = 18/group) were either administered normal saline (vehicle) or treated with C. aronia aqueous extract (200 mg/kg) for 7 days, daily. Fasting plasma glucose and insulin levels were not significantly changed in C. aronia-treated rats but were significantly reduced after both the intraperitoneal glucose or insulin tolerance tests. Besides, C. aronia significantly increased the left ventricular (LV) activities of phosphofructokinase (PFK) and pyruvate dehydrogenase (PDH), two markers of glycolysis and glucose oxidation, respectively, and suppressed the levels of pyruvate dehydrogenase kinase 4 (PDK4), an inhibitor of PDH. Concomitantly, it significantly reduced the LV levels of carnitine palmitoyltransferase 1 (CPT1) and PPARα, two markers of fatty acid (FAs) oxidations. Under basal and insulin stimulation, C. aronia aqueous extract boosted insulin signaling in the LV of rats by increasing the protein levels of p-IRS (Tyr612) and p-Akt (Ser473) and suppressing protein levels of p-mTOR (Ser 2448) and p-IRS (Ser307). In parallel, C. aronia also increased the protein levels of GLUT-4 in the membrane fraction of the treated LVs. All these effects were also associated with a significant increase in AMPK activity (phosphorylation at Thr172), a major energy modulator that stimulates glucose utilization. In conclusion, short-term administration of C. aronia aqueous extract shifts the cardiac metabolism toward glucose utilization, thus making this plant a potential therapeutic medication in cardiac disorders with impaired metabolism.
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Affiliation(s)
- Abdullah S Shatoor
- Department of Medicine, Cardiology Section, College of Medicine, King Khalid University (KKU), Abha, Saudi Arabia
| | - Suliman Al Humayed
- Department of Internal Medicine, College of Medicine, King Khalid University (KKU), Abha, Saudi Arabia
| | - Hussain M Almohiy
- Depatrtment of Radiology Science, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia
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Guidi A, Petrella G, Fustaino V, Saccoccia F, Lentini S, Gimmelli R, Di Pietro G, Bresciani A, Cicero DO, Ruberti G. Drug effects on metabolic profiles of Schistosoma mansoni adult male parasites detected by 1H-NMR spectroscopy. PLoS Negl Trop Dis 2020; 14:e0008767. [PMID: 33044962 PMCID: PMC7580944 DOI: 10.1371/journal.pntd.0008767] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/22/2020] [Accepted: 09/02/2020] [Indexed: 11/25/2022] Open
Abstract
Schistosomiasis is one of the most devastating neglected tropical parasitic diseases caused by trematodes of the genus Schistosoma. Praziquantel (PZQ) is today the only drug used in humans and animals for the treatment of schistosomiasis but unfortunately it is poorly effective on larval and juvenile stages of the parasite. Therefore, it is urgent the discovery of new drug targets and compounds. We have recently showed that the anti-anginal drug perhexiline maleate (PHX) is very active on multiple developmental stages of Schistosoma mansoni in vitro. It is well known that PHX impacts the lipid metabolism in mammals, but the final target on schistosomes still remains unknown. The aim of this study was to evaluate the ability of 1H nuclear magnetic resonance (NMR) spectroscopy in revealing metabolic perturbations due to PHX treatment of S. mansoni adult male worms. The effects of PHX were compared with the ones induced by vehicle and gambogic acid, in order to detect different metabolic profiles and specificity of the PHX action. Remarkably a list of metabolites associated to PHX-treatment was identified with enrichment in several connected metabolic pathways including also the Kennedy pathway mediating the glycerophospholipid metabolism. Our study represents the first 1H-NMR metabolomic approach to characterize the response of S. mansoni to drug treatment. The obtained "metabolic fingerprint" associated to PHX treatment could represent a strategy for displaying cellular metabolic changes for any given drug and to compare compounds targeting similar or distinct biochemical pathways.
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Affiliation(s)
- Alessandra Guidi
- Institute of Biochemistry and Cell Biology, National Research Council, Campus A. Buzzati-Traverso, Monterotondo (Rome) Italy
| | - Greta Petrella
- Department of Chemical Science and Technologies, University of Rome Tor Vergata, Rome, Italy
| | - Valentina Fustaino
- Institute of Biochemistry and Cell Biology, National Research Council, Campus A. Buzzati-Traverso, Monterotondo (Rome) Italy
| | - Fulvio Saccoccia
- Institute of Biochemistry and Cell Biology, National Research Council, Campus A. Buzzati-Traverso, Monterotondo (Rome) Italy
| | - Sara Lentini
- Department of Translational Biology, IRBM Science Park Spa, Pomezia (Rome), Italy
| | - Roberto Gimmelli
- Institute of Biochemistry and Cell Biology, National Research Council, Campus A. Buzzati-Traverso, Monterotondo (Rome) Italy
| | - Giulia Di Pietro
- Department of Chemical Science and Technologies, University of Rome Tor Vergata, Rome, Italy
| | - Alberto Bresciani
- Department of Translational Biology, IRBM Science Park Spa, Pomezia (Rome), Italy
| | - Daniel Oscar Cicero
- Department of Chemical Science and Technologies, University of Rome Tor Vergata, Rome, Italy
| | - Giovina Ruberti
- Institute of Biochemistry and Cell Biology, National Research Council, Campus A. Buzzati-Traverso, Monterotondo (Rome) Italy
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Murphy I, Sivashankar A, Gadoud A. Refractory angina is a growing challenge for palliative medicine: a systematic review of non-invasive interventions. BMJ Support Palliat Care 2020; 12:e869-e881. [PMID: 32499404 DOI: 10.1136/bmjspcare-2020-002202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 03/31/2020] [Accepted: 05/04/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Refractory angina can have a significant effect on quality of life. Non-invasive interventions have been suggested but there are few guidelines on management. Our aim was to systematically review all studies that reported non-invasive interventions for refractory angina and report on their effectiveness and safety. METHODS We performed a literature search of six databases and a grey literature search. Treatments considered first line or second line according to the European Society of Cardiology were excluded, as were interventions that had undergone review within the last 3 years. Design, setting and outcomes were extracted and quality was assessed. A narrative synthesis was undertaken, including an analysis of adverse effects. RESULTS 4476 studies were screened, 14 studies were included in our analysis. Interventions were specialist multidisciplinary programmes, transcutaneous electrical nerve stimulation (TENS), perhexiline, medical optimisation, morphine and intranasal alfentanil. The effects of specialist programmes and perhexiline treatment were mixed. Positive effects were reported with TENS, opioids and medical optimisation, with improvements in symptoms, exercise capacity and quality of life. No major adverse effects were noted in any of the treatments. CONCLUSION There are non-invasive treatments for refractory angina that are overlooked by current guidelines. While the quality of these studies varies, positive changes have been reported in symptoms, exercise tolerance and quality of life with few adverse effects. There is a need for further research into these treatments which could be useful within the contexts of cardiology and palliative care.
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Affiliation(s)
- Iain Murphy
- Palliative Medicine, Trinity Hospice & Palliative Care Services, Blackpool, Lancashire, UK .,Lancaster Medical School, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Akshara Sivashankar
- GP Specialist Training Programme, North Western Deanery GPST School, Manchester, UK
| | - Amy Gadoud
- Palliative Medicine, Trinity Hospice & Palliative Care Services, Blackpool, Lancashire, UK.,Lancaster Medical School, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
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Gawlik M, Trawiński J, Skibiński R. Simulation of phase I metabolism reactions of selected calcium channel blockers by human liver microsomes and photochemical methods with the use of Q-TOF LC/MS. J Pharm Biomed Anal 2019; 175:112776. [PMID: 31351248 DOI: 10.1016/j.jpba.2019.07.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/17/2019] [Accepted: 07/13/2019] [Indexed: 12/13/2022]
Abstract
The in vitro phase I metabolism of perhexiline and flunarizine, two calcium channel blockers was investigated during this study with the use of human liver microsomes (HLM) method compared with TiO2, WO3 and ZnO catalyzed photochemical reaction. In order to determine the structures of metabolites an quadrupole time-of-flight mass spectrometry combined with liquid chromatography (Q-TOF LC/MS) system was used. The obtained high resolution mass spectra enabled to identify thirteen products of metabolism of selected drugs including three not yet described metabolites of perhexiline and two new metabolites of flunarizine. The vast majority of metabolites were confirmed also with the participation of photocatalytic approach of the drug metabolism simulation. The comparison of all metabolic profiles made with the use of computational methods drew attention particularly to TiO2 and WO3 catalyzed photochemical reaction as similar to HLM incubation. Additionally, in silico toxicity assessment of the detected transformation products of the analyzed substances was also evaluated.
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Affiliation(s)
- Maciej Gawlik
- Department of Medicinal Chemistry, Medical University of Lublin, Jaczewskiego 4, 20-090 Lublin, Poland
| | - Jakub Trawiński
- Department of Medicinal Chemistry, Medical University of Lublin, Jaczewskiego 4, 20-090 Lublin, Poland
| | - Robert Skibiński
- Department of Medicinal Chemistry, Medical University of Lublin, Jaczewskiego 4, 20-090 Lublin, Poland.
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Waheed N, Mahmoud A, Rambarat CA, Pepine CJ. Advances in small-molecule therapy for managing angina pectoris in the elderly. Expert Opin Pharmacother 2019; 20:1471-1481. [PMID: 31107109 DOI: 10.1080/14656566.2019.1615881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: As our population ages, the prevalence of angina is growing, leading to increased morbidity and decreased quality of life. The management of angina in the elderly is challenging due to drug intolerance and/or drug resistance as well as frailty. Over the past decades, many new therapeutic small molecules have been investigated for the management of angina. Although none of these studies have specifically focused on the therapies for the elderly, they offer promising new avenues for the treatment of angina in the elderly. Areas covered: Herein, the authors provide a review of the recently published literature on the use of small-molecule therapies for angina management in the elderly and provide a brief overview of these therapies. Expert opinion: A variety of therapeutic classes of existing and newer small molecules are emerging for the management of angina in the elderly. An individualized approach to the management of angina in this growing population is critical for good outcomes. Many small molecules are in their initial stages of clinical use, and further research should be conducted on their utility, especially in the elderly.
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Affiliation(s)
- Nida Waheed
- Resident Physician, Department of Medicine, University of Florida , Gainesville , FL , USA
| | - Ahmad Mahmoud
- Resident Physician, Department of Medicine, University of Florida , Gainesville , FL , USA
| | - Cecil A Rambarat
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida , Gainesville , FL , USA
| | - Carl J Pepine
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida , Gainesville , FL , USA
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11
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Drug repositioning and biomarkers in low-grade glioma via bioinformatics approach. INFORMATICS IN MEDICINE UNLOCKED 2019. [DOI: 10.1016/j.imu.2019.100250] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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12
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Philipson DJ, DePasquale EC, Yang EH, Baas AS. Emerging pharmacologic and structural therapies for hypertrophic cardiomyopathy. Heart Fail Rev 2018; 22:879-888. [PMID: 28856513 DOI: 10.1007/s10741-017-9648-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Hypertrophic cardiomyopathy is the most common inherited heart disease. Although it was first described over 50 years ago, there has been little in the way of novel disease-specific therapeutic development for these patients. Current treatment practice largely aims at symptomatic control using old drugs made for other diseases and does little to modify the disease course. Septal reduction by surgical myectomy or percutaneous alcohol septal ablation are well-established treatments for pharmacologic-refractory left ventricular outflow tract obstruction in hypertrophic cardiomyopathy patients. In recent years, there has been a relative surge in the development of innovative therapeutics, which aim to target the complex molecular pathophysiology and resulting hemodynamics that underlie hypertrophic cardiomyopathy. Herein, we review the new and emerging therapeutics for hypertrophic cardiomyopathy, which include pharmacologic attenuation of sarcomeric calcium sensitivity, allosteric inhibition of cardiac myosin, myocardial metabolic modulation, and renin-angiotensin-aldosterone system inhibition, as well as structural intervention by percutaneous mitral valve plication and endocardial radiofrequency ablation of septal hypertrophy. In conclusion, while further development of these therapeutic strategies is ongoing, they each mark a significant and promising advancement in treatment for hypertrophic cardiomyopathy patients.
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Affiliation(s)
- Daniel J Philipson
- Department of Medicine, UCLA, 200 UCLA Medical Plaza Suite 420, Los Angeles, CA, 90095, USA.
| | - Eugene C DePasquale
- Ahmanson-UCLA Cardiomyopathy Center, Division of Cardiology, Department of Medicine, UCLA, Los Angeles, CA, USA
| | - Eric H Yang
- Division of Cardiology, Department of Medicine, UCLA, Los Angeles, CA, USA
| | - Arnold S Baas
- Ahmanson-UCLA Cardiomyopathy Center, Division of Cardiology, Department of Medicine, UCLA, Los Angeles, CA, USA
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13
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Karlstaedt A, Schiffer W, Taegtmeyer H. Actionable Metabolic Pathways in Heart Failure and Cancer-Lessons From Cancer Cell Metabolism. Front Cardiovasc Med 2018; 5:71. [PMID: 29971237 PMCID: PMC6018530 DOI: 10.3389/fcvm.2018.00071] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 05/24/2018] [Indexed: 12/21/2022] Open
Abstract
Recent advances in cancer cell metabolism provide unprecedented opportunities for a new understanding of heart metabolism and may offer new approaches for the treatment of heart failure. Key questions driving the cancer field to understand how tumor cells reprogram metabolism and to benefit tumorigenesis are also applicable to the heart. Recent experimental and conceptual advances in cancer cell metabolism provide the cardiovascular field with the unique opportunity to target metabolism. This review compares cancer cell metabolism and cardiac metabolism with an emphasis on strategies of cellular adaptation, and how to exploit metabolic changes for therapeutic benefit.
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Affiliation(s)
- Anja Karlstaedt
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Walter Schiffer
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Heinrich Taegtmeyer
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
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14
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Licari G, Milne RW, Somogyi AA, Sallustio BC. Enantioselectivity in the tissue distribution of perhexiline contributes to different effects on hepatic histology and peripheral neural function in rats. Pharmacol Res Perspect 2018; 6:e00406. [PMID: 29864243 PMCID: PMC5980244 DOI: 10.1002/prp2.406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 04/23/2018] [Indexed: 11/10/2022] Open
Abstract
Perhexiline, a chiral drug, is a potent antiischemic agent whose clinical utility is limited by hepatic and neural toxicities. It inhibits mitochondrial carnitine palmitoyltransferase-1, however, excessive inhibition predisposes toward tissue steatosis. This pilot study investigated the distribution of the two enantiomers and their toxicological potential. Dark Agouti rats (n = 4 per group) were administered vehicle or 200 mg/kg daily of racemic, (+)- or (-)-perhexiline maleate orally for 8 weeks. Plasma biochemical liver function tests and Von Frey assessments of peripheral neural function were performed. Hepatic and neuronal histology, including lipid and glycogen content, was assessed using electron microscopy. Concentrations of the perhexiline enantiomers and metabolites were quantified in plasma, liver and heart. Plasma perhexiline concentrations following administration of racemate, (+)- or (-)-enantiomer were within the mid-upper clinical therapeutic range. There was extensive uptake of both enantiomers into liver and heart, with 2.5- to 4.5-fold greater net uptake of (+)- compared to (-)-perhexiline (P < .05) when administered as pure enantiomers, but not when administered as racemate. There was no biochemical or gross histological evidence of hepatotoxicity. However, livers of animals administered (+)-perhexiline had higher lipid (P < .01) and lower glycogen (P < .05) content, compared to those administered (-)-perhexiline. Animals administered racemic perhexiline had reduced peripheral neural function (P < .05) compared to controls or animals administered (-)-perhexiline. For the same plasma concentrations, differences in tissue distribution may contribute to disparities in the effects of (+)- and (-)-perhexiline on hepatic histology and neural function.
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Affiliation(s)
- Giovanni Licari
- Discipline of PharmacologyUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Robert W. Milne
- School of Pharmacy and Medical ScienceUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Andrew A. Somogyi
- Discipline of PharmacologyUniversity of AdelaideAdelaideSouth AustraliaAustralia
- Department of Clinical PharmacologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Benedetta C. Sallustio
- Discipline of PharmacologyUniversity of AdelaideAdelaideSouth AustraliaAustralia
- Department of Clinical PharmacologyThe Queen Elizabeth HospitalWoodvilleSouth AustraliaAustralia
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Guarini G, Huqi A, Morrone D, Capozza PFG, Marzilli M. Trimetazidine and Other Metabolic Modifiers. Eur Cardiol 2018; 13:104-111. [PMID: 30697354 DOI: 10.15420/ecr.2018.15.2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Treatment goals for people with chronic angina should focus on the relief of symptoms and improving mortality rates so the patient can feel better and live longer. The traditional haemodynamic approach to ischaemic heart disease was based on the assumption that increasing oxygen supply and decreasing oxygen demand would improve symptoms. However, data from clinical trials, show that about one third of people continue to have angina despite a successful percutaneous coronary intervention and medical therapy. Moreover, several trials on chronic stable angina therapy and revascularisation have failed to show benefits in terms of primary outcome (survival, cardiovascular death, all-cause mortality), symptom relief or echocardiographic parameters. Failure to significantly improve quality of life and prognosis may be attributed in part to a limited understanding of ischaemic heart disease, by neglecting the fact that ischaemia is a metabolic disorder. Shifting cardiac metabolism from free fatty acids towards glucose is a promising approach for the treatment of patients with stable angina, independent of the underlying disease (macrovascular and/or microvascular disease). Cardiac metabolic modulators open the way to a greater understanding of ischaemic heart disease and its common clinical manifestations as an energetic disorder rather than an imbalance between the demand and supply of oxygen and metabolites.
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Affiliation(s)
- Giacinta Guarini
- Cardiovascular Medicine Division, Cardiothoracic and Vascular Department, University of Pisa Italy
| | - Alda Huqi
- Cardiovascular Medicine Division, Ospedale della Versilia, Lido di Camaiore Italy
| | - Doralisa Morrone
- Cardiovascular Medicine Division, Cardiothoracic and Vascular Department, University of Pisa Italy
| | | | - Mario Marzilli
- Cardiovascular Medicine Division, Cardiothoracic and Vascular Department, University of Pisa Italy
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16
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Graham BB, Robinson JC, Tuder RM. Fatty Acid Metabolism, Bone Morphogenetic Protein Receptor Type 2, and the Right Ventricle. Am J Respir Crit Care Med 2017; 194:655-6. [PMID: 27628075 DOI: 10.1164/rccm.201603-0592ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Brian B Graham
- 1 Department of Medicine University of Colorado Anschutz Medical Campus Aurora, Colorado
| | - Jeffrey C Robinson
- 1 Department of Medicine University of Colorado Anschutz Medical Campus Aurora, Colorado
| | - Rubin M Tuder
- 1 Department of Medicine University of Colorado Anschutz Medical Campus Aurora, Colorado
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17
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18
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Noordali H, Loudon BL, Frenneaux MP, Madhani M. Cardiac metabolism - A promising therapeutic target for heart failure. Pharmacol Ther 2017; 182:95-114. [PMID: 28821397 DOI: 10.1016/j.pharmthera.2017.08.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Both heart failure with reduced ejection fraction (HFrEF) and with preserved ejection fraction (HFpEF) are associated with high morbidity and mortality. Although many established pharmacological interventions exist for HFrEF, hospitalization and death rates remain high, and for those with HFpEF (approximately half of all heart failure patients), there are no effective therapies. Recently, the role of impaired cardiac energetic status in heart failure has gained increasing recognition with the identification of reduced capacity for both fatty acid and carbohydrate oxidation, impaired function of the electron transport chain, reduced capacity to transfer ATP to the cytosol, and inefficient utilization of the energy produced. These nodes in the genesis of cardiac energetic impairment provide potential therapeutic targets, and there is promising data from recent experimental and early-phase clinical studies evaluating modulators such as carnitine palmitoyltransferase 1 inhibitors, partial fatty acid oxidation inhibitors and mitochondrial-targeted antioxidants. Metabolic modulation may provide significant symptomatic and prognostic benefit for patients suffering from heart failure above and beyond guideline-directed therapy, but further clinical trials are needed.
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Affiliation(s)
- Hannah Noordali
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Brodie L Loudon
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Melanie Madhani
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.
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19
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The validation of an LC-MS/MS assay for perhexiline and major hydroxy metabolites, and its application to therapeutic monitoring in patient plasma. Bioanalysis 2017; 9:1011-1025. [PMID: 28692346 DOI: 10.4155/bio-2017-0068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
AIM Perhexiline (PEX), being developed to treat hypertrophic cardiomyopathy, is toxic at levels above the therapeutic range. Plasma level monitoring is therefore essential. The absence of a UV-absorbing chromophore has in the past required quantitative analysis of PEX in plasma using lengthy derivatization methods, followed by HPLC and fluorescence detection. The routine and urgent analysis of a large number of patient plasma samples necessitates faster and reliable analytical methodology. RESULTS An LC-MS/MS method, using two novel internal standards, has been validated for the quantitative measurement of PEX and its major hydroxy metabolites in human plasma. CONCLUSION The assay has been applied to therapeutic drug monitoring (TDM), where PEX and the ratio of the drug to cis-hydroxy perhexiline, were measured at designated intervals.
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20
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Itkonen HM, Brown M, Urbanucci A, Tredwell G, Lau CH, Barfeld S, Hart C, Guldvik IJ, Takhar M, Heemers HV, Erho N, Bloch K, Davicioni E, Derua R, Waelkens E, Mohler JL, Clarke N, Swinnen JV, Keun HC, Rekvig OP, Mills IG. Lipid degradation promotes prostate cancer cell survival. Oncotarget 2017; 8:38264-38275. [PMID: 28415728 PMCID: PMC5503531 DOI: 10.18632/oncotarget.16123] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 03/01/2017] [Indexed: 01/07/2023] Open
Abstract
Prostate cancer is the most common male cancer and androgen receptor (AR) is the major driver of the disease. Here we show that Enoyl-CoA delta isomerase 2 (ECI2) is a novel AR-target that promotes prostate cancer cell survival. Increased ECI2 expression predicts mortality in prostate cancer patients (p = 0.0086). ECI2 encodes for an enzyme involved in lipid metabolism, and we use multiple metabolite profiling platforms and RNA-seq to show that inhibition of ECI2 expression leads to decreased glucose utilization, accumulation of fatty acids and down-regulation of cell cycle related genes. In normal cells, decrease in fatty acid degradation is compensated by increased consumption of glucose, and here we demonstrate that prostate cancer cells are not able to respond to decreased fatty acid degradation. Instead, prostate cancer cells activate incomplete autophagy, which is followed by activation of the cell death response. Finally, we identified a clinically approved compound, perhexiline, which inhibits fatty acid degradation, and replicates the major findings for ECI2 knockdown. This work shows that prostate cancer cells require lipid degradation for survival and identifies a small molecule inhibitor with therapeutic potential.
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Affiliation(s)
- Harri M Itkonen
- Prostate Cancer Research Group, Centre for Molecular Medicine Norway, University of Oslo, Oslo, Norway
| | - Michael Brown
- Genito Urinary Cancer Research Group, Institute of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Alfonso Urbanucci
- Prostate Cancer Research Group, Centre for Molecular Medicine Norway, University of Oslo, Oslo, Norway
- Department of Molecular Oncology, Institute for Cancer Research and Oslo University Hospital, Oslo, Norway
| | - Gregory Tredwell
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Chung Ho Lau
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Stefan Barfeld
- Prostate Cancer Research Group, Centre for Molecular Medicine Norway, University of Oslo, Oslo, Norway
| | - Claire Hart
- Genito Urinary Cancer Research Group, Institute of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Ingrid J. Guldvik
- Prostate Cancer Research Group, Centre for Molecular Medicine Norway, University of Oslo, Oslo, Norway
| | - Mandeep Takhar
- GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - Hannelore V. Heemers
- Department of Cancer Biology, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Urology, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Hematology/Medical Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicholas Erho
- GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - Katarzyna Bloch
- Department of Oncology, Laboratory of Lipid Metabolism and Cancer, LKI Leuven Cancer Institute, KU Leuven-University of Leuven, Leuven, Belgium
| | - Elai Davicioni
- GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - Rita Derua
- Department of Cellular and Molecular Medicine, Laboratory of Protein Phosphorylation and Proteomics, KU Leuven-University of Leuven, Leuven, Belgium
| | - Etienne Waelkens
- Department of Cellular and Molecular Medicine, Laboratory of Protein Phosphorylation and Proteomics, KU Leuven-University of Leuven, Leuven, Belgium
| | - James L. Mohler
- Department of Urology, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Noel Clarke
- Genito Urinary Cancer Research Group, Institute of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- PCUK/Movember Centre of Excellence for Prostate Cancer Research, CRUK Manchester Institute for Cancer Research, University of Manchester, Manchester, UK
- Department of Urology, The Christie NHS Foundation Trust, Manchester, UK
| | - Johan V. Swinnen
- Department of Oncology, Laboratory of Lipid Metabolism and Cancer, LKI Leuven Cancer Institute, KU Leuven-University of Leuven, Leuven, Belgium
| | - Hector C. Keun
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Ole P. Rekvig
- Department of Medical Biology, University of Tromso, Tromso, Norway
| | - Ian G. Mills
- Prostate Cancer Research Group, Centre for Molecular Medicine Norway, University of Oslo, Oslo, Norway
- Department of Molecular Oncology, Institute for Cancer Research and Oslo University Hospital, Oslo, Norway
- PCUK/Movember Centre of Excellence for Prostate Cancer Research, Centre for Cancer Research and Cell Biology (CCRCB), Queen's University Belfast, Belfast, UK
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Abstract
INTRODUCTION Angina pectoris is the most prevalent symptomatic manifestation of ischemic heart disease, frequently leads to a poor quality of life, and is a major cause of medical resource consumption. Since the early descriptions of nitrite and nitrate in the 19th century, there has been considerable advancement in the pharmacologic management of angina. Areas covered: Management of chronic angina is often challenging for clinicians. Despite introduction of several pharmacological agents in last few decades, a significant proportion of patients continue to experience symptoms (i.e., refractory angina) with subsequent disability. For the purpose of this review, we searched PubMed and Cochrane databases from inception to August 2016 for the most clinically relevant publications that guide current practice in angina therapy and its development. In this article, we briefly review the pathophysiology of angina and mechanism-based classification of current therapy. This is followed by evidence-based insight into the traditional and novel pharmacotherapeutic agents, highlighting their clinical usefulness. Expert opinion: Considering the wide array of available therapies with different mechanism efficacy and limiting factors, a personalized approach is essential, particularly for patients with refractory angina. Ongoing research with novel pharmacologic modalities is likely to provide new options for management of angina.
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Affiliation(s)
- Ankur Jain
- a Department of Medicine , University of Florida , Gainesville , FL , USA
| | - Islam Y Elgendy
- a Department of Medicine , University of Florida , Gainesville , FL , USA
| | - Mohammad Al-Ani
- a Department of Medicine , University of Florida , Gainesville , FL , USA
| | - Nayan Agarwal
- a Department of Medicine , University of Florida , Gainesville , FL , USA
| | - Carl J Pepine
- a Department of Medicine , University of Florida , Gainesville , FL , USA
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22
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Elgendy IY, Winchester DE, Pepine CJ. Experimental and early investigational drugs for angina pectoris. Expert Opin Investig Drugs 2016; 25:1413-1421. [PMID: 27791405 DOI: 10.1080/13543784.2016.1254617] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Ischemic heart disease (IHD) is a major cause of death and disability among Western countries and angina pectoris is the most prevalent symptomatic manifestation. Strategies to improve management of chronic stable angina are a priority. Areas covered: A comprehensive review was conducted using the Medline and Cochrane databases as well as the clinical trial databases in the United States and Europe. Traditional therapies for angina will be discussed. This review particularly emphasizes investigational therapies for angina (including pharmacological agents, cell and gene based therapies, and herbal medications). Expert opinion: There has been renewed interest in older anti-angina agents (e.g., perhexiline, amiodarone, and phosphodiestrase-5 inhibitors). Other anti-inflammatory agents (e.g., allopurinol and febuxostat) are currently undergoing evaluation for angina therapy. Therapeutic angiogenesis continues to face some challenges. Future trials should evaluate the optimum patient population that would benefit from this form of therapy.
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Affiliation(s)
- Islam Y Elgendy
- a Division of Cardiovascular Medicine , University of Florida, and North Florida/South Georgia Veterans Health System , Gainesville , FL , USA
| | - David E Winchester
- a Division of Cardiovascular Medicine , University of Florida, and North Florida/South Georgia Veterans Health System , Gainesville , FL , USA
| | - Carl J Pepine
- a Division of Cardiovascular Medicine , University of Florida, and North Florida/South Georgia Veterans Health System , Gainesville , FL , USA
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Abstract
INTRODUCTION Angina pectoris, or symptomatic myocardial ischaemia, reflects an impairment of coronary blood flow, and usually a deficiency of available myocardial energetics. Treatment options vary with the precise cause, which may vary with regards to the roles of increased myocardial oxygen demand versus reduced supply. Traditionally, organic nitrates, β-adrenoceptor antagonists, and non-dihydropyridine calcium antagonists were the only commonly used prophylactic anti-anginal agents. However, many patients failed to respond adequately to such therapy, and/or were unsuitable for their use. Areas covered: A number of 'new' agents have been shown to represent ancillary forms of prophylactic anti-anginal therapy and are particularly useful in patients who are relatively unsuitable for either percutaneous or surgical revascularisation. These include modulators of myocardial metabolic efficiency, such as perhexiline, trimetazidine and ranolazine, as well as high dose allopurinol, nicorandil and ivabradine. The advantages and disadvantages of these various agents are summarized. Expert opinion: 'Optimal' medical treatment of angina pectoris now includes use of agents primarily intended to reduce risk of infarction (e.g. statins, aspirin, ACE inhibitors). In patients whose angina persists despite the use of 'standard' anti-anginal therapy, and who are not ideal for invasive revascularization options, a number of emerging drugs offer prospects of symptomatic relief.
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Affiliation(s)
- Cher-Rin Chong
- a Cardiology and Clinical Pharmacology Departments, Basil Hetzel Institute , Queen Elizabeth Hospital, University of Adelaide , Adelaide , SA , Australia.,b Pharmacy Department , Queen Elizabeth Hospital , Woodville South , SA , Australia
| | - Gao J Ong
- a Cardiology and Clinical Pharmacology Departments, Basil Hetzel Institute , Queen Elizabeth Hospital, University of Adelaide , Adelaide , SA , Australia
| | - John D Horowitz
- a Cardiology and Clinical Pharmacology Departments, Basil Hetzel Institute , Queen Elizabeth Hospital, University of Adelaide , Adelaide , SA , Australia
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24
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The standardized functional observational battery: Its intrinsic value remains in the instrument of measure: The rat. J Pharmacol Toxicol Methods 2016; 82:90-108. [PMID: 27534836 DOI: 10.1016/j.vascn.2016.08.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 07/10/2016] [Accepted: 08/01/2016] [Indexed: 12/13/2022]
Abstract
The International Conference on Harmonisation's (ICH) Tripartite Guideline on Safety Pharmacology Studies for Human Pharmaceuticals has adopted the requirement that each new test substance must be tested for effects on the central nervous system prior to "first dose in man". This assessment is required to measure, at a minimum, the effects of the substance on general motor activity, behavioral changes, coordination, sensory/motor reflex responses, and body temperatures. To achieve this goal, ICH S7A recommends a neurobehavioral assessment (usually a functional observational battery (FOB) or modified Irwin test), which is generally undertaken in the rat. There seems to be a growing lack of consensus on the value of the FOB to determine CNS safety. This review highlights the importance of the time, effort and cost of training technicians to familiarize with their instrument of measure, so that each observer is better able to identify and document very subtle changes in behavior that will serve to increase the reliability and validity of these assays with respect to CNS safety assessments.
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25
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Guidi A, Lalli C, Perlas E, Bolasco G, Nibbio M, Monteagudo E, Bresciani A, Ruberti G. Discovery and Characterization of Novel Anti-schistosomal Properties of the Anti-anginal Drug, Perhexiline and Its Impact on Schistosoma mansoni Male and Female Reproductive Systems. PLoS Negl Trop Dis 2016; 10:e0004928. [PMID: 27518281 PMCID: PMC4982595 DOI: 10.1371/journal.pntd.0004928] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 07/26/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Schistosomiasis, one of the world's greatest human neglected tropical diseases, is caused by parasitic trematodes of the genus Schistosoma. A unique feature of schistosome biology is that the induction of sexual maturation as well as the maintenance of the differentiation status of female reproductive organs and egg production, necessary for both disease transmission and pathogenesis, are strictly dependent on the male. The treatment and most control initiatives of schistosomiasis rely today on the long-term application of a single drug, praziquantel (PZQ), mostly by campaigns of mass drug administration. PZQ, while very active on adult parasites, has much lower activity against juvenile worms. Monotherapy also favors the selection of drug resistance and, therefore, new drugs are urgently needed. METHODS AND FINDINGS Following the screening of a small compound library with an ATP-based luminescent assay on Schistosoma mansoni schistosomula, we here report the identification and characterization of novel antischistosomal properties of the anti-anginal drug perhexiline maleate (PHX). By phenotypic worm survival assays and confocal microscopy studies we show that PHX, in vitro, has a marked lethal effect on all S. mansoni parasite life stages (newly transformed schistosomula, juvenile and adult worms) of the definitive host. We further demonstrate that sub-lethal doses of PHX significantly impair egg production and lipid depletion within the vitellarium of adult female worms. Moreover, we highlighted tegumental damage in adult male worms and remarkable reproductive system alterations in both female and male adult parasites. The in vivo study in S. mansoni-patent mice showed a notable variability of worm burdens in the individual experiments, with an overall minimal schistosomicidal effect upon PHX treatment. The short PHX half-life in mice, together with its very high rodent plasma proteins binding could be the cause of the modest efficacy of PHX in the schistosomiasis murine model. CONCLUSIONS/SIGNIFICANCE Overall, our data indicate that PHX could represent a promising starting point for novel schistosomicidal drug discovery programmes.
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Affiliation(s)
- Alessandra Guidi
- National Research Council, Institute of Cell Biology and Neurobiology, Campus A. Buzzati-Traverso Monterotondo, Roma, Italy
| | - Cristiana Lalli
- National Research Council, Institute of Cell Biology and Neurobiology, Campus A. Buzzati-Traverso Monterotondo, Roma, Italy
| | - Emerald Perlas
- European Molecular Biology Laboratory (EMBL), Mouse Biology Unit, Monterotondo, Italy
| | - Giulia Bolasco
- European Molecular Biology Laboratory (EMBL), Mouse Biology Unit, Monterotondo, Italy
| | - Martina Nibbio
- IRBM Science Park, Department of Preclinical Research, Pomezia, Italy
| | - Edith Monteagudo
- IRBM Science Park, Department of Preclinical Research, Pomezia, Italy
| | | | - Giovina Ruberti
- National Research Council, Institute of Cell Biology and Neurobiology, Campus A. Buzzati-Traverso Monterotondo, Roma, Italy
- * E-mail:
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26
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Guarini G, Huqi A, Morrone D, Marzilli M. Pharmacological Agents Targeting Myocardial Metabolism for the Management of Chronic Stable Angina : an Update. Cardiovasc Drugs Ther 2016; 30:379-391. [DOI: 10.1007/s10557-016-6677-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Sherrid MV. Drug Therapy for Hypertrophic Cardiomypathy: Physiology and Practice. Curr Cardiol Rev 2016; 12:52-65. [PMID: 26818487 PMCID: PMC4807719 DOI: 10.2174/1573403x1201160126125403] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 03/31/2015] [Accepted: 04/02/2015] [Indexed: 12/19/2022] Open
Abstract
HCM is the most common inherited heart condition occurring in 1:500 individuals in the general population. Left ventricular outflow obstruction at rest or after provocation occurs in 2/3 of HCM patients and is a frequent cause of limiting symptoms. Pharmacologic therapy is the first-line treatment for obstruction, and should be aggressively pursued before application of invasive therapy. Beta-blockade is given first, and up-titrated to decrease resting heart rate to between 50 and 60 beats per minute. However, beta-blockade is not expected to decrease resting gradients; its effect rests on decreasing the rise in gradient that accompanies exercise. For patients who fail beta-blockade the addition of oral disopyramide in adequate dose often will decrease resting gradients and offer meaningful relief of symptoms. Disopyramide vagolytic side effects, if they occur, can be greatly mitigated by simultaneous administration of oral pyridostigmine. This combination allows adequate dosing of disopyramide to achieve therapeutic goals. Verapamil utility in obstructive HCM with high resting gradients is limited by its vasodilating effects that can, infrequently, worsen gradient and symptoms. As such, we tend to avoid it in patients with high gradients and limiting heart failure symptoms. In a head-to-head comparison of intravenous drug administration in individual obstructive HCM patients the relative efficacy for lowering gradient was disopyramide > beta-blockade > verapamil. Severe symptoms in non-obstructive HCM are caused by fibrosis or severe myocyte disarray, and often by very small LV chamber size. Severe symptoms caused by these anatomic and histologic abnormalities, in the absence of obstruction, are less amenable to current pharmacotherapy. New pharmacotherapeutic approaches to HCM are on the horizon, that are to be evaluated in formal therapeutic trials.
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Affiliation(s)
- Mark V Sherrid
- New York University Langone Medical Center, 530 First Avenue, NYC, NY 10016, USA.
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28
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George CH, Mitchell AN, Preece R, Bannister ML, Yousef Z. Pleiotropic mechanisms of action of perhexiline in heart failure. Expert Opin Ther Pat 2016; 26:1049-59. [PMID: 27455171 DOI: 10.1080/13543776.2016.1211111] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The re-purposing of the anti-anginal drug perhexiline (PHX) has resulted in symptomatic improvements in heart failure (HF) patients. The inhibition of carnitine palmitoyltransferase-1 (CPT-1) has been proposed as the primary mechanism underlying the therapeutic benefit of PHX. This hypothesis is contentious. AREAS COVERED We reviewed the primary literature and patent landscape of PHX from its initial development in the 1960s through to its emergence as a drug beneficial for HF. We focused on its physico-chemistry, molecular targets, tissue accumulation and clinical dosing. EXPERT OPINION Dogma that the beneficial effects of PHX are due primarily to potent myocardial CPT-1 inhibition is not supported by the literature and all available evidence point to it being extremely unlikely that the major effects of PHX occur via this mechanism. In vivo PHX is much more likely to be an inhibitor of surface membrane ion channels and also to have effects on other components of cellular metabolism and reactive oxygen species (ROS) generation across the cardiovascular system. However, the possibility that minor effects of PHX on CPT-1 underpin disproportionately large effects on myocardial function cannot be entirely excluded, especially given the massive accumulation of the drug in heart tissue.
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Affiliation(s)
- Christopher H George
- a Wales Heart Research Institute, School of Medicine , Cardiff University , Cardiff , UK
| | - Alice N Mitchell
- a Wales Heart Research Institute, School of Medicine , Cardiff University , Cardiff , UK
| | - Ryan Preece
- a Wales Heart Research Institute, School of Medicine , Cardiff University , Cardiff , UK
| | - Mark L Bannister
- a Wales Heart Research Institute, School of Medicine , Cardiff University , Cardiff , UK
| | - Zaheer Yousef
- a Wales Heart Research Institute, School of Medicine , Cardiff University , Cardiff , UK
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29
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Giannopoulos AA, Giannoglou GD, Chatzizisis YS. Pharmacological approaches of refractory angina. Pharmacol Ther 2016; 163:118-31. [DOI: 10.1016/j.pharmthera.2016.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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31
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Taegtmeyer H, Young ME, Lopaschuk GD, Abel ED, Brunengraber H, Darley-Usmar V, Des Rosiers C, Gerszten R, Glatz JF, Griffin JL, Gropler RJ, Holzhuetter HG, Kizer JR, Lewandowski ED, Malloy CR, Neubauer S, Peterson LR, Portman MA, Recchia FA, Van Eyk JE, Wang TJ. Assessing Cardiac Metabolism: A Scientific Statement From the American Heart Association. Circ Res 2016; 118:1659-701. [PMID: 27012580 DOI: 10.1161/res.0000000000000097] [Citation(s) in RCA: 185] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In a complex system of interrelated reactions, the heart converts chemical energy to mechanical energy. Energy transfer is achieved through coordinated activation of enzymes, ion channels, and contractile elements, as well as structural and membrane proteins. The heart's needs for energy are difficult to overestimate. At a time when the cardiovascular research community is discovering a plethora of new molecular methods to assess cardiac metabolism, the methods remain scattered in the literature. The present statement on "Assessing Cardiac Metabolism" seeks to provide a collective and curated resource on methods and models used to investigate established and emerging aspects of cardiac metabolism. Some of those methods are refinements of classic biochemical tools, whereas most others are recent additions from the powerful tools of molecular biology. The aim of this statement is to be useful to many and to do justice to a dynamic field of great complexity.
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Abstract
With improvements in survival from coronary artery disease (CAD) and an ageing population, refractory angina (RA) is becoming an increasingly common clinical problem facing clinicians in routine clinical practice. These patients experience chronic symptoms in the context of CAD, characterised by angina-type pain, which is uncontrolled despite optimal pharmacological, interventional and surgical therapy. Although mortality rates are no worse in this cohort, patients experience a significantly impaired quality of life with disproportionately high utilisation of healthcare services. It has been increasingly recognised that the needs of RA patients are multifactorial and best provided by specialist multi-disciplinary units. In this review, we consider the variety of therapies available to clinicians in the management of RA and discuss the promise of novel treatments.
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Affiliation(s)
- Kevin Cheng
- Specialist Angina Service, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Heart Science, National Heart and Lung Institute, Imperial College London, London, UK
| | - Paul Sainsbury
- Department of Cardiology, Bradford Royal Infirmary, Bradford, UK
| | - Michael Fisher
- Institute for Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital NHS Trust and Royal Liverpool and Broadgreen NHS Trust, Liverpool, UK
| | - Ranil de Silva
- Specialist Angina Service, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Vascular Science, National Heart and Lung Institute, Imperial College London, London, UK
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Abstract
Activation of the neuro-hormonal system is a pathophysiological consequence of heart failure. Neuro-hormonal activation promotes metabolic changes, such as insulin resistance, and determines an increased use of non-carbohydrate substrates for energy production. Fasting blood ketone bodies as well as fat oxidation are increased in patients with heart failure, yielding a state of metabolic inefficiency. The net result is additional depletion of myocardial adenosine triphosphate, phosphocreatine and creatine kinase levels with further decreased efficiency of mechanical work. In this context, manipulation of cardiac energy metabolism by modification of substrate use by the failing heart has produced positive clinical results. The results of current research support the concept that shifting the energy substrate preference away from fatty acid metabolism and towards glucose metabolism could be an effective adjunctive treatment in patients with heart failure. The additional use of drugs able to partially inhibit fatty acids oxidation in patients with heart failure may therefore yield a significant protective effect for clinical symptoms and cardiac function improvement, and simultaneously ameliorate left ventricular remodelling. Certainly, to clarify the exact therapeutic role of metabolic therapy in heart failure, a large multicentre, randomised controlled trial should be performed.
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Stereoselective handling of perhexiline: implications regarding accumulation within the human myocardium. Eur J Clin Pharmacol 2015; 71:1485-91. [PMID: 26376650 DOI: 10.1007/s00228-015-1934-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 08/30/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Perhexiline is a prophylactic anti-ischaemic agent with weak calcium antagonist effect which has been increasingly utilised in the management of refractory angina. The metabolic clearance of perhexiline is modulated by CYP2D6 metaboliser status and stereoselectivity. The current study sought to (1) determine whether the acute accumulation of perhexiline in the myocardium is stereoselective and (2) investigate the relationship between duration of short-term therapy and the potential stereoselective effects of perhexiline within myocardium. METHOD Patients (n = 129) from the active arm of a randomised controlled trial of preoperative perhexiline in cardiac surgery were treated with oral perhexiline for a median of 9 days. Correlates of atrial and ventricular concentrations of enantiomers were sought via univariate followed by multivariate analyses. RESULTS Myocardial uptake of both (+) and (-) perhexiline was greater in ventricles than in atria, and there was more rapid clearance of (-) than (+) perhexiline. The main determinants of atrial uptake of both (+) and (-) perhexiline were the plasma concentrations [(+) perhexiline: β = -0.256, p = 0.015; (-) perhexiline: β = -0.347, p = 0.001] and patients' age [(+) perhexiline: β = 0.300, p = 0.004; (-) perhexiline: β = 0.288, p = 0.005]. Atrial uptake of (+) enantiomer also varied directly with duration of therapy (β = 0.228, p = 0.025), while atrial uptake of (-) perhexiline varied inversely with simultaneous heart rate (β = -0.240, p = 0.015). CONCLUSION (1) Uptake of both perhexiline enantiomers into atrium is greater with advanced age and displays evidence of both saturability and minor stereoselectivity. (2) Atrial uptake of (-) perhexiline may selectively modulate heart rate reduction.
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Abstract
Chronic angina is a common manifestation of ischaemic heart disease. Medical treatments are the mainstay approach to reduce the occurrence of angina and improve patients' quality of life. This Series paper focuses on commonly used standard treatments (eg, nitrates, β blockers, and calcium-channel blockers), emerging anti-angina treatments (which are not available in all parts of the world), and experimental treatments. Although many emerging treatments are available, evidence is scarce about their ability to reduce angina and ischaemia.
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Affiliation(s)
- Steen E Husted
- Department of Medicine, Hospital Unit West, Herning, Denmark; Department of Clinical Pharmacology, Institute of Biomedicine, Aarhus University, Aarhus, Denmark
| | - E Magnus Ohman
- The Program for Advanced Coronary Disease, Division of Cardiology, Duke University and Duke Clinical Research Institute, Durham, NC, USA.
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De Cremer K, Staes I, Delattin N, Cammue BPA, Thevissen K, De Brucker K. Combinatorial drug approaches to tackleCandida albicansbiofilms. Expert Rev Anti Infect Ther 2015; 13:973-84. [DOI: 10.1586/14787210.2015.1056162] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Westley IS, Licari G, Sallustio BC. Validation of a High-Performance Liquid Chromatography-Tandem Mass Spectrometry Method for the Determination of Perhexiline and Cis-Hydroxy-Perhexiline Plasma Concentrations. Ther Drug Monit 2015; 37:821-6. [PMID: 25774703 DOI: 10.1097/ftd.0000000000000207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The polymorphic nature of cytochrome P450 2D6 has made therapeutic drug monitoring of the anti-anginal agent perhexiline a compulsory step in reducing adverse events associated with plasma concentrations above the therapeutic range (0.15-0.60 mg/L). The aim of this study was to develop a high-performance liquid chromatography-mass spectrometry/mass spectrometry method for the determination of plasma perhexiline concentrations and its major metabolite cis-hydroxy-perhexiline to reduce sample extraction procedures and improve sample turnaround times. METHODS The method was validated by determining the precision and accuracy of calibrators and quality control material, comparing quality assurance program samples and patient samples measured by a previously reported liquid-liquid extraction fluorescence (FL) detection high-performance liquid chromatography method and performing matrix effects investigations. RESULTS Replicates of calibrators at concentrations of 3.00 and 0.05 mg/L demonstrated imprecision of <10.8% and inaccuracy of <8.2% for perhexiline and <10.1% and <4.5% for cis-hydroxy-perhexiline, respectively. All samples measured by the 2 methods (n = 102) demonstrated Deming regression of perhexiline = 1.20 FL + 0.00 (Sy.x = 0.08, 1/slope = 0.67); cis-hydroxy-perhexiline = 1.48 FL - 0.20 (Sy.x = 0.40, 1/slope = 0.67). CONCLUSIONS The assay performance was deemed acceptable and integrated into the routine therapeutic drug monitoring program of the department.
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Affiliation(s)
- Ian S Westley
- *Department of Clinical Pharmacology, Basil Hetzel Institute, The Queen Elizabeth Hospital, Woodville; †School of Pharmacy and Biomedical Science, University of South Australia; ‡Vascular Diseases and Therapeutics Research Group, Basil Hetzel Institute, The Queen Elizabeth Hospital; and §Discipline of Pharmacology, University of Adelaide, Australia
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Drury NE, Licari G, Chong CR, Howell NJ, Frenneaux MP, Horowitz JD, Pagano D, Sallustio BC. Relationship between plasma, atrial and ventricular perhexiline concentrations in humans: insights into factors affecting myocardial uptake. Br J Clin Pharmacol 2015; 77:789-95. [PMID: 24117487 DOI: 10.1111/bcp.12254] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 09/22/2013] [Indexed: 11/28/2022] Open
Abstract
AIM Little is known regarding the steady-state uptake of drugs into the human myocardium. Perhexiline is a prophylactic anti-anginal drug which is increasingly also used in the treatment of heart failure and hypertrophic cardiomyopathy. We explored the relationship between plasma perhexiline concentrations and its uptake into the myocardium. METHODS Blood, right atrium ± left ventricle biopsies were obtained from patients treated with perhexiline for a median of 8.5 days before undergoing coronary surgery in the perhexiline arm of a randomized controlled trial. Perhexiline concentrations in plasma and heart tissue were determined by HPLC. RESULTS Atrial biopsies were obtained from 94 patients and ventricular biopsies from 28 patients. The median plasma perhexiline concentration was within the therapeutic range at 0.24 mg l⁻¹ (IQR 0.12-0.44), the median atrial concentration was 6.02 mg kg⁻¹ (IQR 2.70-9.06) and median ventricular concentration was 10.0 mg kg⁻¹ (IQR 5.76-13.1). Atrial (r² = 0.76) and ventricular (r² = 0.73) perhexiline concentrations were closely and directly correlated with plasma concentrations (both P < 0.001). The median atrial : plasma ratio was 21.5 (IQR 18.1-27.1), ventricular : plasma ratio was 34.9 (IQR 24.5-55.2) and ventricular : atrial ratio was 1.67 (IQR 1.39-2.22). Using multiple regression, the best model for predicting steady-state atrial concentration included plasma perhexiline, heart rate and age (r² = 0.83). Ventricular concentrations were directly correlated with plasma perhexiline concentration and length of therapy (r² = 0.84). CONCLUSIONS This study demonstrates that plasma perhexiline concentrations are predictive of myocardial drug concentrations, a major determinant of drug effect. However, net myocardial perhexiline uptake is significantly modulated by patient age, potentially via alteration of myocardial:extracardiac drug uptake.
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Affiliation(s)
- Nigel E Drury
- Departments of Clinical Pharmacology and Cardiology, Basil Hetzel Institute, The Queen Elizabeth Hospital, Woodville, SA, Australia; The Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia; Department of Cardiothoracic Surgery, Queen Elizabeth Hospital, Birmingham, UK
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Beadle RM, Williams LK, Kuehl M, Bowater S, Abozguia K, Leyva F, Yousef Z, Wagenmakers AJM, Thies F, Horowitz J, Frenneaux MP. Improvement in cardiac energetics by perhexiline in heart failure due to dilated cardiomyopathy. JACC-HEART FAILURE 2015; 3:202-11. [PMID: 25650370 DOI: 10.1016/j.jchf.2014.09.009] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 09/05/2014] [Accepted: 09/19/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim of this study was to determine whether short-term treatment with perhexiline improves cardiac energetics, left ventricular function, and symptoms of heart failure by altering cardiac substrate utilization. BACKGROUND Perhexiline improves exercise capacity and left ventricular ejection fraction (LVEF) in patients with heart failure (HF). (31)P cardiac magnetic resonance spectroscopy can be used to quantify the myocardial phosphocreatine/adenosine triphosphate ratio. Because improvement of HF syndrome can improve cardiac energetics secondarily, we investigated the effects of short-term perhexiline therapy. METHODS Patients with systolic HF of nonischemic etiology (n = 50, 62 ± 1.8 years of age, New York Heart Association functional class II to IV, LVEF: 27.0 ± 1.44%) were randomized to receive perhexiline 200 mg or placebo for 1 month in a double-blind fashion. Clinical assessment, echocardiography, and (31)P cardiac magnetic resonance spectroscopy were performed at baseline and after 1 month. A substudy of 22 patients also underwent cross-heart blood sampling at completion of the study to quantify metabolite utilization. RESULTS Perhexiline therapy was associated with a 30% increase in the phosphocreatine/adenosine triphosphate ratio (from 1.16 ± 0.39 to 1.51 ± 0.51; p < 0.001) versus a 3% decrease with placebo (from 1.36 ± 0.31 to 1.34 ± 0.31; p = 0.37). Perhexiline therapy also led to an improvement in New York Heart Association functional class compared with placebo (p = 0.036). Short-term perhexiline therapy did not change LVEF. Cross-heart measures of cardiac substrate uptake and respiratory exchange ratio (which reflects the ratio of substrates used) did not differ between patients who received perhexiline versus placebo. CONCLUSIONS Perhexiline improves cardiac energetics and symptom status with no evidence of altered cardiac substrate utilization. No change in LVEF is seen at this early stage. (Metabolic Manipulation in Chronic Heart Failure; NCT00841139).
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Affiliation(s)
- Roger M Beadle
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland
| | - Lynne K Williams
- Department of Cardiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Michael Kuehl
- Department of Cardiovascular Medicine, University of Birmingham, Birmingham, England
| | - Sarah Bowater
- Department of Cardiovascular Medicine, University of Birmingham, Birmingham, England
| | - Khalid Abozguia
- Department of Cardiovascular Medicine, University of Birmingham, Birmingham, England
| | - Francisco Leyva
- Department of Cardiovascular Medicine, University of Birmingham, Birmingham, England
| | - Zaheer Yousef
- Department of Cardiology, University Hospital of Wales, Cardiff, Wales
| | - Anton J M Wagenmakers
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, England
| | - Frank Thies
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland
| | - John Horowitz
- Department of Cardiology and Pharmacology, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Michael P Frenneaux
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland.
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Licari G, Somogyi AA, Milne RW, Sallustio BC. Comparison of CYP2D metabolism and hepatotoxicity of the myocardial metabolic agent perhexiline in Sprague-Dawley and Dark Agouti rats. Xenobiotica 2014; 45:3-9. [PMID: 25050791 DOI: 10.3109/00498254.2014.942721] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
1. Perhexiline, a chiral anti-anginal agent, may be useful to develop new cardiovascular therapies, despite its potential hepatotoxicity. 2. This study compared Dark Agouti (DA) and Sprague-Dawley (SD) rats, as models of perhexiline's metabolism and hepatotoxicity in humans. Rats (n = 4/group) received vehicle or 200 mg/kg/d of racemic perhexiline maleate for 8 weeks. Plasma and liver samples were collected to determine concentrations of perhexiline and its metabolites, hepatic function and histology. 3. Median (range) plasma and liver perhexiline concentrations in SD rats were 0.09 (0.04-0.13) mg/L and 5.42 (0.92-8.22) ng/mg, respectively. In comparison, DA rats showed higher (p < 0.05) plasma 0.50 (0.16-1.13) mg/L and liver 24.5 (9.40-54.7) ng/mg perhexiline concentrations, respectively, 2.5- and 3.7-fold higher cis-OH-perhexiline concentrations, respectively (p < 0.05), and lower plasma metabolic ratio (0.89 versus 1.55, p < 0.05). In both strains, the (+):(-) enantiomer ratio was 2:1. Perhexiline increased plasma LDH concentrations in DA rats (p < 0.05), but had no effect on plasma biochemistry in SD rats. Liver histology revealed lower glycogen content in perhexiline-treated SD rats (p < 0.05), but no effects on lipid content in either strain. 4. DA rats appeared more similar to humans with respect to plasma perhexiline concentrations, metabolic ratio, enantioselective disposition and biochemical changes suggestive of perhexiline-induced toxicity.
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Affiliation(s)
- Giovanni Licari
- Discipline of Pharmacology, School of Medical Sciences, The University of Adelaide , Adelaide , Australia
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Drury NE, Howell NJ, Calvert MJ, Weber RJM, Senanayake EL, Lewis ME, Hyde JAJ, Green DH, Mascaro JG, Wilson IC, Graham TR, Rooney SJ, Viant MR, Freemantle N, Frenneaux MP, Pagano D. The effect of perhexiline on myocardial protection during coronary artery surgery: a two-centre, randomized, double-blind, placebo-controlled trial. Eur J Cardiothorac Surg 2014; 47:464-72. [PMID: 24948413 PMCID: PMC4324609 DOI: 10.1093/ejcts/ezu238] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES Perhexiline is thought to modulate metabolism by inhibiting mitochondrial carnitine palmitoyltransferase-1, reducing fatty acid uptake and increasing carbohydrate utilization. This study assessed whether preoperative perhexiline improves markers of myocardial protection in patients undergoing coronary artery bypass graft surgery and analysed its effect on the myocardial metabolome. METHODS In a prospective, randomized, double-blind, placebo-controlled trial, patients at two centres were randomized to receive either oral perhexiline or placebo for at least 5 days prior to surgery. The primary outcome was a low cardiac output episode in the first 6 h. All pre-specified analyses were conducted according to the intention-to-treat principle with a statistical power of 90% to detect a relative risk of 0.5 and a conventional one-sided α-value of 0.025. A subset of pre-ischaemic left ventricular biopsies was analysed using mass spectrometry-based metabolomics. RESULTS Over a 3-year period, 286 patients were randomized, received the intervention and were included in the analysis. The incidence rate of a low cardiac output episode in the perhexiline arm was 36.7% (51/139) vs 34.7% (51/147) in the control arm [odds ratio (OR) 0.92, 95% confidence interval (CI) 0.56–1.50, P = 0.74]. Perhexiline was associated with a reduction in the cardiac index at 6 h [difference in means 0.19, 95% CI 0.07–0.31, P = 0.001] and an increase in inotropic support in the first 12 h (OR 0.55, 95% CI 0.34–0.89, P = 0.015). There were no significant differences in myocardial injury with troponin-T or electrocardiogram, reoperation, renal dysfunction or length of stay. No difference in the preischaemic left ventricular metabolism was identified between groups on metabolomics analysis. CONCLUSIONS Preoperative perhexiline does not improve myocardial protection in patients undergoing coronary surgery and in fact reduced perioperative cardiac output, increasing the need for inotropic support. Perhexiline has no significant effect on the mass spectrometry-visible polar myocardial metabolome in vivo in humans, supporting the suggestion that it acts via a pathway that is independent of myocardial carnitine palmitoyltransferase inhibition and may explain the lack of clinical benefit observed following surgery. ClinicalTrials.Gov ID NCT00845364.
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Affiliation(s)
- Nigel E Drury
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Neil J Howell
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Melanie J Calvert
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Ralf J M Weber
- Centre for Systems Biology, School of Biosciences, University of Birmingham, Birmingham, UK
| | - Eshan L Senanayake
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Michael E Lewis
- Department of Cardiothoracic Surgery, Royal Sussex County Hospital, Brighton
| | - Jonathan A J Hyde
- Department of Cardiothoracic Surgery, Royal Sussex County Hospital, Brighton
| | - David H Green
- Department of Cardiac Anesthesia, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Jorge G Mascaro
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Ian C Wilson
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Timothy R Graham
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Stephen J Rooney
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Mark R Viant
- Centre for Systems Biology, School of Biosciences, University of Birmingham, Birmingham, UK
| | - Nick Freemantle
- Department of Primary Care and Population Health, University College London, London, UK
| | | | - Domenico Pagano
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
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Wang W, Lopaschuk GD. Metabolic therapy for the treatment of ischemic heart disease: reality and expectations. Expert Rev Cardiovasc Ther 2014; 5:1123-34. [DOI: 10.1586/14779072.5.6.1123] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Henry TD, Satran D, Jolicoeur EM. Treatment of refractory angina in patients not suitable for revascularization. Nat Rev Cardiol 2013; 11:78-95. [DOI: 10.1038/nrcardio.2013.200] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Sheikh AR, Westley I, Sallustio B, Horowitz JD, Beltrame JF. Interaction of terbinafine (anti-fungal agent) with perhexiline: a case report. Heart Lung Circ 2013; 23:e149-51. [PMID: 24373912 DOI: 10.1016/j.hlc.2013.11.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Revised: 11/19/2013] [Accepted: 11/29/2013] [Indexed: 11/24/2022]
Abstract
Perhexiline is a unique anti-anginal agent that is frequently used in the treatment of chronic refractory angina. Its utility has been limited because of its complex pharmacokinetics that were only appreciated following the development of a therapeutic perhexiline assay. Perhexiline is cleared primarily via formation of mono-hydroxy metabolites (OH-perhexiline) by cytochrome P450 2D6 (CYP2D6). Drugs that are inhibitors of CYP2D6 may therefore inhibit perhexiline metabolism, increase plasma perhexiline concentration and may consequently increase the risk of toxicity. We report a case of a rise in perhexiline plasma concentration to a toxic level following the introduction of terbinafine hydrochloride; a moderate CYP2D6 inhibiting drug.
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Affiliation(s)
- Abdul Rauf Sheikh
- The Discipline of Medicine, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia; Cardiology Unit, The Queen Elizabeth Hospital, Central Adelaide Local Health Network
| | - Ian Westley
- Department of Clinical Pharmacology, The Queen Elizabeth Hospital, Central Adelaide Local Health Network; School of Pharmacy and Medical Sciences, University of South Australia, South Australia
| | - Benedetta Sallustio
- Department of Clinical Pharmacology, The Queen Elizabeth Hospital, Central Adelaide Local Health Network; The Discipline of Pharmacology, The University of Adelaide, Adelaide, South Australia
| | - John D Horowitz
- The Discipline of Medicine, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia; Cardiology Unit, The Queen Elizabeth Hospital, Central Adelaide Local Health Network
| | - John F Beltrame
- The Discipline of Medicine, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia; Cardiology Unit, The Queen Elizabeth Hospital, Central Adelaide Local Health Network.
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Delattin N, De Brucker K, Vandamme K, Meert E, Marchand A, Chaltin P, Cammue BPA, Thevissen K. Repurposing as a means to increase the activity of amphotericin B and caspofungin against Candida albicans biofilms. J Antimicrob Chemother 2013; 69:1035-44. [DOI: 10.1093/jac/dkt449] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Bayeva M, Sawicki KT, Ardehali H. Taking diabetes to heart--deregulation of myocardial lipid metabolism in diabetic cardiomyopathy. J Am Heart Assoc 2013; 2:e000433. [PMID: 24275630 PMCID: PMC3886738 DOI: 10.1161/jaha.113.000433] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Marina Bayeva
- Feinberg Cardiovascular Research Institute, Northwestern University, Chicago, IL
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Huang PY, Lin YT, Kou HS, Wu HL. High-Performance Liquid Chromatographic Analysis of Perhexiline as a Fluorescent Derivative. J CHIN CHEM SOC-TAIP 2013. [DOI: 10.1002/jccs.201000038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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50
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Yamamoto R, Matsushita M, Kitoh H, Masuda A, Ito M, Katagiri T, Kawai T, Ishiguro N, Ohno K. Clinically applicable antianginal agents suppress osteoblastic transformation of myogenic cells and heterotopic ossifications in mice. J Bone Miner Metab 2013; 31:26-33. [PMID: 23011467 DOI: 10.1007/s00774-012-0380-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 07/18/2012] [Indexed: 01/09/2023]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare autosomal dominant disorder characterized by progressive heterotopic ossification. FOP is caused by a gain-of-function mutation in ACVR1 encoding the bone morphogenetic protein type II receptor, ACVR1/ALK2. The mutant receptor causes upregulation of a transcriptional factor, Id1. No therapy is available to prevent the progressive heterotopic ossification in FOP. In an effort to search for clinically applicable drugs for FOP, we screened 1,040 FDA-approved drugs for suppression of the Id1 promoter activated by the mutant ACVR1/ALK2 in C2C12 cells. We found that that two antianginal agents, fendiline hydrochloride and perhexiline maleate, suppressed the Id1 promoter in a dose-dependent manner. The drugs also suppressed the expression of native Id1 mRNA and alkaline phosphatase in a dose-dependent manner. Perhexiline but not fendiline downregulated phosphorylation of Smad 1/5/8 driven by bone morphogenetic protein (BMP)-2. We implanted crude BMPs in muscles of ddY mice and fed them fendiline or perhexiline for 30 days. Mice taking perhexiline showed a 38.0 % reduction in the volume of heterotopic ossification compared to controls, whereas mice taking fendiline showed a slight reduction of heterotopic ossification. Fendiline, perhexiline, and their possible derivatives are potentially applicable to clinical practice to prevent devastating heterotopic ossification in FOP.
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Affiliation(s)
- Ryuichiro Yamamoto
- Department of Neurogenetics, Center for Neurological Diseases and Cancer, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, 466-8550, Japan
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