Effect of Bedaquiline and Delamanid Pharmacokinetics on Sputum Culture Conversion and Adverse Events in Drug-Resistant Tuberculosis

BACKGROUND

Pharmacokinetic studies of bedaquiline and delamanid in patients with pre-extensively drug-resistant tuberculosis (pre-XDR TB) will help in the optimization of these drugs for both culture conversion and adverse events.

METHODS

A prospective cohort of 165 adult patients (56% male with mean [SD] age 29 [9.7] years) with pre-XDR TB was treated with bedaquiline, delamanid, clofazimine, and linezolid for 24 weeks at 5 sites in India. Bedaquiline was administered at 400 mg daily for 2 weeks followed by 200 mg thrice weekly for 22 weeks, whereas delamanid was administered at 100 mg twice daily. In 23 consenting participants at 8 and 16 weeks of treatment, blood was collected at 0, 2, 4, 5, 6, 8, 12, and 24 hours postdosing for an intense pharmacokinetic study. Pharmacokinetic parameters were correlated with sputum culture conversion and adverse events.

RESULTS

The mean (SD) age and weight of patients were 30 (10) years and 54 kg, respectively. The median minimum concentration (C min ) and time-concentration curve (AUC) for bedaquiline, respectively, were 0.6 mcg/mL and 27 mcg/mL·h at week 8 and 0.8 mcg/mL and 36 mcg/mL·h at week 16, suggesting drug accumulation over time. The median C min and AUC of delamanid, respectively, were 0.17 mcg/mL and 5.1 mcg/mL·h at week 8 and 0.20 mcg/mL and 7.5 mcg/mL·h at week 16. Delay in sputum conversion was observed in patients with drug concentrations lower than the targeted concentration. At weeks 8 and 16, 13 adverse events were observed. Adverse events were resolved through symptomatic treatment. Body mass index was found to be significantly associated with drug-exposure parameters.

CONCLUSIONS

Bedaquiline and delamanid when co-administered exhibit plasma drug levels within the targeted concentrations, showing an exposure-response relationship.

The effect of anti-tuberculosis drug pharmacokinetics on QTc prolongation

BACKGROUND

Implementation of newer anti-tuberculosis (TB) drugs may prolong the QT interval, increasing the risk of arrythmias and sudden cardiac death. The potential for cardiac adverse events has prompted recommendations for frequent cardiac monitoring during treatment. However, unknowns remain, including the association between drug concentrations and QT interval.

METHODS

An observational prospective cohort study design was used. Patients undergoing treatment for drug-resistant TB in Georgia were assessed. Serial blood samples were collected at 4-6 weeks for pharmacokinetics. Electrocardiograms were recommended to be performed monthly. A generalized estimating equation spline model was used to investigate (1) the effect difference between bedaquiline and delamanid, (2) the cumulative effect of number of anti-TB drugs, and (3) the relationship between serum drug concentrations on QTc interval.

RESULTS

Among 94 patients receiving either bedaquiline (n = 64) or delamanid (n = 30)-based treatment, most were male (82%), and the mean age was 39 years. The mean maximum QTc increase during the first six months was 37.5 ms (IQR: 17.8-56.8). Bedaquiline- and delamanid-based regimens displayed similar increased mean QTc change from baseline during drug administration (P = 0.12). Increasing number of anti-TB drugs was associated with an increased QTc (P = 0.01), but participants trended back towards baseline after drug discontinuation (P = 0.25). A significant association between AUC, Cmin, Cmax, and increased QTc interval was found for bedaquiline (months 1-6) and levofloxacin (months 1-12).

CONCLUSION

Bedaquiline- and delamanid-based regimens and increasing number of QT prolonging agents led to modest increases in the QTc interval with minimal clinical effect.

Alliance A011801 (compassHER2 RD): postneoadjuvant T-DM1 + tucatinib/placebo in patients with residual HER2-positive invasive breast cancer

This report describes the rationale, purpose and design of A011801 (CompassHER2 RD), an ongoing prospective, multicenter, Phase III randomized trial. Eligible patients in the United States (US) and Canada with high-risk (defined as ER-negative and/or node-positive) HER2-positive (HER2+) residual disease (RD) after a predefined course of neoadjuvant chemotherapy and HER2-directed treatment are randomized 1:1 to adjuvant T-DM1 and placebo, versus T-DM1 and tucatinib. Patients have also received adjuvant radiotherapy and/or endocrine therapy, if indicated per standard of care guidelines. The primary objective of the trial is to determine if the invasive disease-free survival (iDFS) with T-DM1 plus tucatinib is superior to iDFS with T-DM1 plus placebo; other outcomes of interest include overall survival (OS), breast cancer-free survival (BCFS), distant recurrence-free survival (DRFS), brain metastases-free survival (BMFS) and disease-free survival (DFS). Correlative biomarker, quality of life (QoL) and pharmacokinetic (PK) end points are also evaluated.

Tucatinib, Trastuzumab, and Capecitabine for HER2-Positive Metastatic Breast Cancer

BACKGROUND

Patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer who have disease progression after therapy with multiple HER2-targeted agents have limited treatment options. Tucatinib is an investigational, oral, highly selective inhibitor of the HER2 tyrosine kinase.

METHODS

We randomly assigned patients with HER2-positive metastatic breast cancer previously treated with trastuzumab, pertuzumab, and trastuzumab emtansine, who had or did not have brain metastases, to receive either tucatinib or placebo, in combination with trastuzumab and capecitabine. The primary end point was progression-free survival among the first 480 patients who underwent randomization. Secondary end points, assessed in the total population (612 patients), included overall survival, progression-free survival among patients with brain metastases, confirmed objective response rate, and safety.

RESULTS

Progression-free survival at 1 year was 33.1% in the tucatinib-combination group and 12.3% in the placebo-combination group (hazard ratio for disease progression or death, 0.54; 95% confidence interval [CI], 0.42 to 0.71; P<0.001), and the median duration of progression-free survival was 7.8 months and 5.6 months, respectively. Overall survival at 2 years was 44.9% in the tucatinib-combination group and 26.6% in the placebo-combination group (hazard ratio for death, 0.66; 95% CI, 0.50 to 0.88; P = 0.005), and the median overall survival was 21.9 months and 17.4 months, respectively. Among the patients with brain metastases, progression-free survival at 1 year was 24.9% in the tucatinib-combination group and 0% in the placebo-combination group (hazard ratio, 0.48; 95% CI, 0.34 to 0.69; P<0.001), and the median progression-free survival was 7.6 months and 5.4 months, respectively. Common adverse events in the tucatinib group included diarrhea, palmar-plantar erythrodysesthesia syndrome, nausea, fatigue, and vomiting. Diarrhea and elevated aminotransferase levels of grade 3 or higher were more common in the tucatinib-combination group than in the placebo-combination group.

CONCLUSIONS

In heavily pretreated patients with HER2-positive metastatic breast cancer, including those with brain metastases, adding tucatinib to trastuzumab and capecitabine resulted in better progression-free survival and overall survival outcomes than adding placebo; the risks of diarrhea and elevated aminotransferase levels were higher with tucatinib. (Funded by Seattle Genetics; HER2CLIMB ClinicalTrials.gov number, NCT02614794.).

Early efficacy and safety of Bedaquiline and Delamanid given together in a "Salvage Regimen" for treatment of drug-resistant tuberculosis

BACKGROUND

Drug-Resistant Tuberculosis (DR-TB) patients for whom a WHO recommended regimen along with Bedaquiline (BDQ) cannot be prescribed, Delamanid (DLM) was added along with other drugs to provide a "Salvage Regimen". The experience of the Institute in respect of early efficacy and safety of both drugs given together is presented.

OBJECTIVE

To ascertain the early efficacy, safety and tolerability of Bedaquline and Delamanid given together as a part of salvage regimen.

METHODS

BDQ and DLM were used together to make regimens along with other drugs where four effective anti TB drugs could not be prescribed as per WHO recommendations. Patients were followed up for sputum smear and culture conversion and adverse events during the treatment.

RESULTS

In this cohort study, 53 DR-TB patients (Median age-24) were initiated on regimens containing both BDQ and DLM. Sputum smear conversion was seen in 35% and 94% patients at the end of 1st week and 3rd month respectively. 84% patients had culture conversion at the end of 4th month. 29 adverse events (AE) were reported among 17 patients and there were 11 deaths. QTc prolongation more than 500 MS was seen in only 1 patient.

CONCLUSION

BDQ and DLM given together in a salvage regimen is efficacious with low rate of adverse events. The combination provides hope to DR-TB patients with limited treatment options and should be provided as a life saving option.

Effects of the Endocrine-Disrupting Chemicals, Vinclozolin and Polychlorinated Biphenyls, on Physiological and Sociosexual Phenotypes in F2 Generation Sprague-Dawley Rats

BACKGROUND

Exposure to endocrine-disrupting chemicals (EDCs) during gestation influences development of the F1 generation offspring and can result in disease and dysfunction in adulthood. Limited evidence suggests consequences on the F2 generation, exposed as germ cells within the F1 fetus. These F2s provide a unique window into the programming effects of EDCs.

OBJECTIVE

This study assessed intergenerational effects of EDC exposure on adult physiology and behavior in Sprague-Dawley rats.

METHODS

Pregnant rats were exposed to either a polychlorinated biphenyl (PCB) mixture, Aroclor 1,221 (A1221), the fungicide vinclozolin (VIN), or the vehicle (VEH) (6% dimethylsulfoxide in sesame oil) alone. A1221 is weakly estrogenic, while VIN is antiandrogenic, enabling us to compare different classes of EDCs. The F1 male and female offspring were bred to generate the paternal- and maternal-lineage F2 generation. This F2 generation was assessed for physiological outcomes, ultrasonic vocalizations (USVs), and sexual behavior in adulthood.

RESULTS

Each EDC caused phenotypic effects in a sex- and lineage-dependent manner. The most robustly affected group was the paternal-lineage males. F2 VIN paternal male descendants had increased body weight throughout the lifespan, lower concentrations of circulating estradiol, and lower adrenal and testicular indices. Both VIN and A1221 paternal-lineage males also exhibited the greatest number of changes in the characteristics of USVs in response to an opposite-sex animal and changes in sexual behaviors in a mating test.

CONCLUSION

Exposure of rats to EDCs at the germ cell stage led to differences in the physiological and behavioral phenotype later in life, especially in males. This finding has implications for multigenerational physiological and reproductive health in wildlife and humans. https://doi.org/10.1289/EHP3550.

[New antibiotics - standstill or progress]

The development of resistance to antibiotics has been ignored for a long time. But nowadays, increasing resistance is an important topic. For a decade no new antibiotics had been developed and it is not possible to quickly close this gap of new resistance and no new drugs. This work presents six new antibiotics (ceftaroline, ceftobiprole, solithromycin, tedizolid, ceftolozane/tazobactam, ceftazidime/avibactam). In part, only expert opinions are given due to lack of study results.The two 5th generation cephalosporins ceftaroline and ceftobiprole have beside their equivalent efficacy to ceftriaxone (ceftaroline) and cefipim (ceftobiprole) high activity against MRSA. The fluoroketolide solithromycin should help against macrolide-resistant pathogens and has been shown to be noninferior to the fluorochinolones. The oxazolidinone tedizolid is effective against linezolid-resistant MRSA. The two cephalosporins ceftolozane/tazobactam and ceftazidime/avibactam are not only effective against gram-negative pathogens, but they have a very broad spectrum. Due to the efficacy against extended-spectrum β‑lactamases, they can relieve the selection pressure of the carbapenems. We benefit from all new antibiotics which can take the selection pressure from other often used antibiotics. The increasing number of resistant gram-negative pathogens worldwide is alarming. Thus, focusing on the development of new drugs is extremely important.

Combined Use of Delamanid and Bedaquiline to Treat Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis: A Systematic Review

The new drugs delamanid and bedaquiline are increasingly being used to treat multidrug-resistant (MDR-) and extensively drug-resistant tuberculosis (XDR-TB). The World Health Organization, based on lack of evidence, recommends their use under specific conditions and not in combination. No systematic review has yet evaluated the efficacy, safety, and tolerability of delamanid and bedaquiline used in combination. A search of peer-reviewed, scientific evidence was carried out, aimed at evaluating the efficacy/effectiveness, safety, and tolerability of delamanid and bedaquiline-containing regimens in individuals with pulmonary/extrapulmonary disease, which were bacteriologically confirmed as M/XDR-TB. We used PubMed to identify any relevant manuscripts in English up to the 23 December 2016, excluding editorials and reviews. Three out of 75 manuscripts retrieved satisfied the inclusion criteria, whilst 72 were excluded for dealing with only one drug (three studies), being recommendations (one study) or identifying need for their use (one study), focusing on drug resistance aspects (six studies) or being generic reviews/other studies (61 papers). The studies retrieved reported two XDR-TB cases observed for six months and achieving consistent sputum smear and culture conversion. Case 2 experienced a short break of bedaquiline, which was re-started after introducing verapamil. After a transient and symptom-free increase of the QT interval from week 5 to 17, it then decreased below the 500 ms threshold.

Reciprocity and Ethical Tuberculosis Treatment and Control

This paper explores the notion of reciprocity in the context of active pulmonary and laryngeal tuberculosis (TB) treatment and related control policies and practices. We seek to do three things: First, we sketch the background to contemporary global TB care and suggest that poverty is a key feature when considering the treatment of TB patients. We use two examples from TB care to explore the role of reciprocity: isolation and the use of novel TB drugs. Second, we explore alternative means of justifying the use of reciprocity through appeal to different moral and political theoretical traditions (i.e., virtue ethics, deontology, and consequentialism). We suggest that each theory can be used to provide reasons to take reciprocity seriously as an independent moral concept, despite any other differences. Third, we explore general meanings and uses of the concept of reciprocity, with the primary intention of demonstrating that it cannot be simply reduced to other more frequently invoked moral concepts such as beneficence or justice. We argue that reciprocity can function as a mid-level principle in public health, and generally, captures a core social obligation arising once an individual or group is burdened as a result of acting for the benefit of others (even if they derive a benefit themselves). We conclude that while more needs to be explored in relation to the theoretical justification and application of reciprocity, sufficient arguments can be made for it to be taken more seriously as a key principle within public health ethics and bioethics more generally.

Estrogen Receptor-Selective Agonists Modulate Learning in Female Rats in a Dose- and Task-Specific Manner

Estrogens are well known for their enhancing effects on hippocampus-sensitive cognition. However, estrogens can also impair learning and memory, particularly the acquisition of striatum-sensitive tasks. These cognitive shifts appear to be mediated through local estrogen receptor (ER) activation in each neural structure, but little information is known regarding which specific ER subtypes drive the opposing effects on learning. Elucidating the mnemonic roles of discrete ER subtypes is essential for predicting how treatments with distinct ER pharmacology such as drugs, hormone therapies, and phytoestrogen supplements affect cognitive abilities in and thus the daily lives of the women who take them. The present study examined the effects of the ERα-selective compound propyl pyrazole triol and the ERβ-selective compounds diarylpropionitrile and Br-ERb-041 on place and response learning in young adult female rats. Long-Evans rats were ovariectomized and maintained on phytoestrogen-free chow for 3 weeks before behavioral training, with treatments administered via subcutaneous injection 48 and 24 hours before testing. A dose-response paradigm was used, with each compound tested at 4 different doses in separate groups of rats. Propyl pyrazole triol, diarylpropionitrile, and Br-ERb-041 all enhanced place learning and impaired response learning, albeit with distinct dose-response patterns for each compound and task. These results are consistent with the detection of ERα and ERβ in the hippocampus and striatum and suggest that learning is modulated via activation of either ER subtype.

Tedizolid: a novel oxazolidinone with potent activity against multidrug-resistant gram-positive pathogens

Tedizolid phosphate is a novel oxazolidinone prodrug (converted to the active form tedizolid by phosphatases in vivo) that has been developed and recently approved (June 2014) by the United States FDA for the treatment of acute bacterial skin and skin structure infections (ABSSSIs) caused by susceptible Gram-positive pathogens, including methicillin-resistant Staphylococcus aureus (MRSA). Tedizolid is an oxazolidinone, but differs from other oxazolidinones by possessing a modified side chain at the C-5 position of the oxazolidinone nucleus which confers activity against certain linezolid-resistant pathogens and has an optimized C- and D-ring system that improves potency through additional binding site interactions. The mechanism of action of tedizolid is similar to other oxazolidinones and occurs through inhibition of bacterial protein synthesis by binding to 23S ribosomal RNA (rRNA) of the 50S subunit of the ribosome. As with other oxazolidinones, the spontaneous frequency of resistance development to tedizolid is low. Tedizolid is four- to eightfold more potent in vivo than linezolid against all species of staphylococci, enterococci, and streptococci, including drug-resistant phenotypes such as MRSA and vancomycin-resistant enterococci (VRE) and linezolid-resistant phenotypes. Importantly, tedizolid demonstrates activity against linezolid-resistant bacterial strains harboring the horizontally transmissible cfr gene, in the absence of certain ribosomal mutations conferring reduced oxazolidinone susceptibility. With its half-life of approximately 12 h, tedizolid is dosed once daily. It demonstrates linear pharmacokinetics, has a high oral bioavailability of approximately 90 %, and is primarily excreted by the liver as an inactive, non-circulating sulphate conjugate. Tedizolid does not require dosage adjustment in patients with any degree of renal dysfunction or hepatic dysfunction. Studies in animals have demonstrated that the pharmacodynamic parameter most closely associated with the efficacy of tedizolid is fAUC(0-24h)/MIC. In non-neutropenic animals, a dose-response enhancement was observed with tedizolid and lower exposures were required compared to neutropenic cohorts. Two Phase III clinical trials have demonstrated non-inferiority of a once-daily tedizolid 200 mg dose for 6-10 days versus twice-daily 600 mg linezolid for the treatment of ABSSSIs. Both trials used the primary endpoint of early clinical response at 48-72 h; however, one trial compared oral formulations while the other initiated therapy with the parenteral formulation and allowed oral sequential therapy following initial clinical response. Throughout its development, tedizolid has demonstrated that it is well tolerated and animal studies have shown a lower propensity for neuropathies with long-term use than its predecessor linezolid. Data from the two completed Phase III clinical trials demonstrated that the studied tedizolid regimen (200 mg once daily for 6 days) had significantly less impact on hematologic parameters as well as significantly less gastrointestinal treatment-emergent adverse effects (TEAEs) than its comparator linezolid. As with linezolid, tedizolid is a weak, reversible MAO inhibitor; however, a murine head twitch model validated to assess serotonergic activity reported no increase in the number of head twitches with tedizolid even at doses that exceeded the C max in humans by up to 25-fold. Tyramine and pseudoephedrine challenge studies in humans have also reported no meaningful MAO-related interactions with tedizolid. With its enhanced in vitro activity against a broad-spectrum of Gram-positive aerobic bacteria, convenient once-daily dosing, a short 6-day course of therapy, availability of both oral and intravenous routes of administration, and an adverse effect profile that appears to be more favorable than linezolid, tedizolid is an attractive agent for use in both the hospital and community settings. Tedizolid is currently undergoing additional Phase III clinical trials for the treatment of hospital-acquired bacterial pneumonia (HABP) and ventilated nosocomial pneumonia (VNP).

Profile of delamanid for the treatment of multidrug-resistant tuberculosis

New approaches to the treatment of multidrug-resistant and extensively drug-resistant tuberculosis (TB) are badly needed. Not only is the success rate of current treatment regimens suboptimal but existing regimens require multiple drugs and lengthy courses and may lead to significant toxicities. The treatment landscape is beginning to shift, however, with the recent approvals of the new TB drugs bedaquiline and delamanid. Delamanid, a dihydro-imidazooxazole, has been shown to have excellent activity against Mycobacterium tuberculosis in both in vitro and in murine TB models. It has also recently been reported to improve rates of sputum culture conversion in patients with multidrug-resistant TB when added to an optimized background regimen. Although generally well tolerated, delamanid has been associated with QT prolongation, which may be of particular clinical concern when paired with other TB drugs that may also have this effect, most notably the fluoroquinolones. Ongoing studies will help to clarify delamanid's role in the treatment of drug-resistant TB.

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.

Systematic reviews to ascertain the safety of diabetes medications

Clinicians and patients with type 2 diabetes enjoy an expanding list of medications to improve glycemic control. With this expansion has come a flurry of concerns about the safety of these antihyperglycemic agents, concerns that affect judgments about the risk/benefit balance of therapy. Some of these safety signals have been identified through the synthesis of existing research evidence. Thus, it has become important for clinicians and clinical policymakers to understand the strengths and limitations of systematic reviews and meta-analyses in determining the safety of diabetes medications. In this paper, we highlight key safety concerns with diabetes medications and discuss the role evidence synthesis plays in each, with special attention to its strengths and limitations.

Accelerated activation of SOCE current in myotubes from two mouse models of anesthetic- and heat-induced sudden death

Store-operated calcium entry (SOCE) channels play an important role in Ca²⁺ signaling. Recently, excessive SOCE was proposed to play a central role in the pathogenesis of malignant hyperthermia (MH), a pharmacogenic disorder of skeletal muscle. We tested this hypothesis by characterizing SOCE current (I_SkCRAC) magnitude, voltage dependence, and rate of activation in myotubes derived from two mouse models of anesthetic- and heat-induced sudden death: 1) type 1 ryanodine receptor (RyR1) knock-in mice (Y524S/+) and 2) calsequestrin 1 and 2 double knock-out (dCasq-null) mice. I_SkCRAC voltage dependence and magnitude at -80 mV were not significantly different in myotubes derived from wild type (WT), Y524S/+ and dCasq-null mice. However, the rate of I_SkCRAC activation upon repetitive depolarization was significantly faster at room temperature in myotubes from Y524S/+ and dCasq-null mice. In addition, the maximum rate of I_SkCRAC activation in dCasq-null myotubes was also faster than WT at more physiological temperatures (35-37°C). Azumolene (50 µM), a more water-soluble analog of dantrolene that is used to reverse MH crises, failed to alter I_SkCRAC density or rate of activation. Together, these results indicate that while an increased rate of I_SkCRAC activation is a common characteristic of myotubes derived from Y524S/+ and dCasq-null mice and that the protective effects of azumolene are not due to a direct inhibition of SOCE channels.

Delamanid for multidrug-resistant pulmonary tuberculosis

BACKGROUND

Delamanid (OPC-67683), a nitro-dihydro-imidazooxazole derivative, is a new antituberculosis medication that inhibits mycolic acid synthesis and has shown potent in vitro and in vivo activity against drug-resistant strains of Mycobacterium tuberculosis.

METHODS

In this randomized, placebo-controlled, multinational clinical trial, we assigned 481 patients (nearly all of whom were negative for the human immunodeficiency virus) with pulmonary multidrug-resistant tuberculosis to receive delamanid, at a dose of 100 mg twice daily (161 patients) or 200 mg twice daily (160 patients), or placebo (160 patients) for 2 months in combination with a background drug regimen developed according to World Health Organization guidelines. Sputum cultures were assessed weekly with the use of both liquid broth and solid medium; sputum-culture conversion was defined as a series of five or more consecutive cultures that were negative for growth of M. tuberculosis. The primary efficacy end point was the proportion of patients with sputum-culture conversion in liquid broth medium at 2 months.

RESULTS

Among patients who received a background drug regimen plus 100 mg of delamanid twice daily, 45.4% had sputum-culture conversion in liquid broth at 2 months, as compared with 29.6% of patients who received a background drug regimen plus placebo (P=0.008). Likewise, as compared with the placebo group, the group that received the background drug regimen plus 200 mg of delamanid twice daily had a higher proportion of patients with sputum-culture conversion (41.9%, P=0.04). The findings were similar with assessment of sputum-culture conversion in solid medium. Most adverse events were mild to moderate in severity and were evenly distributed across groups. Although no clinical events due to QT prolongation on electrocardiography were observed, QT prolongation was reported significantly more frequently in the groups that received delamanid.

CONCLUSIONS

Delamanid was associated with an increase in sputum-culture conversion at 2 months among patients with multidrug-resistant tuberculosis. This finding suggests that delamanid could enhance treatment options for multidrug-resistant tuberculosis. (Funded by Otsuka Pharmaceutical Development and Commercialization; ClinicalTrials.gov number, NCT00685360.).

Phase 2, randomized, double-blind, dose-ranging study evaluating the safety, tolerability, population pharmacokinetics, and efficacy of oral torezolid phosphate in patients with complicated skin and skin structure infections

Torezolid (TR-700) is the active moiety of the prodrug torezolid phosphate ([TP] TR-701), a second-generation oxazolidinone with 4- to 16-fold greater potency than linezolid against Gram-positive species including methicillin-resistant Staphylococcus aureus (MRSA). A double-blind phase 2 study evaluated three levels (200, 300, or 400 mg) of oral, once-daily TP over 5 to 7 days for complicated skin and skin structure infections (cSSSI). Patients 18 to 75 years old with cSSSI caused by suspected or confirmed Gram-positive pathogens were randomized 1:1:1. Of 188 treated patients, 76.6% had abscesses, 17.6% had extensive cellulitis, and 5.9% had wound infections. S. aureus, the most common pathogen, was isolated in 90.3% of patients (139/154) with a baseline pathogen; 80.6% were MRSA. Cure rates in clinically evaluable patients were 98.2% at 200 mg, 94.4% at 300 mg, and 94.4% at 400 mg. Cure rates were consistent across diagnoses, regardless of lesion size or the presence of systemic signs of infection. Clinical cure rates in patients with S. aureus isolated at baseline were 96.6% overall and 96.8% for MRSA. TP was safe and well tolerated at all dose levels. No patients discontinued treatment due to an adverse event. Three-stage hierarchical population pharmacokinetic modeling yielded a geometric mean clearance of 8.28 liters/h (between-patient variability, 32.3%), a volume of the central compartment of 71.4 liters (24.0%), and a volume of the peripheral compartment of 27.9 liters (35.7%). Results of this study show a high degree of efficacy at all three dose levels without significant differences in the safety profile and support the continued evaluation of TP for the treatment of cSSSI in phase 3 trials.

Aleglitazar, a dual PPARα and PPARγ agonist for the potential oral treatment of type 2 diabetes mellitus

PPARγ and PPARα are nuclear receptors mainly involved in the regulation of glucose homeostasis and lipid levels, respectively. Aleglitazar, being developed by Roche Holding, is a dual agonist for PPARγ and PPARα for the potential simultaneous treatment of hyperglycemia and dyslipidemia in patients with type 2 diabetes mellitus (T2DM). In preclinical studies, aleglitazar decreased non-fasted glucose levels, increased glucose clearance and improved insulin resistance, while also increasing HDL-cholesterol and decreasing LDL-cholesterol levels in serum. In phase I and II clinical trials in patients with T2DM, aleglitazar demonstrated beneficial antidiabetic activities and had a higher antihyperglycemic efficacy than pioglitazone (a PPARγ agonist). Aleglitazar improved the lipid profile in patients and decreased levels of cardiovascular markers of inflammation and clotting. The observed adverse events were characteristic of either PPARγ or PPARα agonists; however, when compared to pioglitazone-PPARγ-mediated effects, such as edema and weight gain, these were less severe. PPARγ-mediated adverse events on bone have not been measured and should be addressed in the future. The PPARα-mediated adverse effects on renal function are of concern and are a primary endpoint of ongoing phase II clinical trials in patients with T2DM. A phase III clinical trial was also ongoing in patients with T2DM who had recently experienced a cardiac event.

Rilmenidine – its antihypertensive efficacy, safety and impact on quality of life in perimenopausal women with mild to moderate essential hypertension

OBJECTIVES

A prospective, open-labeled study to assess the antihypertensive effect of monotherapy with rilmenidine and its impact on quality of life (QoL), as well as on biochemical parameters in perimenopausal women with essential hypertension.

DESIGN AND METHODS

Fifty-five perimenopausal women with mild to moderate essential hypertension (mean age 51.4+/-2.4 years) were enrolled. At baseline and after 12-week monotherapy with rilmenidine, we assessed: systolic (SBP) and diastolic (DBP) blood pressure (BP), heart rate (HR), fasting glucose, serum creatinine and total cholesterol levels. QoL was also assessed at baseline and at 12 weeks by two standardized questionnaires: the Short Form - 36 (SF-36) and the Subjective Symptoms Assessment Profile (SSAP). Statistical analysis was performed using Student's t-test to compare changes in BP, QoL and biochemical parameters during therapy with rilmenidine.

RESULTS

After 12 weeks of therapy, there was a significant decrease in BP and HR. Normalization of BP was observed in 46 (84%) women. Rilmenidine did not influence serum creatinine, fasting glucose and lipid profile. Treatment was very well tolerated by the patients and no side-effects were noted. Both the SF-36 and the SSAP demonstrated improvement in general QoL. We observed a significant improvement in all SF-36 subscales. In the SSAP, a similar significant improvement was found, except dizziness subscale. Improvement in QoL was not related to reduction of BP.

CONCLUSIONS

Monotherapy with rilmenidine is safe and effective in BP treatment and significantly improves QoL in perimenopausal women with essential hypertension.

Efficacy and safety of muraglitazar: a double-blind, 24-week, dose-ranging study in patients with type 2 diabetes

Muraglitazar is a dual (alpha/gamma) PPAR activator. Dual receptor activation may improve glycaemic and lipid profiles in patients with type 2 diabetes mellitus.This randomised double-blind trial in 1,477 drug-naive patients with type 2 diabetes compared the efficacy and safety of muraglitazar (0.5, 1.5, 5, 10, and 20 mg) with pioglitazone (15 mg). Endpoints included changes in HbA(1C) and plasma lipids, last observation carried forward over 24 weeks. At week 24, mean changes from baseline in HbA(1C) ranged from -0.25% to -1.76% with muraglitazar (p<or=0.0008, 0.5 mg versus each higher muraglitazar dose), compared with -0.57% with pioglitazone. At week 12, tri-glycerides decreased 4-41% with muraglitazar and 9% with pioglitazone. High-density lipoprotein cholesterol increased 6-23% with muraglitazar and 10% with pioglitazone. Oedema-related events occurred with muraglitazar in a dose-dependent incidence (range 9-40%), and at 14% with pioglitazone. Overall, muraglitazar produced simultaneous dose-dependent improvements in glycaemic and lipid parameters in drug-naive patients with type 2 diabetes mellitus.

Coadministration of muraglitazar plus glyburide: improvement of glycaemic and lipid profiles in patients with type 2 diabetes

In this trial we evaluated the efficacy and safety of muraglitazar, a dual (alpha/gamma) peroxisome proliferator-activated receptor activator, plus glyburide in patients with type 2 diabetes not controlled with sulphonylurea monotherapy. After 2 weeks of open-label glyburide (15 mg/day), 583 patients were randomised to additionally receive muraglitazar 2.5 mg, 5 mg, or placebo. End points included changes in HbA(1C) and fasting plasma glucose (FPG) at weeks 24 and 102, and changes in lipid parameters at weeks 11/12 and 102.At week 24, mean changes from baseline in HbA(1C) and FPG were significantly greater with glyburide plus muraglitazar 2.5 mg or 5 mg than with glyburide plus placebo (p<0.0001). At week 11/12, triglyceride levels were significantly reduced with muraglitazar (p<0.0001). During the extension phase, muraglitazar demonstrated long-term glycaemic and lipid effects through week 102. Although generally well tolerated, muraglitazar was associated with higher rates of congestive heart failure, cardiovascular events, weight gain and oedema.

Bioequivalence evaluation of rilmenidine in healthy volunteers

The bioavailability of two rilmenidine tablet formulations was compared in healthy male (17) and female (8) subjects, aged 18 to 36 years, during a laboratory-blind, randomized, two-treatment, two-period, cross-over study under fasting conditions. In each treatment phase subjects received a single dose of 1.544 mg rilmenidine dihydrogen phosphate (CAS 85409-38-7), equivalent to 1 mg rilmenidine (CAS 54187-04-1). Consecutive dosing was separated by a drug-free wash-out period of 7 d. Following each dosing, serial venous blood samples were collected over a period of 48 h for the determination of plasma rilmenidine concentrations by means of a validated LCMS/MS method. The most frequently reported drug-related adverse events were dizziness and headache ranging from mild to moderate in intensity. The geometric mean C(max) of rilmenidine for the reference and test products was 3.73 and 3.97 ng/ml, respectively. The corresponding geometric mean AUC(0-infinity)) was 34.0 and 35.1 ng x h/ml. T(max) for both products under investigation appeared at 1.33 h. The test product was shown to be bioequivalent to the reference product with respect to all pharmacokinetic variables investigated.

Improvement of glycaemic and lipid profiles with muraglitazar plus metformin in patients with type 2 diabetes: an active-control trial with glimepiride

The efficacy and safety of muraglitazar versus glimepiride were evaluated in patients with type 2 diabetes. After open-label metformin monotherapy, 1,805 patients received randomised therapy with muraglitazar 2.5 mg or 5 mg or with glimepiride 1 mg in a double-blind 52-week study. The primary end point was change in glycosylated haemoglobin (HbA1C); secondary end points were changes in fasting lipid levels and glycaemic indices. At week 52, the reduction in HbA1C with muraglitazar 5 mg plus metformin was superior (p<0.0001) and with muraglitazar 2.5 mg it was non-inferior in comparison with glimepiride. At week 12, muraglitazar significantly decreased triglyceride levels (p<0.0001) and increased levels of high-density lipoprotein cholesterol (HDL-C) (p<0.0001). Oedema, weight gain and heart failure were more evident with muraglitazar. Muraglitazar 5 mg plus metformin significantly improved HbA1C, triglyceride and HDL-C levels in patients with type 2 diabetes. Cardiovascular events were similar among groups (~2%), but there was an imbalance of total mortality in favour of glimepiride.

Patch-Test Reactions to Formaldehydes, Bioban, and Other Formaldehyde Releasers

BACKGROUND

Contact allergy to formaldehyde, Bioban, and other formaldehyde releasers and cross-reactivity between them have been reported in the literature; however, not many studies have data on this cross-reactivity.

OBJECTIVE

To study (1) the rates of allergy to formaldehyde and to Bioban and other formaldehyde releasers and (2) the rates of cross-reactivity between them.

METHODS

We present a retrospective chart analysis of patch-test results for all patients referred for allergic contact dermatitis testing at the Milton S. Hershey Medical Center from June 2004 to September 2005. Anyone allergic to formaldehyde, Bioban, or other formaldehyde releasers was included. Cross-reactivity between the agents was then analyzed.

RESULTS

The charts of 210 patients were analyzed. Of these patients, 24 (11%) were allergic to formaldehyde, Bioban, or other formaldehyde-releasing agents. Seventeen (8.1%) of the patients were allergic to formaldehyde, 15 (7.1%) were allergic to Bioban, and 20 (9.5%) were allergic to other formaldehyde-releasing agents. Eleven (65%) of the 17 formaldehyde-allergic patients were also allergic to Bioban. Of the 20 patients allergic to formaldehyde-releasing agents, 14 (70%) were also allergic to one of the three Bioban products tested. Of the 15 patients allergic to Bioban, 11 (73%) were allergic to formaldehyde, 14 (93%) were allergic to formaldehyde-releasing agents, and 11 (73%) were allergic to both formaldehyde and formaldehyde-releasing agents.

CONCLUSION

A high cross-reactivity rate between formaldehyde, Bioban, and other formaldehyde-releasing agents was found.

Endocrine disruptor vinclozolin induced epigenetic transgenerational adult-onset disease

The fetal basis of adult disease is poorly understood on a molecular level and cannot be solely attributed to genetic mutations or a single etiology. Embryonic exposure to environmental compounds has been shown to promote various disease states or lesions in the first generation (F1). The current study used the endocrine disruptor vinclozolin (antiandrogenic compound) in a transient embryonic exposure at the time of gonadal sex determination in rats. Adult animals from the F1 generation and all subsequent generations examined (F1-F4) developed a number of disease states or tissue abnormalities including prostate disease, kidney disease, immune system abnormalities, testis abnormalities, and tumor development (e.g. breast). In addition, a number of blood abnormalities developed including hypercholesterolemia. The incidence or prevalence of these transgenerational disease states was high and consistent across all generations (F1-F4) and, based on data from a previous study, appears to be due in part to epigenetic alterations in the male germ line. The observations demonstrate that an environmental compound, endocrine disruptor, can induce transgenerational disease states or abnormalities, and this suggests a potential epigenetic etiology and molecular basis of adult onset disease.

Transgenerational epigenetic imprinting of the male germline by endocrine disruptor exposure during gonadal sex determination

Embryonic exposure to the endocrine disruptor vinclozolin at the time of gonadal sex determination was previously found to promote transgenerational disease states. The actions of vinclozolin appear to be due to epigenetic alterations in the male germline that are transmitted to subsequent generations. Analysis of the transgenerational epigenetic effects on the male germline (i.e. sperm) identified 25 candidate DNA sequences with altered methylation patterns in the vinclozolin generation sperm. These sequences were identified and mapped to specific genes and noncoding DNA regions. Bisulfite sequencing was used to confirm the altered methylation pattern of 15 of the candidate DNA sequences. Alterations in the epigenetic pattern (i.e. methylation) of these genes/DNA sequences were found in the F2 and F3 generation germline. Therefore, the reprogramming of the male germline involves the induction of new imprinted-like genes/DNA sequences that acquire an apparent permanent DNA methylation pattern that is passed at least through the paternal allele. The expression pattern of several of the genes during embryonic development were found to be altered in the vinclozolin F1 and F2 generation testis. A number of the imprinted-like genes/DNA sequences identified are associated with epigenetic linked diseases. In summary, an endocrine disruptor exposure during embryonic gonadal sex determination was found to promote an alteration in the epigenetic (i.e. induction of imprinted-like genes/DNA sequences) programming of the male germline, and this is associated with the development of transgenerational disease states.

Occupational allergic contact dermatitis from N,N-methylene-bis-5-methyl-oxazolidine in coolant oils

Contact with metal working fluids (MWF) is an important factor in the development of occupational hand dermatitis in patients working in the metal processing industry. Biocides are added to MWF as preservatives and are known sensitizers. We analysed 318 patch test reactions to N,N-methylene-bis-5-methyl-oxazolidine 1% in petrolatum (5-methyloxazolidine, Grotan OX, CAS no. 66204-44-2, a formaldehyde releasing biocide) present in coolant oils in patients exposed to MWF and with suspected occupational dermatitis (OD). Positive allergic reactions were noted in 15 (4.7%) cases. In 7 (47%) cases, we were able to confirm relevance by examining the material safety data sheets and these showed that N,N-methylene-bis-5-methyl-oxazolidine was present in the oils used by the patients. No certain relevance could be proved in 8 cases, but in these instances, further information on the biocides used in the oils could not be obtained. Positive reactions to formaldehyde were seen in 11 (73%) patients. Sensitization either to this biocide and/or formaldehyde allergy was considered to have been likely to have made a contribution to the workers' dermatitis.

Muraglitazar: beneficial or detrimental in the treatment of Type 2 diabetes?

Hyperglycaemia in Type 2 diabetes has a major role in the development of microvascular complications, whereas the dyslipidaemia is the major cause of macrovascular complications. In patients with Type 2 diabetes, activation of PPAR-alpha and PPAR-gamma with the fibrates and glitazones improves dyslipidaemia and increases insulin sensitivity, respectively. Muraglitazar is an agonist at both of these receptors and has been shown to increase high-density lipoprotein cholesterol, decrease triglycerides and improve insulin sensitivity. However, there is also some evidence that muraglitazar has detrimental effects on the cardiovascular system. Before muraglitazar is widely used in the treatment of Type 2 diabetes, more safety testing needs to be undertaken.

Improvement of glycemic control, triglycerides, and HDL cholesterol levels with muraglitazar, a dual (alpha/gamma) peroxisome proliferator-activated receptor activator, in patients with type 2 diabetes inadequately controlled with metformin monotherapy: A double-blind, randomized, pioglitazone-comparative study

OBJECTIVE

We sought to evaluate the effects of muraglitazar, a dual (alpha/gamma) peroxisome proliferator-activated receptor (PPAR) activator within the new glitazar class, on hyperglycemia and lipid abnormalities.

RESEARCH DESIGN AND METHODS

A double-blind, randomized, controlled trial was performed in 1,159 patients with type 2 diabetes inadequately controlled with metformin. Patients received once-daily doses of either 5 mg muraglitazar or 30 mg pioglitazone for a total of 24 weeks in addition to open-label metformin. Patients were continued in a double-blind fashion for an additional 26 weeks.

RESULTS

Analyses were conducted at week 24 for HbA1c (A1C) and at week 12 for lipid parameters. Mean A1C at baseline was 8.12 and 8.13% in muraglitazar and pioglitazone groups, respectively. At week 24, muraglitazar reduced mean A1C to 6.98% (-1.14% from baseline), and pioglitazone reduced mean A1C to 7.28% (-0.85% from baseline; P < 0.0001, muraglitazar vs. pioglitazone). At week 12, muraglitazar and pioglitazone reduced mean plasma triglyceride (-28 vs. -14%), apolipoprotein B (-12 vs. -6%), and non-HDL cholesterol (-6 vs. -1%) and increased HDL cholesterol (19 vs. 14%), respectively (P < 0.0001 vs. pioglitazone for all comparisons). At week 24, weight gain (1.4 and 0.6 kg, respectively) and edema (9.2 and 7.2%, respectively) were observed in the muraglitazar and pioglitazone groups; at week 50, weight gain and edema were 2.5 and 1.5 kg, respectively, and 11.8 and 8.9%, respectively. At week 50, heart failure was reported in seven patients (five with muraglitazar and two with pioglitazone), and seven deaths occurred: three from sudden death, two from cerebrovascular accident, and one from pancreatic cancer in the muraglitazar group and one from perforated duodenal ulcer in the pioglitazone group.

CONCLUSIONS

We found that 5 mg muraglitazar resulted in greater improvements in A1C and lipid parameters than a submaximal dose of 30 mg pioglitazone when added to metformin. Weight gain and edema were more common when muraglitazar was compared with a submaximal dose of pioglitazone.

Effect of muraglitazar on death and major adverse cardiovascular events in patients with type 2 diabetes mellitus

CONTEXT

Peroxisome proliferator-activated receptors (PPARs) are nuclear transcription factors that modulate gene expression. Therapeutic agents targeting 2 distinct families of PPARs (alpha and gamma) have been introduced in the United States. The first dual-PPAR agonist, muraglitazar, was reviewed by a US Food and Drug Administration (FDA) advisory committee on September 9, 2005, resulting in a vote of 8:1 recommending approval for its use in controlling blood glucose levels in patients with type 2 diabetes.

OBJECTIVE

To evaluate the incidence of death, myocardial infarction (MI), stroke, congestive heart failure (CHF), and transient ischemic attack (TIA) in diabetic patients treated with muraglitazar compared with controls.

DESIGN, SETTING, AND PARTICIPANTS

The source material for this analysis consisted of documents about phase 2 and 3 clinical trials released under public disclosure laws for the FDA advisory committee meeting. All reviewed trials were prospective, randomized, double-blind, multicenter studies enrolling patients with type 2 diabetes and hemoglobin A(1c) levels between 7% and 10%. Patients (N = 3725) were randomized to receive differing doses of muraglitazar, pioglitazone, or placebo as monotherapy or in combination with metformin or glyburide in trials ranging from 24 to 104 weeks.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of death, nonfatal MI, or nonfatal stroke. A more comprehensive composite outcome included these events plus the incidence of CHF and TIA.

RESULTS

In the muraglitazar-treated patients, death, MI, or stroke occurred in 35 of 2374 (1.47%) patients compared with 9 of 1351 (0.67%) patients in the combined placebo and pioglitazone treatment groups (controls) (relative risk [RR], 2.23; 95% confidence interval [CI], 1.07-4.66; P = .03). For the more comprehensive outcome measure that included TIA and CHF, the incidence was 50 of 2374 (2.11%) for muraglitazar compared with 11 of 1351 (0.81%) for controls (RR, 2.62; 95% CI, 1.36-5.05; P = .004). Relative risks for each of the individual components of the composite end point exceeded 2.1 but were not statistically significant. Incidence of adjudicated CHF was 13 of 2374 (0.55%) muraglitazar-treated patients and 1 of 1351 controls (0.07%) (RR, 7.43; 95% CI, 0.97-56.8; P = .053).

CONCLUSIONS

Compared with placebo or pioglitazone, muraglitazar was associated with an excess incidence of the composite end point of death, major adverse cardiovascular events (MI, stroke, TIA), and CHF. This agent should not be approved to treat diabetes based on laboratory end points until safety is documented in a dedicated cardiovascular events trial.

Efficacy and tolerability of long-term rilmenidine treatment in hypertensive diabetic patients. A retrospective analysis of a general practice study

INTRODUCTION

Rilmenidine is a centrally acting antihypertensive which differs from the other representatives of this class by its very high specificity for the imidazoline I1 receptors and its good tolerability. Recent studies have shown rilmenidine improves glucose tolerance and reduces micro-albuminuria in patients with diabetes mellitus.

METHODOLOGY

The evidence of these potentially favorable characteristics encouraged a secondary retrospective analysis of a subgroup of 2738 diabetic patients included in a previous long-term open study of rilmenidine alone, or in combination with other classes of antihypertensives.

RESULTS

The antihypertensive efficacy of rilmenidine demonstrated previously in controlled studies was confirmed during the 12-month follow-up. In addition, favorable effects of drug treatment on fasting blood glucose and plasma triglyceride levels were consistent with an improvement in glucose and lipid metabolism during treatment. The profile of adverse events was similar to that observed in the nondiabetic population, the occurrence of postural hypotension being observed in <1% of patients and not necessitating any withdrawals from the study.

CONCLUSION

Diabetic hypertensive patients frequently require the use of multiple medications and consideration of the metabolic interactions between treatments. The results of this retrospective analysis support the use of rilmenidine in patients with hypertension and diabetes mellitus and should encourage the conduct of controlled trials of cardiovascular and renal protection and outcome with this compound.

[The effect of analysed hypotensive drugs on certain metabolic parameters]

The aim of this study was to assess the influence of 3 hypotensive drugs on the metabolic disorders: dyslipidemia, insulin resistance, hyperuricemia. There were 39 patients aged 20-55, with mild-to-moderate essential hypertension. The patients with other serious diseases or treated earlier with cholesterol or uric acid lowering drugs were excluded. Patients were divided into 3 groups, each was treated during 8 weeks with one drug: gr 1--trandolapril (T), gr 2--felodipine ER (F), gr 3--rilmenidine (R). Glucose and insulin in oral glucose tolerance test, I/G proportion, serum lipids and uric acid were tested before and after therapy. The therapy did not influence lipid parameters: LDL, HDL, triglyceride. In the T group there could be observed a significant reduction of total cholesterol value. Examined drugs did not induce changes in serum carbohydrate. The significant reduction of serum uric acid could be observed only after F therapy. Analysed drugs are very useful in therapy of hypertension with metabolic disorders.

[Efficacy and acceptability of rilmenidine in a population of 2 738 hypertensive diabetic patients]

CONTEXT

Despite the constant enrichment of the pharmacopoeia, the normalizing of blood pressure in hypertensive diabetic patients remains difficult.

OBJECTIVE

To assess the efficacy and acceptability of rilmenidine in first intention in hypertensive diabetics.

METHODS

In a population of 18 235 hypertensive patients, the sub-population of diabetic patients was followed-up in an open study over one year. These patients were initially treated with 1 mg/day of rilmenidine with the possibility of adapting the dose - increasing to 2 mg/d and association with a second or even third anti-hypertensor, left to the discretion of the physician - when the diastolic blood pressure remained strictly greater than 90 mmHg.

RESULTS

The complete blood pressure data over a period of 12 months were obtained in 2 311 patients out of 2 738 (84.4%). After 12 months' treatment, 75.9% of the 2 311 patients were normalized by the monotherapy with rilmenidine (diastolic blood pressure<90 mmHg according to the recommendations in force at the time of the study). The clinical acceptability was good and comparable to that obtained in the general population of 18 235 hypertensive patients. The biological parameters remained stable.

CONCLUSION

This pharmaco-epidemiological assessment demonstrates, in conditions of current practice, the anti-hypertensive efficacy and acceptability of rilmenidine in hypertensive diabetics, therefore confirming its place in the therapeutic arsenal of these patients.

Pharmacokinetics and safety of JTE-522, a novel selective cyclooxygenase-2 inhibitor, in healthy male volunteers

AIMS

The pharmacokinetics and safety profile of JTE-522, 4-(4-cyclohexyl-2 methyloxazol-5-yl)-2-fluorobenzensulphonamide, a novel selective cyclooxygenase-2 inhibitor were investigated in healthy male volunteers.

METHODS

Initially, as a pilot study, five groups of two subjects were given oral doses of 3-100 mg of JTE-522. After safety assessment, subjects were given 150 and 200 mg of JTE-522. The effect of food-intake on the pharmacokinetics of JTE-522 at a dose of 150 mg was examined. In the multiple-dose study, subjects were given 150 mg of JTE-522 once a day for 7 days. Concentrations of unchanged JTE-522 in plasma, blood and urine were determined by high performance liquid chromatography (h.p.l.c.). Concentrations of metabolites were estimated with h.p.l.c. chromatograms and calibration curves for quantification of unchanged JTE-522.

RESULTS

In the course of this study, no serious abnormality attributable to the test drug was observed, suggesting that JTE-522 was well tolerated in healthy subjects. In a single-dose study, the concentrations of JTE-522 in blood were much higher than the corresponding concentrations in plasma. JTE-522 was readily distributed to blood cells and percentage distribution into blood cells was more than 99.0%. However, the values of Cmax in blood at doses of 100, 150, 200 mg JTE-522 were 15241, 20445 +/- 3918 (16333-24556), 20965 +/- 3260 (17544-24386) ng ml-1, respectively. These findings suggest that JTE-522 has a high affinity for blood cells and the distribution into blood cells is limited at the higher doses of over 100 mg. In a multiple dose study, pharmacokinetic parameters including t1/2 and AUC after the fourth administration were comparable with that of the seventh administration. Thus, these findings suggest the absence of accumulation on the multiple-dosing of JTE-522.

CONCLUSIONS

These results indicate that JTE-522 has an acceptable pharmacokinetic profile for clinical use without any serious adverse events as we verified in healthy young male volunteers.

Concentration-effect relationships of two rilmenidine single-dose infusion rates in hypertensive patients

OBJECTIVES

This study was designed to assess the concentration-effect relationships for the antihypertensive effects of rilmenidine in patients to aid in the design of an optimized concentration profile of a sustained-release formulation.

METHODS

A placebo-controlled, randomized, double-blind, 2-way partial crossover study was performed in subjects with hypertension. Patients were randomized to receive 2 of 3 possible 12-hour infusion regimens, each consisting of a loading phase (2 hours) and a maintenance phase (10 hours): low-profile infusion (total dose of rilmenidine, 1.45 mg), high-profile infusion (total dose, 3.3 mg), or placebo. Drug plasma concentrations, adverse events, blood pressure, heart rate, and visual analog scales were measured frequently, up to 24 hours after dosing. Salivary flow was determined for up to 15 hours.

RESULTS

The high concentration profile was well tolerated and continued to produce a significant blood pressure reduction of 10.4 mm Hg (systolic)/5.8 mm Hg (diastolic) after 24 hours. The low concentration profile showed no significant effects on blood pressure compared with placebo after 24 hours. Decreases in salivary flow were -36% for the high-profile infusion and -20% for the low-profile infusion compared with placebo. Pharmacokinetic-pharmacodynamic analyses showed infusion rate-independent, linear concentration-dependent reductions in diastolic blood pressure and salivary flow up to the maximum observed rilmenidine concentration for both types of infusion.

CONCLUSIONS

The high concentration profile was well tolerated and still produced a significant blood pressure reduction after 24 hours. Pharmacokinetic-pharmacodynamic relationships were linear and unaffected by the rate of infusion. These results should aid in the design of an optimal slow-release profile.

[Efficacy and tolerance of rilmenidine in patients with mild to moderate hypertension. Results of a Czech and Slovak 6-month multicenter study]

AIM OF THE STUDY

To evaluate the efficacy and tolerability of rilmenidine (Tenaxum) in the dose of 1-2 mg in patients with mild to moderate hypertension.

GROUP OF PATIENTS AND METHODS

243 patients (53% men, 47% women, mean age 52 +/- 11 years with mild to moderate essential hypertension were included into the study. Several cardiovascular risk factors for CAD were reported in the investigated group of patients: dyslipidaemia in 54%, obesity in 29%, diabetes mellitus in 14% and smoking in 17% of subjects. 87% of patients were subjects with newly diagnosed untreated or shortly (< 3 months) treated hypertension. In remaining hypertensives the antihypertensive therapy was withdrawn two weeks before the beginning of rilmenidine treatment. The following parameters were studied: BMI, sitting and upright casual blood pressure, heart rate and basal laboratory tests. If necesary, additional therapy with indapamide or perindopril was allowed.

RESULTS

Rilmenidine treatment resulted in normalisation of blood pressure (BP) or significant (decrease of SBP/DBP = 20/10 mm Hg) blood pressure decrease in 69%, 22% of subjects, respectively. At the end of 6-month period significant BP decrease was noted: 134 +/- 6/83 +/- 5 mm Hg vs. 161 +/- 12/99 +/- 6 mm Hg (p < 0.001). Marked BP decrease was observed already during first visit after active treatment for 3 weeks. Six months of rilmenidine treatment led to significant heart rate decrease (71/min. +/- 8 vs. 74/min. +/- 9, p < 0.01). No significant laboratory (plasma Na, K, creatinine, urea, glycemia, triglycerides, haematocrit) changes were reported after rilmenidine treatment with the only exception of mild, but significant plasma cholesterol decrease. Rilmenidine had very good acceptability and mild side effects were noted in small percentage of patients.

CONCLUSION

Rilmenidine is a centraly acting drug of IInd generation (imidazoline I1 receptors agonist) with potent antihypertensive and mild negative chronotropic effect. Rilmenidine has very good clinical tolerability without negative influence on metabolic parameters.

Patch test reactions to Biobans in metalworkers are often weak and not reproducible

Contact allergy to the industrial preservative group of Biobans has been reported in individual cases. We have performed a prospective study on 408 metalworkers who were tested with 6 different Biobans, formaldehyde and 5 other preservatives. Furthermore, retesting was performed after a time interval of 6 months to 4 years. The test results were also compared with those of the multicentric data provided by the Information Network of Departments of Dermatology in Germany and Austria (IVDK), particularly with regard to cross-reactivity between the various Biobans and formaldehyde. In 408 metalworkers 14 (3.4%) showed positive reactions to Biobans (2.2% P 1487, 2.0% CS 1246, 1.5% CS 1135), the majority being + reactions. On retesting 10 patients, the reactions were confirmed in only 2 cases (P 1487 and CS 1135). 4 patients showed positive reactions to 3 Biobans (P 1487, CS 1135, CS 1246), while 9 patients had only solitary sensitizations. Concomitant sensitization to formaldehyde was present in 5 out of 10 patients, being reproducible in 3 of them. In the IVDK data, sensitization prevalence in 3400 patients ranged from 1.8% (P 1487) to 0.8% (CS 1246). A high proportion of doubtful or irritant reactions as well as weak + reactions was observed. Cross-reactivity between the various Biobans was low, moderate agreement being calculated for CS 1135 and CS 1246 (kappa coefficient 0.43). The consensus pattern between formaldehyde and the tested Biobans was even lower. In conclusion, patch test reactions to Biobans are not rare among metalworkers but are often weak and not reproducible. Simultaneous reactivity to various Biobans and formaldehyde may be due to cross-reactivity or cosensitization from common exposure.