RESUMEN
The 2018-2019 Professional Affairs Committee examined the potential roles and needs of clinical educators (faculty and preceptors) in leading transformation in pharmacy practice. The committee was charged to (1) discuss the potential roles and responsibilities of faculty and preceptors leading transformation and enhanced patient care services in pharmacy practice; (2) describe factors, including clinician well-being and resilience, which may influence faculty and preceptor involvement in practice transformation and the enhancement of patient care services; and (3) recommend how the efforts and successes of faculty and preceptors involved in pharmacy practice transformation can be replicated and recognized as well as identify the types of continuing professional development (CPD) that should be available to enable the influence and implementation of patient care services. This report provides a framework for addressing the committee charges by examining the roles of advocacy, collaboration, continuing professional development, and clinician resilience and well-being. The committee provides a revision to a current AACP policy regarding continuing professional development as well as several recommendations to AACP and suggestions to colleges and schools of pharmacy pertaining to the committee charges.
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Educación en Farmacia/organización & administración , Docentes de Farmacia/organización & administración , Facultades de Farmacia/organización & administración , Curriculum , Humanos , Farmacias/organización & administración , Preceptoría/organización & administración , Estudiantes de FarmaciaRESUMEN
Pregnancy in a patient with chronic myeloid leukemia presents a therapeutic challenge. Both dasatinib and nilotinib are indicated for first-line treatment as well as for treatment-resistant chronic myeloid leukemia. Animal studies with dasatinib or nilotinib demonstrate fetal skeletal malformations as well as significant mortality during organogenesis. The goal of this article is to review the experience to date of dasatinib and nilotinib in human pregnancy, specifically dasatinib and nilotinib dose, length of exposure, trimester of use, as well as patient and fetal outcomes. Based on the limited data, both dasatinib and nilotinib may cause fetal harm. Additionally, thorough analysis of the available literature indicates no correlation between dasatinib nor nilotinib dose, length of exposure, trimester of use, and deleterious patient or fetal outcomes can be concluded. Therefore, health care professionals need to regularly counsel women of child bearing potential with chronic myeloid leukemia regarding the risks of taking dasatinib or nilotinib during pregnancy. The safest potential therapeutic options for the management of chronic myeloid leukemia in pregnancy include temporary discontinuation of the tyrosine kinase inhibitor followed by observation or intervention with interferon alfa and/or leukapheresis.
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Antineoplásicos/efectos adversos , Dasatinib/efectos adversos , Enfermedades Fetales/inducido químicamente , Leucemia Mielógena Crónica BCR-ABL Positiva/tratamiento farmacológico , Pirimidinas/efectos adversos , Antineoplásicos/administración & dosificación , Dasatinib/administración & dosificación , Femenino , Humanos , Embarazo , Trimestres del Embarazo , Pirimidinas/administración & dosificaciónRESUMEN
OBJECTIVE: To enhance the achievement of a college of pharmacy's goals for education, research, and service missions by implementing an excellence program based on the Studer Group model for continuous quality improvement. METHODS: The Studer model was combined with university strategic planning for a comprehensive quality-improvement program that was implemented over 5 years. The program included identifying and measuring key performance indicators, establishing specific "pillar" goals, aligning behaviors with goals and values, and training leaders. RESULTS: Assessment of key performance indicators over 5 years demonstrated progress toward achieving college goals for student and faculty satisfaction, research funding, numbers of students seeking formal postgraduate training, and private giving. CONCLUSIONS: Implementation of a continuous quality-improvement program based on the Studer program enabled the college to focus on and meet its yearly and strategic goals for all components of its mission.
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Educación en Farmacia/organización & administración , Educación en Farmacia/normas , Desarrollo de Programa , Evaluación de Programas y Proyectos de Salud , Docentes , Humanos , Mejoramiento de la Calidad , Estudiantes de Farmacia , UniversidadesRESUMEN
OBJECTIVE: To determine the relationship between doses of gemcitabine and absolute neutrophil count and thrombocytopenia in patients with severe hepatic dysfunction (total bilirubin > or =4.5 mg/dL), and the relationship between doses of gemcitabine in patients with severe hepatic dysfunction and nonhematologic toxicity. CASE SUMMARY: A retrospective chart review was conducted for patients receiving gemcitabine at the Medical University of South Carolina from October 2006 through October 2008. Seven patients were identified who had an elevated total bilirubin level (> or =4.5 mg/dL) at the time they were receiving gemcitabine. All 7 patients received gemcitabine 1000 mg/m(2) throughout their treatment, regardless of liver function. Six patients did not experience significant hematologic toxicity warranting a dose reduction or a dose being held. One patient developed thrombocytopenia, warranting a dose being held. DISCUSSION: Gemcitabine is a chemotherapy agent frequently used for the treatment of pancreatic cancer as well as metastatic breast, lung, and ovarian cancer. To date there is limited information on dosing of gemcitabine in patients with an elevated total bilirubin. A previous study looking at lower grades of liver dysfunction suggested empiric dose reductions be made in these patients because of increased incidence of toxicity. CONCLUSIONS: These results indicate the possibility that no initial dose reduction is necessary for patients with liver dysfunction receiving gemcitabine; however, close monitoring of these patients is required.
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Antimetabolitos Antineoplásicos/efectos adversos , Desoxicitidina/análogos & derivados , Hepatopatías/complicaciones , Alanina Transaminasa/sangre , Antimetabolitos Antineoplásicos/administración & dosificación , Antimetabolitos Antineoplásicos/uso terapéutico , Aspartato Aminotransferasas/sangre , Bilirrubina/sangre , Neoplasias de la Mama/complicaciones , Neoplasias de la Mama/tratamiento farmacológico , Desoxicitidina/administración & dosificación , Desoxicitidina/efectos adversos , Desoxicitidina/uso terapéutico , Femenino , Humanos , Recuento de Leucocitos , Masculino , Neoplasias/complicaciones , Neoplasias/tratamiento farmacológico , Neoplasias Pancreáticas/complicaciones , Neoplasias Pancreáticas/tratamiento farmacológico , Recuento de Plaquetas , Estudios Retrospectivos , GemcitabinaRESUMEN
PURPOSE: This study seeks to determine the incidence of vancomycin-resistant enterococci (VRE) infection in high-risk neutropenic fever patients colonized with VRE and to determine patient characteristics associated with VRE infection. METHODS: We conducted a retrospective, single-center, unmatched case-control study. Fifty-three VRE-colonized, high-risk patients with neutropenic fever were identified between January 2006 and February 2009. The two most common diagnoses/conditions included acute myeloid leukemia and hematopoietic stem cell transplantation. Data collected included days of neutropenia, days of fever, demographic data, culture results, and antimicrobial therapy. RESULTS: Twenty of the 53 patients (38%) with VRE colonization developed a VRE infection. The most common VRE infections were bacteremias (26%). The presence of neutropenia lasting longer than 7 days was associated with the development of VRE infection in this high-risk population colonized with VRE. The timeframe to develop VRE infection varied from 1 day to 2 weeks. CONCLUSION: For patients colonized with VRE, approximately 38% of high-risk neutropenic patients developed a VRE infection. This is the first study to specifically evaluate the incidence of VRE infections in febrile neutropenic patients colonized with VRE. Future research into the use and efficacy of empiric VRE coverage is needed.
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Bacteriemia/microbiología , Fiebre/microbiología , Neutropenia/microbiología , Resistencia a la Vancomicina , Acetamidas/uso terapéutico , Antibacterianos/uso terapéutico , Bacteriemia/sangre , Bacteriemia/tratamiento farmacológico , Estudios de Casos y Controles , Ciprofloxacina/efectos adversos , Ciprofloxacina/uso terapéutico , Daptomicina/uso terapéutico , Enterococcus/efectos de los fármacos , Enterococcus/aislamiento & purificación , Femenino , Fiebre/sangre , Fiebre/tratamiento farmacológico , Humanos , Incidencia , Linezolid , Masculino , Persona de Mediana Edad , Neutropenia/sangre , Neutropenia/tratamiento farmacológico , Oxazolidinonas/uso terapéutico , Estudios Retrospectivos , Vancomicina/efectos adversos , Vancomicina/uso terapéuticoRESUMEN
Preformed antidiphtheria toxin (anti-DT) IgG limits the development of diphtheria fusion proteins because the anti-DT IgG binds and removes the diphtheria fusion protein from the circulation. In our phase I trial of DT-granulocyte macrophage colony stimulating factor (GMCSF), a truncated DT linked to human GMCSF, in relapsed or refractory acute myeloid leukemia, patients with high concentrations of preexisting anti-DT IgG (>2.5 microg/ml) had significantly lower DT-GMCSF concentrations. This study details the fate of anti-DT IgG during the patient's treatment with DT-GMCSF and describes how we could lower anti-DT IgG concentrations and increase the patient's exposure to DT-GMCSF. Using an enzyme immunoassay, we measured anti-DT IgG concentrations before the first cycle of treatment (baseline) and on day 2 (after one dose of DT-GMCSF) and on day 5 (after four doses of DT-GMCSF). Thirty-three patients with relapsed or refractory acute myeloid leukemia in the phase 1 trial received DT-GMCSF at doses from 1 to 5 microg/kg/day intravenously for 5 days. The mean anti-DT IgG concentration pretherapy was 1.3 microg/ml (range: undetectable to 7.8) and significantly decreased to a mean concentration of 0.7 microg/ml on day 2 (P=0.007) and to 0.5 microg/ml on day 5 (P<0.0001). In two individuals in whom we measured DT-GMCSF concentrations on day 1 and day 5, we observed that a decrease in anti-DT IgG concentrations was associated with an increase in DT-GMCSF concentrations. No relationship was observed between dose of DT-GMCSF and the absolute change in anti-DT IgG concentrations on day 2 (r=-0.01, P=0.98) or day 5 (r=-0.12, P=0.53). For patients with high baseline anti-DT IgG concentrations, a single dose of DT-GMCSF could be used to lower the anti-DT IgG concentrations and potentially result in a significant increase in DT-GMCSF concentrations and efficacy.
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Toxina Diftérica/uso terapéutico , Factor Estimulante de Colonias de Granulocitos y Macrófagos/uso terapéutico , Inmunoglobulina G/sangre , Leucemia Mieloide Aguda/tratamiento farmacológico , Proteínas Recombinantes de Fusión/uso terapéutico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Toxina Diftérica/inmunología , Femenino , Humanos , Leucemia Mieloide Aguda/sangre , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
Rasburicase is currently approved at a dosage of 0.15-0.2 mg/kg once/day for 5 days in pediatric patients with cancer to lower plasma uric acid concentrations and manage tumor lysis syndrome (TLS). Information on rasburicase dosing in adults is limited, with some data on using rasburicase as a single dose instead of multiple daily doses. Therefore, we evaluated the efficacy of a single dose of rasburicase for preventing or managing TLS in adults. We collected retrospective data for 11 adults with hematologic malignancies who received a single 6-mg dose of rasburicase. All patients received intravenous hydration with urinary alkalinization and allopurinol; however, due to adverse reactions, two patients received short courses of allopurinol. Only patients at high risk for TLS (e.g., large tumor burden, increasing uric acid concentration) or those with TLS received rasburicase. The single dose of rasburicase 6 mg resulted in a median 0.0773-mg/kg dose (range 0.0232-0.1361 mg/kg). The single 6-mg dose rapidly lowered uric acid concentrations in 10 of the 11 patients. The median uric acid concentration of 11.7 mg/dl (range 7.4-17.4 mg/dl) declined to 2.0 mg/dl (range 0.5-15.4 mg/dl) within a day after rasburicase administration (p=0.022). In these 10 patients, uric acid concentrations remained low despite subsequent chemotherapy, and none required additional rasburicase doses. The only patient who did not respond to the single 6-mg rasburicase dose was a morbidly obese man (259 kg, body mass index 87 kg/m2) who subsequently responded to an additional dose of rasburicase 12 mg. These results warrant further investigation of a single 6-mg dose of rasburicase in adults with TLS or at high-risk for developing TLS.
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Síndrome de Lisis Tumoral/tratamiento farmacológico , Urato Oxidasa/uso terapéutico , Adulto , Creatinina/sangre , Relación Dosis-Respuesta a Droga , Femenino , Supresores de la Gota/administración & dosificación , Supresores de la Gota/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Síndrome de Lisis Tumoral/sangre , Síndrome de Lisis Tumoral/patología , Urato Oxidasa/administración & dosificación , Ácido Úrico/sangreRESUMEN
We are developing two fusion proteins consisting of a diphtheria toxin (DT) linked to either granulocyte macrophage colony stimulating factor (DT388-GMCSF) or interleukin-3 (DT388-IL3). In trials, patients with anti-DT IgG concentrations >2.5 microg/ml had significantly lower concentrations of either fusion protein. DT389-IL2 is currently FDA approved for the treatment of cutaneous T-cell lymphomas. We noted increased concentrations of anti-DT IgG after administration of platelet concentrates (PC). Because many of these patients require transfusions, we measured the anti-DT IgG content of FFP and PC. We assayed 14 bags of FFP and 12 bags of single-donor PCs for anti-DT IgG by an enzymoimmunoassay against DT389-IL2, DT388-IL3, DT388-GMCSF. The median (percent of samples positive) of anti-DT IgG concentrations in PC against DT388-GMCSF, DT388-IL3, DT389-IL2 was 0.8 microg/ml (83%), 0.7 microg/ml (83%), and 0.3 microg/ml (58%), respectively. The median (percent of samples positive) anti-DT IgG concentration in FFP against DT388-GMCSF, DT388-IL3, and DT389-IL2 was 2.1 microg/ml (86%), 1.9 microg/ml (93%), and 1.4 microg/ml (86%), respectively. There was a strong association between anti-DT389IL2 IgG, anti-DT388IL3 IgG, and anti-DT388GMCSF IgG concentrations in both the FFP (95.6%) and PC (76.3%). Assuming a plasma volume of 3 l in a 70 kg patient, a single FFP unit would increase the plasma anti-DT389IL2 IgG, anti-DT388IL3 IgG, and anti-DT388GMCSF IgG by 0.13 microg/ml, 0.17 microg/ml, and 0.19 microg/ml, respectively. For PC, a single unit would increase plasma anti-DT389-IL2 IgG, anti-DT388-IL3 IgG, and anti-DT388-GMCSF IgG by 0.03 microg/ml, 0.06 microg/ml, and 0.07 microg/ml, respectively. In conclusion, a single FFP or PC appears to minimally increase anti-DT IgG concentrations, but multiple units may significantly do such.
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Plaquetas , Vacunas contra el Cáncer/inmunología , Toxina Diftérica/inmunología , Inmunoglobulina G/sangre , Plasma , Proteínas Recombinantes de Fusión/inmunología , Ensayos Clínicos como Asunto , Ensayo de Inmunoadsorción Enzimática , Factor Estimulante de Colonias de Granulocitos y Macrófagos/inmunología , Humanos , Inmunotoxinas/sangre , Interleucina-2/inmunología , Interleucina-3/inmunología , Leucemia/terapia , Proteínas Recombinantes de Fusión/uso terapéutico , Proteínas RecombinantesRESUMEN
Fortunately, the occurrence of acute myeloid leukemia (AML) during pregnancy is rare. We report a case of successful fetal outcome with standard induction and consolidation treatment in the second and third trimesters, respectively. A 37-year-old woman in her second trimester (21 wks) of pregnancy was found to have acute myeloid leukemia. She elected to maintain the pregnancy and underwent induction with cytarabine and idarubicin. Her hospital course was complicated by Pseudomonas vesicularis and gram-positive bacilli (not Bacillus anthracis) septicemia, but she obtained complete remission. After discharge, a fetal echocardiogram at 26 weeks revealed a mildly dilated right ventricle with mild systolic dysfunction, and the left ventricle appeared smaller than normal with mild systolic dysfunction. The patient then received consolidation therapy with high-dose cytarabine. On day 14 of consolidation, filgrastim 16 mug/kg was added to improve stem cell mobilization. A total of 19.8x10(6) CD34+ cells/kg were collected with a single apheresis session. At 37 weeks, she delivered a viable female infant weighing 3 lbs 12 oz. Fetal abnormalities included acrocyanosis, shallow sacral dimple, short digits and limbs, and prominent frontal skull with mild macrognathia. A postnatal echocardiogram revealed a moderate-sized membranous ventricular septal defect. The ventricular septal defect proved significant and required surgical repair at 5 months. Approximately 4 weeks after delivery, the mother underwent autologous peripheral stem cell transplantation. Unfortunately, 100 days after transplantation, she had a relapse of AML. After a brief remission from a second induction, the patient died.
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Leucemia Mieloide Aguda/tratamiento farmacológico , Complicaciones Neoplásicas del Embarazo/tratamiento farmacológico , Adulto , Antimetabolitos Antineoplásicos/uso terapéutico , Cesárea , Citarabina/uso terapéutico , Femenino , Monitoreo Fetal , Filgrastim , Factor Estimulante de Colonias de Granulocitos/uso terapéutico , Humanos , Embarazo , Resultado del Embarazo , Segundo Trimestre del Embarazo , Tercer Trimestre del Embarazo , Proteínas Recombinantes , Células Madre/efectos de los fármacosRESUMEN
PURPOSE: The novel fusion protein, DAB389EGF, composed of the catalytic and translocation domains of diphtheria toxin (DAB389) fused with a His-Ala linker to human epidermal growth factor (EGF) was tested for antiglioma efficacy in an in vivo model of human glioma. EXPERIMENTAL DESIGN: Female athymic nude mice (ages 4-6 weeks) were inoculated s.c. with 10 million U87MG human glioma cells in the right flank. When tumor volumes reached approximately 100 mm3 (approximately 6-8 days), i.t. injections of saline, DAB389IL2, or DAB389EGF 1, 3, 5 or 10 microg in 50 microL were given every other day for three to six doses. Animals were monitored twice daily and tumor measurements were made by calipers. RESULTS: The maximal tolerated dose (MTD) of DAB389EGF was 3 microg every other day. Above the MTD, animals experienced loss of activity, reduced oral intake, and dehydration. Blood chemistries confirmed elevated blood urea nitrogen, creatinine, aspartate transaminase, and alanine transaminase. Histopathology revealed renal tubular necrosis. At the MTD, tumor regression was seen in all animals. Relapses occurred in 4 of 16 (25%) of animals after 1 month. These tumors contained EGF receptor, were sensitive in vitro to DAB389EGF, and responded to a second course of i.t. DAB389EGF. CONCLUSIONS: DAB389EGF fusion protein shows in vivo antiglioma efficacy in a s.c. tumor model and warrants further preclinical testing in an i.c. tumor model for eventual treatment of patients with recurrent or refractory EGF receptor-positive glioblastoma multiforme.
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Toxina Diftérica/uso terapéutico , Factor de Crecimiento Epidérmico/uso terapéutico , Glioblastoma/tratamiento farmacológico , Proteínas Recombinantes de Fusión/uso terapéutico , Animales , Nitrógeno de la Urea Sanguínea , Línea Celular Tumoral , Femenino , Glioma/tratamiento farmacológico , Humanos , Concentración 50 Inhibidora , Riñón/metabolismo , Hígado/metabolismo , Dosis Máxima Tolerada , Ratones , Ratones Endogámicos BALB C , Ratones Desnudos , Necrosis , Trasplante de Neoplasias , Nitrógeno/metabolismo , Estructura Terciaria de Proteína , Factores de Tiempo , Resultado del TratamientoRESUMEN
We developed a fusion toxin, DT388IL3, consisting of the catalytic and translocation domains of diphtheria toxin (DT388) linked to interleukin 3 (IL3) for the treatment of patients with acute myeloid leukemia (AML). Our goal in this study was to estimate a range for the maximum tolerated dose (MTD) and to evaluate the dose-limiting toxicity (DLT) of DT388IL3 in cynomolgus monkeys (Macaca fasicularis), which possess cross-reactive IL3 receptors. In our previous study, we administered up to six infusions of DT388IL3 at 40, 60, or 100 microg/kg every other day to three pairs (one male monkey and one female monkey) of young adult monkeys. In five of six monkeys, results showed a dose-dependent increase in malaise and anorexia but no consistent abnormalities in serum chemistries or blood counts. There was no evidence of organ damage by blood tests or histopathology. However, the female treated at 100 microg/kg, died of moderate to severe vasculitis of multiple tissues. Based on these findings, this study repeated the 100 microg/kg group and added a group that received 150 microg/kg in an effort to confirm a dose response. Two female monkeys were treated with up to six infusions of DT388IL3 at 100 microg/kg or 150 microg/kg every other day. One additional female monkey was treated as a negative control. Monkeys in the 100 microg/kg group showed moderate malaise and anorexia, but no consistent abnormalities in blood counts or serum chemistries. Moderate elevations of liver enzymes were noted in the 150 microg/kg group in addition to severe malaise and anorexia. No significant findings were revealed at gross necropsy. The histopathological findings revealed regenerative myeloid hyperplasia and hepatic degeneration and regeneration in the 150 microg/kg group. Similar lesions of less severity were detected in the 100 microg/kg group. DT388IL3 plasma half-life was approximately 20 min with a peak concentration of approximately 2 microg/ml (30,000 pM). The IC50 for AML blasts in vitro was 6 pM. Collectively, our results suggest that DT388IL3 can be tolerated at doses up to 100 microg/kg in a nonhuman primate, which is higher than previously reported for other AML directed diphtheria toxin fusion proteins, and should in principle allow for dose escalation with reduced toxic side effects. Based on these findings a phase I clinical trial has recently been initiated with DT388IL3 for the treatment of AML.
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Toxina Diftérica/toxicidad , Interleucina-3/toxicidad , Proteínas Recombinantes de Fusión/toxicidad , Animales , Toxina Diftérica/administración & dosificación , Femenino , Inyecciones Intravenosas , Interleucina-3/administración & dosificación , Leucemia Mieloide Aguda/patología , Macaca fascicularis , Dosis Máxima Tolerada , Proteínas Recombinantes de Fusión/administración & dosificación , Células Tumorales CultivadasRESUMEN
The fusion toxin DT388IL3 composed of the catalytic and translocation domains of diphtheria toxin (DT388) linked to interleukin-3 (IL3) was administered to 6 cynomolgus monkeys which possessed cross-reactive IL3 receptors. Groups of 2 animals (1 male and 1 female) received up to 6 every other day slow intravenous infusions of 40, 60, or 100 microg/kg DT388IL3. Monkeys given 40 or 60 microg/kg showed mild or moderate transient malaise and anorexia, respectively, without evidence of organ damage by blood tests or histopathology. Animals treated at 100 microg/kg showed severe malaise and anorexia. The female monkey had moderate to severe vasculitis in multiple tissues. Necropsies were performed on the 40 microg/kg monkeys on day 14 and the 100 microg/kg monkeys on days 6 and 7. DT388IL3 plasma half-life was approximately 30 min with a peak concentration of 0.45 microg/ml or 10,000 pM (IC50 for AML blasts treated in vitro was 6 pM). Immune responses were minimal in 4 animals tested at 12 days and 2 animals tested at 30 days post treatment with anti-DT388IL3 levels < 1 microg/ml. Bone marrow aspirates were obtained on all animals at day 19 or at necropsy and revealed myeloid suppression in the females and myeloid hyperplasia in the males irrespective of dose groups. The maximal tolerated dose of 60 microg/kg for 6 doses is markedly higher than other recombinant diphtheria toxins and provides a dose level sufficient for anti-leukemic activity in vitro and in rodent models. Thus, we propose this agent is a promising drug for AML patients.
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Toxina Diftérica/farmacocinética , Toxina Diftérica/toxicidad , Interleucina-3/farmacocinética , Interleucina-3/toxicidad , Proteínas Recombinantes de Fusión/farmacocinética , Proteínas Recombinantes de Fusión/toxicidad , Animales , Anorexia/inducido químicamente , Células de la Médula Ósea/efectos de los fármacos , Femenino , Semivida , Humanos , Infusiones Intravenosas , Macaca fascicularis , Masculino , Dosis Máxima Tolerada , Receptores de Interleucina-3/inmunología , Receptores de Interleucina-3/metabolismo , Vasculitis/inducido químicamenteRESUMEN
A genetically engineered fusion toxin targeted to acute myeloid leukemia (AML) blasts was designed with the first 388 amino acid residues of diphtheria toxin with an H-M linker fused to human interleukin-3. The cDNA was subcloned in the pRK bacterial expression plasmid and used to transform BLR (DE3) Escherichia coli. A single transformed colony was grown in Superbroth with ampicillin; bacteria were centrifuged at an OD(650) of 1.3; master cell bank aliquots of bacteria in 30% glycerol/Superbroth were frozen and stored at -80 degrees C. Master cell bank bacteria were diluted 1500-fold into Superbroth and recombinant protein was induced with 1 mM IPTG at an OD(650) of 0.6. After two additional hours of fermentation, inclusion bodies were isolated, washed, and denatured in guanidine hydrochloride and dithioerythritol. Recombinant protein was refolded by diluted 100-fold in cold buffer with arginine and oxidized glutathione. After dialysis, purified protein was obtained after anion-exchange, size exclusion on FPLC, and polymyxin B affinity chromatography. The final material was filter sterilized, aseptically vialed, and stored at -80 degrees C. Seventy-five 3-L bacterial culture preparations were made and pooled for the AT-1 batch (568 mL) and twenty-four 3-L bacterial culture preparations were made and pooled for the AT-2 batch (169 mL). The final product was characterized by Coomassie Plus protein assay, Coomassie-stained SDS-PAGE, limulus amebocyte lysate endotoxin assay, human AML TF/H-ras cell cytotoxicity assay, sterility, tandem mass spectroscopy, IL3 receptor binding affinity, ADP ribosylation activity, inhibition of normal human CFU-GM, disulfide bond analysis, immunoblots, peptide mapping, stability, HPLC TSK3000, N-terminal sequencing, E. coli DNA contamination, C57BL/6 mouse toxicity, cynomolgus monkey toxicity, and immunohistochemistry. Yields were 25.7+/-5.6 mg/L bacterial culture of denatured fusion toxin. After refolding and chromatography, final yields were 20+/-11% or 5 mg/L. Vialed product was sterile. Batches were in 0.25 M sodium chloride/5 mM Tris, pH 8, and had protein concentrations of 1.8-1.9 mg/mL. Purity by SDS-PAGE was 99+/-1%. Aggregates by HPLC were <1 %. Potency revealed a 48 h IC(50) of 6-8 pM on TF/H-ras cells. Endotoxin levels were 1 eu/mg. The remaining chemical and biologic assays confirmed the purity, composition, and functional activities of the molecule. The LD(10) in mice was 250 microg/kg/day every other day for six doses. The MTD in monkeys was 60 microg/kg/day every other day for six doses. Drug did not react with tested frozen human tissue sections by immunohistochemistry. There was no evidence of loss of solubility, proteolysis aggregation, or loss of potency over 6 months at -80 and -20 degrees C. Further, the drug was stable at 4 and 25 degrees C in the plastic syringe and administration tubing for 24 h and at 37 degrees C in human serum for 24 h. The synthesis of this protein drug should be useful for production for clinical phase I/II clinical trials and may be suitable for other diphtheria fusion toxins indicated for clinical development.
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Toxina Diftérica/biosíntesis , Toxina Diftérica/aislamiento & purificación , Interleucina-3/biosíntesis , Interleucina-3/aislamiento & purificación , Proteínas Recombinantes de Fusión/biosíntesis , Proteínas Recombinantes de Fusión/aislamiento & purificación , Enfermedad Aguda , Adenosina Difosfato Ribosa/metabolismo , Secuencia de Aminoácidos , Animales , Secuencia de Bases , Línea Celular Tumoral , Cromatografía Liquida/métodos , Toxina Diftérica/genética , Toxina Diftérica/farmacología , Ensayos de Selección de Medicamentos Antitumorales , Estabilidad de Medicamentos , Femenino , Expresión Génica , Haplorrinos , Humanos , Interleucina-3/genética , Interleucina-3/metabolismo , Interleucina-3/farmacología , Leucemia Mieloide/tratamiento farmacológico , Ratones , Ratones Endogámicos C57BL , Datos de Secuencia Molecular , Plásmidos/genética , Receptores de Interleucina-3/metabolismo , Proteínas Recombinantes de Fusión/genética , Proteínas Recombinantes de Fusión/farmacologíaRESUMEN
PURPOSE: Patients with relapsed or refractory chronic lymphocytic leukemia (CLL) have a poor prognosis. We tested the safety and efficacy in these patients of a diphtheria fusion protein DAB(389)IL2 (denileukin diftitox) directed against the interleukin 2 receptor that is expressed by CLL cells. EXPERIMENTAL DESIGN: DAB(389)IL2 was administered by 60 min i.v. infusions for 5 days every 21 days at 9 or 18 micro g/kg/day for up to eight cycles. RESULTS: Eighteen patients were treated. The mean age of the patients was 61.8 years. There were 14 males and 4 females. Two had Rai stage I, 6 had Rai stage II, and 10 had Rai stage IV. The mean number of prior treatments was 4.5 (range, 1-11). Responses were evaluated by peripheral CLL counts, computed tomography scans of all nodes and bone marrow biopsies. Twelve patients received greater than or equal to three cycles of DAB(389)IL2 and were evaluable for response. Eleven of 12 patients showed reductions of peripheral CLL cells, with 6 of 11 showing >/==" BORDER="0">95% reductions. Seven of 12 patients showed reductions of node diameters on exam and computed tomography scans, and 2 of 12 showed 60 and 80% shrinkage, respectively. Pre and postbone marrow biopsies showed a reduction in CLL marrow index in 11 patients. Seven of 11 patients had >50% reduction, including >/==" BORDER="0">98% reduction in 3 patients. DAB(389)IL2 produced 2 of 12 (17%) partial remission and 7 of 12 (58%) minimal responses. Progression-free intervals in the responders were 1, 1, 3+, 4, 9, 10, 10+, 14 and 19+ months. Toxicities were mild to moderate and included asymptomatic, transient transaminasemia, fever, asthenia, hypoalbuminemia, nausea, vomiting, myalgias, rash, anorexia, vascular leak syndrome, and elevated creatinine kinase. Antidiphtheria toxin antibody levels were variable and ranged from 0 to 9 micro g/ml (n = 5). CONCLUSIONS: DAB(389)IL2 produced a rapid decrease of leukemic cells in the bone marrow and peripheral blood of most chemotherapy refractory CLL patients. Most patients also tolerated DAB(389)IL2 well, without significant myelosuppression and/or immunosuppression. The prolonged progression-free interval and subjectively observed quality-of-life in responders is intriguing. The results suggest DAB(389)IL2 has biological activity in patients with B-cell CLL. Follow-up studies of combinations or altered schedules or doses to improve the response rate are warranted.
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Toxina Diftérica/uso terapéutico , Resistencia a Antineoplásicos , Interleucina-2/uso terapéutico , Leucemia Linfocítica Crónica de Células B/tratamiento farmacológico , Proteínas Recombinantes de Fusión/uso terapéutico , Vidarabina/análogos & derivados , Vidarabina/uso terapéutico , Anciano , Antineoplásicos/uso terapéutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Médula Ósea/patología , Células de la Médula Ósea , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Factores de Tiempo , Tomografía Computarizada de Emisión , Resultado del TratamientoRESUMEN
PURPOSE: As a novel approach for the treatment of acute myeloid leukemia (AML), the authors are developing a fusion toxin (DT(388)-GMCSF) consisting of a truncated diphtheria toxin (DT(388)) linked to human granulocyte-macrophage colony-stimulating factor (GMCSF). A critical step in the development of DT(388)-GMCSF for clinical use in childhood and adolescent AML is to determine whether children and adolescents have preexisting antibodies to DT(388)-GMCSF due to childhood immunizations against diphtheria toxoid. PATIENTS AND METHODS: Sera from 33 children and adolescents with AML and one with juvenile myelomonocytic leukemia were collected. The median age was 11.8 years. All scheduled diphtheria toxoid vaccinations were current except for the child diagnosed at 4 months of age. Anti-DT(388)-GMCSF antibody concentrations were detected by an enzymoimmunoassay and by an in vitro bioassay. RESULTS: Thirty of 34 (88%) children and adolescents had detectable anti-DT(388)-GMCSF IgG antibody concentrations. The median concentration was 1.5 microg/mL, with a range from undetectable to 191.4 microg/mL. There was a positive correlation between the enzymoimmunoassay and bioassay. There was no difference between the anti-DT(388)-GMCSF IgG concentrations in these children and adolescents with AML and in 43 adults with AML. Preliminary results of the phase 1 trial of DT -GMCSF in adults with AML indicate that patients with baseline anti-DT(388)-GMCSF IgG concentrations of less than 2 microg/mL can achieve circulating DT(388)-GMCSF concentrations and can exhibit antileukemic activity. Twenty-three of 34 (67.6%) children and adolescents had anti-DT(388)-GMCSF IgG concentrations less than 2 microg/mL. CONCLUSIONS: Despite routine diphtheria toxoid vaccinations, most children and adolescents with AML do not have anti-DT -GMCSF IgG concentrations that preclude in vivo activity of DT -GMCSF.
Asunto(s)
Toxina Diftérica/inmunología , Factor Estimulante de Colonias de Granulocitos y Macrófagos/inmunología , Inmunoglobulina G/inmunología , Leucemia Mieloide Aguda/inmunología , Proteínas Recombinantes de Fusión/inmunología , Adolescente , Adulto , Anciano , Niño , Preescolar , Toxoide Diftérico/inmunología , Femenino , Células HL-60 , Humanos , Técnicas para Inmunoenzimas , Inmunoglobulina G/sangre , Lactante , Masculino , Persona de Mediana Edad , VacunaciónRESUMEN
A 43-year-old woman with advanced pulmonary blastoma was admitted for worsening back pain. Her drug regimen included hydromorphone and benazepril. On admission, hydromorphone patient-controlled analgesia (PCA) was started for acute pain control and dexamethasone for possible cord compression. Baseline laboratory tests were unremarkable, but magnetic resonance imaging revealed T3 and L3 lesions. Irradiation was started with improvement in her pain. In anticipation of discharge, a fentanyl transdermal patch was given, and PCA was tapered. Two days later, the patient became progressively confused and fell. Neurologic examination and computed brain tomography were normal. Her serum sodium was 119 mEq/L (normal 136-144 mEq/L) and was confirmed on repeat testing, urine sodium was 194 mEq/L, and urine and serum osmolalities were 554 mOsm/kg (normal 300-900 mOsm/kg) and 245 mOsm/kg (normal 280-300 mOsm/kg), respectively, consistent with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Fluids were restricted, hydromorphone PCA was started again, and fentanyl was discontinued. After 36 hours, her serum sodium increased to 136 mEq/L. Because we were unsure whether the fentanyl or her cancer was causative and were unable to find any published reports of fentanyl-associated SIADH, we readministered the fentanyl patch 2 days later. Within 48 hours, serum sodium dropped to 123 mEq/L. Fentanyl was discontinued, fluids were restricted, and 3% saline was started. Her serum sodium increased to 132 mEq/L in 48 hours. The patient was prescribed oral hydromorphone and benazepril and was discharged. The repeated temporal relationship between the administration of fentanyl and the onset of SIADH strongly implicates fentanyl as the causative agent in this case. To our knowledge, this is the first report of fentanyl-associated SIADH.
Asunto(s)
Analgésicos Opioides/efectos adversos , Fentanilo/efectos adversos , Síndrome de Secreción Inadecuada de ADH/inducido químicamente , Administración Cutánea , Adulto , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Resultado Fatal , Femenino , Fentanilo/administración & dosificación , Fentanilo/uso terapéutico , Humanos , Neoplasias Pulmonares/complicaciones , Neoplasias Pulmonares/patología , Dolor/tratamiento farmacológico , Dolor/etiología , Blastoma Pulmonar/complicaciones , Blastoma Pulmonar/patología , Tomografía Computarizada por Rayos XRESUMEN
PURPOSE: Patients with relapsed or refractory acute myeloid leukemia have a poor prognosis. We tested the safety and efficacy of a diphtheria fusion protein [diphtheria toxin (DT)388 granulocyte-macrophage colony-stimulating factor (GMCSF)] directed against the GMCSF receptor that is strongly expressed by leukemic blasts. EXPERIMENTAL DESIGN: DT388GMCSF fusion protein containing the catalytic and translocation domains of DT388 fused to human GMCSF was administered in an interpatient dose escalation trial by 15 min i.v. infusion daily for up to 5 days. RESULTS: The maximal tolerated dose was 4 microg/kg/day. The dose-limiting toxicity was liver injury and occurred at the 4.5-5-microg/kg/day dose level. Among nine treated patients at these doses, one patient developed liver failure, and one patient had transient hepatic encephalopathy. There was a positive correlation between peak serum DT388GMCSF levels and serum aspartate aminotransferase (P = 0.0002). DT388GMCSF did not damage hepatic cell lines in vitro; however, DT388GMCSF binds macrophages and induces cytokine release in vitro. Among the treated patients, we observed an early elevation in serum levels of interleukin (IL)-18 and a later rise in IL-8 but no significant changes in IL-1beta, IL-6, IFNgamma, macrophage inflammatory protein-1alpha, tumor necrosis factor alpha or IL-12. The IL-18 elevations occurred before elevations of liver enzymes and correlated with peak aspartate aminotransferase levels (P = 0.005). Of the 31 patients who were resistant to chemotherapy, 1 had a complete remission and 2 had partial remissions; all 3 of these patients were treated at or above the maximal tolerated dose, all 3 responding patients had baseline marrow blast percentage of <30%, whereas only 6 of the nonresponding 28 patients had less than 30% marrow blasts. Five of these six patients were treated with subtherapeutic doses. Eight (42%) of 19 patient courses at <4 microg/kg/day and 8 (40%) of 20 patient courses at 4-5 microg/kg/day showed marrow blast reductions at day 12. Patients with higher pretreatment anti-DT388GMCSF levels had significantly lower peak DT388GMCSF levels (P = 0.0001). CONCLUSIONS: DT388GMCSF can produce complete and partial remissions in patients with chemotherapy-resistant acute myeloid leukemia, but methods to prevent liver injury are needed before more widespread application of this novel agent.