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Barsoumian HB, Ramapriyan R, Younes AI, Caetano MS, Menon H, Comeaux NI, Cushman TR, Schoenhals JE, Cadena AP, Reilly TP, Chen D, Masrorpour F, Li A, Hong DS, Diab A, Nguyen QN, Glitza I, Ferrarotto R, Chun SG, Cortez MA, Welsh J. Low-dose radiation treatment enhances systemic antitumor immune responses by overcoming the inhibitory stroma. J Immunother Cancer 2020; 8:jitc-2020-000537. [PMID: 33106386 PMCID: PMC7592253 DOI: 10.1136/jitc-2020-000537] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2020] [Indexed: 12/19/2022] Open
Abstract
Background Despite some successes with checkpoint inhibitors for treating cancer, most patients remain refractory to treatment, possibly due to the inhibitory nature of the tumor stroma that impedes the function and entry of effector cells. We devised a new technique of combining immunotherapy with radiotherapy (XRT), more specifically low-dose XRT, to overcome the stroma and maximize systemic outcomes. Methods We bilaterally established 344SQ lung adenocarcinoma tumors in 129Sv/Ev mice. Primary and secondary tumors were irradiated with either high-dose or low-dose of XRT with systemic anti-programmed cell death protein 1 and anti-cytotoxic T-lymphocyte associated protein 4 administration. Survival and tumor growth were monitored for the various groups, and secondary tumors were phenotyped by flow cytometry for immune populations. Tumor growth factor-beta (TGF-β) cytokine levels were assessed locally after low-dose XRT, and specific immune-cell depletion experiments were conducted to identify the major contributors to the observed systemic antitumor effect. Results Through our preclinical and clinical studies, we observed that when tumor burden was high, there was a necessity of combining high-dose XRT to ‘prime’ T cells at the primary tumor site, with low-dose XRT directed to secondary (metastatic) tumors to ‘modulate the stroma’. Low-dose XRT improved the antitumor outcomes of checkpoint inhibitors by favoring M1 macrophage polarization, enhancing natural killer (NK) cell infiltration, and reducing TGF-β levels. Depletion of CD4+ T cells and NK cells abrogated the observed antitumor effect. Conclusion Our data extend the benefits of low-dose XRT to reprogram the tumor environment and improve the infiltration and function of effector immune cells into secondary tumors.
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Affiliation(s)
| | - Rishab Ramapriyan
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ahmed I Younes
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mauricio S Caetano
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hari Menon
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nathan I Comeaux
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Taylor R Cushman
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jonathan E Schoenhals
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alexandra P Cadena
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Dawei Chen
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Fatemeh Masrorpour
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ailin Li
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David S Hong
- Investigational Cancer Therapeutics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Adi Diab
- Melanoma Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Quynh-Nhu Nguyen
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Isabella Glitza
- Melanoma Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Renata Ferrarotto
- Thoracic Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen G Chun
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria Angelica Cortez
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - James Welsh
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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2
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Schalper KA, Carleton M, Zhou M, Chen T, Feng Y, Huang SP, Walsh AM, Baxi V, Pandya D, Baradet T, Locke D, Wu Q, Reilly TP, Phillips P, Nagineni V, Gianino N, Gu J, Zhao H, Perez-Gracia JL, Sanmamed MF, Melero I. Elevated serum interleukin-8 is associated with enhanced intratumor neutrophils and reduced clinical benefit of immune-checkpoint inhibitors. Nat Med 2020; 26:688-692. [PMID: 32405062 DOI: 10.1038/s41591-020-0856-x] [Citation(s) in RCA: 269] [Impact Index Per Article: 67.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 03/25/2020] [Indexed: 12/18/2022]
Abstract
Serum interleukin-8 (IL-8) levels and tumor neutrophil infiltration are associated with worse prognosis in advanced cancers. Here, using a large-scale retrospective analysis, we show that elevated baseline serum IL-8 levels are associated with poor outcome in patients (n = 1,344) with advanced cancers treated with nivolumab and/or ipilimumab, everolimus or docetaxel in phase 3 clinical trials, revealing the importance of assessing serum IL-8 levels in identifying unfavorable tumor immunobiology and as an independent biomarker in patients receiving immune-checkpoint inhibitors.
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Affiliation(s)
- Kurt A Schalper
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA.
| | - Michael Carleton
- Department of Translational Medicine, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Ming Zhou
- Department of Global Biometric Sciences, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Tian Chen
- Department of Global Biometric Sciences, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Ye Feng
- Department of Global Biometric Sciences, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Shu-Pang Huang
- Department of Global Biometric Sciences, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Alice M Walsh
- Department of Translational Bioinformatics, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Vipul Baxi
- Department of Translational Bioinformatics, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Dimple Pandya
- Department of Research and Early Development, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Timothy Baradet
- Department of Translational Medicine, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Darren Locke
- Department of Translational Medicine, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Qiuyan Wu
- Department of Research and Early Development, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Timothy P Reilly
- Department of Research and Early Development, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Penny Phillips
- Department of Translational Medicine, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Venkata Nagineni
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Nicole Gianino
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Jianlei Gu
- Department of Biostatistics, School of Public Health, Yale University, New Haven, CT, USA
| | - Hongyu Zhao
- Department of Biostatistics, School of Public Health, Yale University, New Haven, CT, USA
| | - Jose Luis Perez-Gracia
- Oncology Department, Clinica Universidad de Navarra, Pamplona, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain
| | - Miguel F Sanmamed
- Oncology Department, Clinica Universidad de Navarra, Pamplona, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain.,Department of Immunobiology, Yale University School of Medicine, New Haven, CT, USA.,Department of Immunology and Immunotherapy, Centro de Investigación Médica Aplicada (CIMA), Universidad de Navarra, Pamplona, Spain
| | - Ignacio Melero
- Oncology Department, Clinica Universidad de Navarra, Pamplona, Spain. .,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain. .,Department of Immunology and Immunotherapy, Centro de Investigación Médica Aplicada (CIMA), Universidad de Navarra, Pamplona, Spain.
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3
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Caetano MS, Younes AI, Barsoumian HB, Quigley M, Menon H, Gao C, Spires T, Reilly TP, Cadena AP, Cushman TR, Schoenhals JE, Li A, Nguyen QN, Cortez MA, Welsh JW. Triple Therapy with MerTK and PD1 Inhibition Plus Radiotherapy Promotes Abscopal Antitumor Immune Responses. Clin Cancer Res 2019; 25:7576-7584. [PMID: 31540976 DOI: 10.1158/1078-0432.ccr-19-0795] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/10/2019] [Accepted: 09/17/2019] [Indexed: 01/07/2023]
Abstract
PURPOSE Radiotherapy (RT) traditionally has been used for local tumor control in the treatment of cancer. The recent discovery that radiotherapy can have anticancer effects on the immune system has led to recognition of its ability to sensitize the tumor microenvironment to immunotherapy. However, radiation can also prompt adverse immunosuppressive effects that block aspects of systemic response at other tumor sites. Our hypothesis was that inhibition of the MER proto-oncogene tyrosine kinase (MerTK) in combination with anti-programmed cell death-1 (α-PD1) checkpoint blockade will enhance immune-mediated responses to radiotherapy. EXPERIMENTAL DESIGN We tested the efficacy of this triple therapy (Radiation + α-PD1 + α-MerTK mAbs) in 129Sv/Ev mice with bilateral lung adenocarcinoma xenografts. Primary tumors were treated with stereotactic radiotherapy (36 Gy in 3 12-Gy fractions), and tumors were monitored for response. RESULTS The triple therapy significantly delayed abscopal tumor growth, improved survival rates, and reduced numbers of lung metastases. We further found that the triple therapy increased the activated CD8+ and NK cells populations measured by granzyme B expression with upregulation of CD8+CD103+ tissue-resident memory cells (TRM) within the abscopal tumor microenvironment relative to radiation only. CONCLUSIONS The addition of α-PD1 + α-MerTK mAbs to radiotherapy could alter the cell death to be more immunogenic and generate adaptive immune response via increasing the retention of TRM cells in the tumor islets of the abscopal tumors which was proven to play a major role in survival of non-small cell lung cancer patients.
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Affiliation(s)
- Mauricio S Caetano
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ahmed I Younes
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Michael Quigley
- Bristol-Myers Squibb (BMS), Redwood City, California and Princeton, New Jersey
| | - Hari Menon
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chan Gao
- Bristol-Myers Squibb (BMS), Redwood City, California and Princeton, New Jersey
| | - Thomas Spires
- Bristol-Myers Squibb (BMS), Redwood City, California and Princeton, New Jersey
| | - Timothy P Reilly
- Bristol-Myers Squibb (BMS), Redwood City, California and Princeton, New Jersey
| | - Alexandra P Cadena
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Taylor R Cushman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.,University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Jonathan E Schoenhals
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.,University of Texas Southwestern Medical School, Dallas, Texas
| | - Ailin Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Radiation Oncology, First Hospital of China Medical University, China
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Maria Angelica Cortez
- Department of Experimental Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - James W Welsh
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
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4
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Simonsen KL, Fracasso PM, Bernstein SH, Wind-Rotolo M, Gupta M, Comprelli A, Reilly TP, Cassidy J. The Fast Real-time Assessment of Combination Therapies in Immuno-ONcology (FRACTION) program: innovative, high-throughput clinical screening of immunotherapies. Eur J Cancer 2018; 103:259-266. [PMID: 30292142 DOI: 10.1016/j.ejca.2018.07.127] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 07/06/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The unprecedented success of immuno-oncology (I-O) agents targeting the cytotoxic T lymphocyte-associated antigen 4 and programmed death-1/programmed death-ligand 1 pathways has stimulated the rapid development of other I-O agents against novel immune targets. Bristol-Myers Squibb has designed a novel phase II platform trial, the Fast Real-time Assessment of Combination Therapies in Immuno-ONcology (FRACTION) Program, to efficiently identify promising combinations for patients with specific malignancies. The concept and study design of the FRACTION Program-currently ongoing in patients with advanced non-small-cell lung cancer (FRACTION-Lung), gastric cancer (FRACTION-Gastric Cancer) and renal cell carcinoma (FRACTION-RCC)-are described. METHODS The FRACTION Program comprises open-label, phase II studies that use adaptive randomisation designs with rolling combination regimens. Master Protocols provide the overall study design framework, whereas Sub-Protocols introduced over time provide details on specific I-O combination therapies to which patients may be randomised. In a Master Protocol, patients are enrolled into different Study Tracks based on characteristics such as prior I-O therapy experience. Patients who progress may be rerandomised to other combination regimens from any ongoing Sub-Protocol. Primary objectives are to assess objective response rate, median duration of response and progression-free survival rate at 24 weeks; the secondary objective is to investigate safety and tolerability. Biomarker collection before and on treatment will facilitate identification of patient subsets who benefit most from each therapy. CONCLUSIONS The FRACTION Program allows for the evaluation of multiple I-O combinations through individual studies for specific tumours using an adaptive trial design and continuous enrolment.
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Affiliation(s)
- Katy L Simonsen
- Global Biometric Sciences - Oncology, Bristol-Myers Squibb, Princeton, NJ, USA.
| | | | | | | | - Manish Gupta
- Clinical Pharmacology and Pharmacometrics - Oncology, Bristol-Myers Squibb, Princeton, NJ, USA.
| | - Adriana Comprelli
- Oncology Clinical Operations Strategy, Bristol-Myers Squibb, Princeton, NJ, USA.
| | | | - Jim Cassidy
- Exploratory Clinical and Translational Research - Early Oncology Development, Bristol-Myers Squibb, Princeton, NJ, USA.
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5
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Carleton M, Zhou M, De Henau O, Phillips P, Chen T, Feng Y, Huang SP, Walsh A, Reilly TP, Melero Bermejo I. Serum interleukin 8 (IL-8) may serve as a biomarker of response to immuno-oncology (I-O) therapy. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.3025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | - Ye Feng
- Bristol-Myers Squibb, Princeton, NJ
| | | | | | | | - Ignacio Melero Bermejo
- CIMA, CUN, University Navarra, Centro de Investigación Biomédica en Red de Oncología (CIBERONC), Pamplona, Spain
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6
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Luke JJ, Azad NS, Edwards R, Huang SMA, Comprelli A, Monga M, Reilly TP, Hodi FS. Phase 1, open-label, adaptive biomarker trial that informs the evolution of combination immuno-oncology (IO) therapies (ADVISE), a precision IO approach to personalized medicine. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.tps3101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jason J. Luke
- University of Chicago Comprehensive Cancer Center, Chicago, IL
| | - Nilofer Saba Azad
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD
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7
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Aanur P, Gutierrez M, Kelly RJ, Ajani JA, Ku GY, Denlinger CS, George TJ, Wind-Rotolo M, Guan X, Gupta M, Reilly TP, Fracasso PM. FRACTION (Fast Real-time Assessment of Combination Therapies in Immuno-Oncology)-gastric cancer (GC): A randomized, open-label, adaptive, phase 2 study of nivolumab in combination with other immuno-oncology (IO) agents in patients with advanced GC. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.tps4137] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS4137 Background: Nivolumab, a fully human IgG4 mAb that targets programmed death-1, alone and in combination with ipilimumab, a fully human IgG1 mAb that targets cytotoxic T-lymphocyte antigen 4, has demonstrated encouraging clinical activity in patients with advanced GC. These data support the rationale that nivolumab in combination with other IO agents or targeted therapies may improve treatment outcomes in patients with advanced GC. Given the rapid development of novel IO agents, traditional studies cannot efficiently evaluate all possible IO-IO and IO-targeted therapy combinations. FRACTION is an innovative clinical trial program with a rolling, adaptive platform design that allows for the addition of new combination regimens, as well as withdrawal of ineffective regimens. Here we describe the study concept, key design components, and the first IO treatment combinations of FRACTION-GC, a phase 2, randomized, open-label, adaptive study in advanced GC (NCT02935634). Methods: Patients with advanced GC or gastroesophageal junction (GEJ) cancer will be enrolled based on prior IO treatment and randomized to receive nivolumab plus BMS-986016 (fully human IgG4 mAb that targets lymphocyte activation gene 3) or nivolumab plus ipilimumab. Enrollment is continuous and may offer patients consecutive treatment options based on their treatment exposure and response. The primary endpoints are objective response rate, duration of response, and progression-free survival rate at 24 weeks. The secondary endpoint is safety. Comprehensive biomarker analyses will also be performed. New treatment combinations will be added over time to explore their potential benefits and to provide a continuous flow of treatment options for patients whose cancer progresses on existing treatments. In this way, FRACTION-GC is envisioned to accelerate the development of the next generation of IO combinations for patients with metastatic GC and GEJ cancer. Clinical trial information: NCT02935634.
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Affiliation(s)
| | - Martin Gutierrez
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ
| | - Ronan Joseph Kelly
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD
| | - Jaffer A. Ajani
- The University of Texas MD Anderson Cancer Center, Houston, TX
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8
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Ptaszynska A, Cohen SM, Messing EM, Reilly TP, Johnsson E, Johnsson K. Assessing Bladder Cancer Risk in Type 2 Diabetes Clinical Trials: the Dapagliflozin Drug Development Program as a 'Case Study'. Diabetes Ther 2015; 6:357-75. [PMID: 26323372 PMCID: PMC4575305 DOI: 10.1007/s13300-015-0128-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Dapagliflozin, a sodium-glucose co-transporter 2 inhibitor, decreases plasma glucose levels by suppressing renal glucose reabsorption and increasing urinary glucose excretion. Previously published pre-clinical data suggest that dapagliflozin lacks carcinogenic potential. This article reviews data on bladder cancer with dapagliflozin to illustrate the challenges in assessing bladder cancer in drug development programs in patients with type 2 diabetes mellitus (T2DM). METHODS Clinical cases of bladder cancer were analyzed in a pooled population of >9000 patients in 21 phase 2b/3 dapagliflozin clinical trials of up to 208 weeks' duration. RESULTS In the 21-study pool, demographic and baseline characteristics were generally consistent between dapagliflozin and comparator groups. The overall incidence of malignancies was also balanced between the treatment groups, with an incidence rate ratio (IRR) of 1.035 [95% confidence interval (CI): 0.724, 1.481]. Nine of 5936 dapagliflozin-treated patients and 1 of 3403 comparator-treated patients reported bladder cancer, with an IRR of 5.168 (95% CI: 0.677, 233.55). All of these patients had clinical attributes typical of bladder cancer in the general population (≥60-year-old males; 8 of the 10 patients were current/former smokers). All cases of bladder cancer were reported within 2 years of starting study treatment. There was an absence of detailed workup of hematuria prior to randomization, and no hematuria workup data were collected proactively in the dapagliflozin trials, which is typical of clinical practice. Failure to exclude bladder cancer prior to randomization increases the chance of recruiting patients with pre-existing bladder cancer in clinical trials and may delay the final diagnosis. Of the nine dapagliflozin-treated patients with bladder cancer, eight had microscopic hematuria prior to start of treatment or within 6 months of initiating study treatment. CONCLUSION The assessment of bladder cancer data illustrates the challenges of characterizing cancer risk in T2DM drug development programs. The totality of evidence to date does not suggest a causal relationship between dapagliflozin and bladder cancer. FUNDING AstraZeneca.
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Affiliation(s)
| | | | - Edward M Messing
- Department of Urology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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9
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Chakraborty M, Fullerton AM, Semple K, Chea LS, Proctor WR, Bourdi M, Kleiner DE, Zeng X, Ryan PM, Dagur PK, Berkson JD, Reilly TP, Pohl LR. Drug-induced allergic hepatitis develops in mice when myeloid-derived suppressor cells are depleted prior to halothane treatment. Hepatology 2015; 62:546-57. [PMID: 25712247 PMCID: PMC6528654 DOI: 10.1002/hep.27764] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 02/21/2015] [Indexed: 12/13/2022]
Abstract
UNLABELLED Clinical evidence suggests that many cases of serious idiosyncratic drug-induced liver injury are mediated by the adaptive immune system in response to hepatic drug-protein adducts, also referred to as "drug-induced allergic hepatitis"; but detailed mechanistic proof has remained elusive due to the lack of animal models. We have hypothesized that drug-induced allergic hepatitis is as rare in animals as it is in humans due at least in part to the tolerogenic nature of the liver. We provide evidence that immune tolerance can be overcome in a murine model of halothane-induced liver injury initiated by trifluoroacetylated protein adducts of halothane formed in the liver. Twenty-four hours after female Balb/cJ mice were initially treated with halothane, perivenous necrosis and an infiltration of CD11b(+) Gr-1(high) cells were observed in the liver. Further study revealed a subpopulation of myeloid-derived suppressor cells within the CD11b(+) Gr-1(high) cell fraction that inhibited the proliferation of both CD4(+) and CD8(+) T cells. When CD11b(+) Gr-1(high) cells were depleted from the liver with Gr-1 antibody treatment, enhanced liver injury was observed at 9 days after halothane rechallenge. Toxicity was associated with increased serum levels of interleukin-4 and immunoglobulins G1 and E directed against hepatic trifluoroacetylated protein adducts, as well as increased hepatic infiltration of eosinophils and CD4(+) T cells, all features of an allergic reaction. When hepatic CD4(+) T cells were depleted 5 days after halothane rechallenge, trifluoroacetylated protein adduct-specific serum immunoglobulin and hepatotoxicity were reduced. CONCLUSION Our data provide a rational approach for developing animal models of drug-induced allergic hepatitis mediated by the adaptive immune system and suggest that impaired liver tolerance may predispose patients to this disease.
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Affiliation(s)
- Mala Chakraborty
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Aaron M. Fullerton
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kenrick Semple
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Lynette S. Chea
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - William R. Proctor
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mohammed Bourdi
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - David E. Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Xiangbin Zeng
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Pauline M. Ryan
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Pradeep K. Dagur
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Julia D. Berkson
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Timothy P. Reilly
- Exploratory Clinical & Translational Research, Bristol-Myers Squibb Company, Princeton, NJ, USA
| | - Lance R. Pohl
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA.,Corresponding Author: Lance R. Pohl, PharmD, PhD, Scientist Emeritus, Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung and Blood Institute, National Institutes of Health, Building 10, Room 8N110, 10 Center Drive, Bethesda, MD 20892-1760, Tel: 1-301-451-1097; Fax: 1-301-480-4852,
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10
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Tirmenstein M, Horvath J, Graziano M, Mangipudy R, Dorr T, Colman K, Zinker B, Kirby M, Cheng PTW, Patrone L, Kozlosky J, Reilly TP, Wang V, Janovitz E. Utilization of the Zucker Diabetic Fatty (ZDF) Rat Model for Investigating Hypoglycemia-related Toxicities. Toxicol Pathol 2015; 43:825-37. [PMID: 26085543 DOI: 10.1177/0192623315581020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Glucokinase (GK) catalyzes the initial step in glycolysis and is a key regulator of glucose homeostasis. Therefore, glucokinase activators (GKa) have potential benefit in treating type 2 diabetes. Administration of a Bristol-Myers Squibb GKa (BMS-820132) to healthy euglycemic Sprague-Dawley (SD) rats and beagle dogs in 1 mo toxicology studies resulted in marked and extended hypoglycemia with associated clinical signs of toxicity and degenerative histopathological changes in the stomach, sciatic nerve, myocardium, and skeletal muscles at exposures comparable to those expected at therapeutic clinical exposures. To investigate whether these adverse effects were secondary to exaggerated pharmacology (prolonged hypoglycemia), BMS-820132 was administered daily to male Zucker diabetic fatty (ZDF) rats for 1 mo. ZDF rats are markedly hyperglycemic and insulin resistant. BMS-820132 did not induce hypoglycemia, clinical signs of hypoglycemia, or any of the histopathologic adverse effects observed in the 1 mo toxicology studies at exposures that exceeded those observed in SD rats and dogs. This indicates that the toxicity observed in euglycemic animals was secondary to the exaggerated pharmacology of potent GK activation. This study indicates that ZDF rats, with conventional toxicity studies, are a useful disease model for testing antidiabetic agents and determining toxicities that are independent of prolonged hypoglycemia.
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Affiliation(s)
- Mark Tirmenstein
- Bristol-Myers Squibb, Drug Safety Evaluation, New Brunswick, New Jersey, USA
| | - Joseph Horvath
- Bristol-Myers Squibb, Drug Safety Evaluation, New Brunswick, New Jersey, USA
| | - Michael Graziano
- Bristol-Myers Squibb, Drug Safety Evaluation, Princeton, New Jersey, USA
| | - Raja Mangipudy
- Bristol-Myers Squibb, Drug Safety Evaluation, New Brunswick, New Jersey, USA
| | - Thomas Dorr
- Bristol-Myers Squibb, Drug Safety Evaluation, New Brunswick, New Jersey, USA
| | - Karyn Colman
- Bristol-Myers Squibb, Drug Safety Evaluation, New Brunswick, New Jersey, USA Present affiliation: Novartis Institutes for BioMedical Research, East Hanover, New Jersey, USA
| | - Bradley Zinker
- Bristol-Myers Squibb, Discovery Biology, Pennington, New Jersey, USA
| | - Mark Kirby
- Bristol-Myers Squibb, Discovery Biology, Pennington, New Jersey, USA Present affiliation: Lilly China Research and Development Center, Shanghai, China
| | - Peter T W Cheng
- Bristol-Myers Squibb, Discovery Chemistry, Pennington, New Jersey, USA
| | - Laura Patrone
- Bristol-Myers Squibb, Drug Safety Evaluation, New Brunswick, New Jersey, USA
| | - John Kozlosky
- Bristol-Myers Squibb, Drug Safety Evaluation, New Brunswick, New Jersey, USA
| | - Timothy P Reilly
- Bristol-Myers Squibb, Exploratory Clinical and Translational Research, Princeton, New Jersey, USA
| | - Victor Wang
- Bristol-Myers Squibb, Drug Safety Evaluation, New Brunswick, New Jersey, USA
| | - Evan Janovitz
- Bristol-Myers Squibb, Discovery Toxicology, Pennington, New Jersey, USA
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Jabbour SA, Whaley JM, Tirmenstein M, Poucher SM, Reilly TP, Boulton DW, Saye J, List JF, Parikh S. Targeting Renal Glucose Reabsorption for the Treatment of Type 2 Diabetes Mellitus Using the SGLT2 Inhibitor Dapagliflozin. Postgrad Med 2015; 124:62-73. [DOI: 10.3810/pgm.2012.07.2569] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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12
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Roy D, Chadwick KD, Tatarkiewicz K, LaCerte C, Bergholm AM, Brodie T, Mangipudy RS, Parkes D, Graziano MJ, Reilly TP. The glucagon-like peptide-1-based therapeutics exenatide and saxagliptin did not cause detrimental effects on the pancreas in mice, rats, dogs and monkeys. Diabetes Obes Metab 2014; 16:910-21. [PMID: 24666399 DOI: 10.1111/dom.12294] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/26/2014] [Accepted: 03/19/2014] [Indexed: 01/12/2023]
Abstract
AIMS Recent reports in the literature have suggested that glucagon-like peptide-1 (GLP-1)-based therapies may lead to increased risk of pancreatic pathology leading to chronic pancreatic injury and pancreatic neoplasia. Extensive non-clinical and clinical safety testing was conducted to support the global development of exenatide twice daily, exenatide once weekly and saxagliptin. Our aim was to integrate these non-clinical data obtained with both mechanisms of GLP-1-based drugs to provide complementary data regarding the potential for drug-induced pancreatic safety signals. METHODS More than 70 regulated non-clinical toxicology studies in rodents and non-rodents were conducted in accordance with International Conference on Harmonisation and US Food and Drug Administration guidance documents, current industry standards, animal welfare regulations and in compliance with Good Laboratory Practice regulations. Treatment duration was up to 2 years in rodents and up to 12 months in non-rodents using high doses representing large multiples of human exposures (up to 130× for exenatide and 2200× for saxagliptin). Comprehensive pancreas assessments involved more than 2400 pancreata from animals exposed to exenatide and over 1700 pancreata from animals exposed to saxagliptin. RESULTS Neither exenatide nor saxagliptin treatment resulted in drug-related microscopic changes indicative of acute or chronic adverse effects (including neoplasia) in the endocrine or exocrine pancreas, at doses far exceeding the maximum human systemic exposures. CONCLUSIONS These data substantially add to the weight of evidence supporting the lack of non-clinical drug-induced pancreatic safety signals in animals exposed to GLP-1-based therapies.
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Affiliation(s)
- D Roy
- Nonclinical Drug Safety, Amylin LLC, a Wholly Owned Subsidiary of Bristol-Myers Squibb Company, San Diego, CA, USA
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13
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Reilly TP, Graziano MJ, Janovitz EB, Dorr TE, Fairchild C, Lee F, Chen J, Wong T, Whaley JM, Tirmenstein M. Carcinogenicity risk assessment supports the chronic safety of dapagliflozin, an inhibitor of sodium-glucose co-transporter 2, in the treatment of type 2 diabetes mellitus. Diabetes Ther 2014; 5:73-96. [PMID: 24474422 PMCID: PMC4065287 DOI: 10.1007/s13300-014-0053-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Dapagliflozin is a selective inhibitor of the sodium-glucose co-transporter 2 (SGLT2) that increases urinary glucose excretion to reduce hyperglycemia in the treatment of type 2 diabetes mellitus. A robust carcinogenicity risk assessment was undertaken to assess the chronic safety of dapagliflozin and SGLT2 inhibition. METHODS Genotoxicity potential of dapagliflozin and its metabolites was assessed in silico, in vitro, and in vivo. Dapagliflozin was administered daily by oral gavage to mice, rats, and dogs to evaluate carcinogenicity risks, including the potential for tumor promotion. SGLT2(-/-) mice were observed to evaluate the effects of chronic glucosuria. The effects of dapagliflozin and increased glucose levels on a panel of human bladder transitional cell carcinoma (TCC) cell lines were also evaluated in vitro and in an in vivo xenograft model. RESULTS Dapagliflozin and its metabolites were not genotoxic. In CD-1 mice and Sprague-Dawley rats treated for up to 2 years at ≥100× human clinical exposures, dapagliflozin showed no differences versus controls for tumor incidence, time to onset for background tumors, or urinary bladder proliferative/preneoplastic lesions. No tumors or preneoplastic lesions were observed in dogs over 1 year at >3,000× the clinical exposure of dapagliflozin or in SGLT2(-/-) mice observed over 15 months. Transcription profiling in Zucker diabetic fatty rats showed that 5-week dapagliflozin treatment did not induce tumor promoter-associated or cell proliferation genes. Increasing concentrations of glucose, dapagliflozin, or its primary metabolite, dapagliflozin 3-O-glucuronide, did not affect in vitro TCC proliferation rates and dapagliflozin did not enhance tumor growth in nude mice heterotopically implanted with human bladder TCC cell lines. CONCLUSION A multitude of assessments of tumorigenicity risk consistently showed no effects, suggesting that selective SGLT2 inhibition and, specifically, dapagliflozin are predicted to not be associated with increased cancer risk.
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Affiliation(s)
- Timothy P Reilly
- Drug Safety Evaluation, Research and Development, Bristol-Myers Squibb, Princeton, NJ, USA,
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14
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Chadwick KD, Fletcher AM, Parrula MC, Bonner-Weir S, Mangipudy RS, Janovitz E, Graziano MJ, Roy D, Reilly TP. Occurrence of spontaneous pancreatic lesions in normal and diabetic rats: a potential confounding factor in the nonclinical assessment of GLP-1-based therapies. Diabetes 2014; 63:1303-14. [PMID: 24222349 DOI: 10.2337/db13-1268] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Glucagon-like peptide 1-based therapies, collectively described as incretins, produce glycemic benefits in the treatment of type 2 diabetes. Recent publications raised concern for a potential increased risk of pancreatitis and pancreatic cancer with incretins based in part on findings from a small number of rodents. However, extensive toxicology assessments in a substantial number of animals dosed up to 2 years at high multiples of human exposure do not support these concerns. We hypothesized that the lesions being attributed to incretins are commonly observed background findings and endeavored to characterize the incidence of spontaneous pancreatic lesions in three rat strains (Sprague-Dawley [S-D] rats, Zucker diabetic fatty [ZDF] rats, and rats expressing human islet amyloid polypeptide [HIP]; n = 36/group) on a normal or high-fat diet over 4 months. Pancreatic findings in all groups included focal exocrine degeneration, atrophy, inflammation, ductular cell proliferation, and/or observations in large pancreatic ducts similar to those described in the literature, with an incidence of exocrine atrophy/inflammation seen in S-D (42-72%), HIP (39%), and ZDF (6%) rats. These data indicate that the pancreatic findings attributed to incretins are common background findings, observed without drug treatment and independent of diet or glycemic status, suggesting a need to exercise caution when interpreting the relevance of some recent reports regarding human safety.
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15
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Martin-Murphy BV, You Q, Wang H, De La Houssaye BA, Reilly TP, Friedman JE, Ju C. Mice lacking natural killer T cells are more susceptible to metabolic alterations following high fat diet feeding. PLoS One 2014; 9:e80949. [PMID: 24465369 PMCID: PMC3896335 DOI: 10.1371/journal.pone.0080949] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Accepted: 10/14/2013] [Indexed: 12/12/2022] Open
Abstract
Current estimates suggest that over one-third of the adult population has metabolic syndrome and three-fourths of the obese population has non-alcoholic fatty liver disease (NAFLD). Inflammation in metabolic tissues has emerged as a universal feature of obesity and its co-morbidities, including NAFLD. Natural Killer T (NKT) cells are a subset of innate immune cells that abundantly reside within the liver and are readily activated by lipid antigens. There is general consensus that NKT cells are pivotal regulators of inflammation; however, disagreement exists as to whether NKT cells exert pathogenic or suppressive functions in obesity. Here we demonstrate that CD1d−/− mice, which lack NKT cells, were more susceptible to weight gain and fatty liver following high fat diet (HFD) feeding. Compared with their WT counterparts, CD1d−/− mice displayed increased adiposity and greater induction of inflammatory genes in the liver suggestive of the precursors of NAFLD. Calorimetry studies revealed a significant increase in food intake and trends toward decreased metabolic rate and activity in CD1d−/− mice compared with WT mice. Based on these findings, our results suggest that NKT cells play a regulatory role that helps to prevent diet-induced obesity and metabolic dysfunction and may play an important role in mechanisms governing cross-talk between metabolism and the immune system to regulate energy balance and liver health.
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Affiliation(s)
- Brittany V. Martin-Murphy
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Qiang You
- Department of Biotherapy, Second Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Hong Wang
- Division of Endocrinology, Diabetes & Metabolism, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Becky A. De La Houssaye
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Timothy P. Reilly
- Drug Safety Evaluation, Research & Development, Bristol-Myers Squibb Company, Princeton, New Jersey, United States of America
| | - Jacob E. Friedman
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Cynthia Ju
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
- * E-mail:
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16
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Tirmenstein M, Dorr TE, Janovitz EB, Hagan D, Abell LM, Onorato JM, Whaley JM, Graziano MJ, Reilly TP. Nonclinical Toxicology Assessments Support the Chronic Safety of Dapagliflozin, a First-in-Class Sodium-Glucose Cotransporter 2 Inhibitor. Int J Toxicol 2013; 32:336-50. [DOI: 10.1177/1091581813505331] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Dapagliflozin, a first-in-class, selective inhibitor of sodium-glucose cotransporter 2 (SGLT2), promotes urinary glucose excretion to reduce hyperglycemia for the treatment of type 2 diabetes. A series of nonclinical studies were undertaken to evaluate dapagliflozin in species where it was shown to have pharmacologic activity comparable with that in humans at doses that resulted in supratherapeutic exposures. In vitro screening (>300 targets; 10 μmol/L) indicated no significant off-target activities for dapagliflozin or its primary human metabolite. Once daily, orally administered dapagliflozin was evaluated in Sprague-Dawley rats (≤6 months) and in beagle dogs (≤1 year) at exposures >5000-fold those observed at the maximum recommended human clinical dose (MRHD; 10 mg). Anticipated, pharmacologically mediated effects of glucosuria, osmotic diuresis, and mild electrolyte loss were observed, but there were no adverse effects at clinically relevant exposures, including in the kidneys or urogenital tract. The SGLT2−/− mice, which show chronic glucosuria, and dapagliflozin-treated, wild-type mice exhibited similar safety profiles. In rats but not dogs, dapagliflozin at >2000-fold MRHD exposures resulted in tissue mineralization and trabecular bone accretion. Investigative studies suggested that the effect was not relevant to human safety, since it was partially related to off-target inhibition of SGLT1, which was observed only at high doses of dapagliflozin and resulted in intestinal glucose malabsorption and increased intestinal calcium absorption. The rigorous assessment of supra- and off-target dapagliflozin pharmacology in nonclinical species allowed for a thorough evaluation of potential toxicity, providing us with confidence in its safety in patients with diabetes.
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Affiliation(s)
- Mark Tirmenstein
- Bristol-Myers Squibb, Drug Safety Evaluation, Research and Development, New Brunswick, NJ, USA
| | - Thomas E. Dorr
- Bristol-Myers Squibb, Drug Safety Evaluation, Research and Development, New Brunswick, NJ, USA
| | - Evan B. Janovitz
- Bristol-Myers Squibb, Discovery Toxicology, Research and Development, Hopewell, NJ, USA
| | - Deborah Hagan
- Bristol-Myers Squibb, Metabolic Disease Discovery Biology, Hopewell, NJ, USA
| | - Lynn M. Abell
- Bristol-Myers Squibb, Lead Evaluation and Mechanistic Biochemistry, Molecular Sciences and Candidate Optimization, Research and Development, Hopewell, NJ, USA
| | - Joelle M. Onorato
- Bristol-Myers Squibb, Bioanalytical and Discovery Analytical Sciences, Research and Development, Hopewell, NJ, USA
| | - Jean M. Whaley
- Bristol-Myers Squibb, Metabolic Disease Discovery Biology, Hopewell, NJ, USA
| | - Michael J. Graziano
- Bristol-Myers Squibb, Drug Safety Evaluation, Research and Development, Princeton, NJ, USA
| | - Timothy P. Reilly
- Bristol-Myers Squibb, Drug Safety Evaluation, Research and Development, Princeton, NJ, USA
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17
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Whaley JM, Tirmenstein M, Reilly TP, Poucher SM, Saye J, Parikh S, List JF. Targeting the kidney and glucose excretion with dapagliflozin: preclinical and clinical evidence for SGLT2 inhibition as a new option for treatment of type 2 diabetes mellitus. Diabetes Metab Syndr Obes 2012; 5:135-48. [PMID: 22923998 PMCID: PMC3422910 DOI: 10.2147/dmso.s22503] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a novel class of glucuretic, antihyperglycemic drugs that target the process of renal glucose reabsorption and induce glucuresis independently of insulin secretion or action. In patients with type 2 diabetes mellitus, SGLT2 inhibitors have been found to consistently reduce measures of hyperglycemia, including hemoglobin A1c, fasting plasma glucose, and postprandial glucose, throughout the continuum of disease. By inducing the renal excretion of glucose and its associated calories, SGLT2 inhibitors reduce weight and have the potential to be disease modifying by addressing the caloric excess that is believed to be one of the root causes of type 2 diabetes mellitus. Additional benefits, including the possibility for combination with insulin-dependent antihyperglycemic drugs, a low potential for hypoglycemia, and the ability to reduce blood pressure, were anticipated from the novel mechanism of action and have been demonstrated in clinical studies. Mechanism-related risks include an increased incidence of urinary tract and genital infections and the possibility of over-diuresis in volume-sensitive patients. Taken together, the results of Phase III clinical studies generally point to a positive benefit-risk ratio across the continuum of diabetes patients. To date, data on dapagliflozin, a selective SGLT2 inhibitor in development, demonstrate that the kidney is an efficacious and safe target for therapy, and that SGLT2 inhibition may have benefits for patients with type 2 diabetes mellitus beyond glycemic control.
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Affiliation(s)
- Jean M Whaley
- Bristol-Myers Squibb, Metabolic Disease Discovery Biology, Research and Development, Princeton, NJ, USA
| | - Mark Tirmenstein
- Bristol-Myers Squibb, Drug Safety Evaluation, Research and Development, New Brunswick and Princeton, NJ, USA
| | - Timothy P Reilly
- Bristol-Myers Squibb, Drug Safety Evaluation, Research and Development, New Brunswick and Princeton, NJ, USA
| | - Simon M Poucher
- AstraZeneca, Cardiovascular and Gastrointestinal Innovative Medicines Science Unit, Alderley Park, Macclesfield, Cheshire, UK
| | - JoAnne Saye
- AstraZeneca, Global Safety Assessment, Research and Development, Wilmington, DE, USA
| | - Shamik Parikh
- AstraZeneca, Cardiovascular, Clinical Development, Wilmington, DE, USA
| | - James F List
- Bristol-Myers Squibb, Global Clinical Development, Research and Development, Princeton, NJ, USA
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Abstract
In this study, the influence of physical efforts on occurrence of match injury in a professional soccer club was investigated. Computerised motion-analysis was used to measure the physical efforts of players during 10 injury situations. Total distance and those covered at different movement intensities were measured across the 5-min period preceding injury. If the final run preceding injury involved a high-intensity action (HIA), the distance, duration and speed of the effort and the recovery time between this and the penultimate HIA were measured. To determine the influence of these physical efforts, the results were compared to a normative profile for players computed from data across 5 games for the same variables; habitual distances covered over a 5-min period and characteristics of and recovery time between HIA. Compared to the normative profile, no differences were reported in physical characteristics during the period leading up to injury or for HIA although the latter were substantially higher in intensity (duration and distance). A lower than normal recovery time between HIA prior to injury was observed (35.6+/-16.8 s vs. 98.8+/-17.5 s, p=0.003). Within the limitations of the small sample, these findings may aid in further understanding injury and physical performance in elite soccer.
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Affiliation(s)
- C Carling
- LOSC Lille Métropole Football Club, Youth Academy, Camphin-en-Pévèle, France.
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Haggerty HG, Abbott MA, Reilly TP, DeVona DA, Gleason CR, Tay L, Dodge R, Aranda R. Evaluation of immunogenicity of the T cell costimulation modulator abatacept in patients treated for rheumatoid arthritis. J Rheumatol 2007; 34:2365-2373. [PMID: 18050376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE The immunogenicity of abatacept, a selective costimulation modulator, administered intravenously, was assessed across Phase II and III trials in patients with rheumatoid arthritis (RA). METHODS Two direct-format enzyme-linked immunosorbent assays evaluated antibody responses [whole abatacept molecule (CTLA-4 and Ig portion) and CTLA-4 portion only (Assay A)] in the Phase II trials. During the Phase III trials and 2-year open-label periods, a similar, but more sensitive, Assay B was employed. Serum samples collected prestudy, during treatment, and 56 and/or 85 days following the last dose were evaluated. Seropositive samples with anti-CTLA-4 reactivity and sufficiently low drug levels were further characterized for neutralizing activity (cell-based bioassay). RESULTS A total of 2237 patients with both pre- and post-baseline serum samples were eligible for assessment. Of these, 62 (2.8%) patients demonstrated an anti-abatacept or anti-CTLA-4 response, determined using either Assay A or B. Using the more sensitive Assay B, 60 of 1990 patients (3.0%) demonstrated an antibody response to the whole abatacept molecule (n = 41, 2.1%) or the CTLA-4 portion (n = 19, 1.0%). Of the 1764 RA patients evaluated in the Phase III studies, 203 discontinued therapy and had sera collected 56 and/or 85 days after discontinuation. Patients who discontinued had a higher incidence of immunogenicity versus patients who did not discontinue (7.4% vs 2.6%, respectively). Of 20 patients positive for anti-CTLA-4 reactivity, 13 were eligible for assessment with the neutralization bioassay. Of these, 8 patients exhibited neutralizing activity. Seroconversion occurred with no adverse safety outcomes or effect on pharmacokinetic parameters. No consistent pattern was observed between antibody response and loss of efficacy (American College of Rheumatology 20 and Health Assessment Questionnaire responses). CONCLUSION Abatacept was associated with a low incidence of immunogenicity in patients with RA and lacked any adverse sequelae.
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Affiliation(s)
- Helen G Haggerty
- Immunotoxicology, Drug Safety Evaluation, Bristol-Myers Squibb, Syracuse, New York 13057, USA.
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20
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Bourdi M, Eiras DP, Holt MP, Webster MR, Reilly TP, Welch KD, Pohl LR. Role of IL-6 in an IL-10 and IL-4 Double Knockout Mouse Model Uniquely Susceptible to Acetaminophen-Induced Liver Injury. Chem Res Toxicol 2007; 20:208-16. [PMID: 17305405 DOI: 10.1021/tx060228l] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Drug-induced hepatitis remains a challenging problem for drug development and safety because of the lack of animal models. In the current work, we discovered a unique interaction that makes mice deficient in both IL-10 and IL-4 (IL-10/4-/-) highly sensitive to the hepatotoxic effects of acetaminophen (APAP). Male C57Bl/6 wild type (WT) and mice deficient in one or more cytokines were treated with 120 mg/kg APAP. Within 24 h after WT, IL-10-/-, IL-4-/-, or IL-10/4-/- mice were administered APAP, 75% of the IL-10/4-/- mice died of massive hepatic injury while all other genotypes were resistant to liver toxicity at this dose of APAP. The unique susceptibility of IL-10/4-/- mice was associated with reduced levels of liver glutathione and remarkably high serum levels of IL-6 and several proinflammatory factors including TNF-alpha, IFN-gamma, macrophage inflammatory protein-1alpha (MIP-1alpha), monocyte chemoattractant protein-1 (MCP-1), macrophage inflammatory protein-2 (MIP-2), and osteopontin (OPN) as well as nitric oxide (NO). IL-6 appeared to have a causal role in controlling the unique susceptibility of IL-10/4-/- mice to APAP-induced liver disease (AILD) because IL-6 neutralizing antibody reversed the high sensitivity of these mice to AILD. Moreover, IL-10/4/6-/- mice were also resistant to the enhanced susceptibility to AILD and expressed relatively low levels of most proinflammatory factor genes that were elevated in the IL-10/4-/- mice. In conclusion, liver homeostasis following AILD appears to be highly dependent on the activities of both IL-10 and IL-4, which together help prevent overexpression of IL-6 and other potential hepatotoxic factors.
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Affiliation(s)
- Mohammed Bourdi
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland 20892, USA.
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Abstract
Drug-induced liver injury (DILI) is a major safety concern in drug development. Its prediction and prevention have been hindered by limited knowledge of the underlying mechanisms, in part the result of a lack of animal models. We developed a mouse model of halothane-induced liver injury and characterized the mechanisms accounting for tissue damage. Female and male Balb/c, DBA/1, and C57BL/6J mice were injected intraperitoneally with halothane. Serum levels of alanine aminotransferase and histology were evaluated to determine liver injury. Balb/c mice were found to be the most susceptible strain, followed by DBA/1, with no significant hepatotoxicity observed in C57BL/6J mice. Female Balb/c and DBA/1 mice developed more severe liver damage compared with their male counterparts. Bioactivation of halothane occurred similarly in all three strains based on detection of liver proteins adducted by the reactive metabolite. Mechanistic investigations revealed that hepatic message levels of tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta); IL-6, and IL-8 were significantly higher in halothane-treated Balb/c mice compared to DBA/1 and C57BL/6J mice. Moreover, a higher number of neutrophils were recruited into the liver of Balb/c mice upon halothane treatment compared with DBA/1, with no obvious neutrophil infiltration detected in C57BL/6J mice. Neutrophil depletion experiments demonstrated a crucial role for these cells in the development of halothane-induced liver injury. The halothane-initiated hepatotoxicity and innate immune response-mediated escalation of tissue damage are consistent with events that occur in many cases of DILI. In conclusion, our model provides a platform for elucidating strain-based and gender-based susceptibility factors in DILI development.
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Affiliation(s)
- Qiang You
- Department of Pharmaceutical Sciences, University of Colorado Health Sciences Center, Denver, CO 80262, USA
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22
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Welch KD, Reilly TP, Bourdi M, Hays T, Pise-Masison CA, Radonovich MF, Brady JN, Dix DJ, Pohl LR. Genomic identification of potential risk factors during acetaminophen-induced liver disease in susceptible and resistant strains of mice. Chem Res Toxicol 2006; 19:223-33. [PMID: 16485898 DOI: 10.1021/tx050285z] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Drug-induced liver disease (DILD) continues to cause significant morbidity and mortality and impair new drug development. Mounting evidence suggests that DILD is a complex, multifactorial disease in which no one factor is likely to be an absolute indicator of susceptibility. As an approach to better understand the multifactorial basis of DILD, we recently compared the hepatic proteomes of mice that were resistant (SJL) and susceptible (C57Bl/6) to APAP-induced liver disease (AILD) wherein we identified potential risk factors and mechanistic pathways responsible for DILD. In this study, we have uncovered additional potential risk factors by comparing hepatic mRNA expression profiles of the same two strains of mice with that of SJLxB6-F1 hybrid (F1) mice, which were found to be of intermediate susceptibility to AILD. Global hepatic gene expression profiling over a 24 h period following APAP treatment revealed elevated patterns in the mRNA expression of cytoprotective genes in resistant SJL mice as compared to susceptible B6 mice, while F1 mice had intermediate mRNA expression levels of these genes. One of these genes encoded for heat shock protein (HSP) 70 whose relative protein expression among the three strains of mice was found to parallel that of their mRNA levels, suggesting that this protein had a protective role against AILD. However, there was no difference in the susceptibility of HSP70 knockout (KO) mice to AILD as compared to wild-type (WT) mice. There were also protoxicant genes, such as osteopontin (OPN), with elevated mRNA expression levels in the B6 mice as compared to the SJL mice and with intermediate levels in the F1 mice, suggesting that they may play a role in exacerbating liver injury after APAP treatment. In support of this hypothesis, OPN KO mice were found to be more resistant to AILD than WT mice. Additionally, the results from both the proteomic and the genomic studies were compared. The two approaches were found to be complementary to each other and not simply overlapping. Our findings suggest that comparative gene expression analysis of susceptible and resistant mouse strains may lead to the identification of factors that could have a role in determining the susceptibility of individuals to DILD.
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Affiliation(s)
- Kevin D Welch
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland 20892, USA.
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Luyendyk JP, Lehman-McKeeman LD, Nelson DM, Bhaskaran VM, Reilly TP, Car BD, Cantor GH, Maddox JF, Ganey PE, Roth RA. Unique gene expression and hepatocellular injury in the lipopolysaccharide-ranitidine drug idiosyncrasy rat model: comparison with famotidine. Toxicol Sci 2006; 90:569-85. [PMID: 16415329 DOI: 10.1093/toxsci/kfj103] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Rats cotreated with lipopolysaccharide (LPS) and ranitidine (RAN) but not LPS and famotidine (FAM) develop hepatocellular injury in an animal model of idiosyncratic drug reactions. Evaluation of liver gene expression in rats given LPS and/or RAN led to confirmation that the hemostatic system, hypoxia, and neutrophils (PMNs) are critical mediators in LPS/RAN-induced liver injury. We tested the hypothesis that unique gene expression changes distinguish LPS/RAN-treated rats from rats given LPS or RAN alone and from those cotreated with LPS/FAM. Rats were treated with a nonhepatotoxic dose of LPS (44.4 x 10(6) endotoxin units/kg, iv) or its vehicle. Two hours thereafter they were given RAN (30 mg/kg, iv), FAM (either 6 mg/kg, a pharmacologically equi-efficacious dose, or 28.8 mg/kg, an equimolar dose, iv), or vehicle. They were killed 2 or 6 h after drug treatment for evaluation of hepatotoxicity (2 and 6 h) and liver gene expression (2 h only). At a time before the onset of hepatocellular injury, hierarchical clustering distinguished rats treated with LPS/RAN from those given LPS alone. 205 probesets were expressed differentially to a greater or lesser degree only in LPS/RAN-treated rats compared to LPS/FAM or LPS alone, which did not develop liver injury. These included VEGF, EGLN3, MAPKAPK-2, BNIP3, MIP-2, COX-2, EGR-1, PAI-1, IFN-gamma, and IL-6. Expression of these genes was confirmed by real-time PCR. Serum concentrations of MIP-2, PAI-1, IFN-gamma, and IL-6 correlated with their respective gene expression patterns. Overall, the expression of several gene products capable of controlling requisite mediators of injury (i.e., hemostasis, hypoxia, PMNs) in this model were enhanced in livers of LPS/RAN-treated rats. Furthermore, enhanced expression of MAPKAPK-2 in RAN-treated rats and its target genes in LPS/RAN-treated rats suggests that p38/MAPKAPK-2 signaling is a regulation point for enhancement of LPS-induced gene expression by RAN.
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Affiliation(s)
- James P Luyendyk
- Department of Pharmacology and Toxicology, Center for Integrative Toxicology, National Food Safety and Toxicology Center, Michigan State University, East Lansing, Michigan 48824, USA
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Luyendyk JP, Lehman-McKeeman LD, Nelson DM, Bhaskaran VM, Reilly TP, Car BD, Cantor GH, Deng X, Maddox JF, Ganey PE, Roth RA. Coagulation-dependent gene expression and liver injury in rats given lipopolysaccharide with ranitidine but not with famotidine. J Pharmacol Exp Ther 2006; 317:635-43. [PMID: 16401727 DOI: 10.1124/jpet.105.096305] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
In an animal model of drug idiosyncrasy, rats cotreated with nonhepatotoxic doses of lipopolysaccharide (LPS) and ranitidine (RAN) develop hepatocellular injury, whereas rats treated with LPS and famotidine (FAM) do not. The coagulation system and neutrophils (PMNs) are requisite mediators of LPS/RAN-induced liver injury. We tested the hypothesis that unique gene expression in LPS/RAN-treated rats requires coagulation system activation and that these changes are absent in rats given LPS and FAM. Rats were treated with a nonhepatotoxic dose of LPS (44.4 x 10(6) endotoxin units/kg i.v.) or its vehicle, and then 1 h later, they were treated with heparin (3000 U/kg) or its vehicle. One hour thereafter, they were given RAN (30 mg/kg), FAM (6 mg/kg, a pharmacologically equiefficacious dose, or 28.8 mg/kg, an equimolar dose), or vehicle (i.v.). They were killed 2 or 6 h after drug treatment for evaluation of hepatotoxicity, coagulation system activation, and liver gene expression (2 h only). Statistical filtering of gene array results and real-time polymerase chain reaction identified groups of genes expressed in LPS/RAN-treated rats but not LPS/FAM-treated rats that were either changed or unchanged by heparin administration. For example, LPS/RAN-induced mRNA expression of the inflammatory mediators interleukin-6, cyclooxygenase-2, and macrophage inflammatory protein-2 (MIP-2) was reduced by anticoagulation. Enhancement of serum MIP-2 and plasminogen activator inhibitor-1 concentrations in LPS/RAN-treated rats was prevented by anticoagulation. The results suggest cross-talk between hemostasis-induced gene expression and inflammation (e.g., PMN function) in the genesis of hepatocellular injury in LPS/RAN-treated rats. In contrast, neither the expression of such genes nor hepatocellular necrosis occurred in rats treated with LPS/FAM.
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Affiliation(s)
- James P Luyendyk
- Department of Pharmacology and Toxicology, Center for Integrative Toxicology, National Food Safety and Toxicology Center, Michigan State University, East Lansing, MI 48824, USA
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Welch KD, Wen B, Goodlett DR, Yi EC, Lee H, Reilly TP, Nelson SD, Pohl LR. Proteomic identification of potential susceptibility factors in drug-induced liver disease. Chem Res Toxicol 2005; 18:924-33. [PMID: 15962927 DOI: 10.1021/tx050011b] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Drug-induced liver disease (DILD) causes significant morbidity and mortality and impairs new drug development. Currently, no known criteria can predict whether a drug will cause DILD or what risk factors make an individual susceptible. Although it has been shown in mouse studies that the disruption of key regulatory factors, such as cyclooxygenase-2 (COX-2), interleukin (IL)-6, and IL-10, increased susceptibility to DILD caused by acetaminophen (APAP), no single factor seems to be absolute. As an approach to better understand the multifactorial basis of DILD, we compared the hepatic proteome of mice that are resistant (SJL) and susceptible (C57Bl/6) to APAP-induced liver disease (AILD), using solution-based isotope-coded affinity tag (ICAT) liquid chromatography mass spectrometry. Several novel factors were identified that were more highly expressed in the livers of SJL mice, including those involved in stress response, cell proliferation and tissue regeneration, and protein modification, implicating these proteins as potential hepatoprotective factors. There was also a selective loss of several mitochondrial proteins from the livers of the susceptible C57Bl/6 mice, suggesting that the loss of functional mitochondria may indeed play a role in AILD. These findings indicate that comparative hepatic proteomic analyses of susceptible and resistant mouse strains may provide a global approach for identifying potential risk factors and mechanistic pathways responsible for DILD.
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Affiliation(s)
- Kevin D Welch
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD 20892, USA.
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Roychowdhury S, Vyas PM, Reilly TP, Gaspari AA, Svensson CK. Characterization of the Formation and Localization of Sulfamethoxazole and Dapsone-Associated Drug-Protein Adducts in Human Epidermal Keratinocytes. J Pharmacol Exp Ther 2005; 314:43-52. [PMID: 15784651 DOI: 10.1124/jpet.105.086009] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Sulfonamide- and sulfone-induced hypersensitivity reactions are thought to be mediated through bioactivation of parent drug molecule(s) to their respective reactive metabolite(s). Recent studies have demonstrated that keratinocytes can bioactivate sulfonamides and sulfones. Using enzyme-linked immunosorbent assay and hapten-specific rabbit antisera developed in our laboratory, we found that incubation of either normal human epidermal keratinocytes (NHEKs) or an immortalized human keratinocyte cell line (HaCaT) with sulfamethoxazole (SMX) or dapsone (DDS) resulted in the formation of drug/metabolite protein adducts. The formation of these adducts with SMX was increased in the presence of ascorbic acid, whereas N-acetylcysteine decreased adduct formation with both SMX and DDS. Adduct formation was confirmed using confocal microscopy when NHEKs were incubated with SMX, DDS, or their respective arylhydroxylamine metabolites. Cellular distribution of adducts was compared in permeable versus nonpermeable NHEKs. Exposure to SMX, DDS, or dapsone hydroxylamine resulted in the formation of intracellular adducts, whereas SMX hydroxylamine also resulted in the presence of adducts on the cell surface. In summary, our work shows that keratinocytes can bioactivate SMX/DDS to form drug-protein adducts, which may be acquired by antigen-presenting cells upon keratinocyte cell death, evoking an immune response. In addition, keratinocytes may themselves present antigen to hapten-specific cytotoxic T lymphocytes. Furthermore, our results also suggest that different sulfonamides/sulfones may have different protein targets for in situ haptenation in keratinocytes.
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Affiliation(s)
- Sanjoy Roychowdhury
- Division of Pharmaceutics, College of Pharmacy, The University of Iowa, 115 South Grand Avenue, S213 PHAR, Iowa City, IA 52242, USA
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Masubuchi Y, Bourdi M, Reilly TP, Graf MLM, George JW, Pohl LR. Role of interleukin-6 in hepatic heat shock protein expression and protection against acetaminophen-induced liver disease. Biochem Biophys Res Commun 2003; 304:207-12. [PMID: 12705907 DOI: 10.1016/s0006-291x(03)00572-2] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Recent experimental data suggest that the idiosyncratic nature of drug-induced liver disease (DILD) may be due in part to a deficiency of one or more hepatoprotective factors. In this study we have investigated whether interleukin (IL)-6 may also be one of these factors. Following the induction of liver injury with acetaminophen (APAP), a time-dependent increase in liver mRNA expression of IL-6 and its family members IL-11, leukemia inhibitory factor, and oncostatin M was observed in wild type (WT) mice, suggesting a possible hepatoprotective role played by this cytokine family. Indeed, mice lacking IL-6 (IL-6-/-) were more susceptible than were WT mice to APAP-induced liver injury. The increased susceptibility of the IL-6-/- mice was associated with a deficiency in the expression of hepatic heat shock protein (HSP)25, 32, and 40 as well as inducible HSP70 following APAP treatment. These results suggest that IL-6 and possibly other family members may protect the liver from injury, at least in part, by up-regulating the hepatic expression of several cytoprotective HSPs.
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Affiliation(s)
- Yasuhiro Masubuchi
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung, and Blood Institute, NIH, DHHS, Building 10, Room 8N110, Bethesda, MD 20892-1760, USA
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Ju C, Reilly TP, Bourdi M, Radonovich MF, Brady JN, George JW, Pohl LR. Protective role of Kupffer cells in acetaminophen-induced hepatic injury in mice. Chem Res Toxicol 2002; 15:1504-13. [PMID: 12482232 DOI: 10.1021/tx0255976] [Citation(s) in RCA: 246] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatic injury induced by various toxic agents, including acetaminophen (APAP), has been attributed, in part, to the production of proinflammatory cytokines and other mediators by resident Kupffer cells within the liver. However, recent evidence from our laboratory has demonstrated that hepato-protective factors, such as interleukin (IL)-10 and cyclooxygenase-derived mediators, are also upregulated in response to hepatic damage to help protect against exacerbated injury, and Kupffer cells have been suggested to be a source of these modulatory factors. In other models, Kupffer cells also serve important regulatory functions in pathophysiological states of the liver. Therefore, we reevaluated the role of Kupffer cells in a murine model of APAP-induced liver injury using liposome-entrapped clodronate (liposome/clodronate) as an effective Kupffer cell-depleting agent. We show that in contrast to pretreatment of mice with a widely used macrophage inhibitor, gadolinium chloride, which did not deplete Kupffer cells but moderately protected against APAP-induced hepatotoxicity as reported previously, the intravenous injection of liposome/clodronate caused nearly complete elimination of Kupffer cells and significantly increased susceptibility to APAP-induced liver injury as compared with mice pretreated with empty liposomes. This increased susceptibility was apparently unrelated to the metabolism of APAP since liposome/clodronate pretreatment did not alter APAP-protein adduct levels. Instead, Kupffer cell depletion by liposome/clodronate led to significant decreases in the levels of hepatic mRNA expression of several hepato-regulatory cytokines and mediators, including IL-6, IL-10, IL-18 binding protein and complement 1q, suggesting that Kupffer cells are a significant source for production of these mediators in this model. Our findings indicate that, in addition to their protoxicant activities, Kupffer cells can also have an important protective function in the liver through the production of a variety of modulatory factors which may counteract inflammatory responses and/or stimulate liver regeneration.
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Affiliation(s)
- Cynthia Ju
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland 20892, USA.
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Abstract
PURPOSE OF REVIEW Idiosyncratic drug reactions continue to limit the therapeutic utility of sulfonamide drugs because of their associated morbidity and mortality. Cutaneous reactions are the predominant reasons for withdrawal of such drugs from use in patients. As a consequence of the recognized metabolic and immunologic capability of the skin, an understanding of the pathogenic role of this tissue in the development of sulfonamide-induced cutaneous drug reactions may provide insight into the mechanisms and risk factors for these and other adverse drug events. RECENT FINDINGS In the present review we discuss currently available mechanistic information, including issues related to drug bioactivation and adduct formation, immunoresponsiveness, and immune dysregulation, for the development of sulfonamide-induced (delayed-type) cutaneous drug reactions. The potential application of findings from several related areas of research are also discussed within the context of the pathogenesis of these cutaneous reactions. SUMMARY Despite progress, numerous unresolved issues support the testing of novel hypotheses, the search for additional risk factors, and the need for a global approach, including links between laboratory and clinical paradigms. These issues must be addressed if we are to gain an understanding of the mechanistic bases for these cutaneous drug reactions.
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Affiliation(s)
- Timothy P Reilly
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, NHLBI/NIH, 9000 Rockville Pike, Building 10, Room 8N110, Bethesda, MD 20892-2760, USA.
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Bourdi M, Reilly TP, Elkahloun AG, George JW, Pohl LR. Macrophage migration inhibitory factor in drug-induced liver injury: a role in susceptibility and stress responsiveness. Biochem Biophys Res Commun 2002; 294:225-30. [PMID: 12051698 DOI: 10.1016/s0006-291x(02)00466-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Idiosyncratic drug-induced hepatitis may depend upon many factors including a balance between pro- and anti-inflammatory mediator production levels. Using a guinea pig model of liver injury induced by bioactivation of the anesthetic drug, halothane, we found that toxicity was commensurate with an increase in serum macrophage migration inhibitory factor (MIF), a pro-inflammatory signal and counter-regulator of glucocorticoids, but only in susceptible animals. The pathogenic role of MIF was further investigated using a murine model in which liver injury was induced by the reactive metabolite of another drug, acetaminophen (APAP). MIF leakage from the liver into the sera preceded peak increases in toxicity following APAP administration. MIF null (-/-) mice were significantly less susceptible to this toxicity at 8 h. At 48 h following a 300 mg/kg dose, complete lethality was observed in wild-type mice, while 46% survival was noted in MIF-/- mice. The decreased hepatic injury in MIF-/- mice correlated with a reduction in mRNA levels of interferon-gamma and a significant increase in heat shock protein expression, but was unrelated to the APAP-protein adduct formation in the liver. These findings support MIF as a critical pro-toxicant signal in drug-induced liver injury with potentially important and novel effects on heat shock protein responsiveness.
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Affiliation(s)
- Mohammed Bourdi
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung, and Blood Institute, National Institutes of Health, 9000 Rockville Pike, Bldg. 10, Rm. 8N110 Bethesda, MD 20892-1760, USA.
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31
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Bourdi M, Masubuchi Y, Reilly TP, Amouzadeh HR, Martin JL, George JW, Shah AG, Pohl LR. Protection against acetaminophen-induced liver injury and lethality by interleukin 10: role of inducible nitric oxide synthase. Hepatology 2002; 35:289-98. [PMID: 11826401 DOI: 10.1053/jhep.2002.30956] [Citation(s) in RCA: 225] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Mechanistic study of idiosyncratic drug-induced hepatitis (DIH) continues to be a challenging problem because of the lack of animal models. The inability to produce this type of hepatotoxicity in animals, and its relative rarity in humans, may be linked to the production of anti-inflammatory factors that prevent drug-protein adducts from causing liver injury by immune and nonimmune mechanisms. We tested this hypothesis by using a model of acetaminophen (APAP)-induced liver injury in mice. After APAP treatment, a significant increase was observed in serum levels of interleukin (IL)-4, IL-10, and IL-13, cytokines that regulate inflammatory mediator production and cell-mediated autoimmunity. When IL-10 knockout (KO) mice were treated with APAP, most of these mice died within 24 to 48 hours from liver injury. This increased susceptibility to APAP-induced liver injury appeared to correlate with an elevated expression of liver proinflammatory cytokines, tumor necrosis factor (TNF)-alpha, and IL-1, as well as inducible nitric oxide synthase (iNOS). In this regard, mice lacking both IL-10 and iNOS genes were protected from APAP-induced liver injury and lethality when compared with IL-10 KO mice. All strains, including wild-type animals, generated similar amounts of liver APAP-protein adducts, indicating that the increased susceptibility of IL-10 KO mice to APAP hepatotoxicity was not caused by an enhanced formation of APAP-protein adducts. In conclusion, these findings suggest that an important feature of the normal response to drug-induced liver injury may be the increased expression of anti-inflammatory factors such as IL-10. Certain polymorphisms of these factors may have a role in determining the susceptibility of individuals to idiosyncratic DIH.
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Affiliation(s)
- Mohammed Bourdi
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1760, USA
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Reilly TP, Brady JN, Marchick MR, Bourdi M, George JW, Radonovich MF, Pise-Masison CA, Pohl LR. A protective role for cyclooxygenase-2 in drug-induced liver injury in mice. Chem Res Toxicol 2001; 14:1620-8. [PMID: 11743745 DOI: 10.1021/tx0155505] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Despite the utility of cyclooxygenase (COX) inhibition as an antiinflammatory strategy, prostaglandin (PG) products of COX-1 and -2 provide important regulatory functions in some pathophysiological states. Scattered reports suggest that COX inhibition may also promote adverse drug events. Here we demonstrate a protective role for endogenous COX-derived products in a murine model of acetaminophen (APAP)-induced acute liver injury. A single hepatotoxic dose caused the selective induction of COX-2 mRNA and increased PGD2 and PGE2 levels within the livers of COX(+/+) male mice suggesting a role for COX-2 in this model of liver injury. APAP-induced hepatotoxicity and lethality were markedly greater in COX-2(-/-) and (-/+) mice in which normal PG responsiveness is altered. The significantly increased toxicity linked to COX-2 deficiency could be mimicked using the selective COX-2 inhibitory drug, celecoxib, in COX(+/+) mice and was not due to alterations in drug-protein adduct formation, a surrogate for bioactivation and toxicity. Microarray analyses indicated that increased injury associated with COX-2 deficiency coincided, most notably, with a profoundly impaired induction of heat shock proteins in COX-2(-/+) mice suggesting that PGs may act as critical endogenous stress signals following drug insult. These findings suggest that COX-2-derived mediators serve an important hepato-protective function and that COX inhibition may contribute to the risk of drug-induced liver injury, possibly through both nonimmunological and immunological pathways.
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Affiliation(s)
- T P Reilly
- Molecular and Cellular Toxicology Section, Laboratory of Molecular Immunology, NHLBI, NIH, 9000 Rockville Pike, Building 10, Room 8N110, Bethesda, Maryland 20892-1760, USA.
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Reilly TP, Bourdi M, Brady JN, Pise-Masison CA, Radonovich MF, George JW, Pohl LR. Expression profiling of acetaminophen liver toxicity in mice using microarray technology. Biochem Biophys Res Commun 2001; 282:321-8. [PMID: 11264010 DOI: 10.1006/bbrc.2001.4576] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Drug-induced hepatotoxicity causes significant morbidity and mortality and is a major concern in drug development. This is due, in large part, to insufficient knowledge of the mechanism(s) of drug-induced liver injury. In order to address this problem, we have evaluated the modulation of gene expression within the livers of mice treated with a hepatotoxic dose of acetaminophen (APAP) using high-density oligonucleotide microarrays capable of determining the expression profile of >11,000 genes and expressed sequence tags (ESTs). Significant alterations in gene expression, both positive and negative, were noted within the livers of APAP-treated mice. APAP-induced toxicity affected numerous aspects of liver physiology causing, for instance, >twofold increased expression of genes that encode for growth arrest and cell cycle regulatory proteins, stress-induced proteins, the transcription factor LRG-21, suppressor of cytokine signaling (SOCS)-2-protein, and plasminogen activator inhibitor-1 (PAI-1). A number of these and other genes and ESTs were detectable within the liver only after APAP treatment suggesting their potential importance in propagating or preventing further toxicity. These data provide new directions for mechanistic studies that may lead to a better understanding of the molecular basis of drug-induced liver injury and, ultimately, to a more rational design of safer drugs.
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Affiliation(s)
- T P Reilly
- Molecular and Cellular Toxicology Section, National Institutes of Health, Bethesda, Maryland, USA.
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Reilly TP, Lash LH, Doll MA, Hein DW, Woster PM, Svensson CK. A role for bioactivation and covalent binding within epidermal keratinocytes in sulfonamide-induced cutaneous drug reactions. J Invest Dermatol 2000; 114:1164-73. [PMID: 10844561 DOI: 10.1046/j.1523-1747.2000.00985.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cutaneous reactions are the most common manifestation of delayed-type hypersensitivity caused by sulfamethoxazole and dapsone. In light of the recognized metabolic and immunologic activity of the skin, we investigated the potential role of normal human epidermal keratinocytes in the development of these reactions. Adult and neonatal normal human epidermal keratinocytes metabolized sulfamethoxazole and dapsone to N-4-hydroxylamine and N-acetyl derivatives in a time-dependent manner. The latter was catalyzed by N-acetyltransferase 1 alone as normal human epidermal keratinocytes did not express mRNA for N-acetyltransferase 2. Investigation of metabolism-dependent toxicity of sulfamethoxazole and dapsone, and subsequent incubation of normal human epidermal keratinocytes with the respective hydroxylamine metabolites, demonstrated that these cells were resistant to the cytotoxic effects of sulfamethoxazole hydroxylamine but not dapsone hydroxylamine. With prior depletion of glutathione, however, normal human epidermal keratinocytes became susceptible to the toxicity of sulfamethoxazole hydroxylamine. Covalent adduct formation by sulfamethoxazole hydroxylamine was detected in normal human epidermal keratinocytes, even in the absence of cell death, and was increased with glutathione depletion. Major protein targets of sulfamethoxazole hydroxylamine were observed in the region of 160, 125, 95, and 57 kDa. Dapsone hydroxylamine also caused covalent adduct formation in normal human epidermal keratinocytes. Together, these observations provide a basis for our hypothesis that normal human epidermal keratinocytes are involved in the initiation and propagation of a cutaneous hypersensitivity response to these drugs.
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Affiliation(s)
- T P Reilly
- Department of Pharmaceutical Sciences, College of Pharmacy and Allied Health Professions, Wayne State University, Detroit, MI 48202, USA
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Reilly TP, MacArthur RD, Farrough MJ, Crane LR, Woster PM, Svensson CK. Is hydroxylamine-induced cytotoxicity a valid marker for hypersensitivity reactions to sulfamethoxazole in human immunodeficiency virus-infected individuals? J Pharmacol Exp Ther 1999; 291:1356-64. [PMID: 10565861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
Hypersensitivity (HS) reactions to sulfonamides and sulfones continue to limit their use in human immunodeficiency virus (HIV)-infected individuals. In vitro cytotoxicity of hydroxylamine metabolites toward peripheral blood mononuclear cells (PBMCs) has been proposed as a marker for these HS reactions. To test the validity of this in vitro system, we determined the selective susceptibility of PBMCs from HIV-infected patients to the cytotoxic effects of hydroxylamine metabolites of sulfamethoxazole (SMX) and dapsone (DDS). Concentration-cytotoxic response data were collected using PBMCs from 12 sulfa-HS (10 SMX-HS and 2 SMX/DDS-HS) and 10 sulfa-tolerant HIV-infected individuals. Although sulfamethoxazole hydroxylamine (SMX-NOH) and dapsone hydroxylamine (DDS-NOH) both caused concentration-dependent increases in cell death, DDS-NOH was significantly more potent in each subject (P <.0001). A comparison of a variety of mean data for sulfa-HS and -tolerant patient populations failed to demonstrate the increased susceptibility of PBMCs from HS patients, noted by others, to either SMX-NOH or DDS-NOH. Moreover, any trend toward an increased susceptibility of PBMCs from HS patients was eliminated when adjusted for control cell death. PBMCs from sulfa-HS patients showed significantly greater susceptibility to the stress of short term in vitro incubation (P <. 02). Mean (S.D.) vehicle control cell death values were 24.1% (7.6%) for HS patients and 17.1% (4.4%) for tolerant patients. No significant correlation was observed between hydroxylamine-induced or control cell death and any of the recorded clinical parameters. Although several potential reasons are proposed to explain the disparity with past investigations, the data suggest that in vitro cytotoxicity is not a valid marker for HS reactions in HIV-infected individuals using currently accepted experimental procedures.
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Affiliation(s)
- T P Reilly
- Department of Pharmaceutical Sciences, Department of Internal Medicine, Wayne State University, Detroit, Michigan 48202, USA
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Reilly TP, Woster PM, Svensson CK. Methemoglobin formation by hydroxylamine metabolites of sulfamethoxazole and dapsone: implications for differences in adverse drug reactions. J Pharmacol Exp Ther 1999; 288:951-9. [PMID: 10027831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
Differences in the incidence of adverse drug reactions to trimethoprim-sulfamethoxazole and dapsone may result from differences in the formation, disposition, toxicity, and/or detoxification of their hydroxylamine metabolites. In this study, we examine whether differences in the biochemical processing of sulfamethoxazole hydroxylamine (SMX-NOH) and dapsone hydroxylamine (DDS-NOH) by erythrocytes [red blood cells (RBCs)] contribute to this differential incidence. The methemoglobin (MetHgb)-forming capacity of both metabolites was compared after a 60-min incubation with washed RBCs from four healthy human volunteers. DDS-NOH was significantly more potent (P =.004) but equally efficacious with SMX-NOH in its ability to form MetHgb. The elimination of potential differences in disposition by lysing RBCs did not change the MetHgb-forming potency of either hydroxylamine. At pharmacologically relevant concentrations, greater reduction to the parent amine occurred with DDS-NOH. Maintenance of MetHgb-forming potency was dependent on recycling with glutathione, but no difference in cycling efficiency was observed between DDS-NOH and SMX-NOH. In contrast, the pharmacodynamics of hydroxylamine-induced MetHgb formation were not changed by pretreatment with the glucose 6-phosphate dehydrogenase inhibitor epiandrosterone or by compounds that alter normal antioxidant enzyme activity. Methylene blue, which stimulates NADPH-dependent MetHgb reductase activity, decreased MetHgb levels but did not alter the differential potency of these hydroxylamines. DDS-NOH was also significantly more potent when incubated with purified human hemoglobin A0. Collectively, these data suggest that the inherently greater reactivity of DDS-NOH with hemoglobin, the greater conversion of DDS-NOH to its parent amine, and potential differences in disposition of hydroxylamine metabolites may contribute to the preferential development of dapsone-induced hemotoxicity and sulfamethoxazole-induced hypersensitivity reactions.
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Affiliation(s)
- T P Reilly
- Department of Pharmaceutical Sciences, Wayne State University, Detroit, Michigan 48202, USA
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Ware JA, Reilly TP, Svensson CK. Cellular distribution of N-acetyltransferase activity in the rat small intestine. Biochem Pharmacol 1998; 55:1475-9. [PMID: 10076540 DOI: 10.1016/s0006-2952(97)00659-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The cellular distribution of AcCoA:arylamine N-acetyltransferase (NAT; EC 2.3.1.5) activities was examined in the rat small intestine to determine if heterogeneous cellular distribution contributes to preferential tumor development in the colonic region after exposure to heterocyclic amines (HAs). A chelation/elution method was used to preferentially isolate villus-tip, mid-villus, and crypt enterocytes. Monomorphic (NAT1) and polymorphic (NAT2) activities were determined using N-acetylprocainamide and N-acetamidobenzoic acid formation, respectively. Sucrase-isomaltase (SI) activity was used to confirm that a villus, mid-villus, and crypt cell gradient had been obtained. Utilizing this marker of villus enrichment, a 4- to 10-fold gradient was achieved. NAT1 and NAT2 activities followed this gradient, with the highest NAT activity occurring in the fraction with the highest SI activity. The ratio of NAT2:NAT1 remained essentially constant along the gradient, indicating a similar pattern of expression for both enzymes. This pattern of cellular distribution for the NATs is similar to that reported for cytochrome P450s. This apparent preferential expression of NAT in the villus cells may result in delivery of bioactivated HAs to the lower regions of the intestines as the villus-tip cells are extruded into the intestinal lumen and enter the fecal stream.
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Affiliation(s)
- J A Ware
- Department of Pharmaceutical Sciences, Wayne State University, Detroit, MI 48202, USA
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Abstract
The differential incidence of adverse drug reactions (ADR) between trimethoprim-sulfamethoxazole and dapsone might be explained, in part, by differences in the inherent toxicity of the hydroxylamine metabolites of sulfamethoxazole and dapsone. To test this hypothesis, the in vitro cytotoxicities of sulfamethoxazole hydroxylamine, dapsone hydroxylamine, and monoacetyldapsone hydroxylamine were compared using peripheral blood mononuclear cells (PBMC) from healthy volunteers. After 3 hr of exposure to hydroxylamine metabolites, PBMC were washed thoroughly to remove residual hydroxylamine, and viability was assessed 16 hr later by determination of 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) conversion. A concentration-dependent toxicity was observed with each hydroxylamine metabolite. While dapsone hydroxylamine and monoacetyldapsone hydroxylamine were not significantly different, both showed significantly greater cytotoxic potency than sulfamethoxazole hydroxylamine (P < 0.05). This differential potency was not a function of differential stability in aqueous medium and was maintained over time. The effects of red blood cells (RBC), impermeable RBC "ghosts," and RBC lysate on hydroxylamine-induced cytotoxicity were determined using a two-compartment dialysis system. Amelioration of hydroxylamine-dependent cytotoxicity occurred when RBC were included in PBMC incubations. This apparent detoxifying effect was markedly greater using RBC lysate in comparison with impermeable "ghosts" (P < 0.05). No difference in detoxification was observed between sulfamethoxazole hydroxylamine and monoacetyldapsone hydroxylamine. Differences in the inherent cytotoxicity of their hydroxylamine metabolites do not appear to explain the differential incidence of ADR between trimethoprim-sulfamethoxazole and dapsone.
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Affiliation(s)
- T P Reilly
- Department of Pharmaceutical Sciences, Wayne State University, Detroit, MI 48202, USA
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Reilly TP. Torts--wrongful death--a viable fetus is a "person" for purposes of the Rhode Island Wrongful Death Act. Univ Cincinnati Law Rev 1977; 46:266-275. [PMID: 11661497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Reimold EW, Worthen HG, Reilly TP. Salicylate poisoning. Comparison of acetazolamide administration and alkaline diuresis in the treatment of experimental salicylate intoxication in puppies. Am J Dis Child 1973; 125:668-74. [PMID: 4699499 DOI: 10.1001/archpedi.1973.04160050022005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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