EMA Review of Isatuximab in Combination with Pomalidomide and Dexamethasone for the Treatment of Adult Patients with Relapsed and Refractory Multiple Myeloma.

Isatuximab is a monoclonal antibody that binds to the human CD38 antigen. On May 30, 2020, a marketing authorization valid through the European Union (EU) was issued for isatuximab in combination with pomalidomide and dexamethasone (IsaPd) for the treatment of adult patients with relapsed and refractory (RR) multiple myeloma (MM). The recommended dose of isatuximab was 10 mg/kg, administered intravenously weekly at cycle 1 and then biweekly in subsequent 28-day cycles. Isatuximab was evaluated in a phase III, open-label, multicenter, randomized trial that randomly allocated IsaPd versus pomalidomide plus dexamethasone (Pd) to adult patients with RR MM. The primary endpoint of the trial was progression-free survival, as assessed by an independent review committee, which was superior for the IsaPd arm (hazard ratio, 0.596; 95% confidence interval, 0.436-0.814; p = .001) compared with the Pd arm. Treatment with IsaPd led to higher incidences of treatment-related adverse events (AEs), grade ≥ 3 AEs, and serious AEs compared with Pd treatment. Most frequently observed AEs that occurred more often in the IsaPd arm were infusion-related reactions, infections, respiratory AEs, neutropenia (including neutropenic complications), and thrombocytopenia. The aim of this article is to summarize the scientific review of the application leading to regulatory approval in the EU. IMPLICATIONS FOR PRACTICE: Isatuximab was approved in the European Union, in combination with pomalidomide and dexamethasone, for the treatment of patients with multiple myeloma who have already received therapy but whose disease did not respond or relapsed afterward. The addition of isatuximab resulted in a clinically meaningful and significant prolongation of the time from treatment initiation to further disease relapse or patient's death. The safety profile was considered acceptable, and the benefit-risk ratio was determined to be positive.

Fluoxetine attenuates the effects of pentylenetetrazol on rat freezing behavior and c-Fos expression in the dorsomedial periaqueductal gray.

The aim of the study was to investigate the role of the periaqueductal gray (PAG) in anxiolytic-like actions of fluoxetine in animals treated with an anxiogenic drug, pentylenetetrazol (PTZ), and subjected to fear conditioning procedure. The data showed that PTZ given at the dose of 30 mg/kg 15 min before a retention trial significantly decreased freezing reaction (p<0.01), and potently enhanced rat locomotor activity (p<0.01), in comparison to the control group. These effects were reversed by prior (60 min) administration of fluoxetine (20 mg/kg). Simultaneously, PTZ significantly increased c-Fos expression in the dorsomedial periaqueductal gray (DMPAG), examined 2h after the retention trial, in comparison to the control group (p<0.01). Fluoxetine (20 mg/kg) administered 60 min before PTZ reversed this effect. PTZ given at the same dose and time interval in the open field test did not affect rat locomotor behavior. Importantly, fluoxetine pretreatment did not change PTZ concentration in brain tissue. Our experiment based on PTZ-enhanced aversive conditioning revealed that acutely administered fluoxetine antagonized PTZ-induced panic-like behavior, and this phenomenon was accompanied by inhibition of activity of DMPAG.

Behavioral, immunocytochemical and biochemical studies in rats differing in their sensitivity to pain.

The aim of the study was to further explore the anatomical and neurochemical background of differences in response to the conditioned aversive stimuli. The different patterns of behavioral coping strategies (a conditioned freezing response and ultrasonic vocalization) were analyzed in animals differing in their response to the acute painful stimulation, a foot-shock (HS: high sensitivity rats, LS: low sensitivity rats, and MS: medium sensitivity rats, according to their behavior in the flinch-jump pre-test), and correlated with plasma corticosterone levels, expression of c-Fos protein, and distribution of 5-HT innervation, in different brain structures. It was found that HS rats showed significantly more freezing behavior, whereas LS animals vocalized much more intensively. The behavior of LS group (less freezing response and stronger vocalization) was related to activation of prefrontal cortex (PFCX), increased activity of adrenal glands and stronger serotonin immunostaining in the PFCX, in comparison with HS animals. The more passive strategy of coping with the aversive event of HS group was related to increased activity of amygdalar nuclei and some areas of the hippocampus, and stronger 5-HT immunostaining in the baso-lateral nucleus of the amygdala, in comparison with LS rats. The present findings suggest that animals more vulnerable to stress might have innate deficits in the activity of brain systems controlling the hypothalamic-pituitary-adrenal axis that would normally allow them to cope with stressful situations. It appears also that response to pain may determine other patterns of emotional behavior, probably reflecting different activation thresholds of some brain structures controlling anxiety, e.g. prefrontal and secondary motor cortex.

Effects of methadone and morphine on c-Fos expression in the rat brain: similarities and differences.

This is the first study designed to compare the pattern of stimulation of c-Fos in selected brain structures after an acute administration of morphine and methadone. Methadone and morphine induced activation of c-Fos protein in the terminal forebrain projecting areas of the brain dopaminergic system, i.e. the striatum and nucleus accumbens. Taking into account generally accepted differences in the potency of pharmacological effects of the two drugs, it is surprising that this effect was most evident after the dose of 5 mg/kg of either drug.

Fluoxetine-induced anxiety and nervousness.

The aim of this study was to model fluoxetine-induced increase in anxiety appearing in the initial phase of the treatment with this antidepressant drug. The effects of acute administration of fluoxetine given alone and co-administered with a subthreshold dose of pentetrazole (PTZ), a proconvulsant agent with well recognized anxiogenic properties, were examined in the open field test of neophobia in rats. It was found that a single injection of fluoxetine at the dose of 5 and 10 mg/kg did not change motor and exploratory behavior of rats. Furthermore, fluoxetine (10.0 mg/kg) co-administered with a subthreshold dose of PTZ (10.0 mg/kg) had a strong and selective inhibitory influence on rat exploratory behavior. Pharmacokinetic study did not show any changes in brain concentration of PTZ in fluoxetine-pretreated animals. The central mechanism of the reported effects might involve stimulation of 5-HT2C receptors by fluoxetine in animals with PTZ-induced decrease in the threshold for emotional arousal. The present data describe a new animal model to study the central action of antidepressants reflecting dysphoric-like effects observed in the initial phase of the treatment.

Buspirone attenuates conditioned fear-induced c-Fos expression in the rat hippocampus.

The role of hippocampus in the anxiolytic-like effect of buspirone in the conditioned emotional response test (CER, a freezing response), was examined by immunocytochemical detection of the c-Fos protein. It was shown that buspirone at the dose of 0.5 and 1.5 mg/kg i.p. given before test session, which was 24 h after the aversive training, significantly decreased freezing response within a limited dose range of the U-shaped dose-response relationship. Exposure of animals to aversively conditioned context (a contextual fear) induced the production of c-Fos protein in the dentate gyrus, CA-1 and CA-3 layers of the hippocampus. Pretreatment with buspirone (1.5 mg/kg) significantly attenuated the effects of aversive memory on c-Fos protein expression in the CA-1 and CA-3 layers of the hippocampus. These immunocytochemical results support previous data obtained in our laboratory with the help of selective neurotoxic lesions and intrahippocampal drug injections suggesting an important role of hippocampus in the anxiolytic effects of buspirone.

The effect of fluoxetine in a model of chemically induced seizures--behavioral and immunocytochemical study.

The aim of this study was to examine the effects of acute fluoxetine treatment on pentylenetetrazol-induced convulsions in order to shape a model of seizures associated with treatment with antidepressants in rats. Moreover, the putative role of the hippocampal formation in this respect was investigated with the help of c-fos immuncytochemistry to mark local neuronal activity. It was found that fluoxetine (10.0 mg/kg, i.p.) enhanced the proconvulsive effect of pentylenetetrazol (50.0 mg/kg, i.p.), and simultaneously inhibited pentylenetetrazol-stimulated c-Fos expression in some areas of the hippocampus. Fluoxetine pretreatment did not alter pentylenetetrazol brain concentration indicating that this phenomenon was not related to the pharmacokinetic interaction. It is suggested that inhibition by fluoxetine of some neuronal populations contributing to the local feedback mechanism controlling excessive epileptiform discharges within the hippocampus might lead to an increase in epileptic activity. The reported in the present paper fluoxetine versus pentylenetetrazol interaction may, therefore, serve as a model of seizures associated with treatment with antidepressants.

Neophobia and cortical and subcortical binding of the dopamine D2 receptor antagonist [3H]-raclopride.

The potential role of dopamine system in response to novelty was analysed using the selective dopamine D2 receptor antagonist, raclopride, in behavioral and biochemical assays, in rats (the open field test, and specific binding of [3H]-raclopride, within different brain structures measured with autoradiography). It was found that raclopride at a low dose (50 microg/kg, IP) caused anxiolytic-like effect (increased the anti-thigmotactic index), whereas at a higher dose (500 microg/kg, IP) produced general inhibitory influence, and decreased the anti-thigmotactic index. Analysis of the behavioral and biochemical results of the experiment revealed a significant negative correlation between the ligand binding in the substantia nigra pars reticulata (SNR), and the number of entries into the central sector of the open field (r=-0.48, p<0.05), as well as the positive correlation between time spent in the central sector of the open field and [3H]-raclopride binding within nucleus accumbens septi (r=0.57, p<0.05). Factor analysis revealed a Factor 1 (eigenvalue=3.361) grouping parameters of central entries into the open field and [3H]-raclopride binding in the SNR (factor loadings are 0.814 and 0.703 respectively), indicating that both phenomena are under control of a similar central process. The above data are discussed in relation to the structure dependent dopamine D2 receptor mechanisms in a rat response to novelty.

Sensitivity to pain and c-Fos expression in brain structures in rats.

The induction of c-Fos protein--a product of the c-fos gene, a marker of changes in neuronal activity, was studied in brain structures of animals differing in their sensitivity to the acute painful stimulation, a foot-shock (MS--more sensitive rats; LS--less sensitive rats, according to the arbitrary criterion in the flinch-jump pretest). After the pretest the animals were dived into the control group, exposed on retest 10 days later to the testing cage only (C1 group), and aversively stimulated animals (MS and LS groups, given five mild footshocks 1.5 h before immunocytochemical part of the experiment). Additional control group of naive, intact animals, was studied in parallel (C group). It was shown that animals subjected to the flinch-jump test retained a strong emotional reaction on re-exposure to the shock cage on retest (a conditioned fear) 10 days later, as revealed by the widespread expression of c-Fos protein in the examined brain structures, as compared with the control, naive rats not exposed to the testing cage. In the lateral habenular nucleus (LHAB) a similar effect has been found in the control animals re-exposed to the testing cage only (C1 group), and in the MS group, suggesting that this brain area participates predominantly in processing of emotional-cognitive component of a painful stimulation. In the periaqueductal gray and basolateral nucleus of amygdala the most pronounced, but significantly higher in comparison with C group only, expression of c-Fos was detected in MS rats. Interestingly, a strong and uniform enhancement of c-Fos expression appeared in all other brain structures examined, including cortical areas, indicating their sensitivity to non-direct (conditioned) aversive stimuli. The only significant difference in c-Fos expression between LS and MS rats found in LHAB points to this brain structure as selectively engaged in processing of the emotional-cognitive component of a painful stimulation. The reactivity of LHAB may be responsible for the genetically determined differences in sensitivity to pain.

Hippocampal mGluR1 and consolidation of contextual fear conditioning.

The effects of post-training intra-hippocampal injections of group I mGluR agonists and antagonists, were examined in the contextual fear test, in rats. It was found that (S)-3,5-dihydroxyphenylglycine (DHPG) (a mGluR1-5 agonist) decreased, and (RS)-1-aminoindan-1,5-dicarboxylic acid (AIDA) (a mGluR1 antagonist) increased fear conditioning (a freezing reaction), examined 24h after conditioning session. (RS)-2-Chloro-5-hydroxyphenylglycine (CHPG) (a mGluR5 agonist), and 2-methyl-6-(phenylethynyl)pyridine hydrochloride (MPEP) (a mGluR5 antagonist) did not cause any effect. In the immunocytochemical study, the post-conditioning administration of AIDA decreased the c-Fos induction in the dentate gyrus and CA1 layer of the hippocampus proper, 2h after exposure of animals to the aversive context, and 24h after conditioning session. It is suggested that overactivation of glutamatergic transmission in the critical for memory trace formation structure and period of time, may result in an attenuation of memory consolidation. On the other hand, reduction of an exaggerated glutamatergic tone can facilitate learning and memory processes. The immunocytochemical study and factor analysis of experimental data revealed that hippocampal mGlu1 receptors significantly influence the memory consolidation in a way dependant on the level of glutamatergic activity. Furthermore, they indicate that changes of glutamatergic activity within brain limbic structures can affect the threshold for the induction of the long-term neuronal plasticity, involved in some forms of learning and memory.

[Neurodevelopmental theories of schizophrenia--preclinical studies]. / Neurorozwojowe koncepcje schizofrenii--badania przedkliniczne.

Schizophrenia is a complex disorder of unknown origin, characterised by abnormalities in the realms of perception, thinking and the experience of emotions that onset is restricted to young adulthood. Many techniques that range from neuropathology to neuroimaging identified subtle brain abnormalities particularly in frontal, temporal cortex, hippocampus, basal ganglia and cerebellum. Neurodevelopmental models of schizophrenia test hypotheses that this disease is caused by a defect in cerebral development which results in altered neural connectivity, brain neurochemistry and aberrant behaviour observed in adult life. Recent evidence indicates that neonatal hippocampal damage may affect prefrontal neuronal integrity. The developmental lesion model appears to have predictive validity because treatment with antipsychotic drugs normalises some abnormal behaviour changes. Therefore it will be a useful paradigm in the work on new therapies and in providing new insights about pathophysiology and etiology of schizophrenia.

The role of neurosteroids in the anxiolytic,antidepressive- and anticonvulsive effects of selective serotonin reuptake inhibitors.

The introduction of SSRIs to the clinic was a turning point in the treatment of depression and related mental disorders. Nowadays, it is becoming more and more evident that SSRIs are equally effective in anxiety states and some types of epilepsy. However, the mechanism of their central action is not fully understood. They not only block the serotonin transporter, but also bind to different types of monoaminergic receptors (serotonergic, dopaminergic) and interact with the synthesis of neurosteroids, in this way modifying the excitability of the central nervous system. The aim of this review is to update information on the preclinical and clinical effects of SSRI, with special emphasis put on the probable role of neurosteroids and the GABAA receptor complex in the mechanism of their action.

Rat behavior in two models of anxiety and brain [3H]muscimol binding: pharmacological, correlation, and multifactor analysis.

The contribution of GABAergic mechanisms to rat emotional behavior in two animal models of anxiety (open field test of neophobia and aversively conditioned freezing reaction), was confirmed by pharmacological analysis, using anxiolytic (midazolam) and anxiogenic (picrotoxin) compounds. Both substances are known to modulate GABA(A) receptors' activity in a positive or negative manner, respectively. It seemed, therefore, worthwhile to check whether the behavioral parameters measured in these animal models of anxiety correlate with [3H]muscimol binding (a highly selective GABA(A) receptor ligand) in different brain structures of nai;ve rats, with a view to establish the role of genetically determined expression of local GABA(A) receptors in the organization of rat emotional and motor behavior. Correlation analysis revealed no links between individually determined expression of GABA(A) receptors (quantitative receptor autoradiography) in the brain structures, and the emotional behavior of nai;ve, drug-free animals, in both tests. Factor analysis confirmed that animal behavior in both tests was under control of different central processes. Moreover, none of the behavioral and ligand binding parameters loaded on the same factor, confirming the negative results of the correlation study. The present results indicate that the origin of emotions is a complex phenomenon, probably involving the interaction between GABA-ergic innervation of many brain structures.

Lack of changes in cortical [3H]-muscimol binding in rats sensitized to nicotine-induced enhancement of dopamine metabolism.

It was proposed that chronic nicotine treatment may induce adaptive changes in GABAA receptors, thus leading to the attenuation of a GABAergic inhibition of dopaminergic neurons. This putative mechanism might underlie the sensitization to nicotine-induced increase in locomotor activity and dopamine metabolism; i.e. phenomena highly significant to the dependence-producing effects of this psychostimulant. To test this hypothesis, in the present study we have analyzed the influence of acute and repeated treatment of rats with nicotine on the binding of a highly selective and competitive GABAA receptor agonist, [3H]-muscimol. The binding was investigated by autoradiography in different brain cortical structures. It was found that nicotine given at the dose stimulating locomotor activity (0.6 mg/kg, sc), markedly increased striatal HVA concentration in the group of animals chronically pretreated (for 6 days) with this psychostimulant. Neither acute nor repeated nicotine administration changed in a significant way the [3H]-muscimol binding to brain cortical structures. Thus, the hypothesis about the role of adaptive changes in GABAA receptors in the enhancement of the biochemical and behavioral effects of nicotine was not confirmed.

Effects of pentylenetetrazol-induced kindling of seizures on rat emotional behavior and brain monoaminergic systems.

The influence of pentylenetetrazol (PTZ)-induced kindling of seizures on the rat emotional behavior, the brain monoamine turnover rate measured in vitro, and correlation between behavioral and biochemical parameters, were examined in rats. The repeated administration of PTZ (35 mg/kg, ip) evoked kindled seizures in rats (Stage 4 or 5 of clonic-tonic convulsions-maximum). PTZ kindling caused selective changes in the rat emotional behavior, present in some models of anxiety only (a decreased freezing time in the conditioned freezing test and a decreased spontaneous and aversively conditioned ultrasonic vocalization). Simultaneously, PTZ kindling decreased the concentration of homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA) in the prefrontal cortex, decreased the DA (HVA/DA ratio) turnover rate in the striatum, and inhibited the serotonin (5-HT) metabolism (5-HIAA/5-HT ratio) in the hippocampus and the prefrontal cortex. Correlations between dopamine (DA) or 5-HT regional metabolic rates in brain structures and animal behavior were either abolished or reversed in PTZ-kindled animals. It is concluded that both DA and 5-HT systems contribute to the emotional effects of PTZ-induced kindling of seizures. The hypothesis is put forward that PTZ kindling-induced inhibition of the serotonergic innervation may lead to the compensatory increase in 5-HT(1A) receptors in the dentate gyrus of the hippocampus, thus evoking the anxiolytic-like changes in animal behavior.