[Pharmaco-economic evaluations of new drugs: potential key to a more efficient allocation of the health care budget]. / Farmaco-economische evaluaties van nieuwe geneesmiddelen: mogelijk de sleutel tot een doelmatiger verdeling van het gezondheidszorgbudget.

In the light of rising expenditure on drugs and health care, a transparent, rational and careful decision-making process is required for the reimbursement of drugs. In the Netherlands, the Ministry of Health intends using pharmaco-economics in this process, i.e., new drugs will not only be judged on their clinical efficacy but also on their cost-effectiveness. Guidelines for pharmaco-economic research in the Netherlands have been published. According to these guidelines, a pharmaco-economic study must contain a cost-effectiveness analysis and/or a cost-utility analysis. In addition, a budgetary impact analysis is required. By 2005, all new drugs with therapeutic added value must supply a pharmaco-economic evaluation in order to apply for reimbursement. It will be the Minister of Health who decides whether a new drug will be reimbursed.

Identification of the cleavage sites in the alpha6A integrin subunit: structural requirements for cleavage and functional analysis of the uncleaved alpha6Abeta1 integrin.

The alpha6A and alpha6B integrin subunits are proteolytically cleaved during biosynthesis into a heavy chain (120 kDa) that is disulphide-linked to one of two light chains (31 or 30 kDa). Analysis of the structure of the alpha6A subunit on the carcinoma cell line T24 and human platelets demonstrated that the two light chains of alpha6 are not differentially glycosylated products of one polypeptide. Rather they possess different polypeptide backbones, which presumably result from proteolytic cleavage at distinct sites in the alpha6 precursor. Mutations were introduced in the codons for the R876KKR879, E883K884, R890K891 and R898K899 sequences, the potential proteolytic cleavage sites, and wild-type and mutant alpha6A cDNAs were transfected into K562 cells. The mutant alpha6A integrin subunits were expressed in association with endogenous beta1 at levels comparable to that of wild-type alpha6Abeta1. A single alpha6 polypeptide chain (150 kDa) was precipitated from transfectants expressing alpha6A with mutations or deletions in the RKKR sequence. Mutations in the EK sequence yielded alpha6A subunits that were cleaved once into a heavy and a light chain, whereas alpha6A subunits with mutations in one of the two RK sequences were, like wild-type alpha6A, cleaved into one heavy and two light chains. Thus a change in the RKKR sequence prevents the cleavage of alpha6. The EK site is the secondary cleavage site, which is used only when the primary site (RKKR) is intact. Microsequencing of the N-termini of the two alpha6A light chains from platelets demonstrated that cleavage occurs after Arg879 and Lys884. Because alpha6(RKKG), alpha6(GKKR) and alpha6(RGGR) subunits were not cleaved it seems that both the arginine residues and the lysine residues are essential for cleavage of RKKR. alpha6A mutants with the RKKR sequence shifted to the EK site, in such a way that the position of the arginine residue after which cleavage occurs corresponds exactly to Lys884, were partly cleaved, whereas alpha6A mutants with the RKKR sequence shifted to other positions in the alpha6A subunit, including one in which it was shifted two residues farther than the EK cleavage site, were not cleaved. In addition, alpha6A mutants with an alpha5-like cleavage site, i.e. arginine, lysine and histidine residues at positions -1, -2 and -6, were not cleaved. Thus both an intact RKKR sequence and its proper position are essential. After activation by the anti-beta1 stimulatory monoclonal antibody TS2/16, both cleaved and uncleaved alpha6Abeta1 integrins bound to laminin-1. The phorbol ester PMA, which activates cleaved wild-type and mutant alpha6Abeta1, did not activate uncleaved alpha6Abeta1. Thus uncleaved alpha6Abeta1 is capable of ligand binding, but not of inside-out signalling. Our results suggest that cleavage of alpha6 is required to generate a proper conformation that enables the affinity modulation of the alpha6Abeta1 receptor by PMA.

The A and B variants of the alpha 3 integrin subunit: tissue distribution and functional characterization.

The alpha subunits of the laminin-binding integrins alpha 3 beta 1, alpha 6 beta 1, and alpha 7 beta 1 have homologous sequences and are similar in structure. Two cytoplasmic variants, A and B, have been identified for each of these alpha subunits, although the alpha 3B splice variant has been detected only at the mRNA level. We prepared a panel of mouse monoclonal antibodies specific for the A and B variants of the alpha 3 subunit to study their tissue distribution. Four monoclonal antibodies react with alpha 3A, one of which recognizes only the nonphosphorylated form; of the three anti-alpha 3B antibodies, one cross-reacts with alpha 6B. Reverse transcriptase-PCR analysis of various human tissues revealed the presence of alpha 3B mRNA in brain, heart, and skeletal muscle. Moreover, the alpha 3B protein was detected by immunoblotting in brain and heart tissue but not in skeletal muscle. In contrast, alpha 3A mRNA and protein were present in all tissues studied. Thus, the expression of alpha 3B in adult tissues is more restricted than that of alpha 3A. Immunohistochemical studies showed that in brain tissue, both variants are exclusively expressed on small blood-vessel endothelium, whereas in heart tissue their distribution patterns differ markedly. Although alpha 3A is strongly expressed on vascular smooth muscle cells, alpha 3B is detected only on endothelial cells of veins. Expression of the two variant forms of alpha 3 in K562 cells revealed that the ligand-binding specificities of alpha 3A beta 1 and alpha 3B beta 1 are identical: both bind human laminin-2 and -4, laminin-5, and laminins isolated from bovine kidney, but not bovine laminin-2 and -4, mouse laminin-1, or human fibronectin. In addition, adhesion mediated by both integrins is induced to the same extent by phorbol 12-myristate 13-acetate. The alpha 3A, but not the alpha 3B subunit, is phosphorylated; and phosphorylation of alpha 3A increases after phorbol 12-myristate 13-acetate stimulation. Thus, we found no differences between the adhesion functions of the A and B variants of alpha 3.

Cleavage of the alpha6A subunit is essential for activation of the alpha6Abeta1 integrin by phorbol 12-myristate 13-acetate.

The alpha6 integrin subunit is proteolytically cleaved during biosynthesis in a covalently associated heavy and light chain. To examine the importance of cleavage for the function of the alpha6 subunit, we introduced mutations in the cDNA encoding the RKKR (876-879) sequence, the presumed cleavage site, in which either one or two basic residues were replaced by glycine. Wild-type and mutant alpha6A cDNAs (alpha6GKKR, alpha6RKKG and alpha6RGGR) were transfected into K562 cells. The mutant alpha6A integrin subunits were expressed in association with endogenous beta1, at levels comparable to that of the wild-type alpha6Abeta1. A single alpha6A polypeptide chain (150 kDa) was precipitated from surface-labeled alpha6GKKR, alpha6RKKG, and alpha6-RGGR transfectants, while the separate heavy (120 kDa) and light chains (31 or 30 kDa) were precipitated from the wild-type alpha6RKKR transfectant. Thus, a change in the RKKR sequence prevents cleavage of alpha6. After activation by the anti-beta1 stimulatory mAb TS2/16 both cleaved and uncleaved alpha6Abeta1 integrins bound and spread on laminin-1. Remarkably, the phorbol ester phorbol 12-myristate 13-acetate, which activates wild-type alpha6Abeta1 to bind to laminin-1, did not activate uncleaved alpha6Abeta1. We conclude that uncleaved alpha6Abeta1 is capable of ligand binding and transducing outside/in signals, like wild-type alpha6A-beta1. However, inside/out signaling is affected. It appears that cleavage of alpha6 is required to generate the proper conformation in alpha6 that enables affinity modulation of the alpha6A-beta1 receptor by phorbol 12-myristate 13-acetate.

An alternatively spliced exon in the extracellular domain of the human alpha 6 integrin subunit--functional analysis of the alpha 6 integrin variants.

Variants in the extracellular domain of the integrin alpha 7 subunit which arise as a consequence of alternative splicing of mRNA have recently been reported. Two alternative exons, X1 and X2, have been identified in the alpha 7 gene, and homologous exons were found for alpha 6 (Ziober et al., 1993). In this study, we have isolated the region of the alpha 6 gene containing exons X1 and X2 that are, like those of alpha 7, located between stretches of DNA that encode the homologous repeat domains III and IV, proximal to the three divalent cation binding sites of the alpha 6 subunit. We demonstrated by reverse transcriptase polymerase chain reactions and confirmed by sequencing that alpha 6X1 and alpha 6X1X2 mRNAs are generated by alternative splicing of exon X2. The alpha 6X1X2 mRNA is expressed in a limited number of tissues and cell lines and it is always co-expressed with the ubiquitous alpha 6X1 mRNA. Stable transfection of K562 cells with full length cDNAs for the alpha 6AX1X2 and beta 4 subunits resulted in cell populations that expressed the alpha 6AX1X2 variant, in association with either beta 1 or beta 4, on their surface. In addition, a population of cells was isolated that expressed the alpha 6AX1X2 variant at low levels and almost exclusively in association with beta 1. Comparison of the alpha 6AX1X2 integrins with alpha 6AX1 using similarly transfected cells showed no obvious differences between the alternative extracellular alpha 6A isoforms with respect to ligand specificity and activation-dependency of ligand binding. After treatment with the anti-beta 1 stimulatory antibody TS2/16, both the alpha 6AX1 beta 1 and alpha 6AX1X2 beta 1 integrin variants mediated cell adhesion to EHS tumor laminin (laminin-1), kalinin (laminin-5), human placental (laminin-2 and -4) and bovine kidney laminins. In contrast, the alpha 6AX1 beta 4 and alpha 6AX1X2 beta 4 integrins also mediated cell adhesion to laminin and kalinin without stimulation. Furthermore, the different transfectants did not differ in their ability to spread on kalinin. The presented data indicate that the X2 region in alpha 6 is not involved in defining ligand specificity or affinity.

The alpha 6 beta 4 integrin is a receptor for both laminin and kalinin.

Previously, we have establish K562 transfectants that express either alpha 6A beta 1 or alpha 6B beta 1 (K alpha 6A or K alpha 6B) on their surface. Both cell lines bind to laminin and kalinin after treatment with the beta 1-stimulatory antibody TS2/16. Here we introduce the full-length beta 4 cDNA into the alpha 6A- and alpha 6B-expressing K562 cells and selected stably transfected cells. The beta 4 subunit was expressed on the surface of both transfectants and it formed dimers with the alpha 6A or alpha 6B subunits. Immunoprecipitation and preclearing analyses revealed that both transfectants expressed alpha 6 beta 1, in addition to alpha 6 beta 4. While K alpha 6A and K alpha 6B cells required TS2/16 stimulation for binding to laminin or kalinin, adhesion of the unstimulated beta 4-transfected K alpha 6A and K alpha 6B cells to these matrix components was already substantial. This adhesion was mediated by both alpha 6 beta 1 and alpha 6 beta 4 since it was completely blocked by an alpha 6-specific antibody or by a combination of anti-beta 1 and anti-beta 4 antibodies, but only partially by either of these latter two antibodies alone. Adhesion to laminin was completely blocked by an antiserum to laminin fragment E8 as was the adhesion to kalinin by an antibody to kalinin, demonstrating the specificity of adhesion. Both transfectants always adhered more strongly to kalinin than to laminin. Furthermore, binding to kalinin was less well blocked by antibodies to beta 4 than binding to laminin, indicating that the affinity of alpha 6 beta 4 for kalinin is higher than that for laminin. The fact that alpha 6 beta 1 mediated adhesion without TS2/16 stimulation on the beta 4-transfected K alpha 6A and K alpha 6B cells suggests that some activation of alpha 6 beta 1 had occurred in these cells, even though binding was increased when they were actively stimulated by the antibody TS2/16. Finally, we show that Mn2+ induced binding of solubilized alpha 6 beta 4 to matrix containing kalinin, deposited by the murine cell line RAC-11P/SD. This binding was inhibited by the anti-alpha 6 mAb GoH3. Together, these results indicate that both alpha 6 beta 1 and alpha 6 beta 4 are receptors for laminin and kalinin and that there are no differences in ligand specificity between the A and B variants of the alpha 6 subunit when associated with either beta 1 or beta 4.

Distinct and overlapping ligand specificities of the alpha 3A beta 1 and alpha 6A beta 1 integrins: recognition of laminin isoforms.

The ligand specificity of the alpha 3A beta 1 integrin was analyzed using K562 cells transfected with full-length alpha 3A cDNA and was compared with that of alpha 6A beta 1 in similarly transfected K562 cells. Clones were obtained that showed comparable surface expression of either alpha 3A beta 1 or alpha 6A beta 1 integrins. Those expressing alpha 3A beta 1 attached to and spread on immunopurified human kalinin and cellular matrices containing human kalinin, which is a particular isoform of laminin. In addition, alpha 3A transfectants adhered to bovine kidney laminins possessing a novel A chain variant. Binding to kalinin was blocked by a monoclonal antibody against the A chain constituent of kalinin and adhesion to both kalinin and kidney laminins by anti-alpha 3 and beta 1 monoclonal antibodies. The alpha 3A transfected cells bound more strongly to kalinin and bovine kidney laminins after treatment with the beta 1 stimulatory antibody TS2/16. A distinctly weaker and activation-dependent adhesion of alpha 3A transfectants was observed on human placental laminins possessing the Am chain variant (merosin), and no adhesion occurred on bovine heart laminins and murine EHS tumor laminin. Further inactive substrates were fibronectin, nidogen, and collagen types IV and VI, indicating that the alpha 3A beta 1 integrin is a much less promiscuous receptor than thought before. By contrast, alpha 6A transfected cells adhered to all laminin isoforms when stimulated with TS2/16. Adhesion also occurred only on bovine kidney laminins in the absence of TS2/16. These results demonstrate that both alpha 3A beta 1 and alpha 6A beta 1 integrins are typical laminin receptors but that their affinity and activation dependence for binding to various laminin isoforms differ considerably.

Expression and function of the cytoplasmic variants of the integrin alpha 6 subunit in transfected K562 cells. Activation-dependent adhesion and interaction with isoforms of laminin.

Two variants of the cytoplasmic domain of the integrin alpha 6 subunit have been identified (alpha 6A and alpha 6B). To determine the role of each variant in mediating cell adhesion to laminin, we have independently expressed the alpha 6A and alpha 6B subunits in K562 cells. Both variants associated with endogenous beta 1 and were present at comparable levels on the surface of transfected K562 cells. After activation with phorbol ester (phorbol 12-myristate 13-acetate; PMA) or the stimulatory anti-beta 1 antibody TS2/16, alpha 6A beta 1 as well as alpha 6B beta 1 mediated cell adhesion to laminin and more specifically to its fragment E8. Furthermore, both integrin variants interacted with the laminin isoforms kalinin and merosin. Cell adhesion to laminin isoforms was inhibited by the alpha 6-specific monoclonal antibody GoH3. PMA was less efficient in stimulating adhesion than TS2/16 and stimulated adhesion of alpha 6B transfectants better than of alpha 6A transfectants. In contrast, TS2/16 stimulated the adhesion of the alpha 6A and alpha 6B transfectants to laminin to a similar extent. These findings indicate that the cells may regulate the activation of the two alpha 6 variants independently. Activation by PMA was associated with the phosphorylation of both alpha 6A and alpha 6B subunits, but there was no relationship between the degree of phosphorylation and the ability of the transfectants to adhere to laminin since alpha 6A became phosphorylated much more strongly by PMA than alpha 6B. Thus, both alpha 6A beta 1 and alpha 6B beta 1 on K562 cells are activation-dependent receptors for different isoforms of laminin.