Dose response in vivo to digoxin in normo-and hyperkalaemia: associated biochemical changes

Release of adenine nucleotide metabolites by toxic concentrations of cardiac glycosides

In isolated perfused guinea-pig hearts the effect of toxic concentrations of cardiac glycosides on the release of the adenine nucleotide metabolites adenosine, inosine, hypoxanthine, xanthine, and uric acid was investigated. Digoxin concentrations of 0.03-1 mumol.l-1 produced moderate to severe tachyarrhythmias. Large amounts of metabolites were released by concentrations of 0.1 mumol.l-1, and higher. Occurrence of glycoside-induced ventricular fibrillation was associated with a particularly high release. Metabolite release was also obtained when fibrillation was elicited electrically in normal control hearts, or in hearts receiving simultaneously a marginally toxic digoxin concentration (0.03 mumol.l-1). Digoxin-induced tachyarrhythmias and metabolite release were almost completely prevented by a high potassium concentration in the coronary perfusion fluid (8.1 mmol.l-1). The antiarrhythmic effect was also obtained with lidocaine (60 mumol.l-1), but the release was only partially antagonized. Similar results concerning arrhythmias and metabolite release as with digoxin were obtained with ouabain. The findings suggest that the decrease in myocardial ATP observed in glycoside-intoxicated heart preparations is partly due to the loss of nucleotide precursor substances. Moreover, it appears likely that liberated adenosine in the interstitium of severely intoxicated heart preparations reaches pharmacologically effective concentrations.

Inhibition of the sodium pump in guinea-pig ventricular muscle by dihydro-ouabain: effects of external potassium and sodium

The inhibition of the electrogenic pump current in quiescent guinea-pig ventricular muscle by dihydro-ouabain (DHO) was studied with the three-micro-electrode voltage-clamp technique described previously (Daut, 1982c). From dose-response curves of the drug-induced current change (ID) the equilibrium dissociation constant of the binding of DHO to the Na-K pump (KD) and the electrogenic pump current flowing in the steady state (Ip) were inferred (Daut & Rüdel, 1982b). The external K concentration ([K]o) was varied between 2 and 4.5 mM (substituted by Na). KD was found to increase with increasing [K]o. A plot of log KD versus log [K]o gave a straight line with a slope of about 1.5. The time constants of the onset (tau on) and decay (tau off) of ID are supposed to represent the chemical kinetics of binding and unbinding of the drug (Daut & Rüdel, 1981, 1982b). Tau on was found to be inversely related to [K]o whereas tau off was found to be independent of [K]o. Ip was found to be independent of [K]o. This was interpreted to indicate that in the steady state Ip is mainly determined by the passive influx of Na into the cell, which may be relatively insensitive to small changes in [K]o. The effects of [K]o on the drug-induced current change are consistent with competitive inhibition of the binding of DHO to the Na-K pump. It is suggested that K ions and cardiac glycosides compete for extracellular binding sites on the same conformation of the Na-K pump. The external Na concentration ([Na]o) was varied between 147 and 49 mM (substituted by choline or Tris). Reduction of [Na]o produced a proportional decrease of Ip. This may be a consequence of the accompanying reduction of passive Na influx and the resulting decrease in intracellular Na activity (alpha iNa). Reduction of [Na]o markedly increased KD. This effect may be mediated by competition between Na and K at the K-loading sites of the pump and/or by separate modulatory Na-binding sites. It is concluded that the well known effects of external Na and K on the positive inotropic action of cardiac glycosides can be fully accounted for by the marked changes in the apparent binding affinity of the drug reported here.

[The problem of the cellular receptor for cardiac glycosides (author's transl)]

This review concerns the Na+, K+ -ATPase as well as the Na+, K+ -pump in the intact membrane and the highly specific inhibition of this transport system by cardiac glycosides. The interaction between glycoside and enzyme and the regulation of the kinetics of glycoside binding by ATP, K+, Na+, Mg2+ and Ca2+ are described. Emphasis is placed on the significance of the Na+, K+ -pump as the pharmacological receptor for cardiac glycosides. The problem encountered and progress made in attempting to correlate the inotropic action of cardiac glycosides with the binding of these drugs to the heart muscle and with the inhibition of the Na+, K+ -pump are reported. Recent results concerning increases of the intracellular Na+ concentration which are obtained by a partial inhibition of the Na+, K+ -pump and which are followed by an elevation of the intracellular Ca2+ -activity are reviewed. The discovery of a digitalis-like endogenous activity corresponds to the high specificity of the receptor for cardiac glycosides.

The influence of reduced serum potassium level on the toxicity of some cardenolides in guinea pigs

Recent experiments on the pharmacological properties of the semisynthetic cardiotonic steroid strophanthidin-3-bromoacetate (SBA) have challenged the well-known potassium digitalis antagonism in isolated heart muscle preparations. In order to establish these results in vivo, the minimum lethal doses (LDmin) of ouabain (OUA), digoxin (DO), digotoxin (DT), k-strophanthidin (STR) and SBA were determined by the infusion toxicity method in guinea pigs at normokalemia and hypokalemia. The experimentally induced decrease of the serum potassium concentration (5.0 mmoles/l vs. 3.3 mmoles/l) significantly reduced the LDmin of DO (1.42 vs. 1.05 mumoles/kg), DT (1.78 vs. 1.24 mumoles/kg) and STR (20.16 vs. 15.98 mumoles/kg), whereas the LDmin of OUA (0.37 vs. 0.34 mumoles/kg) was not altered. Contrary, the LDmin of SBA was even slightly, but not significantly increased during hypokalemia (16.77 vs. 19.04 mumoles/kg). In addition, from the experimental data an optimum time of infusion (Topt), corresponding to the LDmin, can be derived, which is equivalent to the time for optimum "utilization" of the drug. The obtained sequence: STR less than OUA less than DO less than DT less than SBA represents the well-known differences in the onset of the pharmacological action in man resp. animal. Hypokalemia in general resulted in a shortening of the Topt, thus indicating a more rapid "utilization" of the drug tested. The above differences of the cardenolide action at reduced serum potassium concentration may be dependent on the recently reported divergent influence of potassium on the association- resp. dissociation rate constants for the interaction of these drugs with their binding site at the Na+-K+-ATPase.

Saturable adenosine 5'-triphosphate-independent binding of [3H]-ouabain to brain and cardiac tissue in vitro

1. Several investigators have proposed that membrane Na+, K+-adenosine 5'-triphosphatase (Na+, K+-ATPase) is a mechanism for the transmembrane transport of cardiac glycosides, rather than the receptor for pharmacological actions of these agents. This implies that the glycosides bind to an intracellular constituent (receptor) other than Na+, K+-ATPase. 2. In search for such a receptor site, saturable ATP-independent [3H]-ouabain binding was studied in rat brain and dog and guinea-pig heart homogenates. The binding of the glucoside to this site results in a relatively unstable complex which is stabilized by K+ to a lesser extent than is the complex formed with the ATP-dependent binding to Na+, K+-ATPase. 3. The ATP-independent ouabain binding sites are more abundant in rat brain tissue than in cardiac tissue, and have a lower ouabain affinity compared to the binding sites on Na+, K+-ATPase. 4. These results do not support the contention that there are intracellular inotropic receptors for digitalis.

Reduction of the equilibrium binding of cardiac glycosides and related compounds to Na+,K+-ATPase as a possible mechanism for the potassium-induced reversal of their toxicity

The influence of potassium ions on the equilibrium state of the binding of cardiac glycosides and their derivatives to partially purified dog heart and rat brain enzyme preparations was studied in vitro. The addition of potassium to the incubation mixture containing enzyme preparation, 3H-ouabain, Na+, Mg2+ and ATP, at the time when the binding reaction is close to equilibrium, caused an immediate reduction of the bound drug concentration; the concentration apparently shifting toward a lower equilibrium state. The degree of the potassium-induced reduction in bound drug concentration was dependent on the potassium concentration and on the chemical structure of the compound. The binding of aglycones, pentacetyl-gitoxin and cassaine was affected to a greater extent than that of the glycosides. These data suggest that one of the mechanisms by which potassium antagonizes the toxic actions of digitalis on the heart is to reduce the drug binding to cardiac Na+,K+-ATPase.

Membrane adenosinetriphosphatase: a digitalis receptor?

The enzyme Na+,K+-ATPase is a good model for receptor studies because of its known functional correlates. The binding of digitalis to the enzyme observed in vitro satisfied the criteria for receptor binding. Studies of the relationship between the digitalis binding and the drug action reveal an impressive correlation between these events but fail to provide proof of a causal relationship. Studies with other Na+,K+-ATPase inhibitors and agents that affect transmembrane Na+ movements (steps that would follow Na+,K+-ATPase inhibition) provide further supportive evidence that sodium pump inhibition and the resulting enhancement of intracellular Na+ transients cause the inotropic action of digitalis.