Pharmacokinetics of hydroxocobalamin in smoke inhalation victims

Elevated Methemoglobin Levels in a Patient Treated with Hydroxocobalamin After Suspected Cyanide Exposure

BACKGROUND

Cyanide (CN) toxicity commonly occurs during enclosed-space fires. Historically, the first step in treating CN toxicity utilized amyl nitrite and sodium nitrite to induce methemoglobinemia, which can be dangerous in this population. Hydroxocobalamin (OHCob), which binds to CN to form the nontoxic metabolite cyanocobalamin, is now the first-line antidote for CN toxicity, and has the advantage of not inducing methemoglobinemia.

CASE REPORT

A 62-year-old man presented to the Emergency Department (ED) after a house fire. He was intubated for respiratory distress and hypoxia with an initial carboxyhemoglobin of 1.3%, methemoglobin 0.3%, and anion gap 19. Eleven hours after presentation, his serum lactic acid was 9 mmol/L. Given his continued deterioration, 14 h after arrival he received OHCob 5 g i.v. for presumed CN toxicity. Methemoglobin concentration 4 min prior to OHCob administration was 0.7%, and 2 h after administration was 4.2%. This subsequently increased to 14.3% (16 h after OHCob administration) and peaked at 16.3% (47 h after OHCob administration), at which time he was administered a dose of methylene blue 50 mg i.v., 60 h after ED arrival. His methemoglobin concentrations fluctuated until a consistent downward trend starting at 92 h from ED arrival. He continued to deteriorate and expired on hospital day 5 with a methemoglobin concentration of approximately 6.0%. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CN toxicity requires immediate recognition and treatment. The antidote, OHCob, is believed to not induce methemoglobinemia. However, this potential side effect must be considered by emergency physicians when treating suspected CN toxicity, especially if the patient does not improve after antidotal therapy.

Current concepts in the pathophysiology and treatment of inhalation injury

The opinions or assertions contained herein are the private views of the author, and are not to be construed as official or as reflecting the official views of the Department of the Army or Department of Defense. Smoke inhalation injury occurs in about 10% of patients admitted to burn centres, and increases the mortality of burn patients by up to 20% over predictions based on age and burn size alone. The primary lesion in smoke inhalation injury is localized to the small airways, with alveolar injury and pulmonary oedema exercising a less prominent role during the initial phases. Injury incites a cascade of events that include ventilation-perfusion mismatch, secondary lung injury, systemic inflammation, impaired immune function, and pneumonia. The most important recent developments in the treatment of inhalation injury have included improved methods of pulmonary care targeted at the pathophysiology of the injury, such as high-frequency percussive ventilation and gentle mechanical ventilation.

Hydroxocobalamin in cyanide poisoning

INTRODUCTION

On theoretical grounds, hydroxocobalamin is an attractive antidote for cyanide poisoning as cobalt compounds have the ability to bind and detoxify cyanide. This paper reviews the pharmacokinetic and pharmacodynamic aspects of hydroxocobalamin, its efficacy in human cyanide poisoning and its adverse effects.

METHODS

PubMed was searched for the period 1952 to April 2012. A total of 71 papers were identified in this way; and none was excluded. PHARMACOKINETICS AND PHARMACODYNAMICS: Pharmacokinetic studies in dogs and humans suggest a two-compartment model, with first order elimination kinetics. Pharmacodynamic studies in animals suggest that hydroxocobalamin would be a satisfactory antidote for human cyanide poisoning. EFFICACY IN HUMAN POISONING: There is limited evidence that hydroxocobalamin alone is effective in severe poisoning by cyanide salts. The evidence for the efficacy of hydroxocobalamin in smoke inhalation is complicated by lack of evidence for the importance of cyanide exposure in fires and the effects of other chemicals as well as confounding effects of other therapeutic measures, including hyperbaric oxygen. Evidence that hydroxocobalamin is effective in poisoning due to hydrogen cyanide alone is lacking; extrapolation of efficacy from poisoning by ingested cyanide salts may not be valid. The rate of absorption may be greater with inhaled hydrogen cyanide and the recommended slow intravenous administration of hydroxocobalamin may severely limit its clinical effectiveness in these circumstances.

ADVERSE EFFECTS

Both animal and human data suggest that hydroxocobalamin is lacking in clinically significant adverse effects. However, in one human volunteer study, delayed but prolonged rashes were observed in one-sixth of subjects, appearing 7 to 25 days after administration of 5 g or more of hydroxocobalamin. Rare adverse effects have included dyspnoea, facial oedema, and urticaria.

CONCLUSIONS

Limited data on human poisonings with cyanide salts suggest that hydroxocobalamin is an effective antidote; data from smoke inhalation are less clear-cut. Although clinically important reactions to hydroxocobalamin have not been seen, some, non-life threatening, adverse reactions can occur.

Combined methylmalonic acidemia and homocystinuria, cblC type. I. Clinical presentations, diagnosis and management

Combined methylmalonic acidemia and homocystinuria, cblC type, is an inborn error of intracellular cobalamin metabolism with a wide spectrum of clinical manifestations that is stated to be the most common inherited disorder of cobalamin metabolism. This metabolic disease is caused by mutations in the MMACHC gene and results in impaired intracellular synthesis of adenosylcobalamin and methylcobalamin, cofactors for the methylmalonyl-CoA mutase and methionine synthase enzymes. Elevated methylmalonic acid and homocysteine with decreased methionine production are the biochemical hallmarks of this disorder. Awareness of the diverse clinical presentations associated with cblC disease is necessary to provide a timely diagnosis, to guide management of affected individuals and to establish a framework for the future treatment of individuals detected through expanded newborn screening. This article reviews the biochemistry, clinical presentations, genotype-phenotype correlations, diagnosis and management of cblC disease.

Inhibition of nitric oxide synthase by cobalamins and cobinamides

Cobalamins are important cofactors for methionine synthase and methylmalonyl-CoA mutase. Certain corrins also bind nitric oxide (NO), quenching its bioactivity. To determine if corrins would inhibit NO synthase (NOS), we measured their effects on -L-[(14)C]arginine-to-L-[(14)C]citrulline conversion by NOS1, NOS2, and NOS3. Hydroxocobalamin (OH-Cbl), cobinamide, and dicyanocobinamide (CN(2)-Cbi) potently inhibited all isoforms, whereas cyanocobalamin, methylcobalamin, and adenosylcobalamin had much less effect. OH-Cbl and CN(2)-Cbi prevented binding of the oxygen analog carbon monoxide (CO) to the reduced NOS1 and NOS2 heme active site. CN(2)-Cbi did not react directly with NO or CO. Spectral perturbation analysis showed that CN(2)-Cbi interacted directly with the purified NOS1 oxygenase domain. NOS inhibition by corrins was rapid and not reversed by dialysis with L-arginine or tetrahydrobiopterin. Molecular modeling indicated that corrins could access the unusually large heme- and substrate-binding pocket of NOS. Best fits were obtained in the "base-off" conformation of the lower axial dimethylbenzimidazole ligand. CN(2)-Cbi inhibited interferon-gamma-activated Raw264.7 mouse macrophage NO production. We show for the first time that certain corrins directly inhibit NOS, suggesting that these agents (or their derivatives) may have pharmacological utility. Endogenous cobalamins and cobinamides might play important roles in regulating NOS activity under normal and pathological conditions.

Prehospital administration of hydroxocobalamin for smoke inhalation-associated cyanide poisoning: 8 years of experience in the Paris Fire Brigade

INTRODUCTION

This article reports the results of a retrospective study of 8 years of experience of the Paris Fire Brigade with the prehospital use of hydroxocobalamin.

METHODS

The head physician at the Paris Fire Brigade extracted and summarized data from standardized forms completed at the fire scene and, when available, hospital reports to assess survival status and clinical parameters associated with the use of hydroxocobalamin for each patient who received it for smoke inhalation-associated cyanide poisoning from 1995 to 2003.

RESULTS

Of the 101 patients administered hydroxocobalamin, 30 survived, 42 died (17 at the fire scene and 25 at the intensive-care unit), and survival status was not known in the remaining 29 patients. Among the 72 patients for whom survival status was known, survival rate was 41.7% after the administration of hydroxocobalamin. Of the 38 patients found in cardiac arrest, 21 had a return of spontaneous circulation during prehospital care. Of the 12 patients who were initially hemodynamically unstable (systolic blood pressure 0 to < or =90 mmHg), 9 recovered systolic blood pressure an average of 30.6 minutes after the start of hydroxocobalamin infusion. Among nonsedated patients in the sample as a whole (n = 52), mean (SD) Glasgow coma scale score improved from 7.9 (5.4) initially to 8.5 (5.7) after administration of hydroxocobalamin. Among nonsedated patients who were initially neurologically impaired (n = 18), Glasgow coma scale score improved in 9 patients, did not change in 8 patients, and worsened in 1 patient. Two adverse events--red or pink coloration of urine or skin (n = 5) and cutaneous rash (n = 1)--were assessed as being possibly related to hydroxocobalamin.

CONCLUSION

Hydroxocobalamin has a risk:benefit ratio rendering it suitable for prehospital use in the management of acute cyanide poisoning caused by smoke inhalation.

Acute cyanide poisoning in prehospital care: new challenges, new tools for intervention

Effective management of cyanide poisoning from chemical terrorism, inhalation of fire smoke, and other causes constitutes a critical challenge for the prehospital care provider. The ability to meet the challenge of managing cyanide poisoning in the prehospital setting may be enhanced by the availability of the cyanide antidote hydroxocobalamin, currently under development for potential introduction in the United States. This paper discusses the causes, recognition, and management of acute cyanide poisoning in the prehospital setting with emphasis on the emerging profile of hydroxocobalamin, an antidote that may have a risk:benefit ratio suitable for empiric, out-of-hospital treatment of the range of causes of cyanide poisoning. If introduced in the U.S., hydroxocobalamin may enhance the role of the U.S. prehospital responder in providing emergency care in a cyanide incident.

New developments in antidotes

Although some antidotes are rarely used, they have an important, potentially life-saving role in the treatment of toxic exposures. The timely and judicious use of an antidote can prevent death and shorten hospitalization as well as reduce the patient's pain and suffering. Although their importance is recognized, sufficient stocking of antidotes remains a problem.

Cobalamin dose regimen for maximum homocysteine reduction in end-stage renal disease

Plasma total homocysteine (tHcy) concentrations are markedly increased in end-stage renal disease and only partially corrected by folic acid supplementation. We and others have reported that cobalamin, administered parenterally, reduces plasma tHcy substantially below the lowest concentrations attainable with folic acid. We have now carried out a randomized controlled clinical trial to compare the plasma Hcy-lowering effect of 3 intravenous cyanocobalamin dose regimens in maintenance hemodialysis patients: 1 mg postdialysis every 28, 14, and 7 days in addition to routine oral vitamin B supplementation. All patients in the hemodialysis unit where the study was carried out routinely received 1 mg intravenous cyanocobalamin every month, so participants who were randomized to receive the vitamin every 28 days simply continued with their existing treatment program. Serum cobalamin and plasma tHcy concentrations in the control group did not change over the course of the study. As measured after 8 weeks of therapy, intravenous cyanocobalamin every 14 days increased serum cobalamin approximately 2.5-fold and reduced plasma tHcy by 11.5% ( P = .035) below the concentration previously attained with monthly administration, whereas treatment every 7 days increased serum cobalamin concentrations approximately 5-fold and reduced plasma tHcy by 11.0% ( P = .013). These results show that intravenous cyanocobalamin at 7- or 14-day intervals reduces plasma tHcy concentrations of hemodialysis patients below the levels brought about by prior long-term administration every 4 weeks and confirms that plasma tHcy lowering with parenteral cobalamin is a true pharmacological effect and not merely correction of a latent deficiency state.

Carbon Monoxide and Cyanide Poisoning in Fire Related Deaths in Victoria, Australia

OBJECTIVE

This study was undertaken to examine the association of hydrogen cyanide and carboxyhaemoglobin in victims of fire related deaths in Australia. The secondary aim was to document demographic data about Australian fire related deaths.

METHODS

An observational retrospective study was undertaken of autopsy reports from the Victorian Institute of Forensic Medicine. Reports of fire related deaths were electronically searched using the terms burns, "smoke" or "fire" as a cause of death in the calender years 1992 to 1998. Data on the circumstances of the fire and results of toxicological screening were obtained on 178 persons. Additional whole blood cyanide levels were determined if blood samples were available in storage. Demographics of the victims were analysed, as well as the relationship between carboxyhaemoglobin and whole blood cyanide levels.

RESULTS

Most (82%) of the victims died at the scene, whilst 32 victims died after a period of hospitalisation (hours to weeks). Suicide as a result of self-immolation was the reported cause of death in 32 cases. Most of the fires were in houses (114) and cars (29). The blood ethanol level was zero in 112 cases; the remaining cases (53) had a mean level of 0.17%. Other central nervous system (CNS) depressants were recorded in 49 of the 134 cases that received a complete toxicological screen. Carboxyhaemoglobin levels were measured in only 154 of 178 cases. The carboxyhaemoglobin level was zero in 43 cases. The remaining cases (111) had a mean level of 40%; with 44 cases having a level greater than 50%, a level considered to be potentially lethal. Whole blood hydrogen cyanide levels were measured in only 138 of 178 cases. The hydrogen cyanide level was zero in 52 cases. The remaining cases (86) had a mean level of 1.65 mg/L; with 11 cases having a level greater than 3.0 mg/L (potentially fatal). Blood ethanol levels were significantly correlated with both carboxyhaemoglobin (R = 0.22, P < 0.01) and cyanide (R = 0.36, P < 0.001). In addition, a significant correlation (r = 0.34) between carboxyhaemoglobin and hydrogen cyanide levels was noted.

CONCLUSIONS

This study showed a correlation between elevated blood ethanol and whole blood cyanide levels (r = 0.36, p < 0.001) and between elevated carboxyhaemoglobin and hydrogen cyanide levels (r = 0.34). Although the mean cyanide level was 1.3 mg/L (above the level some consider potentially toxic) in those cases with a carboxyhaemoglobin level of greater than 10%, there is insufficient data to permit recommendations for clinical care. Further studies are required on those victims that reach hospital alive.

Toxicology in the critically ill patient

Intoxications present in many forms including: known drug overdose or toxic exposure, illicit drug use, suicide attempt, accidental exposure, and chemical or biological terrorism. A high index of suspicion and familiarity with toxidromes can lead to early diagnosis and intervention in critically ill, poisoned patients. Despite a paucity of evidence-based information on the management of intoxicated patients, a rational and systematic approach can be life saving.

Hydroxocobalamin: improved public health readiness for cyanide disasters

The United States is under the constant threat of a mass casualty cyanide disaster from industrial accidents, hazardous material transportation incidents, and deliberate terrorist attacks. The current readiness for cyanide disaster by the emergency medical system in the United States is abysmal. We, as a nation, are simply not prepared for a significant cyanide-related event. The standard of care for cyanide intoxication is the cyanide antidote kit, which is based on the use of nitrites to induce methemoglobinemia. This kit is both expensive and ill suited for out-of-hospital use. It also has its own inherent toxicity that prevents rapid administration. Furthermore, our hospitals frequently fail to stock this life-saving antidote or decline to stock more than one. Hydroxocobalamin is well recognized as an efficacious, safe, and easily administered cyanide antidote. Because of its extremely low adverse effect profile, it is ideal for out-of-hospital use in suspected cyanide intoxication. To effectively prepare for a cyanide disaster, the United States must investigate, adopt, manufacture, and stockpile hydroxocobalamin to prevent needless morbidity and mortality.

Chemicals and gases

This article covers the major chemicals and gases that are considered to be of the most clinical relevance to the primary care provider. The reader is referred to other comprehensive textbooks of toxicology and occupational medicine for a complete discussion of the numerous additional products found in the workplace that may result in occupational exposure.

Structure and photochemistry of dicyanocobalt(III) tetraphenylporphyrin. Photochromic reaction caused by photodissociation of axial ligand

Chlorocobalt(III) tetraphenylporphyrin, (Cl)CoIIITPP, reacts with potassium cyanide in dichloromethane or benzene containing 18-crown-6 to give a green solution of [crown-K+][(CN)2CoIIITPP-]. The molecular structure of [crown-K+][(CN)2CoIIITPP-] is identified by X-ray crystallography. In methanol, (Cl)CoIIITPP plus KCN also gives a green solution of [(CN)2CoIIITPP-]. The green methanol solution containing 1.4 x 10(-4) M KCN turns orange by continuous photolysis with a 250-W mercury lamp for 5 min. The orange solution returns to green when it is kept in the dark for 5 min. The kinetic study suggests that [(CN)2CoIIITPP-] dissociates CN- by continuous photolysis, giving rise to the formation of the orange species, (CH3OH)(CN)CoIIITPP. The photoproduct, (CH3OH)(CN)CoIIITPP, regenerates the green species, [(CN)2CoIIITPP-], by reaction with CN-. The laser photolysis study of [(CN)2CoIIITPP-] in methanol demonstrates that photodissociation of CN- takes place within 20 ns after the 355-nm laser pulse, resulting in the formation of two transients, I (short-lived) and II (long-lived). The absorption spectra of both transients are similar to that of (CH3OH)(CN)CoIIITPP. These transients eventually return to [(CN)2CoIIITPP-]. The decay of species I follows first-order kinetics with a rate constant k. = 2 x 10(6) s-1, independent of the concentration of KCN. Species II is identified as (CH3OH)(CN)CoIIITPP, which is observed with the continuous photolysis of the solution. The laser photolysis of [crown-K+][(CN)2COIIITPP-] in dichloromethane gives the transient species, which goes back to the original complex according to first-order kinetics with a rate constant k = 5 x 10(6) s-1. [crown-K+][(CN)2CoIIITPP-] is concluded to photodissociate the axial CN- to form [crown-K+CN-][(CN)CoIIITPP] in which an oxygen atom of the crown moiety in [crown-K+CN-] is coordinated to the cobalt(III) atom of [(CN)CoIIITPP] at the axial position. The intracomplex reverse reaction of [crown-K+CN-][(CN)CoIIITPP] leads to the regeneration of [crown-K+][(CN)2CoIIITPP-]. The structure and the reaction of the transient species I observed for [(CN)2CoIIITPP-] in methanol are discussed on the basis of the laser photolysis studies of [crown-K+][(CN)2CoIIITPP-] in dichloromethane.

Cobalamin inhibition of HIV-1 integrase and integration of HIV-1 DNA into cellular DNA

Our prior studies showed that certain cobalamins inhibit productive HIV-1 infection of primary cultures of blood lymphocytes and monocytes. We demonstrate here that this antiviral activity may be mediated by an inhibition of HIV-1 integrase, an enzyme required for productive infection. Purified recombinant HIV-1 integrase activity was inhibited in vitro by hydroxocobalamin (OH-Cbl), methylcobalamin (Me-Cbl), adenosylcobalamin (Ado-Cbl), and dicyanocobinamide (CN2-Cbi) with IC50 values of approximately 17, 17, 17, and 4 microM, respectively. The agents inhibited HIV-1 infection of cultured monocytes (IC50 values for OH-Cbl, Me-Cbl, Ado-Cbl, and CN2-Cbi of 6, 7, 4, and 1 microM, respectively) and of cultured lymphocytes (IC50 values of 60, 50, 60, and 11 microM, respectively). Experiments using cultured monocytes or lymphocytes demonstrated that OH-Cbl inhibited integration of HIV-1 DNA into cellular DNA. Thus, cobalamins and cobinamides represent novel inhibitors of HIV-1 integrase. These or related agents may be useful as anti-viral treatments that target HIV-1 integrase.