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Peng M, Zhang C, Dong Y, Zhang Y, Nakazawa H, Kaneki M, Zheng H, Shen Y, Marcantonio ER, Xie Z. Battery of behavioral tests in mice to study postoperative delirium. Sci Rep 2016; 6:29874. [PMID: 27435513 PMCID: PMC4951688 DOI: 10.1038/srep29874] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 06/23/2016] [Indexed: 12/31/2022] Open
Abstract
Postoperative delirium is associated with increased morbidity, mortality and cost. However, its neuropathogenesis remains largely unknown, partially owing to lack of animal model(s). We therefore set out to employ a battery of behavior tests, including natural and learned behavior, in mice to determine the effects of laparotomy under isoflurane anesthesia (Anesthesia/Surgery) on these behaviors. The mice were tested at 24 hours before and at 6, 9 and 24 hours after the Anesthesia/Surgery. Composite Z scores were calculated. Cyclosporine A, an inhibitor of mitochondria permeability transient pore, was used to determine potential mitochondria-associated mechanisms of these behavioral changes. Anesthesia/Surgery selectively impaired behaviors, including latency to eat food in buried food test, freezing time and time spent in the center in open field test, and entries and duration in the novel arm of Y maze test, with acute onset and various timecourse. The composite Z scores quantitatively demonstrated the Anesthesia/Surgery-induced behavior impairment in mice. Cyclosporine A selectively ameliorated the Anesthesia/Surgery-induced reduction in ATP levels, the increases in latency to eat food, and the decreases in entries in the novel arm. These findings suggest that we could use a battery of behavior tests to establish a mouse model to study postoperative delirium.
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Affiliation(s)
- Mian Peng
- Department of Anesthesia, Zhongnan Hospital of Wuhan University, Wuhan, 430071, P. R. China
- Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129-2060, USA
| | - Ce Zhang
- Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129-2060, USA
- Department of Anesthesia, China-Japan Union Hospital of Jilin University, Changchun, Jilin, 130033, P. R. China
| | - Yuanlin Dong
- Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129-2060, USA
| | - Yiying Zhang
- Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129-2060, USA
| | - Harumasa Nakazawa
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Shriners Hospitals for Children and Harvard Medical School, Charlestown, MA 02129-2060, USA
| | - Masao Kaneki
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Shriners Hospitals for Children and Harvard Medical School, Charlestown, MA 02129-2060, USA
| | - Hui Zheng
- Massachusetts General Hospital Biostatistics Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Yuan Shen
- Department of Psychiatry, Tenth People’s Hospital of Tongji University, Shanghai, 200072, P. R. China
| | - Edward R. Marcantonio
- Divisions of General Medicine and Primary Care and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215
| | - Zhongcong Xie
- Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129-2060, USA
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2
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Matsson P, Doak BC, Over B, Kihlberg J. Cell permeability beyond the rule of 5. Adv Drug Deliv Rev 2016; 101:42-61. [PMID: 27067608 DOI: 10.1016/j.addr.2016.03.013] [Citation(s) in RCA: 188] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 03/25/2016] [Accepted: 03/31/2016] [Indexed: 11/17/2022]
Abstract
Drug discovery for difficult targets that have large and flat binding sites is often better suited to compounds beyond the "rule of 5" (bRo5). However, such compounds carry higher pharmacokinetic risks, such as low solubility and permeability, and increased efflux and metabolism. Interestingly, recent drug approvals and studies suggest that cell permeable and orally bioavailable drugs can be discovered far into bRo5 space. Tactics such as reduction or shielding of polarity by N-methylation, bulky side chains and intramolecular hydrogen bonds may be used to increase cell permeability in this space, but often results in decreased solubility. Conformationally flexible compounds can, however, combine high permeability and solubility, properties that are keys for cell permeability and intestinal absorption. Recent developments in computational conformational analysis will aid design of such compounds and hence prediction of cell permeability. Transporter mediated efflux occurs for most investigated drugs in bRo5 space, however it is commonly overcome by high local intestinal concentrations on oral administration. In contrast, there is little data to support significant impact of transporter-mediated intestinal absorption in bRo5 space. Current knowledge of compound properties that govern transporter effects of bRo5 drugs is limited and requires further fundamental and comprehensive studies.
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Affiliation(s)
- Pär Matsson
- Department of Pharmacy, BMC, Uppsala University, Box 580, SE-751 23 Uppsala, Sweden
| | - Bradley C Doak
- Department of Medicinal Chemistry, MIPS, Monash University, 381 Royal Parade, Parkville, Victoria, Australia
| | - Björn Over
- Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Pepparedsleden 1, SE-431 83 Mölndal, Sweden
| | - Jan Kihlberg
- Department of Chemistry - BMC, Uppsala University, Box 576, SE-751 23 Uppsala, Sweden.
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3
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Abstract
For over 100 years it was believed that dietary protein must be completely hydrolysed before its constituent amino acids could be absorbed via specific amino acid transport systems. It is now known that the uptake of di- and tripeptides into the enterocyte is considerable, being transported across the intestinal endothelium by the PepT1 H+/peptide co-transporter. There is also evidence that some di- and tripeptides may survive cytosolic hydrolysis and be transported intact across the basolateral membrane. However, other than antigen sampling, the transport of larger intact macromolecules across the intestinal endothelium of the healthy adult human remains a controversial issue as there is little unequivocal in vivo evidence to support this postulation. The aim of the present review was to critically evaluate the scientific evidence that peptides/proteins are absorbed by healthy intestinal epithelia and pass intact into the hepatic portal system. The question of the absorption of oliogopeptides is paramount to the emerging science of food-derived bioactive peptides, their mode of action and physiological effects. Overall, we conclude that there is little unequivocal evidence that dietary bioactive peptides, other than di- and tripeptides, can cross the gut wall intact and enter the hepatic portal system in physiologically relevant concentrations.
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4
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Doak B, Over B, Giordanetto F, Kihlberg J. Oral Druggable Space beyond the Rule of 5: Insights from Drugs and Clinical Candidates. ACTA ACUST UNITED AC 2014; 21:1115-42. [DOI: 10.1016/j.chembiol.2014.08.013] [Citation(s) in RCA: 282] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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5
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Over B, McCarren P, Artursson P, Foley M, Giordanetto F, Grönberg G, Hilgendorf C, Lee MD, Matsson P, Muncipinto G, Pellisson M, Perry MWD, Svensson R, Duvall JR, Kihlberg J. Impact of stereospecific intramolecular hydrogen bonding on cell permeability and physicochemical properties. J Med Chem 2014; 57:2746-54. [PMID: 24524242 PMCID: PMC3968888 DOI: 10.1021/jm500059t] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Indexed: 01/17/2023]
Abstract
Profiling of eight stereoisomeric T. cruzi growth inhibitors revealed vastly different in vitro properties such as solubility, lipophilicity, pKa, and cell permeability for two sets of four stereoisomers. Using computational chemistry and NMR spectroscopy, we identified the formation of an intramolecular NH→NR3 hydrogen bond in the set of stereoisomers displaying lower solubility, higher lipophilicity, and higher cell permeability. The intramolecular hydrogen bond resulted in a significant pKa difference that accounts for the other structure-property relationships. Application of this knowledge could be of particular value to maintain the delicate balance of size, solubility, and lipophilicity required for cell penetration and oral administration for chemical probes or therapeutics with properties at, or beyond, Lipinski's rule of 5.
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Affiliation(s)
- Björn Over
- CVMD
iMed, AstraZeneca R&D Mölndal, SE-431 83 Mölndal, Sweden
| | - Patrick McCarren
- Center
for the Science of Therapeutics, Broad Institute, 7 Cambridge Center, Cambridge, Massachusetts 02142, United States
| | - Per Artursson
- Department
of Pharmacy, BMC, Uppsala University, Box 580, SE-751 23 Uppsala, Sweden
- Uppsala
Drug Optimization and Pharmaceutical Profiling Platform (UDOPP), a
Node at the Chemical Biology Consortium Sweden and the Drug Discovery
and Development Platform, Science for Life Laboratory, Department
of Pharmacy, BMC, Uppsala Univerisity, Box 580, SE-751 23 Uppsala, Sweden
| | - Michael Foley
- Center
for the Science of Therapeutics, Broad Institute, 7 Cambridge Center, Cambridge, Massachusetts 02142, United States
| | - Fabrizio Giordanetto
- Medicinal
Chemistry, Taros Chemicals GmbH & Co.
KG, Emil-Figge-Strasse
76a, 44227 Dortmund, Germany
| | - Gunnar Grönberg
- RIA
iMed, AstraZeneca R&D Mölndal, SE-431 83 Mölndal, Sweden
| | - Constanze Hilgendorf
- Drug
Safety and Metabolism, DMPK, AstraZeneca
R&D Mölndal, SE-431 83 Mölndal, Sweden
| | - Maurice D. Lee
- Center
for the Science of Therapeutics, Broad Institute, 7 Cambridge Center, Cambridge, Massachusetts 02142, United States
| | - Pär Matsson
- Department
of Pharmacy, BMC, Uppsala University, Box 580, SE-751 23 Uppsala, Sweden
- Uppsala
Drug Optimization and Pharmaceutical Profiling Platform (UDOPP), a
Node at the Chemical Biology Consortium Sweden and the Drug Discovery
and Development Platform, Science for Life Laboratory, Department
of Pharmacy, BMC, Uppsala Univerisity, Box 580, SE-751 23 Uppsala, Sweden
| | - Giovanni Muncipinto
- Center
for the Science of Therapeutics, Broad Institute, 7 Cambridge Center, Cambridge, Massachusetts 02142, United States
| | - Mélanie Pellisson
- Center
for the Science of Therapeutics, Broad Institute, 7 Cambridge Center, Cambridge, Massachusetts 02142, United States
| | | | - Richard Svensson
- Uppsala
Drug Optimization and Pharmaceutical Profiling Platform (UDOPP), a
Node at the Chemical Biology Consortium Sweden and the Drug Discovery
and Development Platform, Science for Life Laboratory, Department
of Pharmacy, BMC, Uppsala Univerisity, Box 580, SE-751 23 Uppsala, Sweden
| | - Jeremy R. Duvall
- Center
for the Science of Therapeutics, Broad Institute, 7 Cambridge Center, Cambridge, Massachusetts 02142, United States
| | - Jan Kihlberg
- Department
of Chemistry, BMC, Uppsala University, Box 576, SE-751 23 Uppsala, Sweden
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6
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Giordanetto F, Kihlberg J. Macrocyclic drugs and clinical candidates: what can medicinal chemists learn from their properties? J Med Chem 2013; 57:278-95. [PMID: 24044773 DOI: 10.1021/jm400887j] [Citation(s) in RCA: 404] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Macrocycles are ideal in efforts to tackle "difficult" targets, but our understanding of what makes them cell permeable and orally bioavailable is limited. Analysis of approximately 100 macrocyclic drugs and clinical candidates revealed that macrocycles are predominantly used for infectious disease and in oncology and that most belong to the macrolide or cyclic peptide class. A significant number (N = 34) of these macrocycles are administered orally, revealing that oral bioavailability can be obtained at molecular weights up to and above 1 kDa and polar surface areas ranging toward 250 Å(2). Moreover, insight from a group of "de novo designed" oral macrocycles in clinical studies and understanding of how cyclosporin A and model cyclic hexapeptides cross cell membranes may unlock wider opportunities in drug discovery. However, the number of oral macrocycles is still low and it remains to be seen if they are outliers or if macrocycles will open up novel oral druggable space.
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Affiliation(s)
- Fabrizio Giordanetto
- Cardiovascular and Metabolic Disorders Research Area, AstraZeneca R&D Mölndal , SE-431 83 Mölndal, Sweden
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7
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BH3 mimetics antagonizing restricted prosurvival Bcl-2 proteins represent another class of selective immune modulatory drugs. Proc Natl Acad Sci U S A 2010; 107:10967-71. [PMID: 20534453 DOI: 10.1073/pnas.1005256107] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Death by apoptosis shapes tissue homeostasis. Apoptotic mechanisms are so universal that harnessing them for tailored immune intervention would seem challenging; however, the range and different expression levels of pro- and anti-apoptotic molecules among tissues offer hope that targeting only a subset of such molecules may be therapeutically useful. We examined the effects of the drug ABT-737, a mimetic of the killer BH3 domain of the Bcl-2 family of proteins that induces apoptosis by antagonizing Bcl-2, Bcl-X(L), and Bcl-W (but not Mcl-1 and A1), on the mouse immune system. Treatment with ABT-737 reduced the numbers of selected lymphocyte and dendritic cell subpopulations, most markedly in lymph nodes. It inhibited the persistence of memory B cells, the establishment of newly arising bone marrow plasma cells, and the induction of a cytotoxic T cell response. Preexisting plasma cells and germinal centers were unaffected. Notably, ABT-737 was sufficiently immunomodulatory to allow long-term survival of pancreatic allografts, reversing established diabetes in this model. These results provide an insight into the selective mechanisms of immune cell survival and how this selectivity avails a different strategy for immune modulation.
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8
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NAM HYUNSOOK, MCANULTY JONATHONF, KWAK HOHYUN, YOON BYUNGI, HYUN CHANGBAIG, KIM WANHEE, WOO HEUNGMYONG. Gingival Overgrowth in Dogs Associated with Clinically Relevant Cyclosporine Blood Levels: Observations in a Canine Renal Transplantation Model. Vet Surg 2008; 37:247-53. [DOI: 10.1111/j.1532-950x.2008.00373.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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9
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Arora-Gupta N, Davies P, McKiernan P, Kelly DA. The effect of long-term calcineurin inhibitor therapy on renal function in children after liver transplantation. Pediatr Transplant 2004; 8:145-50. [PMID: 15049794 DOI: 10.1046/j.1399-3046.2003.00132.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Calcineurin inhibitor drugs (CNI), cyclosporin and tacrolimus are potent immunosuppressants, which have improved survival after liver transplantation. We evaluated long-term renal function in children receiving calcineurin inhibitors after liver transplantation. A retrospective analysis of all children undergoing orthotopic liver transplantation (OLT) from 1989 to 1999 who survived 1-yr post-transplantation was performed. All received prednisolone and either cyclosporin and azathioprine or tacrolimus. Steroids were withdrawn at 3 months and cyclosporin/tacrolimus monotherapy was initiated 12 months post-OLT. Calculated glomerular filtration rate (cGFR) was calculated using the modified Counahan-Barratt formula and measured pretransplant, 3, 6 and 12 months post-transplant and annually thereafter. Data were analysed in a serial manner to evaluate the trend of cGFR over time selectively using the Wilcoxon signed rank test and paired t-tests as appropriate. A total of 113 patients (65 males:48 females) were followed up for more than 1 yr (maximum 5 yr). Median (range) age at transplantation was 26 months (3-177). There was a significant fall of 35% in cGFR at 3 months compared with the pretransplant value (p = 0.001). By 12 months following the reduction in immunosuppression dosage, renal function stabilized with a slight improvement in cGFR which reached 76% of the pretransplant value at 5 yr (p < 0.001). Children who were <1 yr of age at the time of OLT had better recovery of renal function than older children (p = 0.02). No association was seen with sex, the type of immunosuppression or the underlying diagnosis. Renal dysfunction is a known complication of CNI therapy. Despite an initial reduction in cGFR, which was associated with maximal immunosuppression, long-term low dose CNI therapy was not associated with continued deterioration of renal function, particularly in children who were transplanted as infants.
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10
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del Mar Fernández De Gatta M, Santos-Buelga D, Domínguez-Gil A, García MJ. Immunosuppressive therapy for paediatric transplant patients: pharmacokinetic considerations. Clin Pharmacokinet 2002; 41:115-35. [PMID: 11888332 DOI: 10.2165/00003088-200241020-00004] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Immunosuppressive therapy in paediatric transplant recipients is changing as a consequence of the increasing number of available immunosuppressive agents. Generic and other new formulations are now emerging onto the market, clinical experience is growing, and it is expected that clinicians should tailor immunosuppressive protocols to individual patients by optimising dosages and drugs according to the maturation and clinical status of the child. Most information about the clinical pharmacokinetics of immunosuppressive drugs in paediatrics is centred on cyclosporin, tacrolimus and mycophenolate mofetil in renal and liver transplant recipients; data regarding other immunosuppressants and transplant types are limited. Although the clinical pharmacokinetics of these drugs in paediatric transplant recipients are still under investigation, it is evident that the pharmacokinetic parameters observed in adults may not be applicable to children, especially in younger age groups. In general, patients younger than 5 years old show higher clearance rates irrespective of the organ transplanted or drug used. Another important factor that frequently affects clearance in this patient population is the post-transplant time. In accordance with these findings, and in contrast with the usual under-dosage in children, the need for higher dosages in younger recipients and during the early post-transplant period seems evident. To achieve the best compromise between prevention of rejection and toxicity, dosage individualisation is required and this can be achieved through therapeutic drug monitoring (TDM). This approach is particularly useful to ensure the cost-effective management of paediatric transplant recipients in whom the pharmacokinetic behaviour, target concentrations for clinical use and optimal dosage strategies of a particular drug may not yet be well defined. Although TDM may be a tool for improving immunosuppressive therapy, there is little information concerning its positive contribution to clinical events, including outcomes, for paediatric patients. Substantial information to support the use of TDM exists for cyclosporin and, to a lesser extent, for tacrolimus, but a diversity of options affects their implementation in the clinical setting. The role of TDM in therapy with mycophenolate mofetil and sirolimus has yet to be defined regarding both methods and clinical indications. Pharmacodynamic monitoring appears more suited to other immunosuppressants such as azathioprine, corticosteroids and monoclonal or polyclonal antibodies. If coupled with pharmacokinetic measurements, such monitoring would allow earlier and more precise optimisation of therapy. Very few population pharmacokinetic studies have been carried out in paediatric transplant patients. This type of study is needed so that techniques such as Bayesian forecasting can be applied to optimise immunosuppressive therapy in paediatric transplant patients.
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11
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Arora N, McKiernan PJ, Beath SV, deVille de Goyet J, Kelly DA. Concomitant basiliximab with low-dose calcineurin inhibitors in children post-liver transplantation. Pediatr Transplant 2002; 6:214-8. [PMID: 12100505 DOI: 10.1034/j.1399-3046.2002.01076.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Orthotopic liver transplantation (OLT) is effective therapy for end-stage liver disease but immunosuppression with calcineurin inhibitors (CNI) leads to significant nephrotoxicity, resulting in either a reduction of dosage to below the therapeutic level or omission of the drug altogether. Basiliximab (Bx) is a human/mouse chimeric monoclonal antibody that inhibits binding of interleukin-2 (IL-2) to IL-2 receptors and thus prevents proliferation of T cells, which is the main step in the development of acute cellular rejection. The aim of this study was to identify the role of Bx in the prevention of acute cellular rejection and in the reduction of nephrotoxicity in children post-liver transplantation. We evaluated three children (19 months, 22 months, and 11 yr of age; one male, two female) who were treated with Bx post-OLT on compassionate grounds. The indications were: nephrotoxicity in two children, requiring re-transplantation for hepatic artery thrombosis and recurrent giant cell hepatitis, respectively; and nephrotoxicity secondary to chemotherapy for hepatoblastoma in the third child. All patients received 10 mg of Bx, at OLT and on Day 4. Tacrolimus (0.15 mg/kg/day) was started at 48 h (n = 2) and cyclosporin (5 mg/kg/day) at 2 weeks (n = 1). Trough levels of tacrolimus were maintained at 5-8 ng/mL and trough levels of cyclosporin at 100-150 mg/L for the first 3 months. All patients received methylprednisolone (2 mg/kg) with azathioprine (1.5 mg/kg) (n = 2) and/or mycophenolate mofetil (20 mg/kg) (n = 1). The glomerular filtration rate (cGFR) was calculated using the Schwartz formula before and 10 weeks after transplant. Bx was found to be easy to administer and no major side-effects were reported. One child had two episodes of mild acute rejection at 5 and 9 weeks post-OLT and one developed chronic rejection requiring re-transplantation at 9 weeks post-OLT. One child did not develop rejection. The mean pretransplant cGFR was 58.1 (54.6-64.1) mL/min/m2. Within 10 weeks of transplantation, the cGFR had improved by 69% to a mean of 116 (88-157.6) mL/min/m2. To conclude, Bx was well tolerated in all children and had a renal sparing effect. It was effective in preventing early acute rejection, but the combination of Bx and low-dose CNI drugs did not prevent late acute or chronic rejection. Further studies to evaluate the appropriate levels of CNI immunosuppression with Bx are required.
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Affiliation(s)
- N Arora
- Liver Unit, Birmingham Children's Hospital, Birmingham, UK
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12
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Diav-Citrin O, Ratnapalan S, Grouhi M, Roifman C, Koren G. Medication errors in paediatrics: a case report and systematic review of risk factors. Paediatr Drugs 2000; 2:239-42. [PMID: 10937473 DOI: 10.2165/00128072-200002030-00007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- O Diav-Citrin
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada
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13
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Erdem SR, Yaşar U, Tuncer M. The possible role of endothelin(s) in cyclosporine A preparations--induced contraction of guinea pig isolated gallbladder strips. GENERAL PHARMACOLOGY 1998; 31:607-11. [PMID: 9792224 DOI: 10.1016/s0306-3623(98)00051-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
1. In guinea-pig isolated gallbladder strips, both cyclosporine A (CyA) preparations and their vehicles (10(-7) M-4 x 10(-5) M) caused stable, long-lasting and concentration-dependent contractions. 2. Some gallbladder strips showed spontaneous rhythmic activity. CyA and its vehicles increased this rhythmic activity. Furthermore, they elicited rhythmic activity in the strips that did not show any spontaneous rhythmic activity. 3. Bosentan (10(-5) M) and verapamil (10(-5) M) partly but significantly inhibited the contractions due to CyA preparations and their vehicles except the effect of verapamil on Labrafil-induced contraction. 4. Neither parenteral and oral solutions of CyA nor their vehicles caused any contractile response on the sphincter of Oddi preparations.
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Affiliation(s)
- S R Erdem
- Department of Pharmacology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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14
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Fricker G, Drewe J, Huwyler J, Gutmann H, Beglinger C. Relevance of p-glycoprotein for the enteral absorption of cyclosporin A: in vitro-in vivo correlation. Br J Pharmacol 1996; 118:1841-7. [PMID: 8842452 PMCID: PMC1909843 DOI: 10.1111/j.1476-5381.1996.tb15612.x] [Citation(s) in RCA: 175] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
1. The interaction of cyclosporin A (CyA) with p-glycoprotein during intestinal uptake was investigated by a combination of in vitro experiments with human Caco-2 cells and an intubation study in healthy volunteers. 2. CyA uptake into the cells was not saturable and exhibited only a low temperature sensitivity, suggesting passive diffusion. When the permeation of CyA across Caco-2 monolayers from the apical to the basolateral side was determined, overall transport had an apparently saturable component up to a concentration of 1 microM. At higher concentrations permeation increased over-proportionally. Calculation of the kinetic parameters of apical to basolateral permeation suggested a diffusional process with a KD of 0.5 microliter min-1 per filter, which was overlayed by an active system in basolateral to apical direction with a KM of 3.8 microM and a Jmax of 6.5 picomol min-1 per filter. 3. CyA permeation was significantly higher when the drug was given from the basolateral side as compared to the permeation from the apical side. Apical to basolateral transport of CyA was increased in the presence of vinblastine, daunomycin and a non-immunosuppressive CyA-derivative. All compounds inhibit p-glycoprotein-mediated transport processes. Basolateral to apical permeation of CyA showed a dose-dependent decrease in the presence of vinblastine. Permeation of daunomycin across Caco-2 cell monolayers was also higher from the basolateral to the apical side than vice versa. Basolateral to apical permeation was decreased in the presence of SDZ PSC 833 and cyclosporin A. 4. Western blot analysis of Caco-2 cells with the monoclonal antibody C219 confirmed the presence of p-glycoprotein in the used cell system. 5. When the absorption of CyA in the gastrointestinal (GI)-tract of healthy volunteers was determined, a remarkable decrease of the plasma AUC could be observed dependent on the location of absorption in the rank order stomach > jejunum/ileum > colon. The decrease in absorption exhibited a marked correlation (r = 0.994) to the expression of mRNA for p-glycoprotein over the GI-tract (stomach < jejunum < colon). 6. All data provide evidence that CyA is a substrate of p-glycoprotein in the GI-tract, which might explain the local differences and the high variability in cyclosporin absorption found in vivo.
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Affiliation(s)
- G Fricker
- Institute of Pharmaceutics and Biopharmacy, Heidelberg, Germany
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15
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Abstract
Today there is considerable interest in oral peptide delivery. However, oral administration of peptides is limited by a low bioavailability and a high variability in plasma levels. A review is given of the literature describing the major barriers in peptide absorption, the basic mechanisms of intestinal peptide transport, the experimental models and the pharmaceutical approaches currently used in the investigation of peptide and protein absorption processes.
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Affiliation(s)
- G Fricker
- Institut für Pharmazeutische Technologie und Biopharmazie, Ruprecht-Karls-Universität, Heidelberg, Germany.
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16
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Zylber-Katz E. Multiple drug interactions with cyclosporine in a heart transplant patient. Ann Pharmacother 1995; 29:127-31. [PMID: 7756709 DOI: 10.1177/106002809502900204] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE To report multiple drug interactions with cyclosporine in a heart transplant recipient. CASE SUMMARY A 53-year-old man underwent heart transplantation in December 1990. Immunosuppression therapy consisted of prednisone, azathioprine, and cyclosporine 300 mg/d. For 5 months, the trough specific cyclosporine (parent compound) concentration was stable (range 211-226 ng/mL). More recently, he developed a productive cough accompanied by high fever, chills, and weakness and was admitted to a hospital near his home. Antituberculosis therapy was advised including rifampin and isoniazid. After a week, erythromycin 3.6 g/d i.v. was added. After 10 days of the combined therapy he was transferred to our hospital, where the first cyclosporine blood concentrations measured were 77 and 238 ng/mL for specific and total cyclosporine (parent drug + metabolites). Because of the low cyclosporine blood concentration, the dose was increased to 400 mg/d. In light of negative sputum smears for acid-fast bacilli and culture, the rifampin/isoniazid therapy was withdrawn; the erythromycin was continued. At this time, the specific cyclosporine blood concentration rose to 934 ng/mL and the total cyclosporine concentration reached 1503 ng/mL. High cyclosporine blood concentrations were measured during the intravenous erythromycin treatment period, even though the cyclosporine dose had been decreased to 150 mg/d. A further increase in cyclosporine concentration was observed when erythromycin was given orally (4.0 g/d). The cyclosporine dose was then discontinued for 2 days and started again at 50 mg/d until the end of the erythromycin treatment period. The patient recovered, the cyclosporine dose was increased to 100 mg/d, and on regular monitoring the cyclosporine blood concentrations were within the therapeutic range (100-400 ng/mL for specific and 250-1000 ng/mL for total cyclosporine). DISCUSSION Cyclosporine is metabolized almost completely in the liver by the cytochrome P-450IIIA enzyme system. Drugs such as rifampin and erythromycin, which are known to be inducers or substrates of cytochrome P-450IIIA, have the potential to alter cyclosporine blood concentrations. The present case shows a multiple drug interaction with cyclosporine. Coadministration of rifampin/isoniazid and cyclosporine for a week, and erythromycin for the last 4 days, resulted in low cyclosporine blood concentrations, probably because of microsomal induction by rifampin. When the rifampin/isoniazid treatment was discontinued, the cyclosporine blood concentrations rose, indicating the interacting effect of intravenous erythromycin. This effect was even more pronounced when therapy was changed from intravenous to oral administration. Erythromycin, a substrate that is metabolized with great affinity by the cytochrome P-450IIIA enzyme, prolonged the elimination of cyclosporine by competing for the same site of metabolism. CONCLUSIONS Awareness of potential cyclosporine drug interactions in organ transplant patients of great clinical importance. Regular monitoring of cyclosporine blood concentrations and renal function are essential to detect such interactions, to allow adjustment of drug dosage, and to reduce toxicity and enhance therapeutic effect, in particular in patients coadministered the many drugs known to have pharmacokinetic interactions with cyclosporine.
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Affiliation(s)
- E Zylber-Katz
- Clinical Pharmacology Laboratory, Hadassah University Hospital, Jerusalem, Israel
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17
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Abstract
The systemic effect of the immunosuppressive drug cyclosporine (CS) on formation of new blood vessels was studied quantitatively in rats using the mesenteric-window assay. Angiogenesis was induced by i.p. injection of saline. CS at a s.c. dose of 4 mg/kg/day, which is in the range used clinically, suppressed angiogenesis (inhibiting branching or tortuosity more than spatial expansion), and appeared to be non-toxic. This is the first report on an apparently selective angiostatic effect of CS. The finding is likely to have implications for the clinical use of CS, not only in certain types of organ transplantation but possibly also in psoriasis and other angiogenesis-dependent diseases.
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Affiliation(s)
- K Norrby
- Department of Pathology, University of Göteborg, Sweden
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18
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Abstract
Unilateral lung transplantation has become a successful method for the treatment of end-stage pulmonary disease, whereas double-lung transplantation has provided benefit to patients with nonfibrotic lung disease such as emphysema and cystic fibrosis. In the past 5 years, 16 single-lung and 13 double-lung transplantations have been performed by the Toronto Lung Transplant Group in patients with end-stage lung disease. Seven perioperative and two late deaths have been recorded so far. Since the introduction of heart-lung transplantation at Stanford in 1981 and at Pittsburgh in 1982 for the treatment of Eisenmenger's syndrome and terminal pulmonary vascular disease, more than 350 combined heart-lung transplantations have been carried out throughout the world. Presently, the 2-year actuarial survival is about 62%. The long-term results have not yet reached the same level of success as those of cardiac transplantation alone. Although several factors have played a role in this difference, a prominent cause has been the lack of a reliable and simple method for pulmonary protection against prolonged ischemia. Most of the techniques proposed against ischemia can be classified as normothermic or static hypothermic cardiopulmonary preservation. The use of the normothermic method has not always been successful. For this reason, interest has now been directed toward the potential for hypothermic preservation of the heart-lung bloc and the use of free-radical scavenger therapy in the reduction of reperfusion injury.
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Affiliation(s)
- Y M LeGal
- Department of Surgery, Memorial University of Newfoundland, Canada
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19
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de Meer K, Houwen RH, Bijleveld CM, Uges DR, Slooff MJ. Blood concentrations after accidental cyclosporin overdose. Eur J Pediatr 1989; 149:219-20. [PMID: 2612513 DOI: 10.1007/bf01958287] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Two cases of children are reported with an accidental oral overdose of cyclosporin in whom blood concentrations were monitored. Despite a tenfold oral overdose, the peak blood concentrations of cyclosporin in both patients were only moderately increased above therapeutic levels. Apart from a transient rise in blood pressure in one patient, no toxic effects of cyclosporin were noticed.
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Affiliation(s)
- K de Meer
- Department of Paediatrics, University Hospital Groningen, The Netherlands
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20
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Abstract
The management of liver transplant patients after discharge is a complex balance between immunosuppression and the side-effects and toxicity of such medications. The Queensland Liver Transplant Service (QLTX) has performed 72 transplants in 67 patients; 49 patients (73%) are alive. The actuarial 1-year survival rate is 72%. Death after the first year in patients transplanted for benign HBsAg negative disease has not occurred. The most common technical complications are biliary stenosis and hepatic artery thrombosis. Long-term immunosuppression is with cyclosporin and low dose prednisolone. Regular trough cyclosporin levels and liver function tests are vital. The most limiting side-effect of cyclosporin is nephrotoxicity. Constant vigilance, aggressive investigation, and management of pyrexia and biochemical liver dysfunction by the primary care physician in consultation with the transplant team will ultimately determine long-term outcome. The principles and important details of the management of these patients by the QLTX are presented as a guide to referring practitioners.
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Affiliation(s)
- S V Lynch
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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21
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Abstract
Cyclosporine (CyA) is commonly prescribed as an immunosuppressive to prevent rejection of organ transplants. Numerous pharmacokinetic drug interactions of potential clinical significance exist because other drugs may induce or inhibit the metabolism of CyA. Case reports and studies demonstrate that rifampin, phenytoin, phenobarbital, and carbamazepine may induce the hepatic metabolism of CyA, causing decreased CyA concentrations. Graft rejection through inadequate immunosuppression may be associated with subtherapeutic or decreased CyA levels. Erythromycin, ketoconazole, calcium channel blockers, and sex hormones appear to inhibit CyA metabolism, causing increased CyA concentrations. Signs and symptoms of renal, hepatic, or neurotoxicity may be evident with increased or toxic CyA levels. Mutual inhibition of metabolism occurs between CyA and corticosteroids. Intravenous sulphadimidine and trimethoprim may cause decreased CyA concentrations by an unknown mechanism.
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Affiliation(s)
- A M Baciewicz
- Department of Pharmacy Services, University Hospitals of Cleveland, Ohio 44106
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22
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Smith RE, Berg DD. Coagulation defects in cyclosporine A treated allogeneic bone marrow transplant patients. Am J Hematol 1988; 28:137-40. [PMID: 3044063 DOI: 10.1002/ajh.2830280302] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
CSA toxicity includes renal impairment, microangiopathic hemolytic anemia (MAHA), thrombocytopenia (T), and consumptive coagulopathy (CC). We report five BMT patients who developed CSA-associated hematological toxicity. All were conditioned with Ara-C, Cyclophosphamide, Methylprednisolone, TBI, and in two cases busulfan. IV CSA was started the day after marrow infusion and, when practicable, changed to the enteral route. Five patients developed MAHA and T resulting in significantly increased transfusion requirements. All patients had renal impairment and red cell fragmentation. In all patients fragmentation was noted before renal impairment. All developed disproportionate increases in BUN relative to serum creatinine consistent with decreased renal perfusion. Hypertension followed renal impairment in four cases and occurred at the same time as the renal impairment in one case. Two developed CC, prolongation in APTT, and marked decreases in plasma fibrinogen. All patients improved on reduction of the CSA dose. BMT recipients receiving CSA at variable doses may develop evidence of a TTP-like syndrome and/or CC.
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Affiliation(s)
- R E Smith
- Department of Medicine, Medical College of Wisconsin, Milwaukee
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23
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Zylber-Katz E, Rubinger D, Berlatzky Y. Cyclosporine interactions with metronidazole and cimetidine. DRUG INTELLIGENCE & CLINICAL PHARMACY 1988; 22:504-5. [PMID: 3293960 DOI: 10.1177/106002808802200616] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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24
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Jonasson L, Holm J, Hansson GK. Cyclosporin A inhibits smooth muscle proliferation in the vascular response to injury. Proc Natl Acad Sci U S A 1988; 85:2303-6. [PMID: 3258426 PMCID: PMC279979 DOI: 10.1073/pnas.85.7.2303] [Citation(s) in RCA: 103] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The arterial response to injury is dominated by proliferation of smooth muscle cells and infiltration of blood-borne cells in the vascular intima. Arterial smooth muscle cell proliferation is under growth factor control, but how this regulation operates in vivo is unclear. We studied the effect on arterial response to mechanical injury of cyclosporin A, a drug that inhibits T-lymphocyte activation. Cyclosporin A treatment at surgery caused a persistent inhibition of the intimal proliferative lesion. Cyclosporin A also inhibited expression of Ia antigens on smooth muscle cells in situ but had no direct effects on smooth muscle cell proliferation in culture. Therefore, the inhibition of intimal cell proliferation appears to be mediated via the immune system.
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Affiliation(s)
- L Jonasson
- Department of Clinical Chemistry, Gothenburg University, Sahlgren's Hospital, Sweden
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25
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Chatterjee S, Bose S. Morphological and biochemical effects of gentamicin and cyclosporin-A on urinary cell phospholipids and phospholipases in man. JOURNAL OF BIOCHEMICAL TOXICOLOGY 1988; 3:47-57. [PMID: 3236341 DOI: 10.1002/jbt.2570030106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The morphology, lipid composition, and activity of sphingomyelinase (E.C. 3.1.4.12) and phospholipases A (E.C. 3.1.1.32) and C (E.C. 3.1.4.3) were studied in the urinary cells from four normal subjects, four patients receiving gentamicin (G), and four patients receiving cyclosporin-A (CsA). We report that abnormal urinary excretion of proximal tubular cells occurred in patients receiving G and CsA. Membrane-enclosed sudanophilic material and numerous vacuoles were found in the cytoplasm of the proximal tubular cells from both patients receiving G and those receiving CsA. Patients receiving G shed higher levels of phosphatidylcholine (PC), phosphatidylethanolamine (PE), and sphingomyelin (SM) in the order of 78%, 38%, and 30% relative to normal. In contrast, the excretions of phosphatidylinositol (PI) and PC were 50% and 30% lower, respectively, in patients receiving CsA as compared to control. Sphingomyelin levels, however, were moderately elevated in these patients' urinary renal tubular cells. The activity of acid sphingomyelinase was one half the normal level in the cells of patients receiving G and CsA. The most striking result was a tenfold decrease in the activity of neutral sphingomyelinase in patients receiving G. In contrast, the activity of neutral sphingomyelinase in patients receiving CsA was similar to control. Phospholipase A activity was decreased and increased 35% and 15%, respectively, in urinary proximal tubular cells from patients receiving G and CsA. We conclude that deficient neutral sphingomyelinase activity precedes phospholipid (PL) overloading and gross pathological changes in patients receiving gentamicin but not in patients receiving cyclosporin-A.
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Affiliation(s)
- S Chatterjee
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland 21205
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26
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Allam BF, Tillman JE, Thomson TJ, Crossling FT, Gilbert LM. Effective intravenous cyclosporin therapy in a patient with severe Crohn's disease on parenteral nutrition. Gut 1987; 28:1166-9. [PMID: 3119435 PMCID: PMC1433218 DOI: 10.1136/gut.28.9.1166] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
We report a patient with severe Crohn's disease and the short bowel syndrome on parenteral feeding who was not responding to conventional therapy and underwent treatment with cyclosporin (CyA) given initially intravenously and subsequently orally in each of two courses. Plasma drug concentrations were largely kept within the therapeutic range but wide variability was observed on oral therapy. Improvement both clinically and by objective assessment, was observed on intravenous CyA therapy, but was not sustained when the drug was given orally for several months. None of the side effects observed resisted treatment or was severe enough to warrant discontinuation of therapy. These findings suggest that there may be a place for intravenous CyA therapy in patients with severe Crohn's disease who do not respond to conventional therapy or to oral treatment with CyA.
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Affiliation(s)
- B F Allam
- Department of Biochemistry, Stobhill General Hospital, Glasgow
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27
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Abstract
Human and animal investigations since the mid-1970s have demonstrated the effectiveness of cyclosporine (CsA) as an immunosuppressive agent. In the area of transplantation immunity, it has been shown to enhance success of renal, bone marrow, and liver transplantation. Moreover, certain models of autoimmune disease have been effectively treated with CsA, and a number of studies have reported encouraging results with CsA therapy for ocular inflammatory disorders, notably Behçet's disease. The most serious side effects of CsA are nephrotoxicity and hypertension; thus, conservative dosages of the drug and careful monitoring of renal function during treatment are recommended. The purpose of this review is to provide clinicians and researchers with a clear perspective of both the potential benefits and shortcomings of this agent.
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Ptachcinski RJ, Burckart GJ, Venkataramanan R. Cyclosporine concentration determinations for monitoring and pharmacokinetic studies. J Clin Pharmacol 1986; 26:358-66. [PMID: 3517078 DOI: 10.1002/j.1552-4604.1986.tb03538.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The availability of the immunosuppressant cyclosporin has led to significant improvements in the recent success of clinical organ transplantation. Problems associated with cyclosporine therapy include serious adverse reactions, such as nephrotoxicity, wide variability in the drug's pharmacokinetics, and several complex drug interactions. Monitoring of drug concentrations is accepted as a part of the routine care of patients receiving cyclosporine. However, cyclosporine concentrations can be determined in different biologic fluids by either radioimmunoassay or high-performance liquid chromatographic techniques. Controversy exists regarding the optimal analytic technique to be used for cyclosporine monitoring and pharmacokinetic studies. This commentary addresses factors including: why the monitoring of cyclosporine concentrations is important, the differences between the biologic fluids and analytic techniques, when monitoring and special pharmacokinetic studies are indicated, what some major transplant centers have established as a "therapeutic range" for cyclosporine concentrations, and provides guidelines for the optimal clinical monitoring of cyclosporine concentrations.
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