Cyclosporine exacerbates ketamine toxicity in zebrafish: Mechanistic studies on drug–drug interaction

Abstract

Cyclosporine A (CsA) is an immunosuppressive drug commonly used in organ transplant patients to prevent allograft rejections. Ketamine is a pediatric anesthetic that noncompetitively inhibits the calcium-permeable N-methyl-D-aspartic acid receptors. Adverse drug-drug interaction effects between ketamine and CsA have been reported in mammals and humans. However, the mechanism of such drug-drug interaction is unclear. We have previously reported adverse effects of combination drugs, such as verapamil/ketamine and shown the mechanism through intervention by other drugs in zebrafish embryos. Here, we show that ketamine and CsA in combination produce developmental toxicity even leading to lethality in zebrafish larvae when exposure began at 24 h post-fertilization (hpf), whereas CsA did not cause any toxicity on its own. We also demonstrate that acetyl L-carnitine (ALCAR) completely reversed the adverse effects. Both ketamine and CsA are CYP3A4 substrates. Although ketamine and CsA independently altered the expression of the hepatic marker CYP3A65, a zebrafish ortholog of human CYP3A4, both drugs together induced further increase in CYP3A65 expression. In the presence of ALCAR, however, CYP3A65 expression was normalized. ALCAR has been shown to prevent ketamine toxicity in mammal and zebrafish. In conclusion, CsA exacerbated ketamine toxicity and ALCAR reversed the effects. These results, providing evidence for the first time on the reversal of the adverse effects of CsA/ketamine interaction by ALCAR, would prove useful in addressing potential occurrences of such toxicities in humans. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Mechanistic studies on ketamine-induced mitochondrial toxicity in zebrafish embryos

“…Ketamine (2.0 mM) treatment continued for 20 h (static exposures) in the presence or absence of ALCAR (1.0 mM). In our previous studies, these specific concentrations of ketamine and ALCAR for the specific time of exposure were found to be effective in inducing detectable toxicities and their amelioration, respectively (Kanungo et al, 2012; Robinson et al, 2017). Previously, we have shown that the amount of ketamine accumulation (~8 μM) in the zebrafish embryos/larvae treated with 2 mM is closer to the lower range of human anesthetic range (plasma concentration) (Trickler et al, 2013).…”

“…Ketamine-induced cardiac dysfunction has been reported in human fetus (Saarenmaa et al, 2001), infant non-human primates (Hotchkiss et al, 2007), Xenopus (Guo et al, 2016) and zebrafish (Guo et al, 2017; Kanungo et al, 2012; Robinson et al, 2017). Ketamine can affect the right ventricular function and pulmonary artery pressure since it increases pulmonary vascular resistance (Craven, 2007).…”

“…For treatment with ketamine and ALCAR, 28 h post-fertilization (hpf) embryos were used since our previous studies showed that these embryos as whole organisms respond to ketamine anesthesia (Cuevas et al, 2013; Kanungo et al, 2012) and ketamine exposure at the gastrula stage leads to non-specific effects displayed during later development (Robinson et al, 2017). For each experiment that analyzed all the endpoints, eggs laid at the same time from several females were pooled.…”

N-acetylcysteine prevents ketamine-induced adverse effects on development, heart rate and monoaminergic neurons in zebrafish

“…Therefore, it was difficult to determine what effects ketamine and NAC have on those cells. We have previously shown functional evidence that ALCAR’s ability to open L-type calcium channels could be at play to compensate for ketamine’s blockade of calcium-permeable NMDA receptors, especially during prolonged exposures [8,19,25]. Interestingly, NAC has been shown to increase intracellular calcium [22].…”

“…For treatment with ketamine and NAC, 28 hpf embryos were used since our previous studies showed that these embryos as whole organisms respond to ketamine anesthesia [8,18] and ketamine exposure at the gastrula stage leads to non-specific effects [25]. For each experiment that analyzed all the endpoints, eggs laid at the same time from several females were pooled.…”