Unit : 04 CHEMOTHERAPY

 Chemotherapy
 Urinary tract infections and sexually transmitted diseases. Chemotherapy of
malignancy
 immunopharmacology
 Immunostimulants, Immunosuppressant, Protein drugs, monoclonal antibodies, target
drugs to antigen, biosimilars

DRUGS USED IN URINARY TRACT INFECTION

URINARY ANTISEPTICS Urinary antiseptics are oral agents that exert antibacterial
activity in the urine o but have little or no systemic antibacterial effects. Their usefulness is
limited to lower urinary tract infections.

DRUGS USED AS URINARY ANTISEPTICS Nitrofurantoin Methenamine

Nalidixic acid
NITROFURANTOIN: Primarily bacteriostatic Activity limited to E. coli
Mechanism of Action: Sensitive bacteria reduce the drug to an active agent that inhibits
various enzymes damage bacterial DNA. Antibacterial concentration is not attained in blood
or tissues. Not to be used with Probenecid, azotemic patients: interferes with tubular secretion
of drug.
Gastrointestinal Intolerance: Nausea, epigastric
pain, diarrhoea Hypersensitivity : fever, chills Peripheral neuritis and other neurological
effects with long term use Hematologic disorders: leukopenia, granulocytopenia, Hemolytic
anemia in G6PD deficient patients
NITROFURANTOIN: USES Treatment for uncomplicated lower urinary tract
infection.Not associated with prostatitis. Supportive long term therapy. Long term
porphylaxis. Following catheterization, instrumentation, in women with recurrent cystitis

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METHENAMINE (HEXAMINE) Prodrug Mechanism of Action: Decomposes slowly in
acidic urine( Ph 5.5 or less) to release formaldehyde which inhibits all bacteria. No
antimicrobial activty in blood and tissues. Needs to be administered with mandelic acid or
hippuric acid
Use As Methenamine mandelate in Chronic and resistant UTI not involving kidneys. Not
Effective for Acute UTI Catheter prophylaxis
Side Effects: Gastritis Chemical cystitis, hematuria Occasional CNS Symptoms
NALIDIXIC ACID: Nonfluorinated quinolone
Bactericidal. Mechanism of Action:Inhibit the replication of bacterial by interfering with the
action of DNA gyrase during bacterial growth and development. Resistance Develops rather
rapidly
Uses: Second Line Drugs for UTI Recurrent cases- On the basis of Sensitivity Reports 
ADR: Infrequent: GI upset, rashes  Headache drowsiness, vertigo, visual disturbances 
Seizures in children, Nausea ,Vomiting and abdominal pain, Photosensitivity, urticaria and
Fever Contraindicated in infants

URINARY TRACT INFECTION: TREATMENT Mostly gram negative organisms Acute

episode: single organism, Chronic/recurrent: mixed infection Acute Infection: largely self
limiting High urine flow rate Frequent bladder voiding Lower UTI: Single Dose
Antibiotic or 3 Days Course Suffice Upper UTI: Longer Treatment

URINARY TRACT INFECTION: TREATMENT Bacterial Investigation very important

Smaller than usual doses required for treatment of Lower UTI. Upper UTI requires normal
doses as for any other infection. Least Toxic and cheaper drugs should be chosen, for proper
duration. Drug should not disrupt normal gut and perineal flora Frequent recurrences:
chronic suppressive treatment with co-trimoxazole, nitrofurantoin, methenamine, cephalexin,

STATUS OF ANTIMICROBIAL AGENTS OTHER THAN URINARY ANTISEPTICS IN

UTI Sulfonamides:  Decreased dependability for acute UTI;  Not used as single drug;
employed for suppressive or prophylactic therapy  Cotrimoxazole:  Declined
responsiveness  Employed for acute UTI (broad spectrum)  Prophylaxis for recurrent
cystitis in women, catheterized patients Quinolones:  FQs (norfloxacin and ciprofloxacin)
Ampicillin/Amoxicillin  Frequently used in the past  Higher failure and relapse rates 

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Amoxicillin + Clavulanic Acid used these days  Coamoxiclav+ Gentamycin: initial
treatment for acute pyelonephritis

STATUS OF ANTIMICROBIAL AGENTS OTHER THAN URINARY ANTISEPTICS IN

UTI Cephalosporin:  Increasing use especially in nosocomial Klebsiella and Proteus
infection  Employed on the basis of sensitivity report, employed for community acquired
infections as well  Cephalexin: alternative for prophylaxis of recurrent UTI, especially
women likely to get pregnant  Gentamycin:  Sensitive against Pseudomonas  Narrow
margin of safety, parenteral administration: bacterial sensitivity awaited

URINARY PH AND ANTI MICROBIAL AGENTS  Acidic urine required for

Methenamine  Inadequate response, in complicated cases: measurement and correction of
urinary pH may be attempted  Urease positive Proteus infections: drugs acting at higher pH
should be administered Favourable urinary pH for antimicrobial action Acidic Alkaline pH
immaterial Nitrofurantion Cotrimoxazole Chloramphenicol Methenamine Aminoglycosides
Ampicillin Cloxacillin Cephalosporin Fluoroquinolone

URINARY TRACT INFECTIONS (UTI)

URINARY INFECTION IN PATIENTS WITH RENAL IMPAIRMENT  Difficult to treat
Drugs Contraindicated:Methamine mandelate, Tetracyclines, Cephalosporin (some) Drugs
avoided: Nitrofurantion, Nalidixic acid, Aminoglycosides Potassium salts and acidifying
agents contraindicated

PROPHYLAXIS FOR UTI This may be given when: (a) Women of child bearing age have
recurrent cystitis. (b) Catheterization or instrumentation inflicting trauma to the lining of the
urinary tract is performed; bacteremia frequently occurs and injured lining is especially
susceptible. (c) Indwelling catheters are placed. (d) Uncorrectable abnormalities of the
urinary tract are present. (e) Inoperable prostate enlargement or other chronic obstruction
causes urinary stasis.

Methenamine (Hexamine)
It is hexamethylene-tetramine; inactive as such; decomposes slowly in acidic urine to release
formaldehyde which inhibits all bacteria. This drug exerts no antimicrobial activity in blood
and tissues, including kidney parenchyma. Acidic urine is essential for its action; urinary pH

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must be kept below 5.5 by administering some organic acid which is excreted as such, e.g.
mandelic acid or ascorbic acid. Methenamine is administered in enteric coated tablets to
protect it from decomposing in gastric juice.

Adverse effects Gastritis can occur due to release of formaldehyde in stomach-patient

compliance is often poor due to this . Chemical cystitis and haematuria may develop with
high doses given for long periods. CNS symptoms are produced occasionally. Methenamine
mandelate is contraindicated in renal failure

Treatment for (STD) HIV Infection

Prior to approval of zidovudine in 1987, treatment of HIV infections focused on decreasing
the occurrence of opportunistic infections that caused a high degree of morbidity and
mortality in AIDS patients rather than on inhibiting HIV itself.

This multi drug regimen is commonly referred to as ehighly active antiretroviral therapy,†or
HAART. There are five classes of antiretroviral drugs, each of which targets one of four viral
processes. These classes of drugs are nucleoside and nucleotide reverse transcriptase
inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease
inhibitors, entry inhibitors and the integrase inhibitors. The current recommendation for
primary therapy is to administer two NRTIs with either a protease inhibitor or an NNRTI.
Selection of the appropriate combination is based on
1) avoiding the use of two agents of the same nucleoside analog,
2) avoiding overlapping toxicities and genotypic and phenotypic characteristics of the
Svirus,
3) patient factors such as disease symptoms and concurrent illnesses,
4) impact of drug interactions,
5) ease of adherence to a frequently complex administration regimen. The goals of therapy
are to maximally and durably suppress viral load replication, to restore and preserve
immunologic function, to reduce HIV-relatedmorbidity and mortality, and to improve quality
of life.
Drugs used to prevent HIV from replicating. [NRTI = nucleoside and nucleotide
reverse transcriptase inhibitor; NNRTI = nonnucleoside reverse transcriptase inhibitor.

Nrtis Used to Treat HIV Infection

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A. Overview of NRTIs
Mechanism of action: Nucleoside and nucleotide reverse transcriptase inhibitors (NRTIs)
are analogs of native ribosides (nucleosides or nucleotides containing ribose), which all lack a
3'-hydroxyl group. Once they enter cells, they are phosphorylated by a variety of cellular
enzymes to the corresponding triphosphate analog, which is preferentially incorporated
into the viral DNA by virus reverse transcriptase. Because the 3'-hydroxyl group is not
present, a 3'-5'-phosphodiester bond between an incoming nucleoside triphosphate and the
growing DNA chain cannot be formed, and DNA chain elongation is terminated. Drugs used
to prevent HIV from replicating. [NRTI = nucleoside and nucleotide reverse
transcriptase inhibitor; NNRTI = nonnucleoside reverse transcriptase inhibitor.
VI. Nrtis Used to Treat HIV Infection
Pharmacokinetics: The NRTIs are primarily renally excreted, and all require dosage
adjustment in renal insufficiency except abacavir, which is metabolized by alcohol
dehydrogenase and glucuronyl transferase. Dosage adjustment is required when the creatinine
clearance drops below 50 mL/min.
Adverse effects: Many of the toxicities of the NRTIs are believed to be due to inhibition of
the mitochondrial DNA polymerase in certain tissues. As a general rule, the
dideoxynucleosides, such as zalcitabine, didanosine, and stavudine, have a greater affinity for
the mitochondrial DNA polymerase, leading to such toxicities as peripheral neuropathy,
pancreatitis, and lipoatrophy. When more than one NRTI is given, care is taken not to have
overlapping toxicities. All the NRTIs have been associated with a potentially fatal liver
toxicity characterized by lactic acidosis and hepatomegaly with steatosis.
Drug interactions: Due to the renal excretion of the NRTIs, there are not many drug
interactions encountered with these agents except for zidovudine and tenofovir.
Resistance: NRTI resistance is well characterized, and the most common mutation is the
mutation at viral codon which confers a high degree of resistance to lamivudine but, more
importantly, restores sensitivity to zidovudine and tenofovir. Cross-resistance and antagonism
occur between agents of the same analog class (thymidine, cytosine, guanosine and
adenosine)
Highly active antiretroviral therapy (HAART).
B. Zidovudine (AZT)
Approved in 1987, the first agent available for treatment of HIV infection is the pyrimidine
analog, 3'-azido- 3'-deoxythymidine (AZT). AZT has the generic name of zidovudine [zye-
DOE-vyoo-deen]. AZT is approved for use in children and adults and to prevent prenatal

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infection in pregnancy. It is also recommended for prophylaxis in individuals exposed to HIV
infection. The drug is well absorbed after oral administration. If taken with food, peak levels
may be lower, but the total amount of drug absorbed is not affected. Penetration across the
blood-brain barrier is excellent, and the drug has a half-life of 1 hour. The intracellular half-
life, however, is approximately 3 hours. Most of the AZT is glucuronylated by the liver and
then excreted in the urine.

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 38.16
Highly active antiretroviral therapy (HAART).
B. Zidovudine (AZT)
Approved in 1987, the first agent available for treatment of HIV infection is the pyrimidine
analog, 3'-azido- 3'-deoxythymidine (AZT). AZT has the generic name of zidovudine [zye-

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DOE-vyoo-deen]. AZT is approved for use in children and adults and to prevent prenatal
infection in pregnancy. It is also recommended for prophylaxis in individuals exposed to HIV
infection. The drug is well absorbed after oral administration. If taken with food, peak levels
may be lower, but the total amount of drug absorbed is not affected. Penetration across the
blood-brain barrier is excellent, and the drug has a half-life of 1 hour. The intracellular half-
life, however, is approximately 3 hours. Most of the AZT is glucuronylated by the liver and
then excreted in the urine.

Anticancer Drugs
I. Overview
It is estimated that 25 percent of the population of the United States will face a diagnosis of
cancer during their lifetime, with 1.3 million new cancer patients diagnosed each year. Less
than a quarter of these patients will be cured solely by surgery and/or local radiation. Most of
the remainder will receive systemic chemotherapy at some time during their illness
II. Principles of Cancer Chemotherapy
Cancer chemotherapy strives to cause a lethal cytotoxic event or apoptosis in the cancer cell
that can arrest a tumor's progression. The attack is generally directed toward DNA or against
metabolic sites essential to cell replication ”for example, the availability of purines and
pyrimidines that are the building blocks for DNA or RNA Synthesis. Ideally, these anticancer
drugs should interfere only with cellular processes that are unique to malignant cells.
Unfortunately, most currently available anticancer drugs do not specifically recognize
neoplastic cells but, rather, affect all kinds of proliferating cells both normal and abnormal.
Therefore, almost all antitumor agents have a steep dose-response curve for both toxic and
therapeutic effects.
A. Treatment strategies
Goal of treatment:
 The ultimate goal of chemotherapy is a cure (that is, long-term, disease-free
survival). A true cure requires the eradication of every neoplastic cell.
 If a cure is not attainable, then the goal becomes control of the disease (stop the
cancer from enlarging and spreading) to extend survival and maintain the best
quality of life.
 This allows the individual to maintain a normal existence, with the cancer thus
being treated as a chronic disease. In either case, the neoplastic cell burden is

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 initially reduced (debulked), either by surgery and/or by radiation, followed by
chemotherapy, immunotherapy, or a combination of these treatment modalities.
CLASSI FICATION
A. Drugs acting directly on cells (Cytotoxic drugs)
1. Alkylating agents
Nitrogen mustards: Mechlorethamine (Mustine HCl), Cyclophosphamide, Ifosfamide,
Chlorambucil, Melphalan
Ethylenimine Thio-TEPA
Alkyl sulfonate Busulfan
Nitrosoureas Carmustine (BCNU), Lomustine (CCNU)
Triazine Dacarbazine (OTIC)
2. Antimetabolites: Folate antagonist Methotrexate (Mtx)

Purine antagonist6-Mercaptopurine (6-MP), 6-Thioguanine (6-TG), Azathioprine,

Fludarabine
Pyrimidine antagonist: 5-Fluorouracil (5-FU), Cytarabine, (cytosine arabinoside)
3. Vinca alkaloids Vincristine (Oncovin), Vinblastine

4. Taxanes Paclitaxel, Docetaxel

5. Epipodophyllotoxin: Etoposide

6. Camptothecin analogues: Topotecan, Irinotecan

7. Antibiotics: Actinomycin D, (Dactinomycin), Doxorubicin, Daunorubicin

(Rubidomycin)
Mitoxantrone Bleomycins, Mitomycin C
8. Miscellaneous Hydroxyurea, Procarbazine, L-Asparaginase, Cisplatin Carboplatin
Imatinib
B. Drugs altering hormonal m ilieu
1 . Glucocorticoids Prednisolone and others
2. Estrogens Fosfestrol, Ethinylestradiol
3. Selective estrogen Tamoxifen,
receptor modulators Toremifene

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 4. Selective estrogen receptor down regulators: Fulvestrant
5. Aromatase inhibitors Letrozole, Anastrozole, Exemestane
6. Antiandrogen Flutamide, Bicalutamide
7. 5-a reductase inhibitor Finasteride, Dutasteride
8. GnRH analogues Nafarelin, Triptorelin
9. Progestins Hydroxyprogesterone acetate, etc.

ALKYLATI NG AGE NTS

These compounds produce highly reactive carbonium ion intermediates which transfer alkyl
groups to cellular macromolecules by forming covalent bonds. The position 7 of guanine
residues in DNA is especially susceptible, but other molecular sites are also involved.
Alkylation results in cross linking/ abnormal base pairing/ scission of DNA strand. Cross
linking of nucleic (like ionizing radiation) actions.
Mechlorethamine (Mustine HCI) It is the first nitrogen mustard; highly reactive and local
vesicant-c an be given only by i.v. route. It produces many acute effects like nausea, vomiting
and haemodynamic changes. Extravasation during i.v. injection may cause sloughing.

ANTI MET ABO LITES

These are analogues related to normal components of DNA or of coenzymes involved in
nucleic acid synthesis. They competitively inhibit utilization of the normal substrate or get
themselves incorporated forming dysfunctionalmacromolecules.
1. Folate antagonist Methotrexate (Mtx) It is one of the oldest and highly efficacious
antineoplastic drugs; inhibits dihydrofolate reductase (DHFRase)-blocking the
conversion of dihydrofolic acid (DHFA) to tetrahydrofolic acid (THFA) which is an
essential coenzyme required for one carbon transfer reactions in de novo purine synthesis and
amino acid interconversions. Methotrexate has cell cycle specific actionkills cells in S phase;
primarily inhibits DNA synthesis, but also affects RNA and protein synthesis. It exerts major
toxicity on bone marrow-low doses given repeatedly cause megaloblastic anaemia, but high
doses produce pancytopenia. Desquamation and bleeding may occur in g.i.t.

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2. Purine antagonists
Mercaptopurine (6-MP) and thioguanine (6-TG) These are highly effective antineoplastic
drugs. They are converted in the body to the corresponding monoribonucleotides which
inhibit the conversion of inosine monophosphate to adenine and guanine nucleotides.

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There is also feedbackinhibition of de novo purine synthesis. They are especially useful in
childhood acute leukaemia, choriocarcinoma and have been employed in some solid tumours
as well. In acute leukaemia, both have been used in combination regimens to induce
remission and 6-MP to maintain it as well.

Pyrimidine antagonists: Pyrimidine analogues have varied applications as antineoplastic,

antifungal and antipsoriatic agents.

Fluorouracil U, -FU) is converted in the body to the corresponding nucleotide 5-fluoro-2-

deoxyuridine monophosphate, which inhibits thymidylate synthase and blocks the
conversion of deoxyuridilic acid to deoxythymidylic acid. Selective failure of DNA synthesis
occurs due to non-availability of thymidylate: thymidine can partially reverse its toxicity.
Fluorouracil itself gets incorporated into nucleic acids and this may contribute to its toxicity.
Even resting cells are affected, though rapidly multiplying ones are more susceptible.

VINCA ALKALOIDS
These are mitotic inhibitors, bind to microtubular protein-'tubulin', prevent its
polymerization and assembly of microtubules, cause disruption of mitotic spindle and
interfere with cytoskeletal function. The chromosomes fail to move apart during mitosis:
metaphase arrest occurs. They are cell cycle specific and act in the mitotic phase. Vincristine
and vinblastine, though closely related chemically, have somewhat different spectrum of anti
tumour activity and toxicity.
Vincristine (oncovin) It is a rapidly acting drug, very useful for inducing remission in
childhood acute leukaemia, but is not good for maintenance therapy. Other indications are
lymphosarcoma, Hodgkin's disease, Wilms' tumour, Ewing's sarcoma and carcinoma lung.
Prominent adverse effects are peripheral neuropathy and alopecia. Bone marrow depression is
minimal.

TAXANES
Paclitaxel It is a complex diterpin taxane obtained from bark of the Western yew tree, which
exerts cytotoxic action by a novel mechanism. It enhances polymerization of tubulin: a
mechanism opposite to that of vinca alkaloids. The microtubules are stabilized and their
depolymerization is prevented. This stability results in inhibition of normal
dynamicreorganization of the microtubule network that is essential for vital interphase and

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mitotic functions. Abnormal arrays or 'bundles' of microtubules are produced throughout the
cell cycle.

IMMUNOSUPPRESSANT DRUGS
These are drugs which inhibit cellular /humoral or both immune response and have their
major use in organ transplantation and autoimmune diseases. The drugs are:
1 . Calcineurin inhibitors (Specific T-cell inhibitors) Cyclosporine (Ciclosporin), Tacrolimus
2. Antiproliferative drugs (Cytotoxic drugs) Azathioprine, Cyclophosphamide, Methotrexate,
Chlorambucil, Mycophenolate mofetil (MMF)
3. Glucocorticoids: Prednisolone and others
4. Antibodies: Muromonab CD3, Antithymocyte globulin (ATG), Rho (D) immuneglobulin

Calcineurin inhibitors (Specific T-cell inhibitors)

A. Cyclosporine
Cyclosporine [sye-kloe-SPOR-een] (CsA) is a lipophillic cyclic polypeptide composed of 11
amino acids (several are methylated on the peptidyl nitrogen). The drug is extracted from a
soil fungus. CsA is used to prevent rejection of kidney, liver, and cardiac allogeneic
transplants.
Mechanism of action: Cyclosporine preferentially suppresses cell-mediated immune
reactions, whereas humoral immunity is affected to a far lesser extent. After diffusing into the
T cell, CsA binds to a cyclophilin (more generally called an immunophilin) to form a
complex that binds to calcineurin. The latter is responsible for dephosphorylating NFATc
(cytosolic Nuclear Factor of Activated T cells). The CsA-calcineurin complex cannot perform
this reaction; thus, NFATc cannot enter the nucleus to promote the reactions that are required
for the synthesis of a number of cytokines, including IL-2.
Pharmacokinetics: Cyclosporine may be given either orally or by intravenous infusion. Oral
absorption is variable. Interpatient variability may be due to metabolism by a cytochrome
P450 (CYP3A4) in the gastrointestinal tract, where the drug is metabolized. About 50 percent
of the drug is associated with the blood fraction
Adverse effects: Many of the adverse effects caused by CsA are dose dependent; therefore, it
is important to monitor blood levels of the drug. Nephrotoxicity is the most common and
important adverse effect of CsA. It is therefore critical to monitor kidney function.

B. Tacrolimus

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Tacrolimus (TAC, originally called FK506) is a macrolide that is isolated from a soil fungus.
TAC is approved for the prevention of rejection of liver and kidney transplants and is given
with a corticosteroids and/or an antimetabolite. This drug has found favor over CsA, not only
because of its potency and decreased episodes of rejection but also because lower doses of
corticosteroids can be used, thus reducing the likelihood of steroid-associated adverse effects.
An ointment preparation has been approved for moderate to severe atopic dermatitis that does
not respond to conventional therapies.

Immunosuppressive Antimetabolites
Immunosuppressive antimetabolite agents are generally used in combination with
corticosteroids, and the calcineurin inhibitors, CsA and TAC.
A. Azathioprine
Azathioprine [ay-za-THYE-oh-preen] was the first agent to achieve widespread use in organ
transplantation. It is a prodrug that is converted first to 6-mercaptopurine (6-MP) and then to
the corresponding nucleotide, thioinosinic acid. The immunosuppressive effects of
azathioprine are due to this nucleotide analog. Because of their rapid proliferation in the

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immune response and their dependence on the de novo synthesis of purines required for cell
division, lymphocytes are predominantly affected by the cytotoxic effects of azathioprine.
[Its major nonimmune toxicity is bone marrow suppression. Concomitant use with
angiotensin-converting enzyme inhibitors or cotrimoxazole in renal transplant patients can
lead to an exaggerated leukopenic response.
Immunosuppressant antibodies:
Muromonab CD3 It is a murine monoclonal antibody against the CD3 glycoprotein located
near to the T cell receptor on helper T cells. Binding of muromonab CD3 to the CD3 antigen
obstructs the binding of MHC II-antigen complex to the T cell receptor: antigen recognition
is interfered, so that participation of T cells in the immune response is prevented and T cells
rapidly disappear from circulation leading to an immune blocked state.
Mechanism of action: Binding to the CD3 protein results in a disruption of T-lymphocyte
function, because access of antigen to the recognition site is blocked. Circulating T cells are
depleted; thus, their participation in the immune response is decreased. Because
muromonab-CD3 recognizes only one antigenic site, the immunosuppression is less broad
than that seen with the polyclonal antibodies. T cells usually return to normal within 48
hours of discontinuation of therapy.
Muromonab CD3 has been used as induction therapy together with corticosteroids and
azathioprine with delayed use of cyclosporine in 'sequential regimen' for organ
transplantation. Thls serves to postpone potential nephro- and hepatotoxicity of cyclosporine.

IMMUNOSTIMULANT DRUGS

Immunostimulants, also known as immunostimulators, are substances (drugs and

nutrients) that stimulate the immune system by inducing activation or increasing
activity of any of its components. One notable example is the granulocyte macrophage
colony-stimulating factor. Classification

There are two main categories of immunostimulants:

1. Specific immunostimulants provide antigenic specificity in immune response, such as

vaccines or any antigen.

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2. Non-specific immunostimulants act irrespective of antigenic specificity to augment
immune response of other antigen or stimulate components of the immune system
without antigenic specificity, such as adjuvants and non-specific immunostimulators.

Innate immune response – first line of defense against an antigenic insult. Includes
• defenses like physical (skin),
• Biochemical (complement, lysozyme, interferons)
• cellular components (neutrophils, monocytes, macrophages).
• Adaptive immune response a) Humoral immunity - Antibody production – killing
extracellular organisms. b) Cell mediated immunity – cytotoxic / killer T cells – killing virus
and tumour cells.
IMMUNOSUPPRESSIVE DRUGS • Those drugs that suppress the immune system. •
Particularly important for transplantation, autoimmune disorders, allergies, and all the cases
where immune system is too active.
IMMUNOSTIMULANT DRUGS • Those drugs that stimulate the immune system. •
Particularly important for the treatment of infectious diseases, tumors, immuno deficiencies
and all the cases where the immune system needs a boost.

Immunotherapy deals with the idea of boosting an individuals’ immune system, to allow it to
destroy microbes and tumors.The boost can be biological (microbial-derived products),
pharmacological, or cell-based.

IMMUNOSTIMULANT DRUGS – MICROBIAL PRODUCTS • Many bacterial products

are PAMPs, and they strongly stimulate inflammation by triggering cytokine production in
APCs. These, in turn, stimulate the adaptive immunity and, overall, increase leukocytes
number by boosting hematopoiesis.

The Bacillus Calmette–Guérin (BCG) is an attenuated (less virulent, but still alive)
mycobacterium bovis strain. • This is able to infect human cells, but not to induce any
pathology. Rather, it can stimulate the production of Igs by B-cell and thus behave as a
vaccine against mycobacterium tuberculosis. • It has a strong inflammatory effect on some
tissues, and has thus been also approved as a treatment for bladder cancer.
The bad side is that PAMPs can induce massive cytokine production, which can result in
fever and shock. This is especially true with cytokines, which can also have direct toxic
effects.

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Immunotherapy – cytokine therapies • Since cytokines control the whole immune system, and
mostly stimulate it, it is logical to use them whenever there is the need to boost immune
system activity. • They are used in clinical practice, but they are burdened by severe side
effects.

ACTIVE VACCINATION • Active vaccination is the process of injecting individuals with

microbial antigens, heat- killed microbes or attenuated living microbes to induce antibody
production and memory B-cells formation. • The individual acquires the ability to respond to
the microbe he/she has been vaccinated against.
To ensure memory B-cells formation, whole microbes (either killed or attenuated) are
preferred, as they also trigger fever and inflammation that boost B-cells activation and
memory cells formation. • Attenuated microbes are those living strains which are still able to
infect an individual, but that generate a less-dangerous pathological manifestation, which is
generally inflammation/flu. • Side-effects are generally low, but sometimes they can be
extremely severe.

PASSIVE VACCINATION • In passive vaccination, individuals are injected with preformed

immunoglobulins (from donors). Thus, individuals acquire pools of immunoglobulins (good
for immunodeficiencies) and the ability to respond to certain microbes. Transfusion of
immunoglobulins is called intravenous immunoglobulins (igv). generally, igvs contain igG
and igA. • Anti-microbial igvs are used against hepatitis b, botulism, diphtheria, tetanus,
rabies. • It’s generally well-tolerated, but sporadic side- effects can be extremely severe.

ADJUVANTS USED FOR VACCINATION • Injecting a living microbe can be dangerous,

and reducing the amount of microbe to the minimum is mandatory. Here’s the need for
adjuvants. • Adjuvants are chemical or biological products that can either boost T-cells,
activate inflammation or help to stabilize the antigen so that it can stimulate B-cells for a
longer time. • Adjuvants have been also implicated in clinical side- effects of vaccinations,
like the onset of juvenile diabetes in the case of Freund’s adjuvant.

ADOPTIVE CELL TRANSFER • Adoptive cell transfer deals with the idea of isolating
immune cells from individuals, expand them in culture and then re-infuse them. This is a
wonderful strategy to kill tumors. • Tumor-infiltrated lymphocytes (TIL) are a heterogeneous

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population which includes Th and CTLs able to recognize and kill the tumor. The problem is
that the cytokines released from the tumor suppress them. Taking these “good cells” out of
the tumor mass and re-injecting them upon expansion strongly increases the ability of the
immune system to react against tumors.

CELL-BASED VACCINATION • Dendritic cells can be “prepared” in vitro to show tumor

antigens, and then re-injected into the patient to stimulate tumor antigens’ recognition and
tumor killing. This is currently defined as cell-based vaccination.

IMMUNOSTIMULANTS USES • Immunodeficiency disorders • Chronic infections • Cancer

Thalidomide Isoprinosine . Immunocynin Recombinant Cytokines- Interferons, Interleukins,
Colonystimulating factors Bacillus Calmette- Guerin (BCG) Levamisole Other drugs–
inosiplex, azimexon, imexon, thymosin, methylinosine monophosphate Immunization -
Vaccines , Immune Globulin
Bacillus Calmette-Guerin (BCG) • Live, attenuated culture of BCG strain of Mycobacterium
Bovis MOA • Induction of a granulomatous reaction at the site of administration. It causes
activation of macrophages to make them more effective killer cells
Therapeutic uses • Treatment and prophylaxis of carcinoma of the urinary bladder,
Prophylaxis of primary and recurrent stage of papillary tumors after transurethral resection.
Adverse effects • Hypersensitivity, shock, chills, fever, malaise, and immune complex
disease.
Levamisole /Ergamisol • synthesized originally as an anthelmintic but appears to restore
depressed immune function of B lymphocytes, T lymphocytes, monocytes and macrophages
Therapeutic uses: • Adjuvant therapy with 5-fluorouracil colon cancer, agranulocytosis. Used
to treat immunodeficiency associated with Hodgkins disease Adverse effects : • Flu-like
symptoms, allergic manifestation, nausea and muscle pain .
Thalidomide MOA • Enhanced T-cell production of cytokines – IL-2, IFN- γ • NK cell-
mediated cytotoxicity against tumor cells. Decrease circulating TNF-α in patients with
erythema nodosum leprosum, but increase in HIV-seropositive patients, It affects
angiogenesis also. Therapeutic uses • Severe, refractory rheumatoid arthritis . Multiple
myeloma Adverse effects • Teratogenicity
• Hormone like, small low molecular weight polypeptides. • Maintain communication among
cells to co-ordinate immune response. • Act synergistically or antagonistically thereby
enhancing or supressing their own production • Autocrine, paracrine or endocrine in action. •

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Causes tissue repair and provide resistance to infection
Cytokines : Properties Cytokine: Action Autocrine Paracine Endocrine
Cytokines-based therapies in clinical use
Isoprinosine(Inosiplex) • Complex of the pacetamidobenzoate salt of N,N- dimethylamino-
2- propanol: inosine in a 3:1 molar ratio MOA • Augment production of cytokines such as IL-
1, IL-2 and IFN-γ ,increases proliferation of lymphocytes in response to mitogenic or
antigenic stimuli, increases active T-cell rosettes and induces T-cell surface markers on
prothymocytes
Nonspecific immunoglobulins Antibody-deficiency disorders Specific immune globulins.
High titers of desired antibody Hepatitis B, Rabies, Tetanus.

PROTEIN DRUGS, MONOCLONAL ANTIBODIES, TARGET DRUGS TO

ANTIGEN, BIOSIMILARS

PROTEIN DRUGS

Linear POLYPEPTIDES that are synthesized on RIBOSOMES and may be further modified,
crosslinked, cleaved, or assembled into complex proteins with several subunits. The specific
sequence of AMINO ACIDS determines the shape the polypeptide will take, during
PROTEIN FOLDING, and the function of the protein.
Therapeutic protein drugs are an important class of medicines serving patients most in need
of novel therapies. Recently approved recombinant protein therapeutics have been developed
to treat a wide variety of clinical indications, including cancers, autoimmunity/inflammation,
exposure to infectious agents, and genetic disorders. The latest advances in protein-
engineering technologies have allowed drug developers and manufacturers to fine-tune and
exploit desirable functional characteristics of proteins of interest while maintaining (and in
some cases enhancing) product safety or efficacy or both. In this review, we highlight the
emerging trends and approaches in protein drug development by using examples of
therapeutic proteins approved by the U.S. Food and Drug Administration over the previous
five years (2011–2016, namely January 1, 2011, through August 31, 2016).
Drug Name Drug Description

Page 19
 A protein-based direct thrombin inhibitor used to reverse and prevent thrombus
Lepirudin
formation in heparin-induced thrombocytopenia.

An endothelial growth factor receptor binding fragment used to treat colorectal

Cetuximab
cancer as well as squamous cell carcinoma of the head and neck.

Dornase A synthetic form of human deoxyribonuclease I used to break down extracellular

alfa DNA in the lungs, a major source of mucous viscosity in cystic fibrosis.

A recombinant cytotoxic protein based on a combination of diphtheria toxin

Denileukin
fragments and interleukin-2 used to treat cutaneous T-cell lymphoma by targeting
diftitox
the interleukin-2 receptor.

A protein therapy based on the binding fragment of the tumour necrosis factor alpha
Etanercept receptor used to treat severe rheumatoid arthritis and moderate to severe plaque
psoriasis.

A direct thrombin inhibitor used to treat heparin-induced thrombocytopenia and to

Bivalirudin
prevent thrombosis during percutaneous coronary intervention.

A protein-based luteinizing hormone antagonist used to treat prostate cancer,

Leuprolide
endometriosis, and precocious puberty.

Peginterferon A modified form of recombinant human interferon used to stimulate the

alfa-2a innate antiviral response in the treatment of hepatitis B and C viruses.

A recombinant form of human tissue plasminogen activator used in the emergency

Alteplase
treatment of myocardial infarction, ischemic stroke, and pulmonary emboli.

Sermorelin For the treatment of dwarfism, prevention of HIV-induced weight loss

MONOCLONAL ANTIBODIES

Monoclonal antibodies (mAb or moAb) are antibodies that are made by identical immune
cells that are all clones of a unique parent cell. Monoclonal antibodies can have monovalent
affinity, in that they bind to the same epitope (the part of an antigen that is recognized by the
antibody). In contrast, polyclonal antibodies bind to multiple epitopes and are usually made

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by several different plasma cell (antibody secreting immune cell) lineages. Bispecific
monoclonal antibodies can also be engineered, by increasing the therapeutic targets of one
single monoclonal antibody to two epitopes.

Outline of production of MAbs

The main objective is to produce a homogenous population of MAbs against a pre-fixed

immunogen. The basic strategy includes (i) purification and characterization of the desired
antigen in adequate quantity, (ii) immunization of mice with the purified antigen, (iii) culture
of myeloma cells which are unable to synthesize hypoxanthine-guanine-phosphoribosyl
transferase (HGPRT) enzyme necessary for the salvage pathway of nucleic acids, (iv)
removal of spleen cells from mice and its fusion with the myeloma cells, (v) following
fusion, the hybridomas were grown in hypoxanthine aminopterin thymidine (HAT) medium.
The fused cells are not affected in the absence of HGPRT unless their de novo synthesis
pathway is also disrupted. In the presence of aminopterin, the cells are unable to use the de
novo pathway and thus these cells become auxotrophic for nucleic acids as a supplement to
HAT medium. In this medium, only fused cells will grow. Unfused myeloma cell does not
have ability to grow in this HAT medium because they lack HGPRT, and thus cannot
produce DNA. Unfused spleen cells can¬not grow because of their short life spans. Only
fused hybrid cells or hybridomas can grow in HAT medium. Hybrid cells have the capacity to
grow in the HAT medium since spleen cell partners produce HGPRT. (vi) The hybrid cell
clones are generated from single host cells (vii) the antibodies secreted by the different clones
are then tested for their ability to bind to the antigen using an enzyme-linked immunosorbent
assay (ELISA). (viii) The clone is then selected for future use.

Examples of therapeutic monoclonal antibodies

Monoclonal antibodies for research applications can be found directly from antibody
suppliers, or through use of a specialist search engine like CiteAb. Below are examples of
clinically important monoclonal antibodies.

Main
Type Application Mechanism/Target Mode
category
 rheumatoid
Anti-
infliximab arthritis inhibits TNF-α chimeric
inflammatory
 Crohn's disease

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  ulcerative colitis
 ankylosing
spondylitis

 rheumatoid
arthritis
 Crohn's disease
adalimumab  ulcerative colitis inhibits TNF-α human

 ankylosing
spondylitis

 acute rejection of
kidney inhibits IL-2 on
basiliximab chimeric
transplants activated T cells

 acute rejection of
kidney inhibits IL-2 on
daclizumab humanized
transplants activated T cells

 moderate-to-
inhibits human
severe allergic
omalizumab immunoglobulin E humanized
asthma
(IgE)

 relapsed acute
targets myeloid cell
myeloid
gemtuzumab surface antigen CD33 humanized
leukemia
on leukemia cells

targets an antigen
 B cell leukemia
alemtuzumab CD52 on T- and B- humanized
Anti-cancer
lymphocytes
 non-Hodgkin's
lymphoma targets
rituximab  rheumatoid phosphoprotein CD20 chimeric
arthritis on B lymphocytes

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  breast cancer
with HER2/neu targets the HER2/neu
trastuzumab humanized
overexpression (erbB2) receptor

 approved in
squamous cell
carcinomas,
Glioma
nimotuzumab EGFR inhibitor humanized
 clinical trials for
other indications
underway

 approved in
squamous cell
carcinomas,
cetuximab EGFR inhibitor chimeric
colorectal
carcinoma

 Anti-angiogenic
bevacizumab &
cancer therapy inhibits VEGF humanized
ranibizumab

 cancer, hepatitis immunotherapy,

Anti-cancer
bavituximab C infection targets chimeric
and anti-viral
phosphatidylserine
 RSV infections
inhibits an RSV
palivizumab in children humanized
fusion (F) protein

 prevent
Other
coagulation in inhibits the receptor
abciximab coronary GpIIb/IIIa on chimeric
angioplasty platelets

Page 23
Page 24
Immunization schedule Depending on the purity and nature of the purified antigen, an
immunization protocol is determined. For immunization, the desired protein should be
available in adequate quantity (a few milligrams). However, in case of a complex multi-
molecular antigen, it is quite stringent to purify it in adequate quantity. Thus, depending on
its screening and selection abilities, MAbs can purify a target antigen from an antigen
mixture. Mice must be immunized with antigen 6–10 weeks before fusion to allow them to
develop a robust immune response before generating hybridomas. The injection schedule and
the actual timing may vary depending on the antigen used for the immunization as well as
other factors. It is desirable to immunize mice with a pure antigen, as this simplifies the
screening of hybridomas. However, complex antigenic mixtures can be used. Collection of
pre-immune serum is required prior to immunization to use as a baseline control for antibody
screening. The mouse is bled by cutting approximately 1–2 mm off the tip of the tail thereby
collecting 100–200 μL of blood in a capillary tube from where the serum is collected and can
be cryo-preserved. A typical immunization schedule includes intra-peritonial injections of 2–
4 adult mice (eg, BALB/c mice) with 20–100 μg of purified antigen in a total volume of 200
μL (ie, 200 μL of a 1:1 emulsion of antigen in saline: adjuvant). A stable emulsion is critical
for generating a strong immune response. The injection is repeated 14–30 days later and
booster doses are administered for 2–3 times until a good titer of antibody is obtained. Next,
10–14 days after the last injection, 100–200 μL of blood is collected from the tip of the tail or
from the eye and serum is separated. The antibody levels in serum can be detected by
applying different immune-techniques such as ELISA, immunofluorescence, flow cytometry,
and immuno blotting, and the antibody titer of the post-immune serum is compared with the
pre-immune serum from the same animal. The mouse with the highest antibody titer swas
selected for fusion. Between one and four days prior to fusion, the selected mouse is boosted
intravenously via the tail vein. Following this step, spleen cells are prepared for fusion.

Myeloma cell line culture

In myeloma culture, hybridomas should grow continuously and selectively by suppressing

the growth of the parent myeloma. It is desirable to obtain a parental myeloma cell that has
been proven to yield stable hybridomas. The selected myeloma cell lines should have lost
their capability to produce nucleotides using the salvage pathway. Myeloma cells are cultured
in presence of 8-azaguanine so that they are unable to synthesize the HGPRT enzyme
necessary for the salvage pathway of nucleic acids. Parental myeloma cells are cultured for at
least one week prior to fusion to ensure that the cells are well-adapted to HGPRT-negative

Page 25
conditions. Cells are seeded at a density of approximately 5 × 104 cells/mL and passaged
every 2 days; those growing in the early-mid log phase prior to fusion are selected for fusion.
After fusion, by using the drug aminopterin, de novo synthesis pathways can be blocked
and thus the myeloma cells (where salvage pathway was previously blocked) cannot produce
RNA or DNA and die. On the other hand, hybridomas have a functional salvage pathway
(derived from the spleen cells of mouse) and can grow when they are cultured in medium
containing the substrates for the pathway, ie, thymidine and hypoxanthine. This selective
culture medium is HAT medium containing hypoxanthine, aminopterin, and thymidine
respectively.

Fusion
The parental myeloma cells used to make the hybridoma must match the strain of mouse
being immunized (eg, for BALB/c mice the myeloma cells must be of BALB/c origin) and
must not secrete any of their own immunoglobulin chains. The parental myeloma cells should
be mycoplasma-free, fuse well, and allow the formation of stable hybridomas that continually
secrete specific MAbs. SP2/0 and X63Ag8. 653 are widely used parental myeloma cells that
meet all of these criteria. There are various agents that induce the somatic cell to fuse. There
are some physical agents, such as electro-fusion and chemical agents, including polyethylene
glycol (PEG) and calcium ions, among others. Large numbers of cells can be fused in the
presence of PEG within a short time. During electro-fusion, a continuous electric potential is
maintained in the fusion medium. Current is applied in short pulses at high voltage with short
duration or in low voltage with long duration. The factors that are controlled during electro-
fusion were specific resistance, osmotic strength, field strength, and ionic composition of the
fusion medium. The cells should be given proteolytic pretreatment.
An immunized mouse, 48–72 hours after tail vein injection, is euthanized and the spleen can
be removed and disaggregated into a single cell suspension under sterile conditions. At the
same time, the myeloma cells are harvested and added to fusion medium and mixed with
spleen cells together with PEG solution to yield single hybridoma colonies. The fused cell
mixture is plated in culture plates containing a feeder layer prepared from control un-
immunized mice

Growth and selection of MAbs

Within 7–14 days after fusion, the growth of hybridomas occurs gradually together with the
addition of interleukin 6 (IL-6), the hybridoma growth factor.

Applications of monoclonal antibodies

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MAbs have proved to be extremely valuable for basic immunological and molecular research
because of their high specificity. They are used in human therapy, commercial protein
purification, suppressing immune response, diagnosis of diseases, cancer therapy, diagnosis
of allergy, hormone test, purification of complex mixtures, structure of cell membrane,
identification of specialized cells, preparation of vaccines, and increasing the effectiveness of
medical substances

Diagnostic tools in research and laboratory

To detect the presence of this substance/antigen, MAbs can be used. Different technologies in
which MAbs are used include Western blot, immunodot blot, ELISA, radioimmuno assay
(RIA), flow cytometry, immunohistochemistry, fluorescence microscopy, electron
microscopy, confocal microscopy, as well as other biotechnological applications.

Gene cloning
One of the difficulties of gene cloning is identifying the cells that contain the desired gene. If
an MAb that recognizes that the gene product is available, it can be used as a probe for
detecting those cells that make the product and therapy to detect the gene.

To identify cell types

MAbs contribute to the identification of many different types of cells that participate in the
immune response and to unravel interactions occurring during this process. For example, in
the lymphocytes with B, T helper (TH) cells and suppressor T, the use of MAbs has
established that the various types of T-cells carry cell surface antigens on their surfaces that
allow one type to be distinguished from another. The MAbs were also helpful in defining
changes in T and B-cells during development.

Protein purification
MAb affinity columns are readily prepared by coupling MAbs to a cyanogen bromide-
activated chromatography matrix, eg, Sepharose. Since the MAbs have unique specificity for
the desired protein, the level of contamination by unwanted protein species usually is very
low. Since the MAb-antigen complex has a single binding affinity it is possible to elute the
required protein in a single, sharp peak. The concentration of the relative protein relative to
total protein in a mixture can ever be very low. This method also has limitations. Achieving
100% pure protein is difficult because there is always a tendency for small amounts of

Page 27
immunoglobulin to leak off the immune-affinity column. Additionally, MAb do not
distinguish between intact protein molecules and fragments containing the antigenic site.

Recombinant

The production of recombinant monoclonal antibodies involves repertoire cloning,

CRISPR/Cas9, or phage display/yeast display technologies.[22] Recombinant antibody
engineering involves antibody production by the use of viruses or yeast, rather than mice.
These techniques rely on rapid cloning of immunoglobulin gene segments to create libraries
of antibodies with slightly different amino acid sequences from which antibodies with desired
specificities can be selected. The phage antibody libraries are a variant of phage antigen
libraries.[24] These techniques can be used to enhance the specificity with which antibodies
recognize antigens, their stability in various environmental conditions, their therapeutic
efficacy and their delectability in diagnostic applications. Fermentation chambers have been
used for large scale antibody production.

Chimeric antibodies

While mouse and human antibodies are structurally similar, the differences between them
were sufficient to invoke an immune response when murine monoclonal antibodies were
injected into humans, resulting in their rapid removal from the blood, as well as systemic
inflammatory effects and the production of human anti-mouse antibodies (HAMA).

Recombinant DNA has been explored since the late 1980s to increase residence times. In one
approach, mouse DNA encoding the binding portion of a monoclonal antibody was merged
with human antibody-producing DNA in living cells. The expression of this "chimeric" or
"humanised" DNA through cell culture yielded part-mouse, part-human antibodies.

Human antibodies

Ever since the discovery that monoclonal antibodies could be generated, scientists have
targeted the creation of fully human products to reduce the side effects of humanised or
chimeric antibodies. Two successful approaches have been identified: transgenic mice and
phage display.

Page 28
Applications

Diagnostic tests

Once monoclonal antibodies for a given substance have been produced, they can be used to
detect the presence of this substance. Proteins can be detected using the Western blot and
immuno dot blot tests. In immunohistochemistry, monoclonal antibodies can be used to
detect antigens in fixed tissue sections, and similarly, immunofluorescence can be used to
detect a substance in either frozen tissue section or live cells.

Analytic and chemical uses

Antibodies can also be used to purify their target compounds from mixtures, using the
method of immunoprecipitation.

Therapeutic uses
Main article: Monoclonal antibody therapy

Therapeutic monoclonal antibodies act through multiple mechanisms, such as blocking of

targeted molecule functions, inducing apoptosis in cells which express the target, or by
modulating signalling pathways.[44][45]

Cancer treatment

One possible treatment for cancer involves monoclonal antibodies that bind only to cancer
cell-specific antigens and induce an immune response against the target cancer cell. Such
mAbs can be modified for delivery of a toxin, radioisotope, cytokine or other active
conjugate or to design bispecific antibodies that can bind with their Fab regions both to target
antigen and to a conjugate or effector cell. Every intact antibody can bind to cell receptors or
other proteins with its Fc region.

Page 29
Monoclonal antibodies for cancer. ADEPT, antibody directed enzyme prodrug therapy;
ADCC: antibody dependent cell-mediated cytotoxicity; CDC: complement-dependent
cytotoxicity; MAb: monoclonal antibody; scFv, single-chain Fv fragment.[46]

MAbs approved by the FDA for cancer include

 Alemtuzumab
 Bevacizumab
 Cetuximab
 Gemtuzumab ozogamicin
 Ipilimumab
 Ofatumumab
 Panitumumab
 Pembrolizumab
 Ranibizumab
 Rituximab
 Trastuzumab

Autoimmune diseases

Monoclonal antibodies used for autoimmune diseases include infliximab and adalimumab,
which are effective in rheumatoid arthritis, Crohn's disease, ulcerative colitis and ankylosing
spondylitis by their ability to bind to and inhibit TNF-α. Basiliximab and daclizumab inhibit
IL-2 on activated T cells and thereby help prevent acute rejection of kidney transplants.[48]

Page 30
Omalizumab inhibits human immunoglobulin E (IgE) and is useful in treating moderate-to-
severe allergic asthma.

Page 31
The main categories of targeted therapy are currently small molecules and monoclonal
antibodies.

Small molecules

Mechanism of imatinib

Many are tyrosine-kinase inhibitors.

 Imatinib (Gleevec, also known as STI–571) is approved for chronic myelogenous

leukemia, gastrointestinal stromal tumor and some other types of cancer. Early clinical
trials indicate that imatinib may be effective in treatment of dermatofibrosarcoma
protuberans.
 Gefitinib (Iressa, also known as ZD1839), targets the epidermal growth factor receptor
(EGFR) tyrosine kinase and is approved in the U.S. for non small cell lung cancer.
 Erlotinib (marketed as Tarceva). Erlotinib inhibits epidermal growth factor receptor, and
works through a similar mechanism as gefitinib. Erlotinib has been shown to increase
survival in metastatic non small cell lung cancer when used as second line therapy.
Because of this finding, erlotinib has replaced gefitinib in this setting.
 Sorafenib (Nexavar)[13]
 Sunitinib (Sutent)
 Dasatinib (Sprycel)
 Lapatinib (Tykerb)
 Nilotinib (Tasigna)

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 Bortezomib (Velcade) is an apoptosis-inducing proteasome inhibitor drug that causes
cancer cells to undergo cell death by interfering with proteins. It is approved in the U.S.
to treat multiple myeloma that has not responded to other treatments.
 The selective estrogen receptor modulator tamoxifen has been described as the
foundation of targeted therapy.[14]
 Janus kinase inhibitors, e.g. FDA approved tofacitinib
 ALK inhibitors, e.g. crizotinib
 Bcl-2 inhibitors (e.g. obatoclax in clinical trials, navitoclax, and gossypol.
 PARP inhibitors (e.g. Iniparib, Olaparib in clinical trials)
 PI3K inhibitors (e.g. perifosine in a phase III trial)
 Apatinib is a selective VEGF Receptor 2 inhibitor which has shown encouraging anti-
tumor activity in a broad range of malignancies in clinical trials. Apatinib is currently in
clinical development for metastatic gastric carcinoma, metastatic breast cancer and
advanced hepatocellular carcinoma.
 Zoptarelin doxorubicin (AN-152), doxorubicin linked to [D-Lys(6)]- LHRH, Phase II
results for ovarian cancer.
 Braf inhibitors (vemurafenib, dabrafenib, LGX818) used to treat metastatic melanoma
that harbors BRAF V600E mutation
 MEK inhibitors (trametinib, MEK162) are used in experiments, often in combination
with BRAF inhibitors to treat melanoma
 CDK inhibitors, e.g. PD-0332991, LEE011 in clinical trials
 Hsp90 inhibitors, some in clinical trials
 salinomycin has demonstrated potency in killing cancer stem cells in both laboratory-
created and naturally occurring breast tumors in mice.
 VAL-083 (dianhydrogalactitol), a “first-in-class” DNA-targeting agent with a unique bi-
functional DNA cross-linking mechanism. NCI-sponsored clinical trials have
demonstrated clinical activity against a number of different cancers including
glioblastoma, ovarian cancer, and lung cancer. VAL-083 is currently undergoing Phase 2

Page 33
 and Phase 3 clinical trials as a potential treatment for glioblastoma (GBM) and ovarian
cancer. As of July 2017, four different trials of VAL-083 are registered.

Small molecule drug conjugates

 Vintafolide is a small molecule drug conjugate consisting of a small molecule targeting

the folate receptor. It is currently in clinical trials for platinum-resistant ovarian cancer
(PROCEED trial) and a Phase 2b study(TARGET trial) in non-small-cell lung carcinoma
(NSCLC).

Serine/threonine kinase inhibitors (small molecules)

 Temsirolimus (Torisel)
 Everolimus (Afinitor)
 Vemurafenib (Zelboraf)
 Trametinib (Mekinist)
 Dabrafenib (Tafinlar)

Monoclonal antibodies

Several are in development and a few have been licensed by the FDA and the European
Commission. Examples of licensed monoclonal antibodies include:

 Pembrolizumab (Keytruda) binds to PD-1 proteins found on T cells. Pembrolizumab

blocks PD-1 and help the immune system kill cancer cells.[23] It is used to treat
melanoma, hodgkin's lymphoma, non-small cell lung carcinoma and several other types
of cancer.
 Rituximab targets CD20 found on B cells. It is used in non Hodgkin lymphoma
 Trastuzumab targets the Her2/neu (also known as ErbB2) receptor expressed in some
types of breast cancer
 Alemtuzumab

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  Cetuximab target the epidermal growth factor receptor (EGFR). It is approved for use in
the treatment of metastatic colorectal cancer, and squamous cell carcinoma of the head
and neck.
 Panitumumab also targets the EGFR. It is approved for the use in the treatment of
metastatic colorectal cancer.
 Bevacizumab targets circulating VEGF ligand. It is approved for use in the treatment of
colon cancer, breast cancer, non-small cell lung cancer, and is investigational in the
treatment of sarcoma. Its use for the treatment of brain tumors has been recommended.
 Ipilimumab (Yervoy)

Many antibody-drug conjugates (ADCs) are being developed. See also ADEPT (antibody-
directed enzyme prodrug therapy).

CD antigens as drug target

Special drugs have been designed that identify and attack cells that have a particular type of CD
antigens. These drugs are called monoclonal antibodies and they can attack only the type of cell
that contains the specific target CD antigens. Monoclonal antibodies can also be tagged to drugs
or radiation-emitting substances that add to the ability to kill cells that have the specific CD
marker on their surface.

Examples of CD antigens targeted in lymphoma treatment:

Rituxan (Rituximab) - a monoclonal antibody against CD20.

Zevalin (Ibritumomab Tiuxetan) - another antibody against CD20, tagged with a radiation
emitting substance (Y90).
Bexxar (Tositumomab) - similar to Zevalin, only the radiation emitting substance is different
(I131)
Gazyva (Obinutuzumab): targets CD20 antigen, used in initial treatment for small lymphocytic
lymphoma/chronic lymphocytic leukemia.

Page 35
Arzerra (Ofatumumab): targets CD 20 antigen, used in SLL/CLL.
Campath (Alemtuzumab): targets CD52 antigen in SLL/CLL and peripheral T-cell lymphomas.
Adcetris (Brentuximab vedotin): targets CD30 and is attached to a chemotherapy drug. Used in
anaplastic large cell lymphoma.

Biosimilar

A biosimilar is a biologic medical product (also known as biologic) highly similar to another
already approved biological medicine (the 'reference medicine'). Biosimilars are approved
according to the same standards of pharmaceutical quality, safety and efficacy that apply to all
biological medicines. Biosimilars are officially approved versions of original "innovator"
products and can be manufactured when the original product's patent expires.[2] Reference to the
innovator product is an integral component of the approval.

Unlike with generic drugs of the more common small-molecule type, biologics generally exhibit
high molecular complexity and may be quite sensitive to changes in manufacturing processes.
Despite that heterogeneity, all biopharmaceuticals, including biosimilars, must maintain
consistent quality and clinical performance throughout their lifecycle. A biosimilar is not
regarded as a generic of a biological medicine. This is mostly because the natural variability and
more complex manufacturing of biological medicines do not allow an exact replication of the
molecular micro-heterogeneity. Drug-related authorities such as the EU's European Medicines
Agency (EMA), the US's Food and Drug Administration (FDA), and the Health Products and
Food Branch of Health Canada hold their own guidance on requirements for demonstration of
the similar nature of two biological products in terms of safety and efficacy. According to them,
analytical studies demonstrate that the biological product is highly similar to the reference
product, despite minor differences in clinically inactive components, animal studies (including
the assessment of toxicity), and a clinical study or studies (including the assessment of
immunogenicity and pharmacokinetics or pharmacodynamics). They are sufficient to
demonstrate safety, purity, and potency in one or more appropriate conditions of use for which

Page 36
the reference product is licensed and is intended to be used and for which licensure is sought for
the biological product.

The World Health Organization (WHO) published its "Guidelines for the evaluation of similar
biotherapeutic products (SBPs)" in 2009. The purpose of this guideline is to provide an
international norm for evaluating biosimilars with a high degree of similarity with an already
licensed, reference biotherapeutic medicine.

Europe was the first region in the world to develop a legal, regulatory, and scientific framework
for approving biosimilar medicines. The EMA has granted a marketing authorisation for more
than 50 biosimilars since 2006 (first approved biosimilar Somatropin(Growth hormone)). The
first monoclonal antibody that was approved in 2013, was infliximab, putting the EU at the
forefront of biologics regulatory science.. Meanwhile, on March 6, 2015, the FDA approved the
United States's first biosimilar product, the biosimilar of filgrastim called filgrastim-sndz (trade
name Zarxio) by Sandoz.

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