Clinical efficacy of antazoline in rapid cardioversion of paroxysmal atrial fibrillation -- a protocol of a single center, randomized, double-blind, placebo-controlled study (the AnPAF Study)

ABSTRACT: BACKGROUND: Rapid conversion of atrial fibrillation (AF) to sinus rhythm may be achieved by the administration of class IA, IC and III antiarrhythmic drugs or vernakalant hydrochloride. However, that treatment may be related to potential pro-arrhythmia, lack of efficacy or the exceptionally high cost of a compound used. Antazoline is a first generation antihistaminic agent with chinidin-like properties. When administered intravenously, antazoline exerts a strong antiarrhythmic effect on supraventricular arrhythmia, especially on AF, facilitating rapid conversion to sinus rhythm. Despite a relative lack of published data antazoline has been marketed in Poland and widely used in cardiology wards and emergency rooms for many years due to its efficacy, safety and rapid onset of action within minutes of administration. METHODS: A randomized, double blind, placebo-controlled, superiority clinical trial was designed to assess clinical efficacy of antazoline in rapid conversion of AF to sinus rhythm. Eligible patients will present AF lasting less than 43 hours, will be in stable cardio-pulmonary condition and will have no prior history of advanced heart failure or significant valvular disease. Long-term antiarrhythmic therapy is not considered an exclusion criterion. Subjects who fulfill selection criteria will be randomly assigned to receive intravenously either antazoline or placebo in divided doses and observed for 1.5 hours after conversion to sinus rhythm or after the last i.v. bolus. Primary end point will be the conversion of AF to sinus rhythm confirmed in an electrocardiogram (ECG) during the observation period. Secondary end points will be comprised of time to conversion and return of AF during the observation period. Special consideration will be given to the observation of any adverse events. A sample size of 80 patients was calculated based on the following assumptions: two-tailed test, a type I error of 0.01, a power of 90%, efficacy of placebo 5%, efficacy of antazoline 50% and 20% drop-out rate to fulfill the criteria of intention-to-treat analysis. Due to the presumed lack of statistical power, the secondary end points and safety endpoints will be considered exploratory.Clinical trials registryClinicalTrials.gov, NCT01527279.     

Influence of Feeding Schedule on Chronopharmacological Aspects of Gentamicin in Mice

The effects of the time of day of drug administration on the subchronic toxicity and pharmacokinetics of gentamicin, as well as the role of feeding schedule on circadian rhythms, were investigated in mice. ICR male mice were housed in a light-dark (LD) cycle (12:12) with food and water ad libitum (ALF) or under a time-restricted feeding (TRF) schedule (feeding time: 8 h during the light phase) for 1 day or 14 days before drug administration. The animals were given a single subcutaneous dose of gentamicin 180 mg/kg for the kinetic studies and subcutaneous doses of gentamicin 180 mg/kg/day for 14 days or 220 mg/kg/day for 18 days for the subchronic toxicity studies. A significant dosing-time dependency was shown for mortality and body weight loss, with higher values at midlight and lower ones at the middark (p > 0.05). A significant circadian rhythm was also found for gentamicin kinetics in ALF mice, with the highest clearance at middark and the lowest one at midlight (p > 0.01). The kinetic rhythm of gentamicin coincided well with the toxicity rhythm of the drug. The TRF schedule had a marked influence on the rhythms of gentamicin kinetics and toxicity, showing lowest clearance and higher toxicity at middark. The rhythm of subchronic toxicity of gentamicin seems to be due, at least in part, to the rhythm in kinetics and is strongly influenced by the feeding schedule. Thus, the timing of dosing is an important factor in the kinetics and the subchronic toxicity of gentamicin administration in mice, and the manipulation of feeding schedule can modify the rhythm of the toxicity by changing the rhythm of gentamicin kinetics.     

Chronopharmacokinetics of valproic acid following constant-rate administration in mice.

This study was carried out to investigate the circadian rhythm in the pharmacokinetics of valproic acid (VPA). ICR male mice, housed under a light-dark (12 h:12 h) cycle, were used in these studies. In the constant-rate administration study (536.3 or 1,072.6 micrograms/h), osmotic minipumps were implanted subcutaneously in mice. There was a significant circadian rhythm in plasma VPA concentrations: higher values were obtained in the light phase and lower values were found during the dark phase. A significant circadian rhythm also was shown for clearance (CL) of the drug: lower values were obtained in the light phase and higher values were demonstrated in the dark phase. In the intravenous administration study, VPA (50 mg/kg) was injected into a tail vein of the mice. Mean plasma VPA concentrations were significantly higher in mice injected with the drug at 1700 h than at 0100 h. The CL was higher, the volume of distribution (V) was larger, and the area under the curve (AUC) was smaller (p less than 0.05, respectively) in mice injected with the drug at 0100 h than at 1700 h. As the values of CL and V increased similarly during the dark period, there was no effect on half-life (t 1/2) and obviously on the elimination rate constant (K). These findings indicate that the circadian rhythms of plasma VPA concentrations observed after constant-rate administration are due to those of CL and V. To keep drug concentrations constant, the drug release rate from the osmotic minipump should be controlled according to the rhythm of drug pharmacokinetics.     

Incidence of dual AV node physiology following termination of AV nodal reentrant tachycardia by adenosine-5'-triphosphate: a comparison with drug administration in sinus rhythm

Administration of adenosine triphosphate (ATP) in sinus rhythm identifies dual atrioventricular node physiology (DAVNP) in 75% of patients with inducible slow/fast AV nodal reentrant tachycardia (AVNRT). The incidence of DAVNP following termination of AVNRT with ATP is unknown. Incremental doses of ATP (10-60 mg) were administered, first in sinus rhythm and then during tachycardia induced at electrophysiologic study, to 84 patients with inducible AVNRT and to 18 control patients with inducible AV reentrant tachycardia (AVRT) and no electrophysiologic evidence of DAVNP. Study end-points were the occurrence of DAVNP or > or = 2nd degree AV block following administration of ATP in sinus rhythm and tachycardia termination following administration of ATP during tachycardia. Of the 82 patients with AVNRT who completed the study, 62 (75.6%) exhibited DAVNP following administration of 17.1 +/- 9.4 mg ATP in sinus rhythm, while 30 (36.5%) exhibited DAVNP at the termination of AVNRT following administration of 10.6 +/- 2.4 mg ATP. The occurrence of DAVNP following the administration of 10 mg ATP in sinus rhythm.was a good predictor (62%) of its occurrence after termination of AVNRT with ATP. The dose of ATP had a strong correlation between the presence of DAVNP following AVNRT termination and the ATP doses needed for tachycardia termination. Of the 18 control patients, none had DAVNP at ATP test during sinus rhythm but 1 (5.5%) showed slight (60 msec) PR jump after termination of AVRT with ATP. In conclusion, DAVNP is present in a relatively high proportion (36.5%) of patients following termination of AVNRT with ATP but is much less frequent (5.5%) in control patients. Thus, findings at termination of tachycardia by ATP may be useful in the noninvasive diagnosis of the mechanism of a paroxysmal supraventricular tachycardia.     

5-methoxypsoralen: Effect on the noradrenaline circadian rhythm of sleep-deprived subjects

5-methoxypsoralen (5-MOP), a serotonin analogue, stimulates the secretion of melatonin, which plays an important role in circadian rhythm regulation. Melatonin production is essentially controlled by noradrenaline (NA). To investigate the effect of 5-MOP on the 24 hr NA rhythm, hourly plasma NA concentrations measured over 24 hr in 7 healthy young subjects who took 40 mg 5-MOP orally at 21:00 hr the evening before were compared with values obtained in drug-free subjects. All subjects were sleep-deprived and under conditions in which sympathetic nervous system activation was repeated every hour over 24 hr. In both series of patients, a significant difference was observed between mean morning values and mean night values, reflecting persistence of a circadian rhythm. In subjects given 5-MOP, a significant difference was also observed between mean afternoon values and mean night values. However, MANOVA analysis failed to find any difference between the two series of subjects. Acute administration of 5-MOP thus had no significant effect on the NA circadian rhythm under our study conditions.     

Circadian variation in methotrexate toxicity in streptozotocin-induced diabetes mellitus rats

The effects of diabetes mellitus and circadian rhythm on pharmacokinetics or pharmacodynamics of drugs have been previously separately reviewed. In our previous study, a circadian rhythm has been described in the pharmacokinetics of MTX in streptozotocin-induced diabetes mellitus (SIDM) rats. The aim of the present study was to investigate the effects of circadian rhythm on the toxicity of MTX in SIDM rats. The hematologic parameters and serum folic acid levels were measured in control and SIDM groups before and after MTX administration to evaluate its toxicity. We observed that circadian rhythm in basal peripheral WBC counts disappeared after MTX administration in the first hour and were phase shifted on the fifth day. Circadian variations were not observed in the other blood cells. One hour after MTX administration, folic acid levels were high in both groups. However, a circadian rhythm was present only in the diabetic group. The alteration in the rhythm of WBC counts in diabetic rats may originate not only from the effect of MTX but also physiological alterations due to diabetes and/or the varying cell cycle entry rates in the hematopoetic stem cells.     

Effect of histamine and H1 and H2 receptors antagonists on carbachol-induced wet-dog shakes in rats

Intracerebroventricular administration of carbachol chloride induced a characteristic wet-dog shake response in rats. Histamine did not change the number of wet-dog shakes during a 60 min observation but intensified the number of episodes in the first 30 min of the experiment. Antagonists of H1 (thenalidine and antazoline) and H2 (cimetidine and ranitidine) receptors, attenuated carbachol-induced wet-dog shakes. It may be suggested that inhibition of the central histaminergic structures decreased central cholinergic activity.     

Chronopharmacokinetics and Chronotoxicity of Lithium in Mice Eating Normal and Low-Sodium Diets

The temporal aspects of the pharmacokinetics and toxicity of lithium were studied in mice eating normal and low-sodium diets. ICR male mice, housed under a lightrdark (LD; 12:12) cycle, were injected with variable doses of lithium chloride i.p. A circadian rhythm was found in lithium clearance after a single administration in mice eating the normal diet showed the maximum value in the early dark phase and the minimum in the early light phase. The repeated administration of lithium did not affect the rhythm of the pharmacokinetics of the drug under the LD cycle. Although the low-sodium diet significantly decreased the lithium clearance, it did not influence the rhythm of the clearance. Higher toxicity was demonstrated in mice injected with the drug at the time of day with lower lithium clearance in the single-dose study but not in the repeated-doses study, regardless of the diet conditions. The low-sodium diet increased the acute and chronic toxicity of lithium. The results indicate that there is a circadian rhythm of acute toxicity and clearance of lithium after a single dose or repeated administration of the drug in mice eating normal and low-sodium diets and that the low-sodium diet increases lithium toxicity by reducing the clearance of the drug without influencing the rhythm characteristics.     

Chronopharmacokinetics and Chronotoxicity of Lithium in Mice Eating Normal and Low-Sodium Diets

The temporal aspects of the pharmacokinetics and toxicity of lithium were studied in mice eating normal and low-sodium diets. ICR male mice, housed under a lightrdark (LD; 12:12) cycle, were injected with variable doses of lithium chloride i.p. A circadian rhythm was found in lithium clearance after a single administration in mice eating the normal diet showed the maximum value in the early dark phase and the minimum in the early light phase. The repeated administration of lithium did not affect the rhythm of the pharmacokinetics of the drug under the LD cycle. Although the low-sodium diet significantly decreased the lithium clearance, it did not influence the rhythm of the clearance. Higher toxicity was demonstrated in mice injected with the drug at the time of day with lower lithium clearance in the single-dose study but not in the repeated-doses study, regardless of the diet conditions. The low-sodium diet increased the acute and chronic toxicity of lithium. The results indicate that there is a circadian rhythm of acute toxicity and clearance of lithium after a single dose or repeated administration of the drug in mice eating normal and low-sodium diets and that the low-sodium diet increases lithium toxicity by reducing the clearance of the drug without influencing the rhythm characteristics.     

Suprachiasmatic Nuclei May Regulate the Rhythm of Leptin Hormone Release in Syrian Hamsters (Mesocricetus Auratus)

The suprachiasmatic nuclei (SCN) generate the circadian rhythm of many hormones. The hormone leptin is a metabolic signal that informs the brain about fat and energy stores of the body. We investigated whether the rhythm of leptin hormone release in Syrian hamsters is directly controlled by the SCN. Three experiments were performed: in the first, hamsters were SCN‐lesioned; in the second, hamsters were exposed to different feeding regimes; and in the third, hamsters were adrenalectomized and implanted with cortisol capsules to maintain constant glucocorticoid release. Blood samples were collected before and after the experiments at different clock times and examined for leptin levels by enzyme‐linked immunosorbant assay (ELISA). Different feeding regimes and constant glucocorticoid release did not alter the rhythm of leptin release; whereas, SCN lesions abolished the rhythm. The results of the present study suggest the rhythm in leptin release in Syrian hamsters may be controlled by the SCN.     

Suprachiasmatic nuclei may regulate the rhythm of leptin hormone release in Syrian hamsters (Mesocricetus auratus)

The suprachiasmatic nuclei (SCN) generate the circadian rhythm of many hormones. The hormone leptin is a metabolic signal that informs the brain about fat and energy stores of the body. We investigated whether the rhythm of leptin hormone release in Syrian hamsters is directly controlled by the SCN. Three experiments were performed: in the first, hamsters were SCN-lesioned; in the second, hamsters were exposed to different feeding regimes; and in the third, hamsters were adrenalectomized and implanted with cortisol capsules to maintain constant glucocorticoid release. Blood samples were collected before and after the experiments at different clock times and examined for leptin levels by enzyme-linked immunosorbant assay (ELISA). Different feeding regimes and constant glucocorticoid release did not alter the rhythm of leptin release; whereas, SCN lesions abolished the rhythm. The results of the present study suggest the rhythm in leptin release in Syrian hamsters may be controlled by the SCN.     

Melatonin and circadian rhythms in autism: Case report

Among the most co-occurring conditions in autism spectrum disorders (ASD), there are sleep disorders which may exacerbate associated behavioral disorders and lead to intensification of existing autistic symptoms. Several studies investigating the use of melatonin in the treatment of sleep disorders in ASD have shown comparative efficiency in sleep with little or no side effects. Here we report a case of ASD with non-24-hour rhythm and the effect of melatonin in circadian parameters by actigraphy. Visual analysis of the first 10 days recorded and the periodogram suggest that this patient showed a non-24-hour rhythm. This ASD subject showed before melatonin administration an activity/rest rhythm lower than 24 hours. The results show that melatonin increased approximately 4.7 times the regularity of circadian activity rhythm and resting staying on average between 00:00 and 06:00 and showed positive effects in improving the quality of sleep and behavior. So, the actigraphy showed an ASD subject with a non-24-hour activity/rest rhythm which changed this rhythm to a 24-hour rhythm after melatonin administration. This result reinforces the prospect of therapy with melatonin for synchronization (increased regularity) of endogenous rhythms and improve sleep quality and hence behavior and indicates the actigraphy as a choice tool to characterize several parameters of the activity/rest rhythm of ASD individuals.     

Synthetic adrenocorticotropin for optimizing murine circadian chronotolerance for adriamycin

An attempt to pre-set the circadian rhythm in murine chronotolerance for adriamycin (ADR) given i.p. or i.v. with ACTH was performed in three studies. In CDF1 mice standardized in LD12:12, it was demonstrated that 1) the circadian rhythm in murine chronotolerance for ADR exhibits a different timing depending upon whether the intravenous or intraperitoneal route is used for the administration of this anticancer agent; 2) ACTH or saline pretreatment does not enhance optimal circadian-stage-qualified ADR tolerance, whatever its route of injection, with any of the circadian stages and schedules explored; 3) near-optimal tolerance can be achieved by a fixed 'best' interval (among those investigated) between ACTH and ADR, irrespective of circadian stage. Tolerance equivalent to optimal circadian-stage-qualified ADR tolerance results from the administration of ACTH 1-17 (HOE433 = Synchrodyn) 24 hours before ADR injection; 4) and acrophase advance of over 6 hours of the tolerance rhythm results from ACTH 1-17 administration at 6 HALO. The acrophase changes do not directly account for an optimal ADR tolerance at a fixed interval of 24 hours after ACTH 1-17. Thus, ACTH may be considered a potential relative chronizer of murine chronotolerance for ADR.     

Circadian rhythms in the mating behavior of the cockroach, Leucophaea maderae

Mating behavior of small populations of virgin males and females of the cockroach Leucophaea maderae were continuously monitored via time-lapse video recording in controlled laboratory conditions. The time of onset of copulation was found to be rhythmic in a light cycle of 12 h light alternated with 12 h of darkness, with the peak of mating behavior occurring near the light to dark transition. This rhythm persisted in constant dim red illumination and constant temperature. In constant conditions, the period of the rhythm was slightly less than 24 h, with a peak of copulation during the late subjective day. These data demonstrated that mating behavior is gated by a circadian clock. When males and females were taken from light cycles that were 12 h out of phase, a bimodal rhythm was observed with one peak in the males' late subjective day and a second peak of equal amplitude in the late subjective day of females. The results indicated that circadian systems in both males and females contribute to the circadian rhythm in copulation. Bilateral section of the optic tracts (OTX) of both males and females abolished the rhythm, but the rhythm persisted when OTX females were paired with intact males or when OTX males were paired with intact females. Furthermore, when OTX males or OTX females were paired with intact animals that were 12 h out of phase, a bimodal rhythm was still observed. These results suggested that the circadian pacemaker in the optic lobes of both male and female cockroaches participates in the control of mating, but that a pacemaker outside the optic lobes is also likely involved. Finally, it was shown that the female's olfactory response (measured by electroantennogram) to components of the male sex pheromone exhibited a circadian rhythm, but the data suggested the peripheral olfactory rhythm is not likely to be involved in the rhythm of mating behavior.     

Regulation of neutral cholesterol esterase and acyl-CoA : cholesterol acyltransferase in the rat adrenal gland.

The activities of neutral cholesterol esterase and acyl-CoA : cholesterol acyltransferase in rat adrenal gland were measured at various time intervals over 24 h. The activity of cholesterol esterase displayed diurnal rhythm, with a major peak at the onset of darkness coinciding with the peak in the diurnal rhythm of plasma corticosterone concentration. The activity of acyl-CoA : cholesterol acyltransferase also exhibited a characteristic diurnal rhythm, with the minimum activity occurring 3 h after the onset of darkness. The profile of the rhythm exhibited by the activity of the esterifying enzyme was similar to the mirror image of the pattern of diurnal rhythm in the activity of 3-hydroxy-3-methylglutaryl-CoA reductase. Microsomal non-esterified cholesterol showed a gradual decline with a significant decrease in concentration at the onset of darkness, thus suggesting that diurnal removal of cholesterol in the environment of the esterifying enzyme and hydroxymethylglutaryl-CoA reductase leads to such diurnal decrease or increase in the activities of these two enzymes. Acute administration of corticotropin led to a 3-fold increase in the activity of cholesterol esterase, a 50% decrease in the activity of acyl-CoA : cholesterol acyltransferase and a 2-fold increase in the activity of hydroxymethylglutaryl-CoA reductase. Corticotropin administration also resulted in a significant decrease in microsomal non-esterified cholesterol and increase in plasma corticosterone concentration. These observations suggest that corticotropin plays an important part in generating the diurnal rhythm in the activities of the three enzymes.     

Short-term and circadian rhythms in the behaviour of the vole,Microtus agrestis (L.)

Summary The activity behaviour of the vole, Microtus agrestis, has been recorded in order to investigate the relationship between short-term rhythm and circadian rhythm. A simple device was developed, allowing separate monitoring of the time spent in or outside the nest, wheel-running, eating and drinking. Under natural light conditions during summer, a distinct differentiation between a short term rhythm of eating and drinking during the day-time and a circadian rhythm of wheel-running during the night was observed. The short-term rhythm depends closely on metabolic demands (hunger, thirst, excretion). Control of these demands by an endogenous oscillation could not be substantiated. The circadian rhythm of wheel-running activity is, however, controlled by an endogenous oscillation, synchronized by light conditions. It is subjected to seasonal variations. a) The threshold of light intensity below which wheel-running occurs is lowest during summer (<0.5 lx) and is higher during spring and autum (> 5 lx). b) Wheel-running is controlled by a circadian oscillation during summer only whereas it is an integrated part of the short-term rhythm during spring and autumn (experiments during the winter have not yet been performed). Experiments gave evidence that the properties of the cage can deeply influence the amount and pattern of wheel-running activity. It is concluded that wheel-running reflects a certain level of excitation, which may be caused by different behavioural intentions. The seasonal changes of the control of wheel-running activity are discussed with respect to this assumption. The relevancy of locomotor activity patterns as usually recorded in the laboratory to reveal the physiological and ecological significance of endogenously controlled behavioural patterns is discussed.Supported by the Deutsche Forschungsgemeinschaft     

Human circadian rhythm synchronization by social timers: The role of motivation: IV. Individual features of the free-running 24-hour sleep-wake cycle under simulated conditions of vital activity

The possibility of simulating a free-running 24-h sleep-wake cycle was studied in the group of three subjects under rigid motivation conditions, including a strictly specified sleep time in a free daily routine. In this case, the effect of motivation-dependent social timer (clock) on synchronizing the human 25-h circadian rhythm was studied depending on the individual typological features; whereas the test subjects were not socially isolated and the main biotic and abiotic timers had a 24-h cycle. The typological features of subjects (predominant vagotonia, sympathotonia, normotonia) were studied that provide or limit the circadian rhythm synchronization of the vegetative functions by changing the sleep-weake rhythm (behavioral rhythm). Melatonin administration was shown to be effective in both sympathotonics and normotonics.     

Different Behavior of the Circadian Rhythms of Activity and Body Temperature During Resynchronization Following an Advance of the LD Cycle

Spontaneous activity and the body temperature of laboratory mice were recorded telemetrically using implantable transmitters. Following ten control days (L : D = 12 : 12; light from 07:00 to 19:00), the LD cycle was phase-advanced by shortening the light time by 8 h. Recordings were continued for a further 3 weeks. The raw temperature data were unmasked or 'purified' — that is, the temperature changes due to locomotor activity were removed, so revealing the endogenous component of the rhythm — using a regression method previously developed by us. The circadian rhythms of activity and measured body temperature resynchronized on average after 8 days. During resynchronization, both rhythms tended to show two components, one adjusting by a phase advance and the other by a phase delay. However, after purification of the body temperature rhythm, only the advancing component remained. These results indicate that the delaying component of the measured temperature rhythm was caused by masking due to activity, and that the endogenous component of this rhythm did not divide into two components during the resynchronization process. Also, the endogenous component of the circadian rhythm of body temperature and one component of the activity rhythm seemed to be controlled by the same oscillator. It remains uncertain how the other component of the activity rhythm is regulated.     

Different Behavior of the Circadian Rhythms of Activity and Body Temperature During Resynchronization Following an Advance of the LD Cycle

Spontaneous activity and the body temperature of laboratory mice were recorded telemetrically using implantable transmitters. Following ten control days (L : D = 12 : 12; light from 07:00 to 19:00), the LD cycle was phase-advanced by shortening the light time by 8 h. Recordings were continued for a further 3 weeks. The raw temperature data were unmasked or ‘purified’ — that is, the temperature changes due to locomotor activity were removed, so revealing the endogenous component of the rhythm — using a regression method previously developed by us. The circadian rhythms of activity and measured body temperature resynchronized on average after 8 days. During resynchronization, both rhythms tended to show two components, one adjusting by a phase advance and the other by a phase delay. However, after purification of the body temperature rhythm, only the advancing component remained. These results indicate that the delaying component of the measured temperature rhythm was caused by masking due to activity, and that the endogenous component of this rhythm did not divide into two components during the resynchronization process. Also, the endogenous component of the circadian rhythm of body temperature and one component of the activity rhythm seemed to be controlled by the same oscillator. It remains uncertain how the other component of the activity rhythm is regulated.     

Immediate and Prolonged Effects of Drugs on Rhythm's Characteristics: Relevance to Chronochemotherapy

Four groups of mice were injected with vincristine, each at a different time, for ten successive days. Mortality and daily pattern of peripheral white blood cells (WBC) count were monitored immediately and at various times after the last injection. The results demonstrated that (1) drug administration time dependency was observed in rate of death, recorded for 80 days following the injections; (2) the time of drug administration affected the parameters of WBC count rhythm, and (3) there were differences between immediate effects upon the rhythm parameters (monitored one day after the last injection) to those measured at succeeding times (on days 8 and 15 after injections cessation). The results emphasize the need to consider continuous post administration rhythm changes, especially when scheduling repeated chronotherapeutics, where variables which serve for toxicity-diagnosis are rhythmic in nature.