A phase 2 trial of ponatinib in Philadelphia chromosome-positive leukemias.

BACKGROUND: Ponatinib is a potent oral tyrosine kinase inhibitor of unmutated and mutated BCR-ABL, including BCR-ABL with the tyrosine kinase inhibitor-refractory threonine-to-isoleucine mutation at position 315 (T315I). We conducted a phase 2 trial of ponatinib in patients with chronic myeloid leukemia (CML) or Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph-positive ALL). METHODS: We enrolled 449 heavily pretreated patients who had CML or Ph-positive ALL with resistance to or unacceptable side effects from dasatinib or nilotinib or who had the BCR-ABL T315I mutation. Ponatinib was administered at an initial dose of 45 mg once daily. The median follow-up was 15 months. RESULTS: Among 267 patients with chronic-phase CML, 56% had a major cytogenetic response (51% of patients with resistance to or unacceptable side effects from dasatinib or nilotinib and 70% of patients with the T315I mutation), 46% had a complete cytogenetic response (40% and 66% in the two subgroups, respectively), and 34% had a major molecular response (27% and 56% in the two subgroups, respectively). Responses were observed regardless of the baseline BCR-ABL kinase domain mutation status and were durable; the estimated rate of a sustained major cytogenetic response of at least 12 months was 91%. No single BCR-ABL mutation conferring resistance to ponatinib was detected. Among 83 patients with accelerated-phase CML, 55% had a major hematologic response and 39% had a major cytogenetic response. Among 62 patients with blast-phase CML, 31% had a major hematologic response and 23% had a major cytogenetic response. Among 32 patients with Ph-positive ALL, 41% had a major hematologic response and 47% had a major cytogenetic response. Common adverse events were thrombocytopenia (in 37% of patients), rash (in 34%), dry skin (in 32%), and abdominal pain (in 22%). Serious arterial thrombotic events were observed in 9% of patients; these events were considered to be treatment-related in 3%. A total of 12% of patients discontinued treatment because of an adverse event. CONCLUSIONS: Ponatinib had significant antileukemic activity across categories of disease stage and mutation status. (Funded by Ariad Pharmaceuticals and others; PACE ClinicalTrials.gov number, NCT01207440 .).

Phase I/IIa trial of the mammalian target of rapamycin inhibitor ridaforolimus (AP23573; MK-8669) administered orally in patients with refractory or advanced malignancies and sarcoma.

BACKGROUND: Ridaforolimus is an inhibitor of mTOR with evidence of antitumor activity in an I.V. formulation. This multicenter, open-label, 3 + 3 design nonrandomized, dose-escalation, phase I/IIa trial was conducted to determine the safety, pharmacokinetic (PK) and pharmacodynamic parameters, maximum tolerated dose, and antitumor activity of oral ridaforolimus. PATIENTS AND METHODS: Patients with metastatic or unresectable solid tumors refractory to therapy were eligible. Seven different continuous and intermittent dosing regimens were examined. RESULTS: One hundred and forty-seven patients were enrolled in this study among which 85 were patients with sarcoma. Stomatitis was the most common DLT observed. The dosing regimen, 40 mg QD × 5 days/week, provided the best combination of cumulative dose, dose density, and cumulative exposure, and was the recommended dosing regimen for subsequent clinical development. PK was nonlinear, with less than proportional increases in day-1 blood AUC0-∞ and Cmax, particularly with doses >40 mg. The terminal half-life estimate of ridaforolimus (QD × 5 40 mg) was 42.0 h, and the mean half-life ∼30-60 h. The clinical benefit rate, (complete response, partial response, or stable disease for ≥4 months was 24.5% for all patients and 27.1% for patients with sarcoma. CONCLUSION: Oral ridaforolimus had an acceptable safety profile and exhibited antitumor activity in patients with sarcoma and other malignancies. ClinicalTrials.gov Identifier NCT00112372.

Evaluation of a rapamycin-regulated serotype 2 adeno-associated viral vector in macaque parotid glands.

OBJECTIVES: Salivary glands are useful target organs for local and systemic gene therapeutics. For such applications, the regulation of transgene expression is important. Previous studies by us in murine submandibular glands showed that a rapamycin transcriptional regulation system in a single serotype 2, adeno-associated viral (AAV2) vector was effective for this purpose. This study evaluated if such a vector was similarly useful in rhesus macaque parotid glands. METHODS: A recombinant AAV2 vector (AAV-TF-RhEpo-2.3w), encoding rhesus erythropoietin (RhEpo) and a rapamycin-inducible promoter, was constructed. The vector was administered to macaques at either of two doses [1.5 x 10(11) (low dose) or 1.5 x 10(12) (high dose) vector genomes] via cannulation of Stensen's duct. Animals were followed up for 12-14 weeks and treated at intervals with rapamycin (0.1 or 0.5 mg kg(-1)) to induce gene expression. Serum chemistry, hematology, and RhEpo levels were measured at interval. RESULTS: AAV-TF-RhEpo-2.3w administration led to low levels of rapamycin-inducible RhEpo expression in the serum of most macaques. In five animals, no significant changes were seen in serum chemistry and hematology values over the study. One macaque, however, developed pneumonia, became anemic and subsequently required euthanasia. After the onset of anemia, a single administration of rapamycin led to significant RhEpo production in this animal. CONCLUSION: Administration of AAV-TF-RhEpo-2.3w to macaque parotid glands was generally safe, but led only to low levels of serum RhEpo in healthy animals following rapamycin treatment.

Phase Ib study of weekly mammalian target of rapamycin inhibitor ridaforolimus (AP23573; MK-8669) with weekly paclitaxel.

BACKGROUND: The additive cytotoxicity in vitro prompted a clinical study evaluating the non-prodrug rapamycin analogue ridaforolimus (AP23573; MK-8669; formerly deforolimus) administered i.v. combined with paclitaxel (PTX; Taxol). MATERIALS AND METHODS: Patients with taxane-sensitive solid tumors were eligible. The main dose escalation foresaw 50% ridaforolimus increments from 25 mg with a fixed PTX dose of 80 mg/m(2), both given weekly 3 weeks in a 4-week cycle. Collateral levels with a lower dose of either drug were planned upon achievement of the maximum tolerated dose in the main escalation. Pharmacodynamic studies in plasma, peripheral blood mononuclear cells (PBMCs) and skin biopsies and pharmacokinetic (PK) interaction studies at cycles 1 and 2 were carried out. RESULTS: Two recommended doses were determined: 37.5 mg ridaforolimus/60 mg/m(2) PTX and 12.5 mg/80 mg/m(2). Most frequent toxic effects were mouth sores (79%), anemia (79%), fatigue (59%), neutropenia (55%) and dermatitis (48%). Two partial responses were observed in pharyngeal squamous cell and pancreatic carcinoma. Eight patients achieved stable disease > or =4 months. No drug interaction emerged from PK studies. Decrease of eukaryotic initiation factor 4E-binding protein1 (4E-BP1) phosphorylation was shown in PBMCs. Similar inhibition of phosphorylation of 4E-BP1 and mitogen-activated protein kinase was present in reparative epidermis and vascular tissues, respectively. CONCLUSION: Potential antiangiogenic effects and encouraging antitumor activity justify further development of the combination.

Rapamycin control of transgene expression from a single AAV vector in mouse salivary glands.

Salivary glands (SGs) appear to be a useful target site for gene therapeutics. The ability to control transgene expression is essential for clinical application. Previously, in a proof-of-concept study, we have shown that the rapamycin-inducible transcriptional regulation system can regulate protein expression after adenoviral-mediated gene transfer to SGs. To evaluate the potential ability to utilize this regulatory system for long-term control of transgene expression in this tissue, we employed a 'third generation', single adenoassociated serotype 2 viral (AAV2) vector encoding human erythropoietin (hEPO) under the control of a rapamycin-inducible promoter. The vector, rAAV-TF2.3-hEPO (10(10) particles/animal), was delivered to mouse SGs. No detectable increase in serum hEPO or hematocrit levels was observed in the absence of rapamycin administration. However, rapamycin induced elevation of serum hEPO levels, as well as concomitant hematocrit changes, that were dose-dependent, completely reversible, and relatively stable over the course of this study (6 months), with no appreciable change in rapamycin responsiveness. Our results suggest that the rapamycin transcriptional regulation system delivered in a single AAV2 vector to SGs may be valuable for systemic protein replacement applications.

Modafinil for the treatment of diminished responsiveness in a patient recovering from brain surgery.

PRIMARY OBJECTIVE: This case report reviews the history and post-operative status of a 77-year-old woman who underwent transcallosal resection of an intra-ventricular haemorrhagic subependymoma and who remained in a deep post-operative state of lethargy and listlessness. MAIN OUTCOME MEASURES: Glasgow Coma Scale (GCS) and detailed clinical observations. RESULTS: The patient (GCS=8) was initiated on methylphenidate 20 mg per day on the 6th day after surgery, but treatment was discontinued 2 days later due to elevated blood pressure and persistent tachycardia. Pemoline 37.5 mg per day was initiated, but treatment was stopped after 3 days due to lack of response. Treatment with modafinil 400 mg per day was initiated on the 11th day after surgery and the patient's consciousness level rapidly improved on the 14th day. On the 16th day after surgery, she was completely alert (GCS=15). CONCLUSIONS: Modafinil appeared to be beneficial for improving wakefulness and responsiveness in a patient with central nervous system trauma in the post-operative state.

The utility of MRI in suspected MS: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.

Advancements in imaging technologies and newly evolving treatments offer the promise of more effective management strategies for MS. Until recently, confirmation of the diagnosis of MS has generally required the demonstration of clinical activity that is disseminated in both time and space. Nevertheless, with the advent of MRI techniques, occult disease activity can be demonstrated in 50 to 80% of patients at the time of the first clinical presentation. Prospective studies have shown that the presence of such lesions predicts future conversion to clinically definite (CD) MS. Indeed, in a young to middle-aged adult with a clinically isolated syndrome (CIS), once alternative diagnoses are excluded at baseline, the finding of three or more white matter lesions on a T2-weighted MRI scan (especially if one of these lesions is located in the periventricular region) is a very sensitive predictor (>80%) of the subsequent development of CDMS within the next 7 to 10 years. Moreover, the presence of two or more gadolinium (Gd)-enhancing lesions at baseline and the appearance of either new T2 lesions or new Gd enhancement on follow-up scans are also highly predictive of the subsequent development of CDMS in the near term. By contrast, normal results on MRI at the time of clinical presentation makes the future development of CDMS considerably less likely.

Accuracy of clinical detection of INO in MS: corroboration with quantitative infrared oculography.

The authors compared the accuracy of clinical detection (by 279 physician observers) of internuclear ophthalmoparesis (INO) with that of quantitative infrared oculography. For the patients with mild adduction slowing, INO was not identified by 71%. Intermediate dysconjugacy was not detected by 25% of the evaluators. In the most severe cases, INO was not identified by only 6%. Oculographic techniques significantly enhance the precision of INO detection compared to the clinical exam.

[Deciding on treatment in multiple sclerosis]. / Decisión del tratamiento en la esclerosis múltiple.

The modern history of the treatment of multiple sclerosis is reflected during the last years with the advent of controlled clinical trials design to produce measurable outcomes utilizing MRI techniques and statistical analysis. Addressing in this form the use of disease modifying medications: immunomodulation with interferons and glatiramer acetate in the relapsing/remitting type, and combination therapies or immunosuppression in the progressive forms, these studies based on evidence provide to the clinician direction in the process to decide the most appropriate treatment for the individual patient.

Decisión del tratamiento en la esclerosis múltiple / Deciding on treatment in multiple sclerosis

La historia moderna del tratamiento de la esclerosis múltiple se refleja en los últimos años en el advenimiento de ensayos clínicos controlados diseñados para producir metas medibles utilizando técnicas de resonancia magnética y análisis estadístico. Enfocando de esta manera el uso de medicamentos modificadores de la enfermedad -inmunomodulación con interferones y acetato de glatiramero- en la forma remitente/recurrente, y de terapias combinadas e inmunosupresión en las formas progresivas, estos estudios, basándose en la evidencia, proveen al clínico de una dirección en el proceso de decidir el tratamiento individual más apropiado para el paciente (AU)

Anti-viral properties of interferon beta treatment in patients with multiple sclerosis.

Viral infections are potentially associated with the etiology and pathogenesis of multiple sclerosis (MS). It has been speculated that the treatment efficacy of interferon beta (IFN beta) in MS may relate to its anti-viral properties. The study was undertaken to evaluate the in vivo anti-viral effects of IFN beta-1a in patients with MS. Human herpesvirus-6 (HHV-6) was studied as an example for being a latent neurotropic virus. IFN beta used at concentrations of approximately 0.5 microg/ml was shown to significantly reduce in vitro HHV-6 replication in a susceptible T-cell line. Sera derived from 23 MS patients treated with IFN beta-1a were examined for serum cell-free DNA of HHV-6 as an indicator for viral replication and the reactivity of IgM antibodies to a recombinant HHV-6 virion protein containing a known immunoreactive region. The results were compared with those of control sera obtained from untreated MS (n=29) and healthy individuals (n=21). The findings indicated that IFN beta treatment significantly reduced HHV-6 replication as evident by decreased cell-free DNA in treated MS specimens. The results correlated with decreased IgM reactivity to the HHV-6 antigen in treated MS patients compared to untreated controls, suggesting reduced exposure to HHV-6. The findings were confirmed in paired sera obtained from seven MS patients before and after the treatment The study provides new evidence indicating that IFN beta has potent in vivo anti-viral effects that may contribute to the treatment efficacy in MS.

Constitutive and regulated expression of processed insulin following in vivo hepatic gene transfer.

To test whether hepatocytes engineered in vivo can serve as surrogate beta cells by similarly secreting mature insulin in a glucose-sensitive manner, we prepared adenoviral vectors encoding wild-type proinsulin (hIns-wt), a modified proinsulin cleavable by the ubiquitously expressed protease furin (hIns-M3), or each of the two beta cell specific pro-insulin convertases PC2 and PC3. Following a detailed in vitro characterization of the proteins produced by our vectors, we infected the liver and, for comparison, the muscle of a chemically induced murine model of type I diabetes. Insulin expression from the transduced tissues was extensively characterized and showed to be constitutive rather than regulated. To obtain regulated expression, we placed expression of hIns-M3 under the control of the dimerizer-inducible transcription system. Hormone secretion from mouse liver was negligible in the absence of the dimerizer drug rapamycin, was inducible in a dose-dependent manner upon its administration, and reversible following drug withdrawal. These data confirm liver as a promising target for in vivo expression of processed insulin. While suggesting that hepatocytes cannot provide authentic glucose-responsive regulation, these results demonstrate that pharmacological regulation is a promising alternative route to the controlled delivery of insulin following hepatic gene transfer.

[Neuroimaging in multiple sclerosis]. / Neuroimagen de la esclerosis múltiple.

INTRODUCTION: Multiple sclerosis is currently considered to be a destructive disorder, and a certain degree of alteration in immunity is considered to occur in genetically susceptible persons. DEVELOPMENT: Magnetic resonance (MR) has become the basic technique for diagnosis and evaluation of the response to treatment. The key factor in the information obtained form MR images is the water content. There are several technical situations to be taken into account when using MR in multiple sclerosis: phase T1, phase T2, FLAIR, phase T1 with gadolinium, MR with spectroscopy, cerebral parenchymatous fraction and magnetization transfer MR. Apart from magnetic resonance, immunological changes of multiple sclerosis are seen in the CSF in over 50% of the patients with the disorder. Use of evoked potentials, with the important advantage of detecting lesions not visible on MR and asymptomatic lesions, may also be useful for establishment of the diagnosis. CONCLUSION: In this article we describe the use of neuroimaging in the diagnosis of multiple sclerosis.

[Pharmacologic treatment of multiple sclerosis]. / Tratamiento farmacológico de la esclerosis múltiple.

INTRODUCTION: Multiple sclerosis (MS) is probably caused by many pathological factors, both intrinsic and extrinsic. DEVELOPMENT: When we consider the aetiology of MS, we have to take three basic factors into account: 1. Immunological factors: evidence of involvement of the immune system has been found in plasma, tissues and CSF; 2. Viral factors: epidemiological studies suggest that MS may be a result of contact with environmental factors during childhood or adolescence, and 3. Genetic factors although there is no evidence that MS is inherited directly, there is between 12 and 15 times more involvement of persons from affected families than from the general population. Regarding treatment, since this is a polysymptomatic disorder, the specialist should choose the most suitable drug or intervention in each case, according to the alterations which affect quality of life or the severity of the presenting symptom. Three pharmacological treatments are emphasized: steroids, immunomodulation and immunosuppression. CONCLUSION: In this article we review the aetiology of MS and its pharmacological treatment.

Reactivity pattern and cytokine profile of T cells primed by myelin peptides in multiple sclerosis and healthy individuals.

Autoreactive T cells specific for candidate myelin antigens, including myelin basic protein (MBP) and proteolipid protein (PLP), are thought to play an important role in the pathogenesis of multiple sclerosis (MS). Myelin-reactive T cells primed in vivo by myelin breakdown products or microbial cross-reactive antigens during the disease processes may exhibit a reactivity pattern and cytokine profile different from those in the normal T cell repertoire. In this study, we examined the precursor frequency, the reactivity pattern and cytokine profile of myelin-reactive T cells that were primed in vitro with overlapping peptides of MBP and PLP in patients with MS and healthy individuals. The results revealed that T cells specific for peptides of MBP and PLP occurred at a relatively higher precursor frequency in patients with MS than that in healthy individuals. We identified a number of dominant T cell epitopes within MBP and PLP, some of which were not previously detected using whole myelin antigens as the primary stimuli. Some residues represented common immunodominant regions that were detected in both MS patients and healthy controls while others were associated only with MS. MBP-reactive T cell lines generally exhibited a Th0-like cytokine profile. There was significantly increased Th1 cytokine production (i. e. TNF and IFN-gamma) among MS-derived T cell lines. PLP-reactive T cell lines had a distinct cytokine profile, producing predominantly TNF-alpha and little or not IFN-gamma and IL-4. The findings have important implications in the understanding of the role of myelin-reactive T cells in MS.

Urodynamic pattern changes in multiple sclerosis.

OBJECTIVES: Multiple sclerosis (MS) causes neurologic symptoms to change over time. Voiding dysfunction is common in patients with MS, and few studies have examined the changes in urodynamic patterns in these patients over time. The purpose of this study was to examine the frequency and nature of urodynamic pattern changes in patients with MS who underwent two or more urodynamic studies. METHODS: Twenty-two patients (7 men and 15 women) with well-documented MS were referred to one urologist (T.B.B.) for evaluation of lower urinary tract symptoms. All patients had undergone two or more urodynamic evaluations during a 14-year period for persistent or new symptoms, and a retrospective comparison was made among the urodynamic test results. RESULTS: Overall, 12 (55%) of 22 patients experienced a change in their urodynamic patterns and/or compliance during a mean follow-up interval of 42 +/- 45 months between the urodynamic studies. Most patients initially had urodynamic patterns showing detrusor hyperreflexia, detrusor external sphincter dyssynergia, or detrusor hypocontractility. Fourteen (64%) of the 22 patients studied had the same or worsening of the same symptoms and 8 (36%) of 22 had new urologic symptoms. Six (43%) of 14 patients with no new symptoms and 6 (75%) of 8 with new symptoms had significant changes found with follow-up urodynamic testing. CONCLUSIONS: A significant proportion of patients with MS with and without new urinary symptoms will develop changes in their underlying urodynamic patterns and detrusor compliance. Therefore, urodynamic evaluations should be repeated at regular intervals in symptomatic patients to optimize clinical management, reduce complications, and better enable these patients to manage their neurogenic bladder dysfunction.

Regulation of chemokine receptor CCR5 and production of RANTES and MIP-1alpha by interferon-beta.

Trafficking of inflammatory T cells into the brain is associated with interactions of certain chemokines with their receptors, which plays an important role in the pathogenesis of multiple sclerosis (MS). We examined whether interferon-beta (IFN-beta) had the ability to regulate the production of chemokines and the expression of their receptors in T cells derived from patients with MS. It was demonstrated for the first time that in vitro exposure of T cells to IFN-beta-1a selectively inhibited mRNA expression for RANTES and MIP-1alpha and their receptor CCR5. T cell surface expression of CCR5 was significantly reduced in MS patients treated with IFN-beta, correlating with decreased T cell transmigration toward RANTES and MIP-1alpha. The study provides new evidence suggesting that IFN-beta treatment impairs chemokine-induced T cell trafficking by reducing the production of RANTES and MIP-1alpha and the expression of their receptors CCR5.