levosimendan drug discovery and pharmacology

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