Vitamin K1 in oral solution or tablets: a crossover trial and two randomized controlled trials to compare effects.

BACKGROUND: Vitamin K1 (VK1) reverses the effects of vitamin K antagonists (VKAs). The literature shows that the bioavailability from solutions might be higher than that from tablets, possibly resulting in different effects. OBJECTIVES: To compare the bioavailability and effect on the International Normalized Ratio (INR) of 5-mg VK1 tablets and solution in three randomized clinical trials. METHODS AND RESULTS: The bioavailability was determined in a crossover trial with 25 healthy volunteers. VK1 plasma concentrations were assessed at 0, 2, 4, 5, 6, 8, 10 and 24 h, and the area under the curve was higher in the solution group than in the tablet group (mean difference 365 µg L(-1) h, 95% confidence interval [CI] 230-501, P < 0.0001). In the other two trials, the effects of both formulations on the INR were measured at 0, 24 and 48 h. In the second trial, on 72 patients on phenprocoumon with planned invasive procedures, both formulations were similarly effective, because all patients reached an INR of < 2.0, which was the primary endpoint. In the last trial, on 72 patients on phenprocoumon with an INR of 7.0-11.0, the INR decreased slightly more in the solution group (4.7, 95% CI 4.3-5.1) than in the tablet group (4.2, 95% CI 3.8-4.6). The solution group had a 3.3-fold increased likelihood (95% CI 0.7-15.1) of reaching an INR of < 2.0 at 48 h. Additionally, the increases in VK1 concentrations were similar (tablets, 3.2 µg L(-1) ; solution, 3.4 µg L(-1) ; P = 0.99) after 24 h. CONCLUSIONS: VK1 tablets are at least as clinically effective as the solution in countering VKAs.

Heterophilic antibodies may be a cause of falsely low total IGF1 levels.

BACKGROUND: A low serum total IGF1 is considered as a diagnostic indicator of GH deficiency (GHD) in the presence of hypopituitarism. Introduction of IRMA and chemiluminescent immunometric assay (CLIA) IGF1 immunoassays has introduced endogenous antibodies as a new source of interference. In general, this goes unnoticed and might lead to unnecessary diagnostic and therapeutic interventions. CASE: A 56-year-old man was referred with a decline in physical performance, unexplained osteopenia, and weight loss of 3 kg over the past 8 months. Although clinical signs and symptoms were unremarkable, laboratory results pointed to secondary hypothyroidism and secondary hypogonadism. In addition, the serum total IGF1 level (CLIA; Siemens Medical Solutions Diagnostics) was in the low normal range. Two GH stimulation tests were performed, but these tests did not support the diagnosis GHD. Moreover, IGF1 bioactivity measured by the kinase receptor activation assay was normal. Interference of heterophilic antibodies was considered. After pretreatment with specific heterophilic blocking tubes that contain blocking reagents to eliminate heterophilic antibodies, serum-free thyroxine, testosterone, and IGF1 levels turned out to be normal. CONCLUSION: To the best of our knowledge, we here describe the first case in the literature of a patient with low serum total IGF1 levels due to interference from heterophilic antibodies in the used IGF1 immunoassay. When confronted with low-IGF1 levels that do not fit the clinical picture, interference of heterophilic antibodies should be considered in the differential diagnosis.

Determinants of increased angiotensin II levels in severe chronic heart failure patients despite ACE inhibition.

INTRODUCTION: The beneficial effects of ACE inhibitors are generally ascribed to blockade of neurohormonal activation. However, especially in chronic heart failure (CHF) patients plasma angiotensin II and aldosterone levels can be elevated despite ACE inhibition, the so-called ACE escape. In the present study, we aimed to identify the frequency and determinants of ACE escape in CHF patients. METHODS: We studied 99 stable chronic heart failure patients (NYHA class III and IV, 66% ischemic etiology) receiving long-term therapy with ACE inhibitors. In all patients, cardiac, renal, and neurohormonal parameters were measured. ACE escape was defined as plasma angiotensin level > or = 16 pmol/L. RESULTS: Mean (+/- SD) left ventricular ejection fraction of our 99 patients (79 men and 20 women, age 69 +/- 12 years) was 28 +/- 10%. In addition to an ACE inhibitor, 93% of patients received diuretics, 71% a beta-blocker, and 49% spironolactone. None of the patients used an angiotensin receptor blocker. In our population, 45% of the patients had an angiotensin II plasma concentration higher than 16 pmol/L (median concentration was 14.1 pmol/L). Spironolactone use was an independent predictor of elevated plasma angiotensin II levels. Furthermore, spironolactone users had significantly higher plasma active renin protein and aldosterone levels. Plasma angiotensin II concentration was positively correlated to active renin, plasma angiotensin I and plasma aldosterone. No correlation was found between plasma angiotensin II levels and serum ACE activity, dose of ACE inhibitor, or duration of use. CONCLUSION: In a group of severe chronic heart failure patients, 45% had elevated plasma angiotensin II levels independent of serum ACE activity despite long-term ACE inhibitor use. Although a causal link could not be proven, an association was found between spironolactone use and active renin protein, angiotensin II and aldosterone levels, suggesting that escape from ACE is mainly caused by a feedback mechanism.

Treatment of erythropoietic protoporphyria with hydroxyethylrutosides.

BACKGROUND: Assuming that flavonoids have anti-oxidative properties and may protect against abnormal skin reactions in erythropoietic protoporphyria (EPP), we investigated whether systemic treatment with hydroxyethylrutosides (2.7 g/day) could decrease skin sensitivity to blue light in a 37-year-old female patient who suffered from EPP. DESIGN AND RESULTS: Before treatment, skin exposure during 5 min to a xenon high-pressure gas discharge lamp with filter was sufficient to produce intense erythema, irritation and later swelling. After 1, 2 and 3 months of treatment, the exposure times, necessary to produce similar effects, gradually increased. This improvement coincided with an increased tolerability to sunlight. No adverse effects were observed. CONCLUSION: These results encourage the set-up of a more systematic, placebo-controlled study of the protective effects of hydroxyethylrutosides in EPP.

Decrease of memory T helper cells (CD4+ CD45R0+) in hairy cell leukemia.

Patients with hairy cell leukemia (HCL) are prone to opportunistic infections, which suggests an impaired T-cell functioning. To investigate a possible mechanism of such an impairment, we determined the numbers of naive and memory T cells by measuring the expression of CD45R0 on CD4+ and CD8+ T cells in 23 HCL patients. As control, 13 healthy subjects and 13 patients with other chronic B-cell leukemias were studied. In HCL patients with active disease, the percentage of CD4+ CD45R0+ T cells was significantly lower compared to healthy subjects (41% versus 57%, p = 0.01). Also the absolute numbers of CD4+ CD45R0+ T cells were reduced (396 x 10(6)/l versus 615 x 10(6)/l, p = 0.02) compared to healthy subjects, whereas within the CD8+ subset no differences were found. A contrasting elevation of percentages and numbers of CD45R0-expressing T cells (p < 0.0001) was seen in patients with chronic lymphocytic leukemia or leukemic non-Hodgkin's lymphoma. No relationship between CD4+ CD45R0+ and splenectomy, treatment with alpha-interferon or monocyte numbers was found in the HCL population. Despite the fact that the underlying mechanism of the reduced expression of CD45R0 in CD4+ T cells remains unclear, our observations may contribute to the understanding of an impaired T-cell functioning in HCL.

Comparative study on the determination of the anti-neoplastic drug teniposide in plasma using micellar liquid chromatography and surfactant-mediated plasma clean-up.

The potential of micellar liquid chromatography and of an on-line surfactant-mediated sample cleanup, which involves column-switching prior to conventional reversed-phase high-performance liquid chromatography, has been evaluated for the determination of the anti-neoplastic drug teniposide in plasma by using electrochemical detection. A major advantage of surfactant-mediated techniques is that they allow fully automated processing of plasma samples, because protein precipitation is prevented by the addition of the surfactant sodium dodecylsulphate. With the automated column-switching technique, a degree of sample enrichment and of selectivity can be attained, which is similar to that for the conventional procedure which, however, involves a labour-intensive off-line isolation of teniposide, using liquid-liquid extraction prior to chromatography. An inherent drawback of automated micellar liquid chromatography is that no sample clean-up or preconcentration can be carried out, which results in only a moderate detection limit and selectivity. The linearity, reproducibility and recovery of the surfactant-mediated techniques are similar to those of the conventional procedure. Based on the presented results, it was concluded that the surfactant-mediated column-switching technique is a highly attractive sample enrichment technique with respect to simplicity, speed and cost.

Automated high-performance liquid chromatographic determination of plasma free fatty acids using on-line derivatization with 9-bromomethylacridine based on micellar phase-transfer catalysis.

The on-line use of micellar phase-transfer catalysis is described for the automated reversed-phase high-performance liquid chromatographic (RP-HPLC) determination of free fatty acids in plasma; minimum manual sample handling is involved. After diluting plasma ten-fold with the aqueous micellar system, which contains 25 mM of the non-ionic surfactant, Arkopal N-130 and 6 mM of the ion-pair agent tetrakis(decyl)ammonium bromide, the reaction of the fatty acids with the fluorophore 9-bromomethylacridine is complete within 5 min at 60 degrees C. Prior to RP-HPLC separation, interfering proteins are removed using an on-line filter and a column-switching unit. More than 100 samples can be injected onto a single pre-column. The detection limit is ca. 300 nM; the precision is better than 3% using an internal standard.

High-performance liquid chromatographic determination of amantadine in urine after micelle-mediated pre-column derivatization with 1-fluoro-2,4-dinitrobenzene.

Cationic micelles have been used for the derivatization of the anti-Parkinson drug amantadine with the chromophore 1-fluoro-2,4-dinitrobenzene in urine. In the presence of 90 mM cetyltrimethylammonium bromide (CTAB), the conversion of amantadine into its derivative is complete within 4 min at 60 degrees C and pH 11. Such a short reaction time allows a fully automated pre-column derivatization of amantadine in an on-line combination with reversed-phase high-performance liquid chromatography. This cannot be attained when using purely aqueous derivatization mixtures because then the reaction takes some 20 min at the same temperature. Without the use of an internal standard, the repeatability of the automated determination at the 0.5 microgram ml-1 level is ca. 6%, whilst the detection limit is 75 ng ml-1 (S/N = 3). The present study clearly demonstrates that micellar systems can be beneficially used for the on-line precolumn derivatization of amines in urine.

Automated reversed-phase chromatographic analysis of etoposide and teniposide in plasma by using on-line surfactant-mediated sample clean-up and column-switching.

An automated high-performance liquid chromatographic method for the plasma assay of two neutral drugs, etoposide and teniposide, involving direct plasma injection is presented. The problematic nature of protein precipitation has been circumvented by adding the anionic surfactant sodium dodecyl sulphate to the plasma at a final concentration of 38 mM. Plasma samples are loaded on to a clean-up column with an aqueous mobile phase with which the analyte(s) is (are) retained, whereas the solubilized plasma proteins are flushed to waste. Next, the retained compounds are eluted from the clean-up column on to the analytical column by using the chromatographic mobile phase with a higher elution capacity. The column-switching technique is used to achieve an automated assay. At least 10 ml of plasma, representing 100 repeated injections of 100 microliters or five repeated injections of 2 ml, can pass through the clean-up column without increasing the back-pressure. The recovery increased considerably from 10-30% to 90-95% on adding surfactant to the plasma samples prior to the analysis. The relative standard deviation of the proposed clean-up procedure is 3.5% (n = 6) for both drugs measured at the 2 micrograms/ml level without using an internal standard. The limit of determination with 100-microliters injections is 0.10-0.15 microgram/ml for ultraviolet detection and is seven times lower with electrochemical detection. Teniposide was determined in patients' plasma and the results agreed well with those obtained by the conventional procedure involving manual liquid-liquid extraction prior to chromatographic analysis.

High-performance liquid chromatographic determination of valproic acid in plasma using a micelle-mediated pre-column derivatization.

A method for the determination of valproic acid (2-propylpentanoic acid) in plasma by high-performance liquid chromatography (HPLC) after pre-column derivatization is described. The derivatization of valproic acid with a fluorophore and UV label, 4-bromomethyl-7-methoxycoumarin, is performed in plasma diluted with an aqueous micellar system. No extraction or solvent evaporation steps are required. The mechanism of the derivatization of the carboxylic acid is based on phase-transfer catalysis. The sample preparation, including the derivatization step, is rapid and very simple. The proposed HPLC-method was evaluated and compared with a standard immunological assay used for the determination of valproic acid in plasma.

Study of the derivatization of n-alkylamines with 1-fluoro-2,4-dinitrobenzene in the presence of aqueous cetyltrimethylammonium bromide micelles.

The use of aqueous cetyltrimethylammonium bromide micelles in the derivatization of n-alkylamines with 1-fluoro-2,4-dinitrobenzene was investigated systematically. The rate constants of derivatization of the n-alkylamines (C1-C8) were analysed using liquid chromatography. Up to butylamine the micellar rate enhancement depends on the electrostatic interactions between the amines and cetyltrimethylammonium bromide, and beyond C4 it depends mainly on the hydrophobic interactions. The reaction rates are also enhanced by a micelle-induced decrease of the pKa of the amines, but to a lesser extent. The derivatization rates for the longer alkylamines are comparable with those in dipolar aprotic solvents. Pharmaceutical and biomedical science is likely to benefit from the use of micellar systems in pre-column derivatization reactions in aqueous solutions.