[Show abstract][Hide abstract]ABSTRACT: Treatment of HIV-1 infections with nevirapine is associated with skin and liver toxicity. These two organ toxicities range from mild to severe, in rare cases resulting in life-threatening liver failure or toxic epidermal necrolysis. The study of the mechanistic steps leading to nevirapine-induced skin rash has been facilitated by the discovery of an animal model in which nevirapine causes a skin rash in rats that closely mimics the rash reported in patients. The similarity in characteristics of the rash between humans and rats strongly suggests that the basic mechanism is the same in both. The rash is clearly immune-mediated in rats, and partial depletion of CD4(+) T cells, but not CD8(+) T cells, is protective. We have demonstrated that the rash is related to the 12-hydroxylation of nevirapine rather than to the parent drug. This is presumably because the 12-hydroxy metabolite can be converted to a reactive quinone methide in skin, but that remains to be demonstrated. Although the rash is clearly related to the 12-hydroxy metabolite rather than the parent drug, cells from rechallenged animals respond ex vivo to the parent drug by producing cytokines such as interferon-gamma with little response to the 12-hydroxy metabolite, even when the rash was induced by treatment with the metabolite rather than the parent drug. This indicates that the response of T cells in vitro cannot be used to determine what caused an immune response. We are now studying the detailed steps by which the 12-hydroxy metabolite induces an immune response and skin rash. This animal model provides a unique tool to study the mechanistic details of an idiosyncratic drug reaction; however, it is likely that there are significant differences in the mechanisms of different idiosyncratic drug reactions, and therefore the results of these studies cannot safely be generalized to all idiosyncratic drug reactions.
Article · Jan 2010 · Handbook of experimental pharmacology
[Show abstract][Hide abstract]ABSTRACT: Nevirapine treatment can cause a skin rash. We developed an animal model of this rash and determined that the 12-hydroxylation metabolic pathway is responsible for the rash, and treatment of animals with 12-OH-nevirapine also leads to a rash. In the present study, we investigated the specificity of lymphocytes in nevirapine-induced skin rash. Brown Norway rats were treated with nevirapine or 12-OH-nevirapine to induce a rash. Lymph nodes were removed, and the response of lymphocytes to nevirapine and its metabolites/analogs was determined by cytokine production (enzyme-linked immunosorbent assay, enzyme-linked immunosorbent spot assay, and Luminex) and proliferation (alamar blue assay). Subsets of lymphocytes were depleted to determine which cells were responsible for cytokine production. Lymphocytes from animals rechallenged with nevirapine proliferated to nevirapine, but not to 12-OH-nevirapine or 4-chloro-nevirapine. They also produced interferon-gamma (IFN-gamma) when exposed to nevirapine, significantly less when exposed to 4-chloro-nevirapine, and very little when exposed to 12-OH-nevirapine, even though oxidation to 12-OH-nevirapine is required to induce the rash. Moreover, the specificity of lymphocytes from 12-OH-nevirapine-treated rats was the same, i.e., responding to nevirapine more than to 12-OH-nevirapine, even though these animals had never been exposed to nevirapine. A Luminex immunoassay showed that a variety of other cytokines/chemokines were also produced by nevirapine-stimulated lymphocytes. CD4(+) cells were the major source of IFN-gamma. The specificity of lymphocytes in activation assays cannot be used to determine what initiated an immune response. This has significant implications for understanding the evolution of an immune response and the basis of the pharmacological interaction hypothesis.
Article · Oct 2009 · Journal of Pharmacology and Experimental Therapeutics
[Show abstract][Hide abstract]ABSTRACT: Of the tetracyclines, minocycline is unique in causing a significant incidence of a lupus-like syndrome and autoimmune hepatitis. It is also unique among the tetracyclines in having a para-N,N-dimethylaminophenol ring. Many drugs that cause autoimmune reactions are oxidized to reactive metabolites by the myeloperoxidase (MPO) system of macrophages. In this study, we showed that minocycline is oxidized to reactive intermediates by MPO/H(2)O(2)/Cl(-), HOCl, horseradish peroxidase/H(2)O(2), or hepatic microsomes. When trapped with N-acetylcysteine (NAC), two adducts with protonated molecular ions at m/z 619 were isolated and analyzed by NMR. One represents attack of the aromatic D ring by NAC meta to the N,N-dimethylamino group, which implies that the reactive intermediate was a quinone iminium ion. The NMR of the other adduct, which was not observed when minocycline was oxidized by hepatic microsomes, indicates that the NAC is attached at the junction of the B and C rings. In the oxidation by HOCl, we found an intermediate with a protonated molecular ion of m/z 510 that represents the addition of HOCl to minocycline. The HOCl presumably adds across the double bond of the B ring, and reaction of this intermediate with NAC led to the second NAC adduct. We were surprised to find that the same NAC adduct was not observed after oxidation of tetracycline with HOCl, even though this part of the tetracycline structure is the same as for minocycline. We propose that one or more of these reactive metabolites are responsible for the idiosyncratic drug reactions that are specific to this tetracycline.
Article · Jul 2009 · Drug metabolism and disposition: the biological fate of chemicals
[Show abstract][Hide abstract]ABSTRACT: Idiosyncratic drug reactions (IDRs) represent a major clinical problem, and at present, the mechanisms involved are still poorly understood. One animal model that we have used for mechanistic studies of IDRs is penicillamine-induced autoimmunity in Brown Norway (BN) rats. Previous work in our lab found that macrophage activation preceded the clinical autoimmune syndrome. It is thought that one of the interactions between T cells and macrophages involves reversible Schiff base formation between an amine on T cells and an aldehyde on macrophages, but the identity of the molecules involved is unknown. It is also known that penicillamine reacts with aldehyde groups to form a thiazolidine ring, which unlike a Schiff base, is essentially irreversible. Such binding could lead to macrophage activation. Generalized macrophage activation could lead to the observed autoimmune reaction. Hydralazine and isoniazid also react with aldehydes to form stable hydrazones, and they also cause an autoimmune lupus-like syndrome. In this study, isolated spleen cells from male BN rats were incubated with biotin-aldehyde-reactive probe (ARP, a hydroxylamine), biotin-hydrazide, or D-penicillamine. At all concentrations, ARP, hydrazide, and penicillamine preferentially "stained" macrophages relative to other spleen cells. In addition, preincubation of cells with penicillamine or hydralazine decreased ARP staining of macrophages, which further indicates that most of the ARP binding to macrophages involves binding to aldehyde groups. This provides support for the hypothesis that the interaction between aldehyde-containing signaling molecules on macrophages and penicillamine could be the initial event of penicillamine-induced autoimmunity. Several of the proteins to which ARP binds were identified, and some such as myosin are attractive candidates to mediate macrophage activation.
Article · Jun 2009 · Chemical Research in Toxicology
[Show abstract][Hide abstract]ABSTRACT: The reverse transcriptase inhibitor, nevirapine (NVP), causes skin rashes and hepatotoxicity. We used a rat model to determine if the rash is caused by the parent drug or a reactive metabolite. By manipulation of metabolic pathways and testing analogues, we eliminated all but one pathway, 12-hydroxylation, which involves the oxidation of an exocyclic methyl group, as being responsible for the rash. Treatment with 12-OH-NVP caused a rash, and an analogue in which the methyl hydrogens were replaced by deuterium to inhibit the 12-OH pathway did not cause a rash; however, quite unexpectedly, blood levels of the deuterated analogue were very low. This is due to partitioning of the benzylic free radial intermediate between oxygen rebound to form 12-OH-NVP and loss of another hydrogen atom to form a reactive quinone methide, which inactivates P450. Cotreatment with the P450 inhibitor, 1-aminobenzotriazole, led to comparable levels of NVP and the deuterated analogue, and the deuterated analogue still caused a lower rash incidence. These data clearly point to the 12-hydroxy pathway being responsible for NVP skin rash. We propose that the hepatotoxicity of NVP in humans is due to the quinone methide formed by P450 in the liver, while the skin rash may be due to the quinone methide formed in the skin by sulfation of 12-OH metabolite followed by loss of sulfate. This is the first example in which a valid animal model of an idiosyncratic drug reaction was used to determine the metabolic pathway responsible for the reaction.
Article · Sep 2008 · Chemical Research in Toxicology
[Show abstract][Hide abstract]ABSTRACT: Nevirapine, used for the treatment of HIV infection, is associated with development of skin rash and liver toxicity. The mechanism of these idiosyncratic reactions is unknown. We have previously reported the discovery of a new animal model of nevirapine-induced skin rash in rats. When treated with nevirapine, Brown Norway rats developed red ears on about day 7 and skin rash on about day 21. On rechallenge, ears turn red within 24 h, and skin lesions develop by day 9. In the current study, we analyzed the time course of the sequence of events involved in the development of skin rash. Rats were treated with nevirapine for 7, 14, or 21 days or rechallenged with it for 0, 1, or 9 days. This treatment led to an increase in the total number of auricular lymph node T, B, and macrophage cells. There was also an increase in the activation/infiltration marker ICAM-1 and activation/antigen presentation marker MHC II in these cells compared with those from control rats. Immunohistochemistry analysis showed macrophage infiltration and ICAM-1 expression in the ears of treated rats as early as day 7 of treatment. Macrophage infiltration preceded T cell infiltration, which was not apparent until the onset of rash. Both MHC I and MHC II expression increased in the skin of nevirapine-treated rats that developed rash. A major inducer of MHC is IFNgamma. Although rechallenge with nevirapine led to a large increase in serum levels of IFNgamma, this was not observed during the treatment of naïve rats with nevirapine. These observations provide further clues to the mechanism of nevirapine-induced skin rash.
Article · Oct 2006 · Chemical Research in Toxicology
[Show abstract][Hide abstract]ABSTRACT: The mechanism of proteolysis by serine proteases is a reasonably well-understood process. Typically, a histidine residue acting as a general base deprotonates the catalytic serine residue and the hydrolytic water molecule. We disclose here, the use of an unnatural d-amino acid as a strategic residue in P1 position, designed de novo based on the architecture of the protease catalytic site to impede the catalytic histidine residue at the stage of acyl-enzyme intermediate. Several probe molecules containing d-homoserine or its derivatives at P1 position are evaluated. Compounds 1, 6, and 8-10 produced up to 57% loss of activity against chymotrypsin. More potent and specific inhibitors could be designed with structure optimization as this strategy is completely general and can be used to design inhibitors against any serine or cysteine protease.
Article · Feb 2006 · Bioorganic & Medicinal Chemistry
[Show abstract][Hide abstract]ABSTRACT: BACKGROUND:
Minocycline (1) is a tetracycline antibiotic is associated with serious idiosyncratic adverse reactions such as a hypersensitivity syndrome, hepatitis, and drug-induced lupus (DIL), which are not associated with other tetracyclines. It is also unique among the tetracyclines in having a p-aminophenol structure.
The exact mechanism of minocycline-induced idiosyncratic reactions is unknown. Most of the drugs associated with DIL are oxidized to reactive metabolites by activated monocytes. This may be because monocytes are precursors of antigen presenting cells and their activation could lead to a generalized autoimmune reaction. Therefore, we investigated the oxidation of minocycline by the major oxidation system of these cells, i.e. myeloperoxidase, and the major oxidant produced, i.e. hypochlorous acid. We postulated that the product would be a reactive quinone iminium ion (2 or 3) as shown below.
Oxidation of minocycline by HOCl: Minocycline was reacted with HOCl (varying concentrations) and the reaction products were analyzed by LC/MS.
Trapping minocycline HOCl oxidation products with NAC: Minocycline was treated with HOCl to produce a reactive intermediate for two minutes and then an excess of NAC (N-Acetyl cysteine) was added and the products corresponding to the NAC adduct were analyzed by LC/MS and NMR.
Trapping minocycline myeloperoxidase (MPO) oxidation products with NAC: Minocycline was incubated in the presence of MPO, H2O2 and chloride ion and the reactive intermediate formed was trapped with NAC and analyzed by LC/MS and NMR.
Oxidation of minocycline by HOCl: When minocycline was reacted with HOCl at pH=7, three products were initially observed. A major product corresponding to minocycline+Cl+OH (M1-510 amu), and two minor products corresponding to minocycline+O (M2-474 amu) and minocycline-H+Cl (M3-492 amu) were observed.
Trapping Minocycline HOCl oxidation products with NAC: When minocycline was reacted with HOCl and the reactive intermediate trapped as NAC adducts at pH=7, we initially observed four products. A major NAC adduct corresponding to minocycline-2H+NAC (M4-619 amu) and three minor products corresponding to minocycline+Cl+OH (M1-510 amu), minocycline-H+OH (M2-474 amu) and minocycline-H+Cl (M3-492amu).
Trapping minocycline myeloperoxidase (MPO) oxidation products with NAC: When minocycline were incubated with MPO/H2O2/Cl- and the products trapped as NAC adducts at pH=7, we observed a major NAC adduct of minocycline corresponding to minocycline-2H+NAC (M4-619 amu) at a similar retention time by HPLC as that observed for the HOCl reaction. A minor NAC adduct corresponding to minocycline-2H+NAC (M5-619 amu) at 16 min was also observed.
LC-MS and NMR studies of M4 /M2, suggest that the N-Acetyl cysteine / hydroxyl group is attached to the ipso position of the non aromatic ring in minocycline implying that both these products were possibly formed via the common reactive intermediate 3.
Based on the above data it appears that the reactive intermediate, 3, formed by HOCl as well as MPO, covalently binds to NAC or reacts with water to generate their corresponding ipso adducts. This reactive metabolite of minocycline is also likely to be formed in vivo and may be responsible for minocycline-induced idiosyncratic reactions.