Gefitinib

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Gefitinib
Gefitinib structure.svg
Gefitinib 3D ball-and-stick 3UG2.png
Clinical data
Pronunciation /ɡɛˈfɪtɪnɪb/
Trade names Iressa, others
Other namesZD1839
AHFS/Drugs.com Monograph
MedlinePlus a607002
License data
Pregnancy
category
  • AU:C
Routes of
administration 		By mouth
ATC code
Legal status
Legal status
Pharmacokinetic data
Bioavailability 59% (oral)
Protein binding 90%
Metabolism Liver (mainly CYP3A4)
Elimination half-life 6–49 hours
Excretion Feces
Identifiers
  • N-(3-chloro-4-fluoro-phenyl)-7-methoxy-6-(3-morpholin-4-ylpropoxy)quinazolin-4-amine
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard 100.171.043 OOjs UI icon edit-ltr-progressive.svg
Chemical and physical data
Formula C22H24ClFN4O3
Molar mass 446.91 g·mol−1
3D model (JSmol)
  • C1COCCN1CCCOc2c(OC)cc3ncnc(c3c2)Nc4cc(Cl)c(F)cc4
  • InChI=1S/C22H24ClFN4O3/c1-29-20-13-19-16(12-21(20)31-8-2-5-28-6-9-30-10-7-28)22(26-14-25-19)27-15-3-4-18(24)17(23)11-15/h3-4,11-14H,2,5-10H2,1H3,(H,25,26,27) Yes check.svgY
  • Key:XGALLCVXEZPNRQ-UHFFFAOYSA-N Yes check.svgY
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Gefitinib, sold under the brand name Iressa, is a medication used for certain breast, lung and other cancers. Gefitinib is an EGFR inhibitor, like erlotinib, which interrupts signaling through the epidermal growth factor receptor (EGFR) in target cells. Therefore, it is only effective in cancers with mutated and overactive EGFR, but resistances to gefitinib can arise through other mutations. It is marketed by AstraZeneca and Teva.

Contents

It is on the World Health Organization's List of Essential Medicines. [5] It is available as a generic medication. [6]

Mechanism of action

Gefitinib is the first selective inhibitor of epidermal growth factor receptor's (EGFR) tyrosine kinase domain. Thus gefitinib is an EGFR inhibitor. The target protein (EGFR) is a member of a family of receptors (ErbB) which includes Her1(EGFR), Her2(erb-B2), Her3(erb-B3) and Her4 (Erb-B4). EGFR is overexpressed in the cells of certain types of human carcinomas - for example in lung and breast cancers. This leads to inappropriate activation of the anti-apoptotic Ras signalling cascade, eventually leading to uncontrolled cell proliferation. Research on gefitinib-sensitive non-small cell lung cancers has shown that a mutation in the EGFR tyrosine kinase domain is responsible for activating anti-apoptotic pathways. [7] [8] These mutations tend to confer increased sensitivity to tyrosine kinase inhibitors such as gefitinib and erlotinib. Of the types of non-small cell lung cancer histologies, adenocarcinoma is the type that most often harbors these mutations. These mutations are more commonly seen in Asians, women, and non-smokers (who also tend to more often have adenocarcinoma).

Gefitinib inhibits EGFR tyrosine kinase by binding to the adenosine triphosphate (ATP)-binding site of the enzyme. [9] Thus the function of the EGFR tyrosine kinase in activating the anti-apoptotic Ras signal transduction cascade is inhibited, and malignant cells are inhibited. [10]

Clinical uses

Gefitinib is marketed in many countries.[ citation needed ]

Iressa was approved and marketed in July 2002, in Japan, making it the first country to import the drug.[ citation needed ]

The FDA approved gefitinib in May 2003, for non-small cell lung cancer (NSCLC). [3] It was approved as monotherapy for the treatment of people with locally advanced or metastatic NSCLC after failure of both platinum-based and docetaxel chemotherapies. [3]

In June 2005, the FDA withdrew approval for use in new patients due to lack of evidence that it extended life. [11]

In the European Union, gefitinib is indicated since 2009 in advanced NSCLC in all lines of treatment for patients harbouring EGFR mutations. This label was granted after gefitinib demonstrated as a first-line treatment to significantly improve progression-free survival vs. a platinum doublet regime in patients harbouring such mutations. IPASS has been the first of four phase III trials to have confirmed gefitinib superiority in this patient population. [12] [13]

In most of the other countries where gefitinib is marketed it is approved for people with advanced NSCLC who had received at least one previous chemotherapy regime. However, applications to expand its label as a first-line treatment in patients harbouring EGFR mutations is currently in process based on the latest scientific evidence. [14] [15] As at August 2012 New Zealand has approved gefitinib as first-line treatment for patients with EGFR mutation for naive locally advanced or metastatic, unresectable NSCLC. This is publicly funded for an initial four-month term and renewal if no progression. [16]

In July 2015, the FDA approved gefitinib as a first-line treatment for NSCLC. [17]

Experimental uses

In August 2013, the BBC reported that researchers in Edinburgh and Melbourne found, in a small-scale trial of 12 patients, that the effectiveness of Methotrexate for treating ectopic pregnancy was improved when Gefitinib was also administered. [18]

Studies

IPASS (IRESSA Pan-Asia Study) was a randomized, large-scale, double-blinded study which compared gefitinib vs. carboplatin/ paclitaxel as a first-line treatment in advanced NSCLC. [19] IPASS studied 1,217 patients with confirmed adenocarcinoma histology who were former or never smokers. A pre-planned sub-group analyses showed that progression-free survival (PFS) was significantly longer for gefitinib than chemotherapy in patients with EGFR mutation positive tumours (HR 0.48, 95 per cent CI 0.36 to 0.64, p less than 0.0001), and significantly longer for chemotherapy than gefitinib in patients with EGFR mutation negative tumours (HR 2.85, 95 per cent CI 2.05 to 3.98, p less than 0.0001). This, in 2009, was the first time a targeted monotherapy has demonstrated significantly longer PFS than doublet chemotherapy.

EGFR diagnostic tests

Roche Diagnostics, Genzyme, QIAGEN, Argenomics S.A. & other companies make tests to detect EGFR mutations, designed to help predict which lung cancer patients may respond best to some therapies, including gefitinib and erlotinib.

The tests examine the genetics of tumors removed for biopsy for mutations that make them susceptible to treatment.

The EGFR mutation test may also help AstraZeneca win regulatory approval for use of their drugs as initial therapies. Currently the TK inhibitors are approved for use only after other drugs fail.[ citation needed ] In the case of gefitinib, the drug works only in about 10% of patients with advanced non-small cell lung cancer, the most common type of lung cancer.

Adverse effects

As gefitinib is a selective chemotherapeutic agent, its tolerability profile is better than previous cytotoxic agents. Adverse drug reactions (ADRs) are acceptable for a potentially fatal disease.

Acne-like rash is reported very commonly. Other common adverse effects (≥1% of patients) include: diarrhoea, nausea, vomiting, anorexia, stomatitis, dehydration, skin reactions, paronychia, asymptomatic elevations of liver enzymes, asthenia, conjunctivitis, blepharitis. [20]

Infrequent adverse effects (0.1–1% of patients) include: interstitial lung disease, corneal erosion, aberrant eyelash and hair growth. [20]

Resistance

Gefitinib and other first-generation EGFR inhibitors reversibly bind to the receptor protein, effectively competing for the ATP binding pocket. Secondary mutations can arise that alter the binding site, the most common mutation being T790M, where a threonine is replaced by a methionine at amino acid position 790, which is in the ligand-binding domain that typically binds ATP. [21] Threonine 790 is the gatekeeper residue, meaning it is key in determining specificity in the binding pocket. When it is mutated into a methionine, researchers originally hypothesized that it caused drug inhibition due to the steric hindrance of the bulkier methionine that selected for the binding of ATP instead of gefitinib. [22] As of 2008, the current hypothesized mechanism is that resistance to gefitinib is conveyed by increasing the ATP affinity of EGFR on an enzymatic level, meaning that the protein preferentially binds ATP over gefitinib. [23]

In order to combat this acquired resistance to gefitinib and other first-generation inhibitors, researchers have used irreversible EGFR inhibitors like neratinib or dacomitinib, called tyrosine kinase inhibitors (TKIs). These new drugs covalently bind to the ATP binding pocket, so when they are attached to EGFR, they cannot be displaced by ATP. [24] Even if the mutated versions of EGFR have a higher affinity for ATP, they will eventually use the irreversible inhibitors as ligands, which effectively shuts down their activity. When enough irreversible ligands have bound to EGFR, proliferation will be halted and apoptosis will be triggered through multiple pathways; for example, Bim can be activated after it is no longer inhibited by ERK, one of the kinases in the EGFR signaling pathway. [25] Even with gefitinib halting progression of NSCLC, the development of the cancer progresses after 9 to 13 months due to acquired resistances like the T790M mutation. These TKIs like dacomitinib extended overall survival by close to a year. [26]

Related Research Articles

<span class="mw-page-title-main">Tyrosine kinase</span> Enzyme

A tyrosine kinase is an enzyme that can transfer a phosphate group from ATP to the tyrosine residues of specific proteins inside a cell. It functions as an "on" or "off" switch in many cellular functions.

<span class="mw-page-title-main">Epidermal growth factor receptor</span> Transmembrane protein

The epidermal growth factor receptor is a transmembrane protein that is a receptor for members of the epidermal growth factor family of extracellular protein ligands.

Quinazoline is an organic compound with the formula C8H6N2. It is an aromatic heterocycle with a bicyclic structure consisting of two fused six-membered aromatic rings, a benzene ring and a pyrimidine ring. It is a light yellow crystalline solid that is soluble in water. Also known as 1,3-diazanaphthalene, quinazoline received its name from being an aza derivative of quinoline. Though the parent quinazoline molecule is rarely mentioned by itself in technical literature, substituted derivatives have been synthesized for medicinal purposes such as antimalarial and anticancer agents. Quinazoline is a planar molecule. It is isomeric with the other diazanaphthalenes of the benzodiazine subgroup: cinnoline, quinoxaline, and phthalazine. Over 200 biologically active quinazoline and quinoline alkaloids are identified.

<span class="mw-page-title-main">Erlotinib</span> Medication for treatment of non-small-cell lung cancer

Erlotinib, sold under the brand name Tarceva among others, is a medication used to treat non-small cell lung cancer (NSCLC) and pancreatic cancer. Specifically it is used for NSCLC with mutations in the epidermal growth factor receptor (EGFR) — either an exon 19 deletion (del19) or exon 21 (L858R) substitution mutation — which has spread to other parts of the body. It is taken by mouth.

<span class="mw-page-title-main">Targeted therapy</span> Type of therapy

Targeted therapy or molecularly targeted therapy is one of the major modalities of medical treatment (pharmacotherapy) for cancer, others being hormonal therapy and cytotoxic chemotherapy. As a form of molecular medicine, targeted therapy blocks the growth of cancer cells by interfering with specific targeted molecules needed for carcinogenesis and tumor growth, rather than by simply interfering with all rapidly dividing cells. Because most agents for targeted therapy are biopharmaceuticals, the term biologic therapy is sometimes synonymous with targeted therapy when used in the context of cancer therapy. However, the modalities can be combined; antibody-drug conjugates combine biologic and cytotoxic mechanisms into one targeted therapy.

<span class="mw-page-title-main">Non-small-cell lung cancer</span> Any type of epithelial lung cancer other than small-cell lung carcinoma

Non-small-cell lung cancer (NSCLC), or non-small-cell lung carcinoma, is any type of epithelial lung cancer other than small-cell lung cancer (SCLC). NSCLC accounts for about 85% of all lung cancers. As a class, NSCLCs are relatively insensitive to chemotherapy, compared to small-cell carcinoma. When possible, they are primarily treated by surgical resection with curative intent, although chemotherapy has been used increasingly both preoperatively and postoperatively.

<span class="mw-page-title-main">KRAS</span> Protein-coding gene in humans

KRAS is a gene that provides instructions for making a protein called K-Ras, a part of the RAS/MAPK pathway. The protein relays signals from outside the cell to the cell's nucleus. These signals instruct the cell to grow and divide (proliferate) or to mature and take on specialized functions (differentiate). It is called KRAS because it was first identified as a viral oncogene in the KirstenRAt Sarcoma virus. The oncogene identified was derived from a cellular genome, so KRAS, when found in a cellular genome, is called a proto-oncogene.

Matuzumab is a humanized monoclonal antibody for the treatment of cancer. It binds to the epidermal growth factor receptor (EGFR) with high affinity. The mouse monoclonal antibody (mAb425) from which matuzumab was developed at the Wistar Institute in Philadelphia, Pennsylvania

<span class="mw-page-title-main">ROS1</span> Protein-coding gene in the species Homo sapiens

Proto-oncogene tyrosine-protein kinase ROS is an enzyme that in humans is encoded by the ROS1 gene.

<span class="mw-page-title-main">Afatinib</span> Chemical compound

Afatinib, sold under the brand name Gilotrif among others, is a medication which is used to treat non-small cell lung carcinoma (NSCLC). It belongs to the tyrosine kinase inhibitor family of medications. It is taken by mouth.

Targeted therapy of lung cancer refers to using agents specifically designed to selectively target molecular pathways responsible for, or that substantially drive, the malignant phenotype of lung cancer cells, and as a consequence of this (relative) selectivity, cause fewer toxic effects on normal cells.

<span class="mw-page-title-main">Crizotinib</span> ALK inhibitor for treatment of non-small-cell lung cancer

Crizotinib, sold under the brand name Xalkori among others, is an anti-cancer medication used for the treatment of non-small cell lung carcinoma (NSCLC). Crizotinib inhibits the c-Met/Hepatocyte growth factor receptor (HGFR) tyrosine kinase, which is involved in the oncogenesis of a number of other histological forms of malignant neoplasms. It also acts as an ALK and ROS1 inhibitor.

<span class="mw-page-title-main">ALK inhibitor</span>

ALK inhibitors are anti-cancer drugs that act on tumours with variations of anaplastic lymphoma kinase (ALK) such as an EML4-ALK translocation. They fall under the category of tyrosine kinase inhibitors, which work by inhibiting proteins involved in the abnormal growth of tumour cells. All the current approved ALK inhibitors function by binding to the ATP pocket of the abnormal ALK protein, blocking its access to energy and deactivating it. A majority of ALK-rearranged NSCLC harbour the EML4-ALK fusion, although as of 2020, over 92 fusion partners have been discovered in ALK+ NSCLC. For each fusion partner, there can be several fusion variants depending on the position the two genes were fused at, and this may have implications on the response of the tumour and prognosis of the patient.

<span class="mw-page-title-main">Brigatinib</span> ALK inhibitor for treatment of non-small-cell lung cancer

Brigatinib, sold under the brand name Alunbrig among others, is a small-molecule targeted cancer therapy being developed by Ariad Pharmaceuticals, Inc. Brigatinib acts as both an anaplastic lymphoma kinase (ALK) and epidermal growth factor receptor (EGFR) inhibitor.

<span class="mw-page-title-main">Icotinib</span> Chemical compound

Icotinib is a highly selective, first generation epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI). Icotinib is approved for use in China as first-line monotherapy in patients with non-small-cell lung cancer with somatic EGFR mutations.

<span class="mw-page-title-main">Dacomitinib</span> Drug for the treatment of lung carninoma

Dacomitinib, sold under the brand name Vizimpro, is a medication for the treatment of non-small-cell lung carcinoma (NSCLC). It is a selective and irreversible inhibitor of EGFR.

<span class="mw-page-title-main">Osimertinib</span> Chemical compound, used as a medication to treat lung cancer

Osimertinib, sold under the brand name Tagrisso, is a medication used to treat non-small-cell lung carcinomas with specific mutations. It is a third-generation epidermal growth factor receptor tyrosine kinase inhibitor.

T790M, also known as Thr790Met, is a gatekeeper mutation of the epidermal growth factor receptor (EGFR). The mutation substitutes a threonine (T) with a methionine (M) at position 790 of exon 20, affecting the ATP binding pocket of the EGFR kinase domain. Threonine is a small polar amino acid; methionine is a larger nonpolar amino acid. Rather than directly blocking inhibitor binding to the active site, T790M increases the affinity for ATP so that the inhibitors are outcompeted; irreversible covalent inhibitors such as osimertinib can overcome this resistance.

<span class="mw-page-title-main">Mobocertinib</span> Small molecule tyrosine kinase inhibitor

Mobocertinib, sold under the brand name Exkivity, is used for the treatment of non-small cell lung cancer.

<span class="mw-page-title-main">Sunvozertinib</span> Pharmaceutical drug

Sunvozertinib is a pharmaceutical drug for the treatment of non-small-cell lung cancer (NSCLC). It is an epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor.

References

  1. ↑ https://www.tga.gov.au/resources/auspar/auspar-gefitinib [ bare URL ]
  2. ↑ "Iressa Product information". Health Canada . 17 December 2003. Retrieved 31 March 2024.
  3. 1 2 3 "Iressa- gefitinib tablet, coated". DailyMed. 28 February 2023. Retrieved 31 March 2024.
  4. ↑ "Iressa EPAR". European Medicines Agency (EMA). 24 June 2009. Retrieved 31 March 2024.
  5. ↑ World Health Organization (2023). The selection and use of essential medicines 2023: web annex A: World Health Organization model list of essential medicines: 23rd list (2023). Geneva: World Health Organization. hdl: 10665/371090 . WHO/MHP/HPS/EML/2023.02.
  6. ↑ "First Generic Drug Approvals". U.S. Food and Drug Administration (FDA). 17 October 2022. Retrieved 28 November 2022.
  7. ↑ Pao W, Miller V, Zakowski M, Doherty J, Politi K, Sarkaria I, et al. (September 2004). "EGF receptor gene mutations are common in lung cancers from "never smokers" and are associated with sensitivity of tumors to gefitinib and erlotinib". Proceedings of the National Academy of Sciences of the United States of America. 101 (36): 13306–11. Bibcode:2004PNAS..10113306P. doi: 10.1073/pnas.0405220101 . PMC   516528 . PMID   15329413.
  8. ↑ Sordella R, Bell DW, Haber DA, Settleman J (August 2004). "Gefitinib-sensitizing EGFR mutations in lung cancer activate anti-apoptotic pathways". Science. 305 (5687): 1163–7. Bibcode:2004Sci...305.1163S. doi:10.1126/science.1101637. PMID   15284455. S2CID   34389318.
  9. ↑ Lynch TJ, Bell DW, Sordella R, Gurubhagavatula S, Okimoto RA, Brannigan BW, et al. (May 2004). "Activating mutations in the epidermal growth factor receptor underlying responsiveness of non-small-cell lung cancer to gefitinib" (PDF). The New England Journal of Medicine. 350 (21): 2129–39. doi:10.1056/nejmoa040938. PMID   15118073.
  10. ↑ Takimoto CH, Calvo E. "Principles of Oncologic Pharmacotherapy" Archived 15 May 2009 at the Wayback Machine in Pazdur R, Wagman LD, Camphausen KA, Hoskins WJ (Eds) Cancer Management: A Multidisciplinary Approach Archived 4 October 2013 at the Wayback Machine . 11 ed. 2008.
  11. ↑ "Gefitinib (marketed as Iressa) Information". U.S. Food and Drug Administration (FDA). 3 November 2018.
  12. ↑ Mok TS, Wu YL, Thongprasert S, Yang CH, Chu DT, Saijo N, et al. (September 2009). "Gefitinib or carboplatin-paclitaxel in pulmonary adenocarcinoma". The New England Journal of Medicine. 361 (10): 947–57. doi: 10.1056/nejmoa0810699 . PMID   19692680.
  13. ↑ Sebastian M, Schmittel A, Reck M (March 2014). "First-line treatment of EGFR-mutated nonsmall cell lung cancer: critical review on study methodology". European Respiratory Review. 23 (131): 92–105. doi: 10.1183/09059180.00008413 . PMC   9487257 . PMID   24591666.
  14. ↑ Gijtenbeek RG, Damhuis RA, Groen HJ, van der Wekken AJ, van Geffen WH (November 2020). "Nationwide Real-world Cohort Study of First-line Tyrosine Kinase Inhibitor Treatment in Epidermal Growth Factor Receptor-mutated Non-small-cell Lung Cancer". Clinical Lung Cancer. 21 (6): e647–e653. doi:10.1016/j.cllc.2020.05.019. PMID   32636159. S2CID   219505386.
  15. ↑ Gijtenbeek RG, Damhuis RA, van der Wekken AJ, Hendriks LE, Groen HJ, van Geffen WH (April 2023). "Overall survival in advanced epidermal growth factor receptor mutated non-small cell lung cancer using different tyrosine kinase inhibitors in The Netherlands: a retrospective, nationwide registry study". The Lancet Regional Health. Europe. 27: 100592. doi:10.1016/j.lanepe.2023.100592. PMC   9932646 . PMID   36817181.
  16. ↑ "PHARMAC funds new targeted lung cancer drug" (PDF) (Media release). PHARMAC. 10 July 2012. Archived from the original (PDF) on 27 April 2017. Retrieved 22 January 2017.
  17. ↑ "FDA approves targeted therapy for first-line treatment of patients with a type of metastatic lung cancer". U.S. Food and Drug Administration (FDA). Archived from the original on 26 January 2018. Retrieved 16 December 2019.
  18. ↑ "Lung cancer drug 'could help treat ectopic pregnancy'". BBC News Online. 9 September 2013.
  19. ↑ Mok TS, Wu YL, Thongprasert S, Yang CH, Chu DT, Saijo N, et al. (September 2009). "Gefitinib or carboplatin-paclitaxel in pulmonary adenocarcinoma". The New England Journal of Medicine. 361 (10): 947–57. doi: 10.1056/NEJMoa0810699 . PMID   19692680.
  20. 1 2 Rossi S, ed. (2004). Australian Medicines Handbook . Adelaide: Australian Medicines Handbook. ISBN   0-9578521-4-2.
  21. ↑ Tan CS, Gilligan D, Pacey S (September 2015). "Treatment approaches for EGFR-inhibitor-resistant patients with non-small-cell lung cancer". The Lancet. Oncology. 16 (9): e447–e459. doi:10.1016/S1470-2045(15)00246-6. PMID   26370354.
  22. ↑ Ko B, Paucar D, Halmos B (2017). "EGFR T790M: revealing the secrets of a gatekeeper". Lung Cancer: Targets and Therapy. 8: 147–159. doi: 10.2147/LCTT.S117944 . PMC   5640399 . PMID   29070957.
  23. ↑ Yun CH, Mengwasser KE, Toms AV, Woo MS, Greulich H, Wong KK, et al. (February 2008). "The T790M mutation in EGFR kinase causes drug resistance by increasing the affinity for ATP". Proceedings of the National Academy of Sciences of the United States of America. 105 (6): 2070–5. Bibcode:2008PNAS..105.2070Y. doi: 10.1073/pnas.0709662105 . PMC   2538882 . PMID   18227510.
  24. ↑ Kwak EL, Sordella R, Bell DW, Godin-Heymann N, Okimoto RA, Brannigan BW, et al. (May 2005). "Irreversible inhibitors of the EGF receptor may circumvent acquired resistance to gefitinib". Proceedings of the National Academy of Sciences of the United States of America. 102 (21): 7665–70. Bibcode:2005PNAS..102.7665K. doi: 10.1073/pnas.0502860102 . PMC   1129023 . PMID   15897464.
  25. ↑ O'Reilly LA, Kruse EA, Puthalakath H, Kelly PN, Kaufmann T, Huang DC, Strasser A (July 2009). "MEK/ERK-mediated phosphorylation of Bim is required to ensure survival of T and B lymphocytes during mitogenic stimulation". Journal of Immunology. 183 (1): 261–9. doi:10.4049/jimmunol.0803853. PMC   2950174 . PMID   19542438.
  26. ↑ Lavacchi D, Mazzoni F, Giaccone G (2019). "Clinical evaluation of dacomitinib for the treatment of metastatic non-small cell lung cancer (NSCLC): current perspectives". Drug Design, Development and Therapy. 13: 3187–3198. doi: 10.2147/DDDT.S194231 . PMC   6735534 . PMID   31564835.
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