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In heart failure (HF) patients, current European Society of Cardiology (ESC) guidelines recommend the use of three loop diuretics (furosemide, torasemide, bumetanide) in order to not only reduce HF hospitalizations but also improve symptoms and exercise capacity in patients with signs and/or symptoms of congestion. In addition, for the first time in hypertensive patients, European Society of Hypertension (ESH) guidelines recommend the use of torasemide. This review aimed to summarize the mode of action of loop diuretics, to present their pharmacokinetic characteristics, and to discuss their place in the management of arterial hypertension and heart failure, with special emphasis however on torasemide.

Objective: Recent trials have indicated positive effects of bumetanide in autism spectrum disorder (ASD). We tested efficacy of bumetanide on core symptom domains using a single center, parallel-group, participant-randomized, double-blind, placebo-controlled phase-2 superiority trial in a tertiary hospital in the Netherlands. Method: Unmedicated children aged 7 to 15 years with ASD and IQ ≥55 were block-randomized 1:1 to oral-solution bumetanide versus placebo, titrated to a maximum of 1.0 mg twice daily for 91 days (D91), followed by a 28-day wash-out period. The primary outcome was difference in Social Responsiveness Scale−2 (SRS-2) total score at D91, analyzed by modified intention-to-treat with linear mixed models. Results: A total of 92 participants (mean age 10.5 [SD 2.4] years) enrolled between June 2016 and December 2018. In all, 47 children were allocated to bumetanide and 45 to placebo. Two participants dropped out per treatment arm. After 91 days, bumetanide was not superior to placebo on the primary outcome, the SRS-2 (mean difference −3.16, 95% CI = −9.68 to 3.37, p = .338). A superior effect was found on one of the secondary outcomes, the Repetitive Behavior Scale−Revised (mean difference −4.16, 95% CI = −8.06 to −0.25, p = .0375), but not on the Sensory Profile (mean difference 5.64, 95% CI = −11.30 to 22.57, p = .508) or the Aberrant Behavior Checklist Irritability Subscale (mean difference −0.65, 95% CI = −2.83 to 1.52, p = .552). No significant wash-out effect was observed. Significant adverse effects were predominantly diuretic effects (orthostatic hypotension (17 [36%] versus 5 [11%], p = .007); hypokalemia (24 [51%] versus 0 [0%], p < .0001), the occurrence of which did not statistically influence treatment outcome. Conclusion: The trial outcome was negative in terms of no superior effect on the primary outcome. The secondary outcomes suggest efficacy on repetitive behavior symptoms for a subset of patients. Clinical trial registration information: Bumetanide in Autism Medication and Biomarker Study (BAMBI); https://www.clinicaltrialsregister.eu/; 2014-001560-35.

Mechanisms of saliva formation by wombat parotid glands were investigated in anaesthetized wombats at two levels of cholinergically-stimulated flow viz. mid-range (30–40% maximum flow) and maximum flow using ion-transport and carbonic-anhydrase inhibitors. Bumetanide (0.005–0.1 mmol l−1 carotid plasma) progressively reduced mid-range flow by 52 ± 3.4% (mean ± SEM). Concurrently, saliva [Cl] decreased, [Na] and [HCO3] increased but HCO3 excretion was unaltered. Salivary flow during high-rate cholinergic stimulation was 31 ± 1.1% of the pre-bumetanide maximum. During mid-range stimulation, SITS (0.075 mmol l−1) was without effect whereas 0.75 mmol l−1 stimulated transient increases in fluid output. The higher SITS concentration caused no alterations to flow or electrolyte concentrations during maximal stimulation. Carotid plasma [amiloride] (0.05 mmol l−1) caused immediate falls in flow rate of 20–30% followed by progressive recovery over 25 min to levels above pre-amiloride flow rates despite plasma [amiloride] increasing tenfold. Concurrently, salivary [Na] and [Cl] rose to equal plasma concentrations and [K] fell by 50% indicating blockade of acinar Na/H exchangers and luminal Na channels in the ducts. Increased salivary osmolarity caused the flow recovery. Saliva flow during maximum cholinergic stimulation was reduced by 38–46%. The depression of flow was interpreted as resulting from competition between amiloride and acetylcholine for access to the muscarinic receptors. Plasma [acetazolamide] (0.35–2.5 mmol l−1) did not alter saliva outflow during mid-range or maximum flow regimes whereas salivary [Cl] increased and [HCO3] decreased consistent with reduced anion exchange resulting from inhibition of carbonic anhydrase. Combined with bumetanide, acetazolamide (1.5 mmol l−1) reduced flow by an additional 18–22% relative to bumetanide alone thereby demonstrating that acinar HCO3 synthesis supported a limited proportion of saliva formation and that some HCO3 secretion was independent of carbonic anhydrase activity.

Bumetanide falls in the class of loop diuretics like furosemide. The effects of both have been extensively researched and are well documented. In medical practice furosemide is more widely used in patients both orally and through intravenous administration.

A wide variety of genetic and non-genetic pathologies share serious psychiatric symptoms, which determine a poor quality of life for patients and their families. To evaluate whether bumetanide, a drug initially developed as a diuretic and currently analyzed for a new indication in patients with severe neuropsychiatric pathologies, could improve the disruptive and self-injurious behaviors secondary to Tuberous Sclerosis Complex (TSC) and characteristic of the autistic spectrum the case of this 6-year-old patient is considered. Following preclinical and clinical evidence of the efficacy of bumetanide in Tuberous Sclerosis and other neurodevelopmental disorders, the drug may alleviate the psychiatric manifestations (TAND) of Tuberous Sclerosis pathology. This would allow avoiding the excessive prescription of antipsychotic drugs indicated to control disruptive behaviors. Methodology: The Administracion Nacional de Medicamentos, Alimentos y Tecnologia Medica (ANMAT) approval was requested for compassionate use since it is not an approved drug in Argentina for this indication. The patient was evaluated with laboratory tests at T0, T1, T2, T3 and T4, corresponding to the basal moments, of 7 days, 30 days, 60 days and 90 days after starting the medication. Likewise, behavior was evaluated with the Aberrant Behavior Checklist (ABC) at the same times described. CARS was used for autistic characteristics and TAND Checklist for psychiatric disorders, both at the beginning. Bumetanide was administered at 1 mg/day and increased to 1.5 mg/day one month after the first dose. Results: We observed, in this case, the primary endpoint, irritability, showed moderate improvement. On the contrary, hyperactivity, attention, sociability and better connection through gaze experienced and evident improvement. Regarding isolation scales and stereotyped behaviors, an important improvement was found after 3 months of treatment with bumetanide, an antagonist NKCC1, evaluated through the Aberrant Behavior Checklist (ABC). On the other hand, no remarkable adverse effects were observed.

The article presents the consensus materials of the European Society of Cardiology on the use of diuretics in chronic heart failure (CHF). Diuretics represent an important class of drugs for the treatment of heart failure from the perspective of evidence based medicine. Much attention in the consensus s paid to the algorithm of using diuretics, in particular loop diuretics, in acute decompensation of CHF. Clinical and pharmacological advantages and disadvantages of the main drugs of loop diuretics (furosemide, torasemide, bumetanide) in CHF are discussed. There was analyzed the effectiveness of low and high doses of loop diuretics, the method of administration (bolus or continuous infusion) in terms of effective diuretic therapy and prevention of tolerance to diuretics, as well as the impact on the prognosis of survival during decompensation of heart failure. It also discusses modern approaches to the diagnostic criteria for assessing the effectiveness of diuretic therapy in acute decompensation of CHF, and shows the possibility of determination the level of excretion of Na + ions in the urine as a surrogate marker of the effectiveness of diuretic therapy to optimize the dosage regimen of diuretics. An algorithm of diuretic therapy is proposed (the choice of dosages and regimens for using loop diuretics) for patients with acute decompensation of heart failure, including intravenous use of loop diuretics in an optimal increasing dose for the first 24 hours before stopping stagnation with a further transition to a maintenance dose of loop diuretic for euvolemia status and combined diuretic therapy with thiazides to obtain synergism. The recommendations for correction of electrolyte disturbances against the background of diuretic therapy is considered. Loop diuretics are recommended for CHF to prevent signs and symptoms of congestion: this is the only group of drugs with a level of recommendation as class I in patients with heart failure with a reduced or preserved ejection fraction.

Children with neurodevelopmental disorders (NDDs), such as autism spectrum disorder and attention-deficit/hyperactivity disorder, vary greatly in mechanism and clinical presentation. This heterogeneity, however, is largely denied or ignored in trials and has led to a deadlock in treatment development. The aim of this dissertation was to improve this situation by developing stratified trial designs and improving clinical endpoints. We tested these innovations in the context of a novel, mechanism-based treatment option for NDDs. This treatment is based upon the repurposing of the diuretic bumetanide, a chloride importer antagonist. A large body of (pre)clinical evidence has indicated that elevated chloride levels may cause hyperexcitability in the brain, that may be treated by bumetanide in a yet unknown subset of NDDs. The studies tested behavioral, neurocognitive and genetic stratification techniques to find these responsive subsets. We further conducted a parent-driven approach to develop patient reported outcome measures (PROMs) to improve clinical endpoint measurement. Overall, we found that bumetanide can have a positive effect on behavioral manifestations, such as irritable and repetitive behaviors. Genetic stratification seems especially promising to enhance effectiveness in trial designs. The PROM study showed that the use of generic item banks may be a solution to assess consequences of sensory issues across NDDs as a powerful translational endpoint. In conclusion, these findings highlight the need for a shift from the traditional diagnosis-driven approach to a stratified and etiology-driven approach in NDD clinical trials.

Background There is little evidence on the use of subcutaneous furosemide infusions in heart failure patients, especially in the community setting (Beattie & Johnson, 2012). Integrated working is key to smooth the transition from management in the hospital to community settings, particularly for patients who are increasingly fatigued with short prognoses but who may still benefit from parenteral therapy. Aim To retrospectively evaluate clinical effectiveness of subcutaneous furosemide used in the community setting at end-of-life. Method We reviewed case notes of patients treated with continuous subcutaneous furosemide by the community palliative care team (2019–2021). A standardised proforma was used to assess patient demographics, indications, clinical outcomes and barriers/facilitators to the process. Results 16 patients received a total 22 interventions. Median age 77(50-94), 11(69%) male, primary HF (Heart failure) diagnosis 6 HFrEF, 5 HFpEF,2 RHF, 2 Valvular, 1 unknown aetiology. Phase of Illness, 13 unstable and 9 deteriorating with AKPS 30-60%. Oral diuretics included loop diuretics (furosemide 15/22 and bumetanide 6/22), aldosterone receptor antagonists (spironolactone 4/22), mineralocorticoid receptor antagonists (eplerenone 11/22) and thiazides (indapamide 1/22). Majority of interventions had stage 3 renal function (16/22 episodes). Patients were discussed with cardiology or palliative care consultant. Median dose given was 160mg (range 80-240mg) for 11(1-33) days. Outcomes 15/22 showed symptomatic improvement, 6/22 had side-effects including worsening renal function, hypotension, hypokalaemia and site reaction needing antibiotics. 21/22 interventions avoided a hospital admission; 12/16 patients achieved preferred place of death (1 was admitted to hospital; 3 alive). Barriers to community administration included: challenges obtaining medications, burden of a continuous sub cutaneous infusion [CSCI]. Conclusion There is a clear benefit for individual patients, allowing those in last year of life to spend as much time as possible at home. We plan to develop a decision support tool to aid wider community decision making, facilitating timely use of subcutaneous furosemide, therefore maintaining effective symptom control in community settings.

Sodium-potassium-chloride cotransporter 1 (NKCC1) and potassium-chloride cotransporter 2 (KCC2) are associated with the transmission of peripheral pain. We investigated whether the increase of NKCC1 and KCC2 is associated with peripheral pain transmission in dorsal root ganglion neurons. To this aim, rats with persistent hyperalgesia were randomly divided into four groups. Rats in the control group received no treatment, and the rat sciatic nerve was only exposed in the sham group. Rats in the chronic constriction injury group were established into chronic constriction injury models by ligating sciatic nerve and rats were given bumetanide, an inhibitor of NKCC1, based on chronic constriction injury modeling in the chronic constriction injury + bumetanide group. In the experiment measuring thermal withdrawal latency, bumetanide (15 mg/kg) was intravenously administered. In the patch clamp experiment, bumetanide (10 µg/µL) and acutely isolated dorsal root ganglion neurons (on day 14) were incubated for 1 hour, or bumetanide (5 µg/µL) was intrathecally injected. The Hargreaves test was conducted to detect changes in thermal hyperalgesia in rats. We found that the thermal withdrawal latency of rats was significantly decreased on days 7, 14, and 21 after model establishment. After intravenous injection of bumetanide, the reduction in thermal retraction latency caused by model establishment was significantly inhibited. Immunohistochemistry and western blot assay results revealed that the immune response and protein expression of NKCC1 in dorsal root ganglion neurons of the chronic constriction injury group increased significantly on days 7, 14, and 21 after model establishment. No immune response or protein expression of KCC2 was observed in dorsal root ganglion neurons before and after model establishment. The Cl– (chloride ion) fluorescent probe technique was used to evaluate the change of Cl– concentration in dorsal root ganglion neurons of chronic constriction injury model rats. We found that the relative optical density of N-(ethoxycarbonylmethyl)-6-methoxyquinolinium bromide (a Cl– fluorescent probe whose fluorescence intensity decreases as Cl– concentration increases) in the dorsal root ganglion neurons of the chronic constriction injury group was significantly decreased on days 7 and 14 after model establishment. The whole-cell patch clamp technique revealed that the resting potential and action potential frequency of dorsal root ganglion neurons increased, and the threshold and rheobase of action potentials decreased in the chronic constriction injury group on day 14 after model establishment. After bumetanide administration, the above indicators were significantly suppressed. These results confirm that CCI can induce abnormal overexpression of NKCC1, thereby increasing the Cl– concentration in dorsal root ganglion neurons; this then enhances the excitability of dorsal root ganglion neurons and ultimately promotes hyperalgesia and allodynia. In addition, bumetanide can achieve analgesic effects. All experiments were approved by the Institutional Ethics Review Board at the First Affiliated Hospital, College of Medicine, Shihezi University, China on February 22, 2017 (approval No. A2017-169-01).

The Na+K+2Cl− cotransporter-2 ( Nkcc2, Slc12a1) is abundantly expressed in the kidney and its inhibition with the loop-diuretics bumetanide and furosemide has been linked to transient or permanent hyperglycemia in mice and humans. Notably, Slc12a1 is expressed at low levels in hypothalamic neurons and in insulin-secreting β-cells of the endocrine pancreas. The present study was designed to determine if global elimination of one of the Slc12a1 products, i.e., Nkcc2 variant a ( Nkcc2a), the main splice version of Nkcc2 found in insulin-secreting β-cells, has an impact on the insulin and glucagon secretory responses and fuel homeostasis in vivo. We have used dynamic tests of glucose homeostasis in wild-type mice and mice lacking both alleles of Nkcc2a ( Nkcc2aKO) and assessed their islet secretory responses in vitro. Under basal conditions, Nkcc2aKO mice have impaired glucose homeostasis characterized by increased blood glucose, intolerance to the sugar, delayed/blunted in vivo insulin and glucagon responses to glucose, and increased glycemic responses to the gluconeogenic substrate alanine. Further, we provide evidence of conserved quantitative secretory responses of Nkcc2aKO islets within a context of increased islet size related to hyperplastic/hypertrophic glucagon- and insulin-positive cells (α-cells and β-cells, respectively), normal total islet Cl− content, and reduced β-cell expression of the Cl− extruder Kcc2.

Introduction Signs and symptoms of congestion are the predominant reason for hospital admission with acute heart failure (AHF). Diuretics are mainstay treatment, but their optimal type and dose regimen remains unclear. Hypothesis Acetazolamide in addition to loop diuretics increases natriuresis without further neurohumoral activation, potentially improving decongestion and outcomes in AHF. Methods This prospective, 2-center study included 34 AHF patients on loop diuretics with volume overload. All patients had a serum sodium concentration 50 and/or admission serum creatinine increased with >0.3 mg/dL compared to baseline. Patients were randomized towards acetazolamide 500 mg OD plus bumetanide 1-2 mg BID versus high-dose loop diuretics (bumetanide BID with bolus dose equal to oral maintenance dose). The primary end-point was natriuresis after 24h. Results Natriuresis after 24h was similar in the combinational treatment versus loop-diuretic only arm (264±126 versus 234±133 mmol, respectively; P-value=0.515). Loop diuretic efficiency, defined as natriuresis corrected for loop diuretic dose, was higher in the group receiving acetazolamide (84±46 versus 52±42 mmol/mg bumetanide, respectively; P-value=0.048; Figure). More patients in the combinational treatment arm had an increase in serum creatinine levels >0.3 mg/dL (P-value=0.046). NT-proBNP reduction and peak neurohumoral activation within 72h were comparable among treatment arms. Median time to all-cause mortality or heart failure readmission was 273 versus 803 days in the group receiving high-dose loop diuretic monotherapy versus acetazolamide with low-dose loop diuretics, which favoured the latter group but was not statistically significant (P-value=0.098). Conclusion Addition of acetazolamide increases the natriuretic response to loop diuretics with similar neurohumoral responses compared to an increase in loop diuretic dose in AHF at high risk for diuretic resistance. ClinicalTrials.gov identifier: NCT01973335.

Background and Purpose— Inhibition of brain NKCC1 (Na + -K + -Cl − cotransporter 1) with bumetanide (BMT) is of interest in ischemic stroke therapy. However, its poor brain penetration limits the application. In this study, we investigated the efficacy of 2 novel NKCC1 inhibitors, a lipophilic BMT prodrug STS5 (2-(Dimethylamino)ethyl 3-(butylamino)-4-phenoxy-5-sulfamoyl-benzoate;hydrochloride) and a novel NKCC1 inhibitor STS66 (3-(Butylamino)-2-phenoxy-5-[(2,2,2-trifluoroethylamino)methyl]benzenesulfonamide), on reducing ischemic brain injury. Methods— Large-vessel transient ischemic stroke in normotensive C57BL/6J mice was induced with 50-min occlusion of the middle cerebral artery and reperfusion. Focal, permanent ischemic stroke in angiotensin II (Ang II)–induced hypertensive C57BL/6J mice was induced by permanent occlusion of distal branches of middle cerebral artery. A total of 206 mice were randomly assigned to receive vehicle DMSO, BMT, STS5, or STS66. Results— Poststroke BMT, STS5, or STS66 treatment significantly decreased infarct volume and cerebral swelling by ≈40% to 50% in normotensive mice after transient middle cerebral artery occlusion, but STS66-treated mice displayed better survival and sensorimotor functional recovery. STS5 treatment increased the mortality. Ang II–induced hypertensive mice exhibited increased phosphorylatory activation of SPAK (Ste20-related proline alanine-rich kinase) and NKCC1, as well as worsened infarct and neurological deficit after permanent distal middle cerebral artery occlusion. Conclusions— The novel NKCC1 inhibitor STS66 is superior to BMT and STS5 in reducing ischemic infarction, swelling, and neurological deficits in large-vessel transient ischemic stroke, as well as in permanent focal ischemic stroke with hypertension comorbidity.

Na+ -K+ -2Cl- cotransporter-1 (NKCC1) facilitates basolateral K+ and Cl- uptake, supporting their efflux across mucosal membranes of colonic epithelial cells. NKCC1 activity has also been shown to be critical for electrogenic K+ secretion induced by aldosterone, which is known to stimulate large-conductance K+ (BK) channel expression in mucosal membranes. This study was aimed to (1) identify whether aldosterone enhances NKCC1 expression specifically to support BK-mediated K+ secretion and (2) to determine whether increased NKCC1 supports electrogenic Cl- secretion in parallel to K+ secretion. Dietary Na+ depletion was used to induce secondary hyperaldosteronism in rats, or aldosterone was administered ex vivo to rat distal colonic mucosae. NKCC1-dependent electrogenic K+ or Cl- secretion was measured as a function of short circuit current (ISC ). qRT-PCR, western blot, and immunofluorescence analyses were performed using standard techniques. Aldosterone enhanced NKCC1 and BKα expression and electrogenic K+ secretion in the distal colon, which was inhibited by either serosal bumetanide (NKCC1 inhibitor) or mucosal iberiotoxin (IbTX; BK channel blocker), but not TRAM-34 (IK channel blocker). Expression of NKCC1 and BKα proteins was enhanced in crypt cells of hyper-aldosterone rats. However, neither NKCC1-dependent Cl- secretion nor CFTR (apical Cl- channel) expression was enhanced by aldosterone. We conclude that aldosterone enhances NKCC1 to support BK-mediated K+ secretion independently of Cl- secretion in the distal colon. The regulation of NKCC1 expression/K+ secretion by aldosterone may be a therapeutic target in treating gastrointestinal disorders associated with alterations in colonic K+ transport, such as colonic pseudo-obstruction, and hyperkalemia associated with renal disease.

Background: Amyotrophic lateral sclerosis (ALS) is a devastating neurodegenerative disease characterized by the terminal degenerative disease of the motor units. This clinical trial was aimed to investigate the modulatory effect of bumetanide on physiological symptoms of ALS patients.Methods: This was a double-blind, placebo-controlled trial in which ALS patients were randomized 1:1 to receive bumetanide (2 mg daily) or matching placebo group for up to 4 months. Motor Unit Number Index (MUNIX), motor unit size index (MUSIX), and ALS Functional Rating Scale, revised (ALSFRS-R) was assessed before and after treatment as following bumetanide treatment.Results: 18 patients were allocated to bumetanide and 18 to the placebo group. In final analysis, 16 patients in bumetanide and 15 patients in the placebo group completed the trial. Patients in the placebo group showed a significant decrease in MUNIX value for all examined muscles after treatment, while MUNIX value for trapezius in bumetanide group increased significantly (p˂0.05). MUZIX value for tibialis anterior and trapezius (p˂0.05) improved significantly after bumetanide administration, whereas trapezius (p˂0.05) and abductor pollicis brevis (p˂0.01) in the placebo group showed a significantly decreased value. ALSFRS-R score decreased significantly in the placebo group after treatment (p˂0.001), but ALSFRS-R in bumetanide group improved significantly (p˂0.05). Three adverse effects (polyuria, vertigo, orthostatic hypotension) in bumetanide group were judged to be related to bumetanide.Conclusion: Bumetanide treatment might be effective in modulation of ALS symptoms possibly due to the hyperpolarization of GABA actions and mitigation of cortical hyperexcitability.

International audience; Intravenous mineralocorticoid receptor antagonists (MRAs) have been used in some centers for decades to reduce the risk of hypokalemia and boost diuresis in acutely decompensated heart failure (ADHF). We report the well-tolerated use of intravenous MRAs as a rescue procedure in 3 patients admitted for ADHF with important diuretic resistance. Undertaking trials evaluating the effect of this therapeutic strategy in ADHF could represent a promising avenue.

Medications can help manage behavioral problems associated with autism spectrum disorder (ASD), but no pharmacological treatment has proved effective for the core symptoms of the disorder. The article by Sprengers et al.1 in this issue of the Journal reports the primary results of the randomized clinical trial Bumetanide in Autism Medication and Biomarker (BAMBI), which tested the efficacy of bumetanide, a loop diuretic acting as a selective antagonist of the chloride importer NKCC1, for the core symptoms of ASD in 92 children 7-15 years of age.1 The study by Sprengers and colleagues was carefully designed and powered to detect a medium treatment effect size. Great attention was paid to protecting the blindness of the experiment in light of the adverse effects of the medication. After the 3-month treatment, bumetanide was not better than placebo at decreasing social communication deficits, as measured with the Social Responsiveness Scale-2 (the primary outcome), although a decrease in repetitive behaviors (a secondary outcome) was found. This study attests to the progress from clinical serendipity to pathogenesis-driven treatment research in ASD and is remarkable in a number of ways.

Aims: To determine whether acid-sensing ion channel 1 (ASIC1)–sodium-potassium-chloride cotransporter 1 (NKCC1) signaling pathway participates in chronic visceral pain of adult rats with neonatal maternal deprivation (NMD).Methods: Chronic visceral pain was detected by colorectal distension (CRD). Western blotting and Immunofluorescence were performed to detect the expression and location of ASIC1 and NKCC1. Whole-cell patch-clamp recordings were performed to record spinal synaptic transmission.Results: The excitatory synaptic transmission was enhanced and the inhibitory synaptic transmission was weakened in the spinal dorsal horn of NMD rats. ASIC1 and NKCC1 protein expression in the spinal dorsal horn was significantly up-regulated in NMD rats. Incubation of Amiloride reduced the amplitude of mEPSCs. Incubation of Bumetanide (BMT) increased the amplitude of mIPSCs. Intrathecal injection of ASIC1 or NKCC1 inhibitors reversed the threshold of CRD in NMD rats. Also, Amiloride treatment significantly reversed the expression of NKCC1 in the spinal dorsal horn of NMD rats.Conclusion: Our data suggest that the ASIC1-NKCC1 signaling pathway is involved in chronic visceral pain in NMD rats.

Objectives: The current study evaluated the analgesic effects of bumetanide as an adjunctive treatment in the management of neuropathic pain following spinal cord injury. The peripheral expression of Na-K-Cl-cotransporter-1 1 and K-Cl-cotransporter-2 (KCC2)2 genes in polymorphonuclear lymphocytes (PMLs) assessed as a possible biomarker indicating central mechanisms underlying the observed response. Methods: Through an open-label, single arm, pilot trial of bumetanide (2mg/day), as add-on treatment conducted in 14 SCI patients for 19 weeks. This study consisted of 3 phases: pre-treatment (1month), titration (3 weeks), and active treatment (4 months). Ultimately, 9 patients completed the study. The primary outcome variables were the endpoint pain score using the numeric rating scale (NRS), and also the short-form McGill Pain Questionnaire. Secondary endpoints included the Short-Form Health Survey that assesses the quality of life. Blood samples were collected and used for determining the expression of NKCC1 and KCC2 genes in transcription and translation levels. Results: Bumetanide treatment significantly decreased average pain intensity according to the NRS and the short form of the McGill Pain Questionnaire scores. Baseline expression of KCC2 protein was low between groups and increased significantly following treatment (P

Item does not contain fulltext BACKGROUND: Mechanism-based treatments such as bumetanide are being repurposed for autism spectrum disorder. We recently reported beneficial effects on repetitive behavioral symptoms that might be related to regulating excitation-inhibition (E/I) balance in the brain. Here, we tested the neurophysiological effects of bumetanide and the relationship to clinical outcome variability and investigated the potential for machine learning-based predictions of meaningful clinical improvement. METHODS: Using modified linear mixed models applied to intention-to-treat population, we analyzed E/I-sensitive electroencephalography (EEG) measures before and after 91 days of treatment in the double-blind, randomized, placebo-controlled Bumetanide in Autism Medication and Biomarker study. Resting-state EEG of 82 subjects out of 92 participants (7-15 years) were available. Alpha frequency band absolute and relative power, central frequency, long-range temporal correlations, and functional E/I ratio treatment effects were related to the Repetitive Behavior Scale-Revised (RBS-R) and the Social Responsiveness Scale 2 as clinical outcomes. RESULTS: We observed superior bumetanide effects on EEG, reflected in increased absolute and relative alpha power and functional E/I ratio and in decreased central frequency. Associations between EEG and clinical outcome change were restricted to subgroups with medium to high RBS-R improvement. Using machine learning, medium and high RBS-R improvement could be predicted by baseline RBS-R score and EEG measures with 80% and 92% accuracy, respectively. CONCLUSIONS: Bumetanide exerts neurophysiological effects related to clinical changes in more responsive subsets, in whom prediction of improvement was feasible through EEG and clinical measures.

Loop diuretic medications work by inhibiting sodium reabsorption in the renal tubules. The net effect is increasing in urinary sodium and water excretion. Loop diuretics are routinely used for many clinical indications, and nephrology practitioners are well informed in the management of their use in daily practice. This article highlights key information on the most commonly used loop diuretics (e.g., furosemide and torsemide) and provides important clinical features related to pharmacokinetics properties, dosing consideration, route of administration, side effects, and other considerations for practitioners.

Aim Bumetanide, a diuretic agent, that reduces intracellular chloride - thereby reinforcing GABAergic inhibition - has been reported to improve core symptoms of autism in children. Given the positive results reported from French trials of bumetanide in children with autism, we decided to evaluate its effects in a small-scale pilot study, in advance of a larger randomised controlled study (RCT). Methods This was an open-label, three-month trial of bumetanide on six children (five boys), aged 3-14 years with autism. Ratings according to the PArental Satisfaction Survey (PASS) were used after four and twelve weeks to assess symptom change. Blood electrolyte status was monitored. Results Improvement in the PASS domain "Communicative and cognitive abilities" was marked or very marked in four children and two had some improvements. Few negative side effects were reported. Conclusion Our small cohort responded well to bumetanide, particularly with regard to "Communicative and cognitive abilities". Taken with the evidence from larger-scale RCTs, we suggest that bumetanide should be considered for inclusion in ethically approved treatment/management trials for children with autism, subject to rigorous follow-up in large scale RCTs.

Introduction Current treatment for hypertension and volume overload in chronic kidney disease consists of loop diuretics, nevertheless, chronic use leads to adaptive changes at the distal nephron, which in turn decreases their efficacy. The use of thiazide diuretics could be another treatment option in these patients, notwithstanding, there's not enough evidence to justify their use in this population. Purpose To evaluate the efficacy and safety of treatment with bumetanide plus chlorthalidone in in patients with advanced chronic kidney disease. Methods A double-blind randomized controlled trial was conducted at our hospital. Thirty-two patients with hypertension, chronic kidney disease stage IV/V, and chronic loop diuretic use where divided in two groups. The dual treatment group received bumetanide (4 mg QD) plus chlorthalidone (100 mg QD), while the control group was given bumetanide (4 mg QD) plus placebo, both for twenty-eight days. Systemic blood pressure, bioimpedance, and urinary electrolytes were measured at seven and twenty-eight days of treatment. Results There was a significant decrease of systemic blood pressure in the dual treatment group when compared with the control group; systolic blood pressure −26.1±15.3 vs. −10±23.3 mmHg (p=0.028), diastolic blood pressure −13.5±10.7 vs. −3.4±11.9 mmHg (p=0.018), and mean arterial pressure −18.1±8.7 vs. −5.4±14.3 mmHg (p=0.006). There was also a significant decrease of volume overload in the dual treatment group when compared to the control group; total body water −4.36±3.29 vs. +0.075±1.78 litres (p Conclusions In advanced chronic kidney disease plus hypertension patients whose treatment with loop diuretics is insufficient, combined use of bumetanide plus chlorthalidone can be useful for systemic blood pressure and volume overload control. Figure 1 Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Hospital General de México

In their article in the Journal, Sprengers et al.1 conclude that bumetanide does not attenuate autism spectrum disorder (ASD) despite a nominally significant treatment effect in repetitive behaviors, which is a core symptom of ASD but was defined as a secondary measure in this trial. Four earlier studies performed by 3 independent institutes, including 2 studies2,3 not mentioned by Sprengers et al., testing a total of 169 children (versus 122 placebo) showed a significant amelioration of ASD symptoms. Bumetanide also significantly attenuated behavioral features of patients with tuberous sclerosis according to another study by Sprengers' same group.4.

With the drug therapy for the core symptoms of autism spectrum disorder (ASD) currently limited, here we reported a randomised, double-blind, placebo-controlled trial to investigate the efficacy, safety, and potential neural mechanism of bumetanide in children with ASD aged 3 to 6 years old. There were 120 children entered into the study and randomly assigned to either 0.5mg bumetanide or placebo. In the final sample, 119 received at least one dose of bumetanide (59 children) or placebo (60 children). The primary outcome was the score reduction of Childhood Autism Rating Scale (CARS) and the secondary outcomes were the score of Clinical Global Impressions Scale (CGI) -Global Improvement (CGI-I) at 3 months and the change from baseline to 3-month in Autism Diagnostic Observation Schedule (ADOS). Magnetic resonance spectroscopy (MRS) was used to measure γ-aminobutyric acid (GABA) and glutamate neurotransmitter concentrations in the insular cortex (IC) before and after the treatment. As compared with the placebo, bumetanide treatment was significantly better in reducing severity. No patient withdrew from the trial due to adverse events. The superiority of bumetanide to placebo in reducing insular GABA, measured using MRS, was demonstrated. The clinical improvement was associated with the decrease in insular GABA in the bumetanide group. In conclusion, this trial in a large group of young children with predominantly moderate and severe ASD demonstrated that bumetanide is safe and effective in improving the core symptoms of ASD. However, the clinical significance remains uncertain and future multi-center clinical trials are required to replicate these findings and confirm the clinical significance using a variety of outcome measures.

Background Cognitive deficits after perinatal anesthetic exposure are well established outcomes in animal models. This vulnerability is sex-dependent and associated with expression levels of the chloride transporters NKCC1 and KCC2. The hypothesis was that androgen signaling, NKCC1 function, and the age of isoflurane exposure are critical for the manifestation of anesthetic neurotoxicity in male rats. Methods Flutamide, an androgen receptor antagonist, was administered to male rats on postnatal days 2, 4, and 6 before 6 h of isoflurane on postnatal day 7 (ntotal = 26). Spatial and recognition memory were subsequently tested in adulthood. NKCC1 and KCC2 protein levels were measured from cortical lysates by Western blot on postnatal day 7 (ntotal = 20). Bumetanide, an NKCC1 antagonist, was injected immediately before isoflurane exposure (postnatal day 7) to study the effect of NKCC1 inhibition (ntotal = 48). To determine whether male rats remain vulnerable to anesthetic neurotoxicity as juveniles, postnatal day 14 animals were exposed to isoflurane and assessed as adults (ntotal = 30). Results Flutamide-treated male rats exposed to isoflurane successfully navigated the spatial (Barnes maze probe trial F[1, 151] = 78; P < 0.001; mean goal exploration ± SD, 6.4 ± 3.9 s) and recognition memory tasks (mean discrimination index ± SD, 0.09 ± 0.14; P = 0.003), unlike isoflurane-exposed controls. Flutamide changed expression patterns of NKCC1 (mean density ± SD: control, 1.49 ± 0.69; flutamide, 0.47 ± 0.11; P < 0.001) and KCC2 (median density [25th percentile, 75th percentile]: control, 0.23 [0.13, 0.49]; flutamide, 1.47 [1.18,1.62]; P < 0.001). Inhibiting NKCC1 with bumetanide was protective for spatial memory (probe trial F[1, 162] = 6.6; P = 0.011; mean goal time, 4.6 [7.4] s). Delaying isoflurane exposure until postnatal day 14 in males preserved spatial memory (probe trial F[1, 140] = 28; P < 0.001; mean goal time, 6.1 [7.0] s). Conclusions Vulnerability to isoflurane neurotoxicity is abolished by blocking the androgen receptor, disrupting the function of NKCC1, or delaying the time of exposure to at least 2 weeks of age in male rats. These results support a dynamic role for androgens and chloride transporter proteins in perinatal anesthetic neurotoxicity. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Background In rodents, the period of increased vulnerability to the developmental effects of general anesthetics coincides with the period of age-specific organizing (masculinizing) effects of the major female sex hormone 17β-estradiol (E2) in the male brain and excitatory GABA type A receptor (GABA A R) signaling. We studied whether E2 synthesis and excitatory GABA A R signaling are involved in the mediation of the developmental effects of sevoflurane in male rats. Methods Male Sprague-Dawley rats were pretreated with the inhibitors of E2 synthesis, formestane, or the Na+-K+-2Cl- (NKCC1) Cl- importer, bumetanide, prior to sevoflurane exposure for 6 h on postnatal (P) day 4, P5, or P6. We tested whether a subsequent exposure of these rats to sevoflurane on P∼10 would cause electroencephalography (EEG)-detectable seizures. We also evaluated their behavior during the elevated plus maze (EPM) test on P∼60, prepulse inhibition (PPI) of acoustic startle responses on P∼70, and corticosterone secretion to physical restraint on P∼80. Results The rats neonatally exposed to sevoflurane responded to repeated exposure to sevoflurane with increased EEG-detectable seizures (F(3,24) = 7.445, P = 0.001) and exhibited deficiencies during the EPM (F(3,55) = 4.397, P = 0.008) and PPI (F(3,110) = 5.222, P = 0.003) tests. They also responded to physical restraint with heightened secretion of corticosterone (F(3,16) = 11.906, P < 0.001). These parameters in the sevoflurane-exposed rats that were pretreated with formestane or bumetanide were not different from those in the control rats. Conclusion These results, along with previously published data, suggest that sevoflurane-enhanced E2 synthesis and excitatory GABA A R signaling at the time of sevoflurane anesthesia are involved in the mediation of the neurodevelopmental effects of the anesthetic in male rats.

Background Heart failure is a clinical syndrome with significant morbidity, mortality, and financial burden. These factors are magnified in patients with associated comorbidities. Therefore, addressing such conditions is critical in decreasing healthcare costs and improving patient outcomes. Gout is a major comorbidity in patients with heart failure. Acute gout flares that occur in the context of acute heart failure exacerbations (AHFE) form an independent risk factor for increased readmissions or death. In this study, we characterized the frequency and outcomes of acute gout flares in patients treated with intravenous (IV) bumetanide for AHFE. Methods This single-center retrospective cohort study included 130 adult patients admitted in a tertiary-care hospital between August 2016 and June 2018. Chart review identified patients who were hospitalized for AHFE with International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code I50, received IV bumetanide, and developed an acute gout flare. Data were analyzed using the chi-square test for categorical variables and the two-sample t-test for continuous variables. Results The annualized frequency of acute gout while receiving IV bumetanide for AHFE was 7.17%. Chronic gout patients who were on colchicine and/or allopurinol while hospitalized were less likely to develop acute gout while receiving IV bumetanide for AHFE compared with those taking neither medication (p-value =0.002). There was no significant difference in length of stay or 30-day readmissions between those who developed acute gout and those who did not. Conclusions Acute gout flares occur with a notable frequency in patients hospitalized for AHFE who are administered IV bumetanide. It is important to continue patients' outpatient gout regimens in an effort to mitigate acute gout flares during this time.

Dysregulation of cation-chloride cotransporters NKCC1 and KCC2 expression was shown to be related to drug-resistant epilepsy. Previous studies suggested that bumetanide, an inhibitor of NKCC1, might have antiepileptic effects.The aim of this study was to investigate the safety and efficacy of bumetanide add-on therapy in patients with drug-resistant epilepsy and its relation to cation-chloride cotransporters NKCC1 and KCC2.We conducted an open-label, single-arm clinical trial in drug-resistant temporal lobe epilepsy (TLE) patients. This study consisted of three phases: pretreatment (3 months), titration (3 weeks), and active treatment (6 months). During the pretreatment phase, the dose of antiepileptic drugs was stabilized, and bumetanide was then added at an initial dose of 0.5 mg/day, increasing by 0.5 mg/week until a target dose of 2 mg/day was achieved. Bumetanide treatment was then continued for 6 months. Seizure frequency and adverse events were assessed at every monthly visit. Blood samples were collected from patients and 12 healthy controls were used for polymerase chain reaction and Western blot analyses. Primary clinical outcomes were drug safety and change in seizure frequency. Changes in NKCC1 and KCC2 expression were the non-clinical endpoints.A total of 30 patients were enrolled, 27 of whom completed the study. The mean duration of epilepsy was 16.5 years. Median seizure frequency per month was 9 [interquartile range (IQR) 7-14.5] at baseline, 3.67 (IQR 1.84-6.17) at the first 3 months, and 2 (IQR 0.84-4.34) at the last 3 months (p 0.001). Five adverse events were detected in six patients. The reported adverse events were anorexia in four patients, nausea and vomiting in two patients, and agitation, headache and increased seizure frequency in one patient each. The level of NKCC1 and KCC2 gene transcripts and KCC2 protein did not change significantly following treatment (p 0.05); however, we observed a significant reduction in NKCC1 protein levels (p = 0.042).Bumetanide might be an effective and relatively tolerable drug in patients with drug-resistant TLE. Downregulation of NKCC1 protein following bumetanide treatment may be responsible for its antiepileptic effects.IRCT 201012115368N1.

Introduction Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe and rare adverse drug reaction. Several drugs are known to induce DRESS. Furosemide, a sulfonamide loop diuretic drug, is known to induce hypersensitive reactions such as bullous eruptions, acute generalized exanthematous pustulosis and lichenoid eruptions, but rarely DRESS. We describe herein a case of furosemide-induced DRESS that recurred after bumetanide administration. Case report A 67-year-old man was admitted to the nephrology department for hypertension, gout and chronic renal failure. He received a multidrug therapy including captopril, nifedipine, allopurinol and furosemide. Six weeks after starting this treatment, he developed a maculopapular itchy and edematous skin reaction, facial edemaand fever. The laboratory findings showed 2200/mm3 of eosinophils (20%). Creatinine clearance decreased from 18.9 to 14.4 mL/min. Lactate dehydrogenase was at 600 IU/L (normal range 190-390 IU/L). Chest X-ray showed an interstitial lung injury. Skin biopsy findings were in accordance with a hypersensitive reaction. Furosemide was withdrawn and symptoms resolved completely three weeks later. A patch test with furosemide performed six weeks later was negative. The patient was given bumetanide, another sulfonamide loop diuretic, with recurrence of symptoms two months later. Bumetanide was withdrawn with a complete resolution of both clinical and biological symptoms within three weeks. Conclusion We add to the literature another case of furosemide-induced DRESS with the particularity of cross reactivity with bumetanide.

Background Tuberous sclerosis complex (TSC) is an autosomal dominant disease that affects multiple organs including the brain. TSC is strongly associated with broad neurodevelopmental disorders, including autism spectrum disorder symptomatology. Preclinical TSC studies have indicated altered neuronal chloride homeostasis affecting the polarity of γ-aminobutyric acid (GABA) ergic transmission as a potential treatment target. Bumetanide, a selective NKCC1 chloride importer antagonist, may attenuate depolarizing GABA action, and in that way reduce disease burden. In this open-label pilot study, we tested the effect of bumetanide on a variety of neurophysiological, cognitive, and behavioral measures in children with TSC. Methods Participants were treated with bumetanide (2dd 0.5–1.0 mg) for 13 weeks in an open-label trial. The Aberrant Behavior Checklist-Irritability (ABC-I) subscale was chosen as the primary endpoint. Secondary endpoints included other behavioral questionnaires in addition to event-related potentials (ERP) and neuropsychological tests if tolerated. Additionally, the treatment effect on seizure frequency and quality of life was assessed. Endpoint data were collected at baseline, after 91 days of treatment and after a 28-day wash-out period. Results Fifteen patients (8–21-years old) with TSC were included of which 13 patients completed the study. Treatment was well-tolerated with only expected adverse events due to the diuretic effects of bumetanide. Irritable behavior (ABC-I) showed significant improvement after treatment in 11 out of 13 patients (t(12) = 4.41, p = .001, d = .773). A favorable effect was also found for social behavior (Social Responsiveness Scale) (t(11) = 4.01, p = .002, d = .549) and hyperactive behavior (ABC-hyperactivity subscale) (t(12) = 3.65, p = .003, d = .686). Moreover, patients rated their own health-related quality of life higher after treatment. At baseline, TSC patients showed several atypical ERPs versus typically developing peers of which prepulse inhibition was significantly decreased in the TSC group. Neuropsychological measurements showed no change and bumetanide had no effect on seizure frequency. Limitations The sample size and open-label design of this pilot study warrant caution when interpreting outcome measures. Conclusions Bumetanide treatment is a potential treatment to alleviate the behavioral burden and quality of life associated with TSC. More elaborate trials are needed to determine the application and effect size of bumetanide for the TSC population. Trial registration EU Clinical Trial Register, EudraCT 2016-002408-13 (www.clinicaltrialsregister.eu/ctr-search/trial/2016-002408-13/NL). Registered 25 July 2016.

Autism spectrum disorder (ASD) is a neurodevelopmental disorder. Autism Spectrum Disorder is diagnosed early on in a child’s life, anywhere from eighteen to twenty-four months. The disorder is characterized by variable degrees, by difficulties in nonverbal communication, verbal communication, social interaction, repetitive behaviors, and movement. The occurrence of ASD has been increasing globally, with the most recent prevalence studies indicating that they are present in six per one thousand children and one in every sixty-eight people of all ages, with a higher incidence among males, with a ratio of four to one. There is no specific target demographic for Autism Spectrum Disorder, nor is there a cure. Over the last few decades, there have been advancements in treating the symptoms associated with Autism Spectrum Disorder. Among the many different fields of research associated with Autism Spectrum Disorder, Bumetanide has shown to be a promising drug therapy for children suffering from Autism, treating specifically the behavioral symptoms associated with ASD. Bumetanide is forty times more potent than furosemide and is a loop diuretic mainly acting in the ascending limb of the loop of Henle. A clinical trial conducted found a decrease in the Childhood Autism Rating Scale (CARS) score, showing improvement in Autism Spectrum Disorder symptoms, such as repetitive behavior and initiating or participating in the social interaction.

KEY POINTS: During myotonia congenita, reduced chloride (Cl(−)) conductance results in impaired muscle relaxation and increased muscle stiffness after forceful voluntary contraction. Repetitive contraction of myotonic muscle decreases or even abolishes myotonic muscle stiffness, a phenomenon called ‘warm up’. Pharmacological inhibition of low Cl(−) channels by anthracene‐9‐carboxylic acid in muscle from mice and ADR (‘arrested development of righting response’) muscle from mice showed a relaxation deficit under physiological conditions compared to wild‐type muscle. At increased osmolarity up to 400 mosmol L(–1), the relaxation deficit of myotonic muscle almost reached that of control muscle. These effects were mediated by the cation and anion cotransporter, NKCC1, and anti‐myotonic effects of hypertonicity were at least partly antagonized by the application of bumetanide. ABSTRACT: Low chloride‐conductance myotonia is caused by mutations in the skeletal muscle chloride (Cl(−)) channel gene type 1 (CLCN1). Reduced Cl(−) conductance of the mutated channels results in impaired muscle relaxation and increased muscle stiffness after forceful voluntary contraction. Exercise decreases muscle stiffness, a phenomena called ‘warm up’. To gain further insight into the patho‐mechanism of impaired muscle stiffness and the warm‐up phenomenon, we characterized the effects of increased osmolarity on myotonic function. Functional force and membrane potential measurements were performed on muscle specimens of ADR (‘arrested development of righting response’) mice (an animal model for low gCl(–) conductance myotonia) and pharmacologically‐induced myotonia. Specimens were exposed to solutions of increasing osmolarity at the same time as force and membrane potentials were monitored. In the second set of experiments, ADR muscle and pharmacologically‐induced myotonic muscle were exposed to an antagonist of NKCC1. Upon osmotic stress, ADR muscle was depolarized to a lesser extent than control wild‐type muscle. High osmolarity diminished myotonia and facilitated the warm‐up phenomenon as depicted by a faster muscle relaxation time (T (90/10)). Osmotic stress primarily resulted in the activation of the NKCC1. The inhibition of NKCC1 with bumetanide prevented the depolarization and reversed the anti‐myotonic effect of high osmolarity. Increased osmolarity decreased signs of myotonia and facilitated the warm‐up phenomenon in different in vitro models of myotonia. Activation of NKCC1 activity promotes warm‐up and reduces the number of contractions required to achieve normal relaxation kinetics.

Today, loop diuretics are widely used to treat edema syndrome that occurs in various diseases. The article compares the most common loop diuretics – furosemide, bumetanide and torasemide, features of their pharmacokinetics and pharmacodynamics, clinical efficiency in renal, heart failure and cirrhosis of the liver. It is shown that the effects of loop diuretics are dose-dependent and the dose should be adjusted depending on the diuretic response, На сегодня для лечения отечного синдрома, возникающего при различных заболеваниях, широко применяют петлевые диуретики. В статье проведено сравнение наиболее распространенных петлевых диуретиков – фуросемида, буметанида и торасемида, освещены особенности их фармакокинетики и фармакодинамики, клинической эффективности при почечной и сердечной недостаточности, а также при циррозе печени. Показано, что эффекты петлевых диуретиков дозозависимы и дозу следует регулировать в зависимости от мочегонного ответа, На сьогодні для лікування набрякового синдрому, який виникає при різних захворюваннях, широко застосовують петльові діуретики. У статті проведено порівняння найпоширеніших петльових діуретиків – фуросеміду, буметаніду і торасеміду, висвітлено особливості їх фармакокінетики та фармакодинаміки, клінічної ефективності при нирковій і серцевій недостатності та при цирозі печінки. Показано, що ефекти петльових діуретиків дозозалежні й дозу слід регулювати залежно від сечогінної відповіді.

Autism spectrum disorder is defined by two core symptoms: a deficit in social communication and the presence of repetitive behaviors and/or restricted interests. Currently, there is no US Food and Drug Administration-approved drug for these core symptoms. This article reviews the biological origins of the social function deficit associated with autism spectrum disorder and the drug therapies with the potential to treat this deficit. A review of the history of autism demonstrates that a deficit in social interaction has been the defining feature of the concept of autism from its conception. Abnormalities identified in early social skill development and an overview of the pathophysiology abnormalities associated with autism spectrum disorder are discussed as are the abnormalities in brain circuits associated with the social function deficit. Previous and ongoing clinical trials examining agents that have the potential to improve social deficits associated with autism spectrum disorder are discussed in detail. This discussion reveals that agents such as oxytocin and propranolol are particularly promising and undergoing active investigation, while other agents such as vasopressin agonists and antagonists are being activity investigated but have limited published evidence at this time. In addition, agents such as bumetanide and manipulation of the enteric microbiome using microbiota transfer therapy appear to have promising effects on core autism spectrum disorder symptoms including social function. Other pertinent issues associated with developing treatments in autism spectrum disorder, such as disease heterogeneity, high placebo response rates, trial design, and the most appropriate way of assessing effects on social skills (outcome measures), are also discussed.

Recent studies have revealed an altered expression of NKCC1 and KCC2 in prefrontal cortex (PFC) and hippocampus of schizophrenic patients. Despite extensive considerations, the alteration of NKCC1 and KCC2 co-transporters at different stages of development has not been fully studied. Therefore, we evaluated the expression of these transporters in PFC and hippocampus at time points of four, eight, and twelve weeks in post-weaning social isolation rearing rat model. For this purpose, 23-25 days-old rats were classified into social- or isolation-reared groups. The levels of NKCC1 and KCC2 mRNA expression were evaluated at hippocampus or PFC regions at the time-points of four, eight, and twelve weeks following housing. Post-weaning isolation rearing decreased the hippocampal KCC2 mRNA expression level, but does not affect the NKCC1 mRNA expression. However, no significant difference was observed in the PFC mRNA levels of NKCC1 and KCC2 in the isolation-reared group compared to the socially-reared group during the course of modeling. Further, we assessed the therapeutic effect of selective NKCC1 inhibitor bumetanide (10 mg/kg), on improvement of prepulse inhibition (PPI) test on twelve weeks isolation-reared rats. Intraperitoneal administration of bumetanide (10 mg/kg) did not exert beneficial effects on PPI deficit. Our findings show that isolation rearing reduces hippocampal KCC2 expression level and may underlie hippocampal GABA excitatory. In addition, 10 mg/kg bumetanide is not effective in improving the reduced PPI of twelve weeks isolation-reared rats. Collectively, our findings show that hippocampal chloride transporter KCC2 contributes to excitatory GABA dysregulation in the developmental rat model of schizophrenia.

AIM To investigate the effect of Hemp seed soft capsule (HSCC) on colonic ion transport and its related mechanisms in constipation rats. METHODS Sprague-Dawley male rats were randomly divided into three groups: normal group, constipation group and HSSC group. Rats in the constipation and HSSC groups were administrated loperamide 3 mg/kg per day orally for 12 d to induce the constipation model. Then, the HSSC group was given HSSC 0.126 g/kg per day by gavage for 7 d. The normal and constipation groups were treated with distilled water. After the treatment, the fecal wet weight and water content were measured. The basal short-circuit current (Isc) and resistance were measured by an Ussing Chamber. Besides the in vivo drug delivery experiment above, an in vitro drug application experiment was also conducted. The accumulative concentrations of HSSC (0.1 mg/mL, 0.5 mg/mL, 1.0 mg/mL, 2.5 mg/mL, 5.0 mg/mL, 10.0 mg/mL and 25.0 mg/mL) were added to the normal isolated colonic mucosa and the Isc was recorded. Further, after the application of either ion (Cl- or HCO3-) substitution, ion channel-related inhibitor (N-phenylanthranilic acid, glybenclamide, 4,4-diisothiocyano-2,2-stilbenedisulfonic acid or bumetanide) or neural pathway inhibitor [tetrodotoxin (TTX), atropine, or hexamethonium], the Isc induced by HSSC was also measured. RESULTS In the constipation group, the fecal wet weight and the water content were decreased in comparison with the normal group (P < 0.01). After the treatment with HSSC, the fecal wet weight and the water content in the HSSC group were increased, compared with the constipation group (P < 0.01). In the constipation group, the basal Isc was decreased and resistance was increased, in comparison with the normal group (P < 0.01). After the treatment with HSSC, the basal Isc was increased (P < 0.05) and resistance was decreased (P < 0.01) in the HSSC group compared with the constipation group. In the in vitro experiment, beginning with the concentration of 1.0 mg/mL, differences in Isc were found between the experimental mucosa (with HSSC added) and control mucosa. The Isc of experimental mucosa was higher than that of control mucosa under the same concentration (1.0 mg/mL, P < 0.05; 2.5-25 mg/mL, P < 0.01). After the Cl- or HCO3- removal and pretreated with different inhibitors (cAMP-dependent and Ca2+-dependent Cl- channels, Na+-K+-2Cl- cotransporter (NKCC), Na+-HCO3- cotransporter or Cl-/HCO3- exchanger inhibitor), there were differences between experimental mucosa and control mucosa; the Isc of experimental mucosa was lower than that of control mucosa under the same concentration (P < 0.05). Meanwhile, after pretreatment with neural pathway inhibitor (TTX, atropine, or hexamethonium), there were no differences between experimental mucosa and control mucosa under the same concentration (P > 0.05). CONCLUSION HSSC ameliorates constipation by increasing colonic secretion, which is mediated via the coaction of cAMP-dependent and Ca2+-dependent Cl- channels, NKCC, Na+-HCO3- cotransporter or Cl-/HCO3- exchanger.

Stress is a major risk factor for psychiatric disorders, such as depression, posttraumatic stress disorder, and schizophrenia. Early life stress, such as maternal separation, can have long-term effects on the development of the central nervous system and pathogenesis of psychiatric disorders. In the present study, we found that maternal separation increased the susceptibility to stress in adolescent rats, increased the expression of Na+/K+/2Cl− cotransporter 1 (NKCC1) on postnatal day 14, and increased the expression of K+/2Cl− cotransporter 2 (KCC2) and γ-aminobutyric acid A (GABAA) receptor subunits on postnatal day 40 in the hippocampus. NKCC1 inhibition by the U.S. Food and Drug Administration-approved drug bumetanide during the first two postnatal weeks rescued the depressive- and anxiety-like behavior that was induced by maternal separation and decreased the expression of NKCC1, KCC2 and GABAA receptor α1 and β2,3 subunits in the hippocampus. Bumetanide treatment during early development did not adversely affect body weight or normal behaviors in naive rats, or affect serum osmolality in adult rats. These results suggest that bumetanide treatment during early development may prevent the maternal separation-induced susceptibility to stress and impairments in GABAergic transmission in the hippocampus.

Purpose Review and discuss medications efficacious for seizure control, despite primary indications for other diseases, as treatment options in patients who have failed therapy with traditional antiepileptic drugs (AEDs). Methods Literature searches were conducted utilizing PubMed and MEDLINE databases employing combinations of search terms including, but not limited to, "epilepsy", "refractory", "seizure", and the following medications: acetazolamide, amantadine, bumetanide, imipramine, lidocaine, verapamil, and various stimulants. Results Data from relevant case studies, retrospective reviews, and available clinical trials were gathered, analyzed, and reported. Experience with acetazolamide, amantadine, bumetanide, imipramine, lidocaine, verapamil, and various stimulants show promise for cases of refractory epilepsy in both adults and children. Many medications lack large scale, randomized clinical trials, but the available data is informative when choosing treatment for patients that have failed traditional epilepsy therapies. Conclusions All neurologists have encountered a patient that failed nearly every AED, diet, and surgical option. For these patients, we often seek fortuitous discoveries within small series and case reports, hoping to find a treatment that might help the patient. In the present review, we describe medications for which antiepileptic effect has been ascribed after they were introduced for other indications.

Background The majority of studies evaluating neurocognition in humans who had procedures under anesthesia early in life found long-term deficits even though the typical anesthesia duration normalized to the human life span is much shorter than that shown to induce developmental abnormalities in rodents. Therefore, we studied whether subsequent environmental stressors contribute to deficiencies programmed by a brief neonatal etomidate exposure. Methods Postnatal days (P) 4, 5, or 6, Sprague-Dawley rats, pretreated with vehicle or the Na+-K+-2Cl− (NKCC1) inhibitor, bumetanide, received two injections of etomidate resulting in anesthesia for 2 h. To simulate stress after anesthesia, the animals were exposed to a single maternal separation for 3 h at P10. 3–7 days after exposure to etomidate the rats had increased hypothalamic NKCC1 mRNA and corticotropin releasing hormone (CRH) mRNA and decreased K+-2Cl− (KCC2) mRNA levels with greater changes in males. In rats neonatally exposed to both etomidate and maternal separation, these abnormalities persisted into adulthood. These animals also exhibited extended corticosterone responses to restraint stress with increases in total plasma corticosterone more robust in males, as well as behavioral abnormalities. Pretreatment with the NKCC1 inhibitor ameliorated most of these effects. Conclusions Post-anesthesia stressors may exacerbate/unmask neurodevelopmental abnormalities even after a relatively short anesthetic with etomidate, leading to dysregulated stress response systems and neurobehavioral deficiencies in adulthood. Amelioration by bumetanide suggests a mechanistic role for etomidate-enhanced gamma-aminobutyric acid type A receptor-mediated depolarization in initiating long-lasting alterations in gene expression that are further potentiated by subsequent maternal separation.

Pharmacological treatments for core symptoms of Autism Spectrum Disorder (ASD) are still lacking. The clinical heterogeneity observed in this population (e.g., differences in cognitive functioning or in autism symptom severity) should be taken into account when a new drug is tested. Stratifying this population according to its neurobiological substrate could significantly improve our knowledge regarding the most appropriate pharmacological treatment for individual needs. In this review, we discuss the possible genetic and biological pathways, including the Glutamatergic, GABAergic, and mTOR systems, involved in the pathophysiology of autism, as well as the mechanisms that may be targeted by new drug interventions. Finally, we describe the current progress from the preclinical and clinical studies on some potential therapeutic options for ASD core symptoms.

Hypoxia-ischemia brain damage (HIBD) is one of prevalent causes of neonatal mortality and morbidity. Our data demonstrated that hypoxia-ischemia (HI) induced Na+-K+-Cl--co-transporter 1 (NKCC1) increasing in hippocampus. Previous studies demonstrated that NKCC1 regulates various stages of neurogenesis. In this study, we studied the role of increased NKCC1 in regulating of HI-induced neurogenesis. HIBD model was established in 7days old Sprague-Dawley rat pup, and the expression of NKCC1 was detected by western blot and qPCR. Brain electrical activity in freely rats was monitored by electroencephalography (EEG) recordings. HI-induced neurogenesis was detected by immunofluorescence staining. Neurobehavioral test was to investigate the neuro-protective role of bumetanide, an inhibitor of NKCC1, on neonatal rats after HI. The results showed that bumetanide treatment significantly reduced brain electrical activity and the seizure stage of epilepsy induced by pentylenetetrazol (PTZ) in vivo after HI. In addition, bumetanide restored aberrant hippocampal neurogenesis and associated cognitive function. Our data demonstrated that bumetanide reduces the susceptibility of epilepsy induced by PTZ in rats suffering from HI injury during neonatal period via restoring the ectopic newborn neurons in dentate gyrus (DG) and cognitive function.

No abstract is available since it is structured as a "Letter to the Editor".

Esophageal injury from acid exposure related to gastroesophageal reflux disease is a common problem and a risk factor for development of Barrett’s esophagus and esophageal adenocarcinoma. Our previous work highlights the benefits of using porcine esophagus to study human esophageal disease because of the similarities between porcine and human esophagus. In particular, esophageal submucosal glands (ESMGs) are present in human esophagus and proximal porcine esophagus but not in rodent esophagus. Although CFTR is expressed in the ducts of ESMGs, very little is known about CFTR and alternate anion channels, including ClC-2, in the setting of acid-related esophageal injury. After finding evidence of CFTR and ClC-2 in the basal layers of the squamous epithelium, and in the ducts of the ESMGs, we developed an ex vivo porcine model of esophageal acid injury. In this model, esophageal tissue was placed in Ussing chambers to determine the effect of pretreatment with the ClC-2 agonist lubiprostone on tissue damage related to acid exposure. Pretreatment with lubiprostone significantly reduced the level of acid injury and significantly augmented the recovery of the injured tissue ( P < 0.05). Evaluation of the interepithelial tight junctions showed well-defined membrane localization of occludin in lubiprostone-treated injured tissues. Pretreatment of tissues with the Na+-K+-2Cl−cotransporter inhibitor bumetanide blocked lubiprostone-induced increases in short-circuit current and inhibited the reparative effect of lubiprostone. Furthermore, inhibition of ClC-2 with ZnCl2blocked the effects of lubiprostone. We conclude that ClC-2 contributes to esophageal protection from acid exposure, potentially offering a new therapeutic target.NEW & NOTEWORTHY This research is the first to describe the presence of anion channels ClC-2 and CFTR localized to the basal epithelia of porcine esophageal mucosa and the esophageal submucosal glands. In the setting of ex vivo acid exposure, the ClC-2 agonist lubiprostone reduced acid-related injury and enhanced recovery of the epithelial barrier. This work may ultimately provide an alternate mechanism for treating gastroesophageal reflux disease.

Monocarboxylate transporter 6 (MCT6, SLC16A5) is a recently studied drug transporter that currently has no annotated endogenous function. Currently, only a handful of compounds have been characterized as substrates for MCT6 (e.g., bumetanide, nateglinide, probenecid, and prostaglandin F2&alpha, (PGF2&alpha, )). The objective of our research was to characterize the MCT6-specific transporter kinetic parameters and MCT6-specific in vitro and in vivo interactions of PGF2&alpha, Murine and human MCT6-mediated transport of PGF2&alpha, was assessed in MCT6-transfected oocytes. Additionally, endogenous PGF2&alpha, and a primary PGF2&alpha, metabolite (PGFM) were measured in plasma and urine in Mct6 knockout (Mct6&minus, /&minus, ) and wild-type (Mct6+/+) mice. Results demonstrated that the affinity was approximately 40.1 and 246 &micro, M respectively, for mouse and human, at pH 7.4. In vivo, plasma PGF2&alpha, concentrations in Mct6&minus, mice were significantly decreased, compared to Mct6+/+ mice (3.3-fold). Mct6-/- mice demonstrated a significant increase in urinary PGF2&alpha, concentrations (1.7-fold). A similar trend was observed with plasma PGFM concentrations. However, overnight fasting resulted in significantly increased plasma PGF2&alpha, concentrations, suggesting a diet-dependent role of Mct6 regulation on the homeostasis of systemic PGF2&alpha, Overall, these results are the first to suggest the potential regulatory role of MCT6 in PGF2&alpha, homeostasis, and potentially other PGs, in distribution and metabolism.

Rationale: Autism spectrum disorder (ASD) is a common neurodevelopmental disorder caused by complex interactions between genetic and environmental factors. Recent studies suggest that Vitamin D3 or bumetanide therapy may improve the core symptoms of ASD in some individuals. However, there are no guidelines that provide clinicians with evidence-based treatment regimens for the use of these therapies in ASD. Patient concerns: A 30-month-old female was referred to our department because she did not respond when her name was called. Diagnosis: The patient was diagnosed with ASD by a team of autism experts according to American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. Interventions: The patient was administered Vitamin D3 150,000 IU intramuscularly once a month and Vitamin D3 800 IU orally each day. After 6 months, Vitamin D3 supplementation was discontinued because of lack of effectiveness. Subsequently, oral bumetanide 0.5 mg twice daily was initiated. Outcomes: The patient's symptoms remained unchanged after 6 months of Vitamin D3 supplementation, and her serum 25 (OH) D levels had reached 52.4 ng/mL. At the parent's request, Vitamin D3 supplementation was discontinued because of lack of effectiveness. Thereafter, bumetanide was initiated. After 1 month of bumetanide, the patient's Childhood Autism Rating Scale score was 26, which is below the cutoff score for ASD. This case report suggests that Vitamin D3 and bumetanide target different mechanisms in the pathogenesis of ASD. Lessons: Based on these observations, we discuss three possible scenarios for Vitamin D3 supplementation and propose that bumetanide should be initiated if Vitamin D3 supplementation is ineffective (identifier ChiCTR-CCC-13004498).