Combination Sulfasalazine Research Articles

Esomeprazole and sulfasalazine in combination additively reduce sFlt-1 secretion and diminish endothelial dysfunction: potential for a combination treatment for preeclampsia.

Development and repurposing of therapies that show promise in the prevention or treatment of preeclampsia would be a major advance for the obstetrics field. We recently identified esomeprazole and sulfasalazine as potential candidates for the treatment of preeclampsia. Both reduce placental and endothelial secretion of sFlt-1 and sENG and mitigate endothelial dysfunction in vitro. Here we assessed whether esomeprazole and sulfasalazine in combination would additively attenuate the elevated release of anti-angiogenic factors and markers of endothelial dysfunction, key characteristics of preeclampsia. Primary placental tissue and cells, and primary endothelial cells were treated with esomeprazole and sulfasalazine alone and in combination. We assessed secretion of sFlt-1 and sENG and performed in vitro assays of endothelial dysfunction. Combining esomeprazole and sulfasalazine in lower concentrations caused an additive reduction in sFlt-1 secretion in primary cytotrophoblasts, placental explants and endothelial cells. No additive reduction was observed in sENG secretion when esomeprazole and sulfasalazine were combined. Together, esomeprazole and sulfasalazine additively reduced TNF-α-induced VCAM and ET-1 mRNA expression, and monocyte adhesion to endothelial cells. In conclusion, combining esomeprazole and sulfasalazine additively reduced secretion of sFlt-1 and markers of endothelial dysfunction. Combined administration of esomeprazole and sulfasalazine may provide a more effective treatment or prevention for preeclampsia compared to either as single agents.

Sulfasalazine could modulate the CD44v9-xCT system and enhance cisplatin-induced cytotoxic effects in metastatic bladder cancer.

The prognostic role of CD44v9, a variant isoform of CD44 and a new cell surface marker of cancer stem cells, remains unclear in bladder cancer (BC) patients. Furthermore, limited information is available on the functional role of sulfasalazine (SSZ), which could modulate the CD44v9‐xCT system in order to enhance cisplatin (CDDP)‐induced cytotoxicity and inhibit the metastatic potential of BC. CD44v9 protein expression was examined immunohistochemically in 63 muscle invasive BC (MIBC) patients who underwent radical cystectomy. CD44v9 expression was independently associated with disease recurrence and cancer‐specific death in MIBC. Cytotoxic effects, glutathione levels, and reactive oxygen species production by SSZ and CD44v9 and phospho‐p38MAPK protein expression by SSZ with or without CDDP were assessed in MBT‐2V cells with highly metastatic potential. Sulfasalazine exerted cytotoxic effects against MBT‐2V cells by inhibiting glutathione levels and inducing the production of reactive oxygen species. Sulfasalazine in combination with CDDP appeared to exert strong cytotoxic effects against MBT‐2V cells by inhibiting CD44v9 expression and upregulating phospho‐p38MAPK expression. The inhibitory effects of SSZ with or without CDDP were also investigated using an MBT‐2V lung metastatic model. In the murine lung metastatic BC model, SSZ significantly prolonged animal survival. Furthermore, the combination of SSZ with CDDP exerted stronger inhibitory effects on the establishment of lung tumor nodules than SSZ or CDDP alone. CD44v9 expression could be a clinical biomarker for predicting poor outcomes in MIBC patients. Sulfasalazine in combination with CDDP has potential as a novel therapy against metastatic BC.

190. Combination sulfasalazine and metformin are additive in reducing placental secretion of antiangiogenic factor sFlt

Introduction Preeclampsia is associated with increased placental secretion of antiangiogenic factors sFlt-1 and sENG and a reduction in angiogenic proteins placental growth factor secretion (PlGF) and vascular endothelial growth factor (VEGF). We have identified two medications, safe in pregnancy, that mitigate key aspects of preeclampsia in vitro. We have demonstrated metformin and sulfasalazine independently reduce placental sFlt-1 secretion and vessel dysfunction. In this study we investigate the possibility of combining these medications to reduce the dose required to mitigate key aspects of preeclampsia; sFlt-1 and sENG secretion and PlGF and VEGF expression, using primary human tissues. Methods Metformin and sulfasalazine, at low doses individually and in combination, were administered to primary trophoblasts and placental explants and sFlt-1 secretion assessed. At the mRNA level there are two sFlt-1 splice variants; the primate and placental specific isoform sFlt-1 e15a and the predominately vascular isoform sFlt-1 i13. Both were measured following combination treatment. In addition the expression of angiogenic factors PlGF and VEGFα were assessed. Results Combining low-dose metformin and sulfasalazine additively decreased sFlt-1 secretion from primary trophoblast compared to either drug alone. Similarly, an additive decrease in sFlt-1 e15a and i13 was identified following combination treatment. In placental explants, combination treatment also additively decreased sFlt-1 secretion. Low dose sulfasalazine potently upregulated PlGF expression in primary trophoblasts and this was maintained with the addition of metformin. Metformin and sulfasalazine individually increased VEGFα, and this effect was additive when the two drugs were combined. Conclusion Combination metformin and sulfasalazine additively reduced sFlt-1 secretion and the expression of its splice variants, sFlt-1 e15a and i13. Furthermore, in combination metformin and sulfasalazine upregulate angiogenic factor VEGFα. Therefore we conclude that they might be promising combination therapeutics that could reduce the burden of this devastating disease.

Abstract 3362: Expression of CD44v9, a cancer stem cell marker, in human hepatocellular carcinoma

Abstract Background: CD44 is a cell-surface glycoprotein involved in cell-cell interactions, cell adhesion, and migration. This protein has recently been identified as one of the crucial cell surface markers for cancer stem cells (CSCs) in several types of tumor. It has recently been reported that CD44 variant 9 (CD44v9) interacted with the glutamate-cystine transporter xCT, thereby contributing to increased intracellular synthesis of glutathione (GSH), a strong scavenger of reactive oxygen species (ROS). CSCs having such mechanism are highly resistant to ROS (Cancer Cell 2011). Of note, the function of xCT is inhibited by sulfasalazine (Leukemia 2001), a commonly used drug for ulcerative colitis. Aim: The aims of this study were to assess 1) the expression levels of CD44v9 and xCT in human HCC tissues and HCC cell lines, and 2) possible synergistic anti-tumor effect of cisplatin and sulfasalazine on HCC cells. Methods: Thirty HCC tissues were subjected to immunohistochemistry for CD44v9 and xCT. The human HCC cell lines HAK-1A and HAK-1B were used. HAK-1B was an aggressive sister cell line derived from HAK-1A, a well-differentiated one (Hepatology 1993). The cells were incubated with cisplatin with or without sulfasalazine at concentrations of 0, 50, 100, and 200 μM under attached and sphere-forming conditions. Western blot analysis was employed to evaluate protein expression levels. Results: Membranous localization of CD44v9 was found in 2 HCC tissues, that were moderately and poorly differentiated ones. In such cases, the standard isoform CD44s was also strongly expressed. Expression levels of xCT were ubiquitously demonstrated in all HCC cases studied; however, it was robustly upregulated in sphere-formed HAK-1B cells, in concert with the upregulation of CD44v9 in these cells. Sphere formation of HAK-1B was significantly inhibited by co-treatment with cisplatin and sulfasalazine in a dose-dependent manner. Conclusions: The CD44v9-xCT system was demonstrated in less differentiated HCC tissues. Indeed, poorly differentiated HCC cells (HAK-1B) under sphere formation robustly expressed both CD44v9 and xCT, suggesting that CSC-like cells favored this system. To overcome the ROS resistance of CSCs, delivering sulfasalazine in combination with anti-cancer drugs may open a new avenue to a promising treatment of chemorefractory HCC. Citation Format: Fumitaka Wada. Expression of CD44v9, a cancer stem cell marker, in human hepatocellular carcinoma. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3362.

Methotrexate for maintenance of remission in ulcerative colitis.

Methotrexate, a folate antagonist, is an immunosuppressant drug that is effective for treating several inflammatory disorders including Crohn's disease. Ulcerative colitis, a related chronic inflammatory bowel disease, can be challenging to treat. T his updated systematic review summarizes the current evidence on the use of methotrexate for induction maintenance of remission in ulcerative colitis. The objectives of this review were to assess the efficacy and safety of methotrexate for maintenance of remission in patients with ulcerative colitis. We searched MEDLINE, EMBASE, CENTRAL and the Cochrane IBD/FBD group specialized trials register from inception to June 26, 2014. Study references and review papers were also searched for additional trials. Abstracts from major gastroenterological meetings were searched to identify research published in abstract form only. Randomized controlled trials in which methotrexate was compared to placebo or an active comparator in patients with quiescent ulcerative were considered for inclusion. Two authors independently extracted data and assessed the risk of bias for each study. The primary outcome was the occurrence of clinical or endoscopic relapse as defined by the primary studies. Secondary outcomes included frequency and nature of adverse events, change of disease activity score and steroid-sparing effect. We calculated the risk ratio and corresponding 95% confidence interval for dichotomous outcomes. Data were analyzed on an intention-to-treat basis. The overall quality of the evidence supporting the outcomes was evaluated using the GRADE criteria. Three trials (165 patients) fulfilled the inclusion criteria. One study compared oral methotrexate (12.5 mg/week) to placebo, another compared oral methotrexate (15 mg/week) to 6-mercaptopurine (6-MP, 1.5 mg/kg/day) or 5-aminosalicylic acid (5-ASA, 3 g/day) and the other compared methotrexate (15 mg/week) in combination sulfasalazine (3 g/day) to sulfasalazine. The placebo-controlled study was rated as low risk of bias. The study comparing methotrexate to 6-MP and 5-ASA was rated as high risk of bias and the study assessing methotrexate and sulfasalazine was rated as unclear risk of bias for sequence generation, allocation concealment and blinding. The placebo-controlled study found no statistically significant differences in the proportion of patients who maintained remission. At nine months, 36% (5/14) of methotrexate patients maintained remission compared to 54% (10/18) of placebo patients (RR 0.64, 95% CI 0.28 to 1.45). A GRADE analysis indicated that the overall quality of the evidence for this outcome was low due to very sparse data (15 events). The study comparing combination therapy to sulfasalazine found no statistically significant difference in the proportion of patients who maintained remission. At 12 months, 100% (14/14) of patients in the combination group maintained remission compared to 75% (9/12) of sulfasalazine patients (RR 1.32, 95% CI 0.94 to 0.86), A GRADE analysis indicated that the overall quality of the evidence for this outcome was very low due to unknown risk of bias and very sparse data (23 events). There were no statistically significant differences in maintenance of remission rates between methotrexate and 6-MP or between methotrexate and 5-ASA. At 76 weeks, 14% (1/7) of methotrexate patients maintained remission compared to 64% (7/11) of 6-MP patients (RR 0.22, 95% CI 0.03 to 1.45) and 0% (0/2) of 5-ASA patients (RR 1.13, 95% CI 0.06 to 20.71). A GRADE analysis indicated that the overall quality of the evidence from this study was very low due to high risk of bias and very sparse data. Adverse events reported in these studies included transient leucopenia, migraine, nausea and dyspepsia, mild alopecia, mild increase in aspartate aminotransferase levels, peritoneal abscess, hypoalbuminemia, severe rash and atypical pneumonia The results for efficacy and safety outcomes between methotrexate and placebo, methotrexate and sulfasalazine, methotrexate and 6-mercaptopurine and methotrexate and 5-aminosalicylic acid were uncertain. Whether a higher dose or parenteral administration of methotrexate would be effective in quiescent ulcerative colitis is unknown. At present there is no evidence supporting the use of methotrexate for maintenance of remission in ulcerative colitis. More studies are needed to determine the efficacy and safety of methotrexate maintenance therapy in patients with quiescent ulcerative colitis. Large scale methodologically rigorous randomized controlled trials are needed. These studies should investigate higher doses of methotrexate (e.g. 15 to 25 mg/week) and parenteral administration.

Abstract 686: Regulation of intracellular sequestration of sunitinib by cystine transporter xCT in renal cancer

Abstract Background: Acquired and/or intrinsic resistance to sunitinib, a multikinase inhibitor, is one of the major obstacles for the treatment of renal cell carcinoma (RCC). Recently, lysosomal sequestration of sunitinib has been shown as one of the potential mechanisms of resistance in renal cancer. The current study was initiated to understand the role of the Cystine Transporter xCT (encoded product of Solute Carrier family 7A member 11, SLC7A11 gene), a lysosome regulatory gene, on intracellular sequestration of sunitinib and to evaluate the cytotoxic effects of the xCT inhibitor sulfasalazine alone and in combination with sunitinib on RCC cells. Methods: Intracellular sequestration of sunitinib was evaluated using the fluorescent microscopy technique by determining the autofluorescence of sunitinib. Cytotoxic effects of sulfasalazine alone and in combination with sunitinib were assessed by sulforhodamine B assay. Quantitative RT-PCR analysis and Western blot analysis were utilized to determine the expression of xCT in normal renal tubular HK2 cells, human umbilical vein endothelial cells (HUVEC), and RCC 786-O cells, and to determine the association of sunitinib sequestration and xCT expression. Expression of xCT interacting partner CD44s and its variant forms CD44v6 and CD44v8, which influence the expression of xCT, was determined in 786-O and HK2 cells. Additionally, we utilized The Cancer Genome Atlas (TCGA) data to determine the expression of xCT in ccRCC patients and evaluated the significance of its expression and correlation of patient survival. Results: Our results revealed higher intracellular sequestration of sunitinib in RCC 786-O cells compared to HK2 and HUVEC cells. Furthermore, we found higher expression of xCT in 786-O cells compared to HK2 and HUVEC cells, which was associated with high intracellular sequestration of sunitinib. The pharmacological inhibition of xCT by sulfasalazine revealed the reversal of intracellular sequestration of sunitinib in 786-O cells. The SRB assay showed the enhanced cytotoxic effects of sunitinib in combination with sulfasalazine, which indicates that, the reversal of intracellular sequestration of sunitinib may led to the enhanced cytotoxic effects. Moreover, there was a significant decrease of xCT stabilizing isoform CD44v6 mRNA in 786-O cells compared to HK2 and no change was observed in CD44s and CD44v8. Bioinformatics analysis using cBioPortal Cancer Genomics from MSKCC data of TCGA revealed the significant up regulation of xCT in ccRCC patients correlated with poor prognosis. Conclusions: Our results indicate that lysosome regulatory protein xCT inhibition by sulfasalazine leads to the reversal of intracellular sequestration of sunitinib and enhances the efficacy of sunitinib in renal cancer. These results provide the rationale for the preclinical and clinical testing of sulfasalazine in combination with sunitinib in the treatment of ccRCC. Citation Format: Sreenivasulu Chintala, Hillary Nguyen, Swathi Ramakrishnan, Sheng-Yu Ku, Eric Ciamporcero, Kiersten M. Miles, Roberto Pili. Regulation of intracellular sequestration of sunitinib by cystine transporter xCT in renal cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 686. doi:10.1158/1538-7445.AM2014-686

Sulfasalazine

Sulfasalazine (salazosulfapyridine) [Azulfidine, Salazopyrin] is a well established disease-modifying antirheumatic drug (DMARD) used in the treatment of patients with rheumatoid arthritis. Clinical trials with sulfasalazine have used an array of measures of disease activity, such as the number of tender and swollen joints, Ritchie articular index (RAI) and erythrocyte sedimentation rate (ESR). In randomised, double-blind, placebo-controlled trials, sulfasalazine was associated with statistically significant benefits for various measures of disease activity, according to results of individual trials and/or meta-analysis. Sulfasalazine was associated with broadly similar efficacy to that of various other DMARDs in several randomised, double-blind, comparative trials. Promising results have also been demonstrated with sulfasalazine in combination with other DMARDs (e.g. methotrexate and hydroxychloroquine) in patients with early rheumatoid arthritis and in those with more established disease. Sulfasalazine was generally well tolerated in clinical trials, the most frequently reported adverse effects being adverse gastrointestinal effects, headache, dizziness and rash; myelosuppression can also occur. Sulfasalazine has a relatively short lag time until its onset of action and is often considered to be among the more efficacious traditional DMARDs. Based on considerations of safety, convenience and cost, many rheumatologists (particularly outside of the US) select sulfasalazine as initial therapy, although preferred first-line treatment options vary between countries.

Infliximab‐induced systemic lupus erythematosus

AbstractOnly six cases of clinical drug‐induced lupus (DIL) following infliximab initiation for rheumatoid arthritis and Crohn's disease are documented dispite studies indicating many patients develop asymptomatic antinuclear ANA (62%) and anti‐dsDNA (15%) antibodies. Our 43‐year‐old female patient with 25 years of RA had active synovitis despite combination sulfasalazine, leflunomide and methotrexate. She received infliximab (3 mg/kg) infusion with rapid resolution of synovitis and then again 2, 6 and 14 weeks later. At 21 weeks she developed acute DIL with typical clinical features and laboratory findings which resolved after 8 weeks of prednisolone treatment. New biologic therapies can not only suppress RA but potentiate clinical DIL.

Usage of the NF-kappaB inhibitor sulfasalazine as sensitizing agent in combined chemotherapy of pancreatic cancer.

Sulfasalazine is commonly used as an anti inflammatory agent and is known as a potent inhibitor of NF-kappaB. Some pancreatic carcinomas are characterized by a constitutively elevated NF-kappaB activity accounting for chemoresistance. To elucidate whether blockade of NF-kappaB activity with sulfasalazine is suitable for overcoming this chemoresistance in vivo, we employed a mouse model with subcutaneously xenotransplanted human Capan-1 pancreatic carcinoma cells. Fourteen days upon tumor inoculation, animals were randomized in 6 groups, receiving no treatment, treatment with gemcitabine or with etoposide, either alone or in combination with sulfasalazine, or with sulfasalazine alone. Two therapy regimens were given with a 7-day interval in between. Upon treatment with etoposide or gemcitabine alone, tumor sizes were moderately reduced to 65-68% and 50-65%, respectively, as compared to untreated tumors. Sulfasalazine alone only decreased temporarily the tumor sizes. Sulfasalazine in combination with gemcitabine showed only partially higher reduction in tumor sizes than gemcitabine alone, whereas the combination with etoposide reduced significantly the tumor sizes in all experiments (down to 20%). TUNEL-staining showed higher numbers of apoptotic cells in tumors from the combination groups, in particular with etoposide, and proliferation as indicated by Ki67 staining was strongly reduced. Furthermore, combined treatment of sulfasalazine with the cytostatic drugs led to a decreased blood vessel density. Immunohistochemical staining of the activated p65 subunit showed that sulfasalazine treatment abolished the basal NF-kappaB activity in tumor xenografts. These data imply that the well established anti-inflammatory drug sulfasalazine sensitizes pancreatic carcinoma cells to anti cancer drugs, in particular to etoposide in vivo by inhibition of NF-kappaB. This combined chemotherapy offers great potential for improved anti-tumor responses in pancreatic carcinomas.