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[Astemizole: its pharmacokinetics and pharmacologic properties].

Astemizole (Hismanal) is a chemically novel compound selected from a series of piperidinylaminobenzimidazoles. Further preclinical pharmacological investigations were initiated by experiences with other drugs in the same field. The aim of this review is to illustrate new pharmacological data on astemizole. Astemizole showed the lowest ED50 and the longest duration in mast cell-mediated shock. Binding characteristics to histamine H1 receptors were specificity, selectivity and long duration. Lack of effects on the wakefulness-sleep cycles was evidenced. An equal bioavailability of the drug was demonstrated with different formulations, dosing and food intake. High plasma levels of desmethylastemizole, the major metabolite, and longer half-life than for astemizole, contribute partly to the antihistamine activity. On chronic administration relative amounts of both molecules in the peripheral compartment are most likely responsible for the expected pharmacological effect. The time-course of kinetics shows, the peak plasma levels of the unchanged astemizole followed by a gradual take-over by desmethylastemizole. In patients with hepatic or renal insufficiency the pharmacokinetic background was similar to healthy volunteers.

Astemizole↗

In vivo pharmacology of astemizole, a new type of H1-antihistaminic compound.

Astemizole (R 43 512), a chemically novel compound, has been studied for its in vivo histamine H1-antagonizing properties in laboratory animals. The test models used were: in rats, protection from compound 48/80-induced lethality and inhibition of histamine-induced skin reactions; in guinea-pigs, protection from histamine-induced fatality and bronchoconstriction and in dogs, inhibition of histamine-and Ascaris allergen-provoked skin oedema formation. When compared to standard antihistamines, astemizole showed a higher oral potency and a longer duration of action in all animal models studied. Astemizole's activity was highly specific: it exerted only weak antiserotonin and no anticholinergic actions. Behavioral and drug interaction studies showed that it was devoid of depressant or stimulatory effects on the central nervous system (CNS). Astemizole was very atoxic: safety margins were greater than 25,000 in rats and mice, 30,800 in guinea-pigs and greater than 2000 in dogs. The data of this study indicate that astemizole can be described as a potent, exceptionally long-acting and selective histamine H1-antagonist, free of central and toxic effects.

Animals↗

Carcinogenicity studies of astemizole in mice and rats.

The histamine H1 antagonist astemizole (Hismanal) was tested for carcinogenicity in Swiss mice and Wistar rats. Astemizole was administered with the food to mice for 18 and to rats for 24 consecutive months. The doses given--approximately 5, 20, and 80 mg/kg body weight.day--were equivalent to 25, 100, and 400 times, respectively, the recommended human dose of 10 mg/day. Survival of both mice and rats was comparable between groups. Peto's age-adjusted, dose-related trend analysis for the tumor-bearing rats did not reveal a statistically significant difference for males or females. There was no evidence that astemizole led to an increased incidence of spontaneously or unusually occurring neoplastic lesions in either mice or rats. Special attention was given to the effect of astemizole on the progression of spontaneously occurring mammary gland adenomas and fibroadenomas. Peto's analysis applied to the number of female rats bearing these benign mammary gland tumors disclosed no statistically significant dose-related trend. There was no positive trend for the onset of this tumor type, and the median size of the tumor over time per rat was also not statistically significantly different in a comparison of the control group with each of the dosed groups. The findings from these carcinogenicity studies suggest that astemizole is not tumorigenic and that it does not promote tumor growth.

Aging↗

The pharmacological profile of a specific, safe, effective and non-sedative anti-allergic, astemizole.

In the compound 48/80 lethality test in rats, which is based on the specific activation of mast cells, astemizole was selected as a potent, long-acting and orally very effective inhibitor of anaphylactoid shock. In comparison to other histamine-H1 antagonists astemizole was also a very effective inhibitor of allergic reactions in rats and dogs and remarkably free of non-specific interactions with other biological amines and normal body functions. In numerous tests no evidence of central activity was found and toxicity studies have shown astemizole to be a very safe drug despite of its long duration of action. A daily dose of 10 mg of astemizole was found clinically free of side-effects and more effective than conventional antihistamine treatment.

Anaphylaxis↗

Structure-activity relationships of astemizole derivatives for inhibition of store operated Ca2+ channels and exocytosis.

The effects of a series of analogues of the antiallergic drug astemizole on the exocytosis of the enzyme beta-hexosaminidase were studied in a mast cell model, the rat basophilic leukemia (RBL-2H3) cell. Besides differences in the effects on Fc epsilonRI receptor-stimulated exocytosis, changes were also observed in Ca2+ influx and in the perturbation of the cell membrane. A strong correlation was found between the effects on antigen- and thapsigargin-stimulated 45Ca2+ influx. Furthermore, the inhibition of 45Ca2+ influx was correlated with the inhibition of beta-hexosaminidase release and membrane stabilization. It is concluded that the astemizole analogues are capable of inhibiting mast cell beta-hexosaminidase release through inhibition of Ca2+-store-operated Ca2+ channels (SOC). Compounds with high lipophilicity also released Ca2+ from intracellular stores. Lowering of the hydrophobicity by introduction of nitrogens or truncation at different sites in the astemizole structure decreased inhibitory activity on SOC channels. The inhibition of SOC channels cannot completely be ascribed to non-specific membrane effects. The piperidinyl-benzimidazole moiety was found to be important for inhibition of SOC channels. The observed differences in activity possibly depend on the way the compounds penetrate the membrane bilayer. Astemizole is an interesting new tool to study SOC channels and can be a lead for the design of mast cell-stabilizing antiallergic drugs.

Animals↗

Controlled clinical assessment of astemizole in the treatment of chronic idiopathic urticaria and angioedema.

Astemizole, one of the newer generation of nonsedating antihistamines, was evaluated in a double-blind study of forty-six patients who had chronic idiopathic urticaria with or without angioedema; most had severe disease. Nineteen of twenty-three patients who were on placebo discontinued treatment because of lack of response compared to only five of twenty-three astemizole-treated patients (p less than 0.0001). Fourteen of twenty-two astemizole-treated patients and two of twenty-two placebo-treated patients considered the results to be good or excellent (p less than 0.0001). Blinded assessment by the investigators yielded similar results (p less than 0.0001). Therapeutic response was the same in patients with and without angioedema in addition to urticaria and in those requiring corticosteroids. Duration of urticaria also did not influence the results. Increased appetite and weight gain were the main side effects reported more frequently in the astemizole-treated than in the placebo-treated group, and no significant toxicity was noted. Follow-up after terminating the drug study indicated a high frequency of remissions during the subsequent year.

Adult↗

Mechanism of block of hEag1 K+ channels by imipramine and astemizole.

Ether à go-go (Eag; KV10.1) voltage-gated K+ channels have been detected in cancer cell lines of diverse origin and shown to influence their rate of proliferation. The tricyclic antidepressant imipramine and the antihistamine astemizole inhibit the current through Eag1 channels and reduce the proliferation of cancer cells. Here we describe the mechanism by which both drugs block human Eag1 (hEag1) channels. Even if both drugs differ in their affinity for hEag1 channels (IC50s are approximately 2 microM for imipramine and approximately 200 nM for astemizole) and in their blocking kinetics, both drugs permeate the membrane and inhibit the hEag1 current by selectively binding to open channels. Furthermore, both drugs are weak bases and the IC50s depend on both internal an external pH, suggesting that both substances cross the membrane in their uncharged form and act from inside the cell in their charged forms. Accordingly, the block by imipramine is voltage dependent and antagonized by intracellular TEA, consistent with imipramine binding in its charged form to a site located close to the inner end of the selectivity filter. Using inside- and outside-out patch recordings, we found that a permanently charged, quaternary derivative of imipramine (N-methyl-imipramine) only blocks channels from the intracellular side of the membrane. In contrast, the block by astemizole is voltage independent. However, as astemizole competes with imipramine and intracellular TEA for binding to the channel, it is proposed to interact with an overlapping intracellular binding site. The significance of these findings, in the context of structure-function of channels of the eag family is discussed.

Astemizole↗

Torsade de pointes associated with Astemizole overdose treated with magnesium sulfate.

Astemizole (Hismanal-Janssen, New Brunswick, NJ) is a nonsedating antihistamine that has the advantage of a once-daily dosage schedule. This article reports the case of a 14-year-old female who intentionally ingested 270 mg of Astemizole and developed torsade de pointes, a form of polymorphic ventricular tachycardia that is associated with prolongation of the QTc interval. She was successfully treated with magnesium sulfate infusion and had an uneventful recovery over a period of 36 hours. This case illustrates that Astemizole overdose is not benign and should be considered in the differential diagnosis of ventricular tachyarrhythmias. Use of high-dose Astemizole may not be advisable for patients who are at risk for prolongation of the QTc interval.

Adolescent↗

Astemizole, a potent histamine H1-receptor antagonist: effect in allergic rhinoconjunctivitis, on antigen and histamine induced skin weal responses and relationship to serum levels.

The efficacy of astemizole, a new, long acting, oral histamine H1-receptor antagonist was compared to placebo for the treatment of allergic rhinitis and conjunctivitis during the grass pollen season of 1982. Sixty-three patients with a positive skin prick test to grass pollen and current symptoms participated in an 8 week, double-blind, randomized study. Astemizole, 10 mg, was significantly better than placebo in alleviating both nose (P less than 0.05) and eye (P less than 0.01) symptoms despite significantly greater use of the reserve medication, clemastine, by the placebo group (P less than 0.003). There was a lag period of 5 days after initiation of therapy before treatment benefit became manifest. Subdivision of nasal symptoms indicated significant improvement compared to placebo over the 8 weeks for sneezing (P less than 0.05) and runny nose (P less than 0.05) but not blocked nose. The absence of effect on nasal blockage was confirmed by parallel measurement of nasal calibre by body plethysmography. The antihistaminic potency of astemizole was indicated by an 80% inhibition of the histamine induced skin weal response after 8 weeks therapy. A positive correlation was found between serum drug levels and % inhibition of histamine skin weal (r = 0.64, P less than 0.001). Astemizole was free from adverse sedative or anticholinergic effects but did cause a mean increase in weight of 1.3 kg (P less than 0.01) after 8 weeks therapy, not found with placebo.

Adolescent↗

An open cross-over trial comparing two doses of astemizole and beclomethasone dipropionate in the treatment of perennial rhinitis.

An open cross-over trial comparing astemizole with intra-nasal aqueous beclomethasone dipropionate was carried out in forty-five perennial rhinitis patients attending a S.W. London general practice. Each drug was given for 12 weeks, separated by 4-8 weeks without medication. The principal outcome measure was a 7-day symptom diary completed by patients during weeks 4, 8 and 12. Patients were skin tested to seven common inhalant allergens. Half the patients beginning either regime failed to respond adequately within 2 weeks. Doubling the dose in these patients achieved satisfactory symptom control in an additional 67% on beclomethasone dipropionate and 45% on astemizole. Symptom diary scores showed beclomethasone dipropionate to be significantly more effective than astemizole in the treatment of skin test negative patients; but the two drugs were of equal benefit in the treatment of skin test positive patients. Sneezing and rhinorrhoea were the same on both drugs, but nasal blockage tended to be less severe on beclomethasone dipropionate. There was no significant difference between drugs in the frequency or duration of side effects. Beclomethasone dipropionate and astemizole are equally effective in the symptomatic treatment of atopic perennial rhinitis, but beclomethasone dipropionate may offer superior symptom relief in non-atopic perennial rhinitis.

Administration, Intranasal↗

The effect of astemizole on bronchial hyperresponsiveness and exercise-induced asthma in children.

The ability of the new generation H1-receptor antagonist, astemizole, to prevent histamine-induced airway obstruction and exercise-induced asthma (EIA) was studied in 20 children with asthma. The study was a randomised clinically controlled trial of oral astemizole versus placebo in a cross-over study. In each of the two treatment periods the children were tested at days 0, 6, 15 and 22 of therapy. The two treatment periods were separated by a washout period of 50 days, and at each visit a bronchial challenge with increasing concentrations of histamine followed by an exercise test was performed, and peak flow and asthmatic symptom score were recorded daily. The children tolerated significantly higher mean concentrations of histamine when treated with astemizole compared with placebo (P less than 0.001). Astemizole postponed the response to exercise, but no change in the maximal response was found. No differences between the treatment periods were found regarding frequency of asthmatic symptoms or the daily recording of peak flow.

Administration, Oral↗

A double-blind comparison of nasal budesonide and oral astemizole for the treatment of perennial rhinitis.

Sixty-nine outpatients with symptomatic perennial rhinitis were recruited to this double-blind, parallel-group study to compare budesonide nasal spray with oral astemizole. Following a 1-week run-in on placebo, 67 patients achieved a mean daily total symptom score of at least 4 (scoring for each symptom was 0 = none, 1 = mild, 2 = moderate, 3 = severe), and were randomized to study treatments - 33 to budesonide, 100 micrograms in each nostril morning and evening, and 34 to astemizole, one 10-mg tablet each morning, for a period of 4 weeks. No antihistamine preparations other than eye drops and no corticosteroids were permitted during the active treatment period. Patients recorded symptoms of blocked nose, runny nose, sneezing, itchy nose, sore eyes or runny eyes in diary cards each evening before retiring. Diary card data showed that there was significantly greater improvement in blocked nose, runny nose and runny eyes during the first 2 weeks of budesonide treatment than during the same period on astemizole. A similar, although non-significant, trend was observed for sneezing and itchy nose, but there was no apparent difference in the reporting of sore eyes. After 4 weeks, blocked nose and runny nose remained significantly less troublesome in the budesonide group. Both treatments were well-tolerated and no major adverse effects were reported. Patient ratings for treatment efficacy were significantly higher for budesonide than astemizole at both 2 weeks and 4 weeks.

Administration, Topical↗

Effect of astemizole on antigen-mediated histamine release from the blood of patients with allergic rhinitis.

The main objective of this study was to test the effectiveness of astemizole in vitro in blocking the release of histamine from blood of patients with allergic rhinitis. The results of this investigation indicated that astemizole inhibited allergen-mediated histamine release from blood basophils of patients with this allergic disorder. The inhibition by astemizole (33-156 mumol) was immediate, requiring no pre-incubation of the cells, and was dose-dependent, with maximal inhibition of about 91%. The relatively high potency of astemizole in inhibiting the immunologic release of histamine may provide an additional measure in the treatment of allergic rhinitis with this H1-receptor antagonist.

Adolescent↗

Nedocromil sodium and astemizole, alone or combined, in the treatment of seasonal allergic conjunctivitis. A multicentre double blind clinical trial.

Two hundred and seven patients with active symptoms of allergic conjunctivitis were studied in a four-week multicentre double blind, double dummy, clinical trial comparing efficacy and safety of nedocromil sodium eye drops with oral astemizole, placebo, and the combined active treatments. Clinical signs were evaluated by clinicians after 1, 2 and 4 weeks, while symptoms were recorded by patients on daily diary cards. Overall opinions were recorded at the end of treatment. Nedocromil sodium eye drops and astemizole, alone or combined, significantly reduced ocular symptoms when compared to placebo (diary card total symptom score and patients' opinion). In the clinicians' opinion nedocromil sodium alone or combined (but not astemizole alone) significantly decreased ocular symptoms when compared to placebo. All treatments were safe and well tolerated, drowsiness being the most frequent side effect observed in patients treated with astemizole. These results indicate the effectiveness of nedocromil sodium eye drops in the treatment of seasonal allergic conjunctivitis.

Adolescent↗

Double-blind comparison of astemizole, terfenadine and placebo in hay fever with special regard to onset of action.

In this double-blind study forty-seven patients with hay fever were treated for 8 days with either terfenadine 60 mg twice a day, astemizole 10 mg once a day or placebo. On the second day of treatment terfenadine was statistically significantly superior to astemizole and placebo according to the ratings of symptomatology, efficacy and individual symptoms. The median onset of symptom alleviation was 3 hours for terfenadine and 2 days for astemizole. On the eighth day both astemizole and terfenadine were statistically significantly more efficacious than placebo, but no significant differences were found between the two drugs. Both drugs were well tolerated.

Adult↗

Astemizole-induced torsades de pointes in a patient with vasospastic angina.

Astemizole (Hismanal), an antihistamine agent, has been reported to be associated with ventricular arrhythmias. In this paper we present a case of QT prolongation and torsades de pointes (TdP) in a 77-year-old woman who had been taking astemizole (10 mg/day) for 6 months because of allergic skin disease. At the time of admission, the serum concentration of astemizole and its metabolites was markedly elevated at 15.85 ng/ml, approximately 3 times the normal level. The patient was also taking cimetidine, a known inhibitor of cytochrome P-450 enzymatic activity, and during her admission was diagnosed as having vasospastic angina. To the best of our knowledge, this is the first report of astemizole-induced QT prolongation and TdP in Japan.

Aged↗

Validation of a [3H]astemizole binding assay in HEK293 cells expressing HERG K+ channels.

A radioligand binding assay for the HERG (human ether-a-go-go-related gene) K(+) channel was developed to identify compounds which may have inhibitory activity and potential cardiotoxicity. Pharmacological characterization of the [(3)H]astemizole binding assay for HERG K(+) channels was performed using HERG-expressing HEK293 cells. The assay conditions employed yielded 90% specific binding using 10 microg/well of membrane protein with 1.5 nM of [(3)H]astemizole at 25 degrees C. The K(d) and B(max) values were 5.91 +/- 0.81 nM and 6.36 +/- 0.26 pmol/mg, respectively. The intraassay and interassay variations were 11.4% and 14.9%, respectively. Binding affinities for 32 reference compounds (including dofetilide, cisapride, and terfenadine) with diverse structures demonstrated a similar potency rank order for HERG inhibition to that reported in the literature. Moreover, the [(3)H]astemizole binding data demonstrated a rank order of affinity that was highly correlated to that of inhibitory potency in the electrophysiological studies for HERG in HEK293 (r(SP) = 0.91, P<0.05). In conclusion, the [(3)H]astemizole binding assay is rapid and capable of detecting HERG inhibitors.

Astemizole↗

Single-dose effect of astemizole on bronchoconstriction induced by histamine in asthmatic subjects.

STUDY OBJECTIVE: Astemizole, administered for seven days to asthmatic subjects, had an effect of bronchoconstriction induced by inhaled histamine for a mean period of 42 days. This study evaluates whether a single dose of astemizole would have the same effect. SUBJECTS: Sixteen adult asthmatic subjects took part in the study. DESIGN: They first underwent three inhalation tests and skin prick tests with histamine on three different days. On the last day, a methacholine inhalation test was also performed. They subsequently received either a placebo or an active preparation of astemizole. The histamine inhalation test was repeated one day, two days, one week, and/or ten days after administering the drug. RESULTS: Overall, no significant change in mean PC20 or in the mean diameter of the skin reaction to histamine was observed. However, three out of the eight subjects (38 percent) receiving active and none receiving placebo medication showed significant increases in PC20 histamine (p = 0.05). This effect lasted for one to two days. CONCLUSIONS: We conclude that a single dose of 10 mg/ml of astemizole can have a significant effect on bronchial but not cutaneous reactivity to histamine. This effect is of short duration (one to two days).

Adult↗