Effect of the NMDA-antagonist, MK 801, on benzodiazepine-opioid interactions at the spinal and supraspinal level in rats

Synthesis of the Mechanisms of Opioid Tolerance: Do We Still Say NO?

The use of morphine as a first-line agent for moderate-to-severe pain is limited by the development of analgesic tolerance. Initially opioid receptor desensitization in response to repeated stimulation, thought to underpin the establishment of tolerance, was linked to a compensatory increase in adenylate cyclase responsiveness. The subsequent demonstration of cross-talk between N-methyl-D-aspartate (NMDA) glutamate receptors and opioid receptors led to the recognition of a role for nitric oxide (NO), wherein blockade of NO synthesis could prevent tolerance developing. Investigations of the link between NO levels and opioid receptor desensitization implicated a number of events including kinase recruitment and peroxynitrite-mediated protein regulation. Recent experimental advances and the identification of new cellular constituents have expanded the potential signaling candidates to include unexpected, intermediary compounds not previously linked to this process such as zinc, histidine triad nucleotide-binding protein 1 (HINT1), micro-ribonucleic acid (mi-RNA) and regulator of G protein signaling Z (RGSZ). A further complication is a lack of consistency in the protocols used to create tolerance, with some using acute methods measured in minutes to hours and others using days. There is also an emphasis on the cellular changes that are extant only after tolerance has been established. Although a review of the literature demonstrates a lack of spatio-temporal detail, there still appears to be a pivotal role for nitric oxide, as well as both intracellular and intercellular cross-talk. The use of more consistent approaches to verify these underlying mechanism(s) could provide an avenue for targeted drug development to rescue opioid efficacy.

Effects of midazolam on cardiovascular responses and isoflurane requirement during elective ovariohysterectomy in dogs

Background

A prospective, randomized, placebo-controlled, blinded clinical study was conducted to determine whether a single dose of midazolam affects the cardiovascular response to surgical manipulation of the ovaries during elective ovariohysterectomy. Thirty-nine client-owned dogs undergoing elective ovariohysterectomy were recruited. After scoring cage demeanour, dogs were premedicated with acepromazine (0.03 mg kg^-1) and pethidine (3 mg kg^-1) intramuscularly into the quadriceps muscle and 20 min later sedation was scored. Anaesthesia was induced with propofol intravenously (IV) to effect. The study treatment (group M: midazolam (0.25 mg kg^-1); or group P: placebo (Hartmann’s solution) (0.125 ml kg^-1)) was administered IV before the intra-operative manipulation of the first ovary. Anaesthesia was maintained with isoflurane in oxygen. Morphine (0.3 mg kg^-1 IV) was administered prior to the start of surgery. The vaporizer setting was adjusted according to the depth of anaesthesia. If an end-tidal isoflurane concentration (FE’Iso) above 1.6% was required additional analgesia was provided with fentanyl (2 μg kg^-1). Dogs received meloxicam (0.2 mg kg^-1 IV) at the end of procedure. Heart rate, mean arterial blood pressure, respiratory rate and end-tidal partial pressure of carbon dioxide as well as FE’Iso were recorded and analysed.

Results

A statistical significant difference between groups was detected in FE’Iso, with group M requiring a significantly lower FE’Iso than group P (14.3%) after administration of midazolam. No differences between groups was shown for percentage change in heart rate and mean arterial blood pressure, or end-tidal carbon dioxide and requirement for mechanical ventilation, or rescue analgesia. There was no statistically significant difference in the incidence of complications in group M and P. Group M received significantly more succinylated gelatin solution pre-administration of midazolam than group P, but no differences in fluid administration post-administration of the study treatment (midazolam/placebo) were detected. No statistical significant difference was demonstrated for the use of anticholinergic agents, dobutamine or noradrenaline.

Conclusion

No significant effect on cardiovascular parameters could be observed with administration of midazolam, but a modest (14.3%) isoflurane-sparing effect was detected.

Evaluation the effects of dextromethorphan and midazolam on morphine induced tolerance and dependence in mice

The main aim of this study was to evaluate the effects of dextromethorphan and midazolam and their combination on morphine tolerance and dependence in mice. In the present study, different groups of mice were rendered randomly and received morphine (50 mg kg(-1), s.c.), morphine (50 mg kg(-1), s.c.) + Dextromethorphan (25, 50 and 75 mg kg(-1), i.p.), morphine (50 mg kg(-1), s.c.) + midazolam (0.5, 1 and 2 mg kg(-1), i.p.), morphine (50 mg kg(-1), s.c.) + [Dextromethorphan (25 mg kg(-1), i.p. ) + midazolam (0.5 mg kg(-1), i.p.)] once a day for four days. Tolerance was assessed by administration of morphine (9 mg kg(-1), i.p.) on fifth day. Withdrawal symptoms (markers for dependence) was assessed by administration of naloxone (4 mg kg(-1), i.p.) 2 h after co-administration of morphine with either Dextromethorphan or midazolam or their combination. Results showed that pretreatment with Dextromethorphan or midazolam decreased the degree of tolerance and withdrawal symptoms significantly. Additionally co-administration ofDextromethorphan and midazolam couldn't decreased the tolerance and dependence significantly. From these results it may concluded that Dextromethorphan and midazolam alone or in combination could prevent the development of morphine induced tolerance and dependence. These effects can be related to the N-Methyl-D-Aspartate (NMDA) receptor antagonist behavior of Dextromethorphan and GABA-receptor agonist property of midazolam.

Midazolam attenuates the antinociception induced by d-serine or morphine at the supraspinal level in rats

Our recent study has shown that the intracerebroventricular administration of d-serine, an endogenous and selective agonist for the glycine site of the N-methyl-d-aspartate receptor, alone or in combination with morphine, leads to the potentiation of antinociception on the tail-flick response. Although there is a variety of information concerning the effects of benzodiazepines on opioid-induced antinociception, little is known about the effect of benzodiazepines on the N-methyl-d-aspartate receptor agonist-induced antinociception. To clarify the analgesic interactions among the benzodiazepine/GABA(A), N-methyl-d-aspartate and opioid receptors at the supraspinal level, we investigated the effects of intracerebroventricular administration of midazolam, a benzodiazepine receptor agonist, on the antinociception evoked by the intracerebroventricular application of d-serine or morphine. The intracerebroventricular administration of midazolam alone produced hyperalgesia on the tail-flick response in a benzodiazepine receptor antagonist, flumazenil-reversible manner. The antinociception induced by the intracerebroventricular application of d-serine or morphine was attenuated by the intracerebroventricular administration of midazolam. In addition, this inhibitory effect of midazolam on the antinociception of d-serine or morphine was antagonized by the intracerebroventricular administration of flumazenil. Together with the facts that d-serine and midazolam act as selective agonists for the glycine site of the N-methyl-d-aspartate receptor and benzodiazepine/GABA(A) receptor, respectively, these observations suggest a functional interaction between the NMDA and benzodiazepine/GABA(A) receptors in the regulation of antinociception at the supraspinal level.

Safety of blocking vascular adhesion protein-1 in patients with contact dermatitis

Vascular adhesion protein-1 mediates leukocyte binding to vascular endothelia and migration to tissues. It is upregulated in inflammatory conditions. We studied the safety of vascular adhesion protein-1 blockade by a single dose of the mouse monoclonal antibody vepalimomab in patients with nickel-induced allergic contact dermatitis lesions. Vepalimomab, 0.05-0.50 mg kg(-1) was safe and well tolerated. Four of nine patients reported adverse events of mild to moderate intensity. Human antimouse antibodies were detected after infusion in all the patients and they remained above the basal level for at least one month. Vepalimomab dose-dependently labelled vascular adhesion protein-1 in the inflamed skin. Luminal upregulation of vascular adhesion protein-1 on the endothelium upon inflammation was demonstrated for the first time in patients in vivo. Vepalimomab was found on the endothelium up to 24 hr after dosing whilst it was cleared from the circulation with an apparent half-life of 25-50 min. The results provide in vivo support for the concept of blocking vascular adhesion protein-1 in human disease states and support previous proposals that vascular adhesion protein-1 is a potential target molecule for inhibition of inflammatory reactions.

The spinal nitric oxide involved in the inhibitory effect of midazolam on morphine-induced analgesia tolerance

Previous studies had shown that pretreatment with midazolam inhibited morphine-induced tolerance and dependence. The present study was to investigate the role of spinal nitric oxide (NO) in the inhibitory effect of midazolam on the development of morphine-induced analgesia tolerance. Subcutaneous injection of 100 mg/kg morphine to mice caused an acute morphine-induced analgesia tolerance model. To develop chronic morphine tolerance in mice, morphine was injected for three consecutive days (10, 20, 50 mg/kg sc on Day 1, 2, 3, respectively). In order to develop chronic tolerance model in rats, 10 mg/kg of morphine was given twice daily at 12 h intervals for 10 days. Midazolam was intraperitoneally injected 30 min prior to administration of morphine. Tail-flick test, hot-plate and formalin test were conducted to assess the nociceptive response. Immunocytochemistry, histochemistry and western blot were performed to determine the effect of midazolam on formalin-induced expression of Fos protein, nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d) and nitric oxide synthase (NOS) in chronic morphine-tolerant rats, respectively. The results showed that pretreatment with midazolam significantly inhibited the development of acute and chronic morphine tolerance in mice, which could be partially reversed by intrathecal injection of NO precursor L-arginine (L-Arg). In chronic morphine-tolerant rats, pretreatment with midazolam significantly decreased the formalin-induced expression of Fos and Fos/NADPH-d double-labeled neurons in the contralateral spinal cord and NADPH-d positive neurons in the bilateral spinal cord. Both inducible NOS (iNOS) and neuronal NOS (nNOS) protein levels in the spinal cord were significantly increased after injection of formalin, which could be inhibited by pretreatment with midazolam. The above results suggested that the decrease of the activity and expression of NOS contributed to the inhibitory effect of midazolam on the development of morphine tolerance.

Dopamine and NMDA systems modulate long-term nociception in the rat anterior cingulate cortex

The anterior cingulate cortex (ACC) plays a key role in pain processing. It has been reported that increased activity of glutamatergic projections into the ACC intensifies nociception; whereas dopaminergic projections inhibit it. The aim of this study was to evaluate the role of dopaminergic and NMDA systems of the ACC in the modulation of long-term nociception elicited by sciatic denervation in the rat. Score, onset and incidence of long-term nociception were measured by the autotomy behavior. The effects of a single microinjection into the ACC of different doses of dopamine (100 nM, 100 microM and 100 mM), a NMDA receptor antagonist (MK801 200 nM and 9.34 mM) and amantadine, a dopamine agonist and NMDA receptor antagonist (10, 100 and 1000 microM) were tested on long-term nociception. Dopamine diminished autotomy behavior in an inverse dose-dependent manner, with dopamine 100 nM as most effective concentration. MK801 and amantadine elicited a significant reduction on autotomy score. Prior injections of D1 and D2 receptor antagonists blocked the antinociceptive effects of amantadine on long-term nociceptive behavior. The present study suggests an interaction between dopaminergic and glutamatergic systems within the ACC in the genesis and maintenance of long-term nociception.

The use of intrathecal midazolam in humans: a case study of process

Early preclinical work demonstrated the potential role of spinal benzodiazepine pharmacology in regulating spinal nociceptive transmission. We review this preclinical activity and the evolving implementation of intrathecal midazolam in humans for pain management. Important elements in this development for use in humans are issues pertinent to safety and the preclinical reports that have increased our understanding of intrathecal midazolam toxicity. We seek to emphasize the time course of these studies and how they merged to provide enabling data that drove the clinical implementation. In the case of midazolam, we point to the potential issues that arose when preclinical safety data were unreasonably ignored and how consideration of preclinical safety data can serve to facilitate drug development by demonstrating reasonable safety profiles that document the minimal degree of potential risk to the patient. Issues that are of continuing relevance to the use of intrathecal midazolam, including issues of formulation and kinetics, are considered.

IMPLICATIONS

The intrathecal use of midazolam has evolved over 20 years though a combination of preclinical and clinical investigations. We review the time course of this development to define critical elements that should be pursued in reducing the risk associated with the clinical use of a novel spinal drug.

Effects of NMDA receptor antagonists on opioid-induced respiratory depression and acute antinociception in rats

Although exogenous opioids alter the responses of animals to tissue-damaging stimuli and therefore are the cornerstone in the treatment of acute antinociception, they have profound side effects on ventilation. To diminish ventilatory effects, combination therapies have been advocated. Recent studies reported the effectiveness of the addition of N-methyl-D-aspartate (NMDA) receptor antagonists such as ketamine to morphine in the treatment of acute pain. However, NMDA receptors, together with non-NMDA receptors are known to be involved in the neurotransmission of inspiratory drive to phrenic motoneurons. Co-administration of NMDA and non-NMDA receptor antagonists has been shown to be deleterious to respiratory function. The present study investigated the hypothesis that the association of opioids and NMDA receptor antagonists may add to the impairment of respiratory parameters. In male Wistar rats, combinations of opioids (fentanyl or morphine) at antinociceptive doses and NMDA receptor antagonists (ketamine, 40 mg/kg, or dextromethorphan, 10 mg/kg) at subanesthetic doses were administered intraperitoneally. Antinociception was tested with the tail-withdrawal reaction (TWR) test, while the effect on respiratory parameters was investigated with blood-gas analysis. We found that, in rats, co-administration of NMDA receptor antagonists and opioids may result in an increased respiratory depression as compared to the opioids alone. The effect of the NMDA receptor antagonists on opioid-induced antinociception was limited.

Mood stabilizers in Alzheimer's disease: symptomatic and neuroprotective rationales

OBJECTIVE

This paper provides a case study of 'reverse translational research', in which empirical clinical trials focused on relieving psychopathological symptoms of Alzheimer's disease (AD) ultimately led to mechanism-based trials addressing aspects of the underlying pathophysiology of Alzheimer's disease. AD is multi-dimensional in nature, characterized not only by cognitive and functional decline but by neuropsychiatric symptoms that develop commonly and are associated with considerable morbidity. There have been a large number of empirical trials of various pharmacological agents to reduce these symptoms, such as agitation. Although antipsychotics are used most frequently for agitation, the usual effect size is modest, and there is a range of tolerability and/or safety issues, leading to the hope that alternatives can be found. Furthermore, most clinical trials addressing psychopathology have not been mechanism-based and none have attempted an alternative approach, namely, to delay or prevent the emergence of psychopathology.

FINDINGS

The evidence of clinical trials is reviewed regarding the safety, tolerability, and apparent efficacy of the mood stabilizers carbamazepine and valproate for agitation associated with AD. Possible mechanisms of action of valproate are reviewed, leading to the surprising conclusion that neuroprotective properties may account for some of its clinical effects. These mechanisms (including activation of wnt-dependent signaling and upregulation of bcl-2, among others) may be particularly relevant for long-term treatment of AD.

CONCLUSIONS

These clinical and mechanistic findings were combined in the development of a novel clinical trial examining whether chronic valproate therapy can attenuate the clinical progression of AD, which will be implemented by the Alzheimer's Disease Cooperative Study. The design addresses valproate's potential to delay or prevent the onset of agitation in patients lacking agitation to begin with, as well as to slow progressive decline in cognition and daily functioning.

Uncompetitive NMDA receptor antagonists potentiate morphine antinociception recorded from the tail but not from the hind paw in rats

We investigated the effects of pretreatment with low-affinity, uncompetitive NMDA receptor antagonists on morphine-induced antinociception in rats using the same intensity of thermal stimulus applied to the tail and the paws. Similar baseline responses to thermal stimuli of the same intensity were recorded from tails and hind paws. However, morphine produced equal antinociception from the tail and hind paw when used at doses of 2.5 and 6 mg/kg, respectively. These doses were used in further experiments. Thirty minutes before morphine, rats were administered the NMDA receptor antagonists dextromethorphan (2.5--30 mg/kg), memantine (2.5--15 mg/kg) and MRZ 2/579 (1-amino-1,3,3,5,5-pentamethyl-cyclohexane HCl) (1.25--10 mg/kg). All three compounds significantly and dose-dependently potentiated morphine-induced antinociception recorded from the tail. However, none of these NMDA receptor antagonists affected morphine antinociception recorded from the paw. These findings suggest that low-affinity NMDA receptor antagonists modulate differently morphine antinociceptive activity recorded from the tail and hind paws.

Neurophysiological basis for neurogenic-mediated articular cartilage anabolism alteration

This study was designed to investigate the pathways involved in neurogenic-mediated articular cartilage damage triggered by a nonsystemic distant subcutaneous or intra-articular inflammation. The cartilage damage was assessed 24 h after subcutaneous or intra-articular complete Freund's adjuvant (CFA) injection measuring patellar proteoglycan (PG) synthesis (ex vivo [Na(2)(35)SO(4)] incorporation) in 96 Wistar rats. Unilateral subcutaneous or intra-articular injection of CFA induced significant decrease (25-29%) in PG synthesis in both patellae. Chronic administration of capsaicin (50 mg. kg(-1). day(-1) during 4 days), which blunted the normal response of C fiber stimulation, prevented the bilateral significant decrease in cartilage synthesis. Similarly, intrathecal injection of MK-801 (10 nmol/day during 5 days), which blocked the glutamatergic synaptic transmission at the dorsal horn of signal originating in primary afferent C fibers, eliminated the CFA-induced PG synthesis decrease in both patellae. Chemical sympathectomy, induced by guanethidine (12.5 mg. kg(-1). day(-1) during 6 wk), also prevented PG synthesis alteration. Finally, compression of the spinal cord at the T3-T5 level had a similar protective effect on the reduction of [Na(2)(35)SO(4)] incorporation. It is concluded that the signal that triggers articular cartilage synthesis damage induced by a distant local inflammation 1) is transmitted through the afferent C fibers, 2) makes glutamatergic synaptic connections with the preganglionic neurons of the sympathetic system, and 3) involves spinal and supraspinal pathways.

Subarachnoid Techniques for Cancer Pain Therapy: When, Why, and How?

For cancer patients who obtain inadequate pain relief with conservative treatment, there is a growing list of effective options for subarachnoid therapy. Morphine and bupivacaine have been the most frequently used drugs for intrathecal infusion, and their use has consistently yielded good results. Despite their effectiveness, however, a therapeutic deficit remains, primarily in the treatment of neuropathic cancer pain. Because of this limitation, more recent research has focused on novel compounds for intrathecal therapy such as clonidine, midazolam, ketamine, and SNX-111. In addition to new drug options, there are various catheter delivery systems from which to choose. In reviewing the literature and experience to date with these various medications and delivery systems, we hope to better aid the clinician in tailoring the best treatment for each patient.

The modulatory effect of spermine on the glutamate-NMDA receptor is regionally variable in normal human adult cerebral cortex

The MK-801, glutamate and polyamine binding sites on the N-methyl-D-aspartate class of glutamate receptors labelled with [3H]MK-801 were characterized in four cortical areas (sensorimotor, superior temporal, mid-frontal and occipital) from seven human adult control cases. Age, post-mortem delay, tissue storage time and sex had no significant effects on any of the parameters measured. Dissociation constants (K(D) values) for MK-801 showed similar mean values in the four cortical areas, whereas receptor densities (B(max) values) showed significant differences between sensorimotor or occipital and superior temporal or mid-frontal cortex. There were marked regional differences in the profiles of the spermine- and glutamate-incremented enhancement of specific [3H]MK-801 binding. The EC(50) for the glutamate enhancement was significantly higher in the occipital than in the mid-frontal and sensorimotor cortex, whereas maximal glutamate-enhanced binding values did not differ. The maximal enhancement of [3H]MK-801 binding by spermine and glutamate varied between the cases, ranging from zero to 40.4+/-9.3 fmol x mg protein(-1) for spermine, and from 85+/-5 to 111+/-10 fmol x mg protein(-1) for glutamate. Maximal spermine enhancement of [3H]MK-801 binding was significantly more variable in superior temporal or mid-frontal than in sensorimotor or occipital cortex. The results suggest that N-methyl-D-aspartate receptor sites, especially the polyamine site, are heterogeneous in human cerebral cortex, and show a high degree of regional and individual variability.