Clinical Outcomes and Plasma Concentrations of Baloxavir Marboxil and Favipiravir in COVID-19 Patients: An Exploratory Randomized, Controlled Trial.

BACKGROUND: Effective antiviral drugs for COVID-19 are still lacking. This study aims to evaluate the clinical outcomes and plasma concentrations of baloxavir acid and favipiravir in COVID-19 patients. METHODS: Favipiravir and baloxavir acid were evaluated for their antiviral activity against SARS-CoV-2 in vitro before the trial initiation. We conducted an exploratory trial with 3 arms involving hospitalized adult patients with COVID-19. Patients were randomized assigned in a 1:1:1 ratio into baloxavir marboxil group, favipiravir group, and control group. The primary outcome was the percentage of subjects with viral negative by Day 14 and the time from randomization to clinical improvement. Virus load reduction, blood drug concentration and clinical presentation were also observed. The trial was registered with Chinese Clinical Trial Registry (ChiCTR 2000029544). RESULTS: Baloxavir acid showed antiviral activity in vitro with the half-maximal effective concentration (EC50) of 5.48 µM comparable to arbidol and lopinavir, but favipiravir didn't demonstrate significant antiviral activity up to 100 µM. Thirty patients were enrolled. The percentage of patients who turned viral negative after 14-day treatment was 70%, 77%, and 100% in the baloxavir marboxil, favipiravir, and control group respectively, with the medians of time from randomization to clinical improvement was 14, 14 and 15 days, respectively. One reason for the lack of virological effect and clinical benefits may be due to insufficient concentrations of these drugs relative to their antiviral activities. One of the limitations of this study is the time from symptom onset to randomization, especially in the baloxavir marboxil and control groups, which is higher than the favipiravir group. CONCLUSIONS: Our findings could not prove a benefit of addition of either baloxavir marboxil or favipiravir under the trial dosages to the existing standard treatment.

Co-administration of Magnesium Oxide Reduces the Serum Concentration of Hydrophobic Basic Drugs in Patients Treated with Antipsychotic Drugs.

Magnesium oxide (MgO) is a widely used laxative. Because many antipsychotic drugs are lipophilic-basic-compounds, their solubility decreases with increasing pH and changes markedly as the pH of the solution approaches their pKa. It is highly important to clarify the effect of co-administration of MgO on the serum drug concentration for effective, safe, and appropriate medication therapy. However, the relationship between MgO administration and the serum concentration of antipsychotic drugs in patients with schizophrenia has not been reported. Therefore, in the present study, we investigated the effect of MgO administration on the concentration of antipsychotic drugs in the blood of patients with schizophrenia. The serum concentrations of biperiden, zotepine, and risperidone were assayed using an LC/MS system. The correlation between the daily dose of MgO and the relative-drug-concentration (rCp) in each patient was examined. As the MgO dose was increased, the risperidone concentration decreased. The correlation coefficient decreased for risperidone, zotepine, and biperiden, in the same order. To clarify the difference in the suppression potency of MgO on the three drugs, the relationship between the physical properties and the correlation coefficients of each drug was carefully examined. A strong correlation was observed between the pKa and the correlation coefficient. Patients with schizophrenia are often prescribed antipsychotic drugs, which have anticholinergic action and tend to suppress gastric acid secretion. We concluded that basic drug absorption might be suppressed due to an increase in the stomach pH following MgO administration. Therefore, MgO co-administration is better to avoid while taking antipsychotic drugs and anticholinergic drugs.

Black esophagus: acute esophageal necrosis in fatal haloperidol intoxication.

Herein, we present a case of 53-year-old psychotic woman with acute esophageal necrosis (black esophagus), who was found lying on the floor in the living room of her flat. Pillboxes of antipsychotic drugs were located in the bin. External examination of the body was unremarkable. On internal examination, we found acute esophageal necrosis. Histologically, there was complete epithelial necrosis with focal involvement of muscularis mucosae, dense infiltrate of leukocytes, and ulcerations without any viable cells. There was no evidence of underlying organic diseases or trauma. Toxicological analysis revealed a fatal blood level of antipsychotics (haloperidol, zotepine, and chlorprothixene). Death of the deceased was attributed to fatal intoxication with three various types of antipsychotics. As far we know, this is the first described association between so-called black esophagus and fatal blood level of neuroleptics.

Application of on-line electrochemistry/electrospray/tandem mass spectrometry to a quantification method for the antipsychotic drug zotepine in human serum.

A simple, rapid, and sensitive on-line liquid chromatographic electrochemistry/electrospray/tandem mass spectrometry (LC-EC/ESI-MS/MS) method for the determination of zotepine in human serum was developed using a new generated-electrochemically fragment ion, and was validated. A recent novel technique of LC-EC/ESI-MS/MS that combines LC-MS/MS and the on-line EC reaction is potentially applicable to developing a quantification method for drugs in biological samples. Newly formed products generated by the on-line EC cell are expected to provide appropriate precursor and product ions for the MS/MS determination method. This technique was successfully applied to a drug assay in a biological matrix. After adding imipramine (IS) to a 30-microL aliquot of human serum, the resulting sample was simply deproteinated with acetonitrile for a measurement. The analytical run time was 5 min. The calibration curve was linear in the concentration range of 10-2000 ng/mL. The intra-assay precision and accuracy were in the range of 1.8-8.9 and 98.4-113%, respectively.

Total, free and bound leptin and thyroid function in elderly women with different body weights.

OBJECTIVE: The present study was aimed at evaluating the relationship of total leptin, and its free leptin (FL) and bound leptin (BL) fractions with adipose mass in very old euthyroid women, in relationship to thyroid function. SUBJECTS AND METHODS: Twenty-five older women (age: 73-95 years) were studied. Subjects representing underweight, normal weight and overweight/obese conditions were included. Plasma leptin, TSH, free T(4) (FT(4)) and free T(3), (FT(3)) total and HDL cholesterol were measured. FL and BL were evaluated by Fast Protein Liquid Chromatography (FPLC) analysis. RESULTS: Plasma leptin concentration was positively correlated with body mass index (BMI) (r = 0.64, P = 0.0005) and tricipital skin-fold thickness (TF) (r = 0.46, P = 0.0187). Leptin was positively correlated with TSH (r = 0.50, P = 0.0116) and inversely with FT(3) (r = -0.40, P = 0.0477). TSH correlated with the adiposity indexes BMI (r = 0.40, P = 0.05) and TF (r = 0.42, P = 0.0336). Plasma FT(3) was positively correlated with FT(4) (r = 0.49, P = 0.012). FL and BL were evaluated in 8 out of 25 subjects. FL positively correlated with BMI (r = 0.81, P = 0.0218) and leptin (r = 0.83, P = 0.0004), whereas BL did not correlate with these parameters. CONCLUSIONS: The present results indicate that in very old women, plasma leptin concentrations reflect the extent of adipose mass and suggest that a complex regulatory interaction exists between leptin and thyroid function, possibly taking place at central (hypothalamus-pituitary) and peripheral (deiodinase activity) levels.

Trace analysis of zotepine and its active metabolite in plasma by capillary electrophoresis with solid phase extraction and head-column field-amplified sample stacking.

A sensitive high-performance capillary zone electrophoresis (CZE) with head-column field-amplified sample stacking (FASS) in binary system has been developed for the simultaneous determination of zotepine and its active metabolite, norzotepine, in human plasma. The separation of zotepine and norzotepine was performed using a background electrolyte consisting of 50% ethylene glycol-borate buffer (20mM, pH 8.0) solution with 20% methanol as the running buffer and on-column detection at 200 nm. Under the optimal FASS-CZE condition, good separation with high efficiency and short analysis time is achieved. Several parameters affecting the separation and sensitivity of the drug were studied, including sample matrix, pH and concentrations of the borate buffer, ethylene glycol and methanol. Using clozapine as an internal standard, the linear ranges of the method for the determination of zotepine and norzotepine in human plasma were over 3-100 ng/mL; the detection limits of zotepine and norzotepine in plasma were 2 and 1 ng/mL, respectively. A sample pretreatment by means of solid-phase extraction (SPE) with subsequent quantitation by FASS-CZE was used. The application of the proposed method for determination of zotepine and norzotepine in plasma collected after oral administration of 125 mg zotepine in one schizophrenic patient was demonstrated.

In vivo (123)I IBZM SPECT imaging of striatal dopamine 2 receptor occupancy in schizophrenic patients.

RATIONALE: Single photon emission computed tomography (SPECT) using (123)I iodobenzamide (IBZM) as tracer substance has been shown to be a useful tool to visualize dopamine 2 (D2) receptor occupancy. OBJECTIVES: We investigated the striatal D2 receptor occupancy of zotepine which is referred to the class of atypical antipsychotic drugs. METHODS: (123)I IBZM and SPECT were used to visualize striatal dopamine 2 (D2) receptor occupancy in zotepine-treated schizophrenic patients. Two groups of schizophrenic patients receiving either 150 mg/day zotepine (n=6) or 300 mg/day (n=6) underwent examination. For the quantification of striatal D2 receptor occupancy, striatal IBZM binding in patients treated with antipsychotics was compared to untreated healthy controls (n=8) reported earlier. RESULTS: Zotepine led to a mean overall striatal D2 receptor occupancy of 73%. Patients with 150 mg daily showed a significantly lower occupancy (65.8%, SD=6.2) than patients with 300 mg/day (77.8%, SD=10.7; P<0.05). No clinically relevant extrapyramidal side effects occurred during treatment with zotepine. CONCLUSIONS: There was no correlation between the degree of striatal D2 receptor occupancy and clinical improvement.

Effects of monatepil maleate, a new Ca2+ channel antagonist with alpha1-adrenoceptor antagonistic activity, on cholesterol absorption and catabolism in high cholesterol diet-fed rabbits.

The mechanism of the prophylactic effect against hyperlipidemia by monatepil maleate was investigated in animal models. Monatepil maleate is an antihypertensive agent with Ca2+-channel antagonistic, alpha1-adrenergic receptor-blocking, and lipid peroxidation inhibitory activity. In high cholesterol diet-fed rabbits, monatepil maleate (30 mg/kg, p.o., once daily for 9 weeks) showed a prophylactic effect against increases in total cholesterol and beta-lipoprotein. Monatepil maleate significantly accelerated the clearance of radioactivity from the blood after intravenous injection of low-density lipoprotein (LDL) labeled with [1alpha,2alpha (n)-3H]cholesterol, increasing biliary excretion of [3H]-bile acids without modifying bile acid composition. Furthermore, monatepil maleate tended to inhibit the absorption of orally administered [1alpha,2alpha (n)-3H]cholesterol from the gastrointestinal tract in these rabbits. In Watanabe heritable hyperlipidemic (WHHL) rabbits, an animal model of hepatic LDL receptor deficiency, monatepil maleate (30 mg/kg, p.o., once daily for 6 months) did not suppress the increase in plasma lipids. These results suggest that the plasma lipid lowering effect of monatepil maleate requires the presence of hepatic LDL receptors. It is also suggested that monatepil maleate improves plasma lipid metabolism through two mechanisms: enhancement of clearance of plasma LDL, which may be mediated by up-regulation of hepatic LDL receptors, and acceleration of conversion of free cholesterol to bile acids in the liver.

Simultaneous determination of a novel calcium entry blocker, monatepil maleate, and its metabolites in rat plasma by means of solid-phase extraction and reversed-phase liquid chromatography with electrochemical detection.

A reversed-phase LC method with electrochemical detection is described for the simultaneous determination of monatepil maleate (AJ-2615, AJ), a novel calcium entry blocker, and its three S-oxidized metabolites in plasma. These compounds were extracted from plasma by solid-phase extraction and injected onto an ODS column. The determination limit in plasma (0.5 ml) was 10 ng/ml for AJ and 5 ng/ml for the three metabolites. The method was applied to the determination of AJ and the metabolites in rat plasma samples.

Plasma concentrations of antipsychotic drugs in psychiatric inpatients.

In current psychiatric therapy, two or more kinds of antipsychotic drugs are usually prescribed in Japan. However, there are few data on the therapeutic plasma concentrations of antipsychotic drugs or on the correlation between the daily dose and the plasma concentration, in cases where several antipsychotic drugs had been prescribed for each patient. We measured the therapeutic plasma concentrations of 9 antipsychotic drugs in 24 psychiatric inpatients during a 6-month period. They were treated with fixed dosages of antipsychotic drugs. Plasma samples were collected early in the morning once a month, and the concentrations of antipsychotic drugs were determined by gas chromatography with nitrogen phosphorus detection, high-performance liquid chromatography (HPLC) with fluorescence detection and HPLC with UV detection. The plasma levels of chlorpromazine, levomepromazine, thioridazine, haloperidol, bromperidol, zotepine, oxypertine, sulpiride and sultopride were 21.8-92.4, 31.7-156, 101-203, 16.4-56.2, 2.72-11.7, 13.6-84.0, 29.9-80.4, 70.1-1,120 and 35.7-2,990 ng/ml, respectively. A linear correlation between the daily dose and the plasma concentration was noted for sultopride, levomepromazine, sulpiride, haloperidol, chlorpromazine and zotepine.

Possible inhibitory effect of diazepam on the metabolism of zotepine, an antipsychotic drug.

Effects of smoking and cytochrome P450 2C19 (CYP2C19) status on the single dose kinetics of zotepine and pharmacokinetic interaction between zotepine and diazepam were investigated. In 14 healthy volunteers, the pharmacokinetics of zotepine after a single oral 25 mg dose were compared between eight smokers and six non-smokers, or between seven extensive metabolizers (EMs) and seven poor metabolizers (PMs) of S-mephenytoin. There was no significant difference in any pharmacokinetic parameters between smokers and non-smokers, or between the EM and PM groups. In 17 patients treated with zotepine 80-340 mg/day, intra-individual changes in plasma concentrations of zotepine caused by coadministration of diazepam 10 mg/day for 2 weeks were examined. Plasma concentrations of zotepine were significantly increased after coadministration of diazepam (P < 0.05). Consequently, it is suggested that neither smoking nor CYP2C19 status affects the metabolism of zotepine. The elevation in plasma concentrations of zotepine after coadministration of diazepam may be a result of competitive inhibition of zotepine metabolism by diazepam via other isoenzyme than CYP2C19, e.g., CYP3A4.

A method for rapid determination of zotepine by gas chromatography-mass spectrometry.

A rapid and sensitive method using solid-phase extraction and gas chromatography-mass spectrometry (GC-MS) has been developed for the determination of zotepine (ZTP), an atypical neuroleptic, in human plasma. The detection limit of ZTP was 1 microgram/L. Standard curves over the concentration range from 2.5 to 100 micrograms/L had a good linearity. Intraassay variability ranged from 2.2 to 3.3% and interassay variability from 3.5 to 6.6% at the concentration range of 5-75 micrograms/L. Our preliminary data of single-dose kinetics of ZTP by using this method suggested that the peak time and elimination half-life was much longer than previously reported, and that there appeared to be a second peak after 10-12 h of ZTP administration, indicating the possibility of the presence of enterohepatic recirculation.

A capillary gas-liquid chromatographic method for the assay of the neuroleptic drug zotepine in human serum or plasma.

A capillary gas-liquid chromatographic method suitable for the assay of the atypical neuroleptic drug zotepine in human serum or plasma was developed. A liquid-liquid extraction with three subsequent extraction steps was applied for sample preparation. The minimum detectable concentration was 1.0 ng ml-1. The within-day relative standard deviation (RSD) (n = 6) was 5.3% at 5 ng ml-1, 3.6% at 10 ng ml-1 and 6.1% at 100 ng ml-1. The day-to-day RSD (n = 6) was 9.3% at 10 ng ml-1 and 5.1% at 100 ng ml-1. Steady-state serum levels of four schizophrenic patients were measured.

Adverse effects of zotepine and their relationship to serum concentrations of the drug and prolactin.

Adverse effects of zotepine, an antipsychotic drug, and their relationship to serum concentrations of the drug and prolactin were investigated in 28 schizophrenic in-patients. The daily dose was 100 mg during the first week and 200 mg during the next 3 weeks. Adverse effects were evaluated by the UKU Side Effect Rating Scale (21 items). The mean (+/- SD) total UKU score at the end of the study was 3.1 +/- 2.5, indicating mild adverse effects. The scores of psychic adverse effects at 2 weeks and total adverse effects at 3 and 4 weeks were significantly higher in nonresponders than in responders (p < 0.05). Furthermore, there was a significant inverse correlation between percent improvement in total Brief Psychiatric Rating Scale (BPRS) scores and total UKU scores at 4 weeks (p < 0.05). These results suggest a relationship between poor clinical response and increased adverse effects during zotepine treatment. Only the scores of akathisia at 2 weeks showed a significantly positive correlation with serum zotepine concentrations (p < 0.05). No correlation was found between prolactin response and neurological adverse effects.

Anti-atherosclerotic and plasma lipid lowering effects of the novel calcium blocker with alpha 1-adrenoceptor antagonistic activity, monatepil, in high cholesterol diet-fed Japanese Macaca fuscata monkeys.

1. The preventive effects of atherosclerosis and hyperlipidemia of monatepil ([(+-)-N-(6,11-dihydrodibenzo [b,e]thiepin-11-yl)-4-(4-fluorophenyl)-1-piperazine-butanamide+ + +]monomaleate , AJ-2615, CAS 103377-41-9), a new antihypertensive drug with potent calcium antagonistic and alpha 1-adrenoceptor blocking activities, were investigated in Japanese monkeys (Macaca fuscata) fed with a cholesterol-rich diet (2% cholesterol + 6% corn oil) and compared with those of prazosin. 2. The dose of monatepil selected (30 mg/kg/d, p.o., 6 months) was the plasma concentration dose level of antihypertensive therapy and that of prazosin (2 mg/kg twice daily, p.o., 6 months) was the dose where hypolipidemic effect in cholesterol-fed monkeys has been reported. 3. In the cholesterol diet control group (n = 7), plasma levels of total cholesterol and low-density lipoprotein (LDL) significantly increased and that of high-density lipoprotein-cholesterol (HDL-C) decreased compared with the normal diet group (n = 5). In the monatepil group (n = 5), these changes were significantly suppressed. In the prazosin group (n = 5), these changes were also inhibited but the inhibitory effect was weaker than in the monatepil group. 4. The cholesterol content and sudanophilic area in the aorta indicating atheromatous lesions in the cholesterol-diet fed control group were significantly higher than those in the normal diet control group. In the monatepil group, these changes were significantly suppressed whereas in the prazosin group these changes were partially inhibited. 5. In the histological study, aortic lesions characterized by aggregations of foam cells were observed in the cholesterol-diet control group, while there was little change in the monatepil group. The anti-atherogenic effect of prazosin was weaker than that of monatepil. 6. Coronary atheromatous lesions were found in 4 out of the 7 animals in the cholesterol-diet control group and 3 out of the 5 animals in prazosin group. In contrast, no coronary atheromatous lesion was found in the monatepil group. 7. The treatment with monatepil did not influence food consumption, body weight, physical signs or blood biochemistry. 8. The anti-atherosclerotic and plasma lipid-lowering effects of monatepil may in part be attributable to its calcium antagonistic, alpha 1-adrenoceptor blocking, and anti-lipid peroxidation activities. 9. In conclusion, monatepil is a new class of antihypertensive agent that possesses anti-atherogenic properties and the ability to reduce plasma lipid levels, a main risk factor for atherosclerosis.

Identification of AJ-2615 and its S-oxidized metabolites in rat plasma by use of tandem-mass spectrometry.

The structural elucidation of the metabolites of a new calcium entry blocker, AJ-2615 (AJ), in rat plasma is described. Metabolites in a crude plasma extract from spontaneously hypertensive rats were identified without chromatographic separation by fast atom bombardment tandem mass spectrometry. When the plasma extract was examined by using parent ion scans, the presence of the oxidized metabolites of AJ was suggested. These metabolites were identified as the S-oxide and the S,S-dioxide by comparing their daughter ion spectra with those of authentic samples. The presence of the two diastereomeric S-oxides of AJ in the plasma extract was ascertained by high-performance liquid chromatography. Their relative configurations were determined by infrared and proton nuclear magnetic resonance spectra.

Determination of amidepin in human plasma by reversed-phase high-performance liquid chromatography with fluorescence detection.

An isocratic reversed-phase high-performance liquid chromatographic method for the determination of amidepin has been developed. The method is based on the extraction of alkaline plasma with diethyl ether-dichloromethane, and the injection into the Supelcosil LC-18 column of the evaporated and reconstituted organic phase. After separation, detection is carried out by a fluorescence detector (excitation at 195 nm with no filter). The limit of detection is 10 ng/ml of plasma. The mean coefficient of variation is 12%. The plasma levels after oral administration and after intravenous administration are shown.

Determination of isofloxythepin in biological fluids by gas chromatography-mass spectrometry.

A method for the determination of isofloxythepin in biological fluids by gas chromatography-mass spectrometry is described. Isofloxythepin was readily converted into the trimethylsilyl ether by treatment with N,O-bis(trimethylsilyl)trifluoroacetamide. This derivative was separated on a 5% OV-101 column and determined, employing newly prepared isofloxythepin-d7 as an internal standard. Clean-up of isofloxythepin in blood and urine was efficiently achieved by back-extraction with hexane or hexane-toluene (9:1) under acidic and basic conditions, while isofloxythepin glucuronide in biological fluids was isolated by ion-exchange chromatography on Dowex 50W-X4 resin. The detection limit of isofloxythepin by this method was 50 pg. The blood and urine levels of isofloxythepin after oral administration of the drug to dogs were monitored by the proposed method.