Factors which impact on the response of CML patients to ABL kinase inhibitor therapy: a study of imatinib and nilotinib.

Abstract

The natural history of CML has been transformed in recent years by the introduction of Glivec[superscript TM] (imatinib mesylate), an ABL kinase inhibitor, which provides the new treatment paradigm for chronic phase CML. While the majority of patients with CP-CML respond very well to imatinib, there are approximately 15% of patients who fail to respond, or respond suboptimally. While the major cause of secondary imatinib resistance can be attributable to kinase domain mutations, the underlying cause of primary resistance is yet to be elucidated. Utilizing the phosphorylation of the adaptor protein Crkl, an immediate downstream partner of BCRABL, as a surrogate measure of BCR-ABL kinase activity, a large interpatient variation in the degree of imatinib induced kinase inhibition achieved in-vitro, was observed in previously untreated CP-CML patients. The observed in-vitro sensitivity was a good predictor of molecular response in patients treated with 600mg imatinib as front line therapy. Furthermore, analysis of the in-vivo reduction in p-Crkl mediated measured in blood cells in response to imatinib over the first 28 days of therapy, revealed that patients with higher % reductions respond significantly better over a two year period, than those with lower % reductions. Using 14-C labelled imatinib, it was demonstrated that this intrinsic sensitivity correlated to the amount of drug which was retained within the target haemopoietic cell, and furthermore, that a critical determinant of the active influx of imatinib, was the functional activity of the human organic cation transporter -1 (OCT-1), as determined by a prazosin (potent inhibitor of OCT-1) inhibition assay. Patients with high OCT-1 Activity had superior molecular responses when compared to those with low OCT-1 Activity, but in those patients who could tolerate increased imatinib dose, these inferior responses could be largely overcome. In contrast, Nilotinib, a more potent second generation tyrosine kinase inhibitor, is not dependent on OCT-1 for influx, making it a possible treatment choice for patients with low OCT-1 Activity. Both imatinib and nilotinib interact with the efflux transporters ABCB1, and ABCG2. In combination studies imatinib results in a significantly increased intracellular concentration of nilotinib, most likely through interaction with these efflux transporters. Furthermore, commonly used therapies such as proton pump inhibitors also interact with ABCB1 and ABCG2, and demonstrable changes in intracellular drug concentrations were observed in-vitro with concomitant administration of these agents and imatinib or nilotinib at clinically relevant concentrations. In conclusion, these data demonstrate that the degree of kinase inhibition mediated in-vitro and in-vivo by imatinib, is a critical determinant of subsequent molecular response. This intrinsic sensitivity to imatinib induced kinase inhibition is related to the activity of the OCT-1 protein. This protein is not involved in the transport of nilotinib, suggesting it as a possible treatment alternative in those patients with low OCT-1 Activity.