Everolimus

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Everolimus
Everolimus.svg
Everolimus ball-and-stick.png
Clinical data
License data
Pregnancy
category
  • US: D (Evidence of risk)
Routes of
administration
Oral
ATC code L01XE10 (WHO) L04AA18 (WHO)
Legal status
Legal status
  • ℞ (Prescription only)
Pharmacokinetic data
Biological half-life ~30 hours[1]
Identifiers
Synonyms 42-O-(2-hydroxyethyl)rapamycin
CAS Number 159351-69-6 YesY
PubChem (CID) 6442177
DrugBank DB01590 YesY
ChemSpider 21106307 YesY
UNII 9HW64Q8G6G YesY
KEGG D02714 YesY
ChEMBL CHEMBL1908360 N
Chemical and physical data
Formula C53H83NO14
Molar mass 958.224 g/mol
3D model (Jmol) Interactive image
 NYesY (what is this?)  (verify)

Everolimus (INN) (/ˌɛvəˈrləməs/) (earlier code name RAD001) is the 40-O-(2-hydroxyethyl) derivative of sirolimus and works similarly to sirolimus as an inhibitor of mammalian target of rapamycin (mTOR).

It is currently used as an immunosuppressant to prevent rejection of organ transplants and treatment of renal cell cancer and other tumours. Much research has also been conducted on everolimus and other mTOR inhibitors as targeted therapy for use in a number of cancers.

It is marketed by Novartis under the tradenames Zortress (USA) and Certican (Europe and other countries) in transplantation medicine, and as Afinitor (general tumours) and Votubia (tumours as a result of TSC) in oncology. Everolimus is also available from Biocon, with the brand name Evertor.

Approvals and indications[edit]

Everolimus is approved for various conditions:

  • Advanced kidney cancer (US FDA approved in March 2009)[2]
  • Prevention of organ rejection after renal transplant(US FDA April 2010)[3]
  • Subependymal giant cell astrocytoma (SEGA) associated with tuberous sclerosis (TS) in patients who are not suitable for surgical intervention (US FDA October 2010)[4]
  • Progressive or metastatic pancreatic neuroendocrine tumors not surgically removable (May 2011)[5]
  • Breast cancer in post-menopausal women with advanced hormone-receptor positive, HER2-negative type cancer, in conjunction with exemestane (US FDA July 2012)[6]
  • Prevention of organ rejection after liver transplant(Feb 2013)
  • Progressive, well-differentiated non-functional, neuroendocrine tumors (NET) of gastrointestinal (GI) or lung origin with unresectable, locally advanced or metastatic disease (US FDA February 2016).[7]

UK National Health Service[edit]

NHS England has been criticised for delays in deciding on a policy for the prescription of Everolimus in the treatment of Tuberous Sclerosis. 20 doctors addressed a letter to the board in support of the charity Tuberous Scelerosis Association saying " around 32 patients with critical need, whose doctors believe everolimus treatment is their best or only option, have no hope of access to funding. Most have been waiting many months. Approximately half of these patients are at imminent risk of a catastrophic event (renal bleed or kidney failure) with a high risk of preventable death."[8] In May 2015 it was reported that Luke Henry and Stephanie Rudwick, the parents of a child suffering from Tuberous Sclerosis were trying to sell their home in Brighton to raise £30,000 to pay for treatment for their daughter Bethany who has tumours on her brain, kidneys and liver and suffers from up to 50 epileptic fits a day.[9]

Clinical trials[edit]

As of October 2010, Phase III trials are under way in gastric cancer, hepatocellular carcinoma and lymphoma.[10] The use of everolimus in refractory chronic graft-versus-host disease has been reported in 2012.[11]

Interim phase III trial results in 2011 showed that adding Afinitor (everolimus) to exemestane therapy against advanced breast cancer can significantly improve progression-free survival compared with exemestane therapy alone.[12]

Furthermore, there is a study that shows that there is a different sensitivity to everolimus between patients depending on their genome.[13] Through a Phase II clinical trial done in patients that presented advanced metastasic bladder carcinoma (NCT00805129) [14] they found just one person that positively responded to everolimus treatment for 26 months. Thus, they decided to sequence the genome of this patient and to compare it to different reference genomes and to other patients' genomes. This way, they discovered that mutations in TSC1 lead to an increase in recurrence and to an increase in the response time to everolimus. Thus, it has been determined that everolimus is more efficient in those patients that present somatic mutations in TSC1.

Mechanism[edit]

In a similar fashion to other mTOR inhibitors its effect is solely on the mTORC1 protein complex and not on the mTORC2 complex. This can lead to a hyper-activation of the kinase AKT via inhibition on the mTORC1 negative feedback loop while not inhibiting the mTORC2 positive feedback to AKT. This AKT elevation can lead to longer survival in some cell types. Hence, everolimus has an important effect on cell growth, cell proliferation and cell survival. mTORC1 action is modulated by several mitogens, growth factors and nutrients.

TSC1 and TSC2 (which are the genes involved in tuberous sclerosis disease) act as tumor suppressor genes by regulating mTORC1 activity. Thus, either the loss or inactivation of one of these genes lead to the activation of mTORC1.[15]

Everolimus binds to its protein receptor FKBP12, which directly interacts with mTORC1 inhibiting its downstream signaling. As a consequence, mRNAs that codify proteins implicated in the cell cycle and in the glycolysis process are impaired or altered, so tumor growth is inhibited. Hence, everolimus inhibits tumor cells' growth and proliferation.[15]

Adverse reactions[edit]

A trial using 10 mg/day in patients with NETs of GI or lung origin reported "Everolimus was discontinued for adverse reactions in 29% of patients and dose reduction or delay was required in 70% of everolimus-treated patients. Serious adverse reactions occurred in 42% of everolimus-treated patients and included 3 fatal events (cardiac failure, respiratory failure, and septic shock). The most common adverse reactions (incidence greater than or equal to 30%) were stomatitis, infections, diarrhea, peripheral edema, fatigue and rash. The most common laboratory abnormalities (incidence greater than or equal to 50%) were anemia, hypercholesterolemia, lymphopenia, elevated aspartate transaminase (AST) and fasting hyperglycemia.".[7]

Role in heart transplantation[edit]

Everolimus may have a role in heart transplantation as it has been shown to reduce chronic allograft vasculopathy in such transplants. It also may have a similar role to sirolimus in kidney and other transplants.[16]

Role in Liver Transplantation[edit]

Although, sirolimus, an m-TOR inhibior had generated worries initially while using m-TORs in liver transplantation recipients due to possible early hepatic artery thrombosis and graft loss, use of Everolimus in the setting of liver transplantation is promising. Recent studies have proven the safety of the everolimus when used in early phase after liver transplantation. Jeng et al.[17] in their study of 43 patients concluded the safety of use of everolimus in early phase after living donor liver transplantation. In their study no hepatic artery thrombosis or wound infection was noted. Also, a possible role of everolimus in reducing the recurrence of hepatocellular carcinoma after liver transplantation was correlated. At a target trough level of 3 ng/mL at 3 months was proved to be beneficial in recipients with pre-transplant renal dysfucntion. In their study, 6 of 9 renal failure patients showed significant recovery of renal function, whereas 3 of them showed further deterioration and 1 required hemodialysis. The same study group claims decreased recurrence of hepatocelullar carcinoma recurrence if everolimus was used in early phase after transplantation.[18]

Use in vascular stents[edit]

Everolimus is used in drug-eluting coronary stents as an immunosuppressant to prevent restenosis. Abbott Vascular produces an everolimus-eluting stent (EES) called Xience Alpine. It utilizes the Multi-Link Vision cobalt chromium stent platform and Novartis' everolimus. The product is widely available gobally including USA, Europe, and APAC countries. Boston Scientific also market EES' of which they currently have Promus Premiere and Synergy versions.

Use in aging[edit]

Inhibition of mTOR, the molecular target of Everolimus, extends the lifespan of model organisms including mice,[19] and mTOR inhibition has been suggested as an anti-aging therapy. Everolimus was used in a recent clinical trial by Novartis, and short-term treatment was shown to enhance the response to the influenza vaccine in the elderly, possible by reversing immunosenescence.[20] Everolimus treatment of mice results in reduced metabolic side effects compared to sirolimus.[21]

See also[edit]

References[edit]

  1. ^ R.N Formica Jra; K.M Lorberb; A.L Friedmanb; M.J Biaa; F Lakkisa; J.D Smitha; M.I Lorber (March 2004). "The evolving experience using everolimus in clinical transplantation". Transplantation Proceedings. 36 (2): S495–S499. doi:10.1016/j.transproceed.2004.01.015. 
  2. ^ "Afinitor approved in US as first treatment for patients with advanced kidney cancer after failure of either sunitinib or sorafenib" (Press release). Novartis. 2009-03-30. Retrieved April 6, 2009. 
  3. ^ "Novartis receives US FDA approval for Zortress (everolimus) to prevent organ rejection in adult kidney transplant recipients" (Press release). Novartis. 2010-04-22. Retrieved April 26, 2010. 
  4. ^ "Novartis' Afinitor Cleared by FDA for Treating SEGA Tumors in Tuberous Sclerosis". 1 Nov 2010. 
  5. ^ http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm254350.htm
  6. ^ "US FDA approves Novartis drug Afinitor for breast cancer". Reuters. 20 Jul 2012. 
  7. ^ a b Everolimus (Afinitor). Feb 2016
  8. ^ Lintern, Shaun (14 April 2015). "Policy delays risk 'preventable deaths', doctors warn NHS England". Health Service Journal. Retrieved 20 April 2015. 
  9. ^ "Couple forced to sell home after NHS refuse to fund daughter's treatment for rare illness". Daily Express. 11 May 2015. Retrieved 12 May 2015. 
  10. ^ http://www.genengnews.com/gen-news-highlights/novartis-afinitor-cleared-by-fda-for-treating-sega-tumors-in-tuberous-sclerosis/81244159/
  11. ^ Lutz M, Kapp M, Grigoleit GU, Stuhler G, Einsele H, Mielke S (April 2012). "Salvage therapy with everolimus improves quality of life in patients with refractory chronic graft-versus-host disease" (PDF). Bone Marrow Transplant. 47 (S1): S410–S411. 
  12. ^ "Positive Trial Data Leads Novartis to Plan Breast Cancer Filing for Afinitor by Year End". 2011. 
  13. ^ Iyer, G; Hanrahan, AJ; Milowsky, MI; Al-Ahmadie, H; Scott, SN; Janakiraman, M; Pirun, M; Sander, C; Socci, ND; Ostrovnaya, I; Viale, A; Heguy, A; Peng, L; Chan, TA; Bochner, B; Bajorin, DF; Berger, MF; Taylor, BS; Solit, DB (2012). "Genome sequencing identifies a basis for everolimus sensitivity". Science. 338: 221. doi:10.1126/science.1226344. PMC 3633467Freely accessible. PMID 22923433. 
  14. ^ [1]
  15. ^ a b [2]
  16. ^ Eisen HJ, Tuzcu EM, Dorent R, et al. (August 2003). "Everolimus for the prevention of allograft rejection and vasculopathy in cardiac-transplant recipients". N. Engl. J. Med. 349 (9): 847–58. doi:10.1056/NEJMoa022171. PMID 12944570. 
  17. ^ Jeng LB; Thorat A; Hsieh YY; et al. (April 2014). "Experience of using everolimus in the early stage of living donor liver transplantation.". Transpl Proc. 46 (3): 744–48. doi:10.1016/j.transproceed.2013.11.068. PMID 24767339. 
  18. ^ Jeng L, Thorat A, Yang H, Yeh C-C, Chen T-H, Hsu S-C. Impact of Everolimus On the Hepatocellular Carcinoma Recurrence After Living Donor Liver Transplantation When Used in Early Stage: A Single Center Prospective Study [abstract]. Am J Transplant. 2015; 15 (suppl 3). http://www.atcmeetingabstracts.com/abstract/impact-of-everolimus-on-the-hepatocellular-carcinoma-recurrence-after-living-donor-liver-transplantation-when-used-in-early-stage-a-single-center-prospective-study/. Accessed September 1, 2015.
  19. ^ Harrison, David E.; Strong, Randy; Sharp, Zelton Dave; Nelson, James F.; Astle, Clinton M.; Flurkey, Kevin; Nadon, Nancy L.; Wilkinson, J. Erby; Frenkel, Krystyna (2009-07-16). "Rapamycin fed late in life extends lifespan in genetically heterogeneous mice". Nature. 460 (7253): 392–395. doi:10.1038/nature08221. ISSN 1476-4687. PMC 2786175Freely accessible. PMID 19587680. 
  20. ^ Mannick, Joan B.; Del Giudice, Giuseppe; Lattanzi, Maria; Valiante, Nicholas M.; Praestgaard, Jens; Huang, Baisong; Lonetto, Michael A.; Maecker, Holden T.; Kovarik, John (2014-12-24). "mTOR inhibition improves immune function in the elderly". Science Translational Medicine. 6 (268): 268ra179. doi:10.1126/scitranslmed.3009892. ISSN 1946-6242. PMID 25540326. 
  21. ^ Arriola Apelo, Sebastian I.; Neuman, Joshua C.; Baar, Emma L.; Syed, Faizan A.; Cummings, Nicole E.; Brar, Harpreet K.; Pumper, Cassidy P.; Kimple, Michelle E.; Lamming, Dudley W. (2015-10-13). "Alternative rapamycin treatment regimens mitigate the impact of rapamycin on glucose homeostasis and the immune system". Aging Cell. 15: 28–38. doi:10.1111/acel.12405. ISSN 1474-9726. PMC 4717280Freely accessible. PMID 26463117. 

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