Setting Goals to Reduce Cardiovascular Risk: A Retrospective Chart Review of a Pharmacist-Led Initiative in the Workplace.

Background: Cardiovascular diseases (CVD) are the second leading cause of death in Canada with many modifiable risk factors. Pharmacists at a Canadian university delivered a novel CVD risk management program, which included goal-setting and medication management. Aim: This study aimed to describe what CVD prevention goals are composed of in a workplace CVD risk reduction program, and how might these goals change over time. Methods: A longitudinal, descriptive qualitative study using a retrospective chart review of clinical care plans for 15 patients enrolled in a CVD prevention program. Data across 6 visits were extracted from charts (n = 5413 words) recorded from May 2019-November 2020 and analyzed using quantitative content analysis and descriptive statistics. Results: Behavioural goals were most popular among patients and were more likely to change over the 12-month follow-up period, compared to health measure goals. Behavioural goals included goals around diet, physical activity (PA), smoking, medication, sleep and alcohol; health measure goals centered on weight measures, blood pressure (BP) and blood lipid levels. The most common behavioural goals set by patients were for diet (n = 11) and PA (n = 9). Over time, goals around PA, medication, alcohol and weight were adapted while others were added (e.g. diet) and some only continued. Patients experienced a number of barriers to their goal(s) which informed how they adapted their goal(s). These included environmental limitations (including COVID-19) and work-related time constraints. Conclusions: This study found CVD goal-setting in the pharmacist-led workplace wellness program was complex and evolved over time, with goals added and/or adapted. More detailed qualitative research could provide further insights into the patient-provider goal-setting experience in workplace CVD prevention.

Oral anticoagulant adherence and switching in patients with atrial fibrillation: A prospective observational study.

BACKGROUND: Adherence to oral anticoagulants (OACs) in patients with atrial fibrillation (AF) is important in preventing stroke. The dominance of retrospective studies using administrative data has led to a lack of data on psychosocial determinants of adherence and prevented comparison of adherence between OAC drug classes. OAC switching is another aspect of adherence that is unexplored. METHODS: A prospective design was utilized to measure AF patients' self-reported adherence and OAC switching, and to identify their clinical, demographic, and psychosocial determinants. Participants were recruited from specialized AF clinics in Canada and followed for up to 2 years. Data were collected via telephone every 3-4 months using a structured survey. Adherence was measured using the Morisky Medication Adherence scale (©MMAS-8). RESULTS: The included participants (N = 306) were followed for a median follow up time of 14.1 months and had an average of 3.2(SD 1.4) study visits. The mean self-reported adherence on the ©MMAS-8 was 7.28(SD 0.71) for patients receiving care at specialized AF clinics. Older age, experiencing a bleed, and higher satisfaction with the burden of medications were significantly associated with higher adherence. Drug class did not have any significant impact on adherence. 7.8% of the cohort experienced a switch with most of them being from warfarin to DOAC. Taking warfarin as the index medication, experiencing a bleed and older age were significantly associated with higher odds of switching. CONCLUSION: Patients with AF reported high adherence to their OAC therapy however being on DOAC may not translate to better adherence compared to VKA. Improving satisfaction with the burden of therapy is important in improving adherence.

Satisfaction With Oral Anticoagulants Among Patients With Atrial Fibrillation: A Prospective Observational Study.

BACKGROUND: Satisfaction with treatment has been identified as an important contributing factor to adherence with oral anticoagulant (OAC) therapy in patients with atrial fibrillation (AF). We aimed to evaluate the satisfaction level of patients with AF regarding OAC use over time, using validated patient-reported outcome instruments, and to identify associated patient characteristics. METHODS: Participants were recruited from specialized AF clinics in Canada. Eligible AF patients who were prescribed OACs were followed for up to 2 years. Participants were interviewed via telephone every 3-4 months using a structured survey. The Treatment Satisfaction Questionnaire for Medication (TSQM II) and the Anti-Clot Treatment Scale (ACTS) were used to measure satisfaction over time. RESULTS: Among the 306 participants, satisfaction scores on the TSQM II and ACTS instruments were high. Unadjusted analyses showed significantly greater satisfaction with the burden of therapy with direct OACs (DOACs) compared to that with warfarin (small-magnitude effect) and greater satisfaction with the convenience of rivaroxaban, compared with that of all other OACs (moderate-magnitude effect). After adjustment for all other variables, vitamin K antagonist therapy was associated with greater global satisfaction than was DOAC treatment. Satisfaction with benefit and burden as measured by the ACTS scale, and global satisfaction on the TSQM II scale, tended to increase over time. Patient factors that were somewhat consistently associated with greater satisfaction were female sex and younger age. CONCLUSIONS: Patients with AF were highly satisfied with their therapy, with few differences among OAC classes and individual OACs. Individual patients may or may not be more satisfied with DOAC than VKA therapy, and regardless of the OAC prescribed, the may require significant support to maintain therapy adherence.

CONTEXTE: La satisfaction à l'égard du traitement a été désignée comme un facteur important contribuant à l'adhésion au traitement par anticoagulants oraux (ACO) chez les patients atteints de fibrillation auriculaire (FA). Notre objectif était d'évaluer le degré de satisfaction des patients atteints de FA concernant l'utilisation des ACO au fil du temps, à l'aide d'instruments validés mesurant les résultats signalés par les patients, et de déterminer les caractéristiques connexes des patients. MÉTHODOLOGIE: Les participants ont été recrutés dans des cliniques spécialisées en FA au Canada. Les patients admissibles atteints de FA qui se sont fait prescrire des ACO ont été suivis pendant une période allant jusqu'à 2 ans. Les participants ont été interrogés par téléphone tous les 3 ou 4 mois à l'aide d'une enquête structurée. Le questionnaire Treatment Satisfaction Questionnaire for Medication ­ Version II (TSQM II) et l'échelle Anti-Clot Treatment Scale (ACTS) ont été utilisés pour mesurer la satisfaction au fil du temps. RÉSULTATS: Parmi les 306 participants, les taux de satisfaction indiqués par les instruments TSQM II et ACTS étaient élevés. Les analyses non corrigées ont montré une satisfaction liée au fardeau du traitement significativement plus élevée avec les ACO directs qu'avec la warfarine (effet de faible ampleur) et une plus grande satisfaction concernant la commodité du rivaroxaban par rapport à celle de tous les autres ACO (effet de moyenne ampleur). Après ajustement pour tenir compte de toutes les autres variables, le traitement par antivitamines K (AVK) était associé à une plus grande satisfaction globale que le traitement par ACO direct. La satisfaction à l'égard des avantages et du fardeau, mesurée par l'échelle ACTS, et la satisfaction globale sur l'échelle TSQM II, ont eu tendance à augmenter avec le temps. Les facteurs liés aux patients qui ont été associés de manière assez constante à une plus grande satisfaction étaient le sexe féminin et un âge plus jeune. CONCLUSIONS: Les patients atteints de FA étaient très satisfaits de leur traitement, et peu de différences existaient entre les classes d'ACO et les ACO individuels. Chaque patient peut être ou non plus satisfait du traitement par ACO direct que par AVK et, quel que soit l'ACO prescrit, il peut avoir besoin d'un soutien important pour maintenir l'adhésion au traitement.

Impact of recreational cannabis legalization on patient self-reporting of cannabis use at a pharmacist-led primary care clinic.

BACKGROUND: The Cannabis Act, introduced in Canada in 2018, legalized the use of recreational cannabis. The impact of the announcement and implementation of this act on patient self-reporting of cannabis use has not been explored. OBJECTIVE: The study objective was to determine if patient self-reported cannabis use increased after the announcement and implementation of legislative changes to legalize recreational cannabis. METHODS: A repeated cross-sectional design was used for a retrospective chart review of patients seen at a pharmacist-led primary care clinic. A convenience sample of patient records was divided into 3 panels, corresponding with the preannouncement (November 1, 2013-October 4, 2015), postannouncement (October 5, 2015-October 16, 2018), and postimplementation (October 17, 2018-October 17, 2019) stages of the legalization of recreational cannabis. Search terms used included cannabis, marijuana, marihuana, recreational drugs, natur∗, medicinal, pot, joint, oil, butter, brownies, edibles, cannabin∗, THC, tetrahydro∗, sativa, and indica (∗ = string wild card). The frequency of reporting use and the number of queries related to cannabis were assessed. The analysis of variance test and Pearson correlation (chi-square) were used to compare the 3 panels. RESULTS: A total of 298 patient charts were included in the analysis. One hundred, 99, and 99 patient charts corresponded with panels 1, 2, and 3, respectively. At each time point, 6%, 8%, and 14% of the patients reported cannabis use (P = 0.03). A statistically significant increase in topical oil use and a decrease in prescription tablet or capsule use between panels 1 and 3 (P = 0.036) were identified. CONCLUSION: This study found an increase in self-reporting of cannabis use across the 3 consecutive panels. The change in the product formulations used may reflect the various products available. Frontline pharmacists are encouraged to initiate conversations regarding cannabis use as part of routine practice.

Third-party Reimbursement of Pharmacist-Led Cardiovascular and Diabetes Preventive Health Services for Workplace Health Initiatives: A Narrative Systematic Review.

OBJECTIVE: To summarize available literature describing third-party payer reimbursement models for pharmacist-led preventive health services as part of workplace health initiatives. METHODS: A combination of search terms related to pharmacists, preventive health, and third-party reimbursement were searched in MEDLINE, EMBASE, and PubMed. Included studies described community pharmacist-led cardiovascular and diabetes preventive health service to employees older than 18 years of age as part of a workplace health program with corresponding third-party reimbursement models. Programs that were reimbursed by government resources or studies lacking reimbursement model details were excluded. One reviewer performed level 1 screening and three reviewers analyzed included studies. RESULTS: The search criteria yielded 863 results. Sixteen articles were reviewed after level 1 screening and 13 were ineligible and excluded. Three studies with varying quality of reporting were included. Reimbursement models varied from $40 USD for a 20-minute visit to $391 to $552 USD total per patient with an average of 6 visits per patient. CONCLUSION: There is a lack of quality literature describing third-party reimbursement models for pharmacist-led preventive health services, which hinders the ability to implement a standardized model. High quality studies evaluating the cost of reimbursing pharmacist-led cardiovascular preventive health services compared to the savings to the third-party payer should be performed to inform the standardization of payment models.

Pharmacy students' perspectives on involvement in workplace-based preventative health and wellness events.

INTRODUCTION: Canadian pharmacy students have varied exposure within their academic curricula and limited opportunities for hands-on preventative health experiences prior to practicums. We aimed to explore pharmacy student perceptions of readiness to engage in patient education and assessment activities in health promotion events. METHODS: Under licensed pharmacist supervision, volunteer pharmacy students delivered health promotion events to University of British Columbia staff and faculty between 2017 and 2020. Students attended a one-hour, group training session with a licensed pharmacist prior to participating in four hours of service delivery. Post-event, anonymous, electronic surveys were emailed to student participants to gauge perceived change(s) in knowledge and skill development as a result of participation. Data analysis was by descriptive statistics. RESULTS: Surveys were sent to 151 pharmacy student volunteers from 2017 to 2020. A total of 69 responses were received (response rate = 45.7%), 60 of which were complete (completion rate = 39.7%). Overall, students reported a shift from feeling competent to confident in the various domains assessed as a result of participation. The majority of students strongly agreed or agreed that they were well-prepared for the event and felt supported by pharmacist supervisors. CONCLUSIONS: Pharmacy students felt that participation in a brief preventative health and wellness intervention increased confidence in knowledge and patient care skills, regardless of year of study. Early exposure to health promotion activities may accelerate and enhance clinical abilities of pharmacy students while preparing them for expanding pharmacist roles.

Learner Perceptions of a Video Recording Activity for Patient Consultation Training in a Pharmacist-Led Primary Care Clinic Located in an Academic Institution.

Description of the problem: Development of evidence-based educational activities is needed to provide educators with the tools to aid learners in strengthening patient consultation skills in the primary care practice setting, an emerging area of practice in Canada. Objective: The objective was to develop an educational activity to bring self-awareness to fourth year pharmacy student and pharmacy resident consultation skills and to determine learner perceptions of this educational activity, including identifying the key areas of skill development that learners found were positively impacted. Description of the innovation: An innovative learning activity utilizing audio-video technology to enable recording and reviewing of learner-led patient consultations was developed and implemented within the University of British Columbia Pharmacists Clinic. Learners had the opportunity to lead 60-minute patient consultations. With patient and learner consent, patient consultations were recorded for learner viewing and self-assessment. Pharmacist preceptors supervised and assessed learner performance. Learners completed an online anonymous survey after the learning activity to evaluate its value. Critical analysis: Between September 2018 and July 2019, eight pharmacy learners, consisting of student pharmacists (5) and post-graduate pharmacy residents (3) completed the learning activity and provided their feedback. The majority of learners (87.5%) felt the learning activity was beneficial to the development of patient consultation skills. Learners gained awareness of areas requiring improvement which included appropriate questioning, clear and concise language, time management and non-verbal habits. Next steps: Adapting and modifying this learning activity to align with specific practice settings and learning objectives is feasible for other primary care practice sites offering experiential practicums.

Pharmacist-led cardiovascular risk prevention in Western Canada: a qualitative study.

OBJECTIVES: Preventing cardiovascular diseases (CVD) is a public health and policy priority, including for employers. A novel CVD risk management programme that included medication management was delivered by pharmacists to employees of a Canadian university. This qualitative study describes the experiences and perceptions of participants who received individual health consultations in this programme. METHODS: A qualitative study design using free-text responses was adopted. Data (5658 words) came from evaluation surveys completed by 119 programme participants were iteratively coded and thematically analysed. KEY FINDINGS: We identified four themes characterising participant experiences of pharmacist-led CVD prevention. Theme one was labelled self-efficacy because personalised health information and advice on CVD risk factor management empowered participants to make improvements for their health. Participants expressed a range of positive responses about the longer consultations, supportive communication and safe setting of their pharmacist-led encounters; hence, Theme two is labelled pharmacists' interpersonal skills. The wider context of the programme included a number of enabling factors (Theme three) that either supported or limited participant engagement in the programme. A number of changes to behaviour and health measures were identified and participant suggestions to expand and continue the programme further contributed to perceptions of positive programme impact (Theme four). CONCLUSIONS: This study raises questions about how external resources and broader determinants might enable, or hinder, future programme success and sustainability. It also highlights the need for greater understanding and communication of the importance of primary prevention and the role of pharmacists in CVD risk reduction and workplace health promotion.

Atrial fibrillation patients' experiences and perspectives of anticoagulation therapy changes.

BACKGROUND: Atrial fibrillation (AF) patients' experiences with changes in their oral anticoagulant (OAC) therapy are understudied. OBJECTIVE: The objective of this study was to qualitatively describe AF patients' experiences and perspectives of changes made to their OAC therapy (switches or discontinuations). METHODS: A thematic analysis was performed on systematically-collected qualitative data from AF patients who experienced a therapy change (switching or discontinuing an OAC) as part of their participation in a large 2-year prospective observational study. RESULTS: A total of 56 participants met the inclusion criteria. Six themes emerged from the data: 1. reasons for switch or discontinuation of therapy, 2. attitudes towards changes in therapy attributes, 3. challenges with taking medications after therapy change, 4. relief from perceived burden of medication after discontinuation, 5. patients' limited involvement in decision-making, and 6. inadequate education and follow up. Patients were found to request changes in therapy based on their subjective experience with it (rather than clinically justified reasons). They were found to have limited knowledge about their medications, differing reactions to changes in their therapy attributes after a switch, an overall negative attitude towards taking medications, adherence challenges after switching from once daily to twice daily medication, feelings of being excluded from the decision-making process about their therapy changes and feelings of being unsupported after these changes. CONCLUSIONS: There are clear opportunities to improve patients' experiences with OAC therapy changes through improved shared decision-making and patient education/counselling.

Assessment of Burnout among Canadian Pharmacists Working in Team-based Primary Care Settings.

BACKGROUND: Burnout syndrome is well-documented among healthcare professionals across various practice settings. There has been recent expansion of Canadian pharmacists into team-based primary care and burnout in this setting has not been assessed. Our objective was to assess workplace burnout and to identify factors that play a role in perpetuating or diminishing it. METHOD: An online survey to assess burnout was developed using the Maslach Burnout Inventory (MBI) tool and questions regarding pharmacist background and practice. Invitations to complete the survey were sent to Canadian pharmacists working in team-based primary care settings on November 26, 2019 via a national primary healthcare listserv. RESULTS: A total of 31/433 completed responses were collected. The main analysis focused on the personal accomplishment (PA) domain as it had an adequate response rate. The PA domain had a median score of 5.0 (95% CI 4.69-5.22). We compared medians of the PA domain across different groups of each categorical variable. We found that the number of years working in primary care settings was positively associated with a higher PA domain score (p= 0.029). DISCUSSION: PA was higher in pharmacists who have been practicing in a primary care setting for longer; however, burnout rates could not be properly assessed due to the limited response rate. CONCLUSION: This is the first study to assess burnout among Canadian team-based primary care pharmacists. Personal accomplishment was higher in those who have been practicing in a primary care setting for longer. Future studies should consider alternate methods to evaluate burnout in this population.

Evaluating the Effect of a Patient Decision Aid for Atrial Fibrillation Stroke Prevention Therapy.

BACKGROUND: Stroke prevention therapy decisions for patients with atrial fibrillation (AF) are complex and require trade-offs, but few validated patient decision aids (PDAs) are available to facilitate shared decision making. OBJECTIVE: To evaluate the effects of a novel PDA on decision-making parameters for AF patients choosing stroke prevention therapy. METHODS: We developed an evidence-based individualized online AF PDA for stroke prevention therapy and evaluated it in a prospective observational pilot study. The primary outcome was decisional conflict. Secondary outcomes were knowledge, usability/acceptability, patient preferences, effects on therapy choices, and participant feedback. RESULTS: 37 participants completed the PDA. The PDA could be completed independently and was well accepted. It significantly decreased the mean decisional conflict score ( P < 0.001) and all its subscales and increased participant AF knowledge ( P = 0.02). 76% of participants indicated that their individualized therapy attribute ranking was congruent with their values. The PDA-generated best-match therapy was chosen by 70% of participants in decision 1 (no therapy, aspirin, or oral anticoagulant), and 17% for decision 2 (choice of anticoagulant). Among AF patients, 60% chose a different drug than that currently prescribed to them. Conclusion and Relevance: Our PDA was effective for reducing decisional conflict, increasing patient knowledge, eliciting patients' values, and presenting therapy options that aligned with patients' values and preferences. Using the PDA revealed that many patients have therapy preferences different from their currently prescribed treatment. The PDA is a practical and potentially valuable tool to facilitate decision making about stroke prevention therapy for AF.

Cardiovascular Risk Reduction in the Workplace With CAMMPUS (Cardiovascular Assessment and Medication Management by Pharmacists at the UBC Site).

BACKGROUND: Cardiovascular (CV) disease is a leading cause of death despite being largely preventable. Employers increasingly offer preventive health programs in the workplace, and pharmacists are well suited to provide these programs. OBJECTIVE: To evaluate the impact of a pharmacist-led service on CV risk in University of British Columbia (UBC) employees. METHODS: This was a prospective observational pre-and-post design study, with participants as their own controls. Employees >18 years of age in the UBC health plan with a Framingham Risk Score (FRS) ≥10% or ≥1 medication-modifiable CV risk factor were included. Participants received a baseline assessment, individualized consultation for 12 months, and a final assessment by a pharmacist at the UBC Pharmacists Clinic. The primary end point was FRS reduction. RESULTS: Baseline assessment of 512 participants between September 2015 and October 2016 yielded 207 (40%) participants, of whom 178 (86%) completed the 12-month intervention. Participants were 54% female and 55% Caucasian, with an average age of 51 (SD = 9.1) years. FRS at baseline was <10 in 45.8%, 10 to 19.9 in 37.9%, and ≥20 in 16.4% of participants. Over 12 months, significant reductions in average FRS (from 11.7 [SD = 7.7] to 10.7 [SD = 7.3]; P = 0.0017) and other parameters were observed. Significant improvements in quality of life (EQ5D change of 0.031 [95% CI = 0.001, 0.062] P = 0.023) and medication adherence (MMAS-8 change of 0.42 [ P = 0.019]) were also noted. CONCLUSIONS AND RELEVANCE: UBC employees had improvements in health markers, self-reported quality of life, and medication adherence after receiving a 12-month pharmacist-led intervention. Pharmacists are encouraged to provide CV risk reduction services in workplaces.

Patient values and preferences for antithrombotic therapy in atrial fibrillation. A Narrative Systematic Review.

Guidelines recommend that patients' values and preferences should be considered when selecting stroke prevention therapy for atrial fibrillation (SPAF). However, doing so is difficult, and tools to assist clinicians are sparse. We performed a narrative systematic review to provide clinicians with insights into the values and preferences of AF patients for SPAF antithrombotic therapy. Narrative systematic review of published literature from database inception. RESEARCH QUESTIONS: 1) What are patients' AF and SPAF therapy values and preferences? 2) How are SPAF therapy values and preferences affected by patient factors? 3) How does conveying risk information affect SPAF therapy preferences? and 4) What is known about patient values and preferences regarding novel oral anticoagulants (NOACs) for SPAF? Twenty-five studies were included. Overall study quality was moderate. Severe stroke was associated with the greatest disutility among AF outcomes and most patients value the stroke prevention efficacy of therapy more than other attributes. Utilities, values, and preferences about other outcomes and attributes of therapy are heterogeneous and unpredictable. Patients' therapy preferences usually align with their values when individualised risk information is presented, although divergence from this is common. Patients value the attributes of NOACs but frequently do not prefer NOACs over warfarin when all therapy-related attributes are considered. In conclusion, patients' values and preferences for SPAF antithrombotic therapy are heterogeneous and there is no substitute for directly clarifying patients' individual values and preferences. Research using choice modelling and tools to help clinicians and patients clarify their SPAF therapy values and preferences are needed.

Serum proteomics in multiple sclerosis disease progression.

Multiple sclerosis (MS) is associated with chronic degeneration of the central nervous system and may cause permanent neurological problems and considerable disability. While its causes remain unclear, its extensive phenotypic variability makes its prognosis and treatment difficult. The identification of serum proteomic biomarkers of MS progression could further our understanding of the molecular mechanisms related to MS disease processes. In the current study, we used isobaric tagging for relative and absolute protein quantification (iTRAQ) methodology and advanced multivariate statistical analysis to quantify and identify potential serum biomarker proteins of MS progression. We identified a panel of 11 proteins and combined them into a classifier that best classified samples into the two disease groups. The estimated area under the receiver operating curve of this classifier was 0.88 (p-value=0.017), with 86% sensitivity and specificity. The identified proteins encompassed processes related to inflammation, opsonization, and complement activation. Results from this study are in particular valuable to design a targeted Multiple Reaction Monitoring mass spectrometry based (MRM-MS) assay to conduct an external validation in an independent and larger cohort of patients. Validated biomarkers may result in the development of a minimally-invasive tool to monitor MS progression and complement current clinical practices. BIOLOGICAL SIGNIFICANCE: A hallmark of multiple sclerosis is the unpredictable disease course (progression). There are currently no clinically useful biomarkers of MS disease progression; most work has focused on the analysis of CSF, which requires an invasive procedure. Here, we explore the potential of proteomics to identify panels of serum biomarkers of disease progression in MS. By comparing the protein signatures of two challenging to obtain, but well-defined, MS phenotypic groups at the extremes of progression (benign and aggressive cases of MS), we identified proteins that encompass processes related to inflammation, opsonization, and complement activation. Findings require validation, but are an important step on the pathway to clinically useful biomarker discovery. This article is part of a Special Issue entitled: Protein dynamics in health and disease. Guest Editors: Pierre Thibault and Anne-Claude Gingras.

Induction of autophagy is an early response to gefitinib and a potential therapeutic target in breast cancer.

Gefitinib (Iressa(®), ZD1839) is a small molecule inhibitor of the epidermal growth factor receptor (EGFR) tyrosine kinase. We report on an early cellular response to gefitinib that involves induction of functional autophagic flux in phenotypically diverse breast cancer cells that were sensitive (BT474 and SKBR3) or insensitive (MCF7-GFPLC3 and JIMT-1) to gefitinib. Our data show that elevation of autophagy in gefitinib-treated breast cancer cells correlated with downregulation of AKT and ERK1/2 signaling early in the course of treatment. Inhibition of autophagosome formation by BECLIN-1 or ATG7 siRNA in combination with gefitinib reduced the abundance of autophagic organelles and sensitized SKBR3 but not MCF7-GFPLC3 cells to cell death. However, inhibition of the late stage of gefitinib-induced autophagy with hydroxychloroquine (HCQ) or bafilomycin A1 significantly increased (p<0.05) cell death in gefitinib-sensitive SKBR3 and BT474 cells, as well as in gefitinib-insensitive JIMT-1 and MCF7-GFPLC3 cells, relative to the effects observed with the respective single agents. Treatment with the combination of gefitinib and HCQ was more effective (p<0.05) in delaying tumor growth than either monotherapy (p>0.05), when compared to vehicle-treated controls. Our results also show that elevated autophagosome content following short-term treatment with gefitinib is a reversible response that ceases upon removal of the drug. In aggregate, these data demonstrate that elevated autophagic flux is an early response to gefitinib and that targeting EGFR and autophagy should be considered when developing new therapeutic strategies for EGFR expressing breast cancers.

The combination of gefitinib and RAD001 inhibits growth of HER2 overexpressing breast cancer cells and tumors irrespective of trastuzumab sensitivity.

BACKGROUND: HER2-positive breast cancers exhibit high rates of innate and acquired resistance to trastuzumab (TZ), a HER2-directed antibody used as a first line treatment for this disease. TZ resistance may in part be mediated by frequent co-expression of EGFR and by sustained activation of the mammalian target of rapamycin (mTOR) pathway. Here, we assessed feasibility of combining the EGFR inhibitor gefitinib and the mTOR inhibitor everolimus (RAD001) for treating HER2 overexpressing breast cancers with different sensitivity to TZ. METHODS: The gefitinib and RAD001 combination was broadly evaluated in TZ sensitive (SKBR3 and MCF7-HER2) and TZ resistant (JIMT-1) breast cancer models. The effects on cell growth were measured in cell based assays using the fixed molar ratio design and the median effect principle. In vivo studies were performed in Rag2M mice bearing established tumors. Analysis of cell cycle, changes in targeted signaling pathways and tumor characteristics were conducted to assess gefitinib and RAD001 interactions. RESULTS: The gefitinib and RAD001 combination inhibited cell growth in vitro in a synergistic fashion as defined by the Chou and Talalay median effect principle and increased tumor xenograft growth delay. The improvement in therapeutic efficacy by the combination was associated in vitro with cell line dependent increases in cytotoxicity and cytostasis while treatment in vivo promoted cytostasis. The most striking and consistent therapeutic effect of the combination was increased inhibition of the mTOR pathway (in vitro and in vivo) and EGFR signaling in vivo relative to the single drugs. CONCLUSIONS: The gefitinib and RAD001 combination provides effective control over growth of HER2 overexpressing cells and tumors irrespective of the TZ sensitivity status.

Multivalent rituximab lipid nanoparticles as improved lymphoma therapies: indirect mechanisms of action and in vivo activity.

AIMS: The activity of therapeutic antibodies can be enhanced by creating multivalent constructs, such as antibody lipid nanoparticles (LNPs). Here, we examine differences between rituximab (Ritux) and Ritux-LNPs in terms of their indirect mechanisms of action: complement-dependent cytotoxicity (CDC) and antibody-dependent cell-mediated cytotoxicity (ADCC). MATERIALS & METHODS: We employed two mantle-cell lymphoma cell lines, Z138 and JVM2, which exhibit different in vivo sensitivities to Ritux along with variable expression levels of cell-surface proteins that regulate ADCC and CDC. RESULTS: In both cell lines, CDC and ADCC were found to be significantly enhanced after treatment with Ritux-LNPs compared with Ritux. In vivo efficacy studies, however, suggested that the therapeutic activities of Ritux and Ritux-LNPs were equivalent, which was subsequently explained in part by pharmacokinetic studies indicating rapid elimination of Ritux-LNP. CONCLUSION: Although indirect and direct mechanisms of multivalent Ritux are enhanced, its further development requires methods to improve its circulation lifetime.

Development of a liposomal nanoparticle formulation of 5-fluorouracil for parenteral administration: formulation design, pharmacokinetics and efficacy.

5-Fluorouracil (5-FU) is a small, very membrane permeable drug that is poorly retained within the aqueous compartment of liposomal nanoparticles (LNP). To address this problem a novel method relying on formation of a ternary complex comprising copper, low molecular weight polyethylenimine (PEI) and 5-FU has been developed. More specifically, in the presence of entrapped copper and PEI, externally added 5-FU can be efficiently encapsulated (>95%) in DSPC/Chol (1,2-Distearoyl-sn-Glycero-3-Phosphocholine/cholesterol; 55:45 mol%) liposomes (130-170 nm) to achieve drug-to-lipid ratios of 0.1 (mol:mol). Drug release studies completed using this LNP formulation of 5-FU demonstrated significant improvements in drug retention in vitro and in vivo. Plasma concentrations of 5-FU were 7- to 23-fold higher when the drug was administered intravenously to mice as the LNP 5-FU formulation compared to free 5-FU. Further, the therapeutic effects of the LNP 5-FU formulation, as determined in a HT-29 subcutaneous colorectal cancer model where treatment was given QDx5, was greater than that which could be achieved with free 5-FU when compared at equivalent doses. This is the first time an active loading method has been described for 5-FU. The use of ternary metal complexation strategy to encapsulate therapeutic agents may define a unique platform for preparation of LNP drug formulations.

Silencing Bcl-2 in models of mantle cell lymphoma is associated with decreases in cyclin D1, nuclear factor-kappaB, p53, bax, and p27 levels.

Molecular mechanisms responsible for lymphoma resistance to apoptosis often involve the bcl-2 pathway. In this study, we investigated the cell signaling pathways activated in bcl-2-overexpressing human mantle cell lymphoma cell lines (JVM-2 and Z-138) that have been treated with oblimersen, a molecular gene silencing strategy that effectively suppresses bcl-2 in vitro and in vivo. Z-138 cells expressed higher levels of bcl-2 and were more sensitive to the effects of bcl-2 silencing, mediated by oblimersen or bcl-2 small interfering RNA, in vitro. Tumors derived following injection of Z-138 cells were sensitive to oblimersen as judged by decreases in tumor growth rate and decreases in cell proliferation (as measured by Ki-67). Immunohistochemistry and Western blot analysis of oblimersen-treated Z-138 tumors revealed a dose-dependent decrease in bcl-2 levels and an associated increase in the proapoptotic proteins caspase-3 and caspase-9. Silencing bcl-2 in Z-138 xenografts revealed an associated dose-dependent suppression of bax, a decrease in nuclear factor-kappaB and phospho-nuclear factor-kappaB, and transient loss of p53 levels. Coimmunoprecipitation studies suggest that the latter observation is mediated by an association between bcl-2 and phospho-mdm2. Bcl-2 silencing also led to p27 down-regulation and coimmunoprecipitation studies point to a role for bcl-2 in regulation of p27 localization/degradation. Bcl-2 silencing was also correlated with loss of cyclin D1a protein levels but not cyclin D1b levels. Coimmunoprecipitation studies indicate that bcl-2 may mediate its effects on cyclin D1a via interaction with p38 mitogen-activated protein kinase as well as a previously unreported interaction between bcl-2 and cyclin D1a.