Safety issues of maternal drug therapy during breastfeeding.

Two goals when counseling breastfeeding mothers taking medication are protecting the infant from adverse events and permitting necessary maternal therapy. Madadi et al. report a case-control study of neonatal and maternal opioid toxicity after codeine administration. Therapeutic considerations in counseling breastfeeding mothers include susceptibility to drug toxicity of the very young and/or premature infant, significant interindividual variations in drug response, the dose-response relationship with respect to drug toxicity, and the role of pharmacogenetics in both the mother and the infant. These host factors may combine in a particular patient to act synergistically to produce an adverse reaction.

Recollections from the Kunkel laboratory, 1956-1958.

The Kunkel laboratory provided a unique environment for dedicated young scientists to learn the art of clinical investigation.

The pursuit of clinical truth: role of epidemiology/observation studies.

The need for evidence-based medicine as a foundation for optimal patient care requires application of the best scientific methods. Various methods used in the search for clinical truth are discussed. The most powerful method to test a clinical hypothesis is the randomized, controlled clinical trial. By contrast, epidemiology/observation studies (EOS) have inherent weaknesses that can lead to erroneous conclusions. Five such examples, two older and three very recent, are discussed to provide historical perspective and demonstrate potential problems with EOS. Each incident has produced widespread consternation or confusion among physicians. Types of bias leading to errors in EOS are discussed, and the need is emphasized for more rigorous evaluation of EOS by investigators, as well as editors, to avoid repetition of past mistakes and to ensure publication of correct medical information.

Advances in pharmacogenetics and pharmacogenomics.

Large differences among normal human subjects in the efficacy and safety of many therapeutic agents are caused by genetically controlled polymorphisms of drug-metabolizing enzymes, drug transporters, and drug receptors. Development of pharmacogenomics as a new field has accelerated progress in pharmacogenetics by elucidating at the level of the human genome the inherited basis for those large interindividual variations. Examples discussed in this review illustrate how this approach can be used not only to guide new drug discovery but also to individualize therapy. Adverse drug reactions, often attributable to large differences among subjects in drug response, constitute a leading cause of death in the USA. Such high morbidity and mortality could be reduced by application of the principles of pharmacogenetics and pharmacogenomics, defined broadly as the study of genetically caused variability in drug response.

Studies on pyrazinoylguanidine: a novel antihypertensive, hypoglycemic and lipolytic drug intended for adjunctive use in hypertensive patients with type 2 diabetes mellitus.

Herein are described the development and certain properties of a new drug, pyrazinoylguanidine (PZG), intended for use as an adjunct in the treatment of hypertensive patients with type 2 diabetes, formerly called noninsulin dependent diabetes mellitus. PZG is an analog of the potassium sparing diuretic, amiloride. However, in diabetic patients, amiloride exacerbates hyperglycemia and hyperlipidemia, whereas PZG reduces them. In several studies, PZG not only reduced elevated blood pressure in subjects with essential hypertension, but also downregulated the glucose fatty acid cycle in hypertensive patients with type 2 diabetes. PZG was well tolerated in all patients, as well as in normal subjects whose blood pressures and glucose metabolism were unaffected by PZG. However, in normal subjects made hyperglycemic by giving them hydrochlorothiazide, coadministration of PZG returned blood glucose concentrations to normal. Mechanisms for these effects of PZG in human subjects were investigated in both normal Sprague-Dawley rats and rats made diabetic with streptozotocin (STZ). In isolated rat adipocytes stimulated with theophylline, PZG downregulated both lipolysis and cyclic AMP concentrations. PZG, as well as insulin, increased adipose cyclic nucleotide phosphodiesterase activity, whereas theophylline reduced it. In perfused rat liver, PZG decreased gluconeogenesis and cyclic AMP concentrations. Collectively, these studies illustrate how the side effects (toxicity) of certain drugs, such as the tendency of thiazide diuretics to cause hyperglycemia and hyperlipidemia, can be modulated and even reversed by slight changes in the chemical structure of the molecule, specifically by removal of the 3,5-diamino and 6-chloro substituents on the benzene ring of amiloride to produce PZG.

Are the elderly underrepresented in clinical drug trials?

In many industrialized nations, the elderly comprise the fastest growing subpopulation and constitute an increasing proportion of the total population compared to other age groups. The elderly use a disproportionately larger amount of health care resources since they experience a higher incidence of disease-related morbidities, consume more drugs, are subject to more extensive multiple medication regimens, and account for more adverse drug events. In response to the great demand for geriatric pharmacotherapy, the pharmaceutical industry has targeted more drugs to the elderly. However, the elderly are too often excluded from clinical trials on drugs primarily destined for their consumption. Comprehensive analyses to assess participation of elderly subjects in clinical drug trials are needed to design and implement trials that will enhance the safety and efficacy of drugs intended for this pharmacologically sensitive subpopulation.

Metabolism and disposition of 4-(methylnitrosamino)-1-(3-pyridyl)-1- butanone (NNK) in rhesus monkeys.

Metabolism and disposition of the tobacco-specific N-nitrosamine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), a potent rodent lung carcinogen, were studied in rhesus monkeys. In three males receiving a single i.v. dose of [5-3H]NNK (0.72 mCi; 4.6-9.8 microg/kg), urine was collected for 10 days. Within the first 24 h, 86.0 +/- 0.7% of the dose was excreted. NNK-derived radioactivity was still detectable in urine 10 days after dosing (total excretion, 92.7 +/- 0.7%). Decay of urinary radioactivity was biexponential with half-lives of 1.7 and 42 h. Metabolite patterns in urine from the first 6 h closely resembled those reported previously for patas monkeys; end products of metabolic NNK activation represented more than 50% of total radioactivity. At later time points, the pattern shifted in favor of NNK detoxification products (60-70% of total radioactivity in urine), mainly 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and its O-glucuronide conjugates. One female rhesus monkey received a single i.v. dose of [5-3H]NNK (1.72 mCi; 28.4 microg/kg) under isoflurane anesthesia; biliary excretion over 6 h (0.6% of the dose) was 10 times less than predicted by our previously reported rat model. No preferential excretion of NNAL glucuronide was observed in monkey bile. Collectively, these results suggest that the rhesus monkey could be a useful model for NNK metabolism and disposition in humans.

Studies on pyrazinoylguanidine. 7. Effects of single oral doses in normal human subjects.

In a three-phase study, single oral doses of placebo, followed in 1 week by pyrazinoylguanidine (PZG; 900 mg), followed in 3 weeks by pyrazinoic acid (PZA; 300 mg) were given to 8 normal male subjects. Blood analyses performed 0, 2 and 4 h after administration of placebo or drug revealed that compared to mean 0 h values, PZG and also PZA, but not placebo, decreased mean values for serum glucose, insulin, C-peptide, triglycerides and free fatty acids. In all groups, serum potassium, urea, fibrinogen, high-density lipoprotein and low-density lipoprotein were unchanged. PZA, but not PZG, increased serum uric acid. PZG significantly reduced very-low-density lipoprotein whereas PZA only tended to do so. PZG was well tolerated and without any side effect, but in 7 of the 8 normal volunteers, PZA produced a variable vasomotor response over the blush area of the face and neck lasting from 30 min in 3 subjects to 4 h in 1 subject. Collectively, these results suggest generally similar metabolic responses of normal subjects to PZG and PZA after only a single oral dose of each. Previously, it was unrecognized that acute administration of PZG and PZA could produce such rapid metabolic changes.

Pyrazinoylguanidine in end-stage renal disease: a prospective, placebo-controlled pilot study.

Cardiovascular disease is the leading cause of mortality in end-stage renal disease (ESRD) patients receiving dialysis. In these patients, hypertriglyceridemia appears to increase the risk of accelerated atherosclerosis. The present placebo-controlled study evaluated prospectively lipid-lowering effects of pyrazinoylguanidine (PZG) in 6 ESRD patients undergoing maintenance hemodialysis. The design of the study entailed a placebo phase of 1 week followed by 3 weeks of PZG, 400 mg three times a day. Compared to placebo, PZG reduced serum triglycerides (PZG vs. placebo 370 +/- 171 vs. 414 +/- 182 mg/dl; p = 0.01). PZG also tended to decrease total cholesterol. In addition, PZG selectively lowered blood glucose in hyperglycemic patients. PZG was well tolerated; it did not interfere with hemodynamic parameters or alter liver function tests, nutritional parameters or dialysis clearance.

Pedigree analysis of a subject with abnormally slow renal elimination of 6-hydroxychlorzoxazone.

The family of an unusual subject was studied. When tested with chlorzoxazone (CX; 250 mg p.o.) on four separate occasions 5 years ago, this subject showed abnormally slow renal elimination of 6-hydroxychlorzoxazone (HCX), the primary CX metabolite. Since rates of CX biotransformation to HCX have served as a probe of the important cytochrome P450 isozyme, CYP 2E1, it was of interest that this unusual subject had normal conversion of CX to HCX. The present study revealed that over the past 5 years this subject accelerated his renal rate of HCX elimination which now lies at the slow end of the curve for normal subjects. His wife and 5 children all had more rapid rates than he for renal HCX elimination.

Studies on pyrazinoylguanidine. 5. Temporal effects over 24 weeks demonstrating attenuation of diabetic nephropathy in STZ-diabetic rats.

This study was designed to determine whether pyrazinoylguanidine (PZG) can attenuate diabetic nephropathy in streptozotocin (STZ)-induced diabetic rats. Diabetes was induced within 1 week after a single intraperitoneal dose of STZ (45 mg/kg in 0.05 mol/l sodium citrate buffer). Diabetic rats were divided into five groups. Each group received by gavage for 24 weeks one of the following: vehicle (saline 10 ml/kg, b.i.d.), PZG (35 mg/kg, b.i.d.), captopril (15 mg/kg, b.i.d.), or hydrochlorothiazide (HCTZ, 20 mg/kg, b.i.d.). Insulin (NPH 7.5 U/day) was given subcutaneously. PZG treatment for 24 weeks reduced mortality and attenuated diabetic nephropathy, as indicated by reduced urinary excretion of total protein (79% of control), low-molecular-weight protein (12% of control), and albumin (60% of control). PZG also preserved renal structure and function. Compared to HCTZ or vehicle-treated rats, STZ-diabetic rats receiving either captopril or insulin exhibited decreased excretion of total protein, low-molecular-weight protein, and albumin, as well as amelioration of renal pathology. Collectively, these results indicate that PZG, as well as captopril and insulin, improved longevity and several indices of diabetic nephropathy in STZ-diabetic rats.

Studies on pyrazinoylguanidine. 6. Prevention of cataracts in STZ-diabetic rats.

This study was designed to determine whether pyrazinoylguanidine (PZG) can attenuate cataract development in streptozotocin (STZ)-induced diabetic rats. After a single, intraperitoneal dose of STZ (45 mg/kg in 0.05 mol/l sodium citrate buffer), Sprague-Dawley rats (250-260 g) were divided into three groups. Beginning a week later, each group of diabetic rats received twice daily for 24 weeks by gavage one of the following: vehicle (saline 10 ml/kg), PZG (35 mg/kg), or captopril (15 mg/kg). PZG treatment prevented the development of diabetic cataracts (p = 0.0009 compared to vehicle). In contrast to PZG, 38% of vehicle-treated rats exhibited cataracts after 12 weeks, increasing to 89% after 16 weeks. At week 16, 22% of captopril-treated rats exhibited cataracts, a 75% reduction from vehicle-treated rats (p = 0.4289 compared to vehicle; p = 0.0571 compared to PZG). These results indicate that captopril can attenuate cataract formation in STZ-diabetic rats, whereas PZG completely suppresses it.

Acetylator phenotype in relation to age and gender in the Baltimore Longitudinal Study of Aging.

This study investigated in healthy Caucasians the possible occurrence of age and gender-associated differences in NAT2 acetylator phenotype. Acetylator phenotype was determined after a single oral dose of 100 mg dapsone during testing of oral glucose tolerance in 510 Caucasian volunteers aged from 19 to 93 years, 339 men and 171 women, from the Baltimore Longitudinal Study of Aging. Participants were classified as slow or rapid acetylators according to the ratio of monoacetyldapsone to dapsone concentration in plasma. The ratio dividing the two groups, 0.30, was chosen after inspection of a probit plot and histogram of the monoacetyldapsone/dapsone ratios. Fifty-one percent of the participants were slow acetylators and 49% were rapid acetylators. Because there was no significant difference between the sexes in the monoacetyl-dapsone/dapsone ratios, all 510 participants were pooled into a single group for further analysis. In the combined analysis, there was a small decline in the prevalence of the slow acetylator phenotype with age, but this age effect accounted for less than 1% of the total variance in the monoacetyldapsone/dapsone ratio (r2 = 0.009). Also, it was shown in a group of 20 participants that administration of glucose with dapsone does not influence the determination of acetylator phenotype. In a large healthy Caucasian. American population, there was no biologically important effect of age or sex on the distribution of NAT2 acetylator phenotype.

Reflections from distant cuvettes.

The main events described in this essay occurred between 30 and 40 years ago. Care has been exercised to describe these events as accurately as possible. I have confined myself to the facts as best I can recollect them now. I have also attempted to recapture the spirit and ambiance of the individual laboratories, their directors, and the scientists working there, leaving philosophical interpretations to others. I feel privileged to have been permitted to work in these laboratories and with these scientists. Despite present difficulties besetting those who desire to devote their lives to scientific research, I encourage these hardy souls to pursue their vision and wish for them the good fortune I had in being associated with so many supportive, brilliant, and interesting researchers.

Studies on pyrazinoylguanidine. 3. Downregulation of lipolysis in isolated adipocytes.

The effects of pyrazinoylguanidine (PZG) on lipolysis and intracellular cyclic AMP concentrations were investigated in isolated rat adipocytes. PZG reduced basal cyclic AMP concentrations and blocked in a concentration-dependent manner forskolin (1 mumol/l) and isoproterenol (1 mumol/l) stimulatory effects on intracellular cyclic AMP production and lipolysis. PZG's effects on hormone-sensitive lipase were investigated in the presence and absence of glucagon (1 mumol/l) or isoproterenol (1 mumol/l). PZG inhibited uncompetitively the induction of hormone-sensitive lipase by either glucagon or isoproterenol. PZG's antilipolytic effects appeared to result from downregulation of intracellular cyclic AMP concentrations. In adipose tissue, cyclic AMP controls lipolysis through hormone-sensitive lipase. PZG's downregulation of lipolysis and cyclic AMP concentrations was unaffected by adenosine deaminase or pertussis toxin, suggesting that PZG did not activate Gi, the inhibitory guanyl nucleotide regulatory protein.

Studies on pyrazinoylguanidine. 4. Upregulation of phosphodiesterase activity in rat adipose tissue and downregulation of gluconeogenesis and adenosine 3',5'-monophosphate concentrations in perfused rat liver.

In isolated rat adipocytes stimulated with theophylline (1 mmol/l), pyrazinoylguanidine (PZG) downregulated both lipolysis and cyclic AMP concentrations, raising the possibility that PZG stimulates adipose insulin-sensitive phosphodiesterase. To investigate this directly, we measured PZG's effects on phosphodiesterase activity in rat adipocytes. PZG (10 mumol/l) as well as insulin (0.1-1 mU) increased adipose phosphodiesterase activity, whereas theophylline reduced it. Also investigated were PZG's effects on gluconeogenesis and cyclic AMP in perfused rat liver where PZG decreased gluconeogenesis and cyclic AMP concentrations.