El uso de placebo en ensayos clínicos de fase III en Brasil / The use of placebos in phase III clinical trials in Brazil

El Consejo Federal de Medicina de Brasil (CFM) -órgano normativo y fiscalizador del ejercicio ético de la medicina- prohibió, en 2008, la participación de médicos brasileños en investigaciones que utilizaran placebo para enfermedades con tratamiento eficaz y efectivo, en contraposición a la Declaración de Helsinki, que permite su uso en condiciones metodológicamente justificadas. Con el objetivo de verificar si la normativa ética del CFM modificó el uso de placebo en ensayos clínicos de fase III en Brasil, se analizaron varias características de sus registros en el ClinicalTrials.gov, en los períodos de 2003 a 2007 y de 2009 a 2013. Se concluye que: a) la normativa promulgada por el CFM en 2008 fue ineficaz y prevaleció la posición adoptada por la Declaración de Helsinki; b) el patrocinio de ensayos con placebo por parte de la industria farmacéutica multinacional fue significativo; c) predominaron las investigaciones de fármacos para enfermedades crónicas, y fueron poco significativas para las enfermedades postergadas, de importancia para Brasil.

In 2008, Brazil's Federal Council of Medicine [Conselho Federal de Medicina] (CFM) - regulatory and supervisory agency on the ethical practice of medicine - banned the participation of Brazilian doctors in studies using placebos for diseases with efficient and effective treatment. This position differs with the Helsinki Declaration, which allows the use of placebos in methodologically justified conditions. To ascertain whether the CMF's ethical regulation modified the use of placebos in phase III clinical trials in Brazil, characteristics of the records in ClinicalTrials.gov were researched in the periods from 2003 to 2007 and from 2009 to 2013. The conclusions reached were: a) the regulations issued by the CFM in 2008 were ineffective and the position adopted by the Helsinki Declaration prevails; b) there was significant sponsorship by the multinational pharmaceutical industry of trials with placebos; c) the research was predominantly on new drugs for chronic diseases, with little study done of the neglected diseases which are of great importance to Brazil.

Localization of heme biosynthesis pathway enzymes in Plasmodium falciparum.

Protein trafficking in the malarial parasite Plasmodium falciparum is dictated by a complex life-cycle that involves a variety of intra-cellular and host cell destinations, such as the mitochondrion, apicoplast, rhoptries and micronemes. Of these, the apicoplast and mitochondrion are believed to account for more than 10% of this traffic. Studies have shown that mechanisms for mitochondrion and apicoplast targeting are distinct, despite their close physical proximity. The heme biosynthesis pathway spans both these organelles, making trafficking studies crucial for the spatial demarcation of the constituent interactions. This minireview highlights the challenges in identifying the possible sub-cellular destinations of the heme pathway enzymes using gleanings from literature survey as well as focussed bioinformatic analysis.

¿La hemozoína, presente y futuro? / ¿Hemozoin present and future

La malaria es una enfermedad causada por parásitos del género Plasmodium estos parásitos tienen un ciclo intraeritocítico en el hospedador vertevrado. En el glóbulo rojo, el parásito ingiere la hemoglobina, obteniendo aminácidos y formando hemozoína. La hemozoína es un un material microcristalino oscuro, de color marrón amarillento, insoluble en agua, no tóxico, producido en la vacuola parasitófora del Plasmodium; este compuesto producido por el Plasmodium carece de la toxicidad que tiene el grupo hemo para el parásito. Asimismo se ha evidenciado que la hemozoína es una sustancia inmuno moduladora que tiene diversos efectos, como mediar la activación y migración de neutrófilos, incrementar la producción de óxido nítrico, inducir la activación de mataloproteínas 9, inducir la secreción de diferentes mediadores proinflamatorios, alterar las funciones de los monocitos y macrófagos humanos, tales como el estallido oxidativo, eliminación de bacterias, presentación de antígenos y la habilidad de diferenciarse a células dendríticas funcionales; por lo que la hemozína tiene efectos duales, tanto activadores como supresores de la respuesta inmune. Asimismo, la hemozoína es unblanco terapéutico potente, ya que los fármacos que inhiban su formación provocan toxicidad al parasíto e incluso la muerte del mismo.

Malaria is a disease caused by parasites of the genus Plasmodium. These parasites have intraerythrocytic cycle in the vertbrate host. In the red cell, the parasite ingests hemoglobin, obtaining amino acids and formin hemozoin. The microcrystaline material hemozoin is a dark, yellowish brown, insoluble in water, nontoxic, produced in the Plasmodium parasitophorous vacuole, this compound produced by Plasmodiun lacks the toxicity that has heme to the parasite. It has also been shown that hemozoin is an immune modulating substance that has different ffects, mediating the neutrophils activation and migration, increased nitric oxide production, induce activation of metallproteinase-9, induce the secretion of various proinflammatory mediators, alter the funcions of human monocytes and macrophages such as oxidative burst, removing bacteria, antigen presentation and the ability to differentiate into functional dendritic cells, so the hemozoin has dual effects, both activators and suppressors of the immune response. Also, the hemozoin is a potent therapeutic target, since rugs that inhibit their formation causes toxicity to the parasite and even death itself.

The effect of lead bioaccumulation on haem biosynthetic enzymes in fish.

The bioaccumulations of lead in the liver and hepatic microsomes of fish after 1, 3, 7, 14, 28, and 45 days exposure were studied. In addition, the relationship between the bioaccumulated lead in both hepatic microsomes and the liver and their haem biosynthetic enzymes were studied. Lead toxicity was shown to result in a depression of the microsomal mixed function oxidase system, as assessed by a decrease in hepatic microsomal cytochrome P-450 and b5 content and by a decrease in the activity of the enzymes aniline hydroxylase and aminopyrine demethylase. Lead had a more marked effect on cytochrome P-450 than b5. The activity of the rate-limiting enzyme of haem biosynthesis, delta-aminolevulinic acid synthase, was inversely correlated with the microsomal cytochrome P-450 content. The activity of the heam biosynthetic enzymes delta-aminolevulinic acid dehydratase, coproporphyrinogen oxidase and ferrochelatase were decreased by increasing lead pretreatment. The activity of the haem catabolic enzyme, haem oxygenase, was increased by concentration and length of time to lead exposure.

Haem biosynthesis and human porphyria cutanea tarda: effects of alcohol intake.

The review describes the structural and biochemical properties of the haem biosynthetic enzyme, uroporphyrinogen decarboxylase (UROD), which sequentially catalyzes the removal of the four carboxyl groups from the acetate side chains of octacarboxylic uroporphyrinogen to form coproporphyrinogen, and the possible biochemical mechanism of the genesis of porphyria cutanea tarda (PCT). The disease is caused when the activity of UROD is significantly reduced. PCT is a multifactorial disease where both inherent and environmental factors such as alcohol, estrogens, halogenated aromatic hydrocarbons and viral infection (mainly hepatitis C) are involved in biochemical and clinical expression. In PCT, hepatic iron plays a key role. Alcohol intake could induce mobilization of iron from protein-bound ferritin. PCT should be managed by avoidance of these toxins and removal of iron by vigorous phlebotomy. Such iron-reduction therapy would provide additional benefit for hepatitis C patients by interferon therapy.

Stimulation of iron uptake and Hb synthesis in iron deficient reticulocytes.

The effect of inhibitors and intermediates of heme synthesis, inhibitor of globin synthesis, and some iron proteins on in vitro iron uptake and haemoglobin synthesis by reticulocytes of iron deficient subjects was investigated in this study. Lead, INH, ALA, mesoprophyrin, ferritin and albumin substantially increased iron uptake by iron deficient reticulocytes, while cycloheximide and glycine depressed it. The results showed that it is possible to stimulate iron uptake and Hb synthesis in iron deficiency by substances other than iron; the most effective and remarkable of them was ferritin.

Porfiria intermitente aguda y embarazo: caso clínico / Acute intermittent porphyria and pregnancy: clinical case

Se presenta paciente femenina de 27 años de edad, con antecedente de porfiria intermitente, la cual ingresa a la sala de partos de la Maternidad "Concepción Palacios" con embarazo simple de 33 semanas en trabajo de parto pre término. Al segundo día de puerperio presenta alza térmica, dolor abdominal, parestesia en miembros inferiores, orinas oscuras y trombocitopenia. Se diagnostica porfiria intermitente crónica en crisis, respondiendo al tratamiento indicado

Lead exposure and accumulation in healthy Thais: assessed by lead levels, EDTA mobilization and heme synthesis-related parameters.

Lead is one of the pollutants which is of public concern. The magnitude of lead contamination in Thai people is of interest. The objective of this study was to evaluate the lead status in normal healthy volunteers. Normal volunteers were included. The blood for lead level, Zinc protoporphyrin (ZPP), delta-aminolevulinic acid dehydratase (ALA-D) activity, and baseline urine for lead, delta-aminolevulinic acid (ALA) and coproporphyrinogen III (CP3) were collected. The EDTA mobilization test was done. 24 hour urine after administration of the drug was collected for lead analysis. Thirty volunteers were included in the study. All were men whose average age was 32.5 +/- 6.9 years. The mean lead level was 5.95 +/- 2.01 micrograms/dL and 5.83 +/- 2.32 micrograms/L in urine. The 24 hour urine lead contents before and after EDTA administration were significantly different (11.11 +/- 6.72 and 16.05 +/- 9.51 micrograms respectively). Blood ALA-D activity was 251.6 +/- 80.4 unit/ml of RBC. Urine ALA and CP3 were 0.56 +/- 1.2 mg/L and 22.17 +/- 23.9 micrograms/L respectively. All were in the normal ranges. All parameters suggested that the healthy Thai volunteers had an acceptable magnitude of lead exposure and accumulation.

Oxidative stress in acute intermittent porphyria and lead poisoning may be triggered by 5-aminolevulinic acid

Highly reactive oxyradicals can be generated in vitro by iron-catalyzed aerobic oxidation of synthetic and naturally occuring substances capable of enolization in aqueous medium. Of biological interest are alfa-hydroxy- and alfa-aminocarbonyls such as carbohydrates, 5-aminolevulinic acid, and aminoacetone which tautomerize to the corresponding enediols and enolamines and yield oxyradicals initiated by electron transfer to dioxygen. Free radicals have been implicated in several normal and pathological processes. We briefly review our hypothesis of an in vivo prooxidant role of 5-aminolev-ulinic acid (ALA), the heme precursor accumulated in several porphyric disorders (e.g., lead poisoning, acute intermittent porphyria (AIP), tyrosinosis). Accordingly, i) ALA undergoes transition metal-catalyzed oxidation to give O-2, H2O2 and HO; ii) ALA induces iron release from ferritin, lipid peroxidation of cardiolipin-rich vesicles, single strand breaks in plasmid DNA, and guanosine oxidation in calf thymus DNA; iii) ALA causes Ca2+ -mediated rat liver mitochondria permeabilization; iv) rats chronically treated with ALA exhibit increased glycolytic metabolism; v) brain extracts of ALA-treated rats reveal increased levels of thiobarbituric acid reactive substances, direct chemiluminescence intensity, carbonyl proteins, ferritin, and "free iron"and gama-aminobutyric acid-receptor dissociation constant, and vi) patients with AIP and lead-exposed workers present augmented erythrocytic levels of the antioxidant enzymes superoxide dismutase and glutathione peroxidase. These data indicate the involvement of ALA-generated reactive species in the clinical manifestations (neuropathy, mental changes, muscle weakness, hepatoma) shared by the aforementioned inherited and acquired porphyric diseases.

Preventive action of zinc against lead toxicity.

The study was aimed to assess the protective efficacy of zinc against hemo and hematotoxicity induced by lead. Two groups of 8 rats each, were administered lead acetate 20 mg/kg bw (ip) for 3 days. One group in addition was injected 5 mg/kg bw (ip) zinc acetate for next three days. A third group of 8 rats was given three injections of normal saline and served as control. All the animals were sacrificed on eighth day and assessed for hematological changes, heme synthesizing pathway enzymes, hepatic drug metabolizing status and sulfhydryl levels in blood and liver. Lead administration resulted in decreased hemoglobin, increased reticulocytosis, depression of delta aminolevulinic acid dehydratase (ALAD) and uroporphyrinogen I synthetase (UPS) activity in blood and liver. In vitro metabolism of drugs aminopyrine, aniline and p-nitroanisole by liver homogenate and in vivo metabolism of pentabarbitone was also reduced in lead exposed rate. Zinc treated rats showed improved hematological profile and activated ALAD and UPS activity, recovery of N-demethylation of aminopyrine and O-demethylation of p-nitroanisole and partial restoration of free thiol levels in blood and liver thereby indicating that zinc could confer protection against lead toxicity.

Regulation of cadmium induced porphyria by ascorbic acid in chick embryos.

Sublethal doses of cadmium chloride (2.5, 5.0 and 10.0 mu mole/kg egg weight) were found to significantly alter the first two rate limiting enzymes of heme biosynthesis in chick embryos. Delta-aminolevulinic acid synthase activity was elevated by 2.05 and 2.11 fold with 5.0 and 10.0 mu moles of cadmium treatment respectively. However, this was reduced to 1.25 and 1.3 fold by the simultaneous administration of ascorbic acid. Blood delta-aminolevulinic acid dehydratase (ALA-D) activity was decreased by 48.4 and 55.0 per cent with 5.0 and 10.0 mu moles cadmium treatment respectively; in the presence of ascorbic acid only 18 and 24 per cent inhibition of ALA-D activity was observed. Further 1.39 and 2.08 fold accumulation of delta-aminolevulinic acid and 4.17 and 4.62 fold increase of blood porphyrins was observed in chick embryos treated with 5.0 and 10.0 mu moles cadmium respectively. This elevation of intermediate compounds of heme biosynthesis was effectively checked by the administration of ascorbic acid. Depletion of hepatic heme and free sulfhydryl level by cadmium were countered by the treatment of ascorbic acid. Hence, the present findings suggest the protective role of ascorbic acid against cadmium induced chemical porphyria in chick embryos.