1.

Introduction

Cyanide (CN) poisoning can occur from a diverse range of civilian and military exposures.¹ Sources include medications such as nitroprusside, accidental ingestion of naturally occurring cyanogenic compounds, and industrial accidents involving fumigants, gold mining and electroplating solvents, and other manufacturing by-products.² In addition, smoke from residential or industrial fires contains a complex mixture of gases, including hydrogen cyanide.^{3, 4, 5, 6} Military and civilian exposures to cyanide may occur through acts of terrorism and war, including both the direct use of cyanide or cyanogenic compounds, as well as indirectly as a result of fire-causing incendiary devices and explosives.^{1, 7, 8, 9}

Current treatments for cyanide exposure include three general classes of agents: methemoglobin generators (sodium nitrite, amyl nitrite, and dimethyl aminophenol), sulphur donors (sodium thiosulfate and glutathione), and direct binding agents (hydroxocobalamin and dicobalt edetate).^{1, 2} Each of these treatment modalities has advantages and limitations.^{1, 2} Nitrites are relatively contraindicated in smoke inhalation victims, because the methemoglobin they produce, when combined with carboxyhemoglobin from carbon monoxide, can significantly reduce the oxygen carrying capacity of blood.^{2, 10} Sulfur donors can be used for smoke inhalation victims, but they are slow in onset of activity. Dicobalt ethelynediaminetetraacetic acid (EDTA) can cause hypotension and risks of toxicity from cobalt to the extent that it should be administered only in confirmed cases of cyanide poisoning.² Hydroxocobalamin, which was recently approved for cyanide poisoning by the U.S. Food and Drug Administration, can also be used in the presence of carbon monoxide, but it needs to be given in relatively large volumes.^{11, 12}

New methods for the timely recognition and diagnosis of possible cyanide poisoning, and for determining the effectiveness of various treatment regimes, are essential to improving the likelihood of successful outcomes in military and civilian populations.^{13, 14} Cyanide ion binds to oxidized iron in cytochrome oxidase, preventing its reduction, and thereby blocking electron transport and interrupting cellular respiration.^{1, 2, 15, 16, 17, 18} Tissues are unable to extract oxygen from hemoglobin, and circulating blood becomes more saturated with oxygen.¹⁹ In this study, we used diffuse optical spectroscopy (DOS) to rapidly and continuously monitor cyanide toxicity and therapeutic responses. DOS is able to simultaneously measure near-infrared (NIR) tissue optical scattering and absorption, resulting in accurate, quantitative measures of tissue oxy-, met-, carboxy-, and deoxyhemoglobin.^{20, 21, 22, 23, 24, 25, 26} The measured hemoglobin represents that contained within arterial, capillary, and venous vessels, and the volume of the vascular compartment as a fraction of the total tissue volume. Thus, DOS has the potential to assess the extent of physiologic changes induced by cyanide exposure and quantitatively compare the effectiveness of various treatment regimens.

Cobinamide is a novel agent we are investigating for treating cyanide poisoning^{27, 28, 29} that appears to have some advantages over current treatments, including hydroxocobalamin. Cobinamide is the penultimate precursor in the biosynthesis of cobalamin, lacking the dimethyl-benzimidazole ribonucleotide tail coordinated to the cobalt atom in the lower axial position (Fig. 1 ). Whereas hydroxocobalamin has only an upper ligand binding site, cobinamide has both an upper and a lower ligand binding site. The dimethylbenzimidazole group exerts a negative trans-effect on the upper binding site, thereby reducing hydroxocobalamin’s affinity for ligands.²⁷ The combined effect is that each cobinamide molecule can bind two cyanide molecules and that cobinamide has a much greater affinity for cyanide than hydroxocobalamin, with a $K_A$ overall of $\approx {10}^{22}{\mathrm{M}}^{-1}$ (binding affinity for first cyanide ion is ${10}^{14}{\mathrm{M}}^{-1}$ and for second ion is ${10}^8{\mathrm{M}}^{-1}$ ).³⁰ This suggests that cobinamide should be a more effective cyanide detoxifying agent than hydroxocobalamin (which has a $K_A$ of ${10}^{12}{\mathrm{M}}^{-1}$ for cyanide), as we have observed previously.²⁵ In aqueous solution, cobinamide exists as aquohydroxocobinamide, which is at least five times more water soluble than hydroxocobalamin. The combination of cobinamide’s high binding affinity for cyanide, binding of two cyanide molecules, and relatively high water solubility suggest it could eventually be formulated for administration in concentrated solutions for intramuscular injection (raising the possibility of eventual development of a treatment modality for mass casualty cyanide exposure, which is currently unavailable). For these reasons, we investigated the effects of administration of intravenous cobinamide compared to hydroxocobalamin in reversing cyanide exposure effects in an animal model.²⁰

Fig. 1

Comparison of the molecular structure of (a) hydroxocobalamin to (b) cobinamide (lower panel). Cobinamide lacks the dimethyl-benzimidazole ribonucleotide tail coordinated to the cobalt atom in the lower axial position. Whereas cobalamin has only an upper ligand binding site, cobinamide has both an upper and a lower ligand binding site. The dimethylbenzimidazole group on cobalamin has a negative trans-effect on the upper binding site, thereby reducing cobalamin’s affinity for ligands.¹¹ The combined effect is that each cobinamide molecule can bind two cyanide molecules and that cobinamide has a much greater affinity for cyanide than cobalamin.

We previously showed that DOS detects pathophysiologic events occurring in cyanide-poisoned animals.²⁰ In the current study, we compare cobinamide to hydroxocobalamin in reversing cyanide effects using DOS, as well as measuring standard red blood cell (RBC) cyanide concentrations.

2.

Methods

The methods for cyanide induction and DOS monitoring in rabbits have been previously described²⁰ and are summarized here.

3.

Results

3.1.

Assessment of Oxy- and Deoxyhemoglobin Concentrations

Physiologic effects of cyanide poisoning were readily seen, as evidenced by a marked increase in tissue oxyhemoglobin and decrease in deoxyhemoglobin concentrations within minutes of starting the cyanide infusion (Figs. 2, 2, 2 show representative animals). After stopping the cyanide infusion, the oxy- and deoxyhemoglobin concentrations slowly returned towards baseline in the control group, although they never fully recovered to baseline values, even after $90\min$ [Fig. 2]. In animals that received hydroxocobalamin, oxy- and deoxyhemoglobin concentrations slowly returned to baseline values over about $65\min$ [Fig. 2]. This is in contrast to cobinamide-treated animals in which the oxy- and deoxyhemoglobin concentrations returned to baseline values within $10\min$ of cobinamide infusion [Fig. 2]. The data for all animals in each group were plotted as fractional change in deoxy- [Fig. 3 ] and oxyhemoglobin [Fig. 3] concentrations to calculate rates of reversal. Reversal rates were not significantly different between hydroxocobalamin—at the dose used in this study—and saline-treated animals $(p>0.95)$ , whereas reversal rates were significantly faster in the cobinamide-treated than saline-treated animals $(p<0.05)$ .

Fig. 2

Effects of cobinamide and hydroxocobalamin on tissue oxyhemoglobin, deoxyhemoglobin, and total hemoglobin concentrations in representative cyanide-poisoned rabbits. Changes in tissue oxyhemoglobin (OHb), deoxyhemoglobin (RHb), and total hemoglobin (THb) as measured by DOS are shown during and following cyanide infusion in individual rabbits. The decrease in deoxyhemoglobin concentration during $60\min$ of cyanide infusion is due to the inability of tissues to remove oxygen from circulating blood, leaving more hemoglobin in the oxygenated state. At $60\min$ , when the cyanide infusion was stopped, the animals received either $5\mathrm{cc}$ of saline (a), $5\mathrm{cc}$ of $16.3\mathrm{mM}$ cobalamin in saline (b), or $5\mathrm{cc}$ of $16.3\mathrm{mM}$ cobinamide in saline (c). In the control animal, oxy- and deoxyhemoglobin concentrations gradually returned toward baseline after the cyanide infusion was discontinued but never fully returned to preinfusion values. In the hydroxocobalamin-treated animal, oxy- and deoxyhemoglobin concentrations returned to baseline at $\sim 130\min$ , i.e., $70\min$ following drug administration. In contrast, oxy- and deoxyhemoglobin concentrations returned to baseline within $10\min$ following cobinamide administration.

Fig. 3

Effect of cobinamide and hydroxocobalamin on tissue oxy- and deoxyhemoglobin concentrations in all cyanide-poisoned rabbits. The mean and standard error of percent change in (a) oxyhemoglobin (OHb) and (b) deoxyhemoglobin (RHb) concentrations from baseline are shown during cyanide infusion and treatment for control animals and for hydroxocobalamin-treated (IV OHCob) or cobinamide-treated (IV Cob) animals. (a) Tissue deoxyhemoglobin concentrations rise rapidly from their levels at the end of the cyanide infusion in cobinamide-treated animals compared to controls and hydroxocobalamin animal groups. (b) Tissue oxyhemoglobin concentrations fall significantly faster from their peak value at the end of cyanide infusion following treatment with cobinamide compared to hydroxocobalamin or controls.

As may be seen in Figs. 2 and 3, cobinamide induced an apparent “overshoot” of oxy- and deoxyhemoglobin concentrations beyond baseline pre-cyanide infusion values. This likely is a result of cobinamide binding of nitric oxide (see discussion).

3.4.

Assessment of Blood Cyanide Concentrations

Blood cyanide concentrations were similar at baseline and post-cyanide infusion in all three treatment groups, rising from a mean of $1.8\pm 1.8\text{to}221\pm 10.5\mu \mathrm{M}$ (SEM) over the $60\text{-}\min$ infusion period $(\text{mean}\pm \mathrm{SEM})$ . There was no difference in baseline cyanide levels or peak cyanide levels following cyanide infusion in the three animal groups ( $p=0.30$ ANOVA for differences across groups).

The cyanide concentrations returned more rapidly toward baseline values in cobinamide-treated animals than in hydroxocobalamin- or saline-treated animals (Fig. 4 ; $p<0.01$ ANOVA with repeated measures). Thus, at $30\min$ following completion of the cyanide infusion, blood cyanide concentrations had decreased to $38.2\pm 8\mathrm{\%}$ of peak values in the cobinamide-treated animals, compared to $82.4\pm 8\mathrm{\%}$ and $92.0\pm 7.41\mathrm{\%}$ of peak values in saline- and hydroxocobalamin-treated animals, respectively. By comparing Fig. 4 with Figs. 2 and 3, it can be noted that oxy- and deoxyhemoglobin concentrations reversed more quickly than blood cyanide levels in the cobinamide-treated group.

Fig. 4

RBC cyanide concentrations. The concentration of cyanide in RBCs is shown at the end of the cyanide infusion (zero time) and for $60\min$ thereafter. At zero time, the animals received saline (controls), hydroxocobalamin, or cobinamide. Values are expressed as percent of the peak cyanide levels achieved at the completion of cyanide infusion and shown as mean and standardized error. Cobinamide-treated animals had significantly faster reduction in blood cyanide levels compared to hydroxocobalamin and control groups.

4.

Discussion

Cyanide poisoning presents an ongoing diagnostic and therapeutic challenge. The onset of cyanide poisoning is rapid and difficult to recognize. We investigated the ability of intravenous cobinamide to reverse the physiologic effects of cyanide exposure compared to hydroxocobalamin, an approved cyanide antidote. At equimolar doses of cobinamide and hydroxocobalamin (at a dose calculated to bind the administered molar dose of cyanide by cobinamide), cobinamide reversed the pathophysiological effects of cyanide much more rapidly than hydroxocobalamin, as measured by changes in tissue oxy- and deoxyhemoglobin concentrations and blood cyanide concentrations.

There are two likely reasons for the increased effectiveness of cobinamide to reverse cyanide toxicity compared to hydroxocobalamin. First, cobinamide has a much higher affinity for cyanide than hydroxocobalamin. Second, cobinamide has two ligand binding sites compared to a single binding site on hydroxocobalamin. Thus, at equimolar concentrations, cobinamide would be expected to bind more cyanide molecules and show increased effectiveness. The rate of recovery of oxy- and deoxyhemoglobin concentrations were no different in hydroxocobalamin-treated animals than in controls. At higher hydroxocobalamin concentrations (such as double the hydroxocobalamin concentration, where the dose would be the molar equivalent of the cyanide dose), reversal of cyanide effects would likely have occurred, since hydroxocobalamin is an effective treatment for cyanide toxicity. However, our purpose was to compare cobinamide and hydroxocobalamin at equimolar doses, rather than repeat a demonstration of the effectiveness of hydroxocobalamin. Thus, we selected a drug dose designed to elucidate differences between the two drugs.

In addition to cyanide, cobinamide is capable of reacting with nitric oxide (NO). The binding constant to cobinamide is substantially lower for NO than it is for cyanide ( $\approx {10}^{22}{\mathrm{M}}^{-1}$ for cyanide versus $\approx {10}^{10}{\mathrm{M}}^{-1}$ for NO).^{27, 30} Thus, cobinamide preferentially binds cyanide, and we showed previously that cobinamide can neutralize nitroprusside-released cyanide without having any effect on nitroprusside-released NO.²⁹ However, when given in excess of available cyanide, cobinamide could potentially induce vasoconstriction and increase blood pressure, as has occurred with hydroxocobalamin.³⁶ It is possible that cobinamide’s reaction with NO was responsible for the observed recovery phase “overshoot” in oxy- and deoxyhemoglobin concentrations observed in some cobinamide-treated animals.

Of interest is the variation in correlation between reversal of the physiological effects of cyanide toxicity as measured by oxy- and deoxyhemoglobin concentrations and blood cyanide levels. The oxy- and deoxyhemoglobin changes measured by DOS do show what appears to be complete reversal of cyanide exposure by both cobinamide and hydroxocobalamin, as measured by this limited outcome variable. Blood cyanide levels, especially following cobinamide treatment, are significantly decreased but do not return to baseline levels within the experimental time frame. Cyanide is an extraordinarily complex molecule in terms of its toxicity and detoxification. The nonlinear response behavior and nonlinear relationship between cytochrome inhibition and cellular oxidative metabolism has been described in numerous studies. Extensive studies of dose response (in terms of cyanide doses as well as treatment agent doses), timing of treatment administration, and formal modeling of interactions will be critical to fully defining potential benefits and limitations of cyanide treatment agents such as cobinamide. This was a sacrifice study, and the animals were not awakened. No neurological testing or other investigations of toxicity, organ dysfunction, or other important parameters were done that would be needed before any claims of “complete cyanide reversal” can be made with certainty.

Rapid diagnosis of cyanide toxicity and continuous, quantitative assessment of response to treatment is essential for optimization of cyanide therapy and comparison of effectiveness of treatment agents. Cyanide itself is not easily detected by rapid assay, either in blood samples or through noninvasive monitoring. Furthermore, blood cyanide levels do not correlate closely with the degree of toxicity for a number of well-described reasons.^{14, 37, 38, 39, 40} Therefore, methods for assessing the physiologic effects of cyanide may be more clinically relevant indicators of cyanide effects and response to therapy. The DOS system we used may provide a much-needed ability for noninvasive determination of the impact of cyanide on physiologic function.²⁰ The DOS system used in this study could be miniaturized to a small, hand-held, field-deployable device that could be used for rapid identification and monitoring of cyanide poisoning in the field or in hospital settings.

Hydroxocobalamin absorbs in the $600\text{-}\mathrm{nm}$ region, and we have shown that it can interfere with measurements of oxy- and deoxyhemoglobin concentration by standard cooximetry.⁴¹ The absorption in the $600\text{-}\mathrm{nm}$ region by hydroxocobalamin must be taken into consideration in DOS measurements as well. Therefore, in this study, we utilized laser emitting diode frequencies greater than $650\mathrm{nm}$ and analyzed the continuous absorption spectra greater than $654\mathrm{nm}$ for calculations in order to eliminate possible hydroxocobalamin-induced artifacts. In this manner, DOS has capabilities for assessing the physiologic response to therapeutic interventions in cyanide toxicity and therefore may be an ideal tool for comparing various therapeutic regimens.

In addition to the greater cyanide binding efficiency of cobinamide compared to hydroxocobalamin, cobinamide is more soluble in aqueous medium. Therefore, cobinamide can be administered rapidly in small volumes, e.g., over less than $30\mathrm{s}$ intravenously. As approved, hydroxocobalamin should be administered over $15\min$ (Ref. 42), which may be an issue in acutely cyanide-toxic patients. Furthermore, physical incompatibility (particle formation) was observed in mixtures of hydroxocobalamin with diazepam, dobutamine, dopamine, fentanyl, nitroglycerin, pentobarbital, propofol, and thiopental.⁴² We have not assessed these compatibility issues with cobinamide. However, the ability to rapidly administer cobinamide may alleviate compatibility concerns regarding more prolonged intravenous infusion of hydroxocobalamin.

There are a number of limitations to this study. All animals were anesthetized for comfort and safety assurances in compliance with animal welfare regulations. This could potentially have interfered with our measures of oxy- and deoxyhemoglobin concentrations, but the effect should have been the same across the three treatment groups. This is a sublethal cyanide animal model. All animals survived, even in the control group that did not receive any treatment following cyanide infusion. Therefore, we did not demonstrate whether cobinamide is capable of preventing cyanide-induced mortality from this study. Future investigations will be required for survival efficacy determination. We used a suboptimal hydroxocobalamin dose to compare equal molar effectiveness to cobinamide. To determine whether hydroxocobalamin could be equally, or potentially more, effective than cobinamide when both drugs are used at optimal doses will require future investigation. There are other potential advantages of cobinamide over hydroxocobalamin, even if both drugs are equally effective when administered intravenously. In particular, cobinamide has the potential to be given intramuscularly, and if developed as an intramuscular therapy, would be of significant advantage for potential treatment of mass casualty cyanide exposure victims. Specific DOS limitations include the fact that DOS measures average tissue constituents to a depth of $\sim 4\text{to}8\mathrm{mm}$ (at the source detector separation of $10\mathrm{mm}$ used in the studies). Deeper tissue effects cannot be assessed using the current study design.

The ability of DOS to identify cyanide toxic victims when baseline oxy/deoxyhemoglobin ratios are not available has not been established. Thus, while the ability to track changes occurring during cyanide exposure and reversal has been clearly shown, the ability to obtain an initial definitive diagnosis has not been demonstrated. Furthermore, other potential optically interfering agents or medical conditions that might alter oxyhemoglobin levels could affect the ability to diagnose and monitor cyanide toxicity, and include commonly encountered combined carbon monoxide cyanide toxicity states. DOS capabilities in these scenarios will need to be investigated as well. In addition, regional and organ specific toxicity issues for cyanide were not addressed in this study. Future studies using lethal doses and other modes of administration are indicated to determine the possibility of developing mass casualty cyanide (CN) exposure treatments.

In conclusion, this study demonstrates the effectiveness of cobinamide in reversing the physiologic effects of cyanide on oxy- and deoxyhemoglobin. The high binding capacity of cobinamide for cyanide and its relatively high solubility in aqueous solution may provide advantages in drug delivery and ultimately in treatment effectiveness. This study also demonstrates the capabilities of DOS to noninvasively assess and continuously monitor the physiologic effects of cyanide in vivo. This technology may provide an ideal method for rapid field evaluation of cyanide exposure effects and optimization of therapeutic regimens and may provide a platform for quantitative comparisons among various potential cyanide treatment regimens.