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Clozapine-Induced Toxicity Via Induction of Oxidative Stress and Mitochondrial Dysfunction in Human Blood Lymphocytes and Protecting Role of L-Carnitine

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Clozapine-Induced Toxicity Via Induction of Oxidative Stress and Mitochondrial Dysfunction in Human Blood Lymphocytes and Protecting Role of L-Carnitine Original Research Article 2020;3(1):e9 Clozapine-induced Toxicity via Induction of Oxidative Stress and Mitochondrial Dysfunction in Human Blood Lymphocytes and Protecting role of L-Carnitine a b c,d a b* Ahmad Salimi , Farnaz Imani , Zhaleh Jamali , Negar Ahvar , Jalal Pourahmad a. Department of Pharmacology and Toxicology, School of Pharmacy, Ardabil University of Medical Sciences, Ardabil, Iran. b. Department of Pharmacology and Toxicology, Faculty of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran. c. Student Research Committee, School of Medicine, Shahroud University of Medical Sciences, Shahroud, Iran. d. Department of Addiction Studies, School of Medicine, Shahroud University of Medical Sciences, Shahroud, Iran. Article Info: Abstract: Received: September 2020 Clozapine is a useful antipsychotic drug but with serious, life threatening toxicity Accepted: September 2020 effects. The aim of this study is to assess the direct cytotoxicity effect of clozapine Published online: (CLZ) on human blood lymphocytes and investigate the protective effect of L‐carnitine October 2020 (LC) against clozapine‐induced cytotoxicity. Clozapine at 70 μM concentration induced cytotoxicity following 12 h. The Clozapine induced cytotoxicity was associated with intracellular reactive oxygen species (ROS) generation, mitochondrial * Corresponding Author: membrane potential (MMP) collapse, lysosomal membrane injury, lipid peroxidation, Jalal Pourahmad Email: and depletion of glutathione (GSH) and raising of oxidized glutathione (GSSG). We [email protected] showed that LC (1 mM) has a beneficial cytoprotective effect against clozapine- induced toxicity. Summery, clozapine causes organelles damages and triggers oxidative stress in lymphocytes. These data suggest that using of L‐carnitine could be useful for prevention and treatment of clozapine toxicity. Finally, it could be concluded that LC exerts a beneficial antioxidant and mitochondrial protective effects against oxidative stress induced by CLZ. Keywords: Clozapine; Cytotoxicity; L‐carnitine; Mitochondrial Damages; Oxidative Stress Please Cite this article as: Salimi A., Imani F., Jamali Z., Ahvar N., Pourahmad J., Clozapine-induced Toxicity via Induction of Oxidative Stress and Mitochondrial Dysfunction in Human Blood Lymphocyte and Protecting role of L-Carnitine. Int. Pharm. Acta. 2020;3(1):e9 DOI: https://doi.org/10.22037/ipa.v3i1.32179 1. Introduction neutropenia [3]. Mild neutropenia occurs more frequently than agranulocytosis. Also, transient Clozapine as a dibenzodiazepine, is an atypical neutropenia, occurs frequently in patients. Moreover, antipsychotic drug. Also, clozapine is called an clozapine-treated patients may show a daily variation in antimanic agent and is the most effective agent for the number of circulating neutrophils [4,5]. Because of affective psychotic mania condition. Clozapine can be these serious side-effects of clozapine, all patients used for treatment of refractory schizophrenia. This drug treated with clozapine should be undergo regular white also reduces suicidal behavior in schizophrenia. Because cell count monitoring. Clozapine is immediately of these beneficial effects of clozapine is used in discontinued if a patient develops leucopenia or treatment of schizophrenia, bipolar disorder (BD), acute neutropenia [5]. The incidence of drug-induced manic/hypomanic/mixed and depressive episodes [1,2]. agranulocytosis, is estimated to be approximately seven Previous studies showed that clozapine has adverse cases per one million people, about 1–2% of patients [6]. effects on blood and immune system with life- Approximately 5 to 10 percent is the mortality rate of threatening potential, like agranulocytosis and drug-induced agranulocytosis which decreases with early This open-access article is distributed under the terms of the Creative Commons Attribution Non Commercial 4.0 License (CC BY-NC 4.0). 2 A. Salimi et al. International Pharmacy Acta, 2020;3(1):e9 identification and treatment [7]. Clozapine among the (HEPES), acridine orange, L-carnitine and clozapine antipsychotics, shows the highest tendency to induce were obtained from the Sigma Chemical Co. agranulocytosis. Sudden late onset of blood dyscrasia has been reported after treatment with clozapine [8]. The 2.2. Sampling and Ethic statement exact mechanism of this side effect is not yet known. L‐carnitine (4‐N‐trimethylammonium‐3‐hydroxybutyric This research was done in Shahid Beheshti University of acid), as an endogenous mitochondrial membrane Medical Sciences at faculty of pharmacy and given compound is a small water‐soluble organic solute. For ethical approval by research ethic committee of Shahid the transport of long‐chain fatty acids into the Beheshti University of Medical Sciences. Lymphocytes mitochondria LC is essential [9]. It has been reported that were obtained from 20 healthy donors in the age range of LC has effective ROS scavenging activity, stopping 18 to 30 years old, which did not exhibit any disease at peroxidation via the chelation of ferrous ions and the time of blood samples collection. After became protective effect on oxidative DNA damage in vitro aware of our investigation donors are asked to fill out the models [10,11]. Some studies in mammals have reported approval form. the antioxidant properties of LC, which effectively prevented the lipid and protein resulting from oxidative 2.3. Isolation of Human Lymphocytes stress and damage to DNA [11-13]. LC supplementation increased the levels of glutathione (GSH), enhanced the Lymphocytes were isolated using Ficoll standard method activities of antioxidant enzymes, and decreased the with some modification from blood collected. Diluted concentration of malondialdehyde (MDA) under some blood was layered on 3ml ficoll paque, centrifuged for pathological conditions [11,14]. 20min at 2500rpm and lymphocytes layer were Fluctuation of the immune system could lead to a variety collected, suspended in erythrocyte lysis buffer (150 mM of adverse effects like enhancement or suppression of the NH4Cl, 10 mM NaHCO3, 1 mM EDTA, 183 pH 7.4), immune response [15]. Suppression of the immune and incubated for 5 min at 37 °C. Then, PBS was added response in turn could lead to decrease in the host immediately, and the cells were centrifuged at 1500g for resistance to cancerous cells or infectious agents. 10 min at 20 °C. The supernatant was eliminated, and the Evaluation of drug immunotoxicity in humans is cells were washed twice with RPMI1640 with l- complex than in experimental animals and invitro glutamine and 10% fetal bovine serum (FBS) at 2000g models because of many factors. Moreover, clinical for 7 min. The cells were resuspended in RPMI1640 immunotoxicity data cannot be used in the assessment of medium with L-glutamine and 10 % FBS and counted drug immunotoxicity. Probably, immunotoxicity using trypan blue exclusion dye. The viability of the evaluation in in vitro model would be a good method for cells was over 95% and cells were maintained at 37º C in assessment of these conditions. The aim of our study is a humidified atmosphere with 5% CO2. The lymphocyte to investigate the toxic effect of clozapine and density used in the experiments was 10×106 cells/ml cytoprotective effect of LC on human lymphocytes by [16]. assessing cellular viability, reactive oxygen species (ROS) formation, mitochondrial membrane permeability 2.4. Cell Viability Assay transition (MMP) collapse, lysosomal membrane damage, intracellular reduced glutathione (GSH) and The cell viability of isolated human lymphocyte was extracellular oxidized glutathione (GSSG) and lipid assessed from the intactness of the plasma membrane as peroxidation. determined by the MTT assay. Lymphocytes were plated onto 96 well plate (1×104 cells/ml) and incubated with 2. Materials & Methods different concentration of CLZ (0, 50, 100 and 150 µM), for 12 h or IC50 12h CLZ +1 mM LC. After the 2.1. Chemicals incubation time, the cell viability was measured with MTT assay [16]. RPMI1640 and FBS (Fetal Bovine serum) were taken from GIBCO (USA). Ficoll-paque PLUS was obtained 2.5. Measurement of ROS from Ge Healthcare Bio-Science Company. MTT 3-(4,5- The rate of ROS generation in human lymphocytes were dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide, ′ ′ Trypan blue, 2′,7′-dichlorofuorescin diacetate (DCFH- evaluated by using the probe 2 , 7 - dichlorodihydro- DA), Rhodamine123, bovine serum albumin (BSA), N- fluorescein diacetate (DCFH-DA). In the presence of (2-hydroxyethyl) piperazine-N′-(2-ethanesulfonic acid) ROS, DCFH is oxidized to highly fluorescent This open-access article is distributed under the terms of the Creative Commons Attribution Non Commercial 4.0 License (CC BY-NC 4.0). LC Attenuates CLZ-induced Toxicity. 3 dichlorofluorescein (DCF). Therefore, the intracellular lymphocytes were washed with PBS, and then lysed with DCF fluorescence can be used as an index to quantify PBS contain 2% triton. 100 µl of cell lysate was mixed the overall oxidative stress in cells. Human lymphocytes with 200 µl of TBA reagent (containing 3.75% TCA and were treated for 2, 4 and 6 h with different 0.0925% TBA) and the mixture was incubated at 90 °C concentrations (35, 70 and 140 µM) of CLZ and IC50 for 60 min. After cooling, the mixture was centrifuged at 12h CLZ +1 mM LC. After the incubation time, medium 1000 × g for 10 min. Calorimetric absorption was was replaced by 10 µmol DCFH-DA containing measured at 530 nm [20]. Malondialdehyde standard medium, after 15
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