Hydralazine and magnesium valproate as epigenetic treatment for myelodysplastic syndrome. Preliminary results of a phase-II trial.

Decitabine and azacitidine, two DNA methyltransferase (DNMT) inhibitors, are the current standard of treatment for myelodysplastic syndrome (MDS). Histone deacetylase (HDAC) inhibitors are also being tested against MDS. Both drug classes synergize in their gene reactivating and anticancer activities. The combination of hydralazine and valproate (Transkrip®), a DNMT and HDAC inhibitor, respectively), has been developed as epigenetic therapy under the drug repositioning concept. To evaluate the clinical efficacy and safety of hydralazine and valproate against MDS, an open phase-II study for previously treated patients with MDS was conducted. The hydralazine dose was given according with the acetylator phenotype, and valproate was dosed at 30 mg/kg/day. Response was graded with International Working Group criteria. Toxicity was evaluated by the Common Toxemia Criteria-National Cancer Institute version 3 scale. From November 2007 to January 2010, 12 patients were included. Median age±SD was 53±19.78 years (range, 23-79 years); median time from diagnosis to inclusion in the study was 7.9 months (range 2.6-36.1 months). Median of previous treatment was 2 (range, 1-6). Refractory cytopenia with multilineage dysplasia was diagnosed in ten cases, and refractory anemia with excess of blasts in two. Overall response was documented in six (50%) of 12 cases, including one CR, one PR, and four hematological improvements of the erythroid series. Two patients (16.6%) progressed to acute myeloid leukemia. Hemoglobin increased from 7.4 to 10.3 g/dL (in 13 weeks), neutrophils, from 1.1 to 2.0 (in 3 weeks), and platelets, from 66×10(9) to 72×10(9)/L (in 2 weeks). Transfusional requirements decreased from 2.3 to 0 U bi-monthly for red blood cells and from 0.5 to 0 U bi-monthly for platelets in responding patients. Main toxicities were mild, including somnolence and nausea. Preliminary results of this phase-II study suggest that the combination of hydralazine and valproate is a promising non-toxic and effective therapy for MDS.

A phase II study of epigenetic therapy with hydralazine and magnesium valproate to overcome chemotherapy resistance in refractory solid tumors.

BACKGROUND: Epigenetic aberrations lead to chemotherapy resistance; hence, their reversal by inhibitors of DNA methylation and histone deacetylases may overcome it. PATIENTS AND METHODS: Phase II, single-arm study of hydralazine and magnesium valproate added to the same schedule of chemotherapy on which patients were progressing. Schedules comprised cisplatin, carboplatin, paclitaxel, vinorelbine, gemcitabine, pemetrexed, topotecan, doxorubicin, cyclophosphamide, and anastrozole. Patients received hydralazine at 182 mg for rapid, or 83 mg for slow, acetylators, and magnesium valproate at 40 mg/kg, beginning a week before chemotherapy. Response, toxicity, DNA methylation, histone deacetylase activity, plasma valproic acid, and hydralazine levels were evaluated. RESULTS: Seventeen patients were evaluable for toxicity and 15 for response. Primary sites included cervix (3), breast (3), lung (1), testis (1), and ovarian (7) carcinomas. A clinical benefit was observed in 12 (80%) patients: four PR, and eight SD. The most significant toxicity was hematologic. Reduction in global DNA methylation, histone deacetylase activity, and promoter demethylation were observed. CONCLUSIONS: The clinical benefit noted with the epigenetic agents hydralazine and valproate in this selected patient population progressing to chemotherapy' and re-challenged with the same chemotherapy schedule after initiating hydralazine and valproate' lends support to the epigenetic-driven tumor-cell chemoresistance hypothesis (ClinicalTrials.gov Identifier: NCT00404508).

Lack of bioequivalence between different formulations of isosorbide dinitrate and hydralazine and the fixed-dose combination of isosorbide dinitrate/hydralazine: the V-HeFT paradox.

OBJECTIVE: To investigate whether the apparent discrepancy between the efficacy of the combination of isosorbide dinitrate (ISDN) and hydralazine demonstrated in the first V-HeFT trial (V-HeFT I) and that in V-HeFT II could be explained by pharmacokinetic differences in the study drug formulations, and to compare the pharmacokinetic profile of the fixed-dose combination of ISDN/hydralazine (FDC ISDN/HYD; BiDil) formulation used in A-HeFT with that of the V-HeFT study drug formulations. STUDY PARTICIPANTS AND METHODS: A bioequivalence study was performed (n = 18-19 per group) comparing the ISDN and hydralazine formulations used in V-HeFT I, V-HeFT II and A-HeFT in healthy volunteer men and women aged 18-40 years. In phase A of the study, subjects received a reference solution of hydralazine hydrochloride/ISDN (37.5mg/10mg) orally. Slow acetylators were identified and randomised into three groups in phase B to receive a single oral dose of identical amounts of hydralazine hydrochloride/ISDN (37.5mg/10mg) from either (i) a hydralazine capsule plus an ISDN tablet (the V-HeFT I formulation); (ii) a hydralazine tablet plus an ISDN tablet (the V-HeFT II formulation); or (iii) FDC ISDN/HYD (the A-HeFT formulation). Blood/plasma concentrations of hydralazine and ISDN were determined from the blood samples taken between 0 and 36 hours. RESULTS: In phase B, the maximum observed concentrations (C(max)) were 65.9 +/- 53.9, 28.2 +/- 15.8 and 51.5 +/- 54.3 ng/mL of unchanged hydralazine, and 23.1 +/- 12.3, 21.7 +/- 13.4 and 26.7 +/- 18.7 ng/mL of ISDN for the V-HeFT I, V-HeFT II and A-HeFT formulations, respectively. The area under the blood/plasma concentration-time curve (AUC) values were 32.6 +/- 13.4, 23.3 +/- 15.1 and 32.6 +/- 18.5 ng x h/mL of hydralazine, and 24.4 +/- 9.0, 24.8 +/- 8.0 and 23.5 +/- 6.3 ng x h/mL of ISDN for the V-HeFT I, V-HeFT II and A-HeFT formulations, respectively. For comparison of bioequivalence, the C(max) and AUC were normalised to 65kg bodyweight, and point estimates and 90% confidence intervals of the C(max) ratios, AUC ratios and ratios of the AUC in phase B normalised for clearance by the AUC in phase A (AUCR) were calculated. The three formulations were not bioequivalent based on the C(max) and AUC comparisons. CONCLUSIONS: The blood concentrations of hydralazine obtained with the tablet formulation tested in V-HeFT II were markedly lower than those obtained with the capsule formulation tested in V-HeFT I or the FDC ISDN/HYD single tablet used in A-HeFT. The apparently modest effect on survival observed in V-HeFT II could be explained in part by the poor hydralazine bioavailability of the tablet preparation used in this trial. ISDN exposures were similar in the two trials. The ISDN-hydralazine formulation used in V-HeFT II was not bioequivalent to the formulation used in V-HeFT I or to the FDC ISDN/HYD that had demonstrated a significant survival benefit in A-HeFT.

Effect of food on oral availability of apresoline and controlled release hydralazine in hypertensive patients.

Hydralazine is a vasodilator antihypertensive drug that has been in use for many years. Efficacy after oral administration correlates well with the levels of the drug in blood. Factors such as food ingestion that affect blood levels of hydralazine may therefore be of importance. There is dispute regarding the effect of food intake on blood levels of hydralazine and on the antihypertensive response. This randomized cross-over study examined the effect of food (642 K calories, 25 g protein, 43 g fat, 40 g carbohydrates, 32 mEq sodium, 17 mEq potassium) ingested immediately before hydralazine (taken as Apresoline, Ciba Geigy, or as slow-release hydralazine, SRH, Pennwalt Corporation) on the blood levels of hydralazine in 16 essential hypertensive patients who were slow acetylators currently taking at least 100 mg Apresoline daily. Peak blood hydralazine levels were reduced by food after both Apresoline and SRH, by 69 and 66%, respectively. Time to peak blood hydralazine concentration was delayed significantly with SRH. We could detect a statistically significant food-related reduction of area under blood hydralazine concentration versus time curves (AUC) only with Apresoline (by 44%). The AUC for SRH was decreased only 29% by food. Hydralazine should be taken at a consistent time with respect to meals.

Liquid chromatographic determination of hydralazine in human plasma with 2-hydroxy-1-naphthaldehyde pre-column derivatization.

A selective and sensitive high-performance liquid chromatographic method is described for determination of hydralazine and its metabolites in human plasma. The method involves pre-column derivatization with 2-hydroxy-1-naphthaldehyde at pH 1.2. The reaction product and Methyl Red used as internal standard are extracted into dichloromethane and chromatographed in the reversed-phase mode on an ODS-2 column using acetonitrile-aqueous triethylamine phosphate buffer (80:20, v/v) at pH 3 as eluent. The plasma calibration curve of hydralazine is linear in the concentration range 10-500 ng ml-1. The detection limit is 1 ng ml-1 and the relative standard deviation is less than 2.4. In vivo pharmacokinetics of hydralazine in two volunteers after oral administration of 50 mg of the drug is studied using the proposed LC method.

Assay for hydralazine as its stable p-nitrobenzaldehyde hydrazone.

A new method of analysis for the antihypertensive drug, hydralazine, is introduced. The assay involves the addition of p-nitrobenzaldehyde to blood samples containing hydralazine, to form a stable Schiff's base, hydralazine p-nitrobenzaldehyde hydrazone. The derivative is extracted from the blood into hexane and the samples are dried under a nitrogen stream. The extracts are then dissolved in mobile phase and analyzed using high-performance liquid chromatography. The extracted samples can be stored for at least 7 days at room temperature or at -20 degrees C. The sensitivity of the assay is better than 300 pg/ml using 3-ml blood samples, and the range can extend to 640 ng/ml. The stability of the extracted samples plus the sensitivity and simplicity of the assay are the main advantages of the method over other selective methods for hydralazine.

Determination of hydralazine in human plasma by high-performance liquid chromatography with electrochemical detection.

Hydralazine is used as an antihypertensive vasodilator drug. A specific and sensitive method for extraction and analysis of hydralazine by high-performance liquid chromatography (HPLC) with electrochemical detection was developed. Hydralazine and 4-methylhydralazine (internal standard) in plasma were derivatized at room temperature with salicylaldehyde. The derivatives were extracted in basic medium with a mixture of heptane, methylene chloride and isopentyl alcohol. A very good separation of hydralazine and 4-methylhydralazine from matrix material was achieved on a Supelcosil LC-18-DB (5 microns) reversed-phase column kept at 28 degrees C with a mobile phase of 66% methanol in 0.055 M citric acid/0.02 M dibasic sodium phosphate (pH 2.5). The hydralazine level was measured electrochemically by a screen oxidation mode. This method offers significant advantages in sensitivity, specificity and accuracy. Sample analysis by HPLC required less than 8 min. Application of the method to monitor plasma levels of hydralazine from a patient receiving the drug for the treatment of severe pregnancy-induced hypertension is discussed.

Antihypertensive efficacy of pinacidil--automatic ambulatory blood pressure monitoring.

Forty-three patients with mild essential hypertension were randomized into two double-blind studies: pinacidil vs. placebo or pinacidil vs. hydralazine. Pinacidil (62 +/- 18 mg/day) decreased office systolic and diastolic blood pressures from 145 to 137 mm Hg and from 98 to 89 mm Hg, respectively, after 6 weeks of therapy. Similarly, hydralazine (128 +/- 28 mg/day) reduced supine systolic blood pressure from 140 to 134 mm Hg and supine diastolic blood pressure from 93 mm Hg to 84 mm Hg. Significant tachycardia was not noted with either drug. Ambulatory blood pressure was monitored for 24 h during the placebo-washout and efficacy phases with both pinacidil and hydralazine. Mean 24-h blood pressure was 128 systolic and 81 diastolic with pinacidil and 121 systolic and 76 diastolic with hydralazine. Reduction in awake hypertensive diastolic blood pressure was significant for both pinacidil and hydralazine. Normal sleep diastolic blood pressure was not reduced by pinacidil but was reduced by hydralazine. Side-effects with both drugs included edema, headache, and palpitations. These data demonstrate that pinacidil is as effective an antihypertensive agent as hydralazine.

Liquid chromatographic determination of dihydralazine and hydralazine in human plasma and its application to pharmacokinetic studies of dihydralazine.

An analytical method is described for the concurrent determination of dihydralazine (1) and hydralazine (2) in human plasma as unchanged or apparent compounds. For the assay of the unchanged compounds, plasma samples were acidified with 0.02 M HCI and derivatized first with nitrous acid, and afterwards with sodium methylate. For the assay of the apparent compounds, plasma samples were acidified with 3 M HCI, incubated at 90 degrees C for 30 min and derivatized as above. The derivatives were extracted and chromatographed by reversed-phase mode on a C18 mu Bondapak column. The fluorescence of the compounds was measured (excitation wavelength = 230 nm, emission wavelength = 430 nm). The limits of quantitation were 0.5 ng/mL for the unchanged compounds and 1 ng/ml for the apparent compounds. After oral administration of 25 mg of 1 to 2 healthy volunteers, the mean areas under the plasma concentration-time curves were respectively 43.7 and 590 ng X h/mL for unchanged and apparent 1. The corresponding mean elimination half-lives were 1.03 and 3.9 h. The mean area under the curve measured for 2 amounted to 6.3% of that obtained for 1 for the unchanged compounds and to 10.3% for the apparent compounds.

Pharmacokinetics of formation and excretion of some metabolites of hydralazine and their hypotensive effect in rats.

To evaluate the hypotensive effect and pharmacokinetic properties of some metabolites of hydralazine (HP), blood pressure and plasma concentrations after the i.v. or i.p. administration of HP pyruvate, alpha-ketoglutarate and acetone hydrazones and 3-methyl-s-triazolo[3,4a]phthalazine were estimated in normotensive rats, in addition to in vitro kinetic studies of the formation and decomposition. All the hydrazones studied had an effective hypotensive effect after a high dosing (10 mg/kg); however, their potency was much smaller than that of HP, when plasma-free concentration-response curves were compared. 3-methyl-s-triazolo[3,4a]phthalazine had no hypotensive effect at the same dose. Virtually no effective quantities of HP were generated in plasma after i.v. injection of these hydrazones (10 mg/kg) except for HP acetone hydrazone although a specific and sensitive analytical method for HP was used. The metabolites had larger elimination rate constants and smaller apparent distribution volumes than those of HP. Hydrazones in vitro were formed according to a second-order rate kinetics from HP and various keto acids or ketone at pH 7.4 and 37 degrees C, and these compounds were partly decomposed under the same conditions. Of the metabolites HP pyruvic acid hydrazone was the most readily formed and relatively stable hydrazone, whereas HP acetone hydrazone was unstable. The present results indicate that the contribution of the hydrazones to the vasodepressor properties of HP is only partial or negligible and that the hypotensive effect after dosing of HP is related mainly to its free concentration.

Acute hemodynamic effects of pinacidil and hydralazine in essential hypertension.

In a double-blind, randomized, crossover study, the effects of intravenous pinacidil, 0.2 mg/kg, were compared with those of hydralazine, 0.3 mg/kg, before and after beta-adrenoceptor blockade in six subjects with hypertension. Both drugs equally reduced total peripheral resistance by about 40%. Pinacidil reduced mean blood pressure by an average of 30 mm Hg, while the reduction after hydralazine was 10 mm Hg. The difference in antihypertensive effect resulted from greater increases in heart rate, cardiac contractility (systolic time intervals), and cardiac index (thermodilution) after hydralazine. These effects after hydralazine could not be fully abolished by beta-blockade, as could the effects after pinacidil. Pinacidil decreased pulmonary blood pressure, whereas there was a slight rise in pulmonary blood pressure after hydralazine. Forearm blood flow (venous occlusion strain gauge plethysmography) increased equally after both drugs; thus pinacidil decreased forearm vascular resistance more than hydralazine did. Serum concentrations of both drugs were within the therapeutic range and correlated with the fall in mean blood pressure. Five subjects complained of side effects after hydralazine, but none were reported after pinacidil. Hydralazine increased myocardial oxygen consumption (as estimated from the rate-pressure product) by 35%; there was no change after pinacidil. It is suggested that hydralazine has direct cardiostimulatory effects that limit its antihypertensive effectiveness. These effects increase myocardial oxygen consumption and may be responsible for the common and sometimes severe cardiovascular side effects of hydralazine.

Effect of oral dose size on hydralazine kinetics and vasodepressor response.

Levels of hydralazine in blood are log-linearly related to its vasodepressor effect. We examined the effect of oral dose size on the proportion of hydralazine that reaches systemic circulation. Nine subjects with hypertension were given hydralazine in oral doses in the therapeutic range. Blood hydralazine levels, effective liver blood flow, blood pressure, and heart rate were measured. As the hydralazine dose increased, the ratios of the AUC of hydralazine to hydralazine dose and of peak blood hydralazine concentration to hydralazine dose increased, indicating an increase in the proportion of the dose in blood. Liver blood flow tended to increase (maximum 40%) as dose increased above 0.5 mg/kg. Vasodepressor response and degree of tachycardia increased disproportionately with increasing hydralazine dose. There were strong log-linear relationships between peak hydralazine levels and both vasodepressor response and tachycardia that did not change with increasing hydralazine dose. Thus blood hydralazine and vasodepressor response increase disproportionately with increasing hydralazine doses in hypertension.

Drugs that induce systemic lupus erythematosus inhibit complement component C4.

The syndrome resembling systemic lupus erythematosus (SLE) associated with long-term treatment with hydralazine and isoniazid seems to be due to the drugs themselves rather than their metabolites. This syndrome is associated with deposition of immune complexes; and in the complement system inhibition of C4 is likely to increase deposition of immune complexes. In vitro, hydralazine and isoniazid inhibited 50% of the binding of C4 at 840 mumol/l and 1.05 mmol/l, respectively--ie, within the concentration ranges that have been used in therapy. Acetylated metabolites were not inhibitory at the maximum concentrations tested; and iproniazid, which does not cause SLE, gave 50% inhibition only at a concentration far exceeding that used in therapy.

Effect of food on blood hydralazine levels and response in hypertension.

A study with a nonspecific hydralazine assay reported that food increased hydralazine concentrations in plasma. We used a specific HPLC hydralazine assay to determine the effect of food on hydralazine blood levels and hemodynamic responses after oral hydralazine. Six subjects with uncomplicated essential hypertension were given 1 mg/kg hydralazine solution orally on two occasions at least 3 days apart. On 1 study day subjects fasted and on the other they were given a standard meal 45 min before hydralazine. Mean arterial pressure and heart rate were monitored for 2 hr before and for 4 hr after hydralazine and frequent venous blood samples were drawn for hydralazine assay. Hepatic blood flow was estimated by determination of indocyanine green clearance before food, after food, and 30 min after hydralazine. Peak blood hydralazine concentrations fell in all (46.2% +/- 11.5%; means +/- SE) and areas under the blood hydralazine concentration/time curves fell (45.7% +/- 9.5%) after food. This could not be explained by changes in liver blood flow. Food-related reductions in blood levels of hydralazine were associated with reduced vasodepressor effects (41.5% +/- 5.6%). It is possible that food increases intravascular conversion of hydralazine to hydralazine pyruvic acid hydrazone. The reduction in vasodepressor response suggests that patients with hypertension should take hydralazine at a fixed time in relation to meals.

Haemodynamic response to intravenous hydralazine in patients with pulmonary hypertension.

The acute pulmonary and systemic haemodynamic response to low (0.15 mg/kg) and high (0.30 mg/kg) doses of intravenous hydralazine was evaluated in 26 consecutive patients with severe pulmonary hypertension due to cor pulmonale (nine patients), primary pulmonary hypertension (11 patients), or pulmonary embolism (six patients). Hydralazine did not cause a significant change in pulmonary arterial resistance or pressure in any group but produced a significant reduction in systemic resistance, which correlated with plasma concentration, and a significant increase in pulmonary blood flow index in all groups. Ten patients who experienced a reduction in pulmonary arterial resistance of at least 5 U X m2 after administration of hydralazine had higher initial values for pulmonary arterial resistance and systemic resistance and a lower pulmonary blood flow index than those who did not respond. Maintenance oral hydralazine treatment during nine to 36 months of follow up did not seem to affect symptoms or mortality. These results indicate that hydralazine has limited value in acutely reducing pulmonary arterial pressure or affecting clinical outcome in patients with pulmonary hypertension.

Effect of intravenous dose on hydralazine kinetics after administration.

Six male hypertensive patients, three rapid and three slow acetylators, each received four different intravenous hydralazine doses by constant infusion over 100 sec. Two to four days elapsed between doses. Plasma or whole-blood hydralazine concentrations were measured by HPLC after each dose. There was no influence of acetylator phenotype on hydralazine kinetics after intravenous dosing. There also was no consistent effect of dose size on hydralazine clearance or volume of distribution at doses up to 0.45 mg (2.3 mumol/kg). One subject, who received doses up to 0.6 mg/kg (3.05 mumol), had an apparent decrease in clearance at the higher doses. These findings are consistent with the fact that hydralazine is converted intravascularly to hydralazine pyruvic acid hydrazone and the fact that potentially saturable hepatic metabolic pathways play only a modest role in systemic clearance.

Determination of hydralazine in human whole blood.

The time required for the separation of plasma from the cellular components of blood can permit the in vitro loss of hydralazine. Thus, a high-performance liquid chromatographic (HPLC) procedure for the measurement of hydralazine in blood has been developed. 4-Methylhydralazine was used as an internal standard. The addition of p-anisaldehyde led to the formation of the p-anisaldehyde hydrazones of hydralazine and the internal standard. HPLC on a reverse-phase cyano column provided an analytical procedure in which the average relative standard deviation over the concentration range of 1-160 ng/ml was 8.3%. Hydralazine pyruvic acid hydrazone, a known circulating metabolite of hydralazine, yielded only 0.05 mole % hydralazine when submitted to this assay procedure.