Repurposing Drugs in Oncology (ReDO) —mebendazole as an anti-cancer agent

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Citation Pantziarka, Pan, Gauthier Bouche, Lydie Meheus, Vidula Sukhatme, and Vikas P Sukhatme. 2014. “Repurposing Drugs in Oncology (ReDO)—mebendazole as an anti-cancer agent.” ecancermedicalscience 8 (1): 443. doi:10.3332/ecancer.2014.443. http://dx.doi.org/10.3332/ecancer.2014.443.

Published Version doi:10.3332/ecancer.2014.443

Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:12717512

Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA Repurposing Drugs in Oncology (ReDO)—mebendazole as an anti-cancer agent

Pan Pantziarka1,2, Gauthier Bouche1, Lydie Meheus1, Vidula Sukhatme3 and Vikas P. Sukhatme3,4

1Anticancer Fund, Brussels, 1853 Strombeek-Bever, Belgium 2The George Pantziarka TP53 Trust, London KT1 2JP, UK 3GlobalCures, Inc, Newton, MA 02459, USA 4Beth Israel Deaconess Medical Centre and Harvard Medical School, Boston, MA 02215, USA

Correspondence to: Pan Pantziarka. Email: [email protected]

Abstract

Mebendazole, a well-known anti-helminthic drug in wide clinical use, has anti-cancer properties that have been elucidated in a broad range of pre-clinical studies across a number of different cancer types. Significantly, there are also two case reports of anti-cancer activity in humans. The data are summarised and discussed in relation to suggested mechanisms of action. Based on the evidence presented, it is proposed that mebendazole would synergise with a range of other drugs, including existing chemotherapeutics, and that further exploration of the potential of mebendazole as an anti-cancer therapeutic is warranted. A number of possible combinations with other drugs are discussed in the Appendix. Clinical Study Clinical Keywords: drug repurposing, anti-helminthic, metronomic chemotherapy, cancer, ReDO Project

Published: 10/07/2014 Received: 24/03/2014 ecancer 2014, 8:443 DOI: 10.3332/ecancer.2014.443

Copyright: © the authors; licensee ecancermedicalscience. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1 alternative formulationswithvegetableoils The poor bioavailability has long been recognised, and strategies to improve this remain actively researched, these strategies have included (17.5–116.2µM], ng/ml[0.06–0.39µM]) [0.24 ng/ml 69.5 of level plasma peak mean a produced dose same the at MBZ of treatment initial an treatment, chronic on not [0.47 µM] after a single dose of 10 mg /kg; however, there was high inter-patient variability (99.4–500 ng/ml [0.34–1.69 µM]). For patients series plasma of patients treated with chronic MBZ at dose a dose single of maximum 40 mg/kg/day to for hydatid compared disease, the mean three peak with plasma level and was 137.4 two ng/ml between of circulation, factor a by bioavailability concentration systemic plasma increase increases modestly MBZ of reaches to dosing Chronic known dose is meal oral high-fat the a with of Dosing post-administration. 20% hours 2–4 about reached only concentration that ensures MBZ of metabolism First-pass Pharmacokinetics was changedtoalbendazoledueintolerablesideeffects (reversiblealopecia,psychologicaldisturbance,anddropinperformance) MBZ for alveolar echinococcosis (average: 24 months) experienced few adverse reactions, and in only three patients (of 17), the treatment specific treatment for some patients has to be discontinued. For example, in one open-labelled observational study, the patientsthe tolerated, butwell treated treatmentis general,the within that,echinococcosis, evidenceis forthe long-termadministrationMBZ of of case the In a lackofdatainsuchcases rare on observed been have angioedema, pregnancy.during contraindicated is MBZ occasions. to due primarily 2, of age the below infants treating in recommended also is Caution and urticaria, rash, as such reactions, Hypersensitivity parasites. of excretion massive and of infection cases in diarrhoea and pain abdominal as such symptoms, transient from suffer may patients though toxicity, low has MBZ Toxicity ten ormoreyears of periods treatment of cases documented are there Indeed, disease. inoperable with patients for longer possibly and years, two least at mg/kg/day,for 40–50 treatment is with dose the echinococcosis, alveolar For months. 3–6 least at for mg/kg/day 40–50 of dosage a at is doc.who.int/bulletin/1996/Vol74-No3/bulletin_1996_74%283%29_231-242.pd ( Organisation Health World the by published guidelines the to According disease). hydatid as known (also echinococcosis alveolar and cystic human of treatment the for basis long-term a on used also is albendazole, with along MBZ, days. three for day a twice infection being treated. Pinworms are treated with a single 100 mg treatment, whereas roundworms or hookworms are treated with 100 mg For human use, the most common formulation of MBZ is as 100 mg chewable tablets. The dosage varies according to the type of helminthic Dosage Pharmacy in Atlanta. Foodand Drug Administration(FDA) approval. It is available in the US from compounding pharmacies, for example, Pavillion Compounding European countries, but the last US manufacturer, Teva Pharmaceuticals, ceased production atincluded Vermoxthe end(Janssen Pharamceutica) and of Ovex (McNeil 2011,Products Ltd) in the US althoughand Europe. It is the generally available drugover the retainscounter in US other nematode and trematode infections in humans and domestic animals. MBZ is available as a generic drug; common trade names have parasiticalinfections,wormofincludingrange threadworm, tapeworms, a treatroundworms,commonlyprescribed andto is others.It and Mebendazole(MBZ) is abroad-spectrum benzimidazole anti-helminthic drug, in the same class as albendazole, flubendazole, oxfendazole, Introduction [1, 2] . [3] . [6] . [7–9] , alteringthecrystallinestructureofMBZ 2

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Clinical Study 1.9 μM.MBZalsohadthegreatestinhibitoryeffect dose-dependent againstthemelanomacellsof fourbenzimidazolestested. induce to shown was MBZ pharmacokinetics. of IC50 was line cell melanocyte non-cancerous the for well-characterised equivalent the while μM, of 0.32 IC50 an average with lines cell in both apoptosis and toxicity of lack relative its on based detailed analysis more for selected was MBZ compounds, four these of oxybendazole—and and fenbendazole, albendazole, —mebendazole, benzimidazoles were four compounds, ten these Of melanocytes. normal to non-toxic were but lines, cells melanoma chemoresistant and the SK-Mel-19 M-14 against action had that inhibitory out ten compounds picked lines cells melanoma against molecules small 2000 the 2008, In daily fora70kgperson,ifextrapolatedbysurfacearea. noted in the treated animals. Of note, a dose of 1 mg/day in a mouse weighing 20 gm corresponds effectsside No 75%. to were controls of 50% from metastases of formation to the inhibited dose latter the doses, mg 2 and mg 1 to tumours a human dose primary of the approximately of 500 response mg the between difference little was there While cancers. adrenocortical implanted both in growth tumour inhibited significantly MBZ mg 2 and mg 1 with treatment that showed cancer adrenocortical of models mouse nude athymic of treatment vivo In killed allcancercellsinabout20days. and spheroids tumour the disaggregated completely which MBZ, of µM 1 of dose a against tested was inhibition spheroid Tumourcells. showed dose-dependent growth arrest, with IC50 of 0.23 µM for H295R and 0.27 µM for SW-13 cells, with MBZ no of effect concentrations different on with the treated normal were fibroblast lines cells fibroblast) (normal WI-38 and SW-13 Further pre-clinical evidence of MBZ anti-cancer activity was shown in adrenocortical cancer in 2008 in colonyformation. reduction such no showed paclitaxel agent anti-microtubule established the Treatmentwith controls. than lower 80% count colony mean a showed day other every MBZ of mg 1 with treated Mice days. 21 by lungs the in appeared colonies metastatic 300 approximately controls, untreated In mice. of vein tail the intoinjected cellsandmetastases A549 lung offormation the inhibitmight MBZ whetherassessed also MBZinhibited tumour growth thisinsyngeneic mouse model also. Micetreated withMBZshowed sidenoeffects. Finally, theinvestigators showeddose-dependenta arresttumourin growth. experimentThe alsowasrepeated withmiceC3HK1735theandmouse cellline, and cancer cells the Totest ovary, coloncarcinomas,andosteosarcoma,producingIC50sthatvariedfrom0.1to0.8µM. lungcancer cell growth 5-fold compared to controls. Additionally,the authors confirmed the growth inhibitory effects of MBZ against breast, had no effect on normal HUVECs or WI38 fibroblasts, even at a concentration of 1 µM. Overall, the lines cell In 2002, Mukhopadhyay and colleagues showed that MBZ induced a dose- and time-dependant apoptotic response in a range of lung cancer Pre-clinical evidenceincancer—vitro on thepre-clinicalevidenceassessedinfollowingsection. therapeutic. However,anti-cancer possible it is clear that a plasma levels achieved as by chronic and MBZ high-dosing schedules are to in the range response necessary for clinical activity assessing based in factor important an be may variability inter-patient and intra- High on bioavailabilitywouldbeaninterestingavenuetoexplore. also have some anti-cancer activity may cimetidine that Given effect. anti-cancer the increase to required be that should bioavailability increase to strategy a suggests it that chronic dosing of cimetidine following at 400 mg three MBZ times a day of for 30 days) g 1.5 on µM], 0.10 ± [0.19 levels, ng/ml 30.2 ± plasma 55.7 from ] MBZ µM 0.14 ± increase [0.28 ng/ml to 41.8 ± 82.3 to documented rose levels been serum (maximum has and metabolism inhibits which cimetidine, with interact MBZ and Albendazole [14, 15] [14, response to the MBZ treatment, MBZ the to response vivo in [14] activity of MBZ against chemoresistant melanoma cell lines was assessed by Doudican by assessed was lines cell melanoma chemoresistant against MBZ of activity vitro in . Animals with established tumours (~3 mm diameter) were treated with 1 mg orally of MBZ every other day. Treated animals , with an IC50 of ~0.16 µM. Cells were arrested in the G2-M phase before undergoing apoptosis. Just as importantly, MBZ [13] , it also suggests that an investigation into possible synergies with MBZ over and above the effect mice were inoculated with subcutaneous injections of H460 non-small cell lung cellnon-small H460 of injectionssubcutaneouswith inoculated were mice nu/nu and in vivo 3

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This may be an important interaction with clinical relevance in in vitro results showed that MBZ inhibited , and the two cancer cells lines cells cancer two the and vitro, in [16] , both in vitro and et al et ecancer [17] www.ecancer.org . A screening of of screening A . in vivo. H295R, 2014,8:443

Clinical Study patient suffering from progressive metastatic colon cancer had been treated first with capecitabine, 2013 oxaliplatin, and bevacizumab, in and then Larsson Rolf and Nygren Peter by described was MBZ with treated cancer colon metastatic of case A and everolimuswasaddedtotheMBZbutwithoutadditional benefitindiseasecontrol. to his baseline prior to his initial surgery. However, 24 months after the commencement of oral MBZ a scan showed disease progression, returned life of quality his and effects, side without treatment the monotherapy, tolerating MBZ of months 19 for stable remained the disease overall and lesions, metastatic in regression some experienced patient day. The a twice mg 100 of dose anti-helminthic typical MBZ a with at commenced Monotherapy treatment. of toxicity low relatively the and evidence this on based it use to agreed who clinicians, the patient evidence of discovered pre-clinical MBZ cancer via action against adrenocortical Pubmed and the forwarded to information the progression disease experienced surgery. had of rounds patient several and The protocols disease. chemotherapeutic multiple despite non-resectable of case the in options treatment few with malignancy rare published was cancer adrenocortical metastatic in control tumour long-term 2011,of In case a literature infavourofre-purposingMBZasananti-cancertherapy. No clinical trials of MBZ as a cancer treatment have been completed to date. However, there are two well-documented case reports in the Human dataincancer lines cells GBM two in infections apoptosis MBZ-induced worm and albendazole- pin of spate a fight to albendazole fed were models mice after failing were MBZ activity in glioblastoma multiforme (GBM) was discovered serendipitously in 2011 by investigators, who observed that GBM xenografts high-dose TMZ, but with no observed side effects. toequivalentresponses producedMBZ oral thatshowed resultstreatment.melanoma Thesewell-characterised for optionrepresentsa it as control positive a as used days, 5 for injection intraperitoneal an by (TMZ) temozolomide of mg/kg 100 of activity inhibitory growth the to other day Subsequently, MBZ was shown to inhibit human melanoma xenograft growth in athymic female nude mice fed 1 mg or 2 mg oral MBZ every showed thatMBZinducedcellcyclearrestandapoptosisatdosesareclinicallyachievablewithoraldosing. [21] Some work on and SW626),showedthatalldisplayedIC50of<5µM,whereasthedrugwaslargelyinactiveinnon-malignantcell lines. panel, 80% of cells lines cancer were sensitive colon to MBZ. Detailed the In date. to investigated further been not has that finding a MBZ, to sensitivity of level highest the had panel leukaemia the that noted be should It lines. NSCLC and renal ovarian, breast, in activity lesser with lines, colon cell of cancer,panels melanoma and leukaemia, CNS against activity of level high a showed which data, score z 60 NCI the using assessed was activity Diagnosis-specific registered pharmaceuticalsforclinicaluseinhumans,thuseasilyaccessibletesting’. oxybendazole mebendazole, are ‘they authors, the of words the in because, albendazole and MBZ (albendazole, on performed was analysis further these, Of fenbendazole). and benzimidazoles of cluster a including drugs, candidate 64 found and RKO) and 116 (HCT Nygren by work in molecule candidate colleagues and a as MBZ identified also lines cell cancer colon against activity for compounds of Screening survival upto63%insyngeneicandxenograftorthotopicmousegliomamodels. GBM. human 060919 the in µM 0.1 and line, glioma mouse Finally, Schmit showed that a range of benzimidazoles, including MBZ, possess anti-neoplastic activity against the DS 17 canine canine 17 DS the against activity anti-neoplastic possess MBZ, including line cell benzimidazoles, osteosarcoma of range a that showed Schmit Finally, with flubendazoleandMBZshowingthegreatestlevelofcytotoxicactivity. MBZreducedcellsurvivalby63.1%atadoseof0.5µM. . A range of benzimidazoles, including MBZ and albendazole, were tested and found to cause significant growth arrest and apoptosis, and arrest growth . significant cause to found and tested were Aalbendazole, and MBZ including benzimidazoles, of range [18] . Tumour growth was reduced by 83% for the 1 mg dose and 77% for the 2 mg in comparison to controls. This was comparable in vitro efficacy against a chemoresistant breast cancer cell line (SKBr-3) was performed by Coyne and colleagues in 2013 [20] . The authors set out to screen 1600 existing drugs for activity against two well-established colon cancer cell lines lines cell cancer colon well-established two against activity for drugs existing 1600 screen to out set authors The . in vitro in [22] . Canine osteosarcoma is an excellent animal model of the human disease. The results obtained obtained results The disease. human the of model animal excellent an is osteosarcoma Canine . in vitro treatment against five colon cancer cell lines (HCT 116, RKO, HT29, HT-8 results showed that oral MBZ treatment significantly extended mean mean extended significantly treatment MBZ oral that showed results vivo In and vitro in 4

. The vivo. in After all other treatment options had been exhausted, the the exhausted, been had options treatment other all After IC50 of MBZ was 0.24 µM in the GL261 the in µM 0.24 was MBZ of IC50 vitro in [19] [23] . Further investigation showed that both that showedinvestigation Further . . Adrenocortical cancer is a relatively relatively a is cancer . Adrenocortical [24] ecancer . Here, a 74-year-old a Here, . www.ecancer.org 2014,8:443

Clinical Study ri mtsae ta wr tetd ih aiteay floig y vdne f ies i te yp nds MZ ramn ws not been was have treated, withoneexperiencingaminorremission[PrivatecommunicationfromPeterNygren]. patients treatment five further MBZ Aprogression. disease nodes. subsequent lymph in or the metastases brain in the of disease discovery the of following evidence recommenced by following radiotherapy, with treated were that metastases brain developed patient the months, three approximately for treatment response. ceasing disease After initial lymph the confirmed scans CT of round and lungs the in lesions was temporarily stopped metastatic and then started at half MBZ the dose, with the patient reporting no ill so effects.ALT), and Liver enzymes normalised and a subsequent (AST of enzymes liver elevated remission experienced patient the However,liver. complete the in remission near partial good a showed and nodes evaluation radiological monotherapy, of weeks six pain neuropathic of terms in effect little is there colchicine, like that and domain, colchicine-binding the via acts MBZ that fact the to and the vinca alkaloids taxanes the including agents, disrupting microtubule of effect adverse classic a considered commonly is neuropathy,which peripheral of treated with high-dose MBZ, all adverse effects associated with other microtubule disruption agents, there do not appear to be any reports patients some in neutropenia and leukopenia, upset, gastro-intestinal rash, urticaria, alopecia, reversible of reports rare are there While has notbeenconfirmedinnon-melanomacelllines. melanoma confirmed this result, and also showed that MBZ decreased the levels of X-linked inhibitor of apoptosis (XIAP) latterTheworksuggested thatapoptoticthe responsemicrotubule to disruption mediatedisBcl-2 byphosphorylation. Subsequent workon [26] drugs, including paclitaxel, colchicine, and vincristine. MBZ, as with the other benzimidazoles, binds to the colchicine-binding domain of tubulin helminths, causing the parasites to die The anti-parasitic action of MBZ is due to its action as a microtubule-disrupting agent acting to prevent the polymerisation of tubulin in the gut Mechanism ofaction of are interest progression-free andoverallsurvival.StudycompletionisscheduledforDecember2017(asof2013). of variables outcome study,the the of portion II Phase the For alone. regimen three-drug the receiving group control the of end of Phase I potential subjects the will be offered the chance to receive At the three-drug regimen. regimen + MBZ for 70 weeks, or else to three-drug enrol as part current the with combination in used when ‘well-tolerated’ is daily twice mg 100 MBZ of dose standard the if arms. MBZ plus determine to is trial the of part I Phase the of treatment. objective of primary weeks The 70 care the over day a twice mg 100 is dose MBZ The of standard and care of standard between comparison with label, open and non-randomised is design study The gov/ct2/show/NCT0183786 New of YorkChildren’sCentre Cohen Medical at is trial ( clinical gliomas other low-grade The with patients paediatric in of writinginJanuary2014). to is point determine end if MBZ secondary Awithtemozolomide. current with standard MBZ of careof can slowdose tumourtolerated progression.maximum Study the completiondetermine is scheduledto foris Novemberpoint 2014 end (at the primary time day.The a times ( One is a Phase I open label study, at John Hopkins Hospital, of MBZ in newly diagnosed high-grade glioma patients receiving temozolomide There arecurrentlytwoclinicaltrialsofMBZincancer, bothforbraintumours. Clinical trials MBZ with work pre-clinical previous author’s the on based selected was MBZ day. a twice mg 100 of MBZ of dose oral an on started was available options treatment standard no had who and progression, disease of face the in irinotecan and capecitabine by Of course,itisalsopossiblethattheanticanceractivityofMBZ ismediatedbyadditionalmoleculartargetsyettobeelucidated. http://clinicaltrials.gov/ct2/show/NCT01729260 .The inhibition of tubulin polymerisation by MBZ has been confirmed been has MBZ by polymerisation tubulin of inhibition .The [27] . While this may suggest that the action of MBZ is independent of microtubule disruption, it may also be related 2 ). This is a Phase I and II pilot study of MBZ in combination with vincristine, carboplatin, and temozolomide. and carboplatin, vincristine, with combination in MBZ of study pilot II and I Phase a is This ). [25] . Tubulin is vital to cell division and is therefore a cancer target for several widely used chemotherapy ). Patients recruited to the trial are treated on a 28 day cycle of 500 mg MBZ tablets three three tablets MBZ mg 500 of cycle day 28 a on treated are trial the to recruited Patients ). 5

in a glioblastoma model glioblastoma a in vitro in [19] and in a melanoma model melanoma a in and ecancer [18] www.ecancer.org http://clinicaltrials. , but to date this 2014,8:443 [20] . After . [28] [17] . .

Clinical Study disruption—there are a number of additional agents that warrant investigation for synergy with MBZ, some of which are listed in the in listed Appendix. are which of some MBZ, with synergy for investigation warrant that agents additional of number a case are disruption—there this in which glioma, in treatment care of standard current with MBZ means a using combination protocol with are other drugs, trials principally temozolomide. Given clinical the primary two putative mechanism of first action—microtubule the that noted be should It As with other anti-cancer agents, it is most likely that MBZ will be more effective in combination with other drugs or treatment modalities. Additional cancertypes,whichshouldbefurtherinvestigatedinanimalstudiesinclude: similar effect withMBZand otherbenzimidazoles,andthismayalsobeafactorintheanti-cancereffects ofthesedrugs. a be may mechanistically,dynamics. there speculate, microtubule Therefore, to can related is action immunomodulatory this of some that cancer of effect immunosuppressive the reverse to help may that action immunomodulatory positive a exert alkaloids, vinca and taxanes the including doses, metronomic or low at used agents disrupting microtubule existing that evidence increasing also is There the with echinococcosis alveolar for treated mice in immunotherapeutic agent response liposomal muramyl tripeptide immune phosphatidylethanolamine (L-MTP-PE) cellular used in the the treatment of osteosarcoma stimulate to synergised albendazole some that is there evidence though investigated, been not has cancer in response immune the on benzimidazole other or MBZ of effect the Todate, drug-resistant celllines assay functional action of VEGFR-2 by binding to it, a finding validated compared to controls models xenograft cancer lung human on effect anti-angiogenic an reported colleagues and Mukhopadhyay MBZ, of activity anti-cancer the on work earliest the In that ithasananti-angiogeniceffect andothersfindingnone. There has been conflicting evidence regarding the effect that MBZ has on tumour neo-vascularisation, with some reports finding evidence cell p53 mutant lines weresensitivetoMBZ and wild-type where cells, melanoma of analysis the in evident also is status p53 of independence This PARP and of procaspase-3. cleavage and caspase-8, and caspase-9 of activation accumulation, c cytochrome caused MBZ to exposure cells cancer found was it lines, cell MDM2 and cancer p21 of expression downstream lung the and stabilization in p53 post-translational caused treatment example, MBZ that For pathways. independent and p53-dependent through effective be to appears MBZ glioma. Inadditiontothese,theevidencesuggeststhatcandidatecancertypestakehumantrialinclude: way,in under both getting trials clinical phase early two only Currently,are re-purposing. there for candidate ideal an this make evidence warranted. The known pharmacokinetics, relatively low toxicity (even with extended high-dosing protocols), low cost, and strong pre-clinical in summarised evidence the on Based Next steps Our take • • • • • • •

osteosarcoma. leukaemia, and breast cancer, colon cancer. adrenocortical cancer, and non-small celllungcancer, melanoma, [29] . Of note, the related drug albendazole has shown anti-angiogenic properties in an ovarian cancer model and in in and model cancer ovarian an in properties anti-angiogenic shown has albendazole drug related the note, Of . [16] [30, . Some support for an anti-angiogenic action comes from an [14] [17] 31] . However, . , suggestingthatananti-angiogenicactionmaybecommonacrossanumberofbenzimidazoles. . Table analysis of adrenocortical cancer models failed to detect any anti-angiogenic activity activity anti-angiogenic any detect to failed models cancer adrenocortical of analysis vivo in 1 , it is our contention that human clinical trials of mebendazole in a range of cancer types is types cancer of range a in mebendazole of trials clinical human that contention our is it , using a human umbilical vein endothelial cell (HUVEC) based angiogenesis in angiogenesis based cell (HUVEC) vitro vein a using endothelial umbilical human 6

in silico study, which indicated that MBZ inhibits the ecancer [14] www.ecancer.org . In p53-null lung lung p53-null In . 2014,8:443 [33–36] . We . [32] .

Clinical Study to aim that organisations not-for-profit with associated repurpose drugsforoncologytreatments. are authors the All interests. competing no have they that declare authors The Competing interests read andapprovedthefinalmanuscript. LydieVikasP.VidulaSukhatme, Bouche, Meheus, Gauthier authors: Contributing Pantziarka. Pan author: Primary Sukhatme. authors All Author contributions Peter Nygren,GregoryRigginsandGaryGallia. Acknowledgments combinations inthehopethatclinicianscanactuponthisinformationtoinitiateclinicaltrialsasamatterofsomeurgency. multi-drugthese of number a outlined have We types. cancer specific of number a in agentsrepurposing candidate other alongside and treatments standard existing the with combination in both treatment,oncological an as repurposing drug for candidate strong a is agent drug classes, such as the taxanes and vinca alkaloids. With well-established pharmacokinetics and an excellent toxicity profile, this low-cost chemotherapeutic classical major the of some to rationale similar a provides and laboratory the in characterised well is action microtubule The evidence for an anti-cancer effect of mebendazole treatment comes from Conclusion proposed combinations,itmaybearguedthatsmallpatienttrialsorevenoff-label usagemayalsobewarranted. the of toxicitylow the and needspatient unmet of urgency the given butrequired, pre-clinicaldata.are pre-clinical Additionalstudiesand knowledge, the combinations proposed in the supplementary material are speculative and informed primarily by mechanistic considerations is to create novel treatment options that are multi-targeted and which present minimal risk of toxicity. Of necessity, given our current state of create new protocols that combine MBZ with other repurposed drugs with similar low toxicity whether and potentialtest anti-cancer activity.to opportunity The intentionan provides done, have opportunitiesHowever,alone.seekcaretoalso should standard of we theincremental trials outcomes improvementsarecomparedto there in clinical two first the as protocols, care of standard existing the to MBZ Adding New protocols anti-cancer effect ofMBZ. cysts hydatid the of biomass model animal an in time) survival in increase in significant a and reduction 75–94% a (including effect therapeutic in increase significant very a reported and cimetidine and (albendazole) benzimidazole liposomal a of effect combined the explored that paper one including anti-helminthics, benzimidazole other and MBZ of action anti-parasitic the enhance to done been have area this in work some context, oncological an in explored been not has approach this While MBZ. of MBZ encapsulation liposomal the of through is bioavailability levels the increasing of means plasma effect. alternative An increases cimetidine with MBZ of there combination previously, on the touched that As evidence MBZ. of is bioavailability the in improvements through possible be also may efficacy improved Finally, Other options [37] . It is possible that a similar approach could yield improvements in the the in improvements yield could approach similar a that possible is It . 7

in vitro, in vivo, in silico, and human data. Mechanistically, the [12] , potentially improving the therapeutic therapeutic the improving potentially , ecancer www.ecancer.org 2014,8:443

Clinical Study 10. References 6. 5. 9. 8. 7. 4. 3. 2. 1.

Int JPharm403(1-2)23–8DOI: preliminary resultsEurJClinPharmacol acaRdiuz JJ García-Rodriguez Eur JClinPharmacol PABraithwaite (1980) J Bircher and G Karlaganis GJ, Münst literature J Antimicrob Chemother secondary cystsofEchinococcusgranulosusParasitolRes C Liu sunflower oilinechinococcosis (1989) AA Lur’e and AM Shcherbakov 87–90 DOI: Dawson M and Watson TR (1985) S Reuter Janssen (2013) ten-year clinicaltrialAnnTrop MedParasitol RLRausch 994–8 DOI: RW Ammann (2012) al et (2000) al et (1986) al et 10.1111/j.1365-2125.1985.tb02617. 10.1016/S0168-8278(98)80129- (1998) al et (1982) al et Vermox -Productmonograph Enhanced bioavailability and cysticidal effect of three mebendazole-oil preparations in mice infected with infected mice in preparations mebendazole-oil three of effect cysticidal and bioavailability Enhanced 22(2)161–9DOI: (2011) al et Benzimidazoles in the treatment of alveolar echinococcosis: a comparative study and review of the of review and study comparative a echinococcosis: alveolar of treatment the in Benzimidazoles Consequences of continuous mebendazole therapy in alveolar hydatid disease–with a summary of a of summary a disease–with hydatid alveolar in therapy mebendazole continuous of Consequences Table 1. A summaryofpre-clinicalevidencebycancertype. Ovary Osteosarcoma Melanoma Lung Leukaemia Glioma Colon Breast Adrenocortical Long-term mebendazole therapy may be parasitocidal in alveolar echinococcosis alveolar in parasitocidal be may therapy mebendazole Long-term Clinical pharmacokinetics of high dose mebendazole in patients treated for cystic hydatid disease hydatid cystic for treated patients in mebendazole dose high of pharmacokinetics Clinical Cancer Type 10.1016/j.ijpharm.2010.10.00 The effect of dose form on the bioavailability of mebendazole in man MedParazitol(Mosk) 46(3)451–6DOI: hne cytliiy f eedzl sld iprin ipoe atemni activity anthelmintic improved dispersion: solid mebendazole of crystallinity Changed Clinical trial of the possibility of increasing the bioavailability of mebendazole using mebendazole of bioavailability the increasing of possibility the of trial Clinical 10.1007/BF0054246 17(5)375–8DOI: 3 [14, 21,20] 80(4)403–19 In Vitro [14, 20] [14, 20] [14, 22] [17, 20] x lsa ocnrtos f eedzl drn tetet f echinococcosis: of treatment during mebendazole of concentrations Plasma PMID: [15] [20] [19] [16] 10.1093/jac/46.3.45 346–9 397802 2 10.1007/BF0055845 2 PMID: In Vivo 8 111 4 [18] [15] [19] [14] [16]

PMCID: (3) 1205–11 DOI:

709498 1 146379 PMID: NCT01729260, NCT01837862 6 Case Report/Trial 1 0 1098017 PMID: 10.1007/s00436-012-2954- [24] [23] 741871 3 5 Br J Clin Pharmacol ecancer 2 www.ecancer.org PMID: J Hepatol J 2014,8:443 2266124

29(6) 19(1) 1

Clinical Study 18. 17. 15. 19. 16. 13. 12. 11. 14. 20. 25. 24. 23. 22. 21. 26. 28. 27.

odcn NA Doudican Res 6(8)1308–15DOI: N Doudican Cancer ChemotherPharmacol non-small celllungcancercells J Sasaki Neuro Oncol Anticancer Drugs by preparingsoliddispersionwithpolyethyleneglycol a R Bai D Martarelli Clin CancerRes (2012) M Jameson and S Deva hydatid cystsBrJClinPharmacol (1987) J Pirotte and a Bekhti Y Chiba Cochrane DatabaseSysRev Oncol 139(12)2133–40DOI: Nygren P Mukhopadhyay T Laclette JP, Guerra G and Zetina C (1980) C JP,Zetina Laclette and G Guerra mebendazole inrefractorymetastaticcoloncancer (2013) R Larsson and P Nygren carcinoma EndocrPrac17(3)e59–62DOI: IY Dobrosotskaya Urbana, Illinois (2013) JM Schmit 9110.100010 with mebendazole against chemotherapeutic-resistant mammary adenocarcinoma Coyne CP, Jones T and Bear R (2013) Biophys Acta 630(2)271–8DOI: PA(1980) Friedman EG Platzer and 92(2) 417–23DOI: neuropathy Minerva Anestesiol JP Cata Cancer ManageRes AAArgyriou (2011) al et (1991) al et (2002) al et (2006) al et et al (2013) (2008) al et (2008) al et 13(9)974–82DOI: (2014) al et 9 (2013) al et 8(9)2963–9PMID: 24(2)181–8DOI: et al (2002) University of Illinois, of University line cell D17 osteosarcoma canine the on benzimidazoles of effects anti-cancer vitro In 10.1016/0006-291X(80)90349- (2011) al et niaaii mbnaoe hw sria bnft n pelncl oes f lolsoa multiforme glioblastoma of models preclinical 2 in benefit survival shows mebendazole Antiparasitic 6135–147DOI: Improvement of dissolution and bioavailability for mebendazole, an agent for human echinococcosis, human for agent an mebendazole, for bioavailability and dissolution of Improvement The anthelmintic drug mebendazole induces mitotic arrest and apoptosis by depolymerizing tubulin in tubulin depolymerizing by apoptosis and arrest mitotic induces mebendazole drug anthelmintic The Repositioning of the anthelmintic drug mebendazole for the treatment for colon cancer lncl n eprmna fnig i hmn ad nml wt ceohrp-nue peripheral chemotherapy-induced with animals and humans in findings experimental and Clinical 10.1158/1541-7786.MCR-07-215 Mebendazole induces apoptosis via Bcl-2 inactivation in chemoresistant melanoma cells melanoma chemoresistant in inactivation Bcl-2 via apoptosis induces Mebendazole Mebendazole inhibits growth of human adrenocortical carcinoma cell lines implanted in nude mice nude in implanted lines cell carcinoma adrenocortical human of growth inhibits Mebendazole Chemotherapy-induced peripheral neuropathy in adults: a comprehensive update of the literature the of update comprehensive a adults: in neuropathy peripheral Chemotherapy-induced 8(8)CD007814 IP oneuain copne mbnaoe rwh niiin n eaoa xenografts melanoma in inhibition growth mebendazole accompanies downregulation XIAP Mebendazole elicits a potent antitumor effect on human cancer cell lines both 10.1007/s00432-013-1539- Cimetidine increases serum mebendazole concentrations. Implications for treatment of hepatic of treatment for Implications concentrations. mebendazole serum increases Cimetidine 61(5)809–17DOI: 72(3)151–69PMID: 10.1093/neuonc/nor07 Histamine type 2 receptor antagonists as adjuvant treatment for resected colorectal cancer colorectal resected for treatment adjuvant as antagonists receptor 2 type Histamine 10.1016/0304-4165(80)90431- eedzl mnteay n ln-em ies cnrl n eattc adrenocortical metastatic in control disease long-term and monotherapy Mebendazole MolCancerTher rg eoiinn fo bnh o esd: uor eiso b te niemni drug antihelmintic the by remission Tumour bedside: to bench from repositioning Drug 24(3)390–2DOI: 10.1097/CAD.0b013e32835a43f 1223154 Interaction of anthelmintic benzimidazoles with Ascaris suum embryonic tubulin embryonic suum with Ascaris benzimidazoles anthelmintic of Interaction 10.2147/CMAR.S4426 Gemcitabine-(C4-amide)-[anti-HER2/neu] Gemcitabine-(C4-amide)-[anti-HER2/neu] anti-neoplastic cytotoxicty in dual combination Inhibition of tubulin polymerization by mebendazole by polymerization tubulin of Inhibition 10.4158/EP10390.C 2 6 10.1007/s00280-007-0538- 1(13)1201–9PMID: PMID: 1649339 10.1111/j.1365-2125.1987.tb03186. ActaOncol57(3)427–8 7 PMID: 5 9 PMID: PMID: ChemlPharmBull 735647 1 1 9 6 2176482

R PMID: 2413585 1866759 3 1 738805 2 1247970 PMCID: 5 1 PMCID: 39(8)2158–60DOI: 0 5 1 315801 382553 J Clin Exp Oncol x PMID: 4 4 366345 10.1248/cpb.39.215 Biochem Biophys Res Commun Res Biophys Biochem 2 02(02) DOI: PMCID: ecancer in vitro and www.ecancer.org

J Cancer Res Clin 138626 10.4172/2324- 8 2014,8:443 Mol Cancer Mol 3

Biochim in vivo

Clinical Study are notlistedinorderofpriority. being investigated in clinical trials. They have been selected as potential agents to be used in combination with MBZ. Note that these drugs The agents listed below have a high degree of clinical evidence of efficacy and are currently either in clinical use in oncology or are currently Higher-priority agents expected todisplayrelativelylowtoxicityandusecostgenerallyavailableagents. are combinations proposed these All investigated. being currently agents toxic substitute more and/or but newer the trials, for clinical drugs repurposed in and tested known being currently protocols existing replicate combinations these cases, some In indications. the of in potentially clinical trials. These combinations listed and in studies pre-clinical in both (MBZ), mebendazole with combination in investigation further warrant drugs following The Introduction Appendix 29. 30. 36. 35. 34. 32. 31. 37. 33. •

Dakshanamurthy S 55(15) 6832–48DOI: DOI: MH Pourgholami PMID: PMCID: inflammation in the spontaneous melanoma model echinococcosis and effect of co-administration with cimetidine normal miceJImmunotoxicol ASevko Sevko A concentrations JTransl Med R Kaneno Oncoimmunol 1077- albendazole with treated and echinococcosis alveolar with mice on Dvoroznáková E ovarian cancercellsbyalbendazoleAnticancerRes SWL Chu e H Wen M Roselli an anti-canceragent,thecombinationwithMBZshouldbe explored,bothinanimalmodelsandpotentiallysmallclinicaltrials. cancer types, including endometrial cancers and paediatric sarcomas paediatric and cancers endometrial including types, cancer of range a in drugs disrupting microtubule existing of action the potentiates metformin that evidence pre-clinical Metformin: is There 10.1186/1471-2407-10-14 2 876031 PMID: (1996) al et 357813 (2013) al et (2012) al et (2013) al et (2009) al et (2009) al et 2(10)e27025DOI: 2 1858766 5 et al (2008) (2010) al et et al (2012) Antitumor effect of paclitaxel is mediated by inhibition of myeloid-derived suppressor cells and chronic and cells suppressor myeloid-derived of inhibition by mediated is paclitaxel of effect Antitumor Application of paclitaxel in low non-cytotoxic doses supports vaccination with melanoma antigens in antigens melanoma with vaccination supports doses non-cytotoxic low in paclitaxel of Application 10.1021/jm300576 hraooy n efcc o lpsm-nrpe abnaoe n xeietl eodr alveolar secondary experimental in albendazole liposome-entrapped of efficacy and Pharmacology Potent inhibition of tubulin polymerisation and proliferation of paclitaxel-resistant 1A9PTX22 human 1A9PTX22 paclitaxel-resistant of proliferation and polymerisation tubulin of inhibition Potent 9 fet o cnetoa teaetc nevnin o te ubr n fnto o rgltr T cells T regulatory of function and number the on interventions therapeutic conventional of Effects hmmdlto o hmn edii cl fnto b atnolsi aet i lw noncytotoxic low in agents antineoplastic by function cell dendritic human of Chemomodulation Imunomodulative effect of liposomized muramyltripeptide phosphatidylethanolamine (L-MTP-PE) 758DOI: Potent inhibition of tumoral hypoxia-inducible factor 1alpha by albendazole by 1alpha factor hypoxia-inducible tumoral of inhibition Potent 9(3)275–81DOI: 3 Predicting new indications for approved drugs using a proteochemometric method PMID: 10.4161/onci.2702 Table 2039828 q 10.1186/1479-5876-7-5 PMID: A1 have been selected on the basis of existing pre-clinical and clinical experience in each 9 10.3109/1547691X.2012.65534 2278096 PMCID: 5 29(10)3791–6PMID: J Immunol 1 287338 PMCID: 10 8

PMID: 190(5) 2464–71 DOI: Parasitology 5 341949 [1–3] 1959168 Parasitol Res Parasitol 3 . Given the low toxicity of metformin and its potential as potential its and metformin of toxicity low the Given . 1984691

113 3 4 PMID: PMCID: (Pt 2) 111–21. DOI: 0 10.4049/jimmunol.120278 2244905 (4) 919–29 DOI: 919–29 103(4) 271630 3 6 10.1017/S003118200006635 ecancer 10.1007/s00436-008- Cancer BMC www.ecancer.org 1 PMID: 2014,8:443 J Med Chem 2335950 143 10 X 5

Clinical Study

• • • • • •

fore beofinterest,particularlyincolorectalcancerwherethereishumanevidencethateachagenthassomeanticancer activity. MBZ of levels plasma the increase can cimetidine that evidence also is there cancer colorectal early-stage for treatment adjuvant and/or perioperative as used is cimetidine impact on the immune system. A recent Cochrane Review suggested that there wasaction of methods possible of number a a with models, animal and trendtypes cell of range a in towardsactivity anticancer improved survival outcomes when synergistically, and there are numerous trials exploring multiple combinations of different microtubule agents vinorelbine,act anddocetaxel paclitaxelor example, for microtubuleagents, targetingCombinations of VincaAlkaloids: Taxanes or existing metronomicprotocolsmayincreasetheanti-angiogeniceffect oftreatmentandprolongthetherapeuticbenefit. inhibitionofneo-angiogenesis, andthat escape from angiogenic control isassociated with treatment failure. The addition ofMBZwith celecoxib or other anti-inflammatory). It is theorised that one of the principal methods of action of metronomic chemotherapy is through of a microtubule disrupting agent in combination with low dose oral chemotherapy drugs and other agents used in such protocols (e.g. both low toxicity and evidence of clinical benefit in advanced cancers combination with daily dosing of oral cyclophosphamide or capecitabine. A number of clinical trials using oral vinorelbine have reported infusioninweekly a normallyas ismetronomic settings,itin existing microtubuleformulationsused oralwithouttargeting aredrugs progress has been restricted because of a lack of oral formulations of many Whileintensethereofismetronomicchemotherapy:interest areaof the inMetronomic chemotherapythese usingtaxanesvincadrugs,alkaloids, or with the exception of oral vinorelbine. Where similar evidencefordiclofenac,earlyphasehumantrialsof a combinationtreatmentwouldbewarranted. activity clinical of evidence some another COX-2 inhibitor,vinblastine has also drug been used targeting in combination microtubule with metronomicallythe dosed with paclitaxel combined in metastatic was melanoma and diclofenac shown where cases including tumours, desmoid melanoma with types, cancer of range a in activity pre-clinical shown has diclofenac particular, In role. anticancer direct its surgery following metastases or recurrence cancer of risk lower with associated be may a COX-2 inhibitor, and is available both in topical and oral form. While there is evidence that perioperative or intraoperative diclofenac Diclofenac: The non-steroidal anti-inflammatory drug (NSAID) is a commonly used anti-inflammatory analgesic with known activity as vinblastine and vincristine with synergises flubendazole benzimidazole the that shows anti-angiogenic action and inhibition of Hedgehog signalling pathway : The H2 receptor antagonist cimetidine, primarily used to treat peptic ulcers and heartburn, has shown has heartburn, and ulcers peptic treat to used primarily cimetidine, antagonist receptor H2 Cimetidine: The multi-drug resistanceinresistantHeLacells,atleast ovarian including lines, cell of or tumour size proliferation in changes significant no showed vismodegib with treated previously patients contrast, In disease. stable had four and response partial showed four tumours, multiple with patients untreated previously eight in that showed carcinoma cell basal in trial (e.g. cancer prostate metastatic in principally trials, Itraconazole conditions parasitic treat to hard setting,there pre-clinicalis andclinical evidence thatthe combination that MBZofandalbendazole andmore aiseffective targets moleculartreatment certainin their in vary benzimidazoles differentcombining the them that may evidence improve is efficacy There and benzimidazole: reduce other the risks or of acquiredAlbendazole resistance. While this approach has not been explored in a agents. cancer both of dosingmetronomic at or vinorelbine of dosingstandard toxicity, in loweither with drugs,disruptingmicrotubule oral dual of would seem a promising avenue to explore in human trials. One prospect is to combine MBZ with oral such vinorelbine,low toxicity offeringin comparison theto many prospectexisting microtubule agents, combination therapy of MBZ with taxanes or vinca alkaloid drugs investigation indrug-resistanttumours. factor (HIF-1α) action by down-regulating vascular endothelial growth factor (VEGF), an effect mediated through inhibition of tumoural hypoxia inducible [21] Te nifna du ircnzl hs hw sm eiec o hvn at-acr ciiy psil truh an through possibly activity, anti-cancer having of evidence some shown has itraconazole drug anti-fungal The : [13] [10] and ovarian cancer ovarian and . As HIF-1α is implicated in multi-drug resistance in cancer, the combination of MBZ and albendazole warrants further . There is laboratory evidence that Hedgehog inhibition can reverse resistance to taxane chemotherapy in a range [14] [8, 9] [8, [24] and prostatic cancer prostatic and [22] . Given.thepre-clinical evidence MBZactivityof against melanoma andovarian cancer andthe . There is also some also is There . in particular. Clinically, diclofenac has been used in the treatment of recurrent or aggressive aggressive or recurrent of treatment the in used been particular.Clinically,has in diclofenac www.clinicaltrials.gov/ct2/show/NCT0088745 in vitro,atdosesachievablehumans [15] and vitro in 11 . There is specific evidence that itraconazole itself is able to reverse to able is itself itraconazole that evidence specific is There .

[4, 5] [11, 12] evidencewherevivo albendazole in anti-angiogenicexertsan . MBZ also offers the possibility of exploring daily oral dosing . It is currently being investigated in a number of clinical [19] . Athere- would MBZ and cimetidine of combination and vitro in [20] , there are also active investigationsactiveof also are there , [16] [18] . 8 ). A recently completed Phase II Phase completed recently A). in vivo in . As was mentioned previously,mentioned was As . [17] [7] [6] ecancer . Given that MBZ has has MBZ that Given . . Pre-clinical evidence , including, favourable www.ecancer.org evidence in evidence vivo in and vitro in [23] 2014,8:443 . Celecoxib, . in vivo in

Clinical Study and thereforethislistmustbeviewedasmorespeculative. The drugs listed below may also be suitable for combination treatments with MBZ and other agents, however, the evidence is not as strong Other agents • • • • •

non-small cell lung cancer lung cell non-small advanced and colorectal in outcomes EPA/DHA improve with can supplementation oral that evidence clinical limited also is There bioavailability whentakenwithafattymeal (DHA) can have chemosensitising effects in a range of cancer cell types and for a range of standard chemotherapeutic drugs (EPA)acid acid docosahexaenoic eicosapentaenoic and acids fatty 3 omega that PUFAsevidence 3 pre-clinical Omega is :There MBZ, and losartan of treatment particularly insolidtumours,suchasosteosarcoma,would beofinterest. combination a Therefore, treatment. MBZ with also possibility a therefore and chemotherapy, in (ARB) blocker receptor II angiotensin an as function primary its through effect anticancer an have also may losartan therefore and investigated, being also is angiogenesis mass tumour the within stresses physical by caused perfusion vascular reduced the counter-acting in role its for primarily therapeutic, anticancer possible Losartan reported asignificantlyimprovedsurvivaltime and model cancercolorectalxenograft a inalbendazole and 2Me ofcombination the assessedthat study recent a includingdrugs, [31] proliferationanti-angiogenesis,includeinhibitionactionofmicrotubule and dynamicssuppression of methodsProposedof tumours. solid of range a on-goingintrials with(EntreMedPanzemInc), of nametrade the under drug a developedcurrentlyasbeing is and 2-Methoxyestradiol (2Me): A natural metabolite of estradiol, 2Me has shown promising anti-cancer activity in a number of clinical trials of autophagy in established tumours abrogates a key survival mechanism utilised by cancer cells to protect themselves from a from themselves protect to cells cancer therapies targeted chemotherapy,and including radiotherapy treatments, by cancer of range utilised mechanism survival key a abrogates tumours established in autophagy of [28] therapy with lenalidomide, and dexamethasone for the treatment of multiple myeloma Helicobacter Pylori infection or as a treatment for treatment-associated mycobacterial infection. It has also been used in combination Clarithromycin types arewarranted. where the level of evidence for each agent is stronger, that is in glioblastoma and statistically significant melanoma,not isand sizetherefore sample smallhuman the trialsof resultin thethese though survival, canceroverall longer to tendency a showingtrial clinical small one from results initial glioblastoma,with in hydroxychloroquineis andchloroquine with researchclinical andpre-clinical much of focusparticular A radiotherapy or chemotherapy by initiated stresses cellular to response in apoptosis into move they that such state autophagic inhibitoranchloroquineautophagy,action asactsofof itthat is actingtherefore restrictan toabilitycancertomovethe cells ofto of clinical trials for cancer in combination with radiotherapy and/or alongside existing chemotherapy regimens.Chloroquine/Hydroxychloroquine: The Theanti-malarial drugs putativechloroquine and hydroxychloroquine mechanismare under active investigation in a range of autophagywithchloroquineinadditiontostandardtreatmentimprovedsurvival low-cost andlow-toxicityagents. This would be an approach most warranted in gliomas, whereit has been shownthat the inhibition using but trials existing these of some of strategy underlying the mirror would clarithromycin and MBZ of combination The cancers. combining the autophagy inhibitor chloroquine with a range of chemotherapeutic drugs, including microtubule disrupters, in different autophagy of inhibitor an as action . There have been a number of . One mechanism of action that is being actively explored in relation to the anticancer effects of clarithromycin is a suggested a is clarithromycin of effects anticancer the to relation in explored actively being is that action of mechanism One . : The angiotensin II receptor antagonist losartan, used mainly to treat hypertension, is currently being investigated as a as investigated being currently is hypertension, treat to mainly used losartan, antagonist receptor II angiotensin The : : A well-established macrolide antibiotic, clarithromycin has been used in an oncological setting for the eradication of eradication the for setting oncological an in used been has :clarithromycin antibiotic, Amacrolide well-established [26] [33] . The rationale for a combination of MBZ and chloroquine/hydroxychloroquine is stronger for those indications [36, 37] [36, . The direct role of angiotensin II in cancer progression, particularly with regards to the up-regulation of up-regulation the to regards with particularly progression, cancer in II angiotensin of role direct The . in vitro and [29] . Given this sensitisation of tumours to chemotherapies, and the known improvement in MBZ MBZ in improvement known the and chemotherapies, to tumours of sensitisation this Given . . The role of autophagy in cancer is a complex one, but there is evidence that the inhibition the that evidence is there but one, complex a is cancer in autophagy of role The . [34] [38] . Tumour hypoxia and lack of vascular perfusion are often causes of treatment failure treatment of causes often are perfusion vascular of lack and hypoxia Tumour. [32] in vivo studies assessing the synergistic action of 2Me with other microtubule-targeting , thecombinationofEPA/DHA andMBZshouldalsobeexplored. . 12

[26] [27] . or as a monotherapy for B cell lymphoma [30] . There are a number of clinical trials clinical of number a are There . ecancer www.ecancer.org 2014,8:443 [35] [25] . .

Clinical Study

References 2. 3. 1.

rlfrto ad ouain f h mO pathway mTOR the of modulation and proliferation Hanna RK Hanna 2141516 drug PloSOne8(12)e83832DOI: C Garofalo 2225209 types cell cancer multiple involving xenografts mouse HAHirsch D, (2011)Iliopoulos K Struhl and 3 9 Table A1. ProposeddrugcombinationswithMBZforspecificindications. PMCID: PMCID: (or analogue)hasbeenusedforthespecificindication. Note thatreferencestoclinicaltrialsorpublishedpapersareindicativeofcasereportswherethedrug Ovarian Carcinoma ductal carcinoma) Breast Cancer(ER+ Acute MyeloidLeukaemia Sarcoma Osteosarcoma/ Soft-tissue Colorectal Carcinoma Glioblastoma Multiforme Adrenocortical Carcinoma NSCLC Malignant Melanoma (2012) al et (2013) al et 308557 332227 Disease Metformin potentiates the effects of paclitaxel in endometrial cancer cells through inhibition of cell of inhibition through cells cancer endometrial in paclitaxel of effects the potentiates Metformin Metformin as an adjuvant drug against pediatric sarcomas: Hypoxia limits therapeutic effects of the of effects therapeutic limits Hypoxia sarcomas: pediatric against drug adjuvant an as Metformin 2 6 invasive 10.1371/journal.pone.008383 Ovarian Carcinoma anti-angiogenic Microtubule disruption, AMPK/mTOR, tosis Microtubule disruption,inductionofapop vascularity, anti-angiogenic Hedgehog pathwayinhibition,tumour Microtubule disruption, AMPK/mTOR, IGF-I, immunomodulation, anti-histamine,COX-2 Microtubule disruption, AMPK/mTOR, anti-angiogenic disruption, Hedgehogpathwayinhibition, Inhibition ofautophagy, microtubule Hedgehog signalling Microtubule disruption,anti-angiogenic, Hedgehog signalling,COX-2inhibition Microtubule disruption, AMPK/mTOR, immunomodulation autophagy, anti-angiogenic and Microtubule disruption,inhibitionof Metformin decreases the dose of chemotherapy for prolonging tumor remission in remission tumor prolonging for chemotherapy of dose the decreases Metformin Targets yeo Oncol Gynecol Cancer Res Cancer 13 2

(9) 3196–201 DOI: 3196–201 (9)

2 486 DOI: 458–69 125(2) - Diclofenac Itraconazole Metformin (NCT02050009) vinorelbine Oral cyclophosphamideand/ororal Metformin (NCT01929811) Albendazole ororalvinorelbine Oral cyclophosphamide Losartan Itraconazole Metformin Diclofenac Oral vinorelbine Diclofenac Cimetidine Metformin (NCT01941953) Itraconazole Hydroxychloroquine Oral cyclophosphamide Itraconazole Diclofenac orCelecoxib Itraconazole Metformin (NCT01997775) Oral cyclophosphamide Diclofenac orCelecoxib Hydroxychloroquine Drug Combination (NCT00954135) (NCT01124435) [42] 10.1158/0008-5472.CAN-10-347 [40] [43] 10.1016/j.ygyno.2012.01.00 (NCT00224978) (NCT00962845) [44] [41] [39] (NCT00520845) [24]

[45] ecancer www.ecancer.org 2014,8:443 9 1 PMID: PMID:

Clinical Study

10. 11. 18. 17. 15. 14. 12. 20. 19. 16. 13. 5. 4. 7. 6. 9. 8.

azng ME Cazzaniga 2371890 Briasoulis E locally advanced or metastatic breast cancer patients: The phase I-II VICTOR-1 study VICTOR-1 I-II phase The patients: cancer breast metastatic or advanced locally study translational clinical group oncology cooperative hellenic 10.1155/2014/76979 PMID: Parasit Vectors 5(1)292DOI: 24305 Vinca alkaloids and displays preclinical activity in leukemia and myeloma PASpagnuolo Jordan MA and Wilson L (2004) DOI: MH Pourgholami (10) 586–590.DOI: alone and (2011)in combination in Athe treatment of Olsen Trichuris trichiura in and school-age children in Uganda NB Kabatereine H, Namwanje Keiser J DOI: Chong CR Cochrane DatabaseSystRev Deva S and Jameson M (2012) M Jameson and S Deva 2132975 M Kubecova e40021 DOI: S Singh Steg AD J ClinOncol cancer prostate theoncologist.2012-31 castration-resistant metastatic with men in trial II phase domized ES Antonarakis cb600362 overall survivalinconservativebreastcancersurgery P Forget hydatid cystsBrJClinPharmacol (1987) J Bekhti Pirotte Aand Bull 24(9)1032–6DOI: Iida N DJ Kim 10.1186/1471-2407-10-14 10.1158/1535-7163.MCT-11-105 5 et al (2001) 1505728 PMID: (2014) al et (2012) al et et al (2012) 0 6 (2012) al et (2014) al et d PMCID: et al (2007) PMID: 1–7DOI: et al (2013) (2011)al et 10.1371/journal.pone.004002 2034839 (2010) al et 5 (2014) al et (2013) al et (2010) al et Reversal Reversal effects of antifungal drugs on multidrug resistance in MDR1-overexpressing HeLa cells 1743282 367494 10.1016/j.trstmh.2011.07.009 Open-label, exploratory Phase II trial of oral itraconazole for the treatment of basal cell carcinoma cell basal of treatment the for itraconazole oral of trial II Phase exploratory Open-label, 0 Effect of combinations of marketed human anthelmintic drugs against Trichuris muris Chemoresistance in prostate cancer cells is regulated by miRNAs and Hedgehog pathway Hedgehog and miRNAs by regulated is cells cancer prostate in Chemoresistance Smoothened antagonists reverse taxane resistance in ovarian cancer ovarian in resistance taxane reverse antagonists Smoothened PMID: 4 10.1200/JCO.2013.49.952 nroeaie s o ktrlc r ilfnc s soitd ih mrvd ies-re uvvl and survival disease-free improved with associated is diclofenac or ketorolac of use Intraoperative Inhibition of angiogenesis by the antifungal drug itraconazole PMID: 10.1248/bpb.24.103 4 Dose selection trial of metronomic oral vinorelbine monotherapy in patients with metastatic cancer: a Cimetidine: an anticancer drug? anticancer an Cimetidine: 3 0 The antihelmintic flubendazole inhibits microtubule function through a mechanism distinct from distinct mechanism a through function microtubule inhibits flubendazole antihelmintic The Repurposing itraconazole as a treatment for advanced prostate cancer: a noncomparative ran- noncomparative a cancer: prostate advanced for treatment a as itraconazole Repurposing 2455145 Cimetidine increases serum mebendazole concentrations. Implications for treatment of hepatic of treatment for Implications concentrations. mebendazole serum increases Cimetidine 8(8)CD007814PMID: Potent inhibition of tumoral hypoxia-inducible factor 1alpha by albendazole by 1alpha factor hypoxia-inducible tumoral of inhibition Potent fiay n sft o te l-rl ceue f ernmc ioebn ad aeiaie in capecitabine and vinorelbine metronomic of schedule all-oral the of safety and Efficacy 10.1186/1756-3305-5-29 2334000 3 Microtubules as a target for anticancer drugs PMID: Histamine type 2 receptor antagonists as adjuvant treatment for resected colorectal cancer colorectal resected for treatment adjuvant as antagonists receptor 2 type Histamine 24(3)390–2DOI: 8 5 PMCID: 5 2039828 PMCID: 1 2 PMID: PMID: 391439 9 5 PMCID: 357960 2276820 1155856 2289596 10.1111/j.1365-2125.1987.tb03186. fiay f ige n dul dss f ledzl ad mebendazole and albendazole of doses double and single of Efficacy 2 2 PMID: BrJ Anaesth 1–6 0 287338 3

4 Eur J Pharm Sci Pharm J Eur PMCID: 6 14 2323175

5 BMC Cancer BMC 338691 3 PMCID: 8 (5) 439–44 DOI: 439–44 42(5) Blood Nat Rev Cancer

(1) 263 DOI: 263 13(1) 353397

115(23) 4824–33 DOI: x ACS Chem Biol PMID: 0

Oncologist Int J Breast Cancer Breast J Int

Mol Cancer Therap Cancer Mol 4(4) 253–65 DOI: 366345 10.1186/1471-2407-13-26 10.1016/j.ejps.2011.02.004

Tran R Soc Trop Med Hyg 2 137 DOI: 163–73 18(2) 2 2(4) 263–70 DOI: PMCID: 10.1182/blood-2009-09- ecancer Cancer BMC in vitro and www.ecancer.org 2014 10.1038/nrc131 138626 11 PloS One PloS 2014,8:443 769790 DOI: 769790 (7) 1587–97 (7) Biol Pharm 3 10.1634/ 10.1021/ 3 in vivo PMID: 143 10 PMID: 32(8) 7(6) 105 7

Clinical Study 30. 26. 25. 24. 23. 22. 21. 31. 29. 28. 27. 38. 33. 32. 37. 36. 35. 34.

patients withmetastaticmelanomaCancer Maes H trial placebo-controlled double-blind, randomized, a Sotelo J, Briceño E and López-González MA (2006) Carew JS, Kelly KR and Nawrocki ST (2012) RS Bhatt 1528459 357–65 PMID: ogtdnl bevtoa study observational longitudinal 8(7) e66987DOI: DOI: stress-mediated CHOP inductioninmyelomacells 0000 H Lackner therapy PloSOne6(9)e24285DOI: LF Zerbini E Gottfried pharmacodynamics, and efficacy of oral capsules in hormone-refractory prostate cancer 10.1158/1078-0432.CCR-05-044 C Sweeney S Moriya final resultsofasingle-centrephaseIItrial S Govi 10.1182/blood-2007-05-09025 myeloma multiple symptomatic treatment-naive in rates overall-response and complete- high in R Niesvizky Janssen (2013) nonsmall celllungcancer VP Chauhan tumor-bearing nudemice A Ehteda Murphy RA Murphy Gut DOI: AJ Cockbain Treat Rev39(5)473–88DOI: PBougnoux and (2013) N Hajjaji Cancer Lett328(2)318–24DOI: X Chen tumour bloodvessels 8 10.1016/j.molmed.2013.04.00 PMID: (2010) al et et al (2013) (2013) al et 1 10.1136/gutjnl-2013-30644 (2010) al et (2013) al et (2013) al et (2011)al et (2013) al et (2011) al et (2004) al et (2008) al et (2005) al et 1652047 (2013) al et (2014) al et 2309139 Vermox -Productmonograph 10.1371/journal.pone.006698 Six-month oral clarithromycin regimen is safe and active in extranodal marginal zone B-cell lymphomas: B-cell zone marginal extranodal in active and safe is regimen clarithromycin oral Six-month Autophagy: shaping the tumor microenvironment and therapeutic response Angiotensin II type 1 receptor antagonists inhibit cell proliferation and angiogenesis in breast cancer breast in angiogenesis and proliferation cell inhibit antagonists receptor 1 type II Angiotensin A phase 2 pilot trial of low-dose, continuous infusion, or “metronomic” paclitaxel and oral celecoxib in celecoxib oral and paclitaxel “metronomic” or infusion, continuous low-dose, of trial pilot A2 phase 4 Combinatorial effect of non-steroidal anti-inflammatory drugs and NF-κB inhibitors in ovarian cancer ovarian in inhibitors NF-κB and drugs anti-inflammatory non-steroidal of effect Combinatorial obnto o abnaoe n 2mtoysrdo sgiiaty mrvs h sria o HCT-116 of survival the improves significantly 2-methoxyestradiol and albendazole of Combination NatCommun arld atbois lc atpay lx n sniie o otzmb i edpamc reticulum endoplasmic via bortezomib to sensitize and flux autophagy block antibiotics Macrolide New aspects of an old drug--diclofenac targets MYC and glucose metabolism in tumor cells tumor in metabolism glucose and MYC targets drug--diclofenac old an of aspects New 9 Supplementation with fish oil increases first-line chemotherapy efficacy in patients with advanced with patients in efficacy chemotherapy first-line increases oil fish with Supplementation BiRD (Biaxin [clarithromycin]/Revlimid [lenalidomide]/dexamethasone) combination therapy results therapy combination [lenalidomide]/dexamethasone) [clarithromycin]/Revlimid (Biaxin BiRD PMCID: utmdl ramn o cide wt urscal o rcret emi tmr: n 11-year an tumors: desmoid recurrent or unresectable with children of treatment Multimodal Angiotensin inhibition enhances drug delivery and potentiates chemotherapy by decompressing by chemotherapy potentiates and delivery drug enhances inhibition Angiotensin pae I utcne, admzd dul-ln, aey ra assig h pharmacokinetics, the assessing trial safety double-blind, randomized, multicenter, II phase A BMCCancer niooetl acr ciiy f h oea3 oynauae fty cd ioaeteoc acid eicosapentaenoic acid fatty polyunsaturated omega-3 the of activity cancer Anticolorectal Cancer 10.1016/j.ctrv.2012.07.00 8 0 10.1016/j.canlet.2012.10.00 Selective sensitization of tumors to chemotherapy by marine-derived lipids: a review a lipids: marine-derived by chemotherapy to tumors of sensitization Selective PMID: 347414 5 117(16) 3774–80DOI: 5 PMID: Pdar eao Oncol Hematol Pediatr J 10.1371/journal.pone.002428 42516DOI: PMID: 13(1)86DOI: 1616644 3 2371457 Autophagy as a target for cancer therapy: new developments 2447028 116(7) 1751–6DOI: BrJHaematol150(2)226–9PMID: 7 PMID: 1 10.1038/ncomms351 Adding chloroquine to conventional treatment for glioblastoma multiforme: 4 IntJOncol42(5)1541–50PMID: 1 1 10.1186/1471-2407-13-8 2387440 Ann Intern Med Intern Ann 10.1002/cncr.25933 6 15 8 582 DOI: 518–22 26(8) 5

PMCID: 10.1002/cncr.24902 5 6 (5) 337–43 DOI: 337–43 144(5) PMID: 370658 PMID: 6 2408463 PMID: 2043367 6 10.1097/01.mph.0000130219.26284.b PMID: 2132832 2354622 2343276 1 PMCID: 9 10.7326/0003-4819-144-5-200603070- 2012003

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11 111 284706 www.ecancer.org (18) 6625–33 DOI: 7 8 (3) 1101–9 DOI: 1101–9 (3) 2014,8:443 19(7) 428–46 2 PloS One PloS 3 PMID: Cancer 4

Clinical Study 40. 45. 44. 43. 42. 41. 39.

Rudin CM Rudin Shukla N Shukla André Netal(2011) Pilotstudyofapediatricmetronomic4-drugregimen Cancer Res E Briasoulis sialyl Lewis-A epitopeexpressionontumourcells S Matsumoto carcinoma JEndocrinolInvest Ferrero A non-small-cell lungcancer Borne Eetal(2010)Oralmetronomiccyclophosphamideinelderlywithmetastaticmelanoma or refractoryacuteleukemia (2014) al et et al (2013) (2013) al et 15(20)6454–61 (2009) al et (2002) al et Metronomic chemotherapy may be active in heavily pre-treated patients with metastatic adreno-cortical Phase II trial of clofarabine with topotecan, vinorelbine, and thiotepa in pediatric patients with relapsed with patients pediatric in thiotepa and vinorelbine, topotecan, with clofarabine of trial II Phase Phase 2 study of pemetrexed and itraconazole as second-line therapy for metastatic nonsquamous metastatic for therapy second-line as itraconazole and pemetrexed of study 2 Phase Dose-ranging study of metronomic oral vinorelbine in patients with advanced refractory cancer refractory advanced with patients in vinorelbine oral metronomic of study Dose-ranging Cimetidine increases survival of colorectal cancer patients with high levels of sialyl Lewis-X and Lewis-X sialyl of levels high with patients cancer colorectal of survival increases Cimetidine JThoracOncol8(5)619–23 PediatrBloodCancer 36(3)148–52 61(3)431–5 BrJCancer86(2)161–7 16

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