Potentiating effects of cisplatin and ethacrynic acid in ototoxicity

A Consolidated Understanding of the Contribution of Redox Dysregulation in the Development of Hearing Impairment

The etiology of hearing impairment is multifactorial, with contributions from both genetic and environmental factors. Although genetic studies have yielded valuable insights into the development and function of the auditory system, the contribution of gene products and their interaction with alternate environmental factors for the maintenance and development of auditory function requires further elaboration. In this review, we provide an overview of the current knowledge on the role of redox dysregulation as the converging factor between genetic and environmental factor-dependent development of hearing loss, with a focus on understanding the interaction of oxidative stress with the physical components of the peripheral auditory system in auditory disfunction. The potential involvement of molecular factors linked to auditory function in driving redox imbalance is an important promoter of the development of hearing loss over time.

Significant Drug–Drug Interactions with Antineoplastics

Goal

The goal of this program is to inform the participant about the clinical and economic significance of drug interactions, review their potential mechanisms, present significant interactions related to antineoplastics, and provide resources for managing them.

Objectives

At the completion of this program, the participant will be able to: 1. Describe the scope and economic impact of preventable drug interactions. 2. Explain why oncology patients are at increased risk for drug interactions. 3. Define the pharmacokinetic, pharmacodynamic, and pharmaceutic principles underlying antineoplastic related drug–drug interactions. 4. List specific classes of antineoplastics involved in significant drug–drug interactions. 5. Identify multiple resources for obtaining drug interaction information.

A guide to clinically relevant drug interactions in oncology

This paper presents an overview of new information on clinically relevant drug-drug interactions, particular focuses on negative drug interactions in oncology. We have generated a concise table of drug-drug interactions that provides a synopsis of the clinical outcome of the interaction along with a recommendation for management. We have also generated other tables that describe specific interactions with methotrexate and dosing guidelines for cytotoxic drugs in the presence of renal or hepatic dysfunction. Since warfarin is one of the non-anticancer drugs that is commonly used in cancer patients for the treatment and prevention of venous thromboembolism, its interactions with other anticancer drugs that have been reported in literatures were also reviewed in this paper. In general, drug interactions observed in cancer patients may be categorized into pharmacokinetic, pharmacodynamic and pharmaceutic interactions. Pharmacokinetic interactions involve one drug altering the absorption, distribution, metabolism, or excretion of another drug. Interpatient variability in the pharmacokinetic profile of many anticancer agents often complicates the predictability of the antitumor response and toxicities. Among four pharmacokinetic characteristics, drug interactions involving hepatic metabolism is probably the most common and important mechanism responsible for oncologic drug interactions. For example, several anticancer drugs including taxanes, vinca alkaloids, and irinotecan are known to be metabolized by cytochrome CYP3A4. Enzyme-inducing anticonvulsants have been shown to significantly decrease the plasma levels of these anticancer drugs, thereby compromising the anti-tumor effects. N ephrotoxicity or changes in hepatic function caused by some anticancer drugs (e.g., cisplatin, asparaginase) may also have an impact on the pharmacokinetics of the interacting agents. Pharmacodynamic interactions may occur when two or more drugs acting at a common receptor-binding site impact on the pharmacologic action of the object drug, without influencing the pharmacokinetics of each interacting agent. In clinical setting, a decrease of antitumor efficacy was observed in breast cell lines when gemcitabine or vinorelbine were used in combination with paclitaxel. On the other hand, a decreased incidence of thrombocytopenia was seen in patients receiving combination of carboplatin and palcitaxel compared to those receiving carboplatin alone. The third type of drug-drug interaction is known as pharmaceutic interaction. When one drug may alter the physical or chemical compatibility of another drug that utlimately leads to a change in appearance of the solution or a decrease of effectiveness of the drug due to drug inactivation or degradation.

Comparison of cochlear cell death caused by cisplatin, alone and in combination with furosemide

Establishment of appropriate animal models is an important step in exploring the mechanisms of drug-induced ototoxicity. In the present study, using guinea pigs we compared cochlear lesions induced by cisplatin administered in two regimens: consecutive application alone and in combination with furosemide. The effects of furosemide alone were also evaluated; it was found to cause temporary hearing loss and reversible damage to the stria vascularis. Consecutive application of cisplatin alone appeared to be disadvantageous because it resulted in progressive body weight loss and higher mortality compared to the combined regimen, which used a smaller cisplatin dose. The combined regimen resulted in comparable hearing loss and hair cell loss but a markedly lower mortality. However, their coadministration failed to cause similar damage to spiral ganglion neurons (SGN), as seen in animals that received cisplatin alone. This difference suggests that the combined regimen did not mimic the damage to cochlear neuronal innervation caused by the clinical application of cisplatin. The difference also suggests that the SGN lesion is not caused by cisplatin entering the cochlea via the stria vascularis.

Review: ototoxic characteristics of platinum antitumor drugs

Cisplatin, carboplatin, nedaplatin, and oxaliplatin are widely used in contemporary oncology; however, their ototoxic and neurotoxic side effects are quite different as discussed in this review. Cisplatin is considered the most ototoxic, but despite its reputation, the magnitude of hair cell loss that occurs with a single, large drug bolus is limited and confined to the base of the cochlea. For all of these platinum compounds, a major factor limiting damage is drug uptake from stria vascularis into the cochlear fluids. Disrupting the blood-labyrinth barrier with diuretics or noise exposure enhances drug uptake and significantly increases the amount of damage. Combined treatment with ethacrynic acid (a loop diuretic) and cisplatin results in rapid apoptotic hair cell death characterized by upregulation of initiator caspase-8 and membrane death receptor, TRADD, followed by downstream executioners, caspase-3 and caspase-6. Unlike cisplatin, nedaplatin and oxaliplatin are highly neurotoxic when applied to cochlear cultures preferentially damaging auditory nerve fibers at low concentrations and hair cells at high concentrations. Carboplatin, considered far less ototoxic than cisplatin, is paradoxically highly toxic to chinchilla inner hair cells and type I spiral ganglion neurons; however, at high doses it also damages outer hair cells. Hair cell death from cisplatin and carboplatin is characterized in its early stages by upregulation of p53; blocking p53 expression with pifithrin-α prevents hair cell death. Major differences in the toxicity of these four platinum compounds may arise from several different metal transporters that selectively regulate the influx, efflux, and sequestration of these drugs.

Evaluation of platinum-ethacrynic acid conjugates in the treatment of mesothelioma

Malignant pleural mesothelioma (MPM) cells are characterized by chemoresistance associated with glutathione (GSH) metabolism. Ethacrynic acid (EA) is able to inhibit the detoxifying enzyme glutathione-S-transferase (GST), which catalyzes the conjugation between GSH and Pt-based drugs. With the aim of obtaining active bifunctional drugs, a Pt(II) complex containing two EA moieties as leaving groups, namely cis-diamminobis(ethacrynato)platinum(II), was synthesized, characterized, and tested on four MPM cell lines. The resulting antiproliferative activity was compared with that elicited by the analogue Pt(IV) complex, cis,cis,trans-diamminodichloridobis(ethacrynato)platinum(IV) (ethacraplatin) and by the co-administration of free EA and cisplatin. The Pt(II) and Pt(IV) bifunctional complexes showed poorer performance than the reference drug cisplatin alone or in combination with EA. After treatment, cellular GST activity remained consistently unchanged, while the GSH level increased.

Distortion-product otoacoustic emission test performance for ototoxicity monitoring

INTRODUCTION

A nonbehavioral method for monitoring ototoxicity in patients treated with cisplatin is needed because patients enduring chemotherapy may not be well or cooperative enough to undergo repeated hearing tests. Distortion-product otoacoustic emissions (DPOAEs) provide a nonbehavioral measure of auditory function that is sensitive to cisplatin exposure. However, interpreting DPOAE findings in the context of ototoxicity monitoring requires that their accuracy be determined in relation to a clinically accepted gold standard test.

OBJECTIVES

Among patients receiving cisplatin for the treatment of cancer, we sought to (1) identify the combination of DPOAE metrics and ototoxicity risk factors that best classified ears with and without ototoxic-induced hearing changes; and (2) evaluate the test performance achieved by the composite measure as well as by DPOAEs alone.

DESIGN

Odds of experiencing hearing changes at a given patient visit were determined using data collected prospectively from 24 Veterans receiving cisplatin. Pure-tone thresholds were examined within an octave of each subject's high-frequency hearing limit. DPOAE were collected as a set of four response growth (input/output) functions near the highest f2 frequency that yielded a robust response at L2 = L1 = 65 dB SPL. Logistic regression modeled the risk of hearing change using several DPOAE metrics, drug treatment factors, and other patient factors as independent variables. An optimal discriminant function was derived by reducing the model so that only statistically significant variables were included. Receiver operating characteristic curve analyses were used to evaluate test performance.

RESULTS

At higher cisplatin doses, ears with better hearing at baseline were more likely to exhibit ototoxic hearing changes than those with poorer hearing. Measures of pre-exposure hearing, cumulative drug dose, and DPOAEs generated a highly accurate discriminant function with a cross-validated area under the receiver operating characteristic curve of 0.9. DPOAEs alone also provided an indication of ototoxic hearing change when measured at the highest DPOAE test frequency that yielded a robust response.

CONCLUSIONS

DPOAEs alone and especially in combination with pre-exposure hearing and cisplatin dose provide an indication of whether or not hearing has changed as a result of cisplatin administration. These promising results need to be validated in a separate sample.

Cell death after co-administration of cisplatin and ethacrynic acid

Ethacrynic acid (EA) significantly enhances the ototoxic effects of cisplatin. To gain insights into the mechanisms underlying Cis/EA ototoxicity, cochleas were labeled with several apoptotic markers. Cis/EA treatment caused extensive outer hair cell (OHC) and inner hair cell (IHC) damage; OHC lesions decreased from the base towards apex of the cochlea whereas the IHC lesion was relatively constant (25-60%) along the length of the cochlea. Propidium iodide labeled OHC nuclei appeared relatively normal at 6h post-treatment, were condensed and fragmented at 12h post-treatment and were frequently missing 48 h post-treatment. Initiator caspase 8, associated with membrane death receptors, and TRADD, a protein that recruits caspase 8, were present in OHC at 6h post-treatment. Caspase 8 labeling increased from 6 to 24h, but was largely absent at 48 h post-treatment. Executioner caspase 3 and caspase 6, which lie downstream of caspase 8, were expressed in OHC 12-24h post-treatment. Initiator caspase 9, associated with mitochondrial damage, was only expressed at low levels at 48 h post-treatment. These results suggest that the rapid onset of Cis/EA induced programmed cell death is initiated by membrane death receptors associated with TRADD and caspase 8.

Significant Drug–Drug Interactions with Antineoplastics

Goal

The goal of this program is to inform the participant about the clinical and economic significance of drug interactions, review their potential mechanisms, present significant interactions related to antineoplastics, and provide resources for managing them.

Objectives

At the completion of this program, the participant will be able to: 1. Describe the scope and economic impact of preventable drug interactions. 2. Explain why oncology patients are at increased risk for drug interactions. 3. Define the pharmacokinetic, pharmacodynamic, and pharmaceutic principles underlying antineoplastic related drug–drug interactions. 4. List specific classes of antineoplastics involved in significant drug–drug interactions. 5. Identify multiple resources for obtaining drug interaction information.

Inhibition of glutathione-related enzymes and cytotoxicity of ethacrynic acid and cyclosporine

Glutathione (GSH) is an endogenous thiol that detoxifies active oxygen and reactive species formed during intermediary metabolism and drug detoxification. Compounds with a range of potential toxicities were tested for their abilities to affect GSH reductase and GSH S-transferase activities, which are each components of the two principal detoxification pathways in which GSH participates. A high performance liquid chromatographic method for determining oxidized and reduced GSH was modified to assay GSH reductase activity. With this method it was possible to demonstrate that ethacrynic acid, which inhibits GSH S-transferase, also inhibits the activity of GSH reductase. Inhibition of GSH reductase by ethacrynic acid was similar to that seen with carmustine (BCNU). GSH reductase activity was not affected by cis- or transplatin, buthionine sulfoximine, other loop diuretics, cyclosporine A or aminoglycosides. Cyclosporine inhibited GSH S-transferase at 50 microM and higher concentrations. These results support a role for GSH-mediated detoxification mechanisms in ethacrynic acid- and cyclosporine-associated cytotoxicity, which may mediate their toxicities and their potential as adjunctive agents in antineoplastic therapy. A better understanding of the mechanism of their toxicity can greatly extend the clinical usefulness of these agents, as this toxicity is the basis of both their therapeutic and antitherapeutic actions.

Monitoring of hearing during treatment of leukaemia with special reference to the use of amikacin

Thirty-nine patients with leukaemia were followed audiometrically during treatment with broad-spectrum antibiotics. Amikacin was given during neutropenic febrile episodes. Five patients reported a deterioration of the hearing function after termination of amikacin treatment. Significant hearing threshold loss occurred in 20 patients (51%). The hearing threshold changes were small in general, except for two patients who exhibited bilateral hearing threshold changes in the frequency range 0.5-8 kHz. Using multiple linear regression analysis 22% of the changes in hearing thresholds was estimated to be related to old age, an increased trough concentration of amikacin and an impaired pretreatment hearing state. Factors found not to influence the hearing thresholds were maximum peak concentration of amikacin, cumulative duration of therapy, pretreatment renal dysfunction and concomitant use of vancomycin. It is concluded that administration of amikacin for repeated treatment courses is associated with a low incidence of serious changes in hearing function.

Combined effects of noise and cisplatin: short- and long-term follow-up

The combined effects of noise exposure and intravenous cisplatin injection on electrophysiologic hearing thresholds in guinea pigs were studied with short-term and long-term follow-up. The combined effects on the permanent threshold shift were dependent on the order of exposure. A potentiation was achieved when noise exposure preceded cisplatin injection by 30 minutes or by 3 days. Cisplatin injection 2 or 3 days before noise exposure produced no significant potentiation or inhibition. The combined effects on the temporary threshold shift were not influenced by the sequence of exposure.

Effects on cochlear morphology of repeated insults to the stria vascularis

The interrelationship of stria vascularis and organ of Corti integrity was investigated. Strial morphology was altered by repeated injections of ethacrynic acid in the chinchilla. Although prolonged temporary strial damage was created, neither strial atrophy nor organ of Corti damage resulted.

Drug-induced ototoxicity. Pathogenesis and prevention

Ototoxicity is a disabling adverse effect of several widely used classes of drugs, such as diuretics, anti-inflammatory agents, antineoplastic agents and aminoglycoside antibiotics. High-dose therapy with either diuretics or anti-inflammatory agents is primarily associated with acute and transient impairment of hearing or tinnitus. In contrast, long term treatment with antineoplastic agents or aminoglycoside antibiotics is typically associated with delayed and irreversible loss of hearing; lesion in the organ of Corti include the destruction of auditory sensory cells. Vestibular function can also be compromised by ototoxic drugs. Occasional cases of ototoxicity have been reported for a variety of other therapeutic compounds and environmental toxins. In addition, the simultaneous administration of multiple agents which are potentially ototoxic can lead to synergistic loss of hearing. Exposure to loud noise may also potentiate the hearing loss due to cochleotoxic drugs. Ototoxic agents can impair the sensory processing of sound at many cellular or subcellular sites. However, the molecular mechanisms of ototoxicity have not been established for most of these drugs, and structure-toxicity relationships have not been determined. It has therefore been difficult to predict the ototoxic potential of new drugs, and rational approaches to the prevention of ototoxicity are still lacking. The clinical and experimental features of ototoxicity are reviewed for several classes of drugs, with an emphasis on current knowledge of the mechanism and the possibilities for the prevention of ototoxicity for each.

Comparative vestibular toxicity of dibekacin, habekacin and cisplatin

The vestibular toxicity of two aminoglycoside antibiotics, dibekacin sulfate and habekacin sulfate, and of a drug with potent antimitotic activity, cisplatin (cis-diamminedichloroplatinum) has been investigated in both rats and frogs. In rats, chronic intraperitoneal injection of a saline solution of dibekacin (50 mg/kg/day), habekacin (50 mg/kg/day), cisplatin (0.5 mg/kg/day) for 4 weeks and of cisplatin (1 mg/kg/day) for 5 weeks, produced no behavioral vestibular disorders and the righting reflex could be elicited at any time. In frogs, the spontaneous discharge was recorded from individual fibres of the ampullary nerve of the horizontal semicircular canal before and after acute administration of the drugs, dissolved in Ringer, into the perilymph of the inner ear near the horizontal ampulla. Following injection of 1 microliter of solutions containing 10 micrograms or 20 micrograms of dibekacin, 20 micrograms or 50 micrograms of habekacin, 0.5 micrograms, 2.5 micrograms or 10 micrograms of cisplatin, the spontaneous discharge decreased in a number of fibres and was sometimes completely abolished. The vestibular toxicity of the three drugs tested is discussed with respect to that of aminosides whose ototoxicity is well known.

The ototoxicity of repetitive chronic aminoglycoside administration. An experimental study

To determine whether previous exposure to an aminoglycoside antibiotic would predispose an individual to more severe ototoxic reactions upon subsequent administration, guinea pigs were given up to three courses of gentamicin at a dose of 50 or 100 mg/kg. Each course was separated by a period of 4 weeks, and animals were killed 4 weeks after the date of last injection. Cochlear pathology was assessed by the surface preparation technique and phase contrast microscopy. Detailed counts of sensory hair cell populations were recorded and statistically analysed. No significant ototoxic hair cell loss occurred following the repetition of 50 mg/kg. At 100 mg/kg, repetitive administration produced a significant and cumulative destruction of the most basal outer and inner hair cells. Using this protocol, it was concluded that if the initial exposure proved ototoxic, further administration of gentamicin increased subsequent sensory hair cell loss.

Link between functional and morphological changes in the inner ear--functional changes produced by ototoxic agents and their interactions

Common potentials used to evaluate cochlear function are the ac cochlear potential (ACCP), N1 and the positive dc endocochlear potential (EP). The ACCP is an electrical analogue of the sound stimulus; its source is the electrical activity of the cochlear hair cells. N1 is a volume conductor recorded action potential of the auditory nerve. The EP is the positive polarization of the middle compartment of the cochlea (scala media) with respect to the other compartments (the scalae tympani and vestibuli); the stria vascularis is apparently responsible for the EP. Generally, ototoxic drugs and very intense broad-band noise affect the basal portion of the cochlea first and, because of tonotopic organization, the ACCP responses to high frequency pure tones are affected before those to the low frequencies. However, the correlation between the effect of an ototraumatic agent on the ACCP and its effect on cochlear morphology is not always reliable. The correlations between changes in N1 and EP and in cochlear morphology are even less precise. Also discussed will be the cochlear effects of noise and the ototoxic interactions between drug/drug, noise/drug, and noise/drug/otitis media.

Enhanced cis-platinum neurotoxicity in pediatric patients with brain tumors

Eight children were treated with cis-platinum for recurrent brain tumor. Six of these children were fully evaluable. All received cis-platinum (total dose per course 60 to 120 mg/m2; up to three courses) by infusion with mannitol and hydration. All had received one or more courses of cranial irradiation. Five of the six patients had evidence of significant hearing loss after only one cycle of treatment. All six patients demonstrated significant audiometric or symptomatic hearing loss after a total dose of 110-120 mg/m2. In patients further challenged with cis-platinum hearing loss progressed significantly. Two patients developed profound deterioration in neurologic status within 72 h after infusion. These experiences suggest that Ototoxicity is accentuated in patients who have received cranial irradiation. Further treatment may lead to prohibitive hearing loss. Severe neurologic deterioration may occur secondary to drug infusion.