Preclinical pharmacokinetics and pharmacodynamics of DCLL9718A: An antibody-drug conjugate for the treatment of acute myeloid leukemia.

Few treatment options are available for acute myeloid leukemia (AML) patients. DCLL9718A is an antibody-drug conjugate that targets C-type lectin-like molecule-1 (CLL-1). This receptor is prevalent on monocytes, neutrophils, and AML blast cells, and unlike CD33, is not expressed on hematopoietic stem cells, thus providing possible hematopoietic recovery. DCLL9718A comprises an anti-CLL-1 IgG1 antibody (MCLL0517A) linked to a pyrrolobenzodiazepine (PBD) dimer payload, via a cleavable disulfide-labile linker. Here, we characterize the in vitro and in vivo stability, the pharmacokinetics (PK) and pharmacodynamics (PD) of DCLL9718A and MCLL0517A in rodents and cynomolgus monkeys. Three key PK analytes were measured in these studies: total antibody, antibody-conjugated PBD dimer and unconjugated PBD dimer. In vitro, DCLL9718A, was stable with most (> 80%) of the PBD dimer payload remaining conjugated to the antibody over 96 hours. This was recapitulated in vivo with antibody-conjugated PBD dimer clearance estimates similar to DCLL9718A total antibody clearance. Both DCLL9718A and MCLL0517A showed linear PK in the non-binding rodent species, and non-linear PK in cynomolgus monkeys, a binding species. The PK data indicated minimal impact of conjugation on the disposition of DCLL9718A total antibody. Finally, in cynomolgus monkey, MCLL0517A showed target engagement at all doses tested (0.5 and 20 mg/kg) as measured by receptor occupancy, and DCLL9718A (at doses of 0.05, 0.1 and 0.2 mg/kg) showed strong PD activity as evidenced by notable reduction in monocytes and neutrophils.

Fractionated Dosing Improves Preclinical Therapeutic Index of Pyrrolobenzodiazepine-Containing Antibody Drug Conjugates.

Purpose: To use preclinical models to identify a dosing schedule that improves tolerability of highly potent pyrrolobenzodiazepine dimers (PBDs) antibody drug conjugates (ADCs) without compromising antitumor activity.Experimental Design: A series of dose-fractionation studies were conducted to investigate the pharmacokinetic drivers of safety and efficacy of PBD ADCs in animal models. The exposure-activity relationship was investigated in mouse xenograft models of human prostate cancer, breast cancer, and gastric cancer by comparing antitumor activity after single and fractionated dosing with tumor-targeting ADCs conjugated to SG3249, a potent PBD dimer. The exposure-tolerability relationship was similarly investigated in rat and monkey toxicology studies by comparing tolerability, as assessed by survival, body weight, and organ-specific toxicities, after single and fractionated dosing with ADCs conjugated to SG3249 (rats) or SG3400, a structurally related PBD (monkeys).Results: Observations of similar antitumor activity in mice treated with single or fractionated dosing suggests that antitumor activity of PBD ADCs is more closely related to total exposure (AUC) than peak drug concentrations (Cmax). In contrast, improved survival and reduced toxicity in rats and monkeys treated with a fractionated dosing schedule suggests that tolerability of PBD ADCs is more closely associated with Cmax than AUC.Conclusions: We provide the first evidence that fractionated dosing can improve preclinical tolerability of at least some PBD ADCs without compromising efficacy. These findings suggest that preclinical exploration of dosing schedule could be an important clinical strategy to improve the therapeutic window of highly potent ADCs and should be investigated further. Clin Cancer Res; 23(19); 5858-68. ©2017 AACR.

Modulating Therapeutic Activity and Toxicity of Pyrrolobenzodiazepine Antibody-Drug Conjugates with Self-Immolative Disulfide Linkers.

A novel disulfide linker was designed to enable a direct connection between cytotoxic pyrrolobenzodiazepine (PBD) drugs and the cysteine on a targeting antibody for use in antibody-drug conjugates (ADCs). ADCs composed of a cysteine-engineered antibody were armed with a PBD using a self-immolative disulfide linker. Both the chemical linker and the antibody site were optimized for this new bioconjugation strategy to provide a highly stable and efficacious ADC. This novel disulfide ADC was compared with a conjugate containing the same PBD drug, but attached to the antibody via a peptide linker. Both ADCs had similar efficacy in mice bearing human tumor xenografts. Safety studies in rats revealed that the disulfide-linked ADC had a higher MTD than the peptide-linked ADC. Overall, these data suggest that the novel self-immolative disulfide linker represents a valuable way to construct ADCs with equivalent efficacy and improved safety. Mol Cancer Ther; 16(5); 871-8. ©2017 AACR.

Occupational contact sensitization in female geriatric nurses: Data of the Information Network of Departments of Dermatology (IVDK) 2005-2014.

BACKGROUND: Geriatric nurses (GN) have a high risk of occupational contact dermatitis (OCD), with chronic irritant contact dermatitis predominating. However, allergic contact dermatitis is an important issue as well. Little is known whether the relevant occupational allergen spectrum reported in the 1990s, including fragrances, preservatives, rubber chemicals and ingredients of surface disinfectants to be the most common sensitizers in GN, is still valid. OBJECTIVES: To monitor the current allergen spectrum in GN with OCD and verify the validity of the patch test recommendations (baseline-, preservative-, ointment base-, rubber-, disinfectant, series and fragrances) in GN with suspected OCD given by the German Contact Dermatitis Research Group (DKG). METHODS: Retrospective analysis of IVDK data (2005-2014) of 743 female GN with OCD, in comparison to 695 GN without OCD. RESULTS: GN with OCD reacted significantly more frequently to both fragrance mixes, hydroxyisohexyl 3-cyclohexene carboxaldehyde (HICC), thiuram mix, zinc diethyldithiocarbamate and mercaptobenzothiazole than GN without OCD. Reactions to MDBGN, methylchloroisothiazolinone/methylisothiazolinone and oil of turpentine occurred substantially, but not significantly more frequently among GN with OCD. The latter may be due to former use of a special alcoholic liniment in geriatric care. Among material from the patients' workplaces, tetrazepam was a frequent allergen, due to dust exposure from pill crushing. Furthermore, occupationally used protective gloves, body care products as well as surface disinfectants were often tested positively. CONCLUSIONS: The general allergen spectrum in GN with OCD is unchanged, so the DKG patch test recommendations are still valid. Prevention of occupational sensitization should focus on fragrance-free hygiene and body care products, usage of accelerator-free protective gloves and avoidance of drug dust exposure.

The Relationship Between Sedatives, Sedative Strategy, and Healthcare-Associated Infection: A Systematic Review.

BACKGROUND Healthcare-associated infections (HAIs) cause significant morbidity in critically ill patients. An underappreciated but potentially modifiable risk factor for infection is sedation strategy. Recent trials suggest that choice of sedative agent, depth of sedation, and sedative management can influence HAI risk in mechanically ventilated patients. OBJECTIVE To better characterize the relationships between sedation strategies and infection. METHODS Systematic literature review. RESULTS We found 500 articles and accepted 70 for review. The 3 most common sedatives for mechanically ventilated patients (benzodiazepines, propofol, and dexmedetomidine) have different pharmacologic and immunomodulatory effects that may impact infection risk. Clinical data are limited but retrospective observational series have found associations between sedative use and pneumonia whereas prospective studies of sedative interruptions have reported possible decreases in bloodstream infections, pneumonia, and ventilator-associated events. CONCLUSION Infection rates appear to be highest with benzodiazepines, intermediate with propofol, and lowest with dexmedetomidine. More data are needed but studies thus far suggest that a better understanding of sedation practices and infection risk may help hospital epidemiologists and critical care practitioners find new ways to mitigate infection risk in critically ill patients. Infect Control Hosp Epidemiol 2016;1-9.

Reactivity of commercial benzodiazepine immunoassays to phenazepam.

Phenazepam is a long acting benzodiazepine that is not controlled in Canada, the United States or many European countries. The abuse of phenazepam has gained recent attention due to the number of hospitalizations and fatalities resulting from overdose. The compound is relatively potent with recommended doses of 0.5-1.0 mg, or 1/10th the recommended dose of diazepam, and is easy to obtain locally or from international suppliers via the internet. Increased risk of phenazepam overdose is attributed to its potency and the forms in which it is supplied. Individuals without scales or balances are prone to estimate dose amounts of powder visually, which can result in significant errors. The detection of phenazepam has been described using various methods including GC, GC/MS and LC/MS, but no data regarding the sensitivity of commercially available immunoassays exist. In this study, phenazepam-spiked urine samples were analyzed using five commercial instruments and two point of care devices. The concentrations of phenazepam required for detection ranged from 140-462 ng/mL, which is comparable to those of other benzodiazepines. Laboratorians and clinicians should be confident that phenazepam will be detected via most commercial drugs of abuse screens in patients after significant ingestion.

Topology characterization of a benzodiazepine-binding beta-rich domain of the GABAA receptor alpha1 subunit.

Structural investigation of GABAA receptors has been limited by difficulties imposed by its trans-membrane-complex nature. In the present study, the topology of a membrane-proximal beta-rich (MPB) domain in the C139-L269 segment of the receptor alpha1 subunit was probed by mapping the benzodiazepine (BZ)-binding and epitopic sites, as well as fluorescence resonance energy transfer (FRET) analysis. Ala-scanning and semiconservative substitutions within this segment revealed the contribution of the phenyl rings of Y160 and Y210, the hydroxy group of S186 and the positive charge on R187 to BZ-binding. FRET with the bound BZ ligand indicated the proximity of Y160, S186, R187, and S206 to the BZ-binding site. On the other hand, epitope-mapping using the monoclonal antibodies (mAbs) against the MPB domain established a clustering of T172, R173, E174, Q196, and T197. Based on the lack of FRET between Trp substitutionally placed at R173 or V198 and bound BZ, this epitope-mapped cluster is located on a separate end of the folded protein from the BZ-binding site. Mutations of the five conserved Cys and Trp residues in the MPB domain gave rise to synergistic and rescuing effects on protein secondary structures and unfolding stability that point to a CCWCW-pentad, reminiscent to the CWC-triad "pin" of immunoglobulin (Ig)-like domains, important for the structural maintenance. These findings, together with secondary structure and fold predictions suggest an anti-parallel beta-strand topology with resemblance to Ig-like fold, having the BZ-binding and the epitopic residues being clustered at two different ends of the fold.

Dye-labeled benzodiazepines: development of small ligands for receptor binding studies using fluorescence correlation spectroscopy.

To investigate benzodiazepine receptor binding studies by fluorescence correlation spectroscopy (FCS), the four fluorophores fluorescein, tetramethylrhodamine, Oregon Green 488, and Alexa 532 were coupled to the benzodiazepine Ro 07-1986/602 (Ro). Binding assays to polyclonal antibodies to benzodiazepines and at the native benzodiazepine receptor on the membrane of rat hippocampal neurons were established to examine the dye-labeled ligands for their benzodiazepine character and their binding behavior. Both the fluorescein and the Oregon Green488 moiety led to a loss of the benzodiazepine receptor binding of the corresponding Ro derivatives. Antibody recognition and interactions to the receptor were observed for the tetramethylrhodamine derivative (K(D) = 96.0 +/- 9.5 nM) but with a high amount of nonspecific binding at the cell membrane of about 50%. In saturation experiments a K(D) value of 97.2 +/- 8.5 nM was found for the Alexa Fluor 532 derivative-antibody interaction. Investigation of the binding of this ligand to the benzodiazepine receptor in FCS cell measurements led to confirmation of high specific binding behavior with a K(D) value of 9.9 +/- 1.9 nM. A nonspecific binding of <10% was observed after coincubation with 1 microM of midazolam. The different properties of the labeled benzodiazepine derivatives and the requirements of the fluorophore in small dye-labeled ligands in FCS binding studies, at the membrane of living cells, are discussed.

Validation of a microtiter plate ELISA for screening of postmortem blood for opiates and benzodiazepines.

The object of this study was to evaluate the suitability of the Neogen Corp. microtiter plate enzyme-linked immunoassays (ELISA) for opiates and benzodiazepines for screening of postmortem blood. Ninety postmortem whole blood specimens were obtained from drug-involved deaths which had been screened and confirmed positive for opiates and/or benzodiazepines. Forty negative specimens were obtained from non-opiate-involved deaths. Specimens were tested using the Neogen Opiates Group and Neogen Benzodiazepines Group microtiter plate ELISA assays. No matrix effects were found for whole blood in these assays and a dilution of 1:5 was chosen to facilitate pipetting and to bring the IC50 of the microtiter plate ELISA assay within the range of opiates and benzodiazepines encountered in medical examiner specimens. True positive, true negatives, false positives, and false negatives were determined and graphed for the ELISA results against gas chromatography-mass spectrometry (GC-MS), gas chromatography-nitrogen-phosphorus detection and case histories. From these graphs and the ROC curves, the optimal cut-off for the Neogen Opiates Group ELISA was found to be between 20 and 50 ng/mL morphine equivalents and the optimum cut-off for the Neogen Benzodiazepines Group ELISA was between 20 and 50 ng/mL temazepam equivalents. The Neogen Opiates Group ELISA had a sensitivity of 95.2% +/- 2.7% and a specificity of 92.2% +/- 3.4% versus GC-MS at a cut-off of 20-ng/mL cut-off and a sensitivity of 88.8% +/- 3.9% and specificity of 96.8% +/- 2.1% versus GC-MS at a 50-ng/mL morphine equivalents cut-off. The Neogen Benzodizepines Group ELISA had a sensitivity of 100% +/- 1.3% and a specificity of 94.6% +/- 2.9% versus GC-MS (20-ng/mL temazepam equivalents cut-off) and a sensitivity of 95.8% +/- 2.5% and specificity of 98.2% +/- 1.8% versus GC-MS at a 50-ng/mL cut-off.

New fluorescence polarization immunoassays for analysis of barbiturates and benzodiazepines in serum and urine: performance characteristics.

The performance of the new fluorescence polarization immunoassay reagents Cassette COBAS INTEGRA Serum Benzodiazepines assay (SBENZ) and Cassette Serum Barbiturates assay (SBARB) was evaluated as compared to other immunoassays (Abbott TDx Serum Benzodiazepines, Abbott TDx Urine Benzodiazepines, Behring EMIT Serum Benzodiazepines, Abbott ADx Serum Barbiturates, Behring EMIT Serum Barbiturates, and the COBAS INTEGRA Barbiturates (BARB) urine assay) and gas chromatography-mass spectrometry (GC-MS). Recoveries of nordiazepam and secobarbital using the SBENZ and SBARB assays, respectively, were equivalent for serum, plasma, and urine. Cross-reactivities of structurally related benzodiazepines, barbiturates, and their metabolites were very similar in serum and urine for the SBENZ and SBARB assays. Precision was within 5.4% for SBENZ serum and within 11% from 10 to 100 ng/mL for urine. Precision was within 5% for SBARB serum and within 7% from 136 to 277 ng/mL for the urine application. The standard curves for SBENZ and SBARB were stable for at least 16 weeks with the reagents stored open on the COBAS INTEGRA analyzer. Clinical comparison of the SBENZ serum assay indicated an increased pickup rate, as confirmed by GC-MS, compared to TDx and EMIT. The diagnostic sensitivities of the SBENZ serum application, TDx, and EMIT versus GC-MS were 100%, 89%, and 36%, respectively. The diagnostic specificities were 71%, 79%, and 100%, respectively. The diagnostic sensitivities of the SBENZ urine application and TDx versus GC-MS were 100% and the diagnostic specificities were 88%. The increased positive pick-up of the SBENZ assay compared to the other immunoassays is most probably due to the difference in the limit of detection (LOD) and the increased cross-reactivity for the low-dose benzodiazepines. Clinical comparison of the SBARB serum assay indicated an increased positive pick-up rate, as confirmed by GC-MS. The diagnostic sensitivities of the SBARB serum application, ADx, and EMIT versus GC-MS were 96%, 65%, and 35%, respectively. The diagnostic specificities were all 100%. The diagnostic sensitivities for the SBARB urine application and BARB versus GC-MS were all 100%, and the diagnostic specificities were all 91%. The SBENZ and SBARB kits demonstrated increased sensitivity for the detection of benzodiazepines and barbiturates in both serum and urine compared to the other immunoassays.

Improved CEDIA benzodiazepine assay eliminates sertraline crossreactivity.

Initial experiments demonstrated that the original CEDIA (cloned enzyme donor immunoassay) benzodiazepine assay crossreacted with setraline and sertraline metabolites. In response to this phenomenon, Boehringer Mannheim Corporation developed an improved CEDIA benzodiazepine assay in order to eliminate sertraline crossreactivity. The improved CEDIA assay was evaluated against the original CEDIA product, EMIT II (enzyme multiplied immunoassay technique) benzodiazepine assay, and electron capture negative chemical ionization (ECNCI) gas chromatography-mass spectrometry (GC-MS). Five hundred and thirty-one urine drug screens were tested by the immunoassays. Sensitivity and specificity of these immunoassays for the 5-aryl-7-chloro-1,4-benzodiazepine compounds were 92 and 98%, respectively, for the improved CEDIA assay; 92 and 93%, respectively, for the current CEDIA assay; and 87 and 98%, respectively, for EMIT II. The improved CEDIA assay performed almost identically to the EMIT II assay, both of which had a significant advantage over the original CEDIA product, which was subject to crossreactivity because of sertraline metabolites. The alpha-hydroxy ketone metabolites of sertraline are identified in human urine specimens for the first time using ECNCI GC-MS.

Evaluation of the Abbott TDx serum benzodiazepine immunoassay for the analysis of lorazepam, adinazolam, and N-desmethyladinazolam.

This study involved the evaluation of the Abbott TDx serum benzodiazepine assay, a fluorescence polarization immunoassay (FPIA), for the detection of lorazepam, adinazolam, and N-desmethyladinazolam in serum. Precision of the assay was determined by using three control serums containing 75, 300, and 700 ng/mL nordiazepam. Between-run precision studies (N = 22) gave mean values of 76, 306, and 690 ng/mL with coefficients of variation of 6.5, 3.3, and 5.7%, respectively. Percent cross-reactivity of serum lorazepam standards (35-500 ng/mL) ranged from 29 to 69%. The cross-reactivity of serum adinazolam ranged from 40 to 47% between 50 and 150 ng/mL and from 38 to 55% for N-desmethyladinazolam between 50 and 250 ng/mL. Serum specimens (48) collected from individuals known to be receiving lorazepam were analyzed. Twenty-two specimens were positive for benzodiazepines. Serum specimens were collected from 0.25 to 24 h after administering a 15-mg oral dose of adinazolam to six volunteers. The FPIA results were compared with combined high-performance liquid chromatographic (HPLC) results for adinazolam and N-desmethyladinazolam. The FPIA method did not detect benzodiazepines at 0.25 h after administration of adinazolam but did detect benzodiazepines from 0.5 to 24 h after administration. The correlation between HPLC (N-desmethyladinazolam) and FPIA results by regression analysis gave the following: y = 0.937x + 4.449, r = 0.98, n = 15. It was concluded that the Abbott FPIA assay for benzodiazepines can detect lorazepam when prescribed in therapeutic doses and when present at greater than 25 ng/mL and can semiquantitatively detect adinazolam or N-desmethyladinazolam or both when present at concentrations greater than 50 ng/mL.

Benzodiazepine screening using EMIT II and TDx: urine hydrolysis pretreatment required.

Urine specimens were collected from individuals prescribed oral doses of the following benzodiazepine tablets: diazepam, oxazepam, temazepam, lorazepam, alprazolam, flurazepam, and chlordiazepoxide. An aliquot was hydrolyzed using Helix pomatia beta-glucuronidase. Both the hydrolyzed and unhydrolyzed urine pairs were subjected to EMIT II and TDx immunoassay screening tests and to gas chromatographic-mass spectrometric quantitation. Hydrolysis is required to ensure adequate detection of oxazepam, temazepam, and lorazepam with either screening method. A 100-ng/mL cutoff is required when screening for lorazepam, following therapeutic doses. The EMIT II is more sensitive than the TDx as a screening test for benzodiazepines.

[Immunologic studies of benzodiazepine--the effect of structural characteristics on cross-reactivity]. / Immunologische Untersuchungen auf Benzodiazepine--Der Einfluss von Strukturmerkmalen auf die Kreuzreaktivität.

The manufacturers' descriptions for immunoassays for the detection of benzodiazepines in urine suggest that all therapeutically used benzodiazepines are detected equally. It is unlikely that the different molecular structures do not influence the results of pertinent measurements. Therefore, the cross-reactivity of 35 benzodiazepines and benzodiazepine-metabolites was determined with the TDx-system. As compared to nordiazepam all compounds--except diazepam--had a reduced cross-reactivity. In order to get a TDx result equal to or exceeding 200 ng/ml nordiazepam-equivalents, high benzodiazepine concentrations in urine are required in some cases. These high concentrations are not obtained in the therapeutic range of application. These considerations can be applied to other immunoassays like RIA and EMIT.

Endogenous GABAergic modulators in the pathogenesis of hepatic encephalopathy.

Theories on the neurochemical etiology for hepatic encephalopathy have recently focussed on activation of inhibitory neurotransmitter GABA systems. Modulators of the GABAA receptor complex, including diazepam binding inhibitor, are significantly and selectively altered in hepatic encephalopathy. In animals and humans, benzodiazepine receptor antagonists rapidly ameliorate this syndrome suggesting the possible existence of an endogenous benzodiazepine-like substance. Endogenous GABAergic modulators may contribute to the neurochemical pathogenesis of hepatic encephalopathy.

Immunocytochemical localization of the endogenous benzodiazepine ligand octadecaneuropeptide (ODN) in the rat brain.

In order to study the morphological localization of the endogenous benzodiazepine ligand octadecaneuropeptide (ODN) in rat brain, we have developed antibodies against this peptide. Using a radioimmunoassay for ODN, we have observed that synthetic ODN and serial dilutions of several brain areas gave parallel displacement curves. By light microscope immunocytochemistry, ODN-immunoreactive material was only detected in glial and ependymal cells. Immunolabelled cells were found in high concentrations in the olfactory bulb, hypothalamus, hippocampus, periaqueductal gray, cerebral cortex and the circumventricular organs. In the cerebellar cortex, immunostaining was associated with Bergmann cells. The studies performed at the electron microscopic level confirmed the association of immunoreactive material with glial and ependymal cells. The present results suggest that ODN might play a role in the function of glial cells which have been shown to contain benzodiazepine receptors of the "peripheral type".