Amitriptyline Treatment Mitigates Sepsis-Induced Tumor Necrosis Factor Expression and Coagulopathy

Abstract

During sepsis, the early innate response and inflammatory cytokine cascade are associated with activation of the coagulation cascade. Acute hypercoagulability can contribute to lethal sequela of vascular thrombosis, tissue ischemia, and organ failure. We investigated if amitriptyline (AMIT), an antidepressant drug with a number of anti-inflammatory effects, could ameliorate sepsis in a murine model of sepsis - cecal ligation and puncture (CLP). We hypothesized that AMIT treatment would reduce inflammation and mitigate sepsis-induced coagulopathy. Coagulation was measured using thromboelastometry and ferric chloride-induced carotid artery thrombosis. Our findings demonstrate a dynamic early hypercoagulability, followed by delayed hypocoagulability in septic mice. However, septic mice treated with AMIT were unaffected by these coagulation changes and exhibited a coagulation profile similar to sham mice. TNFα was markedly elevated in septic mice, but decreased in AMIT-treated mice. Exogenous administration of recombinant TNFα in naïve mice recapitulated the acute sepsis-induced hypercoagulability profile. Following sepsis and endotoxemia, peritoneal macrophages were the predominant source of TNFα expression. AMIT treatment significantly decreased macrophage TNFα expression and blunted M1 polarization. Altogether, during polymicrobial sepsis, AMIT treatment suppressed macrophage TNFα expression and the M1 phenotype, mitigating an initial hypercoagulable state, and protecting septic mice from delayed hypocoagulability. We propose that AMIT treatment is a promising therapeutic approach in the treatment of sepsis-associated coagulopathy and prevention of acute thromboembolic events or delayed bleeding complications.

Consumptive coagulopathy is associated with organ dysfunction during PICS

“…All animal protocols were approved by the Institutional Animal Care and Use Committee at the University of Cincinnati (Protocol 10-05-10-01). To induce acute polymicrobial sepsis, mice underwent 33% cecal ligation with a single, full-thickness, 25-gauge needle puncture under 2.5% isoflurane general anesthesia, as previously described (26,32). All surgeries were performed between 8 AM and 12 PM.…”

“…Murine data focused on coagulopathy and PICS are also limited. We recently reported that, after cecal ligation and puncture (CLP), mice were acutely hypercoagulable, but 16 h after injury, they became hypocoagulable (32). These data raise the question of whether coagulation abnormalities continue even after acute infection or sepsis subsides.…”

Potential Targets to Mitigate Trauma- or Sepsis-Induced Immune Suppression

“…Further, the understanding the dynamics of IL-10 expression is essential. Several studies showed time-dependent effects of IL-10 administration or inhibition in sepsis models (75)(76)(77). Given the fact that IL-10 expression is upregulated quickly after trauma and sepsis, as described in the previous section, it seems likely that in the beginning, lower levels of IL-10 may stimulate bacterial clearance but impair functions when the serum levels exceed a certain threshold.…”

“…(C) The dynamics of the immune perturbation in trauma and sepsis was modeled in recent literature (74). In general a time dependent modulation of IL-10 levels might restore immune hemostasis (75)(76)(77). Animal models suggest a beneficial effect of early IL-10 application (76) and the correlation of elevated IL-10 levels and injury severity suggests beneficial effects by IL-10-blockage in later phases (31,45,78).…”

“…However, this approach must be carefully executed as the systemic effects are not yet fully understood. Animal studies show that the effects of IL-10 modulation depend on the injury dynamic in sepsis (75)(76)(77)102). Murine abdominal sepsis studies suggest that the administration of IL-10 within hours after septic onset may have beneficial effects (76,102).…”