________________________________________________________________________________MYLERAN
Einleitung
experimentelle Zwecke und für klinische Studienparenterale Darreichungsformen entwickelt wurden.
1953 berichteten erstmals Haddow et al. und Galtonüber die Wirksamkeit des Busulfan in der Behandlung
Pharmakodynamik
der chronisch myeloischen Leukämie (CML).
Seitdem hat es seine Position in der Therapie der
CML gefestigt, auch wenn es primär nicht kurativwirkt, sondern zum subjektiven Wohlbefinden der
Chemisch gesehen, ist Busulfan das 1,4-Bis-
Patienten durch Reduzierung der erhöhten Zellzahl
(methansulfonyloxi)-butan mit einer Summenformel
und Beseitigung der Sekundärsymptomatik beiträgt.
von C6H14O6S2. Es hat eine molare Masse von 246,3.
Als nicht Zellzyklusspezifisches bifunktionelles
Neben der INN-Bezeichnung, Busulfan, wird dieses
Zytostatikum auch unter den Namen, Myelosan,
proliferierende Zellen, besonders auf die der
Sulfabutin, Misbulban oder Mitosan geführt. 12
Granulopoese im Knochen-mark. Speziell beiniedrigen Dosen wird eine gewisse Selektivität
Die Wirkung des Busulfan als Alkylgruppen-
gegenüber der granulozytären Zellinie sichtbar,
übertragende Substanz ist Konzentrationsabhängig
während bei höheren Busulfan-Dosen auch
und unterliegt dem nukleophilen Substitutionstyp 2
Thrombozyten, Lymphozyten und die erythrozytäre
Zellinie supprimiert werden. (Buggia et al. 1994) 3 - 7
demzufolge nicht nur von der Busulfan-Konzentration
Neben der CML fand Busulfan besonders in den 70er
selbst, sondern auch auf die Konzentration der
Jahren Eingang in die Behandlung der Polycythaemia
Nukleophilen abhängig, die durch Busulfan alkyliert
vera und der essentiellen Thrombozytämie. (Ernst et
werden sollen. Auch andere Bisulfonate mit den
al. 1971; Brodsky et al. 1977) 8,9; (EORTC-Studie
unterschiedlichsten Alkylgruppen zwischen den
1981; Levis und Szur, 1974) 10,11
beiden funktionellen Gruppen wurden auf ihrezytostatische Aktivität hin untersucht. Keine
1983 eröffnete eine Publikation von Santos et al. ein
Verbindung jedoch erreichte die Effizienz des
neues Einsatzgebiet für Busulfan. In Kombination mit
Busulfan mit seinen 4 Methylengruppen zwischen den
Cyclophosphamid hatte sich Busulfan in der
Methylsulfonaten im bezug auf die Hemmung
Konditionierungsbehandlung von Patienten, die sich
einer Knochenmarktransplantation im Rahmen einerAML-Therapie unterzogen hatten, als sehr effizient
Dunn postulierte 1974 zwar für das Busulfan einen
erwiesen. 4 Dieser Studie folgten weitere, in denen
anderen Wirkungsmechanismus als für die Stickstoff-
hochdosiertes Busulfan mit Cyclophosphamid oder
Lostverbindungen, jedoch ist dieses nicht einsehbar,
anderen Substanzen einschließlich einer Radiatio
da Busulfan intrazellulär - vergleichbar den Stickstoff-
kombiniert wurde. So hat es sich seitdem in der
Konditionierungstherapie zur autologen bzw.
seiner Methylsulfonatgruppe alkyliert. Dieses können
allogenen Knochenmarktransplantation im Rahmen
sowohl Proteine wie auch die Nukleinsäuren in der
der Behandlung von Leukämien, soliden Tumoren und
Hämoglobinopathien etabliert und bewährt. 3 Auchwenn die Konditionierungsbehandlung mit Busulfan
Die Aggressivität als Alkylgruppen-übertragendes
bisher nicht zu den zugelassenen Indikationen zählt,
Zytostatikum dürfte sicherlich weit unter der der
wird dieses Alkylanz - offensichtlich wegen seiner
Stickstoff-Lostverbindungen einschließlich des
vorhersehbaren sonstigen toxischen Risiken
Chlorambucil und Melphalan liegen. Dennoch ist
davon auszugehen, daß Thiol- oder Aminogruppen alsintrazelluläre Angriffspunkte für Busulfanfungieren.
Sulfhydryl-Gruppen betrifft, dürfte es sich bei dieserForm der Alkylierung eher um einen Katabolismusdes Zytostatikums, Busulfan, handeln, da sieirreversibel zu harnpflichtigen Thiophen-verbindungen führt. (Roberts et al. 1959) 13,14
Als bifunktionelles Alkylanz substituiert Busulfanzunächst den stark basischen Stickstoff in der Position
Abb. 1 : Strukturformel des Busulfan [1,4-Bis-(methylsulfonyloxi)-
7 des Guanins in der DNS und setzt dort den
butan]. * = Positionen, an denen das Molekül aufgespalten wird. Busulfan wird als Arzneimittel unter dem
Ausgangspunkt für eine weitere nukleophile
Handelsnamen, Myleran, ausschließlich in Form von
Substitutionen an einem zweiten Guaninmolekül.
Tabletten zu 0,5 und 2 mg vertrieben, auch wenn für
Durch die Bifunktionalität des Busulfan, ausgehend
________________________________________________________________________________MYLERAN
von der Quaternierung des N-7-Stickstoffs kann die
Die Ursachen für die Zytotoxizität von Busulfan
Vernetzung innerhalb des gleichen DNS-Stranges
gegenüber Tumorzellen sind vielfältig. Dabei spielt
oder zu dem Nachbarstrang hin erfolgen, was
die Brückenbildung zu den Guaninbasen der DNS
entweder eine intrahelikale oder interhelikale
sicherlich die wichtigste Rolle. Ob dieser Vorgang
kovalente Vernetzung der DNS-Stränge nach sich
allerdings die Hauptwirkung repräsentiert, kann nicht
zieht. 15,16 Brookes und Lawley (1961 und 1965)
uneingeschränkt bejaht werden, da nach Tong et al.
postulierten für die Kreuzvernetzung der DNS durch
Busulfan eine stufenweise ablaufenden nukleophile
Substitution am Guanin, die von Tong et al. (1980)durch den Nachweis des 1,4-Di-(7-guanosyl)-butan
Auf die Möglichkeit, durch Busulfan Bindungen
bzw. des 1,4-Di-(7-guanyl)-butan belegt werden
zwischen der DNS und den DNS-assoziierten
Proteinen zu induzieren, wiesen Lee und Zbinden(1979) hin. Sie konnten allerdings keinen eindeutigenBeweis dafür erbringen, daß Busulfan auch solcheDNS-Proteinverknüpfungen macht.
Alexander und Stacey in der Veresterung der
Phosphatbrücken der DNS einen weiteren, wichtigenbiochemischen Angriffspunkt für Busulfan, der einSistieren des Zellzyklus nach sich ziehen könnte. 21
Bezüglich der verschiedenen Phasen eines Zellzyklusund der Erreichung eines optimalen zytostatischen
Effekts durch Busulfan, gibt es divergierende
Abb. 2 : Vernetzung der DNS durch kovalente Bindungen am N-7
Aussagen. Während Dunn (1974) Zellen in der G0-
Phase, wie Megakaryozyten und enddifferenzierteZellen, als ideal für den Busulfan-Effekt ansah 22,
Tong und Ludlum gelangen allerdings nicht der
geben in-vitro-Studien Hinweise darauf, daß Zellen in
Nachweis, ob die Bisguanylverbindung aus einer
Inter- oder Intra-Strangverknüpfung resultierte. In
empfindlich auf die Busulfan-Gabe reagieren und den
einem von Lee und Zbinden fehlgeschlagenen
Versuch, eine bestimmte DNS-Fraktion aus Zellen
1982) 73 Buggia et al. sehen deshalb in den schnell
von mit Busulfan behandelten Ratten zu eluieren,
proliferierenden Geweben, worunter besonders die
sehen Bishop und Wassom den Beleg für eine vom
granulozytäre Zellreihe des Knochenmarks fällt, die
Busulfan bevorzugte Alkylierung des Einzelstranges,
bevorzugten Angriffspunkte für Busulfan. 3
nicht aber für eine Interstrang-DNS-Verknüpfung odereine DNS-Nukleoprotein-Vernetzung. 16,19,12
Zytotoxizität
Mit einer Substitution des N-7-Stickstoffs im Guaninist eine Instabilität des Imidazolringes verbunden, die
Busulfan entfaltet seine toxische Wirkung auf alle
mit einer Öffnung des Ringsystems verbunden sein
menschlichen und tierischen Gewebe, maligne wie
kann. Ist ein bestimmtes Maß an Vernetzung erreicht,
auch gesunde. Als Folge können Dysplasien
erlaubt die so veränderte DNS keine reguläre
entstehen, von denen die bekannteste die Busulfan-
Transkription und indirekt auch dadurch keine
Lunge ist, die bereits in den 60er Jahren nach
Translation mehr, so daß eine Zellvermehrung und
Einführung von Busulfan in die Therapie der CML als
eine Proteinsynthese nachhaltig gestört, ja sogar
unerwünschte Arzneimittelwirkung erkannt wurde. (Meschan et al. 1973; Koss et al. 1965; Leake et al. 1963) 23,24,25 Ferner sind zytologische Veränderungen
Voraussetzung für die Entfaltung einer solchen
Wirkung ist eine Penetration des Zytostatikums in die
Gastrointestinaltraktes und der neuronalen Gewebe
Zelle, für die nach dem jetzigen Erkenntnisstand
weder ein Rezeptor noch ein aktiver Transport
Offensichtlich wirkt Busulfan nur unwesentlich auf
diskutiert werden. Die geringe Löslichkeit in Wasser
das lymphatische Gewebe und auf Leberzellen von
und hohe Lipophilie ermöglichen nach Wilkinson und
Nagern, obwohl bei Mäusen Lymphknotenatrophien
Turner dem Busulfan eine gute Zellpenetration, die zu
beobachtet wurden. Seiner gonadotoxischen Wirkung
einer erhöhten Zellpermeabilität verbunden mit einer
verdankt in einigen Ländern Busulfan den
Instabilität der Zellwand und somit zu einer Störung
zweifelhaften Einsatz bei der Regulierung von
des Zellwachstums verschiedener maligner Klone
geführt hat. In der unterschiedlichen Permeabilität
dieser Zellen gegenüber Busulfan sehen die Autoreneinen Grund für die relative Selektivität dieses
Zytostatikums gegenüber Granulozyten und
________________________________________________________________________________MYLERAN
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Liste des médicaments disponibles en conditionnement trimestriel Antidiabétiques Spécialité Dénomination Présentation Conditionnement “Prix public TTC commune internationale (décembre 2007-IMS Health)” Liste des médicaments disponibles en conditionnement trimestriel Politique du médicament/Dim – mars 2008 • 1 Liste des médicaments disponibles e
23 IMP ANGELILLO 12-11-2010 15:25 Pagina 349Come hanno sottolineato alcuni fra i maggiori quotidiani indiani1( Times of India 2, Hindustan Times 3), il 21 marzo 2008 è stato ungiorno molto significativo per la maggioranza degli abitanti dell’In-dia, un paese costituzionalmente laico e, al contempo, profondamen-te religioso in un duplice senso, qualitativo e quantitativo. Da unaparte, la pr