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Levosimendan drug discovery and pharmacology

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Levosimendan drug discovery and pharmacology

  1. 1. Levosimendan: drug discovery and pharmacology Piero Pollesello, PhD (cardiovascular pharmacology), docent (Faculty of Medicine, University of Helsinki), Global Brand Manager Critical Care Proprietary Products (Orion Pharma, Finland)
  2. 2. Gs Gi b-receptor Na+/Ca2+ex.Na+/K+ex. ATP cAMP (active) AMP (inactive) PDE Rise in intracellular calcium Ca2+ Na+ K+ e.g.Dobutamine e.g.Milrinone (PRIMACOR) e.g.Digoxin Old school inotropic drugs
  3. 3. With the old school inotropes more contractility is achieved but with higher risks •increase in the oxygen consumption in the myocardium, risk for the ischemic patients •reduced effects in patients on beta-blockers •arrhythmias due to the high level of intracellular calcium •acceleration of the myocardial remodelling, apoptosis •worse prognosis in the middle-long term
  4. 4. recent meta-analyses of inotropes There are strong indications from this meta-analysis that dobutamine worsens outcomes in patients with severe heart failure Effect of dobutamine on mortality in heart failure (vs. placebo or standard care) OR 1.47 Tacon et al. (2011) Intensive Care Med. 38:359-367
  5. 5. The research for a new inotrope, which would not increase either intracellular calcium or the oxygen consumtion on the myocardium… lead to the development of Levosimendan …but is Levosimendan only a good inotrope or a new therapeutic solution for AHF?
  6. 6. Levosimendan: a triple mechanism of action • calcium dependent binding to cTnC • opening of KATP channels on smooth muscle cells in vasculature • opening of KATP channels in cardiac mitochondria
  7. 7. Levosimendan: a triple mechanism of action • calcium dependent binding to cTnC • opening of KATP channels on smooth muscle cells in vasculature • opening of KATP channels in cardiac mitochondria
  8. 8. New target: contractile proteins in cardiomyocytes Actin Tropomyosin TnI TnT Ca2+ cTnC Myosin head (S1 fragment) ATP pocket RLC ELC
  9. 9. Ca2+ Levosimendan binds selectively to calcium saturated cardiac troponin C levosimendan Pollesello et al. (1994) J Biol Chem 269:28584-90
  10. 10. Levosimendan effect on LV contractility and relaxation on HF conscious instrumentyed dogs Masutani S. et al. (2008) J Pharmacol. Exp. Therap. 325:236-47
  11. 11. Papp, Z. et al. (2005) J Cardiovasc Pharmacol 46:369-76 Calcium sensitization and non PDE inhibition acts directly on contractile fibers
  12. 12. No increase in calcium transient 500 ms 0.35 0.20 Indo-1ratio%cellshortening 15 0 Control Levosimendan 0.1 M [Ca2+]i Lancaster and Cook (1997) Eur J Pharmacol 339:97-100
  13. 13. -8 -4 0 4 8 12 16 0,01 0,03 0,1 0,3 1 3 10 Concentration, µM CHANGE IN THE VO2 TO (P)dt RATIO (OXYGEN CONSUMPTION VS. WORK) Kaheinen et al. (2004) J Cardiovasc Pharmacol 43:555-561 Levosimendan: no increase of oxygen consumption MILRINONE LEVOSIMENDAN
  14. 14. 0 0.02 0.04 0.06 0.08 0.1 0.12 Dobutamine Levosimendan Baseline Treatment (2 hrs infusion) 6 µg/kg/min 0.3 µg/kg/min Ukkonen et al. (1997) Clin Pharmacol Ther 61:596-607 No effect on myocardial oxygen consumption in HF patients
  15. 15. from data in Haikala et al. (1997) Cardiovasc Res 34:536-546 Guinea-pig papillary muscle 0.03 0.1 1 3 -50 0 100 200 250 Levosimendan alone (n = 5) Atenolol 1 µM + Levosimendan (n = 5) DTwitchTension,mg Levosimendan, µM No antagonism by b-blockers on positive inotropic effect 0.3
  16. 16. Synergistic effect of b-blockers on the action of levosimendan in HF patients D PCWP (mmHg) D CO (l/min) 0 0.5 1.0 1.5 Levosimendan without b-blockers Levosimendan with b-blockers Dobutamine without b-blockers Dobutamine with b-blockers -8 -6 -4 -2 0 Levosimendan Dobutamine p = 0.01 p = 0.03 b- b+ b- b+ b- b+ b- b+ Follath et al. (2002) - LIDO clinical trial – Lancet 360:196-202
  17. 17. Levosimendan: a new mechanism of action • calcium dependent binding to cTnC • opening of KATP channels on smooth muscle cells in vasculature • opening of KATP channels in cardiac mitochondria
  18. 18. Levosimendan opens the ATP-dependent potassium channels in smooth muscle of vessels Erdei et al. (2006) Br J Pharmacol 148:696-702 Ø: 100 m Levosimendan + GLI (5µM) Levosimendan
  19. 19. Levosimendan increases diastolic coronary flow velocity Kaheinen et al. (2001) J Cardiovasc Pharmacol 37:367-374 Effects of levosimendan on the diastolic coronary flow velocity in isolated guinea- pig hearts in the presence (black) and absence (open) of 0.1 µM glybenclamide (n=6, ** p  0.01)
  20. 20. Levosimendan increases blood perfusion Blood Flow (Solid Columns) and Calculated Vascular Resistance (Hatched Columns) in the Small Intestine. Data are represented as % change from control. (a) significant (p<0.05) difference from baseline, (abc) significant difference from both low and middle doses, (d) significant difference from the corresponding value in the levosimendan group Pagel et al. (1996) Br J Pharmacol 119:609-615 LEVOSIMENDAN %DFROMCONTROL µg kg-1 min-1 0.75 1.5 3.0 MILRINONE 1.0 2.0 4.0 µg kg-1 min-1
  21. 21. Levosimendan: a new mechanism of action • calcium dependent binding to cTnC • opening of KATP channels on smooth muscle cells in vasculature • opening of KATP channels in cardiac mitochondria
  22. 22. Levosimendan opens the ATP-dependent potassium channels in cardiac mitochondria Kopustinskiene et al. (2004) Biochem Pharmacol 68:807 0.1 1 10 0.0 0.1 0.2 0.3 0.4 EC 50 =0.83  M Log [Levosimendan] ( M) Maximalrateofpotassium- specificDdecrease(%/s)
  23. 23. Cardioprotection KATP channels opening Zingman et al. (2007) J Appl Physiol 103:1888-1893
  24. 24. Cardioprotection • Short-term cardioprotection encompasses these three effects: – preconditioning – postconditioning – anti-stunning • Long term cardioprotection encompasses these four effects: – anti-ischemic – anti-remodelling – anti-apoptotic – anti-inflammatory
  25. 25. Preconditioning (1º/7) • Opening of the KATPMITO channels plays a predominant role in the modulation of myocardial infarction following ischemia and reperfusion. • Moreover, opening of the KATPMITO channels plays a role in the reduction of myocardial cell necrosis and apoptosis induced by ischemia–reperfusion injury by the modulation of [Ca2+]MITO accumulation and the stabilization of mitochondrial inner membrane volume and permeability, which would prevent the efflux of cytochrome c and activation of pro-apoptotic proteins. McCully & Levitsky (2003) Arch Biochem Biophys 420:237
  26. 26. Levosimendan has a preconditioning effect stunning ischemia reperfusion ischemic preconditioning control LVDP or dP/dT levosimendan preconditioning infarct size
  27. 27. CONTROL IPC 0 10 20 30 40 50 60 INFARCTSIZE(%OFAREAATRISK) FIGURE 5: INFARCT SIZE - LEVOSIMENDAN PRECONDITION TABLE 8 CONTROL LEVOSIMENDAN du Toit et al. (2008) Br J Pharmacol 154:41-50 Levosimendan has a preconditioning effect
  28. 28. Levosimendan increases survival in animal models Papp et al. (2006) J Cardiovasc Pharmacol Therapeut 11:129 OCCLUSION REPERFUSION SURVIVAL Group Dose µmol kg-1 n Incidence of VF (%) Incidence of VF (%) % Control 10 40 83 10 Levosimendan 0.1 10 0* 30* 70* Milrinone 0.1 10 60 50 20 Ischemia-reperfusion MI model in dogs
  29. 29. Levosimendan has a preconditioning effect Metzsch et al. (2007) Acta Anaesthesiol Scand 51:86  Levosimendan - Ischemic area  Control - Ischemic area  PRE - Control tissue  POST - Control tissue ISCHEMIA levosimendan
  30. 30. Tritapepe et al. (2009) Br J Anaeth 102:198-206 Preconditioning effects of Levosimendan in coronary artery bypass grafting
  31. 31. Remodelling (5º/7) • Remodelling = molecular, cellular and interstitial changes in the failing heart, which are manifested clinically as changes in size, shape and function of the heart resulting from cardiac load or injury1 • Leads to non-reversible myocardial damage – loss of cardiomyocytes – fibrosis of myocardium • Fibrotic myocardium has lost its normal contractile function Cohn et al. 2000 J Am Coll Card 25:569
  32. 32. Levosimendan stops and reverts the remodeling of cardiac tissue in HF myocardial SERCA2/NCXratio 0 0.2 0.4 0.6 0.8 1.0 1.2 MyocardialSERCA2/NCXratio Dah l HS * * Dah l HS+ lev o 10 Dahl HS+ lev o 1 Da hl LS * HF HF+ levosim. cntrl myocardial hyperthrophy HF HF+ levosim. cntrl 0 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 Cardiachypertrophy(mg/g) Dah l HS * * * Dahl HS+ lev o 1 Da hl HS+ le v o 10 Da hl LS * * * Louhelainen et al. (2007) Br J Pharmacol 150:851-61
  33. 33. Apoptosis (6º/7) van Empel et al.(2005) Cardiovasc Res. 67:21 Human heart failure is preceded by a process termed cardiac remodeling in which heart chambers progressively enlarge and contractile function deteriorates. Programmed cell death (apoptosis) of cardiac muscle cells has been identified as an essential process in the progression to heart failure. Unlike necrosis, apoptosis is an orderly regulated process and, by inference, a logical therapeutic target if intervention occurs at an early stage.
  34. 34. Levosimendan protects against apoptosis Maytin & Colucci (2005) Am J Cardiol 96:26G
  35. 35. Louhelainen et al. (2007) Br J Pharmacol 150:851-61
  36. 36. Inflammation (7º/7) In heart failure, a broad spectrum of neurohormonal and inflammatory markers are released
  37. 37. Levosimendan protects against inflammation In HF patients, at therapeutical doses, levosimendan reduces the plasma levels of b-natriuretic peptide1-5, interleukin 62-5, endothelin-I6, a-natriuretic peptide and renin7,8, prevents the increase of norepinephrine and epinephrine levels7 and pre- serves heart rate variability9. 1Moertl et al. Eur J Heart Fail 2005 Aug 3 2Parissis et al. Am J Cardiol 2005;96:423-6. 3Avgeropoulou et al. Eur J Heart Fail 2005;7:882-7 4Kyrzopoulos et al. Int J Cardiol 2005;99:409-13 5Gegenhuber et al.,Clin Chem 2004;50:454-455 6Nicklas et al. Am J Cardiol 1999;83:12(I)-15(I) 7Nieminen et al. J Am Coll Cardiol 2000;36:1903-12 8Sundberg et al. Am J Cardiol 1995;75:1061-6 9Binkley et al. Circulation 2000;102(suppl II)
  38. 38. Levosimendan protects against inflammation Time Since Start of Study Drug Infusion, days SURVIVE study -- Cohen-Solal et al. (2009) JACC 53:2349 MeanChangeFromBaseline inBNP,pg/mL -800 -600 -400 -200 0 0 1 2 3 4 5 Levosimendan Dobutamine * * * p<0.001 levosimendan (n=663) dobutamine (n=664) * * *p<0.001 p<0.001
  39. 39. Papp Z et al. Int J Cardiol 2012;159:82-7

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