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PubMed1999

Potent inhibition of cytochrome P-450 2D6-mediated dextromethorphan O-demethylation by terbinafine.

Cytochrome P-450 (CYP) 2D6 is responsible for the biotransformation of over 35 pharmacologic agents. In the process of studying CYP2D6 we identified phenotype-genotype discordance in two individuals receiving terbinafine. This prompted evaluation of the potential for terbinafine to inhibit CYP2D6 in vitro. Human hepatic microsomes and heterologously expressed CYP2D6 were incubated with terbinafine or quinidine and the formation of dextrorphan from dextromethorphan was determined by HPLC. Additionally, preliminary conformational analyses were conducted to determine the fit of terbinafine into a previously described pharmacophore model for CYP2D6 inhibitors. The apparent Km and Vmax of dextrorphan formation from four human hepatic microsome samples ranged from 5.8 to 6.8 microM and from 172 to 300 pmol/min/mg protein, respectively. Values of Km and Vmax in the heterologously expressed CYP2D6 system averaged 6.5 +/- 2.1 microM and 1342 +/- 147 pmol/min/mg protein, respectively. Terbinafine inhibited dextromethorphan O-demethylation with an apparent Ki ranging from 28 to 44 nM in human hepatic microsomes and averaging 22.4 +/- 0.6 nM for the heterologously expressed enzymes. Results of quinidine in these systems produced values for Ki ranging from 18 to 43 nM. Such strong inhibition of CYP2D6 by terbinafine would not have been predicted by the previously proposed pharmacophore model of CYP2D6 inhibitors based on molecular structure. Terbinafine is a potent inhibitor of CYP2D6 with apparent Ki values well below plasma and tissue concentrations typically achieved during a therapeutic course. This agent needs to be evaluated in vivo to determine the impact of CYP2D6 inhibition by terbinafine on the metabolism of concomitantly administered CYP2D6 substrates.

Cytochrome P-450 CYP2D6↗

PubMed1999

Dextromethorphan. Extrapolation of findings from reproductive studies in animals to humans.

QUESTION: One of my patients, who is now 8 weeks pregnant, just read in the newspaper that dextromethorphan (DM), an antitussive found in a variety of cough medicines, caused birth defects in chicken embryos. The author of the study stated that even one dose could be dangerous and that he would never allow his wife to use this drug if she were pregnant. My patient was understandably very concerned because last week she was suffering from a nasty cough and had been advised by her pharmacist to use a cough mixture containing DM, which she subsequently took for several days. ANSWER: You may reassure your patient that she did not put her baby at risk by using this substance. Dextromethorphan has been on the market for many years and has never been implicated as a human teratogen. Furthermore, chick embryos are not a good model for predicting teratogenic potential in humans and, consequently, were abandoned as such more than 30 years ago.

Abnormalities, Drug-Induced↗

PubMed1999

Limitations of dextromethorphan N-demethylation as a measure of CYP3A activity.

We evaluated the utility of the 3-methoxymorphinan/dextromethorphan (3MM/DM) urinary ratio to reflect baseline CYP3A activity, and its ability to discriminate moderate CYP3A inhibition during fluvoxamine therapy. For 4 months, oral dextromethorphan 30 mg and intravenous midazolam 0.025 mg/kg were administered to nine men every 14 days, and to 10 premenopausal women during the follicular and luteal phases of their menstrual cycles. Phenotyping during the first 3 months or cycles established baseline CYP3A activity. During the fourth month, individuals were given fluvoxamine 150 mg/day. CYP3A activity was expressed as both the urinary 3MM/DM molar ratio and midazolam plasma clearance (MDZ CL). 3MM/DM ratios were independent of dextromethorphan CYP2D6 phenotype (r = 0.13, P = 0.6). Intraindividual variability in baseline CYP3A activity (median, 25-75th percentile), as determined by coefficients of variation, was 48.3% (36.8-68.8%) for 3MM/DM and 10.3% (8.3-11.8%) for MDZ CL. No significant correlation between 3MM/DM and MDZ CL either at baseline (r = -0.22, P = 0.4) or during fluvoxamine therapy (r = -0.15, P = 0.6) was noted. With fluvoxamine 150 mg/day, median percentage change in the 3MM/DM ratios was -50.0% (-105.6-6.0%; P = 0.7), and median percentage change in MDZ CL was -33.7% (-27.0-39.3%; P < 0.0001). Only MDZ CL consistently indicated moderate inhibition of hepatic CYP3A activity. In addition, there was a lack of correlation between the magnitudes of fluvoxamine-induced change in 3MM/DM and MDZ CL (r = 0.41, P = 0.1). The large intraindividual variability of the 3MM/DM urinary ratio, as well as the inability to discriminate moderate CYP3A inhibition, makes this a suboptimal method for accurately assessing CYP3A activity.

Aryl Hydrocarbon Hydroxylases↗

PubMedDate not supplied

Drug extrapyramidal side-effects or not: is there a dextromethorphan phenotype difference?

A recent hypothesis suggests the possible role of cytochrome P450 2D6 (CYP2D6) polymorphism (involved in the metabolism of a large number of drugs), as a potential risk factor for the development of extrapyramidal side-effects of psychotropic drugs. The CYP2D6 metabolizer phenotype (dextromethorphan test) of 31 drug treated psychiatric adult patients suffering from extrapyramidal side-effects (group 1) and of 31 matched patients without drug side effects (group 2) were compared. In the first group, 13 poor metabolizer patients (41.9 per cent) were found, characterized by a dextromethorphan metabolic ratio > 0.3, and only two patients in the second group (6.4 per cent). These data provide some support for the notion that in subjects in whom CYP2D6 is probably saturated, the risk of drug extrapyramidal side-effects may be increased. In such patients the choice of psychotropic drugs 'without' this risk must be preferred.

Adolescent↗

PubMed2001

Variables in human liver microsome preparation: impact on the kinetics of l-alpha-acetylmethadol (LAAM) n-demethylation and dextromethorphan O-demethylation.

We examined three primary variables in the preparation of human liver microsomes. In three experiments, each using three livers, we manipulated 1) the force of the first centrifugation (9,000, 10,500, or 12,000g); 2) the presence of sucrose in the homogenization buffer; and 3) the number of homogenizing strokes (6, 8, or 10). Sedimentation plots for the marker enzymes succinate dehydrogenase, NADPH cytochrome P450 reductase (reductase), and glutathione S-transferase in the resulting premicrosomal, microsomal, and cytosolic fractions suggest that enhanced purity of microsomes can be obtained by reducing force of centrifugation, including sucrose, and increasing the number of homogenization strokes. Each microsomal fraction was also assayed for protein content, cytochrome P450, NADH cytochrome b(5) reductase, cytochrome b(5), absorbance at 420, p-nitrophenol hydroxylation, tolbutamide hydroxylation, dextromethorphan N- and O-demethylation, glucuronidation of morphine and 1-naphthol, and ester cleavage of p-nitrophenolacetate. These microsomal indicators were ranked and tested for statistical differences. The use of 9000g statistically increased optimal recovery (per gram of liver) and specific activity (per milligram of protein). The inclusion of sucrose improved activity specific to reductase activity. Ten homogenization strokes improved activity specific to reductase activity. Substrate-dependent activities of dextromethorphan O-demethylation to dextrorphan and the N-demethylation of l-alpha-acetylmethadol (LAAM) to norLAAM and dinorLAAM were compared in microsomes prepared with or without sucrose and microsomes prepared using 9,000 or 12,000g force, respectively. No significant differences were found in the concentration-dependent activities. Variation of the methods used to prepare human liver microsomes can significantly affect the recovery and specific activity of microsomal components; however, they do not appear to affect enzyme kinetics.

Adolescent↗

PubMed1997

[Distinguishing CYP2D6 homozygous and heterozygous extensive metabolizers by dextromethorphan phenotyping].

A more sensitive procedure was developed to phenotype cytochrome P450 2D6 metabolism by a less toxic probe drug--dextromethorphan. The sensitivity of the determination of dextromethorphan in urine samples was up to 1 ng.ml-1. This method was employed to phenotype three groups of subjects. The results showed that there was a difference between extensive metabolizers which were genotyped as homozygotes and heterozygotes. Although the difference was not as big as the difference with poor metabolizers which were genotyped as homozygous mutants. It suggests that "gene copy" is a true factor in the expression of CYP2D6 genes.

Chromatography, High Pressure Liquid↗

PubMed1992

Cytochrome P450-dependent metabolism of dextromethorphan: fetal and adult studies.

Dextromethorphan undergoes O-demethylation to dextrorphan and N-demethylation to 3-methoxymorphinan. 3-Hydroxymorphinan, a didemethylated compound, is secondarily formed. The O-demethylation pathway to dextrorphan is polymorphic and under CYP2D6 genetic control. Adult and fetal studies were performed to characterize the cytochrome P450 families involved in dextromethorphan metabolism and their ontogeny. In adult volunteers in vivo and in vitro studies demonstrate that the O-demethylation pathway to dextrorphan is dependent on CYP2D6 and is predominant in extensive metabolizers and defective in poor metabolizers of the drug. The N-demethylation pathway to 3-methoxymorphinan is accessory and is dependent on the CYP3A subfamily. In human fetal microsomes, CYP2D6 protein and activity are not detectable until birth, while CYP2D6 RNA is present in significant amounts before birth. CYP3A activity is detectable in large amounts as early as the 17th week of gestation. Fetal and adult members of the CYP3A subfamily have close, although different, properties, as demonstrated by immunoinhibition studies.

Adult↗

PubMed2004

Oral slow release dextromethorphan premedication provides a pethidine spare effect on posthemorrhoidectomy pain management.

BACKGROUND: In our previous study, we had demonstrated that intramuscular (i.m.) dextromethorphan (DM) could provide a preemptive analgesic effect and improve postoperative pain management. Regrow is a long-duration slow-release oral dextromethorphan available for clinical use with good patient compliance. The present study was designed to examine whether oral regrow may also offer the same preemptive analgesic effect as i.m. DM does in postoperative pain management. METHODS: Seventy-five patients, ASA status I and II, scheduled for hemorrhoidectomy were included and randomly assigned to the control and study groups. In the control group patients received placebo orally 8 h before surgical incision. In the study group, patients received regrow orally either 120 mg (R-120) or 240 mg (R-240) 8 h before skin incision. Pethidine (1 mg/kg, i.m.) was given for postoperative pain relief on demand. The time to first pethidine injection, total pethidine consumption, worst pain score, and pethidine-related side effects were recorded for two days. RESULTS: The times to first pethidine injection were 5.4 +/- 3.1, 6.5 +/- 3.5 and 12.7 +/- 5.7 h in the control, R-120 and R-240 groups, respectively. Total pethidine consumptions were 150 +/- 12, 132 +/- 11.8 and 82 +/- 12.5 mg in the control, R-120 and R-240 groups, respectively. The worst visual analog scale pain scores were respectively 7.2 +/- 0.4, 6.9 +/- 0.2 and 5.5 +/- 0.4 in the control, R-120 and R-240 groups during the 2-day observation. Five and three patients suffered pethidine-related side effects in the control and R-120 groups, respectively. CONCLUSIONS: This study revealed that premedication of oral regrow 240 mg provided a preemptive analgesic effect, thus reducing the severity of postoperative pain and pethidine requirement in post-hemorrhoidectomy patients.

Administration, Oral↗

PubMed1991

Lack of effect of dextromethorphan on breathlessness and exercise performance in patients with chronic obstructive pulmonary disease (COPD).

We have previously shown that the exercise performance of patients with severe chronic obstructive pulmonary disease (COPD) can be increased with the administration of oral morphine (0.8 mg.kg-1). The purpose of this study was to determine whether the administration of dextromethorphan (DXT), an antitussive structurally similar to codeine, would result in increased exercise performance and decreased dyspnoea in patients with COPD, without the side-effects of opiates. Six eucapnic patients (mean age = 66 +/- 3.8 yrs) with COPD (mean forced expiratory volume in one second (FEV1) = 1.01 +/- 0.07 l) underwent two incremental cycle ergometer tests to exhaustion (Emax) and assessment of their hypercapnic and hypoxic ventilatory responses and mouth occlusion pressure responses following first the oral administration of placebo (P) and then dextromethorphan (60 mg) in a single-blind fashion. There was no statistically significant difference in the maximal exercise performance, perceived dyspnoea (modified Borg scale), breathing pattern or expired gases after the two different treatments. In addition, the ventilatory response to CO2 production during exercise (delta VE/VCO2) and the ventilatory and mouth occlusion pressure responses to hypoxia and hypercapnia did not differ significantly after DXT as compared with after P. Indeed the exercise performance was poorer and the ventilatory responses were brisker after DXT. We conclude from this study that the administration of this opiate analogue does not improve the exercise capacity or decrease the ventilatory response of patients with COPD.

Aged↗

PubMed1989

Neocortical epileptogenesis in vitro: studies with N-methyl-D-aspartate, phencyclidine, sigma and dextromethorphan receptor ligands.

Slices of rat neocortex have been used to study the role of N-methyl-D-aspartate (NMDA) receptors in the induction of epileptiform activity. The NMDA antagonist potency of a range of compounds with putative anticonvulsant activity has been compared with their ability to reduce epileptiform activity in this tissue. Epileptiform activity was induced by the omission of magnesium from the bathing medium. Competitive and noncompetitive phencyclidine-like NMDA antagonists reduced such spontaneous and stimulus-evoked epileptiform bursts and after potentials. Similar epileptiform activity induced by the addition of proconvulsant drugs, e.g. gamma-aminobutyric acidA antagonists, potassium channel blockers or carbachol was reduced by ketamine and/or D-2-amino-5-phosphonovaleric acid. In magnesium-free medium, the frequency of spontaneous bursts and the number of afterpotentials per burst were reduced in parallel. There was a good correlation (r greater than 0.9) between their potencies against NMDA depolarizations and against epileptiform bursts (MK-801 [(+)-5-methyl-10,11- dihydro-5H-dibenzvo[a,d]cyclohepten-5,10-imine] greater than thienylcyclohexylpiperidine phencyclidine greater than 3-(2-carboxypiperazine-4-yl)propyl-1-phosphonic acid greater than cyclazocine greater than D-2-amino-5-phosphonovaleric acid greater than dextrorphan greater than SKF10,047 (N-allylnormetazocine) greater than ketamine greater than dextromethorphan = or greater than pentazocine). Sigma and dextromethorphan receptor ligands (e.g. ditolyguanidine, carbetapentane and phenytoin), whereas inactive as NMDA antagonists, reduced epileptiform activity by decreasing the number of afterpotentials per burst with less effect on the burst frequency. The quisqualate/kainate antagonist, FG9041 (6,7-dinitro-quinoxaline-2,3-dione), only reduced spontaneous bursts at doses which also reduced NMDA. Our results imply a central role for NMDA receptors in epileptogenesis in neocortical slices.

Animals↗

PubMed1989

[Determination of dextromethorphan and its major metabolite dextrorphan by gas chromatography].

A gas chromatography assay has been developed for the determination of dextromethorphan and dextrorphan in human fluids. Drugs are extracted with chloroform-isopropanol-n-heptane (50/17/33, v/v) form alkalinized samples using cyclizine as an internal standard, analysed using a 3 p. cent OV-17 column, and detected by selective nitrogen detection. The lower detection limits are 0.4 and 0.7 micrograms/l for dextromethorphan and dextrorphan, respectively.

Chromatography, Gas↗

PubMed1989

Inhibition of dermographia, histamine, and dextromethorphan skin tests by ketotifen. A possible effect on cutaneous vascular response to mediators.

Forty-one subjects with dermographia were studied for a 4-week period. Twenty subjects received ketotifen therapy, the other 21 received chlorpheniramine (H1) for 2 weeks, and then chlorpheniramine plus cimetidine (H1 + H2). Both groups had significant suppression of dermographia and skin wheals caused by dextromethorphan and histamine after 2 weeks. The inhibition by ketotifen of dermographia, histamine wheal, and the dextromethorphan wheal increased from week 2 to week 4. During the first 2 weeks, ketotifen's activity was comparable to chlorpheniramine. Ketotifen's activity increased during the second 2 study weeks to match the additional chlorpheniramine. These results suggest that ketotifen may have additional pharmacologic activities besides H1 antagonism, including possible inhibition of mast cell mediator release. As a consequence, cutaneous vascular hyperresponsiveness may decrease. Ketotifen appears promising as treatment for allergic skin disorders.

Adult↗

PubMed1987

Urinary metabolism of dextromethorphan in man.

After an oral dose of 50 mg of (+)-3-methoxy-N-methylmorphinan (dextromethorphan) to volunteers, urinary metabolism was studied by gas chromatography/mass spectrometry. A total of 15 previously unknown metabolites and derivatives of dextromethorphan could be identified by mass spectrometric techniques. The main metabolic pathways were: O,N-demethylation, O,N-acetylation, hydroxylation of the phenyl ring and the saturated ring system with subsequent further oxidation.

Acetylation↗

PubMed1983

High-affinity dextromethorphan binding sites in guinea pig brain. II. Competition experiments.

Binding of dextromethorphan (DM) to guinea pig brain is stereoselective, since levomethorphan is 20 times weaker than DM in competing for DM sites. In general, opiate agonists and antagonists as well as their corresponding dextrorotatory isomers are weak competitors for tritiated dextromethorphan ([3H]DM) binding sites and display IC50 values in the micromolar range. In contrast, several non-narcotic, centrally acting antitussives are inhibitory in the nanomolar range (IC50 values for caramiphen, carbetapentane, dimethoxanate, and pipazethate are 25 nM, 9 nM, 41 nM, and 190 nM, respectively). Other antitussives, such as levopropoxyphene, chlophedianol, and fominoben, have poor affinity for DM sites whereas the antitussive noscapine enhances DM binding by increasing the affinity of DM for its central binding sites. Additional competition studies indicate that there is no correlation of DM binding with any of the known or putative neurotransmitters in the central nervous system. DM binding is also not related to tricyclic antidepressant binding sites or biogenic amine uptake sites. However, certain phenothiazine neuroleptics and typical and atypical antidepressants inhibit binding with IC50 values in the nanomolar range. Moreover, the anticonvulsant drug diphenylhydantoin enhances DM binding in a manner similar to that of noscapine. Preliminary experiments utilizing acid extracts of brain have not demonstrated the presence of an endogenous ligand for DM sites. The binding characteristics of DM sites studied in rat and mouse brain indicate that the relative potencies of several antitussives to inhibit specific DM binding vary according to species. High-affinity, saturable, and stereoselective [3H]DM binding sites are present in liver homogenates, but several differences have been found for these peripheral binding sites and those described for brain. Although the nature of central DM binding sites is not known, the potent interaction of several classes of centrally acting antitussives with DM sites suggests that they may be related to the mechanism of action of this drug.

Animals↗

PubMed1995

Neuroprotective effects of dextromethorphan against transient cerebral ischemia/reperfusion injury in gerbils.

AIM: To study the neuroprotective effects of dextromethorphan against transient cerebral ischemia/reperfusion injury. METHODS: Transient cerebral ischemia/reperfusion injury in gerbils was produced by temporarily clamping the common carotid arteries (CCA) for 10 min. RESULTS: Intrahippocampal (ih) injection of 2.0 microL dextromethorphan (DM, 100 mumol.L-1) 5 min before ischemia quickened the recovery of EEG changes, the total power spectra of EEG, and the power of dominant frequency following reperfusion. The total power of EEG was increased to 92 +/- 30 (P < 0.01) at 240 min following reperfusion. DM substantially reduced the severe ischemic neuronal damage (SIND) after 10 min of cerebral ischemia and 24 h of reperfusion. CONCLUSION: DM has neuroprotective effects against transient cerebral ischemia and reperfusion injury in gerbils.

Animals↗

PubMedDate not supplied

Comparison of quantitative methods to assess hepatic function: Pugh's classification, indocyanine green, antipyrine, and dextromethorphan.

STUDY OBJECTIVES: To compare three quantitative metabolic markers used to assess hepatic function, indocyanine green (ICG), a high-extraction marker; antipyrine, a low-extraction marker; and dextromethorphan, a P-450IID6 marker, with the clinically used Pugh's classification. DESIGN: Comparison of 12 healthy controls with 12 age- and sex-matched patients with different degrees of liver disease. SETTING: Research center in a university-affiliated teaching hospital. PATIENTS: The 12 patients had different degrees of liver disease: 4 mild (Pugh's score 6 or 7); 4 moderate (Pugh's score 8 or 9); and 4 severe (Pugh's score > or = 10). Each level had an equal number of men and women subjects. MEASUREMENTS AND MAIN RESULTS: Clearance of ICG detected mild alterations in hepatic function as efficiently as it did for moderate and severe impairment, but it lacked the specificity to distinguish among the classification groups. In contrast, antipyrine was effective in identifying moderate and severe hepatic impairment; however, its clearance was not reduced in mild liver disease. Pugh's classification appears to be a clinically useful method of assessing the global degree of hepatic impairment in patients with chronic disease, and there was a significant correlation between it and antipyrine clearance (r = 0.67, p = 0.0003) and ICG clearance (r = 0.86, p = 0.0001). Four of eight patients with a Pugh's score greater than 8 had a dextromethorphan metabolic ratio expression reflective of a poor metabolizer phenotype based on 0- to 4-hour urine collection, but only two of those eight patients were classified as poor metabolizers based on 4- to 12-hour urine collection. These percentages of poor metabolizers are substantially higher than for historical controls (8.5-10.4%) and most likely reflect a decrease in the P-450IID6 functional ability with progression of liver disease. However, due to small sample size and lack of knowledge of the patients' genotypes, these data are only suggestive. CONCLUSION: Pugh's classification appears to be a reliable indicator of the degree of chronic liver disease and could be employed as a drug development research classification tool; however, it does not replace quantitative metabolic markers, especially isozyme-specific markers.

Adult↗

PubMed1996

Enzyme polymorphism on the metabolic O-demethylation of dextromethorphan in a South American population.

The polymorphic oxidative metabolism of debrisoquine and sparteine were discovered in the seventies by Mahgoub and Eichelbaum. Since then, many other therapeutic substances were added and one of these drugs is dextromethorphan. The object of this investigation was to ascertain the distribution of the oxidative phenotype of dextromethorphan in the Uruguayan population. The drug and its metabolite, dextrorphan, were quantified in the urine of 165 healthy volunteers by modification of an HPLC method by Chen et al. The metabolic ration was calculated and frequency distribution histograms were drawn. By inspection of the histogram two antimodes can be assigned which determine three sub-populations: on one side the fast extensive metabolizers (n = 30, 18.2%), in the middle the extensive metabolizers (n = 123, 74.5%) and on the other extreme of the histogram the slow metabolizers (n = 12, 7.3%). No other studies have confirmed thus far this trimodal distribution. This research will be continued by genotyping the populations studied in order to confirm these findings and to elucidate the underlying genetic mechanisms of the polymorphism.

Adult↗

PubMed1993

Inhibitory effects of anticancer drugs on dextromethorphan-O-demethylase activity in human liver microsomes.

The dextromethorphan-O-demethylase activity determined in human liver microsomes was used to screen various anticancer drugs for their ability to inhibit this cytochrome CYP2D6-dependent activity. Competitive inhibition indicates that the drug binds the enzyme and is potentially subjected to a polymorphic metabolism. Among the 13 anticancer drugs tested, 4 compounds caused competitive inhibition of dextromethorphan-O-demethylation: lomustine (Ki = 7.7 microM), doxorubicin (Ki = 75 microM), vinorelbine (Ki = 22 microM), and vinblastine (Ki = 42 microM). The results of these studies indicate that the metabolism of the drugs concerned is possibly altered in poor metabolizers of debrisoquine and requires further investigation to study their specific routes of biotransformation. The metabolism of these drugs probably involves various biotransformation pathways, among which the CYP2D6-dependent route would be of minor importance. A second hypothesis is that these drugs could be inhibitors of the isozyme without being a substrate.

Antineoplastic Agents↗