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Benkő BM, Lamprou DA, Sebestyén A, Zelkó R, Sebe I. Clinical, pharmacological, and formulation evaluation of disulfiram in the treatment of glioblastoma - a systematic literature review. Expert Opin Drug Deliv 2023; 20:541-557. [PMID: 36922013 DOI: 10.1080/17425247.2023.2190581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
INTRODUCTION Glioblastoma (GB) is one of the most challenging central nervous system (CNS) tumors in treatment options and response, urging the development of novel management strategies. The anti-alcoholism drug, disulfiram (DS), has a potential anticancer activity, and its complex mechanism of action is assumed to be well exploited against the heterogeneous GB. AREA COVERED Through a systematic literature review about repositioning DS to GB treatment, an evaluation of the clinical, pharmacological, and formulation strategies is provided to specify the challenges of drug delivery and thus to advance its clinical translation. From six databases, 35 articles were selected, including case report (1); clinical trials (3); original articles mainly representing in vitro and preclinical pharmacological data, and 10 dealing with technological approaches. EXPERT OPINION The repositioning of DS in GB treatment is facing drug and tumor-associated limitations due to the oral drug's low bioavailability, unwanted metabolism, and inefficient delivery to brain-tumor tissue. Development strategies using molecular encapsulation of DS and the parenteral dosage forms improve the anticancer pharmacology of the drug. The development of optimized drug delivery systems (DDS) shows promise for the clinical translation of DS into GB adjuvant therapy.
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Affiliation(s)
- Beáta-Mária Benkő
- University Pharmacy Department of Pharmacy Administration, Semmelweis University, Budapest, Hungary
| | | | - Anna Sebestyén
- Tumour Biology, Cell and Tissue Culture Laboratory, 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Romána Zelkó
- University Pharmacy Department of Pharmacy Administration, Semmelweis University, Budapest, Hungary
| | - István Sebe
- University Pharmacy Department of Pharmacy Administration, Semmelweis University, Budapest, Hungary
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Zhong S, Shengyu Liu, Xin Shi, Zhang X, Li K, Liu G, Li L, Tao S, Zheng B, Sheng W, Ye Z, Xing Q, Zhai Q, Ren L, Wu Y, Bao Y. Disulfiram in glioma: Literature review of drug repurposing. Front Pharmacol 2022; 13:933655. [PMID: 36091753 PMCID: PMC9448899 DOI: 10.3389/fphar.2022.933655] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
Gliomas are the most common malignant brain tumors. High-grade gliomas, represented by glioblastoma multiforme (GBM), have a poor prognosis and are prone to recurrence. The standard treatment strategy is tumor removal combined with radiotherapy and chemotherapy, such as temozolomide (TMZ). However, even after conventional treatment, they still have a high recurrence rate, resulting in an increasing demand for effective anti-glioma drugs. Drug repurposing is a method of reusing drugs that have already been widely approved for new indication. It has the advantages of reduced research cost, safety, and increased efficiency. Disulfiram (DSF), originally approved for alcohol dependence, has been repurposed for adjuvant chemotherapy in glioma. This article reviews the drug repurposing method and the progress of research on disulfiram reuse for glioma treatment.
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Kast RE, Alfieri A, Assi HI, Burns TC, Elyamany AM, Gonzalez-Cao M, Karpel-Massler G, Marosi C, Salacz ME, Sardi I, Van Vlierberghe P, Zaghloul MS, Halatsch ME. MDACT: A New Principle of Adjunctive Cancer Treatment Using Combinations of Multiple Repurposed Drugs, with an Example Regimen. Cancers (Basel) 2022; 14:2563. [PMID: 35626167 PMCID: PMC9140192 DOI: 10.3390/cancers14102563] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/11/2022] [Accepted: 05/17/2022] [Indexed: 12/12/2022] Open
Abstract
In part one of this two-part paper, we present eight principles that we believe must be considered for more effective treatment of the currently incurable cancers. These are addressed by multidrug adjunctive cancer treatment (MDACT), which uses multiple repurposed non-oncology drugs, not primarily to kill malignant cells, but rather to reduce the malignant cells' growth drives. Previous multidrug regimens have used MDACT principles, e.g., the CUSP9v3 glioblastoma treatment. MDACT is an amalgam of (1) the principle that to be effective in stopping a chain of events leading to an undesired outcome, one must break more than one link; (2) the principle of Palmer et al. of achieving fractional cancer cell killing via multiple drugs with independent mechanisms of action; (3) the principle of shaping versus decisive operations, both being required for successful cancer treatment; (4) an idea adapted from Chow et al., of using multiple cytotoxic medicines at low doses; (5) the idea behind CUSP9v3, using many non-oncology CNS-penetrant drugs from general medical practice, repurposed to block tumor survival paths; (6) the concept from chess that every move creates weaknesses and strengths; (7) the principle of mass-by adding force to a given effort, the chances of achieving the goal increase; and (8) the principle of blocking parallel signaling pathways. Part two gives an example MDACT regimen, gMDACT, which uses six repurposed drugs-celecoxib, dapsone, disulfiram, itraconazole, pyrimethamine, and telmisartan-to interfere with growth-driving elements common to cholangiocarcinoma, colon adenocarcinoma, glioblastoma, and non-small-cell lung cancer. gMDACT is another example of-not a replacement for-previous multidrug regimens already in clinical use, such as CUSP9v3. MDACT regimens are designed as adjuvants to be used with cytotoxic drugs.
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Affiliation(s)
| | - Alex Alfieri
- Department of Neurosurgery, Cantonal Hospital of Winterthur, 8400 Winterthur, Switzerland; (A.A.); (M.-E.H.)
| | - Hazem I. Assi
- Naef K. Basile Cancer Center, American University of Beirut, Beirut 1100, Lebanon;
| | - Terry C. Burns
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Ashraf M. Elyamany
- Oncology Unit, Hemato-Oncology Department, SECI Assiut University Egypt/King Saud Medical City, Riyadh 7790, Saudi Arabia;
| | - Maria Gonzalez-Cao
- Translational Cancer Research Unit, Dexeus University Hospital, 08028 Barcelona, Spain;
| | | | - Christine Marosi
- Clinical Division of Medical Oncology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria;
| | - Michael E. Salacz
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA;
| | - Iacopo Sardi
- Department of Pediatric Oncology, Meyer Children’s Hospital, Viale Pieraccini 24, 50139 Florence, Italy;
| | - Pieter Van Vlierberghe
- Department of Biomolecular Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium;
| | - Mohamed S. Zaghloul
- Children’s Cancer Hospital & National Cancer Institute, Cairo University, Cairo 11796, Egypt;
| | - Marc-Eric Halatsch
- Department of Neurosurgery, Cantonal Hospital of Winterthur, 8400 Winterthur, Switzerland; (A.A.); (M.-E.H.)
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4
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Drug Repurposing of Metabolic Agents in Malignant Glioma. Int J Mol Sci 2018; 19:ijms19092768. [PMID: 30223473 PMCID: PMC6164672 DOI: 10.3390/ijms19092768] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 09/10/2018] [Accepted: 09/11/2018] [Indexed: 12/21/2022] Open
Abstract
Gliomas are highly invasive brain tumors with short patient survival. One major pathogenic factor is aberrant tumor metabolism, which may be targeted with different specific and unspecific agents. Drug repurposing is of increasing interest in glioma research. Drugs interfering with the patient’s metabolism may also influence glioma metabolism. In this review, we outline definitions and methods for drug repurposing. Furthermore, we give insights into important candidates for a metabolic drug repurposing, namely metformin, statins, non-steroidal anti-inflammatory drugs, disulfiram and lonidamine. Advantages and pitfalls of drug repurposing will finally be discussed.
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Caruso Bavisotto C, Graziano F, Rappa F, Marino Gammazza A, Logozzi M, Fais S, Maugeri R, Bucchieri F, Conway de Macario E, Macario AJL, Cappello F, Iacopino DG, Campanella C. Exosomal Chaperones and miRNAs in Gliomagenesis: State-of-Art and Theranostics Perspectives. Int J Mol Sci 2018; 19:E2626. [PMID: 30189598 PMCID: PMC6164348 DOI: 10.3390/ijms19092626] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 08/30/2018] [Accepted: 08/31/2018] [Indexed: 12/19/2022] Open
Abstract
Gliomas have poor prognosis no matter the treatment applied, remaining an unmet clinical need. As background for a substantial change in this situation, this review will focus on the following points: (i) the steady progress in establishing the role of molecular chaperones in carcinogenesis; (ii) the recent advances in the knowledge of miRNAs in regulating gene expression, including genes involved in carcinogenesis and genes encoding chaperones; and (iii) the findings about exosomes and their cargo released by tumor cells. We would like to trigger a discussion about the involvement of exosomal chaperones and miRNAs in gliomagenesis. Chaperones may be either targets for therapy, due to their tumor-promoting activity, or therapeutic agents, due to their antitumor growth activity. Thus, chaperones may well represent a Janus-faced approach against tumors. This review focuses on extracellular chaperones as part of exosomes' cargo, because of their potential as a new tool for the diagnosis and management of gliomas. Moreover, since exosomes transport chaperones and miRNAs (the latter possibly related to chaperone gene expression in the recipient cell), and probably deliver their cargo in the recipient cells, a new area of investigation is now open, which is bound to generate significant advances in the understanding and treatment of gliomas.
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Affiliation(s)
- Celeste Caruso Bavisotto
- Department of Experimental Biomedicine and Clinical Neuroscience, Section of Human Anatomy, University of Palermo, 90127 Palermo, Italy.
- Euro-Mediterranean Institute of Science and Technology (IEMEST), 90136 Palermo, Italy.
- Institute of Biophysics, National Research Council, 90143 Palermo, Italy.
| | - Francesca Graziano
- Department of Experimental Biomedicine and Clinical Neuroscience, Section of Neurosurgery, University of Palermo, 90127 Palermo, Italy.
| | - Francesca Rappa
- Department of Experimental Biomedicine and Clinical Neuroscience, Section of Human Anatomy, University of Palermo, 90127 Palermo, Italy.
- Euro-Mediterranean Institute of Science and Technology (IEMEST), 90136 Palermo, Italy.
| | - Antonella Marino Gammazza
- Department of Experimental Biomedicine and Clinical Neuroscience, Section of Human Anatomy, University of Palermo, 90127 Palermo, Italy.
- Euro-Mediterranean Institute of Science and Technology (IEMEST), 90136 Palermo, Italy.
| | - Mariantonia Logozzi
- Department of Oncology and Molecular Medicine, National Institute of Health, Viale Regina Elena 299, 00161 Rome, Italy.
| | - Stefano Fais
- Department of Oncology and Molecular Medicine, National Institute of Health, Viale Regina Elena 299, 00161 Rome, Italy.
| | - Rosario Maugeri
- Department of Experimental Biomedicine and Clinical Neuroscience, Section of Neurosurgery, University of Palermo, 90127 Palermo, Italy.
| | - Fabio Bucchieri
- Department of Experimental Biomedicine and Clinical Neuroscience, Section of Human Anatomy, University of Palermo, 90127 Palermo, Italy.
| | - Everly Conway de Macario
- Department of Microbiology and Immunology, School of Medicine, University of Maryland at Baltimore-Institute of Marine and Environmental Technology (IMET), Baltimore, MD 21202, USA.
| | - Alberto J L Macario
- Euro-Mediterranean Institute of Science and Technology (IEMEST), 90136 Palermo, Italy.
- Department of Microbiology and Immunology, School of Medicine, University of Maryland at Baltimore-Institute of Marine and Environmental Technology (IMET), Baltimore, MD 21202, USA.
| | - Francesco Cappello
- Department of Experimental Biomedicine and Clinical Neuroscience, Section of Human Anatomy, University of Palermo, 90127 Palermo, Italy.
- Euro-Mediterranean Institute of Science and Technology (IEMEST), 90136 Palermo, Italy.
| | - Domenico G Iacopino
- Department of Experimental Biomedicine and Clinical Neuroscience, Section of Neurosurgery, University of Palermo, 90127 Palermo, Italy.
| | - Claudia Campanella
- Department of Experimental Biomedicine and Clinical Neuroscience, Section of Human Anatomy, University of Palermo, 90127 Palermo, Italy.
- Euro-Mediterranean Institute of Science and Technology (IEMEST), 90136 Palermo, Italy.
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Roy S, Lu K, Nayak MK, Bhuniya A, Ghosh T, Kundu S, Ghosh S, Baral R, Dasgupta PS, Basu S. Activation of D2 Dopamine Receptors in CD133+ve Cancer Stem Cells in Non-small Cell Lung Carcinoma Inhibits Proliferation, Clonogenic Ability, and Invasiveness of These Cells. J Biol Chem 2016; 292:435-445. [PMID: 27920206 DOI: 10.1074/jbc.m116.748970] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 12/03/2016] [Indexed: 12/22/2022] Open
Abstract
Lung carcinoma is the leading cause of cancer-related death worldwide, and among this cancer, non-small cell lung carcinoma (NSCLC) comprises the majority of cases. Furthermore, recurrence and metastasis of NSCLC correlate well with CD133+ve tumor cells, a small population of tumor cells that have been designated as cancer stem cells (CSC). We have demonstrated for the first time high expression of D2 dopamine (DA) receptors in CD133+ve adenocarcinoma NSCLC cells. Also, activation of D2 DA receptors in these cells significantly inhibited their proliferation, clonogenic ability, and invasiveness by suppressing extracellular signal-regulated kinases 1/2 (ERK1/2) and AKT, as well as down-regulation of octamer-binding transcription factor 4 (Oct-4) expression and matrix metalloproteinase-9 (MMP-9) secretion by these cells. These results are of significance as D2 DA agonists that are already in clinical use for treatment of other diseases may be useful in combination with conventional chemotherapy and radiotherapy for better management of NSCLC patients by targeting both tumor cells and stem cell compartments in the tumor mass.
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Affiliation(s)
- Soumyabrata Roy
- From the Department of Immunoregulation and Immunodiagnostics, Chittaranjan National Cancer Institute, Kolkata 700026, India
| | - Kai Lu
- the Department of Pathology, Ohio State University, Columbus, Ohio 43210
| | - Mukti Kant Nayak
- the Division of Virology, National Institute of Cholera and Enteric Diseases, Kolkata 700010, India
| | - Avishek Bhuniya
- From the Department of Immunoregulation and Immunodiagnostics, Chittaranjan National Cancer Institute, Kolkata 700026, India
| | - Tithi Ghosh
- From the Department of Immunoregulation and Immunodiagnostics, Chittaranjan National Cancer Institute, Kolkata 700026, India
| | - Suman Kundu
- the Cancer Biology and Inflammatory Disorder Division, Indian Institute of Chemical Biology, Kolkata 700032, India, and
| | - Sarbari Ghosh
- From the Department of Immunoregulation and Immunodiagnostics, Chittaranjan National Cancer Institute, Kolkata 700026, India
| | - Rathindranath Baral
- From the Department of Immunoregulation and Immunodiagnostics, Chittaranjan National Cancer Institute, Kolkata 700026, India
| | - Partha Sarathi Dasgupta
- From the Department of Immunoregulation and Immunodiagnostics, Chittaranjan National Cancer Institute, Kolkata 700026, India,
| | - Sujit Basu
- the Department of Pathology, Ohio State University, Columbus, Ohio 43210, .,the Division of Medical Oncology, Department of Internal Medicine, Ohio State University, Columbus, Ohio 43210
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7
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Všianská P, Bezděková R, Kryukov F, Almáši M, Pour L, Penka M, Hájek R, Říhová L. Activity of aldehyde dehydrogenase in B-cell and plasma cell subsets of monoclonal gammopathy patients and healthy donors. Eur J Haematol 2016; 98:19-25. [PMID: 27199264 DOI: 10.1111/ejh.12779] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Aldehyde dehydrogenase (ALDH) is highly active in physiological stem cells as well as in tumor-initiating cells of some malignancies including multiple myeloma (MM). Finding higher activity of ALDH in some cell subsets in monoclonal gammopathies (MG) could identify potential source of myeloma-initiating cells (MICs). METHODS Bone marrow of 12 MM, 9 monoclonal gammopathy of undetermined significance (MGUS), and 10 healthy donors (HD) were analyzed by flow cytometry. ALDH activity of B-cells and plasma cells (PC) was analyzed using Aldefluor. RESULTS Similar changes of ALDH activity were found during B-cell development in HD and MG. Decreasing of ALDH activity from immature to naïve B-cells was found. In postgerminal stages, the activity started to increase, and in PCs, the ALDH activity was the same as in immature B-cells. Increased ALDH activity of all PC subsets compared to naïve B-cells was found in MM as well as in HD, while in MGUS, only CD19- PCs have higher ALDH activity. In HD, ALDH activity was higher in CD19+ PCs compared with MG. CONCLUSIONS Our results indicate that changes of ALDH activity are the natural phenomenon in B-cell development; thus, high ALDH activity as a single marker is not appropriate for MICs identification.
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Affiliation(s)
- Pavla Všianská
- Department of Clinical Haematology, University Hospital Brno, Brno, Czech Republic
| | - Renata Bezděková
- Department of Clinical Haematology, University Hospital Brno, Brno, Czech Republic
| | - Fedor Kryukov
- Department of Haematooncology, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Martina Almáši
- Department of Clinical Haematology, University Hospital Brno, Brno, Czech Republic
| | - Luděk Pour
- Department of Internal Medicine, Haematology and Oncology, University Hospital Brno, Brno, Czech Republic
| | - Miroslav Penka
- Department of Clinical Haematology, University Hospital Brno, Brno, Czech Republic
| | - Roman Hájek
- Department of Clinical Haematology, University Hospital Brno, Brno, Czech Republic.,Department of Haematooncology, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Lucie Říhová
- Department of Clinical Haematology, University Hospital Brno, Brno, Czech Republic
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Kast RE, Ramiro S, Lladó S, Toro S, Coveñas R, Muñoz M. Antitumor action of temozolomide, ritonavir and aprepitant against human glioma cells. J Neurooncol 2015; 126:425-31. [PMID: 26603162 DOI: 10.1007/s11060-015-1996-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 11/05/2015] [Indexed: 02/02/2023]
Abstract
In the effort to find better treatments for glioblastoma we tested several currently marketed non-chemotherapy drugs for their ability to enhance the standard cytotoxic drug currently used to treat glioblastoma- temozolomide. We tested four antiviral drugs- acyclovir, cidofovir, maraviroc, ritonavir, and an anti-emetic, aprepitant. We found no cytotoxicity of cidofovir and discussed possible reasons for discrepancy from previous findings of others. We also found no cytotoxicity from acyclovir or maraviroc also in contradistinction to predictions. Cytotoxicity to glioma cell line GAMG for temozolomide alone was 14%, aprepitant alone 7%, ritonavir alone 14%, while temozolomide + aprepitant was 19%, temozolomide + ritonavir 34%, ritonavir + aprepitant 64 %, and all three, temozolomide + ritonavir + aprepitant 78%. We conclude that a remarkable synergy exists between aprepitant and ritonavir. Given the long clinical experience with these two well-tolerated drugs in treating non-cancer conditions, and the current median survival of glioblastoma of 2 years, a trial is warranted of adding these two simple drugs to current standard treatment with temozolomide.
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Affiliation(s)
- Richard E Kast
- IIAIGC Headquarters, Dean of Studies, 22 Church St, Burlington, VT, 05401, USA.
| | - Susana Ramiro
- Research Laboratory on Neuropeptides (IBIS), Virgen del Rocío University Hospital, Avda. Manuel Siurot s/n, 41013, Seville, Spain
| | - Sandra Lladó
- Research Laboratory on Neuropeptides (IBIS), Virgen del Rocío University Hospital, Avda. Manuel Siurot s/n, 41013, Seville, Spain
| | - Salvador Toro
- Research Laboratory on Neuropeptides (IBIS), Virgen del Rocío University Hospital, Avda. Manuel Siurot s/n, 41013, Seville, Spain
| | - Rafael Coveñas
- Laboratory of Neuroanatomy of the Peptidergic Systems (Lab. 14), Institute of Neurosciences of Castilla y León (INCYL), University of Salamanca, Salamanca, Spain
| | - Miguel Muñoz
- Research Laboratory on Neuropeptides (IBIS), Virgen del Rocío University Hospital, Avda. Manuel Siurot s/n, 41013, Seville, Spain.
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A conceptually new treatment approach for relapsed glioblastoma: coordinated undermining of survival paths with nine repurposed drugs (CUSP9) by the International Initiative for Accelerated Improvement of Glioblastoma Care. Oncotarget 2013; 4:502-30. [PMID: 23594434 PMCID: PMC3720600 DOI: 10.18632/oncotarget.969] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
To improve prognosis in recurrent glioblastoma we developed a treatment protocol based on a combination of drugs not traditionally thought of as cytotoxic chemotherapy agents but that have a robust history of being well-tolerated and are already marketed and used for other non-cancer indications. Focus was on adding drugs which met these criteria: a) were pharmacologically well characterized, b) had low likelihood of adding to patient side effect burden, c) had evidence for interfering with a recognized, well-characterized growth promoting element of glioblastoma, and d) were coordinated, as an ensemble had reasonable likelihood of concerted activity against key biological features of glioblastoma growth. We found nine drugs meeting these criteria and propose adding them to continuous low dose temozolomide, a currently accepted treatment for relapsed glioblastoma, in patients with recurrent disease after primary treatment with the Stupp Protocol. The nine adjuvant drug regimen, Coordinated Undermining of Survival Paths, CUSP9, then are aprepitant, artesunate, auranofin, captopril, copper gluconate, disulfiram, ketoconazole, nelfinavir, sertraline, to be added to continuous low dose temozolomide. We discuss each drug in turn and the specific rationale for use- how each drug is expected to retard glioblastoma growth and undermine glioblastoma's compensatory mechanisms engaged during temozolomide treatment. The risks of pharmacological interactions and why we believe this drug mix will increase both quality of life and overall survival are reviewed.
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