Gefitinib

Gefitinib (ZD1839) (INN, /ɡɛˈfɪtɪnɪb/, trade name Iressa)[1] is a drug 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. It is marketed by AstraZeneca and Teva.

Gefitinib
Clinical data
Trade namesIressa
AHFS/Drugs.comMonograph
MedlinePlusa607002
License data
Pregnancy
category
  • AU: C
  • US: D (Evidence of risk)
    Routes of
    administration    		Oral
    ATC code
    Legal status
    Legal status
    • AU: S4 (Prescription only)
    • UK: POM (Prescription only)
    • US: ℞-only
    Pharmacokinetic data
    Bioavailability59% (oral)
    Protein binding90%
    MetabolismHepatic (mainly CYP3A4)
    Elimination half-life6–49 hours
    ExcretionFaecal
    Identifiers
    CAS Number
    PubChem CID
    IUPHAR/BPS
    DrugBank
    ChemSpider
    UNII
    KEGG
    ChEBI
    ChEMBL
    CompTox Dashboard (EPA)
    ECHA InfoCard100.171.043
    Chemical and physical data
    FormulaC22H24ClFN4O3
    Molar mass446.902 g/mol g·mol−1
    3D model (JSmol)
      (verify)

    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.[2][3] 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.[4] Thus the function of the EGFR tyrosine kinase in activating the anti-apoptotic Ras signal transduction cascade is inhibited, and malignant cells are inhibited.[5]

    Clinical uses

    Gefitinib is currently marketed in over 64 countries.

    Iressa was approved and marketed from July 2002 in Japan, making it the first country to import the drug.

    The FDA approved Gefitinib in May 2003 for non-small cell lung cancer (NSCLC).[6] It was approved as monotherapy for the treatment of patients with locally advanced or metastatic NSCLC after failure of both platinum-based and docetaxel chemotherapies.[6] i.e. as a third-line therapy.

    In June 2005 the FDA withdrew approval for use in new patients due to lack of evidence that it extended life.[7]

    In Europe 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.[8][9]

    In most of the other countries where gefitinib is currently marketed it is approved for patients 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. 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 4-month term and renewal if no progression.[10]

    On July 13, 2015, the FDA approved gefitinib as a first-line treatment for NSCLC.[11]

    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.[12]

    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.[13] 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

    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. 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.[14]

    Infrequent adverse effects (0.1–1% of patients) include: interstitial lung disease, corneal erosion, aberrant eyelash and hair growth.[14]

    See also

    References
    1. "Gefitinib". AdisInsight. Retrieved 28 February 2017.
    2. Pao W, Miller V, Zakowski M, Doherty J, Politi K, Sarkaria I, Singh B, Heelan R, Rusch V, Fulton L, Mardis E, Kupfer D, Wilson R, Kris M, Varmus H (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. doi:10.1073/pnas.0405220101. PMC 516528. PMID 15329413.
    3. 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. doi:10.1126/science.1101637. PMID 15284455.
    4. Lynch TJ, Bell DW, Sordella R, Gurubhagavatula S, Okimoto RA, Brannigan BW, Harris PL, Haserlat SM, Supko JG, Haluska FG, Louis DN, Christiani DC, Settleman J, Haber DA (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.
    5. Takimoto CH, Calvo E. "Principles of Oncologic Pharmacotherapy" in Pazdur R, Wagman LD, Camphausen KA, Hoskins WJ (Eds) Cancer Management: A Multidisciplinary Approach. 11 ed. 2008.
    6. IRESSA (gefitinib) Tablets. 5-2-03
    7. Research, Center for Drug Evaluation and. "Postmarket Drug Safety Information for Patients and Providers - Gefitinib (marketed as Iressa) Information".
    8. Mok TS, Wu YL, Thongprasert S, Yang CH, Chu DT, Saijo N, Sunpaweravong P, Han B, Margono B, Ichinose Y, Nishiwaki Y, Ohe Y, Yang JJ, Chewaskulyong B, Jiang H, Duffield EL, Watkins CL, Armour AA, Fukuoka M (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.
    9. 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. PMID 24591666.
    10. "PHARMAC funds new targeted lung cancer drug" (PDF) (Media release). PHARMAC. July 10, 2012. Retrieved January 22, 2017.
    11. "Press Announcements - FDA approves targeted therapy for first-line treatment of patients with a type of metastatic lung cancer".
    12. "Lung cancer drug 'could help treat ectopic pregnancy'". 9 September 2013 – via www.bbc.co.uk.
    13. Mok TS, Wu YL, Thongprasert S, Yang CH, Chu DT, Saijo N, Sunpaweravong P, Han B, Margono B, Ichinose Y, Nishiwaki Y, Ohe Y, Yang JJ, Chewaskulyong B, Jiang H, Duffield EL, Watkins CL, Armour AA, Fukuoka M (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.
    14. Rossi S, editor. Australian Medicines Handbook 2004. Adelaide: Australian Medicines Handbook; 2004. ISBN 0-9578521-4-2.
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