Different Routes of Proton Pumps Inhibitors Co-Administration have Significant Impact on Mycophenolate Acid (MPA) Serum Levels in Heart Transplant Recipients

Background

Antiproliferative drugs including mycophenolate mofetil (MMF) are widely accepted part of an immunosuppressive therapy following heart transplantation. Proton pump inhibitors (PPIs) are routinely administered after cardiac surgery procedures including transplantation. They may also have impact on mycophenolate acid (MPA) serum levels.

Material/Methods

There were 30 consecutive patients (28 male and 2 female patients) with a mean age of 45±12 years who were enrolled into this study. MPA serum levels were studied; PPIs were intravenously and orally administered.

Results

The mean MPA plasma concentrations were statistically significantly different between parenteral group (2.3±1.4 umg/mL) and oral group (3.1±2.2 umg/mL) (P=0.036) before immunosuppressive drug administration (C-0 time). There was a statistically significant different drug concentration at the second sample time C-30 (30 minutes after drug intake) reaching 4.4±2.8 umg/mL versus 7.9±4.5 umg/mL (P<0.05). There was no statistically significant difference in MPA plasma concentration at the 3^rd measurement C-120 (10.7±4,9 umg/mL versus 9.8±5 umg/mL) (P=0.3). There is a statistically significant different MMF serum concentration after oral intake and intravenous infusion at C-30 (2.4±1.4 in group 1 versus 3.3±2.5 in group 2, P<0.036) but not at C-120 time interval (8.9±5.0 versus 9.8±5.3 in group 1 and 2, respectively) (P=0.3).

Conclusions

Our study was the first study that compared different routes of PPI co-administration on MPA serum levels in a transplant recipient group. Our study revealed that the parenteral route of administration only slowed not decreased MPA pharmacokinetics within 120 minutes following MMF administration.

Clinical presentation, surgical management, and outcomes of patients treated for aortic stenosis and coronary artery disease. Does age matter?

BACKGROUND

Aortic stenosis and coronary artery disease (CAD) sharing similar risk factors are associated with aging of the human population.

AIM

The purpose of this study was to examine whether age affects clinical presentation, intraoperative management, and outcomes of patients who undergo simultaneous operations of aortic valve replacement (AVR) and coronary artery bypass grafting (CABG).

METHODS

The study involved 452 consecutive patients aged 64.8 ± 8.2 years (range 38-79 years), who underwent combined AVR and CABG between 2005 and 2015. They were divided into three groups: Y (young; below the first quartile; n = 114), M (middle-aged; 58-71 years; n = 225) and E (elderly; above the third quartile; n = 113). Pre- and intraoperative variables were analysed. The deaths that occurred in hospital and throughout follow-up were defined as cardiac- or non-cardiac-related. The probability of survival was calculated with the use of Kaplan-Meier curves.

RESULTS

Coronary artery disease was more extensive in group E than in group Y (p < 0.05). Complete myocardial revasculari-sation was performed in 94.1%, 76.2%, and 62.8% in groups Y, M, and E, respectively (p < 0.05). In-hospital mortality was 2.0%, 5.3%, and 6.4%, in groups Y, M, and E, respectively. Early morbidity was significantly higher in group E than in groups M or Y. The 12- and 60-month freedom from cardiac-related death was higher in group Y (0.98 ± 0.02 and 0.94 ± 0.03) than in group E (0.93 ± 0.02 and 0.85 ± 0.03; p = 0.023, respectively). Left ventricular ejection fraction below 0.4 and incomplete revascularisation were associated with worse prognosis, particularly in group E.

CONCLUSIONS

Elderly patients undergoing combined procedures of AVR and CABG having more extensive CAD less often receive complete revascularisation, are at higher risk of early organ failure, and present markedly reduced rates of freedom from cardiac-related deaths throughout follow-up than younger subjects.

Abstract P3-14-16: A phase 2 trial of myocet®, cyclophosphamide +/- trastuzumab followed by weekly paclitaxel +/- trastuzumab as primary systemic therapy in operable and locally advanced breast cancer

BACKGROUND: Anthracycline- and taxane-based chemotherapies are highly effective in primary systemic treatment of breast cancer (BC). Myocet® (M) is a non-pegylated liposomal doxorubicin exhibiting reduced cardiotoxicity as compared to doxorubicin. Combination of M and cyclophosphamide (C) has demonstrated efficacy in first line treatment of metastatic BC, however few data are available in neoadjuvant setting, especially in combination with trastuzumab (T). The aims of the study were activity, in terms of pathological complete response (pCR; ie, no remaining invasive tumor in breast and lymphnodes) and safety of a sequential schedule of M and C +/- T followed by weekly paclitaxel (P) +/- T. METHODS: Estrogen receptor (ER), progesterone receptor (PgR), HER2 positivity (defined as 3+ overexpression by immunoistochemical testing or HER2 amplification by fluorescent in situ hybridisation) and Ki67 index were assessed in core needle biopsies at baseline and in residual tumour after chemotherapy. Patients with stage II/III BC received 4 cycles of MC (myocet 60 mg/m2, cyclophosphamide 600 mg/m2 on day 1 every 3 weeks), followed by 12 weekly doses of P (paclitaxel 80 mg/m2); all patients with HER2+ disease received T in combination with chemotherapy (trastuzumab loading dose of 8 mg/kg followed by 3 cycles of 6 mg/kg alongside MC; 2 mg/kg per week with the following 12 P administrations). RESULTS: 49 patients were enrolled, with 44 patients having completed chemotherapy and undergoing surgery to date. Median age was 56 years (range, 34 to 72). Tumour characteristics were as follows: stage IIA 10 patients, IIB 16, IIIA 13, IIIB 5, IIIC 1, and 4 patients with inflammatory BC; ER+/PgR+ 21 patients, ER+/PgR- 13, triple negative 8, HER2+ 16; Ki67&gt; 15% in 41 patients. Forty-four patients were evaluable for pathological response. pCR was obtained in 12 patients (27.3%). The rate of pCR in HER2+ and HER2- BC was 57.1% and 13.3%, respectively. Clinical response was obtained in 36 out of 41 clinically evaluable patients (87.8%): CR in 20 (48.8%) and PR in 16 (39%). Conservative surgery was performed in 16 patients (36.4%) and mastectomy in 28 (63.6%). The most frequently observed grade 3-4 AEs were: alopecia 47 patients (95.9%), grade 3 neutropenia 2 (4.1%), febrile neutropenia 2 (4,1%), grade 3 paresthesia 2 (4.1%), grade 3 vomiting 1 (2%), grade 3 cutaneous erythema 1 (2%). Only 1 patient experienced an asymptomatic decrease of ejection fraction lower than 50%. Five patients (10.2%) discontinued treatment with M+C because of: allergic reaction to M in 3 patients, grade 2 liver toxicity in 1 and grade 3 vomiting in 1. All of them completed the following treatment with P. Three patients (6.1%) discontinued P because of: allergic reaction in 1 patient, infectious pneumonia in 1 and grade 3 cutaneous erythema in 1. CONCLUSIONS: The use of M in this sequential anthracycline- and taxane-based regimen resulted tolerable even in combination with T and active despite of the high rate of patients with ER+ disease and with locally advanced cancer. Consistently with previous data, pCR was higher in patients with HER2+ BC.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-14-16.

"Short Course" of Nonpegylated Liposomal Doxorubicin Plus Paclitaxel and Trastuzumb as Primary Systemic Therapy for Operable and Locally-Advanced Breast Cancer: A Phase II Study (PacLiDox 07)

Background

Schedules with anthracyclines and taxanes are one of the best options for primary chemotherapy. The addition of trastuzumab showed an impressive percentage of pathological complete responses in Buzdar trial (66.7%). Recently, nonpegylated liposome-encapsulated doxorubicin (NLD) has been widely used in advanced breast cancer with high response rates (98.1 % in Cortes study). The aims of our study were to assess pathological responses and toxicity of NLD plus paclitaxel (and trastuzumab in patients with HER2 overexpression).

Methods

Thirty patients entered the study: 9 locally advanced and 21 operable. Median age was 58.5 years (range: 31-73). 23 patients without HER2 overexpression (or FISH not amplified) were treated with NLD 50 mg/m² every three weeks for 3 courses and weekly paclitaxel 80 mg/m² for 8 courses. 7 patients with HER2 overexpression or FISH amplified were treated with the same schedules plus trastuzumab (Herceptin) 4 mg/kg for the first administration and 2 mg/kg for the following 7 weekly administrations.

Results

Pathological complete response (pCR) was documented in 1 patient (treated with trastuzumab); no residual tumor (infiltrating or “in situ”) on breast was documented in other 2 patients. Objective clinical responses were documented in 22 patients (73.3%): 8 complete, 10 partial and 4 “minimal” responses. 7 patients have shown stable and 1 progressive disease. Clinical response in patients with HER2 overexpression treated with trastuzumab was 100% (4 complete and 3 partial responses). Conservative surgery was performed in 8 (38%) and mastectomy in 13 (62%) out of 21 operable patients; however, 7 out of 14 responding patients with operable disease underwent quadrantectomy (50%). Main toxicity was neutropenia: febrile in 2 patients (7%) and gr. 3-4 in 13 (43%). Other grade 3 toxicities were as follows: vomiting in 1 patient, asthenia in 1 patient, joint symptom in 1 patient. 3 patients were withdrawn from the study. No episodes of left ventricular ejection fraction (LVEF) < 50% were recorded (with a median reduction of 8%).

Conclusions

A “short course” of paclitaxel and NLD is active in terms of clinical response and conservative surgery for patients with potentially operable and locally advanced breast cancer; toxicity was manageable. High activity of the combination with trastuzumab has been confirmed. However, with this “short course” schedule, the result in term of clinical responses didn't turn into complete pathological responses.

Advanced colorectal cancer in elderly patients: tolerance and efficacy of leucovorin and fluorouracil bolus plus continuous infusion

BACKGROUND

Colorectal cancer (CRC) incidence increases sharply with age. In this study we assessed activity, toxicity and both the activity of daily living (ADL) and instrumental activity of daily living (IADL) of the De Gramont schedule in a series of advanced CRC patients aged > or = 70 years.

PATIENTS AND METHODS

Sixty-two previously untreated advanced CRC patients entered the study. Median age was 75 (range 70-88).

RESULTS

447 courses were delivered. All of the 62 patients were evaluable for toxicity, 55 for response and ADL-IADL indexes. We recorded 2 complete and 9 partial responses, for an overall response rate of 20%. ADL and IADL indexes improved in 33%, remained stable in 49% and worsened in 18% of evaluable patients. Treatment was very well-tolerated with no serious hematological or non-hematological toxicities.

CONCLUSIONS

The De Gramont schedule was very well tolerated in advanced CRC elderly patients, although our work could not confirm the original reported activity. ADL and IADL indexes improved or remained stable in 82% of evaluable patients.

Gene polymorphism affecting alpha1-antichymotrypsin and interleukin-1 plasma levels increases Alzheimer's disease risk

Plasma levels of alpha1-antichymotrypsin (ACT) and interleukin-1beta (IL-1beta) were increased in patients with probable Alzheimer's disease (AD). A common polymorphism within ACT and IL-1beta genes affected plasma levels of ACT or IL-1beta, and AD patients with the ACT T,T or IL-1beta T,T genotype showed the highest levels of plasma ACT or IL-1beta, respectively. The concomitant presence of the ACT T,T and IL-1beta T,T genotypes increased the risk of AD (odds ratio: 5.606, confidence interval: 1.654-18.996) and decreased the age at onset of the disease.

Increased plasma levels of interleukin-1, interleukin-6 and alpha-1-antichymotrypsin in patients with Alzheimer's disease: peripheral inflammation or signals from the brain?

Plasma concentrations of interleukin-1beta (IL-1beta), interleukin-6 (IL-6), C reactive protein (CRP) and alpha-1-antichymotrypsin (ACT) in 145 patients with probable Alzheimer's disease (AD) and 51 non-demented controls were measured. To investigate the cellular activation of peripheral immune system, plasma levels of neopterin were also investigated. Plasma levels of IL-1 were detectable in 17 patients with AD (13%) and only in one control (2%) and average levels of IL-1 were higher in AD patients than in controls (p < 0.001). IL-6 plasma levels were detectable in a higher proportion of AD and controls (53% and 27%, respectively), and were increased in patients with AD (p < 0.001). Plasma levels of ACT were increased in patients with AD (p < 0.001) and CRP levels were in the normal range. Plasma levels of neopterin were slightly lower in AD patients than in controls, but differences were not statistically significant. No significant correlation was observed between IL-1 and IL-6 levels or neopterin and cytokine levels in plasma from AD patients. Plasma levels of ACT negatively correlated with cognitive performances, as assessed by the mini mental state examination (MMSE; R = -0.26, p < 0.02) and positively correlated with the global deterioration state (GDS) of AD patients (R = 0.30, p < 0.007). Present findings suggested that detectable levels of circulating cytokines and increased ACT might not be derived by activation of peripheral immune system of AD patients. Detection of these molecules might be used for monitoring the progression of brain inflammation associated with AD.

Apolipoprotein E and alpha-1-antichymotrypsin allele polymorphism in sporadic and familial Alzheimer's disease

Alzheimer disease (AD) patients with both sporadic and familial forms of AD and non-demented controls were genotyped for common polymorphisms in the signal peptide for alpha-1-antichymotrypsin (ACT) gene and in two different regions of apolipoprotein E (APOE) gene. The ACT TT genotype was over-represented (P = 0.025) in patients with early onset of sporadic AD. In this patient's group ACT TT genotype conferred a significant crude odds ratio for the disease (OR = 2.09; 95% CI = 1.09-4.00, P = 0.025). After adjustment for the APOE epsilon4 and APOE -491 genotypes, logistic regression analysis confirmed that the ACT TT genotype resulted independently associated with early onset AD (adjusted OR = 2.56; 85% CI = 1.3-5.2, P = 0.009). The frequency of APOE epsilon4 allele was increased in AD, as expected (OR = 5.92, 95% CI = 3.60-9.70, P = 0.0001). On the contrary, the APOE -491 A/T genotypes were not associated with AD. No preferential association of the APOE epsilon4 allele or APOE -491 A/T genotypes with ACT A/T alleles was observed in AD. Present findings indicated that subjects with ACT TT genotype had an increased risk of developing AD and suggested that this genotype influenced the risk of an early onset of the disease by affecting the production of ACT molecules.

Multimodal biochemical modulation of 5-fluorouracil by leucovorin, methotrexate, and interferon alpha in patients with advanced colorectal cancer

A total of 26 patients with advanced colorectal cancer received 60 mg/m2 methotrexate i.v. on days 1-4; 400 mg/m2 5-fluorouracil i.v. on days 2, 3, 5, and 6; and 100 mg/m2 6S-leucovorin i.v. on days 2, 3, 5, and 6. Interferon-alpha 2b at a dose of 3 million U was given i.m. daily for the 6 days of chemotherapy. Courses were repeated every 3 weeks. There were four partial responses for a response rate of 15% (95% confidence interval 2-28%): In all, 14 patients expressed grade 3 toxicity; 9 patients had diarrhea, 3 had stomatitis, and 2 developed leukopenia. In conclusion, multimodal biochemical modulation of 5-fluorouracil, at least on this schedule, does not seem to be effective, as it results in severe toxicity.

Pamidronate in patients with painful bone metastases, who failed initial treatment with hormones and/or chemotherapy

In an open prospective study. 40 patients with progressing painful bone metastases received 45 mg pamidronate by 1-h infusion every 3 weeks. A total of 27 patients (67%; 95% CI 53%-81%) experienced relief of pain as shown by the significant reduction of the bone pain score after three pamidronate administrations (from 2.25 +/- 0.64 to 1.15 +/- 0.36). Furthermore, 20 patients (60%) reduced their consumption of analgesics. We did not observe any objective response by skeletal radiological examination. In 11 patients presenting a skeletal progressive disease, bone pain improved, as well as their mobility score, but not their fatigue score. Treatment was well tolerated. Only 1 patient discontinued the treatment because of fever and cutaneous rash after the first administration. In conclusion, our results seem to confirm that pamidronate exerts a benefical effect on bone pain and mobility impairment in patients with painful osteolytic bone metastases.