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Elliott E, Rogal S, Song B, Kakajiwala A. Blasting off: persistent hypertension in a child with neuroblastoma. Pediatr Nephrol 2024; 39:1085-1088. [PMID: 37943375 DOI: 10.1007/s00467-023-06188-2] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 11/10/2023]
Abstract
Hypertension in children with neuroblastoma is uncommon and can be difficult to control due to the potential for multiple underlying causes. We present the case of a pediatric patient with high-grade neuroblastoma which was complicated by hypertensive emergency. The patient had imaging suggestive of renal artery compression, as well as significantly elevated normetaphrine levels. Multiple anti-hypertensive agents, including an angiotensin converting enzyme inhibitor, α- and β-adrenergic receptor blockers, and a tyrosine hydroxylase inhibitor, were initiated prior to tumor excision. While her blood pressure improved during the post-operative period, she continued to require multiple antihypertensive medications due to residual tumor burden. In this report, we highlight the importance of careful, multidisciplinary management to avoid peri-operative complications in patients with catecholamine-producing tumors.
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Affiliation(s)
- Elizabeth Elliott
- Department of Critical Care Medicine, Children's National Hospital, Washington, D.C., USA.
| | - Sarah Rogal
- Department of Pediatric Nephrology, Children's National Hospital, Washington, D.C., USA
| | - Boh Song
- Department of Critical Care Medicine, Children's National Hospital, Washington, D.C., USA
- Division of Pharmacy, Children's National Hospital, Washington, D.C., USA
| | - Aadil Kakajiwala
- Department of Critical Care Medicine, Children's National Hospital, Washington, D.C., USA
- Department of Pediatric Nephrology, Children's National Hospital, Washington, D.C., USA
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Ohmachi Y, Yamamoto M, Inaba Y, Makino S, Urai S, Matsumoto R, Bando H, Kanie K, Tsujimoto Y, Motomura Y, Sasaki Y, Oi-Yo Y, Yamamoto N, Suzuki M, Takahashi M, Iguchi G, Kanzawa M, Furukawa J, Shigemura K, Mizobuchi S, Ogawa W, Fukuoka H. The combination of doxazosin and metyrosine as a preoperative treatment for pheochromocytomas and paragangliomas. Endocrine 2024:10.1007/s12020-023-03681-4. [PMID: 38206436 DOI: 10.1007/s12020-023-03681-4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE Preoperative medical management is critical to prevent intraoperative cardiovascular complications in patients with pheochromocytomas and paragangliomas (PPGLs). Initial treatment involves α-adrenergic receptor blockers. However, while the routine use of metyrosine alongside these blockers is not strongly recommended due to a lack of evidence supporting its efficacy and associated safety concerns, there are previous studies on combination therapy with phenoxybenzamine and metyrosine. There are few reports on combination therapy with the selective α1-adrenergic receptor blocker doxazosin. Therefore, we investigated this combination treatment, which theoretically can affect perioperative outcomes in patients with PPGLs. To our knowledge, this is the first such study. METHODS This retrospective single-center observational study involved 51 patients who underwent surgical resection of PPGLs at Kobe University Hospital between 2014 and 2022. All patients received doxazosin at maximum doses. Fourteen patients received concomitant metyrosine, while 37 received doxazosin alone. Their perioperative outcomes were compared. RESULTS No severe event, such as acute coronary syndrome, was observed in either group. Intraoperatively, the doxazosin + metyrosine group exhibited a lower median minimum systolic blood pressure (56 [54-60] vs. 68 [59-74] mmHg, P = 0.03) and required lower median remifentanil (P = 0.04) and diltiazem (P = 0.02) doses than the doxazosin-alone group. CONCLUSION The combination of metyrosine and doxazosin as a preoperative treatment for PPGLs affects intraoperative circulatory hemodynamics, such as a reduced occurrence of blood pressure elevation during surgery. Further research is necessary to identify patients who will benefit most from this combination treatment.
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Affiliation(s)
- Yuka Ohmachi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masaaki Yamamoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Yuiko Inaba
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
- Department of Internal Medicine (I), Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Shohei Makino
- Division of Anesthesiology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shin Urai
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Risa Matsumoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Hironori Bando
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Keitaro Kanie
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Yasutaka Tsujimoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuma Motomura
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuriko Sasaki
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuka Oi-Yo
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naoki Yamamoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masaki Suzuki
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Michiko Takahashi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
- Department of Nutrition, Kobe University Hospital, Kobe, Japan
| | - Genzo Iguchi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
- Medical Center for Student Health, Kobe University, Kobe, Japan
- Division of Biosignal Pathophysiology, Kobe University, Kobe, Japan
| | - Maki Kanzawa
- Department of Diagnostic Pathology, Kobe University Hospital, Kobe, Japan
| | - Junya Furukawa
- Division of Urology, Department of Surgery Related, Faculty of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Katsumi Shigemura
- Division of Urology, Department of Surgery Related, Faculty of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Satoshi Mizobuchi
- Division of Anesthesiology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
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Takekoshi K, Satoh F, Tanabe A, Okamoto T, Ichihara A, Tsuiki M, Katabami T, Nomura M, Tanaka T, Matsuda T, Imai T, Yamada M, Asada S, Kawata N, Naruse M. Correlation between urinary fractionated metanephrines in 24-hour and spot urine samples for evaluating the therapeutic effect of metyrosine: a subanalysis of a multicenter, open-label phase I/II study. Endocr J 2019; 66:1063-1072. [PMID: 31511435 DOI: 10.1507/endocrj.ej19-0125] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We recently conducted an open-label phase I/II study to evaluate the efficacy and safety of preoperative and chronic treatment with metyrosine (an inhibitor of catecholamine synthesis) in pheochromocytoma/paraganglioma (PPGL) in Japan. We compared creatinine-corrected metanephrine fractions in spot urine and 24-hour urine samples (the current standard for the screening and diagnosis of PPGLs) from 16 patients to assess the therapeutic effect of metyrosine. Percent changes from baseline in urinary metanephrine (uMN) or normetanephrine (uNMN) were compared between spot and 24-hour urine samples. Mean percent changes in uMN or uNMN in spot and 24-hour urine were -26.36% and -29.27%, respectively. The difference in the percent change from baseline between uMN or uNMN in spot and 24-hour urine was small (-2.90%). The correlation coefficient was 0.87 for percent changes from baseline between uMN or uNMN measured in spot and 24-hour urine. The area under the receiver operator characteristic (ROC) curve of uMN or uNMN measured in spot urine vs. 24-hour urine (reference standard) to assess the efficacy of metyrosine treatment was 0.93. Correlations and ROCs between 24-hour urinary vanillylmandelic acid, adrenaline, and noradrenaline and 24-hour uMN or uNMN were similar to those between spot uMN or uNMN and 24-hour uMN or uNMN. No large difference was observed between spot and 24-hour urine for the assessment of metyrosine treatment by quantifying uMN or uNMN in Japanese patients with PPGLs. These results suggest that spot urine samples may be useful in assessing the therapeutic effect of metyrosine.
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Affiliation(s)
- Kazuhiro Takekoshi
- Division of Sports Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8577, Japan
| | - Fumitoshi Satoh
- Division of Clinical Hypertension, Endocrinology & Metabolism, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai 980-8574, Japan
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Takahiro Okamoto
- Department of Surgery II, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Atsuhiro Ichihara
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Mika Tsuiki
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
| | - Takuyuki Katabami
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama 241-0811, Japan
| | - Masatoshi Nomura
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume 830-0011, Japan
| | - Tomoaki Tanaka
- Department of Molecular Diagnosis, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Tadashi Matsuda
- Department of Urology and Andrology, Kansai Medical University, Hirakata 573-1010, Japan
| | - Tsuneo Imai
- National Hospital Organization, Higashinagoya National Hospital, Nagoya 465-8620, Japan
| | - Masanobu Yamada
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi 371-8511, Japan
| | - Suguru Asada
- Data Science Development Headquarters, Ono Pharmaceutical Co., Ltd., Osaka 541-8564, Japan
| | - Nobuyuki Kawata
- Clinical Development Planning, Ono Pharmaceutical Co., Ltd., Osaka 541-8564, Japan
| | - Mitsuhide Naruse
- Clinical Research Institute for Endocrinology and Metabolic Diseases, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
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Naruse M, Satoh F, Tanabe A, Okamoto T, Ichihara A, Tsuiki M, Katabami T, Nomura M, Tanaka T, Matsuda T, Imai T, Yamada M, Harada T, Kawata N, Takekoshi K. Efficacy and safety of metyrosine in pheochromocytoma/paraganglioma: a multi-center trial in Japan. Endocr J 2018; 65:359-371. [PMID: 29353821 DOI: 10.1507/endocrj.ej17-0276] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
To assess the efficacy, safety, and pharmacokinetics of metyrosine (an inhibitor of catecholamine synthesis) in patients with pheochromocytoma/paraganglioma (PPGL), we conducted a prospective, multi-center, open-label study at 11 sites in Japan. We recruited PPGL patients aged ≥12 years requiring preoperative or chronic treatment, receiving α-blocker treatment, having baseline urinary metanephrine (uMN) or normetanephrine (uNMN) levels ≥3 times the upper limit of normal values, and having symptoms associated with excess catecholamine. Metyrosine treatment was started at 500 mg/day and modified according to dose-adjustment criteria up to 4,000 mg/day. The main outcome measure was the proportion of patients who achieved at least 50% reduction in uMN or uNMN levels from baseline. Sixteen patients (11 males/5 females) aged 12-86 years participated. After 12 weeks of treatment and at the last evaluation of efficacy, the primary endpoint was achieved in 31.3% of all patients, including 66.7% of those under preoperative treatment and 23.1% of those under chronic treatment. Sedation, anemia, and death were reported in 1 patient each as serious adverse drug reactions during the 24-week treatment. Metyrosine was shown to be tolerated and to relieve symptoms by reducing excess catecholamine in PPGL patients under both preoperative and chronic treatment.
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Affiliation(s)
- Mitsuhide Naruse
- Clinical Research Institute for Endocrinology and Metabolic Diseases, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
| | - Fumitoshi Satoh
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai 980-8574, Japan
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Takahiro Okamoto
- Department of Surgery II, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Atsuhiro Ichihara
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Mika Tsuiki
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
| | - Takuyuki Katabami
- Department of Metabolism and Endocrinology, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama 241-0811, Japan
| | - Masatoshi Nomura
- Department of Endocrine and Metabolic Diseases, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Tomoaki Tanaka
- Department of Molecular Diagnosis, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Tadashi Matsuda
- Department of Urology and Andrology, Kansai Medical University Hospital, Hirakata 573-1191, Japan
| | - Tsuneo Imai
- National Hospital Organization, Higashinagoya National Hospital, Nagoya 465-8620, Japan
| | - Masanobu Yamada
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi 371-8511, Japan
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Butz JJ, Weingarten TN, Cavalcante AN, Bancos I, Young WF Jr, McKenzie TJ, Schroeder DR, Martin DP, Sprung J. Perioperative hemodynamics and outcomes of patients on metyrosine undergoing resection of pheochromocytoma or paraganglioma. Int J Surg 2017; 46:1-6. [PMID: 28803996 DOI: 10.1016/j.ijsu.2017.08.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 08/07/2017] [Indexed: 11/23/2022]
Abstract
INTRODUCTION To describe outcomes of patients with metyrosine (MET) pretreatment for abdominal surgical resection of pheochromocytoma or paraganglioma (PCC/PGL) compared with patients who had phenoxybenzamine (PBZ) pretreatment. METHODS Retrospective review of perioperative outcomes for PCC/PGL patients treated with MET and propensity-matched comparison of MET and PBZ (MET + PBZ) with PBZ alone. RESULTS MET preparation was given in 63 cases (26 laparoscopic and 37 open, of which 55 also received PBZ). All patients had wide perioperative hemodynamic oscillations. Patients with open procedures required more intravenous fluids and blood transfusions; 35% required postoperative vasopressor infusions for hypotension and 38% developed acute kidney injury. One laparoscopic procedure required postoperative vasopressor infusion, and 12% of patients developed acute kidney injury. Forty-five MET + PBZ patients were propensity-matched with PBZ-only patients. Intraoperatively, MET + PBZ patients had lower minimum systolic and diastolic blood pressures than PBZ-only patients (median systolic, 74 vs 80 mm Hg, P = 0.01; median diastolic, 42 vs 46 mm Hg, P = 0.005) and larger intraoperative blood pressure oscillations (median systolic range, 112 vs 93 mm Hg, P = 0.06; median diastolic range, 58 vs 51 mm Hg, P = 0.02). Postoperative vasopressor infusion use was similar between MET + PBZ and PBZ only (16% vs 11%, P = 0.76). Major outcomes were not different between regimens. CONCLUSION Large hemodynamic oscillations were present in our PCC/PGL patients treated with MET + PBZ. These patients had a wider range of intraoperative blood pressure variations than PBZ-only patients. No differences in postoperative comorbid outcomes were found between MET + PBZ and PBZ-only groups.
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Ahiskalioglu A, Ince I, Aksoy M, Ahiskalioglu EO, Comez M, Dostbil A, Celik M, Alp HH, Coskun R, Taghizadehghalehjoughi A, Suleyman B. Comparative Investigation of Protective Effects of Metyrosine and Metoprolol Against Ketamine Cardiotoxicity in Rats. Cardiovasc Toxicol 2016; 15:336-44. [PMID: 25503950 DOI: 10.1007/s12012-014-9301-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
This study investigated the effect of metyrosine against ketamine-induced cardiotoxicity in rats and compared the results with the effect of metoprolol. In this study, rats were divided into groups A, B and C. In group A, we investigated the effects of a single dose of metyrosine (150 mg/kg) and metoprolol (20 mg/kg) on single dose ketamine (60 mg/kg)-induced cardiotoxicity. In group B, we investigated the effect of metyrosine and metoprolol, which were given together with ketamine for 30 days. In group C, we investigated the effect of metyrosine and metoprolol given 15 days before ketamine and 30 days together with ketamine on ketamine cardiotoxicity. By the end of this process, we evaluated the effects of the levels of oxidant-antioxidant parameters such as MDA, MPO, 8-OHGua, tGSH, and SOD in addition to CK-MB and TP I on cardiotoxicity in rat heart tissue. The experimental results show that metyrosine prevented ketamine cardiotoxicity in groups A, B and C and metoprolol prevented it in only group C.
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Affiliation(s)
- Ali Ahiskalioglu
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ataturk University, 25100, Erzurum, Turkey
| | - Ilker Ince
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ataturk University, 25100, Erzurum, Turkey
| | - Mehmet Aksoy
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ataturk University, 25100, Erzurum, Turkey
| | - Elif Oral Ahiskalioglu
- Department of Anaesthesiology And Reanimation, Regional Education And Research Hospital, 25100, Erzurum, Turkey
| | - Mehmet Comez
- Department of Anaesthesiology And Reanimation, Regional Education And Research Hospital, 25100, Erzurum, Turkey
| | - Aysenur Dostbil
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ataturk University, 25100, Erzurum, Turkey
| | - Mine Celik
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ataturk University, 25100, Erzurum, Turkey
| | - Hamit Hakan Alp
- Department of Biochemistry, Faculty of Medicine, 100, Yil University, 65000, Van, Turkey
| | - Resit Coskun
- Department of Cardiology, Bayburt State Hospital, 69000, Bayburt, Turkey
| | | | - Bahadir Suleyman
- Department of Pharmacology, Faculty of Medicine, Recep Tayyip Erdogan University, 53000, Rize, Turkey.
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Salman S, Kumbasar S, Hacimuftuoglu A, Ozturk B, Seven B, Polat B, Gundogdu C, Demirci E, Yildirim K, Akcay F, Uslu T, Tuncel Daloglu F, Suleyman H. The effect of metyrosine/prednisolone combination to oophorectomy-induced osteoporosis. Iran J Reprod Med 2012; 10:363-72. [PMID: 25246899 PMCID: PMC4165955] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2011] [Revised: 09/16/2011] [Accepted: 10/23/2011] [Indexed: 10/25/2022]
Abstract
BACKGROUND Osteoporosis is a chronic disease characterized by a decrease in bone mineral density (BMD) and corruption of the microarchitectural structure of bone tissue. OBJECTIVE It was investigated whether methylprednisolone had a favorable effect on osteoporotic bone tissue in Oophorectomy induced osteoporotic rats whose endogenous adrenaline levels are suppressed with metyrosine. MATERIALS AND METHODS Bone Mineral Density, number of osteoblast-osteoclast, bone osteocalcin levels and alkaline phosphatase (ALP) measurements were performed. Obtained results were compared with that of alendronate. RESULTS Oophorectomy induced osteoporosis was exacerbated by methylprednisolone. Alentronate prevented ovariectomised induced osteoporosis, but it couldn't prevent methylprednisolone +ovariectomised induced osteoporosis in rats. CONCLUSION Combined treatment with methylprednisolon and metyrosine was the best treatment for preventing osteoporosis but metyrosine alone couldn't prevent osteoporosis in ovariectomised rats.
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Affiliation(s)
- Suleyman Salman
- Department of Obstetrics and Gynecology, Igdir National Hospital, Igdir, Turkey.
| | - Serkan Kumbasar
- Department of Obstetrics and Gynecology, Igdir National Hospital, Igdir, Turkey.
| | - Ahmet Hacimuftuoglu
- Department of Pharmacology, Ataturk University, Medical Faculty, Erzurum, Turkey.
| | - Berna Ozturk
- Department of Pharmacology, Ataturk University, Medical Faculty, Erzurum, Turkey.
| | - Bedri Seven
- Department of Nuclear Medicine, Ataturk University, Medical Faculty, Erzurum, Turkey.
| | - Beyzagul Polat
- Department of Pharmacology, Ataturk University, Medical Faculty, Erzurum, Turkey.
| | - Cemal Gundogdu
- Department of Pathology, Ataturk University, Medical Faculty, Erzurum, Turkey.
| | - Elif Demirci
- Department of Pathology, Ataturk University, Medical Faculty, Erzurum, Turkey.
| | - Kadir Yildirim
- Department of Physical Medicine and Rehabilitation, Ataturk University, Medical Faculty, Erzurum, Turkey.
| | - Fatih Akcay
- Department of Biochemistry, Ataturk University, Medical Faculty, Erzurum, Turkey.
| | - Turan Uslu
- Department of Physical Medicine and Rehabilitation, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey.
| | | | - Halis Suleyman
- Department of Pharmacology, Ataturk University, Medical Faculty, Erzurum, Turkey.
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