Effect of Clomethiazole Vs. Clorazepate on Hepatic Fat and Serum Transaminase Activities in Alcohol-Associated Liver Disease: Results from a Randomized, Controlled Phase II Clinical Trial.

AIMS: Alcohol-associated liver disease (ALD) is a global health problem caused, among other factors, by oxidative stress from the formation of reactive oxygen species (ROS). One important source of ROS is microsomal ethanol metabolism catalyzed by cytochrome P450 2E1 (CYP2E1), which is induced by chronic ethanol consumption. Inhibition of CYP2E1 by clomethiazole (CMZ) decreases oxidative stress in cell cultures and improves ALD in animal studies. Our study aimed to assess the benefits of a CYP2E1 inhibitor (clomethiazole) in detoxification of patients with ALD. METHODS: Open label, randomized controlled clinical trial to study whether CYP2E1 inhibition improves ALD in the patients with alcohol use disorders admitted for alcohol detoxification therapy (ADT). Patients had to have a serum aspartate aminotransferase (AST) activity exceeding twice the upper normal limit at time of admission and be non-cirrhotic defined by fibroscan value <12 kPa. Sixty patients were randomly assigned to ADT with either CMZ or clorazepate (CZP) for 7-10 days in a 1:1 ratio. The chlorzoxazone test of CYP2E1 activity was performed at enrolment and at 2 points during the study. RESULTS: ADT improved hepatic steatosis (controlled attenuation parameter) in both groups significantly. A trend towards a greater improvement in hepatic fat content during ADT (-21.5%) was observed in the CMZ group (252 ± 48 dB/m vs. 321 ± 38 dB/m; P < 0.0001) compared with the CZP group (-13.9%; 273 ± 38 dB/m vs. 317 ± 39 dB/m; P < 0.0001). As already reported, serum AST (P < 0.004) and alanine aminotransferase (ALT) activities (P < 0.0006) significantly decreased in CMZ patients as compared with patients on CZP by the end of hospitalization. A significant correlation was found between AST (P = 0.023), ALT (P = 0.009), GGT (P = 0.039) and CAP. CONCLUSION: This study demonstrates that CMZ improves clinical biomarkers for ALD in humans most likely due to its inhibitory effect on CYP2E1. Because of its addictive potential, CMZ can only be given for a short period of time and therefore other CYP2E1 inhibitors to treat ALD are needed.

Structural insight of the 5-(Hydroxyethyl)-methylthiazole kinase ThiM involving vitamin B1 biosynthetic pathway from the Klebsiella pneumoniae.

Thiamin pyrophosphate (TPP) is an essential co-factor in amino acid and carbohydrate metabolic pathways. The TPP-related vitamin B1 biosynthetic pathway is found in most bacterial, plant and lower eukaryotic processes; however, it is not present in humans. In bacterial thiamin synthesis and salvage pathways, the 5-(hydroxyethyl)-methylthiazole kinase (ThiM) is essential in the pathway forming TPP. Thus, ThiM is considered to be an attractive antibacterial drug target. Here, we determined the crystal structures of ThiM from pathogenic Klebsiella pneumoniae (KpThiM) and KpThiM in complex with its substrate 5-(hydroxyethyl)-4-methylthiazole (TZE). KpThiM, consisting of an α-ß-α domain, shows a pseudosymmetric trimeric formation. TZE molecules are located in the interface between the KpThiM subunits in the trimer and interact with Met49 and Cys200. Superimposition of the apo and TZE-complexed structures of KpThiM show that the side chains of the amino acids interacting with TZE and Mg2+ have a rigid configuration. Comparison of the ThiM structures shows that KpThiM could, in terms of sequence and configuration, be different from other ThiM proteins, which possess different amino acids that recognize TZE and Mg2+. The structures will provide new insight into the ThiM subfamily proteins for antibacterial drug development.

The metabolism of clomethiazole in gerbils and the neuroprotective and sedative activity of the metabolites.

A single dose of clomethiazole (600 micromol kg(-1) i.p.) has previously been shown to be neuroprotective in the gerbil model of global ischaemia. In gerbils, clomethiazole (600 micromol kg(-1)) injection produced a rapid appearance (peak within 5 min) of drug in plasma and brain and similar clearance (plasma t(1/2): 40 min) from both tissues. The peak brain concentration (226+/-56 nmol g(-1)) was 40% higher than plasma. One major metabolite, 5-(1-hydroxyethyl-2-chloro)-4-methylthiazole (NLA-715) and two minor metabolites 5-(1-hydroxyethyl)-4-methylthiazole (NLA-272) and 5-acetyl-4-methylthiazole (NLA-511) were detected in plasma and brain. Evidence suggested that clomethiazole is metabolized directly to both NLA-715 and NLA-272. Injection of NLA-715, NLA-272 or NLA-511 (each at 600 micromol kg(-1)) produced brain concentrations respectively 2.2, 38 and 92 times greater than seen after clomethiazole (600 micromol kg(-1)). Clomethiazole (600 micromol kg(-1)) injected 60 min after a 5 min bilateral carotid artery occlusion in gerbils attenuated the ischaemia-induced degeneration of the hippocampus by approximately 70%. The metabolites were not neuroprotective at this dose. In mice, clomethiazole (600 micromol kg(-1)) produced peak plasma and brain concentrations approximately 100% higher than in gerbils, drug concentrations in several brain regions were similar but 35% higher than plasma. Clomethiazole (ED(50): 180 micromol kg(-1)) and NLA-715 (ED(50): 240 micromol kg(-1)) inhibited spontaneous locomotor activity. The other metabolites were not sedative (ED(50) >600 micromol kg(-1)). These data suggest that the neuroprotective action of clomethiazole results from an action of the parent compound and that NLA-715 contributes to the sedative activity of the drug. British Journal of Pharmacology (2000) 129, 95 - 100

Chlormethiazole as an efficient inhibitor of cytochrome P450 2E1 expression in rat liver.

Ethanol-inducible cytochrome P450 (CYP) 2E1 (CYP2E1) is responsible for the metabolism of many xenobiotics which exert toxic effects in humans. Specific inhibitors might constitute valuable tools in the elucidation of the pharmacological and toxicological roles of this isozyme in vivo. In the present investigation we have evaluated the effects of a drug used for treatment of ethanol withdrawal states, chloromethiazole (CMZ), on CYP2E1 expression in rat liver. A 4-fold induction of CYP2E1 was observed after 3 days of starvation, accompanied by a similar increase in the level of the corresponding mRNA. CMZ specifically inhibited the elevation of CYP2E1 mRNA and protein, but did not prevent CYP2B1 and CYP3A1 or CYP1A1 induction caused by treatment with phenobarbital or beta-naphthoflavone, respectively. From nuclear run-off experiments it was apparent that the rate of the CYP2E1 gene transcription was inhibited greatly by CMZ treatment. Rats treated with ethanol in a total enteral nutrition model had higher CYP2E1-dependent hepatic microsomal activities of p-nitrophenol hydroxylase and carbon tetrachloride-induced lipid peroxidation than controls, and simultaneous CMZ treatment abolished the ethanol-dependent induction. In vitro experiments with rat liver microsomes showed that CMZ did not act as an inhibitor of CYP2E1-dependent catalytic activities or as an inhibitor of microsomal NADPH and CYP2E1-dependent lipid peroxidation. In conclusion, we suggest that CMZ might constitute an efficient and specific inhibitor of CYP2E1 expression suitable for in vivo experiments.

The influence of drug sorption on pharmacokinetic studies of chlormethiazole and lignocaine.

The influence of drug sorption on the measurement of dose and blood concentrations during pharmacokinetic studies of chlormethiazole and lignocaine in a chronically catheterized sheep preparation has been examined. There was no sorption to soda glass tubes, borosilicate glass volumetric flasks or soda glass microlitre syringes but minor sorption to polypropylene syringes, polypropylene pipette tips and rubber bottle stoppers after 240 min contact. During infusions through administration sets including either polyvinyl chloride or polyethylene catheters, no significant loss of lignocaine occurred, but only 41.7-63.9% of the chlormethiazole dose was delivered. No significant decreases in either drug occurred from blood sampled through an intravascular catheter and stopcock system. There was negligible degradation of the samples over 4 h. Sorption of chlormethiazole or lignocaine to the laboratory equipment used was not a significant source of error but polyvinyl chloride infusion catheters could result in significant reductions in chlormethiazole dose.

Charcoal-column haemoperfusion does not significantly enhance chlormethiazole removal.

A 26-year-old man had convulsions after taking an overdose of slow-release aminophylline tablets. The convulsions were treated with an infusion of chlormethiazole and theophylline was removed by charcoal-column haemoperfusion. It has been suggested that haemoperfusion might be useful for removing chlormethiazole and this was investigated. There was no evidence that charcoal-column haemoperfusion could remove clinically significant amounts of chlormethiazole.

A sheep preparation for studying interactions between blood flow and drug disposition. VI: Effects of general or subarachnoid anaesthesia on blood flow and chlormethiazole disposition.

Blood flow through and chlormethiazole extraction ratios across lungs, liver, kidneys and gut were measured in awake unrestrained sheep (controls) and with the same animals anaesthetized with 1.5% halothane or whilst undergoing high thoracic subarachnoid blockade with amethocaine. In the control-drug studies, chlormethiazole infused to sub-sedative blood concentrations produced no significant changes in haemodynamics or in the kinetics of iodohippurate (renal and hepatic blood flows). Chlormethiazole was eliminated predominantly by the liver (mean extraction ratio and clearance, respectively, 0.90 and 1.3 litre min-1) and lungs (0.15; 0.6 litre min-1). Renal clearance was absent or negligible (greater than 0.1 litre min-1). Because of pulmonary clearance, mean total body clearance was derived from analysis of pulmonary arterial concentrations. Under general anaesthesia, there were significant reductions in mean cardiac output, hepatic and renal blood flow (to 54%, 63% and 43% of control); chlormethiazole mean hepatic extraction ratios and clearance were reduced, respectively, to 82% and 56% of control, and its pulmonary and renal clearances were abolished. With subarachnoid anaesthesia there were no significant changes in haemodynamics or in chlormethiazole extraction ratios or clearances.

4,5-Dimethylthiazole-N-oxide-S-oxide: a metabolite of chlormethiazole in man.

The metabolic fate of chlormethiazole in healthy male subjects has been investigated following the oral administration of a single dose of chlormethiazole edisylate. Five urinary C-oxidation metabolites were identified and shown to be identical with previously reported metabolites. A novel metabolite, of molecular formula C5H7NO2S, was shown by trimethylsilylation, deuterium exchange, reduction studies and by its i.r., n.m.r. and mass spectrum, to be 4,5-dimethylthiazole-N-oxide-S-oxide. This is the first reported metabolite which involves the oxidation of the two heterocyclic atoms in aromatic rings. The formation and thermal stability of the compound is ascribed to resonance stabilization.

A sheep preparation for studying interactions between blood flow and drug disposition. III: Effects of general and spinal anaesthesia on regional blood flow and oxygen tensions.

In awake unrestrained sheep the infusions i.v. of five drugs (cefoxitin, pethidine, chlormethiazole, tocainide and lignocaine) with potentially flow-limited clearance were shown to have no significant haemodynamic effects of their own, nor to have any effects on arterial or venous oxygen tensions. Under general anaesthesia (1.5% end-tidal halothane), haemodynamic changes similar to those previously documented in man occurred. Cardiac output and hepatic blood flow were decreased to 70%, and renal blood flow to 50% of control values; heart rate was unchanged and mean arterial pressure decreased by an average of 10%. Hepatic and renal vein oxygen tensions were decreased significantly. Under spinal anaesthesia, apart from a 10% decrease in hepatic blood flow, there were no significant changes in any haemodynamic variables or in the arterial or in any of the venous oxygen tensions. The i.v. infusion of adequate volumes of saline at the time of blockade probably contributed to the maintenance of these indices at their baseline values.

A sheep preparation for studying interactions between blood flow and drug disposition. II: Experimental applications.

A sheep preparation has been developed which allows systematic direct studies into the sites and rates of distribution, formation and elimination of both endogenous and exogenous substances and their metabolites. Examples of some experimental applications are presented which provide information not usually available using traditional methods. Substantial metabolism at sites not usually regarded as important (e.g. limbs, lungs) was shown both for exogenous substances (procainamide and chlormethiazole) and for an endogenous substance (choline). Studies on drug clearance by kidney (cefoxitin), liver (chlormethiazole, pethidine and the optical isomers of mepivacaine) and lung (chlormethiazole) demonstrate that simple first-order elimination should not routinely be assumed to occur, as multiple sites and pathways may be involved, and kinetics may be non-linear as a result of characteristics of both organ flow and organ function. It was also shown that large changes (up to three-fold) in arterial blood drug concentrations may occur because of exogenous (anaesthesia) and endogenous (gastric recycling) perturbations, and that simple compartmental kinetics should not be assumed for either the whole body or individual organs. This preparation may be used in conjunction with traditional pharmacokinetic methods to resolve complex problems relating to interactions between drugs and the body, to establish a data base for physiological models of drug disposition, and to gain practical insights for drug treatment in patients.

Cimetidine-drug interactions.

The use of cimetidine, the histamine H2 receptor antagonist, is associated with a relatively low incidence of adverse reactions. However, its liberal use has led to the identification of several clinically significant cimetidine-drug interactions that can lead to drug accumulation, toxicity, and life-threatening sequelae. A review of the literature and the clinical significance and physiologic basis of these interactions are presented. Recommended management of cimetidine-drug interactions is discussed.

Lack of inhibition of clomethiazole metabolism by cimetidine: model experiments in the dog.

The disposition of clomethiazole was studied in six dogs subjected to pretreatment with cimetidine or saline according to a cross-over design. Pretreated dogs received approximately 20 mg/kg of cimetidine p.o. for 4 days and 30 mg/kg i.v. immediately before an intraduodenal infusion of clomethiazole (117 mumol/kg clomethiazole base within 90 min). Compared to controls, cimetidine had no effect on peak plasma concentrations and on areas under the plasma concentration time curves of clomethiazole or of its metabolite 5-acetyl-4-methylthiazole (P greater than 0.05). Identical pretreatment of the same dogs resulted in a 50% inhibition of aminopyrine demethylation (P less than 0.001) as revealed by the aminopyrine breath test. Clomethiazole may be metabolized in the dog through metabolic routes which cannot be inhibited by cimetidine.

Interaction of cimetidine with other drugs.

After five years' extensive use of cimetidine, drug interactions have emerged as one of its major adverse effects. Clinically important interactions with warfarin, phenytoin, diazepam, chlormethiazole, propranolol, lidocaine, and a number of other drugs have been reported. An appreciation of the variety of underlying mechanisms, inhibition of drug metabolism, decreased liver blood flow, and altered drug distribution should reduce the risk of further drug interactions with cimetidine.

Aging and drug disposition--pharmacodynamics.

The pharmacodynamics of a drug is defined as the effect of the drug on physiological functions and pathological processes and can be modified in the elderly by (a) pharmacokinetics, (b) receptor sensitivity (or density), (c) impaired homeostasis or (d) pathology. The alterations in pharmacokinetics in the elderly often result in a reduction of the dose required to achieve the optimum pharmacodynamic effect. Changes in the sensitivity of receptors may be decreased in the elderly (perhaps by a diminution in the number of receptors) as in the case of the beta-adrenergic blockers, but increase in sensitivity may also be found as in the case of warfarin. Impairment of homeostatic mechanisms, while related to aging, are frequently produced by pathological processes and have an important influence on the pharmacodynamics of many drugs. The effect of the multiple pathology often found in the elderly is likely to be the dominant factor in changes in pharmacodynamics in this population. The interaction of the above factors results in a heterogeneity of pharmacodynamic response in the elderly which requires the careful monitoring of both the efficacy and toxicity of their drug treatment.

The effect of ethanol administration on the disposition and elimination of chlormethiazole.

Acutely administered ethanol has been shown to inhibit the hepatic metabolism of a number of drugs. Ethanol might be expected to decrease the first-pass extraction of chlormethiazole leading to higher blood levels of this high clearance sedative frequently used in the management of alcoholic patients. Chlormethiazole has a narrow therapeutic index and the unexpected deaths reported in alcoholics taking this drug may have been due to an effect of ethanol on the metabolism of chlormethiazole. However in this study, acutely administered ethanol maintained at levels around 22 mmol/l had no significant effect on the disposition or elimination of either daily or intravenously administered chlormethiazole.

Thiomethylation and thiohydroxylation--a new pathway of metabolism of heterocyclic compounds.

1. G.l.c.--mass spectral analysis of t.l.c. fractions of urine samples of patients treated with 5-(2-chloroethyl)-4-methylthiazole (clomethiazole), has revealed two minor metabolites, each with two sulphur atoms. 2. Their structures were found to be 2-methylthio-clomethiazole and 5-acetyl-4-methyl-2-mercapto-thiazole, formed by thiomethylation and thiohydroxylation, respectively, of the original compound. 3. The structures of six other minor metabolites resulting from side-chain degradation have been elucidated. 4. The occurrence of metabolites with substituents at position 2 of the heterocyclic nucleus is assumed to be initiated by oxidative attack at the nitrogen, followed by nucleophilic substitution in position 2.

Direct measurement of chlormethiazole extraction by liver, lung and kidney in man.

1 Chlormethiazole was used as a basal sedative for patients undergoing angiographic procedures. 2 Blood samples were drawn opportunistically to examine chlormethiazole extraction across liver, lungs and kidney. 3 Extraction across liver was typically 70-80% and apparently unrelated to input concentrations. Evidence for extraction across lung and kidney was inconclusive but these could each be approximately 20%. 4 Pharmacokinetics of chlormethiazole derived from compartment models were in accord with previous reports and were characterised by a high total body clearance (1-1.5 l/min). 5 Postural changes associated with the radiological procedures caused fluctuating blood concentrations which appear as noise in curve fitting procedures. 6 Pharmacokinetic properties derived from compartment theory cannot cope with these perturbations because of the restriction imposed by time averaging (i.e. mean clearances, half-lives and volumes are produced). Systematic studies of pharmacokinetic properties of perfusion-limited drugs such as chlormethiazole must be developed in such a way as to allow for independent variation of flow and extraction.