RESUMEN
Therapeutic hypothermia is only partially protective for neonatal encephalopathy; there is an urgent need to develop treatments that augment cooling. Our objective was to assess safety, efficacy and pharmacokinetics of 5 and 15â¯mg/kg/24â¯h melatonin (proprietary formulation) administered at 2â¯h and 26â¯h after hypoxia-ischemia (HI) with cooling in a piglet model. Following moderate cerebral HI, 30 piglets were eligible and randomized to: i) Hypothermia (33.5⯰C, 2-26â¯h) and vehicle (HTâ¯+â¯V;nâ¯=â¯13); b) HT and 5â¯mg/kg melatonin over 6â¯h at 2â¯h and 26â¯h after HI (HTâ¯+â¯Mel-5;nâ¯=â¯4); c) HT and 15â¯mg/kg melatonin over 6â¯h at 2â¯h and 26â¯h after HI (HTâ¯+â¯Mel-15;nâ¯=â¯13). Intensive care was maintained for 48â¯h; brain MRS was acquired and cell death (TUNEL) evaluated at 48â¯h. Comparing HTâ¯+â¯V with HTâ¯+â¯Mel-5 and HTâ¯+â¯Mel-15, there was no difference in blood pressure or inotropic support needed, brain Lactate/N Acetylaspartate at 24â¯h and 48â¯h was similar, ATP/phosphate pool was higher for HTâ¯+â¯Mel-15 versus HTâ¯+â¯V at 24â¯h (pâ¯=â¯0.038) but not 48â¯h. A localized reduction in TUNEL positive cell death was observed in the sensorimotor cortex in the 15â¯mg/kg melatonin group (HTâ¯+â¯Mel-15 versus HTâ¯+â¯V; pâ¯<â¯0.003) but not in the 5â¯mg/kg melatonin group (HTâ¯+â¯Mel-5 versus HTâ¯+â¯V; pâ¯=â¯0.808). Putative therapeutic melatonin levels were reached 8â¯h after HI (104 increase from baseline; ~15-30â¯mg/l). Mean⯱â¯SD peak plasma melatonin levels after the first infusion were 0.0014⯱â¯0.0012â¯mg/l in the HTâ¯+â¯V group, 3.97⯱â¯1.53â¯mg/l in the HTâ¯+â¯Mel-5 group and 16.8⯱â¯8.3â¯mg/l in the HTâ¯+â¯Mel-15 group. Protection was dose dependent; 15â¯mg/kg melatonin started 2â¯h after HI, given over 6â¯h, was well tolerated and augmented hypothermic protection in sensorimotor cortex. Earlier attainment of therapeutic plasma melatonin levels may optimize protection by targeting initial events of reperfusion injury. The time window for intervention with melatonin, as adjunct therapy with cooling, is likely to be narrow and should be considered in designing future clinical studies.
Asunto(s)
Encéfalo/efectos de los fármacos , Hipotermia Inducida/métodos , Hipoxia-Isquemia Encefálica/terapia , Melatonina/uso terapéutico , Fármacos Neuroprotectores/uso terapéutico , Animales , Encéfalo/metabolismo , Modelos Animales de Enfermedad , Hipoxia-Isquemia Encefálica/complicaciones , Hipoxia-Isquemia Encefálica/metabolismo , Melatonina/farmacología , Fármacos Neuroprotectores/farmacología , Sus scrofa , Investigación Biomédica TraslacionalRESUMEN
BACKGROUND AND OBJECTIVES: To compare in vitro characteristics and pharmacokinetics of Bramitob, a preservative-free tobramycin solution for nebulization, and Tobi in patients with cystic fibrosis (CF) and Pseudomonas aeruginosa infection. METHODS: In vitro characteristics of Bramitob and Tobi were evaluated using Pari TurboBoy/LC Plus and the Systam 290 LS nebulizers. In the randomized, double-blind, two-way crossover pharmacokinetic study, 11 patients with CF received a single nebulized dose (300mg) of Bramitob or Tobi, separated by a 7-day washout period. Plasma and sputum tobramycin concentrations were measured immediately before and over 24 hours after administration. RESULTS: Bramitob and Tobi performed alike during nebulization. The fine particle fraction was 33-37% and the mass median aerodynamic diameter was <5microm. Nine patients completed the pharmacokinetic study. Tobramycin plasma profiles after administration of Bramitob or Tobi were similar, with a peak at 90 and 72 minutes after inhalation of Bramitob and Tobi, respectively. The elimination half-life was ~5 hours for both products. The relative bioavailability of Bramitob to Tobi was 1.01, indicating comparable systemic exposure. Peak sputum concentration of tobramycin was 816 +/- 681 microg/g for Tobi and 1289 +/- 851 microg/g for Bramitob and was >400 microg/g (threshold sufficient for an antibacterial effect against P. aeruginosa) in 5 out of 9 patients receiving Tobi and 8 out of 9 patients receiving Bramitob. All adverse events were considered mild and judged not related to the study drugs. CONCLUSIONS: In vitro performance of Bramitob((R)) was similar when nebulized with Pari TurboBoy k/LC Plus and Systam 290 LS nebulizers and comparable to that of TobiThe systemic bioavailability of tobramycin was similar after administration of either Bramitob or Tobi; however, in sputum samples the tobramycin peak concentration was slightly greater after administration of Bramitob than after Tobi.