Isepamicin and nephrotoxicity Paul M Tulkens Unit de

Isepamicin and nephrotoxicity Paul M. Tulkens Unité de pharmacologie cellulaire et moléculaire Université catholique de Louvain Brussels, Belgium isepamicin 17/01/2001 1

Isepamicin and nephrotoxicity Lets do a Medline Search … • • • isepamicin and nephrotox* amikacin and nephrotox* gentamicin and nephrotox* 17/01/2001 142 12 4005 245 11525 908 2

The birth of isepamicin… 1 Diaminocyclitol derivatives. Wright, John J. ; Daniels, Peter John L. (Scherico Ltd. , Switz. ). Ger. Offen. (1975), 65 pp. CODEN: GWXXBX DE 2502296 19750925 Patent written in German. Application: DE Priority: US 74 -452571 19740319. Bactericides, 1 -N-(S-4 -amino-2 -hydroxybutyryl) sisomicin, -gentamicin B, -verdamicin, and -gentamicin C 1 a, effective at 1 -15 mg/kg doses, were prepd. by treatment of sisomicin, gentamicin, or verdamicin derivs. with N-(S-4 -phthalimidoor -trifluoroacetamido-2 -hydroxybutyryloxy) succinimide. 1 -N-(S-3 -amino-2 -hydroxypropionyl)gentamicin C 1 was similarly prepd. isepamicin 17/01/2001 3

The birth of isepamicin… 2 Nagabhushan, T. L. ; Cooper, A. B. ; Tsai, H. ; Daniels, P. J. L. ; Miller, G. H. Schering Corp. , Bloomfield, N. J. , USA. J. Antibiot. (1978), 31(7), 681 -7. The syntheses and biological properties of 1 -N-(S-4 -amino-2 -hydroxybutyryl)gentamicin B and 1 -N-(S-3 -amino-2 -hydroxypropionyl)gentamicin B. isepamicin 17/01/2001 4

Why isepamicin ? (1) OH HO H 2 N OH O 2 HN HO HO O O NH 2 OH NH 2 kanamycin A isepamicin 17/01/2001 5

Why isepamicin ? (2) 3’ OH OH O HO H 2 N 2” OH O 2 HN HO HO OH O NH 2 6’ 3 resistance to kanamycin A isepamicin 17/01/2001 6

Why isepamicin ? (3) 3’ OH OH O HO H 2 N 2” OH O HN HOHC HO HO OH O NH 2 6’ 3 amikacin A isepamicin 17/01/2001 7

Why isepamicin ? (4) OH H 3 C HN CH 3 O OH O H 2 N HO H 2 N O O NH 2 CH 2 NH 2 gentamicin C 1 a isepamicin 17/01/2001 8

Why isepamicin ? (5) garosamine = gentamicin c = netillmicin = sisomicin 2’, 3’, 4’ hydroxy = kanamycin A = amikacin OH H 3 C HN CH 3 OH O H 2 N HO HO O O NH 2 OH CH 2 NH 2 gentamicin B isepamicin 17/01/2001 9

Why isepamicin ? (5) 3’ OH OH O H 3 C HN CH 3 2” OH O H 2 N HO HO OH CH 2 O NH 2 3 6’ resistance to gentamicin B isepamicin 17/01/2001 10

Why isepamicin ? (6) 3’ OH H 3 C HN CH 3 OH O HN HOHC HO HO O O NH 2 3 OH CH 2 NH 2 6’ making an ”amikacin-like” gentamicin B. . . isepamicin 17/01/2001 11

The nearly (but not entirely) twins. . . OH OH O HO H 2 N OH O HN HOHC HO HO OH O NH 2 OH NH 2 H 3 C HN Quizz. . . which is amikacin, which is isepamicin… ? ? ? isepamicin 17/01/2001 CH 3 OH O HN HOHC HO HO O O NH 2 OH CH 2 NH 2 12

Aminoglycoside nephrotoxicity Incidence: 0 -50% - patient factors - drug factors gentamicin netilmicin amikacin isepamicin - schedule of administration - concomitant drugs isepamicin 17/01/2001 13

Proximal tubular cells of rats (10 mg/kg. day gentamicin for 7 days) Kosek et al [1974] Lab. Invest 30: 48 -57 isepamicin 17/01/2001 14

Aminoglycoside nephrotoxicity sequence. . . AG uptake (adsorbtive pinocytosis) by proximal tubular cells AG transport, accumulation to lysosomes, and development of a lysosomal phospholipidosis Rupture (? ) of lysosomes, cell necrosis, phospholipiduria Tubular necrosis / tubular regeneration Acute tubular necrosis Non-oliguric renal failure isepamicin 17/01/2001 15

Protection against aminoglycoside nephrotoxicity (see more in AAC 43: 1008, 1999) reduce uptake (adsorbtive pinocytosis) reduce phospholipidosis once-a-day schedule polyaspartic acid stabilize lysosomes and / or prevent the damaging effects of lysosomal rupture desferrioxamine and oxydant scavengers promote cellular regeneration and tissue repair growth factors protect againts glomerular effects corticoids, saline isepamicin 17/01/2001 16

Can better aminoglycosides exist ? (see also more in AAC 43: 1008, 1999) reduce uptake (adsorbtive pinocytosis) tobramycin amikacin isepamicin reduce phospholipidosis amikacin isepamicin stabilize lysosomes and / or prevent the damaging effects of lysosomal rupture netilmicin ? ? promote cellular regeneration and tissue repair ? protect againts glomerular effects ? isepamicin 17/01/2001 17

Lower uptake, lesser phospholipidosis. . . SD rats 10 mg/kg 10 days isepamicin 17/01/2001 C G N A I = saline = gentamicin = netilmicin = amikacin = isepamicin 18

Aminoglycoside-phospholipid interactions leading to inhibition of lysosomal phospholipase activity isepamicin 17/01/2001 19

Experimental (belgian) studies on isepamicin toxicity … 1. . . Schanck A, Mingeot-Leclercq MP, Tulkens PM, Carrier D, Smith IC, Jarrell HC. Interactions of aminoglycoside antibiotics with phospholipids. A deuterium nuclear magnetic resonance study. Chem Phys Lipids. 1992 Sep; 62(2): 153 -63. Mingeot-Leclercq MP, Tulkens PM, Brasseur R. Accessibility of aminoglycosides, isolated and in interaction with posphatidylinositol, to water. A conformational analysis using the concept of molecular hydrophobicity potential. Biochem Pharmacol. 1992 Nov 17; 44(10): 1967 -75. isepamicin 17/01/2001 20

Isepamicin interacts less with phospolipids. . . 15 N NMR Studies (interactions of amines with phospholipids) OH O H 3 C HN OH O HN CH 3 OH HO HO OH O NH 2 5 6’ 3” 3 3” amika 5 6’ OH HO OH O H 2 N H 3 C H 2 N 3 R OH HO OH isepa OH O O H 3 C H 2 N NH 2 OH O HN OH OH O R OH H 3 C H 2 N AG + PI AG alone OH OH O NH 2 kana A 1 3 6’ 3” OH OH O HO H 2 N O OH O H 2 N isepamicin O NH 2 17/01/2001 1 3 OH NH 2 kana B 3” 2’ 6’ 21

Isepamicin interacts less with phospolipids. . . deuterium. NMR Studies (segregation of PI in membrane plane) DPPC d 62 control DPPCd 62: PI 1: 1 control + Kanamycin B + Kanamycin A + Amikacin + Isepamicin isepamicin 17/01/2001 22

Aminoglycoside-phospholipid interactions: correlation between theoretical and experimental studies Aminoglycoside Interaction detected by 15 N NMR equilibrium dialysis Kd (µM) Calculated interaction (KJ / mol) isepamicin 47 weak - 23. 4 amikacin 30 medium - 35. 7 kanamycin A 7 medium - 46. 8 kanamycin B 6 strong - 48. 5 isepamicin 17/01/2001 23

Release of lysophosphatidylcholine (% control) Isepamicin inhibits less the lysosomal phospholipases A 1 Gentamicin Isepamicin 100 80 60 IC 50 = 220 µM IC 50 = 100 µM 40 IC 50 for amikacin = 205 µM 20 0 0 100 200 300 400 Drug concentration (µM) isepamicin 17/01/2001 24

The Japanese trip of isepamicin… everything you’d like to know, the japanese way, on • microbiology, • pharmacology, • toxicology, etc. . . Jpn J Antibiot. 1986 Dec; 39(12) Jpn J Antibiot. 1987 Jan; 40(1) isepamicin 17/01/2001 25

Experimental (belgian) studies on isepamicin toxicity … 2. . . Van Bambeke F, Mingeot-Leclercq MP, Schanck A, Brasseur R, Tulkens PM. Alterations in membrane permeability induced by aminoglycoside antibiotics: studies on liposomes and cultured cells. Eur J Pharmacol. 1993 Oct 15; 247(2): 155 -68. Van Bambeke F, Mingeot-Leclercq MP, Brasseur R, Tulkens PM, Schanck A. Aminoglycoside antibiotics prevent the formation of nonbilayer structures in negatively-charged membranes. Comparative studies using fusogenic (bis(betadiethylaminoethylether)hexestrol) and aggregating (spermine) agents. Chem Phys Lipids. 1996 Mar 29; 79(2): 123 -35. isepamicin 17/01/2001 26

Experimental (belgian) studies on isepamicin toxicity … 3. . . reviewed in Mingeot-Leclercq and Tulkens, 1999, AAC 43: 1003 -1012 isepamicin 17/01/2001 27

Amikacin / Isepamicin animal and clinical studies at UCL • rat studies (0 -100 mg/kg): – low cortical accumulation – low phospholipid accumulation – low incidence of necrosis/regeneration • human studies (young female subjects; 15 mg/kg) – minimal phospholipiduria – no sign of renal dysfunction isepamicin 17/01/2001 28

Conclusions of the modelling, in vitro, animal and human studies of isepamicin at UCL / ULB / Gembloux Isepamicin is systematically either similar or better than amikacin. . . tip. . . Accepted toxicity ranking * • gentamicin > tobramycin > amikacin • gentamicin > netilmicin -----* at equal level of risk factors isepamicin 17/01/2001 29

The European clinical scene… 1. . . Carbon, C. Overview of the efficacy of isepamicin in the adult core clinical trial program. J. Chemother. (Florence) (1995), 7(Suppl. 2), 79 -85. Beaucaire, G. Evaluation of the efficacy and safety of isepamicin compared with amikacin in the treatment of nosocomial pneumonia and septicemia. J. Chemother. (Florence) (1995), 7(Suppl. 2), 165 -73. Sturm-W Isepamicin versus amikacin in the treatment of urinary tract infection. J-Chemother. 1995 Jun; 7 Suppl 2: 149 -54 isepamicin 17/01/2001 30

The European clinical scene… 2…. Vigano-A; Principi-N A randomised comparison of isepamicin and amikacin in the treatment of bacterial infections in paediatric patients. J-Chemother. 1995 Jun; 7 Suppl 2: 95 -101 Covi-M; Velluti-G Comparison of the efficacy and safety of isepamicin and amikacin in the treatment of acute lower respiratory tract infections caused by gram-negative organisms. J-Chemother. 1995 Jun; 7 Suppl 2: 137 -42 Colardyn-F The efficacy and safety of isepamicin and ceftazidime compared with amikacin and ceftazidime in acute lower respiratory tract infection. J-Chemother. 1995 Jun; 7 Suppl 2: 129 -35 isepamicin 17/01/2001 31

The European clinical scene… 3…. Tod-M; Minozzi-C; Beaucaire-G; Ponsonnet-D; Cougnard-J; Petitjean-O Isepamicin in intensive care unit patients with nosocomial pneumonia: population pharmacokinetic-pharmacodynamic study. J-Antimicrob-Chemother. 1999 Jul; 44(1): 99 -108 isepamicin 17/01/2001 32

Conclusions of the (limited) european clinical evaluation Isepamicin is systematically similar or better than amikacin. . . tip. . . Accepted toxicity ranking: • gentamicin > tobramycin > amikacin • gentamicin > netilmicin -----* at equal level of risk factors isepamicin 17/01/2001 33

Very recent experimental (Belgian) data. . . El Mouedden M, Laurent G, Mingeot-Leclercq MP, Taper HS, Cumps J, Tulkens PM. Apoptosis in renal proximal tubules of rats treated with low doses of aminoglycosides. Antimicrob Agents Chemother. 2000 Mar; 44(3): 665 -75. isepamicin 17/01/2001 34

Evidence of apoptosis in proximal tubular cells Laurent et al. , AAC, 1983 Gentamicin 10 mg/kg 10 days; HE staining isepamicin 17/01/2001 35

Evidence of apoptosis in proximal tubular cells: histology HE staining methyl green-pyronin El Mouedden et al. , 2000 gentamicin 10 mg/kg, 10 days isepamicin 17/01/2001 36

Evidence of apoptosis in proximal tubular cells: TUNEL staining El Mouedden et al. , 2000 gentamicin 10 mg/kg, 10 days isepamicin 17/01/2001 37

Aminoglycoside-induced apoptosis occurs at low doses. . . * † 200 (no. / sq mm) TUNEL (+) nuclei 250 100 * 50 0 El Mouedden et al. , 2000 0 10 20 Gentamicin daily dosage (mg/kg) isepamicin 17/01/2001 38

TUNEL (+) nuclei (no. /sq mm) DNA specific radioactivity AG-induced apoptosis severity varies among derivatives. . . isepamicin 150 b 100 b, d 50 a a, d d d 0 b 80 gm nt is am = gentamicin = netilmicin = isepamicin = amikacin 60 c 40 20 0 a El Mouedden et al. , 2000 ct 17/01/2001 gm nt is am 39

Aminoglycosides also induce apoptosis in cultured cells. . . LLC-PK 1 Apoptosis (% of TUNEL (+) nuclei) fibroblasts cells (R = 0. 943) MDCK cell lines (R = 0. 954) LLC-PK 1 cell lines (R = 0. 945) 30 20 10 0 0 20 40 60 gentamicin accumulation (µg/mg prot. ) Fibroblasts isepamicin 17/01/2001 El Mouedden, 2000 40

Conclusions of the apoptosis studies (kidney and cultured cells) Isepamicin is systematically similar or better than amikacin. . . tip. . . isepamicin apoptosis ranking: • gentamicin > tobramycin > amikacin • gentamicin > netilmicin 17/01/2001 41

The isepamicin UCL / ULB / Gembloux team. . . P. Maldague P. Lambricht K. Matsumoto M. El Mouedden M. P. Mingeot B. K. Kishore M. Dellale F. Van Bambeke B. Carlier R. Brasseur G. Laurent J. M. Ruysschaert. . . isepamicin 17/01/2001 42