Poststroke Pharmacotherapy

Abstract

T he term ictus, used medically to denote a stroke or seizure, is a Latin word meaning "a blow." Unfortunately, this definition is also an appropriate descriptor of the International Citicoline Trial on Acute Stroke (ICTUS) 1 -its results are another blow to the search for a safe and effective pharmacological approach for augmenting the clinical benefit of acute reperfusion therapy in patients with ischemic stroke or improving outcomes for those who cannot be recanalized. This carefully designed and conducted, multicenter, doubleblind, randomized trial found that, "citicoline is not efficacious in the treatment of moderate-to-severe acute ischemic stroke," (primary outcome for intention-to treat with citicoline based on a global outcome statistic including the National Institute of Health Stroke Scale, modified Rankin score, and Barthel index; odds ratio, OR=1.03, 95% CI, 0.86-1.25). 1Although referred to as a new drug in the ICTUS report, experimental and clinical data related to citicoline's putative mechanisms of action and potential therapeutic effects have accrued over the last 4 decades.2,3 Exogenous citicoline (cytidine-5′-diphosphocholine) is hydrolyzed to cytidine and choline, rephosphorylated, and then resynthesized by cytidine triphosphate-phosphocholine cytidylyl transferase. 4 Citicoline is the rate limiting intermediate for the synthesis of phosphatidylcholine, an important membrane phospholipid.4 Although brain levels of citicoline after parenteral or oral administration are unknown, about 0.5% of total radioactivity of orally administered radiolabeled citicoline is incorporated into brain tissue compared with about 2% of an intravenous dose. 5In contrast to acute reperfusion interventions such as pharmacological thrombolysis or mechanical clot retrieval, treatment with citicoline had the potential to improve stroke outcomes through both neuroprotective (aimed at reducing the extent of ischemic injury) and neurorestorative (approaches affecting brain plasticity during the recovery process) effects. Neuroprotective actions of citicoline are hypothesized, at least in part, to be mediated through an attenuation of phospholipase A2 activation, preserving mitochondrial membrane cardiolipin, increasing phosphatidylcholine levels, raising glutathione synthesis and glutathione reductase activity, decreasing lipid peroxidation, and improving Na + /K + -ATPase activity.5 Neurorestorative actions may facilitate neural repair and postinjury neuroplasticity in addition to having effects on neurotransmitters such as acetylcholine and dopamine. 5,6 Even before ICTUS, citicoline had been studied in >11 000 patients and volunteers. 1 The theoretical benefits for patients with ischemic stroke were supported by a patient-level pooledanalysis of data from 4 randomized trials (n=1372) that showed a treatment-associated one-third improvement in 3-month outcomes (OR=1.33; 95% CI, 1.10-1.62; P=0.0034), 7 and a studylevel meta-analysis of 5 trials (n=1921) showing a 29% reduction in long-term death or disability (OR=0.71,...

Effects of Citicoline on Level of Consciousness, Serum Level of Fetuin-A and Matrix Gla- Protein (MGP) in Trauma Patients with Diffuse Axonal Injury (DAI) and GCS≤8

“…Citicoline has been reported to have protective and restorative effects on the central nervous system (CNS) by inducing Na + /K + ATPase activity, decreasing lipid peroxidation, preserving mitochondrial membrane cardiolipin, suppressing phospholipase A 2 activity, improving neuroplasticity and synthesis of neurotransmitters like acetylcholine (Ach) or dopamine. [20][21][22] The drug has protective impact on cell membrane through accelerating re-synthesis of structural phospholipids, stabilizing the membrane, and attenuating free radical synthesis. [23] Pre-ischemic administration of citicoline attenuated glutamate and LDH release, banning corticostriatal depletion of high energy phosphates through improving ATP restoration and glutamate uptake, secondary to oxygen-glucose deprivation.…”

Citicolina: revisión farmacológica y clínica, actualización 2022

“…The neurobiological processes involved in the pathophysiology of the cerebral ischemia are extremely complex [ 498 ]. For this reason, some authors postulate the need to use multifunctional treatments for this disease [ 499 - 504 ], for intracerebral hemorrhages [ 505 , 506 ], and for the recovery phase [ 507 , 508 ]. As experimentally shown, citicoline is a drug having pleiotropic actions including activation of neuronal metabolism, stabilization of neuronal membranes and their function, and normalization of neurotransmission [ 20 , 39 - 41 , 180 , 281 , 282 ].…”

“…Los procesos neurobiológicos implicados en la isquemia cerebral son extremadamente complejos [ 498 ], por lo que actualmente se plantea la posibilidad de utilizar tratamientos multifuncionales para abordar esta patología [ 499 - 504 ], las hemorragias intracerebrales [ 505 , 506 ] y las secuelas de éstas [ 507 , 508 ]. Como hemos visto experimentalmente, la citicolina es un fármaco con unas acciones pleiótropas, que implican la activación del metabolismo neuronal, la estabilización de las membranas neuronales y de su función, así como la normaliza­ción de la neurotransmisión [ 20 , 39 - 41 , 180 , 81 , 282 ].…”