Acquired resistance to crizotinib from a mutation in CD74-ROS1.

Crizotinib, an inhibitor of anaplastic lymphoma kinase (ALK), has also recently shown efficacy in the treatment of lung cancers with ROS1 translocations. Resistance to crizotinib developed in a patient with metastatic lung adenocarcinoma harboring a CD74-ROS1 rearrangement who had initially shown a dramatic response to treatment. We performed a biopsy of a resistant tumor and identified an acquired mutation leading to a glycine-to-arginine substitution at codon 2032 in the ROS1 kinase domain. Although this mutation does not lie at the gatekeeper residue, it confers resistance to ROS1 kinase inhibition through steric interference with drug binding. The same resistance mutation was observed at all the metastatic sites that were examined at autopsy, suggesting that this mutation was an early event in the clonal evolution of resistance. (Funded by Pfizer and others; ClinicalTrials.gov number, NCT00585195.).

EVALUATION OF DRUG USE INDICATORS FOR NON-COMMUNICABLE DISEASES IN PAKISTAN.

Irrational drug use practices are a burden to healthcare facilities. Poor prescribing practices affect the overall management and cost of treatment of non-communicable diseases that are the major cause of mortality and morbidity worldwide. In an effort to improve prescribing practices, this study was designed to assess prescribing, consultation and facility indicators in healthcare facilities of Punjab and Sindh provinces of Pakistan from December 2012 to December 2013. In this cross-sectional study, random and convenient sampling were used to collected data from both private and public healthcare facilities. Quantitative data were collected using structured questionnaire, observations and prescription analysis, whereas qualitative information on factors influencing prescribing practices was obtained by interviewing medical practitioners. A total of 13693 prescriptions were obtained from 500 patient-prescriber encounters. Results show that history taking, physical examination and diagnoses were adequate while generic prescribing was four-fold less than drugs prescribed by brands. Average number of drugs prescribed was 4.63 with more prescribing tendency in private facilities. 45.07% prescription costs were less than Rs. 150. Sulfonylureas, statins and ACE inhibitors were highly prescribed drugs for diabetes, hyperlipidemia and hypertension. Prescribing practices were dominantly influenced by severity of disease (73% Punjab; 81% Sindh), patient age (75% Punjab; 68% Sindh) and availability of drugs (62% Punjab; 56% Sindh) whereby 91% practitioners in Sindh and 52% in Punjab rely on medical representatives as the source of drug information. Moreover, the pharmacy and therapeutic committees in all facilities were non-functional along with non-availability of essential drug list in 87% health facilities. Thus, there are considerable opportunities to improve the rational use of medicines in Pakistan including low prices for generics, physician education, prescribing guidelines and formularies.

COMPARATIVE BIOAVAILABILITY ANALYSIS OF ORAL ALENDRONATE SODIUM FORMULATIONS IN PAKISTAN.

Alendronate sodium, a bisphosphonate drug, it is used to treat osteoporosis and other bone diseases. The present study was designed to conduct comparative bioavailability analysis of oral formulations of aledronate sodium through an open-label, randomized, 2-sequence, 2-period crossover study. Healthy adult male Pakistani volunteers received a single 70 mg dose of the test or reference formulation of alendronate sodium followed by a 7 day washout period. Plasma drug concentrations were determined using a validated HPLC post column fluorescence derivatization method. AUC(01,) AUC(0-8,) C(max). and T(max) were determined by non-compartmental analysis and were found within the permitted range of 80% to 125% set by the US Food and Drug Administration (FDA). Results show that both in vitio and in vivo assays of all test brands were within the spec- ification of the US Pharmacopoeial limits and were statistically bioequivalent. No adverse events were reported in this study.

Microbial and chemical analysis of illicit drugs samples confiscated from different areas of PakistanMicrobial and chemical analysis of illicit drugs samples confiscated from different areas of Pakistan.

The microbial and chemical analysis of illicit drug samples from different areas of Pakistan i.e. Quetta, Karachi, Lahore and Islamabad was conducted in a cross-sectional study at National Institute of Health, Islamabad. The drug samples were confiscated by Anti Narcotics Force (ANF), Pakistan. Microbial analysis was done by estimating bioburden which revealed the presence of gram negative and positive bacteria's, fungus, Streptococcus, Staphylococcus species. Trypton soya agar was used for total aerobic count, MacConkey agar for gram-negative bacteria, Sabouraud dextrose agar for fungus and Vogel-Johnson agar for Streptococcus and Staphylococcus species. Colour tests were applied to identify the drug samples. Qualitative and quantitative analysis of suspected samples of Heroin, morphine, cocaine and acetic anhydride was made by employing different chromatographic techniques i.e. Thin-layer chromatography (TLC) and High-performance liquid chromatography (HPLC). The samples were found to be adulterated with paracetamol, diazepam and Dextromethorphen. Acetic anhydride was adulterated with hydrochloric acid (HCl). There is lack of information providing structured advice on responses to the consequences of illicit drug adulteration. Robust and rehearsed interventions and communication strategies would provide a basis for response for a wide variety of organisations. Research into the usefulness of media warnings about adulteration of illicit drugs is required.

Association of TGF-ß2 levels in breast milk with severity of breast biopsy diagnosis.

PURPOSE: TGF-ß plays a dual role in breast carcinogenesis, acting at early stages as tumor-suppressors and later as tumor-promoters. TGF-ß isoforms are expressed in breast tissues and secreted in milk, suggesting that analysis of levels in milk might be informative for breast cancer risk. Accordingly, we assessed TGF-ß2 levels in milk from women who had undergone a breast biopsy and related the concentrations to diagnosis. METHODS: Milk donated by women who had undergone or were scheduled for a breast biopsy was shipped on ice for processing and testing. Breast cancer risk factors were obtained through a self-administered questionnaire, and biopsy diagnoses were extracted from pathology reports. TGF-ß2 levels in milk, assessed as absolute levels and in relation to total protein, were analyzed in bilateral samples donated by 182 women. Linear regression was used to estimate relationships of log-transformed TGF-ß2 levels and TGF-ß2/ total protein ratios to biopsy category. RESULTS: Milk TGF-ß2 levels from biopsied and non-biopsied breasts within women were highly correlated (r (2) = 0.77). Higher mean TGF-ß2 milk levels (based on average of bilateral samples) were marginally associated with more severe breast pathological diagnosis, after adjusting for duration of nursing current child (adjusted p trend = 0.07). CONCLUSIONS: Our exploratory analysis suggests a borderline significant association between higher mean TGF-ß2 levels in breast milk and more severe pathologic diagnoses. Further analysis of TGF-ß signaling in milk may increase understanding of postpartum remodeling and advance efforts to analyze milk as a means of assessing risk of breast pathology.

Combined targeting of HER2 and VEGFR2 for effective treatment of HER2-amplified breast cancer brain metastases.

Brain metastases are a serious obstacle in the treatment of patients with human epidermal growth factor receptor-2 (HER2)-amplified breast cancer. Although extracranial disease is controlled with HER2 inhibitors in the majority of patients, brain metastases often develop. Because these brain metastases do not respond to therapy, they are frequently the reason for treatment failure. We developed a mouse model of HER2-amplified breast cancer brain metastasis using an orthotopic xenograft of BT474 cells. As seen in patients, the HER2 inhibitors trastuzumab and lapatinib controlled tumor progression in the breast but failed to contain tumor growth in the brain. We observed that the combination of a HER2 inhibitor with an anti-VEGF receptor-2 (VEGFR2) antibody significantly slows tumor growth in the brain, resulting in a striking survival benefit. This benefit appears largely due to an enhanced antiangiogenic effect: Combination therapy reduced both the total and functional microvascular density in the brain xenografts. In addition, the combination therapy led to a marked increase in necrosis of the brain lesions. Moreover, we observed even better antitumor activity after combining both trastuzumab and lapatinib with the anti-VEGFR2 antibody. This triple-drug combination prolonged the median overall survival fivefold compared with the control-treated group and twofold compared with either two-drug regimen. These findings support the clinical development of this three-drug regimen for the treatment of HER2-amplified breast cancer brain metastases.

Review: an exposition of medicinal preponderance of Moringa oleifera (Lank.).

Medicinal plants are believed to be a precious natural reservoir as they are assumed to have paranormal effects for the mankind. Moringa oleifera grows throughout most of the tropics and has numerous industrial and medicinal uses. This review acquaints with the consequence of fera (Moringaceae), a fast growing medicinal plant wide spread in tropical regions with height ranging from 5-10m. It has an enormous nutritional worth due to existence of vitamins and proteins. It is subsisted with many constituents. Its oil consists of oleic, tocopherols, stearic, palmitic, behenic and arachidic acid. Flavanoids and phenolics such as gallic acid, chlorogenic acid, ferulic acid, kaempferol, ellagic acid, quercetin and vanillin are present by means of leaf extract, being richest in phenolics and subsequent fruit and seed extract respectively, that are accountable for antioxidant activity of plant. Seeds have been pragmatic with active components as novel O-ethyl-4- (α -L-rhamnosyloxy) benzyl carbamate together with seven known compounds, 4 (α -L-rhamnosyloxy)-benzyl isothiocyanate, niazimicin, niazirin, ß-sitosterol, glycerol-1- (9 -octadecanoate), 3 -O- 6 -O-oleoyl- ß -D-glucopyranosyl-b-sitosterol, and ß - sitosterol- 3-X-O -ß -D-glucopyranoside , that have been discerned to inhibit EBV-EA (Epstein- Barr virus-early antigen), that is persuaded by the cancer promoter. M. oleifera leaves, gums, roots, flowers as well as kernels have been unanimously utilized for managing tissue tenderness, cardiovascular and liver maladies, normalize blood glucose and cholesterol. It has also profound antimicrobial, hypoglycemic and anti-tubercular activities.

Critique of medicinal conspicuousness of Parsley(Petroselinum crispum): a culinary herb of Mediterranean region.

WHO estimates, around 80% of the especially developing world is indigent on complementary and alternative medicines which are prodigiously derived from herbal material. Parsley (Petroselinum crispum) is an important culinary herb originated from the Mediterranean region. It possesses small and dark seeds with volatile oil content. Petroselinum crispum is now planted throughout the world due to its usage in food industry, perfume manufacturing, soaps, and creams. Its main constituents subsume coumarins, furanocoumarins (bergapten, imperatori), ascorbic acid, carotenoids, flavonoids, apiole, various terpenoic compounds, phenyl propanoids, phathalides, and tocopherol. Due to these constituents, it has been annunciated to possess a number of possible medicinal emblematics including, antimicrobial, antianemic, menorrhagic, anticoagulant, antihyperlipidemic, antihepatotoxic, antihypertensive, diuretic effects, hypoglycaemic, hypouricemic, anti oxidative and estrogenic activities. In Morocco, Parsley is mostly used as an elixir to treat arterial hypertension, diabetes, cardiac and renal diseases. Antioxidant and antibacterial activities of parsley, made it propitious in food systems. Its ELI17 gene has been corroborated as a particularly fast-responding gene. There is a requisite for extensive research to avail the maximal benefits of this significant medicinal plant. The aim of this review paper is to divulge the chemical constituents of parsley that are explicitly related to substantial medicinal facets.

Comparative phytochemical, hepatoprotective and antioxidant activities of various samples of Swertia Chirayita collected from various cities of Pakistan.

Medicinal plants are crucial for about 80% of the world population in developing and developed countries for their primary and basic health care needs owing to better tolerability, superior compatibility with human body and having lesser side effects. The present study was conducted on various solvent extracts of three plant samples of Indian and Nepali origin Swertia Chirayita (Roxb.) Buch-ham (Chiratia) collected from various places to establish their comparative phytochemical analysis, chromatographic profile, hepatoprotective and antioxidant activities. Nepali Swertia Chirayita was found to have finest Chromatographic profile (TLC). Phytochemical analysis revealed Alkaloids, flavonoids, saponins, ascorbic acid, glycosides, steroids and triterpenoids in all samples. Different solvent fractions of the methanolic plant extracts of Swertia chirayita were assessed for hepatoprotective activity by carbon tetrachloride-induced liver damage in rats. The grade of protection was measured by using biochemical parameters such as serum glutamate oxalate transaminase (SGOT/AST), alkaline phosphatase (ALP), serum glutamate pyruvate transaminase (SGPT/ALT) and total bilirubin. The in-vitro antioxidant activity of the extracts was also evaluated by the 1, 1-diphenyl-2-picrylhydrazyl (DPPH) free radical scavenging assay. The methanolic and aqueous extracts, at a dose of 200mg/kg and 300mg/kg, produced significant (p<0.05) hepatoprotection by decreasing the activities of the serum enzymes and bilirubin while there were marked scavenging of the DPPH free radicals by the fractions. Decreased observed in the biochemical parameters suggests that the plant extracts possesses hepatoprotective as well as antioxidant activities without any significant variation amongst them. These activities reside mainly in the methanolic extract of whole plant.

Real time and accelerated stability studies of Tetanus toxoid manufactured in public sector facilities of Pakistan.

Tetanus is an acute illness represented by comprehensive increased inflexibility and spastic spasms of skeletal muscles. The poor quality tetanus toxoid vaccine can raise the prevalence of neonatal tetanus. WHO has taken numerous steps to assist national regulatory authorities and vaccine manufacturers to ensure its quality and efficacy. It has formulated international principles for stability evaluation of each vaccine, which are available in the form of recommendations and guidelines. The aim of present study was to ensure the stability of tetanus vaccines produced by National Institute of Health, Islamabad, Pakistan by employing standardized methods to ensure constancy of tetanus toxoid at elevated temperature, if during storage/transportation cold chain may not be maintained in hot weather. A total of three batches filled during full-scale production were tested. All Stability studies determination were performed on final products stored at 2-8°C and elevated temperatures in conformance with the ICH Guideline of Stability Testing of Biological Products. These studies gave comparison between real time shelf-life stability and accelerated stability studies. The findings indicate long-term thermo stability and prove that this tetanus vaccine can remain efficient under setting of routine use when suggested measures for storage and handling are followed in true spirit.

Appraisal of multifarious brands of Cephradine for their in vitro antibacterial activity against varied microorganisms.

The astounding and exceptional growth of generic pharmaceutical Industry in Pakistan has raised certain questions for drug regulatory authorities contemplating their efficacy and quality. The current study focuses on assessing the in-vitro antimicrobial activity of 24 brands of Cephradine 500mg capsules against 4 different strains by employing standardized methods. Disk diffusion method was performed on all brands to look into the susceptibility and resistance patterns. Standard disk of 5µg Cephradine powder were used during evaluation. The zones of inhibitions were ranged from 24-40mm against S. aureus, 24-40mm against E. coli, 20-25mm against K. pneumonia and 19-23mm P. mirabilis. On the basis of mean value, the multinational brands were found to have better zone of inhibitions and were better than local Pharmaceutical companies but ANOVA cooperative study showed that all brands of Cephradine showed similar comparable results. Further investigations by employing MIC method, quality of raw material with special emphasis on the shelf-life, excepients and method of manufacturing will be needed to obtain more authenticated results. The price of National and Multinational brands ranges from Rs.156.00-212.00 for 10 capsules. It is concluded that Public health is at risk because of noticeable growing widespread curse of the manufacture and trade of sub-standard or below par pharmaceuticals. The pecuniary accountability of management of pharmaceutical agents is additionally apparent. The results of the study need to be made public to boost the confidence of medical profession about the quality of locally manufactured pharmaceuticals. It will succour the foreign exchange being incurred on the trade in of medicines.

Prevalence and treatment of neurological and psychiatric disorders among tertiary hospitals in Pakistan; findings and implications.

INTRODUCTION: Mental health and neurological disorders are prevalent in Pakistan. However, there are considerable concerns with their management due to issues of access, availability of trained personnel and stigma alongside paucity of such data. Consequently, there is a need to document current treatment approaches starting with tertiary hospitals in Pakistan where patients with more severe mental and neurological disorders are typically treated. Subsequently, use the findings to help direct future policies and initiatives. METHODS: Multi-centered, cross-sectional, prospective study principally evaluating current medicine usage among patients attending tertiary hospitals in Pakistan with psychiatric and neurological disorders. In addition, possible factors contributing to the prevalence of these disorders in this population to help with future care. All 23 tertiary care hospitals in the ten major Districts in Pakistan were included, which cover 75% of the population. RESULTS: 57,664 patients were evaluated of which 35.3% were females. Both females and males had multiple brain disorders and multiple co-morbidities. Schizophrenia was the most prevalent disorder overall among both females (25.2%) and males (30.4%). A median of six medicines were prescribed per patient, with antipsychotics and antidepressants the most prescribed medicines. Clozapine was the most prescribed medicine in males (12.25%) and females (11.83%) including for psychiatric disorders, with sodium valproate the most prescribed medicine in epilepsy in males (42.44% of all anti-epileptic medicines) as well as females (46.38%). There was a greater prevalence of both disorders among the lower classes. A greater prevalence of schizophrenia was seen in patients abusing alcohol and smokers. The divorce rate was higher among the studied patients and the prevalence of depression was higher among the widowed population. CONCLUSIONS: There were concerns with the quality of prescribing including the extent of polypharmacy as well as possible overuse of clozapine especially in patients with epilepsy, both of which need addressing.

Trends in the prescribing of antipsychotic medicines in Pakistan: implications for the future.

Introduction and objectives: There is a paucity of antipsychotic prescribing and utilization data in Pakistan that needs addressing, especially with issues of availability, affordability, gender differences, and domestic violence, to develop pertinent strategies. The objective of this study was to address these issues by describing current antipsychotic utilization patterns in Pakistan among adult patients attending tertiary care hospitals and private practitioners.Methods: A three staged approach was used including (1) assessment of total antipsychotic utilization, expenditure, and costs per unit between 2010 and 2015, (2) an in-depth retrospective study of prescribing patterns, including co-morbidities among representative hospital patients in Pakistan, and (3) assessment of the quality of prescribing against WHO targets.Results: Total use of antipsychotics increased 4.3-fold and the cost/unit increased by 13.2% during the study period. Risperidone and olanzapine were the most prescribed antipsychotics with more limited use of other typical and atypical antipsychotics. The number of medicines per encounter was 4.56. Prescription using generic instead of brand names was 21.4%. Seven per cent were prescribed more than one antipsychotic concurrently.Conclusion: There has been an appreciable increase in antipsychotic utilization in recent years in Pakistan, especially atypical antipsychotics, with little polypharmacy. Ongoing utilization of typical antipsychotics may be due to comorbidities such as diabetes and cardiovascular disease. Issues of international non-proprietary name prescribing need investigating along with the high number of medicines per encounter and gender inequality.

PF-06463922, an ALK/ROS1 Inhibitor, Overcomes Resistance to First and Second Generation ALK Inhibitors in Preclinical Models.

We report the preclinical evaluation of PF-06463922, a potent and brain-penetrant ALK/ROS1 inhibitor. Compared with other clinically available ALK inhibitors, PF-06463922 displayed superior potency against all known clinically acquired ALK mutations, including the highly resistant G1202R mutant. Furthermore, PF-06463922 treatment led to regression of EML4-ALK-driven brain metastases, leading to prolonged mouse survival, in a superior manner. Finally, PF-06463922 demonstrated high selectivity and safety margins in a variety of preclinical studies. These results suggest that PF-06463922 will be highly effective for the treatment of patients with ALK-driven lung cancers, including those who relapsed on clinically available ALK inhibitors because of secondary ALK kinase domain mutations and/or brain metastases.

The ALK inhibitor ceritinib overcomes crizotinib resistance in non-small cell lung cancer.

UNLABELLED: Non-small cell lung cancers (NSCLC) harboring anaplastic lymphoma kinase (ALK) gene rearrangements invariably develop resistance to the ALK tyrosine kinase inhibitor (TKI) crizotinib. Herein, we report the first preclinical evaluation of the next-generation ALK TKI, ceritinib (LDK378), in the setting of crizotinib resistance. An interrogation of in vitro and in vivo models of acquired resistance to crizotinib, including cell lines established from biopsies of patients with crizotinib-resistant NSCLC, revealed that ceritinib potently overcomes crizotinib-resistant mutations. In particular, ceritinib effectively inhibits ALK harboring L1196M, G1269A, I1171T, and S1206Y mutations, and a cocrystal structure of ceritinib bound to ALK provides structural bases for this increased potency. However, we observed that ceritinib did not overcome two crizotinib-resistant ALK mutations, G1202R and F1174C, and one of these mutations was identified in 5 of 11 biopsies from patients with acquired resistance to ceritinib. Altogether, our results demonstrate that ceritinib can overcome crizotinib resistance, consistent with clinical data showing marked efficacy of ceritinib in patients with crizotinib-resistant disease. SIGNIFICANCE: The second-generation ALK inhibitor ceritinib can overcome several crizotinib-resistant mutations and is potent against several in vitro and in vivo laboratory models of acquired resistance to crizotinib. These findings provide the molecular basis for the marked clinical activity of ceritinib in patients with ALK-positive NSCLC with crizotinib-resistant disease. Cancer Discov; 4(6); 662-73. ©2014 AACR. See related commentary by Ramalingam and Khuri, p. 634 This article is highlighted in the In This Issue feature, p. 621.