\r\n\tComputational fluid dynamics is composed of turbulence and modeling, turbulent heat transfer, fluid-solid interaction, chemical reactions and combustion, the finite volume method for unsteady flows, sports engineering problem and simulations - Aerodynamics, fluid dynamics, biomechanics, blood flow.
",isbn:"978-1-83968-248-3",printIsbn:"978-1-83968-247-6",pdfIsbn:"978-1-83968-321-3",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,hash:"1f8fd29e4b72dbfe632f47840b369b11",bookSignature:"Dr. Suvanjan Bhattacharyya",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10695.jpg",keywords:"Free Turbulent Flow, Discretisation Methods, Aerodynamics, Phase Flow, Bluff-Body, Complex Geometries, Drag Force, Flow Separation, Laminar Diffusion Flame, Non-Premixed Combustion, Fluid Dynamics, Biomechanics",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"January 28th 2021",dateEndSecondStepPublish:"February 25th 2021",dateEndThirdStepPublish:"April 26th 2021",dateEndFourthStepPublish:"July 15th 2021",dateEndFifthStepPublish:"September 13th 2021",remainingDaysToSecondStep:"8 days",secondStepPassed:!0,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Dr. Suvanjan Bhattacharyya is currently working as an Assistant Professor in the Department of Mechanical Engineering of BITS Pilani, Pilani Campus. His research interest lies in computational fluid dynamics, experimental heat transfer enhancement, solar energy, renewable energy, etc.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"233630",title:"Dr.",name:"Suvanjan",middleName:null,surname:"Bhattacharyya",slug:"suvanjan-bhattacharyya",fullName:"Suvanjan Bhattacharyya",profilePictureURL:"https://mts.intechopen.com/storage/users/233630/images/system/233630.png",biography:"Dr. Suvanjan Bhattacharyya is currently working as an Assistant Professor in the Department of Mechanical Engineering of BITS Pilani, Pilani Campus, India. Dr. Bhattacharyya completed his post-doctoral research at the Department of Mechanical and Aeronautical Engineering, University of Pretoria, South Africa. Dr. Bhattacharyya completed his Ph.D. in Mechanical Engineering from Jadavpur University, Kolkata, India and with the collaboration of Duesseldorf University of Applied Sciences, Germany. He received his Master’s degree from the Indian Institute of Engineering, Science and Technology, India (Formerly known as Bengal Engineering and Science University), on Heat-Power Engineering.\nHis research interest lies in computational fluid dynamics in fluid flow and heat transfer, specializing on laminar, turbulent, transition, steady, unsteady separated flows and convective heat transfer, experimental heat transfer enhancement, solar energy and renewable energy. He is the author and co-author of 107 papers in high ranked journals and prestigious conference proceedings. He has bagged the best paper award in a number of international conferences as well. 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\n
1. Introduction
\n
Human immunodeficiency virus (HIV) continues to be an important European public health problem, especially in low-to-medium income countries, such as Romania. UAIDS declared in 2016 between 6100 and 7500 women aged 15 and over as being diagnosed with HIV in our country [1]. The medical system crisis and poverty are the two most important reasons of remaining underdiagnosed. Therefore, the unofficial number is much higher. Worldwide the number is significantly higher.
\n
Pregnancy in HIV-positive females is a challenge due to its risk and fatal complications.
\n
Mother-to-child transmission is particularly analyzed in preventing HIV spreading. The type of birth management in HIV-positive women makes the difference between healthy infants or future new HIV infection sources. Assessing the risks and benefits of every type of birth should be analyzed at the beginning of every pregnancy [2].
\n
The proper method of delivery in HIV-positive female has been analyzed since the beginning of the twenty-first century [3]. Villari et al. in 1993 elaborated an important meta-analysis about six cohort studies regarding the elective caesarian benefits in HIV females. It underlined only a slight effectiveness of C-section in reducing vertical HIV transmission [3, 4]. Until 1999 the international literature was uncertain. A randomized clinical study providing certain information regarding the necessity of selective C-section in preventing HIV transmission was published [5].
\n
In undiagnosed women the vertical transmission is evaluated at 30%. The risk could be higher, depending on the disease evolution/stage and treatment effectiveness [6].
\n
Vaginal birth could lead to newborn infection, increased mortality, and morbidity, especially in undiagnosed or untreated females [6, 7]. To minimize the transmission risk, elective caesarian section (before labor settles or membrane ruptures) is considered the most important method [3].
\n
A scheduled C-section, for the 38th week of pregnancy, to prevent mother-to-child transmission is recommended in women with unknown of high viral load near the delivery time [8]. HIV-positive pregnant women should start their antiretroviral treatment as soon as possible for their own health and to protect their baby [8].
\n
\n
\n
2. Etiology
\n
HIV could be induced in humans by two entities: HIV-1 (with three representative groups: M, major; O, outlier; and N, new) and HIV-2, both from the Retroviridae family. The enzymatic proteins and the most part of the structure are encoded by three genes (gag, pol, and env). HIV-1 is the most frequent. Regarding the expression and infectious release of the virus, there are other six genes involved (regulatory = tat and rev and accessory: vif, vpr, vpu, and nef). On the host cellular membranes, the envelope glycoprotein has contact with CD4, CD1, and CD2 major receptors. HIV-1, a RNA virus, during its replication, enzyme called reverse transcriptase transformed it into a DNA virus. Viral DNA is integrated as proviral DNA. Then, during transcription, proviral DNA is transformed in mRNA, which during translation synthesize immature viral proteins. Assembly viral proteins create mature viral particles and then during budding the new viral particles will be release and they will infect the new cells. HIV-2 is less encountered as HIV-1. It has a slower clinical course, but the outcome is similar to type 1 [9, 10, 11].
\n
The key of infection with HIV is cellular dysfunction, humoral immune dysfunction, and aberrant lymphocyte turnover [9, 10].
\n
The male-female ratio in acquiring HIV infection is 2:3, due to women particular anatomy. After unprotected sexual intercourse, envelope glycoprotein gp120 with the infected particles remains on mucosae surface for a period. Langerhans cells from the cervix have an important affinity for some types of HIV serotypes. The lack of medical education or poverty could interfere with periodical gynecological examination. Females may present multiple entry points for HIV infection, such as ulceration or inflammation of the vaginal mucosae facilitating the entry and multiplication of the virus. Cofactors of transmission are considered the other sexually transmitted diseases (chlamydia, syphilis) [12, 13, 14, 15].
\n
Cultural or religious beliefs could make the women an easier target to sexually transmitted infections. In some communities women are discriminated, are not included in healthcare programs, and do not undergo to periodical gynecological examination. In some situation, women are regarded as “sinners” and blamed for being ill. Social status sometimes prevents women in asking and receiving proper treatment [12, 13, 14, 15].
\n
Due to poverty or sexual inequality, women are involved in illicit commercial sex work. Promiscuity is the main reason in HIV explosion, especially in poor, uneducated environments [15].
\n
\n
\n
3. Epidemiology and risk factors
\n
HIV pandemic has been intensely epidemiologically analyzed. The main purpose was to determine the viable method on reducing mother-to-child transmission. Since the beginning of the twenty-first century until the beginning of the twenty-second century, discussing the more effective method of birth offered contradictory data. In 1999 a European clinical trial underlined the benefits of elective caesarian section in transmitting vertical HIV [5, 11].
\n
HIV could be acquired during blood transfusion or contact with contaminated fluids, dental extractions, vertical transmission, or unprotected sexual intercourse. It is one of the most severe sexually transmitted diseases.
\n
Vertical transmission could occur before or in different stages of pregnancy or postpartum. Pregnancy, labor with membranes ruptured for more than 4 h, infected blood contact or cervicovaginal secretions, and breastfeeding are key points in preventing HIV. Premasticated food could be another method of contamination. In undiagnosed women, the vertical transmission is evaluated at 30% [6, 10].
\n
Infants born from seropositive females should be tested immediately after birth, at 14–21 days, 1–2 months, and 4–6 months. International guidelines recommend viral assay—HIV RNA and HIV DNA. Detection of antibodies is not recommended in children less than 12–18 months due to the presence of residual mother’s antibodies. Mothers diagnosed after birth or incompliant to treatment or with high viral load have a higher risk of HIV transmission. Their infants must be tested at 2–4 weeks from caesarian delivery or antiretroviral prophylaxis. At infants the positive diagnosis is established based on two consecutive positive virologic assays (>1 month and >4 months of life). In children >12–18 months, the HIV antibody tests will be used [16].
\n
HIV genomes had been discovered in different fractions of human milk; therefore breastfeeding should be forbidden. Breastfeeding is not allowed even in women undergoing retroviral treatment because the infected genome could still be present. Replacement formulas are the recommended alternative. If the mother already breastfeeds the infant, without knowing her health status, it is recommended to begin of prophylaxis. Infants born from HIV-positive mother are tested in the first 4–6 weeks of life. Complementary food is offered at 6 months, according to international guidelines [10, 11].
\n
During vaginal delivery, the risk of transmitting HIV to infant is due to microtransfusions during uterine contractions or to exposure to cervicovaginal secretions or blood [3].
\n
Risk factors in HIV vertical transmission were:
Maternal viral load (a higher viral load reflects a lower CD4 T lymphocyte, therefore a more advanced clinical stage).
Period of exposure (undiagnosed before or during the pregnancy, vaginal birth with labor and membranes ruptured, breastfeeding).
Treatment compliance (incompliant mother to antiretroviral treatment has a higher viral load).
Mother’s nutritional and clinical status.
Type of delivery, preterm delivery; membrane ruptures more than 4 h.
The actual data sustain that vertical transmission could be encountered at any maternal viral load, but the risk is lower <1000 copies/ml. The risk is higher when CD4+ count is under 700/mm3 [9, 15].
\n
Establishing the exact moment of contamination is essential in minimizing the risk of vertical transmission. The longer the mother is left untreated, the higher the risk of transmission to her child. In utero contamination had been observed after histological analysis of fetal or placenta tissue. The presence of p24 antigen in fetal tissue represents in utero transmission of the HIV infection [15].
\n
In mother-to-child transmission, the minimum period until clinical manifestations are present is between 12 and 18 months. However, exceptions are frequently encountered, but rarely the diagnosis is established in adolescents [10].
\n
\n
\n
4. Pregnancy planning in HIV-positive women
\n
HIV-positive women are as fertile as healthy ones. The difference is made by the impact of the active virus on the female organism. Therefore, subfertility, underweight, associated diseases (sexually transmitted diseases, respiratory infections), and illicit drug abuse are the reasons of fertility problems or abortion in this social category [17].
\n
HIV-positive women should be guided through a correct contraceptive method (male or female condom, diaphragms, vaginal cups, progesterone injections, transdermal implants, and intrauterine devices). An important discussion subject is represented by the effectiveness of every contraceptive method. There are still uncertain data regarding oral or injectable contraceptive. International studies have not established exactly a connection between hormonal changes—vaginal flora—and mucosae modification and an increased risk of HIV transmission. The Mombasa study underlined a higher predisposition of HIV infection in women undergoing oral or injectable contraceptive therapy, but Beaten et al. in a different cohort could not establish a certain connection. Mombasa study revealed that other sexual transmitted diseases (chlamydia) had a higher incidence and the viral load was higher [17, 18, 19, 20].
\n
The international guidelines underline the necessity of thorough blood evaluation in women who desire to conceive before pregnancy. The same indication is recommended to male partners. The purpose is to eliminate any transmitted diseases to the future child. HIV diagnosis as early as possible before pregnancy or during pregnancy leads to a proper antiretroviral treatment and a close follow-up, reducing the risk of vertical transmission [21]:
\n
Step 1: Complete medical checkup for both parents. Viral load determination is essential.
\n
Step 2: Establishing the correct antiretroviral treatment. Respecting the doses and clinical follow-up.
\n
Step 3: Gynecological evaluation, ultrasound, and cervicovaginal cultures should be done periodically, as the medical team recommends.
\n
Step 4: Discussing and analyzing the prober birth method to prevent or minimize mother-to-child HIV transmission.
\n
\n
\n
5. Pregnancy evolution in HIV-positive women
\n
HIV infection is characterized by cellular and immune dysfunction and aberrant lymphocyte turnover. Pregnancy is regarded as period of decreased immunity due to reduced levels of immunoglobulin or complement. Viral load remains the main tool of viral turnover. Concerns were induced by the impact of pregnancy on HIV progression. Evidence of pregnancy influencing the HIV evolution was noticed in untreated patients or in advanced/complicated stages of disease. Bordeaux University Hospital (France) issued a prospective cohort study on 57 pregnant women that are HIV positive. It revealed that pregnancy had not influence the natural immunosuppression evolution [15, 17, 18, 19, 22]. Madeline Y. Sutton et al. analyzed the immune response (Interleukin-2 low levels secondary determines CD4+ T lymphocyte levels to drop exposing the HIV-positive organism to opportunistic infection) at HIV patients. Sixty-one women were divided in four large groups: 39 pregnant women (20 HIV positive and 19 HIV negative) and 22 nonpregnant equal HIV positive and negative. There were some differences regarding IL-2 production between HIV-positive and HIV-negative pregnant women, but during the third trimester, the differences were insignificant. Therefore, pregnancy does not influence the natural evolution of HIV [15, 22, 23, 24].
\n
Preexisting diseases in HIV-positive women could alter the natural pregnancy evolution. Tuberculosis or other pulmonary infections (Pneumocystis carinii), urinary tract infections, and parasite infections (Toxocara canis) should be mandatorily evaluated or registered in the personal history of the patients. Immunosuppression induced both by the HIV and pregnancy could lead to certain complications that are life-threatening for the mother and fetus [15, 25].
\n
Tuberculosis is considered the most frequent coinfection in seropositive females. Halichidis et al. presented a case report of a 21-year-old pregnant HIV-positive female presenting at admission severe infection signs (fever, right cervical and submandibular painful adenopathy persistent, dry cough). After sputum analysis it established the diagnosis of acute miliary TB. Adequate therapy for both pathologies was implemented. Mother refused abortion, the treatment, and admission. After 20 days she was again admitted but with more severe symptoms. After undergoing emergency caesarian at 30 weeks, she gave birth to a male child (1000 g, small for gestation age) who lived 5 days. One week later the mother died. After biopsy the following diagnosis was established: acute disseminated miliary TB with meningoencephalitis, tuberculoma of the brain, pulmonary edema, acute interstitial nephritis, cardiomyopathy, and atrophic gastritis. The association between these two pathologies has a poor prognosis. It affects the mother and the child; furthermore the drug therapy side effects are multiple and could lead to morbidity or mortality in a high percentage [26].
\n
Spontaneous abortion is higher in HIV seropositive women than in healthy population. It is link to opportunistic infections, anogenital contamination with other sexually transmitted diseases, drug abuse, smoking, and alcohol use [25].
\n
HIV infection can predispose the human host to opportunistic infections and comorbidities. Reitter et al. evaluated 312 pregnant HIV-positive females (Frankfurt HIV cohort) and monitored them over an 11-year period. Complications encountered gestational diabetes mellitus, preeclampsia, and preterm delivery [27].
\n
The type of delivery is also influenced by coexisting urogenital infections. HIV-seropositive females come from promiscuous environments, with unprotected sexual activity, poverty, and lack of medical healthcare systems or medical education. HIV induces an important immunosuppression predisposing to severe forms of sexual transmitted diseases, especially trichomoniasis, gonorrhea, syphilis, and bacterial or fungus vaginitis. The risk of coexisting infections is the same as in healthy women, but its evolution is more severe making it difficult to be eradicated. Group B Streptococcus dominates bacterial urogenital infections. Preinvasive lesions such as different types of neoplasia or inflammatory pelvic disease could be tied to the immunosuppression. Evaluating CIN incidents in 305 HIV-positive females, Ahr et al. underlined its higher prevalence than in healthy women. Human papilloma virus is the frequent responsible agent [24, 28, 29].
\n
A Romanian study evaluated 98 unpregnant HIV-positive female undergoing antiretroviral therapy for cytological modification. Babes-Papanicolau test was performed to determine if there was a connection between immunosuppression and cervical lesions. 73.58% had cervical cytology abnormal results, estimating that squamous cell lesions in seropositive females with peripheral viral load lower than 500 cell/μl are more often encountered than in healthy population (p < 0.02) [30].
\n
Preterm delivery (<37 weeks) and premature birth are two important risk factors in transmitting HIV from mother to child. Kjersti et al. analyzed 219 seropositive pregnant women from Birmingham. It concluded that under the antiretroviral treatment and preterm delivery with ruptured membranes over 4 h, the risk of vertical transmission is minimal. Only two infants whose mother did not receive antiretroviral therapy were seropositive. To reduce to zero, the risk of HIV transmission from mother to child, elective caesarian is the proper attitude [15, 31].
\n
\n
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6. Antiretroviral therapy
\n
The main purpose of antiretroviral therapy is to minimize the transmission and to decrease HIV evolution. Diagnosis timing is essential. Seropositive women antepartum should undergo strict blood count and antiretroviral therapy. Intrapartum or postpartum HIV infection benefits on the same medical steps, underlining that the second category could have a better evolution if the diagnosis is established soon after contamination. Seropositive female may present antiretroviral resistance and lower CD4+ levels [32, 33].
\n
Establishing the correct antiretroviral therapy should be guided by:
The goal of antiretroviral treatment during pregnancy is to drop viral load to undetectability and to maintain it. Secondary risk of transmitting HIV to fetus is minimum. Through the placenta, the antiretroviral drugs are transported to child. In year 2005, in France, a prospective multicenter perinatal cohort, evaluated 8075 HIV+ mother/infant couples over a period of 11 years. Mothers received treatment during pregnancy, they did not breastfeed and viral load was determined. It concluded that the risk of vertical transmitting HIV is zero if antiretroviral therapy is started before pregnancy and the viral load is suppressed [33, 34].
\n
Establishing the moment of HIV contamination is essential in preventing mother-to-child transmission. An English retrospective multicenter cohort study (Read et al.) evaluated 378 pregnancies undergoing retroviral therapy. After analyzing age of gestation, the start of drug therapy, CD4+ count, and viral load, it underlined the following data: if the viral load was under 10,000 copies/ml until a gestational age of 26.3 weeks, the purpose to achieve 50 copies/mlcould be reached. When the viral load was more than 10,000 copies/ml before 20.4 weeks of gestation, the purpose to obtain less than 50 copies/ml until birth was compromised. The level of 50 copies/ml was obtained in 292 pregnancies from a total number of 378 [35].
\n
Zidovudine (dideoxynucleoside reverse transcriptase inhibitors) is the most used antiretroviral drug during pregnancy. Even if there are other types of dideoxynucleoside reverse transcriptase inhibitors (didanosine, zalcitabine, stavudine, lamivudine) with the same action mechanism, they are differentiated by the intracellular phosphorylation and kinetics which lead to other types of side effects/toxicity [36].
\n
Conner et al. evaluated 477 pregnant women seropositive undergoing antiretroviral therapy with zidovudine (antepartum, 100 mg, orally for 5 days; intrapartum 2 mg/kg intravenously until birth). The infant received Zidovudine as well (2 mg/kg, orally for 6 weeks daily). The conclusion is the reducing risk of vertical transmission by 2/3 (70%) of the cases [15, 32, 33, 37].
\n
\n
\n
7. Caesarian vs. natural birth
\n
At the beginning of the twenty-first century, international study tries to evaluate the adequate pathways to minimize the risk of mother-to-child transmission. In an epidemic period in low-income countries, death prevalence due to HIV was increasing.
\n
Previous study results had yield contradictory results. Caesarian section after 4 h since the membranes are ruptured could lead to microtransfusion with mother’s blood to fetus, increasing the risk of HIV transmission. Ignoring the antiretroviral treatment or late diagnosis made it difficult to affirm that caesarian section could or would drop the risk of HIV transmission [2, 38, 39, 40].
\n
The idea of caesarian as method of reducing the risk of transmitting started in France. Duliege et al. observed that in twin pregnancies, the first child to be born has a higher risk of being infected than the second child. One hundred and fifteen twin pairs from HIV-positive females born vaginally or through caesarian section had developed HIV in the following order: vaginal birth, twin A 35% and twin B 15%, and caesarian section, twin A 16% and twin B 8%. The first born from vaginal birth is passing through birth canal in a longer period that the second one. Caesarian section eliminates the risk of contact with blood and vaginal secretions. The main conclusion was that caesarian is a safer method to give birth, preventing the mother-to-child transmission of HIV [36, 40].
\n
International Perinatal HIV Group after analyzing 8533 mother-child pairs established that delivery through caesarian section dropped the risk of HIV transmission with 50% compared with other types of delivery. The percentage was even higher if the seropositive female followed antiretroviral therapy correctly. The combination antiretroviral therapy plus caesarian section before or shortly after membrane ruptures had dropped the transmission with 87% [3].
\n
European Mode of Delivery Collaboration in 1999 after evaluating 370 infants from mothers without any type of delivery indication underlined an 80% reduction of the risk of transmitting HIV in females who gave birth through elective caesarian section [5].
\n
American College of Obstetricians and Gynecologists recommended caesarian section as a prompt intervention in diminishing the mother-to-child transmitting HIV, especially when the peripheral blood count is greater than 1000 copies/ml. The intervention should be established at exact 38 weeks (1 week earlier as in healthy pregnancies), preventing labor or ruptured membranes. Viral load would be analyzed at every 3 months or every time the therapy is changing. Amniocentesis should be avoided in HIV pregnant women [41].
\n
\n
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8. Personal contribution
\n
Romania continues to have a high percentage of HIV infection. In June 2017 UNAID reported a total number of 9074 seropositive women. Data were collected between 1985 and 2017. The group age 15–39 years is presenting the higher incidence—2147 cases. Regarding mother-to-child transmission, there were 480 cases reported [42].
\n
We conducted a 10-year (January 2008–December 2017) retrospective study on 203 pregnant seropositive women, ages between 15 and 41 (average age 24 years), under surveillance at the Hospital for Infectious Diseases, Constanta County. The HIV rate of transmission was 5.8%. From all HIV-positive children, 11 were birth by vaginal delivery and just 1 by caesarian section.
\n
The main purpose was to establish new ways of preventing mother-to-child transmission and to encourage HIV testing as a normal routine screening during pregnancy, even in healthy women. Health status was compromised in all females included in evaluation; 100% had anemia (laboratory inferior limit is 11.7 mg/dl); 32 had values under 8 mg/dl. Coinfection with human papilloma virus (14) and toxoplasmosis (1) was detected in 7.02%. During the third trimester, only four women had undetectable peripheral blood viral load. Levels of CD4+ had values under 500 copies/ml in 116 cases. The HIV stage during pregnancy had been A1, 14 cases; A2, 15 cases; A3, 2 cases; B1, 16 cases; B2, 26 cases; B3, 5 cases; C1, 40 cases; C2, 51 cases; and C3, 27 cases. Seventy-five percent underwent triple antiretroviral therapy, 20% double, and 3% single, and 2% have never received treatment.
\n
Not all patients had reported to the scheduled evaluation; therefore, only in 188 pregnant seropositive females we collected concrete data. Delivery management was divided in caesarian 160 cases and vaginal birth 28 cases.
\n
Analyzing our patients regarding coinfections, we noticed one HIV pregnant women with syphilis, other three with genital warts, six with HCV, and 24 with HBV.
\n
Caesarian section was elected in 28 seropositive women with HCV or HBV coinfection. Two HIV-positive women with coinfection elected vaginal birth. All 30 children were healthy with no viral infections. Caesarian was elected as the proper method of delivery in genital warts and syphilis coinfection. In order to minimize the risk of syphilis transmission, the newborn and mother received Penicillin G treatment. After receiving the correct treatment, mother and child were declared healthy.
\n
In eight cases children were breastfed after delivery. One was HIV negative and the other seven were HIV positive.
\n
As we analyzed in the previous discussions, preterm delivery is frequently encountered. In our study in 60 cases, the delivery was under 37 weeks. Fifty four had weight under 2500 g (the normal inferior weight limit), 28 were preterm, and 26 were declared small for gestational age (it represents the infants born over 37 weeks but with weight under the inferior normal limit). Nine mothers had died due to HIV complications and lack of treatment compliance, after a medium period of 32 months after birth. Nine infants had died (one at 1 day, one at 12 days, four at 1 month, two at 27 months, and one at 7 months). In eight cases of vaginal birth, the infants’ viral load was >10,000 copies/ml. In caesarian section the medium viral load was <50 copies/ml. In two cases we encountered values over 500 copies/ml. In those two situations, mother presented vaginal coinfections, and compliance to treatment is doubtful. In four cases infants were breastfed; three of them were born vaginally, and their mother even if they underwent triple antiretroviral therapy had peripheral viral load over 10,000 copies/ml.
\n
In a study performed between January 2008 and August 2013, we analyze 124 HIV-positive mothers and their newborns. In the studied period, the maternal-fetal rate of HIV transmission was 4.8%.
\n
The mortality rate for children was 5.6% and for mothers was 7.2%. Around 97.5% of the children received antiretroviral treatment after birth, and 93.1% of the mothers received antiretroviral treatment during pregnancy.
\n
The proper health status evaluation in children is by growth charts. It provides information regarding the weight, length, and cranial perimeter. In this study, 22.76% were under the tenth percentile for length and weight, underlying the improper development during in utero life—small for gestational age. In 11.38% we encountered a symmetrical intrauterine delay, represented by weight, length, and cranial perimeter positioned under the tenth percentile.
\n
In this study, we performed a linear regression to find if some parameters of the mothers correlate with difficulties in intrauterine growth appreciate below the level of tenth percentile. We found that the cranial perimeter of children under the percentile of tenth correlates with the hemoglobin value in pregnancy (p = 0.027), the CD4 value in the last trimester of pregnancy (p = 0.003), and the Apgar score (p < 0.0001). The weight of children under the tenth percentile correlates with the CD4 value in the last trimester of pregnancy (p = 0.011), as well as the Apgar score (p < 0.0001). The height of children under the percentile of tenth correlates with the hemoglobin value in pregnancy (p = 0.05), the CD4 value in the last trimester (p = 0.05), and the Apgar score (p < 0.0001). In this study cART duration in pregnancy, duration of gestation, type of delivery (C-section or vaginal delivery), and HIV viral load value do not influence the newborn parameters: weight, length, and cranial perimeter related with tenth percentiles of growth.
\n
Intrauterine growth restriction is often encountered in seropositive females. Our data are sustained by the international literature. Cailhol and Dreyfuss obtained the same results [43, 44, 45].
\n
The study performed on 124 children (66 males and 58 females) underlined a mean hemoglobin level of 10.37 mg/dl in male children, with a 1.33 mg/dl standard deviation. In female children, the mean hemoglobin was 10.32 mg/dl with a standard deviation of 1.32 mg/dl (Figure 1).
\n
Figure 1.
Mean hemoglobin level in pregnancy according with newborn sex.
\n
There are significant differences between the mean hemoglobin values of the two groups [p = 0.196; df = 122; p = 0.845; the 95% confidence interval (IC) for the average is (−0.42; 0.51)].
\n
The mean CD4 value in male children was 421.15 cells/mmc with a standard deviation of 27.83, and in female children, the mean CD4 was 414.46 cells/mmc with a standard deviation of 35.1 (Figure 2). There are no significant differences between the mean CD4 values of the two groups [t = 0.151; df = 122; p = 0.880; the IC 95% for the average is (−81,046; 94,418)].
\n
Figure 2.
Mean CD4 count in mothers according with newborn sex.
\n
The mean cART duration in male children was 28.33 weeks with a standard deviation of 14.095, and in female children, the mean cART duration was 26.74 weeks with a standard deviation of 14.81 (Figure 3). There are no significant differences of the mean cART duration between the two groups [t = 0.613; df = 122; p = 0.541; the IC 95% for the average is (−3551; 6735)].
\n
Figure 3.
Mean cART duration in pregnancy according with newborn sex.
\n
The mean cranial perimeter in all studied newborn was 32.5 cm with a standard deviation of 2.13939. In male children the mean cranial perimeter was 32.5 cm with a standard deviation of 1.95503, and in female children, the mean cranial perimeter was 32.5 cm with a standard deviation of 2.34895 (Figure 4). The obtained cranial perimeters correspond to 3–5th percentiles on growth charts.
\n
Figure 4.
Cranial perimeter according with newborn sex.
\n
The mean length in newborn from HIV-positive mothers was 47.7258, with a standard deviation of 2.67885. In male children it was 47.9 cm with a standard deviation of 2,66,445, and in female children it was 47.51 cm with a standard deviation of 2.70309 (Figure 5). These length values correspond to 10–25th percentiles on growth charts.
\n
Figure 5.
Length according with newborn sex.
\n
The mean weight in male children was 2734.69 g with a standard deviation of 436,65,942, and in female children, the mean weight perimeter was 2677,4138 g with a standard deviation of 542,33,918 (Figure 6). These weight values correspond to 5–10th percentiles on growth charts.
\n
Figure 6.
Weight according with newborn sex.
\n
\n
\n
9. Conclusions
\n
HIV infection continues to be an important public health problem worldwide due to its cost, morbidity, and mortality. Antenatal screening for HIV should be implemented for every woman as the easier method available to reduce transmission, especially mother-to-child transmission.
\n
Although in our study C-section did not make a clear delimitation between HIV-positive and HIV-negative children, it seems that in children born from HIV-positive mothers with high HIV viral load, delivery by C-section is mandatory.
\n
Although the indication of C-section in HIV-positive women is controversial, in situations in which HIV viral load is high or is not affordable near the time of delivery, and in mothers with poor adherence to antiretroviral treatment, C-section remains one of the most important measures of prevention for HIV mother-to-child transmission.
\n
\n\n',keywords:"HIV, delivery, C-section, newborn, HIV viral load",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/61216.pdf",chapterXML:"https://mts.intechopen.com/source/xml/61216.xml",downloadPdfUrl:"/chapter/pdf-download/61216",previewPdfUrl:"/chapter/pdf-preview/61216",totalDownloads:391,totalViews:352,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,dateSubmitted:"November 23rd 2017",dateReviewed:"March 29th 2018",datePrePublished:null,datePublished:"September 26th 2018",dateFinished:null,readingETA:"0",abstract:"The international main goal is to reduce mother-to-child HIV transmission. The appropriate birth delivery for seropositive woman has been analyzed since the beginning of the twenty-first century. Although at the beginning of HIV pandemic delivery by caesarian section (C-section) was considered mandatory in many studies and meta-analyses, recent information reveal limited benefits. Mother-to-child transmission is higher when mothers are diagnosed late during pregnancy, in advanced stages with a high HIV viral load, and labor with membranes ruptured for more than 4 h, especially when the antiretroviral treatment is not respected. During vaginal delivery, the risk of HIV transmitting to infant is due to microtransfusions during uterine contractions or by newborn exposure to cervicovaginal secretions or blood. Although the indication of C-section in HIV-positive women is controversial, there are some situations in which C-section remains mandatory. In mothers diagnosed late during pregnancy, in situation in which HIV viral load is not affordable in real time in the last trimester of pregnancy, and in mothers with poor adherence to antiretroviral treatment, C-section remains one of the most important measures of prevention for HIV mother-to-child transmission.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/61216",risUrl:"/chapter/ris/61216",book:{slug:"caesarean-section"},signatures:"Simona Claudia Cambrea and Anca Daniela Pinzaru",authors:[{id:"189887",title:"Associate Prof.",name:"Simona Claudia",middleName:null,surname:"Cambrea",fullName:"Simona Claudia Cambrea",slug:"simona-claudia-cambrea",email:"cambrea.claudia@gmail.com",position:null,institution:{name:"Ovidius University",institutionURL:null,country:{name:"Romania"}}},{id:"250093",title:"Dr.",name:"Anca Daniela",middleName:null,surname:"Pinzaru",fullName:"Anca Daniela Pinzaru",slug:"anca-daniela-pinzaru",email:"ancadaniela_dumitru@yahoo.com",position:null,institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Etiology",level:"1"},{id:"sec_3",title:"3. Epidemiology and risk factors",level:"1"},{id:"sec_4",title:"4. Pregnancy planning in HIV-positive women",level:"1"},{id:"sec_5",title:"5. Pregnancy evolution in HIV-positive women",level:"1"},{id:"sec_6",title:"6. Antiretroviral therapy",level:"1"},{id:"sec_7",title:"7. Caesarian vs. natural birth",level:"1"},{id:"sec_8",title:"8. Personal contribution",level:"1"},{id:"sec_9",title:"9. Conclusions",level:"1"}],chapterReferences:[{id:"B1",body:'UNAIDS. Country factsheets. Romania 2016. http://www.unaids.org/en/regionscountries/countries/romania [Accessed: February 19, 2018, 18:52]\n'},{id:"B2",body:'Read JS, Newell MK. Efficacy and safety of cesarean delivery for prevention of mother-to-child transmission of HIV-1. 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Determinants of low birth weight among HIV infected pregnant women in Tanzania. The American Journal of Clinical Nutrition. 2001;74(6):814-826\n'},{id:"B45",body:'Cambrea SC, Tanase DE, Ilie MM, Diaconu S, MArcas C, Carp DS, Halichidis S, Petcu CL. Can HIV cause an intrauterine growth restriction? BMC Infectious Diseases. 2013;13(Suppl 1):O5. DOI: 10.1186/1471-2334-13-S1-O5\n'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Simona Claudia Cambrea",address:"cambrea.claudia@gmail.com",affiliation:'
Faculty of Medicine, Ovidius University, Constanta, Romania
Faculty of Medicine, Ovidius University, Constanta, Romania
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1. Introduction
Neurotic disorders (NDs) are among the most common mental diseases leading to a decrease in the quality of life, lack of socialization, and increased mortality [1]. Around 20–40% of primary care outpatients are diagnosed with NDs according to International Disease Classification (ICD)-10 or Diagnostic and Statistical Manual of Mental Disorders (DSM) V criteria [2].
ICD-10 classification of the NDs F40–F48 includes phobic anxiety disorders (F40), other anxiety disorders (AD, F41), obsessive-compulsive disorder (OCD, F42), reaction to severe stress, adjustment disorders (F43), dissociative and conversion disorders (F44), somatoform disorders (SD, F45), and other nonpsychotic mental disorders (F48). In the DSM V, the same disorders are classified as Anxiety Disorders, Obsessive-Compulsive and Related Disorders, Trauma- and Stressor-Related Disorders, Dissociative Disorders, and Somatic Symptom Disorder [3, 4].
Phobias are present in 1.3–5.7% of all NDs [5]. Anxiety symptoms are thought to occur in every 14th person during the lifetime [6]. The prevalence of SD is 20–25%, but at least one medically unexplained symptom is found in 40–49% of patients [7, 8]. Around 10% of all psychiatric patients have dissociative disorder [9, 10]. A lifetime prevalence of OCD is 2.3%, and the rate of adjustment disorder is 1–2% [5].
The overlaps between AD, phobias, and SD were shown and considered a result of similarity of pathogenesis, which involves disturbances in hypothalamic-pituitary-adrenal axis (HPAA), cytokine levels, and changes in the state of receptors in the nervous system [11, 12, 13, 14, 15]. Continued and prolonged stress may disturb the HPAA to such an extent that the negative feedback mechanisms (glucocorticoid negative feedback, in particular) are disrupted, and the adaptive responses of the HPAA may then become maladaptive. Enhanced proinflammatory cytokine production and overactivation of the sympathetic nervous system contribute to a state of chronic low-grade inflammation.
NDs have a great social impact. A British survey (1993) reported that 8.3% of 10,000 responders had ND limiting their daily activities and 3.4% experienced severe “disabling” NDs, associated with a higher chance of being unemployed [16]. The cost of AD treatment in the European Union was approximately 41 billion € in 2004 and 66 billion € in 2010 [17, 18]. Taking into consideration the prediction of the growing influence of mental health problems on the economic output by 2030 [19], we expect the increasing burden of NDs.
The diagnosis and treatment of all types of NDs are challenging. More than 20% of AD patients are undertreated and continue to suffer from symptoms [11]. A study by Wang revealed a 2–3-year delay in the diagnosis of NDs [20]. Around 40–66% of SD cases are underdiagnosed in primary care [21]. The first line of treatment for most of NDs is selective serotonin reuptake inhibitors (SSRIs). Nevertheless, their efficacy and safety are still under consideration. The high placebo effect was shown in randomized controlled studies of SSRI in the treatment of phobic disorder, OCD, and generalized anxiety disorder (GAD) [22]. There are only 40–60% of responders to first-line therapy among OCD patients [23]. In the Cochrane review by Kleinstaeuber et al., low-quality evidence for the efficacy of new generation antidepressants in SD was obtained [24]. Adverse events such as insomnia, nausea, sexual dysfunction, and withdrawal are common for SSRI. Negative drug interactions are also limiting their use in patients receiving therapy for somatic diseases. Other antidepressant drugs such as tricyclic antidepressants (TCA) have been shown to be effective for the treatment of some NDs in several trials, although the Cochrane review did not reveal any significant differences in the comparison of tricyclic antidepressants (TCA) and other medications in SD [24]. The safety profile of TCA is more unfavorable than SSRI. The use of benzodiazepines in ADs is limited due to the sedation, myorelaxant effect, and negative impact on cognition they provoke in long-term use. Among nonpharmacological treatments, only cognitive behavioral therapy was shown to be effective with greater results in combination with medication [22].
In the light of the ongoing search for an effective and safe therapeutic strategy influencing certain aspects of ND pathogenesis, technologically processed highly diluted antibodies to the brain specific S100 protein (TP Abs to S100) seem to be a perspective substance for treatment.
In the central nervous system (CNS), the brain-specific S100 protein is synthesized mainly by astrocytes and then transported to neurons where it is involved in numerous processes. In particular, it was shown that S100 affects the differentiation and survival of neurons, the growth of dendrites, the integrity of cytoskeleton, and energy metabolism [25].
Increased level of S100 is considered a marker of blood brain barrier failure. S100 serum levels are elevated after stroke, subarachnoid hemorrhage, and brain trauma and correlate positively with patient outcome. However, the brain-specific S100 protein may be secreted peripherally, and its elevated serum levels are also found in heart diseases and infections. High serum levels of the brain-specific S100 protein are also found in patients with schizophrenia, depressive/bipolar disorders, and obesity, but which cells are the sources of S-100 protein in these conditions is unknown [25, 26].
A number of nonclinical studies of TP Abs to S100 efficacy, safety, and mechanisms of action using the commonly applied experimental in vivo and in vitro models preceded clinical investigation. While studying the drug’s primary and secondary pharmacodynamics, it was shown that TP Abs to S100 exert stress-protective [27], anxiolytic [28, 29, 30, 31, 32, 33], antidepressant [30, 31, 34], antiamnestic [35, 36, 37], and neuroprotective [38, 39] activities.
Target identification and mechanism-of-action studies revealed that the drug recruits serotonin-, dopamine-, GABA-, noradrenaline-, and glutamatergic systems [29, 30, 40, 41, 42] and thereby might be considered a player in various neurotransmitter-mediated processes. Moreover, TP Abs to S100 influence sigma1 receptor [41] that in turn modulates the activity of almost all neurotransmitter systems and thereby possesses a spectrum of psychotropic activities [43, 44].
Data on the TP Abs to 100 mechanisms of action and identified pharmacodynamics of the drug are consistent with the literature data on the relationship between influencing certain neurotransmitter systems (their receptors) and observing subsequent psychotropic effects. For example, it is known that benzodiazepines mediate their anxiolytic activity and sedation via GABAA receptors [45, 46]. GABAB receptor agonists are known to attenuate the behavioral deficit-restoring effect of antidepressants [47, 48]. Ligands of 5-HT1A, 5-HT1B, 5-HT1F, 5-HT2а, 5-HT2B, 5-HT2C, and 5-HT3 receptors were shown to regulate aggression, anxiety, learning, addiction, locomotion, memory, mood, and so on [49]. Ligands of the glycine site of the NMDA receptor exhibit anxiolytic and antidepressant properties and impact memory-related processes [50, 51, 52, 53, 80]. D3 receptor deficiency can result in chronic depression and anxiety [54]. Sigma1 receptor ligands have a whole spectrum of psychotropic effects due to their modulating effect on all major neurotransmitter systems [43, 44], which also are in line with TP Abs to S100 mechanism of action.
More than 2000 patients with GAD (F41.1), SD (F45), adjustment disorders (AjDs) (F43.2), neurasthenia (F48.0), and anxiety accompanying somatic diseases (cardiovascular and gastrointestinal disorders) took part in phase III, IV, and post-marketing clinical trials (CTs) of TP Abs to S100, including two double-blind placebo-controlled randomized CTs and nine open-label comparative randomized CTs [55, 56, 57]. TP Abs to S100 were shown to be as effective as clonazepam 0.5–1 mg/day, bromdihydrochlorphenylbenzodiazepine 1.5 mg/day (for 7 days), and tofisopam 100 mg/day but causing less adverse events (AEs) [58, 59, 60].
The evidence on the safety of TP Abs to S100 was obtained in clinical and nonclinical trials. In CTs, TP Abs to S100 exerted less AEs typical for other antianxiety medications such as daytime sleepiness and muscle relaxation. No cases of withdrawal symptoms, addiction to TP Abs to S100, or negative drug interactions have been registered up-to-date. In nonclinical trials, no myorelaxant and toxic effects were observed.
In the current review, we describe the mechanisms of action and pharmacological effects of TP Abs to S100 demonstrated in nonclinical (preclinical) and clinical studies. Based on the data, we attempt to evaluate the future perspectives of the TP Abs to S100 as the drug of choice for ND treatment.
2. Preclinical trials of technologically processed highly diluted antibodies to S100 protein
2.1 Pharmacodynamics
2.1.1 Biological activity
2.1.1.1 Antistress activity of TP Abs to S100
Antistress activity of TP Abs to S100 was studied using three approaches.
2.1.1.1.1 Effect on somato-vegetative manifestations of stress
Negative emotions arising from stress caused by the anticipation of pain or other negative expectations (in particular, on the eve of surgical operations, educational tests, important meetings, etc.) are accompanied by anxiety and fear. Concurrently, a cascade of somato-vegetative manifestations of stress is initiated [61].
Modeling of a conditioned emotional reflex to unescapable electric pain stimulation was performed on outbred white male rats weighing 220–280 g [27]. This was followed by monitoring of animal behavior in a stressful situation (repeated placement in an experimental ‘dangerous’ camera) as well as emotional responses when stress was intensified by an additional negative provocation (approaching an unfamiliar object to the animal’s head). Antistress activities of TP Abs to S100 and diazepam (‘classical’ benzodiazepine tranquilizer, positive control) were estimated by administering drugs one day after development of the conditioned reflex.
Rats in the control group (hereinafter, animals that received distilled water as a placebo) when they were subsequently placed in a “dangerous” chamber responded by freezing (45%) or actively trying to escape the chamber (35%) (Table 1A). Only 20% of rats showed calm behavior. At the same time, somato-vegetative manifestations of stress were observed in animals (especially with a passive reaction): increased frequency of breathing, urination, defecation, and squeaking. Both TP Abs to S100 and diazepam caused a decrease in the number of rats with a passive and active response to stress, as well as significantly (three times) increased the number of animals with a calm orientation-exploratory activity. Somato-vegetative manifestations of stress also dissipated in both groups.
Parameter
[A] Stress induced by anticipation of pain
[B] Stress induced by anticipation of pain with additional negative stimulation
TP Abs to S100 antistress activity in a model of a conditioned emotional reflex to unescapable electric pain.
р < 0.05 versus corresponding control.Bold entries were made to emphasize the results in TP Abs to S100 group.
Note: animals were intragastrically administered distilled water (2.5 ml/kg, control), TP Abs to S100 (2.5 ml/kg), or diazepam (1 mg/kg) at a single dose 30 minutes prior to testing. n/a, not applicable; TP Abs to S100, technologically processed highly diluted antibodies to S100 protein.
The emotional reaction of anxiety and anxiety associated with the expectation of pain in a “dangerous” chamber was significantly enhanced when using additional provocation—bringing an unfamiliar object to the head of the animal. This was manifested as an increase in the number of rats with active (up to 40%) and passive (up to 55%) behavior and a decrease in the number of animals with calm behavior (down to 5%) (Table 1B). Respiratory symptoms, squeaking, frequency of defecation, and urination also increased. Both drugs (TP Abs to S100 and diazepam) reduced the severity of stress induced by expectation of pain. TP Abs to S100 reduced both the number of animals with a spontaneous active and passive reaction by 20%, while diazepam reduced the number of animals with active attempts to escape the chamber (by 35%) more than the number of animals with freezing (only by 10%). The same trend continued with additional negative provocation, which may be the result of the sedative activity of diazepam, which TP Abs to S100 do not have.
2.1.1.1.2 Effect on c-Fos protein expression
It is known that immediate-early response c-fos gene expression in the hypothalamic paraventricular nucleus is one of the primary biological markers of stress [62]. The effectiveness of stress-protective compounds can be assessed by their ability to suppress c-fos expression in the brain.
The study was conducted on male Wistar rats weighing 250–280 g [63], classified as active or passive (stress-resistant or predisposed to stress, respectively) in the open field (OF) test [64]. The OF test is widely used to study the behavior of rats [65]: animals are placed in the center of the OF arena and the horizontal and vertical activity, the number of entries into the center zone, as well as the number of acts of defecation and urination (emotionality) is recorded.
Rats were administered TP Abs to S100 or imipramine (antidepressant drug that modulates c-fos expression) and then subjected to 1-hour immobilization with simultaneous electrocutaneous irritation. Immunohistochemical detection of c-Fos protein in the parvocellular neurons of the paraventricular nucleus of the hypothalamus was performed in samples obtained 90 min after the procedure, at the peak of the protein expression [62].
In response to stress, c-Fos protein level significantly increased (vs. intact animals) in both active and passive animals (20–25 fold), and in the latter, this increase was more pronounced (Figure 1). TP Abs to S100 and imipramine demonstrated equally and pronounced antistress activity in passive animals: 1.2- and 1.5-fold decrease in the number of Fos-positive cells was observed, respectively.
Figure 1.
TP Abs to S100 effect on c-Fos protein expression (stress marker) in the rat hypothalamic paraventricular nucleus after 1-hour immobilization with simultaneous electrocutaneous irritation. Note: animals were intragastrically administered distilled water (2.5 ml/kg, control), TP Abs to S100 (2.5 ml/kg) or imipramine (12 mg/kg) at a single dose or for 20 days preceding stress exposure. Data are expressed as M ± SD. *р < 0.05 (#р < 0.001) versus corresponding control. TP Abs to S100, technologically processed highly diluted antibodies to S100 protein.
2.1.1.1.3 Effect on gastric ulcers after an immobilization stress
Another important biological marker of stress is development of ulcers in the gastric mucosa. For example, it is known that immobilization stress is accompanied by severe gastric ulceration [66].
The study of antistress activity of TP Abs to S100 was carried out on male Wistar rats weighing 250–280 g, classified as active or passive in the OF test [67]. Animals were administered TP Abs to S100 at a dose of 2.5 ml/kg for 5 consecutive days or placebo. On the 6th day, half of the rats from each group were immobilized by fixing their paws on a special platform for 1 h, and then the number of animals with ulcers and total number of ulcers formed in the stomach was counted.
TP Abs to S100 decreased by 33.4% the number of animals with ulcers in the group of passive (but not active) rats, which complements the previously obtained results on the higher efficacy of the drug in passive, highly sensitive to stress animals.
TP Abs to S100 also reduced the total number of ulcers in both groups by more than 50%. Again, in control passive animals, there were 1.3 times more ulcers than in control active ones. However, after TP Abs to S100 administration, there was no such difference.
2.1.1.2 Anxiolytic activity of TP Abs to S100
The studies were carried out on outbred white male rats weighing 230–250 g [31] using the most widely validated tests (the Vogel conflict test, the elevated plus maze test, and the OF test) [65]. The activity of TP Abs to S100 was compared to diazepam.
The conflict situation in the Vogel test was created by exposing animals to opposing behavioral tendencies: motivation to drink and fear, when every attempt to drink was punished by an electric shock. This lead to a significant reduction in water consumption. Drugs with anxiolytic properties alter behavior and cause an increase in drinking.
To study the activity of TP Abs to S100, depending on the individual reaction to stress, animals were grouped into highly (stress-resistant) and low active (predisposed to stress) in the forced swim test with water wheel (Nomura test), in which stress is modeled, and asthenia and depressive behavior are evaluated. Then, animals were treated with TP Abs to S100 or diazepam, and the Vogel conflict test was performed.
Anxiolytic effect of TP Abs to S100 was not inferior to that of diazepam: the number of punished water intakes in highly active groups increased by 27.4 and 28.7%, respectively (Figure 2). Meanwhile, in low-activity animals characterized by a predisposition to asthenia and depressive behavior [64], TP Abs to S100 efficacy was superior to diazepam (2.8 and 2 times vs. control, respectively). The data obtained indicate that in addition to the anxiolytic activity TP Abs to S100 have an antiasthenia activating effect, which distinguishes them from diazepam that induces both anxiolytic and sedative effects.
Figure 2.
TP Abs to S100 demonstrate anxiolytic activity in the Vogel conflict test. Note: animals were intragastrically administered distilled water (2.5 ml/kg, control), TP Abs to S100 (2.5 ml/kg) or diazepam (2 mg/kg) at a single dose 30 minutes prior to testing. Data are expressed as M ± SD. *р < 0.05 versus corresponding control. TP Abs to S100, technologically processed highly diluted antibodies to S100 protein.
The elevated plus maze test is based on the fear of heights and open spaces: animals are placed on the central platform of the maze and the latent period before the first entry into the open arms, the number of full and incomplete entries and the duration of stay in them, as well as the number of head dips below the level of the open arms is recorded.
It was established that TP Abs to S100 and diazepam had a similar anxiolytic effect in this test: both drugs increased the number of entries into the open arms (1.9 and 2.3 times, respectively), the time spent in the open arms (5.4 and 7 times), as well as the number of head dips (5 and 9 times) versus control animals (Table 2).
TP Abs to S100 anxiolytic activity in the elevated plus maze test.
р < 0.05 versus control.Bold entries were made to emphasize the results in TP Abs to S100 group.
Note: animals were intragastrically administered distilled water (2.5 ml/kg, control), TP Abs to S100 (2.5 ml/kg), or diazepam (2 mg/kg) at a single dose 30 minutes prior to testing. Data are expressed as M ± SD. TP Abs to S100, technologically processed highly diluted antibodies to S100 protein.
In the OF test, the antianxiety activity of TP Abs to S100 and diazepam was demonstrated by the fact that rats began to go to the center of the field, which was not observed in the control group (Table 3). However, unlike diazepam, which reduced the horizontal activity of animals by 1.5 times, TP Abs to S100 did not change this parameter and, therefore, did not have a sedative effect.
TP Abs to S100 anxiolytic activity in the open field test.
р < 0.05 versus control.Bold entries were made to emphasize the results in TP Abs to S100 group.
Note: animals were intragastrically administered distilled water (2.5 ml/kg, control), TP Abs to S100 (2.5 ml/kg), or diazepam (2 mg/kg) at a single dose 30 minutes prior to testing. Data are expressed as M ± SD. TP Abs to S100, technologically processed highly diluted antibodies to S100 protein.
2.1.1.3 Antiaggressive activity of TP Abs to S100
Anxiety disorders are often accompanied by covert or overt aggression. The antiaggressive activity of TP Abs to S100 was studied in the tests of motivated and unmotivated aggression on outbred adult white male rats weighing 200–250 g in comparison with diazepam [68].
In the test of unmotivated aggression caused by inescapable shock, the threshold of aggressive response of a pair of animals placed on a grid floor was determined by increasing the stimulating current. Animals manifested shock-elicited aggression when they assumed upright “boxing” posture and tried to bite and strike each other with front and hind paws.
TP Abs to S100 and diazepam after a single dose and course administration exerted antiaggressive activity: single TP Abs to S100 administration increased the threshold of aggressive response by 23.1%, and after a 4-day administration—by 31.3% compared with the control, while diazepam increased this threshold by 26.3 and 34.9%, respectively (Figure 3).
Figure 3.
TP Abs to S100 and diazepam effects on rat’s aggressive reaction parameters in the tests of motivated and unmotivated aggression. Note: animals were intragastrically administered distilled water (2.5 ml/kg, control), TP Abs to S100 (2.5 ml/kg) or diazepam (2 mg/kg) at a single dose or for 5 days (2 times per day) prior to testing. Data are expressed as M ± SD. *р < 0.05 versus corresponding control. TP Abs to S100, technologically processed highly diluted antibodies to S100 protein.
The test of motivated aggression is based on the study of the intensity of the aggressive reaction elicited in a pair of rats trying to escape electric shock. Rats were individually taught to avoid pain caused by electric irritation of the paws on a safe bench installed in the center of the chamber. Then, they were placed in pairs in the chamber, and their behavior was observed for 2 min. Control animals began to fight for a safety on the bench, which had a capacity to tightly fit both animals. The criterion for the effectiveness of substances with antiaggressive action in this test was the duration of joint avoidance of pain exposure.
TP Abs to S100 and diazepam had a pronounced antiaggressive effect, increasing the duration of joint avoidance: with a single dose, respectively, 3.4 and 3.1 times, and with a course—3.8 and 3.3 times (Figure 3).
2.1.1.4 Other psychotropic and neurotropic activities of TP Abs to S100
Along with the above-described activities (stress-protective and anxiolytic), TP Abs to S100 were shown to exert:
antidepressant effect in Porsolt’s and Nomura’s forced swimming tests [30, 31, 34];
antiamnestic and neuroprotective effects in the models of ischemic and hemorrhagic stroke [35, 36, 37, 38, 39], multiple sclerosis [69], Alzheimer\'s disease [36], attention deficit hyperactivity disorder [37], and in vitro glucose and oxygen deprivation [70].
2.2 Mechanisms of action of TP Abs to S100
TP Abs to S100 belong to a novel class of drugs that are produced from various antibodies (drug substances) using a single technological platform. This technology allows to obtain active pharmaceutical ingredients that, while retaining antibody specificity (targeting), exert a modulating effect on the target and its biological activity [71, 72, 73]. As the endogenous target of TP Abs to S100 is the brain-specific protein S100 that can influence functional activity of GABA-, serotonin-, dopamine-, noradrenaline-, and glutamatergic systems and sigma1 receptors [74, 75, 76, 77, 78], these CNS elements had been studied while screening TP Abs to S100 mechanisms of action (Figure 7). For this purpose, various in vivo and in vitro approaches have been used (including the in vitro assessment of receptor’s functional activity providing the validated protocols existed).
2.2.1 GABA-ergic system involvement in TP Abs to S100 mechanisms of action
2.2.1.1 GABA-A-ergic system
To assess the role of this system in the implementation of TP Abs to S100 anxiolytic effect, GABA-A receptors were selectively blocked, and the behavior of animals was evaluated in the Vogel conflict test [29].
The study was performed on outbred white male rats weighing 230–250 g. Before testing, animals were administered TP Abs to S100 or diazepam. For blockade of the GABA-A receptors and the chloride channel of the GABA-benzodiazepine receptor complex, bicuculline and picrotoxin, respectively, were administered simultaneously with the tested drugs.
With blockade of the GABA-A receptor, a 1.8-fold decrease in the anticonflict effect of TP Abs to S100 was observed, and a 2-fold decrease with diazepam; with blockade of the chlorine channel—1.6 and 2.4-fold decrease, respectively (Figure 4). The data obtained indicate the involvement of the abovementioned subunits of the GABA-benzodiazepine-chloride ionophore receptor complex in the implementation of the anxiolytic effect of TP Abs to S100.
Figure 4.
Influence of GABA-A-ergic agents on anxiolytic activity of TP Abs to S100 and diazepam in the Vogel conflict test. Note: animals were intragastrically administered distilled water (2.5 ml/kg, control), TP Abs to S100 (2.5 ml/kg) or diazepam (2 mg/kg) at a single dose alone or simultaneously with GABA-A receptor antagonist bicuculline (1 mg/kg) or GABA-benzodiazepine receptor complex chloride channel blocker picrotoxin (1 mg/kg) 30 minutes prior to testing. Data are expressed as M ± SD. * р < 0.05 versus control, # р < 0.05 versus TP Abs to S100 or diazepam. TP Abs to S100, technologically processed highly diluted antibodies to S100 protein.
2.2.1.2 GABA-B-ergic system
In this experiment, GABA-B receptors were selectively stimulated or blocked and anxiolytic or antidepressant effects of TP Abs to S100, diazepam and amitriptyline were evaluated in the Vogel conflict test and the Nomura test [40].
Outbred white male rats weighing 200–250 g were pretreated with baclofen, a selective agonist of GABA-B receptors, or phaclofen, an antagonist of GABA-B receptors. Then, the animals were administered test drugs, and their effect was evaluated.
In the Vogel conflict test, baclofen reduced the anxiolytic effect of TP Abs to S100 by 2.2-fold and did not affect the effect of diazepam. Phaclofen increased the anxiolytic effect of TP Abs to S100 by 1.4-fold (Figure 5). Moreover, as expected, none of the ligands influenced the effect of diazepam.
Figure 5.
Influence of GABA-В-ergic agents on anxiolytic and antidepressant activity of TP Abs to S100, diazepam, and amitriptyline in the Vogel conflict test and the Nomura test. Note: animals were intragastrically administered distilled water (2.5 ml/kg, control), TP Abs to S100 (2.5 ml/kg), diazepam (2 mg/kg), or amitriptyline (10 mg/kg) at a single dose. GABA-B receptors agonist baclofen (1 mg/kg) or antagonist phaclofen (10 mg/kg) were intraperitoneally administered 40 min prior to testing and 10 min prior to the administration of the drugs. Data are expressed as M ± SD. * р < 0.05 versus control, # р < 0.05 versus TP Abs to S100. TP Abs to S100, technologically processed highly diluted antibodies to S100 protein.
In the forced swim test, baclofen and phaclofen reduced the antidepressant effect of TP Abs to S100 by 1.5 and 2-fold, respectively, whereas these ligands did not affect the effectiveness of amitriptyline.
Thus, it was shown that the GABA-B-ergic system is involved in the realization of both the anxiolytic and antidepressant effects of TP Abs to S100.
In an in vitro study, the ability of TP Abs to S100 to influence binding of the standard radioligands to the corresponding GABA receptors and to change the effect of the standard GABA-B1А/B2 receptor agonist (using functional analysis—measuring [35S]GTPγS incorporation into G-proteins) was investigated [41]. The study was performed on the cell membranes of Chinese hamster cells (CHO) and human embryonic kidney cells (HEK293) that expressed human recombinant GABA-B1А/B2 receptors.
In the presence of TP Abs to S100, a 25.8% decrease in standard ligand binding to GABA-B1А/B2 receptor was observed, as well as 30.2% inhibition of the GABA-B1A/B2 receptor\'s agonist-induced response was observed.
2.2.2 Serotoninergic system involvement in TP Abs to S100 mechanisms of action
Similarly, this hypothesis was studied in experiments in vivo and in vitro.
For the in vivo experiments, ketanserin, a blocker of 5-НТ2/5-НТ1С receptors involved in the development of both anxiety and depression, and the 5HT precursor, 5-hydroxytryptophan (5HTP), were used [79].
The anxiolytic effect of TP Abs to S100 was studied using the Vogel conflict test [30]. The antidepressant effect of the drugs was determined using the Nomura test [30]. Outbred white male rats weighing 200–250 g were pretreated with ketanserin or 5HTP, and before testing, they received a single dose of TP Abs to S100 or diazepam.
Ketanserin and 5HTP reduced both anxiolytic (2 and 1.3-fold, respectively) and antidepressant effects of TP Abs to S100 (2- and 1.6-fold, respectively) (Figure 6).
Figure 6.
Influence of serotoninergic agents on anxiolytic and antidepressant activity of TP Abs to S100, diazepam, and amitriptyline in the Vogel conflict test and the Nomura test. Note: animals were intragastrically administered distilled water (2.5 ml/kg, control), TP Abs to S100 (2.5 ml/kg), diazepam (2 mg/kg), or amitriptyline (15 mg/kg) at a single dose. 5-НТ2 receptors antagonist ketanserin (1 mg/kg) or the serotonin precursor 5-hydroxytryptophan (5-HTP, 50 mg/kg) were intraperitoneally administered 40 min prior to testing and 10 min prior to administration of the drugs. Data are expressed as M ± SD. * р < 0.05 versus control, # р < 0.05 versus TP Abs to S100. TP Abs to S100, technologically processed highly diluted antibodies to S100 protein.
Thus, it was demonstrated that the 5HT system is involved in the realization of both the anxiolytic and antidepressant effects of TP Abs to S100.
In an in vitro study, the ability of TP Abs to S100 to influence binding of standard radiolabeled ligands to the corresponding 5HT receptors and the ability to change the magnitude of the effect on binding of standard ligands to their receptors were tested. The latter was investigated using a functional analysis of the binding of [35S]GTPγS, calcium mobilization assay, and dielectric spectroscopy or by measuring the intracellular concentration of cAMP using HTRF (Homogenous Time Resolved Fluorescence) technology. The experiments were performed on CHO cells stably expressing human 5HT1A, 5HT1B, 5HT1D, 5HT1E, 5HT1F, 5HT2A, 5HT2B, 5HT2Cedited, 5HT3, 5HT4, 5HT6, or 5HT7 receptors [41].
TP Abs to S100 increased binding of the corresponding standard ligands to 5HT1A (19.0%), 5HT1F (42.0%), 5HT2B (31.9%), 5HT2Cedited (49.3%), and 5HT3 (20.7%) receptors. Moreover, the drug enhanced the effect of 5HT1A receptor agonist by 27.8% and reduced the effect of 5HT1B receptor agonist by 27.5%.
2.2.3 Dopaminergic system involvement in TP Abs to S100 mechanisms of action
The in vitro experiment was carried out similar to the study of the effect of TP Abs to S100 on dopamine receptors [41].
The study was performed on CHO, HEK293, and pituitary rat tumor cells (GH4) stably expressing human D1, D2L, D2S, D3, D4.4 or D5 receptors.
TP Abs to S100 increased binding of the standard ligand to the human D3 receptor by 26.3% and reduced the effect of an agonist of this type of receptor by 32.8%.
2.2.4 Glutamatergic system involvement in TP Abs to S100 mechanisms of action
In this study that was performed in vitro using rat cerebral cortex cells, TP Abs to S100 significantly reduced binding of the standard radiolabeled ligand to the glycine site of NMDA receptors [80].
2.2.5 Sigma1 receptors involvement in TP Abs to S100 mechanisms of action
The study was carried out in vitro using MCF-7 or Jurkat cells [41].
TP Abs to S100 significantly (by 24.7–56.7%) reduced binding of the standard radiolabeled ligand to human sigma1 receptors (Figure 7).
Figure 7.
Schematic representation of TP Abs to S100 mechanisms of action. Note: TP Abs to S100 (technologically processed highly diluted antibodies to S100 protein) molecular target—brain-specific S100 protein. This protein is secreted mainly by astrocytes in the CNS and considered to be an important regulator of many intracellular and extracellular processes (e.g., protein phosphorylation, activity of various enzymes, the dynamics of cytoskeleton components, binding of transcription factors, calcium homeostasis, cell proliferation and differentiation, generation and transmission of nerve impulses, and synaptic transmission [81]). Moreover, S100 proteins interact with almost every neurotransmitter system (serotonin-, dopamine-, GABA-, glutamatergic, etc.) and sigma1 receptors [74, 75, 76, 77, 78]. TP Abs to S100 possess their pharmacological effects via modulating activity of brain-specific S100 protein and influencing functions of the major neurotransmitter systems as well as sigma1 receptors. In vivo studies [29, 40] revealed 5-HT2a, GABAA, and GABAB receptor involvement in the drug psychotropic effects. Also, the drug was shown to normalize noradrenaline level [82]. In vitro studies [41, 42] have shown that TP Abs to S100 increase standard radioligand binding to 5-HT1F, 5-HT2B, 5-HT2Cedited, 5-HT3, NMDA, and D3 receptors. In addition, the drug inhibits binding of specific radioligands to GABAB1A/B2 and sigma1 receptors and exerts antagonism at GABAB1A/B2, 5-HT1B, and D3 receptors and agonism at 5-HT1A receptor. The above listed TP Abs to S100 activities at the molecular level are involved in maintaining both emotional and physiological homeostasis, and thereby, the drug exerts its stress-protective, anxiolytic, antiamnestic, antidepressant, neuroprotective, and other activities.
2.3 Safety investigation
2.3.1 Assessment of a possible sedative effect
The study was performed on outbred white male rats weighing 230–250 g. Prior to testing (in OF test), animals were administered TP Abs to S100 or diazepam. The sedative effect was evaluated by a decrease in the horizontal activity of rats [7].
TP Abs to S100 did not decrease the motor activity of animals, while diazepam decreased this parameter by 1.5 times.
2.3.2 Assessment of a possible muscle relaxant effect
This activity was investigated in the rotarod test on outbred white male rats weighing 230–250 g [33]. Before testing, animals were administered TP Abs to S100 or diazepam. Then, the time before falling off the rotating rod and the number of rats that fell off were recorded.
TP Abs to S100 did not affect the coordination of movements and did not have a muscle relaxant effect. In contrast, only 30% of rats from diazepam group were able to keep balance.
2.3.3 Toxicological studies of TP Abs to S100
The drug safety investigation was performed in accordance with principles of Good Laboratory Practice. It included studies of the single and repeat dose toxicities, genotoxicity, reproductive and developmental toxicity, immunotoxicity, and local tolerance.
TP Abs to S100 exerted no toxic effects even at a dose significantly exceeding the human recommended daily dose. The drug was shown to be well tolerated and thereby considered to be a low-hazard substance.
3. Clinical efficacy and safety of TP Abs to S100 protein in the treatment of NDs
3.1 Treatment of AD, AjD, SD, and neurasthenia
To date, 453 patients with AD, AjD, and neurasthenia took part in double-blind randomized controlled CTs (n = 2), and open-label comparative randomized CTs (n = 4) conducted in the Russian Federation and Kazakhstan according to International Conference on Harmonisation Good Clinical Practice and Declaration of Helsinki [55, 57, 58, 59, 60, 83]. Two studies were registered and approved by the regulatory agency (Ministry of Health of the Russian Federation) [55, 57].
3.1.1 Placebo-controlled studies
3.1.1.1 CT in patients with AD and neurological diseases
A double-blind placebo-controlled CT of TP Abs to S100 in the treatment of AD in patients with neurological diseases [Parkinson’s disease (PD) (G.20) and chronic cerebrovascular diseases (CCD)—cerebral atherosclerosis (I67.2), hypertensive encephalopathy (I67.4), unspecified sequelae of cerebral infarction (I69.3)] was conducted in 2010 ([55], unpublished data). Sixty-two patients of both sexes aged 18–75 years were enrolled and randomized in two groups to receive TP Abs to S100 (n = 32) 10 tablets/day or placebo 10 tablets/day. Data from all 62 patients were included in the analysis, so that intention-to-treat and per-protocol sets were equal. The use of any antidepressants, antipsychotics, or antianxiety medications was prohibited in CT. The therapy of concurrent somatic and neurological diseases was permitted.
The study duration was 4 weeks with a 4-week follow-up period. Inclusion criteria were: manifested AD, the Hospital Anxiety and Depression Scale-Anxiety (HADS-A) score ≥ 11, signed informed consent form (ICF). The percentage of patients with a ≥50% decrease in the severity of anxiety according to the Hamilton Anxiety Rating Scale (HAM-A) after 4 weeks of treatment and 4-week follow-up was set as a primary efficacy endpoint. Other efficacy endpoints were: mean decrease in HAM-A, HADS-A, and State-Trait Anxiety Inventory (STAI) scores after 4 weeks of treatment and 4-week follow-up. Safety was assessed based on the results of laboratory tests (blood and urine analysis) and adverse events reports. Mann-Whitney U test, Wilcoxon signed-rank test, Student t-test, and Fisher\'s exact test were used for analysis.
The mean age of patients enrolled was 59.5 ± 2.0 years in the TP Abs to S100 group and 60.0 ± 1.9 years in the placebo group. The mean duration of neurological disease was 6.13 ± 1.2 years in the TP Abs to S100 group and 6.55 ± 0.89 years in the placebo group. No differences in demographic and clinical characteristics of patients were found (Table 4).
TP Abs to S100
Placebo
Total (n = 32)
Patients with PD (n = 16)
Patients with CCD (n = 16)
Total (n = 30)
Patients with PD (n = 15)
Patients with CCD (n = 15)
Demographic and clinical characteristics
Age, years
59.5 ± 2.0
61.4 ± 3.0
57.9 ± 2.5
60.0 ± 1.9
61.1 ± 2.9
58.9 ± 2.6
Duration of neurological disease, years
6.13 ± 1.22
6.13 ± 1.15
5.94 ± 2.03
6.55 ± 0.89
8.0 ± 1.48
5.29 ± 2.56
Baseline data
HADS-A, score
14.75 ± 0.46
15 ± 0.68
14.24 ± 0.63
15.7 ± 0.41
16.93 ± 0.34
14.47 ± 0.59
STAI, trait anxiety, score
62.28 ± 0.97
62.69 ± 1.76
60.82 ± 0.88
59.5 ± 1.25
61.53 ± 1.82
57.47 ± 1.61
STAI, state anxiety, score
60.09 ± 1.05
59.31 ± 1.71
59.82 ± 1.24
60.8 ± 1.07
63 ± 1.06
58.6 ± 1.7
HAM-A, score
27.28 ± 0.66
26.38 ± 0.82
28.19 ± 1.01
26.37 ± 0.6
27.13 ± 0.65
25.6 ± 0.9
After 4 weeks of treatment
HADS-A, score
7.74 ± 0.53
8.8 ± 0.97
6.75 ± 0.39
12.93 ± 0.8
16.0 ± 0.53
9.87 ± 1.0
STAI, trait anxiety, score
50.58 ± 1.25
53.2 ± 2.27
48.13 ± 0.82
55.93 ± 1.55
61.07 ± 1.55
50.8 ± 1.95
STAI, state anxiety, score
43.48 ± 1.06
46.4 ± 1.57
40.75 ± 1.07
54.0 ± 1.58
58.6 ± 1.59
49.4 ± 2.19
HAM-A, score
14.74 ± 0.74
16.4 ± 1.21
13.19 ± 0.7
22.83 ± 1.05
26.07 ± 1.05
19.6 ± 1.41
After 4 weeks of follow-up
HADS-A, score
7.61 ± 0.49
8.8 ± 0.74
6.5 ± 0.52
13.1 ± 0.69
15.6 ± 0.36
10.6 ± 0.97
STAI, trait anxiety, score
49.45 ± 1.04
51.0 ± 1.91
48.0 ± 0.84
56.47 ± 1.33
60.6 ± 1.43
52.33 ± 1.69
STAI, state anxiety, score
43.65 ± 0.85
46.67 ± 1.13
40.81 ± 0.78
56.67 ± 1.27
60.47 ± 1.19
60.47 ± 1.19 52.87 ± 1.8
HAM-A, score
14.13 ± 0.68
15 ± 1.01
13.31 ± 0.9
24.03 ± 0.89
26.78 ± 0.64
21.2 ± 1.31
Table 4.
Demographic and clinical characteristics, baseline, and post-treatment data on patients in double-blind placebo controlled CT of TP Abs to S100.
Note: Data are expressed as M ± SD. HAM-A, Hamilton Anxiety Rating scale; HADS-A, Hospital Anxiety and Depression Scale-Anxiety; STAI, State-Trait Anxiety Inventory; CCD, chronic cerebrovascular disease; PD, Parkinson’s disease; TP Abs to S100, technologically processed highly diluted antibodies to S100 protein.
The percentage of patients with a ≥50% decrease in HAM-A total score was 41.3% in the TP Abs to S100 group and 6.7% in the placebo group (p < 0.05 compared to placebo) after 4 weeks of therapy (Table 4). After 4 weeks of therapy, the total HAM-A score significantly decreased in the TP Abs to S100 group [a 1.8-fold decrease (−45.63 ± 2.61%) from baseline in the TP Abs to S100 group versus a 1.1-fold (or −13.09 ± 3.3%) decrease in the placebo group; Student’s t-test р < 0.05]. The result of therapy persisted during the follow-up period in the TP Abs to S100 group. The anxiety level additionally decreased by 3% (−48.19 ± 2.1% from baseline in total) by the end of the follow-up period (p < 0.05 compared to placebo). The percentage of patients with a ≥50% decrease in HAM-A total score additionally increased by 3.3% after 4 weeks of follow-up (p < 0.05 compared to placebo) (Figure 8).
Figure 8.
Dynamics of the severity of anxiety in TP Abs to S100 and placebo groups. *р < 0.05 versus placebo (Student’s t-test). HAM-A, Hamilton Anxiety Rating scale; TP Abs to S100, technologically processed highly diluted antibodies to S100 protein.
A significant decrease in the severity of anxiety was shown in patients receiving TP Abs to S100 according to HADS-A after 4 weeks of therapy and 4 weeks of follow-up (p < 0.05 compared to the placebo group). There was a 1.4-fold decrease (60.09 ± 1.05 vs. 43.65 ± 0.85) in state anxiety according to STAI in the TP Abs to S100 group after 4 weeks of therapy and result of therapy persisted during the follow-up period. The efficacy rate in reduction of the anxiety was higher in CCD patients than in PD patients according to STAI.
Data from 62 patients were included in the safety analysis. There were two AEs (pyrosis and burping) in one patient received TP Abs to S100 and one AE (pyrosis) in one patient in the placebo group. There was no significant difference in the frequency of AEs between groups. Neither TP Abs to S100 nor placebo influenced results of blood or urine tests in patients. All AEs were of medium severity and had no definite relationship with the study drug. No serious AEs were registered.
TP Abs to S100 were shown to be an effective drug for the treatment of AD in adult patients with concurrent neurological diseases.
3.1.1.2 Clinical trials in patients with SD
An international multicenter double-blind randomized placebo-controlled study in 390 patients of both sexes aged 18–45 years with SD (mostly), AjD, or neurasthenia and ≥11 HADS-A points was conducted in 2017–2019 in the Russian Federation and Kazakhstan [57]. There were four treatment groups receiving TP Abs to S100 or placebo in two dosage regimens: 4 or 8 tablets/day. Preliminary (yet unpublished) data on primary efficacy endpoint showed the decrease in the mean HAM-A score by 11.25 points in TP Abs to S100 group (4 tablets/day) and by 11.91 points in TP Abs to S100 8 tablets/day groups observed after 12 weeks of treatment (vs. 9.71 points in merged placebo group; ANCOVA: pTP Abs to S100 4 tablets per day/placebo = 0.0055, pTP Abs to S100 8 tablets per day /placebo < 0.0001). A detailed analysis of the results is currently being prepared for a publication. Complete information on the study design is available at clinicaltrials.gov NCT 03036293 [57].
3.1.2 Comparison of the TP Abs to S100 efficacy and safety with benzodiazepines
To evaluate the advantages and limitations of novel medication, especially in the treatment of mental disorders, it is necessary to compare its efficacy and safety not only with placebo but also with the “golden standard” treatment [84]. Benzodiazepines are usually chosen as such a standard in CTs in patients with NDs and, in particular, ADs. Therefore, four CTs with the use of bromdihydrochlorphenylbenzodiazepine, diazepam, clonazepam, and tofisopam as the control therapy were conducted [58, 59, 60].
3.1.2.1 Open-label comparative randomized CT of TP Abs to S100 and bromdihydrochlorphenylbenzodiazepine
Outpatients aged 18–65 years (n = 59) with a diagnosis of GAD (F41.1), AjD (F43.2), or neurasthenia (F48.0) who signed ICF participated in this open-label randomized CT [58]. One group of patients (n = 32) received TP Abs to S100 4 tablets/day, and the other (n = 27) was administered bromdihydrochlorphenylbenzodiazepine 1.5 mg/day for 28 days. Exclusion criteria were other mental diseases, severe somatic diseases, pregnancy, or lactation period. Any medications that could influence the emotional state of participants were prohibited for use for 1 week prior to the initiation of CT and during the study.
Efficacy was evaluated based on the results of the HAM-A test and Clinical Global Impression-Improvement scale (CGI-I) after 7, 14, and 28 days of treatment. The frequency of AEs and any deviations from the reference ranges in blood and urine tests was used for safety assessment. The Kruskal-Wallis test, ANOVA, and Mann-Whitney U-test were used for statistical analysis.
The mean age of patients was 34.8 ± 3.6 years in TP Abs to S100 and 36.3 ± 4.6 years in bromdihydrochlorphenylbenzodiazepine group. The mean duration of disease was 0.8 ± 0.6 years and 0.9 ± 0.5 years in TP Abs to S100 and bromdihydrochlorphenylbenzodiazepine groups, respectively (Table 5). No significant differences between groups in any demographic and clinical characteristics were found.
TP Abs to S100
Bromdihydrochlorphenylbenzodiazepine
p
Demographic and clinical characteristics
Age, years
34.8 ± 3.6
36.3 ± 4.6
>0.05
Disease duration, years
0.8 ± 0.6
0.9 ± 0.5
>0.05
Baseline data
HAM-A, score
18.2 ± 3.91
21.24 ± 3.25
0.41
After 7 days of treatment
HAM-A, score
10.73 ± 5.02
9.29 ± 4.24
0.46
CGI-I, score
3.41 ± 1.1
3.05 ± 0.97
0.28
After 14 days of treatment
HAM-A, score
11.14 ± 5.49
6.62 ± 2.80
0.003
CGI-I, score
3.14 ± 1.13
2.33 ± 1.39
0.004
After 28 days of treatment
HAM-A, score
9.59 ± 6.08
5.62 ± 2.18
0.000023
CGI-I, score
2.86 ± 1.58
2.33 ± 1.06
0.21
Table 5.
Demographic and clinical characteristics, baseline, and post-treatment data of patients in comparative CT of TP Abs to S100 and bromdihydrochlorphenylbenzodiazepine.
Note: Data are expressed as M ± SD. HAM-A, Hamilton Anxiety Rating scale; CGI-I, Clinical Global Impression-Improvement scale; TP Abs to S100, technologically processed highly diluted antibodies to S100 protein.
After 7 days of treatment, the severity of anxiety was reduced by 41% (from 18.2 ± 3.91 to 10.73 ± 5.02) in the TP Abs to S100 group and by 56.2% (from 21.24 ± 3.25 to 9.29 ± 4.24) in the comparison group according to HAM-A scale. No significant differences between groups were found after the first week of treatment (p = 0.41), and TP Abs to S100 were shown to be as effective as bromdihydrochlorphenylbenzodiazepine in the short-term period. After 14 and 28 days the anxiolytic effect in the group, receiving benzodiazepine drug was superior to that in the TP Abs to S100 group (p < 0.05 between groups). In accordance with CGI-I results, the level of improvement was found to be similar in both groups (p = 0.004) on the 7th and 14th days, but later, bromdihydrochlorphenylbenzodiazepine led to a significant decrease in the severity of illness after 28 days of treatment (p > 0.05 between groups).
The frequency of AEs was higher in the benzodiazepine group. There were several cases of severe daytime sleepiness, disturbance of accommodation, and muscle weakness in patients that received bromdihydrochlorphenylbenzodiazepine. Some patients in the study group reported mild sleepiness. No severe AEs were registered in the TP Abs to S100 group. Neither TP Abs to S100 nor benzodiazepine administration affected results of blood or urine tests in patients.
Thus, TP Abs to S100 were as effective as the control medication only in the short-term period according to HAM-A but caused no severe AEs in patients with GAD, AjD, and neurasthenia comparing to benzodiazepine.
3.1.2.2 Open-label comparative randomized CT of TP Abs to S100 and diazepam
Diazepam is the most frequent standard drug used in CTs of anxiolytic agents [85]. This open-label randomized CT was conducted under the regulation of the Ministry of Health of the Russian Federation [unpublished data]. Outpatients aged 18–65 years with GAD (F41.1), AjD (F43.2), neurasthenia (F48.0) (total n = 272), and mixed anxiety and depressive disorder (mADD) (F41.2) signed ICF and then were randomized to receive TP Abs to S100 (n = 142) 6 tablets/day or diazepam (n = 130) 15 mg/day for 28 days. All medications influencing the emotional state were prohibited for use 1 week prior to CT initiation and during the study. Diagnosis of any other psychiatric disorder, pregnancy, lactation period, substance abuse, and severe somatic diseases were set as the exclusion criteria. Efficacy was measured using the HAM-A scale and STAI. Safety was assessed based on the AE reports and results of blood and urine tests.
The mean age of patients was 40.4 ± 1.13 in TP Abs to S100 group and 39.6 ± 1.06 in the diazepam group. The mean duration of NDs was 31.9 ± 4.1 and 29.2 ± 3.23 months in the TP Abs to S100 and diazepam groups, respectively. In the TP Abs to S100 group, 27.5% of patients had GAD, 31.3%—neurasthenia, 24.4%—AjD, and 17%—mADD. Among patients administered diazepam 31.6% had GAD, 37%—neurasthenia, 17.5%—AjD, and 14.8%—mADD. Mean HAM-A score was 27.1 ± 0.5 in the TP Abs to S100 group and 28.1 ± 0.46 in the diazepam group (p = 0.3). No differences in baseline characteristics were observed.
The total HAM-A score decreased to 22.0 ± 0.5 in TP Abs to S100 group at the end of the first week of therapy (p < 0.001 compared to baseline). There was a 57.2% decrease in total HAM-A score in the TP Abs to S100 group after 28 days of treatment (vs. 63% in the diazepam group, p = 0.02) (Figure 9).
Figure 9.
Dynamics of the severity of anxiety in the TP Abs to S100 and diazepam groups. * р < 0.05 versus baseline. HAM-A, Hamilton Anxiety Rating Scale; TP Abs to S100, technologically processed highly diluted antibodies to S100 protein.
The percentage of patients with a ≥50% decrease in HAM-A total score was 72.6% in the TP Abs to S100 group (vs. 65.8% in the diazepam group) after 28 days of treatment. There were 12.8% of patients in TP Abs to S100 group with anxiety remission (less than 7 HAM-A scores) (vs. 22.1% in diazepam group). There were no significant differences between the TP Abs to S100 and diazepam groups on 7th and 28th days of treatment according to the HAM-A section “anxiety mood” (p = 0.2 and p = 0.1 between groups). Treatment with diazepam was more effective only at the 14th day of treatment [48.0 ± 0.62 (diazepam) vs. 50.0 ± 0.52 (TP Abs to S100), p = 0.02 comparing to the TP Abs to S100 group] according to STAI (state anxiety). The influence of TP Abs to S100 and diazepam on state anxiety was equal on the 7th and 28th days of therapy (p = 0.2 between groups). Diazepam and TP As to S100 were of equal efficacy in reducing the trait anxiety after 14 days [49.7 ± 0.60 (TP Abs to S100) vs. 51.0 ± 0.55 (diazepam); p = 0.1 between groups].
Only eight (5.6%) patients in the TP Abs to S100 group reported AEs (sleepiness, dizziness, dry mouth, pyrosis, bloating, excessive sweating, decreased libido, and tachycardia) of mild and moderate severity. In contrast, in the diazepam group, 51 (39.2%) patients had AEs (most frequent—daytime sleepiness, muscle relaxation, orthostatic hypotension) (p < 0.01).
To summarize the data, we consider TP Abs to S100 less effective than diazepam, though TP Abs to S100 were well tolerated by patients with GAD, AjD, neurasthenia, or mADD and exerted significantly less AEs in contrast to diazepam.
3.1.2.3 Open-label comparative randomized CT of TP Abs to S100 and clonazepam
In this open-label CT, 60 patients with AjD (n = 35) or SD (n = 25) and cardiovascular diseases (CVDs) (coronary heart disease (CHD), arterial hypertension (AH) grades II–III, postmyocarditis cardiosclerosis, dyshormonal myocardial dystrophy with cardiac arrhythmias, ventricular and supraventricular extrasystoles, atrial fibrillation, and heart defects) were randomly prescribed to receive TP Abs to S100 6 tablets/day (n = 30) or clonazepam 0.5–1 mg/day (n = 20) as an anxiolytic treatment in addition to standard therapy of CVD for 28 days after signing an ICF [59]. The control group (n = 10) was not administered any antianxiety medication. No drugs influencing the mental status of participants were allowed 1 week prior to CT and after the onset of CT. The reduction of HAM-A score was set as an efficacy endpoint. Safety was assessed based on the number of reported AEs, changes in electrocardiogram (in TP Abs to S100 group), and results of blood and urine tests.
At the baseline mean, HAM-A score was 20.75 ± 8.3 in the TP Abs to S100 group, 22.3 ± 8.1 in the clonazepam group, and 14.7 ± 5.6 in control. After 28 days of treatment, the mean HAM-A score was reduced by 30.1% in patients that received TP Abs to S100 (to 14.5 ± 5.6; p < 0.01 vs. baseline), by 30.04% in the clonazepam group (to 15.6 ± 6.2; p < 0.01 vs. baseline) and 24.5% in the control group (to 11.1 ± 4.1; p > 0.05 vs. baseline). Patients in the TP Abs to S100 group reported no AEs and no changes were found on electrocardiogram or blood and urine tests. On the contrary, the extrasystoles in two participants with dyshormonal myocardial dystrophy that received TP Abs to S100 became less frequent (from 3122 to 2040) after 14 days of treatment. Patients in the clonazepam group (n = 5) noted a slowdown in mental and motor reactions, a feeling of tiredness, and daytime sleepiness.
Thus, TP Abs to S100 appeared to be slightly less effective than clonazepam but at the same time exerted less AEs that are important for patients with not only the AjD alone but also for those with CVD.
3.1.2.4 Open-label comparative randomized CT of TP Abs to S100 and tofisopam
Patients (n = 51) with GAD or mADD and CVD (CHD or AH grades II–III) signed ICF and then were randomized into two groups. The first group (n = 31) received TP Abs to S100 4 tablets/day, the second (n = 20)—tofisopam 100 mg/day for 4 weeks in addition to standard CVD therapy [60]. After 4 weeks of treatment, patients were followed up for the next 4 weeks. Patients that previously received antianxiety or antidepressant medications, diagnosed with other mental diseases, having a history of substance abuse or lactose intolerance were not included in CT. The changes in HAM-A score after 2 and 4 weeks of treatment and after 4-week follow-up were set as efficacy endpoints. Safety was evaluated by analysis of AEs.
The mean age of patients in the TP Abs to S100 group was 49.3 ± 7.0 years, and the mean duration of CVD was 8.2 ± 4.5 years. In the tofisopam group, the mean age was 54 ± 5.2, and the duration of CVD was 7.6 ± 2.9 years. No differences in baseline characteristics were registered. During the treatment, anxiety was reduced by 63% after 1 week, by 73.1% after 2 weeks, and by 78.5% after 4 weeks in the TP Abs to S100 group according to HAM-A. There was a decrease in HAM-A scores by 62.5% after 1 week, by 75% after 2 weeks, and by 78.5% after 4 weeks in the tofisopam group. A positive effect of TP Abs to S100 on anxiety state was maintained for 4 weeks during follow-up, while there was a tendency for an increase in HAM-A score in the tofisopam group. The addition of TP Abs to S100 to standard CVD therapy helped to decrease the mean systolic blood pressure (SBP) by 25% (from 161.5 ± 18.5 mmHg to 122 ± 5.0 mmHg) after 4 weeks of treatment, whereas only 15.9% decrease in mean SBP was shown in the tofisopam group. No serious AEs were registered in both groups. In the TP Abs to S100 and tofisopam groups, 3.2 and 10% of patients, respectively, discontinued the treatment for personal reasons.
Thus, TP Abs to S100 were shown to be as effective as tofisopam. The compliance in the TP Abs to S100 group was slightly higher than that in the tofisopam group. The addition of TP Abs to S100 to standard CVD treatment led to a more prominent decrease in the mean SBP than the addition of tofisopam. TP Abs to S100 achieved more prolonged action on anxiety state than tofisopam.
3.2 Treatment of anxiety, accompanying somatic diseases
The use of anxiolytic treatment in the patients with chronic somatic diseases is challenging [86]. Many side effects of benzodiazepines such as drowsiness, sleepiness, cognitive impairment, dizziness, and addiction can be crucial for these patients [87]. Polypharmacy is also an unwanted phenomenon. The negative interaction of antianxiety medications with standard therapy of somatic diseases is frequently observed [88]. For instance, the use of SSRI in combination with nonsteroidal anti-inflammatory drugs increases the risk of gastrointestinal tract bleeding [89]. Some authors described the association between high risk of myocardial infarction and the use of benzodiazepines and antidepressants [90]. So, the search for a possible role of TP Abs to S100 in treatment of patients with the somatic disease is relevant.
3.2.1 Cardiovascular diseases
Around 40% of patients with CVD experience anxiety that can have a negative impact on the risk of adverse cardiovascular events [91, 92]. Thus, it is important to reduce anxiety symptoms in CVD patients.
Two CTs that compared TP Abs to S100 with clonazepam and tofisopam in patients with CVD were described above [59, 60]. The results showed equal efficacy of TP Abs to S100 and tofisopam in CVD patients.
In another open-label randomized comparative CT by Nikol\'skaya et al., TP Abs to S100 were used in combination with the standard treatment of patients with AH grades II–III and anxiety (n = 60, 23 women, 37 men; mean age—61.4 ± 6.9, mean AH duration—10.6 ± 4.1 years) [93]. All patients received diuretics, β blockers, and angiotensin-converting-enzyme inhibitors (ACE inhibitors). Randomly chosen participants (n = 30) were additionally prescribed TP Abs to S100 6 tablets/day for 4 weeks. At the baseline, there were 40% of patients with severe anxiety and 60% with the anxiety of moderate severity in the TP Abs to S100 group according to the Taylor Manifest Anxiety Scale (TMAS) modified by Nemchinov. Sixty percent of patients with severe anxiety and 56.6% with the anxiety of moderate severity made up the control group were receiving no antianxiety therapy.
The 1.3-fold reduction of severity of anxiety (from 23.76 ± 2.81 to 18.83 ± 2.75 TMAS points) after 2 weeks of therapy was shown in the TP Abs to S100 group (p < 0.0001 vs. baseline and the control group). There was a 24.28% decrease in SBP from 181.7 ± 10.8 to 140.0 ± 8.3 (p < 0.0001 vs. baseline and control) after 4 weeks of therapy in the TP Abs to S100 group. There was a 17.7% decrease in diastolic blood pressure from 102.3 ± 4.3 to 85.0 ± 5.7 in the study drug group after 4 weeks of therapy (p < 0.0001 vs. baseline and the control group). No negative interactions with standard therapy were registered for TP Abs to S100.
Matyushin et al. demonstrated the efficacy and safety of TP Abs to S100 in an open-label randomized comparative CT in patients (n = 60) with anxiety measured with HAM-A and CHD, AH grades II–III, angina pectoris I–III functional classes by Canadian Cardiovascular Society Classification, heart rhythm disturbances (extrasystole, paroxysmal supraventricular tachyarrhythmias) receiving standard CVD therapy (β blockers, amiodarone, sotalol, lappaconitine hydrobromide, diethylaminopropionylethoxycarbonylaminophenothiazine, etc.) [94]. The study drug group (n = 30) received TP Abs to S100 6 tablets/day, and the control group (n = 30) was administered only CVD treatment for 8 weeks. The mean age of patients in TP Abs to S100 and control groups was 64.4 ± 8.6 and 63.1 ± 8.5, respectively.
The addition of TP Abs to S100 to the standard therapy in patients with angina pectoris I–III functional classes helped to decrease the severity of anxiety (50.4% decrease vs. 32.3% decrease in the TP Abs to S100 group vs. the control group; p < 0.05) and caused cardiac rhythm normalization [80% patients with more than 75% decrease in the frequency of daily episodes of rhythm disturbances in the study group (p < 0.05 vs. control)]. There were 60% of patients with a decrease in angina pectoris functional class in the study drug group (vs. 33.3% in control; p < 0.05 between groups). No AEs and negative drug interactions were registered.
An open-label placebo-controlled study in 85 patients with acute coronary syndrome and anxiety (diagnosed with HADS-A) showed significant improvement in the quality of life assessed with the Short Form-36 in the TP Abs to S100 group after 6 month of therapy [95]. The 1.7-fold decrease in HADS-A score (from 12.1 [9;17] to 7.1 [6;8]) was observed in patients receiving TP Abs to S100 in combination with standard therapy after 6 months (p = 0.00008 vs. baseline). No reduction of anxiety according to HADS-A was found in the placebo group after 6 months (p = 0.07 vs. baseline). No negative interaction with standard therapy (acetylsalicylic acid, clopidogrel, enoxaparin, statins, ACE inhibitors, β blockers, nitrates, calcium agonists) was registered.
Thus, TP Abs to S100 is an effective anxiolytic medication that helps to reduce the severity of anxiety as well as to avoid drug interaction, polypharmacy and increase the quality of life. According to some CTs mentioned above, TP Abs to S100 increase the efficacy of standard treatment in patients with AH, angina pectoris, and some heart rhythm disturbances due to their antianxiety action. Due to reduction in severity of anxiety, the improvement of compliance in CVD patients is possible, though this consideration requires further investigation.
3.2.2 Gastrointestinal diseases
Anxiety is common in 20% of patients with gastrointestinal (GI) problems [96] and in 27% of patients with gastritis in particular [97]. Some publications revealed an association between mood disorders and the risk of carcinogenesis in patients with GI diseases [98, 99]. The necessity for antianxiety therapy in these patients is justified.
An open-label comparative study by Tsukanov et al. in patients with anxiety (diagnosed with HAM-A) complicating ulcerative gastritis associated with Helicobacter pylori and duodenal ulcers was conducted [100]. One hundred and two participants received standard helicobacter eradication therapy (clarithromycin, amoxicillin, omeprazole, algeldrate—magnesium hydroxide combination drug), and 49 of them were prescribed TP Abs to S100 6 tablets/day for 20 days. Mean age of participants was 41.8 ± 2.4 in the TP Abs to S100 group (n = 49) and 42.3 ± 2.8 in the control group (n = 53). The dynamics of HAM-A scale scores was evaluated.
Anxiety was significantly reduced in the TP Abs to S100 group after 20 days of treatment. The mean HAM-A score decreased by 55.2% from 23.43 ± 1.8 to 10.5 ± 0.98 (vs. 28% in the control group; p < 0.001 vs. baseline; p < 0.001 vs. control group). No serious AEs were registered in both groups.
According to another open-label noncomparative CT by Karpin et al. in patients with chronic gastritis and duodenal ulcers, the addition of TP Abs to S100 to standard treatment leads to a prominent reduction in GI symptoms (pain, intestinal dyspepsia, appetite changes) (p = 0.003 vs. baseline for pain and dyspepsia, p = 0.045 for appetite changes) [101].
So, the treatment of patients with GI diseases with TP Abs to S100 helps to reduce anxiety and indirectly decrease the severity of somatic symptoms via its anxiolytic action.
4. Conclusions
In this review, the data obtained from experimental and clinical studies of TP Abs to S100 efficacy, safety, and mechanisms of action are summarized.
In nonclinical trials, TP Abs to S100 were shown to exert stress-protective, anxiolytic, antidepressant, antiamnestic, and neuroprotective activities. All these effects were manifested at the same level as the activity of comparator drugs. At the same time, toxicological studies have shown a high safety level of TP Abs to S100: there was no any toxic activity of drug reviled even when it was administered to laboratory animals at the maximal dose for 6 consecutive months (every day).
The mechanisms of action studies confirmed the hypothesis that TP Abs to S100 biological effects are realized via recruiting of GABA-, serotonin-, dopamine-, noradrenaline-, and glutamatergic systems, as well as via sigma1 receptors.
Clinical efficacy and safety of TP Abs to S100 were demonstrated in multicenter double-blind randomized placebo-controlled trials and in open-label randomized comparative trials. In all conducted placebo-comparative studies or studies with nonmedicated control group, the main symptom of most NDs—the anxiety—was significantly reduced in TP Abs to S100 action. It should be stressed that in these CTs, the equal efficacy of TP Abs to S100, tofisopam, and bromdihydrochlorphenylbenzodiazepine (in the short-term use) with a notably higher tolerance level was demonstrated. Meanwhile, TP Abs to S100 increased the efficacy of standard treatment of somatic diseases (due to its anxiolytic activity), and there was a lower number of AEs and lack of drug interactions observed in the TP Abs to S100 group.
Thus, the discussed drug—TP Abs to S100—has been extensively studied and demonstrated favorable efficacy and safety profile. The presented evidence justifies TP Abs to S100 to be a promising treatment option for patients with NDs.
Acknowledgments
We thank Dr. Kovalchuk A.L. for valuable comments on the paper and language editing.
Conflict of interest
All authors are the employees of OOO NPF Materia Medica Holding pharmaceutical company. The substance TP ABS to S100 is produced and marketed by OOO NPF Materia Medica Holding.
Abbreviations
ACE
angiotensin-converting-enzyme
AD
anxiety disorder
AE
adverse event
AH
arterial hypertension
AjD
adjustment disorder
CCD
chronic cerebrovascular disease
CHD
coronary heart disease
CGI-I
global impression-improvement scale
GI
gastrointestinal
CNS
central nervous system
CT
clinical trial
CVD
cardiovascular diseases
DSM
Diagnostic and Statistical Manual of Mental Disorders
HADS-A
Hospital Anxiety and Depression Scale-Anxiety
HAM-A
Hamilton Anxiety Rating Scale
HPAA
hypothalamic-pituitary-adrenal axis
HTP
hydroxytryptophan
GABA
γ-aminobutyric acid
GAD
generalized anxiety disorder
ICD
International Disease Classification
ICF
informed consent form
mADD
mixed anxiety and depressive disorder
ND
neurotic disorder
NMDA
N-methyl-d-aspartate
OCD
obsessive-compulsive disorder
OF
open field test
PD
Parkinson’s disease
SBP
systolic blood pressure
SD
somatoform disorder
SSRI
selective serotonin reuptake inhibitors
STAI
State-Trait Anxiety Inventory
TCA
tricyclic antidepressants
TMAS
Taylor Manifest Anxiety Scale
\n',keywords:"neurotic disorder, anxiety, anxiolytic therapy, S100 protein, somatoform disorder",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/71930.pdf",chapterXML:"https://mts.intechopen.com/source/xml/71930.xml",downloadPdfUrl:"/chapter/pdf-download/71930",previewPdfUrl:"/chapter/pdf-preview/71930",totalDownloads:123,totalViews:0,totalCrossrefCites:0,dateSubmitted:"December 13th 2019",dateReviewed:"March 20th 2020",datePrePublished:"April 24th 2020",datePublished:null,dateFinished:null,readingETA:"0",abstract:"Neurotic disorders (NDs) are among the most common mental diseases leading to a decrease in the quality of life, lack of socialization, and increased mortality. The diagnosis and treatment of all types of NDs are challenging. In the light of the ongoing search for an effective and safe therapeutic strategy influencing certain aspects of ND pathogenesis, technologically processed highly diluted antibodies to S100 protein (TP Abs to S100) seem to be a promising treatment option for patients with NDs. TP Abs to S100 possess stress-protective, anxiolytic, antidepressant, antiamnestic, and neuroprotective activities. In the current review, we describe the mechanisms of action and pharmacological effects of TP Abs to S100 demonstrated in nonclinical (preclinical) and clinical studies. Based on the data, we tried to evaluate the future prospects of the TP Abs to S100 as the drug of choice for ND treatment.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/71930",risUrl:"/chapter/ris/71930",signatures:"Kristina Konstantinovna Khacheva, Gulnara Rinatovna Khakimova, Alexey Borisovich Glazunov and Victoria Vyacheslavovna Fateeva",book:{id:"9530",title:"Anxiety Disorders",subtitle:null,fullTitle:"Anxiety Disorders",slug:null,publishedDate:null,bookSignature:"Prof. Vladimir Kalinin, Prof. Cicek Hocaoglu and Dr. Shafizan Mohamed",coverURL:"https://cdn.intechopen.com/books/images_new/9530.jpg",licenceType:"CC BY 3.0",editedByType:null,editors:[{id:"31572",title:"Prof.",name:"Vladimir",middleName:null,surname:"Kalinin",slug:"vladimir-kalinin",fullName:"Vladimir Kalinin"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Preclinical trials of technologically processed highly diluted antibodies to S100 protein",level:"1"},{id:"sec_2_2",title:"2.1 Pharmacodynamics",level:"2"},{id:"sec_2_3",title:"Table 1.",level:"3"},{id:"sec_2_4",title:"Table 1.",level:"4"},{id:"sec_2_5",title:"Table 1.",level:"5"},{id:"sec_3_5",title:"2.1.1.1.2 Effect on c-Fos protein expression",level:"5"},{id:"sec_4_5",title:"2.1.1.1.3 Effect on gastric ulcers after an immobilization stress",level:"5"},{id:"sec_6_4",title:"Table 2.",level:"4"},{id:"sec_7_4",title:"2.1.1.3 Antiaggressive activity of TP Abs to S100",level:"4"},{id:"sec_8_4",title:"2.1.1.4 Other psychotropic and neurotropic activities of TP Abs to S100",level:"4"},{id:"sec_11_2",title:"2.2 Mechanisms of action of TP Abs to S100",level:"2"},{id:"sec_11_3",title:"2.2.1 GABA-ergic system involvement in TP Abs to S100 mechanisms of action",level:"3"},{id:"sec_11_4",title:"2.2.1.1 GABA-A-ergic system",level:"4"},{id:"sec_12_4",title:"2.2.1.2 GABA-B-ergic system",level:"4"},{id:"sec_14_3",title:"2.2.2 Serotoninergic system involvement in TP Abs to S100 mechanisms of action",level:"3"},{id:"sec_15_3",title:"2.2.3 Dopaminergic system involvement in TP Abs to S100 mechanisms of action",level:"3"},{id:"sec_16_3",title:"2.2.4 Glutamatergic system involvement in TP Abs to S100 mechanisms of action",level:"3"},{id:"sec_17_3",title:"2.2.5 Sigma1 receptors involvement in TP Abs to S100 mechanisms of action",level:"3"},{id:"sec_19_2",title:"2.3 Safety investigation",level:"2"},{id:"sec_19_3",title:"2.3.1 Assessment of a possible sedative effect",level:"3"},{id:"sec_20_3",title:"2.3.2 Assessment of a possible muscle relaxant effect",level:"3"},{id:"sec_21_3",title:"2.3.3 Toxicological studies of TP Abs to S100",level:"3"},{id:"sec_24",title:"3. Clinical efficacy and safety of TP Abs to S100 protein in the treatment of NDs",level:"1"},{id:"sec_24_2",title:"3.1 Treatment of AD, AjD, SD, and neurasthenia",level:"2"},{id:"sec_24_3",title:"Table 4.",level:"3"},{id:"sec_24_4",title:"Table 4.",level:"4"},{id:"sec_25_4",title:"3.1.1.2 Clinical trials in patients with SD",level:"4"},{id:"sec_27_3",title:"Table 5.",level:"3"},{id:"sec_27_4",title:"Table 5.",level:"4"},{id:"sec_28_4",title:"3.1.2.2 Open-label comparative randomized CT of TP Abs to S100 and diazepam",level:"4"},{id:"sec_29_4",title:"3.1.2.3 Open-label comparative randomized CT of TP Abs to S100 and clonazepam",level:"4"},{id:"sec_30_4",title:"3.1.2.4 Open-label comparative randomized CT of TP Abs to S100 and tofisopam",level:"4"},{id:"sec_33_2",title:"3.2 Treatment of anxiety, accompanying somatic diseases",level:"2"},{id:"sec_33_3",title:"3.2.1 Cardiovascular diseases",level:"3"},{id:"sec_34_3",title:"3.2.2 Gastrointestinal diseases",level:"3"},{id:"sec_37",title:"4. 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Zavisimost’ anksioliticheskoy aktivnosti ot usloviy provedeniya testa konfliktnoy situatsii po VOGEL na primere tenotena i diazepama. Byulleten’ eksperimental’noy biologii i meditsiny. 2011;3:311-314 [in Russian]'},{id:"B33",body:'Voronina TA, Molodavkin GM, Sergeeva SA, Epstein OI. Anksioliticheskiy effekt “Proprotena” v usloviyah nakazuemogo i nenakazuemogo povedeniya. Byulleten’ eksperimental’noy biologii i meditsiny. 2003;1:31-33 [in Russian]'},{id:"B34",body:'Epstein OI, Molodavkin GM, Voronina TA, Sergeeva SA. Antidepressivnye svoystva proprotena i amitriptilina: Sravnitel’noe eksperimental’noe issledovanie. Byulleten’ eksperimental’noy biologii i meditsiny. 2003;145(6):34-36 [in Russian]'},{id:"B35",body:'Voronina TA, Borodavkina MV, Heyfets IA, et al. Eksperimental’noe izuchenie nootropnoy i antiamnesticheskoy aktivnosti deystviya tenotena v teste uslovnogo refleksa passivnogo izbeganiya u krys. In: Vtoroy natsional’nyy kongress po sotsial’noy psihiatrii «Sotsial’nye preobrazovaniya i psihicheskoe zdorov’e»; Moskva. 2006. p. 171 [in Russian]'},{id:"B36",body:'Voronina TA, Belopol’skaya MV, Heyfets IA, Dugina YL, Sergeeva SA, Epstein OI. Deystvie sverhmalyh doz antitel k S-100 pri narushenii kognitivnyh funktsiy, emotsional’nogo i nevrologicheskogo statusov v usloviyah eksperimental’noy modeli bolezni Al’tsgeymera. Byulleten’ eksperimental’noy biologii i meditsiny. 2009;148(8):174-176 [in Russian]'},{id:"B37",body:'Voronina TA, Molodavkin GM, Borodavkina MV, Heyfets IA, Dugina YL, Sergeeva SA. Nootropnyy i antiamnesticheskiy effekty tenotena detskogo u nepolovozrelyh krysyat. Byulleten’ eksperimental’noy biologii i meditsiny. 2009;148(8):164-166 [in Russian]'},{id:"B38",body:'Romanova GA, Voronina TA, Sergeeva SA, Barskov IV, Dugina YL, Epstein OI. Issledovanie protivoishemicheskogo, neyroprotektornogo deystviy proprotena. Sibirskiy vestnik psihiatrii i narkologii. 2003;1(27):123-125 [in Russian]'},{id:"B39",body:'Voronina TA, Heyfets IA, Dugina YL, Sergeeva SA, Epstein OI. Izuchenie effektov preparata sverhmalyh doz antitel k S-100 v usloviyah eksperimental’noy modeli gemorragicheskogo insul’ta. Byulleten’ eksperimental’noy biologii i meditsiny. 2009;148(8):170-173 [in Russian]'},{id:"B40",body:'Heyfets IA, Molodavkin GM, Voronina TA, Dugina YUL, Sergeeva SA, Epstein OI. Uchastie GAMK-V-sistemy v mekhanizme deystviya antitel k belku S-100 v sverhmalyh dozah. Byulleten’ eksperimental’noy biologii i meditsiny. 2008;145(5):552-554 [in Russian]'},{id:"B41",body:'Gorbunov EA, Ertuzun IA, Kachaeva EV, Tarasov SA, Epstein OI. In vitro screening of major neurotransmitter systems possibly involved in the mechanism of action of antibodies to S100 protein in released-active form. Neuropsychiatric Disease and Treatment. 2015;11:2837-2846. DOI: 10.2147/NDT.S92456'},{id:"B42",body:'Ertuzun IA. Mekhanizmy anksioliticheskogo i antidepressatnogo deystviya Tenotena (eksperimental’noe issledovanie). Avtoreferat dissertatsii na soiskanie uchenoy stepeni kandidata meditsinskih nauk. 2012;23 [in Russian]'},{id:"B43",body:'Matsumoto RR. σ receptors: Historical perspective and background. In: Su TP, Matsumoto RR, Bowen WD, editors. Sigma Receptors. Boston: Springer; 2007. pp. 1-23. DOI: 10.1007/978-0-387-36514-5_1'},{id:"B44",body:'Nguyen L, Lucke-Wold BP, Mookerjee S, Kaushal N, Matsumoto RR. Sigma-1 receptors and neurodegenerative diseases: Towards a hypothesis of sigma-1 receptors as amplifiers of neurodegeneration and neuroprotection. In: Sigma Receptors: Their Role in Disease and as Therapeutic Targets. Springer; 2017. pp. 133-152. DOI: 10.1007/978-3-319-50174-1_10'},{id:"B45",body:'Mohler H. GABAA receptors in central nervous system disease: Anxiety, epilepsy, and insomnia. Journal of Receptor and Signal Transduction Research. 2006;26(5–6):731-740. 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S100: A multigenic family of calcium-modulated proteins of the EF-hand type with intracellular and extracellular functional roles Cause of spectral variation in the luminescence of semisynthetic aequorins Semi-synthetic aequorins with improved sensitivity. International Journal of Biochemistry & Cell Biology. 2001;33(7):637-668. DOI: 10.1016/S1357-2725(01)00046-2'},{id:"B82",body:'Titkova AM, Epstein OI. Vliyanie potentsirovannyh antitel k mozgospetsificheskomu belku S-100 na sistemu biogennyh monoaminov i intensivnost’ perekisnogo okisleniya lipidov u krys v usloviyah alkogolizatsii. Proproten-100 Sbornik Statey. 2002:95-99 [in Russian]'},{id:"B83",body:'ICH Good Clinical Practice [Internet]. Available from: https://ichgcp.net/ [Accessed: 05 March 2020]'},{id:"B84",body:'Hertzman M, Adler L. Clinical Trials in Psychopharmacology: A Better Brain. Chichester: John Wiley & Sons; 2010. p. 403'},{id:"B85",body:'Costa M, Kirchner H, Klotz U, Kraker J, Patierno R, Werner G. Essential and Non-Essential Metals Metabolites with Antibiotic Activity Pharmacology of Benzodiazepines Interferon Gamma Research. Vol. 1. Berlin: Springer Science & Business Media; 2012. 204 p. DOI: 10.1007/978-3-642-69872-9'},{id:"B86",body:'Arbanas G, Arbanas D, Dujam K. Adverse effects of benzodiazepines in psychiatric outpatients. Psychiatria Danubina. 2009;21(1):103-107'},{id:"B87",body:'Baldwin DS, Aitchison K, Bateson A, et al. Benzodiazepines: Risks and benefits. A reconsideration. Journal of Psychopharmacology. 2013;27(11):967-971. DOI: 10.1177/0269881113503509'},{id:"B88",body:'Low Y, Setia S, Lima G. Drug–drug interactions involving antidepressants: Focus on desvenlafaxine. Neuropsychiatric Disease and Treatment. 2018;14:567. DOI: 10.2147/NDT.S157708'},{id:"B89",body:'de Abajo FJ, Garcia-Rodriguez LA. Risk of upper gastrointestinal tract bleeding associated with selective serotonin reuptake inhibitors and venlafaxine therapy: Interaction with nonsteroidal anti-inflammatory drugs and effect of acid-suppressing agents. Archives of General Psychiatry. 2008;65:795-803. DOI: 10.1001/archpsyc.65.7.795'},{id:"B90",body:'Balon R, Rafanelli C, Sonino N. Benzodiazepines: A valuable tool in the management of cardiovascular conditions. Psychotherapy and Psychosomatics. 2018;87(6):327-330. DOI: 10.1159/000493015'},{id:"B91",body:'Ouakinin SRS. Anxiety as a risk factor for cardiovascular diseases. Frontiers in Psychiatry. 2016;7:25. DOI: 10.3389/fpsyt.2016.00025'},{id:"B92",body:'Małyszczak K, Rymaszewska J. Depression and anxiety in cardiovascular disease. Kardiologia Polska (Polish Heart Journal). 2016;74(7):603-609. DOI: 10.5603/KP.a2016.0063'},{id:"B93",body:'Nikol’skaya IN, Guseva IA, Bliznevskaya EV, Tret’yakova TV. 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Journal of Psychiatric Research. 2016;47(1):128-132. DOI: 10.1016/j.jpsychires.2012.09.016'},{id:"B98",body:'Hou N, Zhang X, Zhao L, et al. A novel chronic stress-induced shift in the Th1 to Th2 response promotes colon cancer growth. Biochemical and Biophysical Research Communications. 2013;439:471-476. DOI: 10.1016/j.bbrc.2013.08.101'},{id:"B99",body:'Lee SP, Sung IK, Kim JH, et al. The effect of emotional stress and depression on the prevalence of digestive diseases. Journal of Neurogastroenterology and Motility. 2015;21(2):273. DOI: 10.5056/jnm14116'},{id:"B100",body:'Tsukanov VV, Kupershteyn EY, Sharypova VN. Effektivnost’ primeneniya protivotrevozhnogo preparata Tenoten v sostave kompleksnoy terapii u patsientov s Helicobacter Pylori – assotsiirovannoy yazvennoy bolezn’yu dvenadtsatiperstnoy kishki. Poliklinika. 2008;2:52-53 [in Russian]'},{id:"B101",body:'Karpin VA, Burmasova AV, Voronova EI. Vliyanie Tenotena na neyrovegetativnyy status i konsolidatsiyu remissii u bol’nyh hronicheskim gastroduodenitom i yazvennoy bolezn’yu dvenadtsatiperstnoy kishki. Poliklinika. 2010;1:78-83 [in Russian]'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Kristina Konstantinovna Khacheva",address:"hachevakk@materiamedica.ru",affiliation:'
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