The Journal of International Medical Research 1990; 18: 257 - 265
Fibrinolytic Activity of Oral Cyclandelate in Patients with Generalized Atherosclerotic Vasculopathy: a Double-blind Study s. Forconi, R. Cappelli, M. Guerrini, C. Frigerio, G.L. Messa and L. Furesi Division of Gerontology and Geriatrics, Institute of Special Medical Pathology, University ofSiena, Siena, Italy
In a double-blind study, a single dose of 1600 mg cyclandelate or placebo was administered to 10 patients with cerebrovascular and! or peripheral vascular disease, and fibrinolytic activity was evaluated before and 1, 2, 4 and 6 h after treatment. Cyclandelate induced a reduction in euglobulin lysis time, an increase in tissue plasminogen activator concentration and a reduction in plasminogen activator inhibitor, (X2-antiplasmin and immunological fibrinogen concentrations, but no changes in antithrombin III and plasminogen concentrations were observed. After placebo administration no significant changes were observed. After treating two patients with 800 mg cyclandelate twice daily for 14 days, 1600 mg cyclandelate stimulated fibrinolysis for 8 h. It is concluded that the fibrinolytic activity of cyclandelate has implications for the treatment of cardiovascular complications of atherosclerosis. KEY WORDS: Cyclandelate; cerebrovascular disease; peripheral vascular disease; fibrinolysis.
INTRODUCTION
C
yclandelate, the mandelic acid ester of 3,3,5-trimethylcyclohexanol with vasoactive properties, is used in the treatment of cerebrovascular disease and peripheral vascular disorders. 1 - 10 Received for publication 15 March 1990; accepted 20 March 1990. Address for correspondence: Professor S. Forconi, Canedra di Gerontologia e Geriatria Universita di Siena, Viale Bracci, 53100 Siena, Italy.
© Copyright 1990 by Cambridge Medical Publications Ltd
In a previous study, it has been demonstrated that oral administration ofl200 mg cyclandelate to patients with peripheral obliterative arterial disease produced a rheological improvement in blood, characterized by a statistically significant decrease in blood viscosity and fibrinogen concentration, together with a reduction in blood filterability.!':" The effect on blood viscosity and filterability reached a peak 1 h after giving cyclandelate, whereas the effect on the concentration of fibrinogen 257
S. Forconi, R. Cappelli, M. Guerrini et at.
seemed to increase progressively until the fourth hour and no changes in the haematocrit were observed. The activity of the drug on the microcirculation has been confirmed and changes in blood flow in the calf have been reported, evaluated by a decrease in the half-time and in the total time of the reactive hyperaemia. A rheological effect of cyclandelate has also been demonstrated in human blood in vitro by Hall and Van den Hoven,13,14 and has been attributed to the inhibition of calcium entering the red blood cells. Although this mechanism might contribute to the rheological improvement of the blood, it is thought that the in vitro results were mainly due to a reduction in the plasma fibrinogen concentration. The importance of this protein as a determinant of viscosity and of red blood cell fIlterability is well established. As the acute fibrinogenolytic effect of cyclandelate suggested a concurrent fibrinolytic activity, a double-blind, placebocontrolled study was carried out to determine the effect of cyclandelate on fibrinolysis in patient with generalized atherosclerotic vasculopathy. PATIENTS AND METHODS
Patients The study consisted of 10 patients (six males, four females; age range 51 - 81 years) suffering from a generalized atherosclerotic vasculopathy with predominantly cerebral and/or peripheral localization but with no recent ischaemic attacks. Study design Patients received 1600 mg cyclandelate or placebo administered randomly after an overnight fast. After administration of the drug, patients remained without food and rested in bed for the following 6 h. Blood samples were taken before drug administration and after I, 2, 4 and 6 h. The same test was repeated after not less than 1 week, in a crossover sequence, administering the treatment not previously received.
258
In two cases, after a single dose of 1600 mg cyclandelate blood samples were collected at intervals over 24 h. These patients were then treated with 800 mg cyclandelate twice daily for 14 days, after which the acute test using 1600 mg cyclandelate was repeated. During these tests the patients were allowed to eat lunch and dinner, but not breakfast. The test was performed in another patient following the administration of400, 800 and 1600 mg cyclandelate or placebo on four different days, with an interval of not less than 3 days between tests. Blood samples were taken 1,2,3,4,6,8, 12 and 24 h after drug administration.
Laboratory assessments The following assays were performed on each blood sample: euglobulin lysis time; 15 tissue plasminogen activator and plasminogen activator inhibitor concentrations, using chromogen substrate (Kabi- Vitrum Ortho Diagnostic Systems); 16,17 (X2-antiplasmin, using chromogen substrate Berichrom (X2-antiplasmin (Behring Institute); clotting fibrinogen, using Multifibren (Behring Institute); immunological fibrinogen, using Nor-Partigen (Behring Institute) radial immunodiffusion according to Mancini et al,18) plasminogen, using M-Partigen (Behring Institute) radial immunodiffusion according to Mancini et al. 18; antithrombin III, using Berichrom Antithrombin III (Behring Institute); fibrinogen degradation products, using the Thrombo-Wellco Test (Wellcome); D-dimer, using the latex test (Ortho-Dimer Test, Ortho Diagnostic Systems). Statistical analysis The mean results were analysed using the Student's t-test for paired data. RESULTS
Important changes in blood chemistry occurred after the administration of 1600 mg cyclandelate (Table 1), whereas no significant variations were seen following pla-
N
\0
Ul
0
Euglobulin lysis time (min) 291 ± 125 r-value P-value Plasminogen (mg%) 13.3 ± l.l t-value P-value a.2-Antiplasmin (%) 98.8 ± 13.5 t-value P-value Antithrombin III (%) 106.0 ± 12.8 r-value P-value Clotting fibrinogen (mg%) 326.8 ± 65.7 r-value P-value Immunological fibrinogen (mg%) 359.1 ± 72.6 r-value P-value Tissue plasminogen activator (IV/mI) 1.8 ± 0.7 r-value P-value Plasminogen activator inhibitor (IV/ml) 19.2 ± 4.8 t-value
Measure
351.7 ± 69.9 0.29 1.12 3.2 ± 1.5 4.02 0.003
344.2 ±78.5 2.1 0.05 3.01 ± 1.6 3.3 0.008 16.5 ± 4.5 2.06
349.1 ± 73.7 2.26 0.04 2.3 ± 1.5 1.6 0.12 17.3 ± 5.6 1.12
16.2 ± 3.2 2.2
151.0 ± 65.5 4.28 0.002 13.1 ± 1.0 3.2 0.009 89.0 ± 14.7 3.38 0.008 106.0 ± 14.1 0.01 0.99 308.4 ± 69.8 2.07 0.06
4
179.5 ± 62.7 3.85 0.003 13.1 ± 1.0 3.25 0.009 92.3 ± 11.7 3.38 0.008 107.2 ± 13.4 0.83 0.42 314.2 ± 62.7 1.87 0.09
2
239.0 ± 107.1 4.36 0.001 13.2 ± l.l 2.33 0.04 94.5 ± 12.1 2.36 0.04 101.5 ± 16.1 1.57 0.15 316.4 ± 60.0 3.45 0.007
1
Time (h)
16.9 ± 2.8 2.05
2.9 ± 1.3 3.4 0.007
358.9 ± 67.7 0.03 0.97
165.5 ± 74.9 4.65 0.001 13.1 ± 1.2 1.8 0.10 91.1 ± 16.0 3.27 0.009 103.6 ± 15.4 1.09 0.30 325.9 ± 73.2 0.12 0.90
6
Table 1 Blood chemistry (mean ± SD) in patients (n = 10) suffering from generalized atherosclerotic vasculopathy before and after oral treatment with 1600 mg cyclandelate
'T1
6'
~
§ 1i'
~.
'.c
J I
200
0
1 1
0
~
-J'"
.~ 400 ,
I ....
g...
700
.5600 .,
.§
Placebo 400 mg cyclandelate 800 mg cyclandelate 1600 mg cyclandelate
"
~
0 1 2 3 4
6
8
12
24
Time (h)
Fig. 3. Changes in (a) euglobulin lysis time and (b) tissue plasminogen activator concentrations following oral administration of placebo or 400 - 1600 mg cyclandelate in a patient with generalized atherosclerotic vasculopathy.
REFERENCES 1. Ball JAC, Taylor AR: Effect of cyclandelate on mental functions and cerebral blood flow in elderly patients. Br Med J 1967; iii: 525 - 528. 2. Rao DB: Cyc1andelate in the treatment of senile mental changes: a double-blind evaluation. JAm Geriatr Soc 1978; 25: 548 - 551. 3. Capote B, Parikh N: Cyclande1ate in the treatment of senility; a controlled study. JAm Geriatr Soc 1978; 26: 360 - 362. 4. Sourander L, Blakemore CB: Effects of Cyclospasmol upon sensory parameters in patients recovering from cerebrovascular accidents. Angiology 1978; 29: 133 - 138. 5. Kuhn RA: Effect of cyclandelate upon cerebral blood flow in patients with stroke. Angiology 1966; 17: 422 - 430. 6. Eichhorn 0: The effect of cyclandelate on cerebral circulation: a double-blind trial with clinical and radiocirculographic investigations. Vascul Dis 1965; 2: 305 - 315. 7. Van Wijk TD: The treatment of peripheral vascular diseases with Cyclospasmol. Angiology 1953; 4: 103 - 113. 8. Ravina A: Traitement des troubles de la circulation peripherique par l' ester amygdalique du 3,3,5-trimethyl-cyclohexanol. Presse Med 1963; 71: 727 - 728.
264
9. Reich T: Cyclandelate: effect on circulatory measurements and exercise tolerance in chronic arterial insufficiency of the lower limbs. J Am Geriatr Soc 1977; 25: 202 - 205. 10. Timmerman H, Wall RJ, Benyon JSE, et al: Cyclospasmol: new insights into basic mechanisms in relation to clinical effects. Br J Clin Pract 1984; 38: 1 - 79. 11. Forconi S, Guerrini M, Di Perri T: Rheological approach to the treatment of cardiovascular disease. In: Endpoints for Cardiovascular Drug Studies (Hegyeli RJ, ed). New York:" Raven Press, 1984; pp 25 - 37. 12. Forconi S, Cappelli R, Pieragalli D, et al: Effect of a single administration of cyclandelate on some rheological and peripheral haemodynamic parameters of peripheral arterial disease patients. In: Microcirculation - an Update (Tsuchiya M, Asano M, Mishima Y, et al, eds). Amsterdam: Elsevier, 1987; pp 537 - 538. 13. Hall DWR, Van den Hoven WE: Influence of cyclandelate on in 'vitro red blood cell deformability. Drugs 1987: 33 (2): 30 - 40. 14. Van den Hoven WE, Hall DWR, Bums JW: Cyclandelate and a number of its metabolites inhibit discocyte echinocyte transformations of human erythrocytes. Br J Clin Pract 1984; 38: 26-29.
Fibrinolytic activity of cyc1andelate 15. Von Kaulla KN, Schulz RL: Methods for the evaluation of human fibrinolysis. Am J Clin Patho11958; 29: 104 - 108. 16. Verheijen JH, Mullart E, Chang GTG, et al: A simple sensitive spectrophotometric assay for extrinsic (tissue-type) plasminogen activator applicable to measurements in plasma. Thromb Haemost 1982; 48: 266 - 269. 17. Chmielewska J, Wiman B: Determination of tissue plasminogen activator and its 'fast' inhibitor in plasma. Clin Chern 1986; 32: 482 - 485. 18. Mancini G, Carbonara AO, Heremans JF: Im-
munochemical quantitation of antigens by single radial immunodiffusion. Immunochemistry 1965; 2: 235. 19. Angleton P, Chandler WL, Schmer G: Diurnal variation of tissue-type plasminogen activator and its rapid inhibitor (PAl-I). Circulation 1989; 79: 101 - 106. 20. Kluft C, Jie AFH, Rijken DC, et al: Daytime fluctuations in blood tissue-type plasminogen activator (t-PA) and its fast-acting inhibitor (PAl-I). Thromb Haemost 1988; 59: 329- 332.
265
Fibrinolytic Activity of Oral Cyclandelate in Patients with Generalized Atherosclerotic Vasculopathy: a Double-blind Study s. Forconi, R. Cappelli, M. Guerrini, C. Frigerio, G.L. Messa and L. Furesi Division of Gerontology and Geriatrics, Institute of Special Medical Pathology, University ofSiena, Siena, Italy
In a double-blind study, a single dose of 1600 mg cyclandelate or placebo was administered to 10 patients with cerebrovascular and! or peripheral vascular disease, and fibrinolytic activity was evaluated before and 1, 2, 4 and 6 h after treatment. Cyclandelate induced a reduction in euglobulin lysis time, an increase in tissue plasminogen activator concentration and a reduction in plasminogen activator inhibitor, (X2-antiplasmin and immunological fibrinogen concentrations, but no changes in antithrombin III and plasminogen concentrations were observed. After placebo administration no significant changes were observed. After treating two patients with 800 mg cyclandelate twice daily for 14 days, 1600 mg cyclandelate stimulated fibrinolysis for 8 h. It is concluded that the fibrinolytic activity of cyclandelate has implications for the treatment of cardiovascular complications of atherosclerosis. KEY WORDS: Cyclandelate; cerebrovascular disease; peripheral vascular disease; fibrinolysis.
INTRODUCTION
C
yclandelate, the mandelic acid ester of 3,3,5-trimethylcyclohexanol with vasoactive properties, is used in the treatment of cerebrovascular disease and peripheral vascular disorders. 1 - 10 Received for publication 15 March 1990; accepted 20 March 1990. Address for correspondence: Professor S. Forconi, Canedra di Gerontologia e Geriatria Universita di Siena, Viale Bracci, 53100 Siena, Italy.
© Copyright 1990 by Cambridge Medical Publications Ltd
In a previous study, it has been demonstrated that oral administration ofl200 mg cyclandelate to patients with peripheral obliterative arterial disease produced a rheological improvement in blood, characterized by a statistically significant decrease in blood viscosity and fibrinogen concentration, together with a reduction in blood filterability.!':" The effect on blood viscosity and filterability reached a peak 1 h after giving cyclandelate, whereas the effect on the concentration of fibrinogen 257
S. Forconi, R. Cappelli, M. Guerrini et at.
seemed to increase progressively until the fourth hour and no changes in the haematocrit were observed. The activity of the drug on the microcirculation has been confirmed and changes in blood flow in the calf have been reported, evaluated by a decrease in the half-time and in the total time of the reactive hyperaemia. A rheological effect of cyclandelate has also been demonstrated in human blood in vitro by Hall and Van den Hoven,13,14 and has been attributed to the inhibition of calcium entering the red blood cells. Although this mechanism might contribute to the rheological improvement of the blood, it is thought that the in vitro results were mainly due to a reduction in the plasma fibrinogen concentration. The importance of this protein as a determinant of viscosity and of red blood cell fIlterability is well established. As the acute fibrinogenolytic effect of cyclandelate suggested a concurrent fibrinolytic activity, a double-blind, placebocontrolled study was carried out to determine the effect of cyclandelate on fibrinolysis in patient with generalized atherosclerotic vasculopathy. PATIENTS AND METHODS
Patients The study consisted of 10 patients (six males, four females; age range 51 - 81 years) suffering from a generalized atherosclerotic vasculopathy with predominantly cerebral and/or peripheral localization but with no recent ischaemic attacks. Study design Patients received 1600 mg cyclandelate or placebo administered randomly after an overnight fast. After administration of the drug, patients remained without food and rested in bed for the following 6 h. Blood samples were taken before drug administration and after I, 2, 4 and 6 h. The same test was repeated after not less than 1 week, in a crossover sequence, administering the treatment not previously received.
258
In two cases, after a single dose of 1600 mg cyclandelate blood samples were collected at intervals over 24 h. These patients were then treated with 800 mg cyclandelate twice daily for 14 days, after which the acute test using 1600 mg cyclandelate was repeated. During these tests the patients were allowed to eat lunch and dinner, but not breakfast. The test was performed in another patient following the administration of400, 800 and 1600 mg cyclandelate or placebo on four different days, with an interval of not less than 3 days between tests. Blood samples were taken 1,2,3,4,6,8, 12 and 24 h after drug administration.
Laboratory assessments The following assays were performed on each blood sample: euglobulin lysis time; 15 tissue plasminogen activator and plasminogen activator inhibitor concentrations, using chromogen substrate (Kabi- Vitrum Ortho Diagnostic Systems); 16,17 (X2-antiplasmin, using chromogen substrate Berichrom (X2-antiplasmin (Behring Institute); clotting fibrinogen, using Multifibren (Behring Institute); immunological fibrinogen, using Nor-Partigen (Behring Institute) radial immunodiffusion according to Mancini et al,18) plasminogen, using M-Partigen (Behring Institute) radial immunodiffusion according to Mancini et al. 18; antithrombin III, using Berichrom Antithrombin III (Behring Institute); fibrinogen degradation products, using the Thrombo-Wellco Test (Wellcome); D-dimer, using the latex test (Ortho-Dimer Test, Ortho Diagnostic Systems). Statistical analysis The mean results were analysed using the Student's t-test for paired data. RESULTS
Important changes in blood chemistry occurred after the administration of 1600 mg cyclandelate (Table 1), whereas no significant variations were seen following pla-
N
\0
Ul
0
Euglobulin lysis time (min) 291 ± 125 r-value P-value Plasminogen (mg%) 13.3 ± l.l t-value P-value a.2-Antiplasmin (%) 98.8 ± 13.5 t-value P-value Antithrombin III (%) 106.0 ± 12.8 r-value P-value Clotting fibrinogen (mg%) 326.8 ± 65.7 r-value P-value Immunological fibrinogen (mg%) 359.1 ± 72.6 r-value P-value Tissue plasminogen activator (IV/mI) 1.8 ± 0.7 r-value P-value Plasminogen activator inhibitor (IV/ml) 19.2 ± 4.8 t-value
Measure
351.7 ± 69.9 0.29 1.12 3.2 ± 1.5 4.02 0.003
344.2 ±78.5 2.1 0.05 3.01 ± 1.6 3.3 0.008 16.5 ± 4.5 2.06
349.1 ± 73.7 2.26 0.04 2.3 ± 1.5 1.6 0.12 17.3 ± 5.6 1.12
16.2 ± 3.2 2.2
151.0 ± 65.5 4.28 0.002 13.1 ± 1.0 3.2 0.009 89.0 ± 14.7 3.38 0.008 106.0 ± 14.1 0.01 0.99 308.4 ± 69.8 2.07 0.06
4
179.5 ± 62.7 3.85 0.003 13.1 ± 1.0 3.25 0.009 92.3 ± 11.7 3.38 0.008 107.2 ± 13.4 0.83 0.42 314.2 ± 62.7 1.87 0.09
2
239.0 ± 107.1 4.36 0.001 13.2 ± l.l 2.33 0.04 94.5 ± 12.1 2.36 0.04 101.5 ± 16.1 1.57 0.15 316.4 ± 60.0 3.45 0.007
1
Time (h)
16.9 ± 2.8 2.05
2.9 ± 1.3 3.4 0.007
358.9 ± 67.7 0.03 0.97
165.5 ± 74.9 4.65 0.001 13.1 ± 1.2 1.8 0.10 91.1 ± 16.0 3.27 0.009 103.6 ± 15.4 1.09 0.30 325.9 ± 73.2 0.12 0.90
6
Table 1 Blood chemistry (mean ± SD) in patients (n = 10) suffering from generalized atherosclerotic vasculopathy before and after oral treatment with 1600 mg cyclandelate
'T1
6'
~
§ 1i'
~.
'.c
J I
200
0
1 1
0
~
-J'"
.~ 400 ,
I ....
g...
700
.5600 .,
.§
Placebo 400 mg cyclandelate 800 mg cyclandelate 1600 mg cyclandelate
"
~
0 1 2 3 4
6
8
12
24
Time (h)
Fig. 3. Changes in (a) euglobulin lysis time and (b) tissue plasminogen activator concentrations following oral administration of placebo or 400 - 1600 mg cyclandelate in a patient with generalized atherosclerotic vasculopathy.
REFERENCES 1. Ball JAC, Taylor AR: Effect of cyclandelate on mental functions and cerebral blood flow in elderly patients. Br Med J 1967; iii: 525 - 528. 2. Rao DB: Cyc1andelate in the treatment of senile mental changes: a double-blind evaluation. JAm Geriatr Soc 1978; 25: 548 - 551. 3. Capote B, Parikh N: Cyclande1ate in the treatment of senility; a controlled study. JAm Geriatr Soc 1978; 26: 360 - 362. 4. Sourander L, Blakemore CB: Effects of Cyclospasmol upon sensory parameters in patients recovering from cerebrovascular accidents. Angiology 1978; 29: 133 - 138. 5. Kuhn RA: Effect of cyclandelate upon cerebral blood flow in patients with stroke. Angiology 1966; 17: 422 - 430. 6. Eichhorn 0: The effect of cyclandelate on cerebral circulation: a double-blind trial with clinical and radiocirculographic investigations. Vascul Dis 1965; 2: 305 - 315. 7. Van Wijk TD: The treatment of peripheral vascular diseases with Cyclospasmol. Angiology 1953; 4: 103 - 113. 8. Ravina A: Traitement des troubles de la circulation peripherique par l' ester amygdalique du 3,3,5-trimethyl-cyclohexanol. Presse Med 1963; 71: 727 - 728.
264
9. Reich T: Cyclandelate: effect on circulatory measurements and exercise tolerance in chronic arterial insufficiency of the lower limbs. J Am Geriatr Soc 1977; 25: 202 - 205. 10. Timmerman H, Wall RJ, Benyon JSE, et al: Cyclospasmol: new insights into basic mechanisms in relation to clinical effects. Br J Clin Pract 1984; 38: 1 - 79. 11. Forconi S, Guerrini M, Di Perri T: Rheological approach to the treatment of cardiovascular disease. In: Endpoints for Cardiovascular Drug Studies (Hegyeli RJ, ed). New York:" Raven Press, 1984; pp 25 - 37. 12. Forconi S, Cappelli R, Pieragalli D, et al: Effect of a single administration of cyclandelate on some rheological and peripheral haemodynamic parameters of peripheral arterial disease patients. In: Microcirculation - an Update (Tsuchiya M, Asano M, Mishima Y, et al, eds). Amsterdam: Elsevier, 1987; pp 537 - 538. 13. Hall DWR, Van den Hoven WE: Influence of cyclandelate on in 'vitro red blood cell deformability. Drugs 1987: 33 (2): 30 - 40. 14. Van den Hoven WE, Hall DWR, Bums JW: Cyclandelate and a number of its metabolites inhibit discocyte echinocyte transformations of human erythrocytes. Br J Clin Pract 1984; 38: 26-29.
Fibrinolytic activity of cyc1andelate 15. Von Kaulla KN, Schulz RL: Methods for the evaluation of human fibrinolysis. Am J Clin Patho11958; 29: 104 - 108. 16. Verheijen JH, Mullart E, Chang GTG, et al: A simple sensitive spectrophotometric assay for extrinsic (tissue-type) plasminogen activator applicable to measurements in plasma. Thromb Haemost 1982; 48: 266 - 269. 17. Chmielewska J, Wiman B: Determination of tissue plasminogen activator and its 'fast' inhibitor in plasma. Clin Chern 1986; 32: 482 - 485. 18. Mancini G, Carbonara AO, Heremans JF: Im-
munochemical quantitation of antigens by single radial immunodiffusion. Immunochemistry 1965; 2: 235. 19. Angleton P, Chandler WL, Schmer G: Diurnal variation of tissue-type plasminogen activator and its rapid inhibitor (PAl-I). Circulation 1989; 79: 101 - 106. 20. Kluft C, Jie AFH, Rijken DC, et al: Daytime fluctuations in blood tissue-type plasminogen activator (t-PA) and its fast-acting inhibitor (PAl-I). Thromb Haemost 1988; 59: 329- 332.
265
