Synergy: a concept in search of a definition

Acute and chronic ecotoxicological effects of pharmaceuticals and their mixtures in Daphnia similis

Pharmaceuticals have increasingly received attention from the scientific community due to their growing intake, improved detection and potential ecological risks. Several pharmaceuticals, including antidepressants, anti-inflammatory and antidiabetic compounds and antibiotics, have been described as contaminants in different water matrices. In this context, the aim of the present study was to assess the acute and chronic effects of four classes of pharmaceuticals (acetylsalicylic acid, fluoxetine, metformin and ciprofloxacin) individually and in binary and quartenary mixture. Furthermore, the toxicity of binary mixtures containing the antidepressant fluoxetine was also evaluated. The results of the single acute and chronic toxicity assays indicate lower acetylsalicylic acid and higher fluoxetine toxicity towards Daphnia similis. Regarding the evaluated mixture toxicity, the nature of potential toxicological interactions was predicted by applying mathematical concentration addition and independent action models. The findings revealed both antagonistic and synergistic features, depending on the applied amounts and doses. Finally, the chronic assays performed with the quaternary mixture indicated the presence of a hormetic effect at low concentrations. In sum, the present study demonstrated that the effects of individual pharmaceuticals can underestimate the risk level of these contaminants in the environment.

Allosteric modulators of the δ GABAA receptor subtype demonstrate a therapeutic effect in morphine-antinociceptive tolerance and withdrawal in mice

The present study evaluated the effects of compounds targeting extrasynaptic δ subunit-containing γ-aminobutyric acid type A receptors (δ*-GABAARs) to interrogate the role of tonic inhibition in the development of antinociceptive tolerance caused by repeated morphine administration. We investigated the effect of subchronic or acute treatment with non-steroidal positive allosteric modulators (PAMs) of δ*-GABAARs, such as 2-261, on the morphine-antinociceptive tolerance. Mice were treated twice daily with morphine for 9 days and antinociception was measured using the hot water tail immersion test. Co-treatment with 2-261 and morphine prevented morphine-antinociceptive tolerance and acute administration of 2-261 on day 9 was sufficient to reverse the tolerance. Other compounds with activity at δ*-GABAARs also reversed morphine tolerance, whereas an enaminone that lacked activity at δ*-GABAARs did not. Acute administration of 2-261 did not cause an additive or synergistic antinociceptive effect when combined with an acute submaximal dose of morphine. We then used Cre/LoxP recombination to generate GABAA δ-subunit knockout mice to corroborate the pharmacological results. Observations of male δ-knockout mice demonstrated that the δ*-GABAARs was necessary for 2-261 modulation of both analgesic tolerance and somatic withdrawal symptoms produced by subchronic morphine. While female mice still benefited from the positive effects of 2-261, the δ-subunit was not necessary for these effects, highlighting a distinction of the different pathways that could have implications for some of the sex-related differences seen in human opioid-induced outcomes. Consequently, subtype-specific allosteric modulators of GABAARs may warrant further investigation as pharmacological targets to manage tolerance and withdrawal from opioids.

Ecotoxicological risk assessment of contaminants of emerging concern identified by "suspect screening" from urban wastewater treatment plant effluents at a territorial scale

Urban wastewater treatment plants (WWTP) are a major vector of highly ecotoxic contaminants of emerging concern (CECs) for urban and sub-urban streams. Ecotoxicological risk assessments (ERAs) provide essential information to public environmental authorities. Nevertheless, ERAs are mainly performed at very local scale (one or few WWTPs) and on pre-selected list of CECs. To cope with these limits, the present study aims to develop a territorial-scale ERA on CECs previously identified by a "suspect screening" analytical approach (LC-QToF-MS) and quantified in the effluents of 10 WWTPs of a highly urbanized territory during three periods of the year. Among CECs, this work focused on pharmaceutical residue and pesticides. ERA was conducted following two complementary methods: (1) a single substance approach, based on the calculation for each CEC of risk quotients (RQs) by the ratio of Predicted Environmental Concentration (PEC) and Predicted No Effect Concentration (PNEC), and (2) mixture risk assessment ("cocktail effect") based on a concentration addition model (CA), summing individual RQs. Chemical results led to an ERA for 41 CEC (37 pharmaceuticals and 4 pesticides) detected in treated effluents. Single substance ERA identified 19 CECs implicated in at least one significant risk for streams, with significant risks for DEET, diclofenac, lidocaine, atenolol, terbutryn, atorvastatin, methocarbamol, and venlafaxine (RQs reaching 39.84, 62.10, 125.58, 179.11, 348.24, 509.27, 1509.71 and 3097.37, respectively). Mixture ERA allowed the identification of a risk (RQmix > 1) for 9 of the 10 WWTPs studied. It was also remarked that CECs leading individually to a negligible risk could imply a significant risk in a mixture. Finally, the territorial ERA showed a diversity of risk situations, with the highest concerns for 3 WWTPs: the 2 biggest of the territory discharging into a large French river, the Rhône, and for the smallest WWTP that releases into a small intermittent stream.

Synergy across the drugs approved for the treatment of asthma

INTRODUCTION

Inhaled corticosteroids are the cornerstone for the treatment of stable asthma, however, when disease severity increases, escalating therapy to combinations of drugs acting on distinct signalling pathways is required. It is advantageous to providing evidence of a synergistic interaction across drug combinations, as it allows optimizing bronchodilation while lowering the dose of single agents. In the respiratory pharmacology field, two statistical models are accepted as gold standard to characterize drug interactions, namely the Bliss Independence criterion and the Unified Theory. In this review, pharmacological interactions across drugs approved for the treatment of asthma have been systematically assessed.

EVIDENCE ACQUISITION

A comprehensive literature search was performed in MEDLINE for studies that used a validated pharmacological method for assessing drug interaction. The results were extracted and reported via qualitative synthesis.

EVIDENCE SYNTHESIS

Overall, 45 studies were identified from literature search and 5 met the inclusion criteria. Current evidence coming from ex vivo models of asthma indicates that drug combinations modulating bronchial contractility induce a synergistic bronchorelaxant effect. In murine models of lung inflammation, the combination between inhaled corticosteroids and β2- adrenoceptor agonists synergistically improve lung function and the inflammatory profile.

CONCLUSIONS

There is still limited knowledge regarding the mechanistic basis underlying pharmacological interactions across drugs approved for asthma. The synergism elicited by combined agents is an effect of class. Specifically designed clinical trials are needed to confirm the results coming from preclinical evidence, but also to establish the minimal dose for combined agents to induce a synergistic interaction and maximize bronchodilation.

Mixture toxicity effects of chloramphenicol, thiamphenicol, florfenicol in Daphnia magna under different temperatures

Acute toxicities of chloramphenicol (CAP), thiamphenicol (TAP), and florfenicol (FLO) and their mixtures on Daphnia magna under two representative temperatures of the aquatic environment (20 and 25 °C) have been examined. Their toxicities depicted with an order of 72-h EC₅₀ values were as follows: CAP > FLO > TAP and CAP ≈ FLO > TAP under 20 and 25 °C, separately. Furthermore, the acute toxicity significantly increased with the rise of temperature from 20 to 25 °C in nearly all separate and mixture phenicol antibiotics. Meanwhile, the most toxic combination under two different temperatures was diverse. The nature of toxicological interactions of phenicol antibiotic mixtures was analyzed by Combination Index (CI) equation. In general, a dual synergism-antagonism effect was dominant in nearly all mixtures at both temperatures. The prediction suitability of Concentration Addition (CA), Independent Action (IA) models, and CI method was compared, suggesting that the CI equation seems to be more appropriate for predicting the toxicity values of phenicol drugs than CA and IA models. In brief, phenicol antibiotic mixtures with temperature variation may pose more significant hazards and risks to aquatic organisms; hence, the environment.

Synergistic ideas in oncology: prospects for practical implementation

The review is devoted to the analysis of the problem of synergistic ideas application in oncology after simultaneous combined application of agents. An example of the determination and quantification of the synergistic enhancement ratio is presented. It is emphasized that independent addition is determined by product of probabilities of the effects induced by each agent applied separately. Elevated temperatures synergistically enhance the lethal effect of ionizing radiation and chemical compounds used in the treatment of cancer. Analyzing the dependence of the synergistic effect on the acting temperature after its simultaneous application with ionizing radiation or cisplatin, the existence of an optimal temperature ensuring the greatest synergistic interaction was shown for cultured mammalian and yeast cells. The universal regularities of the manifestation of synergism, independent on the agents, biological objects and tests used, are noted. The greatest synergy is observed with the simultaneous application of agents. The synergism recorded as a result of the combined effects of two factors is observed only with a certain ratio of the effects induced by each agent. Synergism depends on the intensity of the factors used — the current temperature, the dose rate of ionizing radiation or the concentration of chemical agents. These universal patterns have been demonstrated for proand eukaryotic cells, including oncological origin. The existence of universal patterns of synergism indicates the need to develop a new paradigm and theoretical model of synergism, which should take into account the identified patterns. An original biophysical concept of synergistic interaction is proposed. Concrete results are presented that demonstrate the possible ways of using the ideas of synergism in oncology by achieving the greatest synergistic enhancement ratio for the combined effects of various physical and chemical agents. It is concluded that the knowledge and the application of the ideas and general patterns of synergy described in this paper can be useful for specialists using the simultaneous action of various agents to optimize combined treatment methods in modern oncology.

Single and mixture toxicity of four pharmaceuticals of environmental concern to aquatic organisms, including a behavioral assessment

Pharmaceuticals are frequently detected in aquatic environments as mixtures and can cause toxic effects to non-target organisms. We aimed to evaluate the single and mixture effects of the pharmaceuticals metformin, bisoprolol, ranitidine and sotalol using Daphnia similis and Danio rerio. In addition, we aimed to test the predictive accuracy of the mathematical models concentration addition and independent action and to evaluate the nature of the possible toxicological interactions among these pharmaceuticals using the combination index-isobologram model. The acute toxicity of these four pharmaceuticals individually and of their binary mixtures were evaluated using the D. similis tests. Developmental and behavioral effects induced by the pharmaceuticals in quaternary mixtures were evaluated using D. rerio embryos. We observed that most of the binary mixture effects were in the zone between the effects predicted by the concentration addition and the independent action model. The combination index-isobologram model showed to be adequate to describe the nature of possible interactions occurring between the combined pharmaceuticals. Developmental and behavioral acute adverse effects seem not to be induced by the joint action of the quaternary mixture of the evaluated pharmaceuticals on D. rerio embryos, at the concentrations at which they are usually found in surface fresh waters. However, from the results obtained with D. similis, we can conclude that assessing the ecological risk based on the effects of individual pharmaceuticals can underestimate the risk level posed by these environmental contaminants.

Current Methods for Quantifying Drug Synergism

The effectiveness of drug combinations for treatment of a variety of complex diseases is well established. "Drug cocktail" treatments are often prescribed to improve the overall efficacy, decrease toxicity, alter pharmacodynamics, etc in an overall treatment strategy. Specifically, if when combined, drugs interact in some way that causes the total effect to be greater than that predicted by their individual potencies, then drugs are considered synergistic. While there are established ways to quantify the impact of drug combinations clinically, it is an open challenge to quantitatively summarize a synergistic interaction. In this paper, we discuss an overview of the current statistical and mathematical methods for the study of drug combination effects, especially drug synergy quantification (where the interaction effect is not just detected, but quantified according to its magnitude). We first introduce two popular reference models for testing to null hypothesis of non-interaction for a combination, including the Bliss independence model and the Loewe additivity model. Then we discuss several methods for quantifying drug synergism. The advantages and disadvantages with these methods are also provided, and finally, we discuss important next directions in this area.

Rhinovirus and Bacteria Synergistically Induce IL-17C Release from Human Airway Epithelial Cells To Promote Neutrophil Recruitment

Virus-bacteria coinfections are associated with more severe exacerbations and increased risk of hospital readmission in patients with chronic obstructive pulmonary disease (COPD). The airway epithelium responds to such infections by releasing proinflammatory and antimicrobial cytokines, including IL-17C. However, the regulation and role of IL-17C is not well understood. In this study, we examine the mechanisms regulating IL-17C production and its potential role in COPD exacerbations. Human bronchial epithelial cells (HBE) obtained from normal, nontransplanted lungs or from brushings of nonsmokers, healthy smokers, or COPD patients were exposed to bacteria and/or human rhinovirus (HRV). RNA and protein were collected for analysis, and signaling pathways were assessed with pharmacological agonists, inhibitors, or small interfering RNAs. HBE were also stimulated with IL-17C to assess function. HRV-bacterial coinfections synergistically induced IL-17C expression. This induction was dependent on HRV replication and required NF-κB-mediated signaling. Synergy was lost in the presence of an inhibitor of the p38 MAP kinase pathway. HBE exposed to IL-17C show increased gene expression of CXCL1, CXCL2, NFKBIZ, and TFRC, and release CXCL1 protein, a neutrophil chemoattractant. Knockdown of IL-17C significantly reduced induction of CXCL1 in response to HRV-bacterial coinfection as well as neutrophil chemotaxis. HBE from healthy smokers release less IL-17C than cells from nonsmokers, but cells from COPD patients release significantly more IL-17C compared with either nonsmokers or healthy smokers. These data suggest that IL-17C may contribute to microbial-induced COPD exacerbations by promoting neutrophil recruitment.

When the Whole is Not Greater than the Sum of the Parts: A Critical Review of Laboratory Bioassay Effects Testing for Insecticidal Protein Interactions

Many studies have been conducted to investigate synergism among insecticidal proteins; however, a consensus on minimal data requirements and interpretation is lacking. While some have concluded that all additive predictive-type models should be abandoned, we advocate that additivity models can remain useful as assessment tools and that an appropriately designed interaction study will never systematically underestimate the existence of synergism, irrespective of which additivity model (or none at all) may be used. To generate the most meaningful synergy assessment datasets in support of safety assessments, we highlight two beneficial steps to follow: (i) select a testing model which is the most consistent with current knowledge regarding the action of the insecticidal proteins and (ii) avoid using bioassay methods which may result in excess response heterogeneity. We also outline other experimental design elements to consider, which may be crucial for conducting future studies of this type. A contrast of underlying testing assumptions associated with the additivity models is provided, along with a comprehensive review of interaction data for Cry1, Cry2, Cry3, Cry9, and Vip3A insecticidal proteins. Our review captures four recurrent findings: i) experiments reporting synergistic interactions are a minority, ii) the degree of synergism reported is low in magnitude, iii) reported interactions are sometimes equivocal/inconclusive due to unconfirmed model assumptions or other bioassay challenges, and iv) due to biological response variation many of the reported interactions may be artefactual. A brief overview of the positioning of interaction testing data in safety assessments of GM food crops is also provided.

An Introduction to Terminology and Methodology of Chemical Synergy-Perspectives from Across Disciplines

The idea of synergistic interactions between drugs and chemicals has been an important issue in the biomedical world for over a century. As complex diseases, especially cancer, are being treated with various drug cocktails, understanding the interactions among these drugs is increasingly vital to ensuring successful treatment regimens. However, the idea of synergy is not limited to only the biomedical realm and these ideas have developed across many different disciplines, as well. In this review, we first discuss the various terminology surrounding the idea of synergy, providing a comprehensive list of terms defined across numerous disciplines. We then review the most common methodology for detection and quantification of synergy, including the two most prominent reference models for describing additive interactions: Loewe Additivity and Bliss Independence. We also discuss advantages and limitations to each method, with a focus on the Chou-Talalay Combination Index method. Finally, we describe how methods development and terminology have developed among disciplines outside of biomedicine and pharmacology, to synthesize the literature for readers.

Analysis of drug combinations: current methodological landscape

Combination therapies exploit the chances for better efficacy, decreased toxicity, and reduced development of drug resistance and owing to these advantages, have become a standard for the treatment of several diseases and continue to represent a promising approach in indications of unmet medical need. In this context, studying the effects of a combination of drugs in order to provide evidence of a significant superiority compared to the single agents is of particular interest. Research in this field has resulted in a large number of papers and revealed several issues. Here, we propose an overview of the current methodological landscape concerning the study of combination effects. First, we aim to provide the minimal set of mathematical and pharmacological concepts necessary to understand the most commonly used approaches, divided into effect-based approaches and dose-effect-based approaches, and introduced in light of their respective practical advantages and limitations. Then, we discuss six main common methodological issues that scientists have to face at each step of the development of new combination therapies. In particular, in the absence of a reference methodology suitable for all biomedical situations, the analysis of drug combinations should benefit from a collective, appropriate, and rigorous application of the concepts and methods reviewed here.

Synergistic metabolic benefits of an exenatide analogue and cholecystokinin in diet-induced obese and leptin-deficient rodents

AIM

To test the impact of cholecystokinin (CCK) plus either amylin or a glucagon-like peptide-1 receptor (GLP-1R) agonist on metabolic variables in diet-induced obese (DIO) rodents.

METHODS

A stabilized acetylated version of CCK-8 (Ac-Y*-CCK-8), selective CCK1 receptor (CCK1R) or CCK2 receptor (CCK2R) agonists, amylin or the GLP-1R agonist and exenatide analogue AC3174 were administered in select combinations via continuous subcutaneous infusion to DIO rats for 14 days, or Lep(ob) /Lep(ob) mice for 28 days, and metabolic variables were assessed.

RESULTS

Combined administration of Ac-Y*-CCK-8 with either amylin or AC3174 induced greater than additive weight loss in DIO rats, with the overall magnitude of effect being greater with AC3174 + Ac-Y*-CCK-8 treatment. Co-infusion of AC3174 with a specific CCK1R agonist, but not a CCK2R agonist, recapitulated the weight loss mediated by AC3174 + Ac-Y*-CCK-8 in DIO rats, suggesting that synergy is mediated by CCK1R activation. In a 4 × 4 full-factorial response surface methodology study in DIO rats, a synergistic interaction between AC3174 and the CCK1R-selective agonist on body weight and food intake was noted. Co-administration of AC3174 and the CCK1R-selective agonist to obese diabetic Lep(ob) /Lep(ob) mice elicited a significantly greater reduction in percentage of glycated haemoglobin and food intake relative to the sum effects of monotherapy groups.

CONCLUSIONS

The anti-obesity and antidiabetic potential of combined GLP-1R and CCK1R agonism is an approach that warrants further investigation.

Nature, nurture and epigenetics

Real life by definition combines heritability (e.g., the legacy of exposures) and experience (e.g. stress during sensitive or 'critical' periods), but how to study or even model this interaction has proven difficult. The hoary concept of evaluating traits according to nature versus nurture continues to persist despite repeated demonstrations that it retards, rather than advances, our understanding of biological processes. Behavioral genetics has proven the obvious, that genes influence behavior and, vice versa, that behavior influences genes. The concept of Genes X Environment (G X E) and its modern variants was viewed as an improvement on nature-nurture but has proven that, except in rare instances, it is not possible to fractionate phenotypes into these constituent elements. The entanglement inherent in terms such as nature-nurture or G X E is a Gordian knot that cannot be dissected or even split. Given that the world today is not what it was less than a century ago, yet the arbitrator (differential survival and reproduction) has stayed constant, de novo principles and practices are needed to better predict what the future holds. Put simply, the transformation that is now occurring within and between individuals as a product of global endocrine disruption is quite independent of what has been regarded as evolution by selection. This new perspective should focus on how epigenetic modifications might revise approaches to understand how the phenotype and, in particular its components, is shaped. In this review we summarize the literature in this developing area, focusing on our research on the fungicide vinclozolin.