Department of Anesthesiology, University of Hirosaki, School of Medicine, Hirosaki 036-8562, Japan
Corresponding author. E-mail: masuika@cc.hirosaki-u.ac.jp
Accepted for publication: January 20, 2003
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Abstract |
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Methods. Tension of guinea-pig tracheal strips was measured isometrically in vitro with a force displacement transducer. Strips were precontracted with carbachol 107 M with or without 4-aminopyridine 103 M, a voltage-sensitive K+ channel blocker. Then, nifedipine 108104 M, diltiazem 1083x104 M or verapamil 1083x104 M was added cumulatively to the organ bath (n=6 each). The bronchial cross-sectional area of pentobarbital-anaesthetized dogs was assessed using a bronchoscopy method. Bronchoconstriction was elicited with methacholine 0.5 µg kg1 plus 5 µg kg1 min1, and then nicardipine 01000 µg kg1, diltiazem 03000 µg kg1 or verapamil 03000 µg kg1 were given i.v. (n=7 each).
Results. In the in vitro experiments, nifedipine and diltiazem fully reversed carbachol-mediated tracheal contraction with logIC50 values of 4.76 (SEM 0.22) (mean 17.5 µM) and 4.60 (0.33) (mean 24.8 µM), respectively. Although verapamil 106104 M reversed the contraction by 87.2%, strip tension re-increased by 18.1% following maximal relaxation with verapamil 3x104 M. This re-increase was almost fully abolished by pretreatment with 4-aminopyridine. In the in vivo experiments, nicardipine and diltiazem dose-dependently reversed methacholine-induced bronchoconstriction, with logID50 values of 3.22 (0.05) (mean 0.60 mg kg1) and 1.85 (0.32) (mean 14.0 mg kg1), respectively. Verapamil worsened methacholine-induced bronchoconstriction.
Conclusions. Although supraclinical doses of dihydropyridines and benzothiazepines can produce airway relaxant effects, these agents are unlikely to be used in the treatment of bronchoconstriction. In addition, verapamil may aggravate airway constriction.
Br J Anaesth 2003; 90: 6715
Keywords: ions, ion channels; receptors, muscarinic; muscle, smooth
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Introduction |
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There are three different binding sites on L-type Ca2+ channels: for dihydropyridine, benzothiazepine and phenyl alkylamine. These distinct high-affinity binding sites are located on the 1 subunit of the L-channel. However, the binding domains for dihydropyridines3 and benzothiazepines4 have been reported to be located on the extracellular side of the membrane in myocytes, while the phenylalkyl amine binding site is located on the intracellular surface.5 These antagonists may therefore produce differential effects on airway smooth muscle contractility.
As described above, the important role of intracellular Ca2+ led to speculation that Ca2+ entry blockers may be beneficial in the treatment of asthma. However, most clinical investigations suggest that Ca2+ entry blockers may produce only modest and highly variable effects on airway tone. It has been reported that an acute asthmatic attack increases sympathetic tone as plasma norepinephrine levels are significantly elevated.6 Moreover, theophylline, and ß-adrenoceptor agonists such as epinephrine administered as bronchodilators also produce positive inotropic effects. Thus, Ca2+ entry blockers are often used in the treatment of tachycardia and hypertension in asthmatic patients even if these agents are not used as bronchodilators. Verapamil has been reported to attenuate catecholamine-induced acceleration of AV junctional automaticity in patients7 and to inhibit sympathetically induced tachycardia and pressor responses in anaesthetized cats.8
Ca2+ mobilization by muscarinic stimulation consists of two components: an initial transient increase resulting from inositol-1,4,5-triphosphate-induced Ca2+ release and a sustained rise in intracellular Ca2+ concentration, resulting from Ca2+ influx via L-type Ca2+ channels.10 Thus, in the present study, we used a muscarinic-receptor-mediated airway constriction model. Using this model, we have evaluated the relaxant effect of three different types of Ca2+ entry blockers: dihydropyridines (nicardipine and nifedipine), benzothiazepines (diltiazem) and phenylalkylamines (verapamil).
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Methods |
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In vitro study
Female guinea pigs (350400 g) were killed with an overdose of pentobarbital 75 mg kg1 i.p. and the aorta was sectioned. The trachea was removed, carefully dissected from surrounding connective tissues, and then cut spirally into two tracheal strips (3x15 mm). Each strip was mounted in a 10 ml organ bath filled with Krebs-bicarbonate buffer (NaCl 124 mM, NaHCO3 25 mM, CaCl2 2.5 mM, MgSO4 1.3 mM, KCl 5 mM, NaH2PO4 0.6 mM, glucose 10 mM) oxygenated with oxygen/carbon dioxide 95%/5% at 37°C. Strip tension was measured isometrically with a force displacement transducer (Isometric transducer TB651T, Nihon Kohden, Tokyo, Japan). Each strip was subjected to a load of 2 g for at least 2 h, with frequent changes of the bath fluid until a stable baseline tension was obtained. This baseline was set as 0. The strips were then contracted with carbachol 107 M (EC50 for contraction). Nifedipine 108104 M (n=7), diltiazem 1083x104 M (n=7) or verapamil 1083x104 M (n=7) were added cumulatively to the organ bath. To confirm that carbachol-induced tension did not change during the experiment, one of four organ baths received saline only. Each strip received only one Ca2+ entry blocker or saline. Relaxant effects of verapamil 3x104 M (n=7) in the presence of 4-aminopyridine 103 M, a voltage-sensitive K+ channel blocker, was also evaluated.
In vivo study
Twenty-one mongrel dogs (810 kg) were anaesthetized with pentobarbital 30 mg kg1 i.v. plus 10 mg kg1 h1 and paralysed with pancuronium 0.2 mg kg1 h1 infusion. Dogs were randomly assigned to three groups (n=7 each): nicardipine, diltiazem or verapamil. The trachea was intubated with a special tracheal tube (ID 7 mm) with a second lumen for insertion of a superfine fibreoptic bronchoscope (OD 2.2 mm) and the lungs were ventilated using a volume-controlled respirator (Servo 900C, Siemens-Elema AB, Sonnla, Sweden) with oxygen 100%. End-tidal CO2 was maintained at 4.04.5%. A femoral artery was cannulated to monitor arterial pressure and to obtain arterial blood samples. A femoral vein was also cannulated with a double-lumen catheter to infuse methacholine and fluid and to administer Ca2+ entry blockers and propranolol. Airway tone was assessed as change in the bronchial cross-sectional area, as described previously.11 Briefly, images of the bronchial cross-sectional area were printed using a videoprinter (Videoprinter VY-170, Hitachi, Tokyo, Japan) during the end-expiratory pause, and then measured using image analysis software (MacSCOPE 2.56, Mitani Co., Fukui, Japan). The measured bronchial cross-sectional area was expressed as a percentage of the basal (=100%). The coefficient of variation for this measurement was 2.36%. Bronchoconstriction was elicited with methacholine 0.5 µg kg1 i.v. plus continuous i.v. infusion at 5 µg kg1 min1 until the end of the experiment. Thirty min later, when stable bronchoconstriction was achieved, Ca2+ entry blockers (nicardipine 0 [saline], 1, 10, 100, 1000 µg kg1, diltiazem 0, 3, 30, 300, 3000 µg kg1 or verapamil 0, 3, 30, 300, 3000 µg kg1) were administered cumulatively i.v. Propranolol 0.4 mg kg1 was then administered. At least 15 min elapsed between each dose of Ca2+ entry blocker. Propranolol was given immediately after printing out the bronchial cross-sectional area at the highest dose of Ca2+ entry blockers. Bronchial cross-sectional area was assessed before (basal) and 30 min after methacholine infusion started and 5 min after each dose of Ca2+ entry blocker and propranolol. Arterial blood (6 ml) was collected simultaneously and centrifuged at 3000 rpm for 10 min at 10°C to separate the plasma, which was kept frozen at 70 °C until assay. Plasma catecholamine concentrations were determined by high performance liquid chromatography with electrochemical detection. The intra-assay coefficients of variation for epinephrine and norepinephrine were 3.31% and 2.93%, respectively. The lower limits of detection for epinephrine and norepinephrine were 9 pg ml1 and 12.5 pg ml1, respectively.
Data analysis
All data are expressed as mean (SEM). Bronchial cross-sectional area is presented as percentage of the basal value. Data were analysed using one-way or repeated measures analysis of variance followed by Fishers protected least significant difference test, as appropriate, using Stat View II on a Macintosh computer. P<0.05 was considered significant.
Doseresponse curves for Ca2+ entry blocker induced relaxation were expressed as percentage relaxation where peak constriction by carbachol or methacholine was taken as 0% and fully relaxed (baseline) as 100%. Sigmoid doseresponse curves were fitted using GraphPad Prism 1.03, from which log[concentration or dose producing 50% relaxation] (pC50 or pD50) for each Ca2+ entry blocker were estimated.
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Results |
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In vivo study
In agreement with our in vitro data, nicardipine and diltiazem dose-dependently reversed methacholine-induced bronchoconstriction, with pID50 values of 3.22 (SEM 0.05) (mean ID50 0.60) mg kg1 and 1.85 (0.32) (mean ID50 14.0) mg kg1, respectively. Verapamil worsened the constriction (Fig. 2). Propranolol did not change the airway tone (Fig. 2). Plasma epinephrine and norepinephrine concentrations were increased by all Ca2+ entry blockers (Table 1).
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Discussion |
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In the present study, nicardipine and diltiazem concentrations above 10 and 300 µg kg1, respectively, produced significant spasmolytic effects on methacholine-induced bronchoconstriction in vivo. Verapamil 300 µg kg1 significantly worsened bronchoconstriction. Are these doses in dogs clinically relevant? The steady-state distribution volumes of nicardipine, diltiazem and verapamil, respectively, are 2- to 3-fold, 1- to 2-fold and 1- to 3-fold higher in dogs1315 than humans.1619 Thus, nicardipine 100 µg kg1 and diltiazem or verapamil 300 µg kg1 would be clinically relevant in the present study. Collectively, the present data suggest that clinically relevant doses of nicardipine and diltiazem may produce significant broncho dilation. However, as the ID50 values of nicardipine (0.60 mg kg1) and diltiazem (14.0 mg kg1) were much higher than clinically relevant doses, bronchodilation may not be large. Hence, nicardipine and diltiazem may not be particularly useful therapeutic agents for treatment of bronchoconstriction.
Several reports suggest that verapamil may have bronchodilating effects. However, the present in vivo data show that verapamil may worsen bronchoconstriction. In addition, as described above, clinically relevant doses may also do this. Similarly, inhaled verapamil has been reported to produce bronchoconstriction2022 or reduce atropine-induced relaxant effects,23 although several reports demonstrated a small bronchodilating action.24 25 In the present in vitro study, we observed that verapamil 3x104 M produced a maximal decrease in tension of tracheal smooth muscle followed by a re-increase of 18%. Verapamil has been reported to inhibit voltage-sensitive K+ channels26 and it is known that blockade of these channels increases airway tone.27 In the present study, the re-increase in tension was almost fully abolished in the presence of 4-aminopyridine, a voltage-sensitive K+ channel blocker. Thus, the inhibitory effects of verapamil on voltage-sensitive K+ channels might be involved in the mechanism of deterioration of methacholine-induced bronchoconstriction in vivo. In contrast to our in vitro data showing relaxant effects of verapamil, bronchodilating effects of verapamil were not observed in vivo. Further studies will be necessary to explain the discrepancies between these in vitro and in vivo data.
Plasma levels of the catecholamines increased significantly following i.v. administration of Ca2+ entry blockers in the present study. This may be because Ca2+-entry-blocker-induced vasodilatation promoted baroreceptor reflexes to increase sympathetic tone.28 Direct neural supply of the sympathetic system in the lung is limited. Thus, as circulating catecholamines mainly influence airway tone,29 Ca2+-entry-blocker-induced catecholamine release may attenuate bronchoconstriction. However, as propranolol 0.4 mg kg1 did not antagonize the relaxant effects of Ca2+ entry blockers, spasmolytic effects of Ca2+ entry blockers may not be caused by catecholamine release.
In the present study, pancuronium was infused i.v. to prevent spontaneous respiration and bucking. As pancuronium has been reported to antagonize M2 rather than M1 or M3 muscarinic receptors,30 this relaxant may antagonize M2 receptors activated by methacholine. As M2 activation reduces acetylcholine release and counteracts ß-agonist-induced relaxation, pancuronium might potentiate broncho dilation caused by endogenous epinephrine (a ß-agonist) release. However, methacholine-induced bronchoconstriction is mainly mediated via M3 receptors. In addition, we previously observed that aminophylline-induced relaxant effects on methacholine-induced bronchoconstriction with pancuronium infusion were antagonized by the same dose of propranolol as used in the present dose. Thus, in the present study, the absence of antagonistic effects of propranolol could not be the result of M2 antagonism by pancuronium. Therefore, the dose of pancuronium used in this study is unlikely to have affected our results.
In conclusion, the present data suggest that dihydropyridines and benzothiazepines may not be useful therapeutic agents for the treatment of bronchoconstriction, although supraclinical doses of these agents may produce airway relaxation. Moreover, verapamil may aggravate airway constriction.
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Acknowledgement |
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