Πέμπτη 22 Ιουνίου 2017

Performance of QuantiFERON ® -TB Gold In-Tube assay in children receiving disease modifying anti-rheumatic drugs

Abstract

Background

To evaluate the performance of the Quantiferon®-TB Gold In-Tube (QFT-IT) interferon (IFN)-γ assay for the detection of latent tuberculosis infection (LTBI) in children receiving anti-rheumatic treatment in a tertiary referral hospital of Northern Greece.

Methods

A total of 79 consecutive children receiving anti-rheumatic treatment [of which 18 screened prior to antitumor necrosis factor (TNF)-α treatment] were tested using Mantoux tuberculin skin test (TST) and QFT-IT. Association of both tests with risk factors for latent tuberculosis and Bacillus Calmette-Guerin immunization was determined. Influence of age, TNF-α inhibitors, systemic corticosteroids, conventional disease modifying anti-rheumatic drugs (DMARDs) and total duration of therapy on the QFT-IT mitogen-induced response was evaluated.

Results

Agreement between TST and QFT-IT results was moderate (k=0.38). Frequency of QFT-IT indeterminate results was low (2.5%). In patients with risk factors for LTBI, the odds of a positive IFN-γ assay was increased by a factor of 27.6 (P=0.002), whereas there was no positive TST. There was a significant difference in the mitogeninduced IFN-γ secretion among various treatments (P=0.038). TNF-α inhibitors were associated with increased mitogen-induced IFN-γ secretion compared to monotherapy with conventional DMARDs (P=0.008). All children screened prior to anti-TNF-α treatment exhibited a negative QFT-IT and no active TB disease was detected during a 2-year follow-up.

Conclusion

QFT-IT may be a more reliable test than TST for detection of LTBI in children with rheumatic diseases receiving anti-rheumatic treatment. Drug regimen might influence the mitogen-induced IFN-γ secretion and the effect of TNF-α inhibitors might vary according to the specific agent administered.



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Oxcarbazepine oral suspension in pediatric patients with partial seizures and/or generalized tonic-clonic seizures: a multi-center, single arm, observational study in China

Abstract

Background

To assess efficacy and safety of oxcarbazepine (OXC) oral suspension in pediatric patients aged 2-16 years with partial seizures (PS) and/ or generalized tonic-clonic seizures (GTCS) in real-world clinical practice in China.

Methods

This 26-week, single arm, multicenter and observational study recruited patients aged 2-16 years with PS or GTCS suitable for OXC oral suspension treatment. Enrolled patients received OXC oral suspension treatment for 26 weeks. Primary endpoints included mean seizure frequency at the end of the treatment and mean seizure frequency reduction at the end of the treatment vs. baseline. Secondary efficacy-related endpoints and safety parameters were also assessed.

Results

Nine hundred and eighty-seven pediatric patients were enrolled and 912 (92.4%) completed the study. The mean seizure frequencies at baseline and the end of week 26 were 13.40±64.92 and 1.62±19.47 times/month, respectively. The mean seizure frequency reduction was 10.03±63.67 times/month and the mean seizure frequency reduction percentage was 90.02%±5127.0% (P<0.0001). After 26 weeks of treatment, 82.36%, 7.24% and 3.86% of the patients became controlled, significantly improved and improved, respectively. Adverse events (AEs) were reported in 74 (7.65%) patients. Rash was the most common AE. The efficacy of OXC was not affected by seizure types, age or gender.

Conclusion

This study confirms the efficacy and good safety profile of OXC oral suspension in Chinese pediatric patients aged 2-16 years with PS and/or GTCS.



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A protracted infectious swelling on the neck



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Asynchronus bilateral ovarian torsions in girls-systematic review

Abstract

Background

Bilateral ovarian torsions with complete loss of ovaries is devastating. This study analyzed the literature on bilateral ovarian torsions in girls to evaluate surgical options and outcomes.

Methods

Literature was searched on Pubmed® (1987-2014) using terms "bilateral", "adnexal", "ovary", "torsion" and "children". Data were collected on age, surgical preference, pathology and outcomes.

Results

Thirteen articles were identified, and 9 met the inclusion criteria (5 case reports, 4 original articles); and analyzed 17 girls (mean age: 8.75 years, range: 1-16). Bilateral oophorectomies (n=4), ipsilateral oophorectomy of severely affected ovary and contralateral oophoropexy (n=10), and detorsion of bilateral ovaries and bilateral oophoropexy (n=3) were performed. One torsion recurrence occurred after two oophoropexies. Laparoscopy and open surgery was done in 2 and 15 girls, respectively. Considering etiology, there were simple tubo-ovarian torsions (n=8), polycystic ovary (n=1), polycystic ovary associated with Down syndrome (n=1) and corpus luteum cyst (n=1). No tumors were reported. Serial ultrasound follow-ups of ipsilateral oophorectomy and contralateral oophoropexy (n=5) confirmed follicular function (n=4) and viability and position of the ovary (n=1).

Conclusion

Though extremely rare, school age girls present bilateral ovarian torsion. Ipsilateral oophorectomy and contralateral detorsion with oophoropexy has been the preferred approach.



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Imatinib may be considered as first-line treatment for both locally advanced and distant primary multifocal oral melanoma, for which surgery or radiotherapy of the primary tumor is impossible.

Πέμπτη, 22 Ιουνίου 2017

Treatment of Primary and Metastatic Multifocal Mucosal Melanoma of the Oral Cavity with Imatinib

Treatment of Primary and Metastatic Multifocal Mucosal Melanoma of the Oral Cavity with Imatinib: Background: Mucosal melanoma of the oral cavity is a rare entity and accounts for less than 1–3% of all melanomas. Contrary to cutaneous melanoma, primary oral melanoma more commonly harbors mutations in c-KIT. Methods: A 64-year-old man presented with asymptomatic, multiple, brown-to-black macules in the oral cavity. A biopsy was taken and histopathology exhibited mucosal melanoma. In molecular analysis, a c-KIT mutation was proven and a CT scan revealed pulmonary metastases. Due to the multifocality of the lesions, the metastases, and the mutation status, a therapy with imatinib was initiated. Results: After 1 year of therapy, progressive disease in the lung was noticed. Therefore, the therapy was switched to a PD-1 antagonist and a CTL-4 antibody. Conclusions: Our case suggests that imatinib may be considered as first-line treatment for both locally advanced and distant primary multifocal oral melanoma, for which surgery or radiotherapy of the primary tumor is impossible.

Case Rep Oncol 2017;10:558–563






Ιματινίμπη

Μοιραστείτε

 Ευρετήριο Αναφορές

Δραστική ουσία

Ονομασίες

ELΕλληνικάΙματινίμπη

ENΑγγλικάImatinib

Σύντομη περιγραφή

Η ιματινίμπη (imatinib) είναι ένας αναστολέας της πρωτεϊνικής τυροσινικής κινάσης, που ανστέλλει την Bcr-Abl τυροσινική κινάση, που παράγεται παθολογικά από το χρωμόσωμα Φιλαδέλφειας στην χρόνια μυελογενή λευκαιμία. Η ιματινίμπη αναστέλλει επίσης τον υποδοχέα της τυροσινικής κινάσης για τον αυξητικό παράγοντα των αιμοπεταλίων [platelet derived growth factor (PDGF)] και τον παράγοντα των βλαστικών κυττάρων (SCF), που ονομάζεται c-kit.



Ανατομική/θεραπευτική/χημική (ATC) ταξινόμηση

ΚωδικόςΤίτλοςΚατηγοριοποίηση

 L01XE01 ImatinibL Αντινεοπλασματικοί και ανοσοτροποποιητικοί παράγοντες → L01 Aντινεοπλασματικά φάρμακα → L01X Άλλοι αντινεοπλασματικοί παράγοντες → L01XE Αναστολείς των πρωτεϊνικών κινασών

Κεφάλαια συνταγολογίου ΕΟΦ

ΑριθμόςΤίτλοςΚατηγοριοποίηση

 08.06.05.03 Ιματινίμπη (Imatinib)08 Αντινεοπλασματικά και ανασοκατασταλτικά φάρμακα → 08.06 Άλλα αντινεοπλασματικά φάρμακα → 08.06.05 Αναστολείς της πρωτεϊνικής κινάσης

Αναγνωριστικό UNII



BKJ8M8G5HI - IMATINIB



Αριθμοί CAS



152459-95-5 - ιματινίμπη



Έννοια SNOMED-CT



414460008 - Imatinib (substance)





Φάρμακα που περιέχουν σε αποκλειστικότητα τη δραστική

Ομαδοποίηση κατά:  Οδό χορήγησηςΦαρμακοτεχνική μορφήΣυγκέντρωσηΔιανομέας

Κ Όνομα σκευάσματος Οδός χ/σης Φ/κή μορφή Συγκέντρωση Λ.Τ. Κόστος

 Aenorasis Α.Ε.

 IMATINIB/AENORASIS F.C.TAB 100MG/TAB BTx60 (PVC/PE/PVDC/Alu Blisters)  ORAL TAB_FILM_COATED  100MG/TAB  734,35 €  97,0217 € / g

 IMATINIB/AENORASIS F.C.TAB 400MG/TAB BTx30 (PVC/PE/PVDC/Alu Blisters)  ORAL TAB_FILM_COATED  400MG/TAB  1.385,56 €  93,9433 € / g

 Demo Α.Β.Ε.Ε.

 IMATINIB/DEMO CAPS 100MG/CAP BTx60 (PA-Aluminium/PVC/Aluminium Blisters) ORAL  CAP  100MG/CAP  734,35 €  97,0217 € / g

 IMATINIB/DEMO CAPS 400MG/CAP BTx30 (PA-Aluminium/PVC/Aluminium Blisters) ORAL  CAP  400MG/CAP  1.385,56 €  93,9433 € / g

 Novartis Europharm Ltd

    GLIVEC 100MG/CAP ΒΤΧ120  ORAL  CAP  100MG/CAP  1.803,79 €  135,9233 € / g

    GLIVEC F.C.TAB 100MG/TAB BTX60  ORAL  TAB_FILM_COATED  100MG/TAB  1.113,94 €  149,2683 € / g

    GLIVEC F.C.TAB 400MG/TAB BTX30  ORAL  TAB_FILM_COATED  400MG/TAB  2.111,17 €  144,5308 € / g

 Proton Pharma Α.Ε.

    IMATEK CAPS 100MG/CAP BTx60 CAPS (PA/ALU/PVC/ALU BLISTERS) (Τα blister είναι των 15 ή 10 καψακίων)  ORAL  CAP  100MG/CAP  734,35 €  97,0217 € / g

    IMATEK CAPS 400MG/CAP BTx30 CAPS (PA/ALU/PVC/ALU BLISTERS) (Τα blister είναι των 15 ή 10 καψακίων)  ORAL  CAP  400MG/CAP  1.385,56 €  93,9433 € / g

 Sandoz Pharmaceuticals d.d.

 IMATINIB/SANDOZ F.C.TAB 100MG/TAB BTx6 x10 (PVC-ALU BLISTERS)  ORAL TAB_FILM_COATED  100MG/TAB  734,35 €  97,0217 € / g

 IMATINIB/SANDOZ F.C.TAB 400MG/TAB BTx3 x10 (PVC/PE/PVDC-ALU BLISTERS)  ORAL TAB_FILM_COATED  400MG/TAB  1.385,56 €  93,9433 € / g

 Teva Pharmaceuticals B.V.

 IMATINIB TEVA F.C.TAB 100MG/TAB BTx60 σε OPA/AL/PVC/AL BLISTER OPA/AL/PVC/AL BLISTER  ORAL  TAB_FILM_COATED  100MG/TAB  697,78 €  92,1900 € / g

    IMATINIB TEVA F.C.TAB 100MG/TAB BTx60 σε PVC/PE/PVDC/PE/PVC/AL BLISTER PVC/PE/PVDC/PE/PVC/AL BLISTER  ORAL  TAB_FILM_COATED  100MG/TAB  697,78 € 92,1900 € / g

 IMATINIB TEVA F.C.TAB 100MG/TAB BTx60x1 σε OPA/AL/PVC/AL BLISTER OPA/AL/PVC/AL BLISTER  ORAL  TAB_FILM_COATED  100MG/TAB  697,78 €  92,1900 € / g

 IMATINIB TEVA F.C.TAB 100MG/TAB BTx60x1 σε PVC/PE/PVDC/PE/PVC/AL BLISTER PVC/PE/PVDC/PE/PVC/AL BLISTER  ORAL  TAB_FILM_COATED  100MG/TAB  697,78 € 92,1900 € / g

 IMATINIB TEVA F.C.TAB 400MG/TAB BTx30 σε OPA/AL/PVC/AL BLISTER OPA/AL/PVC/AL BLISTER  ORAL  TAB_FILM_COATED  400MG/TAB  1.385,56 €  93,9433 € / g

    IMATINIB TEVA F.C.TAB 400MG/TAB BTx30 σε PVC/PE/PVDC/PE/PVC/AL BLISTER PVC/PE/PVDC/PE/PVC/AL BLISTER  ORAL  TAB_FILM_COATED  400MG/TAB  1.385,56 € 93,9433 € / g

 IMATINIB TEVA F.C.TAB 400MG/TAB BTx30x1 σε OPA/AL/PVC/AL BLISTER OPA/AL/PVC/AL BLISTER  ORAL  TAB_FILM_COATED  400MG/TAB  1.385,56 €  93,9433 € / g

 IMATINIB TEVA F.C.TAB 400MG/TAB BTx30x1 σε PVC/PE/PVDC/PE/PVC/AL BLISTER PVC/PE/PVDC/PE/PVC/AL BLISTER  ORAL  TAB_FILM_COATED  400MG/TAB  1.385,56 € 93,9433 € / g

 Vianex A.E.

 VIANIB CAPS 100MG/CAP BTx60 (PA-Alu/PVC/Alu Blisters)  ORAL  CAP  100MG/CAP 734,35 €  97,0217 € / g

 VIANIB CAPS 400MG/CAP BTx30 (PA-Alu/PVC/Alu Blisters)  ORAL  CAP  400MG/CAP 1.385,56 €  93,9433 € / g

 Vocate Α.Ε.

    IMATINIB/VOCATE CAPS 100MG/CAP BTx60 caps σε blisters (PVC/PE/PVDC/ALU)  ORAL CAP  100MG/CAP  697,79 €  92,1900 € / g

    IMATINIB/VOCATE CAPS 400MG/CAP BTx30 caps σε blisters (PVC/PE/PVDC/ALU)  ORAL CAP  400MG/CAP  1.385,56 €  93,9433 € / g



Πηγή: Γαληνός Οδηγός Φαρμάκων







Imatinib

From Wikipedia, the free encyclopedia
Imatinib
Imatinib2DACS.svg
Ball-and-stick model of the imatinib molecule
Clinical data
Trade namesGleevec, Glivec, others
AHFS/Drugs.comMonograph
MedlinePlusa606018
License data
Pregnancy
category
  • AU: D
  • US: D (Evidence of risk)
    Routes of
    administration    		by mouth
    ATC code
    Legal status
    Legal status
    Pharmacokinetic data
    Bioavailability98%
    Protein binding95%
    Metabolismliver (mainly CYP3A4-mediated)
    Biological half-life18 h (imatinib)
    40 h (active metabolite)
    ExcretionFecal (68%) and kidney (13%)
    Identifiers
    SynonymsSTI-571
    CAS Number
    PubChem CID
    IUPHAR/BPS
    DrugBank
    ChemSpider
    UNII
    KEGG
    ChEBI
    ChEMBL
    PDB ligand
    ECHA InfoCard100.122.739
    Chemical and physical data
    FormulaC29H31N7O
    Molar mass493.603 g/mol
    589.7 g/mol (mesilate)
    3D model (Jmol)
      (verify)
    Imatinib, sold under the brand names Gleevec among others, is a chemotherapy medicationused to treat cancer. Specifically, it is used for chronic myelogenous leukemia (CML) and acute lymphocytic leukemia (ALL) that is Philadelphia chromosome-positive (Ph+) and certain types ofgastrointestinal stromal tumors (GIST), systemic mastocytosis, and myelodysplastic syndrome. It is taken by mouth.[1]
    Common side effects include vomiting, diarrhea, muscle pain, headache, and rash. Severe side effects may include fluid retention, gastrointestinal bleeding, bone marrow suppression, liver problems, and heart failure. Use during pregnancy may result in harm to the baby. Imatinib works by stopping the Bcr-Abl tyrosine-kinase. This either slows growth or results in programmed cell death of certain type of cancer cells.[1]
    Imatinib was approved for medical use in the United States in 2001.[1] It is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in ahealth system.[2] The wholesale cost in the developing world is about 1,386.49 to 19,162.50 USD a year.[3] In the United States a typical dose for a year has a wholesale cost of $84,408.78,[4] while in the United Kingdom the NHS was paying about 20,980 pounds ($28327) in 2016.[5] A generic version became available in the UK as of 2017.[6]

    Medical uses[edit]

    Imatinib is used to treat chronic myelogenous leukemia (CML), gastrointestinal stromal tumors(GISTs) and a number of other malignancies.

    Chronic myelogenous leukemia[edit]

    The U.S. Food and Drug Administration (FDA) has approved imatinib as first-line treatment forPhiladelphia chromosome-positive CML, both in adults and children. The drug is approved in multiple contexts of Philadelphia chromosome-positive CML, including after stem cell transplant, in blast crisis, and newly diagnosed.[7]
    Due in part to the development of imatinib and related drugs, the five year survival rate for people with chronic myeloid leukemia increased from 31% in 1993 to 59% in 2003 to 2009.[8]

    Gastrointestinal stromal tumors[edit]

    The FDA first granted approval for advanced GIST patients in 2002. On 1 February 2012, imatinib was approved for use after the surgical removal of KIT-positive tumors to help prevent recurrence.[9] The drug is also approved in unresectable KIT-positive GISTs.[7]

    Other[edit]

    The FDA has approved imatinib for use in adults with relapsed or refractory Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL), myelodysplastic/ myeloproliferative diseases associated with platelet-derived growth factor receptor gene rearrangements, aggressive systemic mastocytosis without or an unknown D816V c-KIT mutation, hypereosinophilic syndrome and/or chronic eosinophilic leukemia who have the FIP1L1-PDGFRα fusion kinase (CHIC2 allele deletion) or FIP1L1-PDGFRα fusion kinase negative or unknown, unresectable, recurrent and/or metastatic dermatofibrosarcoma protuberans.[7] On 25 January 2013, Gleevec was approved for use in children with Ph+ ALL.[10]
    For treatment of progressive plexiform neurofibromas associated with neurofibromatosis type I, early research has shown potential for using the c-KIT tyrosine kinase blocking properties of imatinib.[11][12][13][14]

    Contraindications and cautions[edit]

    The only known contraindication to imatinib is hypersensitivity to imatinib.[15] Cautions include:[16]
    • Hepatic impairment
    • Risk of severe CHF or left ventricular dysfunction, especially in patients with comorbidities
    • Pregnancy, risk of embryo-fetal toxicity
    • Risk of fluid retention
    • Risk of growth stunting in children or adolescents

    Side effects[edit]

    See also: List of adverse effects of imatinib
    bcr-abl kinase (green), which causes CML, inhibited by imatinib (red; small molecule).
    The most common side effects include feeling sick (nausea), diarrhea, headaches, leg aches/cramps, fluid retention, visual disturbances, itchy rash, lowered resistance to infection, bruising or bleeding, loss of appetite;[17] weight gain, reduced number of blood cells (neutropenia, thrombocytopenia, anemia), andedema.[18] Although rare, restoration of hair color has been reported as well.[19][20] Severe congestive cardiac failure is an uncommon but recognized side effect of imatinib and mice treated with large doses of imatinib show toxic damage to their myocardium.[21]
    If imatinib is used in prepubescent children, it can delay normal growth, although a proportion will experience catch-up growth during puberty.[22]

    Interactions[edit]

    Its use is advised against in patients on strong CYP3A4 inhibitors such as clarithromycin, chloramphenicol,ketoconazole, ritonavir and nefazodone due to its reliance on CYP3A4 for metabolism.[16] Likewise it is a CYP3A4, CYP2D6 and CYP2C9 inhibitor and hence concurrent treatment with substrates of any of these enzymes may increase plasma concentrations of said drugs.[16]

    Overdose[edit]

    Medical experience with imatinib overdose is limited.[23] Treatment is supportive.[23] Imatinib is highly plasma protein-bound:[23] dialysis is unlikely to be helpful removing imatinib.

    Mechanism of action[edit]

    Mechanism of action of imatinib
    Imatinib
    Drug mechanism
    1IEP.png
    Crystallographic structure of tyrosine-protein kinase ABL (rainbow colored, N-terminus = blue, C-terminus = red) complexed with imatinib (spheres, carbon = white, oxygen = red, nitrogen = blue).[24]
    Therapeutic usechronic myelogenous leukemia
    Biological targetABL, c-kit, PDGF-R
    Mechanism of actionTyrosine-kinase inhibitor
    External links
    ATC codeL01XE01
    PDB ligand idSTI: PDBe, RCSB PDB
    LIGPLOT1iep
    Imatinib is a 2-phenyl aminopyrimidine derivative that functions as a specific inhibitor of a number of tyrosine kinase enzymes. It occupies the TKactive site, leading to a decrease in activity.
    There are a large number ofTK enzymes in the body, including the insulin receptor. Imatinib is specific for the TKdomain in abl (the Abelson proto-oncogene), c-kit andPDGF-R (platelet-derived growth factor receptor).
    In chronic myelogenous leukemia, the Philadelphia chromosome leads to a fusion protein of abl withbcr (breakpoint cluster region), termed bcr-abl. As this is now a constitutively active tyrosine kinase, imatinib is used to decrease bcr-abl activity.
    The active sites of tyrosine kinases each have a binding site for ATP. The enzymatic activitycatalyzed by a tyrosine kinase is the transfer of the terminal phosphate from ATP to tyrosine residues on its substrates, a process known as protein tyrosine phosphorylation. Imatinib works by binding close to the ATP binding site of bcr-abl, locking it in a closed or self-inhibited conformation, and therefore inhibiting the enzyme activity of the protein semi-competitively.[25] This fact explains why many BCR-ABL mutations can cause resistance to imatinib by shifting its equilibrium toward the open or active conformation.[26]
    Imatinib is quite selective for bcr-abl, though it does also inhibit other targets mentioned above (c-kit and PDGF-R), but acts on no other knowntyrosine kinases. Imatinib also inhibits the abl protein of non-cancer cells, but these cells normally have additional redundant tyrosine kinases, which allows them to continue to function even if abl tyrosine kinase is inhibited. Some tumor cells, however, have a dependence on bcr-abl.[27]Inhibition of the bcr-abl tyrosine kinase also stimulates its entry in to the nucleus, where it is unable to perform any of its normal anti-apoptopicfunctions, leading to tumor cell death.[28]

    Other pathways affected[edit]

    The Bcr-Abl pathway has many downstream pathways including[29]
    • the Ras/MapK pathway, which leads to increased proliferation due to increased growth factor-independent cell growth.
    • It also affects the Src/Pax/Fak/Rac pathway. This affects the cytoskeleton, which leads to increased cell motility and decreased adhesion.
    • The PI/PI3K/AKT/BCL-2 pathway is also affected. BCL-2 is responsible for keeping the mitochondria stable; this suppresses cell death by apoptosis and increases survival.
    • The last pathway that Bcr-Abl affects is the JAK/STAT pathway, which is responsible for proliferation.[29]

    Pharmacokinetics[edit]

    Imatinib is rapidly absorbed when given by mouth, and is highly bioavailable: 98% of an oral dose reaches the bloodstream. Metabolism of imatinib occurs in the liver and is mediated by several isozymes of the cytochrome P450 system, including CYP3A4 and, to a lesser extent, CYP1A2,CYP2D6, CYP2C9, and CYP2C19. The main metabolite, N-demethylated piperazine derivative, is also active. The major route of elimination is in the bile and feces; only a small portion of the drug is excreted in the urine. Most of imatinib is eliminated as metabolites; only 25% is eliminated unchanged. The half-lives of imatinib and its main metabolite are 18 h and 40 h, respectively. It blocks the activity of Abelson cytoplasmic tyrosine kinase (ABL), c-Kit and the platelet-derived growth factor receptor (PDGFR). As an inhibitor of PDGFR, imatinib mesylate appears to have utility in the treatment of a variety of dermatological diseases. Imatinib has been reported to be an effective treatment for FIP1L1-PDGFRalpha+ mast cell disease, hypereosinophilic syndrome, and dermatofibrosarcoma protuberans.[30]

    Interactions[edit]

    Since imatinib is mainly metabolised via the liver enzyme CYP3A4, substances influencing the activity of this enzyme change the plasma concentration of the drug. An example of a drug that increases imatinib activity and therefore side effects by blocking CYP3A4 is ketoconazole. The same could be true of itraconazole, clarithromycin, grapefruit juice, among others. Conversely, CYP3A4 inductors like rifampicin and St. John's Wort reduce the drug's activity, risking therapy failure. Imatinib also acts as an inhibitor of CYP3A4, 2C9 and 2D6, increasing the plasma concentrations of a number of other drugs like simvastatin, ciclosporin, pimozide, warfarin, metoprolol, and possibly paracetamol. The drug also reduces plasma levels of levothyroxin via an unknown mechanism.[18]
    As with other immunosuppressants, application of live vaccines is contraindicated because the microorganisms in the vaccine could multiply and infect the patient. Inactivated and toxoid vaccines do not hold this risk, but may not be effective under imatinib therapy.[31]

    History[edit]

    Imatinib was invented in the late 1990s by scientists at Ciba-Geigy (which merged with Sandoz in 1996 to become Novartis), in a team led by biochemist Nicholas Lydon and that included Elisabeth Buchdunger and Jürg Zimmermann[32] and its use to treat CML was driven by oncologistBrian Druker of Oregon Health & Science University (OHSU).[33] Other major contributions to imatinib development were made by Carlo Gambacorti-Passerini, a physician, scientist, and hematologist at University of Milano Bicocca, Italy, John Goldman at Hammersmith Hospital in London, UK, and later on by Charles Sawyers of Memorial Sloan-Kettering Cancer Center.[34] Druker led the clinical trials confirming its efficacy inCML.[35]
    Imatinib was developed by rational drug design. After the Philadelphia chromosome mutation and hyperactive bcr-abl protein were discovered, the investigators screened chemical libraries to find a drug that would inhibit that protein. With high-throughput screening, they identified 2-phenylaminopyrimidine. This lead compound was then tested and modified by the introduction of methyl and benzamide groups to give it enhanced binding properties, resulting in imatinib.[36]
    When Novartis tested imatinib in rats, mice, rabbits, dogs, and monkeys in 1996, it was found to have several toxic effects; in particular, results indicating liver damage in dogs nearly stopped drug development completely. However, favorable results in studies with monkeys and in vitrohuman cells allowed testing to continue in humans.[37][38][39]
    The first clinical trial of Gleevec took place in 1998 and the drug received FDA approval in May 2001, only two and a half years after the new drug application was submitted.[32][40] On the same month it made the cover of TIME magazine as a "bullet" to be used against cancer. Druker, Lydon and Sawyers received the Lasker-DeBakey Clinical Medical Research Award in 2009 for "converting a fatal cancer into a manageable chronic condition".[34]
    During the FDA review, the tradename of the drug for the US market was changed from "Glivec" to "Gleevec" at the request of the FDA, to avoid confusion with Glyset, a diabetes drug.[41][42][43]
    A Swiss patent application was filed on imanitib and various salts on in April 1992, which was then filed in the EU, the US, and other countries in March and April 1993.[44][45] and in 1996 United States and European patent offices issued patents listing Jürg Zimmermann as the inventor.[44][46]
    In July 1997, Novartis filed a new patent application in Switzerland on the beta crystalline form of imatinib mesylate (the mesylate salt of imatinib). The "beta crystalline form" of the molecule is a specific polymorph of imatinib mesylate; a specific way that the individual molecules pack together to form a solid. This is the actual form of the drug sold as Gleevec/Glivec; a salt (imatinib mesylate) as opposed to a free base, and the beta crystalline form as opposed to the alpha or other form.[47]:3 and 4 In 1998, Novartis filed international patent applications claiming priority to the 1997 filing.[48][49] A United States patent was granted in 2005.[50]

    Costs[edit]

    A box of 400-milligram Glivec tablets (Novartis), as sold in Germany.
    In 2013, more than 100 cancer specialists published a letter in Blood saying that the prices of many new cancer drugs, including imatinib, are so high that people in the United States couldn't afford them, and that the level of prices, and profits, was so high as to be immoral. Signatories of the letter included Brian Druker, Carlo Gambacorti-Passerini, and John Goldman, developers of imatinib.[51][52] They wrote that in 2001, imatinib was priced at $30,000 a year, which was based on the price of interferon, then the standard treatment, and that at this price Novartis would have recouped its initial development costs in two years. They wrote that after unexpectedly becoming a blockbuster, Novartis increased the price to $92,000 per year in 2012, with annual revenues of $4.7 billion. Other physicians have complained about the cost.[53][54][55] By 2016, the average wholesale price had increased to $120,000 a year, according to an analysis prepared for the Washington Post by Stacie Dusetzina of the University of North Carolina at Chapel Hill. When competitive drugs came on the market, they were sold at a higher price to reflect the smaller population, and Novartis raised the price of Gleevec to match them.[56]
    A 2012 economic analysis funded by Bristol-Myers Squibb estimated that the discovery and development of imatinib and related drugs had created $143 billion in societal value at a cost to consumers of approximately $14 billion. The $143 billion figure was based on an estimated 7.5 to 17.5 year survival advantage conferred by imatinib treatment, and included the value (discounted at 3% per annum) of ongoing benefits to society after the imatinib patent expiration.[57]
    Prices for a 100 mg pill of Gleevec internationally range from $20 to $30,[58] although generic imatinib is cheaper, as low as $2 per pill.[59]

    Patent litigation in India[edit]

    Main article: Novartis v. Union of India & Others
    Novartis fought a seven-year, controversial battle to patent Gleevec in India, and took the case all the way to the Indian Supreme Court. The patent application at the center of the case was filed by Novartis in India in 1998, after India had agreed to enter the World Trade Organization and to abide by worldwide intellectual property standards under the TRIPS agreement. As part of this agreement, India made changes to its patent law, the biggest of which was that prior to these changes, patents on products were not allowed, while afterwards they were, albeit with restrictions. These changes came into effect in 2005, so Novartis' patent application waited in a "mailbox" with others until then, under procedures that India instituted to manage the transition. India also passed certain amendments to its patent law in 2005, just before the laws came into effect.[60]
    The patent application[49][61] claimed the final form of Gleevec (the beta crystalline form of imatinib mesylate).[62]:3 In 1993, during the time India did not allow patents on products, Novartis had patented imatinib, with salts vaguely specified, in many countries but could not patent it in India.[44][46]The key differences between the two patent applications, were that 1998 patent application specified the counterion (Gleevec is a specific salt – imatinib mesylate) while the 1993 patent application did not claim any specific salts nor did it mention mesylate, and the 1998 patent application specified the solid form of Gleevec – the way the individual molecules are packed together into a solid when the drug itself is manufactured (this is separate from processes by which the drug itself is formulated into pills or capsules) – while the 1993 patent application did not. The solid form of imatinib mesylate in Gleevec is beta crystalline.[63]
    As provided under the TRIPS agreement, Novartis applied for Exclusive Marketing Rights (EMR) for Gleevec from the Indian Patent Office and the EMR was granted in November 2003.[64] Novartis made use of the EMR to obtain orders against some generic manufacturers who had already launched Gleevec in India.[65][66]
    When examination of Novartis' patent application began in 2005, it came under immediate attack from oppositions initiated by generic companies that were already selling Gleevec in India and by advocacy groups. The application was rejected by the patent office and by an appeal board. The key basis for the rejection was the part of Indian patent law that was created by amendment in 2005, describing the patentability of new uses for known drugs and modifications of known drugs. That section, 3d, specified that such inventions are patentable only if "they differ significantly in properties with regard to efficacy."[65][67] At one point, Novartis went to court to try to invalidate Section 3d; it argued that the provision was unconstitutionally vague and that it violated TRIPS. Novartis lost that case and did not appeal.[68] Novartis did appeal the rejection by the patent office to India's Supreme Court, which took the case.
    The Supreme Court case hinged on the interpretation of Section 3d. The Supreme Court issued its decision in 2013, ruling that the substance that Novartis sought to patent was indeed a modification of a known drug (the raw form of imatinib, which was publicly disclosed in the 1993 patent application and in scientific articles), that Novartis did not present evidence of a difference in therapeutic efficacy between the final form of Gleevec and the raw form of imatinib, and that therefore the patent application was properly rejected by the patent office and lower courts.[69]

    Research[edit]

    One study demonstrated that imatinib mesylate was effective in patients with systemic mastocytosis, including those who had the D816V mutation in c-KIT.[70] However, since imatinib binds to tyrosine kinases when they are in the inactive configuration and the D816V mutant of c-KIT is constitutively active, imatinib does not inhibit the kinase activity of the D816V mutant of c-KIT. Experience has shown, however, that imatinib is much less effective in patients with this mutation, and patients with the mutation comprise nearly 90% of cases of mastocytosis.
    Imatinib was initially thought to have a potential role in the treatment of pulmonary hypertension. It was shown to reduce both the smooth muscle hypertrophy and hyperplasia of the pulmonary vasculature in a variety of disease processes, including portopulmonary hypertension.[71] However, a long-term trial of Imatinib in people with pulmonary arterial hypertension was unnsuccessful, and serious and unexpected adverse events were frequent. These included 6 subdural hematomas and 17 deaths during or within 30 days of study end.[72]
    In systemic sclerosis, the drug has been tested for potential use in slowing down pulmonary fibrosis. In laboratory settings, imatinib is being used as an experimental agent to suppress platelet-derived growth factor (PDGF) by inhibiting its receptor (PDGF-Rβ). One of its effects is delayingatherosclerosis in mice without[73] or with diabetes.[74]
    Mouse animal studies have suggested that imatinib and related drugs may be useful in treating smallpox, should an outbreak ever occur.[75]
    In vitro studies identified that a modified version of imatinib can bind to gamma-secretase activating protein (GSAP). GSAP selectively increases the production and accumulation of neurotoxic beta-amyloid plaques,which suggests that molecules which target GSAP and are able to crossblood–brain barrier are potential therapeutic agents for treating Alzheimer's disease.[76] Another study suggests that imatinib may not need to cross the blood–brain barrier to be effective at treating Alzheimer's, as the research indicates the production of beta-amyloid may begin in the liver. Tests on mice indicate that imatinib is effective at reducing beta-amyloid in the brain.[77] It is not known whether reduction of beta-amyloid is a feasible way of treating Alzheimer's, as an anti-beta-amyloid vaccine has been shown to clear the brain of plaques without having any effect on Alzheimer symptoms.[78]
    A formulation of imatinib with a cyclodextrin (Captisol) as a carrier to overcome the blood–brain barrier is also currently considered as an experimental drug for lowering and reversing opioid tolerance. Imatinib has shown reversal of tolerance in rats.[79] Imatinib is an experimental drug in the treatment of desmoid tumor or aggressive fibromatosis.

    See also[edit]

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