Severe Cardiovascular Toxicity Research Articles

Cardiovascular toxicity with CTLA‐4 inhibitors in cancer patients: A meta‐analysis

AbstractBackgroundWith the emergence of cytotoxic T lymphocyte‐associated protein‐4 (CTLA‐4) inhibitors, the outcomes of patients with malignant tumors have improved significantly. However, the incidence of cardiovascular adverse events has also increased, which can affect tumor treatment. In this study, we evaluated the incidence and severity of adverse cardiovascular events caused by CTLA‐4 inhibitors by analyzing reported trials that involved CTLA‐4 inhibitor therapy.MethodsRandomized clinical trials published in English from January 1, 2013, to November 30, 2022, were searched using the Cochrane Library and PubMed databases. All included trials examined all grade and grades 3–5 cardiac and vascular adverse events. These involved comparisons of CTLA‐4 inhibitors to placebo, CTLA‐4 inhibitors plus chemotherapy to chemotherapy alone, CTLA‐4 inhibitors combined with PD‐1/PD‐L1 inhibitors to PD‐1/PD‐L1 inhibitors alone, and CTLA‐4 inhibitors plus target agent to PD‐1/PD‐L1 inhibitors plus target agent. The odds ratio (OR) and corresponding 95% confidence intervals (CIs) were calculated using the Mantel‐Haenszel method.ResultsOverall, 20 trials were included. CTLA‐4 inhibitors significantly increased the incidence of all‐grade cardiovascular toxicity (OR = 1.33, 95% CI: 1.00–1.75, p = 0.05). The incidence of all‐grade cardiovascular toxicity increased in malignant tumor patients who received single‐agent CTLA‐4 inhibitors (OR = 1.73, 95% CI: 1.13–2.65, p = 0.01), as well as the incidence rate of grades 3–5 cardiovascular adverse events (OR = 2.00, 95% CI: 1.08–3.70, p = 0.03). Compared with the non‐CTLA‐4 inhibitor group, CTLA‐4 inhibitors plus chemotherapy, PD‐1/PD‐L1 inhibitors, or target agent did not significantly affect the incidence of cardiac and vascular toxicity. The incidence of grades 3–5 cardiac failure, hypertension, pericardial effusion, myocarditis, and atrial fibrillation were much higher among patients exposed to CTLA‐4 inhibitor, but the data were not statistically significant.ConclusionOur findings suggest that the incidence rate of all cardiovascular toxicity and severe cardiovascular toxicity increased in patients who were administered CTLA‐4 inhibitors. In addition, the risk of serious cardiovascular toxic events was independent of the type of adverse event. From these results, physicians should assess the benefits and risks of CTLA‐4 inhibitors when treating malignancies.

SGK1 is involved in doxorubicin-induced chronic cardiotoxicity and dysfunction through activation of the NFκB pathway

Breast cancer is the predominant cancer among women worldwide, and chemotherapeutic agents, such as doxorubicin (DOX), have the potential to significantly prolong survival, albeit at the cost of inducing severe cardiovascular toxicity. Inflammation has emerged as a crucial biological process contributing to the remodeling of cardiovascular toxicity. The role of serum glucocorticoid kinase 1 (SGK1) in various inflammatory diseases has been extensively investigated. Here, we studied the molecular mechanisms underlying the function of SGK1 in DOX-induced cardiotoxicity in HL-1 cardiomyocyte cell lines and in a tumor-bearing mouse model. SGK1 was upregulated in the DOX-induced cardiotoxicity model, accompanied by increased levels of inflammatory factors. Furthermore, inhibition of SGK1 suppresses the phosphorylation of nuclear factor-kappa B (NFκB) in cardiomyocytes, which inhibits the production of inflammatory factors and apoptosis of cardiomyocytes, and has cardioprotective effects. Simultaneously, small interfering RNA targeting SGK1 inhibited the proliferation of breast cancer cells. Conversely, overexpression of SGK1 increases the phosphorylation of NFκB and aggravates myocardial injury. In conclusion, our study demonstrates that SGK1 promotes DOX-induced cardiac inflammation and apoptosis by promoting NFκB activity. Our results indicate that inhibiting SGK1 might be an effective treatment strategy that can provide both tumor-killing and cardioprotective functions. Further in vivo research is needed to fully elucidate the effects and mechanisms of combination therapy with SGK1 inhibitors and DOX in breast cancer treatment.

Abstract 17489: Bupropion Poisoning: Extracorporeal Membrane Oxygenation as a Rescue Strategy

Introduction: Bupropion is a commonly prescribed antidepressant. Although generally well-tolerated, bupropion overdose can lead to severe cardiovascular and neurological toxicity. We present a case of cardiogenic shock and status epilepticus as a result of bupropion intoxication. Case Presentation: A 29-year-old female with history of depression and borderline personality disorder presented to the emergency department unresponsive after ingesting large quantities of bupropion, alprazolam and lisdexamfetamine. Vital signs were unremarkable and physical exam revealed pupil asymmetry. CT head was unremarkable. Urine toxicology was positive for amphetamines and benzodiazepines, with a blood alcohol level of 104. QTc was 522. Patient received versed for status epilepticus and was placed on mechanical ventilation. She developed sustained ventricular tachycardia and hypotension, unresponsive to bicarbonate and amiodarone. The patient was placed on venoarterial extracorporeal membrane oxygenation (VA ECMO) to provide hemodynamic support while eliminating bupropion from circulation. Following repeated episodes of VT, the patient was successfully cardioverted and started on amiodarone. TTE demonstrated left ventricular ejection fraction (LVEF) of <30%. Notably, lipid emulsion therapy was not administered as patient stabilized with ECMO support. After 48 hours of electrical stability, she was weaned off ECMO and inotropes and transitioned to guideline-directed medical therapy. Repeat TTE demonstrated LVEF of 60% on day 12. Mental status improved and patient was admitted to psychiatry with outpatient cardiology follow-up. Discussion: Bupropion overdose can cause prolonged QTc, ventricular arrhythmias, and seizures. Cardiotoxicity results from inhibition of gap junction ion channels, compromising conduction and contractility. Various approaches, including ECMO and lipid emulsion therapy, have been effectively employed in such cases. This case demonstrates that ECMO can serve as a hemodynamic bridge during the elimination of bupropion while augmenting its clearance via increased flow, underscoring the benefits of mechanical circulatory support in cases of intoxication affecting cardiac contractility and conduction.

Rising prescription stimulant poisoning in Australia: a retrospective case series

With rising therapeutic use worldwide, prescription stimulants are increasingly implicated in poisonings. Most of the limited research on stimulant poisoning focuses on illicit amphetamines. We aimed to investigate the clinical effects of intentional prescription stimulant poisoning. This is a retrospective review of hospitalised patients referred to a Poisons Information Centre and a toxicology unit following intentional exposures to prescription stimulants (dexamfetamine, lisdexamfetamine and methylphenidate) from 1 January 2018 through 31 December 2021. Patients were identified from both units’ databases and data extracted from medical records. To facilitate comparison a dexamfetamine-equivalent dose was calculated. There were 186 intentional exposures in 178 patients (median age 17 years, males 54%) over the study period, consisting of 44 (24%) dexamfetamine, 50 (27%) lisdexamfetamine and 92 (49%) methylphenidate exposures. Stimulant exposures rose annually from 34 presentations in 2018 to 61 in 2021. Deliberate self-poisoning accounted for 139 (75%) presentations and the remaining 47 (25%) were recreational. Co-ingestions were taken in 101 (54%) presentations, leaving 85 (46%) single-agent exposures with a median dexamfetamine-equivalent dose ingested of 135 mg (range 15-4500 mg). Of the single-agent exposures tachycardia (69%), hypertension (47%) and agitation (58%) were the commonest clinical features. Most patients (58%) had mild-moderate symptoms, managed solely with supportive cares or oral sedation. Twenty-three (27%) patients had severe agitation receiving parenteral sedation. Rhabdomyolysis occurred in 3 single-agent exposures (4%) and 8 (9%) had an acute kidney injury. Severe cardiovascular toxicity was rare, with one patient developing hypertensive crisis and another having a supraventricular tachycardia. The median length of stay for single-agent exposures was 11 h (IQR 5-19 h). Prescription stimulant poisoning appears to be rising and commonly results in tachycardia, hypertension, and agitation. Severe cardiovascular toxicity was rare.

Cardiovascular Toxicity of Proteasome Inhibitors: Underlying Mechanisms andManagement Strategies: JACC: CardioOncology State-of-the-Art Review.

Proteasome inhibitors (PIs) are the backbone of combination treatments for patients with multiple myeloma and AL amyloidosis, while also indicated in Waldenström's macroglobulinemia and other malignancies. PIs act on proteasome peptidases, causing proteome instability due to accumulating aggregated, unfolded, and/or damaged polypeptides; sustained proteome instability then induces cell cycle arrest and/or apoptosis. Carfilzomib, an intravenous irreversible PI, exhibits a more severe cardiovascular toxicity profile as compared with the orally administered ixazomib or intravenous reversible PI such as bortezomib. Cardiovascular toxicity includes heart failure, hypertension, arrhythmias, and acute coronary syndromes. Because PIs are critical components of the treatment of hematological malignancies and amyloidosis, managing their cardiovascular toxicity involves identifying patients atrisk, diagnosing toxicity early at the preclinical level, and offering cardioprotection if needed. Future research isrequired to elucidate underlying mechanisms, improve risk stratification, define the optimal management strategy, and develop new PIs with safecardiovascular profiles.

Clinical Features and Outcomes of Immune Checkpoint Inhibitor-Associated Cardiovascular Toxicities.

Despite the increasing prevalence of therapies utilizing immune checkpoint inhibitors (ICIs), the associated cardiovascular complications have been poorly reported. Given the fatality of ICI-related complications, especially myocarditis, optimal risk stratification to predict major adverse cardio- and cerebrovascular events (MACCEs) in patients receiving ICIs is mandatory. We collected clinical data from patients receiving ICIs, and the primary outcomes were MACCEs, including myocarditis, heart failure, and ischemic stroke. Other systemic immune responses relating to ICIs were also recorded. The median follow-up duration was 3 years. Among 580 patients, the incidence of MACCEs was 3.9%. Older patients, male patients, and patients with lung cancer, liver cirrhosis, or diabetes had higher risks of MACCEs. There was no significant difference between the use of PD-1/PD-L1 inhibitors or CTLA inhibitors in terms of developing cardiovascular toxicities. The development of ICI-related MACCEs was associated with worse survival. Notably, after re-review by specialists, three patients eventually diagnosed with ICI-related myocarditis had not previously been identified. Only one was treated with pulse steroids, and none survived. The most common concomitant extracardiac immune-related adverse events were myositis/dermatitis, endocrine toxicity and hepatitis. Collectively, ICIs may lead to severe cardiovascular toxicities and require more attention. Early identification, proper diagnosis, and prompt treatment are pivotal for improving survival.

Hemoglobin Changes during Long-Lasting Frontline Treatment with Tyrosine-Kinase Inhibitors in Patients with Chronic Myeloid Leukemia

Introduction Chronic Myeloid Leukemia (CML) has become highly curable after introduction of Tyrosine-Kinase Inhibitors (TKIs). However, several side-effects have been reported with the prolonged use of TKIs: in particular, severe cardiovascular and pulmonary toxicities were observed with 2 nd generation TKIs (2G-TKIs), nilotinib and dasatinib. Imatinib is generally considered safer, even if some concerns were recently raised on its renal toxicity and occurrence of late anemia.Aims To evaluate the impact of imatinib compared to 2G-TKIs on the hemoglobin (Hb) levels in the long-lasting frontline treatment of CML patients.Methods From 1/2002 to 12/2015, 365 CML patients were diagnosed and treated frontline with TKIs in 2 different Centres in Italy: of them, 123 permanently discontinued the treatment before the 5 th year from the start due to intolerance (31 cases, 25.2%), primary resistance (41, 33.3%), secondary resistance (16, 13.0%), blastic evolution (4, 3.2%), unrelated death (12, 9.8%) or were lost to follow-up (19, 15.5%). At 5 years, the remaining 242 patients were still receiving frontline TKI treatment and were considered for the present analysis. Hb levels were recorded at baseline and thereafter every 12 months up to the 5 th year of treatment.Results As to frontline treatment, 186 patients (76.8%) received imatinib and 56 (23.2%) 2G-TKIs (nilotinib in 44 cases and dasatinib in 12, respectively). The main clinical features at diagnosis of the entire cohort and according to frontline treatment are reported in the table: median Hb value at baseline was significantly lower in patients treated with 2G-TKIs. Median Hb values at different time-points according to frontline treatment are reported in the Figure. In patients treated with imatinib, median Hb levels at 12 th (12.5 g/dl, IQR 11.6-13.5) and 60 th month (12.4 g/dl, IQR 11.4-13.3) were stable compared to baseline (12.8 g/dl, IQR 11.3-13.8) (p=0.248 and p=0.075, respectively). On the contrary, median Hb levels at 12 th (13.4 g/dl, IQR 12.2-14.3) and 60 th month (13.6 g/dl, IQR 12.0-14.6) showed a significant increase compared to baseline (11.8 g/dl, IQR 10.6-13.7) in patients treated with 2G-TKIs (p<0.001 in both cases). As a consequence, during the treatment median Hb values became significantly higher at any different time-point in patients treated with 2G-TKIs compared to patients treated with imatinib (p=0.005 at the 12 th month, p=0.010 at the 60 th month). At baseline, the rate of patients with mild to moderate anemia (Hb < 11 g/dl) was significantly lower in those treated with imatinib [34/186 (18.2%) vs 20/56 (35.7%) treated with 2G-TKIs, p=0.006]: at the 12 th month, no difference was observed [15/186 (8.0%) in patients treated with imatinib vs 3/56 (5.3%) in patients treated with 2G-TKIs, p=0.498], while at the 60 th months the rate of patients with mild to moderate anemia became significantly higher in those treated with imatinib [29/186 (15.6%) vs 2/56 (3.6%) treated with 2G-TKI, p=0.018].Conclusions Present data highlight that long-lasting treatment with imatinib can have a negative late effect on erythropoiesis, with incomplete recovery of hemoglobin levels and occurrence of late anemia in about 15% of patients at the 60 th month of therapy.This possible adverse event, which is still unrecognized and seems very rare with 2G-TKIs, could affect quality of life and should be recognized in the long-term management of CML patients. [Display omitted] DisclosuresLatagliata: BMS Cellgene: Honoraria; Pfizer: Honoraria; Novartis: Honoraria. Martelli: Novartis: Other: advisory board; Gilead: Other: advisory board. Breccia: Pfizer: Honoraria; Novartis: Honoraria; Incyte: Honoraria; Bristol Myers Squibb/Celgene: Honoraria; Abbvie: Honoraria.

Safety and heart rate changes in Covid-19 patients treated with Remdesivir

ObjectivesLimited data are available regarding the occurrence and the extent of cardiac rhythm disturbances in patients with COVID-19 treated with Remdesivir. MethodsWe present a case series of 52 patients who underwent daily electrocardiogram (ECG) examination after Remdesivir administration. ResultsCompared to baseline, a significant heart rate reduction was observed after initiation of Remdesivir; however, no case of severe bradycardia or arrhythmias leading to significant clinical complications or Remdesivir discontinuation occurred. Heart rate reduction was proportional to baseline heart rate values (r=0.75, p<0.001). By multivariate analysis, a less severe clinical presentation of Covid-19 (beta=0.47, p<0.01) was related to lower heart rate levels observed after Remdesivir administration. ConclusionsDespite a significant reduction in heart rate observed after Remdesivir administration, no severe cardiovascular toxicity was observed in Covid-19 patients, even in the case of cardiovascular comorbidities.

Aconitine Induces TRPV2-Mediated Ca2+ Influx through the p38 MAPK Signal and Promotes Cardiomyocyte Apoptosis.

Aconitine is the main effective component of traditional Chinese medicine Aconitum, which has been proved to have severe cardiovascular toxicity. The toxic effect of aconitine on cardiomyocytes is related to intracellular calcium overload, but the mechanism remains unclear. The aim of this study was to explore the mechanism of aconitine inducing intracellular Ca2+ overload and promoting H9c2 cardiomyocyte apoptosis through transient receptor potential cation channel subfamily V member 2 (TRPV2). After treated with different concentrations of aconitine, the level of cell apoptosis, intracellular Ca2+, and expression of p-p38 MAPK and TRPV2 of H9c2 cardiomyocytes were detected. The results showed that aconitine induced Ca2+ influx and H9c2 cardiomyocyte apoptosis in a dose-dependent manner and promoted p38 MAPK activation as well as TRPV2 expression and plasma membrane (PM) metastasis. siTRPV2, tranilast, and SB202190 reversed intracellular Ca2+ overload and H9c2 cardiomyocyte apoptosis induced by aconitine. These results suggested that aconitine promoted TRPV2 expression and PM metastasis through p38 MAPK signaling, thus inducing intracellular Ca2+ overload and cardiomyocyte apoptosis. Furthermore, TRPV2 is a potential molecular target for the treatment of aconitine poisoning.

Novel Presentation of Cardiotoxicity and Other Complications in Tricyclic Antidepressant Poisoning

Tricyclic antidepressant (TCA) is a known frequently used and highly potent antidepressant that serves as an unsuspecting source of acute human poisoning. We present a case of an Asian female in her mid-30s who suffered TCA toxidrome that manifested as severe cardiovascular toxicities including arrhythmia characterized by QT elongation that was managed emergently. Hemodynamics and ECG findings improved gradually following appropriate therapy in the intensive care unit. Following two days of treatment, the patient regained consciousness and after seven days the patient made a full clinical recovery and was discharged with no residual neurological effects. The relevant medical literature on TCA poisoning is reviewed.

Resuscitation Following a Bupivacaine Injection for a Cervical Paravertebral Block.

BackgroundCardiac arrest related to nerve blockade using a local anaesthetic is a rare event. We report a case of bupivacaine severe cardiovascular toxicity following cervical paravertebral nerve block.Case presentationA 44-year-old female was admitted to Republican Vilnius University Hospital, with symptoms of sustained severe pain in her neck that radiated to both arms. Multiple cervical intervertebral hernias with spinal stenosis were confirmed by magnetic resonance imaging. Following infiltration of the subcutaneous tissue with a 0.5 % bupivacaine solution, an 18-gauge spinal needle was used to perform the paravertebral block at the C6 level. Bupivacaine was injected in incremental doses to a total of 10 mL. Rapid loss of consciousness and cardiovascular collapse suggested a neuraxial injection of bupivacaine. Long-lasting cardiopulmonary resuscitation, including chest compressions, defibrillation attempts for refractory ventricular fibrillation, medications, mechanical ventilation, and intravenous lipid emulsion infusion, was successful. No severe adverse outcomes other than acute kidney injury and chest pain related to prolonged chest compressions were documented.ConclusionsThis case report emphasizes the necessity of ensuring adequate safety precautions to avoid local anaesthetic systemic toxicity. Lipid emulsion preparations should be available in all hospital settings where local anaesthetics are used for regional anaesthesia or pain management.

Pharmacological characterization of the aminorex analogs 4-MAR, 4,4′-DMAR, and 3,4-DMAR

4,4′-Dimethylaminorex (4,4′-DMAR) is a novel psychoactive substance (NPS) that appeared on the illicit drug market in addition to the psychostimulant 4-methylaminorex (4-MAR). Both substances are methylated derivatives of aminorex, an amphetamine-like anorectic used in the 1960ies and withdrawn from the marked due to severe cardiovascular toxicity. The aim of the present study was to characterize the in vitro pharmacological profiles of 4-MAR, 4,4′-DMAR, and 3,4-dimethylaminorex (3,4-DMAR, direx). We assessed norepinephrine (NE), dopamine (DA), and serotonin (5-HT) transporter inhibition potencies and monoamine release in transporter-transfected human embryonic kidney (HEK) 293 cells. We also assessed monoamine receptor and transporter binding affinities. 4,4′-DMAR potently inhibited all monoamine transporters (IC50<1 μM) with greater potency than 3,4-methlyenedioxymethamphetaime (MDMA) and displayed a higher serotonergic over dopaminergic preference, relatively similar to MDMA (DA transporter / 5-HT transporter inhibition ratio of 0.4 and 0.08 for 4,4′-DMAR and MDMA, respectively). In contrast, 4-MAR preferentially inhibited the NE and DA transporter, exhibiting a pharmacological profile more similar to amphetamine. Both 4-MAR and 4,4′-DMAR were also substrate releasers at the DAT. 3,4-DMAR only weakly inhibited the NE transporter and showed no relevant activity at the DA and 5-HT transporter. Binding affinities of all three aminorex derivatives at various monoamine receptors were negligible (Ki values >2 μM). The in vitro pharmacological profiles indicate that 4,4′-DMAR has comparable psychoactive properties and serotonergic toxicity to MDMA and may be more potent. 4-MAR is a psychostimulant similar to amphetamine or methamphetamine. 3,4-DMAR likely has only weak psychostimulant properties.

High-mobility group box 1 protein-mediated necroptosis contributes to dasatinib-induced cardiotoxicity

Dasatinib shows remarkable activity against imatinib-refractory chronic myelogenous leukemia (CML) and Philadelphia chromosome positive acute lymphoblastic leukemia (Ph+ALL). However, severe cardiovascular toxicity limits the clinical applications of dasatinib. Since the underlying mechanism of dasatinib-induced cardiotoxicity is still elusive, we aim to clarify this. Recent studies have shown that necroptosis and apoptosis participate in multiple toxicity development. Here, we first report that dasatinib could directly induce cardiomyocytes death, as analyzed by the Sulforhodamine B (SRB) assay. This type of cardiomyocytes death was mediated by the necrosis pathway rather than apoptosis, as determined by using flow cytometry to characterize the mode of dasatinib-induced cell death. Inhibition of receptor-interacting protein kinase 1 (RIP1)activity and knockdown of receptor-interacting protein kinase 3 (RIP3)expression can block dasatinib-evoked cardiotoxicity, which further confirmed the involvement of necroptosis. We next found that the classic substrates of RIP3, mixed lineage kinase domain-like protein (MLKL) and Ca2+-calmodulin-dependent protein kinase II (CaMKII) were not involved in dasatinib-induced cardiomyocytes necroptosis. What’s more, unlike the inflammation-associated necroptosis, dasatinib-triggered necroptosis was dependent on intracellular instead of secreted High-mobility group box 1 (HMGB1) protein. Collectively, our study revealed that dasatinib-induced cardiotoxicity acted via leading cardiomyocytes to HMGB1-mediated necroptosis, indicating a viable strategy for prevention of dasatinib-induced cardiotoxicity.

Alkynylnicotinamide-Based Compounds as ABL1 Inhibitors with Potent Activities against Drug-Resistant CML Harboring ABL1(T315I) Mutant Kinase.

The introduction of imatinib into the clinical scene revolutionized the treatment of chronic myelogenous leukemia (CML). The overall eight-year survival rate for CML has increased from about 6 % in the 1970s to over 90 % in the imatinib era. However, about 20 % of CML patients harbor primary or acquired resistance to tyrosine kinase inhibitors. ABL1 point mutations in the BCR-ABL1 fusion protein, such as ABL1(T315I), typically emerge after prolonged kinase inhibitor treatment. Ponatinib (AP24534) is currently the only approved CML drug that is active against the ABL1(T315I) mutation. However, ponatinib has severe cardiovascular toxicities; hence, there have been efforts to find safer CML drugs that work against ABL1 secondary mutations. We reveal that isoquinoline- or naphthyridine-based compounds, such as HSN431, HSN576, HSN459, and HSN608 potently inhibit the enzymatic activities of ABL1, ABL1(T315I), and ABL1(E255K). These compounds inhibit the proliferation of ABL1-driven CML cell lines, K652 and KCL22 as well as the drug-resistant cell line, KCL22-IR, which harbors the secondary mutated ABL1(T315I) kinase.

Estrogen therapy in patients with prostate cancer: a contemporary systematic review

To evaluate the effectiveness and harms of DES in treating prostate cancer compared to other forms of androgen deprivation therapy (orchiectomy, LHRH agonists, and anti-androgens). We included clinical trials comparing DES with other forms of ADT (bicalutamide, flutamide, LHRH agonists, or orchiectomy) in PCa treatment. The primary outcomes were overall survival, cancer-specific survival, and progression-free survival, and secondary outcomes were cardiovascular effects. We searched in MEDLINE, EMBASE, Central, and Lilacs from inception to nowadays and saturated information for unpublished data in other sources. We performed a qualitative analysis of all included studies. It was not possible to perform meta-analysis due to low-quality trials and high heterogeneity. Overall, 1700 references were scanned and 14 prospective randomized trials with a total of 3986 patients were included in the final analysis. Although trials showed DES as similarly effective to another forms of ADT, evidences about cardiovascular toxicity in out of date high doses have discouraged its use. In doses of 1mg, DES has been used as secondary line PCa treatment with safety. DES might be similarly effective to other forms of ADT on advanced PCa patients, with potential important roles. Intriguingly, the burden of severe cardiovascular toxicity is mainly related to old-fashioned doses of 5.0 and 3.0mg. Modern PCa hormonal knowledge warrants stout high-quality prospective randomized trials in the low-dose 1mg DES scenario.

Bevacizumab+chemotherapy versus chemotherapy alone in elderly patients with untreated metastatic colorectal cancer: a randomized phase II trial—PRODIGE 20 study results

BackgroundMetastatic colorectal cancer frequently occurs in elderly patients. Bevacizumab in combination with front line chemotherapy (CT) is a standard treatment but some concern raised about tolerance of bevacizumab for these patients. The purpose of PRODIGE 20 was to evaluate tolerance and efficacy of bevacizumab according to specific end points in this population.Patients and methodsPatients aged 75 years and over were randomly assigned to bevacizumab + CT (BEV) versus CT. LV5FU2, FOLFOX and FOLFIRI regimen were prescribed according to investigator’s choice. The composite co-primary end point, assessed 4 months after randomization, was based on efficacy (tumor control and absence of decrease of the Spitzer QoL index) and safety (absence of severe cardiovascular toxicities and unexpected hospitalization). For each arm, the treatment will be consider as inefficient if 20% or less of the patients met the efficacy criteria and not safe if 40% or less met the safety criteria.ResultsAbout 102 patients were randomized (51 BEV and 51 CT), median age was 80 years (range 75–91). Primary end point was met for efficacy in 50% and 58% and for safety in 61% and 71% of patients in BEV and CT, respectively. Median progression-free survival was 9.7 months in BEV and 7.8 months in CT. Median overall survival was 21.7 months in BEV and 19.8 months in CT. The 36-month overall survival rate was 27% in BEV and 10.1% in CT. Severe toxicities grade 3/4 were mainly non-hematologic toxicities (80.4% in BEV, 63.3% in CT).ConclusionBevacizumab combined with CT was safe and efficient. Both arms met the primary safety and efficacy criteria.

Fatalities, Cerebral Hemorrhage, and Severe Cardiovascular Toxicity After Exposure to the New Psychoactive Substance 4-Fluoroamphetamine: A Prospective Cohort Study

We study adverse health effects after use of the new psychoactive substance 4-fluoroamphetamine. All patients who reported 4-fluoroamphetamine exposure and for whom the Dutch Poisons Information Center was consulted by their physician in 2016 were included in a prospective cohort study. The clinical course was investigated through telephone interviews with the physician and/or patient, using standardized questionnaires. 4-Fluoroamphetamine was analyzed in remaining drug material and biological samples with liquid and gas chromatography-mass spectrometry techniques. We included 45 patients, and follow-up with the physician and/or patient was performed in 33 cases. All patients experienced adverse effects after 4-fluoroamphetamine use. Severe toxicity was reported in 8 patients. In 5 of these patients, 4-fluoroamphetamine exposure was confirmed in biological specimens. Severe toxicity that was reported included 2 fatalities, 4 patients with cerebral hemorrhage (1 fatal), 2 patients with inverted Takotsubo's cardiomyopathy, 1 patient with myocardial infarction, 1 patient with acute heart failure, and an overall high prevalence of pronounced hypertension and tachycardia. Since the introduction of 4-fluoroamphetamine to the Dutch drug market in 2007, its use continues to increase, possibly because users perceive it as "ecstasy light" and thus relatively safe. However, the proportion of patients with severe toxicity after 4-fluoroamphetamine use is relatively large in our study population. Therefore, users should be warned about the risks of 4-fluoroamphetamine.

Redox-responsive PEGylated self-assembled prodrug-nanoparticles formed by single disulfide bond bridge periplocymarin-vitamin E conjugate for liver cancer chemotherapy

Periplocymarin (PPM), a cardiac glycoside, has a narrow therapeutic index, poor tumor selectivity and severe cardiovascular toxicity which hinder its wide clinical applications in cancer treatment. Herein, we report novel redox-responsive prodrug-nanoparticles (MPSSV-NPs) self-assembled by co-nanoprecipitation of PPM-vitamin E conjugate and a PEG derivative of linoleate (mPEG2000-LA) in water. It was found that the characteristics of PPM-vitamin E nanoparticles (PSSV-NPs) were improved through co-nanoprecipitation with increased percentages of mPEG2000-LA. Moreover, the MPSSV-NPs were optimized according to the in vitro release and cytotoxicity study. Furthermore, the optimized MPSSV-NPs dramatically enhanced the circulation time and tumor distribution of PSSV-NPs after single intravenous injection. The in vivo studies in malignant H22-bearing mice revealed that MPSSV-NPs could effectively suppress tumor growth without causing obvious systemic toxicity. Altogether, these results suggested that MPSSV-NPs could offer a safe, multifunctional and viable nanoplatform for cardiac glycosides in cancer treatment.

Octreotide-periplocymarin conjugate prodrug for improving targetability and anti-tumor efficiency: synthesis, in vitro and in vivo evaluation.

Cardiac glycosides could increase intracellular Ca2+ ion by inhibiting the Na+/K+ATPase to induce apoptosis in many tumor cells. However, narrow therapeutic index, poor tumor selectivity and severe cardiovascular toxicity hinder their applications in cancer treatment. To improve the safety profile and tumor targetablility of cardiac glycosides, we designed octreotide conjugated periplocymarin, a cardiac glycoside isolated from Cortex periplocae. The conjugate showed higher cytotoxicity on MCF-7 cells and HepG2 tumor cells (SSTRs overexpression) but much less toxicity in L-02 normal cells. Tissue distribution studies of the conjugate using H22 tumor model in mice showed higher accumulation in tumor and lower distribution in heart and liver than periplocymarin. Furthermore, in vivo anticancer effects of the conjugate on mice bearing H22 cancer xenografts confirmed enhanced anti-tumor efficacy and decreased systemic toxicity. Altogether, octreotide-conjugated periplocymarin demonstrated tumor selectivity and may be useful as a targeting agent to improve the safety profile of cardiac glycosides for cancer therapy.

Poly (caprolactone) microparticles and chitosan thermogels based injectable formulation of etoricoxib for the potential treatment of osteoarthritis

This study aimed to evaluate Poly (caprolactone) microparticles (MPs) loaded composite injectable Chitosan gel (CICGs) as a dual purpose (visco-supplement and intra articular drug delivery depot) therapeutic agent for the treatment of Osteoarthritis. Etoricoxib (COX-2 inhibitor), a highly hydrophobic drug was chosen as a model drug for the study. When administered orally, Etoricoxib poses severe cardiovascular toxicity issues. So, we have attempted to deliver this drug intra-articularly, which could retain the drug longer in the joint region and thus could ameliorate these toxicity issues. CICGs were prepared by dispersing MPs in the chitosan-Ammonium hydrogen phosphate solution and incubated at 37°C. Rheology studies proved that gels were stable and had visco-elastic properties comparable to that of existing visco-supplements. The in vitro drug release profiles of CICGs were found to be more controlled when compared to MPs and bare chitosan gel (BCGs). In vitro and in vivo biocompatibility studies proved that the gels were biocompatible. In vivo synovial drug clearance studies proved that CICGs had a better drug retention capacity than BCGs and MPs. In vivo fluorescence imaging results confirmed that CICGs could stay longer in the joint region when compared to BCGs and MPs. Thus this novel CICGs could be a potential dual purpose gel for the treatment of diseased joint regions especially for Osteoarthritis.