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The Journal of Pharmacology and Experimental Therapeutics logoLink to The Journal of Pharmacology and Experimental Therapeutics
. 2024 Feb;388(2):576–585. doi: 10.1124/jpet.123.001683

Mesna Improves Outcomes of Sulfur Mustard Inhalation Toxicity in an Acute Rat Model

Heidi J Nick 1,✉, Carly A Johnson 1, Amber R Stewart 1, Sarah E Christeson 1, Leslie A Bloomquist 1, Amanda S Appel 1, Abigail B Donkor 1, Livia A Veress 1, Brian A Logue 1, Preston E Bratcher 1, Carl W White 1
PMCID: PMC10801720  PMID: 37541763

Abstract

Inhalation of high levels of sulfur mustard (SM), a potent vesicating and alkylating agent used in chemical warfare, results in acutely lethal pulmonary damage. Sodium 2-mercaptoethane sulfonate (mesna) is an organosulfur compound that is currently Food and Drug Administration (FDA)-approved for decreasing the toxicity of mustard-derived chemotherapeutic alkylating agents like ifosfamide and cyclophosphamide. The nucleophilic thiol of mesna is a suitable reactant for the neutralization of the electrophilic group of toxic mustard intermediates. In a rat model of SM inhalation, treatment with mesna (three doses: 300 mg/kg intraperitoneally 20 minutes, 4 hours, and 8 hours postexposure) afforded 74% survival at 48 hours, compared with 0% survival at less than 17 hours in the untreated and vehicle-treated control groups. Protection from cardiopulmonary failure by mesna was demonstrated by improved peripheral oxygen saturation and increased heart rate through 48 hours. Additionally, mesna normalized arterial pH and pACO2. Airway fibrin cast formation was decreased by more than 66% in the mesna-treated group at 9 hour after exposure compared with the vehicle group. Finally, analysis of mixtures of a mustard agent and mesna by a 5,5′-dithiobis(2-nitrobenzoic acid) assay and high performance liquid chromatography tandem mass spectrometry demonstrate a direct reaction between the compounds. This study provides evidence that mesna is an efficacious, inexpensive, FDA-approved candidate antidote for SM exposure.

SIGNIFICANCE STATEMENT

Despite the use of sulfur mustard (SM) as a chemical weapon for over 100 years, an ideal drug candidate for treatment after real-world exposure situations has not yet been identified. Utilizing a uniformly lethal animal model, the results of the present study demonstrate that sodium 2-mercaptoethane sulfonate is a promising candidate for repurposing as an antidote, decreasing airway obstruction and improving pulmonary gas exchange, tissue oxygen delivery, and survival following high level SM inhalation exposure, and warrants further consideration.

Introduction

Exposure to mustard agents, including the chemical weapon sulfur mustard (SM; bis[2-chloroethyl] sulfide; “mustard gas”), results in extensive cellular damage and death through mechanisms involving crosslinking of critical biomolecules, including proteins and nucleic acids, DNA damage, oxidative stress, and disruptions in metabolism (Papirmeister et al., 1991; Naghii, 2002; Ghabili et al., 2011). SM attacks epithelial tissues, the lungs being a primary target. Acute respiratory symptoms from exposure during combat and/or conflict include discomfort resulting from inflammation of the upper airways, cough, rhinorrhea, and, after exposure to high concentrations, dyspnea; importantly, the majority of fatalities that occur within hours, days, or a few weeks after exposure to SM are due to injuries to the respiratory tract (Papirmeister et al., 1991; Ghabili et al., 2010). Currently, there are no effective antidotes for SM inhalation.

Mustard agents form toxic intermediates, especially in an aqueous milieu, such as the airway’s epithelial lining fluid. These electrophilic intermediates attack electron-rich regions, such as sulfhydryl groups (Naghii, 2002). We and others have reported previously that thiol compounds, such as N-acetylcysteine (NAC) and glutathione (GSH), as well as thiopurines and thiosulfates, may directly interact with mustards or decrease their cytotoxicity indirectly (Callaway and Pearce, 1958; Gross et al., 1993; Rappeneau et al., 2000a,b; Liu et al., 2010; Tewari-Singh et al., 2011; Stenger et al., 2017; Sawyer, 2020). Moreover, these agents appear to diminish the toxicity of SM and SM analogs in porcine, rat, and mouse models (Callaway and Pearce, 1958; Kumar et al., 2001; McClintock et al., 2006; Jugg et al., 2013; Gupta et al., 2021). In prior studies, we also found that intratracheally delivered tissue plasminogen activator (tPA) clears fibrin casts from the airways after mustard agent inhalation exposure, substantially decreasing morbidity and mortality in an acute rat model (Veress et al., 2013, 2015). Despite the demonstration of some degree of efficacy, none of these compounds are currently Food and Drug Administration (FDA)-approved for clinical use in the treatment of inhalational exposure to SM.

Sodium 2-mercaptoethane sulfonate (mesna; brand names Mesnex and Uromitexan) is a water-soluble thiol compound currently used as a chemoprotective agent that reacts with and detoxifies metabolites of chemotherapeutic drugs such as cyclophosphamide and ifosfamide (Shaw and Graham, 1987; Schoenike and Dana, 1990; Dechant et al., 1991). Cyclophosphamide and ifosfamide are nitrogen mustard derivatives and alkylating agents that are metabolized in the liver to active metabolites. Mesna can interact with these activated forms, and/or with further breakdown products thereof (e.g., acrolein) to limit toxicity from the off-target effects of these chemotherapy drugs, thereby preventing dose-limiting side effects. Due to the chemical similarity between the activated cyclophosphamide/ifosfamide intermediates and reactive mustard intermediates, there is potential for the therapeutic use of mesna to treat individuals exposed to SM.

During in vitro model experiments utilizing the exposure of cultured cells to mustard compounds, mesna treatment provided protection from the toxic effects of mustards, including DNA damage and cell death (Jost et al., 2017, 2019). These findings were similar to what was previously observed with NAC (Rappeneau et al., 2000a). Mesna-mediated protection from mustards was observed in experiments involving the pretreatment of cells with mesna before mustard exposure (Jost et al., 2017, 2019), and the degree of NAC-mediated protection was greatest when cells were treated concomitantly with mustard exposure (Rappeneau et al., 2000a). Consequently, it is plausible that the direct interaction of mustards with these compounds is at least partly responsible for the protective effects.

Mesna exhibits antioxidant properties, due to the ability of its thiol group to scavenge reactive oxygen species, and has demonstrated a protective effect in numerous animal models of disease and/or injury involving oxidative stress and damage (Shusterman et al., 2003; El-Medany et al., 2005; Sener et al., 2005; Ypsilantis et al., 2008; Keeney et al., 2018; Hagar et al., 2020; Abd El-Baset et al., 2021). It can also inhibit the activity of molecules involved in reactive oxygen species production, such as myeloperoxidase (MPO) (Jeelani et al., 2017). In addition, mesna has been found to have significant anti-inflammatory effects on upstream and downstream targets (Shusterman et al., 2003; Ypsilantis et al., 2008; Hagar et al., 2020; Abd El-Baset et al., 2021). Therefore, mesna treatment may provide benefit by acting on the severe inflammation and oxidative stress that occur as a result of exposure to mustards.

Although preliminary studies have described potential therapeutics to treat SM inhalation exposures, an ideal candidate for use in real-world casualty situations has not yet been identified. Based on the biochemical evidence for the neutralization of mustard compounds by mesna, the relative success of thiols in the treatment of cells and animals exposed to mustards, and the detoxifying, antioxidant, and anti-inflammatory capabilities of mesna, we sought to test the efficacy of mesna in an acutely lethal animal model of high-dose SM inhalation injury and further characterize the interaction between the reactive groups of mesna and mustard. Here, we demonstrate the efficacy of mesna in decreasing acute lung injury and protecting from mortality in a rat model of SM inhalation and describe the direct interaction between mesna and mustard.

Materials and Methods

Chemicals

For rat inhalation exposures, SM (99.4% purity by NMR) was synthesized at the University of Colorado Denver-Anschutz Medical Campus (UCD-AMC) and pharmaceutical mesna was used (Baxter Healthcare Corporation, NDC 10019-953-01). The pharmaceutical formulation of mesna consists of 100 mg/ml mesna, 0.25 mg/ml disodium EDTA, 10.4 mg/ml benzyl alcohol, and NaOH for pH adjustment to 7.5–8.5 in sterile water for injection and has an osmolarity of 1000–1500 mOsmol/l. Details regarding the corresponding vehicle control can be found in the Supplemental Materials and Methods. Chemicals used for in vitro studies are listed in the Supplemental Materials and Methods.

Study Animals and SM Inhalation Exposures

All animal procedures were approved by the UCD-AMC Institutional Animal Care and Use Committee and conducted in accordance with the National Institutes of Health Guide for the Care and Use of Laboratory Animals. Male Sprague-Dawley rats (8 to 9 weeks old, weighing 250–275 g, obtained from Charles River Laboratories) were housed in an Association for Assessment and Accreditation of Laboratory Animal Care International accredited facility and provided food and water ad libitum. Rats were given at least 7 days to acclimate to the UCD-AMC housing facility prior to study.

On the morning of exposure, animals were randomized into treatment groups and then exposed to 4.2 mg/kg SM vapor for 50 minutes using a previously described model (Anderson et al., 1996; Veress et al., 2015). Naive control animals were housed in the same location as SM-exposed animals but were not subject to anesthesia/intubation/vapor generators.

Rats were euthanized at 9 hours, 24 hours, 48 hours, or 15 days postexposure, or earlier if severe distress criteria were met, which was assessed as previously described (Veress et al., 2013; Nick et al., 2020). For studies lasting 15 days, loss of more than 30% of pre-exposure body weight served as an additional criterion for euthanasia prior to end of study. Additional details regarding animal monitoring, care, and euthanasia criteria are provided in the Supplemental Materials and Methods.

Administration of Mesna to Study Animals

Prior to SM exposure, animals were randomized into four treatment groups: naive, SM-exposed and given no treatment (SM), SM-exposed and given vehicle (SM + vehicle), and SM-exposed and given mesna (SM + mesna). Mesna (300 mg/kg/dose, undiluted from its pharmaceutical formulation) was administered by intraperitoneal injection. Vehicle control animals received an equivalent volume (3 ml/kg) of the vehicle formulation (see Supplemental Materials and Methods). Treatments were administered at 20 minutes, 4 hours, and 8 hours post-SM exposure. In selected studies, treatments were administered at 2 hours, 4 hours, and 8 hours postexposure.

Peripheral Oxygen Saturation (SpO2) and Heart Rate Measurements

SpO2 and heart rate were measured in conscious rats using a MouseOx Plus with a large Rat Collar Sensor (Starr Life Sciences, Oakmont, PA). Baseline measurements were taken 1 day prior to study. At each time point, the average of three SpO2 and three heart rate measurements taken within 5 minutes were used.

Arterial Blood Gas Measurements

Immediately prior to euthanasia, arterial blood was collected from anesthetized animals, and arterial blood gas analysis performed as previously detailed (Nick et al., 2020).

Lung Fixation and Airway Cast Scoring

At euthanasia, lungs were inflation-fixed with 4% paraformaldehyde in PBS at 20 cm H2O for 20 minutes then removed en bloc. Airways cast scoring of all five lobar bronchi was conducted, and a composite cast score was calculated using a previously described microdissection technique and quantification methodology (Veress et al., 2010, 2013; Nick et al., 2020).

Reverse Transcription Quantitative Real-Time PCR (RT-qPCR)

RT-qPCR was performed on whole lung tissue (perfused blood-free) collected at 9 hours postexposure. Methodology for RT-qPCR analysis is detailed in the Supplemental Materials and Methods.

In Vitro Analyses of the Mesna-Nitrogen Mustard (NM) Reaction

5,5′-Dithiobis(2-Nitrobenzoic Acid) (DTNB) Assay

Stock solutions of NM (in ethanol) and mesna (in distilled, deionized, and Milli-Q-purified water) were made less than an hour before mixing and then diluted in reaction buffer (0.1 M Na2HPO4, 1 mM EDTA, pH 8.0), mixed together or with reaction buffer alone, and incubated in the dark at room temperature. At the indicated times, 10 μl of the mixture was removed, added to 100 μl of reaction buffer and 2 μl of 10 mM DTNB, and immediately analyzed by measuring the absorbance at 412 nm.

High Performance Liquid Chromatography Tandem Mass Spectrometry (HPLC-MS/MS) Analysis of Mesna-NM

Stocks of mesna and NM were prepared in ultrapure water and absolute ethanol, respectively, immediately before use. Mesna (1.5 mM) and NM (6 mM) were then combined in 0.1 M Na2HPO4, 1 mM EDTA, pH 8.0 (DTNB reaction buffer), incubated for 30 minutes at room temperature, and then transferred to –80°C. Samples were then shipped on dry ice to South Dakota State University and stored at –80°C until analysis. The frozen sample solutions (10 ml each; stored in 15-ml centrifuge tubes) of mesna, NM, a mixture of mesna and NM, and solvent blank were placed in separate polypropylene disposable beakers and allowed to thaw at room temperature. The entire volume of the thawed solution was syringe filtered with a 33 mm, 0.2 μm polyethersulfone (PES) syringe filter into another 15-ml centrifuge tube. An aliquot (1 ml) of the filtered solution was then placed in a 2-ml autosampler vial and capped for HPLC-MS/MS analysis. The remaining solution was placed in a –80°C freezer until needed. Methodology for HPLC-MS/MS analysis is detailed in the Supplemental Materials and Methods.

Data Analysis and Statistics

Statistical analyses were performed using GraphPad Prism versions 8.4.3 and 9.5.0 (GraphPad, San Diego, CA). Details of statistical analyses are provided in the Supplemental Materials and Methods. Arterial blood gas and cast score data are presented using violin plots (medium smoothing), with a solid line for the median and dashed lines for the quartiles. All other summary data are displayed as means with S.D. A P value <0.05 was considered significant.

Results

Mesna Increases Survival and Improves Outcomes in a Rat Model of SM Inhalation Exposure

To examine the efficacy of mesna treatment in vivo, rats were exposed to high-concentration SM using an established vapor inhalation model (Anderson et al., 1996; Veress et al., 2015). The regimen used for treatment was based on an established administration scheme for mesna to prevent toxicity from alkylating chemotherapy agents in rats and humans (Menétrey et al., 1999; Kanat et al., 2006; Hensley et al., 2009) and the measurement of a circulating half-life of mesna of 36.3 minutes in naive rats (Supplemental Fig. 1), which was in close agreement with that observed in previous studies (Shaw et al., 1986; Verschraagen et al., 2004). Although mesna is FDA-approved only for oral and intravenous use, neither of those routes were deemed practical for this study, thus mesna was administered intraperitoneally as we have done previously (Stabler et al., 2009).

At the dose of SM used (4.2 mg/kg), the animals consistently succumbed to the SM-induced injury within 16.5 hours when no intervention was introduced (0% survival for SM and SM + vehicle control groups, Fig. 1). In animals given three sequential doses of mesna intraperitoneally at 20 minutes, 4 hours, and 8 hours post-SM exposure, 85.7% survival was observed at 24-hour postexposure and 73.5% of rats survived until 48 hours (end of the study) (SM + mesna, Fig. 1). In two smaller, subsequent studies utilizing this mesna treatment regimen, animals were monitored for 15 days post-SM exposure. Remarkably, an 18.4% survival proportion was observed for the mesna-treated group on day 15, compared with 0% survival for the SM + vehicle group, which had all succumbed to injury by 16.2 hours postexposure (Supplemental Fig. 2). When the initial mesna dose was delayed until 2 hours post-SM exposure, 90.0% of animals survived to 24 hours, but proportionally fewer animals survived to 48 hours compared with the regimen in which mesna was initiated at 20 minutes postexposure (45.0% vs. 73.5%, respectively) (Supplemental Fig. 3).

Fig. 1.

Fig. 1.

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Survival proportions of SM-exposed rats treated with mesna or vehicle. At 20 minutes, 4 hours, and 8 hours after SM inhalation exposure (denoted by arrows), mesna (red line) or vehicle (blue line) was administered intraperitoneally and survival was monitored for 48 hours. Survival of animals exposed to SM that received no treatment is shown by the black line. Data are from three independent experiments. P < 0.0001 for mesna to vehicle comparison (Mantel-Cox log-rank test).

After exposure to SM, rapid decreases in tissue oxygen delivery (assessed by SpO2 measured via pulse oximetry) and heart rate were observed (Fig. 2). Mesna-treated animals demonstrated a delay in the decrease in tissue oxygen delivery compared with the SM and SM + vehicle control groups (Fig. 2A). Although the heart rates of both control and mesna-treated animals declined immediately after exposure (2 hours; note that animals have not fully recovered from the effects of anesthesia during this time), the heart rates of mesna-treated animals improved modestly and were better maintained following this initial drop as compared with the continued decrease in heart rate observed in the control animals (Fig. 2B).

Fig. 2.

Fig. 2.

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Effect of mesna treatment on SpO2 and heart rate in SM-exposed rats. (A) SpO2 and (B) heart rate (beats per minute) were monitored at regular intervals in conscious animals using a rodent pulse oximeter. At the beginning of the study, animal numbers were as follows: n = 21 SM, n = 14 SM + vehicle, and n = 21 SM + mesna. Time points of treatment administration are denoted by arrows. Data are expressed as mean + SD from three independent experiments. a: Significant difference between vehicle and mesna groups at 5 hpe and from 7–13 hpe (Kruskal-Wallis with Dunn’s multiple comparisons tests). b: Significant difference between vehicle and mesna groups from 5–13 hpe (5–9 hpe: ANOVA with Tukey’s multiple comparisons tests; 10–13 hpe: Kruskal-Wallis with Dunn’s multiple comparisons tests).

Upon meeting euthanasia criteria (due to distress or end of study), rats were anesthetized and arterial blood was collected. SM exposure induced a decrease in blood pH that was prevented by mesna treatment (Fig. 3A). Arterial partial pressures of CO2 (pACO2) and O2 (pAO2) were significantly altered in SM-exposed control animals, indicating a decrease in pulmonary gas exchange in these animals (Fig. 3, B and C). Mesna treatment decreased pACO2 and increased pAO2 relative to control animals. Blood concentrations of bicarbonate were not significantly different between vehicle- and mesna-treated animals (Fig. 3D).

Fig. 3.

Fig. 3.

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Effect of mesna treatment on arterial blood gas measurements. Arterial blood was collected from anesthetized rats immediately prior to euthanasia (≤48 hpe). (A) Blood pH. (B) Partial pressure of carbon dioxide (pACO2). (C) Partial pressure of oxygen (pAO2). (D) Bicarbonate. n = 16 naive, n = 9 SM, n = 10 SM + vehicle, and n = 10 SM + mesna. Solid lines specify the median, and dashed lines specify the quartiles for each data set. Data are from three independent experiments. ns, not significant; ****P < 0.0001, **P = 0.0049, *P = 0.0382 (one-way ANOVA with Tukey’s multiple comparisons test).

Mesna Treatment Decreases Airway Obstruction in SM-Exposed Rats

As previously described in rats, rabbits, dogs, swine, and humans, inhalation of SM results in destruction of the respiratory epithelium and the formation of obstructive, fibrin-rich casts within the airways (Papirmeister et al., 1991; Anderson et al., 1996; Fairhall et al., 2010; Veress et al., 2010, 2013, 2015). In the current investigation, histologic examination of lung tissue from SM-exposed rats (11- to 20-hours postexposure) demonstrated epithelial sloughing and necrosis, along with epithelial and smooth muscle hypertrophy and hyperplasia, septal thickening, and inflammatory cell infiltration (Supplemental Fig. 4). An increase in fine fibers was also noted in the peri-airway and perivascular areas, which may be indicative of collagen deposition as previously reported (Veress et al., 2010). Through the use of morphometric analysis using airway microdissection, obstructive casts were observed and measured in the present study, and the airways became progressively more occluded over time after SM exposure (Fig. 4 and Supplemental Fig. 4). Treatment with mesna resulted in a 66.4% reduction in the degree of occlusion at 9 hours postexposure (hpe) (Fig. 4A). In animals meeting euthanasia criteria (due to distress or end of study) between 9 and 24 hpe, airway occlusion trended lower for the mesna-treated group, but a statistically significant difference compared with the vehicle-treated group was not observed (Fig. 4B). This decrease and/or delay in airway casts may account for the improvement in the clinical outcomes described above, in particular the normalization of arterial carbon dioxide and pH.

Fig. 4.

Fig. 4.

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Assessment of airway occlusion following SM inhalation and treatment with mesna. Airway obstruction was evaluated by microdissection. A score of 7 indicates 100% occlusion of all five lobar bronchi. (A) Extent of airway obstruction in animals terminated at 9 hpe. n = 5 per group. (B) Extent of airway obstruction in animals euthanized between 9 and 24 hpe. n = 16 SM, n = 14 SM + vehicle, and n = 7 SM + mesna. Solid lines specify the median, and dashed lines specify the quartiles for each data set. Data are from two independent experiments. *P = 0.0286 (Mann-Whitney U test); ns, not significant (P = 0.18) (Kruskal-Wallis with Dunn’s multiple comparisons test).

SM Exposures Induces Changes in Whole Lung Transcripts that are Not Significantly Impacted by Mesna Treatment

RNA was isolated from whole lung homogenates of SM-exposed animals obtained at 9 hpe, and transcripts for targets of interests were quantified using RT-qPCR. To examine for changes in pathways of interest and relevance to SM-induced acute lung injury (Dillman et al., 2005; Tewari-Singh et al., 2012; Jowsey and Blain, 2014; Jugg et al., 2016; Tahmasbpour et al., 2016; White et al., 2016; Borna et al., 2019), an initial gene expression study on a small group of animals (n = 3–4 per treatment group) was performed using PrimePCR Arrays (Supplemental Figs. 5–8). Targets of potential importance were investigated in a larger, subsequent study (n = 7–8 animals per treatment group) (Supplemental Table 1, Fig. 5 and Supplemental Fig. 9). Transcripts with expression levels that were significantly altered after SM exposure were identified (Fig. 5). These included transcripts for genes with roles in coagulation (e.g., F3 and Plat), hypoxia response (e.g., Nos2 and Hmox1), oxidative stress (e.g., Sod2 and Nfe2l2), and anti-apoptosis/tumor necrosis factor (TNF)/nuclear factor-κB (NF-κB) signaling (e.g., Nfkbib and Tnfrsf1a). Interestingly, although the expression levels of several targets trended toward being different between mesna- and vehicle-treated animals (e.g., F3, Hmox2, IL-6, and Nfkbib), no transcript levels in SM-exposed animals were significantly impacted by treatment with mesna.

Fig. 5.

Fig. 5.

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Relative gene expression changes measured in the lung at 9 hpe. Expression of genes involved in (A) coagulation, (B) hypoxia response, (C) oxidative stress, and (D) anti-apoptosis/TNF/NF-κB signaling pathways was examined in whole lung tissue by RT-qPCR. Target gene quantification cycle was normalized to Rpl13a and quantified relative to the mean expression of the naive control group. n = 7 naive, n = 8 SM + vehicle, and n = 8 SM + mesna. Means ± SD are shown. ns, not significant; *P < 0.05, **P < 0.01, ***P < 0.001 compared with the naive control group (Kruskal-Wallis with Dunn’s multiple comparisons test).

Reaction of the Mesna Thiol with Mustard Compounds

For in vitro studies examining the reaction of mesna with a mustard compound, NM (mechlorethamine; mustine) was used in place of SM due to safety, security, and infrastructure required for handling and transporting SM. NM is structurally similar to SM, mimics SM-induced toxicity and injury, and is a suitable substitute for examining the reaction of mesna with the reactive group of a mustard.

Examination of the kinetics of the reaction of NM with mesna was performed by monitoring the loss of the thiol of mesna using DTNB (Ellman’s Reagent) in the presence of increasing concentrations of NM. The reaction of a thiol with DTNB yields spectrophotometrically detectable 2-nitro-5-thiobenzoate (TNB2–), allowing the measurement of free thiols in solution. Reaction mixtures of various concentrations of NM with a fixed concentration of mesna were sampled over a 4-hour time course for measurement of thiol content (Fig. 6A). In the absence of NM, the thiol of mesna reacted with DTNB to form a colored product; in the presence of NM, there was a reduction in the formation of colored product, which is interpreted as a loss of the free thiol of mesna due to the reaction of this group with NM. NM alone had no observable effect on DTNB (Supplemental Fig. 10).

Fig. 6.

Fig. 6.

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Direct interaction between mesna and NM. (A) The formation of a colored product through the reaction of the thiol group of mesna with DTNB was measured in reaction mixtures with NM after incubation across a dose and time course. Mesna concentration was held constant at 3 mM. Data are means + SD from three independent experiments. (B) Proposed reaction between mesna and NM. Product ion scan mass spectrometric analysis (negative ion mode) of the NM-mesna reaction product (242 m/z) was performed, and chemical structures were assigned to the abundant fragments.

Using an HPLC-MS/MS approach (modified from Donkor et al., 2022), the formation of a reaction product between NM and mesna via interaction of the thiol group of mesna with NM was identified (Fig. 6B). HPLC-MS/MS analysis of aqueous solutions of NM and mesna showed an abundant 242 mass-to-charge ratio (m/z) ion, corresponding to the 1:1 reaction of a mercaptoethanesulfate (MES) and NM with subsequent hydrolysis to form the product shown in Fig. 6B. This product was further evaluated by performing a product ion scan of the precursor 242 m/z ion. The fragmentation of this ion produced abundant fragments that were assigned to the NM-MES product and included portions of both NM and MES. For example, the signal at 198 m/z corresponds to the NM-MES product following fragmentation of the ethyl hydroxylate moiety.

Discussion

Mesna is an effective rescue countermeasure for severe SM inhalation in an acute rat model. Treatment with mesna delayed airway fibrin cast formation, improved oxygenation, and improved alveolar ventilation, cardiopulmonary function, and survival in a uniformly lethal model. Arterial blood gas findings, especially pH and pACO2, indicate that alveolar ventilation was improved with mesna treatment, and this, combined with the delay in cast formation in the larger airways, suggests that airways obstruction may have been diminished by mesna treatment. Because it is widely and safely used in cancer medicine and rheumatology, FDA-approved, and inexpensive, mesna may be a useful adjunctive therapy for casualties of high concentration SM inhalation exposure.

Although several RNA transcripts impacted by SM exposure demonstrated a trend toward a difference with mesna treatment, there were no SM-related changes in gene expression that were significantly altered by mesna therapy. One important caveat of the RT-qPCR data are that all analyses were performed on samples obtained from animals 9 hours after exposure because, after this time, control animals begin meeting euthanasia criteria; this short time period may not be sufficient for the detection of all transcript changes resulting from SM exposure, and this may especially not be long enough to detect mesna-mediated impacts. Additionally, these analyses were performed on whole lung tissue, which dramatically decreases the ability to detect transcriptional changes in specific cell types and/or subsets. Inflammatory cells, particularly neutrophils and macrophages/monocyte-derived macrophages, infiltrate the lungs and airways after SM inhalation (Calvet et al., 1996, 1999; Anderson et al., 2000; Malaviya et al., 2010; Veress et al., 2010; Jugg et al., 2013; Xiaoji et al., 2016) (Supplemental Fig. 4). These cells (as well as airway epithelial cells) have been shown to produce numerous inflammatory cytokines, chemokines, and other pro-inflammatory mediators in response to mustard agents (reviewed in Shakarjian et al., 2010; Weinberger et al., 2011; Khazdair et al., 2015). Differences in inflammatory cell recruitment (numbers and/or cell subtypes) could, in part, account for the heterogeneity of the inflammatory response transcripts that were observed. Future work to clarify the mechanisms of protection by mesna may require more sensitive analyses, such as single-cell RNA sequencing. Furthermore, it is plausible that mesna might not affect transcript levels but might affect protein expression and/or function at the protein level. Previous studies have described the ability of mesna to regulate the enzymatic activity of MPO (Jeelani et al., 2017), inhibit the activity of NF-κB in the presence of oxidative damage (Ypsilantis et al., 2008), and normalize SOD2 activity and protein levels of TNF-α and interleukin-1β in an acute pancreatitis rat model (Hagar et al., 2020). Interestingly, mice that are genetically deficient in MPO are resistant to mustard toxicity in exposed skin (Jain et al., 2014).

The results obtained using a DTNB assay and HPLC-MS/MS demonstrate a direct interaction between mesna and a mustard. This observation is not unexpected, as previous interactions between mesna and mustard derivatives (e.g., cyclophosphamide, ifosfamide) as well as similar alkylating agents (e.g., cisplatin) have been described both in vitro (Oprea et al., 2001) and in vivo (Manz et al., 1985). Although mesna is also able to decrease urotoxicity of cyclophosphamide/ifosfamide by neutralizing acrolein (metabolite of these compounds) (Scheef et al., 1979; Brock et al., 1981), acrolein is not a metabolite of sulfur mustard or cisplatin. However, because acrolein can be generated endogenously in the presence of inflammation and oxidative stress (Stevens and Maier, 2008), acrolein produced from host molecules may be a target for mesna in the SM inhalation model. Interestingly, although mesna administration decreases the off-target (i.e., noncancerous cell) effects of activated alkylating agents and their metabolites, it does not decrease in vivo anti-tumor efficacy of cyclophosphamide/ifosfamide (Scheef et al., 1979), and the same is true for cisplatin, as long as mesna is given after cisplatin in a separate injection (Dorr and Lagel, 1989). Although mesna predominantly accumulates in the kidney and/or urinary tract after administration, low levels of mesna can be detected in other tissues, including the lungs (Shaw et al., 1986; Verschraagen et al., 2004), and the observations made in our study suggest it is having effects in the airways. Given that, in the present study, the highly reactive mustard compound was delivered to the airways and mesna was delivered intraperitoneally, it is possible that mesna is acting on less reactive intermediates, metabolites, or other endogenous compounds involved in response to oxidative stress and defense against reactive chemicals and chemical imbalances. For example, relationships between GSH levels and the cellular metabolism of SM, cyclophosphamide, and cisplatin have been reported (Ono and Shrieve, 1987; Mistry et al., 1991; Gross et al., 1993; Pendyala et al., 1997; Townsend et al., 2003). Further, mesna has been shown to impact levels of GSH and its precursor, cysteine (Stofer-Vogel et al., 1993; Souid et al., 2001; Stabler et al., 2009; Li et al., 2013; Abd El-Baset et al., 2021). Because mesna treatment can increase intracellular cysteine levels (Stofer-Vogel et al., 1993), resulting in increased intracellular GSH, this pathway may be involved in the mechanism of mesna efficacy in our model. Unlike tPA or matrix proteases, mesna is not thought to have the ability to break down airway casts. Rather, we believe that neutralization of mustard or mustard intermediates and/or metabolites and decreasing of mustard-induced epithelial damage may be responsible for the delay and/or slight decrease in airway cast formation. Because casts were still observed in mesna-treated animals, future studies will explore the impact of combination therapy with tPA, as we speculate that treatment with tPA (or other effective fibrinolytics) might provide additive, if not synergistic, beneficial effects in this model.

Importantly, in the model used in the current study, mesna treatments were given subsequent to SM inhalation (beginning 20 minutes or 2 hours after the 50-minute SM exposure was terminated). Other thiol compounds like NAC, GSH, and thiosulfate often have required administration to cells or in vivo prior to SM exposure to be maximally effective (Callaway and Pearce, 1958; Rappeneau et al., 2000a; Jost et al., 2017, 2019). During our experiments, drug delivery was performed after the inhalation event to simulate scenarios more relevant to real-world conditions (e.g., military conflicts and accidental exposures) for antidote administration. Also relevant to real-world conditions is the route of drug delivery. Because it is less palatable due to its bad taste, mesna was administered to animals parenterally in this study, using the intraperitoneal route, as we and others have done previously (Shusterman et al., 2003; El-Medany et al., 2005; Sener et al., 2005; Stabler et al., 2009; Jeelani et al., 2017; Keeney et al., 2018; Hagar et al., 2020; Abd El-Baset et al., 2021). For field use of mesna, an alternative mode of administration such as intramuscular or subcutaneous would likely be preferable, although it is currently FDA-approved for use orally and intravenously. Several studies have tested the efficacies of therapeutics delivered via intubation under general anesthesia. In previous work performed by our group, tPA delivered in this manner demonstrated substantial efficacy in an SM-exposure model similar to that used in the present report, but the treatment regimen consisted of repeat intratracheal administration every 4 hours for 48 hours (Veress et al., 2015). Mesna usage could offer a practical therapeutic option or adjunctive therapy that avoids this disadvantage. However, although intubation may not be ideal for rapid and immediate drug delivery after real-world exposure (that may be incredibly important for decreasing mustard-induced injury), it is possible that candidate therapeutic compounds, including mesna, could be formulated for delivery to the airways by a hand-held inhaler. In the future, it may be desirable to evaluate alternate routes of mesna delivery, including direct delivery to the site of exposure.

Although testing various routes of drug delivery is one potential avenue for the optimization of mesna treatment, other factors that may significantly impact the efficacy of mesna in our SM exposure model include the amount of drug given and the timing(s) of drug delivery. When delivered intraperitoneally in rats, the LD50 of mesna is 1529 (male) and 1251 (female) mg/kg (Brock et al., 1982); given the severe damage and intense physiologic stress induced by SM exposure in our inhalation model, approaching the LD50 values may result in additional stress as opposed to clinical benefit. However, it is possible that doses higher than those given in this study (300 mg/kg/dose) may provide increased efficacy. Because mesna has a short half-life (Shaw et al., 1986; Verschraagen et al., 2004) (Supplemental Fig. 1), administering lower doses of mesna repeatedly at intervals may be a more effective approach than a single high-dose bolus. Delivering mesna at shorter or longer intervals, administering the initial dose at an earlier or later time post-exposure, and/or continuing the dosing beyond the three administrations given in our study may also provide additional clinical benefit. Although dosing optimization was not explored in the current study, the treatment regimen employed resulted in the extended survival (to at least 15 days) of 18.4% of the animals exposed to SM. Therefore, the use of mesna therapy for SM exposure is promising and, with dosing optimization, more dramatic improvements in outcome and survival may be obtained.

As mentioned above, previous studies have evaluated the efficacy of various compounds for the treatment of SM exposure in animal models. However, some of these models may be less relevant than others with regards to real-world exposures for humans; for instance, results obtained from models utilizing systemically delivered SM may not be pertinent to human exposure during conflict and/or combat (although they may be informative regarding mustard-derived chemotherapeutics used clinically). It is also important to note that additional differences in experimental models may strongly influence the measured effectiveness of therapies. Because of this, it is difficult to compare the therapeutic potential of a drug tested in a lethal exposure model with that of a drug tested in a sublethal model. Furthermore, it is not possible to conclude whether the therapy-mediated improvements in outcomes reported for studies following animals over a short time course postexposure will be maintained over a longer time period. To more accurately compare the efficacy of various candidate therapies, it will be necessary to test these using the same model of SM exposure. We suggest that both lethal and sublethal models have direct relevance to real-world exposures, and longer-term studies may be more valuable than shorter-term studies for developing a therapy for real-world application. However, short-term studies may be valuable for determining mechanisms of drug actions and identifying pathways for targeted therapies.

In addition to the efficacy observed in the SM exposure model used in this study, mesna has a number of strengths as a therapeutic. The clinical utilization of mesna has a strong safety record over the past 40–50 years due to its repeated use in fragile patients receiving ifosfamide or cyclophosphamide for severe oncologic and rheumatologic diagnoses. It is also easily administered to the patient. Furthermore, mesna is inexpensive and, due to its chemical stability in water, it is easily stored and prepared for use. Therefore, mesna may be an ideal candidate countermeasure against SM exposure.

Further studies are required to fully elucidate the mechanisms involved in mesna-mediated protection from SM inhalation, including the identification and measurement of SM reaction products in the presence of mesna in vivo. Additionally, future experiments will explore the impact of timing and route of delivery on the efficacy of mesna-mediated protection. Overall, we have demonstrated the excellent potential in the therapeutic use of mesna for the treatment of SM inhalation exposures.

Acknowledgments

The authors thank Taya Yeager, Mohamed Basiouny, and Jeannette Eagen for assistance with animal studies, and data collection and entry, Tessa Vallin for assistance with isolation and initial qPCR screens, and Jacqueline Rioux for general support and assistance.

Data Availability

The authors declare that all the data supporting the findings of this study are available within the paper and the Supplemental Material.

Abbreviations

DTNB, 5

5′-dithiobis(2-nitrobenzoic acid)

FDA

Food and Drug Administration

GSH

glutathione

hpe

hours postexposure

HPLC-MS/MS

high performance liquid chromatography tandem mass spectrometry

MES

mercaptoethanesulfate

mesna

sodium 2-mercaptoethane sulfonate

MPO

myeloperoxidase

m/z

mass-to-charge ratio

NAC

N-acetylcysteine

NM

nitrogen mustard

NF-κB

nuclear factor-κB

RT-qPCR

reverse transcription quantitative polymerase chain reaction

SM

sulfur mustard

SpO2

peripheral oxygen saturation

TNF

tumor necrosis factor

tPA

tissue plasminogen activator

Authorship Contributions

Participated in research design: Nick, Veress, Logue, Bratcher, White.

Conducted experiments: Nick, Johnson, Stewart, Christeson, Bloomquist, Appel, Donkor, Bratcher.

Contributed new reagents or analytic tools: Logue.

Performed data analysis: Nick, Appel, Donkor, Logue, Bratcher, White.

Wrote or contributed to the writing of the manuscript: Nick, Bratcher, White.

Footnotes

This work was supported by the National Institute of Health National Institute of Environmental Health Sciences Countermeasures Against Chemical Threats Program [Grant U54ES027698] (to C.W.W.).

1P.E.B. and C.W.W. contributed equally to this work.

H.J.N., B.A.L., P.E.B., and C.W.W. have a patent pending for the use of mesna in treatment of subjects exposed to toxic inhaled chemicals. The remaining authors have no conflicts of interest to declare.

Inline graphicThis article has supplemental material available at jpet.aspetjournals.org.

References

  1. Abd El-Baset SA, Abd El-Haleem MR, Abdul-Maksoud RS, Kattaia AAA (2021) Mesna ameliorates acute lung injury induced by intestinal ischemia-reperfusion in rats. Sci Rep 11:13356. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Anderson DR, Byers SL, Vesely KR (2000) Treatment of sulfur mustard (HD)-induced lung injury. J Appl Toxicol 20 (Suppl 1):S129–S132. [DOI] [PubMed] [Google Scholar]
  3. Anderson DR, Yourick JJ, Moeller RB, Petrali JP, Young GD, Byers SL (1996) Pathologic changes in rat lungs following acute sulfur mustard inhalation. Inhal Toxicol 8:285–297. [Google Scholar]
  4. Borna H, Hosseini Qale Noe SH, Harchegani AB, Talatappe NR, Ghatrehsamani M, Ghanei M, Shahriary A (2019) A review on proteomics analysis to reveal biological pathways and predictive proteins in sulfur mustard exposed patients: roles of inflammation and oxidative stress. Inhal Toxicol 31:3–11. [DOI] [PubMed] [Google Scholar]
  5. Brock N, Pohl J, Stekar J (1981) Detoxification of urotoxic oxazaphosphorines by sulfhydryl compounds. J Cancer Res Clin Oncol 100:311–320. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Brock N, Pohl J, Stekar J, Scheef W (1982) Studies on the urotoxicity of oxazaphosphorine cytostatics and its prevention--III. Profile of action of sodium 2-mercaptoethane sulfonate (mesna). Eur J Cancer Clin Oncol 18:1377–1387. [DOI] [PubMed] [Google Scholar]
  7. Callaway S, Pearce KA (1958) Protection against systemic poisoning by mustard gas, di(2-chloroethyl) sulphide, by sodium thiosulphate and thiocit in the albino rat. Br J Pharmacol Chemother 13:395–398. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Calvet JH, Coste A, Levame M, Harf A, Macquin-Mavier I, Escudier E (1996) Airway epithelial damage induced by sulfur mustard in guinea pigs, effects of glucocorticoids. Hum Exp Toxicol 15:964–971. [DOI] [PubMed] [Google Scholar]
  9. Calvet JH, Planus E, Rouet P, Pezet S, Levame M, Lafuma C, Harf A, D’Ortho MP (1999) Matrix metalloproteinase gelatinases in sulfur mustard-induced acute airway injury in guinea pigs. Am J Physiol 276:L754–L762. [DOI] [PubMed] [Google Scholar]
  10. Dechant KL, Brogden RN, Pilkington T, Faulds D (1991) Ifosfamide/mesna. A review of its antineoplastic activity, pharmacokinetic properties and therapeutic efficacy in cancer. Drugs 42:428–467. [DOI] [PubMed] [Google Scholar]
  11. Dillman JF 3rd, Phillips CS, Dorsch LM, Croxton MD, Hege AI, Sylvester AJ, Moran TS, Sciuto AM (2005) Genomic analysis of rodent pulmonary tissue following bis-(2-chloroethyl) sulfide exposure. Chem Res Toxicol 18:28–34. [DOI] [PubMed] [Google Scholar]
  12. Donkor AB, White CW, Nick HJ, Logue BA (2022) Analysis of sodium 2-mercaptoethane sulfonate in rat plasma using high performance liquid chromatography tandem-mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 1189:123088. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Dorr RT, Lagel K (1989) Interaction between cisplatin and mesna in mice. J Cancer Res Clin Oncol 115:604–605. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. El-Medany A, Hagar HH, Moursi M, At Muhammed R, El-Rakhawy FI, El-Medany G (2005) Attenuation of bleomycin-induced lung fibrosis in rats by mesna. Eur J Pharmacol 509:61–70. [DOI] [PubMed] [Google Scholar]
  15. Fairhall SJ, Jugg BJ, Read RW, Stubbs SJ, Rutter SJ, Smith AJ, Mann TM, Jenner J, Sciuto AM (2010) Exposure-response effects of inhaled sulfur mustard in a large porcine model: a 6-h study. Inhal Toxicol 22:1135–1143. [DOI] [PubMed] [Google Scholar]
  16. Ghabili K, Agutter PS, Ghanei M, Ansarin K, Panahi Y, Shoja MM (2011) Sulfur mustard toxicity: history, chemistry, pharmacokinetics, and pharmacodynamics. Crit Rev Toxicol 41:384–403. [DOI] [PubMed] [Google Scholar]
  17. Ghabili K, Agutter PS, Ghanei M, Ansarin K, Shoja MM (2010) Mustard gas toxicity: the acute and chronic pathological effects. J Appl Toxicol 30:627–643. [DOI] [PubMed] [Google Scholar]
  18. Gross CL, Innace JK, Hovatter RC, Meier HL, Smith WJ (1993) Biochemical manipulation of intracellular glutathione levels influences cytotoxicity to isolated human lymphocytes by sulfur mustard. Cell Biol Toxicol 9:259–267. [DOI] [PubMed] [Google Scholar]
  19. Gupta A, Vijayaraghavan R, Gautam A (2021) Combination therapy of N-acetyl-L-cysteine and S-2(2-aminoethylamino) ethylphenyl sulfide for sulfur mustard induced oxidative stress in mice. Toxicol Rep 8:599–606. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Hagar HH, Almubrik SA, Attia NM, Aljasser SN (2020) Mesna alleviates cerulein-induced acute pancreatitis by inhibiting the inflammatory response and oxidative stress in experimental rats. Dig Dis Sci 65:3583–3591. [DOI] [PubMed] [Google Scholar]
  21. Hensley ML, Hagerty KL, Kewalramani T, Green DM, Meropol NJ, Wasserman TH, Cohen GI, Emami B, Gradishar WJ, Mitchell RB, et al. (2009) American Society of Clinical Oncology 2008 clinical practice guideline update: use of chemotherapy and radiation therapy protectants. J Clin Oncol 27:127–145. [DOI] [PubMed] [Google Scholar]
  22. Jain AK, Tewari-Singh N, Inturi S, Orlicky DJ, White CW, Agarwal R (2014) Myeloperoxidase deficiency attenuates nitrogen mustard-induced skin injuries. Toxicology 320:25–33. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Jeelani R, Jahanbakhsh S, Kohan-Ghadr HR, Thakur M, Khan S, Aldhaheri SR, Yang Z, Andreana P, Morris R, Abu-Soud HM (2017) Mesna (2-mercaptoethane sodium sulfonate) functions as a regulator of myeloperoxidase. Free Radic Biol Med 110:54–62. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Jost P, Fikrova P, Svobodova H, Pejchal J, Stetina R (2017) Protective potential of different compounds and their combinations with MESNA against sulfur mustard-induced cytotoxicity and genotoxicity. Toxicol Lett 275:92–100. [DOI] [PubMed] [Google Scholar]
  25. Jost P, Pejchal J, Kucera T, Muckova L, Stetina R (2019) Screening of the chemoprotective effect of 13 compounds and their mixtures with sodium 2-mercaptoethanesulfonate against 2-chloroethyl ethyl sulfide. J Appl Biomed 17:136–145. [DOI] [PubMed] [Google Scholar]
  26. Jowsey PA, Blain PG (2014) Whole genome expression analysis in primary bronchial epithelial cells after exposure to sulphur mustard. Toxicol Lett 230:393–401. [DOI] [PubMed] [Google Scholar]
  27. Jugg B, Fairhall S, Smith A, Rutter S, Mann T, Perrott R, Jenner J, Salguero J, Shute J, Sciuto AM (2013) N-acetyl-L-cysteine protects against inhaled sulfur mustard poisoning in the large swine. Clin Toxicol (Phila) 51:216–224. [DOI] [PubMed] [Google Scholar]
  28. Jugg BJ, Hoard-Fruchey H, Rothwell C, Dillman JF, David J, Jenner J, Sciuto AM (2016) Acute gene expression profile of lung tissue following sulfur mustard inhalation exposure in large anesthetized swine. Chem Res Toxicol 29:1602–1610. [DOI] [PubMed] [Google Scholar]
  29. Kanat O, Kurt E, Yalcinkaya U, Evrensel T, Manavoglu O (2006) Comparison of uroprotective efficacy of mesna and amifostine in cyclophosphamide-induced hemorrhagic cystitis in rats. Indian J Cancer 43:12–15. [DOI] [PubMed] [Google Scholar]
  30. Keeney JTR, Ren X, Warrier G, Noel T, Powell DK, Brelsfoard JM, Sultana R, Saatman KE, Clair DKS, Butterfield DA (2018) Doxorubicin-induced elevated oxidative stress and neurochemical alterations in brain and cognitive decline: protection by MESNA and insights into mechanisms of chemotherapy-induced cognitive impairment (“chemobrain”). Oncotarget 9:30324–30339. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Khazdair MR, Boskabady MH, Ghorani V (2015) Respiratory effects of sulfur mustard exposure, similarities and differences with asthma and COPD. Inhal Toxicol 27:731–744. [DOI] [PubMed] [Google Scholar]
  32. Kumar O, Sugendran K, Vijayaraghavan R (2001) Protective effect of various antioxidants on the toxicity of sulphur mustard administered to mice by inhalation or percutaneous routes. Chem Biol Interact 134:1–12. [DOI] [PubMed] [Google Scholar]
  33. Li X, Yang S, Lv X, Sun H, Weng J, Liang Y, Zhou D (2013) The mechanism of mesna in protection from cisplatin-induced ovarian damage in female rats. J Gynecol Oncol 24:177–185. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Liu J, Powell KL, Thames HD, MacLeod MC (2010) Detoxication of sulfur half-mustards by nucleophilic scavengers: robust activity of thiopurines. Chem Res Toxicol 23:488–496. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Malaviya R, Sunil VR, Cervelli J, Anderson DR, Holmes WW, Conti ML, Gordon RE, Laskin JD, Laskin DL (2010) Inflammatory effects of inhaled sulfur mustard in rat lung. Toxicol Appl Pharmacol 248:89–99. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Manz I, Dietrich I, Przybylski M, Niemeyer U, Pohl J, Hilgard P, Brock N (1985) Identification and quantification of metabolite conjugates of activated cyclophosphamide and ifosfamide with mesna in urine by ion-pair extraction and fast atom bombardment mass spectrometry. Biomed Mass Spectrom 12:545–553. [DOI] [PubMed] [Google Scholar]
  37. McClintock SD, Hoesel LM, Das SK, Till GO, Neff T, Kunkel RG, Smith MG, Ward PA (2006) Attenuation of half sulfur mustard gas-induced acute lung injury in rats. J Appl Toxicol 26:126–131. [DOI] [PubMed] [Google Scholar]
  38. Menétrey D, Bon K, Michiels JF, Lantéri-Minet M (1999) The uroprotection of mesna on cyclophosphamide cystitis in rats. Its consequences on behaviour and brain activities. C R Acad Sci III 322:505–515. [DOI] [PubMed] [Google Scholar]
  39. Mistry P, Kelland LR, Abel G, Sidhar S, Harrap KR (1991) The relationships between glutathione, glutathione-S-transferase and cytotoxicity of platinum drugs and melphalan in eight human ovarian carcinoma cell lines. Br J Cancer 64:215–220. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Naghii MR (2002) Sulfur mustard intoxication, oxidative stress, and antioxidants. Mil Med 167:573–575. [PubMed] [Google Scholar]
  41. Nick HJ, Rioux JS, Veress LA, Bratcher PE, Bloomquist LA, Anantharam P, Croutch CR, Tuttle RS, Peters E, Sosna W, et al. (2020) Alleviation of methyl isocyanate-induced airway obstruction and mortality by tissue plasminogen activator. Ann N Y Acad Sci 1479:134–147. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Ono K, Shrieve DC (1987) Effect of glutathione depletion by L-buthionine sulfoximine on the cytotoxicity of cyclophosphamide in single and fractionated doses to EMT6/SF mouse tumors and bone marrow. J Natl Cancer Inst 79:811–815. [PubMed] [Google Scholar]
  43. Oprea A, Bazzazi H, Kangarloo B, Wolff JE (2001) The kinetics and mechanisms of the reaction of Mesna with cisplatin, oxiplatin and carboplatin. Anticancer Res 21 (2A):1225–1229. [PubMed] [Google Scholar]
  44. Papirmeister B, Feister AJ, Robinson SI, Ford RD (1991) Medical Defense Against Mustard Gas: Toxic Mechanisms and Pharmacological Implications, CRC Press, Boca Raton. [Google Scholar]
  45. Pendyala L, Perez R, Weinstein A, Zdanowicz J, Creaven PJ (1997) Effect of glutathione depletion on the cytotoxicity of cisplatin and iproplatin in a human melanoma cell line. Cancer Chemother Pharmacol 40:38–44. [DOI] [PubMed] [Google Scholar]
  46. Rappeneau S, Baeza-Squiban A, Jeulin C, Marano F (2000a) Protection from cytotoxic effects induced by the nitrogen mustard mechlorethamine on human bronchial epithelial cells in vitro. Toxicol Sci 54:212–221. [DOI] [PubMed] [Google Scholar]
  47. Rappeneau S, Baeza-Squiban A, Marano F, Calvet J (2000b) Efficient protection of human bronchial epithelial cells against sulfur and nitrogen mustard cytotoxicity using drug combinations. Toxicol Sci 58:153–160. [DOI] [PubMed] [Google Scholar]
  48. Sawyer TW (2020) N-Acetylcysteine as a treatment for sulphur mustard poisoning. Free Radic Biol Med 161:305–320. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Scheef W, Klein HO, Brock N, Burkert H, Günther U, Hoefer-Janker H, Mitrenga D, Schnitker J, Voigtmann R (1979) Controlled clinical studies with an antidote against the urotoxicity of oxazaphosphorines: preliminary results. Cancer Treat Rep 63:501–505. [PubMed] [Google Scholar]
  50. Schoenike SE, Dana WJ (1990) Ifosfamide and mesna. Clin Pharm 9:179–191. [PubMed] [Google Scholar]
  51. Sener G, Sehirli O, Cetinel S, Yeğen BG, Gedik N, Ayanoğlu-Dülger G (2005) Protective effects of MESNA (2-mercaptoethane sulphonate) against acetaminophen-induced hepatorenal oxidative damage in mice. J Appl Toxicol 25:20–29. [DOI] [PubMed] [Google Scholar]
  52. Shakarjian MP, Heck DE, Gray JP, Sinko PJ, Gordon MK, Casillas RP, Heindel ND, Gerecke DR, Laskin DL, Laskin JD (2010) Mechanisms mediating the vesicant actions of sulfur mustard after cutaneous exposure. Toxicol Sci 114:5–19. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Shaw IC, Graham MI (1987) Mesna--a short review. Cancer Treat Rev 14:67–86. [DOI] [PubMed] [Google Scholar]
  54. Shaw IC, Graham MI, Jones MS (1986) The fate of [14C]-mesna in the rat. Arzneimittelforschung 36:487–489. [PubMed] [Google Scholar]
  55. Shusterman T, Sela S, Cohen H, Kristal B, Sbeit W, Reshef R (2003) Effect of the antioxidant Mesna (2-mercaptoethane sulfonate) on experimental colitis. Dig Dis Sci 48:1177–1185. [DOI] [PubMed] [Google Scholar]
  56. Souid AK, Fahey RC, Aktas MK, Sayin OA, Karjoo S, Newton GL, Sadowitz PD, Dubowy RL, Bernstein ML (2001) Blood thiols following amifostine and mesna infusions, a pediatric oncology group study. Drug Metab Dispos 29:1460–1466. [PubMed] [Google Scholar]
  57. Stabler SP, Sekhar J, Allen RH, O’Neill HC, White CW (2009) Alpha-lipoic acid induces elevated S-adenosylhomocysteine and depletes S-adenosylmethionine. Free Radic Biol Med 47:1147–1153. [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Stenger B, Popp T, John H, Siegert M, Tsoutsoulopoulos A, Schmidt A, Mückter H, Gudermann T, Thiermann H, Steinritz D (2017) N-Acetyl-L-cysteine inhibits sulfur mustard-induced and TRPA1-dependent calcium influx. Arch Toxicol 91:2179–2189. [DOI] [PubMed] [Google Scholar]
  59. Stevens JF, Maier CS (2008) Acrolein: sources, metabolism, and biomolecular interactions relevant to human health and disease. Mol Nutr Food Res 52:7–25. [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Stofer-Vogel B, Cerny T, Küpfer A, Junker E, Lauterburg BH (1993) Depletion of circulating cyst(e)ine by oral and intravenous mesna. Br J Cancer 68:590–593. [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Tahmasbpour E, Ghanei M, Qazvini A, Vahedi E, Panahi Y (2016) Gene expression profile of oxidative stress and antioxidant defense in lung tissue of patients exposed to sulfur mustard. Mutat Res Genet Toxicol Environ Mutagen 800–801:12–21. [DOI] [PubMed] [Google Scholar]
  62. Tewari-Singh N, Agarwal C, Huang J, Day BJ, White CW, Agarwal R (2011) Efficacy of glutathione in ameliorating sulfur mustard analog-induced toxicity in cultured skin epidermal cells and in SKH-1 mouse skin in vivo. J Pharmacol Exp Ther 336:450–459. [DOI] [PMC free article] [PubMed] [Google Scholar]
  63. Tewari-Singh N, Jain AK, Inturi S, Agarwal C, White CW, Agarwal R (2012) Silibinin attenuates sulfur mustard analog-induced skin injury by targeting multiple pathways connecting oxidative stress and inflammation. PLoS One 7:e46149. [DOI] [PMC free article] [PubMed] [Google Scholar]
  64. Townsend DM, Deng M, Zhang L, Lapus MG, Hanigan MH (2003) Metabolism of cisplatin to a nephrotoxin in proximal tubule cells. J Am Soc Nephrol 14:1–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  65. Veress LA, Anderson DR, Hendry-Hofer TB, Houin PR, Rioux JS, Garlick RB, Loader JE, Paradiso DC, Smith RW, Rancourt RC, et al. (2015) Airway tissue plasminogen activator prevents acute mortality due to lethal sulfur mustard inhalation. Toxicol Sci 143:178–184. [DOI] [PMC free article] [PubMed] [Google Scholar]
  66. Veress LA, Hendry-Hofer TB, Loader JE, Rioux JS, Garlick RB, White CW (2013) Tissue plasminogen activator prevents mortality from sulfur mustard analog-induced airway obstruction. Am J Respir Cell Mol Biol 48:439–447. [DOI] [PMC free article] [PubMed] [Google Scholar]
  67. Veress LA, O’Neill HC, Hendry-Hofer TB, Loader JE, Rancourt RC, White CW (2010) Airway obstruction due to bronchial vascular injury after sulfur mustard analog inhalation. Am J Respir Crit Care Med 182:1352–1361. [DOI] [PMC free article] [PubMed] [Google Scholar]
  68. Verschraagen M, Boven E, Torun E, Erkelens CA, Hausheer FH, van der Vijgh WJ (2004) Pharmacokinetic behaviour of the chemoprotectants BNP7787 and mesna after an i.v. bolus injection in rats. Br J Cancer 90:1654–1659. [DOI] [PMC free article] [PubMed] [Google Scholar]
  69. Weinberger B, Laskin JD, Sunil VR, Sinko PJ, Heck DE, Laskin DL (2011) Sulfur mustard-induced pulmonary injury: therapeutic approaches to mitigating toxicity. Pulm Pharmacol Ther 24:92–99. [DOI] [PMC free article] [PubMed] [Google Scholar]
  70. White CW, Rancourt RC, Veress LA (2016) Sulfur mustard inhalation: mechanisms of injury, alteration of coagulation, and fibrinolytic therapy. Ann N Y Acad Sci 1378:87–95. [DOI] [PMC free article] [PubMed] [Google Scholar]
  71. Xiaoji Z, Xiao M, Rui X, Haibo C, Chao Z, Chengjin L, Tao W, Wenjun G, Shengming Z (2016) Mechanism underlying acute lung injury due to sulfur mustard exposure in rats. Toxicol Ind Health 32:1345–1357. [DOI] [PubMed] [Google Scholar]
  72. Ypsilantis P, Tentes I, Lambropoulou M, Anagnostopoulos K, Papadopoulos N, Kortsaris A, Simopoulos C (2008) Prophylaxis with mesna prevents oxidative stress induced by ischemia reperfusion in the intestine via inhibition of nuclear factor-kappaB activation. J Gastroenterol Hepatol 23:328–335. [DOI] [PubMed] [Google Scholar]

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