1
|
Yeoh SE, Osmanska J, Petrie MC, Brooksbank KJM, Clark AL, Docherty KF, Foley PWX, Guha K, Halliday CA, Jhund PS, Kalra PR, McKinley G, Lang NN, Lee MMY, McConnachie A, McDermott JJ, Platz E, Sartipy P, Seed A, Stanley B, Weir RAP, Welsh P, McMurray JJV, Campbell RT. Dapagliflozin vs. metolazone in heart failure resistant to loop diuretics. Eur Heart J 2023; 44:2966-2977. [PMID: 37210742 PMCID: PMC10424881 DOI: 10.1093/eurheartj/ehad341] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/11/2023] [Accepted: 05/16/2023] [Indexed: 05/23/2023] Open
Abstract
BACKGROUND AND AIMS To examine the decongestive effect of the sodium-glucose cotransporter 2 inhibitor dapagliflozin compared to the thiazide-like diuretic metolazone in patients hospitalized for heart failure and resistant to treatment with intravenous furosemide. METHODS AND RESULTS A multi-centre, open-label, randomized, and active-comparator trial. Patients were randomized to dapagliflozin 10 mg once daily or metolazone 5-10 mg once daily for a 3-day treatment period, with follow-up for primary and secondary endpoints until day 5 (96 h). The primary endpoint was a diuretic effect, assessed by change in weight (kg). Secondary endpoints included a change in pulmonary congestion (lung ultrasound), loop diuretic efficiency (weight change per 40 mg of furosemide), and a volume assessment score. 61 patients were randomized. The mean (±standard deviation) cumulative dose of furosemide at 96 h was 977 (±492) mg in the dapagliflozin group and 704 (±428) mg in patients assigned to metolazone. The mean (±standard deviation) decrease in weight at 96 h was 3.0 (2.5) kg with dapagliflozin compared to 3.6 (2.0) kg with metolazone [mean difference 0.65, 95% confidence interval (CI) -0.12,1.41 kg; P = 0.11]. Loop diuretic efficiency was less with dapagliflozin than with metolazone [mean 0.15 (0.12) vs. 0.25 (0.19); difference -0.08, 95% CI -0.17,0.01 kg; P = 0.10]. Changes in pulmonary congestion and volume assessment score were similar between treatments. Decreases in plasma sodium and potassium and increases in urea and creatinine were smaller with dapagliflozin than with metolazone. Serious adverse events were similar between treatments. CONCLUSION In patients with heart failure and loop diuretic resistance, dapagliflozin was not more effective at relieving congestion than metolazone. Patients assigned to dapagliflozin received a larger cumulative dose of furosemide but experienced less biochemical upset than those assigned to metolazone. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04860011.
Collapse
Affiliation(s)
- Su Ern Yeoh
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Joanna Osmanska
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Mark C Petrie
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Katriona J M Brooksbank
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Andrew L Clark
- Department of Cardiology, Hull University Teaching Hospitals NHS Trust, Castle Hill Hospital, Cottingham HU3 2JZ, UK
| | - Kieran F Docherty
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Paul W X Foley
- Department of Cardiology, The Great Western Hospital, Swindon SN3 6BB, UK
| | - Kaushik Guha
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth PO6 3LY, UK
| | - Crawford A Halliday
- Department of Cardiology, Royal Alexandria Hospital, NHS Greater Glasgow and Clyde, Paisley, UK
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth PO6 3LY, UK
- Faculty of Science and Health, University of Portsmouth, Portsmouth PO1 2DT, UK
| | - Gemma McKinley
- Robertson Centre for Biostatistics, School of Health and Wellbeing, University of Glasgow, Glasgow G12 8TB, UK
| | - Ninian N Lang
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Matthew M Y Lee
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, School of Health and Wellbeing, University of Glasgow, Glasgow G12 8TB, UK
| | - James J McDermott
- Biopharmaceuticals, Medical Affairs, AstraZeneca, Wilmington, DE 19803, USA
| | - Elke Platz
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Peter Sartipy
- Cardiovascular, Renal and Metabolism, AstraZeneca, BioPharmaceuticals R&D, Gothenburg 431 83, Sweden
| | - Alison Seed
- Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Trust, Blackpool FY3 8NP, UK
| | - Bethany Stanley
- Robertson Centre for Biostatistics, School of Health and Wellbeing, University of Glasgow, Glasgow G12 8TB, UK
| | - Robin A P Weir
- Cardiology Department, University Hospital Hairmyres, Lanarkshire G75 8RG, UK
| | - Paul Welsh
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Ross T Campbell
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| |
Collapse
|
2
|
Zeid AM, Aboshabana R, Ibrahim FA. First-order derivative synchronous spectrofluorimetric determination of two antihypertensive drugs, metolazone and valsartan, in pharmaceutical and biological matrices. Spectrochim Acta A Mol Biomol Spectrosc 2022; 267:120591. [PMID: 34789407 DOI: 10.1016/j.saa.2021.120591] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 10/30/2021] [Accepted: 11/03/2021] [Indexed: 06/13/2023]
Abstract
In this study, a facile, rapid, and sensitive spectrofluorimetric method was evolved to analyse two antihypertensive drugs, namely, metolazone (MTZ) and valsartan (VST), in pharmaceutical and biological matrices. Both analytes exhibited intrinsic fluorescence activities which were significantly affected by environmental factors such as pH and solvent systems. However, simultaneous determination of MTZ and VST by conventional spectrofluorometry cannot be achieved simply because of the strong overlap between their fluorescence spectra. Thus, a combination of derivative and synchronous spectrofluorometry was conducted to overcome this dilemma. The proposed method relies on measurement of the first-order derivative of synchronous fluorescence intensity of the studied drugs at Δλ = 160 nm using 0.1 M acetic acid as the optimum solvent. The amplitudes of the first derivative synchronous fluorescence spectra of MTZ and VST were recorded at 236.0 nm (zero-crossing point of VST) and at 262.8 nm (zero-crossing point of MTZ) for simultaneous analysis of MTZ and VST, respectively. The fluorescent method was optimized efficiently to get the maximum selectivity and sensitivity by investigating different solvents, different buffer pHs, and different surfactants. The highest sensitivity and selectivity were achieved when 0.1 M acetic acid was used as a solvent. The method showed a linear concentration range of 10.0-100.0 ng mL-1 and a limit of detection of <3.0 ng mL-1 for each analyte. Statistical data analysis confirmed that no significant difference between the proposed spectrofluorometric method and the reference methods. The validity of the proposed spectrofluorometric method approved its suitability for quality control work. The proposed spectrofluorometric method was applied to assay the studied drugs in pharmaceutical dosage and in biological matrices with acceptable %recoveries and small RSD values.
Collapse
Affiliation(s)
- Abdallah M Zeid
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Mansoura University, Mansoura 35516, Egypt.
| | - Rasha Aboshabana
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Mansoura University, Mansoura 35516, Egypt
| | - Fawzia A Ibrahim
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Mansoura University, Mansoura 35516, Egypt
| |
Collapse
|
3
|
Ito A, Zhao Q, Tanaka Y, Yasui M, Katayama R, Sun S, Tanimoto Y, Nishikawa Y, Kage-Nakadai E. Metolazone upregulates mitochondrial chaperones and extends lifespan in Caenorhabditis elegans. Biogerontology 2020; 22:119-131. [PMID: 33216250 DOI: 10.1007/s10522-020-09907-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/11/2020] [Indexed: 01/01/2023]
Abstract
Accumulating studies have argued that the mitochondrial unfolded protein response (UPRmt) is a mitochondrial stress response that promotes longevity in model organisms. In the present study, we screened an off-patent drug library to identify compounds that activate UPRmt using a mitochondrial chaperone hsp-6::GFP reporter system in Caenorhabditis elegans. Metolazone, a diuretic primarily used to treat congestive heart failure and high blood pressure, was identified as a prominent hit as it upregulated hsp-6::GFP and not the endoplasmic reticulum chaperone hsp-4::GFP. Furthermore, metolazone specifically induced the expression of mitochondrial chaperones in the HeLa cell line. Metolazone also extended the lifespan of worms in a atfs-1 and ubl-5-dependent manner. Notably, metolazone failed to increase lifespan in worms with knocked-down nkcc-1. These results suggested that metolazone activates the UPRmt across species and prolongs the lifespan of C. elegans.
Collapse
Affiliation(s)
- Ai Ito
- Faculty of Human Life Science, Department of Food and Nutrition, Osaka City University, Sugimoto 3-3-138 Sumiyoshi-ku, Osaka, 558-8585, Japan
| | - Quichi Zhao
- Faculty of Human Life Science, Department of Food and Nutrition, Osaka City University, Sugimoto 3-3-138 Sumiyoshi-ku, Osaka, 558-8585, Japan
| | - Yoichiro Tanaka
- Faculty of Human Life Science, Department of Food and Nutrition, Osaka City University, Sugimoto 3-3-138 Sumiyoshi-ku, Osaka, 558-8585, Japan
| | - Masumi Yasui
- Faculty of Human Life Science, Department of Food and Nutrition, Osaka City University, Sugimoto 3-3-138 Sumiyoshi-ku, Osaka, 558-8585, Japan
| | - Rina Katayama
- Faculty of Human Life Science, Department of Food and Nutrition, Osaka City University, Sugimoto 3-3-138 Sumiyoshi-ku, Osaka, 558-8585, Japan
| | - Simo Sun
- Faculty of Human Life Science, Department of Food and Nutrition, Osaka City University, Sugimoto 3-3-138 Sumiyoshi-ku, Osaka, 558-8585, Japan
| | - Yoshihiko Tanimoto
- Faculty of Human Life Science, Department of Food and Nutrition, Osaka City University, Sugimoto 3-3-138 Sumiyoshi-ku, Osaka, 558-8585, Japan
| | - Yoshikazu Nishikawa
- Faculty of Human Life Science, Department of Food and Nutrition, Osaka City University, Sugimoto 3-3-138 Sumiyoshi-ku, Osaka, 558-8585, Japan
| | - Eriko Kage-Nakadai
- Faculty of Human Life Science, Department of Food and Nutrition, Osaka City University, Sugimoto 3-3-138 Sumiyoshi-ku, Osaka, 558-8585, Japan.
- The OCU Advanced Research Institute for Natural Science and Technology, Osaka City University, Osaka, 558-8585, Japan.
| |
Collapse
|
4
|
Zaazaa HE, Abdel-Ghany R, Abdelkawy M, Sayed M. Development and Validation of Two Robust Stability-Indicating Chromatographic Methods for Determination of Metolazone in Drug Substance and Pharmaceutical Dosage Form in the Presence of Its Degradation Products and Characterization of Main Degradation Products Based on LC-MS. J Chromatogr Sci 2020; 58:251-261. [PMID: 31879759 DOI: 10.1093/chromsci/bmz110] [Citation(s) in RCA: 1] [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: 12/12/2018] [Revised: 08/26/2019] [Accepted: 10/31/2019] [Indexed: 11/15/2022]
Abstract
Two robust and selective stability-indicating chromatographic methods were developed and validated for the determination of metolazone in drug substance and pharmaceutical dosage form in the presence of its degradation products. The HPLC method employed a Kromasil C18 (250 × 4.6,5 μm) column and a mobile phase of acetonitrile: 0.2% orthophosphoric acid (32:68 v/v) at a flow rate 2 mL/min and detection at 238 nm. The separation was performed in HPLC isocratic mode. The robustness of the suggested method was assessed using the Plackett-Burman design, parameters affecting system suitability were established and non-significant intervals for the significant parameters were considered. The HPTLC method employed Nano-SIL-20 UV254 HPTLC plates as adsorbent, ethyl acetate: toluene: acetic acid solution (4:4:0.5, v/v/v), as a developing solvent system and densitometric detection at 238 nm. Metolazone was exposed to different stress conditions, including acid and alkaline hydrolysis and oxidative and photolytic degradation. The main degradation products obtained have been characterized and interpreted based on LC-MS. The linearity of the suggested methods was proved in the concentration range of 20-75 μg/mL for the HPLC method and 100-900 ng/spot for the HPTLC method. The suggested methods were validated according to international conference on harmonization guidelines. These methods were successfully dedicated for the estimation of metolazone in drug substance and pharmaceutical dosage form in the presence of its degradation products. The results of the suggested methods were evaluated and compared statistically with results obtained by an official method without finding any significant difference.
Collapse
Affiliation(s)
- Hala E Zaazaa
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr ElـAini St, Cairo 11562, Egypt
| | - Rasha Abdel-Ghany
- Pharmaceutical Analytical Chemistry Department,National Organization for Drug Control and Research (NODCAR), 51 wezaret El-Zeraa St, Agouza, P.O. Box 12553, Giza 35521, Egypt
| | - M Abdelkawy
- Pharmaceutical Chemistry Department,Faculty of Pharmaceutical Science and Pharmaceutical Industries, Future University, End of 90th St., Fifth Settlement, New Cairo 12311, Egypt
| | - Mahmoud Sayed
- Pharmaceutical Analytical Chemistry Department,National Organization for Drug Control and Research (NODCAR), 51 wezaret El-Zeraa St, Agouza, P.O. Box 12553, Giza 35521, Egypt
| |
Collapse
|
5
|
Wise RT, Moffett BS, Akcan-Arikan A, Galati M, Afonso N, Checchia PA. Enhancement of diuresis with metolazone in infant paediatric cardiac intensive care patients. Cardiol Young 2018; 28:27-31. [PMID: 28889825 DOI: 10.1017/S1047951117001330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Few data are available regarding the use of metolazone in infants in cardiac intensive care. Researchers need to carry out further evaluation to characterise the effects of this treatment in this population. METHODS This is a descriptive, retrospective study carried out in patients less than a year old. These infants had received metolazone over a 2-year period in the paediatric cardiac intensive care unit at our institution. The primary goal was to measure the change in urine output from 24 hours before the start of metolazone therapy to 24 hours after. Patient demographic variables, laboratory data, and fluid-balance data were analysed. RESULTS The study identified 97 infants with a mean age of 0.32±0.25 years. Their mean weight was 4.9±1.5 kg, and 58% of the participants were male. An overall 63% of them had undergone cardiovascular surgery. The baseline estimated creatinine clearance was 93±37 ml/minute/1.73 m2. Initially, the participants had received a metolazone dose of 0.27±0.10 mg/kg/day, the maximum dose being 0.43 mg/kg/day. They had also received other diuretics during metolazone initiation, such as furosemide (87.6%), spironolactone (58.8%), acetazolamide (11.3%), bumetanide (7.2%), and ethacrynic acid (1%). The median change in urine output after metolazone was 0.9 ml/kg/hour (interquartile range 0.15-1.9). The study categorised a total of 66 patients (68.0%) as responders. Multivariable analysis identified acetazolamide use (p=0.002) and increased fluid input in the 24 hours after metolazone initiation (p0.05). CONCLUSIONS Metolazone increased urine output in a select group of patients. Efficacy can be maximised by strategic selection of patients.
Collapse
|
6
|
Li X, Wang R, Liu Y, Liu Y, Zheng H, Feng Y, Zhao N, Geng H, Zhang W, Wen A. Pharmacokinetic study of single- and multiple-dosing with metolazone tablets in healthy Chinese population. BMC Pharmacol Toxicol 2017; 18:73. [PMID: 29145890 PMCID: PMC5689141 DOI: 10.1186/s40360-017-0178-x] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 10/30/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Metolazone is a diuretic, saluretic and antihypertensive chemical compound from the quinazoline category that possesses medicinal features similar to those of other thiazide diuretic drugs. However, the pharmacokinetics of metolazone in the Chinese population has rarely been studied. This study aimed to examine the pharmacokinetic characteristics, safety characteristic, and tolerability of metolazone in healthy Chinese subjects after single and multiple doses taken orally as well as the effects that food and gender have on oral metolazone pharmacokinetic parameters. METHODS An open-label, randomized, and single- and multiple-dosing investigation was performed in healthy Chinese subjects. The investigation included 3 study groups: the 0.5 mg, 1 mg and 2 mg dose groups were the single-dose study groups in the first stage. Eligible volunteers were randomly and orally administered a single 0.5 mg, 1 mg, or 2 mg metolazone tablet. The 0.5 mg dose group was also part of the multiple-dose study group, and the 1 mg dose group was the food-effect study group in the second stage. Human plasma samples were gathered pre-dosing and up to 48 h after dosing. The human plasma sample concentration of metolazone was quantified using a validated liquid chromatography tandem mass spectrometry method. Pharmacokinetic data were calculated by a noncompartmental analysis method using WinNonlin version 6.4. Tolerability was evaluated based on adverse events, medical examination, 12-lead ECG, and other clinical laboratory exams. RESULTS Thirty eligible subjects (15 men and 15 women) were registered in our investigation and completed all of the study stages. The AUC and Cmax showed dose proportionality after a single dose based on the linear-regression analysis. A comparison of the pharmacokinetic data revealed that the differences between the male and female groups were not statistically significant. The tmax of metolazone was increased by approximately 100% in the fed condition. Metolazone was well tolerated at the tested dose, and no adverse effects were observed. CONCLUSIONS Single dosing with 0.5 mg, 1 mg, or 2 mg metolazone yielded linear plasma pharmacokinetic properties in healthy Chinese subjects. Multiple oral doses of metolazone did not display significantly different distributions or elimination characteristics from those observed for a single dose. Gender factors did not appear to influence the pharmacokinetic parameter variation of metolazone. The tmax of metolazone increased in the fed condition. Metolazone was well tolerated at the tested dose in this study. TRIAL REGISTRATION This investigation is retrospectively registered at chictr.org.cn (ChiCTR-IIR-17012929, October 09 2017).
Collapse
Affiliation(s)
- Xueqing Li
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Rutao Wang
- Xi'an Libang Zhaoxin Biological Technology Co., Ltd, Xi'an, China
| | - Yang Liu
- Eliving Pharmaceutical Co., Ltd, Shenyang, China
| | - Yun Liu
- Xi'an Libang Zhaoxin Biological Technology Co., Ltd, Xi'an, China
| | - Heng Zheng
- Department of Pharmacy, Tongji Hospital, Wuhan, China
| | - Yabo Feng
- Eliving Pharmaceutical Co., Ltd, Shenyang, China
| | - Na Zhao
- Eliving Pharmaceutical Co., Ltd, Shenyang, China
| | - Hongbin Geng
- Xi'an Libang Zhaoxin Biological Technology Co., Ltd, Xi'an, China
| | - Wanzhi Zhang
- Xi'an Libang Zhaoxin Biological Technology Co., Ltd, Xi'an, China
| | - Aidong Wen
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| |
Collapse
|
7
|
Snitker S, Doerfler RM, Soliman EZ, Deo R, St Peter WL, Kramlik S, Fischer MJ, Navaneethan S, Delafontaine P, Jaar BG, Ojo A, Makos GK, Slaven A, Weir MR, Zhan M, Fink JC. Association of QT-Prolonging Medication Use in CKD with Electrocardiographic Manifestations. Clin J Am Soc Nephrol 2017; 12:1409-1417. [PMID: 28793999 PMCID: PMC5586585 DOI: 10.2215/cjn.12991216] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 05/26/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Several drugs used in CKD can prolong electrocardiographic conduction. We examined the use of electrocardiogram QT-prolonging medications in predialysis CKD and their association with QT duration. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In total, 3252 Chronic Renal Insufficiency Cohort participants with at least one study electrocardiogram between 2003 and 2011 were included. QT-prolonging medications used in 100 or more visits (n=16,451 visits) along with diuretics and proton pump inhibitors, given their potential for electrolyte disturbances, were examined for QT interval prolongation. RESULTS Mean QT interval corrected for heart rate was at 414±21 (±SD) milliseconds and prolonged (≥450 milliseconds) in 4.6% of electrocardiograms. QT interval corrected for heart rate was inversely related to serum potassium and calcium. Medications classified as QT prolonging were taken at 76% of visits, with two or more of these taken at 33% of visits. Of 30 medications examined, eight were associated with statistically significant QT interval corrected for heart rate prolongation after adjustment for comorbidities, potassium, and calcium, including amiodarone (+10±2 milliseconds), metolazone (+7±2 milliseconds), fluoxetine (+4±1 milliseconds), citalopram (+4±1 milliseconds), hydroxyzine (+4±1 milliseconds), escitalopram (+3±2 milliseconds), venlafaxine (+3±1 milliseconds), and furosemide (+3±0 milliseconds). Potassium-depleting diuretics were associated with minimal decrements in potassium (between 0.1 and 0.3 mEq/L) and smaller changes in calcium. Diuretics associated with a change in QT interval corrected for heart rate before adjustment for potassium and calcium were metolazone (+8±3 milliseconds), furosemide (+4±1 milliseconds), and spironolactone (-3±3 milliseconds). Most of the QT prolongation associated with metolazone and furosemide, but not spironolactone, remained after adjustment for potassium and calcium. Proton pump inhibitors were not associated with QT prolongation. CONCLUSIONS Use of medications associated with QT prolongation is common in CKD; the safety implications of these findings should be considered in these high-risk patients. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_08_09_CJASNPodcast_17_09_b.mp3.
Collapse
Affiliation(s)
- Soren Snitker
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Banerjee M, Chen T. Thiazide-like diuretic drug metolazone activates human pregnane X receptor to induce cytochrome 3A4 and multidrug-resistance protein 1. Biochem Pharmacol 2014; 92:389-402. [PMID: 25181459 PMCID: PMC4252478 DOI: 10.1016/j.bcp.2014.08.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 08/22/2014] [Accepted: 08/25/2014] [Indexed: 01/14/2023]
Abstract
Human pregnane X receptor (hPXR) regulates the expression of drug-metabolizing enzyme cytochrome P450 3A4 (CYP3A4) and drug transporters such as multidrug-resistance protein 1 (MDR1). PXR can be modulated by small molecules, including Federal Drug Administration (FDA)-approved drugs, thus altering drug metabolism and causing drug-drug interactions. To determine the role of FDA-approved drugs in PXR-mediated regulation of drug metabolism and clearance, we screened 1481 FDA-approved small-molecule drugs by using a luciferase reporter assay in HEK293T cells and identified the diuretic drug metolazone as an activator of hPXR. Our data showed that metolazone activated hPXR-mediated expression of CYP3A4 and MDR1 in human hepatocytes and intestine cells and increased CYP3A4 promoter activity in various cell lines. Mammalian two-hybrid assays showed that hPXR recruits its co-activator SRC-1 upon metolazone binding in HepG2 cells, explaining the mechanism of hPXR activation. To understand the role of other commonly-used diuretics in hPXR activation and the structure-activity relationship of metolazone, thiazide and non-thiazide diuretics drugs were also tested but only metolazone activates hPXR. To understand the molecular mechanism, docking studies and mutational analysis were carried out and showed that metolazone binds in the ligand-binding pocket and interacts with mostly hydrophobic amino acid residues. This is the first report showing that metolazone activates hPXR. Because activation of hPXR might cause drug-drug interactions, metolazone should be used with caution for drug treatment in patients undergoing combination therapy.
Collapse
Affiliation(s)
- Monimoy Banerjee
- Department of Chemical Biology and Therapeutics, St. Jude Children's Research Hospital, Mail Stop 1000, 262 Danny Thomas Place, Memphis, TN 38105-3678, USA
| | - Taosheng Chen
- Department of Chemical Biology and Therapeutics, St. Jude Children's Research Hospital, Mail Stop 1000, 262 Danny Thomas Place, Memphis, TN 38105-3678, USA.
| |
Collapse
|
9
|
Lazkani M, Ota KS. The role of outpatient intravenous diuretic therapy in a transitional care program for patients with heart failure: a case series. J Clin Med Res 2012; 4:434-8. [PMID: 23226178 PMCID: PMC3513427 DOI: 10.4021/jocmr1106w] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2012] [Indexed: 01/16/2023] Open
Abstract
We present a case series of seven patients with an established diagnosis of heart failure enrolled in a transitional care program that were treated with intravenous diuretic therapy in the outpatient setting. The patients presented in this cases series were treated due to the development of decompensated heart failure within 30 days of their discharge from our hospital. All seven patients stated that they would have originally presented to the emergency department for their symptoms, but consented to alternative treatment by a transitional care physician, or transitionalist. These patients with decompensated heart failure (four male and three female) with a median age of 55 years (24 - 84 years) were evaluated and treated from November 2011 to March 2012. Of the seven patients, four presented with decompensated systolic heart failure (three with diastolic). All seven patients were treated with an intravenous diuretic for hypervolemia in our outpatient infusion room. All of the patients experienced relief of their dyspnea the day of diuretic administration or the following day. No adverse effects or emergency department transfers occurred as a result of outpatient intravenous diuretic therapy. Through the use of outpatient intravenous diuretic therapy, we have avoided the need for emergency department visits and potential hospitalization in select patients with decompensated heart failure. Based on our preliminary findings, the clinical efficacy of this approach to the treatment of heart failure decompensation is not only due to the pharmacologic effectiveness of intravenous diuretics, but also due to the bidirectional open line of communication that exists between transitionalist and patients in the program. The direct telephone access that patients have to the transitionalist allows for close post-hospitalization monitoring and facilitates timely evaluation and treatment when acute issues arise. The added benefit of our particular transitional care program is that we have an alternate venue in the hospital where our transitional care patients can be treated for heart failure decompensation (our outpatient infusion room), thus, enabling us to avoid emergency department transfers and possible hospital admissions. Further investigation of this therapy in a non-emergency department setting is warranted as our experience with this treatment modality is limited to the case series presented.
Collapse
Affiliation(s)
- Mohamad Lazkani
- Department of Transitional Care Medicine, Banner Good Samaritan Medical Center; Phoenix, AZ, USA
| | | |
Collapse
|
10
|
Dubey R, Bhusari VK, Dhaneshwar SR. Validated RP-HPLC Method for Simultaneous Quantitation of Losartan Potassium and Metolazone in Bulk Drug and Formulation. Sci Pharm 2011; 79:545-54. [PMID: 21886902 PMCID: PMC3163373 DOI: 10.3797/scipharm.1105-13] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [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: 05/16/2011] [Accepted: 06/26/2011] [Indexed: 11/22/2022] Open
Abstract
A HPLC method has been described for simultaneous determination of Losartan potassium and Metolazone in formulation. This method is based on a HPLC separation of the two drugs on the Thermo Hypersil BDS–C18 (250 mm × 4.6 mm, 5.0 μm) with isocratic conditions and a simple mobile phase containing acetonitrile:water (60:40) at a flow rate of 0.8 mL/min using UV detection at 237 nm. This method has been applied to a marketed formulation without interference of excipients. The linear regression analysis data for the calibration plots showed a good linear relationship over the concentration range of 2–12 μg/mL for Losartan potassium and 0.2–1.2 μg/mL for Metolazone, respectively. The method was validated for precision, robustness and recovery. Statistical analysis showed that the method is repeatable and selective for the estimation of Losartan potassium and Metolazone.
Collapse
Affiliation(s)
- Ramkumar Dubey
- Department of Pharmaceutical Chemistry, Bharati Vidyapeeth University, Poona College of Pharmacy, Pune, Maharashtra, 411038, India
| | | | | |
Collapse
|