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Sabri A, Omran MM, Azim SA, Abdelfattah R, Allam RM, Shouman SA. A Study to Explore the Role of IDH1 (R132) Mutation on Imatinib Toxicity and Effect of ABCG2/OCT1 Expression on N-Desmethyl Imatinib Plasma Level in Egyptian Chronic Myeloid Leukemia Patients. Drug Res (Stuttg) 2023; 73:146-155. [PMID: 36630991 DOI: 10.1055/a-1924-7746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Imatinib mesylate (IM) is the gold standard for treatment of Chronic Myeloid Leukemia (CML). This study aimed to gain more knowledge of the altered PK, pharmacogenetic factors, and gene expression leading to variable IM levels. Fifty patients with chronic phase-CML were enrolled in this study and divided as 25 responders and 25 non-responders (patients are directly recruited after response assessment). HPLC/MS/MS was used to determine trough and peak concentration of imatinib and N-desmethyl imatinib in the blood. PCR-RFLP technique was used to detect IDH1 gene mutation (R132). The median value of IM trough level was significantly higher, the P/T ratio was significantly lower and the α-1-acid glycoprotein (AGP) was significantly higher among responders compared to non-responders (P=0.007, 0.009 and 0.048, respectively). Higher N-desmethyl imatinib peak plasma concentration was observed with low mRNA expression of ABCG2 and OCT1 (P=0.01 and 0.037, respectively). IDH1 R132 gene mutation was associated with a significant increase in toxicities (P=0.028). In conclusion, IM trough level, P/T ratio and AGP was significantly higher in responders. In addition, ABCG2 and OCT1 gene expression may affect the interindividual PK variation. Although a prospective study with a larger patient population is necessary to validate these findings. IDH1 mutation is a predictor of increased toxicity with IM treatment.
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Affiliation(s)
- Alaa Sabri
- Egyptian Pharmaceutical Vigilance Center, Egyptian Drug Authority
| | - Mervat M Omran
- Pharmacology Unit, Cancer Biology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - S Abdel Azim
- Biochemistry Department, Faculty of Pharmacy, Cairo University
| | - Raafat Abdelfattah
- Medical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Rasha Mahmoud Allam
- Cancer Epidemiology and Biostatistics Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Samia A Shouman
- Pharmacology Unit, Cancer Biology Department, National Cancer Institute, Cairo University, Cairo, Egypt
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Adattini JA, Gross AS, Wong Doo N, McLachlan AJ. Real-world efficacy and safety outcomes of imatinib treatment in patients with chronic myeloid leukemia: An Australian experience. Pharmacol Res Perspect 2022; 10:e01005. [PMID: 36106342 PMCID: PMC9475133 DOI: 10.1002/prp2.1005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 08/12/2022] [Indexed: 11/28/2022] Open
Abstract
Tyrosine kinase inhibitors (TKI) have revolutionized the treatment of chronic myeloid leukemia (CML), but patients still experience treatment-limiting toxicities or therapeutic failure. To investigate the real-world use and outcomes of imatinib in patients with CML in Australia, a retrospective cohort study of patients with CML commencing imatinib (2001-2018) was conducted across two sites. Prescribing patterns, tolerability outcomes, and survival and molecular response were evaluated. 86 patients received 89 imatinib treatments. Dose modifications were frequently observed (12-month rate of 58%). At last follow-up, 62 patients (5-year rate of 55%) had permanently discontinued imatinib treatment, of which 44 switched to another TKI (5-year rate of 46%). Within 3 months of starting imatinib, 43% (95% CI, 32%-53%) of patients experienced imatinib-related grade ≥3 adverse drug reactions (ADRs). Higher comorbidity score, lower body weight, higher imatinib starting dose, and Middle Eastern or North African ancestry were associated with a higher risk of grade ≥3 ADR occurrence on multivariable analysis (MVA). Estimated overall survival and event-free survival rates at 3 years were 97% (95% CI, 92%-100%) and 81% (95% CI, 72%-92%), respectively. Cumulative incidence of major molecular response (MMR) at 3 years was 63% (95% CI, 50%-73%). On MVA, imatinib starting dose, ELTS score, BCR-ABL1 transcript type, pre-existing pulmonary disease, and potential drug-drug interactions were predictive of MMR. In conclusion, imatinib induced deep molecular responses that translated to good survival outcomes in a real-world setting, but was associated with a higher incidence of ADRs, dose modifications and treatment discontinuations than in clinical trials.
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Affiliation(s)
| | - Annette S. Gross
- Sydney Pharmacy SchoolThe University of SydneySydneyNew South WalesAustralia
- Clinical Pharmacology Modelling & SimulationGlaxoSmithKline R &DSydneyNew South WalesAustralia
| | - Nicole Wong Doo
- Concord Cancer CentreConcord Repatriation General HospitalSydneyNew South WalesAustralia
| | - Andrew J. McLachlan
- Sydney Pharmacy SchoolThe University of SydneySydneyNew South WalesAustralia
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Bozkurt Bulakcı B, Daglar Aday A, Gurtekin B, Yavuz AS, Ozturk S, Cefle K, Palanduz A, Palanduz S. OCT-1 Expression in Patients with Chronic Myeloid Leukemia: A Comparative Analysis with Respect to Response to Imatinib Treatment. Indian J Hematol Blood Transfus 2022; 38:668-674. [PMID: 36258734 PMCID: PMC9569262 DOI: 10.1007/s12288-022-01532-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 03/09/2022] [Indexed: 10/18/2022] Open
Abstract
The introduction of tyrosine kinase inhibitors (TKI) has resulted in a significant improvement in the treatment of CML patients. However, some CML patients are resistant to imatinib therapy, the initial TKI therapy in the CML. Therefore, it is important to find prognostic markers for resistance. The OCT-1 gene involved in imatinib uptake is also suspected to cause imatinib resistance. The aim of this study was to investigate the role of OCT-1 in imatinib resistance by comparing OCT-1 expression levels in imatinib resistant and imatinib sensitive patients with chronic myeloid leukemia (CML). This study was conducted on 101 patients with CML [imatinib sensitive (n = 51) and imatinib resistant (n = 50)] who were treated with imatinib. Gene expression analysis was done using QRT-PCR. The relative expression levels of OCT-1 were calculated using 2(-ΔΔCT) method. OCT1 mRNA expression levels were 0.149 (0.011-2.532) and 0.119 (0.008-2.868) in imatinib-sensitive group and imatinib-resistant group, respectively. OCT-1 expression levels were not significantly different in the imatinib-sensitive group when compared to imatinib resistant group (p > 0.05). OCT-1 expression was also similar in BCR-ABL1 kinase domain mutation positive and negative cases (p > 0.05). The imatinib-resistant group had a higher rate of hydroxyurea or interferon-alpha treatment prior to imatinib therapy and a lower rate for first-line imatinib as the only treatment than the imatinib-sensitive group (p = 0.002 and p = 0.002, respectively). According to the results of our study, OCT-1 does not have a biomarker feature in the evaluation of imatinib response. In addition, the study should be performed in larger patient groups.
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Affiliation(s)
- Betul Bozkurt Bulakcı
- Department of Family Medicine, Cemil Tascıoglu City Hospital, University of Health Sciences, Istanbul, Turkey
| | - Aynur Daglar Aday
- Division of Medical Genetics, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Basak Gurtekin
- Department of Biostatistics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Akif Selim Yavuz
- Division of Hematology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sukru Ozturk
- Division of Medical Genetics, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Kivanc Cefle
- Division of Medical Genetics, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ayse Palanduz
- Department of Family Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sukru Palanduz
- Division of Medical Genetics, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Stukan I, Gryzik M, Hoser G, Want A, Grabowska-Pyrzewicz W, Zdioruk M, Napiórkowska M, Cieślak M, Królewska-Golińska K, Nawrot B, Basak G, Wojda U. Novel Dicarboximide BK124.1 Breaks Multidrug Resistance and Shows Anticancer Efficacy in Chronic Myeloid Leukemia Preclinical Models and Patients' CD34 +/CD38 - Leukemia Stem Cells. Cancers (Basel) 2022; 14:cancers14153641. [PMID: 35892900 PMCID: PMC9332833 DOI: 10.3390/cancers14153641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/20/2022] [Accepted: 07/23/2022] [Indexed: 02/05/2023] Open
Abstract
Simple Summary Chemotherapy is a first line treatment in many cancer types, but the constant exposition to chemotherapeutics often leads to therapy resistance. An example is chronic myeloid leukemia that, due to the use of tyrosine kinase inhibitors such as imatinib, remains manageable, however incurable. Overall, 20–25% of imatinib responders develop secondary resistance, and among them, 20–40% is due to mechanisms such as expression of P-glycoprotein (MDR1) or leukemia stem cells’ mechanisms of survival and cancer regrowth. This study provides the first evidence from animal and cellular models that this resistance can be overcome with the novel dicarboximide BK124.1. The compound causes no visible toxicity in mice, and has proper pharmacokinetics for therapeutic applications. It was efficient against both multidrug resistant CML blasts and CD34+/CD38− leukemia stem cells coming from CML patients. Future development of BK124.1 could offer curative treatment of CML and of other cancers resistant or intolerant to current chemotherapy. Abstract The search is ongoing for new anticancer therapeutics that would overcome resistance to chemotherapy. This includes chronic myeloid leukemia, particularly suitable for the studies of novel anticancer compounds due to its homogenous and well-known genetic background. Here we show anticancer efficacy of novel dicarboximide denoted BK124.1 (C31H37ClN2O4) in a mouse CML xenograft model and in vitro in two types of chemoresistant CML cells: MDR1 blasts and in CD34+ patients’ stem cells (N = 8) using immunoblotting and flow cytometry. Intraperitoneal administration of BK124.1 showed anti-CML efficacy in the xenograft mouse model (N = 6) comparable to the commonly used imatinib and hydroxyurea. In K562 blasts, BK124.1 decreased the protein levels of BCR-ABL1 kinase and its downstream effectors, resulting in G2/M cell cycle arrest and apoptosis associated with FOXO3a/p21waf1/cip1 upregulation in the nucleus. Additionally, BK124.1 evoked massive apoptosis in multidrug resistant K562-MDR1 cells (IC50 = 2.16 μM), in CD34+ cells from CML patients (IC50 = 1.5 µM), and in the CD34+/CD38− subpopulation consisting of rare, drug-resistant cancer initiating stem cells. Given the advantages of BK124.1 as a potential chemotherapeutic and its unique ability to overcome BCR-ABL1 dependent and independent multidrug resistance mechanisms, future development of BK124.1 could offer a cure for CML and other cancers resistant to present drugs.
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Affiliation(s)
- Iga Stukan
- Laboratory of Preclinical Testing of Higher Standard, Nencki Institute of Experimental Biology of Polish Academy of Sciences, 3 Pasteur Street, 02-093 Warsaw, Poland; (I.S.); (M.G.); (G.H.); (A.W.); (W.G.-P.); (M.Z.)
| | - Marek Gryzik
- Laboratory of Preclinical Testing of Higher Standard, Nencki Institute of Experimental Biology of Polish Academy of Sciences, 3 Pasteur Street, 02-093 Warsaw, Poland; (I.S.); (M.G.); (G.H.); (A.W.); (W.G.-P.); (M.Z.)
| | - Grażyna Hoser
- Laboratory of Preclinical Testing of Higher Standard, Nencki Institute of Experimental Biology of Polish Academy of Sciences, 3 Pasteur Street, 02-093 Warsaw, Poland; (I.S.); (M.G.); (G.H.); (A.W.); (W.G.-P.); (M.Z.)
- Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland
| | - Andrew Want
- Laboratory of Preclinical Testing of Higher Standard, Nencki Institute of Experimental Biology of Polish Academy of Sciences, 3 Pasteur Street, 02-093 Warsaw, Poland; (I.S.); (M.G.); (G.H.); (A.W.); (W.G.-P.); (M.Z.)
| | - Wioleta Grabowska-Pyrzewicz
- Laboratory of Preclinical Testing of Higher Standard, Nencki Institute of Experimental Biology of Polish Academy of Sciences, 3 Pasteur Street, 02-093 Warsaw, Poland; (I.S.); (M.G.); (G.H.); (A.W.); (W.G.-P.); (M.Z.)
| | - Mikolaj Zdioruk
- Laboratory of Preclinical Testing of Higher Standard, Nencki Institute of Experimental Biology of Polish Academy of Sciences, 3 Pasteur Street, 02-093 Warsaw, Poland; (I.S.); (M.G.); (G.H.); (A.W.); (W.G.-P.); (M.Z.)
| | - Mariola Napiórkowska
- Department of Biochemistry, Medical University of Warsaw, 02-097 Warsaw, Poland;
| | - Marcin Cieślak
- Centre of Molecular and Macromolecular Studies, Polish Academy of Sciences, 90-363 Lodz, Poland; (M.C.); (K.K.-G.); (B.N.)
| | - Karolina Królewska-Golińska
- Centre of Molecular and Macromolecular Studies, Polish Academy of Sciences, 90-363 Lodz, Poland; (M.C.); (K.K.-G.); (B.N.)
| | - Barbara Nawrot
- Centre of Molecular and Macromolecular Studies, Polish Academy of Sciences, 90-363 Lodz, Poland; (M.C.); (K.K.-G.); (B.N.)
| | - Grzegorz Basak
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-097 Warsaw, Poland;
| | - Urszula Wojda
- Laboratory of Preclinical Testing of Higher Standard, Nencki Institute of Experimental Biology of Polish Academy of Sciences, 3 Pasteur Street, 02-093 Warsaw, Poland; (I.S.); (M.G.); (G.H.); (A.W.); (W.G.-P.); (M.Z.)
- Correspondence: ; Tel.: +48-22-5892-578
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Stuckey R, López Rodríguez JF, Gómez-Casares MT. Discontinuation of Tyrosine Kinase Inhibitors in Patients with Chronic Myeloid Leukemia: a Review of the Biological Factors Associated with Treatment-Free Remission. Curr Oncol Rep 2022; 24:415-426. [PMID: 35141859 PMCID: PMC8930955 DOI: 10.1007/s11912-022-01228-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2021] [Indexed: 11/30/2022]
Abstract
Purpose of Review Clinical factors alone do not enable us to differentiate which patients will maintain treatment-free remission (TFR) from those who are likely to relapse. Thus, patient-specific factors must also play a role. This review will update the reader on the most recent studies presenting biological factors that can help predict tyrosine kinase inhibitor (TKI) discontinuation success. Recent Findings Cellular and molecular factors with a suggested role in TFR include immune factors and leukemic stem cell (LSC) persistence; the BCR::ABL1 transcript type, halving time, and BCR::ABL1 DNA and RNA positivity; as well as other molecular factors such as somatic mutations, RNA expression, and telomere length. Summary Our review presents several biomarkers with predictive value for TFR but also highlights areas of unmet need. Future discontinuation guidelines will likely include biological factors for the personalization of TFR prediction. However, it will be important that such advances do not prevent more patients from making a TKI discontinuation attempt.
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Affiliation(s)
- Ruth Stuckey
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Barranco de la Ballena s/n, Las Palmas, Spain.
| | | | - María Teresa Gómez-Casares
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Barranco de la Ballena s/n, Las Palmas, Spain
- Medical Science Department, Universidad de Las Palmas de Gran Canaria, Las Palmas, Spain
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Breccia M, Scalzulli E, Pepe S, Colafigli G, Bisegna ML, Capriata M, Martelli M. Emerging concepts for assessing and predicting treatment-free remission in chronic myeloid leukemia patients. Expert Rev Hematol 2021; 15:25-32. [PMID: 34894984 DOI: 10.1080/17474086.2022.2018296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION In chronic myeloid leukemia (CML) patients who have reached a deep and sustained reduction of residual disease can attempt a discontinuation. The 'treatment-free remission' (TFR) has become a real long-term endpoint for 30-40% of chronic phase patients. AREAS COVERED In this review, we focus our attention on possible prognostic features who can predict the success of tyrosine kinase inhibitors discontinuation and how we can assess the minimal residual disease (MRD) during the TFR phase. Broad research was made on Medline, Embase and archives from EHA and ASH congresses. EXPERT OPINION Median duration of TKI therapy and of deep molecular response are the main prognostic factors identified in most trials and real-life experiences on discontinuation. Immunological pathways have been proposed as possible control on successful TFR as also early molecular response dynamics. Appropriate molecular monitoring by RQ-PCR in the TFR phase has been proposed by several international recommendations and digital droplet PCR (ddPCR) seems to have a possible role in the future for a better identification of candidate to this possible therapeutic strategy.
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Affiliation(s)
- Massimo Breccia
- Department of Translational and precision medicine-Az., Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Emilia Scalzulli
- Department of Translational and precision medicine-Az., Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Sara Pepe
- Department of Translational and precision medicine-Az., Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Gioia Colafigli
- Department of Translational and precision medicine-Az., Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Maria Laura Bisegna
- Department of Translational and precision medicine-Az., Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Marcello Capriata
- Department of Translational and precision medicine-Az., Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Maurizio Martelli
- Department of Translational and precision medicine-Az., Policlinico Umberto I-Sapienza University, Rome, Italy
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Chen Y, Zou J, Cheng F, Li W. Treatment-Free Remission in Chronic Myeloid Leukemia and New Approaches by Targeting Leukemia Stem Cells. Front Oncol 2021; 11:769730. [PMID: 34778088 PMCID: PMC8581243 DOI: 10.3389/fonc.2021.769730] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/11/2021] [Indexed: 12/11/2022] Open
Abstract
The therapeutic landscape for chronic myeloid leukemia (CML) has improved significantly with the approval of tyrosine kinase inhibitors (TKIs) for therapeutic use. Most patients with optimal responses to TKIs can have a normal life expectancy. Treatment-free remission (TFR) after discontinuing TKI has increasingly become a new goal for CML treatment. However, TKI only "control" CML, and relapse after discontinuation has become a key factor hindering patient access to attempt TFR. In this study, we reviewed studies on TKI discontinuation, including both first and second-generation TKI. We also reviewed predictors of relapse, new monitoring methods, and strategies targeting leukemic stem cells.
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Affiliation(s)
| | | | | | - Weiming Li
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Resistance to Tyrosine Kinase Inhibitors in Chronic Myeloid Leukemia-From Molecular Mechanisms to Clinical Relevance. Cancers (Basel) 2021; 13:cancers13194820. [PMID: 34638304 PMCID: PMC8508378 DOI: 10.3390/cancers13194820] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 01/18/2023] Open
Abstract
Simple Summary Chronic myeloid leukemia (CML) is a myeloproliferative neoplasia associated with a molecular alteration, the fusion gene BCR-ABL1, that encodes the tyrosine kinase oncoprotein BCR-ABL1. This led to the development of tyrosine kinase inhibitors (TKI), with Imatinib being the first TKI approved. Although the vast majority of CML patients respond to Imatinib, resistance to this targeted therapy contributes to therapeutic failure and relapse. Here we review the molecular mechanisms and other factors (e.g., patient adherence) involved in TKI resistance, the methodologies to access these mechanisms, and the possible therapeutic approaches to circumvent TKI resistance in CML. Abstract Resistance to targeted therapies is a complex and multifactorial process that culminates in the selection of a cancer clone with the ability to evade treatment. Chronic myeloid leukemia (CML) was the first malignancy recognized to be associated with a genetic alteration, the t(9;22)(q34;q11). This translocation originates the BCR-ABL1 fusion gene, encoding the cytoplasmic chimeric BCR-ABL1 protein that displays an abnormally high tyrosine kinase activity. Although the vast majority of patients with CML respond to Imatinib, a tyrosine kinase inhibitor (TKI), resistance might occur either de novo or during treatment. In CML, the TKI resistance mechanisms are usually subdivided into BCR-ABL1-dependent and independent mechanisms. Furthermore, patients’ compliance/adherence to therapy is critical to CML management. Techniques with enhanced sensitivity like NGS and dPCR, the use of artificial intelligence (AI) techniques, and the development of mathematical modeling and computational prediction methods could reveal the underlying mechanisms of drug resistance and facilitate the design of more effective treatment strategies for improving drug efficacy in CML patients. Here we review the molecular mechanisms and other factors involved in resistance to TKIs in CML and the new methodologies to access these mechanisms, and the therapeutic approaches to circumvent TKI resistance.
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Early BCR-ABL1 kinetics are predictive of subsequent achievement of treatment-free remission in chronic myeloid leukemia. Blood 2021; 137:1196-1207. [PMID: 32871588 DOI: 10.1182/blood.2020005514] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 08/09/2020] [Indexed: 02/08/2023] Open
Abstract
With treatment-free remission (TFR) rapidly becoming the ultimate goal of therapy in chronic myeloid leukemia (CML), there is a need to develop strategies to maximize sustained TFR by improving our understanding of its key determinants. Chronic-phase CML patients attempting TFR were evaluated to identify the impact of multiple variables on the probability of sustained TFR. Early molecular response dynamics were included as a predictive variable, assessed by calculating the patient-specific halving time of BCR-ABL1 after commencing tyrosine kinase inhibitor (TKI) therapy. Overall, 115 patients attempted TFR and had ≥12 months of follow-up. The probability of sustained TFR, defined as remaining in major molecular response off TKI therapy for 12 months, was 55%. The time taken for the BCR-ABL1 value to halve was the strongest independent predictor of sustained TFR: 80% in patients with a halving time of <9.35 days (first quartile) compared with only 4% if the halving time was >21.85 days (last quartile) (P < .001). The e14a2 BCR-ABL1 transcript type and duration of TKI exposure before attempting TFR were also independent predictors of sustained TFR. However, the BCR-ABL1 value measured at 3 months of TKI was not an independent predictor of sustained TFR. A more rapid initial BCR-ABL1 decline after commencing TKI also correlated with an increased likelihood of achieving TFR eligibility. The association between sustained TFR and the time taken for BCR-ABL1 to halve after commencing TKI was validated using an independent dataset. These data support the critical importance of the initial kinetics of BCR-ABL1 decline for long-term outcomes.
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Kaehler M, Cascorbi I. Pharmacogenomics of Impaired Tyrosine Kinase Inhibitor Response: Lessons Learned From Chronic Myelogenous Leukemia. Front Pharmacol 2021; 12:696960. [PMID: 34262462 PMCID: PMC8273252 DOI: 10.3389/fphar.2021.696960] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 06/17/2021] [Indexed: 12/25/2022] Open
Abstract
The use of small molecules became one key cornerstone of targeted anti-cancer therapy. Among them, tyrosine kinase inhibitors (TKIs) are especially important, as they were the first molecules to proof the concept of targeted anti-cancer treatment. Since 2001, TKIs can be successfully used to treat chronic myelogenous leukemia (CML). CML is a hematologic neoplasm, predominantly caused by reciprocal translocation t(9;22)(q34;q11) leading to formation of the so-called BCR-ABL1 fusion gene. By binding to the BCR-ABL1 kinase and inhibition of downstream target phosphorylation, TKIs, such as imatinib or nilotinib, can be used as single agents to treat CML patients resulting in 80 % 10-year survival rates. However, treatment failure can be observed in 20-25 % of CML patients occurring either dependent or independent from the BCR-ABL1 kinase. Here, we review approved TKIs that are indicated for the treatment of CML, their side effects and limitations. We point out mechanisms of TKI resistance focusing either on BCR-ABL1-dependent mechanisms by summarizing the clinically observed BCR-ABL1-mutations and their implications on TKI binding, as well as on BCR-ABL1-independent mechanisms of resistances. For the latter, we discuss potential mechanisms, among them cytochrome P450 implications, drug efflux transporter variants and expression, microRNA deregulation, as well as the role of alternative signaling pathways. Further, we give insights on how TKI resistance could be analyzed and what could be learned from studying TKI resistance in CML in vitro.
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Affiliation(s)
| | - Ingolf Cascorbi
- Institute of Experimental and Clinical Pharmacology, University Hospital Schleswig-Holstein, Kiel, Germany
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11
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Loscocco F, Visani G, Ruzzo A, Bagaloni I, Fuligni F, Galimberti S, Di Paolo A, Stagno F, Pregno P, Annunziata M, Gozzini A, Barulli S, Gabucci E, Magnani M, Isidori A. Clinical Relevance of ABCB1, ABCG2, and ABCC2 Gene Polymorphisms in Chronic Myeloid Leukemia Patients Treated With Nilotinib. Front Oncol 2021; 11:672287. [PMID: 34055641 PMCID: PMC8155509 DOI: 10.3389/fonc.2021.672287] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/21/2021] [Indexed: 12/05/2022] Open
Abstract
Tyrosine kinase inhibitors (TKIs) have radically changed the outcome of chronic myeloid leukemia (CML) patients in the last 20 years. Moreover, the advent of second generation TKIs, namely nilotinib and dasatinib, have largely increased the number of CML patients achieving deep and sustained molecular responses. However, the possible mechanisms capable of influencing the maintenance of the long-term molecular response are not yet fully known and understood. In this light, polymorphisms in MDR-ABC transporters may influence the efficacy and safety of TKIs. In this study, we examined seven single nucleotide polymorphisms (SNPs) in four ABC transporter genes: ABCC1 rs212090 (5463T>A), ABCC2 rs3740066 (3972C>T), ABCC2 rs4148386 G>A, ABCC2 rs1885301 (1549G>A), ABCG2 rs2231137 (34G>A), ABCG2 rs2231142 G>C, ABCB1 rs1045642 (3435C>T), to determine their effect on the achievement and/or loss of molecular response in 90 CML patients treated with nilotinib. We found that ABCC2 rs3740066 CC and CT as well as the ABCB1 rs1045642 TT genotypes correlated with a higher probability to achieve MR3 in a shorter time (p=0.02, p=0.004, and p=0.01), whereas ABCG2 rs2231137 GG was associated with lower probability of MR3 achievement (p=0.005). Moreover, ABCC2 rs3740066 CC genotype, the ABCB1 rs1045642 CC and TT genotypes were positively correlated with MR4 achievement (p=0.02, p=0.007, and p=0.003). We then generated a predictive model incorporating the information of four genotypes, to evaluate the combined effect of the SNPs. The combination of SNPs present in the model affected the probability and the time to molecular response. This model had a high prognostic significance for both MR3 and MR4 (p=0.005 and p=0.008, respectively). Finally, we found ABCG2 rs2231142 GG genotype to be associated with a decrease risk of MR3 loss. In conclusion, MDR-transporters SNPs may significantly affect the achievement and loss of molecular response in CML patients treated with nilotinib.
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Affiliation(s)
- Federica Loscocco
- Hematology and Hematopoietic Stem Cell Transplant Center, AORMN, Pesaro, Italy
| | - Giuseppe Visani
- Hematology and Hematopoietic Stem Cell Transplant Center, AORMN, Pesaro, Italy
| | - Annamaria Ruzzo
- Department of Biomolecular Sciences, University of Urbino "Carlo Bo", Fano, Italy
| | - Irene Bagaloni
- Department of Biomolecular Sciences, University of Urbino "Carlo Bo", Fano, Italy
| | - Fabio Fuligni
- Genetics and Genome Biology, Paediatric Laboratory Medicine (PLM), The Hospital for Sick Children, Toronto, ON, Canada
| | - Sara Galimberti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Antonello Di Paolo
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Fabio Stagno
- AOU Policlinico Vittorio Emanuele, Divisioni Clinicizzata di Ematologia con Trapianto di Midollo Osseo, Catania, Italy
| | - Patrizia Pregno
- AOU Città Della Scienza e Della Salute di Torino, Hematology, Torino, Italy
| | | | | | - Sara Barulli
- Hematology and Hematopoietic Stem Cell Transplant Center, AORMN, Pesaro, Italy
| | - Elisa Gabucci
- Hematology and Hematopoietic Stem Cell Transplant Center, AORMN, Pesaro, Italy
| | - Mauro Magnani
- Department of Biomolecular Sciences, University of Urbino "Carlo Bo", Fano, Italy
| | - Alessandro Isidori
- Hematology and Hematopoietic Stem Cell Transplant Center, AORMN, Pesaro, Italy
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12
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Peixoto da Silva S, Caires HR, Bergantim R, Guimarães JE, Vasconcelos MH. miRNAs mediated drug resistance in hematological malignancies. Semin Cancer Biol 2021; 83:283-302. [PMID: 33757848 DOI: 10.1016/j.semcancer.2021.03.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 02/11/2021] [Accepted: 03/16/2021] [Indexed: 12/12/2022]
Abstract
Despite improvements in the therapeutic approaches for hematological malignancies in the last decades, refractory disease still occurs, and cancer drug resistance still remains a major hurdle in the clinical management of these cancer patients. The investigation of this problem has been extensive and different mechanism and molecules have been associated with drug resistance. MicroRNAs (miRNAs) have been described as having an important action in the emergence of cancer, including hematological tumors, and as being major players in their progression, aggressiveness and response to treatments. Moreover, miRNAs have been strongly associated with cancer drug resistance and with the modulation of the sensitivity of cancer cells to a wide array of anticancer drugs. Furthermore, this role has also been reported for miRNAs packaged into extracellular vesicles (EVs-miRNAs), which in turn have been described as essential for the horizontal transfer of drug resistance to sensitive cells. Several studies have been suggesting the use of miRNAs as biomarkers for drug response and clinical outcome prediction, as well as promising therapeutic tools in hematological diseases. Indeed, the combination of miRNA-based therapeutic tools with conventional drugs contributes to overcome drug resistance. This review addresses the role of miRNAs in the pathogenesis of hematological malignances, namely multiple myeloma, leukemias and lymphomas, highlighting their important action (either in their cell-free circulating form or within circulating EVs) in drug resistance and their potential clinical applications.
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Affiliation(s)
- Sara Peixoto da Silva
- i3S - Instituto de Investigação e Inovação em Saúde, University of Porto, 4200-135 Porto, Portugal; Cancer Drug Resistance Group, IPATIMUP - Institute of Molecular Pathology and Immunology of the University of Porto, 4200-135, Porto, Portugal
| | - Hugo R Caires
- i3S - Instituto de Investigação e Inovação em Saúde, University of Porto, 4200-135 Porto, Portugal; Cancer Drug Resistance Group, IPATIMUP - Institute of Molecular Pathology and Immunology of the University of Porto, 4200-135, Porto, Portugal
| | - Rui Bergantim
- i3S - Instituto de Investigação e Inovação em Saúde, University of Porto, 4200-135 Porto, Portugal; Cancer Drug Resistance Group, IPATIMUP - Institute of Molecular Pathology and Immunology of the University of Porto, 4200-135, Porto, Portugal; Clinical Hematology, Hospital São João, 4200-319, Porto, Portugal; Clinical Hematology, FMUP - Faculty of Medicine, University of Porto, 4200-319, Porto, Portugal
| | - José E Guimarães
- i3S - Instituto de Investigação e Inovação em Saúde, University of Porto, 4200-135 Porto, Portugal; Cancer Drug Resistance Group, IPATIMUP - Institute of Molecular Pathology and Immunology of the University of Porto, 4200-135, Porto, Portugal; Clinical Hematology, FMUP - Faculty of Medicine, University of Porto, 4200-319, Porto, Portugal; Instituto Universitário de Ciências da Saúde, Cooperativa de Ensino Superior Politécnico e Universitário, IUCSCESPU, 4585-116, Gandra, Paredes, Portugal
| | - M Helena Vasconcelos
- i3S - Instituto de Investigação e Inovação em Saúde, University of Porto, 4200-135 Porto, Portugal; Cancer Drug Resistance Group, IPATIMUP - Institute of Molecular Pathology and Immunology of the University of Porto, 4200-135, Porto, Portugal; Department of Biological Sciences, FFUP - Faculty of Pharmacy, University of Porto, 4050-313, Porto, Portugal.
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13
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Ito F, Miura M, Fujioka Y, Abumiya M, Kobayashi T, Takahashi S, Yoshioka T, Kameoka Y, Takahashi N. The BCRP inhibitor febuxostat enhances the effect of nilotinib by regulation of intracellular concentration. Int J Hematol 2020; 113:100-105. [PMID: 33025461 DOI: 10.1007/s12185-020-03000-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 01/26/2023]
Abstract
Nilotinib is a substrate of the breast cancer resistance protein (BCRP), which is a drug efflux transporter encoded by ABCG2 and regulates the pharmacokinetics of its substrates. We investigated the interaction between nilotinib and BCRP in chronic myeloid leukemia (CML) cells. An imatinib-resistant K562 cell line (K562/IM-R) treated with nilotinib was analyzed for BCRP expression, proliferation, apoptosis, and intracellular nilotinib concentration. K562/IM-R cells cultured with tyrosine kinase inhibitors (TKIs) showed an increased cell count and retained viability, whereas the growth of parental K562 cells was severely inhibited, suggesting that BCRP is involved in developing resistance to TKIs. Nilotinib-treated K562/IM-R cells showed a reduction in apoptosis; however, febuxostat pretreatment resulted in increased apoptosis. The intracellular concentration of nilotinib in K562/IM-R cells was significantly reduced compared to that in parental K562 cells, and febuxostat-pretreated K562/IM-R cells showed an increased intracellular nilotinib level compared to cells without pretreatment. The reduction in nilotinib levels caused by BCRP in CML cells might play a crucial role in resistance to TKIs. Moreover, febuxostat, as a BCRP inhibitor, could enhance nilotinib sensitivity, and combination therapy with nilotinib and febuxostat may represent a promising strategy for treatment of CML.
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Affiliation(s)
- Fumiko Ito
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Masatomo Miura
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Yuki Fujioka
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Maiko Abumiya
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Takahiro Kobayashi
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Saori Takahashi
- Clinical Research Promotion and Support Center, Akita University Hospital, Akita, Japan
| | - Tomoko Yoshioka
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan
| | - Yoshihiro Kameoka
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan.,Clinical Research Promotion and Support Center, Akita University Hospital, Akita, Japan
| | - Naoto Takahashi
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Akita, 010-8543, Japan.
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14
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Pharmacology of tyrosine kinase inhibitors in chronic myeloid leukemia; a clinician's perspective. ACTA ACUST UNITED AC 2020; 28:371-385. [PMID: 31900888 DOI: 10.1007/s40199-019-00321-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 12/17/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVE In this review, we have summarized the pharmacokinetics, pharmacodynamics and adverse effects of imatinib, dasatinib, nilotinib, bosutinib, ponatinib and radotinib with focus on pharmacogenomic studies with clinical end points. We have discussed the key phase 3 trials of tyrosine kinase inhibitors (TKI) comparing with each other, treatment free remission (TFR) and selection of TKI. Upcoming concepts and related trials in the management of chronic myeloid leukemia (CML) along with future directions have been touched upon. EVIDENCE ACQUISITION PubMed, Embase, Google, Cochrane library and Medline were searched to identify relevant literature for the review. Clinicaltrial.gov was searched for upcoming data and trials. RESULTS There are lot of gap in pharmacokinetics and pharmacodynamics of TKI. Imatinib appears to be the safest TKI. Newer TKI's achieve better achievement of therapeutic milestones, deeper molecular response and less chances of progression of CML compared to imatinib. Newer TKI appears to be better choice for achieving TFR. When the objective is survival, imatinib is still the TKI of choice. Primary prophylaxis with antiplatelet drugs for TKI having cardiovascular and thromboembolic side effects should be considered. CONCLUSION Pharmacogenetic data of TKI is still immature to guide in therapeutic decision making in clinical practice. There is need for further research in pharmacology and pharmacogenomics of newer TKI's. Randomized controlled trials are required to decide the optimum TKI for TFR. Safe and effective TKI for targeting T315I mutation, CML accelerated phase and blast crisis are an active area of research.
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15
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Yamaguchi H, Takezako N, Ohashi K, Oba K, Kumagai T, Kozai Y, Wakita H, Yamamoto K, Fujita A, Igarashi T, Yoshida C, Ohyashiki K, Okamoto S, Sakamoto J, Sakamaki H, Inokuchi K. Treatment-free remission after first-line dasatinib treatment in patients with chronic myeloid leukemia in the chronic phase: the D-NewS Study of the Kanto CML Study Group. Int J Hematol 2020; 111:401-408. [PMID: 31894533 DOI: 10.1007/s12185-019-02801-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 12/20/2022]
Abstract
Treatment outcomes for chronic myeloid leukemia (CML) have dramatically improved with the development of tyrosine kinase inhibitors (TKI). However, due to the improved prognosis for CML, problems have arisen from long-term administration of TKI. The present study sought to verify whether more patients could achieve treatment-free remission (TFR) after stopping the administration of dasatinib using dasatinib as frontline treatment. Treatment-naïve chronic phase CML cases were treated with dasatinib as frontline treatment. Dasatinib treatment was stopped for 26 patients who achieved deep molecular response (DMR) within 24 months and were able to maintain DMR for an additional 2 years. Ten patients (38.5%) achieved DMR maintenance after 12 months. Recurrence was confirmed in 16 patients, and the median recurrence-free survival time was 5.1 months. The cumulative DMR rates at six and 12 months after restarting treatment were 84.6% and 100%, respectively. The results of this study demonstrated that the DMR maintenance rate after 12 months was 38.5%, which was not significantly different from previous TKI stop trials. The 2-year dasatinib administration period after reaching DMR did not contribute to improve TFR rates. These results suggest that the type of TKI is not associated with better TFR rates.
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Affiliation(s)
- Hiroki Yamaguchi
- Department of Hematology Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan.
| | - Naoki Takezako
- Department of Hematology, National Hospital Organization Disaster Medical Center, Tachikawa, Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Koji Oba
- Interfactulty Initiative in Information Studies, The University of Tokyo, Tokyo, Japan.,Department of Biostatistics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takashi Kumagai
- Department of Hematology, Ome Municipal General Hospital, Tokyo, Japan
| | - Yasuji Kozai
- Department of Hematology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Hisashi Wakita
- Division of Hematology and Oncology, Japanese Red Cross Society, Narita Red Cross Hospital, Narita, Japan
| | - Koh Yamamoto
- Department of Hematology, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Akira Fujita
- Hematology Division, Showa General Hospital, Tokyo, Japan
| | - Tadahiko Igarashi
- Division of Hematology and Oncology, Gunma Prefectural Cancer Center, Ohta, Japan
| | - Chikashi Yoshida
- Department of Hematology, National Hospital Organization, Mito Medical Center, Higashiibarakigun, Ibaraki, Japan
| | - Kazuma Ohyashiki
- Department of Hematology, Tokyo Medical University, Tokyo, Japan
| | - Shinichiro Okamoto
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | | | - Hisashi Sakamaki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Koiti Inokuchi
- Department of Hematology Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
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16
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Izzo B, Gottardi EM, Errichiello S, Daraio F, Baratè C, Galimberti S. Monitoring Chronic Myeloid Leukemia: How Molecular Tools May Drive Therapeutic Approaches. Front Oncol 2019; 9:833. [PMID: 31555590 PMCID: PMC6742705 DOI: 10.3389/fonc.2019.00833] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 08/13/2019] [Indexed: 12/25/2022] Open
Abstract
More than 15 years ago, imatinib entered into the clinical practice as a "magic bullet"; from that point on, the prognosis of patients affected by chronic myeloid leukemia (CML) became comparable to that of aged-matched healthy subjects. The aims of treatment with tyrosine kinase inhibitors (TKIs) are for complete hematological response after 3 months of treatment, complete cytogenetic response after 6 months, and a reduction of the molecular disease of at least 3 logs after 12 months. Patients who do not reach their goal can switch to another TKI. Thus, the molecular monitoring of response is the main consideration of management of CML patients. Moreover, cases in deep and persistent molecular response can tempt the physician to interrupt treatment, and this "dream" is possible due to the quantitative PCR. After great international effort, today the BCR-ABL1 expression obtained in each laboratory is standardized and expressed as "international scale." This aim has been reached after the establishment of the EUTOS program (in Europe) and the LabNet network (in Italy), the platforms where biologists meet clinicians. In the field of quantitative PCR, the digital PCR is now a new and promising, sensitive and accurate tool. Some authors reported that digital PCR is able to better classify patients in precise "molecular classes," which could lead to a better identification of those cases that will benefit from the interruption of therapy. In addition, digital PCR can be used to identify a point mutation in the ABL1 domain, mutations that are often responsible for the TKI resistance. In the field of resistance, a prominent role is played by the NGS that enables identification of any mutation in ABL1 domain, even at sub-clonal levels. This manuscript reviews how the molecular tools can lead the management of CML patients, focusing on the more recent technical advances.
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Affiliation(s)
- Barbara Izzo
- Department of Clinical Medicine and Surgery, Molecular Biology, University Federico II, Naples, Italy
| | | | - Santa Errichiello
- Department of Clinical Medicine and Surgery, Molecular Biology, University Federico II, Naples, Italy
| | - Filomena Daraio
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Claudia Baratè
- Section of Hematology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Sara Galimberti
- Section of Hematology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Assaraf YG, Brozovic A, Gonçalves AC, Jurkovicova D, Linē A, Machuqueiro M, Saponara S, Sarmento-Ribeiro AB, Xavier CP, Vasconcelos MH. The multi-factorial nature of clinical multidrug resistance in cancer. Drug Resist Updat 2019; 46:100645. [DOI: 10.1016/j.drup.2019.100645] [Citation(s) in RCA: 196] [Impact Index Per Article: 39.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/05/2019] [Accepted: 09/14/2019] [Indexed: 12/16/2022]
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