Subcutaneous Granulocyte-macrophage Colony-stimulating Factor Research Articles

Cytokines in liposomes: Preliminary studies with IL-1, IL-2, IL-6, GM-CSF and interferon-γ

A simple, generally applicable method to incorporate cytokine proteins into multilamellar liposomes is presented. A variety of human cytokines including granulocyte-macrophage colony stimulating factor (GM-CSF), interleukins 1α, 2 and 6 (IL-1α, IL-2, IL-6) and interferon-γ (IFN-γ) were incorporated into liposomes containing a single saturated synthetic lipid, dimyristoyl phosphatidyl choline (DMPC). Sterile cytokine liposomes were produced by gamma irradiation of DMPC lipid powder prior to use in cytokine liposome synthesis. A highly sensitive and reliable fluorescamine assay to detect microgram quantities of cytokine protein associated with liposomes is also described. When a high lipid:aqueous ratio [e.g. 300 mg DMPC lipid:1.0 ml aqueous cytokine solution] was utilized, aqueous cytokines (1 mg/ml) could be incorporated with efficiencies ranging from 19% (IL-1) to >80% (IL-2). Combinations of cytokines (e.g. IL-2 + GM-CSF) were also co-incorporated into liposomes. Experiments with IL-2, IL-6, and GM-CSF demonstrated that these cytokines remain stably associated with the DMPC lipid and do not significantly leak from liposomes when stored at 4°C for at least 3 months. Washing IL-6 liposome or GM-CSF liposome preparations reliably increased the proportion of cytokine protein associated with the liposome pellet compared to free cytokine in the supernatant of centrifuged specimens. For example the proportion of GM-CSF associated with the lipid carrier increased from 34.8% (SD 2.6%) in the original preparation to 98.0% (SD 0.6%) after three washes. Differences in the pharmacokinetics of subcutaneous (sc) free GM-CSF and GM-CSF liposomes (14 mcg/mouse) were studied in BALB/c mice. Both free GM-CSF and free GM-CSF mixed with saline loaded liposomes exhibited biphasic pharmacokinetics with very high peak levels 1 and 2 h after sc injection of 14 mcg the rapid decline to very low levels after 24 h. In contrast, sc GM-CSF liposomes provided sustained and stable levels of cytokine in the serum (≈100 pg/ml) for 24 h. Intraperitoneal injection of GM-CSF liposomes had > 10-fold more cytokine in the peritoneal wash than free GM-CSF mixed with saline loaded liposomes. In summary, the liposome synthesis procedure described is simple and utilizes a single synthetic lipid to reliably produce sterile cytokine preparations with in vivo depot effects after either sc or ip administration. Furthermore, the method is feasible for quantities of sterile cytokine liposomes sufficient for in vivo experiments.

Recall of Cutaneous Toxicity From Fluorouracil

To the Editor.— Fluorouracil administered as a single agent has been the standard therapy for patients with metastatic colorectal carcinoma. This chemotherapeutic agent has multiple cutaneous side effects. We report a case of reactivation or recall of a previous toxic cutaneous reaction resulting from intravenous fluorouracil. This occurred in a patient with metastatic gastrointestinal carcinoma who received several cycles of intravenous fluorouracil and/or leucovorin followed by daily subcutaneous granulocyte-macrophage colony-stimulating factor. With each successive cycle, a more severe toxic erythema developed on the arm receiving the infusion. When the infusion site was switched to the opposite limb, a cutaneous flare occurred not only on the arm currently receiving the infusion but on the previously reactive, resting arm. Report of a Case.— A 43-year-old white man with adenocarcinoma of the colon (stage D) was entered in a phase I protocol of intravenous bolus fluorouracil (490 mg/m 2 ) and leucovorin calcium (500

Recombinant human granulocyte-macrophage colony-stimulating factor ameliorates zidovudine-induced neutropenia in patients with acquired immunodeficiency syndrome (AIDS)/AIDS-related complex

To evaluate the effect of recombinant granulocyte-macrophage colony-stimulating factor (GM-CSF) on patients with acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC) who were intolerant to zidovudine because of neutropenia, we performed a randomized, open-label study in which patients were assigned to one of two groups. Zidovudine was discontinued in group A patients before instituting GM-CSF treatment and was restarted in a graduated fashion over 4 weeks. Group B patients continued on full-dose (1,200 mg/d) zidovudine therapy while beginning GM-CSF therapy. A total of 17 patients were entered, eight in group A and nine in group B. Five of eight patients in group A and seven of nine in group B had a history of Pneumocystis carinii pneumonia (PCP). All were homosexual males, except one female in group A who was the sex partner of a bisexual male with AIDS. All patients had neutropenia (absolute neutrophil count [ANC] less than 1,000/microL) while taking full-dose zidovudine. The mean CD4 (+/- SD) lymphocyte level was 37 (+/- 29)/microL and 39 (+/- 44)/microL in groups A and B, respectively. After randomization, patients were begun on subcutaneous GM-CSF at a dose of 1.0 microgram/kg/d. Patients in group A received 2 weeks of daily GM-CSF, at which time zidovudine was restarted if the ANC was greater than 1,000/microL; if the ANC was less than 1,000/microL, the dose of GM-CSF was increased to 3.0 micrograms/kg, and at 2-week intervals either zidovudine was restarted or the dose of GM-CSF was increased to 5 micrograms/kg and then 10 micrograms/kg, to maintain the ANC greater than 1,000/microL. Group B patients received full-dose zidovudine concurrently with GM-CSF administration. The dose of GM-CSF was increased every 2 weeks if necessary to keep the ANC greater than 1,000/microL while maintaining full-dose zidovudine therapy. Patients in each group showed an increase in total white blood cell (WBC) count. Neutrophils and eosinophils were responsible for the majority of this increase. Patients in group A had a more rapid increase in WBC than those in group B; however, by week 8, the WBC in each group was essentially equal. Viral replication as measured by human immunodeficiency virus (HIV) p24 antigen (Ag) was decreased in four patients in each group, increased in one patient in each group, and remained unchanged in the remainder. The ability to culture virus from peripheral blood mononuclear cells was not changed by the regimen. The major toxicities of the regimen were fever and malaise.(ABSTRACT TRUNCATED AT 400 WORDS)

Recombinant Human Granulocyte-Macrophage Colony-Stimulating Factor Ameliorates Zidovudine-Induced Neutropenia in Patients With Acquired Immunodeficiency Syndrome (AIDS)/AIDS-Related Complex

Abstract To evaluate the effect of recombinant granulocyte-macrophage colony- stimulating factor (GM-CSF) on patients with acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC) who were intolerant to zidovudine because of neutropenia, we performed a randomized, open- label study in which patients were assigned to one of two groups. Zidovudine was discontinued in group A patients before instituting GM- CSF treatment and was restarted in a graduated fashion over 4 weeks. Group B patients continued on full-dose (1,200 mg/d) zidovudine therapy while beginning GM-CSF therapy. A total of 17 patients were entered, eight in group A and nine in group B. Five of eight patients in group A and seven of nine in group B had a history of Pneumocystis carinii pneumonia (PCP). All were homosexual males, except one female in group A who was the sex partner of a bisexual male with AIDS. All patients had neutropenia (absolute neutrophil count [ANC] less than 1,000/microL) while taking full-dose zidovudine. The mean CD4 (+/- SD) lymphocyte level was 37 (+/- 29)/microL and 39 (+/- 44)/microL in groups A and B, respectively. After randomization, patients were begun on subcutaneous GM-CSF at a dose of 1.0 microgram/kg/d. Patients in group A received 2 weeks of daily GM-CSF, at which time zidovudine was restarted if the ANC was greater than 1,000/microL; if the ANC was less than 1,000/microL, the dose of GM-CSF was increased to 3.0 micrograms/kg, and at 2-week intervals either zidovudine was restarted or the dose of GM-CSF was increased to 5 micrograms/kg and then 10 micrograms/kg, to maintain the ANC greater than 1,000/microL. Group B patients received full-dose zidovudine concurrently with GM-CSF administration. The dose of GM-CSF was increased every 2 weeks if necessary to keep the ANC greater than 1,000/microL while maintaining full-dose zidovudine therapy. Patients in each group showed an increase in total white blood cell (WBC) count. Neutrophils and eosinophils were responsible for the majority of this increase. Patients in group A had a more rapid increase in WBC than those in group B; however, by week 8, the WBC in each group was essentially equal. Viral replication as measured by human immunodeficiency virus (HIV) p24 antigen (Ag) was decreased in four patients in each group, increased in one patient in each group, and remained unchanged in the remainder. The ability to culture virus from peripheral blood mononuclear cells was not changed by the regimen. The major toxicities of the regimen were fever and malaise.(ABSTRACT TRUNCATED AT 400 WORDS)

Subcutaneous granulocyte-macrophage colony-stimulating factor in patients with myelodysplastic syndrome: toxicity, pharmacokinetics, and hematological effects.

The toxicity, pharmacokinetics, and hematologic effects of granulocyte-macrophage colony-stimulating (GM-CSF) were studied in a phase I/II trial of 16 patients with myelodysplastic syndrome (MDS). The GM-CSF was administered subcutaneously (SC) daily so as to achieve prolonged blood levels and to establish an outpatient treatment regimen. Four dose levels were administered for ten days: 0.3 microgram/kg/d (three patients), 1.0 microgram/kg/d (three), 3.0 micrograms/kg/d (four), and 10.0 micrograms/kg/d (six). The most common toxicities were fever and a flu-like syndrome, which were dose-dependent. The maximum-tolerated dose was 10.0 micrograms/kg/d, which induced severe rigors (two patients), fever greater than 40 degrees C (one), severe bronchospasm (one), and WBC 60,000 (one). In one patient, refractory anemia with excess blasts in transformation (RAEB-T) progressed to acute nonlymphocytic leukemia after two doses of GM-CSF, and the patient died of leukemia that did not respond to chemotherapy. After doses of 3.0 and 10.0 micrograms/kg, serum GM-CSF levels peaked at 3.8 to 6.3 hours, and persisted for 14 and 24 hours, respectively. Circulating granulocytes (neutrophils and bands) increased in a dose-dependent manner, as 11 of 13 patients who received greater than or equal to 1.0 microgram/kg/d responded with a two- to 194-fold increase. Although the neutrophils usually returned to pretreatment levels shortly after stopping GM-CSF, two patients continue to exhibit an elevation of neutrophils for 6 months. Dose-related increases in circulating monocytes and eosinophils were also noted. Transient increases in platelet and reticulocyte counts were observed in two and three patients, respectively. Five of the 16 patients later received maintenance GM-CSF at 3 micrograms/kg/d for 2 to 9 weeks. All showed a dramatic increase in neutrophils after 2 weeks. Thereafter, despite continued therapy, the neutrophil count in four patients declined markedly. In conclusion, GM-CSF is well tolerated by the SC route and induces striking, but usually temporary, improvement in the neutropenia of MDS. Larger prospective phase III trials will determine the duration of hematologic responses and the impact on infection, morbidity, and mortality.