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Wu WW, Choe M, Johannesen L, Vicente J, Bende G, Stockbridge NL, Strauss DG, Garnett C. ICH S7B In Vitro Assays Do Not Address Mechanisms of QT C Prolongation for Peptides and Proteins - Data in Support of Not Needing Dedicated QT C Studies. Clin Pharmacol Ther 2023; 114:1332-1341. [PMID: 37702218 DOI: 10.1002/cpt.3047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/29/2023] [Indexed: 09/14/2023]
Abstract
Current cardiac safety testing focuses on detecting drug-induced QTC prolongation as a surrogate for risk of Torsade de Pointes. The nonclinical strategy, described in International Conference on Harmonization (ICH) S7B, includes in vitro assessment of hERG block or ventricular repolarization delay and in vivo QT prolongation. Several studies have reported predictive values of ICH S7B results for clinical QTC outcomes for small molecules; none has examined peptides and proteins other than monoclonal antibodies. To address this knowledge gap, information for peptides and proteins submitted to the US Food and Drug Administration (FDA) was collected. Results of hERG assays, ventricular repolarization assays, and in vivo QT assessment were compared with clinical QTC study outcomes. The results show that 14% clinical QTC studies for approved and investigational products failed to exclude 10-ms QTC prolongation. Clinical QTC prolongation for these molecules lacked concentration-dependence which is expected for hERG block-mediated mechanism or QTC prolongation could not be excluded due to characterization in the clinical study. The hERG and ventricular repolarization assays do not identify clinical QTC prolongation potential for peptides and proteins. Lack of alignment between hERG and ventricular repolarization assay results and clinical QTC outcomes suggests that the mechanisms of QTC prolongation by some peptides and proteins are unrelated to direct cardiac ion channel block. Similar to large targeted proteins and monoclonal antibodies, peptides and proteins regardless of size have a low likelihood of direct cardiac ion channel interactions. This characteristic supports waiving the requirement for thorough QT assessment for products comprised of naturally occurring amino acids unless proarrhythmia potential is suggested by nonclinical or clinical data.
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Affiliation(s)
- Wendy W Wu
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Moran Choe
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
- Division of Hematology, Oncology, Toxicology, Office of Oncologic Diseases, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lars Johannesen
- Division of Cardiology and Nephrology, Office of Cardiology, Hematology, Endocrinology and Nephrology, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jose Vicente
- Division of Cardiology and Nephrology, Office of Cardiology, Hematology, Endocrinology and Nephrology, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Girish Bende
- Division of Cardiometabolic and Endocrine Pharmacology, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
- Takeda Pharmaceutical Company Limited, Cambridge, Massachusetts, USA
| | - Norman L Stockbridge
- Division of Cardiology and Nephrology, Office of Cardiology, Hematology, Endocrinology and Nephrology, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - David G Strauss
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Christine Garnett
- Division of Cardiology and Nephrology, Office of Cardiology, Hematology, Endocrinology and Nephrology, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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Tran PN, Sheng J, Randolph AL, Baron CA, Thiebaud N, Ren M, Wu M, Johannesen L, Volpe DA, Patel D, Blinova K, Strauss DG, Wu WW. Mechanisms of QT prolongation by buprenorphine cannot be explained by direct hERG channel block. PLoS One 2020; 15:e0241362. [PMID: 33157550 PMCID: PMC7647070 DOI: 10.1371/journal.pone.0241362] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/13/2020] [Indexed: 12/04/2022] Open
Abstract
Buprenorphine is a μ-opioid receptor (MOR) partial agonist used to manage pain and addiction. QTC prolongation that crosses the 10 msec threshold of regulatory concern was observed at a supratherapeutic dose in two thorough QT studies for the transdermal buprenorphine product BUTRANS®. Because QTC prolongation can be associated with Torsades de Pointes (TdP), a rare but potentially fatal ventricular arrhythmia, these results have led to further investigation of the electrophysiological effects of buprenorphine. Drug-induced QTC prolongation and TdP are most commonly caused by acute inhibition of hERG current (IhERG) that contribute to the repolarizing phase of the ventricular action potentials (APs). Concomitant inhibition of inward late Na+ (INaL) and/or L-type Ca2+ (ICaL) current can offer some protection against proarrhythmia. Therefore, we characterized the effects of buprenorphine and its major metabolite norbuprenorphine on cardiac hERG, Ca2+, and Na+ ion channels, as well as cardiac APs. For comparison, methadone, a MOR agonist associated with QTC prolongation and high TdP risk, and naltrexone and naloxone, two opioid receptor antagonists, were also studied. Whole cell recordings were performed at 37°C on cells stably expressing hERG, CaV1.2, and NaV1.5 proteins. Microelectrode array (MEA) recordings were made on human induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs). The results showed that buprenorphine, norbuprenorphine, naltrexone, and naloxone had no effect on IhERG, ICaL, INaL, and peak Na+ current (INaP) at clinically relevant concentrations. In contrast, methadone inhibited IhERG, ICaL, and INaL. Experiments on iPSC-CMs showed a lack of effect for buprenorphine, norbuprenorphine, naltrexone, and naloxone, and delayed repolarization for methadone at clinically relevant concentrations. The mechanism of QTC prolongation is opioid moiety-specific. This remains undefined for buprenorphine, while for methadone it involves direct hERG channel block. There is no evidence that buprenorphine use is associated with TdP. Whether this lack of TdP risk can be generalized to other drugs with QTC prolongation not mediated by acute hERG channel block warrants further study.
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Affiliation(s)
- Phu N. Tran
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, United States of America
- Division of Immunology and Hematology Devices, Center for Devices and Radiological Health, US Food and Drug Administration. Silver Spring, Maryland, United States of America
| | - Jiansong Sheng
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, United States of America
- CiPALab, Gaithersburg, Maryland, United States of America
| | - Aaron L. Randolph
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Claudia Alvarez Baron
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Nicolas Thiebaud
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, United States of America
- Vertex Pharmaceuticals (Europe) Ltd, Abingdon, Oxfordshire, United Kingdom
| | - Ming Ren
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Min Wu
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, United States of America
- Division of Immunology and Hematology Devices, Center for Devices and Radiological Health, US Food and Drug Administration. Silver Spring, Maryland, United States of America
| | - Lars Johannesen
- Division of Cardiology and Nephrology, Office of Cardiology, Hematology, Endocrinology and Nephrology, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Donna A. Volpe
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Dakshesh Patel
- Division of Biomedical Physics, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, United States of America
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ksenia Blinova
- Division of Biomedical Physics, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - David G. Strauss
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Wendy W. Wu
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, United States of America
- * E-mail:
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Breidablik HJ, Johannesen L, Kleiven OT, Lysebo DE, Skare Å, Andersen JR. Can adenosine triphosphate be a proxy measure in evaluation of hand disinfection effect? J Hosp Infect 2020; 105:S0195-6701(20)30228-0. [PMID: 32380030 DOI: 10.1016/j.jhin.2020.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/27/2020] [Indexed: 11/29/2022]
Abstract
Contaminated hands may contribute to the transmission of pathogens. In the prevention of healthcare-associated infections the effect of disinfection methods should ideally be possible to measure in a simple way. Microbial cultivation is the reference standard, but it is a rather complicated and time-consuming procedure, and the use of swabs for measuring adenosine triphosphate (ATP) has become a much-used proxy measurement (bioluminescence). We evaluated the effect of three hand-disinfection methods on eradication of Escherichia coli from artificially contaminated hands, using cultivation and ATP measurements in parallel. ATP measurement was found to be an unsuitable method as this reflects the total amount of cellular material left on the hands, not only the viable bacteria.
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Affiliation(s)
| | - L Johannesen
- Thelma Indoor Air & Working Environment AS, Microbiology Department, Trondheim, Norway
| | - O T Kleiven
- Faculty of Western Norway University of Applied Sciences, Førde, Norway
| | - D E Lysebo
- Haukeland University Hospital, Bergen, Norway
| | - Å Skare
- Førde Hospital Trust, Department for Infection Control, Førde, Norway
| | - J R Andersen
- Faculty of Western Norway University of Applied Sciences, Førde, Norway
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Garnett C, Johannesen L, McDowell T. Redefining Blood Pressure Assessment — The Role of the Ambulatory Blood Pressure Monitoring Study for Drug Safety. Clin Pharmacol Ther 2019; 107:147-153. [DOI: 10.1002/cpt.1690] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/15/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Christine Garnett
- Division of Cardiovascular and Renal Products Center for Drug Evaluation and Research, Food and Drug Administration Silver Spring Maryland USA
| | - Lars Johannesen
- Division of Cardiovascular and Renal Products Center for Drug Evaluation and Research, Food and Drug Administration Silver Spring Maryland USA
| | - Tzu‐Yun McDowell
- Division of Cardiovascular and Renal Products Center for Drug Evaluation and Research, Food and Drug Administration Silver Spring Maryland USA
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Hnatkova K, Vicente J, Johannesen L, Garnett C, Strauss DG, Stockbridge N, Malik M. Detection of T Wave Peak for Serial Comparisons of JTp Interval. Front Physiol 2019; 10:934. [PMID: 31402872 PMCID: PMC6670189 DOI: 10.3389/fphys.2019.00934] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/09/2019] [Indexed: 11/17/2022] Open
Abstract
Electrocardiogram (ECG) studies of drug-induced prolongation of the interval between the J point and the peak of the T wave (JTp interval) distinguished QT prolonging drugs that predominantly block the delayed potassium rectifier current from those affecting multiple cardiac repolarisation ion channel currents. Since the peak of the T wave depends on ECG lead, a “global” T peak requires to combine ECG leads into one-dimensional signal in which the T wave peak can be measured. This study aimed at finding the optimum one-dimensional representation of 12-lead ECGs for the most stable JTp measurements. Seven different one-dimensional representations were investigated including the vector magnitude of the orthogonal XYZ transformation, root mean square of all 12 ECG leads, and the vector magnitude of the 3 dominant orthogonal leads derived by singular value decomposition. All representations were applied to the median waveforms of 660,657 separate 10-s 12-lead ECGs taken from repeated day-time Holter recordings in 523 healthy subjects aged 33.5 ± 8.4 years (254 women). The JTp measurements were compared with the QT intervals and with the intervals between the J point and the median point of the area under the T wave one-dimensional representation (JT50 intervals) by means of calculating the residuals of the subject-specific curvilinear regression models relating the measured interval to the hysteresis-corrected RR interval of the underlying heart rate. The residuals of the regression models (equal to the intra-subject standard deviations of individually heart rate corrected intervals) expressed intra-subject stability of interval measurements. For both the JTp intervals and the JT50 intervals, the curvilinear regression residuals of measurements derived from the orthogonal XYZ representation were marginally but statistically significantly lower compared to the other representations. Using the XYZ representation, the residuals of the QT/RR, JTp/RR and JT50/RR regressions were 5.6 ± 1.1 ms, 7.2 ± 2.2 ms, and 4.9 ± 1.2 ms, respectively (all statistically significantly different; p < 0.0001). The study concludes that the orthogonal XYZ ECG representation might be proposed for future investigations of JTp and JT50 intervals. If the ability of classifying QT prolonging drugs is further confirmed for the JT50 interval, it might be appropriate to replace the JTp interval since with JT50 it appears more stable.
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Affiliation(s)
- Katerina Hnatkova
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Jose Vicente
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food & Drug Administration, Silver Spring, MD, United States
| | - Lars Johannesen
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food & Drug Administration, Silver Spring, MD, United States
| | - Christine Garnett
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food & Drug Administration, Silver Spring, MD, United States
| | - David G Strauss
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food & Drug Administration, Silver Spring, MD, United States
| | - Marek Malik
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Hnatkova K, Vicente J, Johannesen L, Garnett C, Stockbridge N, Malik M. Errors of Fixed QT Heart Rate Corrections Used in the Assessment of Drug-Induced QTc Changes. Front Physiol 2019; 10:635. [PMID: 31275152 PMCID: PMC6591442 DOI: 10.3389/fphys.2019.00635] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 05/06/2019] [Indexed: 02/06/2023] Open
Abstract
The accuracy of studies of drug-induced QTc changes depends, among others, on the accuracy of heart rate correction of QT interval. It has been recognized that when a drug leads to substantial heart rate changes, fixed universal corrections cannot be used and that alternative methods such as subject-specific corrections established for each study participant need to be considered. Nevertheless, the maximum heart rate change that permits use of fixed correction with reasonable accuracy has not been systematically investigated. We have therefore used full QT/heart-rate profiles of 751 healthy subjects (mean age 34.2 ± 9.6, range 18–61 years, 335 females) and compared their subject-specific corrections with 6 fixed corrections, namely Bazett, Fridericia, Framingham, Hodges, Rautaharju, and Sarma formulae. The comparison was based on statistical modeling experiments which simulated clinical studies of N = 10 or N = 50 female or male subjects. The experiments compared errors of ΔQTc intervals calculated as differences between QTc intervals at an initial heart rate (in the range of 40 to 120 beats per minute, bpm) and after a heart rate change (in the range from −20 to +20 bpm). The experiments also investigated errors due to spontaneous heart rate fluctuation and due to omission of correction for QT/RR hysteresis. In each experiment, the absolute value of the single-sided 90th percentile most remote from zero was used as the error estimate. Each experiment was repeated 10,000 times with random selection of modeled study group. From these repetitions, median and upper 80th percentile was derived and graphically displayed for all different combinations of initial heart rate and heart rate change. The results showed that Fridericia formula might be reasonable (with estimated errors of ΔQTc below 8 ms) in large studies if the heart rate does not change more than ± 10 bpm and that the errors by fixed corrections and the errors due to omission of QR/RR hysteresis are additive. Additionally, the results suggest that the variability introduced into QTc data by not correcting for the underlying heart rate accurately might have a greater impact in smaller studies. The errors by Framingham formula were practically the same as with the Fridericia formula. Other investigated fixed heart rate corrections led to larger ΔQTc errors.
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Affiliation(s)
- Katerina Hnatkova
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Jose Vicente
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Lars Johannesen
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Christine Garnett
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Marek Malik
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Malik M, Garnett C, Hnatkova K, Vicente J, Johannesen L, Stockbridge N. Correction to: Implications of Individual QT/RR Profiles-Part 1: Inaccuracies and Problems of Population-Specific QT/Heart Rate Corrections. Drug Saf 2019; 42:473. [PMID: 30852794 PMCID: PMC6426817 DOI: 10.1007/s40264-019-00801-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The Open Access license, which previously read.
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Affiliation(s)
- Marek Malik
- National Heart and Lung Institute, Imperial College, Dovehouse Street, London, SW3 6LY, England, UK.
| | - Christine Garnett
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Katerina Hnatkova
- National Heart and Lung Institute, Imperial College, Dovehouse Street, London, SW3 6LY, England, UK
| | - Jose Vicente
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Lars Johannesen
- Division of Clinical Pharmacology I, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
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Malik M, Garnett C, Hnatkova K, Vicente J, Johannesen L, Stockbridge N. Correction to: Implications of Individual QT/RR Profiles-Part 2: Zero QTc/RR Correlations Do Not Prove QTc Correction Accuracy in Studies of QTc Changes. Drug Saf 2019; 42:475. [PMID: 30725335 PMCID: PMC6426818 DOI: 10.1007/s40264-019-00802-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License which permits unrestricted use.
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Affiliation(s)
- Marek Malik
- National Heart and Lung Institute, Imperial College, Dovehouse Street, London, SW3 6LY, England, UK.
| | - Christine Garnett
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Katerina Hnatkova
- National Heart and Lung Institute, Imperial College, Dovehouse Street, London, SW3 6LY, England, UK
| | - Jose Vicente
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Lars Johannesen
- Division of Clinical Pharmacology I, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
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Vicente J, Zusterzeel R, Johannesen L, Ochoa-Jimenez R, Mason JW, Sanabria C, Kemp S, Sager PT, Patel V, Matta MK, Liu J, Florian J, Garnett C, Stockbridge N, Strauss DG. Assessment of Multi-Ion Channel Block in a Phase I Randomized Study Design: Results of the CiPA Phase I ECG Biomarker Validation Study. Clin Pharmacol Ther 2019; 105:943-953. [PMID: 30447156 PMCID: PMC6654598 DOI: 10.1002/cpt.1303] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/20/2018] [Indexed: 11/24/2022]
Abstract
Balanced multi‐ion channel‐blocking drugs have low torsade risk because they block inward currents. The Comprehensive In Vitro Proarrhythmia Assay (CiPA) initiative proposes to use an in silico cardiomyocyte model to determine the presence of balanced block, and absence of heart rate corrected J‐Tpeak (J‐Tpeakc) prolongation would be expected for balanced blockers. This study included three balanced blockers in a 10‐subject‐per‐drug parallel design; lopinavir/ritonavir and verapamil met the primary end point of ΔΔJ‐Tpeakc upper bound < 10 ms, whereas ranolazine did not (upper bounds of 8.8, 6.1, and 12.0 ms, respectively). Chloroquine, a predominant blocker of the potassium channel encoded by the ether‐à‐go‐go related gene (hERG), prolonged ΔΔQTc and ΔΔJ‐Tpeakc by ≥ 10 ms. In a separate crossover design, diltiazem (calcium block) did not shorten dofetilide‐induced ΔQTc prolongation, but shortened ΔJ‐Tpeakc and prolonged ΔTpeak‐Tend. Absence of J‐Tpeakc prolongation seems consistent with balanced block; however, small sample size (10 subjects) may be insufficient to characterize concentration‐response in some cases.
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Affiliation(s)
- Jose Vicente
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robbert Zusterzeel
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lars Johannesen
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Roberto Ochoa-Jimenez
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jay W Mason
- Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City, Utah, USA.,Spaulding Clinical Research, West Bend, Wisconsin, USA
| | | | - Sarah Kemp
- Spaulding Clinical Research, West Bend, Wisconsin, USA
| | | | - Vikram Patel
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Murali K Matta
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jiang Liu
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jeffry Florian
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Christine Garnett
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Norman Stockbridge
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - David G Strauss
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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Hosseini M, Vicente J, Johannesen L, Wong A, McAfee DC, Stockbridge N, Strauss DG. Map of thorough QT studies with QTc and J-T peak c biomarkers. J Electrocardiol 2018. [DOI: 10.1016/j.jelectrocard.2017.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Vicente J, Zusterzeel R, Johannesen L, Mason J, Sager P, Patel V, Matta MK, Li Z, Liu J, Garnett C, Stockbridge N, Zineh I, Strauss DG. Mechanistic Model-Informed Proarrhythmic Risk Assessment of Drugs: Review of the "CiPA" Initiative and Design of a Prospective Clinical Validation Study. Clin Pharmacol Ther 2018; 103:54-66. [PMID: 28986934 DOI: 10.1002/cpt.v103.110.1002/cpt.896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 09/20/2017] [Accepted: 10/01/2017] [Indexed: 05/26/2023]
Abstract
The Comprehensive in vitro Proarrhythmia Assay (CiPA) initiative is developing and validating a mechanistic-based assessment of the proarrhythmic risk of drugs. CiPA proposes to assess a drug's effect on multiple ion channels and integrate the effects in a computer model of the human cardiomyocyte to predict proarrhythmic risk. Unanticipated or missed effects will be assessed with human stem cell-derived cardiomyocytes and electrocardiogram (ECG) analysis in early phase I clinical trials. This article provides an overview of CiPA and the rationale and design of the CiPA phase I ECG validation clinical trial, which involves assessing an additional ECG biomarker (J-Tpeak) for QT prolonging drugs. If successful, CiPA will 1) create a pathway for drugs with hERG block / QT prolongation to advance without intensive ECG monitoring in phase III trials if they have low proarrhythmic risk; and 2) enable updating drug labels to be more informative about proarrhythmic risk, not just QT prolongation.
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Affiliation(s)
- Jose Vicente
- Office of New Drugs, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robbert Zusterzeel
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lars Johannesen
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jay Mason
- Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City, Utah, USA
- Spaulding Clinical Research, West Bend, Wisconsin, USA
| | | | - Vikram Patel
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Murali K Matta
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Zhihua Li
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jiang Liu
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Christine Garnett
- Office of New Drugs, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Norman Stockbridge
- Office of New Drugs, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Issam Zineh
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - David G Strauss
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
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12
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Daluwatte C, Galeotti L, Vicente J, Johannesen L, Strauss DG, Scully CG. Relationship between ECG beat detector performance over short time intervals and correct detection of arrhythmic events. J Electrocardiol 2018. [DOI: 10.1016/j.jelectrocard.2017.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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13
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Johannesen L, Garnett C, Luo M, Targum S, Sørensen JS, Mehrotra N. Quantitative Understanding of QTc Prolongation and Gender as Risk Factors for Torsade de Pointes. Clin Pharmacol Ther 2017; 103:304-309. [PMID: 29219167 DOI: 10.1002/cpt.783] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 06/20/2017] [Accepted: 06/27/2017] [Indexed: 12/19/2022]
Abstract
Several risk factors for development of a potentially fatal ventricular arrhythmia, torsade de pointes, have been observed, including female gender. However, in most investigations, only few torsade events were included and/or rarely were postdose heart rate corrected QT (QTc) measurements included, as a surrogate of drug exposure. We developed a multivariate logistic regression model using data from 22,214 patients (33% women) with 84 torsade events (56% women) to evaluate the relationship between risk factors for torsade using data from four anti-arrhythmic drug development programs. Before model development, we evaluated different QT/QTc postdose metrics (average, maximum, etc.) to determine which QT metric should be included into the model. The developed multivariate model showed that, after accounting for known risk factors for torsade and postdose QTc, that female gender remained a significant risk factor for torsade.
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Affiliation(s)
- Lars Johannesen
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Christine Garnett
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Man Luo
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Shari Targum
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jens Stampe Sørensen
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Nitin Mehrotra
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
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14
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Vicente J, Zusterzeel R, Johannesen L, Mason J, Sager P, Patel V, Matta MK, Li Z, Liu J, Garnett C, Stockbridge N, Zineh I, Strauss DG. Mechanistic Model-Informed Proarrhythmic Risk Assessment of Drugs: Review of the "CiPA" Initiative and Design of a Prospective Clinical Validation Study. Clin Pharmacol Ther 2017; 103:54-66. [PMID: 28986934 PMCID: PMC5765372 DOI: 10.1002/cpt.896] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 09/20/2017] [Accepted: 10/01/2017] [Indexed: 12/19/2022]
Abstract
The Comprehensive in vitro Proarrhythmia Assay (CiPA) initiative is developing and validating a mechanistic‐based assessment of the proarrhythmic risk of drugs. CiPA proposes to assess a drug's effect on multiple ion channels and integrate the effects in a computer model of the human cardiomyocyte to predict proarrhythmic risk. Unanticipated or missed effects will be assessed with human stem cell‐derived cardiomyocytes and electrocardiogram (ECG) analysis in early phase I clinical trials. This article provides an overview of CiPA and the rationale and design of the CiPA phase I ECG validation clinical trial, which involves assessing an additional ECG biomarker (J‐Tpeak) for QT prolonging drugs. If successful, CiPA will 1) create a pathway for drugs with hERG block / QT prolongation to advance without intensive ECG monitoring in phase III trials if they have low proarrhythmic risk; and 2) enable updating drug labels to be more informative about proarrhythmic risk, not just QT prolongation.
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Affiliation(s)
- Jose Vicente
- Office of New Drugs, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robbert Zusterzeel
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lars Johannesen
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jay Mason
- Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City, Utah, USA.,Spaulding Clinical Research, West Bend, Wisconsin, USA
| | | | - Vikram Patel
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Murali K Matta
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Zhihua Li
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jiang Liu
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Christine Garnett
- Office of New Drugs, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Norman Stockbridge
- Office of New Drugs, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Issam Zineh
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - David G Strauss
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
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15
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Daluwatte C, Galeotti L, Johannesen L, Scully CG, Strauss DG, Vicente J. Relationship between ECG beat detector performance over short time intervals and correct detection of arrhythmic events. J Electrocardiol 2017. [DOI: 10.1016/j.jelectrocard.2017.08.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Vicente J, Hosseini M, Johannesen L, Strauss DG. Electrocardiographic biomarkers to confirm drug's electrophysiological effects used for proarrhythmic risk prediction under CiPA. J Electrocardiol 2017; 50:808-813. [DOI: 10.1016/j.jelectrocard.2017.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Indexed: 10/19/2022]
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17
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Daluwatte C, Vicente J, Galeotti L, Johannesen L, Strauss DG, Scully CG. A novel ECG detector performance metric and its relationship with missing and false heart rate limit alarms. J Electrocardiol 2017; 51:68-73. [PMID: 28964425 DOI: 10.1016/j.jelectrocard.2017.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE Performance of ECG beat detectors is traditionally assessed on long intervals (e.g.: 30min), but only incorrect detections within a short interval (e.g.: 10s) may cause incorrect (i.e., missed+false) heart rate limit alarms (tachycardia and bradycardia). We propose a novel performance metric based on distribution of incorrect beat detection over a short interval and assess its relationship with incorrect heart rate limit alarm rates. BASIC PROCEDURES Six ECG beat detectors were assessed using performance metrics over long interval (sensitivity and positive predictive value over 30min) and short interval (Area Under empirical cumulative distribution function (AUecdf) for short interval (i.e., 10s) sensitivity and positive predictive value) on two ECG databases. False heart rate limit and asystole alarm rates calculated using a third ECG database were then correlated (Spearman's rank correlation) with each calculated performance metric. MAIN FINDINGS False alarm rates correlated with sensitivity calculated on long interval (i.e., 30min) (ρ=-0.8 and p<0.05) and AUecdf for sensitivity (ρ=0.9 and p<0.05) in all assessed ECG databases. Sensitivity over 30min grouped the two detectors with lowest false alarm rates while AUecdf for sensitivity provided further information to identify the two beat detectors with highest false alarm rates as well, which was inseparable with sensitivity over 30min. PRINCIPAL CONCLUSIONS Short interval performance metrics can provide insights on the potential of a beat detector to generate incorrect heart rate limit alarms.
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Affiliation(s)
- Chathuri Daluwatte
- Office of Science and Engineering Laboratories, CDRH, US FDA, Silver Spring, MD, USA.
| | - Jose Vicente
- Office of New Drugs, CDER, US FDA, Silver Spring, MD, USA
| | - Loriano Galeotti
- Office of Device Evaluation, CDRH, US FDA, Silver Spring, MD, USA
| | - Lars Johannesen
- Office of Clinical Pharmacology, CDER, US FDA, Silver Spring, MD, USA
| | - David G Strauss
- Office of Clinical Pharmacology, CDER, US FDA, Silver Spring, MD, USA
| | - Christopher G Scully
- Office of Science and Engineering Laboratories, CDRH, US FDA, Silver Spring, MD, USA
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18
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Blinova K, Patel D, Stohlman J, Schocken D, Kondratovich M, Johannesen L, Vicente J, Strauss D. Abstract 56: Individual Susceptibility to Drug-induced QTc Prolongation Did Not Correlate With Subject-specific Induced Pluripotent Stem Cells in a Small Sample of Healthy Subjects. Circ Res 2017. [DOI: 10.1161/res.121.suppl_1.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Induced pluripotent stem cells (iPSCs) carry patient-specific genetic information and have the potential to become an important tool for predicting individual clinical response to therapies in an
in vitro
assay. Here, we investigate if subject-specific iPSC cardiomyocytes (iPSC-CMs) derived from healthy volunteers could be used to predict individual response to 2 QT-prolonging drugs which they received in a clinical trial.
Methods and Results:
Independent stem cell manufacturer (Stem Cell Theranostics) used commercially available Sendai virus encoding for
Oct4
,
Sox2
,
Klf4
, and
c-Myc
to reprogram subject’s peripheral blood mononuclear cells (PBMCs) into iPSCs. They then applied chemically defined growth factors, and serum-free protocols to successfully differentiate iPSCs into iPSC-CMs for 17 out of 20 subjects (one batch per subject) enrolled in a randomized, double-blind, placebo-controlled, cross-over trial of dofetilide and moxifloxacin. Effects of the same 2 drugs on cellular action potential duration (APD) were recorded for 16 iPSC-CMs lines using a high-throughput optical imaging system (CellOPTIQ, Clyde Biosciences) using consistent
in vitro
protocols, including reproducible drug doses and exposure, cell culture and recording conditions. Both dofetilide (0.5-8 nM) and moxifloxacin (10-200 μM) induced dose-dependent prolongation of rate-corrected action potential duration (APD) in each iPSC-CM line. iPSC-CM drug responses were compared with individual clinical response represented by the slope of the linear regression fit through baseline and placebo-controlled drug-induced changes in QTc interval vs. plasma drug concentration. We found no statistical significant correlation between subject-specific iPSC-CMs drug-induced APD prolongation and individual QTc prolongation to either moxifloxacin [Spearman’s ρ = 0.191] or dofetilide [Spearman’s ρ = 0.068].
Conclusion:
This study failed to find correlation between clinical and stem cell drug responses in a small sample of healthy subjects. More experiments with a larger sample size and iPSC-CMs batch-to-batch variability controls are required to further investigate the potential of patient-derived stem cells to predict individual clinical response.
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Strauss DG, Vicente J, Johannesen L, Blinova K, Mason JW, Weeke P, Behr ER, Roden DM, Woosley R, Kosova G, Rosenberg MA, Newton-Cheh C. Common Genetic Variant Risk Score Is Associated With Drug-Induced QT Prolongation and Torsade de Pointes Risk: A Pilot Study. Circulation 2017; 135:1300-1310. [PMID: 28213480 DOI: 10.1161/circulationaha.116.023980] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 01/26/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Drug-induced QT interval prolongation, a risk factor for life-threatening ventricular arrhythmias, is a potential side effect of many marketed and withdrawn medications. The contribution of common genetic variants previously associated with baseline QT interval to drug-induced QT prolongation and arrhythmias is not known. METHODS We tested the hypothesis that a weighted combination of common genetic variants contributing to QT interval at baseline, identified through genome-wide association studies, can predict individual response to multiple QT-prolonging drugs. Genetic analysis of 22 subjects was performed in a secondary analysis of a randomized, double-blind, placebo-controlled, crossover trial of 3 QT-prolonging drugs with 15 time-matched QT and plasma drug concentration measurements. Subjects received single doses of dofetilide, quinidine, ranolazine, and placebo. The outcome was the correlation between a genetic QT score comprising 61 common genetic variants and the slope of an individual subject's drug-induced increase in heart rate-corrected QT (QTc) versus drug concentration. RESULTS The genetic QT score was correlated with drug-induced QTc prolongation. Among white subjects, genetic QT score explained 30% of the variability in response to dofetilide (r=0.55; 95% confidence interval, 0.09-0.81; P=0.02), 23% in response to quinidine (r=0.48; 95% confidence interval, -0.03 to 0.79; P=0.06), and 27% in response to ranolazine (r=0.52; 95% confidence interval, 0.05-0.80; P=0.03). Furthermore, the genetic QT score was a significant predictor of drug-induced torsade de pointes in an independent sample of 216 cases compared with 771 controls (r2=12%, P=1×10-7). CONCLUSIONS We demonstrate that a genetic QT score comprising 61 common genetic variants explains a significant proportion of the variability in drug-induced QT prolongation and is a significant predictor of drug-induced torsade de pointes. These findings highlight an opportunity for recent genetic discoveries to improve individualized risk-benefit assessment for pharmacological therapies. Replication of these findings in larger samples is needed to more precisely estimate variance explained and to establish the individual variants that drive these effects. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01873950.
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Affiliation(s)
- David G Strauss
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.).
| | - Jose Vicente
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Lars Johannesen
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Ksenia Blinova
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Jay W Mason
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Peter Weeke
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Elijah R Behr
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Dan M Roden
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Ray Woosley
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Gulum Kosova
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Michael A Rosenberg
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.)
| | - Christopher Newton-Cheh
- From Office of Clinical Pharmacology, Center for Drug Evaluation and Research (D.G.S., J.V., L.J.) and Office of Science and Engineering Laboratories, Center for Devices and Radiological Health (D.G.S., J.V., L.J., K.B.), US Food and Drug Administration, Silver Spring, MD; BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Spain (J.V.); Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J.); Division of Cardiology, University of Utah, Salt Lake City (J.W.M.); Spaulding Clinical Research, West Bend, WI (J.W.M.); Departments of Medicine (P.W., D.R.), Pharmacology (D.R.), and Biomedical Informatics (D.R.), Vanderbilt University Medical Center, Nashville, TN; Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark (P.W.); Cardiology Clinical Academic Group, St. George's University of London, London, UK (E.R.B.); AZCERT, Inc, Oro Valley, AZ (R.W.); Center for Genomic Medicine and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA (G.K., M.A.R., C.N.-C.); Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (G.K., M.A.R., C.N.-C.); and Division of Cardiac Electrophysiology, Veterans Administration Hospital System of Boston, Harvard Medical School, West Roxbury, MA (M.A.R.).
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20
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Johannesen L, Vicente J, Hosseini M, Strauss DG. Automated Algorithm for J-Tpeak and Tpeak-Tend Assessment of Drug-Induced Proarrhythmia Risk. PLoS One 2016; 11:e0166925. [PMID: 28036330 PMCID: PMC5201230 DOI: 10.1371/journal.pone.0166925] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 11/07/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Prolongation of the heart rate corrected QT (QTc) interval is a sensitive marker of torsade de pointes risk; however it is not specific as QTc prolonging drugs that block inward currents are often not associated with torsade. Recent work demonstrated that separate analysis of the heart rate corrected J-Tpeakc (J-Tpeakc) and Tpeak-Tend intervals can identify QTc prolonging drugs with inward current block and is being proposed as a part of a new cardiac safety paradigm for new drugs (the "CiPA" initiative). METHODS In this work, we describe an automated measurement methodology for assessment of the J-Tpeakc and Tpeak-Tend intervals using the vector magnitude lead. The automated measurement methodology was developed using data from one clinical trial and was evaluated using independent data from a second clinical trial. RESULTS Comparison between the automated and the prior semi-automated measurements shows that the automated algorithm reproduces the semi-automated measurements with a mean difference of single-deltas <1 ms and no difference in intra-time point variability (p for all > 0.39). In addition, the time-profile of the baseline and placebo-adjusted changes are within 1 ms for 63% of the time-points (86% within 2 ms). Importantly, the automated results lead to the same conclusions about the electrophysiological mechanisms of the studied drugs. CONCLUSIONS We have developed an automated algorithm for assessment of J-Tpeakc and Tpeak-Tend intervals that can be applied in clinical drug trials. Under the CiPA initiative this ECG assessment would determine if there are unexpected ion channel effects in humans compared to preclinical studies. The algorithm is being released as open-source software. TRIAL REGISTRATION NCT02308748 and NCT01873950.
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Affiliation(s)
- Lars Johannesen
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, United States of America
- * E-mail: (DGS); (LJ)
| | - Jose Vicente
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, United States of America
- BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Zaragoza, Spain
| | - Meisam Hosseini
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, United States of America
| | - David G. Strauss
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, United States of America
- * E-mail: (DGS); (LJ)
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21
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Vicente J, Johannesen L, Hosseini M, Mason JW, Sager PT, Pueyo E, Strauss DG. Electrocardiographic Biomarkers for Detection of Drug-Induced Late Sodium Current Block. PLoS One 2016; 11:e0163619. [PMID: 28036334 PMCID: PMC5201270 DOI: 10.1371/journal.pone.0163619] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 09/12/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Drugs that prolong the heart rate corrected QT interval (QTc) on the electrocardiogram (ECG) by blocking the hERG potassium channel and also block inward currents (late sodium or L-type calcium) are not associated with torsade de pointes (e.g. ranolazine and verapamil). Thus, identifying ECG signs of late sodium current block could aid in the determination of proarrhythmic risk for new drugs. A new cardiac safety paradigm for drug development (the "CiPA" initiative) will involve the preclinical assessment of multiple human cardiac ion channels and ECG biomarkers are needed to determine if there are unexpected ion channel effects in humans. METHODS AND RESULTS In this study we assess the ability of eight ECG morphology biomarkers to detect late sodium current block in the presence of QTc prolongation by analyzing a clinical trial where a selective hERG potassium channel blocker (dofetilide) was administered alone and then in combination with two late sodium current blockers (lidocaine and mexiletine). We demonstrate that late sodium current block has the greatest effect on the heart-rate corrected J-Tpeak interval (J-Tpeakc), followed by QTc and then T-wave flatness. Furthermore, J-Tpeakc is the only biomarker that improves detection of the presence of late sodium current block compared to using QTc alone (AUC: 0.83 vs. 0.72 respectively, p<0.001). CONCLUSIONS Analysis of the J-Tpeakc interval can differentiate drug-induced multichannel block involving the late sodium current from selective hERG potassium channel block. Future methodologies assessing drug effects on cardiac ion channel currents on the ECG should use J-Tpeakc to detect the presence of late sodium current block. TRIAL REGISTRATION NCT02308748 and NCT01873950.
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Affiliation(s)
- Jose Vicente
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, United States of America
- Division of Biomedical Physics, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD, United States of America
- BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Zaragoza, Spain
| | - Lars Johannesen
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, United States of America
| | - Meisam Hosseini
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, United States of America
- Division of Biomedical Physics, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD, United States of America
| | - Jay W. Mason
- Cardiology Division, University of Utah, Salt Lake City, UT, United States of America
- Spaulding Clinical Research, West Bend, WI, United States of America
| | - Philip T. Sager
- Stanford University, Palo Alto, CA, United States of America
| | - Esther Pueyo
- BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Zaragoza, Spain
- Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Zaragoza, Spain
| | - David G. Strauss
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, United States of America
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22
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Blinova K, Stohlman J, Vicente J, Chan D, Johannesen L, Hortigon-Vinagre MP, Zamora V, Smith G, Crumb WJ, Pang L, Lyn-Cook B, Ross J, Brock M, Chvatal S, Millard D, Galeotti L, Stockbridge N, Strauss DG. Comprehensive Translational Assessment of Human-Induced Pluripotent Stem Cell Derived Cardiomyocytes for Evaluating Drug-Induced Arrhythmias. Toxicol Sci 2016; 155:234-247. [PMID: 27701120 DOI: 10.1093/toxsci/kfw200] [Citation(s) in RCA: 176] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Induced pluripotent stem cell-derived cardiomyocytes (iPSC-CM) hold promise for assessment of drug-induced arrhythmias and are being considered for use under the comprehensive in vitro proarrhythmia assay (CiPA). We studied the effects of 26 drugs and 3 drug combinations on 2 commercially available iPSC-CM types using high-throughput voltage-sensitive dye and microelectrode-array assays being studied for the CiPA initiative and compared the results with clinical QT prolongation and torsade de pointes (TdP) risk. Concentration-dependent analysis comparing iPSC-CMs to clinical trial results demonstrated good correlation between drug-induced rate-corrected action potential duration and field potential duration (APDc and FPDc) prolongation and clinical trial QTc prolongation. Of 20 drugs studied that exhibit clinical QTc prolongation, 17 caused APDc prolongation (16 in Cor.4U and 13 in iCell cardiomyocytes) and 16 caused FPDc prolongation (16 in Cor.4U and 10 in iCell cardiomyocytes). Of 14 drugs that cause TdP, arrhythmias occurred with 10 drugs. Lack of arrhythmic beating in iPSC-CMs for the four remaining drugs could be due to differences in relative levels of expression of individual ion channels. iPSC-CMs responded consistently to human ether-a-go-go potassium channel blocking drugs (APD prolongation and arrhythmias) and calcium channel blocking drugs (APD shortening and prevention of arrhythmias), with a more variable response to late sodium current blocking drugs. Current results confirm the potential of iPSC-CMs for proarrhythmia prediction under CiPA, where iPSC-CM results would serve as a check to ion channel and in silico modeling prediction of proarrhythmic risk. A multi-site validation study is warranted.
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Affiliation(s)
- Ksenia Blinova
- US Food and Drug Administration, Center for Devices and Radiological Health, Office of Science and Engineering Laboratories, Silver Spring, Maryland;
| | - Jayna Stohlman
- US Food and Drug Administration, Center for Devices and Radiological Health, Office of Science and Engineering Laboratories, Silver Spring, Maryland
| | - Jose Vicente
- US Food and Drug Administration, Center for Devices and Radiological Health, Office of Science and Engineering Laboratories, Silver Spring, Maryland.,US Food and Drug Administration, Center for Drug Evaluation and Research, Office of New Drugs, Silver Spring, Maryland.,BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Zaragoza, Spain
| | - Dulciana Chan
- US Food and Drug Administration, Center for Devices and Radiological Health, Office of Science and Engineering Laboratories, Silver Spring, Maryland
| | - Lars Johannesen
- US Food and Drug Administration, Center for Devices and Radiological Health, Office of Science and Engineering Laboratories, Silver Spring, Maryland
| | | | - Victor Zamora
- University of Glasgow, Glasgow, UK.,Clyde Biosciences, Glasgow, UK
| | - Godfrey Smith
- University of Glasgow, Glasgow, UK.,Clyde Biosciences, Glasgow, UK
| | | | - Li Pang
- Division of Biochemical Toxicology, US Food and Drug Administration, National Center for Toxicological Research, Jefferson, Arkansas
| | - Beverly Lyn-Cook
- Division of Biochemical Toxicology, US Food and Drug Administration, National Center for Toxicological Research, Jefferson, Arkansas
| | | | | | | | | | - Loriano Galeotti
- US Food and Drug Administration, Center for Devices and Radiological Health, Office of Science and Engineering Laboratories, Silver Spring, Maryland
| | - Norman Stockbridge
- US Food and Drug Administration, Center for Drug Evaluation and Research, Office of New Drugs, Silver Spring, Maryland
| | - David G Strauss
- US Food and Drug Administration, Center for Devices and Radiological Health, Office of Science and Engineering Laboratories, Silver Spring, Maryland; .,US Food and Drug Administration, Center for Drug Evaluation and Research, Office of Clinical Pharmacology, Silver Spring, Maryland
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23
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Garnett C, Johannesen L. Commentary on: "Levofloxacin-Induced QTc Prolongation Depends on the Time of Drug Administration". CPT Pharmacometrics Syst Pharmacol 2016; 5:452-4. [PMID: 27647678 PMCID: PMC5036419 DOI: 10.1002/psp4.12128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 08/22/2016] [Indexed: 01/03/2023] Open
Abstract
Circadian variations in the corrected QT (QTc) interval have been documented in clinical trials. Animal models show circadian variations in expression of the cardiac ion channels that are necessary to maintain the heart's electrophysiological properties. Can these diurnal rhythms in QTc affect the ability of a drug to delay cardiac repolarization?
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Affiliation(s)
- C Garnett
- Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA.
| | - L Johannesen
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
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Crumb WJ, Vicente J, Johannesen L, Strauss DG. An evaluation of 30 clinical drugs against the comprehensive in vitro proarrhythmia assay (CiPA) proposed ion channel panel. J Pharmacol Toxicol Methods 2016; 81:251-62. [DOI: 10.1016/j.vascn.2016.03.009] [Citation(s) in RCA: 178] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 03/28/2016] [Accepted: 03/30/2016] [Indexed: 02/05/2023]
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25
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Blinova K, Stohlman J, Vicente J, Chan D, Hortigon M, Rodriguez VZ, Smith G, Ross J, Brock M, Chvatal S, Millard D, Johannesen L, Galeotti L, Pang L, Lyn-Cook B, Crumb W, Stockbridge N, Strauss D. Comprehensive assessment of multiple induced pluripotent stem cell-derived cardiomyocyte cell lines with microelectrode arrays and voltage sensitive dyes. J Pharmacol Toxicol Methods 2016. [DOI: 10.1016/j.vascn.2016.02.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Daluwatte C, Johannesen L, Galeotti L, Vicente J, Strauss DG, Scully CG. Assessing ECG signal quality indices to discriminate ECGs with artefacts from pathologically different arrhythmic ECGs. Physiol Meas 2016; 37:1370-82. [PMID: 27454007 DOI: 10.1088/0967-3334/37/8/1370] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
False and non-actionable alarms in critical care can be reduced by developing algorithms which assess the trueness of an arrhythmia alarm from a bedside monitor. Computational approaches that automatically identify artefacts in ECG signals are an important branch of physiological signal processing which tries to address this issue. Signal quality indices (SQIs) derived considering differences between artefacts which occur in ECG signals and normal QRS morphology have the potential to discriminate pathologically different arrhythmic ECG segments as artefacts. Using ECG signals from the PhysioNet/Computing in Cardiology Challenge 2015 training set, we studied previously reported ECG SQIs in the scientific literature to differentiate ECG segments with artefacts from arrhythmic ECG segments. We found that the ability of SQIs to discriminate between ECG artefacts and arrhythmic ECG varies based on arrhythmia type since the pathology of each arrhythmic ECG waveform is different. Therefore, to reduce the risk of SQIs classifying arrhythmic events as noise it is important to validate and test SQIs with databases that include arrhythmias. Arrhythmia specific SQIs may also minimize the risk of misclassifying arrhythmic events as noise.
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Affiliation(s)
- C Daluwatte
- Office of Science and Engineering Laboratories, CDRH, US FDA, Silver Spring, MD, USA
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Schocken D, Stohlman J, Zhang X, Abassi Y, Johannesen L, Vicente J, Strauss D, Blinova K. Abstract 384: Evaluating Late Sodium Current in Human Induced Pluripotent Stem Cell Derived Cardiomyocytes. Circ Res 2016. [DOI: 10.1161/res.119.suppl_1.384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Inhibiting late sodium current (I
NaL
) reduced drug-induced QTc prolongation in a recent clinical trial. Induced pluripotent stem cell derived cardiomyocytes (iPSC-CMs) have emerged as a valuable tool in preclinical assessment of multichannel blocking drugs’ potential to prolong QT and induce arrhythmias. However, sodium channels in commercially available iPSC-CMs are known to be under expressed, necessitating investigation into the presence and effects of I
NaL
in this electrophysiological model.
Methods and Results:
A platform combining simultaneous measurements of field potential and contraction (xCELLigence RTCA CardioECR, ACEA Biosciences) was used to assess the acute effects of three I
NaL
enhancing drugs, ATX-II, ibutilide, and alfuzosin, given alone or in combination with an I
NaL
blocker, lidocaine in iPSC-CMs (iCell Cardiomyocytes
2
, Cellular Dynamics). Additionally, dofetilide, diltiazem, and lidocaine alone were included as positive controls for hERG, L-type calcium, and sodium channel block.
ATX-II, a potent and specific I
NaL
enhancer, caused significant dose dependent rate-corrected field potential duration (FPDc) prolongation, which was then subsequently reduced in a dose dependent manner by the addition of lidocaine. At 100 nM ATX-II prolonged the FPDc by 1153.8 ± 135.8 ms from 360.5 ± 16.4 ms at the baseline, which was then reduced to 537 ± 37.4 ms with the addition of 30 μM lidocaine. Ibutilide (0.1-1 μM), a class III antiarrhythmic, caused beating rate decreases and early after depolarizations (EADs) that were not affected by lidocaine addition. Alfuzosin, which increases both peak and late sodium currents, caused dose-dependent reduction of beating rate, FPDc prolongation, and EADs at 5 μM and 10 μM. Alfuzosin-induced EADs were mitigated by addition of lidocaine (5-15 μM).
Conclusions:
Late sodium current enhancers prolonged repolarization and induced arrhythmias in human iPSC-CMs. These effects were reversed by addition of lidocaine, a specific late sodium current blocker. These results are consistent with the late sodium current being present in iPSC-CMs in the presence of a late sodium current enhancer, which may have implications for drug safety testing.
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Stohlman J, Schocken D, Vicente J, Chan D, Johannesen L, Zhang X, Abassi Y, Strauss D, Blinova K. Abstract 234: Physiological Toxicity Assessment of Tyrosine Kinase Inhibitors with Human Induced Pluripotent Stem Cell Cardiomyocytes. Circ Res 2016. [DOI: 10.1161/res.119.suppl_1.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Tyrosine kinase inhibitors (TKIs) have improved targeted therapeutics for cancer management despite possible cardiac side effects, including decreased contractility. A combination microelectrode and impedance platform was used to assess field potential (FP) electrical activity and contractility, respectively, after acute and chronic exposure of six TKIs on human induced pluripotent stem cell derived cardiomyocytes (hiPSC-CMs). Four non-TKI drugs were tested to confirm assay sensitivity.
hERG current inhibitors dofetilide and pentamidine increased beat rate (BR) corrected FP duration (FPDc). Dofetilide (6μM) induced transient early afterdepolarizations (EADs), characterized as ectopic beats/notching in the FP signal, and decreased impedance amplitude (BAmp) at 48hrs. Multi-channel blocker amiodarone (2μM) acutely decreased FPDc, with quiescence up to 1hr, and increased BAmp after 24hrs. Doxorubicin decreased BAmp, inducing quiescence starting at 48hrs (5μM and 10μM). Nilotinib, sorafenib and sunitinib, which have varying documented risks of clinical QT prolongation and/or cardiotoxicity, increased FPDc. With highest tested doses, nilotinib (6μM) generated persistent EADs and increased BR, sunitinib (2.5μM) produced tachyarrhythmias with minimal impedance-evident contractions that recovered by 24hrs, and sorafenib (10μM) induced quiescence that recovered by 3hrs. Imatinib, erlotinib and lapatinib, which have fewer clinical cardtiotoxic effects, did not cause rhythm disturbances. Erlotinib and lapatinib had no significant effect on FPDc, lapatinib (2.5μM and 5μM) decreased BR, while imatinib (15μM) acutely increased FPDc and increased BR after 48hrs.
Tandem electrical and impedance screening in hiPSC-CMs for drug cardiotoxicity was consistent with the clinical experience for TKIs, suggesting its potential utility for preclinical cardiotoxicity assessment for proarrhythmia and decreased contractility.
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Ferber G, Johannesen L. A Comparison of Methods for Thorough QT Analysis for the Assessment of Cardiac Safety. Pharmaceut Med 2016. [DOI: 10.1007/s40290-015-0123-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Johannesen L, Vicente J, Mason JW, Erato C, Sanabria C, Waite-Labott K, Hong M, Lin J, Guo P, Mutlib A, Wang J, Crumb WJ, Blinova K, Chan D, Stohlman J, Florian J, Ugander M, Stockbridge N, Strauss DG. Late sodium current block for drug-induced long QT syndrome: Results from a prospective clinical trial. Clin Pharmacol Ther 2015; 99:214-23. [PMID: 26259627 DOI: 10.1002/cpt.205] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 08/05/2015] [Indexed: 12/19/2022]
Abstract
Drug-induced long QT syndrome has resulted in many drugs being withdrawn from the market. At the same time, the current regulatory paradigm for screening new drugs causing long QT syndrome is preventing drugs from reaching the market, sometimes inappropriately. In this study, we report the results of a first-of-a-kind clinical trial studying late sodium (mexiletine and lidocaine) and calcium (diltiazem) current blocking drugs to counteract the effects of hERG potassium channel blocking drugs (dofetilide and moxifloxacin). We demonstrate that both mexiletine and lidocaine substantially reduce heart-rate corrected QT (QTc) prolongation from dofetilide by 20 ms. Furthermore, all QTc shortening occurs in the heart-rate corrected J-Tpeak (J-Tpeak c) interval, the biomarker we identified as a sign of late sodium current block. This clinical trial demonstrates that late sodium blocking drugs can substantially reduce QTc prolongation from hERG potassium channel block and assessment of J-Tpeak c may add value beyond only assessing QTc.
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Affiliation(s)
- L Johannesen
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA.,Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - J Vicente
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA.,Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA.,BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Zaragoza, Spain
| | - J W Mason
- Spaulding Clinical, West Bend, Wisconsin, USA.,University of Utah, Salt Lake City, Utah, USA
| | - C Erato
- Spaulding Clinical, West Bend, Wisconsin, USA
| | - C Sanabria
- Spaulding Clinical, West Bend, Wisconsin, USA
| | | | - M Hong
- Frontage Laboratories, Exton, Pennsylvania, USA
| | - J Lin
- Frontage Laboratories, Exton, Pennsylvania, USA
| | - P Guo
- Frontage Laboratories, Exton, Pennsylvania, USA
| | - A Mutlib
- Frontage Laboratories, Exton, Pennsylvania, USA
| | - J Wang
- Frontage Laboratories, Exton, Pennsylvania, USA
| | - W J Crumb
- Zenas Technologies, Metairie, Louisiana, USA
| | - K Blinova
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - D Chan
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - J Stohlman
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - J Florian
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - M Ugander
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA.,Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - N Stockbridge
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - D G Strauss
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA.,Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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Vicente J, Johannesen L, Mason JW, Pueyo E, Stockbridge N, Strauss DG. Sex differences in drug-induced changes in ventricular repolarization. J Electrocardiol 2015; 48:1081-7. [DOI: 10.1016/j.jelectrocard.2015.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Indexed: 10/23/2022]
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Galeotti L, van Dam PM, Johannesen L, Vicente J, Strauss DG. Computer simulations to investigate the causes of T-wave notching. J Electrocardiol 2015; 48:927-32. [DOI: 10.1016/j.jelectrocard.2015.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Indexed: 11/30/2022]
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Galeotti L, Scully CG, Vicente J, Johannesen L, Strauss DG. Robust algorithm to locate heart beats from multiple physiological waveforms by individual signal detector voting. Physiol Meas 2015. [DOI: 10.1088/0967-3334/36/8/1705] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Blinova K, Stohlman J, Chan D, Hortigon M, Rodriquez VZ, Smith G, Crumb W, Pang L, Lyn-Cook B, Vicente J, Johannesen L, Stockbridge N, Stockbridge N, Strauss D. Abstract 245: Assessing Proarrhythmic Potential of Drugs Using Human Induced Pluripotent Stem Cell Derived Cardiomyocytes and Optical Recordings With Voltage-sensitive Dyes. Circ Res 2015. [DOI: 10.1161/res.117.suppl_1.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Drug-induced arrhythmias have been a leading reason for withdrawing drugs from the market and abandoning the development of new drugs. For the past decade FDA has required new drugs to be tested for block of the hERG potassium channel and QT interval prolongation. While these requirements have prevented arrhythmia-related drug recalls, some new drugs affecting multiple ion channels are being dropped from development inappropriately. Human induced pluripotent stem cell derived cardiomyocytes (iPS-CMs) are a new technology for preclinical risk assessment; however they have not been fully characterized or validated.
Methods:
We studied 26 drugs and 3 drug combinations that block multiple cardiac ion channels with two commercially available iPS-CM lines from Axiogenesis and Cellular Dynamics using optical recordings of action potentials with voltage-sensitive dyes. Drug-induced action potential duration (APD) prolongation was compared to clinical QT prolongation from two FDA-sponsored clinical trials. The effects of the drugs on multiple individual cardiac ion channels were assessed using manual patch clamp of overexpressed cell lines. Cardiac ion channel gene expression in the iPS-CMs was quantified and compared to primary human heart cell controls.
Results:
Of 19 drugs with an FDA label of clinical QT prolongation, 15 exhibited iPS-CM APD prolongation after acute drug exposure. None of the 6 drugs without clinical QT prolongation caused iPS-CM APD prolongation. Of 14 drugs with arrhythmia risk on the FDA label, nine caused arrhythmias in iPS-CMs. iPS-CM response had good correlation with clinical QT data for drugs that block hERG and calcium channels, while drugs blocking the late sodium current had variable response. This was in line with gene expression data, which showed most robust expression of hERG and calcium channels.
Conclusion:
Optical recordings from iPS-CMs with voltage sensitive dyes is a promising technology for high-throughput toxicity assessment for drug-induced arrhythmias. This study provides a comprehensive characterization of the cardiac ion channel properties of multiple commercially available iPS-CMs to support a potential new paradigm for assessing the arrhythmia risk of all new drugs.
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Affiliation(s)
| | | | | | | | | | | | | | - Li Pang
- US Food and Drug Administration, Jefferson, AR
| | | | - Jose Vicente
- US Food and Drug Administration, Silver Spring, MD
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Vicente J, Simlund J, Johannesen L, Sundh F, Florian J, Ugander M, Wagner GS, Woosley RL, Strauss DG. Investigation of potential mechanisms of sex differences in quinidine-induced torsade de pointes risk. J Electrocardiol 2015; 48:533-8. [DOI: 10.1016/j.jelectrocard.2015.03.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Indexed: 11/25/2022]
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Darpo B, Benson C, Dota C, Ferber G, Garnett C, Green CL, Jarugula V, Johannesen L, Keirns J, Krudys K, Liu J, Ortemann-Renon C, Riley S, Sarapa N, Smith B, Stoltz RR, Zhou M, Stockbridge N. Results from the IQ-CSRC prospective study support replacement of the thorough QT study by QT assessment in the early clinical phase. Clin Pharmacol Ther 2015; 97:326-35. [PMID: 25670536 DOI: 10.1002/cpt.60] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 11/24/2014] [Accepted: 11/25/2014] [Indexed: 11/09/2022]
Abstract
The QT effects of five "QT-positive" and one negative drug were tested to evaluate whether exposure-response analysis can detect QT effects in a small study with healthy subjects. Each drug was given to nine subjects (six for placebo) in two dose levels; positive drugs were chosen to cause 10 to 12 ms and 15 to 20 ms QTcF prolongation. The slope of the concentration/ΔQTc effect was significantly positive for ondansetron, quinine, dolasetron, moxifloxacin, and dofetilide. For the lower dose, an effect above 10 ms could not be excluded, i.e., the upper bound of the confidence interval for the predicted mean ΔΔQTcF effect was above 10 ms. For the negative drug, levocetirizine, a ΔΔQTcF effect above 10 ms was excluded at 6-fold the therapeutic dose. The study provides evidence that robust QT assessment in early-phase clinical studies can replace the thorough QT study.
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Affiliation(s)
- B Darpo
- Karolinska Institutet, Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd's Hospital, Stockholm, Sweden; iCardiac Technologies, Rochester, New York, USA
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Vicente J, Johannesen L, Mason JW, Crumb WJ, Pueyo E, Stockbridge N, Strauss DG. Comprehensive T wave morphology assessment in a randomized clinical study of dofetilide, quinidine, ranolazine, and verapamil. J Am Heart Assoc 2015; 4:e001615. [PMID: 25870186 PMCID: PMC4579946 DOI: 10.1161/jaha.114.001615] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Accepted: 03/06/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Congenital long QT syndrome type 2 (abnormal hERG potassium channel) patients can develop flat, asymmetric, and notched T waves. Similar observations have been made with a limited number of hERG-blocking drugs. However, it is not known how additional calcium or late sodium block, that can decrease torsade risk, affects T wave morphology. METHODS AND RESULTS Twenty-two healthy subjects received a single dose of a pure hERG blocker (dofetilide) and 3 drugs that also block calcium or sodium (quinidine, ranolazine, and verapamil) as part of a 5-period, placebo-controlled cross-over trial. At pre-dose and 15 time-points post-dose, ECGs and plasma drug concentration were assessed. Patch clamp experiments were performed to assess block of hERG, calcium (L-type) and late sodium currents for each drug. Pure hERG block (dofetilide) and strong hERG block with lesser calcium and late sodium block (quinidine) caused substantial T wave morphology changes (P<0.001). Strong late sodium current and hERG block (ranolazine) still caused T wave morphology changes (P<0.01). Strong calcium and hERG block (verapamil) did not cause T wave morphology changes. At equivalent QTc prolongation, multichannel blockers (quinidine and ranolazine) caused equal or greater T wave morphology changes compared with pure hERG block (dofetilide). CONCLUSIONS T wave morphology changes are directly related to amount of hERG block; however, with quinidine and ranolazine, multichannel block did not prevent T wave morphology changes. A combined approach of assessing multiple ion channels, along with ECG intervals and T wave morphology may provide the greatest insight into drug-ion channel interactions and torsade de pointes risk. CLINICAL TRIAL REGISTRATION URL: http://clinicaltrials.gov/ Unique identifier: NCT01873950.
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Affiliation(s)
- Jose Vicente
- Office of Science and Engineering Laboratories, CDRH, US FDA, Silver Spring, MD (J.V., L.J., E.P., D.G.S.)
- Division of Cardiovascular and Renal Products, Office of New Drugs, CDER, US FDA, Silver Spring, MD (J.V., N.S.)
- BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Zaragoza, Spain (J.V., E.P.)
| | - Lars Johannesen
- Office of Science and Engineering Laboratories, CDRH, US FDA, Silver Spring, MD (J.V., L.J., E.P., D.G.S.)
- Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J., D.G.S.)
| | - Jay W. Mason
- Spaulding Clinical Research, West Bend, WI (J.W.M.)
| | | | - Esther Pueyo
- Office of Science and Engineering Laboratories, CDRH, US FDA, Silver Spring, MD (J.V., L.J., E.P., D.G.S.)
- BSICoS Group, Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, Zaragoza, Spain (J.V., E.P.)
- Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER‐BBN), Zaragoza, Spain (E.P.)
| | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, Office of New Drugs, CDER, US FDA, Silver Spring, MD (J.V., N.S.)
| | - David G. Strauss
- Office of Science and Engineering Laboratories, CDRH, US FDA, Silver Spring, MD (J.V., L.J., E.P., D.G.S.)
- Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.J., D.G.S.)
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Johannesen L, Garnett C, Malik M. Impact of Electrocardiographic Data Quality on Moxifloxacin Response in Thorough QT/QTc Studies. Drug Saf 2014; 37:183-9. [DOI: 10.1007/s40264-014-0142-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Darpo B, Sarapa N, Garnett C, Benson C, Dota C, Ferber G, Jarugula V, Johannesen L, Keirns J, Krudys K, Ortemann-Renon C, Riley S, Rogers-Subramaniam D, Stockbridge N. The IQ-CSRC prospective clinical Phase 1 study: "Can early QT assessment using exposure response analysis replace the thorough QT study?". Ann Noninvasive Electrocardiol 2013; 19:70-81. [PMID: 24372708 DOI: 10.1111/anec.12128] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
A collaboration between the Consortium for Innovation and Quality in Pharmaceutical Development and the Cardiac Safety Research Consortium has been formed to design a clinical study in healthy subjects demonstrating that the thorough QT (TQT) study can be replaced by robust ECG monitoring and exposure-response (ER) analysis of data generated from First-in-Man single ascending dose (SAD) studies. Six marketed drugs with well-characterized QTc effects were identified in discussions with FDA; five have caused QT prolongation above the threshold of regulatory concern. Twenty healthy subjects will be enrolled in a randomized, placebo-controlled study designed with the intent to have similar power to exclude small QTc effects as a SAD study. Two doses (low and high) of each drug will be given on separate, consecutive days to 9 subjects. Six subjects will receive placebo. Data will be analyzed using linear mixed-effects ER models. Criteria for QT-positive drugs will be the demonstration of an upper bound (UB) of the 2-sided 90% confidence interval (CI) of the projected QTc effect at the peak plasma level of the lower dose above the threshold of regulatory concern (currently 10 ms) and a positive slope of ER relationship. The criterion for QT-negative drug will be an UB of the CI of the projected QTc effect of the higher dose <10 ms. It is expected that a successful outcome in this study will provide evidence supporting replacement of the TQT study with ECG assessments in standard early clinical development studies for a new chemical entity.
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Affiliation(s)
- Borje Darpo
- Karolinska Institutet, Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd's Hospital, Stockholm, Sweden and iCardiac Technologies, Rochester, NY
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Johannesen L, Vicente J, Gray RA, Galeotti L, Loring Z, Garnett CE, Florian J, Ugander M, Stockbridge N, Strauss DG. Improving the Assessment of Heart Toxicity for All New Drugs Through Translational Regulatory Science. Clin Pharmacol Ther 2013; 95:501-8. [DOI: 10.1038/clpt.2013.238] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 12/04/2013] [Indexed: 11/09/2022]
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Abstract
An algorithm to determine the quality of electrocardiograms (ECGs) can enable inexperienced nurses and paramedics to record ECGs of sufficient diagnostic quality. Previously, we proposed an algorithm for determining if ECG recordings are of acceptable quality, which was entered in the PhysioNet Challenge 2011. In the present work, we propose an improved two-step algorithm, which first rejects ECGs with macroscopic errors (signal absent, large voltage shifts or saturation) and subsequently quantifies the noise (baseline, powerline or muscular noise) on a continuous scale. The performance of the improved algorithm was evaluated using the PhysioNet Challenge database (1500 ECGs rated by humans for signal quality). We achieved a classification accuracy of 92.3% on the training set and 90.0% on the test set. The improved algorithm is capable of detecting ECGs with macroscopic errors and giving the user a score of the overall quality. This allows the user to assess the degree of noise and decide if it is acceptable depending on the purpose of the recording.
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Affiliation(s)
- Lars Johannesen
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Building 51, RM 2168, 10903 New Hampshire Avenue, Silver Spring 20933, MD, USA.
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Malik M, Zhang J, Johannesen L, Hnatkova K, Garnett C. Assessing electrocardiographic data quality and possible replacement of pharmacologic positive control in thorough QT/QTc studies by investigations of drug-free QTc stability. Heart Rhythm 2011; 8:1777-85. [DOI: 10.1016/j.hrthm.2011.06.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2011] [Accepted: 06/09/2011] [Indexed: 10/18/2022]
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Sørensen J, Johannesen L, Grove U, Lundhus K, Couderc JP, Graff C. A Comparison of IIR and Wavelet Filtering for Noise Reduction of the ECG. Comput Cardiol (2010) 2010; 37:489-492. [PMID: 22068831 PMCID: PMC3134259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
This study compares the ability to preserve information and reduce noise contaminants on the ECG for five wavelet filters and three IIR filters. Two 3-lead Holter ECGs were used. White Gaussian Noise was added to the first ECG in increments of 10% coverage. The second ECG contained alternating muscle transients and noise-free segments. Computation times and SNR improvements for different noise coverages were calculated and compared. RMS errors were calculated from noise-free segments on the ECG with transient muscle noise. Wavelet filters improved SNR more than IIR filters when the signal coverage was more than 50% noise. In contrast, the computation times were shorter for IIR filters (6 s) than for wavelet filters (88 s). On the ECG with transient muscle noise there was a trade-off in performance between wavelet and IIR filtering. In a clinical setting where the amount of noise is unknown, using IIR filters appears to be preferred for consistent performance.
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Affiliation(s)
- Js Sørensen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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Johannesen L, Grove U, Sørensen J, Schmidt M, Graff C, Couderc JP. Analysis of T-wave Amplitude Adaptation to Heart Rate Using RR-binning of Long-Term ECG Recordings. Comput Cardiol (2010) 2010; 37:369-372. [PMID: 22068719 PMCID: PMC3128376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The prognosis of patients with coronary artery disease at the early stage of the disease is a challenge of modern cardiology. There is an urgent need to risk stratify these patients. Holter technology is a cheap and cost effective tool to evaluate electrical abnormalities in the heart. We propose to investigate T-amplitude adaptation to heart rate (HR) using RR-binning. We used daytime recordings from healthy subjects and subjects with acute myocardial infarction (AMI) from the Telemetric and Holter ECG Warehouse. The AMI subjects were divided into two groups based on location of their infarction (group A: anterior or anterior lateral, group B: inferior or inferior lateral). Both AMI groups had acute and stable phase recordings. Population-based T-adaptation to HR was observed for healthy subjects (R2 = 0.92) but was less pronounced for AMI subjects: [Formula: see text].
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Affiliation(s)
- L Johannesen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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Johannesen L, Grove U, Sørensen J, Schmidt M, Couderc JP, Graff C. A Wavelet-Based Algorithm for Delineation and Classification of Wave Patterns in Continuous Holter ECG Recordings. Comput Cardiol (2010) 2010; 37:979-982. [PMID: 21779544 PMCID: PMC3139228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Quantitative analysis of the electrocardiogram (ECG) requires delineation and classification of the individual ECG wave patterns. We propose a wavelet-based waveform classifier that uses the fiducial points identified by a delineation algorithm. For validation of the algorithm, manually annotated ECG records from the QT database (Physionet) were used. ECG waveform classification accuracies were: 85.6% (P-wave), 89.7% (QRS complex), 92.8% (T-wave) and 76.9% (U-wave). The proposed classification method shows that it is possible to classify waveforms based on the points obtained during delineation. This approach can be used to automatically classify wave patterns in long-term ECG recordings such as 24-hour Holter recordings.
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Affiliation(s)
- L Johannesen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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Snippe H, Johannesen L, Lizzio E, Merchant B. Variable expression of delayed hypersensitivity in different mouse strains using dimethyl dioctadecyl ammonium bromide as an adjuvant. Immunology 1980; 39:399-405. [PMID: 7002767 PMCID: PMC1457805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Delayed-type hypersensitivity measured as footpad swelling was studied in large number of inbred mouse strains. A conjugate of bovine serum albumin (BSA) with the small 2,4-dinitrophenyl (DNP) hapten served to generate strong reactions, specific for the DNP group. Delayed hypersensitivity was produced with the DNP-BSA complex mixed with the cationic, surface active lipid, dimethyl dioctadecyl ammonium bromide (DDA). Great variation was observed in delayed hypersensitivity among different mouse strains. For convenience, the mice were classified into five groups, notably: non-, low, moderate, good and high responders. The highest responding animals were BALB/cJ mice, the lowest were P/JN and outbred nu/nu mice. No correlation was observed between H-2 type and the intensity of the elicited reactions.
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Snippe H, Johannesen L, Inman JK, Merchant B. Specificity of murine delayed-type hypersensitivity to conjugates of large or small haptens on protein carriers bearing lipid groups. Immunology 1978; 34:947-54. [PMID: 77841 PMCID: PMC1457205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Delayed-type hypersensitivity (DH) in the mouse was provoked with different hapten-carrier complexes mixed with the cationic, surface-active lipid, dimethyl dioctadecyl ammonium bromide (DDA). DH was measured as footpad swelling. Conjugates of bovine serum albumin (BSA) with the small haptens dinitrophenyl (DNP), 'arsonate' (ARS) and 'sulphonate' (SULPH) served to generate strong DH reactions towards the homologous antigen. Insertion of a tripeptide spacer between the hapten and carrier resulted in lower DH reactivity. Optimal dosages and optimal time intervals between sensitization and DH elicitation were determined for the enlarged hapten-carrier complexes. Cyclophosphamide (CY) treatment, before priming with complexes mixed with DDA, caused a 5-6 day delay in the expression of DH but failed to evoke enhanced DH for any of the antigens tested. A broad array of cross reactions between small and enlarged hapten-carrier complexes showed a relative lack of specificity in these DH responses. The results are compared with others reported in the literature and are explained mainly by the effects of electrostatically bound lipid groups of DDA in the sensitizing conjugates.
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Friis-Hasché E, Holmstrup P, Høffding J, Johannesen L, Kjeldsen K, Schwarz E. [Dental care in Denmark 1974. IV. Socioeconomic aspects]. Tandlaegebladet 1976; 80:103-7. [PMID: 830052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Friis-Hasché E, Holmstrup P, Høffding J, Johannesen L, Kjeldsen K, Schwarz E. [Dental care in Denmark 1974. II. The patients]. Tandlaegebladet 1976; 80:29-34. [PMID: 1078146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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