Chemistry:Sirolimus

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Short description: Pharmaceutical drug
Sirolimus
Sirolimus structure.svg
Sirolimus-from-1C9H-3D-sticks.png
Clinical data
Trade namesRapamune, Fyarro, Hyftor
Other namesRapamycin, ABI-009
License data
Pregnancy
category
  • AU: C
Routes of
administration		By mouth, intravenous, topical
ATC code
Legal status
Legal status
Pharmacokinetic data
Bioavailability14% (oral solution), lower with high-fat meals; 18% (tablet), higher with high-fat meals[6]
Protein binding92%
MetabolismLiver
Elimination half-life57–63 hours[7]
ExcretionMostly fecal
Identifiers
CAS Number
PubChem CID
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
PDB ligand
Chemical and physical data
FormulaC51H79NO13
Molar mass914.187 g·mol−1
3D model (JSmol)
Solubility in water0.0026 [8]
  (verify)

Sirolimus, also known as rapamycin and sold under the brand name Rapamune among others, is a macrolide compound that is used to coat coronary stents, prevent organ transplant rejection, treat a rare lung disease called lymphangioleiomyomatosis, and treat perivascular epithelioid cell tumor (PEComa).[1][2][9][10] It has immunosuppressant functions in humans and is especially useful in preventing the rejection of kidney transplants. It is a mechanistic target of rapamycin (mTOR) kinase inhibitor[2] that reduces the sensitivity of T cells and B cells to interleukin-2 (IL-2), inhibiting their activity.[11]

This compound also has a use in cardiovascular drug-eluting stent technologies to inhibit restenosis.

It is produced by the bacterium Streptomyces hygroscopicus and was isolated for the first time in 1972, from samples of Streptomyces hygroscopicus found on Easter Island.[12][13][14] The compound was originally named rapamycin after the native name of the island, Rapa Nui.[9] Sirolimus was initially developed as an antifungal agent. However, this use was abandoned when it was discovered to have potent immunosuppressive and antiproliferative properties due to its ability to inhibit mTOR. It was approved by the U.S. Food and Drug Administration (FDA) in September 1999.[15] Hyftor was approved for treatment of facial angiofibroma in the European Union in May 2023.[5]

Medical uses

Sirolimus is indicated for the prevention of organ transplant rejection and for the treatment of lymphangioleiomyomatosis (LAM).[1]

Sirolimus (Fyarro), as protein-bound particles, is indicated for the treatment of adults with locally advanced unresectable or metastatic malignant perivascular epithelioid cell tumor (PEComa).[2][16]

In the EU, sirolimus, as Rapamune, is indicated for the prophylaxis of organ rejection in adults at low to moderate immunological risk receiving a renal transplant[4] and, as Hyftor, is indicated for the treatment of facial angiofibroma associated with tuberous sclerosis complex.[5]

Prevention of transplant rejection

The chief advantage sirolimus has over calcineurin inhibitors is its low toxicity toward kidneys. Transplant patients maintained on calcineurin inhibitors long-term tend to develop impaired kidney function or even kidney failure; this can be avoided by using sirolimus instead. It is particularly advantageous in patients with kidney transplants for hemolytic-uremic syndrome, as this disease is likely to recur in the transplanted kidney if a calcineurin-inhibitor is used. However, on 7 October 2008, the FDA approved safety labeling revisions for sirolimus to warn of the risk for decreased renal function associated with its use.[17][18] In 2009, the FDA notified healthcare professionals that a clinical trial conducted by Wyeth showed an increased mortality in stable liver transplant patients after switching from a calcineurin inhibitor-based immunosuppressive regimen to sirolimus.[19] A 2019 cohort study of nearly 10,000 lung transplant recipients in the US demonstrated significantly improved long-term survival using sirolimus + tacrolimus instead of mycophenolate mofetil + tacrolimus for immunosuppressive therapy starting at one year after transplant.[20]

Sirolimus can also be used alone, or in conjunction with a calcineurin inhibitor (such as tacrolimus), and/or mycophenolate mofetil, to provide steroid-free immunosuppression regimens. Impaired wound healing and thrombocytopenia are possible side effects of sirolimus; therefore, some transplant centers prefer not to use it immediately after the transplant operation, but instead administer it only after a period of weeks or months. Its optimal role in immunosuppression has not yet been determined, and it remains the subject of a number of ongoing clinical trials.[11]

Lymphangioleiomyomatosis

In May 2015, the FDA approved sirolimus to treat lymphangioleiomyomatosis (LAM), a rare, progressive lung disease that primarily affects women of childbearing age. This made sirolimus the first drug approved to treat this disease.[21] LAM involves lung tissue infiltration with smooth muscle-like cells with mutations of the tuberous sclerosis complex gene (TSC2). Loss of TSC2 gene function activates the mTOR signaling pathway, resulting in the release of lymphangiogenic growth factors. Sirolimus blocks this pathway.[1]

The safety and efficacy of sirolimus treatment of LAM were investigated in clinical trials that compared sirolimus treatment with a placebo group in 89 patients for 12 months. The patients were observed for 12 months after the treatment had ended. The most commonly reported side effects of sirolimus treatment of LAM were mouth and lip ulcers, diarrhea, abdominal pain, nausea, sore throat, acne, chest pain, leg swelling, upper respiratory tract infection, headache, dizziness, muscle pain and elevated cholesterol. Serious side effects including hypersensitivity and swelling (edema) have been observed in renal transplant patients.[21]

While sirolimus was considered for treatment of LAM, it received orphan drug designation status because LAM is a rare condition.[21]

The safety of LAM treatment by sirolimus in people younger than 18 years old has not been tested.[1]

Coronary stent coating

Further information: Medicine:Drug-eluting stent

The antiproliferative effect of sirolimus has also been used in conjunction with coronary stents to prevent restenosis in coronary arteries following balloon angioplasty. The sirolimus is formulated in a polymer coating that affords controlled release through the healing period following coronary intervention. Several large clinical studies have demonstrated lower restenosis rates in patients treated with sirolimus-eluting stents when compared to bare-metal stents, resulting in fewer repeat procedures. A sirolimus-eluting coronary stent was marketed by Cordis, a division of Johnson & Johnson, under the tradename Cypher.[10] However, this kind of stent may also increase the risk of vascular thrombosis.[22]

Vascular malformations

Sirolimus is used to treat vascular malformations. Treatment with sirolimus can decrease pain and the fullness of vascular malformations, improve coagulation levels, and slow the growth of abnormal lymphatic vessels.[23] Sirolimus is a relatively new medical therapy for the treatment of vascular malformations[24] in recent years, sirolimus has emerged as a new medical treatment option for both vascular tumors and vascular malformations, as a mammalian target of rapamycin (mTOR), capable of integrating signals from the PI3K/AKT pathway to coordinate proper cell growth and proliferation. Hence, sirolimus is ideal for "proliferative" vascular tumors through the control of tissue overgrowth disorders caused by inappropriate activation of the PI3K/AKT/mTOR pathway as an antiproliferative agent.[25][26]

Angiofibromas

Sirolimus has been used as a topical treatment of angiofibromas with tuberous sclerosis complex (TSC). Facial angiofibromas occur in 80% of patients with TSC, and the condition is very disfiguring. A retrospective review of English-language medical publications reporting on topical sirolimus treatment of facial angiofibromas found sixteen separate studies with positive patient outcomes after using the drug. The reports involved a total of 84 patients, and improvement was observed in 94% of subjects, especially if treatment began during the early stages of the disease. Sirolimus treatment was applied in several different formulations (ointment, gel, solution, and cream), ranging from 0.003 to 1% concentrations. Reported adverse effects included one case of perioral dermatitis, one case of cephalea, and four cases of irritation.[27]

In April 2022, sirolimus was approved by the FDA for treating angiofibromas.[28]

Adverse effects

The most common adverse reactions (≥30% occurrence, leading to a 5% treatment discontinuation rate) observed with sirolimus in clinical studies of organ rejection prophylaxis in individuals with kidney transplants include: peripheral edema, hypercholesterolemia, abdominal pain, headache, nausea, diarrhea, pain, constipation, hypertriglyceridemia, hypertension, increased creatinine, fever, urinary tract infection, anemia, arthralgia, and thrombocytopenia.[1]

The most common adverse reactions (≥20% occurrence, leading to an 11% treatment discontinuation rate) observed with sirolimus in clinical studies for the treatment of lymphangioleiomyomatosis are: peripheral edema, hypercholesterolemia, abdominal pain, headache, nausea, diarrhea, chest pain, stomatitis, nasopharyngitis, acne, upper respiratory tract infection, dizziness, and myalgia.[1]

The following adverse effects occurred in 3–20% of individuals taking sirolimus for organ rejection prophylaxis following a kidney transplant:[1]

System Adverse effects
Body as a whole Sepsis, lymphocele, herpes zoster infection, herpes simplex infection
Cardiovascular Venous thromboembolism (pulmonary embolism and deep venous thrombosis), rapid heart rate
Digestive Stomatitis
Hematologic/lymphatic Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS), leukopenia
Metabolic Abnormal healing, increased lactic dehydrogenase (LDH), hypokalemia, diabetes
Musculoskeletal Bone necrosis
Respiratory Pneumonia, epistaxis
Skin Melanoma, squamous cell carcinoma, basal cell carcinoma
Urogenital Pyelonephritis, ovarian cysts, menstrual disorders (amenorrhea and menorrhagia)

Diabetes-like symptoms

While sirolimus inhibition of mTORC1 appears to mediate the drug's benefits, it also inhibits mTORC2, which results in diabetes-like symptoms.[29] This includes decreased glucose tolerance and insensitivity to insulin.[29] Sirolimus treatment may additionally increase the risk of type 2 diabetes.[30] In mouse studies, these symptoms can be avoided through the use of alternate dosing regimens or analogs such as everolimus or temsirolimus.[31]

Lung toxicity

Lung toxicity is a serious complication associated with sirolimus therapy,[32][33][34][35][36][37][38][excessive citations] especially in the case of lung transplants.[39] The mechanism of the interstitial pneumonitis caused by sirolimus and other macrolide MTOR inhibitors is unclear, and may have nothing to do with the mTOR pathway.[40][41][42] The interstitial pneumonitis is not dose-dependent, but is more common in patients with underlying lung disease.[32][43]

Lowered effectiveness of immune system

There have been warnings about the use of sirolimus in transplants, where it may increase mortality due to an increased risk of infections.[1]

Cancer risk

Sirolimus may increase an individual's risk for contracting skin cancers from exposure to sunlight or UV radiation, and risk of developing lymphoma.[1] In studies, the skin cancer risk under sirolimus was lower than under other immunosuppressants such as azathioprine and calcineurin inhibitors, and lower than under placebo.[1][44]

Impaired wound healing

Individuals taking sirolimus are at increased risk of experiencing impaired or delayed wound healing, particularly if they have a body mass index in excess of 30 kg/m2 (classified as obese).[1]

Interactions

Sirolimus is metabolized by the CYP3A4 enzyme and is a substrate of the P-glycoprotein (P-gp) efflux pump; hence, inhibitors of either protein may increase sirolimus concentrations in blood plasma, whereas inducers of CYP3A4 and P-gp may decrease sirolimus concentrations in blood plasma.[1]

Pharmacology

Pharmacodynamics

Unlike the similarly named tacrolimus, sirolimus is not a calcineurin inhibitor, but it has a similar suppressive effect on the immune system. Sirolimus inhibits IL-2 and other cytokine receptor-dependent signal transduction mechanisms, via action on mTOR, and thereby blocks activation of T and B cells. Ciclosporin and tacrolimus inhibit the secretion of IL-2, by inhibiting calcineurin.[11]

The mode of action of sirolimus is to bind the cytosolic protein FK-binding protein 12 (FKBP12) in a manner similar to tacrolimus. Unlike the tacrolimus-FKBP12 complex, which inhibits calcineurin (PP2B), the sirolimus-FKBP12 complex inhibits the mTOR (mammalian Target Of Rapamycin, rapamycin being another name for sirolimus) pathway by directly binding to mTOR Complex 1 (mTORC1).[11]

mTOR has also been called FRAP (FKBP-rapamycin-associated protein), RAFT (rapamycin and FKBP target), RAPT1, or SEP. The earlier names FRAP and RAFT were coined to reflect the fact that sirolimus must bind FKBP12 first, and only the FKBP12-sirolimus complex can bind mTOR. However, mTOR is now the widely accepted name, since Tor was first discovered via genetic and molecular studies of sirolimus-resistant mutants of Saccharomyces cerevisiae that identified FKBP12, Tor1, and Tor2 as the targets of sirolimus and provided robust support that the FKBP12-sirolimus complex binds to and inhibits Tor1 and Tor2.[45][11]

Pharmacokinetics

Sirolimus is metabolized by the CYP3A4 enzyme and is a substrate of the P-glycoprotein (P-gp) efflux pump.[1] It has an elimination half-life of 57–63 hours.[7]

The absorption of sirolimus into the blood stream from the intestine varies widely between patients, with some patients having up to eight times more exposure than others for the same dose. Drug levels are, therefore, taken to make sure patients get the right dose for their condition.[11] This is determined by taking a blood sample before the next dose, which gives the trough level. However, good correlation is noted between trough concentration levels and drug exposure, known as area under the concentration-time curve, for both sirolimus (SRL) and tacrolimus (TAC) (SRL: r2 = 0.83; TAC: r2 = 0.82), so only one level need be taken to know its pharmacokinetic (PK) profile. PK profiles of SRL and of TAC are unaltered by simultaneous administration. Dose-corrected drug exposure of TAC correlates with SRL (r2 = 0.8), so patients have similar bioavailability of both.[46][non-primary source needed]

Chemistry

Sirolimus is a natural product and macrocyclic lactone.[7]

Biosynthesis

The biosynthesis of the rapamycin core is accomplished by a type I polyketide synthase (PKS) in conjunction with a nonribosomal peptide synthetase (NRPS). The domains responsible for the biosynthesis of the linear polyketide of rapamycin are organized into three multienzymes, RapA, RapB, and RapC, which contain a total of 14 modules (figure 1). The three multienzymes are organized such that the first four modules of polyketide chain elongation are in RapA, the following six modules for continued elongation are in RapB, and the final four modules to complete the biosynthesis of the linear polyketide are in RapC.[47] Then, the linear polyketide is modified by the NRPS, RapP, which attaches L-pipecolate to the terminal end of the polyketide, and then cyclizes the molecule, yielding the unbound product, prerapamycin.[48]

Figure 1: Domain organization of PKS of rapamycin and biosynthetic intermediates
Figure 2: Prerapamycin, unbound product of PKS and NRPS
Figure 3: Sequence of "tailoring" steps, which convert unbound prerapamycin into rapamycin
Figure 4: Proposed mechanism of lysine cyclodeaminase conversion of L-lysine to L-pipecolic acid

The core macrocycle, prerapamycin (figure 2), is then modified (figure 3) by an additional five enzymes, which lead to the final product, rapamycin. First, the core macrocycle is modified by RapI, SAM-dependent O-methyltransferase (MTase), which O-methylates at C39. Next, a carbonyl is installed at C9 by RapJ, a cytochrome P-450 monooxygenases (P-450). Then, RapM, another MTase, O-methylates at C16. Finally, RapN, another P-450, installs a hydroxyl at C27 immediately followed by O-methylation by Rap Q, a distinct MTase, at C27 to yield rapamycin.[49]

The biosynthetic genes responsible for rapamycin synthesis have been identified. As expected, three extremely large open reading frames (ORF's) designated as rapA, rapB, and rapC encode for three extremely large and complex multienzymes, RapA, RapB, and RapC, respectively.[47] The gene rapL has been established to code for a NAD+-dependent lysine cycloamidase, which converts L-lysine to L-pipecolic acid (figure 4) for incorporation at the end of the polyketide.[50][51] The gene rapP, which is embedded between the PKS genes and translationally coupled to rapC, encodes for an additional enzyme, an NPRS responsible for incorporating L-pipecolic acid, chain termination and cyclization of prerapamycin. In addition, genes rapI, rapJ, rapM, rapN, rapO, and rapQ have been identified as coding for tailoring enzymes that modify the macrocyclic core to give rapamycin (figure 3). Finally, rapG and rapH have been identified to code for enzymes that have a positive regulatory role in the preparation of rapamycin through the control of rapamycin PKS gene expression.[52] Biosynthesis of this 31-membered macrocycle begins as the loading domain is primed with the starter unit, 4,5-dihydroxocyclohex-1-ene-carboxylic acid, which is derived from the shikimate pathway.[47] Note that the cyclohexane ring of the starting unit is reduced during the transfer to module 1. The starting unit is then modified by a series of Claisen condensations with malonyl or methylmalonyl substrates, which are attached to an acyl carrier protein (ACP) and extend the polyketide by two carbons each. After each successive condensation, the growing polyketide is further modified according to enzymatic domains that are present to reduce and dehydrate it, thereby introducing the diversity of functionalities observed in rapamycin (figure 1). Once the linear polyketide is complete, L-pipecolic acid, which is synthesized by a lysine cycloamidase from an L-lysine, is added to the terminal end of the polyketide by an NRPS. Then, the NSPS cyclizes the polyketide, giving prerapamycin, the first enzyme-free product. The macrocyclic core is then customized by a series of post-PKS enzymes through methylations by MTases and oxidations by P-450s to yield rapamycin.

Research

A plaque, written in Portuguese, commemorating the discovery of sirolimus on Easter Island, near Rano Kau

Cancer

The antiproliferative effects of sirolimus may have a role in treating cancer. When dosed appropriately, sirolimus can enhance the immune response to tumor targeting[53] or otherwise promote tumor regression in clinical trials.[54] Sirolimus seems to lower the cancer risk in some transplant patients.[55]

Sirolimus was shown to inhibit the progression of dermal Kaposi's sarcoma in patients with renal transplants.[56] Other mTOR inhibitors, such as temsirolimus (CCI-779) or everolimus (RAD001), are being tested for use in cancers such as glioblastoma multiforme and mantle cell lymphoma. However, these drugs have a higher rate of fatal adverse events in cancer patients than control drugs.[57]

A combination therapy of doxorubicin and sirolimus has been shown to drive Akt-positive lymphomas into remission in mice. Akt signalling promotes cell survival in Akt-positive lymphomas and acts to prevent the cytotoxic effects of chemotherapy drugs, such as doxorubicin or cyclophosphamide. Sirolimus blocks Akt signalling and the cells lose their resistance to the chemotherapy. Bcl-2-positive lymphomas were completely resistant to the therapy; eIF4E-expressing lymphomas are not sensitive to sirolimus.[58][59][60][61][62]

Tuberous sclerosis complex

Sirolimus also shows promise in treating tuberous sclerosis complex (TSC), a congenital disorder that predisposes those afflicted to benign tumor growth in the brain, heart, kidneys, skin, and other organs. After several studies conclusively linked mTOR inhibitors to remission in TSC tumors, specifically subependymal giant-cell astrocytomas in children and angiomyolipomas in adults, many US doctors began prescribing sirolimus (Wyeth's Rapamune) and everolimus (Novartis's RAD001) to TSC patients off-label. Numerous clinical trials using both rapamycin analogs, involving both children and adults with TSC, are underway in the United States.[63]

Effects on longevity

mTOR, specifically mTORC1, was first shown to be important in aging in 2003, in a study on worms; sirolimus was shown to inhibit and slow aging in worms, yeast, and flies, and then to improve the condition of mouse models of various diseases of aging.[64][65] Sirolimus was first shown to extend lifespan in wild-type mice in a study published by NIH investigators in 2009; the studies have been replicated in mice of many different genetic backgrounds.[65] A study published in 2020 found late-life sirolimus dosing schedules enhanced mouse lifespan in a sex-specific manner where limited rapamycin exposure enhanced male lifespan but not female, providing evidence for sex differences in sirolimus response.[66][67] The results are further supported by the finding that genetically modified mice with impaired mTORC1 signalling live longer.[65]

Sirolimus has potential for widespread use as a longevity-promoting drug, with evidence pointing to its ability to prevent age-associated decline of cognitive and physical health. In 2014, researchers at Novartis showed a related compound, everolimus, increased elderly patients' immune response on an intermittent dose.[68] This led to many in the anti-aging community self-experimenting with the compound.[69] However, because of the different biochemical properties of Sirolimus the dosing is potentially very different than everolimus. Ultimately, due to known side effects of sirolimus, as well as inadequate evidence for optimal dosing, more research is required before sirolimus could be widely prescribed for this purpose.[65][70]

Sirolimus has complex effects on the immune system—while IL-12 goes up and IL-10 decreases, which suggests an immunostimulatory response, TNF and IL-6 are decreased, which suggests an immunosuppressive response. The duration of the inhibition and the exact extent to which mTORC1 and mTORC2 are inhibited play a role, but are not yet well understood.[71]

Topical administration

When applied as a topical preparation, researchers showed that rapamycin can regenerate collagen and reverse clinical signs of aging in elderly patients.[72] The concentrations are far lower than those used to treat angiofibromas.

SARS-CoV-2

Rapamycin has been proposed as a treatment for severe acute respiratory syndrome coronavirus 2 insofar as its immunosuppressive effects could prevent or reduce the cytokine storm seen in very serious cases of COVID-19.[73] Moreover, inhibition of cell proliferation by rapamycin could reduce viral replication.[73]

Atherosclerosis

Rapamycin can accelerate degradation of oxidized LDL cholesterol in endothelial cells, thereby lowering the risk of atherosclerosis.[74] Oxidized LDL cholesterol is a major contributor to atherosclerosis.[75]

Lupus

As of 2016, studies in cells, animals, and humans have suggested that mTOR activation as process underlying systemic lupus erythematosus and that inhibiting mTOR with rapamycin may be a disease-modifying treatment.[76] As of 2016 rapamycin had been tested in small clinical trials in people with lupus.[76]

Lymphatic malformation

Lymphatic malformation, or cystic hygroma, is an abnormal growth of lymphatic vessels that usually affects children around the head and neck. Treatment often consists of to removal of the tissue, but the rate of recurrence is high. Sirolimus has shown evidence of being helpful in alleviating symptoms and reducing the size of the malformation.[77]

Graft-versus-host disease

Due to its immunosuppressant activity, Rapamycin has been assessed as prophylaxis or treatment agent of Graft-versus-host disease (GVHD), a complication of hematopoietic stem cell transplantation. While contrasted results were obtained in clinical trials,[78] pre-clinical studies have shown that Rapamycin can mitigate GVHD by increasing the proliferation of regulatory T cells, inhibiting cytotoxic T cells and lowering the differentiation of effector T cells.[79][80]

Applications in biology research

Rapamycin is used in biology research as an agent for chemically induced dimerization.[81] In this application, rapamycin is added to cells expressing two fusion constructs, one of which contains the rapamycin-binding FRB domain from mTOR and the other of which contains an FKBP domain. Each fusion protein also contains additional domains that are brought into proximity when rapamycin induces binding of FRB and FKBP. In this way, rapamycin can be used to control and study protein localization and interactions.

Veterinary uses

A number of veterinary medicine teaching hospitals are participating in a long-term clinical study examining the effect of rapamycin on the longevity of dogs.[82]

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 "Rapamune- sirolimus solution Rapamune- sirolimus tablet, sugar coated". https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=3275b824-3f82-4151-2ab2-0036a9ba0acc. 
  2. ↑ 2.0 2.1 2.2 2.3 "Fyarro- sirolimus injection, powder, lyophilized, for suspension". https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0f9bb784-53e2-46f9-a65d-1c6c2a230eaf. 
  3. ↑ "Hyftor- sirolimus gel". 28 January 2021. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=edb3ea90-5adc-48ec-99f5-ab963e302f18. 
  4. ↑ 4.0 4.1 "Rapamune EPAR". 17 September 2018. https://www.ema.europa.eu/en/medicines/human/EPAR/rapamune. 
  5. ↑ 5.0 5.1 5.2 "Hyftor EPAR". 9 June 2023. https://www.ema.europa.eu/en/medicines/human/EPAR/hyftor.  Text was copied from this source which is copyright European Medicines Agency. Reproduction is authorized provided the source is acknowledged.
  6. ↑ "Immunosuppression With Sirolimus After Solid Organ Transplantation in Children". Pediatric Pharmacotherapy 12 (2). 2006. https://www.medscape.com/viewarticle/524753_4. Retrieved 4 April 2022. 
  7. ↑ 7.0 7.1 7.2 "Rapamycin". National Center for Biotechnology Information. https://pubchem.ncbi.nlm.nih.gov/compound/5284616. 
  8. ↑ "Solubilization of rapamycin". International Journal of Pharmaceutics 213 (1–2): 25–29. February 2001. doi:10.1016/s0378-5173(00)00617-7. PMID 11165091. 
  9. ↑ 9.0 9.1 "Rapamycin (AY-22,989), a new antifungal antibiotic. I. Taxonomy of the producing streptomycete and isolation of the active principle". The Journal of Antibiotics 28 (10): 721–726. October 1975. doi:10.7164/antibiotics.28.721. PMID 1102508. 
  10. ↑ 10.0 10.1 "Cypher Sirolimus-eluting Coronary Stent". Cypher Stent. http://www.cypherusa.com/. 
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 "A comprehensive review of immunosuppression used for liver transplantation". Journal of Transplantation 2009: 701464. 1 January 2009. doi:10.1155/2009/701464. PMID 20130772. 
  12. ↑ "The Dirty Drug and the Ice Cream Tub". 21 May 2021. https://www.wnycstudios.org/podcasts/radiolab/articles/dirty-drug-and-ice-cream-tub. 
  13. ↑ "Rapamycin and mTOR: a serendipitous discovery and implications for breast cancer". Clinical and Translational Medicine 1 (1): 29. November 2012. doi:10.1186/2001-1326-1-29. PMID 23369283. 
  14. ↑ "Sourcing a chemical succession for cyclosporin from parasites and human pathogens". Drug Discovery Today 10 (10): 688–691. May 2005. doi:10.1016/S1359-6446(05)03395-7. PMID 15896681. 
  15. ↑ "Drug Approval Package: Rapamune (Sirolimus) NDA# 021083". https://www.accessdata.fda.gov/drugsatfda_docs/nda/99/21083A.cfm. 
  16. ↑ "Aadi Bioscience Announces FDA Approval of its First Product Fyarro for Patients with Locally Advanced Unresectable or Metastatic Malignant Perivascular Epithelioid Cell Tumor (PEComa)". Aadi Bioscience, Inc. (Press release). 23 November 2021. Archived from the original on 27 November 2021. Retrieved 26 November 2021.
  17. ↑ Drug Discovery: Practices, Processes, and Perspectives. John Wiley & Sons. 3 April 2013. ISBN 978-1-118-35446-9. https://books.google.com/books?id=mIyxO5cLEAcC. Retrieved 1 August 2016. 
  18. ↑ Nanotechnology in Medicine: Emerging Applications. Momentum Press. 7 February 2012. ISBN 978-1-60650-250-1. https://books.google.com/books?id=CVloCgAAQBAJ. Retrieved 1 August 2016. 
  19. ↑ "Sirolimus (marketed as Rapamune) Safety". U.S. Food and Drug Administration (FDA). 11 June 2009. https://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm165731.htm. 
  20. ↑ "Survival Associated With Sirolimus Plus Tacrolimus Maintenance Without Induction Therapy Compared With Standard Immunosuppression After Lung Transplant". JAMA Network Open 2 (8): e1910297. August 2019. doi:10.1001/jamanetworkopen.2019.10297. PMID 31461151. 
  21. ↑ 21.0 21.1 21.2 "FDA approves Rapamune to treat LAM, a very rare lung disease". U.S. Food and Drug Administration (FDA). 28 May 2015. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm448523.htm. 
  22. ↑ "Trading restenosis for thrombosis? New questions about drug-eluting stents". The New England Journal of Medicine 355 (19): 1949–1952. November 2006. doi:10.1056/NEJMp068234. PMID 17093244. 
  23. ↑ "Venous Malformation: Treatments". Boston Children's Hospital. http://www.childrenshospital.org/conditions-and-treatments/conditions/v/venous-malformation/treatments. 
  24. ↑ "Theranostic Advances in Vascular Malformations". The Journal of Investigative Dermatology 140 (4): 756–763. April 2020. doi:10.1016/j.jid.2019.10.001. PMID 32200879. 
  25. ↑ "Sirolimus in the treatment of vascular anomalies". Journal of Vascular Surgery 71 (1): 328. January 2020. doi:10.1016/j.jvs.2019.08.246. PMID 31864650. 
  26. ↑ "Sirolimus in the Treatment of Vascular Anomalies". European Journal of Pediatric Surgery 27 (1): 86–90. February 2017. doi:10.1055/s-0036-1593383. PMID 27723921. 
  27. ↑ "Analysis of current data on the use of topical rapamycin in the treatment of facial angiofibromas in tuberous sclerosis complex". Journal of the European Academy of Dermatology and Venereology 29 (1): 14–20. January 2015. doi:10.1111/jdv.12665. PMID 25174683. 
  28. ↑ "FDA Approves Nobelpharma's Topical Treatment for Facial Angiofibroma". 7 April 2022. https://www.fdanews.com/articles/207319-fda-approves-nobelpharmas-topical-treatment-for-facial-angiofibroma. 
  29. ↑ 29.0 29.1 "Rapamycin-induced insulin resistance is mediated by mTORC2 loss and uncoupled from longevity". Science 335 (6076): 1638–1643. March 2012. doi:10.1126/science.1215135. PMID 22461615. Bibcode: 2012Sci...335.1638L. 
  30. ↑ "Sirolimus is associated with new-onset diabetes in kidney transplant recipients". Journal of the American Society of Nephrology 19 (7): 1411–1418. July 2008. doi:10.1681/ASN.2007111202. PMID 18385422. 
  31. ↑ "Alternative rapamycin treatment regimens mitigate the impact of rapamycin on glucose homeostasis and the immune system". Aging Cell 15 (1): 28–38. February 2016. doi:10.1111/acel.12405. PMID 26463117. 
  32. ↑ 32.0 32.1 "Patterns of pulmonary complications associated with sirolimus". Respiration; International Review of Thoracic Diseases 73 (3): 367–374. 2006. doi:10.1159/000087945. PMID 16127266. 
  33. ↑ "Characteristics of sirolimus-associated interstitial pneumonitis in renal transplant patients". Transplantation 72 (5): 787–790. September 2001. doi:10.1097/00007890-200109150-00008. PMID 11571438. 
  34. ↑ "Sirolimus-induced pneumonitis complicated by pentamidine-induced phospholipidosis in a renal transplant recipient: a case report". Transplantation Proceedings 43 (7): 2792–2797. September 2011. doi:10.1016/j.transproceed.2011.06.060. PMID 21911165. https://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1087&context=medfp. Retrieved 24 September 2019. 
  35. ↑ "Sirolimus-associated pulmonary toxicity". Transplantation 77 (8): 1215–1220. April 2004. doi:10.1097/01.TP.0000118413.92211.B6. PMID 15114088. 
  36. ↑ "Sirolimus-induced interstitial pneumonitis in a renal transplant patient". Respiratory Care 50 (12): 1659–1661. December 2005. PMID 16318648. http://rc.rcjournal.com/content/respcare/50/12/1659.full.pdf. Retrieved 4 April 2022. 
  37. ↑ "Acute sirolimus pulmonary toxicity in an infant heart transplant recipient: case report and literature review". The Journal of Heart and Lung Transplantation 26 (3): 296–298. March 2007. doi:10.1016/j.healun.2006.12.004. PMID 17346635. 
  38. ↑ "Sirolimus-associated interstitial pneumonitis in 3 heart transplant recipients". The Journal of Heart and Lung Transplantation 25 (9): 1171–1174. September 2006. doi:10.1016/j.healun.2006.05.013. PMID 16962483. 
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  42. ↑ "Drug-related pneumonitis in patients with advanced renal cell carcinoma treated with temsirolimus". Journal of Clinical Oncology 29 (13): 1750–1756. May 2011. doi:10.1200/JCO.2010.29.2235. PMID 21444868. 
  43. ↑ "Pneumonitis associated with mammalian target of rapamycin inhibitors in renal transplant recipients: a single-center experience". Transplantation Proceedings 42 (8): 3053–3054. October 2010. doi:10.1016/j.transproceed.2010.07.066. PMID 20970608. 
  44. ↑ "Sirolimus and secondary skin-cancer prevention in kidney transplantation". The New England Journal of Medicine 367 (4): 329–339. July 2012. doi:10.1056/NEJMoa1204166. PMID 22830463. 
  45. ↑ "Targets for cell cycle arrest by the immunosuppressant rapamycin in yeast". Science 253 (5022): 905–909. August 1991. doi:10.1126/science.1715094. PMID 1715094. Bibcode: 1991Sci...253..905H. 
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  47. ↑ 47.0 47.1 47.2 "The biosynthetic gene cluster for the polyketide immunosuppressant rapamycin". Proceedings of the National Academy of Sciences of the United States of America 92 (17): 7839–7843. August 1995. doi:10.1073/pnas.92.17.7839. PMID 7644502. Bibcode: 1995PNAS...92.7839S. 
  48. ↑ "Isolation and characterization of pre-rapamycin, the first macrocyclic intermediate in the biosynthesis of the immunosuppressant rapamycin by S. hygroscopicus". Angewandte Chemie 43 (19): 2551–2553. May 2004. doi:10.1002/anie.200453764. PMID 15127450. 
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  50. ↑ "Recent advances in the chemistry, biosynthesis and pharmacology of rapamycin analogs". Natural Product Reports 26 (5): 602–609. May 2009. doi:10.1039/b804602f. PMID 19387497. 
  51. ↑ "Biosynthesis of pipecolic acid by RapL, a lysine cyclodeaminase encoded in the rapamycin gene cluster". Journal of the American Chemical Society 128 (11): 3838–3847. March 2006. doi:10.1021/ja0587603. PMID 16536560. 
  52. ↑ "Organization of the biosynthetic gene cluster for rapamycin in Streptomyces hygroscopicus: analysis of the enzymatic domains in the modular polyketide synthase". Gene 169 (1): 9–16. February 1996. doi:10.1016/0378-1119(95)00800-4. PMID 8635756. 
  53. ↑ "Regulating mammalian target of rapamycin to tune vaccination-induced CD8(+) T cell responses for tumor immunity". Journal of Immunology 188 (7): 3080–3087. April 2012. doi:10.4049/jimmunol.1103365. PMID 22379028. 
  54. ↑ "mTOR and cancer therapy". Oncogene 25 (48): 6436–6446. October 2006. doi:10.1038/sj.onc.1209886. PMID 17041628. 
  55. ↑ "Rapamycin: an anti-cancer immunosuppressant?". Critical Reviews in Oncology/Hematology 56 (1): 47–60. October 2005. doi:10.1016/j.critrevonc.2004.09.009. PMID 16039868. 
  56. ↑ "A new role for sirolimus: regression of Kaposi's sarcoma in kidney-transplant recipients" (in en). Nature Clinical Practice Urology 2 (5): 211. May 2005. doi:10.1038/ncponc0156x. ISSN 1743-4289. 
  57. ↑ "Fatal AEs Higher with mTOR Drugs in Cancer". Med Page Today. 17 February 2013. http://www.medpagetoday.com/MeetingCoverage/MGUCS/37404. 
  58. ↑ "Activation of Akt and eIF4E survival pathways by rapamycin-mediated mammalian target of rapamycin inhibition". Cancer Research 65 (16): 7052–7058. August 2005. doi:10.1158/0008-5472.CAN-05-0917. PMID 16103051. 
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  63. ↑ "Efficacy and safety of mTOR inhibitors (rapamycin and its analogues) for tuberous sclerosis complex: a meta-analysis". Orphanet Journal of Rare Diseases 14 (1): 39. February 2019. doi:10.1186/s13023-019-1012-x. PMID 30760308. 
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  66. ↑ "Rapamycin-mediated mouse lifespan extension: Late-life dosage regimes with sex-specific effects". Aging Cell 19 (11): e13269. November 2020. doi:10.1111/acel.13269. PMID 33145977. 
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  72. ↑ "Topical rapamycin reduces markers of senescence and aging in human skin: an exploratory, prospective, randomized trial". GeroScience 41 (6): 861–869. December 2019. doi:10.1007/s11357-019-00113-y. PMID 31761958. 
  73. ↑ 73.0 73.1 "Rapamycin as a potential repurpose drug candidate for the treatment of COVID-19". Chemico-Biological Interactions 331: 109282. November 2020. doi:10.1016/j.cbi.2020.109282. PMID 33031791. 
  74. ↑ "Rapamycin: A Bacteria-Derived Immunosuppressant That Has Anti-atherosclerotic Effects and Its Clinical Application". Frontiers in Pharmacology 9: 1520. 2019. doi:10.3389/fphar.2018.01520. PMID 30666207. 
  75. ↑ "Role of oxidative modifications in atherosclerosis". Physiological Reviews 84 (4): 1381–1478. October 2004. doi:10.1152/physrev.00047.2003. PMID 15383655. 
  76. ↑ 76.0 76.1 "Activation of the Mechanistic Target of Rapamycin in SLE: Explosion of Evidence in the Last Five Years". Current Rheumatology Reports 18 (12): 73. December 2016. doi:10.1007/s11926-016-0622-8. PMID 27812954. 
  77. ↑ "Efficacy of sirolimus in children with lymphatic malformations of the head and neck". European Archives of Oto-Rhino-Laryngology 279 (8): 3801–3810. August 2022. doi:10.1007/s00405-022-07378-8. PMID 35526176. 
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  79. ↑ "Rapamycin inhibits the generation of graft-versus-host disease- and graft-versus-leukemia-causing T cells by interfering with the production of Th1 or Th1 cytotoxic cytokines". Journal of Immunology 160 (11): 5355–5365. June 1998. doi:10.4049/jimmunol.160.11.5355. PMID 9605135. 
  80. ↑ "Comprehensive analysis of the immunomodulatory effects of rapamycin on human T cells in graft-versus-host disease prophylaxis". American Journal of Transplantation 21 (8): 2662–2674. August 2021. doi:10.1111/ajt.16505. PMID 33512760. 
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  82. ↑

Further reading

  • "Rapamycin passes the torch: a new generation of mTOR inhibitors". Nature Reviews. Drug Discovery 10 (11): 868–880. October 2011. doi:10.1038/nrd3531. PMID 22037041. 
  • "Efficacy and safety of sirolimus in the treatment of vascular anomalies: A systematic review". Journal of Vascular Surgery 71 (1): 318–327. January 2020. doi:10.1016/j.jvs.2019.06.217. PMID 31676179. 
  • "A narrative review of the role of sirolimus in the treatment of congenital vascular malformations". Journal of Vascular Surgery. Venous and Lymphatic Disorders 9 (5): 1321–1333. September 2021. doi:10.1016/j.jvsv.2021.03.001. PMID 33737259. 

External links



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