Clinical trials of WR-2721 with radiation therapy.

The radioprotector with clinical potential, S-2-(3 aminopropylamino)-ethylphosphorothioic acid (WR-2721) is undergoing two Phase I trials. The objectives of these trials are 1) to determine the maximum tolerated dose (MTD) of WR-2721 in a single dose and 2) to determine the highest dose of WR-2721 that can be tolerated daily in the greatest number of fractions per week. A total of 65 patients have been treated. The single maximum tolerated dose has not yet been reached, though 740 mg/m2 is well tolerated. A single dose of 910 mg/m2 has been successfully administered to one patient. The multiple dose MTD is at an early stage with patients currently receiving 170 mg/m2 four times a week. Among the toxicities noted in both trials are hypotension, hypertension, emesis and somnolence. In addition, in the multiple dose trial there have been three patients who have had allergic reactions including one which was life-threatening. Phase II studies are planned and will begin when the maximum tolerated dose is established from each Phase I trial.

SK&F 89124, a potent and selective agonist at prejunctional dopamine receptors.

SK&F 89124 (4-[2-(N,N-di-n-propylamino)ethyl]-7-hydroxy-2(3H) indolone) can be considered as a derivative of N,N-di-n-propyldopamine (DPDA) in which the meta-hydroxyl is replaced by a cyclic amide function. SK&F 89124 is at least one order of magnitude more potent than DPDA as an agonist at peripheral inhibitory prejunctional dopamine receptors (DA2 receptors) in the isolated perfused rabbit ear artery. A potent agonist action of SK&F 89124 at the DA2 receptor can also be demonstrated by inhibition of radioactive overflow from prelabelled canine coronary artery or saphenous vein, and in the anesthetized dog as an inhibition of the tachycardia induced by cardioaccelerator nerve stimulation or the increase in hind-limb perfusion pressure induced by stimulation of the lumbar sympathetic chain. SK&F 89124 is a potent inhibitor of the binding of [3H]spiroperidol to D2 receptors in bovine pituitary homogenates. High concentrations of SK&F 89124 do not activate the adenylate cyclase D1 receptor in rat caudate homogenates, nor produce activation of alpha 2-adrenoceptors or H2-histamine receptors in the guinea pig atrium. Although some alpha 1-adrenoceptor mediated vasoconstriction is produced in the rabbit ear artery and rabbit aorta, the concentrations required are several orders of magnitude higher than those active at the DA2 receptor. From these data it is evident that this structural modification can increase both the potency and selectivity of DPDA as a DA2 receptor agonist. The potency and selectivity of SK&F 89124 make this agent a useful tool for determination of the functional role of the DA2 receptor.

Pressor effects of indomethacin in two anephric patients with chronic hypotension.

Two anephric patients with chronic hypotension were treated with indomethacin (150 mg/day). Indomethacin increased supine blood pressures from 63 +/- 4/37 +/- 3 mm Hg (mean +/- SD) to 76 +/- 5/48 +/- 6 mm Hg (patient 1) and 93 +/- 6/47 +/- 6 mm Hg to 112 +/- 8/61 +/- 5 mm Hg (patient 2), P less than .01. Similar changes occurred in standing pressures. The increases in pressures were associated with decreases in blood concentrations of prostaglandins 6-keto-F1 alpha, E2, and F2 alpha, measured by radioimmunoassay. These results suggest that indomethacin may raise blood pressure in certain anephric patients by inhibiting synthesis of extra-renal, vasoactive prostaglandins. Indomethacin may be useful in the treatment of chronic hypotension in anephric patients.

Fluorometric assessment of skin flap viability in the rat: effect of radiation therapy.

The fluorescein test is widely used to assess perfusion in skin flaps but tends to underestimate skin viability when visual inspection under ultraviolet light is employed. Fiberoptic dermofluorometry, which has recently been introduced, more accurately assesses fluorescein distribution in skin flaps than does visual inspection. Viability of the back flap in rats receiving ionizing radiation was evaluated by dermofluorometry. This technique was highly accurate in predicting viability and has great applicability for studying blood flow in irradiated tissues.

Definitive irradiation following breast-conserving surgery for early stage breast cancer.

Definitive irradiation following breast-conserving surgery for early stage breast cancer can be offered in a community cancer center and achieve excellent local control, survival and cosmesis. The results confirm the validity of patient choice in selecting this breast-conserving modality as an alternative to mastectomy for selected patients with stage I and II breast cancer.

Neuroinhibitory effects of SK&F 85174, a novel dopamine receptor agonist.

SK&F 85174 (3-allyl-6-chloro-2,3,4,5-tetra-hydro-1-(4-hydroxy-phenyl)-1-H-3-benzaze pine-7, 8-diol methanesulfonate) the N-allyl derivative of SK&F 82526, a selective postjunctional dopaminergic agonist, retains the potent agonist activity of the parent molecule at the postjunctional dopamine receptor, as evidenced by activation of the dopamine-sensitive adenylate cyclase in rat caudate homogenates (EC50 = 11 nM). However, unlike SK&F 82526, SK&F 85174 is a potent inhibitor of adrenergic neurotransmission. This neuroinhibitory effect can be demonstrated both in isolated vascular preparations, and in in situ preparations in the anesthetized dog measuring both cardiac and vascular neurotransmission. In each of these preparations, the effect of SK&F 85174 can be blocked by the dopamine receptor antagonists, metoclopramide, or 1-sulpiride, showing that its action occurs via activation of prejunctional dopamine receptors. Inhibition of the responses to sympathetic nervous system activation, when combined with the ability to increase renal blood flow by stimulation of postjunctional dopamine receptors, could make SK&F 85174 an effective therapeutic agent for a variety of cardiovascular disorders, including angina pectoris, hypertension, and congestive heart failure.

Total skin electron beam therapy in mycosis fungoides.

Thirty-nine patients with mycosis fungoides were treated with total skin electron beam irradiation from 1971 to 1976, and all received minimum follow-up of 12 months. Details of treatment technique and dosimetry are given. Sixteen patients cleared completely. Seven patients are in long-term remission (1 1/2 to 4 1/2 years). Eleven patients died. Those who failed are now being treated with topical therapy with varying degrees of control. Some have been retreated with local irradiation. Most of the patients had extensive disease; for this group, total skin electron beam therapy was especially useful, as many of those who failed developed only minimal disease that was well controlled by topical measures.

Differentiation of neurogenic and myocardial angiotensin II receptors in isolated rabbit atria.

The effect of angiotensin on the action of tyramine was studied in isolated rabbit left atria paced by point and field stimulation to more clearly define the interaction of angiotensin with the sympathetic nervous system. Administration of angiotensin resulted in similar increases in contractility in both point- and field-stimulated atria. In point-stimulated preparations only the muscle is stimulated to contract, whereas in field-stimulated preparations both nerve and muscle are stimulated. 1-Sar-8-Ala-angiotensin II completely blocked the direct inotropic effect of angiotensin in a molar dose ratio of 3:1 in both point- and field-stimulated preparations. However, angiotensin (0.05-10 ng/ml) potentiated the inotropic effect of tyramine in field-stimulated atria only. This facilitatory effect was not inhibited by 1-Sar-8-Ala-angiotensin II at a molar dose ratio of 3:1; indeed, a ratio of 500:1 was necessary for complete blockade of this angiotensin-induced potentiation. This antagonist in odses of 0.1-1000 ng/ml was without contractile effect in any preparation, regardless of whether tyramine was present. The data suggest the presence of (1) a presynaptic angiotensin receptor that, in the presence of sympathetic nerve stimulation, modulates the release of norepinephrine and (2) a second angiotensin receptor in cardiac tissue that directly influences myocardial contractility.

Blood vessel-hormone interactions: angiotensin, bradykinin, and prostaglandins.

Isolated Krebs-perfused rabbit-mesentery blood vessels release a prostaglandin E-like substance (PGE) when treated with angiotensin II, angiotensin I, arachidonic acid, or bradykinin. The specific competitive antagonist [Sar1,Ile8]angiotensin II, was found to inhibit angiotensin II-induced PGE release. The angiotensin antagonist did not block PGE release by bradykinin, whereas indomethacin blocked PGE release induced by all agonists. SQ-20881, the converting-enzyme and bradykininase inhibitor, decreased the PGE release by angiotensin I, enhanced the release by bradykinin, and did not affect release by angiotensin II. Pressor and depressor responses were obtained in mesenteric preparations constricted by epinephrine to a pressure of 60 mmHg. Angiotensin II induced an initial increase in mesenteric vascular resistance followed by a depressor response below basal pressure. The pressor responses were enhanced by indomethacin and the depressor responses were eliminated. Bolus injections of both bradykinin and arachidonic acid produced decreases in perfusion pressure, but indomethacin completely inhibited only the arachidonic acid-induced responses while only diminishing bradykinin-induced responses. The ability of angiotensin to increase mesenteric vascular resistance and to release PGE which decrease vascular resistance is discussed.

Angiotensin (A I, A II, A III) receptor characterization. Correlation of prostaglandin release with peptide degradation.

We examined the ability of the angiotensins (A I, A II, A III) to release a prostaglandin E (PGE)-like substance in the isolated Krebs' perfused kidney and mesenteric vasculature of the rabbit by parallel bioassay. In the kidney, the order of potency for PGE release was A II greater than A III greater than A I with ED50's of 36, 100, and 500 pmol, respectively. In the mesenteric preparation, on the other hand, the order of potency was A III greater than A II greater than A I with ED50's of 75, 125, and 500 pmol, respectively. During one transit through the kidney 72-76% of bioassayable A I and A II was degraded. A III was 89% metabolized. In contrast, the mesenteric vasculature inactivated only 27% of A II and 23% of A III. This data suggests an inverse relationship between renal peptide degradation and PGE release. For characterization of the renal angiotensin receptor-mediating PGE release, dissociation constants (KB) of the competitive angiotensin antagonists [IIe7]-A III and [Sar1, IIe3]-A II were determined with each angiotensin. KB values of the individual antaganists were not significantly different with A I, A II, or A III; this finding suggests that one renal angiotensin receptor is involved with PGE release.

Suppression of sympathetic ganglionic neurotransmission by the selective dopamine-1 receptor agonist fenoldopam (SK&F 82526) in the anesthetized dog.

This study was designed to determine the role of dopamine (DA) receptors in modulation of sympathetic ganglionic neurotransmission utilizing the selective DA-1 agonist fenoldopam. Preganglionic stimulation of cardiac sympathetic nerves (0.5-2.0 Hz), in pentobarbital anesthetized dogs, resulted in frequency-dependent tachycardia. Fenoldopam (10 and 30 micrograms/kg/min i.v.) suppressed the tachycardic response 45% at 0.5 Hz with no significant effect at higher stimulation frequencies. In the presence of SK&F 83566 (10 micrograms/kg/min i.v.), a selective DA-1 receptor antagonist, fenoldopam no longer elicited significant inhibition of the preganglionic response. When postganglionic cardiac nerves were stimulated (0.5 Hz), fenoldopam (100 micrograms/kg/min i.v.) inhibited the response 55% with no significant effect at lower doses. Stimulation of sympathetic preganglionic fibers in the autoperfused hindlimb of the dog induced vasoconstriction. Fenoldopam (3 micrograms/kg/min i.a.) produced marked inhibition of nerve-induced constriction that was partially antagonized by SK&F 83566 (3 micrograms/kg/min i.a.). Complete inhibition of the effect of fenoldopam on sympathetic nerve stimulation in the hindlimb could not be achieved, as a component of this action was apparently due to postjunctional alpha-2 adrenoceptor blockade. This was evidenced by a reduction in the pressor response to the selective alpha-2 adrenoceptor agonist B-HT 920 by fenoldopam. These data indicate that fenoldopam stimulates DA-1 receptors in sympathetic ganglia to inhibit neurotransmission and this effect can be reversed by a selective DA-1 receptor antagonist.

Selectivity of metoclopramide for endocrine versus renal effects of dopamine in normal humans.

The purpose of the present study was to evaluate the effect on renal function of dopamine (low dose, 2 micrograms/kg/min) inhibition by a low-dose infusion of metoclopramide. Prolactin and aldosterone levels were measured to assess metoclopramide's endocrine effects. Six salt-loaded subjects were studied by standard renal clearance techniques during water diuresis. Dopamine infusion produced an increase in renal plasma flow, fractional excretion of sodium, osmolar and free water clearances, urine volume, and solute delivery out of the proximal tubule. Solute and fluid absorption decreased in the distal nephron. These effects were evident within the first hour and peaked during the third hour. Metoclopramide slightly attenuated the dopamine-induced increase in renal plasma flow; statistical significance was obtained only during the second hour. None of the other renal function changes were inhibited. Serum prolactin and aldosterone levels were significantly increased following metoclopramide. Dopamine infusion attenuated the rise in prolactin levels but did not significantly affect aldosterone levels. The variance between previous reports and the present one may be due to the use of water diuresis, salt-loading, or methodological factors. Metoclopramide infused at 0.1 mg/kg/h appears selective for DA2 receptors, and low-dose dopamine-induced changes in renal function are DA1 receptor-mediated.

Hemodynamic effects of selective dopamine receptor agonists in the rat and dog.

The availability of highly selective dopamine receptor agonists has allowed the characterization of the role of DA1 and DA2 receptors in the cardiovascular system. Fenoldopam (SK&F 82526) is a potent agonist at DA1 receptors, with much less agonist activity at the DA2 subtype or at alpha and beta adrenoceptors. In contrast, SK&F 89124 activates only the DA2 subtype. SK&F 85174, the N-allyl derivative of fenoldopam, retains potent DA1 agonist activity but also has moderately potent agonist activity at the DA2 receptor. All three compounds will reduce blood pressure in hypertensive rats. In the anesthetized dog, each agonist will reduce blood pressure and total peripheral resistance. The overall hemodynamic profile is remarkably similar, despite the marked difference in dopamine receptor subtype selectivity. The principal pharmacologic difference is enhanced bradycardia with the compounds having DA2 agonist activity, resulting from activation of neuroinhibitory DA2 receptors on cardiac sympathetic nerve terminals. In the dog, each compound will increase renal blood flow. Studies in the anesthetized rat with fenoldopam and SK&F 89124, using radiolabelled microspheres to measure blood flow to various vascular beds, also show a significant increase in renal flow, with a tendency toward increased blood flow in the splenic and intestinal beds. Hence, dopamine receptor agonists offer a useful approach to cardiovascular therapy via DA1 mediated vascular dilation, DA2 mediated modulation of sympathetic tone or a combination of both activities.

Contact activation of human plasma prorenin in vitro.

Acid activation of plasma prorenin occurs during dialysis to pH 3.3. and also during subsequent dialysis to pH 7.4. The latter, alkaline phase, involves Hageman factor-dependent formation of kallikrein, which in turn activates prorenin. The present study evaluates whether prorenin activation always occurs whenever kallikrein is activated in plasma. TAME esterase activity was used as a measure of plasma kallikrein activity an increase was observed during the alkaline phase of acid activation of prorenin. TAME esterase activity was absent when Hageman factor- or prekallikrein-deficient plasmas were similarly assayed and prorenin was not activated. Kaolin treatment of normal plasma rapidly increased TAME esterase activity at both 25 degrees and -4 degrees C, but no prorenin activation occurred. Similar changes in TAME esterase activity were observed in acid-treated plasma, in which setting prorenin was activated. No change in TAME esterase or renin activity occurred after addition of kaolin to acid-treated plasma deficient in Hageman factor; however, both enzymatic activities increased slightly in acidified prekallikrein-deficient plasma. Mixtures of these deficient plasmas exhibited normal kaolin activation of both TAME esterase and prorenin after acidification. Thus both Hageman factor and prekallikrein are needed for optimal contact activation of prorenin. These results demonstrate that prorenin activation does not always occur when active kallikrein is present in plasma. Prior acidification appears to be a prerequisite. Acidified prorenin may be more susceptible to cleavage; alternatively, competing substrates and/or inhibitors of kallikrein may be destroyed at acid pH, thereby permitting kallikrein to activate prorenin. Under normal conditions, activation of the plasma kallikrein-kinin system appears unlikely to result in activation of prorenin in vivo.

Potential usefulness of renal vasodilators in hypertension and renal disease: SK&F 82526.

SK&F 82526 and its enantiomers have been shown to increase renal blood flow and decrease renal vascular resistance in the anesthetized dog. The effect of the racemate on lowering systemic blood pressure in the anesthetized dog and the spontaneously hypertensive rat has been shown to be caused by the R-enantiomer with the S-enantiomer being devoid of significant activity on blood pressure. The mechanism by which the R-enantiomer decreases blood pressure is not systemic vasodilatation or prejunctional inhibition of norepinephrine release but appears to result from a unique stimulation of the postjunctional dopamine receptor. Racemic SK&F 82526 also has been shown to increase renal blood flow in an ischemic model of acute renal failure.

Angiotensin antogonists as pharmacological tools.

The availability of specific competitive antagonists stimulated investigation of the physiological and pathological role of angiotensin (A-II) and permitted the qualitative and quantitative characterization of numerous angiotensin receptor sites. The specific, competitive antogonists for A-II inhibit both the direct actions of A-II on isolated smooth muscle preparations and the stimulation of specific vascular receptor sites by which A-II evokes prostaglandin biosynthesis and release. Converting enzyme inhibitors a) block the action of exogenous A-I; b) lower blood pressure in conditions associated with high plasma renin levels (e.g., two-kidney renal hypertension, dehydrated diabetes insipidus rats, or in hemorrhagic shock); c) enhance responses to exogenous bradykinin (by inhibiting bradykininase); but d) do not block the effects of A-II at its receptor sites. A-II-receptor antagonists a) block the action of both A-I and A-II, b) lower blood pressure in high renin states, but c) have no effect on bradykinin degradation or action. Angiotensin receptor and synthesis antagonists have been shown to decrease the overall peripheral resistance and to reverse the renal cortical vasoconstriction during hemorrhagic shock and to prolong survival time in hemorrhaged dogs. It is our belief that angiotensin antogonists have therapeutic potential in hemorrhagic shock and would be expected (alone or in combination with alpha-andrenergic blockade) to overcome vascular shutdown and enhance organ perfusion (especially in the kidney).

Phase I trials of WR2721 in combination with radiation therapy and with the alkylating agents cyclophosphamide and cis-platinum.

Three phase I trials of the radioprotector S-2-(3-aminopropylamino) ethylphosphorothioic acid (WR2721) have accessed 60 patients. Study 1 is devised to determine the maximum tolerated dose (MTD) of a single dose of the protector 15 to 30 minutes before a single radiation treatment of a size used routinely in palliative management. Study 2 plans to determine the MTD for up to 15 daily doses of the drug over 3 weeks during palliative radiotherapy. Also, the multipe-dose study will establish the MTD before palliative irradiation for fewer than five fractions a week. Study 3 uses the existing single-dose MTD determined in Study 1 as pretreatment 15 to 30 minutes before cyclophosphamide or cis-platinum. Toxic symptoms include emesis, hypotension, hypertension, somnolence, and sneezing. Only one serious episode of hypotension, considered idiosyncratic, and one instance of moderate to severe vomiting have occurred. Forty-one patients have been entered in Study 1 and a dose of 600 mg/m2 has been reached. The next step is to proceed to the planned highest level of 740 mg/m2. Of five patients in the multiple-dose study, one has been given, without toxicity, WR2721 at the level of 100 mg/m2 for 15 fractions over 3 weeks. Fourteen patients are accessed to the alkylating agent study. Using protector doses of 450 mg/m2, a cyclophosphamide level of 1500 mg/m2 has been accomplished. However, two of three patients who received 450 mg/m2 of WR2721 before 120 mg/m2 of cis-platinum have shown moderate elevation of the serum creatinine, both of which returned to normal.