Scientific considerations for global drug development.

Requiring regional or in-country confirmatory clinical trials before approval of drugs already approved elsewhere delays access to medicines in low- and middle-income countries and raises drug costs. Here, we discuss the scientific and technological advances that may reduce the need for in-country or in-region clinical trials for drugs approved in other countries and limitations of these advances that could necessitate in-region clinical studies.

Phase IA Clinical Trial Evaluating the Tolerability, Pharmacokinetics, and Analgesic Efficacy of an Intrathecally Administered Neurotensin A Analogue in Central Neuropathic Pain Following Spinal Cord Injury.

We evaluated CGX-1160 in a Phase Ia clinical trial to determine the safety of escalating doses in patients with central neuropathic pain following spinal cord injury (SCI). Our secondary objective was to detect a trend toward analgesic efficacy. Four subjects received 3 consecutive escalating doses of CGX-1160 starting at 25 µg/h over 6 hours until 2 consecutive subjects experienced any adverse effect; 2 of the 4 subjects received 2 sequences of 3 consecutive dose escalations. Maximum tolerated dose was defined by the development of diarrhea (900 µg/h over 6 hours). Cerebrospinal fluid (CSF) and blood were collected for pharmacokinetic (PK) evaluation. The CSF concentration-versus-time data fit to a biexponential PK model, showing a rapid redistribution phase followed by a significantly slower terminal elimination phase. Incorporating an effect site delay into the model improved the fit to the data (concentration producing 50% of the maximum effect [C50 ], 58.7 ug/mL at the site of drug effect). Maximal reduction from the baseline pain intensity was 63%. In summary, CGX-1160 was generally well tolerated when administered intrathecally at doses up to 1000 µg/h. Peak analgesic effect occurred after the peak intrathecal concentration, indicating the presence of an effect site compartment to the PK model to represent the concentration and effect profiles for this unique compound.

Effect of a Pluronic(®) P123 formulation on the nitric oxide-generating drug JS-K.

PURPOSE: O(2)-(2,4-dinitrophenyl)1-[(4-ethoxycarbonyl)piperazin-1-yl]diazen-1-ium-1,2-diolate] or JS-K is a nitric oxide-producing prodrug of the arylated diazeniumdiolate class with promising anti-tumor activity. JS-K has challenging solubility and stability properties. We aimed to characterize and compare Pluronic(®) P123-formulated JS-K (P123/JS-K) with free JS-K. METHODS: We determined micelle size, shape, and critical micelle concentration of Pluronic(®) P123. Efficacy was evaluated in vitro using HL-60 and U937 cells and in vivo in a xenograft in NOD/SCID IL2Rγ (null) mice using HL-60 cells. We compared JS-K and P123/JS-K stability in different media. We also compared plasma protein binding of JS-K and P123/JS-K. We determined the binding and Stern Volmer constants, and thermodynamic parameters. RESULTS: Spherical P123/JS-K micelles were smaller than blank P123. P123/JS-K formulation was more stable in buffered saline, whole blood, plasma and RPMI media as compared to free JS-K. P123 affected the protein binding properties of JS-K. In vitro it was as efficacious as JS-K alone when tested in HL-60 and U937 cells and in vivo greater tumor regression was observed for P123/JS-K treated NOD/SCID IL2Rγ (null) mice when compared to free JS-K-treated NOD/SCID IL2Rγ (null) mice. CONCLUSIONS: Pluronic(®) P123 solubilizes, stabilizes and affects the protein binding characteristics of JS-K. P123/JS-K showed more in vivo anti-tumor activity than free JS-K.

Cellular distribution studies of the nitric oxide-generating antineoplastic prodrug O(2) -(2,4-dinitrophenyl)1-((4-ethoxycarbonyl)piperazin-1-yl)diazen-1-ium-1,2-diolate formulated in Pluronic P123 micelles.

OBJECTIVE: Nitric oxide (NO) possesses antitumour activity. It induces differentiation and apoptosis in acute myeloid leukaemia (AML) cells. The NO prodrug O(2) -(2,4-dinitrophenyl)1-((4-ethoxycarbonyl)piperazin-1-yl)diazen-1-ium-1,2-diolate, or JS-K, has potent antileukaemic activity. JS-K is also active in vitro and in vivo against multiple myeloma, prostate cancer, non-small-cell lung cancer, glioma and liver cancer. Using the Pluronic P123 polymer, we have developed a micelle formulation for JS-K to increase its solubility and stability. The goal of the current study was to investigate the cellular distribution of JS-K in AML cells. METHODS: We investigated the intracellular distribution of JS-K (free drug) and JS-K formulated in P123 micelles (P123/JS-K) using HL-60 AML cells. We also studied the S-glutathionylating effects of JS-K on proteins in the cytoplasmic and nuclear cellular fractions. KEY FINDINGS: Both free JS-K and P123/JS-K accumulate primarily in the nucleus. Both free JS-K and P123/JS-K induced S-glutathionylation of nuclear proteins, although the effect produced was more pronounced with P123/JS-K. Minimal S-glutathionylation of cytoplasmic proteins was observed. CONCLUSIONS: We conclude that a micelle formulation of JS-K increases its accumulation in the nucleus. Post-translational protein modification through S-glutathionylation may contribute to JS-K's antileukaemic properties.

Comparison between cerebral state index and bispectral index as measures of electroencephalographic effects of sevoflurane using combined sigmoidal E(max) model.

AIM: The cerebral state index (CSI) was recently introduced as an electroencephalographic monitor for measuring the depth of anesthesia. We compared the performance of CSI to the bispectral index (BIS) as electroencephalographic measures of sevoflurane effect using two combined sigmoidal E(max) models. METHODS: Twenty adult patients scheduled for laparotomy were studied. After induction of general anesthesia, sevoflurane concentrations were progressively increased and then decreased over 70 min. An analysis of the BIS and CSI with the sevoflurane effect-site concentration was conducted using two combined sigmoidal E(max) models. RESULTS: The BIS and CSI decreased over the initial concentration range of sevoflurane and then reached a plateau in most patients. A further increase in sevoflurane concentration produced a secondary plateau in the pharmacodynamic response. The CSI was more strongly correlated with effect-site sevoflurane concentration (R(2)=0.95±0.04) than the BIS was (R(2)=0.87±0.07) (P<0.05). The individual E(max) and C(eff50) (effect-site concentration associated with 50% decrease from baseline to plateau) values for the upper and lower plateaus were significantly greater for BIS (12.7±7.3, 1.6±0.4, and 4.2±0.5, respectively) than for CSI (3.4±2.2, 1.2±0.4, and 3.8±0.5, respectively) (P<0.05). The remaining pharmacodynamic parameters for the BIS and CSI were similar. CONCLUSION: The overall performance of the BIS and CSI during sevoflurane anesthesia was similar despite major differences in their algorithms. However, the CSI was more consistent and more sensitive to changes in sevoflurane concentration, whereas the measured BIS seemed to respond faster. The newly developed combined E(max) model adequately described the clinical data, including the pharmacodynamic plateau.

Community screening and treatment of asymptomatic carriers of Plasmodium falciparum with artemether-lumefantrine to reduce malaria disease burden: a modelling and simulation analysis.

BACKGROUND: Asymptomatic carriers of Plasmodium falciparum serve as a reservoir of parasites for malaria transmission. Identification and treatment of asymptomatic carriers within a region may reduce the parasite reservoir and influence malaria transmission in that area. METHODS: Using computer simulation, this analysis explored the impact of community screening campaigns (CSC) followed by systematic treatment of P. falciparum asymptomatic carriers (AC) with artemether-lumefantrine (AL) on disease transmission. The model created by Okell et al (originally designed to explore the impact of the introduction of treatment with artemisinin-based combination therapy on malaria endemicity) was modified to represent CSC and treatment of AC with AL, with the addition of malaria vector seasonality. The age grouping, relative distribution of age in a region, and degree of heterogeneity in disease transmission were maintained. The number and frequency of CSC and their relative timing were explored in terms of their effect on malaria incidence. A sensitivity analysis was conducted to determine the factors with the greatest impact on the model predictions. RESULTS: The simulation showed that the intervention that had the largest effect was performed in an area with high endemicity (entomological inoculation rate, EIR > 200); however, the rate of infection returned to its normal level in the subsequent year, unless the intervention was repeated. In areas with low disease burden (EIR < 10), the reduction was sustained for over three years after a single intervention. Three CSC scheduled in close succession (monthly intervals) at the start of the dry season had the greatest impact on the success of the intervention. CONCLUSIONS: Community screening and treatment of asymptomatic carriers with AL may reduce malaria transmission significantly. The initial level of disease intensity has the greatest impact on the potential magnitude and duration of malaria reduction. When combined with other interventions (e.g. long-lasting insecticide-treated nets, rapid diagnostic tests, prompt diagnosis and treatment, and, where appropriate, indoor residual spraying) the effect of this intervention can be sustained for many years, and it could become a tool to accelerate the reduction in transmission intensity to pre-elimination levels. Repeated interventions at least every other year may help to prolong the effect. The use of an effective diagnostic tool and a highly effective ACT, such as AL, is also vital. The modelling supports the evaluation of this approach in a prospective clinical trial to reduce the pool of infective vectors for malaria transmission in an area with marked seasonality.

The need for modeling and simulation to design clinical investigations in children.

Recent legislation in the United States and Europe has resulted in an increased number of clinical trials of pharmaceutical agents in children. Creating a well-designed clinical trial that can be successfully completed is a challenging task, particularly as the study population includes younger and smaller children. Although there are some established principles for initially estimating appropriate doses of pharmaceutical agents in children based on known effective doses in adults, these rules are inadequate as the sole basis for designing a clinical trial in children. Factors such as maturation of metabolizing enzymes, relative physical maturation of the child, and altered absorption because of physiological differences in adults and children may contribute to alterations in the dose-exposure relationship. To account for the impact of these potential factors on a clinical trial, the use of modeling and simulation is necessary to anticipate the influence these variables can have on the desired clinical question to be addressed. The examples presented in this article highlight the principle that modeling and simulation is critical for adequately designing pediatrics trials.

Modeling the effect of sevoflurane on corrected QT prolongation: a pharmacodynamic analysis.

BACKGROUND: Sevoflurane may prolong the corrected QT (QTc) interval in healthy humans when administered for induction and maintenance of anesthesia. Little information is available about the dose-response relationship of sevoflurane on the QTc interval. We performed a pharmacodynamic analysis of the relationship between end-tidal sevoflurane concentration (CET) and the QTc. METHODS: Twenty-one patients aged 20-50 yr were enrolled in this study. Sevoflurane concentrations were progressively increased and then decreased over 15 min at the start of anesthesia; CET and automated QT interval were recorded continuously. Pharmacodynamic analysis using a sigmoid Emax model was performed to assess the concentration-effect relationship. RESULTS: Maximal CET was 4.30 ± 0.33%. Measured baseline and maximally prolonged QTc interval values were 351.7 ± 15.4 ms and 397.8 ± 17.5 ms, respectively. During sevoflurane anesthesia, increased concentrations were correlated with prolonged QTc interval. Hysteresis between the CET and QTc interval were observed and accounted for in the model. Ce50 and ke0 were 2.5 ± 1.4 and 2.0 ± 1.0, respectively. The median prediction error, median absolute prediction error, and the coefficient of determination (R) were 0.02%, 0.75%, and 0.95, respectively. The effect-site concentration (Ce50) and QTc interval data fit to a sigmoid Emax model. CONCLUSIONS: Among patients receiving sevoflurane for anesthesia, QTc interval changes correlate to anesthetic level. The Ce50 for significant QTc change is at clinically relevant levels of sevoflurane anesthesia.

The effect of food consumption on lumefantrine bioavailability in African children receiving artemether-lumefantrine crushed or dispersible tablets (Coartem) for acute uncomplicated Plasmodium falciparum malaria.

OBJECTIVES: Artemether-lumefantrine (AL) is first-line treatment for uncomplicated malaria in many African countries. Concomitant food consumption may affect absorption of lumefantrine but data in the most important target population, i.e. children, are lacking. Therefore, we evaluated the effect of food intake on oral lumefantrine bioavailability in African children with malaria. METHODS: In a randomised, investigator-blinded, multicentre phase III efficacy trial, 899 infants and children with acute uncomplicated Plasmodium falciparum malaria received six doses of AL according to body weight over 3 days either as crushed tablets (Coartem) or as dispersible tablets. Single blood samples were obtained for lumefantrine plasma concentration determination in a subset of 621 patients, and a two-compartment pharmacokinetic model was constructed. RESULTS: The mean observed lumefantrine plasma concentration for crushed tablet and dispersible tablet, respectively, was 100% and 55% higher with a concomitant meal at the time of dose intake than when taken alone. Similarly, consumption of milk (the most common meal) increased model-estimated lumefantrine bioavailability by 57% (90% CI: 29-96%) with crushed tablets and 65% (90% CI: 28-109%) with dispersible tablets compared to no food. The 28-day PCR-corrected cure rate (primary study endpoint) in the evaluable population was 582/587 [99.1% (95% CI: 98.0-99.7%)] and was not related to food intake. CONCLUSIONS: AL was highly efficacious. Concomitant food intake increased lumefantrine absorption in children with malaria.

Modelling the genesis and treatment of cancer: the potential role of physiologically based pharmacodynamics.

Physiologically based modelling of pharmacodynamics/toxicodynamics requires an a priori knowledge on the underlying mechanisms causing toxicity or causing the disease. In the context of cancer, the objective of the expert meeting was to discuss the molecular understanding of the disease, modelling approaches used so far to describe the process, preclinical models of cancer treatment and to evaluate modelling approaches developed based on improved knowledge. Molecular events in cancerogenesis can be detected using 'omics' technology, a tool applied in experimental carcinogenesis, but also for diagnostics and prognosis. The molecular understanding forms the basis for new drugs, for example targeting protein kinases specifically expressed in cancer. At present, empirical preclinical models of tumour growth are in great use as the development of physiological models is cost and resource intensive. Although a major challenge in PKPD modelling in oncology patients is the complexity of the system, based in part on preclinical models, successful models have been constructed describing the mechanism of action and providing a tool to establish levels of biomarker associated with efficacy and assisting in defining biologically effective dose range selection for first dose in man. To follow the concentration in the tumour compartment enables to link kinetics and dynamics. In order to obtain a reliable model of tumour growth dynamics and drug effects, specific aspects of the modelling of the concentration-effect relationship in cancer treatment that need to be accounted for include: the physiological/circadian rhythms of the cell cycle; the treatment with combinations and the need to optimally choose appropriate combinations of the multiple agents to study; and the schedule dependence of the response in the clinical situation.

Preclinical pharmacokinetic/pharmacodynamic models to predict synergistic effects of co-administered anti-cancer agents.

PURPOSE: Pharmacokinetic/pharmacodynamic (PK/PD) models have been shown to be useful in predicting tumor growth rates in mouse xenografts. We applied novel PK/PD models to the published anticancer combination therapies of tumor growth inhibition to simulate synergistic changes in tumor growth rates. The parameters from the PK/PD model were further used to estimate clinical doses of the combination. METHODS: A PK/PD model was built that linked the dosing regimen of a compound to the inhibition of tumor growth in mouse xenograft models. Two subsequent PK/PD models were developed to simulate the published tumor growth profiles of combination treatments. Model I predicts the tumor growth curve assuming that the effect of two anticancer drugs, AZD7762 and irinotecan, is synergistic when given in combination. Model II predicts the tumor growth curve assuming that the effect of co-administering flavopiridol and irinotecan is maximally synergistic when dosed at an optimal interval. RESULTS: Model I was able to account for the synergistic effects of AZD7762 following the administration of irinotecan. When Model II was applied to the antitumor activity of irinotecan and flavopiridol combination therapy, the modeling was able to reproduce the optimal dosing interval between administrations of the compounds. Furthermore, Model II was able to estimate the biologically active dose of flavopiridol recommended for phase II studies. CONCLUSIONS: The timing of clinical combination therapy doses is often selected empirically. PK/PD models provide a theoretical structure useful in the design of the optimal clinical dose, frequency of administration and the optimal timing of administration between anticancer agents to maximize tumor suppression.

In-vitro Release of Rapamycin from a Thermosensitive Polymer for the Inhibition of Vascular Smooth Muscle Cell Proliferation.

Hemodialysis arteriovenous grafts are often plagued by stenosis at the anastomosis, which is due to the proliferation of vascular smooth muscle cells (SMCs). To prevent the stenosis, we have been developing a strategy for the sustained perivascular delivery of an antiproliferative agent, rapamycin, using an injectable biodegradable polymer, ReGel(®). In this study we examined the in-vitro kinetics of rapamycin released from ReGel and its efficacy for inhibiting the proliferation of human and porcine venous and arterial SMCs. To study the release from ReGel, rapamycin was mixed with ReGel and incubated at 37°C in a release medium. The release medium was periodically sampled and assayed for rapamycin concentration by UV. Cellular uptake and release of rapamycin were examined by incubating SMCs with rapamycin for various durations. Intracellular drug was extracted and measured by HPLC. Antiproliferative effects and cytotoxicity of stock rapamycin and that released from ReGel were examined using cell counting and lactate dehydrogenase (LDH)-release assay, respectively. Rapamycin exhibited a sustained-release pattern from ReGel for 52 days. The kinetics of rapamycin transport through the cell membrane was compatible with a passive diffusion mechanism. Rapamycin released from ReGel exhibited antiproliferative activity similar to the free drug. Our results support the concept of sustained delivery of rapamycin using ReGel as a promising strategy to inhibit SMC proliferation for the prevention of hemodialysis arteriovenous graft stenosis.

Challenges in conducting clinical trials in children: approaches for improving performance.

Recent legislative changes in both Europe and the USA have increased the responsibility of drug developers to purposefully study the agents they market in children so that specific dosing recommendations can be made to assist clinicians in their use. Typically, clinicians use empiricalor experiential-based rationales for selecting the dose to use in children, generally in a manner that attempts to achieve the same dose-exposure or pharmacokinetic profile in children as in adults. However, whether this approach achieves the necessary dose exposure or exposure effect needed may not be systematically explored during off-label use. This creates the opportunity for under- or over-exposure in children, particularly in very young children (i.e., less than 2 years old) where a combination of factors during development can effect both pharmacokinetics and pharmacodynamics. The ethical, physiological and statistical differences of studying new therapeutic agents in children present economic challenges that may create unintended incentives - both positive and negative - for any individual developer who tries to meet the requirements of new legislation to study pharmaceutical agents in children. There should be a continued emphasis in academic clinical pharmacology programs towards creative methods and approaches to better understand these differences in children compared with adults. The ability to use information from knowledge obtained from adult studies, from preclinical studies, from studies of compounds with similar chemistry or pharmacology, or from known physiological differences between children and adults is essential to choosing a suitable dose for children and achieving these regulatory aims.

The pharmacokinetics of the conopeptide contulakin-G (CGX-1160) after intrathecal administration: an analysis of data from studies in beagles.

BACKGROUND: The synthetic peptide agent Contulakin-G (CGX-1160), isolated from the toxin of the snail Conus geographus, produces significant analgesia in animals. Its peptide structure requires intrathecal administration for effectiveness, therefore we determined the intrathecal pharmacokinetics of CGX-1160 after bolus dose and multiple day infusions to beagles. METHODS: For the bolus dose study, eight animals received a dose ranging from 16.7 to 1000 nmol under isoflurane anesthesia. Cerebral spinal fluid sampling for drug assay occurred up to 24 h. For the multiple day infusion study, three animals received infusions of 10, 40, and 160 microg/h respectively for 24 h at each rate. Cerebral spinal fluid sampling occurred during the infusion rate and the washout period after the 72 h of cumulative drug delivery. Data from the two study designs were modeled separately using NONMEM. RESULTS: The results showed a biexponential disposition profile for both experiments with a rapid rate constant that was an order of magnitude greater than the slow rate constant. The bolus results showed a nonlinear dependence of the slow rate constant on administered dose due to the large bolus range used in the study. CONCLUSION: These data, coupled with clinical pharmacology results, provide a basis for determining appropriate dosing strategies to achieve therapeutic intrathecal concentrations of Contulakin-G.

Pharmacokinetics and pharmacodynamics of propofol microemulsion and lipid emulsion after an intravenous bolus and variable rate infusion.

BACKGROUND: The aim of this trial was to evaluate the induction and recovery characteristics of microemulsion propofol (Aquafol; Daewon Pharmaceutical Co., Ltd., Seoul, Korea). Pharmacokinetics, pharmacodynamics, and safety profile were investigated. Lipid emulsion propofol (Diprivan; AstraZeneca, London, United Kingdom) was used as a comparator. METHODS: Thirty-one healthy volunteers aged 20-79 yr were given an intravenous bolus of propofol 2 mg/kg, followed by variable rate infusion for 60 min. Each volunteer was studied twice with different formulations at an interval of 1 week. Arterial concentrations of propofol were measured, and Bispectral Index was used as a surrogate measure of propofol effect. The induction and recovery characteristics including bioequivalence were evaluated by noncompartmental analysis. The pharmacokinetics and pharmacodynamics were investigated using a population approach with mixed effects modeling. The rate, severity, and causal relation of adverse events were analyzed. RESULTS: Both formulations were bioequivalent. The observed time to peak effect after a bolus of both formulations was 1.5 min. Plasma concentration of propofol at loss of consciousness, time to loss of consciousness after a bolus, and time to recovery of consciousness after discontinuation of infusion did not show significant differences. The population pharmacokinetics and pharmacodynamics revealed a variety of differences between two formulations. Aquafol showed similar safety profile to Diprivan. CONCLUSIONS: The efficacy and safety of Aquafol were not different from those of Diprivan within the dose range in this study.

Intracellular kinetics of non-viral gene delivery using polyethylenimine carriers.

PURPOSE: Polymeric nucleic acid carriers are designed to overcome one or more barriers to delivery. High molecular weight polyethylenimine (PEI) shows high transfection efficiency but exhibits high cytotoxicity (Fischer et al. Biomaterials, 24:1121-1131 (2003); Peterson et al. Bioconjug. Chem., 13:845-854 (2002)). Nontoxic water-soluble lipopolymer (WSLP) was previously developed using branched poly(ethylenimine) (PEI, mw 1,800) and cholesteryl chloroformate (Han, Mahato, and Kim. Bioconjug. Chem., 12:337-345 (2001)) and is an effective non-viral gene carrier with transfection levels equal or above high molecular weight PEI with a lower cytotoxicity profile. To understand how differences in these polymeric carriers influence transfection, we studied the pharmacokinetics of polymer gene carriers at the cellular level. MATERIALS AND METHODS: Cells were exposed in vitro to different polymeric carriers and the transport of the carriers into different cellular compartments was determined using cellular fractionation and real-time quantitative PCR. A multi-compartment mathematical model was applied to time series measurements of the trafficking of plasmids across each cellular barrier. RESULTS: Our result indicates that the chemical modification of WSLP increased the rate parameter for endosomal escape significantly compared to conventional PEI carriers thereby increasing the overall transfection efficiency. CONCLUSIONS: These results are consistent with the goal of endosomal destabilization of the carrier design. This method provides a quantitative means for assessing different polymer construct designs for gene delivery.

Evaluation of histological techniques for quantifying haemodialysis arteriovenous (AV) graft hyperplasia.

BACKGROUND: Assessing treatment efficacies for preventing haemodialysis arteriovenous (AV) graft stenosis requires a reproducible method for quantifying intimal hyperplasia. We identified sources of variability in three histological methods for assessing hyperplasia in a porcine AV graft model. METHODS: Carotid-jugular synthetic grafts were placed in pigs. After explantation at 3-6 weeks, the tissue was stained with haematoxylin and eosin (H&E), Masson's trichrome or elastic tissue Van Gieson (EVG) stains and examined histologically. Hyperplasia at the anastomosis of 14 grafts was quantified using three different methods, each by four blinded observers. These methods were visual scoring, ratio of intima-to-media surface area (I/M ratio), and ratio of intra-graft hyperplasia to graft surface area (H/G ratio) at the graft-vessel interface. RESULTS: The EVG stain proved superior in delineation of the elastic lamina yet quantification of the intimal and medial layers was still often difficult. This is illustrated by the greater inter-observer median coefficient of variances (CV) found using the I/M ratio method (intimal area CV=13.7%; medial area CV=32.7%; I/M ratio CV=44.0%) than with the H/G method (intra-graft hyperplasia area CV=7.3%, graft area CV=5.3%; H/G ratio CV=6.9%) or by visual scoring (CV=26.8%). The H/G ratios correlated positively with visual scores (r=0.941; P=0.0007; n=14) and the I/M ratio (r=0.719; P=0.0095; n=14). While hyperplasia was seen in both native vessel and graft lumen, in only one of the 14 anastomoses was the degree of hyperplasia greater in the native vessel than in the graft lumen, suggesting that the degree of hyperplasia occurring within the graft lumen predicted the total hyperplasia around the anastomosis. CONCLUSIONS: The H/G method for assessing hyperplasia is preferred in a porcine model of AV graft because it is quantitative, less variable and does not require the delineation of the elastic lamina, although it infrequently underestimates the total hyperplasia that occurs.

Cellular pharmacokinetics and pharmacodynamics of dipyridamole in vascular smooth muscle cells.

Hemodialysis arteriovenous grafts are often plagued by stenosis at the vein-graft anastomosis, which is due to the proliferation of venous smooth muscle cells (SMCs). Perivascular delivery of dipyridamole, a potent antiproliferative agent, has been proposed for the prevention of graft stenosis. In order to develop an optimal delivery system for dipyridamole, we examined its pharmacokinetics and pharmacodynamics in human and porcine venous and arterial SMCs in vitro. SMCs were incubated with dipyridamole for various durations, and visualized for the uptake and release by fluorescence microscopy, which were further quantified by fluorospectrometry. The antiproliferative effect of dipyridamole was examined by cell counting or the methylthiazoletetrazolium (MTT) dye-reduction assay. Cytotoxicity was examined by the lactate dehydrogenase (LDH)-release assay. The kinetics of dipyridamole transport through the cell membrane was compatible with a passive diffusion mechanism. Dipyridamole inhibited SMC proliferation in a dose-dependent manner and was more effective in venous than arterial cells in both species. The inhibition was completely reversible at 15microg/ml upon drug removal from the medium. At 25microg/ml, however, the effect was partially irreversible, which might be attributed to the cytotoxicity of dipyridamole. These data support the need for sustained delivery of dipyridamole to achieve the long-term inhibition of SMC proliferation in the prevention of stenosis since SMCs are continuously stimulated at the anastomosis of hemodialysis arteriovenous grafts.

Flexible interaction model for complex interactions of multiple anesthetics.

BACKGROUND: Minto et al. (Anesthesiology 2000) described a mathematical approach based on response surface methods for characterizing drug-drug interactions between several intravenous anesthetic drugs. To extend this effort, the authors developed a flexible interaction model based on the general Hill dose-response relation that includes a set of parameters that can be statistically assessed for interaction significance. METHODS: This new model was developed to identify pharmacologically meaningful interaction-related parameters and address mathematical limitations in previous models. The flexible interaction model and the model of Minto et al. were compared in their assessment of additivity using simulated sample data sets. The flexible interaction model was also compared with the Minto model in describing drug interactions using data from several other clinical studies of propofol, opioids, and benzodiazepines from Short et al. (Anesthesiology 2002) and Kern et al. (Anesthesiology 2004). RESULTS: The flexible interaction model was able to accurately classify an additive interaction based on the classic definition proposed by Loewe, with at most an 8% difference between the two surfaces. Also, the proposed model fit the clinical interaction data as well or slightly better than that of Minto et al. CONCLUSIONS: The new model can accurately classify additive and synergistic drug interactions. It also can classify antagonistic interactions with biologically rational surfaces. This has been a problem for other interaction models in the past. The statistically assessable interaction parameters provide a quantitative manner to assess the interaction significance.