[Imaging and radial approach]. / Imagerie et voie radiale.

Radial approach allows in a large majority of cases to perform endovascular imaging. If we can assess anatomical variations with angiography, echography approach begins a mandatory tool to do the puncture safely, but also allows to identify anatomical variations and complications.

Effects of polytherapy with phenytoin, carbamazepine, and stiripentol on formation of 4-ene-valproate, a hepatotoxic metabolite of valproic acid.

The incidence of valproic acid hepatotoxicity has been reported to increase in patients who are receiving polytherapy. A minor valproic acid metabolite, 2-propyl-4-pentenoic acid (4-ene-VPA), formed by a cytochrome P450-mediated reaction, has been shown to be a potent inducer of microvesicular steatosis in rats. This study tested the hypothesis that formation of 4-ene-VPA would be increased in patients taking valproic acid with carbamazepine or with phenytoin but decreased with coadministration of an inhibitor of cytochrome P450 (the antiepileptic drug stiripentol in 300 to 1200 mg daily doses) in healthy subjects. Blood and urine samples in the studies were collected during a dosing interval at steady state. Valproic acid was assayed in plasma by capillary gas chromatography; valproic acid and 15 metabolites were measured in urine by gas chromatography/mass spectrometry. The formation clearance (CLf) of 4-ene-VPA was increased twofold in the valproic acid-carbamazepine and valproic acid-phenytoin groups. In the valproic acid/stiripentol studies, the CLf of 4-ene-VPA decreased by 32% in the 1200 mg/day stiripentol study. Similar findings were obtained at 600 and 300 mg/day stiripentol. These findings provide evidence supporting a role for cytochrome P450 in the formation of the hepatotoxic metabolite, 4-ene-VPA, in humans. The increased formation of 4-ene-VPA associated with carbamazepine and phenytoin is striking in relation to the epidemiologic finding of increased incidence of valproic acid-related hepatotoxicity during polytherapy with P450 inducers.

Interaction between valproate and branched-chain amino acid metabolism.

Structural similarities between valproate metabolites and metabolites formed from the beta-oxidation of branched-chain amino acids (isoleucine, leucine, and valine) suggest that valproate may utilize key enzymes of branched-chain amino acid metabolism. Genetic deficiencies in these enzymes may decrease beta-oxidation of valproate and increase formation of valproate hepatotoxic metabolites. We attempted to determine if valproate interacts with branched-chain amino acid enzymes and also evaluated the effect of valproate on the urinary excretion of the straight-chain fatty acids butyrate (C4), valerate (C5), and hexanoate (C6). We collected dosage interval urine samples from three groups of 10 valproate patients: (1) valproate monotherapy, (2) valproate with carbamazepine, and (3) valproate with phenytoin. We also collected 12-hour urine samples from 10 normal volunteers who served as controls. Valproate caused a significant increase in the excretion of the deaminated acid metabolites of valine, isoleucine, and leucine. There were also significant increases in the excretion of the isoleucine metabolites 2-methylbutyrate and 2-methyl-3-OH-butyrate in the valproate patients. Valproate caused a significant increase in the excretion of all three of the straight-chain fatty acids evaluated, and valproate appears to inhibit the four types of acyl-CoA dehydrogenases involved in branched-chain amino acid and short- and medium-chain fatty acid metabolism.

Quantitative structure-anticonvulsant activity relationships of valproic acid, related carboxylic acids and tetrazoles.

Valproic acid and several structurally related carboxylic acids and tetrazole analogues have been shown to antagonize seizures induced by pentylenetetrazole in mice. To investigate the influence of the alkyl substituents on the anticonvulsant activity, the octanol-water partition coefficients and relative pKa values were determined. Within the series of active carboxylic acids, there was a good correlation between the anticonvulsant activity and the partition coefficient (r = 0.86). The influence of pKa on the anticonvulsant activity was small but of statistical significance. When the most active compound, 5-heptyltetrazole was added to the carboxylic acid series, a low correlation between the anticonvulsant activity and a linear combination of lipophilicity and pKa resulted. The effect of the polar moieties in alkyl-substituted anticonvulsant compounds was assessed by comparison of the regression equations with either an added pKa or dipole moment term to the term for lipophilicity. It appears that other factors, such as the nature of the alkyl substituent, influence the anticonvulsant activity. The inactivity of the cyclohexylmethyl-substituted compounds, cyclohexylacetic acid and 5-cyclohexylmethyltetrazole may be due to subtle steric effects at a critical step, either involving oxidative metabolism or an interaction at an active site.

Use of hexadeuterated valproic acid and gas chromatography-mass spectrometry to determine the pharmacokinetics of valproic acid.

Di-[( 3,3,3-2H3]propyl)acetic acid, a hexadeuterated analogue of valproic acid, was synthesized and its pharmacokinetic properties compared with valproic acid. Concentrations of valproic acid and [2H]valproic acid in serum and saliva were determined by GC-MS using selected-ion monitoring. Saliva drug levels were measured with good precision down to 0.1 microgram/mL. Kinetic equivalence of valproic acid and [2H]valproic acid was demonstrated in a single-dose study in a human volunteer. An isotope effect was observed for omega-oxidation, but the difference in metabolism was not sufficient to make [2H]valproic acid biologically nonequivalent. The application of [2H]valproic acid to determine the kinetics of valproic acid under steady-state concentrations was evaluated in the same volunteer. The kinetic data obtained with [2H]valproic acid was consistent with previously reported values for valproic acid including kinetic differences observed between single-dose and steady-state experiments. Saliva levels of valproic acid were found to give a good correlation (r = 0.953) with total serum valproic acid under multiple-dose conditions. A concentration dependence was found for the ratio of saliva valproic acid to free valproic acid in serum, low ratios being observed at high serum concentrations of valproic acid.

Distribution of cyclosporin A in ocular tissues after topical administration to albino rabbits and beagle dogs.

PURPOSE: To determine the ocular pharmacokinetics of cyclosporin A after topical ophthalmic administration. METHODS: Radiolabled cyclosporin A in either a castor oil-in-water emulsion or a corn oil ointment was applied to the eyes of beagle dogs or albino rabbits using the following paradigms: (i) single doses of 0.2% emulsion to rabbits and dogs, (ii) single doses of 0.05%, 0.2%, or 0.4% emulsion to rabbits, (iii) multiple doses of 0.2% emulsion to dogs, (iv) single and multiple doses of 0.2% ointment to rabbits. The distribution of cyclosporin A was determined by measuring the distribution of radioactivity. RESULTS: After a single dose, cyclosporin A was rapidly absorbed into the conjunctiva (Cmax: dogs, 1490 ng/g; rabbits, 1340 ng/g) and cornea (Cmax: dogs, 311 ng/g; rabbits, 955 ng/g). High concentrations (>300 ng/g) could be detected in the cornea up to 96 hours post-dose. Lower concentrations were found in the intraocular tissues, and systemic absorption was minimal. After multiple doses, there was some accumulation in the cornea, lens, lacrimal gland, and iris-cilliary body, but limited accumulation in the conjunctiva and sclera. Ocular tissue concentrations of cyclosporin A increased with increasing dose concentration; proportionally in lacrimal gland and intraocular tissues; less than proportionally in conjunctiva and cornea. The pharmacokinetic profile of the cyclosporin A corn oil ointment was similar to that of the emulsion. CONCLUSIONS: Topical ophthalmic cyclosporin A penetrated into extraocular tissues at concentrations adequate for local immunomodulation while penetration into intraocular tissues was much less and absorption into the blood was minimal.

Measurement of brimonidine concentrations in human plasma by a highly sensitive gas chromatography/mass spectrometric assay.

Brimonidine is an alpha 2-adrenergic agonist that is efficacious in lowering intraocular pressure in humans. A highly sensitive and selective gas chromatography/mass spectrometry (GC/MS) assay is described for quantitation of brimonidine in human plasma following ocular installation. Brimonidine in 1 ml of plasma was extracted together with tetradeuterated brimonidine (internal standard) and clonidine (carrier) by solvent extraction. After solvent evaporation, 3,5-bis(trifluoromethyl)benzoyl derivatives were formed and injected onto a GC/MS apparatus under negative chemical ionization conditions. The ions monitored for derivatized brimonidine and tetradeuterated brimonidine were m/z 691 [M-HBr] and m/z 694 [M-DBr], respectively. Calibration curves were linear from 2 to 1000 pg ml-1 (r2 = 0.981-0.996). The method was specific for brimonidine relative to endogenous compounds in plasma. The inter-day relative standard deviation for analysis of quality controls was 12% or less, and the inter-day assay accuracy ranged from 97 to 104% of nominals. The GC/MS assay showed adequate sensitivity for analysis of human samples from volunteers ocularly dosed with 0.5% brimonidine tartrate solution. Overall, the GC/MS assay showed excellent precision and accuracy, and a minimum quantifiable concentration of 2 pg ml-1.

Comparison of concentration-time profiles of levobunolol and timolol in anterior and posterior ocular tissues of albino rabbits.

The potential effects of anti-glaucoma drugs, such as levobunolol and timolol, on blood flow in the posterior segment of the eye are of great interest in terms of changes in optic nerve head perfusion and prevention of visual field loss. These effects are related to the rate and extent of their absorption into the site of action. In this study, the concentrations of timolol and levobunolol in the aqueous humor, iris-ciliary body, vitreous humor, choroid-retina, and optic nerve were compared following instillation of a single drop of 0.5% ophthalmic solutions into albino rabbit eyes. Tissue drug and metabolite concentrations were measured by liquid chromatography-mass spectrometry. Dihydrobunolol (DHB) is an equipotent metabolite of levobunolol. In the anterior segment of the eye, levobunolol plus DHB concentrations were higher than timolol concentrations in aqueous humor and were comparable to those of timolol in iris-ciliary body. However, in the choroid-retina and optic nerve, timolol concentrations were greater than those of levobunolol plus DHB. Overall, the study demonstrates comparable concentrations of levobunolol and timolol in the anterior section of the eye. The low availability of levobunolol in the posterior segment as compared to timolol may be a key advantage for levobunolol in producing less adverse effect on blood flow in the choroid-retina and optic nerve.

Preclinical safety profile of brimonidine.

Brimonidine is a selective alpha 2-adrenergic agonist developed for lowering intraocular pressure in glaucoma patients. Since brimonidine will be used in long-term theraphy, the safety of this drug is an important feature for its clinical success. Brimonidine has been evaluated in a number of safety studies using doses much greater than those in humans. In this paper chronic and carcinogenicity studies are presented. The results of the 6-month ocular/systemic study in rabbits and the 1-year ocular/systemic study in monkeys with 0.2, 0.5, and 0.8% brimonidine ophthalmic formulations showed no ocular or organ toxicity. The highest concentration of 0.8% used in rabbits and monkeys resulted in plasma drug concentrations of 95 (Cmax) and 10 (C2hr) times, respectively, higher than those seen in humans following topical dosing. Dose-related transient exaggerated pharmacologic effects of sedation were observed in the 1-year oral study in monkeys without any organ toxicity. The dose that elicited an apparent pharmacologic effect produced a plasma drug concentration that was approximately 115 times higher than that in humans. In 2-year carcinogenicity studies in mice and rats using doses that produced plasma concentrations 77 and 118 times, respectively, higher than those seen in humans, no oncogenic effect was observed. Based on the extensive safety research on brimonidine, it was concluded that this drug has an excellent safety profile.

Characterization of benzimidazole and other oxidative and conjugative metabolites of brimonidine in vitro and in rats in vivo using on-line HID exchange LC-MS/MS and stable-isotope tracer techniques.

The characterization of brimonidine metabolites presents some challenges since brimonidine and its metabolites generate few structurally informative fragment ions in the LC-MS/MS spectra. The objective of the current study is to use on-line hydrogen/deuterium (H/D) exchange LC-MS/MS and stable-isotope tracer techniques to further characterize unknown brimonidine metabolites in vitro and in vivo. Brimonidine and D4-brimonidine were co-incubated in rat and human microsomes and rabbit aldehyde oxidase in vitro. In addition, the urine was collected from rats co-administered orally with brimonidine and D4-brimonidine. The hepatic microsomal and urinary metabolites were then characterized by H/D LC-MS/MS system. In addition to previously characterized 2-oxobrimonidine, 3-oxobrimonidine and 2,3-dioxobrimonidine, the results show that oxidation occurs at quinoxaline ring producing oxo-hydroxybrimonidine and hydroxyquinoxaline metabolites. The hydroxyquinoxaline metabolite was only observed in microsomal incubations with hydroxylation at the 7- or 8- position. The dehydro-hydroxybrimonidine metabolites were characterized as 2-oxo or 3-oxo -4', 5'-dehydrobrimonidine. A novel metabolite ((4-bromo-lH-benzoimidazol-5-yl)-imidazolidin-2-ylidene-amine) of benzimidazole derivative of brimonidine in rats in vivo was identified and confirmed with reference standard. In conclusion, on-line H/D exchange LC-MS/MS and stable-isotope tracer techniques are useful for the characterization of brimonidine metabolites.

Synthesis and stereochemical determination of diunsaturated valproic acid analogs including its major diunsaturated metabolite.

Valproic acid, an antiepileptic drug, is transformed into diunsaturated metabolites in humans. Synthesis of the geometric isomers of 2-(1'-propenyl)-2-pentenoic acid and 2-(1'-propenyl)-3-pentenoic acid was attempted using known procedures. The final product, a mixture of isomers, was converted into tert-butyldimethylsilyl or ethyl derivatives. Capillary gas-liquid chromatography-mass spectrometry analysis of the derivatives showed at least three isomeric dienoic acids from synthesized products. Argentation thin-layer chromatography was effective in resolving the isomeric mixture into a single isomer or mixture of two isomers. Thin-layer chromatography and gas-liquid chromatography retention data, photochemical isomerization studies, and nuclear magnetic resonance spectrometry were used to characterize the dienoic acids. By comparison of the retention times of the diunsaturated metabolites with synthesized reference compounds, the structure assigned to the major diunsaturated metabolite is 2-[(E)-1'-propenyl](E)-2-pentenoic acid.

Identification of valproic acid metabolites in human serum and urine using hexadeuterated valproic acid and gas chromatographic mass spectrometric analysis.

Valproic acid, an antiepileptic drug, is extensively metabolized in humans. A hexadeuterated valproic acid was used in this study to aid the identification of metabolites and their artifacts in serum and urine extracts. A 600 mg oral dose of hexadeuterated valproic acid was administered to a human volunteer at steady state serum concentrations of unlabelled valproic acid. By using gas chromatography mass spectrometry, metabolites were characterized as their methyl, tert-butyldimethylsilyl, or trimethylsilyl derivatives. A di-unsaturated metabolite with concentrations comparable to 2-ene valproic acid was identified in serum and urine. The presence of a molecular ion doublet in the mass spectrum corresponding to the unlabelled and hexadeuterated dienes reduces the possible structures for this metabolite. A new metabolite, 2-propyl-4-ketopentanoic acid was also identified in serum and in urine. The dicarboxylic acids, 2-propylsuccinic and 2-propylmalonic were identified in the urine extract as metabolites. Identification of isolated metabolites was aided by comparison of the retention times and mass spectra to those of synthesized reference compounds. Diagnostic fragment ions and ion doublets in the mass spectra of the derivatives of newly identified metabolites were compared to those of known metabolites.

Comparative ocular pharmacokinetics of brimonidine after a single dose application to the eyes of albino and pigmented rabbits.

Brimonidine is a potent ocular hypotensive drug. The ocular pharmacokinetics of 14C-brimonidine in albino and pigmented rabbits were compared after ocular instillation of a 35-microliters drop of a 0.5% 14C-brimonidine solution. Ocular drug and metabolite concentrations were measured as total radioactivity and by a selective HPLC method. Rapid ocular absorption resulted in peak drug concentrations in aqueous humor of 2.16 +/- 0.75 micrograms/ml (mean +/- SD) and 1.52 +/- 0.38 micrograms/ml at 0.67 hr postdosing in albino and pigmented rabbits, respectively. Drug elimination from aqueous humor was rapid initially with a half-life of 1 hr in rabbits, followed by a slower decline phase in pigmented rabbits. Radioactivity concentration in iris-ciliary body of albino rabbit reached a peak of 5.04 micrograms-eq/g at 40 minutes and declined to 0.10 micrograms-eq/g at 6 hr postdosing with a half-life of 1 hr. The radioactivity concentrations in pigmented iris-ciliary body rose to a peak of 20.1 micrograms-eq/g at 1.5 hr and stayed relatively steady for at least 4 hr before declining slowly to 0.43 micrograms-eq/g 90 days postdose. The terminal half-life of brimonidine in pigmented iris-ciliary body was 160 hr. Three metabolites were detected in the conjuctiva and iris-ciliary body, and brimonidine was the major drug-related substance in aqueous humor and iris-ciliary body. The results indicate that brimonidine is absorbed rapidly into rabbit eyes, metabolized in ocular tissues, and has significant affinity for melanin-containing tissues.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of valproate dose on formation of hepatotoxic metabolites.

Valproate (VPA) therapy has been associated with a rare but fatal hepatotoxicity. 4-ene-VPA and 2(E),4-diene-VPA, unsaturated metabolites of VPA, are hepatotoxins several times more potent than VPA. In a previous study, a dose-dependent excretion of hepatotoxic metabolites was noted in patients receiving VPA. Our study was designed to evaluate the effect of dose on VPA metabolism under controlled conditions. Nineteen healthy volunteers sequentially received three different daily doses of VPA (250, 500, and 1,000 mg). Each dose was given twice daily for 4 days. Urine was collected for one dosage interval (12 h) at steady state for each dose and assayed for 15 VPA metabolites by gas chromatography/mass spectrometry (GCMS). Blood samples were also obtained from eight of the subjects, and VPA was assayed by GCMS. No effect of dose was noted on total plasma clearance. There was a significant dose-dependent decrease in intrinsic hepatic clearance. The intrinsic formation clearance (Clf) of the 4-ene-VPA pathway showed a statistically significant dose-dependent increase (0.22, 0.33, 0.40 ml/h/kg). The corresponding percentage of dose recovered as 4-ene-VPA and its sequential metabolites showed significant dose-dependent increases (0.15, 0.27, 0.62%). The role of VPA dose in the pathogenesis of hepatotoxicity may be more important than was previously believed.

Capillary gas chromatography-mass spectrometry of valproic acid metabolites in serum and urine using tert.-butyldimethylsilyl derivatives.

A quantitative method has been developed for valproic acid and twelve of its metabolites using capillary gas chromatography--mass spectrometry with selected-ion monitoring. The method is applicable to serum or urine and all metabolites are measured in a single run. Ions selected for quantitative purposes were the characteristic (M-57)+ ions of the tert.-butyldimethylsilyl (tBDMS) derivatives. The 4-hydroxyvalproic acid was measured as the gamma-lactone. Calibration curves were found to be linear and the sensitivities in the order of 0.1 microgram/ml. Patient data are presented. A comparison of tBDMS and trimethylsilyl (TMS) derivatives showed that tBDMS gave superior sensitivity for the unsaturated metabolites and a shorter analysis time. Mixed tBDMS-TMS derivatives were also investigated.

Topical Cyclosporine A in the management of postkeratoplasty glaucoma and corticosteroid-induced ocular hypertension (CIOH) and the penetration of topical 0.5% cyclosporine A into the cornea and anterior chamber.

PURPOSE: To evaluate the effect on intraocular pressure (IOP) of substituting topical Cyclosporine A 0.5% for topical corticosteroids in patients with postkeratoplasty glaucoma and corticosteroid-induced ocular hypertension (CIOH). We also sought to determine the penetration of topical 0.5% Cyclosporine A into the cornea and anterior chamber. METHODS: Topical Cyclosporine A 0.5% was prospectively substituted for topical corticosteroids in 47 patients (52 eyes) with postkeratoplasty glaucoma and CIOH in order to eliminate the IOP-elevating effect of topical corticosteroids, while maintaining protection against allograft rejection. Ten patients received 0.5% topical Cyclosporine before keratoplasty. Their corneal tissue and aqueous samples were evaluated by high pressure liquid chromatography for Cyclosporine levels. RESULTS: Forty-eight of 52 eyes (92.3%) demonstrated a reduction of IOP at first followup (mean: -7.9 mmHg; range: -19 to +2). Mean followup was 10.3 months, ranging from 1 to 37 months. At last follow-up, mean IOP was -8.2 mm Hg. There were six allograft rejections, five of which were reversed with the reintroduction of topical corticosteroids. Graft clarity was maintained in 46 of 52 eyes (88%). The mean cornea Cyclosporine concentration was 3679 ng/gm (range: 1980 to 5520 ng/ gm) and aqueous humor mean concentration was 6.05 ng/mL (range: 0.4 to 15.5 ng/mL). CONCLUSIONS: Topical Cyclosporine A 0.5% may be substituted for topical corticosteroids to aid in the management of postkeratoplasty glaucoma and CIOH. However, the use of Cyclosporine in place of corticosteroids may be associated with an increased risk of immune rejections. The corneal penetration of topical Cyclosporine is excellent while the penetration into the anterior chamber is poor.

Characterization of brimonidine metabolism with rat, rabbit, dog, monkey and human liver fractions and rabbit liver aldehyde oxidase.

1. In vitro metabolism of 14C-brimonidine by the rat, rabbit, dog, monkey and human liver fractions was studied to assess any species differences. In vitro metabolism with rabbit liver aldehyde oxidase and human liver slices, and in vivo metabolism in rats were also investigated. The hepatic and urinary metabolites were characterized by liquid chromatography and mass spectrometry. 2. Up to seven, six, 11 and 14 metabolites were detected in rat liver S9 fraction, human liver S9 fraction, human liver slices and rat urine respectively. Rabbit liver aldehyde oxidase catalysed the metabolism of brimonidine to 2-oxobrimonidine and 3-oxobrimonidine, and further oxidation to the 2,3-dioxobrimonidine. Menadione inhibited the liver aldehyde oxidase-mediated oxidation. 3. Hepatic oxidation of brimonidine to 2-oxobrimonidine, 3-oxobrimonidine and 2,3-dioxobrimonidine was a major pathway in all the species studied, except the dog whose prominent metabolites were 4',5'-dehydrobrimonidine and 5-bromo-6-guanidinoquinoxaline. 4. These results indicate extensive hepatic metabolism of brimonidine and provide evidence for aldehyde oxidase involvement in brimonidine metabolism. The species differences in hepatic brimonidine metabolism are likely related to the low activity of dog liver aldehyde oxidase. The principal metabolic pathways of brimonidine are alpha(N)-oxidation to the 2,3-dioxobrimonidine, and oxidative cleavage of the imidazoline ring to 5-bromo-6-guanidinoquinoxaline.