Tamoxifen

Hormonal Therapy for breast cancer

1. Tamoxifen By. Dr. Ketan A. Kalariya DNB 1 st Year Radiotherapy Jupiter Hospital Thane.

2. Introduction Tamoxifen is come under a class of Selective Estrogen Receptor Modulator (SERM) The most important drug worldwide for hormone receptor positive breast cancer

3. Cont. Approved by the FDA for treatment of High-risk patients DCIS Pre and Postmenopausal breast cancer Metastatic disease

4. Mech

5. Mech. Of Action

6. Tamoxifen itself is a prodrug , having relatively little affinity for its target protein, the oestrogen receptor.

7. It is metabolized in the liver by the cytochrome P450 isoform CYP2D6 and CYP3A4 into active metabolites such as 4-hydroxytamoxifen (afimoxifene) and N-desmethyl-4-hydroxytamoxifen (endoxifen) which have 30-100 times more affinity with the estrogen receptor than tamoxifen itself

8. These active metabolites compete with estrogen in the body for binding to the estrogen receptor. In breast tissue, 4-hydroxytamoxifen acts as an estrogen receptor antagonist so that transcription of estrogen-responsive genes is inhibited . 4-hydroxytamoxifen binds to estrogen receptors (ER), the ER/tamoxifen complex recruits other proteins known as co-repressors and then binds to DNA to modulate gene expression

9. 4-Hydroxytamoxifen binds to estrogen receptors competitively (with respect to the endogenous agonist estrogen) in tumor cells and other tissue targets, producing a nuclear complex that decreases DNA synthesis and inhibits estrogen effects

10. It is a nonsteroidal agent with potent antiestrogenic properties which compete with estrogen for binding sites in breast and other tissues . Tamoxifen causes cells to remain in the G0 and G1 phases of the cell cycle. Because it prevents (pre)cancerous cells from dividing but does not cause cell death, tamoxifen is cytostatic rather than cytocidal .

11. Pharmacokinetic Long t 1/2 : 7 -14 days. OD dose can be used Reduced bioavailability is not a cause for resistance. False negative receptor assays for several months after stopping Rx in tumor tissue. Metabolism in liver and excretion in feces ► Renal dysfunction not a contraindication. Metabolized by CYP 450 3A4 enzyme: Can reduce warfarin metabolism. Careful INR monitoring needed in patients receiving warfarin with tamoxifen.

12. Pharmaco - genetics and drug interactions Patients with variant forms of the gene CYP2D6 (also called simply 2D6) may not receive full benefit from tamoxifen because of too slow metabolism of the tamoxifen prodrug into its active metabolite 4-hydroxytamoxifen .

13. Certain CYP2D6 variations in breast cancer patients leads to a worse clinical outcome for tamoxifen treatment Genotyping therefore has the potential for identification of women who have these CYP2D6 phenotypes and for whom the use of tamoxifen is associated with poor outcomes.

14. Recent studies suggest that taking the selective serotonin reuptake inhibitors (SSRIs) antidepressants paroxetine (Paxil), fluoxetine (Prozac), and sertraline (Zoloft) can decrease the effectiveness of tamoxifen, as these drugs compete for the CYP2D6 enzyme which is needed to metabolize tamoxifen into the active form, endoxifen .

15. A U.S. study presented at the American Society of Clinical Oncology's annual meeting in 2009 found that after two years, 7.5 percent of women who took only tamoxifen had a recurrence, compared with 16 percent who took either paroxetine, fluoxetine or sertraline, drugs considered to be the most potent CYP2D6 inhibitors

16. . That difference translates to a 120 percent increase in the risk of breast cancer recurrence. Patients taking the SSRIs; Celexa (citalopram), Lexapro ( escitalopram ), and Luvox (fluvoxamine), did not have an increased risk of recurrence, due to their lack of competitive metabolism for the CYP2D6 enzyme .

17. A newer study demonstrated a clearer and stronger effect from paroxetine in causing the worst outcomes. Patients treated with both paroxetine and tamoxifen have a 67% increased risk of death from breast cancer, from 24% to 91%, depending on the duration of coadministration

18. Recent research has shown that 7-10% of women with breast cancer may not receive the full medical benefit from taking tamoxifen due to their unique genetic make- up

19. . DNA Drug Safety Testing can examine DNA variations in the CYP2D6 and other important drug processing pathways. More than 20% of all clinically used medications are metabolized by CYP2D6 and knowing the CYP2D6 status of a person can help the doctor with the future selection of medications

20. Other molecular biomarkers may also be used to select appropriate patients likely to benefit from tamoxifen

21. Therapeutic Use Breast cancer Premature puberty Infertility Gynecomastia Bipolar disorder (in research ) blocking protein kines C in brain neuron

22. Side effect Hot Flush Nausea Vomiting Vaginal bleeding/ discharge On Endometrium Ocular side effect

23. Thromboembolic events Osteoporosis in postmenopausal

24. Beneficial effect On CVS

25. Tamoxifen use along with GnRH analog ?? Improved overall survival than either alone [ Klinj et al.]

26. Aromatase Inhibitors Include a class of drugs which prevent peripheral conversion of androgens to estrogen. Also cause selective impairment of gonadal steroidogenesis . Thus are capable of selective estrogen deprivation without impairment of adrenal androgen synthesis. Two types exist: Type I : Enzyme inactivators (Steroidal) Type II : Competitive antagonists ( Non steroidal) 3 generations exist: 1 st generation: Aminoglutethemide 2 nd generation: Formestane (Type I) , Fadrazole 3 rd generation: Exemestane (Type I) , Anastrazole , Letrozole , Vorozole

27. 3 rd generation AI These drugs inhibit the Aromatase enzyme selectively by blocking the heme moiety of the enzyme. Active sites of other steroidogenic enzymes remain free. 3 rd generation AIs are 3 times more potent than aminoglutethemide . Dose: Letrozole ( Femara ) – 2.5 mg OD Anastrazole ( Arimidex ) – 1 mg OD Exemestane ( Aromasin ) – 25 mg OD

28. Special Properties Anastrazole : Less than 10% of the drug is cleared as unchanged drug because of its extensive metabolism. Letrozole : Only 5% is excreted in the urine, letrozole can be safely used in patients with renal insufficiency. Used with caution when patients have severe liver impairment. Produces the greatest suppression of estrogen synthesis Exemestane : Weakly androgenic metabolite (17-hydroexemestane) that may ameliorate bone loss associated with estrogen deprivation