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La kétamine est un antagoniste des récepteurs NMDA fréquemment utilisée pour des procédures anesthésiques et moins fréquemment pour traiter la douleur chronique. Des travaux de notre laboratoire ont montré que l’utilisation de la kétamine en combinaison avec la xylazine chez des rats âgés d’environ deux ans pouvait prolonger la durée d’anesthésie. Considérant que les patients gériatriques présentent des caractéristiques physiologiques demandant des adaptations au niveau de la pharmacothérapie, que cette classe de patient requiert fréquemment des anesthésies afin de réaliser des interventions chirurgicales et qu’elle représente la sous-population qui consomme le plus de médicaments pour traiter des problèmes de douleur aiguë et chronique, il convient alors d’investiguer l’impact que l’âge peut avoir sur le métabolisme des médicaments. Le but de ce projet est donc d’évaluer l’impact de l’âge sur le métabolisme de la kétamine à l’aide de fractions cellulaires (in vitro) et d’une technique de chromatographie en phase liquide couplée à la spectrométrie de masse. En premier lieu, nous avons dû confirmer la voie métabolique principale de formation de la norkétamine en utilisant le substrat et l’inhibiteur de référence de la voie métabolique du CYP3A qui sont respectivement le midazolam et le kétoconazole. De plus, nous avons caractérisé l’interaction métabolique de la kétamine fréquemment combinée au midazolam. Ensuite, nous avons comparé les profils de dégradation de la kétamine par des fractions S9 hépatiques de rats âgés de 3, 6, 12 et 18 mois. Les valeurs (±ÉT) de Vmax obtenues étaient respectivement de 2.39 (±0.23), 2.61 (±0.18), 2.07 (±0.07) pour les plus jeunes comparé à 0.68 (±0.02) pour le groupe de 18 mois (p < 0.001). Ces résultats suggèrent donc que le CYP3A est rapidement saturé par la présence de kétamine. De plus, la valeur de Km a diminué de 6 à 7 fois pour le groupe de 18 mois comparé aux autres groupes (p < 0.05). Ainsi, on peut émettre l’hypothèse que l’enzyme subit une modification de sa conformation tridimentionnelle, ce qui résulte en une diminution de formation de norkétamine. Finalement, nous avons tenté d’évaluer la contribution du métabolisme cérébral au métabolisme de la kétamine. Toutefois, nous n’avons pas trouvé de différence significative dans les concentrations de kétamine ou de midazolam entre le début de la réaction et 60 minutes plus tard. Le même constat a été observé pour d’autres substrats du CYP3A et CYP2D (dextromethorphan et codéine). D’autres expériences sont nécessaires afin d’arriver à des conclusions définitives. Les différences observées entre les différents groupes d’âge suggèrent que la voie métabolique hépatique du CYP3A est détériorée de façon importante. Les protocoles anesthésiques pour patients âgés devraient donc tenir compte de cette importante diminution d’activité métabolique étant donné que l’exposition aux concentrations systémiques risque d’être significativement augmentée. / Ketamine is a NMDAR antagonist widely used for anesthetic procedures and less often to treat chronic pain. Work in our laboratory showed that the use of ketamine combined to xylazine is a poor anesthetic choice for aged rats of approximately 2 years. Considering that geriatric patients present physiological characteristics demanding adaptations of the pharmacotherapy, that this class of patients frequently needs anesthesia to perform surgeries and that they represent the subpopulation that uses many drugs to treat acute and chronic pain, it is relevant to investigate the impact of aging on drug metabolism. The goal of this project was to assess the impact of aging on ketamine metabolism using cellular fractions (in vitro) and liquid chromatography tandem mass spectrometry. First, we needed to confirm the main metabolic pathway of norketamine formation using well-established reference substrate and inhibitor of CYP3A metabolic pathway which are respectively midazolam and ketoconazole. Furthermore, we also characterized the metabolic interaction of ketamine frequently combined with midazolam. Second, we compared the degradation profiles of ketamine in liver S9 fractions of rats aged of 3, 6, 12 and 18 months. Vmax values (±SD) were respectively of 2.39 (±0.23), 2.61 (±0.18), 2.07 (±0.07) for the younger groups compared to 0.68 (±0.02) for the 18 month older group (p < 0.001). Those results suggest that CYP3A is quickly saturated by the presence of ketamine. Moreover, Km value showed a 6 to 7 fold decrease for the oldest group compared to the younger one (p < 0.05). Therefore, we hypothesized that the enzyme undergoes conformational changes, which results in a decrease of norketamine formation. Finally, we intend to assess the contribution of brain metabolism to the overall ketamine metabolism. Unfortunately, we did not find any significative difference in ketamine or midazolam concentrations between the beginning of the reaction and 60 minutes later. The same ascertainment has been observed with other susbstrates of CYP3A and CYP2D (dextromethorphan and codeine). Other experiences are needed to definetely conlude that brain metabolism is negligible. The differences observed between age groups suggest that the hepatic metabolic pathway of CYP3A is severely impaired. Anesthetic protocols for aging patients should take into consideration the diminished metabolic activity since it may lead to a significant increase of exposition to systemic drug concentrations.

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Made available in DSpace on 2016-06-02T19:22:08Z (GMT). No. of bitstreams: 1 4470.pdf: 1297687 bytes, checksum: f9b62c4b271de961a3a6053528edf8c2 (MD5) Previous issue date: 2012-02-10 / Universidade Federal de Sao Carlos / Animal models have often been used to investigate the neurobiology of emotional states (fear and anxiety). In this sense, the elevated plus maze (EPM) and the rat exposure test are effective to evaluate these states and EPM exposure (aversive stimulus) can result in activation of serotonergic pathways with projections to structures belonging to the defense system, such as , amygdala, septum, hypothalamus, periaqueductal gray (PAG) and hippocampus. The hippocampus has a large amount of serotonin receptors (5- HT) and gamma-aminobutyric acid (GABA). In the present study, we used male mice of Swiss Albino, received surgical implantation of guide cannula and subsequent administration of drugs in the ventral hippocampus. After recovery, the animals were tested in EPM (Experiment 1 and 2) or the test exposure to the rat (Experiment 3 and 4). In Experiment 1, administration of midazolam (3.0 and 30.0 nmol) produced anxiolytic effect characterized by increased percentages of entries and time spent in the open arms of the EPM reduction measures and ethological (risk assessment) as percentages of dives stretched and secured. In Experiment 2, mice received combined injections Saline + Saline, Saline + MDZ, ondansetron (OND) + Saline and MDZ (30.0 nmol) + OND (0.03 nmol, antagonist of 5-HT3). Combined treatment of Sal + MDZ produced anxiolytic effect and this effect was reversed by the combined administration of OND + MDZ. The porcentanges of entries and time spent in open arms were lower (P> 0.05) than those found in group Sal + MDZ. Experiment 3 showed the effects of exposure of mice in the presence of mouse toy (RB = neutral stimulus) or mouse real (VR = aversive stimulus, Long Evans rats), under the administration of midazolam (3.0 14 and 30.0nmol). The animals were exposed to RV shortening the holding box (model effect) compared to animals exposed to RB. Animals treated with MDZ in two doses, there was an increase in transitions between the sides of the apparatus, increased time in the area of operation and increases the latency of escape to the protected area and contact time with the grid. In Experiment 4, we evaluated the effect of combined injection of midazolam and ondansetron protocol (Experiment 2). The MDZ 30.0 nmol produced anxiolytic effects and the blockade of this effect when the mice were combined administration of ondansetron and midazolam in the ventral hippocampus. Data from this study suggest that, first, control over emotional reactions and defense of the ventral hippocampus of mice exposed to EPM test or exposure to the rat are mediated via GABABenzodiazepines. Furthermore, there is a likely cross-modulation between GABAergic interneurons and 5-HT3, for blocking 5-HT3 via ondansetron can decrease the GABA release. / Modelos animais têm sido frequentemente utilizados para a investigação da neurobiologia dos estados emocionais (ansiedade e medo). Neste sentido, o labirinto em cruz elevado (LCE) e teste de exposição ao rato são eficazes para avaliar esses estados e a exposição ao LCE (situação aversiva) pode resultar em ativação das vias serotonérgicas com projeções para estruturas pertencentes ao sistema de defesa, tais como, amídala, septo, hipotálamo, substância cinzenta periaquedutal (SCP) e hipocampo. O hipocampo apresenta grande quantidade de receptores de serotonina (5-HT) e do ácido gama-aminobutírico (GABA). No presente estudo, foram utilizados camundongos machos, da cepa Suíco Albino, que receberam implantação cirúrgica de cânulas guia e posterior administração de drogas no hipocampo ventral. Após recuperação, os animais foram avaliados nos testes LCE (Experimento 1 e 2) ou exposição ao rato (Experimento 3 e 4). No Experimento 1, a administração de midazolam (3,0 e 30 nmol) produziu efeito ansiolítico caracterizado pelo aumento das porcentagens de entradas e tempo gasto nos braços abertos do LCE e redução de medidas etológicas (avaliação de risco) como porcentagens de mergulhos e esticadas protegidas. No Experimento 2, os camundongos receberam injeção combinada de Salina+Salina, Salina+MDZ, ondansetron (OND)+Salina e MDZ (30 nmol) + OND (0,03 nmol, antagonista dos receptores 5-HT3). O tratamento combinado de Sal+MDZ produziu, efeito ansiolítico sendo este revertido pela administração combinada de OND+MDZ. As porcentagens de entradas e tempo gasto nos braços abertos foram menores (P>0,05) do que àqueles encontrados no grupo Sal+MDZ. O Experimento 3 mostrou os efeitos da exposição dos camundongos na presença 12 do rato de brinquedo (RB= estímulo neutro) ou rato de verdade (RV= estímulo aversivo, rato Long Evans), sob a administração de Midazolam (3,0 e 30 nmol). Os animais expostos ao RV apresentaram diminuição do tempo de exploração da caixa (efeito do modelo) quando comparados aos animais expostos ao RB. Para os animais tratados com MDZ nas duas doses, houve aumento nas transições entre os lados do aparato, aumento do tempo na área de exploração e aumentos da latência de fuga para a área protegida e tempo de contato com a grade. No Experimento 4, foi avaliado o efeito da injeção combinada de midazolam e ondansetron (conforme descrito no Experimento 2). O MDZ 30 nmol produziu efeito ansiolítico e a administração combinada de ondansetron e midazolam no hipocampo ventral, reverteu este efeito. Os dados deste trabalho sugerem que, o controle sobre as reações emocionais e de defesa do hipocampo ventral de camundongos expostos ao LCE ou ao teste de exposição ao rato são mediados via receptores GABA-Benzodiazepínicos. Além disso, provavelmente ocorre modulação cruzada entre os interneurônios GABAérgicos e os serotoninérgicos do tipo 5-HT3, pois o bloqueio desses receptores com o ondansetron, pode diminuir a liberação de GABA.

<p>In this case study research project I have determined that multidrug sedation in children younger than eight years are possible.<br /> Conscious sedation [or sedation where verbal contact with the patient is possible] can be used successfully to decrease anxiety and fear for unpleasant experiences, like dental procedures.</p> <p><br /> Behaviour therapy in conjunction with one or more drugs can be used to depress the central nervous system in order to decrease the patient&rsquo / s awareness of unpleasant stimuli. This enables treatment to be carried out without patient interference. Extensive literature surveys were done to determine the ideal drugs as well as the ideal route for conscious sedation in dental treatment for children. In this study project drugs like midazolam, propofol, alfentanyl and ketamine were titrated intravenously to achieve conscious sedation.</p>

The purpose of the project was to investigate the impact of IV and PO routes difference for MDZ, a prototypical CYP3A substrate, and two CYP3A inhibitors (CYP3AI) -FLZ and ERY-, on the magnitude and time course of their inhibitory metabolic DDI. Individual semi-PBPK models for MDZ, FLZ and ERY were developed and validated separately, using pharmacokinetic (PK) parameters from clinical/in-vitro studies and published physiological parameters. Subsequently, DDI sub-models between MDZ and CYP3AIs incorporated non-competitive and mechanism-based inhibition (MBI) for FLZ and ERY, respectively, on hepatic and gut wall (GW) CYP3A metabolism of MDZ, using available in-vitro/in-vivo information. Model-simulated MDZ PK profiles were compared with observed data from available clinical PK and DDI studies, by visual predictive check and exposure metrics comparison. DDI magnitude and time course for CYP3AI (IV vs. PO) followed by MDZ (IV vs. PO) at various time points were predicted by the validated semi-PBPK-DDI models. Two hypothetical CYP3A substrates and four CYP3AI (derived from MDZ, FLZ and ERY, with GW metabolism removed, hepatic metabolism reduced, or oral bioavailability (Foral) and/or elimination half-life (t1/2) modified) were also simulated to generalize conclusions. The final semi-PBPK-DDI models predict well the PK profiles for IV/PO MDZ in absence/presence of IV/PO CYP3AI, with deviations between model-predicted and observed exposure metrics within 30%. Prospective simulations demonstrate that: 1) CYP3A substrates, e.g., MDZ, are consistently more sensitive to metabolic inhibition after PO than after IV administration, due to pre-systemic hepatic and/or GW metabolism. For substrates without GW metabolism and limited hepatic metabolism, only a marginal route difference for substrate administration is observed. 2) For high-Foral CYP3AIs, e.g., FLZ, no inhibitor IV-PO route DDI differences are expected, unless they are given simultaneously with PO MDZ. 3) For low-Foral CYP3AIs, e.g., ERY, greater inhibition is expected after IV than after PO administration for IV MDZ, but is difficult to predict for PO MDZ. 4) In addition to Foral and plasma t1/2 of CYP3AIs, the DDI onset, peak and duration are determined by their oral absorption rate and by the resulting hepatic and/or GW concentration profiles relative to Ki for noncompetitive CYP3AIs, but by CYP3A kinetics (synthesis, degradation rate) for MBI CYP3AIs.

<p>In this case study research project I have determined that multidrug sedation in children younger than eight years are possible.<br /> Conscious sedation [or sedation where verbal contact with the patient is possible] can be used successfully to decrease anxiety and fear for unpleasant experiences, like dental procedures.</p> <p><br /> Behaviour therapy in conjunction with one or more drugs can be used to depress the central nervous system in order to decrease the patient&rsquo / s awareness of unpleasant stimuli. This enables treatment to be carried out without patient interference. Extensive literature surveys were done to determine the ideal drugs as well as the ideal route for conscious sedation in dental treatment for children. In this study project drugs like midazolam, propofol, alfentanyl and ketamine were titrated intravenously to achieve conscious sedation.</p>

Orientador: Telma Gonçalves Carneiro Spera de Andrade / Banca: Miriam Mendonça Morato Andrade / Banca: Hélio Zangrossi Junior / Resumo: Ainda pouco se conhece a respeito da atividade serotonérgica sobre receptores 5-HT1A no hipocampo ventral na regulação de diferentes tipos de ansiedade. O Labirinto em T elevado (LTE) é um teste que avalia separadamente dois subtipos de ansiedade: a ansiedade generalizada e o pânico, respectivamente através da avaliação dos comportamentos defensivos de esquivas inibitórias e das fugas. Assim, este estudo teve por objetivo investigar o envolvimento de receptores 5-HT1A no HV sobre a manifestação dos transtornos de ansiedade generalizada (TAG) e pânico (TP) no LTE, tendo como parâmetro a ativação de receptores gabaérgicos (GABAA) nessa área do hipocampo. Foram conduzidos dois experimentos em ratos Wistar: o Experimento 1, visando avaliar o efeito do midazolam (10, 20 ou 40nmol) - um benzodiazepínico que potencializa a ação do GABA em receptores GABAA; e o Experimento 2, para avaliar o efeito de 8-OH-DPAT (0,6, 3 ou 15nmol) - um agonista de receptores 5-HT1A. Animais dos grupos controles nos dois experimentos foram tratados com salina. Dez minutos após as microinjeções foram submetidos ao LTE para avaliação das latências (em segundos) para esquivas e fugas. Imediatamente após, os animais foram colocados no centro da arena para avaliação da atividade motora (número de quadrados percorridos). Os resultados apontaram que a maior dose de midazolam microinjetada no hipocampo ventral causou ansiólise, comprovada pela diminuição na latência das esquivas em relação aos animais controle... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The little is known about the serotoninergic activity on 5-HT1A receptors in the ventral hippocampus in the regulation of different types of anxiety. The Elevated T Maze (ETM) is a test that evaluates separately two subtypes of anxiety: generalized anxiety and panic, respectively by evaluating the defensive behaviors of inhibitory avoidance and escapes. Therefore this study aimed to investigate the involvement of 5-HT1A receptors in VH on the manifestation of generalized anxiety disorder (GAD) and Panic (PD) in ETM, having as parameter the activation of gabaergic receptors (GABAA) in that area of the hippocampus. Two experiments were conducted in rats: Experiment 1, to evaluate the effect of midazolam (10, 20 or 40nmol) - a benzodiazepine that potentiates the action of the GABA on GABAA receptors; and Experiment 2 to evaluate the effect of 8-OH-DPAT (0.6, 3 or 15nmol) - an agonist of 5-HT1A receptors. Animal control groups in both experiments were treated with saline. Ten minutes after microinjection, the animals were submitted for evaluation to the ETM latencies (in seconds) for avoidances and escapes. Immediately after, the animals were placed in the center of the arena to eavaluation of motor activity (number of covered squares). The results showed that the highest dose of midazolam microinjected in the ventral hippocampus caused anxiolysis, evidenced by the decrease in latency of avoidances compared to controls and those treated animals 10nmol of the same drug. A similar ... (Complete abstract click electronic access below) / Mestre