Thalidomide: a review of approved and investigational uses

Venous ulcers of the lower limbs due to congenital thalidomide-related valve defect

A 44-year-old woman with fetal thalidomide syndrome and congenital pseudoainhum of the left big toe had a 5-year history of painful nonhealing ulcers in the left malleolar region. Venous Doppler ultrasonography showed hypoagenesis of the valve flaps of the deep and superficial venous circuit. To our knowledge, this is the first description of congenital pseudoainhum associated with fetal thalidomide syndrome. The coexistence of cutaneous ulcers in our case might be coincidental but may be related to a congenital valve defect (hypoagenesis) caused by thalidomide.

An analysis of clinical trials assessing the efficacy and safety of single-agent thalidomide in patients with relapsed or refractory multiple myeloma

Given that the efficacy/safety of thalidomide for relapsed or refractory multiple myeloma have not been well characterized in a randomized, controlled setting, an analysis of larger, single-agent trials was conducted. Nine trials met the following inclusion criteria: primary population of multiple myeloma; all patients relapsed or refractory; single-agent thalidomide; and sample size > or =50. At median doses of 200 - 800 mg per day, the pooled overall response rate (ORR) was 28.2% (95% CI: 22.6 - 33.7%), including a complete response (CR) rate of 1.6% (95% CI: 0.3 - 2.9%) and partial response rate of 26.0% (95% CI: 20.1 - 32.0%). Response was typically based on M-protein reduction alone. Peripheral neuropathy (PN) incidence varied from 12 - 44%, possibly impacted by the short median follow-up (9 - 29 months). Pooled venous thromboembolism (VTE) incidence was 2.7% (95% CI: 1.1 - 4.3%) and discontinuation due to intolerance (DDI) rate was 14.9% (95% CI: 12.0 - 17.7%). Overall survival (OS), progression-free survival (PFS) and PN incidence were not pooled due to lack of reporting and trial heterogeneity. Prognostic factors identified included B2M (PFS) and advanced age (PFS and OS). Overall, thalidomide demonstrated an ORR approaching 30%, with low CR rate of 1.6% and VTE and DDI incidences of 3% and 15%, respectively.

Dietary supplements in patients with cancer: risks and key concepts, part 1

PURPOSE

The risks and key concepts regarding the use of dietary supplements in patients with cancer are described.

SUMMARY

There are six common characteristics of dietary supplements that must be addressed when used by patients with cancer. Clinicians must establish if the supplement is an antioxidant, is an anticoagulant or procoagulant, has immunosuppressive or immunomodulating properties, has hormonal properties, has known safety issues, and has known or theoretical drug interactions. These six characteristics of the dietary supplements commonly used by patients with cancer are reviewed to aid in the analysis of the scientific data and communication of the results with the patient or family members. A framework upon which clinicians can adequately help patients make informed decisions regarding the use of complimentary and alternative medicine and dietary supplements is also described. When evaluating the appropriateness of a supplement for use by a patient with cancer, clinicians must conduct a safety review (evaluate the six characteristics). If the supplement is considered safe, an efficacy review must be conducted, after which the clinicians can recommend the supplement's use, accept the patient's decision to use the supplement if no or inconclusive evidence exists, or discourage use if there is conclusive evidence supporting inefficacy. Available resources for locating information regarding dietary supplements are also discussed.

CONCLUSION

Counseling patients with cancer about dietary supplements requires a systematic thought process that considers the available theories and data, as well as the patients' views about the agents.

Reversal effect of thalidomide on established hepatic cirrhosis in rats via inhibition of nuclear factor-kappaB/inhibitor of nuclear factor-kappaB pathway

BACKGROUND

Suppression of nuclear factor-kappaB (NF-kappaB)/inhibitor of nuclear factor-kappaB (IkappaB) signaling pathway is a potential property of thalidomide. This study was designed to investigate the effects of thalidomide on expressions of NF-kappaB, IkappaB and intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule (VCAM-1) in established rat liver cirrhosis.

METHODS

Rat liver cirrhosis was achieved by IP injection of carbon tetrachloride (CCl4) three times weekly for 8 weeks. CCl4 was then discontinued and thalidomide (100 mg/kg) or its vehicle was administered daily by gavage for 6 weeks. Hydroxyproline (HYP) content in liver was detected by biochemical assay. NF-kappaBp65, ICAM-1, VCAM-1 and alpha-smooth muscle actin (alpha-SMA) protein in the liver, IkappaBalpha protein in cytoplasm and NF-kappaBp65 protein in nucleus and ICAM-1, VCAM-1 mRNA levels in the liver were studied using immunohistochemistry, Western blot, and reverse transcriptase polymerase chain reaction, respectively.

RESULTS

Compared with the spontaneous recovery of cirrhosis, the histopathology of liver of rats given thalidomide was significantly improved. HYP content in liver, the expressions of ICAM-1, VCAM-1 mRNA and protein, NF-kappaBp65 and alpha-SMA protein were decreased significantly and IkappaBalpha protein in liver was elevated significantly in this group.

CONCLUSIONS

Thalidomide may exert its effect on downregulation of NF-kappaB-induced adhesion molecules and activation of hepatic stellate cell via inhibition of degradation of IkappaB to reverse established rat hepatic cirrhosis.

Thalidomide and lenalidomide in multiple myeloma

Multiple myeloma is a treatable but not necessarily a curable plasma-cell cancer. After decades of minimal progress, two new classes of drugs with novel mechanisms of action - immunomodulatory drugs (thalidomide and lenalidomide) and proteasome inhibitors (bortezomib) - have been introduced for the treatment of this disease. Thalidomide and lenalidomide have shown great activity as single agents and in combination with glucocorticoids for the treatment of chemotherapy-refractory myeloma. Thalidomide - and more recently lenalidomide - in combination with dexamethasone have shown promising results as induction therapy. These drugs can easily be combined with other chemotherapeutic agents to potentiate the anti-myeloma effect. The immunomodulatory function of these drugs can be successfully exploited to control residual disease during remission. Thus, both thalidomide and lenalidomide have ushered in a new era of optimism in the management of this incurable cancer.

A phase I study of paclitaxel/doxorubicin/ thalidomide in patients with androgen- independent prostate cancer

PURPOSE

The antiangiogenic and immunomodulatory effects of thalidomide induce responses in patients with androgen-independent prostate cancer (AIPC). Paclitaxel and doxorubicin also have significant antitumor activity. A phase I dose-escalation study was conducted to evaluate the use of these agents in combination to enhance the chemotherapeutic effects of treatment for refractory cancer.

PATIENTS AND METHODS

Twelve men with AIPC (mean age, 64.5 years) and a median prostate-specific antigen (PSA) level of 30 ng/mL were enrolled. Patients received starting doses of weekly paclitaxel (100 mg/m(2)) as a 1-hour intravenous infusion, weekly doxorubicin (20 mg/m(2)) as a 24-hour intravenous infusion, and daily oral thalidomide at escalating dose levels of 200 mg (dose level 0), 300 mg (dose level +1), and 400 mg (dose level +2). Paclitaxel and doxorubicin were administered for 3 consecutive weeks of a 5-week cycle. Exposure to thalidomide was daily. Patients were evaluated weekly for dose-limiting toxicities to determine the maximum tolerated dose. In addition, PSA levels were measured before each cycle of treatment. Response to treatment was defined as a > or =50% decrease in baseline PSA levels associated with stable radiographic disease, improvement of bone scan results with plain radiograph correlation, or improvement in soft tissue disease.

RESULTS

Four patients were treated on dose level 0, 5 were treated on dose level +1, and 3 were treated on dose level +2. The thalidomide 400-mg dose level resulted in 3 of 3 patients experiencing grade 3 leukopenia. The maximum tolerated dose was 300 mg of thalidomide in combination with paclitaxel/doxorubicin. Nine of the 12 patients were evaluable for PSA response, with 88% exhibiting partial responses or stable disease. One patient (11%) had a significant response, with PSA levels decreasing > 90% from baseline values. Overall, PSA-level decreases ranged from 0.5 ng/mL to 39.5 ng/mL among the 9 evaluable patients. A maximum of 7 cycles of therapy were administered. Twelve patients were evaluable for toxicity: neutropenia (grade 3, 27%; grade 4, 54%), leukopenia (grade 3, 63%), constipation (grade 3, 27%), fatigue (grade 3, 27%), nausea (grade 3, 9%), and deep vein thrombosis (grade 3, 9%) were reported.

CONCLUSION

The combined dosing of paclitaxel (100 mg/m(2) weekly), doxorubicin (20 mg/m(2) weekly), and thalidomide (300 mg daily) is tolerated by men with AIPC and merits continued phase II study.

Dermatologic toxicity of chemotherapeutic agents

Due to its high metabolic rate, skin represents one of the major target organs of chemotherapy-associated toxicity. Reactions range from common, nonspecific exanthematous eruptions to rare but distinctive cutaneous lesions that may not become apparent until a drug transitions from clinical trials to widespread oncologic use. The challenge of the physician is to recognize reaction patterns that reflect a drug reaction, identify a likely causative drug, and determine whether the reaction is a dose-limiting toxicity. This review will focus on the cutaneous side effects of the newer classes of chemotherapy drugs, including targeted monoclonal antibody therapy and small molecule inhibitors.

Treatment of chronic hepatitis C in non-responsive patients with pegylated interferon associated with ribavirin and thalidomide: report of six cases of total remission

Hepatitis C virus (HCV) infection is an important public health issue worldwide. It is estimated that over 170 million people are infected with the virus. The present study reports six cases in which patients did not respond to combination therapy with pegylated interferon and ribavirin. However, after the addition of thalidomide to the therapy, the patients presented negative RNA PCR. The use of thalidomide combined with pegylated interferon and ribavirin for the treatment of hepatitis C is described here for the first time in the related literature.

Thalidomide in multiple myeloma

Multiple myeloma is an incurable bone marrow cancer, the treatment of which is notoriously difficult. Only modest advances have been achieved using complex polychemotherapeutic regimens, transplant strategies and supportive therapy. In 1999, when new drugs for myeloma were urgently needed, thalidomide was introduced and opened up a completely new line of therapy for the disease. Although the mechanism of action is not yet completely understood, thalidomide has demonstrated efficacy in patients with refractory, relapsed myeloma, even in late-stage cases. This article reviews the current knowledge of thalidomide in myeloma treatment, focusing especially on the possible mechanisms of action, clinical results and adverse events of this drug.

Phase II trial of thalidomide for advanced and recurrent gynecologic sarcoma: A brief communication from the New York Phase II consortium

OBJECTIVE

To define the efficacy of thalidomide on the overall survival of patients with metastatic recurrent gynecologic sarcomas.

PATIENTS AND METHODS

All patients with sarcoma or carcinosarcoma of gynecologic origin and documented recurrence or persistence of disease after appropriate surgery, radiation therapy and/or chemotherapy were recruited to the study. All patients were ambulatory and had measurable disease that could be documented on CT scan. Patients were started on 200 mg/day of thalidomide orally every night and escalated by 100-200 mg every 7 to 14 days. The length of the treatment was separated into 2 cycles with the first 84 days defined as the first cycle and the next 56 days as the second cycle. Common Toxicity Criteria were used to record toxicities. Because thalidomide was postulated to induce cytostasis, the end-points were progression-free and overall survival in this mixed group of patients.

RESULTS

Seventeen patients were enrolled. The drug was not well tolerated because of constipation, fatigue, worsening performance status, drowsiness and sleepiness. The total dosage of medication given to each patient ranged from 3200 mg to 40,500 mg. The maximum dosage reached in each patient ranged from 300 mg to 750 mg, with the total time of treatment ranging from 13 to 99 days. All patients had progression of disease with a median progression-free survival time of 1.84 months (CI 1.54-2.79 months) and a median overall survival of 6.64 months.

DISCUSSION

Thalidomide has no activity in patients with advanced or recurrent gynecologic sarcomas and was not well-tolerated. The overall survival was <7 months. The progression-free survival was <3 months, and, since the therapy was not tolerated well, we unanimously decided to close the study at this point. Despite the poor result, we still believe in the strategy of anti-angiogenesis and will continue to pursue other potential treatment options using the same concept.

HIV-associated neuropathic pain: epidemiology, pathophysiology and management

Peripheral neuropathy is associated with numerous systemic illnesses including HIV infection. Neuropathic pain constitutes approximately 25-50% of all pain clinic visits. Distal symmetrical polyneuropathy (DSP) is the most common form of peripheral neuropathy in individuals with HIV infection. DSP is distinguished from other forms of neuropathy on the basis of history and neurological examination. The pain associated with DSP can be debilitating. Therefore, it is important to diagnose HIV-associated DSP properly and treat the neuropathic pain in order to improve quality of life. We review the clinical manifestations, epidemiology, pathophysiology and management strategies for HIV-associated DSP.

Immunomodulatory intervention in sepsis by multidrug-resistant Pseudomonas aeruginosa with thalidomide: an experimental study

Background

Thalidomide is an inhibitor of tumour necrosis factor-alpha (TNFα) that has been proven effective for the treatment of experimental sepsis by Escherichia coli. It was tested whether it might behave as an effective immunomodulator in experimental sepsis by multidrug-resistant (MDR) Pseudomonas aeruginosa.

Methods

Sepsis was induced by the intraperitoneal injection of 1 × 10⁸ cfu/kg inoculum of the test isolate in a total of 109 Wistar rats divided in three groups as follows: group A controls; group B administered seed oil 30 minutes before bacterial challenge; and group C administered 50 mg/kg of thalidomide diluted in seed oil 30 minutes before bacterial challenge. Blood was sampled for estimation of endotoxins (LPS), TNFα, interferon-gamma (IFNγ), nitric oxide (NO) and malondialdehyde (MDA). LPS was measured by the QCL-1000 LAL assay, TNFα and IFNγ by ELISA, NO by a colorimetric assay and MDA by the thiobarbiturate assay.

Results

Mean (± SE) survival of groups A, B and C were 18.60 ± 1.84, 12.60 ± 0.60 and 30.50 ± 6.62 hours (p of comparisons A to C equal to 0.043 and B to C equal to 0.002). Decreased TNFα and NO levels were found in sera of animals of group C compared to group A. Plasma levels of LPS, MDA and IFNγ did not differ between groups.

Conclusion

Intake of thalidomide considerably prolonged survival in experimental sepsis by MDR P.aeruginosa an effect probably attributed to decrease of serum TNFα.

Thalidomide : mécanismes d'action et indications en hématologie

Purpose. - Thalidomide, a major teratogen drug, was rehabilitated mainly in malignant hemopathy. Current knowledge and key points. - Thalidomide-mechanisms of action are well known, multiple, they combine immunomodulatory, antiangiogenic properties, and the modulation of cytokines, particularly tumour necrosis factor-alpha. Multiple trials are ongoing, however, the main indication remain multiple myeloma with a response rate of 30% in relapsed patients. Future prospects and projects. - New structural analogues of the thalidomide which priviligiate some of the thalidomide-specific mechanisms of action, the selected cytokine inhibitory drugs (SelCIDS) and the immunomodulatory drugs (IMiDs) family are under evaluation. The IMiDs, which mechanism is based on stimulation of T lymphopoiesis rather than inhibition of tumour necrosis factor-alpha, are under clinical trials in multiple myeloma with interesting results.

Psoriasis: emerging therapeutic strategies

Psoriasis is a chronic inflammatory skin disorder that is characterized by thickened, scaly plaques, and is estimated to affect approximately 1-3% of the Caucasian population. Traditional treatments, although effective in patients with limited disease, have numerous shortcomings, including inconvenience and toxicity. These drawbacks mean that many patients experience cycles of disease clearance, in which normal quality of life alternates with active disease and poor quality of life. However, as this review discusses, recent advances have highlighted the key role of the immune system in the pathogenesis of psoriasis, and have provided new defined targets for therapeutic intervention, offering hope for safe and effective psoriasis treatment.

UVB radiation-mediated expression of inducible nitric oxide synthase activity and the augmenting role of co-induced TNF-alpha in human skin endothelial cells

Nitric oxide (NO) plays a pivotal role in ultraviolet radiation-induced inflammation in human skin. We had earlier reported on the inducible nitric oxide synthase (iNOS) inducing activity of UVA radiation. We now demonstrate that UVB-exposure induces expression of the iNOS in vessel endothelia of normal human skin and in cultured human dermal endothelial cells (HUDEC), although by a molecular mechanism different from UVA-mediated induction. With HUDEC, UVB induces iNOS expression and leads to significant enzyme activities, although at app. 5-fold lower levels than can be achieved with proinflammatory cytokines. In contrast to our earlier observation with UVA, cytokine-challenge combined with simultaneous UVB-exposure had no additive effects on iNOS expression nor activity. Interestingly, a time-delay between UVB-irradiation and cytokine-challenge enhances endothelial iNOS enzyme activity 2.5-fold over cytokines activation only. This time-dependent effect strongly correlates with UVB-induced endothelial TNF-alpha expression. In HUDEC addition of TNF-alpha results in enhanced expression of the inducible arginine transporter system CAT-2 essential for substrate supply and thus iNOS activity. In summary, UVB induces iNOS mRNA and enzyme activity in HUDEC. Moreover, UVB augments CAT-2 expression through a TNF-alpha- dependent mechanism which essentially contributes to increased iNOS activity.

Evaluating antiangiogenesis agents in the clinic: the Eastern Cooperative Oncology Group Portfolio of Clinical Trials

Recent evidence indicates that treatment with a humanized monoclonal antibody (bevacizumab) directed at vascular endothelial growth factor improves response and survival in metastatic colorectal cancer when added to standard chemotherapy, validating angiogenesis as a therapeutic target. Investigators from the Eastern Cooperative Oncology Group (ECOG) have initiated a number of Phase III studies that will help further define the role of antiangiogenic agents for the treatment of breast, colon, lung, renal, and head and neck cancer, as well as melanoma and myeloma. The agents being evaluated target various biological functions involved in angiogenesis, including vascular endothelial growth factor (bevacizumab), endothelial cell proliferation (thalidomide, IFN-alpha), and matrix metalloproteinases (marimastat). These clinical trials include correlative laboratory studies aimed at elucidating how these agents may exert their clinical effects. The portfolio of Eastern Cooperative Oncology Group studies will serve to further define the role of this therapeutic strategy for patients with advanced cancer.

Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection

Infection with the human immunodeficiency virus (HIV) and the development of acquired immunodeficiency syndrome (AIDS) have had a significant impact on domestic and global health, social, political, and economic outcomes. Prevention and treatment efforts to control HIV infection are more demanding than in previous decades. Achieving food and nutrition security, and managing nutrition-related complications of HIV infection and the multiple aspects of disease initiated by or surrounding HIV infection, referred to as HIV disease, remain challenges for patients and for those involved with HIV/AIDS prevention, care, and treatment efforts. Confounding clinical issues include medication interactions, coinfection with other infections and diseases, wasting, lipodystrophy, and others. Dietetics professionals, other health care professionals, and people infected with HIV will need to understand and address multiple complex aspects of HIV infection and treatment to improve survival, body functions, and overall quality of life. Individualized nutrition care plans will be an essential feature of the medical management of persons with HIV infection and AIDS.

Treatment with immunosuppressive and anti-inflammatory agents delays onset of canine genetic narcolepsy and reduces symptom severity

All Doberman pinschers and Labrador retrievers homozygous for a mutation of the hypocretin (orexin) receptor-2 (hcrtr2) gene develop narcolepsy under normal conditions. Degenerative changes and increased display of major histocompatibility complex class II antigens have been linked to symptom onset in genetically narcoleptic Doberman pinschers. This suggests that the immune system may contribute to neurodegenerative changes and narcoleptic symptomatology in these dogs. We therefore attempted to alter the course of canine genetic narcolepsy, as an initial test of principle, by administering a combination of three immunosuppressive and anti-inflammatory drugs chosen to suppress the immune response globally. Experimental dogs were treated with a combination of methylprednisolone, methotrexate and azathioprine orally starting within 3 weeks after birth, and raised in an environment that minimized pathogen exposure. Symptoms in treated and untreated animals were quantified using the food elicited cataplexy test (FECT), modified FECT and actigraphy. With drug treatment, time to cataplexy onset more than doubled, time spent in cataplexy during tests was reduced by more than 90% and nighttime sleep periods were consolidated. Short-term drug administration to control dogs did not reduce cataplexy symptoms, demonstrating that the drug regimen did not directly affect symptoms. Treatment was stopped at 6 months, after which experimental animals remained less symptomatic than controls until at least 2 years of age. This treatment is the first shown to affect symptom development in animal or human genetic narcolepsy. Our findings show that hcrtr2 mutation is not sufficient for the full symptomatic development of canine genetic narcolepsy and suggest that the immune system may play a role in the development of this disorder.

Modulation of antiapoptotic cell signaling pathways in non-small cell lung cancer: the role of NF-κB

Apoptosis, or programmed cell death, is a natural phenomenon that is critical for normal embryonic development and the maintenance of homeostasis in multicellular organisms. In adults, apoptosis represents a protective strategy that limits the spread of infection and helps prevent the development of malignancies. Cells acquiring nonrepairable DNA mutations are capable of "committing suicide" to prevent propagation of acquired genetic mutations and to eliminate their own malignant potential. Although malignant cells maintain the necessary intracellular apoptotic machinery, inappropriate inhibition of apoptosis allows for continued tumor growth and metastases. The majority of nonsmall cell lung cancer (NSCLC) exhibits dysregulated antiapoptotic pathways involving the transcription factor NF-kappaB. In addition, in NSCLC both chemotherapy and radiation upregulate antiapoptotic and cell-cycle regulatory proteins through NF-kappaB-dependent signaling mechanisms. Preclinical and phase I clinical trials suggest that inhibition of NF-kappaB markedly attenuates the resistance of NSCLC to undergo apoptosis and sensitizes these cells to chemotherapy. Modulation of the antiapoptotic cascade mediated by NF-kappaB, combined with either traditional or novel chemotherapeutic agents, represents a promising treatment strategy for patients with NSCLC.

A novel hypothesis for thalidomide-induced limb teratogenesis: redox misregulation of the NF-kappaB pathway

Several hypotheses have been proposed to explain the mechanisms of thalidomide teratogenesis, although none adequately accounts for the observed malformations and explains the basis for species specificity. Recent observations that thalidomide increases the production of free radicals and elicits oxidative stress, coupled with new insights into the redox regulation of nuclear transcription factors, lead to the suggestion that thalidomide may act through redox misregulation of the limb outgrowth pathways. Oxidative stress, as marked by glutathione depletion/oxidation and a shift in intracellular redox potential toward the positive, occurs preferentially in limbs of thalidomide-sensitive rabbits, but not in resistant rats. DNA binding of nuclear factor kappa-B (NF-kappaB), a redox-sensitive transcription factor and key regulator of limb outgrowth, was shown to be significantly attenuated in rabbit limb cells and could be restored following the addition of a free radical spin-trapping agent, phenyl N-tert-butyl nitrone. The inability of NF-kappaB to bind to its DNA promoter results in the failure of limb cells to express fibroblast growth factor (FGF)-10 and twist in the limb progress zone (PZ) mesenchyme, which in turn attenuates expression of FGF-8 in the apical ectodermal ridge (AER). Failure to establish an FGF-10/FGF-8 feedback loop between the PZ and AER results in the truncation of limb outgrowth. We hypothesize that species-selective alterations in redox microenvironment caused by free radical production from thalidomide results in attenuation of the NF-kappaB-mediated gene expression that is responsible for limb outgrowth.