Compounded Low-dose Naltrexone for the Treatment of Guttate Psoriasis: A Case Report.

The ancient autoimmune skin condition psoriasis is still ubiquitous worldwide, produces the same, often-intolerable effects noted in its earliest recorded descriptions, and remains without cure. Management options designed to resolve the itchy, scaly, weeping, erythematous, and often widespread lesions of that disorder are now available, but they vary in efficacy, most are associated with the development of severe adverse effects, and many are prohibitively expensive. In this article, we describe the successful use of a compounded formulation of oral low-dose naltrexone to manage guttate psoriasis in a 75-year-old white male patient. That therapy produced only 1 adverse effect (dry skin near the lesions on the patient's arms and legs) and was relatively inexpensive. The formulation for that preparation and comments from the patient, the pharmacist who suggested its use, the prescriber, and the compounder who prepared it are included. Many clinicians are unaware of the benefits of compounded low-dose naltrexone in treating autoimmune diseases. We hope that this case report will encourage compounding pharmacists to consider and suggest it as an alternative therapy for patients who cannot tolerate or afford manufactured medications to treat psoriasis.

Protein Degradation via CRL4CRBN Ubiquitin Ligase: Discovery and Structure-Activity Relationships of Novel Glutarimide Analogs That Promote Degradation of Aiolos and/or GSPT1.

We previously disclosed the identification of cereblon modulator 3 (CC-885), with potent antitumor activity mediated through the degradation of GSPT1. We describe herein the structure-activity relationships for analogs of 3 with exploration of the structurally related dioxoisoindoline class. The observed activity of protein degradation could in part be rationalized through docking into the previously disclosed 3-CRBN-GSPT1 cocrystal ternary complex. For SAR that could not be rationalized through the cocrystal complex, we sought to predict SAR through a QSAR model developed in house. Through these analyses, selective protein degradation could be achieved between the two proteins of interest, GSPT1 and Aiolos.

A Cereblon Modulator (CC-220) with Improved Degradation of Ikaros and Aiolos.

The drugs lenalidomide and pomalidomide bind to the protein cereblon, directing the CRL4-CRBN E3 ligase toward the transcription factors Ikaros and Aiolos to cause their ubiquitination and degradation. Here we describe CC-220 (compound 6), a cereblon modulator in clinical development for systemic lupus erythematosis and relapsed/refractory multiple myeloma. Compound 6 binds cereblon with a higher affinity than lenalidomide or pomalidomide. Consistent with this, the cellular degradation of Ikaros and Aiolos is more potent and the extent of substrate depletion is greater. The crystal structure of cereblon in complex with DDB1 and compound 6 reveals that the increase in potency correlates with increased contacts between compound 6 and cereblon away from the modeled binding site for Ikaros/Aiolos. These results describe a new cereblon modulator which achieves greater substrate degradation via tighter binding to the cereblon E3 ligase and provides an example of the effect of E3 ligase binding affinity with relevance to other drug discovery efforts in targeted protein degradation.

Compounded drugs of value in outpatient hospice and palliative care practice.

A compounded preparation is needed when no commercially manufactured medication is available to adequately address a patient's medical needs. Among the greatest therapeutic challenges faced by both patients and caregivers is the treatment required by individuals who have a terminal condition. It is difficult to find evidence-based studies on the management of end-of-life situations because each patient's medical case is unique. In addition, maintaining a controlled environment for such patients is difficult. End-of-life care is multifaceted; it does not lend itself to "cookbook medicine," and people with a terminal illness are among the most vulnerable patients in need of effective and compassionate care. When those patients suffer in spite of commercially available therapies, the innovation and experience of clinicians and compounding pharmacists can often yield a solution to the most challenging treatment problems. In this article, we discuss some of the most often prescribed compounds used in outpatient hospice and palliative care to treat common conditions (wounds, pain and dyspnea, intractable cough, nausea and vomiting, depression, bladder infections caused by an indwelling catheter, rectal pain). The effectiveness of the preparations we describe is substantiated in the medical literature and by our personal experience, which together encompasses nearly 100 years of clinical practice. The medications described in this report have been shown over time to be effective. Formulations for the preparations presented in this article are provided on the International Journal of Pharmaceutical Compounding website at www.ijpc.com/webcontent.

Isosteric analogs of lenalidomide and pomalidomide: synthesis and biological activity.

A series of analogs of the immunomodulary drugs lenalidomide (1) and pomalidomide (2), in which the amino group is replaced with various isosteres, was prepared and assayed for immunomodulatory activity and activity against cancer cell lines. The 4-methyl and 4-chloro analogs 4 and 15, respectively, displayed potent inhibition of tumor necrosis factor-α (TNF-α) in LPS-stimulated hPBMC, potent stimulation of IL-2 in a human T cell co-stimulation assay, and anti-proliferative activity against the Namalwa lymphoma cell line. Both of these analogs displayed oral bioavailability in rat.

Phosphodiesterase-4 inhibition alters gene expression and improves isoniazid-mediated clearance of Mycobacterium tuberculosis in rabbit lungs.

Tuberculosis (TB) treatment is hampered by the long duration of antibiotic therapy required to achieve cure. This indolent response has been partly attributed to the ability of subpopulations of less metabolically active Mycobacterium tuberculosis (Mtb) to withstand killing by current anti-TB drugs. We have used immune modulation with a phosphodiesterase-4 (PDE4) inhibitor, CC-3052, that reduces tumor necrosis factor alpha (TNF-α) production by increasing intracellular cAMP in macrophages, to examine the crosstalk between host and pathogen in rabbits with pulmonary TB during treatment with isoniazid (INH). Based on DNA microarray, changes in host gene expression during CC-3052 treatment of Mtb infected rabbits support a link between PDE4 inhibition and specific down-regulation of the innate immune response. The overall pattern of host gene expression in the lungs of infected rabbits treated with CC-3052, compared to untreated rabbits, was similar to that described in vitro in resting Mtb infected macrophages, suggesting suboptimal macrophage activation. These alterations in host immunity were associated with corresponding down-regulation of a number of Mtb genes that have been associated with a metabolic shift towards dormancy. Moreover, treatment with CC-3052 and INH resulted in reduced expression of those genes associated with the bacterial response to INH. Importantly, CC-3052 treatment of infected rabbits was associated with reduced ability of Mtb to withstand INH killing, shown by improved bacillary clearance, from the lungs of co-treated animals compared to rabbits treated with INH alone. The results of our study suggest that changes in Mtb gene expression, in response to changes in the host immune response, can alter the responsiveness of the bacteria to antimicrobial agents. These findings provide a basis for exploring the potential use of adjunctive immune modulation with PDE4 inhibitors to enhance the efficacy of existing anti-TB treatment.

1,1-Diarylalkenes as anticancer agents: dual inhibitors of tubulin polymerization and phosphodiesterase 4.

A series of 1,1-diarylalkene derivatives were prepared to optimize the properties of CC-5079 (1), a dual inhibitor of tubulin polymerization and phosphodiesterase 4 (PDE4). By using the 3-ethoxy-4-methoxyphenyl PDE4 pharmacophore as one of the aromatic rings, a significant improvement in PDE4 inhibition was achieved. Compound 28 was identified as a dual inhibitor with potent PDE4 (IC(50)=54 nM) and antitubulin activity (HCT-116 IC(50)=34 nM and tubulin polymerization IC(50) ∼1 µM). While the nitrile group at the alkene terminus was generally required for potent antiproliferative activity, its replacement was tolerated if there was a hydroxyl or amino group on one of the aryl rings. Conveniently, this group could also serve as a handle for amino acid derivatization to improve the compounds' solubility. The glycinamide analog 45 showed significant efficacy in the HCT-116 xenograft model, with 64% inhibition of tumor growth upon dosing at 20 mg/kg qd.

Phosphodiesterase-4 inhibition combined with isoniazid treatment of rabbits with pulmonary tuberculosis reduces macrophage activation and lung pathology.

Tuberculosis (TB) is responsible for significant morbidity and mortality worldwide. Even after successful microbiological cure of TB, many patients are left with residual pulmonary damage that can lead to chronic respiratory impairment and greater risk of additional TB episodes due to reinfection with Mycobacterium tuberculosis. Elevated levels of the proinflammatory cytokine tumor necrosis factor-α and several other markers of inflammation, together with expression of matrix metalloproteinases, have been associated with increased risk of pulmonary fibrosis, tissue damage, and poor treatment outcomes in TB patients. In this study, we used a rabbit model of pulmonary TB to evaluate the impact of adjunctive immune modulation, using a phosphodiesterase-4 inhibitor that dampens the innate immune response, on the outcome of treatment with the antibiotic isoniazid. Our data show that cotreatment of M. tuberculosis infected rabbits with the phosphodiesterase-4 inhibitor CC-3052 plus isoniazid significantly reduced the extent of immune pathogenesis, compared with antibiotic alone, as determined by histologic analysis of infected tissues and the expression of genes involved in inflammation, fibrosis, and wound healing in the lungs. Combined treatment with an antibiotic and CC-3052 not only lessened disease but also improved bacterial clearance from the lungs. These findings support the potential for adjunctive immune modulation to improve the treatment of pulmonary TB and reduce the risk of chronic respiratory impairment.

Phosphodiesterase 4 inhibition reduces innate immunity and improves isoniazid clearance of Mycobacterium tuberculosis in the lungs of infected mice.

Tuberculosis (TB) caused by Mycobacterium tuberculosis (Mtb) is one of the leading infectious disease causes of morbidity and mortality worldwide. Though current antibiotic regimens can cure the disease, treatment requires at least six months of drug therapy. One reason for the long duration of therapy is that the currently available TB drugs were selected for their ability to kill replicating organisms and are less effective against subpopulations of non-replicating persistent bacilli. Evidence from in vitro models of Mtb growth and mouse infection studies suggests that host immunity may provide some of the environmental cues that drive Mtb towards non-replicating persistence. We hypothesized that selective modulation of the host immune response to modify the environmental pressure on the bacilli may result in better bacterial clearance during TB treatment. For this proof of principal study, we compared bacillary clearance from the lungs of Mtb-infected mice treated with the anti-TB drug isoniazid (INH) in the presence and absence of an immunomodulatory phosphodiesterase 4 inhibitor (PDE4i), CC-3052. The effects of CC-3052 on host global gene expression, induction of cytokines, and T cell activation in the lungs of infected mice were evaluated. We show that CC-3052 modulates the innate immune response without causing generalized immune suppression. Immune modulation combined with INH treatment improved bacillary clearance and resulted in smaller granulomas and less lung pathology, compared to treatment with INH alone. This novel strategy of combining anti-TB drugs with an immune modulating molecule, if applied appropriately to patients, may shorten the duration of TB treatment and improve clinical outcome.

A review of the history, properties, and use of the immunomodulatory compound lenalidomide.

Lenalidomide (REVLIMID), an immunomodulatory compound targeting both cancer cells and their microenvironment, has substantial activity in several difficult-to-manage hematological malignancies. In previously treated multiple myeloma, lenalidomide produces high-quality responses combined with sustained disease control. Recently, several randomized studies have demonstrated a clinical benefit of continuous lenalidomide treatment in newly diagnosed multiple myeloma. In many patients with refractory anemia associated with lower risk myelodysplastic syndromes and a 5q chromosome deletion, lenalidomide leads to transfusion independence, considerably improving quality of life. It has a manageable safety profile, and its oral formulation reduces the burden on patients. Several phase III trials are ongoing in other indications currently underserved by conventional therapy, such as chronic lymphocytic leukemia, non-Hodgkin's lymphoma, and prostate cancer. Several early-stage studies are exploring lenalidomide alone and in combination across different hematological malignancies, solid tumors, and immune-related disorders.

A pandemic influenza modeling and visualization tool.

The National Strategy for Pandemic Influenza outlines a plan for community response to a potential pandemic. In this outline, state and local communities are charged with enhancing their preparedness. In order to help public health officials better understand these charges, we have developed a visual analytics toolkit (PanViz) for analyzing the effect of decision measures implemented during a simulated pandemic influenza scenario. Spread vectors based on the point of origin and distance traveled over time are calculated and the factors of age distribution and population density are taken into effect. Healthcare officials are able to explore the effects of the pandemic on the population through a geographical spatiotemporal view, moving forward and backward through time and inserting decision points at various days to determine the impact. Linked statistical displays are also shown, providing county level summaries of data in terms of the number of sick, hospitalized and dead as a result of the outbreak. Currently, this tool has been deployed in Indiana State Department of Health planning and preparedness exercises, and as an educational tool for demonstrating the impact of social distancing strategies during the recent H1N1 (swine flu) outbreak.

CC-5079: a small molecule with MKP1, antiangiogenic, and antitumor activity.

INTRODUCTION: CC-5079, a small molecule inhibitor of tubulin polymerization and phosphodiesterase-4 activity, was evaluated for antiangiogenic and antitumor activities. MATERIALS AND METHODS: First, CC-5079 in vitro activity on human umbilical vein endothelial cells (HUVECs), fibroblasts, and MC38 were evaluated by proliferation, migration, and invasion assays. Second, CC-5079 effect on microvessel formation was evaluated ex vivo by chick chorioallantoic membrane (CAM), rat aortic rings assays, and with directed in vivo angiogenesis assay (DIVAA). Third, CC-5079 antitumor effect was determined in treatment of C57BL/6 mice with MC38 tumors. Finally, CC-5079 modulation of MKP1 in HUVECs, human fibroblast, and MC38 were determined by RNA isolation for qRT-PCR. RESULTS: At the 0.1 µM concentration CC-5079 significantly inhibited HUVEC, fibroblast, and MC38 proliferation and migration (all P < 0.001). At the 0.1 µM concentration, CC-5079 also inhibited HUVEC invasion (P < 0.05) but not fibroblast. In the CAM and rat aortic ring assays, CC-5079 at 0.1 µM inhibited microvessel formation (P < 0.05). By DIVAA, CC-5079 at 1 mg/kg/d continuous delivered inhibited microvessel formation (P < 0.05). Intraperitoneal CC-5079 was well tolerated and inhibited the growth of subcutaneous MC38 at 100 mg/kg/d (P < 0.01). By qRT-PCR, CC-5079 stimulated MKP1 expression in HUVEC and fibroblast. CONCLUSION: CC-5079 demonstrated stimulation of MKP1, antiangiogenic, and antitumor properties.

Diverse challenges in pediatric compounding: treating pulmonary hypertension, uncombable hair syndrome, and acanthamoeba keratitis.

The market for commercially manufactured drugs for pediatric patients is smaller than that for adults, and most of the medications currently used to treat children, including many over-the-counter products, have not been clinically studied in the pediatric population. Thus a customized medication that is formulated to meet the unique needs of the pediatric patient and that can be quickly adjusted to more effectively address a child's changing medical needs can be essential to a successful therapeutic outcome. Compounding pharmacists are often faced with the demand for a novel pediatric preparation that overcomes the patient's taste aversions or resistance to a particular dosage form, and successful treatment can depend on the compounder's problem-solving skills and therapeutic innovation. In this article, we describe the effective treatment of three children whose medical needs were unmet by manufactured medications. The formulations for the preparations used are also provided.

Compounded analgesic therapy for disorders of movement: arthritis, neuropathic pain, and postpolio syndrome.

Pain caused by disorders of movement is often chronic and severe and may not be alleviated by commercially available medications. In such cases, the use of a compounded formulation can provide relief, either as sole therapy or as part of a combination treatment regimen. In this report, we review the effects of compounded analgesic preparations on chronic severe pain like that produced by arthritis, neuropathy, or postpolio syndrome. Case reports are included, formulations are presented, and two patients (one of whom, RFM III, is a coauthor of this paper) with a painful movement disorder describe their response to custom compounded therapy.

Compounded gabapentin suspension for lower back pain in an older cat: a case report.

Lower back pain in cats, especially that caused by intervertebral disk disease, inhibits movement, greatly compromises quality of life, and, without treatment can persist unabated long term. The basic diagnostic workup available to many feline patients with low back discomfort can yield inconclusive results, and in confirmed cases of intervertebral disk disease, decompression surgery can be relatively expensive for the client and not without risk to the patient. Thus empirical treatment with an effective analgesic that is safe for and well tolerated by cats with low back pain is a welcome and reasonable option for many pet owners. In this case report, the use of a compounded suspension of gabapentin in an older cat with suspected lumbosacral intervertebral disk disease is described. That preparation was prescribed because commercially available tablets of gabapentin cannot be split to yield an accurate dose for this feline patient and manufactured gabapentin solution, which is not available as a generic but only as the branded product Neurontin, contains xylitol, which can be toxic to cats.

Conservative management of chronic kidney disease in cats: recommendations for veterinarians and compounding pharmacists.

Chronic kidney disease is a major cause of morbidity and mortality in aging cats, and assessment of that condition suggest that conservative management can provide substantial benefit for patients. The veterinarian's armamentarium is augmented each year with effective therapies for treating renal disease that are designed for human patients but can be successfully adapted for use in cats. The help of an experienced compounding pharmacist is invaluable in converting many of those treatments to the doses and dosage forms appropriate for veterinary patients. In this report, we examine effective approaches to the conservative treatment of chronic kidney disease in cats. Formulations useful in relieving the signs and symptoms of that disorder and in improving both adherence and the patient's quality of life are made available.

Tetracaine lollipops for the suppression of extreme gag reflex in dental patients.

An extreme gag reflex renders prophylactic dental care and undergoing operative dental procedures impossible for many people. Commercially available oral spray and lozenge anesthetics have an unpleasant taste and provide an insufficient duration of anesthesia. Compounded flavored tetracaine lollipops are an excellent alternative to other oral anesthetics and have enabled the treatment of many patients who have a strong aversion to dental care. In this report, we describe the use of the preparation in such patients. A formulation for tetracaine lollipops 0.5% is included.

U.S. airport entry screening in response to pandemic influenza: modeling and analysis.

BACKGROUND: A stochastic discrete event simulation model was developed to assess the effectiveness of passenger screening for Pandemic Influenza (PI) at U.S. airport foreign entry. METHODS: International passengers arriving at 18 U.S. airports from Asia, Europe, South America, and Canada were assigned to one of three states: not infected, infected with PI, infected with other respiratory illness. Passengers passed through layered screening then exited the model. 80% screening effectiveness was assumed for symptomatic passengers; 6% asymptomatic passengers. RESULTS: In the first 100 days of a global pandemic, U.S. airport screening would evaluate over 17 M passengers with 800 K secondary screenings. 11,570 PI infected passengers (majority asymptomatic) would enter the U.S. undetected from all 18 airports. Foreign airport departure screening significantly decreased the false negative (infected/undetected) passengers. U.S. attack rates: no screening (26.9%-30.9%); screening (26.4%-30.6%); however airport screening results in 800 K-1.8 M less U.S. PI cases; 16 K-35 K less deaths (2% fatality rate). Antiviral medications for travel contact prophylaxis (10 contacts/PI passenger) were high - 8.8M. False positives from all 18 airports: 100-200/day. CONCLUSIONS: Foreign shore exit screening greatly reduces numbers of PI infected passengers. U.S. airport screening identifies 50% infected individuals; efficacy is limited by the asymptomatic PI infected. Screening will not significantly delay arrival of PI via international air transport, but will reduce the rate of new US cases and subsequent deaths.

Pomalidomide and lenalidomide induce p21 WAF-1 expression in both lymphoma and multiple myeloma through a LSD1-mediated epigenetic mechanism.

Lenalidomide and pomalidomide have both been evaluated clinically for their properties as anticancer agents, with lenalidomide being available commercially. We previously reported that both compounds cause cell cycle arrest in Burkitt's lymphoma and multiple myeloma cell lines by increasing the level of p21(WAF-1) expression. In the present study, we unravel the molecular mechanism responsible for p21(WAF-1) up-regulation using Namalwa cells as a human lymphoma model. We show that the increase of p21(WAF-1) expression is regulated at the transcriptional level through a mechanism independent of p53. Using a combination of approaches, we show that several GC-rich binding transcription factors are involved in pomalidomide-mediated up-regulation of p21(WAF-1). Furthermore, we report that p21(WAF-1) up-regulation is associated with a switch from methylated to acetylated histone H3 on p21(WAF-1) promoter. Interestingly, lysine-specific demethylase-1 (LSD1) silencing reduced both pomalidomide and lenalidomide up-regulation of p21(WAF-1), suggesting that this histone demethylase is involved in the priming of the p21(WAF-1) promoter. Based on our findings, we propose a model in which pomalidomide and lenalidomide modify the chromatin structure of the p21(WAF-1) promoter through demethylation and acetylation of H3K9. This effect, mediated via LSD1, provides GC-rich binding transcription factors better access to DNA, followed by recruitment of RNA polymerase II and transcription activation. Taken together, our results provide new insights on the mechanism of action of pomalidomide and lenalidomide in the regulation of gene transcription, imply possible efficacy in p53 mutated and deleted cancer, and suggest new potential clinical uses as an epigenetic therapy.

Discovery of (S)-N-[2-[1-(3-ethoxy-4-methoxyphenyl)-2-methanesulfonylethyl]-1,3-dioxo-2,3-dihydro-1H-isoindol-4-yl] acetamide (apremilast), a potent and orally active phosphodiesterase 4 and tumor necrosis factor-alpha inhibitor.

In this communication, we report the discovery of 1S (apremilast), a novel potent and orally active phosphodiesterase 4 (PDE4) and tumor necrosis factor-alpha inhibitor. The optimization of previously reported 3-(1,3-dioxo-1,3-dihydroisoindol-2-yl)-3-(3,4-dimethoxyphenyl)propionic acid PDE4 inhibitors led to this series of sulfone analogues. Evaluation of the structure-activity relationship of substitutions on the phthalimide group led to the discovery of an acetylamino analogue 1S, which is currently in clinical trials.