VEGFR-2 inhibitor, also known as kinase insert domain receptor(KDR) inhibitor, are tyrosine kinase receptor inhibitors that reduce angiogenesis or lymphangiogenesis, leading to anticancer activity. Generally they are small, synthesised molecules that bind competitively to the ATP-site of the tyrosine kinase domain. VEGFR-2 selective inhibitor can interrupt multiple signaling pathways involved in tumor, including proliferation, metastasis and angiogenesis.
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VEGFR The VEGF receptor family contains three members, which are all receptor tyrosine kinases (VEGFR-1, VEGFR-2 and VEGFR-3). VEGFR-1, or FLT-1 (fms-like tyrosine kinase), are important for hematopoietic stem cell development, VEGFR-2 (KDRor FLK-1 (fetal liver kinase)) are vital to vascular endothelial cell development and VEGFR-3 (FLT-4) for lymphatic endothelial cell development. Binding of VEGF to the VEGFR induces a conformational change in the receptor producing a signaling pathway.
VEGFR-2
VEGFR-2 is a 210-230 kDa glycoprotein expressed in vascular endothelial cells and in hematopoietic stem cells and binds VEGF-A. VEGFR-2 is closely related to VEGFR-1 for they have common and specific ligands but VEGFR-2 is a highly active kinase while VEGFR1 is an impaired receptor tyrosine kinase. This receptor is a regulator in responses in the endothelial cells of VEGF. These regulations include permeability, proliferation, invasion and migration. The signaling pathways, Y1175 and Y1214, are the main autophosphorylation sites of the human VEGFR-2 followed by VEGF binding. Autophosphorylated VEGFR-2 is required for activation of several downstream pathways, which are hyperactivated in some tumors. These signaling pathways are important in tumor angiogenesis, which stimulates tumor growth by supplying the tumor with oxygen and nutrients. VEGFR-2 is overexpressed in several cancers, for example ovarian, thyroid, melanoma and medulloblastoma.
Structure VEGFR-2 are a part of the VEGF family. The other receptors in the family are VEGFR-1 and VEGFR-3. These receptors are a type of transmembrane kinase receptors and have similar structure. They have an extracellular part that is made up of an N-terminus signal and a 7 immunoglobulin-like domain. The intracellular part of the receptor consists of a juxtamembrane (the tyrosine kinase domain), which is divided to proximal and distal kinase domains and a C-terminus tail.
Medical Uses
Sorafenib is used as an oral drug which inhibits angiogenesis and tumor cell growth in VEGFR-2 and VEGFR-3 (inhibits the phosphorylation), PDGFRβ (platelet-derived growth factor receptor), RAF kinase, FLT3 (Fms-like tyrosine kinase-3) and KIT (stem cell factor receptor). Sorafenib is used in the treatment of advanced renal cell carcinoma. As of October 2018, it is in phase III of clinical trials for hepatocellular carcinoma, metastatic melanoma and non-small cell lung cancer (NSCLC). Sunitinib is an oral drug that inhibits the phosphorylation of all the VEGF receptors, PDGFR-ß, KIT FLT3, CSF1R and GDNF. Sunitinib is used in the treatment of advanced renal cell carcinoma and gastrointestinal stromal tumors. Bevacizumab is a humanized monoclonal antibody, which binds selectively to VEGF. It is used as an injection therapy, often in combination with other drugs. It is used in combination with 5-fluorouracil as a first-line treatment of metastatic carcinoma in the colon or rectum. In advanced non-small cell lung cancer bevacizumab (Avastin) is used as a first-line treatment in combination with paclitaxel and carboplatin. It can also be used in the treatment for breast cancer and kidney cancer.
Lenvatinib and vandetanib are used for the treatment of progressive and locally advanced differentiated thyroid cancer (DTC). Pazopanib and axitinib are used orally for the treatment of advanced renal cell carcinoma. Cabozantinib has the same indication but it is only used on patients who have already received an anti-angiogenic therapy. Regorafenib is administered orally for the treatment of colorectal cancer, gastrointestinal stromal cancer and hepatocellular carcinoma. Nintedanib is used for the treatment of idiopathic pulmonary fibrosis. Tests for liver function have to be made to modify doses before the therapy can start. Apatinib is used for the treatment of advanced gastric cancer. It is often diagnosed in late stages because there are no early signs or symptoms.
Mechanism of action Binding to VEGF receptor induces dimerization, which modifies the conformation in the intracellular domain. This modification leads to the exposure of the ATP-binding site, which causes ATP binding on the receptor and also transphosphorylation on specific tyrosine residues. Tyrosine phosphorylation on the receptor is regulated by internalization, degradation and by dephosphorylation through different protein tyrosine phosphatases. This can then lead to the initial receptor signal transduction cascade, which activates several downstream enzymatic pathways. The signaling inhibition of VEGFR is through tumor vessels and not the tumor cells. Reduction of VEGF expression reduces blood flow to tumor and stops tumor angiogenesis.
Adverse Effects VEGF inhibitors in the treatment of cancer often cause adverse effects. Treatment with VEGF inhibitors suppresses cellular signalling pathways that are important in microvasculature regulation and maintenance. The effects on normal organs can then lead to vascular disturbances and regression of blood vessels.
FDA has approved three drugs, bevacizumab, sunitinib and sorafenib, that were developed for antiangiogenic actions and are used in the treatment of patients with specific cancer types. All of these drugs have the mechanism of inhibiting VEGF signalling by blocking either the function of the VEGF ligand or VEGF receptor.
Bevacizumab is a function-blocking monoclonal antibody that binds selectively to VEGF. Generally it is well tolerated and safe but can have adverse effects which can be intensified by chemotherapeutic agents used at the same time. For bevacizumab the most common adverse effects are hypertension, epistaxis, proteinuria, upper respiratory infection, stomatitis, diarrhea or other symptoms from the gastrointestinal tract as well as dyspnea, fatigue and dermatitis. Serious adverse effects connected to bevacizumab are infrequent but among those listed are gastrointestinal perforation, arterial thromboembolic events, hypertensive crisis, neutropenia, complications with wound healing, haemorrhage, nephrotic syndrome, heart failure and reversible posterior leukoencephalopathy syndrome.
Sunitinib is a small molecule inhibitor which inhibits phosphorylation of VEGF receptor among other receptors. Sunitinib is mostly well tolerated. Common adverse effects which have an incidence rate of 20% are fatigue, asthenia, diarrhea, nausea, dyspepsia, abdominal pain, constipation, hypertension, skin discoloration, altered taste, stomatitis and mild bleeding.
Sorafenib is a small molecule inhibitor of many tyrosine kinase receptors such as VEGFR-2. Side effects are in most cases mild to moderate such as rash, hand-foot skin reaction, diarrhea and dermatitis, and occur in about 33-38% patients using sorafenib. Other side effects are mild hypertension, leukopenia and bleeding. Uncommon side effects are cardiac ischaemia or infarction, gastrointestinal perforation, life-threatening haemorrhage and reversible posterior leukoencephalopathy syndrome.
Hypertension is one of the most common side effects regarding inhibition of VEGF signalling. VEGF increases synthesis of NO through upregulation of endothelial NO synthase and therefore inhibition of VEGF diminishes NO synthesis. Decrease in NO causes vasoconstriction, increased peripheral resistance and increased blood pressure. Hypertension caused by VEGF inhibition can usually be treated with oral antihypertensive agents.
Proteinuria is common when VEGF signalling is inhibited which shows how important VEGF is for normal renal function. VEGFR-2 can be found on the glomerular capillary endothelial cells and is activated by VEGF. Proteinuria is in most cases asymptomatic and usually decreases when treatment ends.
Impaired wound healing can be an adverse effect of VEGF inhibition as angiogenesis is an important step in wound healing.
Gastrointestinal perforation can be caused by VEGF inhibition although the mechanism is unknown. Abscesses, diverticula as well as bowel resection and anastomosis have been related to some cases.
Haemorrhage and thrombosis can occur when VEGF is inhibited as VEGF promotes endothelial cell survival and helps maintaining vascular integrity. When VEGF is inhibited, the regenerative capacity of endothelial cells may diminish and pro-coagulant phospholipids could be exposed on the plasma membrane or the underlying matrix, possibly leading to either thrombosis or haemorrhage. Since VEGF increases production of NO and prostacyclin, the inhibition of VEGF leads to decrease in both chemicals which contributes to thromboembolic events.
Reversible posterior leukoencephalopathy is often attributed to hypertensive encephalopathy as well as endothelial dysfunction. This can cause focal cerebral oedema, vasospasms, and even a breakdown in the blood–brain barrier. Inhibition of VEGF is implicated as a factor in the pathophysiology of the disease but has not yet been replicated after VEGF inhibition in preclinical models.
Endocrine dysfunction has been reported as an adverse effect of VEGF inhibition. Hyperthyroidism is one such, since thyroid function can be damaged by capillary regression around the follicles of the thyroid. The fenestrated capillaries of the pituitary, adrenal cortex and pancreatic isle have also been known to regress as an effect of VEGF inhibition. The thyroid-hypothalamic feedback loop can also be impaired due to VEGF inhibition, followed by raised TSH blood concentration.
Interactions Lenvatinib inhibits the liver enzyme CYP3A, which also happens to be a metabolic enzyme for the drug. It inhibits the UDP-glucuronosyltransferases UGT1A1 and UGT1A4. Lenvatinib induces CYP3A but not UGT1A1 and UGT1A4. Use of other drugs, especially ones metabolized by the liver enzyme CYP3A, should be monitored in case their plasma concentration changes. In vitro studies have shown that lenvatinib inhibits organic anion transporters 1 and 3 (OAT1 and OAT3). Sunitinib is metabolized in the liver by CYP3A4. It interacts with inducers and inhibitors of CYP3A4 leading to a decrease or increase in the plasma concentration of particular drugs metabolized by the same pathway. It will not change the amount of drug metabolized by the enzyme, because it does not inhibit or induce the enzyme directly. Sunitinib is a substrate of P-glycoprotein and ABCG2 transporters. It acts as an inhibitor for both transporters, especially for ABCG2. Therefore, drugs that are substrates of these carriers will have modified pharmacokinetics.