The composite of cardiovascular or all-cause death and worsening heart failure (WHF) has become the principal efficacy endpoint of heart failure trials. Yet WHF is not one event: it spans outpatient oral-diuretic escalation, urgent intravenous-diuretic visits, hospitalisation, and HF-related death-tiers that differ markedly in frequency, ascertainment, and prognostic weight. A composite WHF benefit therefore cannot be properly interpreted without knowing which tier carries the signal, and we argue that this tier is both phenotype- and setting-dependent. Two trials published on the same day in 2026 make the point with unusual clarity. In the Dig-RHD trial of digoxin in rheumatic heart disease, the benefit concentrated in outpatient diuretic events, with neutral results at hospitalisation and death; in a contemporaneous meta-analysis of digitalis glycosides in reduced or mildly reduced ejection fraction, the same drug class reduced worsening heart failure mainly through hospitalisation, again without a mortality benefit. We use this contrast to propose a severity-gradient framework for reporting and interpreting worsening heart failure, and discuss its implications for trial design, for the translation of guideline-based evidence across health systems, and for the use of inexpensive therapies such as digoxin in low- and middle-income settings.

Ferroptosis has attracted significant attention for its potential to treat drug resistant tumors, along with its role in neurodegeneration and ischemia. Several ferroptosis targets were identified in the past decade, yet it is also highly affected by cellular metabolism and epithelial or mesenchymal phenotypes which limits the utility of these targets across diverse cell and tissue types. To address this, we utilized chemo-resistant cancer cell lines with different metastatic potential and tissue origins and discovered a common role of cytoplasmic ion changes during ferroptosis. We observed significant changes in intracellular potassium, sodium and chloride levels upon induction of ferroptosis. Therefore, we screened several ion channel inhibitors and activators (i.e. modulators) and identified Kv7.2 and CFTR modulators influence ferroptosis execution despite the fact that these cell lines do not express these proteins. We demonstrated that clinically approved modulators of CFTR and Kv7.2 can inhibit ferroptosis which indicates that these inhibitors could be repurposed as treatments in ferroptosis-associated diseases such as neurodegeneration and kidney diseases independent of ion channel expression. These modulators also influenced potassium and chloride levels in different contexts indicating off-target effects may also lead to changes in ion levels and may serve as a ferroptosis target. Further, we demonstrated that sustained imbalance of sodium, potassium and chloride ions with ferroptosis inducer salinomycin and digoxin, a Na [+] /K [+] ATPase inhibitor, enhanced ferroptosis. The combination of salinomycin and digoxin successfully enhanced ferroptotic cell death across both cell lines with different metabolic signatures in vitro, offering a novel ferroptosis target. This combination significantly reduced tumor growth in vivo compared with the single agent alone, offering a new therapeutic modality against drug resistant tumors.

Oral drug delivery remains the predominant administration route, but formulation strategies rarely account systematically for the gut microbiome. The microbiome can alter drug metabolism, excipient behavior, nanocarrier interactions, and interpatient variability. This review integrates evidence on microbial drug metabolism, excipient-microbiome interactions, nanocarrier engineering, microbiota-responsive delivery, and experimental models. Clinically relevant examples include digoxin inactivation by Eggerthella lenta, bacterial levodopa metabolism, and microbial beta-glucuronidase-mediated irinotecan toxicity. Microbiota-degradable polysaccharides may serve as colon-targeted release triggers, whereas some surfactants and polymers may create context-dependent microbiome or barrier risks. Nanocarrier size, charge, coating, mucoadhesion, mucus penetration, biodegradability, enzyme responsiveness, and surfactant burden are treated as microbiome-interface variables. We propose an authors' evidence-informed framework comprising an excipient classification, nanocarrier design rules, microbiota-responsive decision logic, and a tiered testing roadmap. These proposals are not established regulatory classifications; they are intended to support more predictable and patient-relevant oral formulation development.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are widely prescribed, and two additional oral products received US approval in 2025 and 2026. All eleven US labels examined describe delayed gastric emptying as potentially affecting the absorption of co-administered oral medications. Since the exenatide program, no study has evaluated a narrow therapeutic index victim across more than one administration schedule; the original warfarin and digoxin studies each used a single schedule. The omission may reflect an interaction paradigm built around enzymes and transporters. Current frameworks do not routinely trigger motility-specific studies because the standard in vitro screening cascade does not address gastric emptying. Total area under the concentration-time curve (AUC) may also fail to characterize rate-dependent effects in some victim drugs. Once a class warning is established, further study may receive less priority, and interactions managed by routine dose adjustment may go unreported. Of eleven US prescribing-information documents screened, six contributed quantitative data showing that the direction of effect is not uniform: thyroxine, atorvastatin and ramipril exposures have all been reported to increase under specific conditions, so a reduction in exposure should not be assumed. The class is also pharmacologically heterogeneous; ICH M12 places absorption-mediated interactions outside its scope, and the European Medicines Agency has adopted a concept paper proposing guidance covering them. I propose an evaluation framework built on biopharmaceutically stratified probe panels, timing- and titration-explicit designs, selective use of prespecified partial AUC endpoints for rate-sensitive victims, and physiologically based pharmacokinetic models qualified against human gastric emptying data.

Microbial transformation of drugs is experimentally established, but no agreed method determines when a detected pathway materially contributes to drug disposition. This minireview proposes a 5-gate framework for evaluating microbial metabolism as a source of drug-disposition variability. Evaluation begins by asking whether drug-related material reaches a microbial compartment, whether a defined drug-specific problem exists, and whether confirmation could change a development or therapeutic decision. Candidates then require demonstration of a defined microbial function, confirmation of an in vivo drug-specific consequence, comparison of effect magnitude with a prespecified pharmacologic benchmark, and evidence that the microbial measure improves prediction or decision-making beyond established covariates. The benchmark serves as the drug-specific denominator for interpreting microbial effect size. Route and formulation determine substrate access, sampling compartment, assay selection, and the relevant disposition endpoint. Transformation catalogs and genome-scale community models can prioritize pathways and estimate population heterogeneity, but predicted capacity is not equivalent to expressed activity, realized flux, or altered human exposure. A worked digoxin example compares the maximum reported increase of approximately 2-fold in serum concentration after suppression of microbial inactivation with recognized digoxin drug interactions. The framework complements existing microbiome tools by defining when mechanistic findings justify targeted drug-metabolism, pharmacokinetic, or drug-development evaluation. Microbial metabolism becomes a drug-disposition variable when measured function produces a reproducible, quantitatively material effect on drug behavior and provides information beyond established covariates. SIGNIFICANCE STATEMENT: Microbial biotransformation is increasingly detectable, but detection alone does not establish that microbial activity materially alters drug disposition. This minireview proposes a 5-gate framework that connects microbial-compartment exposure and demonstrated function to an in vivo drug-specific consequence, compares effect magnitude with a prespecified pharmacologic benchmark that serves as the drug-specific denominator, and requires incremental predictive or decision value before microbial measures advance beyond targeted drug-development evaluation.

Osteoarthritis (OA) is a chronic degenerative joint disease and a leading cause of disability worldwide, yet no disease-modifying therapies are currently available. The role of synovial macrophages in OA pathogenesis remains incompletely understood, and the molecular mechanisms by which they drive cartilage destruction have not been fully elucidated. By integrating human OA microarrays, synovial single-cell RNA-seq, and multi-level validation, we identified lymphocyte-specific protein 1 (LSP1) as a macrophage-specific hub gene upregulated in OA. Mechanistically, LSP1 directly binds to and inhibits superoxide dismutase 1 (SOD1), inducing a redox imbalance that concurrently activates the NADPH oxidase (NOX) and mitochondrial reactive oxygen species (mtROS) pathways. This cascade drives the release of macrophage extracellular traps (METs), which directly damage chondrocytes and accelerate OA progression. Virtual screening of the DrugBank database identified the cardiac glycoside digoxin as a compound that competitively binds LSP1, restores SOD1 activity, and suppresses the NOX/mtROS-METs axis. This study defines a novel LSP1-SOD1-METs pathogenic axis in OA and nominates digoxin as a repurposable therapeutic candidate. Unlike its previously reported cartilage-targeting mechanism, digoxin alleviates OA by suppressing synovial inflammation via LSP1 targeting, highlighting its dual-target potential for concurrent modulation of synovial and cartilage pathology.

This study characterized the pharmacokinetic interaction between Compound Danshen Tablets (CDT) and atorvastatin (ATV) and investigated absorption- and transporter-related mechanisms underlying this interaction. ATV pharmacokinetics were evaluated after oral and intravenous administration in normal and hyperlipidemic/diabetic rats, with or without repeated CDT treatment. Mechanistic studies included single-pass intestinal perfusion, Caco-2 bidirectional transport assays, human multidrug resistance protein 1 inside-out vesicle transport assays, ileal P-glycoprotein (P-gp) immunoblotting, an in vivo digoxin probe-substrate experiment, and molecular docking. Repeated CDT administration increased oral ATV exposure in both normal and model rats, with the area under the plasma concentration-time curve from 0 to 24 hours and maximum plasma concentration increasing by up to 85.83% and 306.53%, respectively, whereas intravenous ATV pharmacokinetics were not significantly altered. In Caco-2 monolayers, ATV exhibited marked directional efflux, with an efflux ratio of 39.32, which was reduced to 10.99 by verapamil. CDT increased the apical-to-basolateral apparent permeability coefficient of ATV from 0.41 to 1.31 × 10[-6] cm/s and reduced the efflux ratio to 9.82, whereas the basolateral-to-apical apparent permeability coefficient decreased from 16.27 to 12.90 × 10[-6] cm/s. In human multidrug resistance protein 1 inside-out vesicles, CDT concentration dependently reduced ATP-dependent N-methylquinidine transport, with inhibition rates ranging from 24.97% to 80.45% at 50-800 μg/mL. Together with the ileal P-gp protein data and the digoxin probe-substrate experiment, these findings indicate that CDT enhances intestinal absorption of ATV primarily by attenuating intestinal P-gp-mediated efflux through reducing both P-gp transport activity and protein abundance. These results provide mechanistic evidence that modulation of intestinal efflux transport contributes to the increased systemic exposure of ATV after repeated CDT administration. SIGNIFICANT STATEMENT: This study identifies a clinically relevant herb-drug interaction in which repeated administration of compound Danshen tablets increases oral atorvastatin exposure in normal and hyperlipidemic/diabetic rats without materially altering intravenous atorvastatin pharmacokinetics. Integrated pharmacokinetic, single-pass intestinal perfusion, Caco-2 transport, human multidrug resistance protein 1 vesicle, ileal P-glycoprotein, and digoxin probe-substrate data support attenuation of intestinal P-glycoprotein-mediated efflux, through reduced transporter activity and protein abundance, as a mechanism enhancing atorvastatin absorption.

A novel method of in-situ functionalized magnetic dispersive solid phase microextraction was established and coupled with high performance liquid chromatography-ultraviolet detection to determine four cardiac glycosides in human plasma. The adsorbent was prepared by in-situ functionalization of Fe3O4/SBA-15 with surfactant during the extraction process. The synthesized material was characterized using N2 physisorption, infrared spectroscopy, transmission electron microscopy, and vibrating sample magnetometry. Key parameters affecting extraction efficiency, including type of surfactant, concentration and volume of hexadecyl trimethyl ammonium bromide, adsorbent dosage, pH of sample solution, salt addition, extraction time, elution program, were systematically evaluated and optimized. The method demonstrated good linearity, satisfactory lower limit of quantification (deslanoside at 8.0 ng/mL, lanatoside C at 2.0 ng/mL, digoxin and digitoxin each at 1.6 ng/mL), high precision (RSD between 0.6% and 9.0%), good accuracy (RE within -8.8% to 11%), and acceptable extraction recoveries (56.1%-70.3%) under optimal conditions. Additionally, the method showed no significant matrix effect in human plasma, and the stability of the analytes was confirmed. The proposed method features simple and convenient adsorbent preparation and extraction processes, as well as high extraction efficiency for cardiac glycosides, making it a promising approach for trace analysis in complex matrices.

UBE2C (Ubiquitin-Conjugating Enzyme E2C) is an E2 ubiquitin-conjugating enzyme involved in the ubiquitin-proteasome system which plays a crucial role in protein degradation and regulation of cell cycle. Overexpression of UBE2C can lead to mitotic defects, genomic instability and uncontrolled cell division, contributing to tumorigenesis. Overexpression of UBE2C in multiple cancers and its association with enhanced tumor progression, metastasis and drug resistance has led to its consideration as a potential therapeutic target. We report association of high UBE2C expression with poor overall survival across cancers, present p53-status-stratified expression analysis, determine its essentiality based on dependency scores in multiple cancer cell lines, association with immune cell infiltration, and analyze the effect of UBE2C silencing on cancer pathways, thus corroborating it as a viable pan-cancer target. We then identify potential UBE2C targeting repositioned therapeutics at both mRNA and protein levels by employing structure-based virtual screening, using CMap database, ceSAR based sig2lead application, and performing molecular dynamic simulations. Finally, we provide the effect of selected compounds on cell viability in NCI60 panel of cancer cell lines from different tissue origins. The compounds anisomycin, cephaeline, digitoxin, mitoxantrone, digoxin, digitoxigenin, homoharringtonine, NCI724448, midostaurin, withaferin A and NCI718581 were found to be effective UBE2C targeting candidates which could result in significant growth inhibition at low doses across multiple cell lines. Our results lay a strong groundwork for further preclinical exploration of the efficacy of these compounds against different cancers individually as also in combination with existing therapeutics for their future development as novel anticancer drugs.