Novel 2-substituted tetrahydro-3H-benz[e]indolamines: highly potent and selective agonists acting at the 5-HT1A receptor as possible anxiolytics and antidepressants.

The synthesis of (+)-(R)-2-cyano-N,N-dipropyl-8-amino-6,7,8,9-tetrahydro-3H- benz[e]indole [(R)-14, U92016A], a potent 5-HT1A agonist, and related analogs is described. In vitro binding studies show that the (R)-enantiomers of this series possess the highest potency for the 5-HT1A receptor. In vivo hypothermia correlates with this, with the (R)-enantiomers causing a greater temperature drop than the (S)-enantiomers. The most active compound in 5-HT1A binding and in the in vivo models was (R)-14, which was found to be highly potent as an agonist in single cell firing studies, as well as potent and of very high intrinsic activity in mouse hypothermia and the sympathetic nerve discharge (SND) models. An in vivo duration of action study, following SND, showed (R)-14 to possess a long duration of action. The synthesis via a nitrene insertion, determination of absolute configuration, and biological activities of this series is described.

A comprehensive phase I and II clinical investigation of fludarabine phosphate.

This article presents data from the phase I and II clinical investigations of Fludara I.V. (fludarabine phosphate) (NSC 312887), which is the 5'-phosphorylated derivative of the novel antimetabolite, 9-beta-D-arabinofuranosyl-2-fluoroadenine. The comprehensive phase I evaluation of this new antitumor agent was conducted in 51 patients with advanced malignancy and 15 additional patients with aggressive forms of leukemia. Three separate phase I schedules of drug administration were examined. Myelosuppression was the dose-limiting toxicity on each schedule administered to patients with solid tumors. The drug was also examined at higher doses in patients with leukemia, and the dose-limiting toxicity on the high-dose protocol was unacceptable: serious neurologic toxicity. The observation of antitumor responses in patients with advanced non-Hodgkin's lymphoma prompted additional phase II investigation in patients with lymphoproliferative malignancy. The encouraging phase II data demonstrate that Fludara I.V. has promise for patients with low-grade histologic subtypes of non-Hodgkin's lymphoma and chronic lymphocytic leukemia. While interesting additional basic and clinical research projects regarding Fludara I.V. remain, it is important to expeditiously pursue approval for this drug. Adequate data exists to demonstrate that the low-dose administration of Fludara I.V. is both safe and effective. While the development of this drug has stimulated renewed interest in the clinical investigation of the chronic lymphoproliferative malignancies, the time for making it readily available to these patients has arrived.

Hydrazide pharmaceuticals as conjugates to polyaldehyde dextran: syntheses, characterization, and stability.

The coupling of ellipticine and CI-921, two antineoplastic pharmaceuticals, to polyaldehyde dextran can be carried out under mild reaction conditions with novel acid hydrazides of the parent drugs. The resulting acyl hydrazones resist hydrolytic and enzymatic cleavage and offer a method for drug loading via dextran conjugates to monoclonal antibodies.

Phase I clinical investigation of fludarabine phosphate by a loading-dose and continuous-infusion schedule.

Fludarabine phosphate was studied in a phase I trial of a loading-dose/continuous-infusion schedule. The schedule was chosen to rapidly achieve and maintain concentrations that have been shown in vitro to achieve maximal inhibition of cell growth. The initial level was a loading dose of 20 mg/m2 followed by a 48-hour continuous iv (CIV) infusion of 30 mg/m2 every 24 hours. For the single-dose escalation, the loading dose was held constant while the CIV dose was increased to 45 mg/m2/24 hours for 48 hours. The dose-limiting toxicity was myelosuppression, especially leukopenia. No other significant toxicity was encountered. The maximum tolerated dose was 20 mg/m2 by iv push followed by a 48-hour CIV infusion of 30 mg/m2/24 hours for 48 hours. The recommended starting dose for phase II trials is 20 mg/m2 by iv push followed by a 48-hour CIV infusion of 30 mg/m2/24 hours. This dose level achieved the target plasma levels in the 2 patients studied.

Trimetrexate: a phase 2 study in previously treated patients with metastatic breast cancer.

Trimetrexate, a nonclassical antifolate, was administered to 28 patients with progressive, metastatic breast cancer. The starting dose was 8 mg/m2 administered intravenously (IV) as a short infusion daily for 5 days, repeated every 3 weeks with dose adjustments depending on patient tolerance. The median age of the 28 females in this study was 58.5 years. Their median performance status on the Zubrod scale was 1. Nine of the patients were estrogen-receptor positive. The sites of metastasis included the pulmonary system (50%), bone (40%), and liver (35%). Twenty patients were evaluable for response. Three patients (15%; [95% confidence interval 0.0, 30.6]) achieved a partial response with a median time to partial response of 9.1 weeks and a median duration of partial response of 13.1 weeks. Two of the responders were estrogen-receptor positive. Median survival for all 28 patients was 41 + weeks with 15 patients alive at the last follow-up. Hematologic grade 3-4 toxicity occurred as follows: leukopenia (21%), thrombocytopenia (18%), and granulocytopenia (18%). There was no significant nonhematologic toxicity seen.

Phase II trial of 9-beta-D-arabinofuranosyl-2-fluoroadenine 5'-monophosphate in non-Hodgkin's lymphoma: prospective comparison of response with deoxycytidine kinase activity.

A phase II study of 9-beta-D-arabinofuranosyl-2-fluoroadenine 5'-monophosphate was done in non-Hodgkin's lymphoma with a loading dose/continuous intravenous infusion schedule, consisting of a 20 mg/m2 loading dose followed by a continuous i.v. infusion of 30 mg/m2/24 h for 48 h. The loading dose was held constant while the continuous i.v. dose was escalated or decreased as appropriate for toxicity. Twenty-six patients were entered on the study; 25 are evaluable for response. The patients' median age was 61 years (range 25 to 73); their mean performance status was 1.1. They had received a mean of 2.6 prior chemotherapeutic regimens, and six also had prior radiation therapy. There was one complete response lasting 9+ months, and there were seven partial responses lasting 20, 13, 11, 11, 10, 5, and 2 months (response rate 32%). Toxicity was acceptable and consisted mainly of myelosuppression. 9-beta-D-arabinofuranosyl-2-fluoroadenine 5'-monophosphate is dephosphorylated in vivo and then is thought to be activated intracellularly to 9-beta-D-arabinofuranosyl-2-fluoroadenine 5'-triphosphate. The rate-limiting enzyme is deoxycytidine kinase. Deoxycytidine kinase activity was determined on pretreatment tumor samples for correlation with response. There was no difference between the values for responders and nonresponders. There was a trend for higher values in more malignant histological subtypes.

High-dose mitoxantrone in metastatic breast cancer: a phase I-II trial.

Eighteen women with metastatic breast cancer entered a phase I-II study of high-dose mitoxantrone (MXT). They were heavily pretreated (mean, 2.3 prior regimens) with drugs including both doxorubicin (14 patients) and MXT at usual doses (three). Doses studied were 16, 20, 25, and 30 mg/m2, repeated every 3-4 weeks. Marked leukopenia was seen at all dose levels (four episodes of infection were successfully treated). Fatigue and malaise were the most common nonhematologic toxic effects. At 25 mg/m2, six of 13 courses resulted in severe fatigue and malaise. MXT is tolerated at doses up to 25 mg/m2 every 3-4 weeks. Cardiac function must be closely monitored. No responses were seen in these heavily pretreated patients.

Low-dose deoxycoformycin in lymphoid malignancy.

Deoxycoformycin (dCF), a potent inhibitor of adenosine deaminase (ADA), was explored for its antineoplastic potential in 28 patients with advanced lymphoid malignancy. Both normal and malignant B lymphocytes have low levels of ADA activity, and low doses of dCF profoundly inhibit this enzyme in the peripheral blood of patients with chronic lymphocytic leukemia (CLL). The low doses of dCF administered in this trial (4 mg/m2) were not associated with prohibitive toxicity. Five of 28 patients had an objective response. Four additional patients had clinical improvement. No significant difference in the pretreatment ADA activity existed between responding patients and treatment failures. The demonstration of responses to dCF following failure on standard alkylating agents suggests that dCF may not be cross-resistant with current agents used to treat CLL. Additional studies should be pursued using low-dose dCF in patients with advanced malignancy.

GNP effectiveness in a rehabilitation center.

Gerontological nurse practitioners have proved to be of immense value to patient care in a moderate sized (124-bed), busy (100 percent capacity), long-term care facility. A program that was established to handle a staffing problem with financial constraints has worked very well in providing extended medical services to a demanding patient load. GNPs have successfully been integrated into the facility with wide acceptance by the hospital staff and the clinic physicians to whom the facility's patients are referred when needed.