Generic versus branded pharmacotherapy in Parkinson's disease: does it matter? A review

There is an ongoing debate about generic drug use for a multitude of conditions including epilepsy, psychosis, hypertension, post-organ transplantation, and several infectious diseases. Most of the concerns involve drugs with narrow therapeutic indices. There is a heightened attention to health care costs and macroeconomic policy as well as microeconomic business decisions that may impact the use of generic drugs. The issues surrounding generic substitution for chronic degenerative conditions such as in Parkinson's disease (PD) continue to be controversial subjects for physicians, pharmacists, patients, Medicare/governmental insurance programs, and for private insurance companies. The United States Food and Drug Administration (FDA) requires that generic drugs meet a standard for bioequivalence prior to market approval, but this may not translate to therapeutic efficacy or to overall patient tolerance. In this review we will address issues related to the use of generics versus branded drugs in PD, and the potential impact substitution of generics may have on patients and on clinicians. Having proper documentation may help in deciding the appropriate usage of these drugs in PD. Medicare, governmental run health care systems, and third party insurance companies should in a complex disease such as PD, allow physicians and patients the chance to properly document the superiority of brand versus generic approaches. Currently, in the U.S, and in many countries around the world, there is no obligation for payers to respect these types of patient specific bedside trials, and there has been no standardization of the process.     

Acquisition of resistance toward HYD1 correlates with a reduction in cleaved α4 integrin expression and a compromised CAM-DR phenotype

We recently reported that the β1 integrin antagonist, referred to as HYD1, induces necrotic cell death in myeloma cell lines as a single agent using in vitro and in vivo models. In this article, we sought to delineate the determinants of sensitivity and resistance toward HYD1-induced cell death. To this end, we developed an HYD1 isogenic resistant myeloma cell line by chronically exposing H929 myeloma cells to increasing concentrations of HYD1. Our data indicate that the acquisition of resistance toward HYD1 correlates with reduced levels of the cleaved α4 integrin subunit. Consistent with reduced VLA-4 (α4β1) expression, the resistant variant showed ablated functional binding to fibronectin, VCAM-1, and the bone marrow stroma cell line HS-5. The reduction in binding of the resistant cell line to HS-5 cells translated to a compromised cell adhesion-mediated drug resistant phenotype as shown by increased sensitivity to melphalan- and bortezomib-induced cell death in the bone marrow stroma coculture model of drug resistance. Importantly, we show that HYD1 is more potent in relapsed myeloma specimens than newly diagnosed patients, a finding that correlated with α4 integrin expression. Collectively, these data indicate that this novel d-amino acid peptide may represent a good candidate for pursuing clinical trials in relapsed myeloma and in particular patients with high levels of α4 integrin. Moreover, our data provide further rationale for continued preclinical development of HYD1 and analogues of HYD1 for the treatment of multiple myeloma and potentially other tumors that home and/or metastasize to the bone.     

Pharmacokinetics and magnetic resonance imaging of biodegradable macromolecular blood‐pool contrast agent PG–Gd in non‐human primates: a pilot study

The purpose of this study was to evaluate poly(L ‐glutamic acid)‐benzyl‐DTPA–Gd (PG–Gd), a new biodegradable macromolecular magnetic resonance imaging contrast agent, for its pharmacokinetics and MRI enhancement in nonhuman primates. Studies were performed in rhesus monkeys at intravenous doses of 0.01, 0.02 and 0.08 mmol Gd/kg. T₁‐weighted MR images were acquired at 1.5 T using fast spoiled gradient recalled echo and fast spin echo imaging protocols. The small‐molecule contrast agent Magnevist was used as a control. PG–Gd in the monkey showed a bi‐exponential disposition. The initial blood concentrations within 2 h of PG–Gd administration were much higher than those for Magnevist. The high blood concentration of PG–Gd was consistent with the MR imaging data, which showed prolonged circulation of PG–Gd in the blood pool. Enhancement of blood vessels and organs with a high blood perfusion (heart, liver, and kidney) was clearly visualized at 2 h after contrast injection at the three doses used. A greater than proportional increase of the area under the blood concentration–time curve was observed when the administered single dose was increased from 0.01 to 0.08 mmol/kg. By 2 days after PG–Gd injection, the contrast agent was mostly cleared from all major organs, including kidney. The mean residence time was 15 h at the 0.08 mmol/kg dose. A similar pharmacokinetic profile was observed in mice, with a mean residence time of 5.4 h and a volume of distribution at steady‐state of 85.5 ml/kg, indicating that the drug was mainly distributed in the blood compartment. Based on this pilot study, further investigations on the potential systemic toxicity of PG–Gd in both rodents and large animals are warranted before testing this agent in humans. Copyright © 2011 John Wiley & Sons, Ltd.     

Two years of follow-up validates the echocardiographic criteria for the diagnosis and screening of rheumatic heart disease in asymptomatic populations

Objectives: Out of 1,059 school children aged 6–15 years, screened 2 years ago, 54 children were diagnosed with rheumatic heart disease (RHD) and put on penicillin prophylaxis. Significant regurgitation of mitral valves was detected in 39 cases of echocardiography diagnosed RHD, and in 15 cases significant regurgitation was detected to coexist with valve deformities. Three children had isolated mitral valve thickening without regurgitation. They were not given penicillin prophylaxis. These cases were followed up for 2 years. Methods: After 2 years, 54 children diagnosed with RHD and three children with isolated mitral valve thickening, were evaluated again. Lot quality assurance sampling was employed to screen a selected group of school children declared normal during the earlier evaluation. Lot was to be rejected, if, one child with significant regurgitation of mitral valve was found among the first 10 screened children of each of the 10 lots. Findings: No lot was rejected and thus it was inferred that the prevalence of new onset RHD was negligible in the subset declared normal 2 years ago. Isolated significant mitral regurgitation disappeared more often when present (35.9%) in comparison to when it (26.7%) was originally found coexistent with valve deformities. Conclusions: Highlight of the study is the greater reversibility of earlier lesions as compared to the later stages of RHD. Spontaneous regression of isolated mitral valve thickening in two‐thirds of the cases even without antibiotic prophylaxis, undermines the value of morphological criteria for the diagnosis of RHD. (Echocardiography 2011;28:929‐933)     

Mislocalization or low expression of mutated Shwachman–Bodian–Diamond syndrome protein

Shwachman–Diamond syndrome (SDS) is an autosomal-recessive disorder characterized by exocrine pancreatic insufficiency and bone marrow failure. Mutations in the SBDS gene are identified in most patients with SDS. Recent studies have shown that SBDS is involved in ribosome biogenesis and is localized to the nucleolus. The significance of cellular localization in SBDS is unknown, particularly as SBDS does not exhibit canonical nuclear localization signals. In this study, we have constructed wild-type deletion mutants of the critical domains and disease-associated mutants of the SBDS gene. These constructs were expressed in HeLa cells to explore the subcellular distribution of normal and mutant proteins. Wild-type SBDS was detected in the nucleus. However, constructs lacking N-terminal Domain I and two disease-associated mutants (C31W and N34I) failed to localize SBDS to the nucleus. Moreover, the amount of mutated SBDS protein was decreased. When N-terminal Domain I was overexpressed in HeLa cells, the localization of endogenous SBDS protein was changed from nuclei to cytosolic fraction. These data indicate that the N-terminal Domain I is responsible for nuclear localization. Furthermore, low expression of SBDS, as exhibited in some of the disease-associated mutants, may be associated with the pathogenesis of SDS.     

Insulinotropic and antidiabetic effects of 17β-estradiol and the GPR30 agonist G-1 on human pancreatic islets

We have recently shown that 17β-estradiol (E2) and the synthetic G protein-coupled receptor 30 (GPR30) ligand G-1 have antiapoptotic actions in mouse pancreatic islets, raising the prospect that they might exert beneficial effects also in human islets. The objective of the present study was to identify the expression of GPR30 in human islets and clarify the role of GPR30 in islet hormone secretion and β-cell survival. GPR30 expression was analyzed by confocal microscopy, Western blot, and quantitative PCR in islets from female and male donors. Hormone secretion, phosphatidylinositol hydrolysis, cAMP content, and caspase-3 activity in female islets were determined with conventional methods and apoptosis with the annexin-V method. Confocal microscopy revealed GPR30 expression in islet insulin, glucagon, and somatostatin cells. GPR30 mRNA and protein expression was markedly higher in female vs. male islets. An amplifying effect of G-1 or E2 on cAMP content and insulin secretion from isolated female islets was not influenced by the E2 genomic receptor (ERα and ERβ) antagonists ICI 182,780 and EM-652. Cytokine-induced (IL-1β plus TNFα plus interferon-γ) apoptosis in islets cultured for 24 h at 5 mmol/liter glucose was almost abolished by G-1 or E2 treatment and was not affected by the nuclear estrogen receptor antagonists. Concentration-response studies on female islets from healthy controls and type 2 diabetic subjects showed that both E2 and G-1 displayed important antidiabetic actions by improving glucose-stimulated insulin release while suppressing glucagon and somatostatin secretion. In view of these findings, we propose that small molecules activating GPR30 could be promising in the therapy of diabetes mellitus.