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Karlsson JOG, Jynge P. Comments on "Clinically relevant therapeutic approaches against acetaminophen (APAP) hepatotoxicity and acute liver failure". Biochem Pharmacol 2024; 225:116276. [PMID: 38735443 DOI: 10.1016/j.bcp.2024.116276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 04/28/2024] [Accepted: 05/07/2024] [Indexed: 05/14/2024]
Affiliation(s)
- Jan Olof G Karlsson
- Department of Biomedical and Clinical Sciences, Division of Clinical Chemistry and Pharmacology, Linköping University, 581 83 Linköping, Sweden.
| | - Per Jynge
- Department of Radiology, Innlandet Trust Hospital, Gjøvik Hospital, 2819 Gjøvik, Norway
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Karlsson JOG, Jynge P. Manganese- and Platinum-Driven Oxidative and Nitrosative Stress in Oxaliplatin-Associated CIPN with Special Reference to Ca 4Mn(DPDP) 5, MnDPDP and DPDP. Int J Mol Sci 2024; 25:4347. [PMID: 38673932 PMCID: PMC11050347 DOI: 10.3390/ijms25084347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/11/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
Platinum-containing chemotherapeutic drugs are efficacious in many forms of cancer but are dose-restricted by serious side effects, of which peripheral neuropathy induced by oxidative-nitrosative-stress-mediated chain reactions is most disturbing. Recently, hope has been raised regarding the catalytic antioxidants mangafodipir (MnDPDP) and calmangafodipir [Ca4Mn(DPDP)5; PledOx®], which by mimicking mitochondrial manganese superoxide dismutase (MnSOD) may be expected to overcome oxaliplatin-associated chemotherapy-induced peripheral neuropathy (CIPN). Unfortunately, two recent phase III studies (POLAR A and M trials) applying Ca4Mn(DPDP)5 in colorectal cancer (CRC) patients receiving multiple cycles of FOLFOX6 (5-FU + oxaliplatin) failed to demonstrate efficacy. Instead of an anticipated 50% reduction in the incidence of CIPN in patients co-treated with Ca4Mn(DPDP)5, a statistically significant increase of about 50% was seen. The current article deals with confusing differences between early and positive findings with MnDPDP in comparison to the recent findings with Ca4Mn(DPDP)5. The POLAR failure may also reveal important mechanisms behind oxaliplatin-associated CIPN itself. Thus, exacerbated neurotoxicity in patients receiving Ca4Mn(DPDP)5 may be explained by redox interactions between Pt2+ and Mn2+ and subtle oxidative-nitrosative chain reactions. In peripheral sensory nerves, Pt2+ presumably leads to oxidation of the Mn2+ from Ca4Mn(DPDP)5 as well as from Mn2+ in MnSOD and other endogenous sources. Thereafter, Mn3+ may be oxidized by peroxynitrite (ONOO-) into Mn4+, which drives site-specific nitration of tyrosine (Tyr) 34 in the MnSOD enzyme. Conformational changes of MnSOD then lead to the closure of the superoxide (O2•-) access channel. A similar metal-driven nitration of Tyr74 in cytochrome c will cause an irreversible disruption of electron transport. Altogether, these events may uncover important steps in the mechanism behind Pt2+-associated CIPN. There is little doubt that the efficacy of MnDPDP and its therapeutic improved counterpart Ca4Mn(DPDP)5 mainly depends on their MnSOD-mimetic activity when it comes to their potential use as rescue medicines during, e.g., acute myocardial infarction. However, pharmacokinetic considerations suggest that the efficacy of MnDPDP on Pt2+-associated neurotoxicity depends on another action of this drug. Electron paramagnetic resonance (EPR) studies have demonstrated that Pt2+ outcompetes Mn2+ and endogenous Zn2+ in binding to fodipir (DPDP), hence suggesting that the previously reported protective efficacy of MnDPDP against CIPN is a result of chelation and elimination of Pt2+ by DPDP, which in turn suggests that Mn2+ is unnecessary for efficacy when it comes to oxaliplatin-associated CIPN.
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Affiliation(s)
- Jan Olof G. Karlsson
- Department of Biomedical and Clinical Sciences, Division of Clinical Chemistry and Pharmacology, Linköping University, 581 83 Linköping, Sweden
| | - Per Jynge
- Department of Radiology, Innlandet Trust Hospital, Gjøvik Hospital, 2819 Gjøvik, Norway;
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Karlsson JOG, Jynge P, Ignarro LJ. Exacerbated Neuropathy in POLAR A and M Trials Due to Redox Interaction of PledOx-Associated Mn2+ and Oxaliplatin-Associated Pt2+. Antioxidants (Basel) 2023; 12:antiox12030608. [PMID: 36978857 PMCID: PMC10045419 DOI: 10.3390/antiox12030608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/30/2023] [Accepted: 02/25/2023] [Indexed: 03/06/2023] Open
Abstract
Disappointing results from the POLAR A and M phase III trials involving colorectal cancer patients on chemotherapy with FOLFOX6 in curative (A) and palliative (M) settings have been reported by the principal investigators and the sponsor (PledPharma AB/Egetis Therapeutics AB). FOLFOX6, oxaliplatin in combination with 5-fluorouracil (5-FU), possesses superior tumoricidal activity in comparison to 5-FU alone, but suffers seriously from dose-limiting platinum-associated Chemotherapy-Induced Peripheral Neuropathy (CIPN). The aim of the POLAR trials was to demonstrate that PledOx [calmangafodipir; Ca4Mn(DPDP)5] reduced the incidence of persistent CIPN from 40% to 20%. However, this assumption was based on “explorative” data in the preceding PLIANT phase II trial, which did not mirror the expected incidence of unwanted toxicity in placebo patients. In POLAR A and M, the assessment of PledOx efficacy was conducted in patients that received at least six cycles of FOLFOX6, enabling analyses of efficacy in 239 A and 88 M patients. Instead of a hypothesized improvement from 40% to 20% incidence of persistent CIPN in the PledOx group, i.e., a 50% improvement, the real outcome was the opposite, i.e., an about 50% worsening in this bothersome toxicity. Mechanisms that may explain the disastrous outcome, with a statistically significant number of patients being seriously injured after having received PledOx, indicate interactions between two redox active metal cations, Pt2+ (oxaliplatin) and Mn2+ (PledOx). A far from surprising causal relationship that escaped prior detection by the study group and the sponsor. Most importantly, recently published data (ref 1) unequivocally indicate that the PLIANT study was not suited to base clinical phase III studies on. In conclusion, the POLAR and PLIANT trials show that PledOx and related manganese-containing compounds are unsuited for co-treatment with platinum-containing compounds. For use as a therapeutic adjunct in rescue treatment, like in ischemia-reperfusion of the heart or other organs, or in acetaminophen (paracetamol)-associated liver failure, there is little or nothing speaking against the use of PledOx or other PLED compounds. However, this must be thoroughly documented in more carefully designed clinical trials.
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Affiliation(s)
- Jan Olof G. Karlsson
- Department of Biomedical and Clinical Sciences, Division of Clinical Chemistry and Pharmacology, Linköping University, 581 83 Linköping, Sweden
- Correspondence:
| | - Per Jynge
- Department of Radiology, Innlandet Trust Hospital, Gjøvik Hospital, 2819 Gjøvik, Norway
| | - Louis J. Ignarro
- Department of Pharmacology, UCLA School of Medicine, 264 El Camino Drive, Beverly Hills, CA 90212, USA
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Karlsson JOG, Jynge P, Ignarro LJ. The Damaging Outcome of the POLAR Phase III Trials Was Due to Avoidable Time-Dependent Redox Interaction between Oxaliplatin and PledOx. Antioxidants (Basel) 2021; 10:antiox10121937. [PMID: 34943040 PMCID: PMC8750726 DOI: 10.3390/antiox10121937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/30/2021] [Indexed: 11/28/2022] Open
Abstract
On 2 July 2021, highly negative results were reported from the POLAR A and M phase III trials in patients with colorectal cancer, treated with an oxaliplatin-based regimen and co-treated with calmangafodipir (CaM; PledOx®; PledPharma AB/Egetis Therapeutics AB) or placebo. The results revealed persistent chemotherapy-induced peripheral neuropathy (CIPN) in 54.8% of the patients treated with PledOx, compared with 40.0% of the patients treated with the placebo (p < 0.05), i.e., a 37% increase in incidence of the side effect that the trial was aimed to prevent. The damaging outcome of the trials differed diametrically from an in-parallel conducted mice study and from a clinical trial with mangafodipir, the active ingredient of CaM. According to the authors of the POLAR report, the etiology of the profound increase in CIPN in the PledOx arm is unclear. However, these devastating effects are presumably explained by intravenous administrations of PledOx and oxaliplatin being too close in time and, thereby, causing unfavorable redox interactions between Mn2+ and Pt2−. In the mice study as well as in the preceding phase II clinical trial (PLIANT), PledOx was administered 10 min before the start of the oxaliplatin infusion; this was clearly an administration procedure, where the devastating interactions between PledOx and oxaliplatin could be avoided. However, when it comes to the POLAR trials, PledOx was administered, for incomprehensible reasons, “on Top of Modified FOLFOX6” at day one, i.e., after the two-hour oxaliplatin infusion instead of before oxaliplatin. This is a time point when the plasma concentration of oxaliplatin and Pt2+-metabolites is at its highest, and where the risk of devastating redox interactions between PledOx and oxaliplatin, in turn, is at its highest.
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Affiliation(s)
- Jan Olof G. Karlsson
- Department of Biomedical and Clinical Sciences, Division of Clinical Chemistry and Pharmacology, Linköping University, 581 83 Linköping, Sweden
- Correspondence:
| | - Per Jynge
- Department of Radiology, Innlandet Trust Hospital, Gjøvik Hospital, 2819 Gjøvik, Norway;
| | - Louis J. Ignarro
- Department of Pharmacology, UCLA School of Medicine, 264 El Camino Drive, Beverly Hills, CA 90212, USA;
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Stankovic JSK, Selakovic D, Mihailovic V, Rosic G. Antioxidant Supplementation in the Treatment of Neurotoxicity Induced by Platinum-Based Chemotherapeutics-A Review. Int J Mol Sci 2020; 21:E7753. [PMID: 33092125 PMCID: PMC7589133 DOI: 10.3390/ijms21207753] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 10/10/2020] [Accepted: 10/16/2020] [Indexed: 12/11/2022] Open
Abstract
Cancer represents one of the most pernicious public health problems with a high mortality rate among patients worldwide. Chemotherapy is one of the major therapeutic approaches for the treatment of various malignancies. Platinum-based drugs (cisplatin, oxaliplatin, carboplatin, etc.) are highly effective chemotherapeutic drugs used for the treatment of several types of malignancies, but their application and dosage are limited by their toxic effects on various systems, including neurotoxicity. Simultaneously, researchers have tried to improve the survival rate and quality of life of cancer patients and decrease the toxicity of platinum-containing drugs by combining them with non-chemotherapy-based drugs, dietary supplements and/or antioxidants. Additionally, recent studies have shown that the root cause for the many side effects of platinum chemotherapeutics involves the production of reactive oxygen species (ROS) in naive cells. Therefore, suppression of ROS generation and their inactivation with antioxidants represents an appropriate approach for platinum drug-induced toxicities. The aim of this paper is to present an updated review of the protective effects of different antioxidant agents (vitamins, dietary antioxidants and supplements, medicaments, medicinal plants and their bioactive compounds) against the neurotoxicity induced by platinum-based chemotherapeutics. This review highlights the high potential of plant antioxidants as adjuvant strategies in chemotherapy with platinum drugs.
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Affiliation(s)
- Jelena S. Katanic Stankovic
- Institute for Information Technologies Kragujevac, Department of Science, University of Kragujevac, Jovana Cvijica bb, 34000 Kragujevac, Serbia;
| | - Dragica Selakovic
- Faculty of Medical Sciences, Department of Physiology, University of Kragujevac, Svetozara Markovica 69, 34000 Kragujevac, Serbia;
| | - Vladimir Mihailovic
- Faculty of Science, Department of Chemistry, University of Kragujevac, Radoja Domanovica 12, 34000 Kragujevac, Serbia
| | - Gvozden Rosic
- Faculty of Medical Sciences, Department of Physiology, University of Kragujevac, Svetozara Markovica 69, 34000 Kragujevac, Serbia;
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Argyriou AA, Bruna J, Park SB, Cavaletti G. Emerging pharmacological strategies for the management of chemotherapy-induced peripheral neurotoxicity (CIPN), based on novel CIPN mechanisms. Expert Rev Neurother 2020; 20:1005-1016. [PMID: 32667212 DOI: 10.1080/14737175.2020.1796639] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Based on results of available clinical trials, the treatment and prevention of chemotherapy-induced peripheral neurotoxicity (CIPN) largely remains an unmet clinical need. However, new approaches have emerged in the last few years, attempting to modify the natural history of acute and late CIPN effects through a better knowledge of the pathogenic process on the molecular level. AREAS COVERED Clinical results of recently published (last 5 years) or ongoing emerging therapeutic/preventive pharmacological approaches based on novel CIPN mechanisms have been identified from Pubmed and ClinicalTrials.gov. Results are reviewed and discussed, in order to assess the trend of new clinical studies but also to infer the role novel approaches may have in the future. EXPERT OPINION The large heterogeneity of disease-causing mechanisms prevents researchers from identifying a reliable approach to effectively and safely treat or prevent CIPN. Understanding of novel pathophysiologic processes is leading the way to novel therapies, which, through targeting the sphingosine 1-phosphate receptor or pharmacologically inhibiting axonal degeneration might achieve in the future both treatment and prevention of CIPN. Toward this end, a multi-targeting approach, combining drugs to target different CIPN pathomechanisms seems to be a rational approach that warrants testing.
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Affiliation(s)
- Andreas A Argyriou
- Department of Neurology, Saint Andrew's State General Hospital of Patras , Patras, Greece
| | - Jordi Bruna
- Unit of Neuro-Oncology, Hospital Universitari de Bellvitge-ICO L'Hospitalet-IDIBELL , Barcelona, Spain
| | - Susanna B Park
- Brain and Mind Centre, Faculty of Medicine and Health, The University of Sydney , Sydney, Australia
| | - Guido Cavaletti
- Experimental Neurology Unit and Milan Center for Neuroscience, University of Milano-Bicocca , Monza, Italy
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Affiliation(s)
- Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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