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Fettiplace A, Matis-Mitchell S, Molodetskyi O, Söderbergh M, Oscarsson J, Lin M, Ravikiran S, Billger M, Ambery P. A comprehensive analysis of liver safety across zibotentan oncology trials: knowledge of the past offers new perspectives on the present. Expert Opin Drug Saf 2024; 23:477-486. [PMID: 38469902 DOI: 10.1080/14740338.2024.2328816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/05/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Endothelin receptor antagonists (ERAs) are associated with liver injury. We used data from previous oncology clinical trials to determine the liver safety profile of zibotentan, which is currently in clinical development (in combination with dapagliflozin) for chronic kidney disease and cirrhosis. RESEARCH DESIGN AND METHODS Six global, double-blinded, phase 2b and 3 clinical trials from the zibotentan oncology development program were pooled to analyze liver safety. Descriptive statistics, proportion of liver-related adverse events, liver biochemistry parameter elevation, and shifts from baseline were analyzed, with individual case assessment. RESULTS A total of 1532 patients received zibotentan for 285 days (mean), and 1486 patients received placebo for 320 days (mean). The frequency of any hepatic disorder preferred term was similar across zibotentan monotherapy (22/947 patients, 2.3%) and placebo monotherapy arms (30/881 patients, 3.4%). A total of 4 (0.4%) patients receiving zibotentan monotherapy experienced ALT elevations >5× ULN versus 8 (0.9%) receiving placebo. Of the seven patients receiving zibotentan who met criteria for potential Hy's Law, there were no cases of drug-induced liver injury. CONCLUSIONS We found no evidence of zibotentan-related liver biochemistry changes among cancer-treated patients, suggesting that hepatotoxicity of ERAs is molecule-dependent, and allowing exploration of zibotentan for new indications.
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Affiliation(s)
| | | | - Oleksandr Molodetskyi
- Global Patient Safety, Biopharmaceuticals, Chief Medical Office, R&D, AstraZeneca, Gothenburg, Sweden
| | - Malin Söderbergh
- Global Patient Safety, Biopharmaceuticals, Chief Medical Office, R&D, AstraZeneca, Gothenburg, Sweden
| | - Jan Oscarsson
- Late-Stage Clinical Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Min Lin
- Biometrics Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - Srivathsa Ravikiran
- Biometrics Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - Martin Billger
- Safety Sciences Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Philip Ambery
- Late-Stage Clinical Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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Scott JV, Moutchia J, McClelland RL, Al-Naamani N, Weinberg E, Palevsky HI, Minhas J, Appleby DK, Smith A, Pugliese SC, Ventetuolo CE, Kawut SM. Novel Liver Injury Phenotypes and Outcomes in Pulmonary Arterial Hypertension. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.28.23296316. [PMID: 37808731 PMCID: PMC10557839 DOI: 10.1101/2023.09.28.23296316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Background Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are disorders of the pulmonary vasculature that cause right ventricular dysfunction. Systemic consequences of right ventricular dysfunction include damage to other solid organs, such as the liver. However, the profiles and consequences of hepatic injury due to PAH and CTEPH have not been well-studied. Methods We aimed to identify underlying patterns of liver injury in a cohort of PAH and CTEPH patients enrolled in 15 randomized clinical trials conducted between 1998 and 2012. We used unsupervised machine learning to identify liver injury clusters in 13 trials and validated the findings in two additional trials. We then determined whether these liver injury clusters were associated with clinical outcomes or treatment effect heterogeneity. Results Our training dataset included 4,219 patients and our validation dataset included 1,756 patients with complete liver laboratory panels (serum total bilirubin, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, and albumin). Using k-means clustering paired with factor analysis, we identified four unique liver phenotypes (no liver injury, hepatocellular injury, cholestatic injury, and combined injury patterns). Patients in the cholestatic injury liver cluster had the shortest time to clinical worsening and highest chance of worsening World Health Organization functional class. Randomization to the experimental arm was associated with a transition to healthier liver clusters compared to randomization to the control arm. The cholestatic injury group experienced the greatest placebo-corrected treatment benefit in terms of six-minute walk distance. Conclusions Liver injury patterns were associated with adverse outcomes in patients with PAH and CTEPH. Randomization to active treatment of pulmonary hypertension in these clinical trials had beneficial effects on liver health compared to placebo. The independent role of liver disease (often subclinical) in determining outcomes warrants prospective studies of the clinical utility of liver phenotyping for PAH prognosis and contribution to clinical disease.
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3
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Lattanzio M, Ferrari M, Martini S, Ceriani F, Imporzani A, Marino F, De Ponti R, Cosentino M. Pharmacological counseling in hepatotoxicity induced by macitentan and selexipag: a case report. J Med Case Rep 2022; 16:385. [PMID: 36258237 PMCID: PMC9578229 DOI: 10.1186/s13256-022-03571-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 08/13/2022] [Indexed: 12/02/2022] Open
Abstract
Background Pulmonary arterial hypertension is a progressive, debilitating condition characterized by increased resistance in the pulmonary arterial circulation. Current treatments for pulmonary arterial hypertension include endothelin receptor antagonists such as bosentan, sitaxentan, ambrisentan, macitentan, and oral prostacyclin receptor agonists such as selexipag. Endothelin receptor antagonists have been associated with liver injury, while hepatotoxicity was not reported for selexipag. Although genetic variability has been indisputably associated with variability in drug response, no study has been designed until now to assess its effects on the pharmacokinetics of endothelin receptor antagonists or selexipag. Case presentation We report the case of a 58-year-old female Caucasian patient with a dramatic increase in plasma levels of transaminases after treatment with macitentan and selexipag, drugs whose risk of causing liver injury has so far been considered limited. After therapy discontinuation, plasma levels of transaminases returned to baseline, thus suggesting a role of these drugs in the observed hepatotoxicity. After pharmacological counseling, we decided to introduce ambrisentan for the patient’s treatment. After 7 months of treatment, no liver injury has been reported. To evaluate the role of genetic factors in the observed hepatotoxicity, we genotyped the patient for single-nucleotide polymorphisms previously associated with macitentan, ambrisentan, or selexipag metabolism. We found a genetic profile associated with a poor metabolizer (PM) phenotype for CYP2C8 and CYP2C9, key enzymes for elimination of both macitentan and selexipag. The reported results suggest that an allelic profile associated with low activity for CYP2C8 and CYP2C9 enzyme could be a potential risk factor for macitentan and selexipag-induced liver injury and could provide a possible marker for early identification of subjects at higher risk of developing hepatotoxicity. Conclusions A multidisciplinary approach based on clinical evaluation, as well as pharmacological counseling and evaluation of the patient’s genetic profile, might be useful for identification of patients with a high chance of drug-induced liver injury, avoiding unnecessary risks in therapy selection and prescription.
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Affiliation(s)
- Mariangela Lattanzio
- Pulmonary Hypertension Unit, Department of Heart and Vessels, Ospedale di Circolo and Fondazione Macchi, University of Insubria, Varese, Italy
| | - Marco Ferrari
- Center of Research in Medical Pharmacology, University of Insubria, Via Monte Generoso 71, 21100, Varese, Italy.
| | - Stefano Martini
- Center of Research in Medical Pharmacology, University of Insubria, Via Monte Generoso 71, 21100, Varese, Italy
| | - Francesca Ceriani
- Pulmonary Hypertension Unit, Department of Heart and Vessels, Ospedale di Circolo and Fondazione Macchi, University of Insubria, Varese, Italy
| | - Andrea Imporzani
- Pulmonary Hypertension Unit, Department of Heart and Vessels, Ospedale di Circolo and Fondazione Macchi, University of Insubria, Varese, Italy
| | - Franca Marino
- Center of Research in Medical Pharmacology, University of Insubria, Via Monte Generoso 71, 21100, Varese, Italy
| | - Roberto De Ponti
- Pulmonary Hypertension Unit, Department of Heart and Vessels, Ospedale di Circolo and Fondazione Macchi, University of Insubria, Varese, Italy
| | - Marco Cosentino
- Center of Research in Medical Pharmacology, University of Insubria, Via Monte Generoso 71, 21100, Varese, Italy
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4
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Nekoukar Z, Moghimi M, Salehifar E. A narrative review on adverse effects of dasatinib with a focus on pharmacotherapy of dasatinib-induced pulmonary toxicities. Blood Res 2021; 56:229-242. [PMID: 34776414 PMCID: PMC8721448 DOI: 10.5045/br.2021.2021117] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/15/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022] Open
Abstract
Chronic myeloid leukemia (CML), a myeloproliferative disorder caused by the over activity of BCR-ABL1 (breakpoint cluster region-Abelson), has been successfully treated by Tyrosine kinase inhibitors (TKIs). While imatinib is known as the first-line treatment of CML, in some cases other TKIs including dasatinib, nilotinib, bosutinib, and ponatinib may be preferred. Dasatinib, a second-generation TKI, inhibits multiple family kinases including BCR-ABL, SRC family kinases, receptor kinases, and TEC family kinases. It is effective against most imatinib-resistant cases except T315I mutation. Despite the superiority of dasatinib in its hematologic and cytogenetic responses in CML compared to imatinib, its potentially harmful pulmonary complications including pleural effusion (PE) and pulmonary arterial hypertension (PAH) may limit its use. Appropriate management of these serious adverse reactions is critical in both improving the quality of life and the outcome of the patient. In this narrative review, we will scrutinize the pulmonary complications of dasatinib and focus on the management of these toxicities.
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Affiliation(s)
- Zahra Nekoukar
- Department of Clinical Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Minoo Moghimi
- Department of Clinical Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ebrahim Salehifar
- Pharmaceutical Sciences Research Center, Hemoglobinopathy Institute, Department of Clinical Pharmacy, Mazandaran University of Medial Scienses, Sari, Iran
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5
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Advancements in practical and scientific bioanalytical approaches to metabolism studies in drug development. Bioanalysis 2021; 13:913-930. [PMID: 33961500 DOI: 10.4155/bio-2021-0050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Advancement in metabolism profiling approaches and bioanalytical techniques has been revolutionized over the last two decades. Different in vitro and in vivo approaches along with advanced bioanalytical techniques are enabling the accurate qualitative and quantitative analysis of metabolites. This review summarizes various modern in vitro and in vivo approaches for executing metabolism studies with special emphasis on the recent advancement in the field. Advanced bioanalytical techniques, which can be employed in metabolism studies, have been discussed suggesting their particular application based on specific study objectives. This article can efficiently guide the researchers to scientifically plan metabolism studies and their bioanalysis during drug development programs taking advantage of a detailed understanding of instances of failure in the past.
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6
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Middelkoop MA, Bet PM, Drenth JPH, Huirne JAF, Hehenkamp WJK. Risk-efficacy balance of ulipristal acetate compared to surgical alternatives. Br J Clin Pharmacol 2021; 87:2685-2697. [PMID: 33341097 PMCID: PMC8359338 DOI: 10.1111/bcp.14708] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/26/2020] [Accepted: 12/07/2020] [Indexed: 01/12/2023] Open
Abstract
Aims Uterine fibroids are benign tumours that cause various complaints. These complaints may significantly compromise quality of life, necessitating a clinical intervention in 25–50% of the affected women. Hysterectomy, myomectomy or embolization may offer symptomatic relief, but are costly, include a recovery period, can cause serious side‐effects, sometimes fail to treat symptoms completely and are not always desired by patients. Ulipristal is a conservative long‐term treatment that has a fibroid‐volume decreasing effect, acceptable side‐effects while preserving fertility and may be an alternative to surgical alternatives. Currently, ulipristal is investigated by the European Medicine Agency and suspended from marketing authorization because it may cause drug‐induced liver injury (DILI). However, many drugs can cause severe DILI and prospective studies estimate 14–19 DILI cases/100 000 people. Methods This overview will discuss the risk–benefit balance between ulipristal and DILI, describe the safety–efficacy balance of ulipristal and its alternative treatments and the arguments that led to the suspension of its marketing authorization. Results Ulipristal may be associated with DILI resulting in a risk of severe liver injury in 1.5:100 000 patients and fatal liver injury in 0.1:100 000 patients. This risk needs to be weighed against the higher mortality risk of >1:1000 and higher incidence of severe complications after surgery. Conclusion The DILI risk of ulipristal is considerably lower than that of other medicines that are not suspended, nor need additional safety measures. When evaluating drugs and drug safety, risks that apply to the alternative nonpharmacological treatment options should be taken into consideration.
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Affiliation(s)
- Mei-An Middelkoop
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development research institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Pierre M Bet
- Department of Clinical Pharmacology and Pharmacy, Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology, Radboud UMC, Nijmegen, The Netherlands
| | - Judith A F Huirne
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development research institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Wouter J K Hehenkamp
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development research institute, Amsterdam UMC, Amsterdam, The Netherlands
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7
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Enevoldsen FC, Sahana J, Wehland M, Grimm D, Infanger M, Krüger M. Endothelin Receptor Antagonists: Status Quo and Future Perspectives for Targeted Therapy. J Clin Med 2020; 9:jcm9030824. [PMID: 32197449 PMCID: PMC7141375 DOI: 10.3390/jcm9030824] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 02/06/2023] Open
Abstract
The endothelin axis, recognized for its vasoconstrictive action, plays a central role in the pathology of pulmonary arterial hypertension (PAH). Treatment with approved endothelin receptor antagonists (ERAs), such as bosentan, ambrisentan, or macitentan, slow down PAH progression and relieves symptoms. Several findings have indicated that endothelin is further involved in the pathogenesis of certain other diseases, making ERAs potentially beneficial in the treatment of various conditions. In addition to PAH, this review summarizes the use and perspectives of ERAs in cancer, renal disease, fibrotic disorders, systemic scleroderma, vasospasm, and pain management. Bosentan has proven to be effective in systemic sclerosis PAH and in decreasing the development of vasospasm-related digital ulcers. The selective ERA clazosentan has been shown to be effective in preventing cerebral vasospasm and delaying ischemic neurological deficits and new infarcts. Furthermore, in the SONAR (Study Of Diabetic Nephropathy With Atrasentan) trial, the selective ERA atrasentan reduced the risk of renal events in patients with diabetes and chronic kidney disease. These data suggest atrasentan as a new therapy in the treatment of diabetic nephropathy and possibly other renal diseases. Preclinical studies regarding heart failure, cancer, and fibrotic diseases have demonstrated promising effects, but clinical trials have not yet produced measurable results. Nevertheless, the potential benefits of ERAs may not be fully realized.
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Affiliation(s)
- Frederik C. Enevoldsen
- Department of Biomedicine, Aarhus University, Høegh-Guldbergsgade 10, 8000 Aarhus C, Denmark; (F.C.E.); (J.S.); (D.G.)
| | - Jayashree Sahana
- Department of Biomedicine, Aarhus University, Høegh-Guldbergsgade 10, 8000 Aarhus C, Denmark; (F.C.E.); (J.S.); (D.G.)
| | - Markus Wehland
- Clinic for Plastic, Aesthetic and Hand Surgery, Otto von Guericke University, Leipziger Str. 44, 39120 Magdeburg, Germany; (M.W.); (M.I.)
| | - Daniela Grimm
- Department of Biomedicine, Aarhus University, Høegh-Guldbergsgade 10, 8000 Aarhus C, Denmark; (F.C.E.); (J.S.); (D.G.)
- Clinic for Plastic, Aesthetic and Hand Surgery, Otto von Guericke University, Leipziger Str. 44, 39120 Magdeburg, Germany; (M.W.); (M.I.)
| | - Manfred Infanger
- Clinic for Plastic, Aesthetic and Hand Surgery, Otto von Guericke University, Leipziger Str. 44, 39120 Magdeburg, Germany; (M.W.); (M.I.)
| | - Marcus Krüger
- Clinic for Plastic, Aesthetic and Hand Surgery, Otto von Guericke University, Leipziger Str. 44, 39120 Magdeburg, Germany; (M.W.); (M.I.)
- Correspondence: ; Tel.: +49-391-6721267
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8
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King A, Baginski M, Morikawa Y, Rainville PD, Gethings LA, Wilson ID, Plumb RS. Application of a Novel Mass Spectral Data Acquisition Approach to Lipidomic Analysis of Liver Extracts from Sitaxentan-Treated Liver-Humanized PXB Mice. J Proteome Res 2019; 18:4055-4064. [DOI: 10.1021/acs.jproteome.9b00334] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Adam King
- Waters Corporation, Stamford Avenue, Wilmslow SK9 4AX, U.K
| | - Matthew Baginski
- PhoenixBio USA Corporation, 65 Broadway, Suite 605, New York, New York 10006, United States
| | - Yoshio Morikawa
- PhoenixBio USA Corporation, 65 Broadway, Suite 605, New York, New York 10006, United States
| | - Paul D. Rainville
- Waters Corporation, 34 Maple Street, Milford, Massachusetts 01757, United States
| | | | - Ian D. Wilson
- Department of Surgery and Cancer, Imperial College, Exhibition Road, South Kensington, London SW7 2AZ, U.K
| | - Robert S. Plumb
- Waters Corporation, 34 Maple Street, Milford, Massachusetts 01757, United States
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9
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Evaluation of Drug Biliary Excretion Using Sandwich-Cultured Human Hepatocytes. Eur J Drug Metab Pharmacokinet 2019; 44:13-30. [PMID: 30167999 DOI: 10.1007/s13318-018-0502-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Evaluation of hepatobiliary transport of drugs is an important challenge, notably during the development of new molecular identities. In this context, sandwich-cultured human hepatocytes (SCHH) have been proposed as an interesting and integrated tool for predicting in vitro biliary excretion of drugs. The present review was therefore designed to summarize key findings about SCHH, including their establishment, their main functional features and their use for the determination of canalicular transport and the prediction of in vivo biliary clearance and hepatobiliary excretion-related drug-drug interactions. Reviewed data highlight the fact that SCHH represent an original and probably unique holistic in vitro approach to predict biliary clearance in humans, through taking into account sinusoidal drug uptake, passive drug diffusion, drug metabolism and sinusoidal and canalicular drug efflux. Limits and proposed refinements for SCHH-based analysis of drug biliary excretion, as well as putative human alternative in vitro models to SCHH are also discussed.
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10
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Wu Y, Wang G. Machine Learning Based Toxicity Prediction: From Chemical Structural Description to Transcriptome Analysis. Int J Mol Sci 2018; 19:E2358. [PMID: 30103448 PMCID: PMC6121588 DOI: 10.3390/ijms19082358] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 07/31/2018] [Accepted: 08/08/2018] [Indexed: 02/07/2023] Open
Abstract
Toxicity prediction is very important to public health. Among its many applications, toxicity prediction is essential to reduce the cost and labor of a drug's preclinical and clinical trials, because a lot of drug evaluations (cellular, animal, and clinical) can be spared due to the predicted toxicity. In the era of Big Data and artificial intelligence, toxicity prediction can benefit from machine learning, which has been widely used in many fields such as natural language processing, speech recognition, image recognition, computational chemistry, and bioinformatics, with excellent performance. In this article, we review machine learning methods that have been applied to toxicity prediction, including deep learning, random forests, k-nearest neighbors, and support vector machines. We also discuss the input parameter to the machine learning algorithm, especially its shift from chemical structural description only to that combined with human transcriptome data analysis, which can greatly enhance prediction accuracy.
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Affiliation(s)
- Yunyi Wu
- Department of Biology, Guangdong Provincial Key Laboratory of Cell Microenviroment and Disease Research, Southern University of Science and Technology, Shenzhen 518055, China.
| | - Guanyu Wang
- Department of Biology, Guangdong Provincial Key Laboratory of Cell Microenviroment and Disease Research, Southern University of Science and Technology, Shenzhen 518055, China.
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11
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Burbank MG, Sharanek A, Burban A, Mialanne H, Aerts H, Guguen-Guillouzo C, Weaver RJ, Guillouzo A. From the Cover: MechanisticInsights in Cytotoxic and Cholestatic Potential of the Endothelial Receptor Antagonists Using HepaRG Cells. Toxicol Sci 2018; 157:451-464. [PMID: 28369585 DOI: 10.1093/toxsci/kfx062] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Several endothelin receptor antagonists (ERAs) have been developed for the treatment of pulmonary arterial hypertension (PAH). Some of them have been related to clinical cases of hepatocellular injury (sitaxentan [SIT]) and/or cholestasis (bosentan [BOS]). We aimed to determine if ambrisentan (AMB) and macitentan (MAC), in addition to BOS and SIT, could potentially cause liver damage in man by use of human HepaRG cells. Our results showed that like BOS, MAC-induced cytotoxicity and cholestatic disorders characterized by bile canaliculi dilatation and impairment of myosin light chain kinase signaling. Macitentan also strongly inhibited taurocholic acid and carboxy-2',7'-dichlorofluorescein efflux while it had a much lower inhibitory effect on influx activity compared to BOS and SIT. Moreover, these three drugs caused decreased intracellular accumulation and parallel increased levels of total bile acids (BAs) in serum-free culture media. In addition, all drugs except AMB variably deregulated gene expression of BA transporters. In contrast, SIT was hepatotoxic without causing cholestatic damage, likely via the formation of reactive metabolites and AMB was not hepatotoxic. Together, our results show that some ERAs can be hepatotoxic and that the recently marketed MAC, structurally similar to BOS, can also cause cholestatic alterations in HepaRG cells. The absence of currently known or suspected cases of cholestasis in patients suffering from PAH treated with MAC is rationalized by the lower therapeutic doses and Cmax, and longer receptor residence time compared to BOS.
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Affiliation(s)
- Matthew Gibson Burbank
- Inserm UMR 991, Foie, Métabolismes et Cancer, Rennes, France.,Université Rennes 1, Rennes, France.,Biologie Servier, Gidy, France
| | - Ahmad Sharanek
- Inserm UMR 991, Foie, Métabolismes et Cancer, Rennes, France.,Université Rennes 1, Rennes, France
| | - Audrey Burban
- Inserm UMR 991, Foie, Métabolismes et Cancer, Rennes, France.,Université Rennes 1, Rennes, France
| | | | | | | | | | - André Guillouzo
- Inserm UMR 991, Foie, Métabolismes et Cancer, Rennes, France.,Université Rennes 1, Rennes, France
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12
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Light DS, Aleo MD, Kenna JG. Interpretation, Integration, and Implementation of In Vitro Assay Data: The Predictive Toxicity Challenge. METHODS IN PHARMACOLOGY AND TOXICOLOGY 2018. [DOI: 10.1007/978-1-4939-7677-5_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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13
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Sandwich-Cultured Hepatocytes as a Tool to Study Drug Disposition and Drug-Induced Liver Injury. J Pharm Sci 2016; 105:443-459. [PMID: 26869411 DOI: 10.1016/j.xphs.2015.11.008] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 11/06/2015] [Accepted: 11/09/2015] [Indexed: 12/21/2022]
Abstract
Sandwich-cultured hepatocytes (SCH) are metabolically competent and have proper localization of basolateral and canalicular transporters with functional bile networks. Therefore, this cellular model is a unique tool that can be used to estimate biliary excretion of compounds. SCH have been used widely to assess hepatobiliary disposition of endogenous and exogenous compounds and metabolites. Mechanistic modeling based on SCH data enables estimation of metabolic and transporter-mediated clearances, which can be used to construct physiologically based pharmacokinetic models for prediction of drug disposition and drug-drug interactions in humans. In addition to pharmacokinetic studies, SCH also have been used to study cytotoxicity and perturbation of biological processes by drugs and hepatically generated metabolites. Human SCH can provide mechanistic insights underlying clinical drug-induced liver injury (DILI). In addition, data generated in SCH can be integrated into systems pharmacology models to predict potential DILI in humans. In this review, applications of SCH in studying hepatobiliary drug disposition and bile acid-mediated DILI are discussed. An example is presented to show how data generated in the SCH model were used to establish a quantitative relationship between intracellular bile acids and cytotoxicity, and how this information was incorporated into a systems pharmacology model for DILI prediction.
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14
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Chan EAW, Buckley B, Farraj AK, Thompson LC. The heart as an extravascular target of endothelin-1 in particulate matter-induced cardiac dysfunction. Pharmacol Ther 2016; 165:63-78. [PMID: 27222357 PMCID: PMC6390286 DOI: 10.1016/j.pharmthera.2016.05.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Exposure to particulate matter air pollution has been causally linked to cardiovascular disease in humans. Several broad and overlapping hypotheses describing the biological mechanisms by which particulate matter exposure leads to cardiovascular disease have been explored, although linkage with specific factors or genes remains limited. These hypotheses may or may not also lead to particulate matter-induced cardiac dysfunction. Evidence pointing to autocrine/paracrine signaling systems as modulators of cardiac dysfunction has increased interest in the emerging role of endothelins as mediators of cardiac function following particulate matter exposure. Endothelin-1, a well-described small peptide expressed in the pulmonary and cardiovascular systems, is best known for its ability to constrict blood vessels, although it can also induce extravascular effects. Research on the role of endothelins in the context of air pollution has largely focused on vascular effects, with limited investigation of responses resulting from the direct effects of endothelins on cardiac tissue. This represents a significant knowledge gap in air pollution health effects research, given the abundance of endothelin receptors found on cardiac tissue and the ability of endothelin-1 to modulate cardiac contractility, heart rate, and rhythm. The plausibility of endothelin-1 as a mediator of particulate matter-induced cardiac dysfunction is further supported by the therapeutic utility of certain endothelin receptor antagonists. The present review examines the possibility that endothelin-1 release caused by exposure to PM directly modulates extravascular effects on the heart, deleteriously altering cardiac function.
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Affiliation(s)
- Elizabeth A W Chan
- Oak Ridge Institute for Science and Education (ORISE) Fellow at the National Center for Environmental Assessment, U.S. Environmental Protection Agency (EPA), Research Triangle Park, NC, USA
| | - Barbara Buckley
- National Center for Environmental Assessment, U.S. EPA, Research Triangle Park, NC, USA
| | - Aimen K Farraj
- Environmental Public Health Division, U.S. EPA, Research Triangle Park, NC, USA
| | - Leslie C Thompson
- Environmental Public Health Division, U.S. EPA, Research Triangle Park, NC, USA.
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Monaco TJ, Davila CD. Safety, efficacy, and clinical utility of macitentan in the treatment of pulmonary arterial hypertension. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:1675-82. [PMID: 27274200 PMCID: PMC4876803 DOI: 10.2147/dddt.s88612] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Pulmonary arterial hypertension is a progressive, debilitating disease caused by a dysregulation of the pulmonary vascular tone that inevitably leads to right heart failure and death without treatment. Until relatively recently, the treatment options for those afflicted by pulmonary arterial hypertension were limited; today, a greater understanding of the pathophysiology behind this disease has led to several evidence-based therapies that can improve pulmonary function and quality of life for these patients. One of the primary mediators of pulmonary vascular tone is endothelin-1, which is a potent and long-lasting vasoconstrictor. Macitentan is a second-generation endothelin receptor antagonist that acts selectively as a pulmonary vasodilator without the significant side effects noted with previous endothelin receptor antagonists. This review focuses on the mechanism of action and pharmacokinetics of macitentan, as well as the adverse effects, efficacy, and clinical uses of macitentan in the clinical trials to date. In addition, the authors briefly review clinical trials currently underway to illustrate possible future directions for the use of macitentan.
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Affiliation(s)
- Thomas J Monaco
- Division of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Carlos D Davila
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
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Thompson RA, Isin EM, Ogese MO, Mettetal JT, Williams DP. Reactive Metabolites: Current and Emerging Risk and Hazard Assessments. Chem Res Toxicol 2016; 29:505-33. [DOI: 10.1021/acs.chemrestox.5b00410] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Richard A. Thompson
- DMPK, Respiratory, Inflammation & Autoimmunity iMed, AstraZeneca R&D, 431 83 Mölndal, Sweden
| | - Emre M. Isin
- DMPK, Cardiovascular & Metabolic Diseases iMed, AstraZeneca R&D, 431 83 Mölndal, Sweden
| | - Monday O. Ogese
- Translational Safety, Drug Safety and Metabolism, AstraZeneca R&D, Darwin Building 310, Cambridge Science Park, Milton Rd, Cambridge CB4 0FZ, United Kingdom
| | - Jerome T. Mettetal
- Translational Safety, Drug Safety and Metabolism, AstraZeneca R&D, 35 Gatehouse Dr, Waltham, Massachusetts 02451, United States
| | - Dominic P. Williams
- Translational Safety, Drug Safety and Metabolism, AstraZeneca R&D, Darwin Building 310, Cambridge Science Park, Milton Rd, Cambridge CB4 0FZ, United Kingdom
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Affiliation(s)
- Rogerio Souza
- Pulmonary Dept, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Steven M Kawut
- Dept of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Abstract
INTRODUCTION Pulmonary hypertension is a hemodynamic condition occurring rarely in pediatrics. Nevertheless, it is associated with significant morbidity and mortality. When characterized by progressive pulmonary vascular structural changes, the disease is called pulmonary arterial hypertension (PAH). It results in increased pulmonary vascular resistance and eventual right ventricular failure. In the vast majority of cases, pediatric PAH is idiopathic or associated with congenital heart disease, and, contrary to adult PAH, is rarely associated with connective tissue, portal hypertension, HIV infection or thromboembolic disease. AREAS COVERED This article reviews the current drug therapies available for the management of pediatric PAH. These treatments target the recognized pathophysiological pathways of PAH with endothelin-1 receptor antagonists, prostacyclin analogs and PDE type 5 inhibitors. New treatments and explored pathways are briefly discussed. EXPERT OPINION Although there is still no cure for PAH, quality of life and survival have been improved significantly with specific drug therapies. Nevertheless, management of pediatric PAH remains challenging, and depends mainly on results from adult clinical trials and pediatric experts. Further research on PAH-specific treatments in the pediatric population and data from international registries are needed to identify optimal therapeutic strategies and treatment goals in the pediatric population.
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Affiliation(s)
- Frédéric Lador
- Hôpitaux Universitaires de Genève, Département des Spécialités de Médecine, Service de Pneumologie, Programme Hypertension Pulmonaire , Geneva , Switzerland
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Kenna JG, Stahl SH, Eakins JA, Foster AJ, Andersson LC, Bergare J, Billger M, Elebring M, Elmore CS, Thompson RA. Multiple compound-related adverse properties contribute to liver injury caused by endothelin receptor antagonists. J Pharmacol Exp Ther 2015; 352:281-90. [PMID: 25467130 DOI: 10.1124/jpet.114.220491] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Drug-induced liver injury has been observed in patients treated with the endothelin receptor antagonists sitaxentan and bosentan, but not following treatment with ambrisentan. The aim of our studies was to assess the possible role of multiple contributory mechanisms in this clinically relevant toxicity. Inhibition of the bile salt export pump (BSEP) and multidrug resistance-associated protein 2 was quantified using membrane vesicle assays. Inhibition of mitochondrial respiration in human liver-derived HuH-7 cells was determined using a Seahorse XF(e96) analyzer. Cytochrome P450 (P450)-independent and P450-mediated cell toxicity was assessed using transfected SV40-T-antigen-immortalized human liver epithelial (THLE) cell lines. Exposure-adjusted assay ratios were calculated by dividing the maximum human drug plasma concentrations by the IC50 or EC50 values obtained in vitro. Covalent binding (CVB) of radiolabeled drugs to human hepatocytes was quantified, and CVB body burdens were calculated by adjusting CVB values for fractional drug turnover in vitro and daily therapeutic dose. Sitaxentan exhibited positive exposure-adjusted signals in all five in vitro assays and a high CVB body burden. Bosentan exhibited a positive exposure-adjusted signal in one assay (BSEP inhibition) and a moderate CVB body burden. Ambrisentan exhibited no positive exposure-adjusted assay signals and a low CVB body burden. These data indicate that multiple mechanisms contribute to the rare, but potentially severe liver injury caused by sitaxentan in humans; provide a plausible rationale for the markedly lower propensity of bosentan to cause liver injury; and highlight the relative safety of ambrisentan.
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Affiliation(s)
- J Gerry Kenna
- Drug Safety Consultant, Macclesfield, Cheshire, United Kingdom (J.G.K.); DMPK (S.H.S.), Discovery Safety (J.A.E.), and Translational Safety (A.J.F.), Drug Safety and Metabolism, AstraZeneca R&D Alderley Park, Macclesfield, Cheshire, United Kingdom; DMPK (L.C.A., J.B., C.S.E.), Regulatory Safety (M.B.), Drug Safety and Metabolism, AstraZeneca R&D Mölndal, Mölndal, Sweden; and DMPK, Cardiovascular and Metabolic Diseases (M.E.), and Respiratory, Inflammation, and Autoimmunity (R.A.T.), iMED AstraZeneca R&D Mölndal, Mölndal, Sweden
| | - Simone H Stahl
- Drug Safety Consultant, Macclesfield, Cheshire, United Kingdom (J.G.K.); DMPK (S.H.S.), Discovery Safety (J.A.E.), and Translational Safety (A.J.F.), Drug Safety and Metabolism, AstraZeneca R&D Alderley Park, Macclesfield, Cheshire, United Kingdom; DMPK (L.C.A., J.B., C.S.E.), Regulatory Safety (M.B.), Drug Safety and Metabolism, AstraZeneca R&D Mölndal, Mölndal, Sweden; and DMPK, Cardiovascular and Metabolic Diseases (M.E.), and Respiratory, Inflammation, and Autoimmunity (R.A.T.), iMED AstraZeneca R&D Mölndal, Mölndal, Sweden
| | - Julie A Eakins
- Drug Safety Consultant, Macclesfield, Cheshire, United Kingdom (J.G.K.); DMPK (S.H.S.), Discovery Safety (J.A.E.), and Translational Safety (A.J.F.), Drug Safety and Metabolism, AstraZeneca R&D Alderley Park, Macclesfield, Cheshire, United Kingdom; DMPK (L.C.A., J.B., C.S.E.), Regulatory Safety (M.B.), Drug Safety and Metabolism, AstraZeneca R&D Mölndal, Mölndal, Sweden; and DMPK, Cardiovascular and Metabolic Diseases (M.E.), and Respiratory, Inflammation, and Autoimmunity (R.A.T.), iMED AstraZeneca R&D Mölndal, Mölndal, Sweden
| | - Alison J Foster
- Drug Safety Consultant, Macclesfield, Cheshire, United Kingdom (J.G.K.); DMPK (S.H.S.), Discovery Safety (J.A.E.), and Translational Safety (A.J.F.), Drug Safety and Metabolism, AstraZeneca R&D Alderley Park, Macclesfield, Cheshire, United Kingdom; DMPK (L.C.A., J.B., C.S.E.), Regulatory Safety (M.B.), Drug Safety and Metabolism, AstraZeneca R&D Mölndal, Mölndal, Sweden; and DMPK, Cardiovascular and Metabolic Diseases (M.E.), and Respiratory, Inflammation, and Autoimmunity (R.A.T.), iMED AstraZeneca R&D Mölndal, Mölndal, Sweden
| | - Linda C Andersson
- Drug Safety Consultant, Macclesfield, Cheshire, United Kingdom (J.G.K.); DMPK (S.H.S.), Discovery Safety (J.A.E.), and Translational Safety (A.J.F.), Drug Safety and Metabolism, AstraZeneca R&D Alderley Park, Macclesfield, Cheshire, United Kingdom; DMPK (L.C.A., J.B., C.S.E.), Regulatory Safety (M.B.), Drug Safety and Metabolism, AstraZeneca R&D Mölndal, Mölndal, Sweden; and DMPK, Cardiovascular and Metabolic Diseases (M.E.), and Respiratory, Inflammation, and Autoimmunity (R.A.T.), iMED AstraZeneca R&D Mölndal, Mölndal, Sweden
| | - Jonas Bergare
- Drug Safety Consultant, Macclesfield, Cheshire, United Kingdom (J.G.K.); DMPK (S.H.S.), Discovery Safety (J.A.E.), and Translational Safety (A.J.F.), Drug Safety and Metabolism, AstraZeneca R&D Alderley Park, Macclesfield, Cheshire, United Kingdom; DMPK (L.C.A., J.B., C.S.E.), Regulatory Safety (M.B.), Drug Safety and Metabolism, AstraZeneca R&D Mölndal, Mölndal, Sweden; and DMPK, Cardiovascular and Metabolic Diseases (M.E.), and Respiratory, Inflammation, and Autoimmunity (R.A.T.), iMED AstraZeneca R&D Mölndal, Mölndal, Sweden
| | - Martin Billger
- Drug Safety Consultant, Macclesfield, Cheshire, United Kingdom (J.G.K.); DMPK (S.H.S.), Discovery Safety (J.A.E.), and Translational Safety (A.J.F.), Drug Safety and Metabolism, AstraZeneca R&D Alderley Park, Macclesfield, Cheshire, United Kingdom; DMPK (L.C.A., J.B., C.S.E.), Regulatory Safety (M.B.), Drug Safety and Metabolism, AstraZeneca R&D Mölndal, Mölndal, Sweden; and DMPK, Cardiovascular and Metabolic Diseases (M.E.), and Respiratory, Inflammation, and Autoimmunity (R.A.T.), iMED AstraZeneca R&D Mölndal, Mölndal, Sweden
| | - Marie Elebring
- Drug Safety Consultant, Macclesfield, Cheshire, United Kingdom (J.G.K.); DMPK (S.H.S.), Discovery Safety (J.A.E.), and Translational Safety (A.J.F.), Drug Safety and Metabolism, AstraZeneca R&D Alderley Park, Macclesfield, Cheshire, United Kingdom; DMPK (L.C.A., J.B., C.S.E.), Regulatory Safety (M.B.), Drug Safety and Metabolism, AstraZeneca R&D Mölndal, Mölndal, Sweden; and DMPK, Cardiovascular and Metabolic Diseases (M.E.), and Respiratory, Inflammation, and Autoimmunity (R.A.T.), iMED AstraZeneca R&D Mölndal, Mölndal, Sweden
| | - Charles S Elmore
- Drug Safety Consultant, Macclesfield, Cheshire, United Kingdom (J.G.K.); DMPK (S.H.S.), Discovery Safety (J.A.E.), and Translational Safety (A.J.F.), Drug Safety and Metabolism, AstraZeneca R&D Alderley Park, Macclesfield, Cheshire, United Kingdom; DMPK (L.C.A., J.B., C.S.E.), Regulatory Safety (M.B.), Drug Safety and Metabolism, AstraZeneca R&D Mölndal, Mölndal, Sweden; and DMPK, Cardiovascular and Metabolic Diseases (M.E.), and Respiratory, Inflammation, and Autoimmunity (R.A.T.), iMED AstraZeneca R&D Mölndal, Mölndal, Sweden
| | - Richard A Thompson
- Drug Safety Consultant, Macclesfield, Cheshire, United Kingdom (J.G.K.); DMPK (S.H.S.), Discovery Safety (J.A.E.), and Translational Safety (A.J.F.), Drug Safety and Metabolism, AstraZeneca R&D Alderley Park, Macclesfield, Cheshire, United Kingdom; DMPK (L.C.A., J.B., C.S.E.), Regulatory Safety (M.B.), Drug Safety and Metabolism, AstraZeneca R&D Mölndal, Mölndal, Sweden; and DMPK, Cardiovascular and Metabolic Diseases (M.E.), and Respiratory, Inflammation, and Autoimmunity (R.A.T.), iMED AstraZeneca R&D Mölndal, Mölndal, Sweden
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Sidharta PN, Krähenbühl S, Dingemanse J. Pharmacokinetic and pharmacodynamic evaluation of macitentan , a novel endothelin receptor antagonist for the treatment of pulmonary arterial hypertension. Expert Opin Drug Metab Toxicol 2015; 11:437-49. [PMID: 25604973 DOI: 10.1517/17425255.2015.1000859] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is a chronic disorder of the pulmonary vasculature characterized by elevated mean pulmonary arterial pressure eventually leading to right-sided heart failure and premature death. Macitentan is an oral, once-daily, dual endothelin (ET)A and ETB receptor antagonist with high affinity and sustained receptor binding that was approved in the USA, Europe, Canada, and Switzerland for the treatment of PAH. AREAS COVERED This review discusses the pharmacokinetics (PK) and pharmacodynamics (PD) of macitentan and its drug interaction potential based on preclinical and clinical data. EXPERT OPINION Up to date, macitentan is the only registered treatment for PAH that significantly reduced morbidity and mortality as a combined endpoint in a long-term event-driven study. The safety profile of macitentan is favorable with respect to hepatic safety and edema/fluid retention and may be better than that of other ET receptor antagonists such as bosentan and ambrisentan. The PK profile supports a once-a-day dosing regimen. Macitentan has limited interactions with other drugs. Based on these characteristics macitentan is an important new addition to the treatment of PAH.
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Affiliation(s)
- Patricia N Sidharta
- Actelion Pharmaceuticals Ltd., Department of Clinical Pharmacology , Gewerbestrasse 16, CH-4123 Allschwil , Switzerland +41 61 656686 ; +41 61 5656200 ;
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Ahn LY, Kim SE, Yi S, Dingemanse J, Lim KS, Jang IJ, Yu KS. Pharmacokinetic-pharmacodynamic relationships of macitentan, a new endothelin receptor antagonist, after multiple dosing in healthy Korean subjects. Am J Cardiovasc Drugs 2014; 14:377-85. [PMID: 24906252 DOI: 10.1007/s40256-014-0081-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Macitentan is a novel dual endothelin (ET)-1 receptor antagonist to be used in patients with pulmonary arterial hypertension. This study aimed to assess the pharmacokinetics (PK) and pharmacodynamics (PD) of macitentan after administration of multiple doses to healthy Korean male subjects. METHODS A randomized, double-blind, placebo-controlled, multiple-ascending dose study was performed in 30 healthy male subjects receiving oral macitentan (3, 10, or 30 mg) or placebo once daily for 10 days. Plasma concentrations of macitentan, its active metabolite ACT-13277, and ET-1 were evaluated. Safety and tolerability measurements were conducted throughout the study. RESULTS The concentration-time profile of macitentan was characterized by slow absorption (median time to maximum plasma concentration [t(max)] 9-10 h) and slow elimination (mean elimination half-life [t ½] 11-15 h). After repeated doses of 3, 10, and 30 mg of macitentan over the course of 10 days, the peak concentration (C(max)) increased as the dose increased and the area under the plasma concentration-time curve during the dosing interval (AUC(τ)) increased in a dose-proportional manner. Plasma concentrations showed approximately 1.5- to 1.9-fold accumulation on day 10 compared with day 1. ACT-132577 showed higher levels of exposure than macitentan, its mean half-life was 46-48 h, and it accumulated 7- to 12-fold. Macitentan increased plasma ET-1 concentrations at all doses tested and was well tolerated and elicited no serious adverse events. CONCLUSION Multiple oral doses of 3, 10, and 30 mg of macitentan were well tolerated in healthy Korean subjects, and its pharmacokinetics correlated positively with ET-1 concentrations.
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Affiliation(s)
- Li Young Ahn
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
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Nasser SA, El-Mas MM. Endothelin ETA receptor antagonism in cardiovascular disease. Eur J Pharmacol 2014; 737:210-3. [PMID: 24952955 DOI: 10.1016/j.ejphar.2014.05.046] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 05/19/2014] [Accepted: 05/20/2014] [Indexed: 12/27/2022]
Abstract
Since the discovery of the endothelin system in 1988, it has been implicated in numerous physiological and pathological phenomena. In the cardiovascular system, endothelin-1 (ET-1) acts through intracellular pathways of two endothelin receptors (ETA and ETB) located mainly on smooth muscle and endothelial cells to regulate vascular tone and provoke mitogenic and proinflammatory reactions. The endothelin ETA receptor is believed to play a pivotal role in the pathogenesis of several cardiovascular disease including systemic hypertension, pulmonary arterial hypertension (PAH), dilated cardiomyopathy, and diabetic microvascular dysfunction. Growing evidence from recent experimental and clinical studies indicates that the blockade of endothelin receptors, particularly the ETA subtype, grasps promise in the treatment of major cardiovascular pathologies. The simultaneous blockade of endothelin ETB receptors might not be advantageous, leading possibly to vasoconstriction and salt and water retentions. This review summarizes the role of ET-1 in cardiovascular modulation and the therapeutic potential of endothelin receptor antagonism.
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Affiliation(s)
- Suzanne A Nasser
- Department of Pharmacology, Faculty of Pharmacy, Beirut Arab University, Lebanon
| | - Mahmoud M El-Mas
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Alexandria University, Egypt.
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de Zeeuw D, Coll B, Andress D, Brennan JJ, Tang H, Houser M, Correa-Rotter R, Kohan D, Lambers Heerspink HJ, Makino H, Perkovic V, Pritchett Y, Remuzzi G, Tobe SW, Toto R, Viberti G, Parving HH. The endothelin antagonist atrasentan lowers residual albuminuria in patients with type 2 diabetic nephropathy. J Am Soc Nephrol 2014; 25:1083-93. [PMID: 24722445 DOI: 10.1681/asn.2013080830] [Citation(s) in RCA: 192] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Despite optimal treatment, including renin-angiotensin system (RAS) inhibitors, patients with type 2 diabetic nephropathy have high cardiorenal morbidity and mortality related to residual albuminuria. We evaluated whether or not atrasentan, a selective endothelin A receptor antagonist, further reduces albuminuria when administered concomitantly with maximum tolerated labeled doses of RAS inhibitors. We enrolled 211 patients with type 2 diabetes, urine albumin/creatinine ratios of 300-3500 mg/g, and eGFRs of 30-75 ml/min per 1.73 m(2) in two identically designed, parallel, multinational, double-blind studies. Participants were randomized to placebo (n=50) or to 0.75 mg/d (n=78) or 1.25 mg/d (n=83) atrasentan for 12 weeks. Compared with placebo, 0.75 mg and 1.25 mg atrasentan reduced urine albumin/creatinine ratios by an average of 35% and 38% (95% confidence intervals of 24 to 45 and 28 to 47, respectively) and reduced albuminuria≥30% in 51% and 55% of participants, respectively. eGFR and office BP measurements did not change, whereas 24-hour systolic and diastolic BP, LDL cholesterol, and triglyceride levels decreased significantly in both treatment groups. Use of atrasentan was associated with a significant increase in weight and a reduction in hemoglobin, but rates of peripheral edema, heart failure, or other side effects did not differ between groups. However, more patients treated with 1.25 mg/d atrasentan discontinued due to adverse events. After stopping atrasentan for 30 days, measured parameters returned to pretreatment levels. In conclusion, atrasentan reduced albuminuria and improved BP and lipid spectrum with manageable fluid overload-related adverse events in patients with type 2 diabetic nephropathy receiving RAS inhibitors.
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Affiliation(s)
- Dick de Zeeuw
- Department of Clinical Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands;
| | | | | | | | - Hui Tang
- Data and Statistical Sciences, AbbVie, North Chicago, Illinois
| | | | - Ricardo Correa-Rotter
- Salvador Zubiran National Medical Science and Nutrition Institute, Mexico City, Mexico
| | - Donald Kohan
- Division of Nephrology, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Hiddo J Lambers Heerspink
- Department of Clinical Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hirofumi Makino
- Okayama University Graduate School of Medicine, Okayama, Japan
| | - Vlado Perkovic
- George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Yili Pritchett
- Astellas Global Pharma Development, Inc., Northbrook, Illinois
| | - Giuseppe Remuzzi
- Azienda Ospedaliera Papa Giovanni XXIII and IRCCS-Instituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy
| | - Sheldon W Tobe
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Robert Toto
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Giancarlo Viberti
- Kings' College London School of Medicine, London, United Kingdom; and
| | - Hans-Henrik Parving
- Department of Medical Endocrinology, Rigshospitalet University Hospital of Copenhagen, Copenhagen, Denmark
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Hepatotoxicidad en pacientes tratados con antagonistas del receptor de la endotelina: revisión sistemática y metaanálisis de ensayos clínicos aleatorizados. Med Clin (Barc) 2014; 142:333-42. [DOI: 10.1016/j.medcli.2013.01.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 12/19/2012] [Accepted: 01/10/2013] [Indexed: 12/31/2022]
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Zile MR, Bourge RC, Redfield MM, Zhou D, Baicu CF, Little WC. Randomized, double-blind, placebo-controlled study of sitaxsentan to improve impaired exercise tolerance in patients with heart failure and a preserved ejection fraction. JACC-HEART FAILURE 2014; 2:123-30. [PMID: 24720918 DOI: 10.1016/j.jchf.2013.12.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 12/02/2013] [Accepted: 12/04/2013] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the efficacy and safety of the selective endothelin type A (ETA) receptor antagonist sitaxsentan in patients who have heart failure with preserved ejection fraction (HFpEF). BACKGROUND Fifty percent of heart failure (HF) patients have a preserved ejection fraction. No treatment has been shown to improve their clinical outcomes. Previous studies have suggested that ETA receptor antagonists might improve diastolic function and exercise tolerance in some forms of HF. METHODS In all, 192 HFpEF patients (EF ≥50%) were randomly assigned 2:1 to sitaxsentan 100 mg/day (n = 128) versus placebo (n = 64) for 24 weeks. The primary endpoint was change in treadmill exercise time after 24 weeks of treatment. Secondary objectives included changes in left ventricular mass, transmitral inflow velocity to early diastolic mitral annulus velocity ratio, and Minnesota Living With Heart Failure questionnaire, and New York Heart Association functional class. Subjects were age 65 ± 11 years, 63% female, 29% non-Caucasian, and in functional class II (56.5%) or III (43.5%). RESULTS Subjects treated with sitaxsentan had an increase in median treadmill time (90 s) compared with placebo-treated subjects (37 s, p = 0.0302). There was no significant treatment differences in transmitral inflow velocity to early diastolic mitral annulus velocity ratio, left ventricular mass, Minnesota Living With Heart Failure questionnaire, New York Heart Association functional class, deaths, or HF hospital stay. The incidence of adverse events was similar for sitaxsentan and placebo. CONCLUSIONS In HFpEF patients, treatment with a selective ETA receptor antagonist increased exercise tolerance but did not improve any of the secondary endpoints such as left ventricular mass or diastolic function. Further studies will be necessary to determine whether ETA receptor antagonists may be useful in the treatment of HFpEF. (A Study of the Effectiveness of Sitaxsentan Sodium in Patients With Diastolic Heart Failure; NCT00303498).
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Affiliation(s)
- Michael R Zile
- Division of Cardiology, Medical University of South Carolina and RHJ Department of Veterans Affairs Medical Center, Charleston, South Carolina.
| | - Robert C Bourge
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Duo Zhou
- Pfizer, Inc., Groton, Connecticut
| | - Catalin F Baicu
- Division of Cardiology, Medical University of South Carolina and RHJ Department of Veterans Affairs Medical Center, Charleston, South Carolina
| | - William C Little
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
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Lepist EI, Gillies H, Smith W, Hao J, Hubert C, St. Claire RL, Brouwer KR, Ray AS. Evaluation of the endothelin receptor antagonists ambrisentan, bosentan, macitentan, and sitaxsentan as hepatobiliary transporter inhibitors and substrates in sandwich-cultured human hepatocytes. PLoS One 2014; 9:e87548. [PMID: 24498134 PMCID: PMC3907537 DOI: 10.1371/journal.pone.0087548] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 12/30/2013] [Indexed: 11/25/2022] Open
Abstract
Background Inhibition of the transporter-mediated hepatobiliary elimination of bile salts is a putative mechanism for liver toxicity observed with some endothelin receptor antagonists (ERAs). Methods Sandwich-cultured human hepatocytes were used to study the hepatobiliary distribution and accumulation of exogenous taurocholate, ERAs and endogenous bile acids. The molecular mechanisms for findings in hepatocytes or clinical observations were further explored using either vesicular assays (efflux transporters) or transfected cell-lines (uptake transporters). Inhibition constants (IC50) were measured for the human hepatobiliary transporters bile salt export pump (BSEP), sodium taurocholate cotransporting polypeptide (NTCP), multidrug resistance protein 2 (MRP2), P-glycoprotein (Pgp), breast cancer resistance protein (BCRP), organic anion-transporting polypeptide 1B1 (OATP1B1) and OATP1B3. Results The ERAs showed dose-dependent reductions in exogenous taurocholate cellular accumulation in human hepatocytes, with macitentan having the greatest effect. Consistent with their effects on bile acids, the ERAs inhibited bile transporters. IC50 values for OATP1B1 and OATP1B3 ranged from 2 µM for macitentan to 47 µM for ambrisentan. Macitentan and bosentan also inhibited NTCP with IC50 values of 10 and 36 µM, respectively. Similar to previously reported findings with sitaxsentan, BSEP inhibition was observed for bosentan and macitentan with IC50 values of 42 and 12 µM, respectively. In contrast, ambrisentan showed little or no inhibition of these transporters. Other transporters tested were weakly inhibited by the ERAs. Accumulation in hepatocytes was also a factor in the effects on bile transport. Macitentan demonstrated the greatest accumulation in human hepatocytes (∼100x) followed by sitaxsentan (∼40x), bosentan (∼20x) and ambrisentan (∼2x). Conclusions Significant differences in the inhibition of hepatic transporters were observed between the evaluated ERAs in vitro. Macitentan had the highest level of cellular accumulation and caused the greatest effects on bile acid distribution in human hepatocytes followed by sitaxsentan and bosentan. Ambrisentan showed a low potential to affect bile acids.
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Affiliation(s)
- Eve-Irene Lepist
- Gilead Sciences, Inc., Foster City, California, United States of America
| | - Hunter Gillies
- Gilead Sciences, Inc., Foster City, California, United States of America
| | - William Smith
- Qualyst Transporter Solutions, LLC, Durham, North Carolina, United States of America
| | - Jia Hao
- Gilead Sciences, Inc., Foster City, California, United States of America
| | - Cassandra Hubert
- Qualyst Transporter Solutions, LLC, Durham, North Carolina, United States of America
| | - Robert L. St. Claire
- Qualyst Transporter Solutions, LLC, Durham, North Carolina, United States of America
| | - Kenneth R. Brouwer
- Qualyst Transporter Solutions, LLC, Durham, North Carolina, United States of America
| | - Adrian S. Ray
- Gilead Sciences, Inc., Foster City, California, United States of America
- * E-mail:
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Don GW, Joseph F, Celermajer DS, Corte TJ. Ironic case of hepatic dysfunction following the global withdrawal of sitaxentan. Intern Med J 2013; 42:1351-4. [PMID: 23253000 DOI: 10.1111/imj.12007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Accepted: 07/15/2012] [Indexed: 11/29/2022]
Abstract
A patient with pulmonary arterial hypertension secondary to systemic sclerosis was successfully treated with sitaxentan prior to its worldwide withdrawal (because of hepatotoxicity concerns), but then ironically experienced acute hepatic dysfunction during substitute bosentan therapy, and was eventually stabilised on a phosphodiesterase-5 inhibitor.
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Affiliation(s)
- G W Don
- Royal Prince Alfred Hospital and Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
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Fraidenburg D, Yuan J. Current and Future Therapeutic Targets for Pulmonary Arterial Hypertension. High Alt Med Biol 2013; 14:134-43. [DOI: 10.1089/ham.2013.1007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
| | - Jason Yuan
- Department of Medicine and Pharmacology, University of Illinois, Chicago, Illinois
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Abstract
Major advances have been made in the treatment of World Health Organization Group 1 pulmonary arterial hypertension (PAH). Since the mid-1990s, nine medications have become available in the United States to target three key pathophysiologic derangements in PAH - the prostacyclin, endothelin, and nitric oxide pathways. As a group, these agents have led to improvements in functional capacity, symptoms, hemodynamics, and survival. Most patients with mild to moderate PAH are started on orally active agents such as endothelin receptor antagonists or phosphodiesterase inhibitors. Patients with more severe disease, particularly those with evidence of right heart failure, should be treated with continuous prostacyclin infusion or a combination of a prostacyclin and oral therapy. Each medication has unique properties and clinical considerations, and the selection of an appropriate therapy must be tailored to the individual patient. None of the currently available WHO Group 1 PAH therapies are curative, however, and it is the hope that new therapies in development may halt or reverse disease progression. This review will discuss the major therapeutic classes of presently available medications and their role in managing the patient with PAH. We will also review data supporting the use of combination therapy, adjuvant background therapy, and new agents currently under investigation.
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Fox B, Langleben D, Hirsch AM, Schlesinger RD, Eisenberg MJ, Joyal D, Blenkhorn F, Lesenko L. Hemodynamic stability after transitioning between endothelin receptor antagonists in patients with pulmonary arterial hypertension. Can J Cardiol 2012; 29:672-7. [PMID: 22819360 DOI: 10.1016/j.cjca.2012.05.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 05/09/2012] [Accepted: 05/23/2012] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Maintenance of a favourable hemodynamic profile is central to therapeutic success in pulmonary arterial hypertension (PAH). There is little information about the safety of transitioning patients between oral therapies for PAH. Endothelin receptor antagonists (ERAs) have been a therapeutic mainstay in PAH, providing benefit to many patients. Three ERAs, bosentan, sitaxsentan, and ambrisentan have been approved for clinical use. Sitaxsentan was voluntarily withdrawn from the market in late 2010 resulting in the need to quickly transition a large number of stable patients. METHODS We transitioned 30 clinically stable patients to either ambrisentan or bosentan. Patients underwent a right heart catheterization, measurement of serum N-terminal pro-brain natriuretic peptide (NT-proBNP), and assessment of functional class before changing ERA and again 4 months later. We present a retrospective analysis of those data. RESULTS Of the 30 patients transitioned (15 to ambrisentan, 15 to bosentan), 23 had complete hemodynamic data. No significant change was observed in the groups in right atrial, mean pulmonary artery, and pulmonary artery wedge pressures, or in cardiac output, pulmonary vascular resistance, or NT-proBNP levels. There was no change in World Health Organization functional class. Four ambrisentan and 2 bosentan-treated patients reported fluid retention, and 3 bosentan-treated patients had elevation of hepatic transaminases. Two of the patients had a right atrial pressure increase of ≥5 mm Hg, and 4 had pulmonary artery wedge pressure increase of ≥5 mm Hg. CONCLUSIONS Transitioning between ERAs in stable PAH patients does not result in hemodynamic or clinical deterioration during the first 4 months posttransition. A minority of patients have developed increased cardiac filling pressures.
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Affiliation(s)
- Benjamin Fox
- Center for Pulmonary Vascular Disease, Jewish General Hospital and McGill University, Montreal, Québec, Canada
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Iontophoresis of endothelin receptor antagonists in rats and men. PLoS One 2012; 7:e40792. [PMID: 22808263 PMCID: PMC3396598 DOI: 10.1371/journal.pone.0040792] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 06/13/2012] [Indexed: 11/19/2022] Open
Abstract
Introduction The treatment of scleroderma-related digital ulcers is challenging. The oral endothelin receptor antagonist (ERA) bosentan has been approved but it may induce liver toxicity. The objective of this study was to test whether ERAs bosentan and sitaxentan could be locally delivered using iontophoresis. Methods Cathodal and anodal iontophoresis of bosentan and sitaxentan were performed on anaesthetized rat hindquarters without and during endothelin-1 infusion. Skin blood flow was quantified using laser-Doppler imaging and cutaneous tolerability was assessed. Iontophoresis of sitaxentan (20 min, 20 or 100 µA) was subsequently performed on the forearm skin of healthy men (n = 5). Results In rats neither bosentan nor sitaxentan increased skin blood flux compared to NaCl. When simultaneously infusing endothelin-1, cathodal iontophoresis of sitaxentan increased skin blood flux compared to NaCl (AUC0–20 were 44032.2±12277 and 14957.5±23818.8 %BL.s, respectively; P = 0.01). In humans, sitaxentan did not significantly increase skin blood flux as compared to NaCl. Iontophoresis of ERAs was well tolerated both in animals and humans. Conclusions This study shows that cathodal iontophoresis of sitaxentan but not bosentan partially reverses endothelin-induced skin vasoconstriction in rats, suggesting that sitaxentan diffuses into the dermis. However, sitaxentan does not influence basal skin microvascular tone in rats or in humans.
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Frumkin LR. The pharmacological treatment of pulmonary arterial hypertension. Pharmacol Rev 2012; 64:583-620. [PMID: 22659328 DOI: 10.1124/pr.111.005587] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a life-threatening and progressive disease of various origins characterized by pulmonary vascular remodeling that leads to increased pulmonary vascular resistance and pulmonary arterial pressure, most often resulting in right-sided heart failure. The most common symptom at presentation is breathlessness, with impaired exercise capacity as a hallmark of the disease. Advances in understanding the pathobiology over the last 2 decades have led to therapies (endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, and prostacyclins or analogs) initially directed at reversing the pulmonary vasoconstriction and more recently directed toward reversing endothelial cell dysfunction and smooth muscle cell proliferation. Despite these advances, disease progression is common even with use of combination regimens targeting multiple mechanistic pathways. Overall 5-year survival for PAH has increased significantly from approximately 30% in the 1980s to approximately 60% at present, yet remains abysmal. This review summarizes the mechanisms of action, clinical data, and regulatory histories of approved PAH therapies and describes the latest agents in late-stage clinical development.
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de Bisschop C, Martinot JB, Leurquin-Sterk G, Faoro V, Guénard H, Naeije R. Improvement in lung diffusion by endothelin A receptor blockade at high altitude. J Appl Physiol (1985) 2011; 112:20-5. [PMID: 21979801 DOI: 10.1152/japplphysiol.00670.2011] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Lung diffusing capacity has been reported variably in high-altitude newcomers and may be in relation to different pulmonary vascular resistance (PVR). Twenty-two healthy volunteers were investigated at sea level and at 5,050 m before and after random double-blind intake of the endothelin A receptor blocker sitaxsentan (100 mg/day) vs. a placebo during 1 wk. PVR was estimated by Doppler echocardiography, and exercise capacity by maximal oxygen uptake (Vo(2 max)). The diffusing capacities for nitric oxide (DL(NO)) and carbon monoxide (DL(CO)) were measured using a single-breath method before and 30 min after maximal exercise. The membrane component of DL(CO) (Dm) and capillary volume (Vc) was calculated with corrections for hemoglobin, alveolar volume, and barometric pressure. Altitude exposure was associated with unchanged DL(CO), DL(NO), and Dm but a slight decrease in Vc. Exercise at altitude decreased DL(NO) and Dm. Sitaxsentan intake improved Vo(2 max) together with an increase in resting and postexercise DL(NO) and Dm. Sitaxsentan-induced decrease in PVR was inversely correlated to DL(NO). Both DL(CO) and DL(NO) were correlated to Vo(2 max) at sea level (r = 0.41-0.42, P < 0.1) and more so at altitude (r = 0.56-0.59, P < 0.05). Pharmacological pulmonary vasodilation improves the membrane component of lung diffusion in high-altitude newcomers, which may contribute to exercise capacity.
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Affiliation(s)
- Claire de Bisschop
- Laboratory of Physiologic Adaptations to Physical Activities, UPRES EA 3813, Poitiers University, Poitiers, France
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