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Chemokine IP-10 is correlated with cardiac responses and status of infection with HIV and HCV in methadone maintenance patients
International Journal of Cardiology 194 (2015) 36–38
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Chemokine IP-10 is correlated with cardiac responses and status of infection with HIV and HCV in methadone maintenance patients☆ Sheng-Wen Liu a,1, Yu-Li Liu a,⁎,1, Ling-Ling Hwang b, Sheng-Chang Wang a, Hsiang-Wei Kuo a, Shiow-Ling Wu c, Yu-Wen E. Dai b, Shu Chih Liu a, Ing-Kang Ho d,e, Andrew C.H. Chen f,g, Chin-Fu Hsiao h,i, Hsiao-Hui Tsou i,j,⁎⁎ a
Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan Graduate Institute of Medical Sciences and Department of Physiology, College of Medicine, Taipei Medical University, 250 Wu-Hsing Street, Taipei 110, Taiwan Center for Research, Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taipei, Taiwan d Center for Drug Abuse and Addiction, China Medical University Hospital, Taichung, Taiwan e Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan f Department of Psychiatry, The Zucker Hillside Hospital, North Shore-Long Island Jewish Medical Center Health System, Glen Oaks, NY, USA g The Feinstein Institute for Medical Research, Hofstra North Shore-LIJ School of Medicine at Hofstra University, Manhasset, NY, USA h Division of Clinical Trial Statistics, Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan i Division of Biostatistics and Bioinformatics, Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan j Graduate Institute of Biostatistics, College of Public Health, China Medical University, Taichung, Taiwan b c
a r t i c l e
i n f o
Article history: Received 7 May 2015 Accepted 9 May 2015 Available online 12 May 2015 Keywords: HIV HCV Electrocardiogram Methadone IP-10 TNF-α
To the Editor, Methadone is a synthetic opioid usually used as a maintenance therapy for heroin dependence [1]. It has been reported that the infection rates with human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV) were higher in patients undergoing methadone maintenance treatment (MMT) [2]. However, the influence of co-infection with HIV and HCV on the treatment responses to methadone has yet
☆ Trial registration number: NCT01059747 (National Institutes of Health Clinical Trial database, http://www.clinicaltrial.gov/ct/show/NCT01059747). ⁎ Correspondence to: Yu-Li Liu, Center for Neuropsychiatric Research, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County 350, Taiwan. ⁎⁎ Correspondence to: Hsiao-Hui Tsou, Division of Biostatistics and Bioinformatics, Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County 350, Taiwan. E-mail addresses: [email protected] (Y.-L. Liu), [email protected] (H.-H. Tsou). 1 Both authors contributed equally to the study.
http://dx.doi.org/10.1016/j.ijcard.2015.05.055 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
to be studied. A higher plasma level of chemokine interferon gammainducible protein 10 (IP-10, also called chemokine (C-X-C motif) ligand 10, CXCL 10) has been reported in patients infected with both HIV and HCV than those infected with only single virus [3]. Increased expression of IP-10, CXCR3 receptors in the CD8(+) lymphocytes has also been reported in patients co-infected with HIV and HCV [4]. Furthermore, IP-10 has been suggested as a biomarker for predicting the HCV treatment outcome for patients infected with both HIV and HCV [5]. However, the influence of chemokines/cytokines on the treatment responses to methadone and HIV/HCV infection remains unclear. We recruited 366 Han Chinese subjects with heroin dependence undergoing MMT in outpatient settings in Taiwan to investigate the impact of HIV/HCV infection on the levels of chemokines or cytokines and the treatment responses to methadone. 331 patients were screened for HCV, and 329 for HIV antibody. Detailed demography of subjects is shown in Table 1. Only one patient was tested positive for HIVantibody but not HCV, hence it was excluded from further analysis because of the small sample size. A higher initial methadone dose (P = 0.038), higher plasma concentrations of (R,S)-methadone (P = 0.038) and R-methadone (P = 0.028), lower ratio of S-EDDP/methadone dose (P = 0.043), higher levels of AST (P = 0.048) and ALT (P = 0.046), and a longer addiction duration (P b 0.0001) were found in the HIV(+)/HCV(+) or HCV(+) patients than the HIV(−)/HCV(−) patients (Table 1). The results of urine morphine test, which was used as a surrogate indicator for the effectiveness of opioid dependence treatment [6], were not statistically different among subjects grouped by their status of HIV and/or HCV infection. The plasma level of IP-10 was highest in the MMT patients coinfected with HIV and HCV, followed by those infected with HCV only, then those without any infection (Table 1). Similar rank order trend was also noted for the level of TNF-α. The plasma levels of MCP-3 and MIP-1β were significantly higher only in HCV(+) patients. The levels of other chemokines, IL-8, eotaxin, MCP-1, cytokines, IFNα2 and IFNγ were independent of the status of HIV or HCV infection (Table 1).
S.-W. Liu et al. / International Journal of Cardiology 194 (2015) 36–38
37
Table 1 Demography of subjects under methadone treatment and their HIV/HCV infection status. HIV(+)/HCV(+)
HCV(+)
Variable
Overall N
Mean ± SD
N
Mean ± SD
N
Mean ± SD
HIV(−)/HCV(−) N
Mean ± SD
Age (years) (Minimum–maximum) Male Methadone dose Addiction duration (year) Methadone metabolism (R,S)-Methadone (ng/ml) R-Methadone (ng/ml) S-EDDP/methadone dose ratio Urine morphine (+) Liver function AST, U/l ALT, U/l CXC chemokines IP-10, pg/ml IL-8, pg/ml CC chemokines Eotaxin, pg/ml MCP-1, pg/ml MCP-3, pg/ml MIP-1β, pg/ml Cytokines IFNα2, pg/ml IFNγ, pg/ml TNF-α, pg/ml
331
73
192 233 238
38.6 ± 7.77 (25–66) (80.67%) 32.79 ± 11.85 13.5 ± 7.81
17
62 70 73
37.36 ± 7.86 (24–63) (84.93%) 30.29 ± 9.08 13.07 ± 6.74
238
272 323 331
38.26 ± 7.71 (24–66) (82.18%) 31.95 ± 11.17 13.05 ± 7.58
16 17 17
36.76 ± 6.31 (25–48) (94.12%) 27.65 ± 7.93 5.88 ± 3.71
331 331 327 168
336.89 ± 211.18 194.21 ± 123.3 0.32 ± 0.51 (51.06%)
73 73 73 43
366.23 ± 251 218.52 ± 165.73 0.31 ± 0.37 (58.90%)
238 238 235 118
335.83 ± 196.65 191.9 ± 107.51 0.3 ± 0.34 (50.00%)
17 17 16 7
234.76 ± 176.85 130.58 ± 88.71 0.74 ± 1.71 (41.18%)
0.038b,c 0.028b,c 0.043b,c 0.28
317 323
52.77 ± 57.79 61.48 ± 76.19
69 73
57.1 ± 51.33 50.52 ± 42.81
229 231
53.23 ± 61.56 66.94 ± 85.89
17 17
31.35 ± 12.08 37.59 ± 28.70
0.048b,c 0.046c
327 327
1162.35 ± 806.54 5.80 ± 6.88
73 73
1561.78 ± 906.07 5.13 ± 5.57
234 234
1079.43 ± 730.94 6.12 ± 7.45
17 17
512.84 ± 315.85 4.58 ± 2.94
b0.0001a,b,c 0.36
327 327 327 327
73.37 ± 34.48 222.56 ± 146.57 15.68 ± 29.66 29.59 ± 33.25
73 73 73 73
68.83 ± 38.15 199.16 ± 82.77 13.21 ± 36.94 24.08 ± 37.55
234 234 234 234
73.72 ± 32.90 228.88 ± 163.86 16.79 ± 28.20 31.76 ± 32.46
17 17 17 17
86.02 ± 37.25 248.02 ± 100.65 13.26 ± 10.70 26.21 ± 23.97
0.09 0.16 0.019a 0.0001a
327 327 327
32.19 ± 114.34 14.62 ± 164.76 10.58 ± 8.82
73 73 73
29.59 ± 121.38 4.46 ± 7.52 13.23 ± 8.92
234 234 233
34.27 ± 116.98 18.68 ± 194.69 9.56 ± 6.39
17 17 17
19.6 ± 20.26 4.72 ± 4.54 7.86 ± 3.32
P-value 0.37 0.30 0.038c b0.0001b,c
0.25 0.28 b0.0001a,b
Continuous data used Kruskal–Wallis tests. Categorical data used Chi-square tests. N: subject number. SD: standard deviation. AST: aspartate aminotransferase. ALT: alanine aminotransferase. P-value b 0.05 is in bold. The post-hoc tests were performed by Wilcoxon rank-sum test. a P b 0.05 between HIV/HCV(+) and HCV(+). b P b 0.05 between HIV/HCV(+) and HIV/HCV(−). c P b 0.05 between HCV(+) and HIV/HCV(−).
Of interest, we found that the plasma levels of chemokine/cytokines were correlated with methadone treatment responses: in single variate correlation analyses, the level of IP-10 was significantly correlated with the current QTc (corrected QT interval) in ECG (r = 0.15, P = 0.011), tachycardia/palpitation side effect symptom scores (r = 0.4, P = 0.047), and skin irritation side effect symptom scores (r = 0.62, P = 0.023). The level of MCP-3 was correlated with tachycardia/palpitation side effect symptom scores (r = − 0.41, P = 0.042), and runny nose or tearing withdrawal symptom scores (r = −0.13, P = 0.021). When patients were further sub-grouped according to their urine morphine test results, the level of IP-10 was significantly correlated with constipation side effect symptom score (r = 0.22, P = 0.023) and heart rate (r =−0.16, P = 0.042) in patients with positive urine morphine test, while levels of MCP-3, MIP-1β and TNF-α with gooseflesh skin withdrawal symptom score (r = 0.18, 0.18, and 0.16, P = 0.022, 0.019 and 0.044, respectively). The level of TNF-α was correlated with pupil size withdrawal symptom score (r = −0.22, P = 0.005). For patients with negative urine morphine test, the level of IP-10 was correlated with the current QTc (r = 0.23, P = 0.009), and diastolic blood pressure (r = 0.16, P = 0.043). The level of MCP-3 was correlated with irritability and increase appetite symptom score (r = −0.89 and 0.50, P = 0.017 and 0.036, respectively). The level of MIP-1β was correlated with menstrual irregularity symptom score (r = −0.89, P = 0.041), and TNF-α level was correlated with diastolic blood pressure (r = 0.26, P = 0.001). In the analyses to test the correlation between plasma levels of chemokine/cytokines and liver functional parameters, IP-10 level showed significant correlations with levels of AST (r = 0.294, P b 0.0001), ALT (r = 0.232, P b 0.0001) and γ-GT (r = 0.247, P b 0.0001) in both urine morphine test positive and negative patients. TNF-α level was correlated with AST level (r = 0.176, P = 0.002), while MIP-1β level was mainly correlated with ALT level (r = 0.195, P = 0.001). In the area under the curve (AUC)/receiver operating characteristic (ROC) analyses, the level of IP-10 had the largest AUC to predict both HCV and HIV infection (AUC = 0.78;
95% CI 0.66–0.90; P b 0.0001 and AUC = 0.71; 95% CI 0.64–0.77; P b 0.0001). This indicated that IP-10 may be a potential biomarker for the prediction of HCV and HIV infection. In contrast, the level of TNF-α had a larger AUC (0.67; 95% CI 0.60–0.74; P b 0.0001) related to the status of HIV infection only. We further selected and analyzed those variates that showed a P-value less than 0.05 in univariate regression analyses as predictors by multiple regression analyses, and found a significant correlation between the level of IP-10 but not other chemokines/cytokines (e.g., MCP3, MIP-1β, TNF-α) and the current QTc in ECG (β = 5.16, P = 0.013) (Table 2). Furthermore, we found that the increase in the levels of IP10, MCP-3, MIP-1β and TNF-α persisted over the course of addiction to heroin as there was no difference in the levels among MMT patients grouped by the duration of addiction to heroin (i.e., less than 5, 5–10, 10–20, and above 20 years). In conclusion, we reported the first time that the level of chemokine IP-10 was significantly correlated with the current QTc in ECG and with Table 2 Multiple regression analyses with the level of chemokine IP-10. Variables in stepwise model
β
S.E.
t
P-value
VIF
TNF-α, pg/ml Current ECG QTc (ms) ALT, U/l γ-GT, U/l HBsAg (+/−) HIV and HCV (ref. = HIV/HCV(−)) HIV/HCV(+) HCV(+)
11.95 5.16 1.36 0.95 −481.32
5.14 2.07 0.89 0.45 110.57
2.33 2.49 1.53 2.09 −4.35
0.021 0.013 0.13 0.037 b0.0001
1.05 1.08 1.20 1.15 1.04
1137.08 493.85
228.82 211.52
4.97 2.33
b0.0001 0.020
3.97 3.96
F = 11.72, P b 0.0001, adjusted r2 = 24.21%. P-value b 0.05 is in bold. HBsAg: Surface antigen of hepatitis B virus. β: regression coefficient. S.E.: standard error of regression coefficient. t: the test statistics on slope of the regression line. VIF: variance inflation factor.
38
S.-W. Liu et al. / International Journal of Cardiology 194 (2015) 36–38
tachycardia/palpitation side effects from methadone treatment. Because QT prolongation can also be contributed by the methadone per se or HCV infection [7–10], we further verified the role of IP-10 on QTc through intraperitoneal injection of IP-10 (100 ng/g) to mice. The results showed that IP-10 did cause a significant increase in current QTc (data not shown). This is the first translational study providing evidence that the human recombinant IP-10 increases QTc. Detailed mechanisms of action and the role of HIV infection in the elevation of IP-10 level are not clear. Further studies to explore the mechanisms warrant. Conflict of interest No conflict of interest to declare. Acknowledgments We thank research nurses Ming-Chu Tseng, Pei-Fang Li, Shu-Chuan Ting, Yu-Ching Lin, Miao-Fang Lee, Chi-Yun Huang, and Yu-Hun Tsai at the six participating hospitals for recruiting patients and the help from Prof. Pao-Luh Tao for supporting cytokine and chemokine analyses. We also thank the Clinical Trial Information Management System (CTIMeS) at NHRI for data collection. We acknowledge the significant contributions of the Tao-yuan Mental Hospital, En-Chu-Kong Hospital, Far-Eastern Memorial Hospital, Taipei City Hospital Song-De and Yang-Ming Branches, China Medical University Hospital, and Wei Gong Memorial Hospital. This study was supported by grants from the National Research Program for Genomic Medicine [NSC 98-3112-B400-011, NSC 99-3112-B-400-003 and NSC 100-3112-B-400-015], National Science Council [NSC 97-2314-B- 400-001-MY3 and NSC 1002314-B-400-002-MY3] and the National Health Research Institutes, Taiwan [PH-102-PP-11, PH-103-PP-11, PH-104-PP-11, PH-098-PP-41, PH-098-PP-46, PH-098-PP-38, PH-098-PP-36, PH-098, 99-PP-42, PH-
099,100-PP-37, PH-101-PP-32, NP-102-PP-04, NP-103-PP-04, NP-104PP-04, PH-98, 99, 100-SP-11, PH-101-SP-03, NP-102-SP-04, NP-103SP-04, NP-104-SP-04 and NHRI-101, 102, 103A1-PDCO-1312141].
References [1] M.H. Ng, J.Y. Chou, T.J. Chang, P.C. Lee, W.C. Shao, T.Y. Lin, et al., High prevalence but low awareness of hepatitis C virus infection among heroin users who received methadone maintenance therapy in Taiwan, Addict. Behav. 38 (2013) 2089–2093. [2] X. Zhuang, Y. Wang, E.P. Chow, Y. Liang, D.P. Wilson, L. Zhang, Risk factors associated with HIV/HCV infection among entrants in methadone maintenance treatment clinics in China: a systematic review and meta-analysis, Drug Alcohol Depend. 126 (2012) 286–295. [3] B. Roe, S. Coughlan, J. Hassan, A. Grogan, G. Farrell, S. Norris, et al., Elevated serum levels of interferon-gamma-inducible protein-10 in patients coinfected with hepatitis C virus and HIV, J. Infect. Dis. 196 (2007) 1053–1057. [4] P. Kimball, F. McDougan, R. Stirling, CXCR3 expression elevated on peripheral CD8(+) lymphocytes from HIV/HCV coinfected individuals, Viral Immunol. 24 (2011) 441–448. [5] M. Zeremski, M. Markatou, Q.B. Brown, G. Dorante, S. Cunningham-Rundles, A.H. Talal, Interferon gamma-inducible protein 10: a predictive marker of successful treatment response in hepatitis C virus/HIV-coinfected patients, J. Acquir. Immune Defic. Syndr. 45 (2007) 262–268. [6] S.L. Wu, S.C. Wang, H.H. Tsou, H.W. Kuo, I.K. Ho, S.W. Liu, et al., Hepatitis C virus infection influences the S-methadone metabolite plasma concentration, PLoS ONE 8 (2013) e69310. [7] S. Mujtaba, J. Romero, C.C. Taub, Methadone, QTc prolongation and torsades de pointes: current concepts, management and a hidden twist in the tale? J. Cardiovasc. Dis. Res. 4 (2013) 229–235. [8] A. Fareed, D. Patil, K. Scheinberg, R. Blackinton Gale, S. Vayalapalli, J. Casarella, et al., Comparison of QTc interval prolongation for patients in methadone versus buprenorphine maintenance treatment: a 5-year follow-up, J. Addict. Dis. 32 (2013) 244–251. [9] G. Vallecillo, S. Mojal, A. Roquer, D. Martinez, P. Rossi, F. Fonseca, et al., Risk of QTc prolongation in a cohort of opioid-dependent HIV-infected patients on methadone maintenance therapy, Clin. Infect. Dis. 57 (2013) 1189–1194. [10] N. Gholami, L. Boesch, L. Falcato, R. Stohler, P. Bruggmann, QTc prolongation in methadone maintenance—the role of HCV infection, Swiss Med. Wkly. 143 (2013) w13852.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Chemokine IP-10 is correlated with cardiac responses and status of infection with HIV and HCV in methadone maintenance patients☆ Sheng-Wen Liu a,1, Yu-Li Liu a,⁎,1, Ling-Ling Hwang b, Sheng-Chang Wang a, Hsiang-Wei Kuo a, Shiow-Ling Wu c, Yu-Wen E. Dai b, Shu Chih Liu a, Ing-Kang Ho d,e, Andrew C.H. Chen f,g, Chin-Fu Hsiao h,i, Hsiao-Hui Tsou i,j,⁎⁎ a
Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan Graduate Institute of Medical Sciences and Department of Physiology, College of Medicine, Taipei Medical University, 250 Wu-Hsing Street, Taipei 110, Taiwan Center for Research, Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taipei, Taiwan d Center for Drug Abuse and Addiction, China Medical University Hospital, Taichung, Taiwan e Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan f Department of Psychiatry, The Zucker Hillside Hospital, North Shore-Long Island Jewish Medical Center Health System, Glen Oaks, NY, USA g The Feinstein Institute for Medical Research, Hofstra North Shore-LIJ School of Medicine at Hofstra University, Manhasset, NY, USA h Division of Clinical Trial Statistics, Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan i Division of Biostatistics and Bioinformatics, Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan j Graduate Institute of Biostatistics, College of Public Health, China Medical University, Taichung, Taiwan b c
a r t i c l e
i n f o
Article history: Received 7 May 2015 Accepted 9 May 2015 Available online 12 May 2015 Keywords: HIV HCV Electrocardiogram Methadone IP-10 TNF-α
To the Editor, Methadone is a synthetic opioid usually used as a maintenance therapy for heroin dependence [1]. It has been reported that the infection rates with human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV) were higher in patients undergoing methadone maintenance treatment (MMT) [2]. However, the influence of co-infection with HIV and HCV on the treatment responses to methadone has yet
☆ Trial registration number: NCT01059747 (National Institutes of Health Clinical Trial database, http://www.clinicaltrial.gov/ct/show/NCT01059747). ⁎ Correspondence to: Yu-Li Liu, Center for Neuropsychiatric Research, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County 350, Taiwan. ⁎⁎ Correspondence to: Hsiao-Hui Tsou, Division of Biostatistics and Bioinformatics, Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County 350, Taiwan. E-mail addresses: [email protected] (Y.-L. Liu), [email protected] (H.-H. Tsou). 1 Both authors contributed equally to the study.
http://dx.doi.org/10.1016/j.ijcard.2015.05.055 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
to be studied. A higher plasma level of chemokine interferon gammainducible protein 10 (IP-10, also called chemokine (C-X-C motif) ligand 10, CXCL 10) has been reported in patients infected with both HIV and HCV than those infected with only single virus [3]. Increased expression of IP-10, CXCR3 receptors in the CD8(+) lymphocytes has also been reported in patients co-infected with HIV and HCV [4]. Furthermore, IP-10 has been suggested as a biomarker for predicting the HCV treatment outcome for patients infected with both HIV and HCV [5]. However, the influence of chemokines/cytokines on the treatment responses to methadone and HIV/HCV infection remains unclear. We recruited 366 Han Chinese subjects with heroin dependence undergoing MMT in outpatient settings in Taiwan to investigate the impact of HIV/HCV infection on the levels of chemokines or cytokines and the treatment responses to methadone. 331 patients were screened for HCV, and 329 for HIV antibody. Detailed demography of subjects is shown in Table 1. Only one patient was tested positive for HIVantibody but not HCV, hence it was excluded from further analysis because of the small sample size. A higher initial methadone dose (P = 0.038), higher plasma concentrations of (R,S)-methadone (P = 0.038) and R-methadone (P = 0.028), lower ratio of S-EDDP/methadone dose (P = 0.043), higher levels of AST (P = 0.048) and ALT (P = 0.046), and a longer addiction duration (P b 0.0001) were found in the HIV(+)/HCV(+) or HCV(+) patients than the HIV(−)/HCV(−) patients (Table 1). The results of urine morphine test, which was used as a surrogate indicator for the effectiveness of opioid dependence treatment [6], were not statistically different among subjects grouped by their status of HIV and/or HCV infection. The plasma level of IP-10 was highest in the MMT patients coinfected with HIV and HCV, followed by those infected with HCV only, then those without any infection (Table 1). Similar rank order trend was also noted for the level of TNF-α. The plasma levels of MCP-3 and MIP-1β were significantly higher only in HCV(+) patients. The levels of other chemokines, IL-8, eotaxin, MCP-1, cytokines, IFNα2 and IFNγ were independent of the status of HIV or HCV infection (Table 1).
S.-W. Liu et al. / International Journal of Cardiology 194 (2015) 36–38
37
Table 1 Demography of subjects under methadone treatment and their HIV/HCV infection status. HIV(+)/HCV(+)
HCV(+)
Variable
Overall N
Mean ± SD
N
Mean ± SD
N
Mean ± SD
HIV(−)/HCV(−) N
Mean ± SD
Age (years) (Minimum–maximum) Male Methadone dose Addiction duration (year) Methadone metabolism (R,S)-Methadone (ng/ml) R-Methadone (ng/ml) S-EDDP/methadone dose ratio Urine morphine (+) Liver function AST, U/l ALT, U/l CXC chemokines IP-10, pg/ml IL-8, pg/ml CC chemokines Eotaxin, pg/ml MCP-1, pg/ml MCP-3, pg/ml MIP-1β, pg/ml Cytokines IFNα2, pg/ml IFNγ, pg/ml TNF-α, pg/ml
331
73
192 233 238
38.6 ± 7.77 (25–66) (80.67%) 32.79 ± 11.85 13.5 ± 7.81
17
62 70 73
37.36 ± 7.86 (24–63) (84.93%) 30.29 ± 9.08 13.07 ± 6.74
238
272 323 331
38.26 ± 7.71 (24–66) (82.18%) 31.95 ± 11.17 13.05 ± 7.58
16 17 17
36.76 ± 6.31 (25–48) (94.12%) 27.65 ± 7.93 5.88 ± 3.71
331 331 327 168
336.89 ± 211.18 194.21 ± 123.3 0.32 ± 0.51 (51.06%)
73 73 73 43
366.23 ± 251 218.52 ± 165.73 0.31 ± 0.37 (58.90%)
238 238 235 118
335.83 ± 196.65 191.9 ± 107.51 0.3 ± 0.34 (50.00%)
17 17 16 7
234.76 ± 176.85 130.58 ± 88.71 0.74 ± 1.71 (41.18%)
0.038b,c 0.028b,c 0.043b,c 0.28
317 323
52.77 ± 57.79 61.48 ± 76.19
69 73
57.1 ± 51.33 50.52 ± 42.81
229 231
53.23 ± 61.56 66.94 ± 85.89
17 17
31.35 ± 12.08 37.59 ± 28.70
0.048b,c 0.046c
327 327
1162.35 ± 806.54 5.80 ± 6.88
73 73
1561.78 ± 906.07 5.13 ± 5.57
234 234
1079.43 ± 730.94 6.12 ± 7.45
17 17
512.84 ± 315.85 4.58 ± 2.94
b0.0001a,b,c 0.36
327 327 327 327
73.37 ± 34.48 222.56 ± 146.57 15.68 ± 29.66 29.59 ± 33.25
73 73 73 73
68.83 ± 38.15 199.16 ± 82.77 13.21 ± 36.94 24.08 ± 37.55
234 234 234 234
73.72 ± 32.90 228.88 ± 163.86 16.79 ± 28.20 31.76 ± 32.46
17 17 17 17
86.02 ± 37.25 248.02 ± 100.65 13.26 ± 10.70 26.21 ± 23.97
0.09 0.16 0.019a 0.0001a
327 327 327
32.19 ± 114.34 14.62 ± 164.76 10.58 ± 8.82
73 73 73
29.59 ± 121.38 4.46 ± 7.52 13.23 ± 8.92
234 234 233
34.27 ± 116.98 18.68 ± 194.69 9.56 ± 6.39
17 17 17
19.6 ± 20.26 4.72 ± 4.54 7.86 ± 3.32
P-value 0.37 0.30 0.038c b0.0001b,c
0.25 0.28 b0.0001a,b
Continuous data used Kruskal–Wallis tests. Categorical data used Chi-square tests. N: subject number. SD: standard deviation. AST: aspartate aminotransferase. ALT: alanine aminotransferase. P-value b 0.05 is in bold. The post-hoc tests were performed by Wilcoxon rank-sum test. a P b 0.05 between HIV/HCV(+) and HCV(+). b P b 0.05 between HIV/HCV(+) and HIV/HCV(−). c P b 0.05 between HCV(+) and HIV/HCV(−).
Of interest, we found that the plasma levels of chemokine/cytokines were correlated with methadone treatment responses: in single variate correlation analyses, the level of IP-10 was significantly correlated with the current QTc (corrected QT interval) in ECG (r = 0.15, P = 0.011), tachycardia/palpitation side effect symptom scores (r = 0.4, P = 0.047), and skin irritation side effect symptom scores (r = 0.62, P = 0.023). The level of MCP-3 was correlated with tachycardia/palpitation side effect symptom scores (r = − 0.41, P = 0.042), and runny nose or tearing withdrawal symptom scores (r = −0.13, P = 0.021). When patients were further sub-grouped according to their urine morphine test results, the level of IP-10 was significantly correlated with constipation side effect symptom score (r = 0.22, P = 0.023) and heart rate (r =−0.16, P = 0.042) in patients with positive urine morphine test, while levels of MCP-3, MIP-1β and TNF-α with gooseflesh skin withdrawal symptom score (r = 0.18, 0.18, and 0.16, P = 0.022, 0.019 and 0.044, respectively). The level of TNF-α was correlated with pupil size withdrawal symptom score (r = −0.22, P = 0.005). For patients with negative urine morphine test, the level of IP-10 was correlated with the current QTc (r = 0.23, P = 0.009), and diastolic blood pressure (r = 0.16, P = 0.043). The level of MCP-3 was correlated with irritability and increase appetite symptom score (r = −0.89 and 0.50, P = 0.017 and 0.036, respectively). The level of MIP-1β was correlated with menstrual irregularity symptom score (r = −0.89, P = 0.041), and TNF-α level was correlated with diastolic blood pressure (r = 0.26, P = 0.001). In the analyses to test the correlation between plasma levels of chemokine/cytokines and liver functional parameters, IP-10 level showed significant correlations with levels of AST (r = 0.294, P b 0.0001), ALT (r = 0.232, P b 0.0001) and γ-GT (r = 0.247, P b 0.0001) in both urine morphine test positive and negative patients. TNF-α level was correlated with AST level (r = 0.176, P = 0.002), while MIP-1β level was mainly correlated with ALT level (r = 0.195, P = 0.001). In the area under the curve (AUC)/receiver operating characteristic (ROC) analyses, the level of IP-10 had the largest AUC to predict both HCV and HIV infection (AUC = 0.78;
95% CI 0.66–0.90; P b 0.0001 and AUC = 0.71; 95% CI 0.64–0.77; P b 0.0001). This indicated that IP-10 may be a potential biomarker for the prediction of HCV and HIV infection. In contrast, the level of TNF-α had a larger AUC (0.67; 95% CI 0.60–0.74; P b 0.0001) related to the status of HIV infection only. We further selected and analyzed those variates that showed a P-value less than 0.05 in univariate regression analyses as predictors by multiple regression analyses, and found a significant correlation between the level of IP-10 but not other chemokines/cytokines (e.g., MCP3, MIP-1β, TNF-α) and the current QTc in ECG (β = 5.16, P = 0.013) (Table 2). Furthermore, we found that the increase in the levels of IP10, MCP-3, MIP-1β and TNF-α persisted over the course of addiction to heroin as there was no difference in the levels among MMT patients grouped by the duration of addiction to heroin (i.e., less than 5, 5–10, 10–20, and above 20 years). In conclusion, we reported the first time that the level of chemokine IP-10 was significantly correlated with the current QTc in ECG and with Table 2 Multiple regression analyses with the level of chemokine IP-10. Variables in stepwise model
β
S.E.
t
P-value
VIF
TNF-α, pg/ml Current ECG QTc (ms) ALT, U/l γ-GT, U/l HBsAg (+/−) HIV and HCV (ref. = HIV/HCV(−)) HIV/HCV(+) HCV(+)
11.95 5.16 1.36 0.95 −481.32
5.14 2.07 0.89 0.45 110.57
2.33 2.49 1.53 2.09 −4.35
0.021 0.013 0.13 0.037 b0.0001
1.05 1.08 1.20 1.15 1.04
1137.08 493.85
228.82 211.52
4.97 2.33
b0.0001 0.020
3.97 3.96
F = 11.72, P b 0.0001, adjusted r2 = 24.21%. P-value b 0.05 is in bold. HBsAg: Surface antigen of hepatitis B virus. β: regression coefficient. S.E.: standard error of regression coefficient. t: the test statistics on slope of the regression line. VIF: variance inflation factor.
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S.-W. Liu et al. / International Journal of Cardiology 194 (2015) 36–38
tachycardia/palpitation side effects from methadone treatment. Because QT prolongation can also be contributed by the methadone per se or HCV infection [7–10], we further verified the role of IP-10 on QTc through intraperitoneal injection of IP-10 (100 ng/g) to mice. The results showed that IP-10 did cause a significant increase in current QTc (data not shown). This is the first translational study providing evidence that the human recombinant IP-10 increases QTc. Detailed mechanisms of action and the role of HIV infection in the elevation of IP-10 level are not clear. Further studies to explore the mechanisms warrant. Conflict of interest No conflict of interest to declare. Acknowledgments We thank research nurses Ming-Chu Tseng, Pei-Fang Li, Shu-Chuan Ting, Yu-Ching Lin, Miao-Fang Lee, Chi-Yun Huang, and Yu-Hun Tsai at the six participating hospitals for recruiting patients and the help from Prof. Pao-Luh Tao for supporting cytokine and chemokine analyses. We also thank the Clinical Trial Information Management System (CTIMeS) at NHRI for data collection. We acknowledge the significant contributions of the Tao-yuan Mental Hospital, En-Chu-Kong Hospital, Far-Eastern Memorial Hospital, Taipei City Hospital Song-De and Yang-Ming Branches, China Medical University Hospital, and Wei Gong Memorial Hospital. This study was supported by grants from the National Research Program for Genomic Medicine [NSC 98-3112-B400-011, NSC 99-3112-B-400-003 and NSC 100-3112-B-400-015], National Science Council [NSC 97-2314-B- 400-001-MY3 and NSC 1002314-B-400-002-MY3] and the National Health Research Institutes, Taiwan [PH-102-PP-11, PH-103-PP-11, PH-104-PP-11, PH-098-PP-41, PH-098-PP-46, PH-098-PP-38, PH-098-PP-36, PH-098, 99-PP-42, PH-
099,100-PP-37, PH-101-PP-32, NP-102-PP-04, NP-103-PP-04, NP-104PP-04, PH-98, 99, 100-SP-11, PH-101-SP-03, NP-102-SP-04, NP-103SP-04, NP-104-SP-04 and NHRI-101, 102, 103A1-PDCO-1312141].
References [1] M.H. Ng, J.Y. Chou, T.J. Chang, P.C. Lee, W.C. Shao, T.Y. Lin, et al., High prevalence but low awareness of hepatitis C virus infection among heroin users who received methadone maintenance therapy in Taiwan, Addict. Behav. 38 (2013) 2089–2093. [2] X. Zhuang, Y. Wang, E.P. Chow, Y. Liang, D.P. Wilson, L. Zhang, Risk factors associated with HIV/HCV infection among entrants in methadone maintenance treatment clinics in China: a systematic review and meta-analysis, Drug Alcohol Depend. 126 (2012) 286–295. [3] B. Roe, S. Coughlan, J. Hassan, A. Grogan, G. Farrell, S. Norris, et al., Elevated serum levels of interferon-gamma-inducible protein-10 in patients coinfected with hepatitis C virus and HIV, J. Infect. Dis. 196 (2007) 1053–1057. [4] P. Kimball, F. McDougan, R. Stirling, CXCR3 expression elevated on peripheral CD8(+) lymphocytes from HIV/HCV coinfected individuals, Viral Immunol. 24 (2011) 441–448. [5] M. Zeremski, M. Markatou, Q.B. Brown, G. Dorante, S. Cunningham-Rundles, A.H. Talal, Interferon gamma-inducible protein 10: a predictive marker of successful treatment response in hepatitis C virus/HIV-coinfected patients, J. Acquir. Immune Defic. Syndr. 45 (2007) 262–268. [6] S.L. Wu, S.C. Wang, H.H. Tsou, H.W. Kuo, I.K. Ho, S.W. Liu, et al., Hepatitis C virus infection influences the S-methadone metabolite plasma concentration, PLoS ONE 8 (2013) e69310. [7] S. Mujtaba, J. Romero, C.C. Taub, Methadone, QTc prolongation and torsades de pointes: current concepts, management and a hidden twist in the tale? J. Cardiovasc. Dis. Res. 4 (2013) 229–235. [8] A. Fareed, D. Patil, K. Scheinberg, R. Blackinton Gale, S. Vayalapalli, J. Casarella, et al., Comparison of QTc interval prolongation for patients in methadone versus buprenorphine maintenance treatment: a 5-year follow-up, J. Addict. Dis. 32 (2013) 244–251. [9] G. Vallecillo, S. Mojal, A. Roquer, D. Martinez, P. Rossi, F. Fonseca, et al., Risk of QTc prolongation in a cohort of opioid-dependent HIV-infected patients on methadone maintenance therapy, Clin. Infect. Dis. 57 (2013) 1189–1194. [10] N. Gholami, L. Boesch, L. Falcato, R. Stohler, P. Bruggmann, QTc prolongation in methadone maintenance—the role of HCV infection, Swiss Med. Wkly. 143 (2013) w13852.