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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)
Gs Gi
b-receptor
Na+/Ca2+ex.Na+/K+ex.
ATP cAMP (active)
AMP (inactive)
PDERise in intracellular calcium
Ca2+
Na+
K+
e.g.Dobutamine
e.g.Milrinone (PRIMACOR)
e.g.Digoxin
Old school inotropic drugs
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
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
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?
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
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
New target: contractile proteins in cardiomyocytes
Actin
Tropomyosin
TnI
TnT
Ca2+
cTnC
Myosin head (S1 fragment)
ATP pocketRLC
ELC
Ca2+
Levosimendan binds selectivelyto calcium saturated cardiac troponin C
levosimendan
Pollesello et al. (1994) J Biol Chem 269:28584-90
Levosimendan effect on LV contractility and relaxation on HF conscious instrumentyed dogs
Masutani S. et al. (2008) J Pharmacol. Exp. Therap. 325:236-47
Papp, Z. et al. (2005) J Cardiovasc Pharmacol 46:369-76
Calcium sensitization and non PDEinhibition acts directly on contractile fibers
No increase in calcium transient
500 ms
0.35
0.20Ind
o-1
rat
io
% c
ell
sho
rten
ing
15
0
Control Levosimendan0.1 M
[Ca2+
] i
Lancaster and Cook (1997) Eur J Pharmacol 339:97-100
-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 increaseof oxygen consumption
MILRINONELEVOSIMENDAN
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
from data in Haikala et al. (1997) Cardiovasc Res 34:536-546
Guinea-pigpapillary muscle
0.03 0.1 1 3-50
0
100
200
250
Levosimendan alone (n = 5)
Atenolol 1 µM + Levosimendan (n = 5)
D T
wit
ch T
ensi
on
, mg
Levosimendan, µM
No antagonism by -blockers on positive inotropic effect
0.3
Synergistic effect of b-blockers onthe 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
0Levosimendan 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
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
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
Levosimendan increases diastoliccoronary 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)
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%
D F
RO
M C
ON
TR
OL
µg kg-1 min-1
0.75 1.5 3.0
MILRINONE
1.0 2.0 4.0
µg kg-1 min-1
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
Levosimendan opens the ATP-dependent potassium channels in cardiac mitochondria
Kopustinskiene et al. (2004) Biochem Pharmacol 68:807
0.1 1 100.0
0.1
0.2
0.3
0.4
EC50=0.83 M
Log [Levosimendan] (M)
Max
imal
rat
e o
f p
ota
ssiu
m-
spec
ific
d
ecre
ase
(%/s
)
Cardioprotection
KATP channels opening
Zingman et al. (2007) J Appl Physiol 103:1888-1893
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
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
Levosimendan has a preconditioning effect
stunning
ischemia reperfusion
ischemic preconditioning
control
LVDPor dP/dT
levosimendan preconditioning
infarctsize
CONTROL IPC0
10
20
30
40
50
60
INF
AR
CT
SIZ
E (
%O
F A
RE
A A
T R
ISK
)FIGURE 5: INFARCT SIZE - LEVOSIMENDAN PRECONDITIONING
TABLE 8
CONTROL LEVOSIMENDAN
du Toit et al. (2008) Br J Pharmacol 154:41-50
Levosimendan has a preconditioning effect
Levosimendan increases survival in animal models
Papp et al. (2006) J Cardiovasc Pharmacol Therapeut 11:129
OCCLUSION REPERFUSION SURVIVAL
Group Doseµmol kg-1
n Incidenceof VF (%)
Incidenceof 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
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
Tritapepe et al. (2009) Br J Anaeth 102:198-206
Preconditioning effects of Levosimendanin coronary artery bypass grafting
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
Levosimendan stops and reverts theremodeling of cardiac tissue in HF
myo
card
ial
SE
RC
A2/
NC
X r
atio
0
0.2
0.4
0.6
0.8
1.0
1.2
My
oca
rdia
l S
ER
CA
2/N
CX
rat
io
Dahl HS
* *
Dahl HS+levo 10
Dahl HS+levo 1
Dahl LS
*
HF HF+levosim.
cntrl
myo
card
ial
hyp
erth
roph
y
HF HF+levosim.
cntrl
0
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
Car
dia
c h
yp
ertr
op
hy
(m
g/g
)
Dahl HS
**
*
Dahl HS+levo 1
Dahl HS+levo 10
Dahl LS
*
* *
Louhelainen et al. (2007) Br J Pharmacol 150:851-61
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.
Levosimendan protects against apoptosis
Maytin & Colucci (2005) Am J Cardiol 96:26G
Louhelainen et al. (2007) Br J Pharmacol 150:851-61
Inflammation (7º/7)
In heart failure, a broad spectrum of neurohormonal and inflammatory markers are released
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 32Parissis et al. Am J Cardiol 2005;96:423-6. 3Avgeropoulou et al. Eur J Heart Fail 2005;7:882-74Kyrzopoulos et al. Int J Cardiol 2005;99:409-135Gegenhuber et al.,Clin Chem 2004;50:454-4556Nicklas et al. Am J Cardiol 1999;83:12(I)-15(I)7Nieminen et al. J Am Coll Cardiol 2000;36:1903-128Sundberg et al. Am J Cardiol 1995;75:1061-69Binkley et al. Circulation 2000;102(suppl II)
Levosimendan protects against inflammation
Time Since Start of Study Drug Infusion, days
SURVIVE study -- Cohen-Solal et al. (2009) JACC 53:2349
Mea
n C
han
ge
Fro
m B
asel
ine
in B
NP,
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
Papp Z et al. Int J Cardiol 2012;159:82-7