Identification of tyrosine kinase inhibitors from Panax bipinnatifidus and Panax pseudoginseng for RTK-HER2 and VEGFR2 receptors, by in silico approach.

Breast and stomach cancer is reported as a leading cause for human mortality across the world. The overexpression of receptor tyrosine kinase (RTK) proteins, namely the human epidermal growth factor receptor2 (HER2) and the vascular endothelial growth factor receptor2 (VEGFR2), is reported to be responsible for development and metastasis of breast and stomach cancer. Although several synthetic tyrosine kinase inhibitors (TKIs) as drug candidates targeting RTK-HER2 and VEGFR2 are currently available in the market, these are expensive with the reported side effects. This confers an opportunity for development of alternative novel tyrosine kinase inhibitors (TKIs) for RTK-HER2 and VEGFR2 receptors from the botanical sources. In the present study, we characterized 47 bioactive phytocompounds from the methanol extracts of the rhizomes of Asiatic traditional medicinal herbs-Panax bipinnatifidus and Panax pseudoginseng, of Indian Himalayan landraces using HPLC, GC-MS and high-sensitivity LC-MS tools. We performed molecular docking and molecular dynamics simulation analysis using Schrödinger suite 2020-3 to confirm the TKI phytocompounds showing the best binding affinity towards RTK-HER2 and VEGFR2 receptors. The results of molecular docking studies confirmed that the phytocompound (ligand) luteolin 7-O-glucoside (IHP15) showed the highest binding affinity towards receptor HER2 (PDB ID: 3PP0) with docking score and Glide g score (G-Score) of - 13.272, while chlorogenic acid (IHP12) showed the highest binding affinity towards receptor VEGFR2 (PDB ID: 4AGC) with docking score and Glide g score (G-Score) of - 10.673. Molecular dynamics (MD) simulation analysis carried out for 100 ns has confirmed strong binding interaction between the ligand and receptor complex [luteolin 7-O-glucoside (IHP15) and HER2 (PDB ID: 3PP0)] and is found to be stabilized within 40 to 100 ns of MD simulation, whereas ligand-receptor complex [chlorogenic acid (IPH12) and VEGFR2 (PDB ID: 4AGC)] also showed strong binding interaction and is found to be stabilized within 18-30 ns but slightly deviated during 100 ns of MD simulation. In silico ADME-Tox study using SwissADME revealed that the ligands luteolin 7-O-glucoside (IHP15) and chlorogenic acid (IHP12) have passed majority parameters of the common drug discovery rules. The present study has confirmed luteolin 7-O-glucoside (IHP15) and chlorogenic acid (IHP12) as potential tyrosine kinase inhibitors (TKIs) which were found to inhibit RTKs-HER2 and VEGFR2 receptor proteins, and thus paving the way for development of alternative potential TKIs (drug molecules) for treatment of HER2- and VEGFR2-positive breast and stomach cancer.

Autophagic flux inhibition enhances cytotoxicity of the receptor tyrosine kinase inhibitor ponatinib.

BACKGROUND: Despite reported advances, acquired resistance to tyrosine kinase inhibitors still represents a serious problem in successful cancer treatment. Among this class of drugs, ponatinib (PON) has been shown to have notable long-term efficacy, although its cytotoxicity might be hampered by autophagy. In this study, we examined the likelihood of PON resistance evolution in neuroblastoma and assessed the extent to which autophagy might provide survival advantages to tumor cells. METHODS: The effects of PON in inducing autophagy were determined both in vitro, using SK-N-BE(2), SH-SY5Y, and IMR-32 human neuroblastoma cell lines, and in vivo, using zebrafish and mouse models. Single and combined treatments with chloroquine (CQ)-a blocking agent of lysosomal metabolism and autophagic flux-and PON were conducted, and the effects on cell viability were determined using metabolic and immunohistochemical assays. The activation of the autophagic flux was analyzed through immunoblot and protein arrays, immunofluorescence, and transmission electron microscopy. Combination therapy with PON and CQ was tested in a clinically relevant neuroblastoma mouse model. RESULTS: Our results confirm that, in neuroblastoma cells and wild-type zebrafish embryos, PON induces the accumulation of autophagy vesicles-a sign of autophagy activation. Inhibition of autophagic flux by CQ restores the cytotoxic potential of PON, thus attributing to autophagy a cytoprotective nature. In mice, the use of CQ as adjuvant therapy significantly improves the anti-tumor effects obtained by PON, leading to ulterior reduction of tumor masses. CONCLUSIONS: Together, these findings support the importance of autophagy monitoring in the treatment protocols that foresee PON administration, as this may predict drug resistance acquisition. The findings also establish the potential for combined use of CQ and PON, paving the way for their consideration in upcoming treatment protocols against neuroblastoma.

Role of TKI for Metastatic Osteogenic Sarcoma.

OPINION STATEMENT: Osteosarcomas (OS) belong to a large family of mesenchymal tumor entities which exhibit heterogenous histological, genetic, and molecular features. Current OS treatment regimen consists of the combination of surgery and intensive multi-agent chemotherapy. Ever since the introduction of chemotherapy, 5-year survival rate among OS patients has improved to 60-75%. However, 30-35% of OS patients are associated with pulmonary metastasis and relapse, which have significantly poor prognosis, with an overall 5-year survival rate of about 20%. The fact that OS are both rare forms of cancer and highly heterogeneous may explain why patients' survival has not improved in the past three decades, especially for metastatic/relapsed and unresectable osteosarcomas. Patients who experience relapse with metastatic disease have limited therapeutic options, often receiving additional cytotoxic therapy such as ifosfamide and etoposide and/or carboplatin or gemcitabine plus docetaxel. Novel precise OS-targeted thrapies are being developed with the hope of improving metastatic/relapsed OS prognosis. This review provides an overview of the most updated targeted therapies in relapsed/metastatic osteosarcoma and dicusses some clinical options in order to improve progression-free survival.

The Global Phosphorylation Landscape of SARS-CoV-2 Infection.

The causative agent of the coronavirus disease 2019 (COVID-19) pandemic, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has infected millions and killed hundreds of thousands of people worldwide, highlighting an urgent need to develop antiviral therapies. Here we present a quantitative mass spectrometry-based phosphoproteomics survey of SARS-CoV-2 infection in Vero E6 cells, revealing dramatic rewiring of phosphorylation on host and viral proteins. SARS-CoV-2 infection promoted casein kinase II (CK2) and p38 MAPK activation, production of diverse cytokines, and shutdown of mitotic kinases, resulting in cell cycle arrest. Infection also stimulated a marked induction of CK2-containing filopodial protrusions possessing budding viral particles. Eighty-seven drugs and compounds were identified by mapping global phosphorylation profiles to dysregulated kinases and pathways. We found pharmacologic inhibition of the p38, CK2, CDK, AXL, and PIKFYVE kinases to possess antiviral efficacy, representing potential COVID-19 therapies.

Bufalin down-regulates Axl expression to inhibit cell proliferation and induce apoptosis in non-small-cell lung cancer cells.

Axl, a member of the TAM (Tyro3, AXL, Mer) receptor tyrosine kinase family, plays critical roles in cell growth, proliferation, apoptosis, and migration. In the present study, we demonstrated that the anti-cancer activity of bufalin, a major bioactive component of the Chinese traditional medicine Chan Su, is mediated by the down-regulation of Axl in non-small-cell lung cancer (NSCLC) cells. We observed the inhibitory effect of bufalin on the proliferation of A549 and H460 NSCLC cells and the clonogenicity of these cells was reduced by bufalin treatment in a dose-dependent manner. Next, we found that the protein level of Axl was decreased in proportion to the concentration of bufalin in both A549 and H460 cells. Moreover, the promoter activity of the Axl gene was decreased by bufalin in a dose- and time-dependent manner, indicating that bufalin down-regulates Axl gene expression at the transcriptional level. We further examined if the anti-proliferative property of bufalin is influenced by Axl at the protein level. Axl overexpression attenuated the effect of bufalin in inhibiting cell proliferation and colony formation and inducing apoptosis in H460 cells, while knockdown of Axl gene expression induced the opposite effect. Taken together, our data indicate that the anti-proliferative and pro-apoptotic effects of bufalin were associated with the protein level of Axl, suggesting that Axl is a potent therapeutic target of bufalin in suppressing proliferation and inducing apoptosis in NSCLC cells.

Eficacia y seguridad de osimertinib como primera línea de tratamiento en pacientes adultos con cáncer de pulmón de células no pequeñas metastásico, con mutación del receptor del factor de crecimiento epidérmico / Efficacy and safety of osimertinib as first-line treatment in adult patients with metastatic non-small cell lung cancer with epidermal growth factor receptor mutation

INTRODUCCIÓN: El presente dictamen expone la evaluación de la eficacia y seguridad de osimertinib en comparación con erlotinib como primera línea de tratamiento sistémico de los pacientes adultos con cáncer de pulmón de células no pequeñas (CPCNP) metastásico con mutación del receptor del factor de crecimiento epidérmico (EGFR, del inglés Epidermal Growth Factor Receptor). El cáncer de pulmón de células no pequeñas (CPCNP) metastásico, con mutación del receptor del factor de crecimiento epidérmico (EGFR, por sus siglas en inglés) ha sido abordado ampliamente en dictámenes preliminares previos (Dictámenes Preliminares de Evaluación de Tecnología Sanitaria N° 002-SDEPFyOTS-DETS- IETSI-2015 y N° 029-SDEPFyOTS-DETS-IETSI-2019). Brevemente, el tratamiento de primera línea de los pacientes adultos con CPCNP metastásico que presentan la mutación del EGFR (mEGFR) corresponde al uso de un inhibidor de la tirosina quinasa (TKI) específico para dicha mutación (i. e. un TKI-EGFR). El Petitorio Farmacológico de EsSalud cuenta con erlotinib, un TKI-EGFR, como primera línea de tratamiento sistémico de los pacientes con CPCNP metastásico con mEGFR. Cabe indicar que, en el dictamen preliminar, donde se aprueba el uso de erlotinib (Dictamen Preliminar de Evaluación de Tecnología Sanitaria N° 002-SDEPFyOTS-DETS-IETSI-2015), se estableció que todos los TKI-EGFR disponibles a la fecha de su elaboración presentaban similares perfiles de eficacia y seguridad, motivo por el cual las guías de práctica clínica (GPC) internacionales o habían realizado recomendaciones específicas que favorezcan algunos TKI-EGFR sobre otros. En ese contexto, en abril y junio del 2018, la Food and Drug Administration (FDA) y la European Medicines Agency (EMA), respectivamente, autorizaron la comercialización de osimertinib, un TKI-EGFR, como primera línea de tratamiento de los pacientes adultos con CPCNP localmente avanzado o metastásico con mEGFR, la FDA restringió su uso para aquellos pacientes que presentaban específicamente las mutaciones en EGFR [mEGFR] de tipo L858R y Ex19del. Este punto cobra relevancia por el hecho de que en el Perú cerca del 66 % y 28 % de los pacientes con CPCNP metastásico con mEGFR tendrían las mutaciones Ex19del y L858R, respectivamente. En ese sentido, los especialistas han sugerido la evaluación de uso de osimertinib, bajo la hipótesis de que este tendría un mejor perfil de seguridad y eficacia que erlotinib. METODOLOGÍA: Se llevó a cabo una búsqueda bibliográfica sistemática, exhaustiva y jerárquica con respecto a la eficacia y seguridad del osimertinib, comparado con erlotinib, como primera línea de tratamiento de los pacientes adultos con CPCNP metastásico con mEGFR. La búsqueda se inició revisando la información sobre el uso del medicamento de acuerdo con entidades reguladoras como FDA, EMA y DIGEMID en el Perú. Se realizó tanto una búsqueda sistemática en las principales bases de datos, tales como MEDLINE vía PubMed y en Cochrane Library. Asimismo, se realizó una búsqueda manual en las páginas web de grupos dedicados a la investigación y educación en salud que elaboran guías de práctica clínica: National Institute for Health and Care Excellence (NICE), Canadian Agency for Drugs and Technologies in Health (CADTH), Scottish Medicines Consortium (SMC), Haute Authorité de Santé (HAS), el Institute for Quality and Efficiency in Healthcare (IQWiG), la Institute for Clinical and Economic Review y el Ministerio de Salud del Perú (MINSA). Además, se realizó una búsqueda de las guías de las principales sociedades o instituciones especializadas en cáncer, tales como el Instituto Nacional de Enfermedades Neoplásicas (INEN) del Perú, la National Comprehensive Cancer Network (NCCN), la American Society of Clinical Oncology (ASCO), la American Cancer Society, la European Society for Medical Oncology (ESMO),la Association for Cancer Physicians, Association of European Cancer Leagues, Cancer Australia, Cancer Counsil Australia, Canadian Cancer Society y Health Canada. Por último, se buscaron ensayos clínicos en desarrollo o que no hayan sido publicados aún en la página web www.clinicaltrials.gov que ayuden a responder la pregunta PICO, con el fin de disminuir el sesgo de publicación. RESULTADOS: De acuerdo con la pregunta PICO, se llevó a cabo una búsqueda sistemática de la evidencia científica relacionada al uso de osimertinib, comparado con erlotinib, como tratamiento de primera línea de los pacientes adultos con CPCNP metastásico con mEGFR. En la presente sinopsis se describe la evidencia disponible según el tipo de publicación, siguiendo lo indicado en los criterios de elegibilidad (GPC, ETS, RS, MA y ECA fase III). CONCLUSIONES: El presente dictamen preliminar tiene como objetivo la evaluación de la mejor evidencia disponible sobre la eficacia y seguridad del uso de osimertinib, comparado con erlotinib, como primera línea de tratamiento de los pacientes con CPCNP metastásico con mEGFR. En general, las recomendaciones a favor de osimertinib por parte de las GPC en nuestra población de interés están basadas principalmente en ganancias respecto al desenlace intermedio SLP, el cual no ha demostrado ser un predictor de los desenlaces clínicos de alta relevancia clínica como la SG y la calidad de vida en los pacientes con CPCNP metastásico con mEGFR. La evidencia procedente del ECA FLAURA no muestra una ventaja adicional con osimertinib en comparación con erlotinib, respecto a desenlaces clínicamente relevantes, como la SG, la calidad de vida o los desenlaces clave de seguridad, en la población de la pregunta PICO del presente dictamen preliminar. Es decir, al realizar el ajuste por ECA truncado, con una madurez de los datos de mortalidad del 58 %, los cálculos realizados por el Equipo Técnico del IETSI no mostraron diferencias estadísticamente significativas entre los grupos de tratamiento respecto al RR de muerte ni antes de realizar el ajuste (RR 0.93; p = 0.304), consecuentemente, ni después del ajuste (RRa 1.31). Además, se presentaron una serie de limitaciones en la validez del estudio que dificultan la interpretación de los resultados de SG para efectos del presente dictamen. Asimismo, no se reportaron diferencias estadísticamente significativas ni clínicamente relevantes respecto a los cinco DRP ni el dominio estado de salud global (calidad de vida), entre los grupos osimertinib y TE, en la población total del estudio. En cuanto a los EA, los resultados finales del ECA FLAURA no mostraron diferencias estadísticamente significativas entre los grupos de tratamiento en las tasas de EA serios, descontinuación del tratamiento por EA, y EA de grado 3 o mayor. En ese sentido, considerando que la evidencia científica procedente del ECA truncado FLAURA muestra un balance riesgo beneficio similar entre osimertinib y erlotinib en la población de la pregunta PICO, no es posible justificar la financiación de osimertinib, considerando la gran diferencia de costos entre ambas alternativas (costo anual por paciente de S/ 345,976.80 vs. S/ 3,577.00). Asimismo, erlotinib se encuentra actualmente disponible en el Petitorio Farmacológico de EsSalud y cuenta con amplia experiencia de uso por parte de los especialistas. Por lo expuesto, el IETSI no aprueba el uso de osimertinib como primera línea de tratamiento de los pacientes adultos con CPCNP metastásico con mEGFR.

Target-Mediated Drug Disposition Pharmacokinetic/Pharmacodynamic Model-Informed Dose Selection for the First-in-Human Study of AVB-S6-500.

AVB-S6-500 neutralized growth arrest-specific 6 (GAS6) protein and effectively inhibited AXL signaling in preclinical cancer models. A target-mediated drug disposition (TMDD) pharmacokinetic/pharmacodynamic (PK/PD) model was used to select first-in-human (FIH) doses for AVB-S6-500 based on predicted target (GAS6) suppression in the clinic. The effect of TMDD on AVB-S6-500 clearance was incorporated into a standard two-compartment model, providing parallel linear and nonlinear clearance. Observed AVB-S6-500 and GAS6 concentration data in cynomolgus monkeys and relevant interspecies differences were used to predict the PK (serum concentration)/PD (GAS6 suppression) relationship in humans. Human exposure and GAS6 suppression were simulated for the proposed FIH doses of 1, 2.5, 5, and 10 mg/kg. A dose of 1 mg/kg was selected to target GAS6 suppression for 2 weeks in the initial healthy volunteer study. The cynomolgus monkey:human ratios for the highest proposed FIH dose were anticipated to yield more than a 10-fold margin to the nonclinical no observed adverse event level while maintaining > 90% GAS6 suppression. In human subjects, the first dose (1 mg/kg) model-projected and clinically observed maximal concentration (Cmax ) was within 10% of predicted; repeat dosing at 5 mg/kg was within 1% (Cmax ) and 45% (area under the serum concentration-time curve from time 0 to end of dosing interval) of predicted. Predicted GAS6 suppression duration of 14 days was accurate for the 1 mg/kg dose. A PK/PD model expedited clinical development of AVB-S6-500, minimized exposure of patients with cancer to subtherapeutic doses, and rationally guided the optimal dosing in patients.

AXL degradation in combination with EGFR-TKI can delay and overcome acquired resistance in human non-small cell lung cancer cells.

Acquired resistance to epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) has been a major obstacle in the treatment of non-small cell lung cancer (NSCLC) patients. AXL has been reported to mediate EGFR-TKIs. Recently, third generation EGFR-TKI osimertinib has been approved and yet its acquired resistance mechanism is not clearly understood. We found that AXL is involved in both gefitinib and osimertinib resistance using in vitro and in vivo model. In addition, AXL overexpression was correlated with extended protein degradation rate. We demonstrate targeting AXL degradation is an alternative route to restore EGFR-TKIs sensitivity. We confirmed that the combination effect of YD, an AXL degrader, and EGFR-TKIs can delay or overcome EGFR-TKIs-driven resistance in EGFR-mutant NSCLC cells, xenograft tumors, and patient-derived xenograft (PDX) models. Therefore, combination of EGFR-TKI and AXL degrader is a potentially effective treatment strategy for overcoming and delaying acquired resistance in NSCLC.

Adjuvant Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors (TKIs) in Resected Non-Small Cell Lung Cancer (NSCLC): A Systematic Review and Meta-analysis.

The role of adjuvant tyrosine kinase inhibitors (TKIs) in non-small cell lung cancer (NSCLC) is not well defined. Recent randomized controlled trials showed a disease-free survival (DFS) benefit in patients harboring an epidermal growth factor receptor (EGFR) mutation. Yet, older trials on patients with any EGFR status did not demonstrate the same benefit. We aimed to assess the efficacy and safety of adjuvant TKIs in NSCLC patients. The electronic databases Medline (PubMed) and EMBASE were searched for relevant randomized controlled trials. Random effect models were used. The primary outcome was DFS measured as hazard ratio (HR). The secondary outcomes were overall survival (OS) measured as HR, 2-year DFS and toxicity expressed as risk ratio and odds ratio (OR), respectively. Subgroup analyses assessed DFS by trial design. Six trials incorporating 1860 patients were included. In patients harboring an EGFR mutation, adjuvant TKIs decreased the risk of disease recurrence by 48% (HR: 0.52, 95% confidence interval [CI]: 0.35-0.78), improved 2-year DFS (HR: 0.53, 95% CI: 0.43-0.66) but did not improve OS (HR: 0.64, 95% CI: 0.22-1.89). The risk of developing ≥grade 3 skin toxicity (OR: 6.07, 95% CI: 4.34-8.51) and diarrhea (OR: 4.05; 95% CI: 2.44-6.74) was increased. In subgroup analyses, the DFS benefit was more pronounced in trials using TKIs over chemotherapy compared with trials using TKIs postchemotherapy. In conclusion, adjuvant TKIs decrease the risk of recurrence in NSCLC patients harboring an EGFR mutation but do not improve OS. Longer follow-up is needed for a definitive assessment of OS and to define the role of adjuvant TKI for NSCLC in the clinical practice.

Integrated analysis of multiple receptor tyrosine kinases identifies Axl as a therapeutic target and mediator of resistance to sorafenib in hepatocellular carcinoma.

BACKGROUND: Aberrant activation of Axl is implicated in the progression of hepatocellular carcinoma (HCC). We explored the biologic significance and preclinical efficacy of Axl inhibition as a therapeutic strategy in sorafenib-naive and resistant HCC. METHODS: We evaluated Axl expression in sorafenib-naive and resistant (SR) clones of epithelial (HuH7) and mesenchymal origin (SKHep-1) using antibody arrays and confirmed tissue expression. We tested the effect of Axl inhibition with RNA-interference and pharmacologically with R428 on a number of phenotypic assays. RESULTS: Axl mRNA overexpression in cell lines (n = 28) and RNA-seq tissue datasets (n = 373) correlated with epithelial-to-mesenchymal transition (EMT). Axl was overexpressed in HCC compared to cirrhosis and normal liver. We confirmed sorafenib resistance to be associated with EMT and enhanced motility in both HuH7-SR and SKHep-1-SR cells documenting a 4-fold increase in Axl phosphorylation as an adaptive feature of chronic sorafenib treatment in SKHep-1-SR cells. Axl inhibition reduced motility and enhanced sensitivity to sorafenib in SKHep-1SR cells. In patients treated with sorafenib (n = 40), circulating Axl levels correlated with shorter survival. CONCLUSIONS: Suppression of Axl-dependent signalling influences the transformed phenotype in HCC cells and contributes to adaptive resistance to sorafenib, providing a pre-clinical rationale for the development of Axl inhibitors as a measure to overcome sorafenib resistance.

Rational Drug Design Approach of Receptor Tyrosine Kinase Type III Inhibitors.

Rational drug design is accomplished through the complementary use of structural biology and computational biology of biological macromolecules involved in disease pathology. Most of the known theoretical approaches for drug design are based on knowledge of the biological targets to which the drug binds. This approach can be used to design drug molecules that restore the balance of the signaling pathway by inhibiting or stimulating biological targets by molecular modeling procedures as well as by molecular dynamics simulations. Type III receptor tyrosine kinase affects most of the fundamental cellular processes including cell cycle, cell migration, cell metabolism, and survival, as well as cell proliferation and differentiation. Many inhibitors of successful rational drug design show that some computational techniques can be combined to achieve synergistic effects.

Eficacia y seguridad del uso de alectinib en el tratamiento de primera línea de pacientes con cáncer metastásico de pulmón de células no pequeñas alk-positivo / Efficacy and safety of the use of alectinib in the first-line treatment of patients with metastatic non-small-cell lung metastatic cancer

INTRODUCCIÓN: El cáncer de pulmón de células no pequeñas se encuentra entre los tipos más letales de cáncer. De todos los tipos de cáncer de pulmón, alrededor del 85% corresponden al cáncer de pulmón de células no pequeñas (NSCLC), y entre el 3 % y el 7 % presentan mutaciones de la quinasa del linfoma anaplásico (ALK). La sobrevida a 5 años de los pacientes con NSCLC se encuentra entre 1 % y 16 %. El tratamiento para pacientes en estadio IV es por lo general terapia sistémica o manejo paliativo. Dependiendo del perfil clínico del paciente, existe la posibilidad de quimioterapia, terapia molecular dirigida o inmunoterapia. Para pacientes con cáncer metastásico ALK-positivo específicamente, la recomendación de primera línea por parte de las guías de práctica clínica (GPC) es el uso de inhibidores de ALK. Un inhibidor de ALK, crizotinib, ha sido evaluado previamente por el IETSI para el tratamiento de primera línea de NSCLC metastásico ALK-positivo, mediante el Dictamen Preliminar N° 004-SDEPFyOTS-DETS-IETSI-2018 y el Dictamen Preliminar N° 019-SDEPFyOTS-DETS-IETSI-2016, en los cuales no se aprobó el uso por fuera del petitorio de dicho fármaco ya que no ha probado con solidez ser mejor que quimioterapia para los desenlaces de relevancia desde la perspectiva del paciente (i.e., SG y calidad de vida). Así, crizotinib ha mostrado únicamente una diferencia de 3 meses en la SLP con respecto a quimioterapia. TECNOLOGÍA SANITARIA DE INTERÉS: Alectinib es un inhibidor competitivo del receptor de tirosina quinasa ALK (y sus variantes oncogénicas) de segunda generación. El mecanismo de acción de alectinib se basa en la inhibición selectiva del crecimiento tumoral y la inducción de la apoptosis de las células tumorales que expresan receptores ALK, interrumpiendo la proliferación y supervivencia de las mismas (Avrillon and Pérol 2017) . A diferencia de otros inhibidores de ALK y de la quimioterapia basada en platino, alectinib tiene la capacidad de cruzar la barrera hematoencefálica. METODOLOGÍA: Se llevó a cabo una búsqueda de la literatura con respecto a la eficacia y seguridad de alectinib en el tratamiento de cáncer de pulmón ALK-positivo en las bases de datos de PubMed, TRIP y www.clinicaltrials.gov. Adicionalmente, se realizó una búsqueda de evaluaciones de tecnologías y guías de práctica clínica en las páginas web de grupos dedicados a la investigación y educación en salud en general como la National Institute for Health and Care Excellence (NICE), Canadian Agency for Drugs and Technologies in Health (CADTH), Scottish Medicines Consortium (SMC), Instituto de Evaluación de Efectividad Clínica y Sanitaria (IECS), Instituto de Evaluación de Tecnología en Salud (IETS); y especializados en oncología como European Society for Medical Oncology (ESMO), National Comprehensive Cancer Network (NCCN) y American Society of Clinical Oncology (ASCO). La estrategia de búsqueda en PubMed se encuentra desarrollada en la Tabla 1 del material suplementario. RESULTADOS: Los resultados del ECA ALEX muestran que, al momento del cierre de la data de sobrevida libre de progresión (SLP, desenlace primario del ensayo), los datos de sobrevida global (SG) se encontraban aun inmaduros. Los resultados de SG a la fecha de cierre de la data de SLP (mediana de seguimiento alrededor de 18 meses) no mostraron diferencias entre los grupos para este desenlace. La calidad de vida no se reportó en el artículo identificado, ni en otro artículo separado. Se obtuvo los resultados de calidad de vida de la pagina web clinicaltrials.gov, donde se observó que, para los diferentes desenlaces de calidad de vida evaluados, por lo general no se observaron diferencias entre los grupos. Aunque se reporta una mayor frecuencia de disnea en los pacientes que recibieron alectinib, en comparación con los que recibieron crizotinib (17.1 % vs 9.9 %). Los resultados del ECA ALEX muestran un beneficio del uso de alectinib en comparación con crizotinib en términos de SLP, con una ganancia de aproximadamente 15 meses en la mediana de SLP. Sin embargo, a la fecha no se han publicado estudios que evalúen la capacidad predictiva de la SLP sobre la SG o la calidad de vida, desenlaces de relevancia desde la perspectiva del paciente, por lo que su validez como desenlace subrogado es aún desconocida. Frente a ello, el beneficio de alectinib sobre la SG o la calidad de vida es aún incierto, hasta que se publiquen los resultados de seguimiento del ensayo ALEX o de otros ensayos en desarrollo. CONCLUSIONES: La evidencia central en torno a alectinib en NSCLC proviene del ECA de fase III de etiqueta abierta ALEX de la comparación entre alectinib y crizotinib, como una aproximación a la comparación entre alectinib y quimioterapia, siendo que crizotinib se ha comparado previamente con quimioterapia. Este ECA ha sido utilizado también por las GPC (ESMO y NCCN) y ETS (NICE, CADTH y SMC) identificadas y descritas. Adicionalmente, se consideran los resultados del ECA J-ALEX, a sugerencia del especialista. Las GPC identificadas de ESMO y NCCN recomiendan el uso de alectinib en el tratamiento de primera línea de pacientes con NSCLC metastásico ALK-positivo sobre la base de los ensayos ALEX, sin mencionar quimioterapia como una alternativa para esta población especifica. En estas guías, la quimioterapia está recomendada como primera línea en los pacientes que mostraron resultados negativos a las pruebas moleculares, ya que ha sido el estándar de tratamiento para NSCLC en general antes de la aparición de las terapias dirigidas, y lo sigue siendo para pacientes sin las variaciones moleculares estudiadas a la fecha. Con respecto a esto, es importante mencionar que ninguno de los inhibidores de ALK incluidos en las GPC como alternativas de primera línea para pacientes ALK-positivo ha mostrado a la fecha ser mejor que quimioterapia en términos de SG, que es el desenlace duro de relevancia desde la perspectiva del paciente. A pesar de ello, los inhibidores de ALK se han consolidado en las GPC como la alternativa de primera línea por las diferencias con quimioterapia en términos de SLP, que como se mencionó, no ha sido validado como subrogado de SG. Por otra parte, las ETS de NICE del Reino Unido, SMC de Escocia y CADTH de Canadá recomiendan el financiamiento de alectinib en sus respectivos contextos, en todos los casos sujeta a un descuento confidencial por parte de la compañía comercializadora de manera que el fármaco sea costo-efectivo en cada país. De acuerdo con los elaboradores de las ETS, la necesidad de un acuerdo económico surge de la incertidumbre con respecto al beneficio neto de alectinib en términos de SG, basándose en el ECA ALEX; y en el diseño de etiqueta abierta del estudio por los potenciales sesgos que se pueden introducir sobre los desenlaces blandos de relevancia (i.e., calidad de vida) como el sesgo del observador. El ECA ALEX identificado no permite, a la fecha, concluir con respecto al beneficio neto de alectinib, en comparación con crizotinib, sobre los desenlaces definidos como de relevancia clínica, que son la SG y la calidad de vida. Este reporta un aumento en la SLP de aproximadamente 15 meses. Sin embargo, la capacidad predictiva de la SLP sobre la SG y la calidad de vida aún no ha sido estudiada, por lo que su validez como desenlace subrogado de estos desenlaces de relevancia clínica es aún desconocida. Frente a ello, el beneficio de alectinib sobre la SG y la calidad de vida aún no se ha podido determinar, hasta que se publiquen los resultados de seguimiento del ensayo ALEX o de otros ensayos en desarrollo. Entonces, se tiene que, con la evidencia disponible a la fecha sobre alectinib, y considerando su alto costo, no es posible asumir un perfil de costo-oportunidad favorable para sistemas públicos de servicios de salud, ya que no se ha encontrado que este sea superior a quimioterapia (ni a crizotinib como una aproximación a quimioterapia) en términos de calidad de vida a la fecha de publicación del ECA, ni que presente un mejor perfil de seguridad, y aun no se ha podido determinar su beneficio neto en cuanto a la SG. Ello impide que se pueda sustentar técnicamente una recomendación favorable para el uso de este medicamento. Se queda a la espera de las futuras publicaciones con un mayor tiempo de seguimiento que permitan determinar si el aumento en 15 meses de la SLP observado con el uso de alectinib con respecto a crizotinib (como una aproximación a la comparación con quimioterapia, siendo que crizotinib ha mostrado previamente aumentar la SLP frente a quimioterapia), se llega a traducir en una ganancia en SG y calidad de vida, lo cual a este punto aún no se puede llegar a calcular dado que no se tienen estudios de validación que permitan conocer la capacidad predictiva de la SLP respecto a dichos desenlaces finales. Por lo expuesto, el el Instituto de Evaluación de Tecnologías en Salud e Investigación (IETSI), no aprueba el uso fuera del petitorio de alectinib en el tratamiento de primera línea de pacientes con NSCLC metastásico ALK-positivo.

Discovery of N-{2-Methoxy-4-[4-(4-methylpiperazin-1-yl)piperidin-1-yl]phenyl}-N'-[2-(propane-2-sulfonyl)phenyl]-1,3,5-triazine-2,4-diamine (ASP3026), a Potent and Selective Anaplastic Lymphoma Kinase (ALK) Inhibitor.

Anaplastic lymphoma kinase (ALK) is a validated therapeutic target for treating echinoderm microtubule-associated protein-like 4 (EML4)-ALK positive non-small cell lung cancer (NSCLC). We synthesized a series of 1,3,5-triazine derivatives and identified ASP3026 (14a) as a potent and selective ALK inhibitor. In mice xenografted with NCI-H2228 cells expressing EML4-ALK, once-daily oral administration of 14a demonstrated dose-dependent antitumor activity. Here, syntheses and structure-activity relationship (SAR) studies of 1,3,5-triazine derivatives are described.

Development of Potent Inhibitors of Receptor Tyrosine Kinases by Ligand-Based Drug Design and Target-Biased Phenotypic Screening.

Pyrazolopyrimidines with potent antiproliferative properties were developed by an adaptive strategy that applies ligand-based design and phenotypic screening iteratively and is informed by biochemical assays. To drive development toward specific oncopathways, compounds were tested against cancer cells that overexpress, or not, AXL kinase. Identified phenotypic hits were found to inhibit oncotargets AXL, RET, and FLT3. Subsequent optimization generated antiproliferative lead compounds with unique selectivity profiles, including selective AXL inhibitors and a highly potent inhibitor of FLT3.

A major component of vitamin E, α-tocopherol inhibits the anti-tumor activity of crizotinib against cells transformed by EML4-ALK.

Crizotinib is an inhibitor of anaplastic lymphoma kinase (ALK) and is of significant therapeutic benefit to patients with non-small cell lung cancer (NSCLC) harboring the EML4-ALK fusion gene. In the present study, we demonstrated that α-tocopherol, a major component of vitamin E, attenuated the effects of crizotinib independently of its anti-oxidant properties. α-Tocopherol significantly inhibited crizotinib-induced apoptosis in cells transformed by EML4-ALK. It also effectively attenuated the crizotinib-induced inhibition of EML4-ALK and its downstream molecules, STAT3 and ERK, and suppressed the inhibitory effects of crizotinib on EML4-ALK-mediated transformation in the focus formation assay. On the other hand, other members of the vitamin E family, namely, ß-tocopherol, γ-tocopherol, δ-tocopherol, and α-tocotrienol, and a water-soluble analog of vitamin E, Trolox had no effects on the anti-tumor activity of crizotinib in cells transformed by EML4-ALK. Collectively, these results revealed the risk of the anti-tumor activity of crizotinib being attenuated when it is administrated in combination with vitamin E supplements containing α-tocopherol as a major component.

Combined chemical genetics and data-driven bioinformatics approach identifies receptor tyrosine kinase inhibitors as host-directed antimicrobials.

Antibiotic resistance poses rapidly increasing global problems in combatting multidrug-resistant (MDR) infectious diseases like MDR tuberculosis, prompting for novel approaches including host-directed therapies (HDT). Intracellular pathogens like Salmonellae and Mycobacterium tuberculosis (Mtb) exploit host pathways to survive. Only very few HDT compounds targeting host pathways are currently known. In a library of pharmacologically active compounds (LOPAC)-based drug-repurposing screen, we identify multiple compounds, which target receptor tyrosine kinases (RTKs) and inhibit intracellular Mtb and Salmonellae more potently than currently known HDT compounds. By developing a data-driven in silico model based on confirmed targets from public databases, we successfully predict additional efficacious HDT compounds. These compounds target host RTK signaling and inhibit intracellular (MDR) Mtb. A complementary human kinome siRNA screen independently confirms the role of RTK signaling and kinases (BLK, ABL1, and NTRK1) in host control of Mtb. These approaches validate RTK signaling as a drugable host pathway for HDT against intracellular bacteria.

Discovery of Potent ALK Inhibitors Using Pharmacophore-Informatics Strategy.

Anaplastic lymphoma kinase is a tyrosine kinase receptor protein belonging to insulin receptor superfamily. Gene fusions in anaplastic lymphoma kinase are associated with non-small cell lung cancer development. Hence, they are of immense importance in targeted therapies. Thus, for the treatment of non-small cell lung cancer, effective anaplastic lymphoma kinase inhibitors are of great significance. Therefore, our objective is to find hit compounds that could have better inhibitory activity than the existing anaplastic lymphoma kinase inhibitors. Keeping this in mind, in the present study pharmacophore based virtual screening was performed to identify possible anaplastic lymphoma kinase inhibitors. Initially, a five-point common pharmacophore hypothesis was generated based on twelve anaplastic lymphoma kinase inhibitors using PHASE module of Schrödinger. Subsequently, common pharmacophore hypothesis-based screening was conducted against in-trials subset of ZINC database and a total of 1000 hits were identified. The molecules obtained were further screened by three stages of docking using GLIDE software. The docking results reveal that six hit molecules showed higher glide score in comparison with the reference molecules. Finally, pharmacokinetic properties of the hit molecules were also analysed using QikProp programme. The results indicate that molecules namely videx, dexecadotril, chloramphenicol, naficillin were found to have good pharmacokinetic properties and human oral absorption. Moreover, videx, naficillin and chloramphenicol were found to have significant inhibitory activity for mutant (F1174L) anaplastic lymphoma kinase. It was also found that videx exhibited crucial interactions with the Met1199 residue of the native and mutant anaplastic lymphoma kinase protein. Furthermore, PASS algorithm predicted anti-neoplastic activity for all the four molecules. Thus these hits are found to be promising leads for anaplastic lymphoma kinase inhibitors. We believe that this study will be useful for the discovery and designing of more potent anaplastic lymphoma kinase inhibitors in the near future.

Molecular and clinical features of second-generation anaplastic lymphoma kinase inhibitors: ceritinib.

The discovery of ALK rearrangement in non-small-cell lung cancer (NSCLC) triggered rapid clinical development of a family of specific drugs targeting this alteration, called ALK inhibitors. Despite high rate of responses, the vast majority of patients treated with first-generation ALK inhibitor crizotinib will ultimately develop disease progression. The second-generation ALK inhibitor, ceritinib, is an oral, small-molecule that inhibits the ALK kinase activity with a potency 20-fold greater than crizotinib, being able to tackle some of the principal mechanisms of resistance to crizotinib. Evidences from five large prospective clinical trials have so far showed impressive activity of ceritinib in ALK inhibitor pretreated and naive NSCLC patients. This review will focus on the preclinical and clinical data available regarding ceritinib pharmacology, clinical efficacy and safety profile.

First macrocyclic 3rd-generation ALK inhibitor for treatment of ALK/ROS1 cancer: Clinical and designing strategy update of lorlatinib.

Non-small cell lung cancers (NSCLC) harboring anaplastic lymphoma kinase (ALK) gene rearrangements invariably develop resistance to 2nd-generation ALK inhibitors. Lorlatinib (PF-06463922) (6) is a 3rd-generation macrocyclic ALK-TKI that demonstrates many advantages over 2nd-generation ALK inhibitors. Lorlatinib has demonstrated decent kinase selectivity, promising pharmacokinetic profile, selective brain-penetration and strong antiproliferative activity in several ALK/ROS1-driven tumor models. The current review describes the activity spectrum, key events from discovery to clinical applications and the evidences that lorlatinib acts as an ALK/ROS1 inhibitor in clinical settings.