Successful treatment of steroid refractory active ulcerative colitis with natural interferon-beta--an open long-term trial

INTRODUCTION

In some steroid refractory patients with active ulcerative colitis (UC), treatment with immunosuppressive agents, such as cyclosporin, azathioprine or 6-mercaptopurin is effective. However, there are patients who fail to respond to these treatment options or who cannot tolerate them. Application of natural interferon-beta (nIFN-beta) may offer an alternative. Following our positive results with nIFN-beta in a previously published open-labeled study, the present study was designed as an extension with the hypothesis that administration of higher dosage of nIFN-beta (1.0 vs. 0.5 MIU) could result in fewer relapse events.

PATIENTS AND METHODS

46 steroid refractory patients with active UC and a mean clinical activity index (CAI) of 13.2 +/- 3.7 (range 9-23) were treated with nIFN-beta in addition to existing basic medication (5-ASA/SASP plus corticosteroids). During an induction period of eight weeks, 18 patients (group A) received 0.5 MIU nIFN-beta daily and 28 patients (group B), 1.0 MIU nIFN-beta daily intravenously as a bolus injection. Patients who achieved complete remission (decrease of CAI to < or = 4) during the induction period received maintenance therapy with nIFN-beta at the same dose level three times a week and corticosteroids were withdrawn. Remissions and maintenance of remissions were evaluated.

RESULTS

In both groups, a comparable number of complete remissions occurred during the induction period: in 16 / 18 patients (89 %) in group A and in 24 / 28 patients (86 %) in group B. Duration of maintenance treatment was 60.0 +/- 90.0 weeks in group A and 52.7 +/- 9.6 weeks in group B. Under this treatment, relapses (increase of CAI to > or = 6) occurred in 5 / 16 patients (31 %) vs. 1 / 24 patients (4 %) (p < or = 0.05). Hence, regarding maintaining remissions, the 1.0 MIU group outscored the 0.5 MIU group. Apart from known flu-like side effects, the therapy was well tolerated by all patients in both groups.

CONCLUSION

nIFN-beta may be a safe and effective alternative to induce and maintain remissions in patients with steroid refractory active UC. To validate the presented results, its effect has to be investigated in a randomized, placebo-controlled dose-finding trial.

Experimental study on the use of intravenous immunoglobulin (IVIg) in patients with steroid-resistant Crohn's disease

INTRODUCTION

Treatment of Crohn's disease is based on anti-inflammatory and immunosuppressive therapy. Over time, however, approx. 20 % of patients develop steroid resistance. In these cases, alternative treatment methods are required. Short-term application of intravenous immunoglobulin (IVIg) may serve as an additional alternative.

PATIENTS AND METHODS

In 19 steroid-resistant patients (case collection over 15 years) suffering from Crohn's disease (mean CDAI 284.1 +/- 149.8), IVIg therapy with Venimmun, Gamimmun, Octagam, respectively (7 days 10 g/day i. v.) or Sandoglobin (total dose: 72 g or 90 g i. v., respectively, over a period of 8 or 10 days) was applied in addition to basic medication (5-ASA/SASP plus corticosteroids). CDAI according to Best was assessed on a weekly basis starting 3 weeks prior to and ending 4 weeks after completion of therapy. 8 patients could be followed for a longer period.

RESULTS

All patients benefited from this treatment and the effectiveness of IVIg therapy could not only be observed during therapy, but also during the four consecutive weeks after therapy. At 4 weeks after therapy, a total of 14 patients (73.7%) reached a clinical remission (CDAI < 150) and 14 patients (73.7%) showed a CDAI decrease of > 100 points. In the 8 patients who could be followed over a longer period of time, a mean remission duration of 20.6 months was observed. Apart from a slight rise in temperature in one patient, no significant side effects occurred.

CONCLUSION

In patients suffering from Crohn's disease, IVIg therapy may be applied effectively and with few side effects, however, not as remission maintenance, but as a stopgap treatment during an acute attack with steroid resistance, e. g., until therapy with other immunosuppressive agents becomes effective. To validate our presented results, a prospective, randomised, placebo-controlled trial has to be proposed.

Akute Hepatitis durch Kava-Kava und Johanniskraut: immun-vermittelter Mechanismus?

HISTORY AND CLINICAL FINDINGS

In an otherwise healthy 48-year-old female patient, acute hepatitis with transaminase increase (GOT up to 613 U/l, GPT up to 752 U/l), inconspicuous hepatitis serology findings, negative autoantibody status and negative virus serology was observed after a 10-week long intake of kava-kava (1-3 x 200 mg/day) and St John's Wort (1 x 425 mg/day). Biopsy of the liver showed lobular and portal necroinflammatory activity without indication of cirrhosis.

DIAGNOSIS

Due to these findings with proven T-cell activity (lymphocyte typing, neopterin determination) as well as the aetiopathology, this form of hepatitis with histological characteristics of a nutritive/medicinal toxic origin was classified as induced immunologic idiosyncratic hepatitis, possibly in terms of an antibody-negative autoimmune hepatitis.

TREATMENT AND CLINICAL COURSE

Discontinuation of the existing medication and simultaneous onset of immunosuppressive combination therapy of cortisone, azathioprine and ursodeoxycholic acid resulted in normalisation of the liver parameters within a period of two months.

CONCLUSION

On the one hand, it appears that simultaneous intake of St John's Wort possibly potentiates the toxicity of kavapyrones. On the other hand, an immune-mediated mechanism, induced by kava-kava, cannot be completely excluded in the present case. It must be stressed that in patients with autoimmune hepatitis, precise history of medication intake should also be available.

Randomized, controlled trial with IFN-alpha combined with ribavirin with and without amantadine sulphate in non-responders with chronic hepatitis C

BACKGROUND/AIMS

Efficacy and safety of interferon-alpha (IFN-alpha)/ribavirin retreatment with or without amantadine sulphate were evaluated in non-responders with chronic hepatitis C.

METHODS

Two hundred twenty five consecutive non-responders to previous antiviral treatment(s) with IFN-alpha alone or in combination with ribavirin or amantadine were treated with IFN-alpha 2b 5 MU daily for 4 weeks, 5 MU tiw for 20 weeks, followed by 3 MU tiw for additional 24 weeks combined with ribavirin 1000-1200 mg/d. One hundred fifteen of 225 patients were randomized to receive amantadine sulphate 100 mg bid for 48 weeks. Treatment was discontinued in patients with detectable serum hepatitis C virus (HCV)-RNA at treatment week 24.

RESULTS

An overall sustained virologic response with undectable serum HCV-RNA levels was observed in 49/225 patients (22%). Patients infected with HCV-genotype non-1 (P<0.001), low viremia (P=0.011) and only one previous antiviral treatment (P=0.032) were more likely to respond to antiviral retreatment. There was a trend towards higher sustained virologic response rates in patients receiving triple retreatment compared with those treated with IFN-alpha/ribavirin alone (25 versus 18%, P=0.172).

CONCLUSIONS

The addition of amantadine was well tolerated and led to an improvement of sustained virologic responses compared with retreatment with IFN-alpha/ribavirin alone, in particular in patients with low baseline viremia.

[Severe exacerbation of chronic hepatitis B during therapy with corticosteroids and lamivudine therapy and successful short-term combination therapy with interferon-beta and interferon-gamma]

Following an acute episode of undifferentiated collagenosis/autoimmune disease with joint pain, a 50-year-old female patient with known long-standing chronic hepatitis B was treated orally with corticosteroids (30 mg prednisolone in decreasing doses over a period of six months). During this treatment, exacerbation of hepatitis B and massive flare-up under simultaneous treatment with lamivudine occurred (GOT 530 U/L, GPT 791 U/L). Serology was positive for HBs-Ag and anti-HBc-lgM. HBV-DNA titer was > 400,000 copies/ml in polymerase chain reaction. Considering the increased risk of reactivation of autoimmune phenomena during a six months therapy with interferon-alpha, an intensive combination therapy with interferon-beta and -gamma (2 weeks: 1 x 3 MIU nIFN-beta Fiblaferon i.v.; 3 weeks: 1 x 3 MIU nIFN-beta i.v. plus 1 x 50 microg rIFN-gamma Imukine) was carried out over five weeks. After two months this resulted in a complete viral and biochemical response. During an observation period of twelve months no reactivation of the autoimmune disease occurred.

Intrapericardial instillation of mitoxantrone in palliative therapy of malignant pericardial effusion

BACKGROUND

Pericardial effusions occurring with pericardial or myocardial metastases often cause serious complications, necessitating temporary or emergency relief by percutaneous pericardiocentesis. However, this often results in recurrences. For long-term therapy success, the intrapericardial instillation of anti-neoplastic agents is an alternative to surgical methods, which are stressful for the patient. Following our positive experiences with mitoxantrone in the treatment of malignant pleural effusions, we applied this substance for the therapy of malignant pericardial effusions.

PATIENTS AND METHODS

16 patients with cytologically verified malignant pericardial effusions (8 with bronchial carcinoma, 7 with carcinoma of the breast, 1 with adenocarcinoma of the stomach) received an intrapericardial instillation of mitoxantrone 1-3 x10-20 mg. Responses were evaluated by echocardiography 30 days after completion of therapy.

RESULTS

12 of 16 patients showed complete remission (no recurrence of a detectable effusion). 3 patients showed a partial remission (recurrence of non-drainage-dependent effusion) (CR + PR = 94%). Within the mean follow-up period of 189 days no recurrences occurred. The rate of side effects was low.

CONCLUSION

Intrapericardial instillation of mitoxantrone is a feasible and effective palliative method for the control of malignant pericardial effusions with little strain on the patients, short duration of hospital stay, cytotoxic characteristics of the substance with a correspondingly high rate of response and low side effects.

Amifostine plus erythropoietin in a patient with low-risk myelodysplastic syndrome

Increasingly, the therapeutic use of hematopoietic growth factors and immunomodulatory agents is under investigation in patients with low-risk myelodysplastic syndrome (MDS). Studies on amifostine therapy-alone or in combination with erythropoietin (EPO)-indicate that long-term treatment is possibly a decisive factor for therapy success. Therefore, we treated an 81-year-old female, transfusion-dependent patient with MDS and refractory anemia (RA) with amifostine and EPO over a period of 2 years. Following a 4-week induction phase of 5 x 500 mg amifostine plus 3 x 10000 IU EPO per week and maintenance therapy of 1 x 500 mg amifostine plus 3 x 10000 IU EPO per week, normal hemoglobin values were reached in week 14. A long-lasting erythroid response could be observed with a reduction of EPO to 2 x 10000 IU and 1 x 10000 IU and, at present, once a week application of amifostine alone (1 x 500 mg). Apart from the 1st week, the treatment was carried out at the outpatient department and was well tolerated by the patient. The patient experienced a good general clinical condition without further need for hospitalization or blood transfusions.

Induction and maintenance of clinical remission by interferon-beta in patients with steroid-refractory active ulcerative colitis-an open long-term pilot trial

BACKGROUND

The imbalance of pro- and anti-inflammatory cytokines plays an important role in the pathogenesis of inflammatory bowel disease. Shifting this disturbed ratio by means of TNF-antibodies or interferon has been shown to be helpful in treating Crohn's disease and multiple sclerosis, respectively.

AIM

This pilot study investigated whether interferon-beta can induce clinical remission in corticoid-refractory ulcerative colitis.

METHODS

Twenty-five patients with steroid-refractory active ulcerative colitis (Clinical activity index according to Rachmilewitz: 13.5 +/- 5.2) were treated in an open pilot trial with 0.5 MIU human natural interferon-beta (hn-IFN-beta) i.v. (n=18) or 1 MIU recombinant interferon-beta-1a (r-IFN-beta-1-a) s.c. (n=7) daily with the goal of induction of remission. Subsequent maintenance treatment was carried out for 52.0 +/- 78.8 weeks (range 4-336 weeks) with the same dose, three times per week.

RESULTS

Twenty-two of 25 patients (88%) went into remission during induction treatment (hn-IFN-beta 16/18, r-IFN-beta-1a 6/7). Mean time to response was 3.0 +/- 1.3 weeks. Mean length of remission was 13.0 +/- 19.7 months. Only eight of 22 patients in remission relapsed during maintenance treatment. Five of these went into remission again after increasing the dose. Adverse events consisted of slight to moderate flu-like symptoms and slight to moderate hair loss in five of 15 female patients.

CONCLUSION

Although this open pilot study included only a small number of patients, the high response rate suggests that interferon-beta may be a safe and effective treatment for steroid-refractory active ulcerative colitis.

Palliation by intratumoral infiltration with natural interferon-beta

BACKGROUND

Curative approaches to tumor therapy have achieved greater importance through new developments such as cytostatic agents and their combination with other therapy concepts, but for the majority of tumor patients only palliative therapy is possible. Size or location of tumor manifestations can result in severe discomfort for patients, in some cases even in a reduction of functionality.

PATIENTS AND METHODS

For the purpose of this study, a total of 55 patients with a variety of advanced malignant diseases nonresponding or progressive under radio- and/or chemotherapy were treated by intratumoral injection of natural human fibroblast interferon (nIFN-beta). nIFN-beta was administered intralesionally 3 times per week for at least 4 weeks at doses of 2-8 MIU, depending on tumor size. Local tumor response was observed over a median follow-up period of 18 weeks.

RESULTS

In 37 patients (67%) a complete or partial remission of the local tumor manifestation was achieved. Survival times of these patients were improved compared with those of patients without local tumor remission. 16 patients without significant change of tumor volume benefited from the palliative (extensive analgesic) effect of the nIFN-beta therapy. During treatment, none of the patients showed a progression of the locally treated tumor, even when the basic malignant disease progressed. The side effects of the nIFN-beta therapy were tolerable, and no patient discontinued therapy.

CONCLUSION

From these observations, intralesional nIFN-beta therapy of malignant tumors appears to be a useful palliative addition to radio- and/or chemotherapy with the aim of local control of tumor growth.

Are better eye movements an advantage in ball games? A study of prosaccadic and antisaccadic eye movements

The aim of this study was to compare prosaccadic and antisaccadic eye movements of experts in ball sports and controls. In the prosaccadic and antisaccadic task, subjects made saccades respectively towards and away from a suddenly appearing stimulus. By means of infrared-oculography, we compared horizontal eye movements of experts (n=18) and controls (n=20). Experts had shorter overall saccadic latencies, but significantly shorter latencies occurred only on the antisaccade task, not on the prosaccade task. Our findings seem to support the concept that prosaccades and antisaccades have different underlying mechanisms and that expertise in ball games mainly improves antisaccadic performance in terms of latency and variability.

Intercepting moving objects during self-motion: effects of environmental changes

The purpose of this study was to examine the role of background texture on an interception task during self-motion. Twenty-six participants modulated tricycle speed along one arm of a V-shaped track so as to intercept a ball approaching horizontally on the other arm of the V. Either a plain or a textured background (consisting of contrasting vertical stripes) was used. Velocity modulations occurred so as to keep the angle beta between the direction of heading and the line head-ball constant (constant bearing angle, or CBA strategy), indicating that this observer-environment relation might regulate the approach phase. In the textured condition, participants initially drove faster than predicted by the CBA model and compensated by slowing down in the second half. This is in line with the texture-induced overestimation of the ball velocity and implies that absolute velocity information is also used.

Ecological relevance of stereopsis in one-handed ball-catching

The aim of this study was to compare one-handed catching performance between catchers with high (n = 10) and low (n = 10) binocular depth vision or stereopsis. In two sessions of 90 trials, tennis balls were projected at three different velocities towards the subject's shoulder region. Participants with good stereopsis were more successful, although the difference in number of correct catches fell short of significance. More specifically, catchers with low stereopsis made more temporal errors, but no differences in spatial errors. As the velocity of the ball increased, the initiation of the catch was delayed and catching performance decreased. The finding that stereopsis affected timing of the catch challenges the 'monocular tau hypothesis' in the control of interceptive timing, while the velocity effect shows that the act of catching a ball is not initiated at a constant time-to-contact.

Intercepting Moving Objects During Self-Motion

It is generally assumed that in catching a fly ball, an efficient strategy for dealing with the horizontal component of the ball's trajectory is for the observer to keep the angular position of the ball constant with respect to his head. That strategy is called the constant bearing angle or CBA strategy. Maintenance of angular constancy results in the simultaneous arrival of both observer and ball at the landing spot. The authors analyzed the approach behavior of 26 subjects in a ball-interception task with straight paths for both the subjects and the ball. Subjects moved at a velocity that maintained a close-to-constant horizontal angular position of the ball with respect to the end effector throughout the approach phase rather than a constant bearing angle with respect to their head. Velocity adaptations occurred as a function of the changes in the angular velocity of the ball in such a way that a positive or negative angular velocity was canceled. Thus, an actor following the CBA strategy does not need to know where and when the ball will arrive (i.e., a predictive strategy), because reliance on the CBA strategy ensures that he will make the appropriate adaptations that enable him to arrive at the right place in the right time.

Phase II clinical trial of combined natural interferon-beta plus recombinant interferon-gamma treatment of chronic hepatitis B

BACKGROUND/AIMS

Alpha-interferon (IFN-alpha) is an effective treatment for chronic hepatitis B but only 25-40% of patients will profit from a long-term beneficial response to the currently recommended schedule of 3-6 MU given 3 times a week for 6 months. Clinical trials are therefore needed to investigate alternative modifications of interferon therapy, including combinations of different antivirals or immune modulators in order to improve the therapeutic approach to chronic hepatitis B infection. In a phase II trial we evaluated whether a combination of natural interferon-beta (nIFN-beta) with strong antiviral activity plus recombinant interferon-gamma (rIFN-gamma) with a predominantly immunomodulatory activity is able to increase the response rate compared to historical controls treated with IFN-alpha in a conventional regimen.

METHODOLOGY

Forty patients with chronic hepatitis B were included in this trial of combined interferon therapy at a dosage of 6 MU nIFN-beta during week 1 followed by 3 MU for weeks 2-4 plus rIFN-gamma at a daily subcutaneous (s.c.) injection of 150 microg during the entire 4 weeks of the treatment period. Patients entered the trial on the basis of the following criteria: hepatitis B surface antigen (HBsAG), HBeAG and HBV-DNA positive for at least 6 months, HDV, EBV, CMV, anti-HIV negative, and chronic hepatitis proven on biopsy taken within 4 weeks of entry as well as 6 and/or 12 months after interferon therapy. The final diagnosis and classification of chronic hepatitis has been based on guidelines according to a revised classification of chronic hepatitis (Desmet 1994). The post-treatment follow-up was 12 months.

RESULTS

The combined interferon therapy achieved complete responses with seroconversion from HBeAG to anti-HBe and a negative HBV-DNA (dot blot) test, as well as normalization of ALT activity in 15 patients, and partial response with negativation of HBV-DNA concomitant to a decrease in aminotransferase activity to near normal levels in 6 patients. Nineteen patients showed no response to viral markers but showed relief of clinical symptoms as well as pronounced decrease of serumtransaminase activity. Grading of liver biopsies demonstrated an improvement of histologic parameters after the interferon regimen in half of the evaluable patients (n=22). Histological response has been quantified by a reduction in the score of histological activity (HAI-index) from 12.6 before to 7.6 after interferon therapy, and in the inflammation and cellular degeneration score (ICD) from 9.9 to 5.2. Histological response, however, failed to show a consistent correlation with serologic response. This medium-dose combination of interferon-beta and interferon-gamma was tolerated very well by the patients, this good tolerability being explained by tachyphylaxis in response to daily interferon doses. No serious side effects or decompensation of liver function were observed during the 4-week period of therapy or the follow-up, despite the special clinical situation where 60% of the patients included in the study presented with histologically proven cirrhosis (35% of them with clinical manifestation of mildly decompensated cirrhosis).

CONCLUSIONS

This short-term regimen of combined nIFN-beta + rIFN-gamma therapy in patients with chronic hepatitis B proved to be equieffective to long-term treatment with interferon-alpha and combines high clinical tolerability with good practicability, as it can be administered on an in-patient basis, ensuring close patient monitoring.

[Tuberculous anal fistula in acquired immunologic deficiency syndrome]

We report here on a 36-year old, HIV-positive patient, who was sent to hospital with an anal fistula. A short time later during the course of an extensive diagnosis the anal fistula was recognized as an extrapulmonary manifestation of a miliary tuberculosis stemming from an immunodeficiency syndrome. A rapid conversion of the sputum, a normalization of the radiological findings and the absence of relapse are the results of the classic systemic fourfold therapy with myambutol, isoniazid, rifampicin and streptomycin. The danger of overlooking the fact that an anal fistula can be the clinically primary manifestation of a tuberculosis and the problems of a mixed infection within the scope of the acquired immunodeficiency syndrome are discussed. Tuberculosis as a frequent complicating infection of HIV-positive patients--often diagnosed some time before the AIDS-infection as in our patient--can be successfully cured by a high dose of intravenous pharmacotherapy, even when additional complications (parasitic stomatitis, increasing deterioration of the immunological parameters) are present. In order to show the large spectrum of the problems involved in the diagnosis, the therapy and the course of the active acquired immunodeficiency syndrome, we have focused here on the detailed description of the case report.

Cryoglobulinemia: a complication of infectious disease

We report on a 23-year-old male patient with general weakness, subfebrile temperatures, and arthralgia. The first symptoms were observed some months after a severe cytomegalovirus mononucleosis-gastroenteritis. High titers of cryoglobulins suggested an autoimmunological process. This case is interesting because of the association between cytomegalovirus infection and cryoglobulinemia. In conclusion, the differential diagnosis of autoimmune disease should be considered in the course of viral infections.

Lipid peroxides in the polychemotherapy of cancer patients

There is evidence that a variety of anticancer drugs exert their cytotoxic activity by a free-radical-mediated mechanism. These drugs include anthracyclines such as adriamycin, daunorubicin, 4-epi-adriblastin as well as bleomycin, procarbazine, vincristin, cyclophosphamide, etoposide and mitomycin C. The aim of this study was to investigate whether cancer patients who underwent polychemotherapy (n = 44) show more signs of oxidative stress in plasma than a group of healthy controls (n = 52). As an index of free radical generation, plasma concentrations of thiobarbituric-acid-reactive substances (TBARS), well-accepted as markers for oxidative stress, were determined by fluorometric detection after separation by high-performance liquid chromatography. In 12 cases, the TBARS were measured both before and after a chemotherapy course. After chemotherapy, 10 of 12 patients showed a marked increase in plasma TBARS concentration compared to values measured before therapy [9.02 +/- 1.84 nmol/ml (n = 12) vs. 11.58 +/- 2.49 nmol/ml (n = 12); p = 0.002, t-test for paired observations]. Tumor patients in general had significantly larger amounts of TBARS in plasma in comparison with a control group [mean 11.88 +/- 3.51 nmol/ml (n = 44) vs. 7.51 +/- 2.14 nmol/ml (n = 52); p < 0.001, t test]. Our results are evidence that repetitive polychemotherapy with radical-generating compounds may exceed the antioxidative capacities of cancer patients and may lead to oxidative stress.

Interleukin-2 followed by fluorouracil and folinic acid in refractory colorectal cancer--results of a clinical phase II study

In a clinical phase II study, 23 patients with progressive metastatic colorectal cancer and failure after first-line chemotherapy with fluorouracil (5-FU) and folinic acid (FA) were treated with a 5-day continuous infusion of recombinant interleukin-2 (IL-2), 3 x 10(6) cetus U/m2/d, followed after a rest period of 2 days by 5-FU, 600 mg/m2/d, and FA, 300 mg/m2/d over an additional 3 days. After two to four treatment cycles, eight of 22 evaluable patients (36%) revealed antitumor responses, with three partial remissions and five minor responses or stable disease. Side effects consisted most frequently of fever, nausea and vomiting, an elevation of liver enzymes, hypotension, and skin toxicity, and required a 50% reduction of IL-2 dose in 17 of 71 treatment courses (24%). In four of the 23 patients (18%), treatment had to be stopped completely. These data indicate a significant antitumor activity of IL-2 combined with 5-FU/FA therapy in chemotherapy-resistant colorectal cancer. Hence, in spite of a substantial treatment-related toxicity, further studies are warranted to substantiate these findings and to elucidate the underlying mechanisms of the IL-2-5-FU/FA combination therapy.

Cellular kinetics of prednimustine versus chlorambucil plus prednisolone in vitro

Intracellular concentrations of prednimustine (PM), chlorambucil (CLB), phenylacetic acid mustard (PAAM) and prednisolone (P) were measured in different experimental tumor cell lines that had been incubated with either PM or CLB + P. For intracellular analytical determination, we modified a high-pressure liquid chromatographic method for the detection of these substances in plasma. Intact PM could be detected in the intracellular compartment of the incubated tumor cells. PM-incubated cells from PM-injected rats exhibited a higher intracellular concentration-time integral (PAAM) and longer concentration-time profiles for drugs with alkylating capacity than did cells exposed to the CLB + P mixture or to CLB. PAAM was not detectable after incubation of cells with PM, whereas in CLB-incubated cells the AUC of PAAM exceeded that of the parent drug CLB. Our in vitro results therefore favour the concept of a facilitated intracellular uptake and an increased antiproliferative effect for PM versus CLB and CLB + P.

[Free transverse colon perforation in a hemophilic HIV-infected patient with diarrhea and fever]

We describe a case of free perforation of the transverse colon in a patient with HIV-infection. No underlying infectious agent could be identified. Differential diagnosis is discussed. This case demonstrates the need for increased attention for unexpected complications of acquired immunodeficiency syndrome ever after a ten year experience.

Comparative pharmacokinetics of chlorambucil and prednimustine after oral administration

The pharmacokinetics of chlorambucil, phenylacetic acid mustard (the beta-oxidation product of chlorambucil), and prednisolone were investigated in a cross-over study after oral administration of chlorambucil (30 mg) + prednisolone (50 mg) versus prednimustine (300 mg), the ester of chlorambucil and prednisolone. Intact prednimustine could not be detected in plasma at any time. After administration of prednimustine, the plasma concentration-time curves of chlorambucil, phenylacetic acid mustard, and prednisolone showed a retarded profile compared to the administration of the single components. The mean bioavailability was 14% for chlorambucil, 21% for phenylacetic acid mustard, and 22% for prednisolone, when given as prednimustine, compared to the administration of free compounds in stoichiometrically equivalent doses. When given in the oral dosages mentioned above, the average dose-intensity was 62% for chlorambucil, 95% for phenylacetic acid mustard, and 72% for prednisolone, indicating sufficient therapeutic concentrations of the detectable agents.

[Tuberculosis and atypical mycobacterioses in HIV infection. Results from the Bonn Center 1985 to 1989]

485 HIV-positive patients have been treated at our institution in Bonn during 1985 to 1989. Mycobacterial infections occurred in twelve (2.5%) HIV-positive patients. Of 166 AIDS-manifestations according to CDC, eleven (6.6%) were mycobacterial infections. There occurred one case of miliary tuberculosis, six cases of extrapulmonary, one of disseminated tuberculosis and four cases of atypical mycobacteriosis. Mycobacteriosis other than tuberculosis (MOTT) were caused three times by Mycobacterium kansasii and once by Mycobacterium scrofulaceum. Tuberculosis was seen less often in haemophiliacs. Disseminated tuberculosis and atypical mycobacteriosis developed in late stages of HIV-infection with underlying severe immunodeficiency. The lung was the main target organ of tuberculosis. MOTT most often affected the gastrointestinal tract additionally. Noninvasive materials, first of all sputum and gastric acid, were reliably diagnostic but available with delay in particular cases. In those cases histologic studies proved helpful. Application of five-fold regimen (INH, RMP, EMB, PZA and SM) always succeeded in negative cultures in a mean of 15 days in all cases of tuberculosis. Two cases of atypical mycobacteriosis with Mycobacterium kansasii were treated with a five-fold regimen (one case with ciprofloxacin additionally) and culture-negative after six resp. 28 weeks of therapy.

[Change in liver size caused by antitubercular combination therapy]

In 23 patients undergoing antituberculous combination treatment, an ultrasonographic study of the dimensions of the liver was carried out every two weeks for the first two to three months of treatment. Starting with the fourth to sixth week on the therapeutic regimen, significant increases in the width of the left, and the length of the right liver lobes amounting to an average of 1 cm (11%) were established. Differences in the time course of changes in liver size were not to be found, neither in connection with adverse reactions, nor as a function of sex. Between the age of the patient and the depth parameters of the right liver lobe, however, significant positive regressions were observed with the course of treatment. Patients older than 40 years experienced a more marked increase in liver size under therapy. Patients with a history of alcohol abuse and those with side effects, have, on average, larger livers. Slow acetylators manifest a slightly greater increase in the size of the liver during treatment than do rapid acetylators. None of the patients investigated revealed any clinically relevant hepatotoxic side effects. There was no strict correlation between transient transaminase elevations and ultrasonographic changes in the hepatic architecture.

[Significance of the acetylator phenotype and initial oral/intravenous rifampicin administration in the treatment of tuberculosis]

In a pilot study involving 62 patients with open pulmonary tuberculosis, we established that slow acetyators and patients receiving intravenous rifampicin treatment showed a tendency towards a more rapid negativisation of the sputum culture than did fast acetyators (lower levels of isoniazid) or patients receiving oral rifampicin therapy (decreasing bioavailability of the rifampicin during treatment).

[Clinico-pharmacokinetic interactions of rifampicin, pyrazinamide and isoniazide]

We investigated the pharmacokinetic interaction of RMP (administered from the first day of treatment onwards), PZA (given from the second day onwards), and INH (day 17 onwards) in ten, previously untreated patients with pulmonary tuberculosis (five slow acetylators and five fast acetylators). In the case of the slow acetylators, higher INH and acetylhydrazine concentrations were measured than in the fast acetylators. RMP revealed the well-known autoinduction of its metabolism. During the course of continuing treatment, the PZA levels increased. No increased incidence of hepatoxic reactions was to be seen.

[A high pressure liquid chromatography method for detecting the isoniazid derivative isonicotinoyl-hydrazine sodium glucuronide, free isoniazid and acetylisoniazid and its use in pharmacologic studies]

A specific direct method for determining the isoniazid derivative isonicotinoyl-hydrazine sodium glucuronide (INHG-Na) with the aid of high-pressure liquid chromatography has been developed, which permits the analysis of this derivative of isoniazid in addition to isoniazid itself and acetylisoniazid in the plasma of patients. In initial pharmacokinetic applications of the method, it has been shown that plasma INHG-Na is a stable substance that liberates only negligible concentrations of INH.

Prognostic significance of glucocorticoid receptor determination in patients with chronic lymphocytic leukemia and immunocytoma--lack of a positive correlation between receptor levels and clinical responsiveness

Glucocorticoid receptors (GR) have been suggested to have prognostic significance in patients with CLL treated with chemotherapy containing glucocorticoid. In this study, the GR levels in 65 patients with advanced CLL and immunocytoma (clinical stages III and IV according to Rai) were determined by means of a whole cell assay. The median GR-level was 1,920 bs/c with a range from 0 to 9591. The patients were subsequently treated according to a prospective, randomized trial with either a combination of chlorambucil and prednisolone, or with prednimustine. No significant difference in receptor levels was found between responders (median = 1940 bs/c; n = 47) and nonresponders (median = 1950 bs/c; n = 14). To assess the influence of receptor content on prognosis we have analyzed the relationship between GR content and survival time and duration of response. There was no significant difference in duration of response and in survival between those patients with high (greater than 1920 bs/c) and those with low GR levels (less than 1920 bs/c) (log-rank test). Our data suggest that determination of GR provides no reliable indicator for clinical response to regimens with glucocorticoid as a component in patients with CLL and immunocytoma.

Studies on the pharmacokinetics of chlorambucil and prednimustine in patients using a new high-performance liquid chromatographic assay

Following the oral administration of either chlorambucil/prednisolone or prednimustine to patients, the plasma levels of free chlorambucil and phenylacetic acid mustard, the beta-oxidation product of chlorambucil, were measured using a new high-performance liquid chromatographic (HPLC) assay. This assay permitted the simultaneous detection of the analyzed compounds with a lower limit of detection of 30 ng/ml. The pharmacokinetics of chlorambucil and phenylacetic acid mustard were found to be entirely different when prednimustine was administered as opposed to its components chlorambucil and prednisolone together. After the ingestion of the conjugate, the plasma concentration-time curves of chlorambucil and phenylacetic acid mustard showed a "delayed" pattern compared with those obtained after the administration of the components. The mean area under the concentration-time curves (AUCs) of prednimustine-derived chlorambucil and phenylacetic acid mustard were 25% and 40%, respectively, of the areas obtained after a stoichiometrically equivalent dose of chlorambucil. Free plasma prednimustine could not be detected at any time. This different pharmacokinetic behavior might offer an explanation for the superior therapeutic effects of prednimustine demonstrated by clinical studies.

Relevance of the hydrolysis and protein binding of melphalan to the treatment of multiple myeloma

Experiments to determine the hydrolysis and protein binding of melphalan (L-phenylalanine mustard, L-PAM) were carried out in vitro for therapeutic concentration of the drug: the decrease in L-PAM concentration in plasma and whole blood during 24 h incubation at 37 degrees C was only 5% due to hydrolysis. Serum protein binding was about 90%, whereby 60% and 20% of this binding was due to interactions with albumin and acid alpha 1-glycoprotein, respectively. Immunoglobulins did not participate in the binding of L-PAM. The covalently bound part of L-PAM in serum was 30% in the concentration range of 1-30 micrograms/ml. The binding of dihydroxymelphalan (DOH) in serum did not exceed 20%. Glucocorticoids used in combination with L-PAM for treating multiple myeloma did not influence its protein binding. Our study with 35 sera from 15 patients with multiple myeloma shows that high levels of paraproteins do not increase but may decrease the binding of L-PAM, resulting in an elevated concentration of free drug.

[Tolerance of intraoperative, intraperitoneal chemotherapy in advanced gynecologic malignancies]

Assuming that cells and portions of tumor may remain in the abdominal cavity after surgery to reduce tumor size in cases of ovarian carcinoma, and that a change in cell kinetics could result in accelerated growth in the event of a recurrence, 23 patients with advanced tumors were given local (intraperitoneal) treatment intraoperatively. The treatment consisted of 15 mg Mitomycin C or 30 or 40 mg of Mitoxantron, in 1000 ml normal saline. Since the observation time was so short, the tolerance and side effects of this form of treatment were of primary interest, rather than remission quotas and survival times. The principal abdominal complaints included two subileus conditions which responded well to therapy and the problem of postoperative nausea. Four patients reacted to the treatment described with temperatures of over 38 degrees C. Chemical changes detected in the laboratory included 18 cases of leukopenia, which in one case reached WHO Grade 4. Intermittent changes in liver values and electrolytes were observed in isolated cases. Wound-healing impairments occurred in three cases. In one of them, a patient who sustained a prolapse of the small intestine with tumor growth into the abdominal wall, reoperation was necessary. Taken overall, the side effects of the intraoperative, intraperitoneal cytostatic therapy were acceptable. In view of the courses observed and with the idea of employing a form of therapy to combat aggressive growth of tumor cells remaining after surgery, it appears justified to continue with this form of treatment.

A sensitive high-performance liquid chromatographic assay for melphalan and its hydrolysis products in blood and plasma

A sensitive high-performance liquid chromatographic assay has been developed for the measurement of the alkylating cytostatic drug melphalan (4-[bis(2-chloroethyl)amino]-L-phenyl-alanine, or L-phenylalanine-mustard, L-PAM) and its two hydrolysis products, monohydroxy melphalan (MOH) and dihydroxy melphalan (DOH). A reversed-phase phenyl column and a mobile phase consisting of acetonitrile/citrate buffer made possible an isocratic separation and quantification. N,N-[bis(2-hydroxy-ethyl)]toluidine has been synthesized as an internal standard structurally related to DOH. A new, accurate "kinetic" calibration procedure enabled us to determine even the concentration of the unstable MOH. The lower limit of quantification was 30 ng/ml for L-PAM and 20 ng/ml for both DOH and MOH with fluorescence detection. The use of this method is illustrated by some pharmacokinetic data in systemic and locoregional melphalan therapy.

The pharmacokinetics of melphalan during intermittent therapy of multiple myeloma

During intermittent melphalan-prednisone therapy the area under the plasma concentration-time curve of melphalan increased by an average of 45% after oral or intravenous administration of the drug in myeloma patients during the initial three courses at six-week intervals. The rise in melphalan plasma concentrations could not be referred to an alteration in melphalan elimination, metabolism, erythrocyte/plasma partition ratio, or protein binding. A possible explanation could be that covalent binding sites of melphalan were successively saturated during intermittent treatment, resulting in higher drug concentrations during successive courses of therapy.

[Fulminant liver failure in tuberculostatic therapy. A contribution to clinical aspects and pharmacokinetics]

A 23-year old female patient on a prolonged regimen of tuberculostatic chemotherapy finally developed fulminant hepatic failure shortly after addition of hormonal contraception. The pathophysiology of this almost fatal drug reaction is described as a pharmacokinetic interaction: the inherent hepatotoxicity of prothionamide-the drug finally prescribed during convalescence-was significantly potentiated by the Cyt-P-450-inducing effect of the progestagen component of the hormonal contraceptive. Potentiation of hepatotoxicity in connection with tuberculostatic regimes containing rifampicin is well known and this pharmacokinetic phenomenon also pertains to the combination with other Cyt-P-450-inducing drugs such as, for instance, anticonvulsants. However, since the maximum of rifampicin-related Cyt-P-450-inducing effect is limited to the initial 2-3 weeks of therapy, the hepatotoxic risk triggered by this rifampicin-related induction may decline during continuation of therapy. This, unfortunately, does not pertain to the other Cyt-P-450-inducers, whose inductive effect is not time-limited. Progressive severe hepatic damage may follow from such interaction as demonstrated in this case report.

[Neopterin in the serum and urine in the differential diagnosis of disorders of kidney function following kidney transplantation]

In a period of 10 months neopterin in serum and urine was determined by radioimmunoassay in 33 renal allograft recipients treated with cyclosporin A. While in allograft rejections the highest neopterin concentrations were found in the serum, patients with viral infections after renal transplantation showed the most elevated concentrations in the urine. For early diagnosis of allograft rejection the ratio of neopterin clearance and serum-neopterin was the most significant criterion of the parameters measured in this study. Patients without complications during the follow-up showed slightly elevated and stable neopterin levels in serum and urine. The presented results indicate that neopterin is a useful parameter for the follow-up after renal allograft transplantation and for the diagnosis of immunological complications.

Pharmacokinetics of oral and intravenous rifampicin during chronic administration

We investigated the pharmacokinetics of rifampicin and its major metabolites, 25-desacetylrifampicin and 3-formylrifampicin, in two groups of six patients with active pulmonary tuberculosis, who received either multiple oral or intravenous rifampicin therapy in combination with intravenous isoniazid and ethambutol. Serum concentrations of rifampicin were each determined after a single oral and intravenous test dose of 600 mg rifampicin at the beginning and after 1 and 3 weeks of tuberculostatic treatment. Analysis of rifampicin and its metabolites was performed by high-pressure liquid chromatography. It was found that, due to autoinduction of its metabolizing hepatic enzymes, the systemic clearance of rifampicin increased from 5.69 to 9.03 l/h after 3 weeks of multiple dosing. The volume of distribution of the drug was constant over the period of this study. The bioavailability of the active, orally administered rifampicin decreased from 93% after the first single oral dose to 68% after 3 weeks of oral and intravenous rifampicin therapy. Relating to the increase in systemic (hepatic) clearance, a bioavailability no lower than 90% can be predicted. The reduction to 68% indicates that, in addition to an increase of hepatic metabolism, an induction of a prehepatic "first-pass" effect resulted from multiple rifampicin doses. Our study of rifampicin metabolites confirm that prehepatic metabolism was induced, since a higher metabolic ratio resulted after the oral doses than after the intravenous rifampicin test doses. A preabsorptive process can therefore be excluded as a cause of reduced bioavailability.

Determination of isoniazid, acetylisoniazid, acetylhydrazine and diacetylhydrazine in biological fluids by high-performance liquid chromatography

A high-performance liquid chromatographic assay for the determination of isoniazid, acetylisoniazid, acetylhydrazine and diacetylhydrazine (plasma and urine) was developed. The m-chlorobenzoyl derivatives of isoniazid, acetylhydrazine and the internal standard propionylhydrazine were prepared, separated on a RP-18 column and detected at 220 nm. Acetylisoniazid, diacetylhydrazine and the internal standard dipropionylhydrazine were converted to isoniazid, acetylhydrazine, and propionylhydrazine by acidic hydrolysis and subsequently derivatized with m-fluorobenzoyl chloride, separated on a RP-18 column and detected at 220 nm. The lower limits of detection in plasma are acetylhydrazine 0.5 nmol/ml, isoniazid 1.0 nmol/ml, diacetylhydrazine 1.0 nmol/ml and acetylisoniazid 2.0 nmol/ml, and in urine, acetylhydrazine 10 nmol/ml, isoniazid 15 nmol/ml, diacetylhydrazine 20 nmol/ml and acetylisoniazid 40 nmol/ml. This method is sensitive, reproducible, accurate and precise; therefore, it is well suited for detailed pharmacokinetic studies.

[Acute isoniazid poisoning]

Acute isoniazid intoxication is characterised by high mortality and vomiting, seizures, coma and metabolic acidosis as main symptoms. Besides isoniazid, its metabolites may also cause neurotoxicity, as demonstrated in a patient. Delayed onset of neurotoxicity should be considered. The therapy of intoxication with special emphasis on high-dose vitamin B6 application is discussed.

[Metabolic effects of antacids and interactions with other drugs]

The incidence of side effects from antacids is low, but patients with renal insufficiency are at risk to develop alkalosis with high doses of calcium carbonate or magnesium hydroxides, or to develop hypercalcemia due to insufficient calcium elimination by the kidneys.--A great potential exists for drug interactions with antacids. In most instances, the effectiveness of other drugs is decreased in the presence of antacids, but effectiveness may be increased for L-dopa (less degradation in stomach) or quinidine (renal elimination reduced). Interactions at the absorption level can be avoided by administering the antacid one hour after intake of the other drugs (one hour after meals) which is also the optimum dosing schedule to ensure good antacid effect. Interactions through changes of urine pH are not eliminated by observing special dosing time schedules, but by modifying the dose or by selecting alternative drug treatment.