Pharmacokinetics and bioavailability of a new formulation of teicoplanin following intravenous and intramuscular administration to humans.

Pharmacokinetics, bioavailability, and local tolerance (at the site of intramuscular administration) of a new formulation of teicoplanin (400 mg/3 mL) were investigated in 24 normal, healthy, male volunteers. A single dose of 6 mg/kg was administered intravenously and intramuscularly using a randomized crossover design. Volunteers and investigator were blinded as to the route of administration; placebo was administered by the other route. Blood and urine samples were collected for 21 days and were analyzed for microbiological activity. The median (range) pharmacokinetic parameters of teicoplanin following single-dose iv administration were as follows: steady-state volume of distribution of 1.6 (1.2-2.8) L/kg; total clearance of 10.2 (8.6-15.1) mL/h/kg; renal clearance of 10.0 (7.9-13.8) mL/h/kg; and terminal disposition half-life of 168 (111-278) h. Following single-dose im administration, significantly more subjects complained of pain following administration of teicoplanin (58%) compared with placebo (4%). Teicoplanin was completely absorbed with a median (range) peak serum concentration of 12.3 (6.6-37.5) micrograms/mL occurring at a median (range) time of 4.1 (0.7-6.1) h. Since the 90% confidence interval for the ratio of areas under the serum concentration-time curve falls within the range of 80 to 120%, the extent of systemic absorption of teicoplanin following im administration is equivalent to that following iv administration.

Anger management and temper control: critical components of posttraumatic stress disorder and substance abuse treatment.

Recent studies have shown associations among combat experience, PTSD, anger and hostility, and involvement in violence. Clinical observations of veterans enrolled in the Substance Use/Posttraumatic Stress Disorder Team (SUPT) program at the San Francisco Veterans Affairs Medical Center revealed relatively high levels of anger and aggressive behavior, including physical assaults and property damage. In response to this anger and aggressive behavior, an anger management treatment was added to the SUPT program's treatment of substance abuse and PTSD. Anger management consisted of a 12-week cognitive-behavioral group treatment. Session topics included identifying the physical, emotional, and situational cues to anger, developing individualized anger-control plans, recognizing and altering destructive self-talk, utilizing time-out, practicing conflict resolution techniques, and using the group to discuss and evaluate high-risk anger situations. Special attention was given to self-monitoring anger-escalating behavior (using an anger meter) and avoiding negative consequences. This article describes the components of the anger management treatment. A clinical vignette is also presented to illustrate the benefits of anger management treatment.

Immunoregulatory dysfunctions in type I diabetes: natural and antibody-dependent cellular cytotoxic activities.

Peripheral blood lymphocytes from 13 patients with established insulin-dependent diabetes mellitus (IDDM) and 2 prediabetic patients were examined for natural killer (NK) and antibody-dependent cellular cytotoxic activities (ADCC), lectin-dependent cellular cytotoxicity (LDCC), interferon- and interleukin-2-induced cytotoxicity, and concanavalin A-induced suppressor-cell activities in comparison with age-matched normal controls. IDDM patients demonstrated normal levels of NK and ADCC activities against K562 and antibody-coated SB target cells, respectively, compared to controls. IDDM patients showed normal levels of LDCC activity. Notable deviations from control values were, however, observed with diabetic lymphocytes in the following systems. Interferon- and interleukin-2-induced NK activities were significantly higher with IDDM lymphocytes than with control cells. IDDM lymphocytes precultured with concanavalin A demonstrated lower NK and ADCC activities than control cells and manifested decreased suppressor effects on the NK activity of normal allogeneic lymphocytes. Lymphocytes from one of two prediabetic patients showed increased NK, ADCC, and LDCC activities in comparison to controls. The increased interferon- and interleukin-2-induced enhancement of NK activity and reduced suppressor activity of lymphocytes from IDDM patients may be involved in the pathogenesis of the disease.

Mechanisms of replication-deficient vaccinia virus/T7 RNA polymerase hybrid expression: effect of T7 RNA polymerase levels and alpha-amanitin.

Components of the eukaryotic vaccinia virus/T7 RNA polymerase hybrid expression system were assessed using recombinant and nonrecombinant forms of modified vaccinia Ankara (MVA), a replication-deficient vaccinia virus strain. Recombinant MVA virus expressing T7 RNA polymerase (Wyatt, L. S., Moss, B., and Rozenblatt, S. (1995). Virology 210, 202-205) stimulated high levels of expression from a T7 promoter-chloramphenicol acetyltransferase (CAT) reporter. Most, but not all, of the virally induced expression was T7 RNA polymerase and T7 promoter dependent, with no viral enhancement of translation of T7 transcripts. The efficacy of supplying T7 RNA polymerase expression from nonviral sources was evaluated using a self-amplifying T7 RNA polymerase autogene or an inducible T7 RNA polymerase expression vector. The latter modes yielded CAT activity dependent on T7 RNA polymerase expression; however, expression required viral factors independent of T7 RNA polymerase and did not reach that attained using the recombinant virus. In further experiments, MVA-induced T7 RNA polymerase expression was upregulated by alpha-amanitin, an inhibitor of eukaryotic polymerases. This indicates that MVA/T7 RNA polymerase hybrid expression may be rendered still more efficient by ameliorating transcriptional interference due to an alpha-amanitin-sensitive eukaryotic factor(s).

Selecting a treatment for primary varicose veins.

The treatment of varicose veins includes injection/compression sclerotherapy and surgical stripping or ligation or both. Surgery appears to be favoured when the saphenous system is involved or when the patient is 35 to 64 years old or presents with ankle edema or flare. On the other hand, sclerotherapy has been found to be more effective in patients with dilated superficial veins or incompetent perforating veins in the lower legs and to be more acceptable and less expensive than surgical treatment.

PIP: At present 3 treatment alternatives for primary varicose veins are available: surgical stripping and ligation, injection/compression sclerotherapy, and a combination of the 2. At least 4 factors contribute to the decision of whether to treat the patient: pregnancy, obesity, oral contraceptive (OC) use, and age. Since varicose veins in pregnant women may later recede, only palliative treatment is recommended before delivery. Deep vein thrombosis may develop as a result of OC use during varicose vein treatment, leading some to advise OC discontinuation. Numerous clinical trials have endeavored to examine the relative effectiveness of treatment methods currently in use. The only randomized trial to evaluate all 3 treatment options over a 3-year period found that surgical stripping was significantly more effective than a combination of ligation and sclerotherapy, and that the combination was significantly more effective than sclerotherapy alone. Surgery appears to be the recommended treatment when the saphenous system is involved; surgery is also preferred for patients 35-64 years of age and for those presenting with signs of ankle edema and flare. Sclerotherapy seems to be more effective for dilated superficial veins and incompetent perforating veins in the lower leg. In addition, sclerotherapy is the most acceptable and least expensive method for the patient. The prevalence of primary varicose veins has been estimated at 20% in Europe and North America, with a female:male ratio of 5:1.

Interactions of the nonsedating antihistamine loratadine with a Kv1.5-type potassium channel cloned from human heart.

The use of nonsedating antihistamines may, on rare occasions, be associated with cardiac arrhythmias. This could be due to blockade of voltage-dependent K+ channels in the heart, leading to a prolongation in repolarization in the human myocardium. For this reason, we examined the effects of the nonsedating antihistamine loratadine on a rapidly activating delayed-rectifier K+ channel (Kv1.5) cloned from human heart and stably expressed in HEK 293 cells or mouse Ltk- cells. Using patch-clamp electrophysiology, we found that loratadine blocked Kv1.5 current measured from inside-out membrane patches at concentrations of > or = 100 nM, resulting in an IC50 value of 808 nM at +50 mV. The drug enhanced the rate of Kv1.5 current decay, and block was enhanced at membrane potentials near threshold relative to higher potentials. Loratadine did not alter the kinetics of Kv1.5 current activation or deactivation. Unitary Kv1.5 currents were recorded in cell-attached patches. At the single-channel level, the main effect of loratadine was to reduce the mean probability of opening of Kv1.5. This effect of loratadine was achieved by a reduced number of openings in bursts and burst duration. Finally, loratadine (10 microM) failed to inhibit HERG K+ channel currents expressed in Xenopus laevis oocytes. It is concluded that loratadine is an effective blocker of Kv1.5 that interacts with an activated state or states of the channel. This interaction suggests a potential for loratadine to alter cardiac excitability in vivo.

The antipsychotic agent sertindole is a high affinity antagonist of the human cardiac potassium channel HERG.

Acquired long QT syndrome is a side effect seen with some pharmacological agents, including antipsychotic drugs, and is associated with the development of ventricular arrhythmias. This syndrome is often caused by the blockade of repolarizing potassium channels the human heart. A new antipsychotic agent, sertindole, has been shown to produce QT prolongation after therapeutic doses in humans. We therefore examined the effects of sertindole on two cloned human cardiac potassium channels, the human ether-a-go-go-related gene (HERG) and Kv1.5, stably transfected into mammalian cell lines. Using patch clamp electrophysiology, we found sertindole blocked HERG currents with an IC50 value of 14.0 nM when tail currents at -40 mV were measured after a 2-sec depolarization to +20 mV. When currents were measured at the end of prolonged (20 sec) depolarizing pulses, the IC50 of sertindole measured 2.99 nM. Sertindole enhanced the rate of current decay during these prolonged voltage steps and displayed a positive voltage dependence. Sertindole was approximately 1000-fold less active at blocking Kv1.5 displaying an IC50 value of 2.12 microM. By comparison, the potent class III antiarrhythmic agent dofetilde blocked HERG with an IC50 value of 9.50 nM but did not enhance HERG current decay or block Kv1. 5 channel currents. It is concluded that sertindole is a high affinity antagonist of the human cardiac potassium channel HERG and that this blockade underlies the prolongation of QT interval observed with this drug. Furthermore, the sertindole molecule may provide a useful starting point for the development of very high affinity ligands for HERG.

Successful treatment of meningitis due to multiply resistant Enterococcus faecium with a combination of intrathecal teicoplanin and intravenous antimicrobial agents.

Following neurosurgery necessitated by intractable seizures, Enterococcus faecium meningitis that was resistant to ampicillin, a high-level aminoglycoside (MIC, > 2,000 micrograms/mL), and vancomycin developed in a 6-year-old boy. Treatment with intrathecal teicoplanin in combination with intravenous clindamycin, rifampin, and ampicillin was successful. The role of intravenous and intrathecal antibiotics in treatment of this infection is discussed. This case is illustrative of the safety and potential usefulness of intrathecally administered teicoplanin.

Pharmacokinetics of teicoplanin upon multiple dose intravenous administration to normal healthy male volunteers.

Teicoplanin pharmacokinetics were investigated upon multiple dose intravenous administration of 6 and 12 mg kg-1 in 10 normal, healthy, male volunteers, using a two-period, randomized, crossover design; six subjects completed both periods. On day 1, 6 or 12 mg kg-1 was administered every 12 h as a 30-min constant rate intravenous infusion (two doses). Starting on day 2, the same dose (6 or 12 mg kg-1) was administered every 24 h for an additional 13 days. Blood and urine samples were collected over 21 days. Serum and urine were analyzed using a microbiological assay. Following a minimum of 3 weeks after completion of the first period, subjects were crossed over to the other dose. Following multiple dose intravenous administration of 6 and 12 mg kg-1, median pharmacokinetic parameters included: steady-state volume of distribution of 1.4 and 1.2 l kg-1; total clearance of 12.2 and 14.0 ml h-1 kg-1; renal clearance of 11.1 and 10.3 ml h-1 kg-1; and terminal disposition half-life of 159 and 155 h, respectively. No statistically significant dose-related difference was observed. In addition, a cross-study comparison further supports dose proportionality of teicoplanin upon multiple dose intravenous administration of 3 to 12 mg kg-1.

Population pharmacokinetics of teicoplanin in patients with endocarditis.

Teicoplanin is a new glycopeptide antibiotic, active against aerobic and anaerobic gram-positive bacteria. The drug is intended for the treatment of systemic infections including endocarditis. In two U.S. clinical safety and efficacy trials, loading doses of 6 to 30 mg/kg doses of teicoplanin were administered initially to 197 patients, followed by once-a-day treatment of approximately the same doses over several weeks. Blood samples were collected sporadically during the study to monitor serum teicoplanin concentrations either by FPIA or microbiological assay. Nonlinear mixed-effects modeling was performed on these data to characterize the population pharmacokinetics of teicoplanin that were best described by a two-compartment model. Patient body weight, concomitant gram-positive drug treatment, and serum creatinine had significant influences on systemic clearance (CL) of the glycopeptide. In addition, body weight affected the volume of distribution of the central compartment (Vc). Other demographic factors such as age, gender, etc., had no effects. The FPIA assay method was more precise than the microbiological assay.

Pharmacokinetics of teicoplanin upon multiple-dose intravenous administration of 3, 12, and 30 milligrams per kilogram of body weight to healthy male volunteers.

Teicoplanin pharmacokinetics were evaluated after multiple-dose intravenous administration to healthy male volunteers by using a randomized, double-blind, parallel design. Doses of 3, 12, or 30 mg of teicoplanin per kg of body weight were administered every 24 h for 14 days as 60-min constant-rate intravenous infusions. Blood and urine samples were collected over 21 days and analyzed by a microbiological assay. Twenty-three subjects were included in the pharmacokinetic analysis. The median pharmacokinetic parameters upon multiple-dose intravenous administration of 3, 12, and 30 mg/kg included steady-state volumes of distribution of 0.94, 0.77, and 0.68 liter/kg; total clearances of 11.9, 12.0, and 13.2 ml/h/kg; and terminal disposition half-lives of 143, 166, and 96 h, respectively. Renal clearance accounted for approximately 95% of total clearance. No dose-related differences existed for teicoplanin total or renal clearance. The steady-state volume of distribution decreased significantly with increasing doses. As a result of the decrease in the volume of distribution, the terminal disposition half-life at 30 mg/kg was significantly decreased. However, the decreases in the volume of distribution and terminal disposition half-life are of limited clinical importance, since steady-state trough concentrations in serum increase in proportion to dose. Combined results of all multiple-dose studies with similar durations of sample collection indicate no dose-related differences for any pharmacokinetic parameters from 3 to 12 mg/kg. As observed in the present study, no dose-related differences exist for teicoplanin total and renal clearances from 3 to 30 mg/kg. However, at 30 mg/kg, a significant decrease in the steady-state volume of distribution is observed. As a consequence of the reduction in the volume of distribution at 30 mg/kg with no change in clearance, the terminal disposition half-life is decreased.

Applicability of teicoplanin dosage adjustment guidelines for renally impaired patients over the range of 3 to 30 mg kg-1.

The pharmacokinetics of teicoplanin were investigated in 13 subjects with various degrees of renal impairment using a randomized two-period crossover design; 11 subjects completed both periods. Doses of 3 and 30 mg kg-1 were administered as single dose, 60-min constant rate intravenous infusions. Blood samples were obtained over 28 days and urine was collected over 48 h. Serum and urine were analyzed using a microbiological assay. As previously observed in studies conducted in renally impaired subjects, teicoplanin total and renal clearance significantly decreased with decreasing creatinine clearance (p < 0.0001). However, for these parameters, no differences between doses were observed. Dosage adjustment guidelines for renally impaired patients are usually developed using the ratio of total clearance in renally impaired patients to the total clearance in patients with normal renal function. Since no dose-related differences existed in the relationship between teicoplanin total clearance and creatinine clearance, initial dosage adjustment guidelines for renally impaired patients developed at 3 or 30 mg kg-1 are applicable over the range of 3 to 30 mg kg-1.