Two-drug Combination Research Articles

Connected by the cord—comparison of drug positivity rates and concentrations in a large cohort of paired umbilical cord and meconium specimens

Abstract Substance abuse during pregnancy has significant short- and long-term health, social, and legal implications. Hence, prompt determination of a neonate’s drug exposure status can aid the healthcare team in making treatment choices. Umbilical cord tissue (UC) and meconium are two commonly used specimens to detect fetal drug exposure. However, the current evidence on the sensitivity of one specimen over the other is both limited and conflicting. By utilizing a large cohort (n=4036) of paired UC and meconium samples originating from 13 states, we retrospectively investigated the qualitative and quantitative drug positivity rates for 31 analytes from 5 drug classes (i.e. cannabis, opioids, stimulants, barbiturates, and benzodiazepines). Semi-quantitative drug detection in UC samples was conducted by LC-MS-based assays, whereas an immunoassay screen preceded quantitative LC-MS analysis for meconium specimens. Data were analyzed using R-programming, Microsoft Excel, and GraphPad Prism packages. The overall drug positivity rate for UC was 56.57% compared to 52.38% in meconium. Opioids were the top drug class detected in UC at 35.53% compared to 20.64% in meconium. The detection rates for individual opioid analytes were also higher in UC (0.97-15.49%) relative to meconium (0.0 to 9.09%). Notably, 6-acetylmorphine (heroin metabolite) was only detected in UC (0.97%). In contrast, 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (THC) was more frequently detected in meconium at 34.99% compared to 19.89% in UC. In the stimulant drug class, the overall amphetamine positivity rate was 7.73% in UC while 8.57% in the meconium specimens. Conversely, the cocaine positivity rate in the UC was 3.84% and 2.23% in meconium samples. In the barbiturate drug class, the positivity rate for butalbital was twice as high in UC (1.91%) relative to meconium (0.99%). Phenobarbital positivity rate was comparable in both matrices (~0.15%). The positivity rates for 6 common benzodiazepine drugs ranged from 0.40-0.94% in UC compared to 0.01-0.35% in meconium. Interestingly, a multidrug combination analysis revealed that THC−opioids was the most common two-drug combination detected in both matrices at a rate of 7.22% in UC compared to 5.39% in meconium. Subsequent examination of analyte concentrations between the two matrices revealed higher concentrations in meconium. THC was 48.13 times more concentrated in meconium relative to UC. Amphetamines and cocaine were 6.45-15.01 times more concentrated in meconium relative to UC. For the opioids, the overall concentrations were 21.61-1845.01 times higher in meconium specimens relative to UC. For barbiturates, butalbital had comparable concentrations in the two matrices whereas phenobarbital was 33.10 times more concentrated in the meconium. Lastly, benzodiazepines were overall 6.21-38.75 times more concentrated in meconium than UC. In conclusion, this study shows that despite most drugs being more concentrated in meconium, drug positivity rates were higher with UC for all analytes except THC and amphetamines, suggesting higher detection potential of the UC specimen.

Evolutive Aspects Of Patients With Cirrhosis After Harvoni Therapy

Introduction: Cirrhosis, is a final pathway of chronic liver diseases. In recent years, Direct-Acting Antiviral Agents (DAAs) gained a leading role in the treatment of chronic hepatitis of viral etiology. Aim of the study: The proposed aims of this research are to estimate the virological response after 12 weeks after treatment completion and to evaluate the beneficial effects of the treatment on patients with decompensated cirrhosis. Patients and methods: The study was of a descriptive type, longitudinal and retrospective, conducted over a 15 months period, including patients with HCV-related cirrhosis patients. It was established the correlation between liver function, metabolic function, comorbidities and severity of cirrhosis and the level of HCV RNA before and after treatment. It was assessed also the neuroinflammatory activity from the results of Fibromas and the complication after therapy. Results: From January 2018 to April 2019, patients with liver cirrhosis were hospitalized. 48 HCV- related cirrhosis patients have fulfilled the eligibility criteria for antiviral treatment and they have constituted the study group. From all the HCV-infected patients with cirrhosis, 41.66% were women and 58.33% were men, most of them in the interval 60-70 years (37.5%) and 70-80 years (33,33%). 87.5% from the patients had compensated cirrhosis (Child-Pugh A class) and 12.5% had decompensated cirrhosis (Child-Pugh B and C class). 77.08% of the patients had severe neuroinflammatory activity – A3, 10.41% had moderate -A2 activity and 12.5% had lower neuroinflammatory activity-A1. The treatment with direct antiviral agents for the study group consisted in three treatment regimens.60% received a two-drug fixed-dose combination- sofosbuvir (SOF)/ledipasvir (LDV). 10% received SOF/LDV combination with Ribavirin. Only 1 patient with Child-Pugh C decompensated cirrhosis received SOF/LDV combination without Ribavirin. Also, a double combination received 10.48% of the patients- grazoprevir (GZR)/ elbasvir (EBR) 20.83% received quadruple combination ombitasvir (OBV)/ paritaprevir (PTV)/ritonavir(r) and dasabuvir (DSV). After 12 weeks from treatment completion, all the HCV-RNA’s level were undetectable. There were no side effects of the treatment. None of the patients didn’t stop the treatment during the period of treatment. There was a statistically significant difference between the ASAT and ALAT level before and after treatment (p<0.0001). 1 patient with Child-Pugh score C, died and another patient with Child-Pugh score B had an episode of variceal bleeding. Conclusion: Treatment with direct antiviral agents as Harvoni regimen, is a safe therapy and effective for HCV-infection and advanced liver disease. Despite the efficiency of the treatment on HCV-RNA, there were patients with complications due to the cirrhotic status of the subjects. The patients with existing decompensated cirrhosis remain at an elevated risk of numerous other complications.

Quantitative Analysis of the Potency of Equimolar Two-Drug Combinations and Combi-Molecules Involving Kinase Inhibitors In Vitro: The Concept of Balanced Targeting.

The median-effect principle proposed by Chou and Talalay is the most effective approach to parameterize interactions between several agents in combination. However, this method cannot be used to evaluate the effectiveness of equimolar drug combinations, which are comparative references for dual-targeting molecular design. Here, using data acquired through the development of “combi-molecules” blocking two kinases (e.g., EGFR-c-Src and EGFR-c-Met), we established potency indices for equimolar and dual-targeted inhibitors. If the fold difference (κ) between the IC50 of the two individual kinase inhibitors was >6, the IC50 of their equimolar combination resembled that of the more potent inhibitor. Hence, the “combi-targeting” of the two kinases was considered “imbalanced” and the combination ineffective. However, if κ ≤ 6, the IC50 of the combination fell below that of each individual drug and the combi-targeting was considered “balanced” and the combination effective. We also showed that combi-molecules should be compared with equimolar combinations only under balanced conditions and propose a new parameter Ω for validating their effectiveness. A multi-targeted drug is effective if Ω < 1, where Ω is defined as the IC50 of the drug divided by that of the corresponding equimolar combination. Our study provides a methodology to determine the in vitro potency of equimolar two-drug combinations as well as combi-/hybrid molecules inhibiting two different kinase targets.

In vitro Synergism of Six Antituberculosis Agents Against Drug-Resistant Mycobacterium tuberculosis Isolated from Retreatment Tuberculosis Patients

BackgroundRetreatment tuberculosis (TB) has become a major source of drug-resistant TB. In contrast to the combination of isoniazid (INH) and rifampicin (RIF), that of pasiniazid (Pa) and rifabutin (RFB) or rifapentine (RFP) appears to have better activity in vitro against drug-resistant Mycobacterium tuberculosis (MTB), especially when combined with moxifloxacin (MXF). However, there has been limited study of potential synergism among Pa, RFB, RFP, and MXF, or simultaneous comparison with the standard INH and RIF combination.MethodsIn vitro synergism of four two-drug combinations (INH and RIF, Pa and RFB, Pa and RFP, MXF and Pa) and two three-drug combinations (MXF and Pa combined with RFB or RFP) was evaluated against 90 drug-resistant MTB strains isolated from retreatment TB patients by the checkerboard method. The fractional inhibitory concentration index (FICI) was calculated for each combination.ResultsThe synergistic activity of the combination of Pa with RFB or RFP was higher than that of INH and RIF or MXF and Pa, and the synergistic activity of Pa in combination with RFP was even higher than that of RFB, although RFP yielded an MIC90 of 64 mg/liter, higher than that of RFB of 8 mg/liter against 90 drug-resistant MTB strains. Meanwhile, for three-drug combinations, the synergistic effects of MXF and Pa combined with RFB or RFP were similar. Further stratification analysis showed that, for XDR-MTB strains, the synergistic effect of the Pa and RFP combination was also better than those of other two-drug combinations.ConclusionThe combination of Pa with RFP shows better in vitro synergism than Pa with RFB and standard INH with RIF combinations, which can provide a reference for new regimens for retreatment TB patients.

Predicting the Effects of Drug Combinations Using Probabilistic Matrix Factorization.

Drug development is costly and time-consuming, and developing novel practical strategies for creating more effective treatments is imperative. One possible solution is to prescribe drugs in combination. Synergistic drug combinations could allow lower doses of each constituent drug, reducing adverse reactions and drug resistance. However, it is not feasible to sufficiently test every combination of drugs for a given illness to determine promising synergistic combinations. Since there is a finite amount of time and resources available for finding synergistic combinations, a model that can identify synergistic combinations from a limited subset of all available combinations could accelerate development of therapeutics. By applying recommender algorithms, such as the low-rank matrix completion algorithm Probabilistic Matrix Factorization (PMF), it may be possible to identify synergistic combinations from partial information of the drug interactions. Here, we use PMF to predict the efficacy of two-drug combinations using the NCI ALMANAC, a robust collection of pairwise drug combinations of 104 FDA-approved anticancer drugs against 60 common cancer cell lines. We find that PMF is able predict drug combination efficacy with high accuracy from a limited set of combinations and is robust to changes in the individual training data. Moreover, we propose a new PMF-guided experimental design to detect all synergistic combinations without testing every combination.

Evaluation of the efficacy and treatment sequence of paclitaxel and gemcitabine-loaded microparticles in a serous-like endometrial cancer cell line: a novel treatment strategy

<h3>Objectives:</h3> Uterine serous carcinoma (USC) presents a clinical challenge due its propensity to present at advanced stages, high recurrence rate and development of chemoresistance. The majority of patients with advanced disease will progress or recur following first-line platinum-based chemotherapy. As a result, new treatment strategies are urgently needed. Poly (lactic-co-glycolic acid)-based (PLGA) microparticles (MP) are a promising tool for delivery of chemotherapy due to prolonged drug elution over a period of several weeks, offering the benefit of sustained anti-cancer activity in the target tissue while limiting systemic toxicity. This is an attractive treatment strategy for USC, which can be accessed vaginally, allowing for the delivery of drug-loaded MP directly to the tumor. Previous work demonstrates paclitaxel and gemcitabine can be successfully loaded to PLGA-MP for drug delivery. <h3>Methods:</h3> The human endometrial cancer (EC) cell line KLE, representing a poorly differentiated serous-like EC was obtained from ATCC. Cells were treated with paclitaxel-loaded MP only (PMP), gemcitabine-loaded MP only (GMP), PMP-GMP sequence (PG), GMP-PMP sequence (GP) and PMP-GMP delivered concurrently (C). Blank MP (BMP) were used as control for each treatment. Cells were then collected at 6-days post-treatment for isolation of protein and assessment of cytotoxicity by cell viability assay. Protein lysates were analyzed for expression of multiagent chemoresistance protein AXL and paclitaxel resistance protein beta III tubulin (TUBB3) and apoptotic protein cleaved-PARP by Western Blot. <h3>Results:</h3> We observed morphologic changes and a decrease in cell density in all treatment regimens versus controls. These changes were most marked in the two-drug combination regimens. A significant increase in cleaved-PARP was observed in all treatments compared to controls. Chemoresistance proteins AXL and TUBB3 were not expressed in controls. AXL expression was increased in all treatment regimens. TUBB3 expression was significantly greater in PMP and GP regimens compared to PG (p=0.05). All treatment regimens were associated with a significantly decrease in cell viability versus controls (p<0.001). GMP containing regimens produced a greater decrease in cell viability compared to single agent paclitaxel. C treatment produced a significantly greater decrease in cell viability compared to all other regimens (p<0.001). <h3>Conclusions:</h3> PMP and GMP demonstrated significant cytotoxicity in a serous-like EC cell line. Concurrent PMP-GMP administration elicited the greatest decrease in cell viability. TUBB3 expression was markedly less when cells received PG, indicating the sequence of paclitaxel followed by gemcitabine may counteract paclitaxel resistance observed with single agent paclitaxel and alternate sequencing. Chemotherapy delivered via MP is an attractive treatment strategy for advanced and recurrent USC. Future <i>in vivo</i> studies are needed to validate this new treatment approach.

Clinical efficacy of apatinib as a second-line treatment for advanced pancreatic cancer in a Chinese tertiary cancer health facility

Purpose: To study the effectiveness and safety of apatinib as second-line treatment for advanced pancreatic cancer (APC) in a Chinese tertiary cancer hospital.&#x0D; Methods: Two groups of APC patients who received treatment with single-agent or two-drug combination of gemcitabine-based first-line therapy (50 per group) in The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing were assessed. The study group received apatinib at or above the second line treatment, while the control group was treated with second-line chemotherapy, which was different from first-line single-drug chemotherapy. Patients received treatments until there was improvement in their conditions, or until adverse reactions became intolerable. Complete remission (CR), partial remission (PR), disease stabilization (SD), disease progression (PD), incidence of adverse reactions, and progression-free survival (PFS) of the patients were recorded.&#x0D; Results: The number of PR cases in APC patients who received apatinib as second-line therapy, and the number of PD patients were higher than the corresponding populations in the control group (p &lt; 0.05). Treatment effectiveness was significantly higher in study group patients than in control subjects (p &lt; 0.05). However, the incidence of adverse reactions was lower in the study group than in control group. Median PFS in the study group (5 months) was significantly higher than that of the control group (4.1 months, p &lt; 0.05).&#x0D; Conclusion: The clinical efficacy of apatinib as second-line treatment for advanced pancreatic cancer is higher than that of the single drug. Apatinib is associated with low incidence of adverse reactions which prolongs PFS. Thus, apatinib has potentials for the clinical management of pancreatic cancer.

Computational Modeling of Protein Networks Predicts Treatment Outcomes in Multiple Myeloma (MM)

Background: MM is a highly refractory disease that is rarely cured. While introduction of novel therapies has improved survival and overall response rates (ORR), complete remission (CR) rates remain low (30%) and relapse is still frequent. Although nearly all newly diagnosed MM patients respond to standard of care (SOC) therapy, the depth of response varies. Triplet regimens, such as RVd (lenalidomide [R], bortezomib [V] and dexamethasone [d]), are accepted as SOC, but four-drug regimens are being investigated in an effort to improve CR rates. Doublet regimens are commonly initiated in older, transplant ineligible patients. Limitations of combination therapies include treatment-related adverse events, resulting in patients receiving suboptimal therapy. Unfortunately, no precise method exists to predict MM response to SOC, or to predict which patients will respond with two-drug combinations, making MM management challenging. Computational biological modeling (CBM) is a genomics-based tool to identify aberrant protein signaling networks within disease cells, and predict how each MMD case will respond to FDA-approved drugs and combinations. Predicting disease response would improve MM patient management and potentially reduce unnecessary treatment-related adverse events by identifying drug regimens with high potential for therapeutic activity against patient-specific, MM protein networks.Aim: To test the application of a genomics-informed CBM in MM patients treated with RVd.Methods: Forty newly-diagnosed patient profiles were identified from the publicly available MMRF CoMMpass dataset and divided into training (n=15) and test (n=25) cohorts. For each patient, all available genomic information was entered into computational biology program (Cellworks Group) that uses PubMed and other online resources to generate patient-specific protein network maps of activated and inactivated protein networks. Digital drug simulations with standard of care (SOC) drugs were conducted by quantitatively measuring drug effect on a composite MM disease inhibition score (i.e. cell proliferation, viability, and apoptosis) to predict patient clinical outcomes. Additionally, the dynamics of antibody (heavy and light chains) transcription, translation, folding, and secretion were modeled to measure the extent that SOC therapy reduced paraprotein expression. Clinically, patients received SOC treatment and clinical responses were recorded. CR, VGPR, and PR were considered as responsive, while stable disease (SD) was considered non-response. Predictive values were calculated based on comparisons of the computer predictions and actual clinical outcomes.Results: The computational modeling correctly predicted 36 out of 40 clinical outcomes resulting in 94.12% PPV, 66.67% NPV (p=0.02), 94.12% sensitivity, and 66.67% specificity, and 90% accuracy. Additionally, 33 of 34 simulated paraprotein reductions were matched to actual clinical reductions in paraprotein levels, resulting in 97% accuracy. CBM was used to identify the minimum number of drugs each responder needed to achieve a simulated response, and selected the drug within the doublet or triplet regimen that had no therapeutic effect due to absence of the drug's target within the disease profiles.Conclusions: Computational modeling and digital drug simulations using MM patient genomic data resulted in highly accurate matching of clinical response to SOC treatment. CBM also accurately predicted the extent by which each patient's therapy reduced paraprotein levels, which can precede improved clinical outcomes. The computational approach identified each patient's anchor drug in their combination therapy that was most likely responsible for achieving improved clinical outcome. For patients who were clinical non-responders, the CBM identified probable protein networks responsible for drug resistance and rapidly screened for alternative drug combinations with predicted efficacy in light of the patients' drug-resistant pathways. Thus, CBM may be a useful tool for clinicians and translational scientists in search of personalized treatment or newer therapies for patients with MM. DisclosuresGrover:Cellworks: Employment. Narvekar:Cellworks: Employment. Kumari:Cellworks: Employment. Narayanabhatia:Cellworks: Employment. Bhowmick:Cellworks: Employment. Abbasi:Cellworks Group Inc.: Employment. Vali:Cellworks Group Inc.: Employment. Usmani:Takeda: Consultancy, Honoraria, Research Funding, Speakers Bureau; Skyline: Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy, Honoraria, Speakers Bureau; Bristol-Myers Squibb: Honoraria, Research Funding; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Millennium: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Onyx: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Novartis: Speakers Bureau; Sanofi: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pharmacyclics: Honoraria, Research Funding; Array BioPharma: Honoraria, Research Funding. Cogle:Celgene: Other: Membership on Steering Committee for Connect MDS/AML Registry.

Phase III trial comparing XELOX regimen (oxaliplatin plus capecitabine) versus EOX regimen (epirubicin, oxaliplatin and capecitabine) as first-line treatment for advanced gastric cancer: EXELOX trial.

4014 Background: At present, there is no standard chemotherapy regimen for advanced gastric cancer (AGC), and there is no consensus whether the three-drug combination is better than two-drug combination in first-line treatment. Both of XELOX regimen and EOX regimen are widely recommended as firs-line chemotherapy regimens for AGC. In this EXELOX trial, we aimed to compare the efficacy and safety of EOX and XELOX regimens. Methods: EXELOX is an open-label, multicenter, prospective, randomized phase III trial that enrolled 448 previously untreated patients with histologically confirmed advanced gastric adenocarcinoma from 7 hospitals in China. Patients were randomly assigned (1:1) to receive XELOX regimen (oxaliplatin 130mg/m2 d1; xeloda 1000mg/m2 bid d1-14) or EOX regimen (epirubicin 50mg/m2 d1; oxaliplatin 130mg/m2 d1; xeloda 1000mg/m2 bid d1-14) in this study. Treatment was repeated every 3 weeks until disease progression, intolerable toxicity, patient death, withdrawal of informed consent, or up to eight cycles, followed by xeloda single-agent maintenance. We stratified randomization by Eastern Cooperative Oncology Group status, extent of disease(locally advanced/metastatic) and clinical trial center. Patients and clinicians were not masked to the allocated treatment. The primary endpoint was progression-free survival (PFS) on an intention-to-treat basis with a non-inferiority upper margin of 1.3 for the hazard ratio (HR). The clinical trial was a non-inferiority study that was registered with ClinicalTrials.gov, Number NCT02395640. The study is ongoing, but no longer recruit new participants. Results: Between Apr 10,2015 and Aug 20,2020, a total of 448 AGC patients were randomized to receive XELOX (n = 222) or EOX (n = 226). In ITT basis, the median PFS was 5.0 months (95%CI 4.5-6.0) in XELOX group and 5.5 months (95%CI 5.0-6.0) in EOX group (HR 0.989, 95%CI 0.812-1.203; Pnon-inferiority= 0.0032). In Per-protocol population (n = 428), the median PFS was 5.0 months (95%CI 5.0-6.0) in XELOX group and 5.5 months (95%CI 5.0-6.0) in EOX group (HR 0.983, 95%CI 0.807-1.198; Pnon-inferiority= 0.0028). The incidence of grade 3-4 adverse events (AEs) was 42.2% (90/213) in XELOX group and 72.5(156/215) in EOX group ( p= 0.001). The most common grade 3-4 AEs were neutropenia (affecting 13.1% (28/213) in XELOX group and 48.4%(104/215) in EOX group ( p= 0.000). The incidence of chemotherapy dose reduction was 35% (75/213) in XELOX group and 55% (120/215) in EOX group( p= 0.009). One treatment-related death (lung infection) was observed in EOX group, and none in XELOX group. Conclusions: XELOX regimen is noninferior to EOX regimen in PFS with a better safety profile as first-line treatment for AGC patients, therefore XELOX is a more favorable choice and might be one of the standard first-line chemotherapy regimens. Clinical trial information: NCT02395640.

Evaluation of Small Molecule Combinations against Respiratory Syncytial Virus In Vitro.

Respiratory syncytial virus (RSV) is a major pathogen that causes severe lower respiratory tract infection in infants, the elderly and the immunocompromised worldwide. At present no approved specific drugs or vaccines are available to treat this pathogen. Recently, several promising candidates targeting RSV entry and multiplication steps are under investigation. However, it is possible to lead to drug resistance under the long-term treatment. Therapeutic combinations constitute an alternative to prevent resistance and reduce antiviral doses. Therefore, we tested in vitro two-drug combinations of fusion inhibitors (GS5806, Ziresovir and BMS433771) and RNA-dependent RNA polymerase complex (RdRp) inhibitors (ALS8176, RSV604, and Cyclopamine). The statistical program MacSynergy II was employed to determine synergism, additivity or antagonism between drugs. From the result, we found that combinations of ALS8176 and Ziresovir or GS5806 exhibit additive effects against RSV in vitro, with interaction volume of 50 µM2% and 31 µM2% at 95% confidence interval, respectively. On the other hand, all combinations between fusion inhibitors showed antagonistic effects against RSV in vitro, with volume of antagonism ranging from −50 µM2 % to −176 µM2 % at 95% confidence interval. Over all, our results suggest the potentially therapeutic combinations in combating RSV in vitro could be considered for further animal and clinical evaluations.

Drug target ranking for glioblastoma multiforme

BackgroundGlioblastoma Multiforme, an aggressive primary brain tumor, has a poor prognosis and no effective standard of care treatments. Most patients undergoing radiotherapy, along with Temozolomide chemotherapy, develop resistance to the drug, and recurrence of the tumor is a common issue after the treatment. We propose to model the pathways active in Glioblastoma using Boolean network techniques. The network captures the genetic interactions and possible mutations that are involved in the development of the brain tumor. The model is used to predict the theoretical efficacies of drugs for the treatment of cancer.ResultsWe use the Boolean network to rank the critical intervention points in the pathway to predict an effective therapeutic strategy for Glioblastoma. Drug repurposing helps to identify non-cancer drugs that could be effective in cancer treatment. We predict the effectiveness of drug combinations of anti-cancer and non-cancer drugs for Glioblastoma.ConclusionsGiven the genetic profile of a GBM tumor, the Boolean model can predict the most effective targets for treatment. We also identified two-drug combinations that could be more effective in killing GBM cells than conventional chemotherapeutic agents. The non-cancer drug Aspirin could potentially increase the cytotoxicity of TMZ in GBM patients.

IMPLEMENTATION OF THE 2018 ESC/ESH GUIDELINES FOR THE TREATMENT AND CONTROL OF HYPERTENSION IN PRIMARY CARE IN GREECE: THE HYPEDIA STUDY

Objective: To evaluate office blood pressure (OBP) levels for antihypertensive drug treatment initiation/intensification, drug choices, and hypertension control in primary care in Greece. Design and method: A prospective nationwide non-interventional single-visit study was performed in consecutive untreated or treated hypertensives recruited by primary care doctors and hospital clinics. Participants’ characteristics, OBP measurements (triplicate; automatically transferred to PC; Microlife BPA3 PC) and treatment changes were recorded using an online cloud system. The study was supported by Menarini Hellas S.A. Results: A total of 3,122 patients were analyzed (mean age 64 ± 12.5 [SD] years, 52% males, 25% untreated). In untreated hypertensives (N = 772), drug treatment was initiated with monotherapy in 53% and with two-drug combination in 36%. ARB monotherapy was used for treatment initiation in 30%, ARB/CCB 20%, ARB/Thiazide 8%, ACEI-based 19%. Of the combinations used, single-pill were 97%. Among treated hypertensives aged &lt;65 years (N = 977), 79% had OBP &gt; = 130/80 mmHg (systolic and/or diastolic), whereas among those aged &gt; = 65 years (N = 1,373) 66% had OBP &gt; = 140/80 mmHg. ARBs were used in 69% of treated hypertensives, ACEIs 19%, CCBs 47%, diuretics 39%, b-blockers 19%. Single-pill combinations were administered in 85% of patients receiving drug combinations. Treatment intensification (mainly dose increase or drug addition) was performed in 54% of treated hypertensives aged &lt;65 years with OBP &gt; = 130/80 mmHg (systolic and/or diastolic), and in 62% of those &gt; = 65 years with OBP &gt; = 140/80 mmHg. Binary logistic regression in treated hypertensives aged &lt;65 years showed that age (OR 3.2, 95% CI 1.0–9.9), BMI (OR 7.9, 2.8–22.8), male gender (OR 1.6, 1.1–2.2) and primary care (vs. hospital) setting (OR 1.5, 1.0–1.8) predicted OBP &gt; = 130/80 mmHg. In treated hypertensives &gt; = 65 years, BMI (OR 2.5, 1.1–5.7), primary care setting (OR 1.4, 1.0–1.7) and male gender (OR 1.3, 1.0–1.6) predicted OBP &gt; = 140/80 mmHg. Conclusions: RAS blocker-based therapy, mainly ARBs, is the basis of antihypertensive drug treatment in the vast majority of patients in primary care, with single-pill combinations being widely used. In almost half of treated uncontrolled hypertensives treatment is not intensified (physician inertia), suggesting suboptimal implementation of the 2018 ESC/ESH targets in primary care.

PRIVATE HEALTH SECTOR PREFERENCES IN TREATMENT OF HYPERTENSION IN INDIA: EVIDENCE FROM HYPERTENSION DRUGS MARKET DATA

Objective: In India, there are an estimated 200 million adults with high blood pressure. National and international guidelines recommend calcium channel blockers (CCB), diuretics, angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) for first line treatment of uncomplicated hypertension, while beta-blockers (BB) have been relegated to second-line treatment. As the private sector provides 70% of out-patient care in the country, we assessed private health sector preferences of antihypertensive medications using market data. Design and method: Sales of all antihypertensive formulations in India from 2016–2018 were analysed, using a large nationally representative dataset for the private sector pharmaceuticals market. In addition to analysis at the National level, data for five states was analysed to determine any inter-state variations. Results: The Indian hypertension drug market grew at a compounded annual growth rate of 6.9% from 2016 to 2018 with a total of 21,066 million tablet or capsule sales in 2018. Two-drug single pill combinations (SPCs) had the highest market share in 2018, with 36% of market volumes, followed by CCBs (18%), BBs (16%), ARBs (14%), diuretics (5%), ACEI (3.6%), and three-or-more-drug SPCs (2.8%). Among two-drug SPCs, amlodipine/atenolol (9.8%) was the most preferred, followed by telmisartan/hydrochlorothiazide (4.1%) and amlodipine/telmisartan (3.8%). There were inter-state variations in the market share of antihypertensive drugs. In four states, two-drug SPCs accounted for approximately 40% of all antihypertensives sold (range 38%-42%). This was followed by BBs as the second most preferred drug class in two states (range 18%-19%), while CCBs were preferred in the other two states (range 16%-18%). In the fifth state, CCBs (25%) were most preferred, followed closely by BBs (21%). Amlodipine/atenolol was the most preferred molecule in two states, amlodipine in another two states and telmisartan in the fifth state. Conclusions: Despite changes in standard hypertension treatment guidelines, evidence from pharmacy sales data indicate variable treatment practices in the private health sector in India, with a preference for beta blockers. This study highlights the need to improve hypertension care quality through private sector engagement strategies including sensitisation, regular training programmes and possibly provider incentives for evidence-based practice.

ANTIHYPERTENSIVE EFFECTIVENESS OF SWITCHING TO SINGLE PILL COMBINATION OF PERINDOPRIL/AMLODIPINE IN PATIENTS INEFFECTIVELY TREATED BY ARB-CONTAINING FREE COMBINATIONS (AVANGARD STUDY)

Objective: Objectives. To evaluate the effectiveness of perindopril arginine/ amlodipine single-pill combination (SPC) in patients with grade 1–2 hypertension uncontrolled on previous therapy with ARB-containing free combinations. Design and method: AVANGARD was a multicenter, open-label, 3-month Russian observational study, in 658 patients with suboptimal efficacy (SBP/DBP 140–179/90–109 mm Hg) of previous antihypertensive therapy with two drugs in free combination (one of which was an ARB), who were switched to perindopril arginine/amlodipine SPC. Data were collected at four visits: V1 (inclusion visit and treatment initiation), V2 (2 weeks), V3 (1 month), V4 (3 months). Results: The SBP/DBP values gradually and significantly decreased with Perindopril/amlodipine SPC from 159.9 ± 8.5/ 92.1 ± 7.4 mmHg to 141.3 ± 11.0/83.7 ± 7.5 mmHg after 2 weeks, 131.7 ± 9.2/79.5 ± 6.0 mmHg after 1 month and finally 125.8 ± 7.1 /77.4 ± 5.5 mm Hg; all p &lt; 0.001). The controlled BP was achieved in 36.2%, 73.4 and 93.5% of patients at V2, V3 and V4, respectively. The mean HR followed the same patern (V1: 73.9 ± 7.3 beats per minute (bpm); V4: 68.9 ± 5.0 bpm; p &lt; 0.001). Daytime 24-hour BP variability decreased from V2 to V4, from 4.4 ± 2.9/3.0 ± 2.0 to 3.0 ± 2.2/2.2 ± 1.7 mm Hg (p &lt; 0.001). Treatment acceptability was very high considering couple related adverse events (0,21%) in accordance with the well-known side effects of the drugs (oedema and cough) Conclusions: This study showed the antihypertensive effectiveness of perindopril/amlodipine SPC in hypertensive patients previously uncontrolled on two-drug free combinations containing an ARB.

Combined effect of chrysin and apigenin on inhibiting the development and progression of colorectal cancer by suppressing the activity of P38-MAPK/AKT pathway.

Either apigenin or chrysin alone has been found to exert anti-inflammatory and tumor suppressive effect. However, the combined effect of apigenin and chrysin on colorectal cancer (CRC) has not been fully clarified. We attempted to explore the effect of chrysin and apigenin on CRC and its related mechanism. SW480 and HCT-116 cells were treated with either apigenin or chrysin alone or two-drug combination at different doses of 5, 25, 50, 100 μM for optimal concentration determination. Then, we focused on the individual and combined effect of apigenin and chrysin on clonogenicity, apoptosis, metastasis-related behaviors of CRC cells by colony formation assay, cell scratch assay, flow cytometry, and transwell assay. The changes of the activation of P38-MAPK/AKT pathway were evaluated underlying apigenin and chrysin intervention, further after co-treated with P38-MAPK agonist anisomycin. Apigenin (25 μM) combined with chrysin (25 μM) were determined to be optimal. Treatment with the combination of apigenin (25 μM) and chrysin (25 μM) significantly reduced cell clone numbers, migration, and invasion ability, while increased the cell apoptosis in both CRC cell lines. The combined effect was higher than chrysin or apigenin alone. Meanwhile, p-P38 and p-AKT were significantly downregulated by chrysin and apigenin treatment. The tumor inhibitive effect of apigenin combined with chrysin was obviously reversed by adding P38 agonist, anisomycin. Apigenin (25 μM) combined with chrysin (25 μM) showed synergetic effect in inhibiting the growth and metastasis of CRC cells by suppressing the activity of P38-MAPK/AKT pathway.

Randomized phase II study evaluating the addition of pembrolizumab to radium-223 in metastatic castration-resistant prostate cancer.

98 Background: Treatment (tx) options for patients (pts) with metastatic castration-resistant prostate cancer (mCRPC) to bone are limited. Radium-223 (R223) has demonstrated overall survival (OS) benefit, but objective clinical responses to R223 or the anti-PD1 checkpoint inhibitor (CPI) pembrolizumab (pem) are infrequent. As R223 may increase immunogenicity of mCRPC to bone and increase activity of CPI, we undertook a Phase 2 study to assess safety of the combination and differences in immune cell infiltrate in bone biopsies (bx) and preliminary clinical activity of R223 + pem vs. R223 alone. Methods: Eligibility required mCRPC to bone with no visceral metastases (mets) or lymph nodes &gt; 2 cm, ECOG PS 0 or 1, Hgb ≥ 9 g/dL, and no prior R223 or CPI. Pts underwent bone bx at screening and at 8 wks. Pts were stratified by alkaline phosphatase ≥220 vs. &lt; 220 U/L and high vs. low volume bony mets (CHAARTED criteria) and randomized 2:1 to receive R223 55 kBq/kg q4wks + pem 200 mg q3wks (Arm A) or R223 55 kBq/kg q4wks alone (Arm B). If restaging after 3 doses R223 showed at least stable disease, pts in Arm A continued pem alone until progressive disease (PD). Upon PD, R223 was resumed if no new visceral mets. Pts continued tx until clinical/radiologic PD, unacceptable toxicity or completion of 6 R223 doses. The primary endpoint was difference in CD4+ and CD8+ T-cell infiltrate in 8 wk vs. baseline bx; secondary endpoints were safety/tolerability, radiographic progression-free survival (rPFS) and OS. Exploratory endpoints included PSA response and rate of symptomatic skeletal events (SSEs). Results: Of 45 pts enrolled, 42 received study tx (29 Arm A, 13 Arm B) and were eligible for analysis. 21 pts in Arm A and 5 in Arm B had evaluable paired bone bx. Median fold-change of proportion of CD4+ T-cells/total cell count from baseline to 8 wks was 0.90 (range 0.0-26.6) in Arm A and 0.40 (0.0-13.0) in Arm B (P = 0.87); for CD8+ cells, median 0.67 (0.0-40.4) in Arm A and 0.40 (0.1-28.8) in Arm B (P = 0.77). Grade 3 treatment-related non-hematologic adverse events (AEs) occurred in 3 pts (10%) in Arm A (pneumonitis, diarrhea, AST increased); none in Arm B. Median rPFS was 6.7 mo (95% CI 2.7-11.0 mo) in Arm A and 5.7 mo (2.6-NR) in Arm B. Median OS was 16.9 mo (12.7-NR) in Arm A and 16.0 mo (9.0-NR) in Arm B. 3 pts (10%) in Arm A and 0 in Arm B had PSA reduction of ≥ 50%. SSE rate was 38% in Arm A and 54% in Arm B, with pathologic fractures in 0% of pts in Arm A and 23% in Arm B. Conclusions: In the 62% of treated pts with evaluable paired bx at baseline and after 8 wks, there was no evidence of increased CD4+ or CD8+ T-cell infiltration with R223 + pem. Additional biomarker analyses will be presented. This study revealed that R233 + pem did not result in unexpected AEs, but did not lead to prolonged rPFS or OS compared to R223 alone to support this two-drug combination in a biomarker-unselected population in this setting. Clinical trial information: NCT03093428.

Mycobacterium tuberculosis sterilizing activity of faropenem, pyrazinamide and linezolid combination and failure to shorten the therapy duration

BackgroundFaropenem (F), an orally bioavailable β-lactam, kills Mycobacterium tuberculosis (Mtb) without the help of a β-lactamase inhibitor. This study explored the sterilizing effect of adding F once or twice daily to a linezolid (L) plus pyrazinamide (Z) backbone regimen. MethodsIn vitro studies were performed using the hollow fiber model of tuberculosis (HFS-TB) to compare the kill rates of: 1) ZL two-drug combination; 2) F administered once daily plus ZL (F1ZL); 3) F administered twice-daily plus once daily ZL (F2ZL); 4) F2ZL with high-dose Z (F2ZhiL); 5) standard therapy of isoniazid, rifampin and Z; and 6) non-treated controls. The study was performed over 56 days with three HFS-TB replicates for each regimen. ResultsMtb in the non-treated HFS-TB grew at a rate of 0.018 ± 0.007 log10 CFU/mL/day. The exponential kill rates for standard therapy were 6.6–13.2-fold higher than ZL dual therapy. The F1ZL and F2ZL regimens ranked third. The pre-existing isoniazid-resistant sub-population in the inoculum (1.34 ± 0.57 log10 CFU/mL) grew to 4.21 ± 0.58 log10 CFU/mL in 56 days in non-treated HFS-TB. However, no isoniazid-resistant sub-population was recorded in any of the FZL combination regimens. ConclusionDue to the slow kill rate compared to standard therapy, FZL regimens are unlikely to shorten therapy duration. Efficacy of these regimens against drug-resistant tuberculosis needs to be determined.

English

BACKGROUND The current study was undertaken to evaluate the prescribing pattern of drugs in relation to the duration of diabetes in outdoor patients with type 2 diabetes mellitus in a tertiary care teaching hospital. There is scanty data on assessment of prescribing pattern of antidiabetic drugs in relation to the duration of diabetes especially from Indian population and no such study has been cited in our setup. METHODS This is a prospective observational study conducted in outdoor patients with type 2 diabetes mellitus for a period of 6 months. Our study sample included 155 patients whose prescriptions were analysed and detailed information such as demographic details, presenting complaints, past medical history of patients were recorded in their patient profile form after taking informed consent from those patients who fulfilled our study criteria. RESULTS Data of 155 patients was collected and analysed. The average age was 51.21 ± 9.73 with 92 % of patients being more than 40 years of age and most of the patients (50 %) have diabetes of duration &lt; 5 years. The female to male ratio was 1.76. A Multidrug antidiabetic regimen (72 %) was more common than monotherapy (28 %). Commonly prescribed drugs were biguanides (metformin) (87 %) followed by sulfonylureas (SU) (45 %), dipeptidyl peptidase 4 inhibitor (DPP4i) (42 %), and insulin (14 %). Metformin was the most commonly used drug followed by glimepiride and teneligliptin. Drug combinations were more common than a single drug. Metformin + glimepiride was the most common drug combination followed by metformin + teneligliptin. Commonly prescribed drugs for comorbid conditions were telmisartan, levothyroxine and atorvastatin. CONCLUSIONS It was found that the prescribing pattern of drugs was mostly as per the recommendations of different guidelines. The study exhibited a significant increase in the utilization of two-drug combination therapies. Biguanides were the most commonly prescribed oral hypoglycaemic and metformin with glimepiride has been widely used. There was a proportionate rise in the use of insulin with an increase in the duration of diabetes. Brand names were commonly used compared to generic names, so we need to promote generic prescriptions. KEYWORDS Antidiabetic Drugs, Type 2 Diabetes Mellitus, Prescribing Pattern, Duration of Diabetes

The Funnel: a Screening Technique for Identifying Optimal Two-Drug Combination Chemotherapy Regimens.

The Mycobacterium tuberculosis drug discovery effort has generated a substantial number of new/repurposed drugs for therapy for this pathogen. The arrival of these drugs is welcome, but another layer of difficulty has emerged. Single agent therapy is insufficient for patients with late-stage tuberculosis because of resistance emergence. To achieve our therapeutic ends, it is requisite to identify optimal combination regimens. These regimens go through a lengthy and expensive evaluative process. If we have a modest group of 6 to 8 new or repurposed agents, this translates into 15 to 28 possible 2-drug combinations. There is neither time nor resources to give an extensive evaluation for all combinations. We sought a screening procedure that would identify combinations that had a high likelihood of achieving good bacterial burden decline. We examined pretomanid, moxifloxacin, linezolid, and bedaquiline in log-phase growth, acid-phase growth, and nonreplicative persister (NRP) phase in the Greco interaction model. We employed the interaction term α and the calculated bacterial burden decline as metrics to rank different regimens in different metabolic states. No relationship was found between α and bacterial kill. We chose bacterial kill as the prime metric. The combination of pretomanid plus moxifloxacin emerged as the clear frontrunner, as the largest bacterial declines were seen in log phase and acid phase with this regimen and it was second best in NRP phase. Bedaquiline also produced good kill. This screening process may identify optimal combinations that can be further evaluated in both the hollow-fiber infection model and in animal models of Mycobacterium tuberculosis infection.

Tedizolid, Faropenem, and Moxifloxacin Combination With Potential Activity Against Nonreplicating Mycobacterium tuberculosis.

Background: Mycobacterium tuberculosis [Mtb] could be present in different metabolic population in the lung lesions, and nonreplicating persisters [NRP], associated with latent tuberculosis [TB], are the most difficult to kill. Objective: Test the combination of tedizolid, moxifloxacin, and faropenem for activity against NRP using Mtb SS18b in the hollow fiber model [HFS-TB]. Methods: Tedizolid and moxifloxacin were tested as, first, two-drug combination against log-phase growth [LPG] and, second, slowly replicating bacilli [SRB] under acidic condition and with faropenem to create a three-drug combination regimen. Finally, standard regimen [isoniazid-rifampin-pyrazinamide] was used as comparator in the HFS-TB experiment with NRP Mtb. HFS-TB units were sampled for drug-concentration measurement as well as for estimation of bacterial burden using solid agar and mycobacterial growth indicator tube [MGIT] method. Linear regression was used to calculate the kill slopes with each treatment regimen and analysis of variance (ANOVA) to compare the regimen. Results: Tedizolid at standard dose in combination with high-dose moxifloxacin killed 3.05 log10 CFU/ml LPG Mtb and 7.37 log10 CFU/ml SRB in the bactericidal and sterilizing activity HFS-TB experiments, respectively. There was no statistical difference between tedizolid-moxifloxacin-faropenem combination and the standard regimen as both killed 7.35 log10 CFU/ml NRP Mtb in 21 days. There was no emergence of resistance to any of the drugs studied in the three HFS-TB experiments. Conclusion: The experimental regimen of tedizolid, moxifloxacin, and faropenem could effectively kill NRP population of Mtb, and given the efficacy against different metabolic population of Mtb could serve as a pan-TB regimen. Clinical studies are warranted to validate the in vitro findings.