“Cisatracurium besilate”的意思、由来-开放百科全书

The generic name cisatracurium was conceived by scientists at Burroughs Wellcome Co. (now part of GlaxoSmithKline) by combining the name "atracurium" with "cis" [hence cisatracurium] because the molecule is one of the three cis-cis isomers comprising the ten isomers of the parent, atracurium.^[2] Atracurium itself was invented at Strathclyde University and licensed to Burroughs Wellcome Co., Research Triangle Park, NC, for further development and subsequent marketing as Tracrium. As the secondary pharmacology of atracurium was being developed, it became clear that the primary clinical disadvantage of atracurium was likely to be its propensity to elicit histamine release. To address this issue, a program was initiated to investigate the individual isomer constituents of atracurium to identify and isolate the isomer(s) associated with the undesirable histamine effects as well as identify the isomer that might possibly retain the desirable properties without the histamine release. Thus, in 1989, D A Hill and G L Turner, PhD (both chemists at Burroughs Wellcome Co., Dartford, UK) first synthesized cisatracurium as an individual isomer molecule. The pharmacological research of cisatracurium and the other individual isomers^[4] was then developed further primarily by R. Brandt Maehr and William B. Wastila, PhD (both of whom were pharmacologists within the Division of Pharmacology at Burroughs Wellcome Co.) in collaboration with John J. Savarese MD (who at the time was an anesthesiologist in the Dept. of Anesthesia, Harvard Medical School at the Massachusetts General Hospital, Boston, MA). Thereafter, the entire clinical development of cisatracurium was completed in a record short period from 1992 to 1994: the team of scientists was led by J. Neal Weakly PhD, Martha M. Abou-Donia PhD, and Steve Quessy PhD, in the Division of Clinical Neurosciences at Burroughs Wellcome Co., Research Triangle Park, NC. By the time of its approval for human use, in 1995, by the US Food and Drug Administration, Burroughs Wellcome Co. had merged with Glaxo Inc., and cisatracurium was approved to be marketed as Nimbex by GlaxoWellcome Inc. The trade name "Nimbex" was derived from inserting an "i" to the original proposal "Nmbex," which stood for excellent Neuromuscular blocker.

Preclinical pharmacology

Clinical pharmacology

As is evident with the parent molecule, atracurium,^[5]^[6] cisatracurium is also susceptible to degradation by Hofmann elimination and ester hydrolysis as components of the in vivo metabolic processes.{{Citation needed|date=April 2010}} See the atracurium page for information on Hofmann elimination in vivo versus the Hofmann degradation chemical reaction.

Because Hofmann elimination is a temperature- and plasma pH-dependent process, cisatracurium's rate of degradation in vivo is highly influenced by body pH and temperature just as it is with the parent molecule, atracurium: thus, an increase in body pH favors the elimination process,{{Citation needed|date=April 2010}} whereas a decrease in temperature slows down the process.

One of the metabolites of cisatracurium via Hofmann elimination is laudanosine – see the atracurium page for further discussion of the issue regarding this metabolite. 80% of cisatracurium is metabolized eventually to laudanosine and 20% is metabolized hepatically or excreted renally.{{Citation needed|date=April 2010}} 10-15% of the dose is excreted unchanged in the urine.{{Citation needed|date=April 2010}}

The two reverse ester linkages in the bridge between the two isoquinolinium groups make atracurium and cisatracurium poor targets for plasma cholinesterase, unlike mivacurium which has two conventional ester linkages.

Adverse effects

Histamine release – hypotension, reflex tachycardia and cutaneous flush

Unlike the parent, atracurium, cisatracurium affords a much better pharmacological profile with respect to eliciting histamine release.

Bronchospasm – Pulmonary compliance

To date, cisatracurium has not been reported to elicit bronchospasm at doses that are clinically prescribed.

Laudanosine – Epileptic foci

Cisatracurium undergoes Hofmann elimination as a primary route of chemodegradation: consequently one of the metabolites from this process is laudanosine, a tertiary amino alkaloid reported to be a modest CNS stimulant with epileptogenic activity^[8] and cardiovascular effects such as low blood pressure and a slowed heart rate.^[9] As a tertiary amine, Laudanosine is unionised and readily crosses the blood–brain barrier. Presently, there is little evidence that laudanosine accumulation and related toxicity will likely ever be seen with the doses of cisatracurium that are administered in clinical practice especially given that the plasma concentrations of laudanosine generated are lower with cisatracurium than those seen with atracurium.^[9]

Research

A recent study showed that cisatracurium pretreatment effectively decreases the incidence and severity of pain induced by propofol general anaesthesia.

Synthesis

Treatment of 1,5-Pentanediol with 3-bromopropionyl chloride gives the corresponding ester; dehydrohalogenation of the ester with triethylamine then gives the bis-acrylate (2). Reaction of that unsaturated ester with tetrahydropapaverine^[12]^[13] (3) leads to conjugate addition of the secondary amine and formation of the intermediate (4). Alkylation with methyl benzenesulfonate forms the bis-quaternary salt, affording cisatracuronium (5).

References

1. ^{{cite journal | doi = 10.1093/bja/74.1.6 | vauthors = Meretoja OA, Taivainen T, Wirtavuori K | title = Pharmacodynamic effects of 51W89, an isomer of atracurium, in children during halothane anaesthesia | journal = Br J Anaesth |date=Jan 1995 | volume = 74 | issue = 1 | pages = 6–11 | pmid = 7880708}}
2. ^¹{{cite journal | vauthors = Stenlake JB, Waigh RD, Dewar GH, Dhar NC, Hughes R, Chapple DJ, Lindon JC, Ferrige AG | title = Biodegradable neuromuscular blocking agents. Part 6. Stereochemical studies on atracurium and related polyalkylene di-esters. | journal = Eur J Med Chem | year = 1984 | volume = 19 | issue = 5 | pages = 441–450}}
3. ^¹²{{cite journal | doi = 10.1002/rcm.1290091425 | vauthors = Dear GJ, Harrelson JC, Jones AE, Johnson TE, Pleasance S | title = Identification of urinary and biliary conjugated metabolites of the neuromuscular blocker 51W89 by liquid chromatography/mass spectrometry | journal = Rapid Commun Mass Spectrom | year = 1995 | volume = 9 | issue = 14 | pages = 1457–1464| pmid = 8534894}}
4. ^{{cite journal | doi = 10.1097/00000542-199607000-00023 | vauthors = Wastila WB, Maehr RB, Turner GL, Hill DA, Savarese JJ | title = Comparative pharmacology of cisatracurium (51W89), atracurium, and five isomers in cats | journal = Anesthesiology |date=Jul 1996 | volume = 85 | issue = 1 | pages = 169–177 | pmid = 8694363}}
5. ^{{cite journal | doi = 10.1093/bja/57.11.1085 | vauthors = Stiller RL, Cook DR, Chakravorti S | title = In vitro degradation of atracurium in human plasma | journal = Br J Anaesth | year = 1985 | volume = 57 | issue = 11 | pages = 1085–1088 | pmid = 3840382}}
6. ^{{cite journal | doi = 10.1097/00000542-199103000-00010 | vauthors = Nigrovic V, Fox JL | title = Atracurium decay and the formation of laudanosine in humans | journal = Anesthesiology | year = 1991 | volume = 74 | issue = 3 | pages = 446–454 | pmid = 2001023}}
7. ^{{cite book|last=Katzung|first=Bertram G.|title=Basic and clinical pharmacology.|year=2011|publisher=Mcgraw-Hill|location=New York|isbn=978-0-07-176401-8|edition=12th}}
8. ^{{cite journal | doi = 10.1097/00000542-198512000-00002 | author = Standaert FG | title = Magic bullets, science, and medicine | journal = Anesthesiology | volume = 63 | pages = 577–578 |date=Dec 1985 | pmid = 2932980 | issue = 6}}
9. ^¹{{cite journal | vauthors = Fodale V, Santamaria LB | title = Laudanosine, an atracurium and cisatracurium metabolite | journal = Eur J Anaesthesiol | volume = 19| pages = 466–473 |date=Jul 2002| pmid = 12113608 | issue = 7 | doi=10.1017/s0265021502000777}}
10. ^{{cite journal | author = Kim YH | title = Cisatracurium pretreatment with tourniquet reduces propofol injection pain: a double-blind randomized controlled trial.. | journal = J Int Med Res. | volume = 42 | issue = 2|date=Apr 2014 | pmid = 24573971 | url = http://imr.sagepub.com/content/42/2/360.long | pages = 360–7 | doi=10.1177/0300060514522602}}
11. ^D. A. Hill, G. L. Turner {{US patent|5453510}} (1995).
12. ^{{cite book|doi=10.1016/S0065-2725(03)85002-X|chapter=Heterocyclic Mesomeric Betaines and Analogs in Natural Product Chemistry. Betainic Alkaloids and Nucleobases|title=Advances in Heterocyclic Chemistry Volume 85|volume=85|pages=67|series=Advances in Heterocyclic Chemistry|year=2003|last1=Schmidt|first1=Andreas|isbn=978-0-12-020785-5}}
13. ^{{cite journal |doi=10.3998/ark.5550190.0002.814|title=Synthesis and antispasmodic effect of aryl substituted N-carbamoyl/thiocarbamoyl isoquinolines|journal=Arkivoc|volume=2001|issue=8|pages=129|year=2001}}

History