Thalidomide and thalidomide analogues for maintenance of remission in Crohn's disease

Exploring the Targets and Molecular Mechanisms of Thalidomide in the Treatment of Ulcerative Colitis: Network Pharmacology and Experimental Validation

BACKGROUND

Ulcerative colitis (UC) is a chronic, nonspecific, inflammatory disease of the intestine with an unknown cause. Thalidomide (THA) has been shown to be an effective drug for the treatment of UC. However, the molecular targets and mechanism of action of THA for the treatment of UC are not yet clear.

OBJECTIVES

Combining network pharmacology with in vitro experiments, this study aimed to investigate the potential targets and molecular mechanisms of THA for the treatment of UC.

METHODS

Firstly, relevant targets of THA against UC were obtained from public databases. Then, the top 10 hub targets and key molecular mechanisms of THA for UC were screened based on the network pharmacology approach and bioinformatics method. Finally, an in vitro cellular inflammation model was constructed using lipopolysaccharide (LPS) induced intestinal epithelial cells (NCM460) to validate the top 10 hub targets and key signaling pathways.

RESULTS

A total of 121 relevant targets of THA against UC were obtained, of which the top 10 hub targets were SRC, LCK, MAPK1, HSP90AA1, EGFR, HRAS, JAK2, RAC1, STAT1, and MAP2K1. The PI3K-Akt pathway was significantly associated with THA treatment of UC. In vitro experiments revealed that THA treatment reversed the expression of HSP90AA1, EGFR, STAT1, and JAK2 differential genes. THA was able to up- regulate the mRNA expression of pro-inflammatory factor IL-10 and decrease the mRNA levels of anti-inflammatory factors IL-6, IL-1β, and TNF-α. Furthermore, THA also exerted anti-inflammatory effects by inhibiting the activation of the PI3K/Akt pathway.

CONCLUSION

THA may play a therapeutic role in UC by inhibiting the PI3K-Akt pathway. HSP90AA1, EGFR, STAT1, and JAK2 may be the most relevant potential therapeutic targets for THA in the treatment of UC.

Design, synthesis, and biological evaluation of novel bioactive thalidomide analogs as anticancer immunomodulatory agents

Cancer is still a dangerous disease with a high mortality rate all over the world. In our attempt to develop potential anticancer candidates, new quinazoline and phthalazine based compounds were designed and synthesized. The new derivatives were built in line with the pharmacophoric features of thalidomide. The new derivatives as well as thalidomide were examined against three cancer cell lines, namely: hepatocellular carcinoma (HepG-2), breast cancer (MCF-7) and prostate cancer (PC3). Then the effects on the expression levels of caspase-8, VEGF, NF-κB P65, and TNF-α in HepG-2 cells were evaluated. The biological data revealed the high importance of phthalazine based compounds (24a-c), which were far better than thalidomide with regard to the antiproliferative activity. 24b showed IC₅₀ of 2.51, 5.80 and 4.11 μg mL^-1 compared to 11.26, 14.58, and 16.87 μg mL^-1 for thalidomide against the three cell lines respectively. 24b raised caspase-8 level by about 7 folds, compared to 8 folds reported for thalidomide. Also, VEGF level in HepG-2 cells treated with 24b was 185.3 pg mL^-1, compared to 432.5 pg mL^-1 in control cells. Furthermore, the immunomodulatory properties were proven to 24b, which reduced TNF-α level by approximately half. At the same time, NF-κB P65 level in HepG-2 cells treated with 24b was 76.5 pg mL^-1 compared to 278.1 and 110.5 pg mL^-1 measured for control cells and thalidomide treated HepG-2 cells respectively. Moreover, an in vitro viability study against Vero non-cancerous cell line was investigated and the results reflected a high safety profile of all tested compounds. This work suggests 24b as a promising lead compound for development of new immunomodulatory anticancer agents.

Targeted protein degradation and regulation with molecular glue: past and recent discoveries

The evolution in research and clinical settings of targeted therapies has been inspired by the progress of cancer chemotherapy to use small molecules and monoclonal antibodies for targeting specific disease-associated genes and proteins for noninfectious chronic diseases. In addition to conventional protein inhibition and activation strategies as drug discovery modalities, new methods of targeted protein degradation and regulation using molecular glues have become an attractive approach for drug discovery. Mechanistically, molecular glues trigger interactions between the proteins that originally did not interact by forming ternary complexes as protein-protein interaction (PPI) modulators. New molecular glues and their mechanisms of action have been actively investigated in the past decades. An immunomodulatory imide drug, thalidomide, and its derivatives have been used in the clinic and are a class of molecular glue that induces degradation of several neo-substrates. In this review, we summarize the development of molecular glues and share our opinions on the identification of novel molecular glues in an attempt to promote the concept and inspire further investigations.

Thalidomide and thalidomide analogues in treatment of patients with inflammatory bowel disease: Meta-analysis

AIM

To examine the efficacy and safety of thalidomide and thalidomide analogues in induction and maintenance of remission in patients with inflammatory bowel disease (IBD).

METHODS

A literature search was performed in the following databases: PubMed, EMBASE, Web of Science, Ovid and the Cochrane Library, and Chinese databases such as the China National Knowledge Infrastructure, China Science and Technology Journal Database (VIP), Wanfang Data. The randomized controlled analysis was performed to assess the effects of thalidomide therapy on inflammatory bowel disease for patients who did show good response with other therapies.

RESULTS

Three studies (n = 212) met the inclusion criteria were used in this Meta-analysis. No difference was found between thalidomide/thalidomide analogues and placebo in the induction of remission (RR = 1.36, 95%CI: 0.83-2.22, P = 0.22), the induction of clinical response (RR = 1.14, 95%CI: 0.75-1.72, P = 0.54) and the induction of adverse events (RR = 1.41, 95%CI: 0.99-2.02, P = 0.06).

CONCLUSION

Currently, there is not enough evidence to support use of thalidomide or its analogue for the treatment in patients of any age with IBD. However, it warrants a reanalysis when more data become available.

Treatment and outcomes: medical and surgical treatment for intestinal Behçet's disease

Behçet's disease (BD) is a chronic relapsing disease involving multiple organ systems. BD is characterized clinically by oral and genital aphthae, cutaneous lesions, and ophthalmological, neurological, and/or gastrointestinal manifestations. It is widely recognized that the presence of intestinal lesions may be a poor prognostic factor in intestinal BD, increasing the risk of surgery and decreasing the quality of life. Despite this, the management of intestinal BD has not been standardized. Empirical therapies including 5-aminosalicylic acid and corticosteroids have been used anecdotally to treat intestinal BD, but recent studies have provided evidence for the efficacy of anti-tumor necrosis factor α monoclonal antibodies. The development of agents targeting tumor necrosis factor α continues, it seems likely that they will change the therapeutic strategy and clinical outcomes of intestinal BD and inflammatory bowel disease. Monitoring disease activity such as endoscopic evaluation will become more important to obtain better outcomes. Here, we review current and future perspectives in the treatment and outcomes of intestinal BD.

Thalidomide for inflammatory bowel disease: Systematic review

BACKGROUND

Thalidomide is an immunomodulatory drug used in the experimental treatment of refractory Crohn disease and ulcerative colitis. We aimed to review the existing evidence on the efficacy and safety of thalidomide in the treatment of inflammatory bowel diseases.

METHODS

CENTRAL, MEDLINE, LILACS, POPLINE, CINHAL, and Web of Science were searched in March 2016. Manual search included conference and reference lists. All types of studies, except single case reports, were included. Outcomes evaluated were: induction of remission; maintenance of remission; steroid reduction; effect on penetrating Crohn disease; endoscopic remission; adverse events.

RESULTS

The research strategies retrieved 722 papers. Two randomized controlled trials and 29 uncontrolled studies for a total of 489 patients matched the inclusion criteria. Thalidomide induced a clinical response in 296/427 (69.3%) patients. Clinical remission was achieved in 220/427 (51.5%) cases. Maintenance of remission was reported in 128/160 (80.0%) patients at 6 months and in 96/133 (72.2%) at 12 months. Reduction in steroid dosage was reported in 109/152 (71.7%) patients. Fistulas improved in 49/81 (60.5%) cases and closed in 28/81 (34.6%). Endoscopic improvement was observed in 46/66 (69.7%) and complete mucosal healing in 35/66 (53.0%) patients. Cumulative incidence of total adverse events and of those leading to drug suspension was 75.6 and 19.7/1000 patient-months, respectively. Neurological disturbances accounted for 341/530 (64.3%) adverse events and were the most frequent cause of drug withdrawal.

CONCLUSION

Existing evidence suggests that thalidomide may be a valid treatment option for patients with inflammatory bowel diseases refractory to other first- and second-line treatments.

Immunomodulatory drugs in AL amyloidosis

Immunoglobulin light chain amyloidosis (AL amyloidosis) is indeed a rare plasma cell disorder, yet the most common of the systemic amyloidoses. The choice of adequate treatment modality is complicated and depends dominantly on the risk stratification of these fragile patients. Immunomodulatory drugs (IMiDs) are currently used in newly diagnosed patients as well as in salvage therapy in relapsed/refractory patients. IMiDs have a pleiotropic effect on malignant cells and the exact mechanism of their action has been described recently. Thalidomide is the most ancient representative, effective but toxic. Lenalidomide seems to be more effective, nevertheless the toxicity remains high, especially in patients with renal insufficiency. Pomalidomide is the newest IMiD used in this indication with a good balance between efficacy and tolerable toxicity and represents the most promising compound. This review is focused on the evaluation of all three representatives of IMiDs and their roles in the treatment of this malignant disorder.

Long-term therapeutic effectiveness of maintenance enteral nutrition for Crohn's disease

BACKGROUND

Long-term effectiveness of enteral nutrition for maintaining remission in pediatric Crohn's disease (CD) is poorly documented. The aim of this study was therefore to examine the long-term effectiveness of enteral nutrition with aminosalicylates as maintenance therapy for those in whom remission was primarily induced by total parenteral nutrition or exclusive enteral nutrition with aminosalicylates.

METHODS

We retrospectively analyzed data for 58 pediatric patients with newly diagnosed CD during a median follow-up period of 50 months (range, 12-216 months). Data for remission-induced patients in whom enteral nutrition with aminosalicylates was used as maintenance therapy were analyzed with particular reference to time to first relapse and time to first intestinal surgery.

RESULTS

Twenty-five (43.1%) of the patients relapsed with a median duration of remission of 32.4 months (range, 6-73.2 months). The cumulative rates of continuous remission were 0.88 (95%CI: 0.79-0.96) at 1 year, 0.73 (95%CI: 0.61-0.85) at 2 years, and 0.52 (95%CI: 0.35-0.68) at 5 years. None of the patients received corticosteroids, immunomodulators or anti-tumor necrosis factor agents until relapse. Disease location had no impact on timing of relapse, but with regard to disease behavior there was a trend towards earlier relapse in patients with penetrating type. Only six of the 58 patients (10.3%) needed intestinal surgery. There was a trend towards need for surgery in patients with ileal disease and with stricturing type.

CONCLUSIONS

Enteral nutrition therapy with aminosalicylates is effective for maintaining remission and decreasing the rate of intestinal surgery in pediatric CD.

Effect of vascular endothelial cells on the pathogenesis of inflammatory bowel disease

Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), are a group of chronic recurrent intestinal autoimmune diseases characterized by intestinal chronic intestinal inflammation. The important characteristics of persistent intestinal inflammation in IBD are the aggregation of inflammatory cells and the release of inflammatory factors in the intestinal mucosa. Functional alternations of immune cells and intestinal microvascular endothelial cells play an important role in the mucosal immunity and intestinal function. Moreover, alternation of the structure and function of microvascular endothelial cells can regulate the migration of immune cells, blood supply and homeostasis of intestinal tissue. Endothelial cells in newly formed vessels can induce tissue injury by regulating the recruitment of blood cells and inflammatory mediators to maintain the inflammatory reaction.

Oral 5-aminosalicylic acid for maintenance of surgically-induced remission in Crohn's disease

BACKGROUND

The use of 5-aminosalicylates (5-ASAs) in Crohn's disease (CD) is controversial.  A recent Cochrane review found that 5-ASAs are not effective for the maintenance of medically-induced remission in CD, but their role in the maintenance of surgically-induced remission is unclear.

OBJECTIVES

The objectives were to evaluate the efficacy and safety of 5-ASA agents for the maintenance of surgically-induced remission in CD.

SEARCH STRATEGY

The search was standardised and not limited by language and included electronic searching (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Inflammatory Bowel Disease Group Specialized Trials Register), reference searching of all included studies, abstracts from major meetings, personal contacts and drug companies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) which compared 5-ASAs with either placebo or another intervention, with treatment durations of at least 6 months were considered for inclusion. Participants were patients of any age with CD in remission following surgery. Primary outcome measures were clinical relapse or endoscopic recurrence as defined by the primary studies. Secondary endpoints were the occurrence of adverse events.

DATA COLLECTION AND ANALYSIS

Relevant papers were identified and the authors independently assessed the eligibility of trials. Methodological quality was assessed using the Cochrane risk of bias tool.The Cochrane RevMan software was used for analyses. Patients with final missing outcomes were assumed to have relapsed. Odds ratio (OR) and 95% confidence intervals (95% CI) were calculated based on the fixed effects model. The chi square and I(2) statistics were used to assess statistical heterogeneity.

MAIN RESULTS

Nine RCTs were included in the review. Seven studies compared oral 5-ASA with placebo and two compared oral 5-ASA with purine antimetabolites (azathioprine or 6-mercaptopurine). 5-ASA was significantly more effective than placebo for preventing relapse (OR 0.68, 95% CI, 0.52 to 0.90). There was no statistically significant heterogeneity among the 8 trials comparing 5-ASA with placebo (P=0.47). No statistically significant difference in adverse events was found for 5-ASA versus placebo (OR 1.02, 95%CI, 0.60 to 1.76). No statistically significant difference was found between 5-ASA and purine antimetabolites for preventing relapses (OR 1.08 95% CI, 0.63 to 1.85).

AUTHORS' CONCLUSIONS

The pooled analyses suggest that 5-ASA preparations may be superior to placebo for the maintenance of surgically-induced remission in patients with CD. The results of the pooled analyses should be interpreted with caution because adequately powered studies demonstrated no difference and publication bias (failure to publish negative studies) may be an issue. The potential benefit provided by 5-ASA drugs is modest with a number needed to treat of approximately 16 to 19 patients to avoid one relapse which raises issues about the cost-effectiveness of this therapy. However, 5-ASA drugs are safe and well tolerated. The incidence of adverse events was not different in patients receiving 5-ASA compared with those receiving placebo. There is insufficient evidence to allow any conclusions on how 5-ASA preparations compare with azathioprine or 6-mercaptopurine.

Mechanism of action of immunomodulatory drugs (IMiDS) in multiple myeloma

Immunomodulatory drugs (IMiDs) are thalidomide analogues, which possess pleiotropic anti-myeloma properties including immune-modulation, anti-angiogenic, anti-inflammatory and anti-proliferative effects. Their development was facilitated by an improved understanding in myeloma (MM) biology and initiated a profound shift in the therapeutic approach towards MM. Despite the diverse effects of IMiDs in vitro, the relative contribution of each effect towards their ultimate anti-MM activity is still unclear. Based on in vitro data, it appears that anti-proliferative effects and downregulation of crucial cytokines are their most important anti-MM attributes. Although the co-stimulatory effects on T and NK cells have been heralded as a unique and important property of IMiDs towards enhancing anti-MM immune activity, these in vitro effects have yet to be firmly corroborated in vivo. Much is yet to be elucidated regarding the complex interplay of immunomodulatory cytokines that occurs in vivo, which ultimately dictates the net effects of IMiDs in MM-the understanding of which is necessary to facilitate optimal manipulation of these drugs in future MM management.