Preclinical Pharmacologic Basis for Clinical Use of rhIL-11 as an Effective Platelet-Support Agent

ABSTRACT: Preclinical studies have shown that rhIL-11, also known as oprelvekin (Neumega), stimulates early and later stages of megakaryocytopoiesis (including proliferation and differentiation of megakaryocyte precursors and maturation of megakaryocytes), to produce an increase in peripheral platelet count. Because of these effects, rhIL-11 must be administered to patients with cancer sufficiently in advance of the platelet nadir (within 6 to 24 hours postchemotherapy) to allow adequate time for megakaryocyte maturation and platelet formation. Therefore, the maximum platelet response coincides with the time when the platelet nadir would normally be experienced. In myelosuppressed, nonhuman primates, optimal platelet response occurred following 14 days of treatment at a dose equivalent to the 50-µg/kg daily dose recommended in humans; lower doses and shorter durations were less effective. These data support the current dosing recommendation in humans, which states that rhIL-11 dosing continues until platelet recovery to ³ 50,000/µL has been achieved for 2 consecutive days or for a total of 10 to 21 days in each cycle. The nonhematopoietic effects of rhIL-11 include a renal effect, resulting in plasma-volume expansion, as well as potential beneficial clinical effects in damaged or inflamed intestinal mucosa, including potential mitigation of mucositis and a rationale for future studies in inflammatory bowel disease. [ONCOLOGY 14(Suppl 8):12-20, 2000]

Introduction

Recombinant human interleukin-11 (rhIL-11), also known as oprelvekin (Neumega), is the first platelet growth factor to be approved by the United States Food and Drug Administration (FDA) for the prevention of severe chemotherapy-induced thrombocytopenia (CIT) in patients with solid tumors, lymphoma, or those who are at high risk of developing thrombocytopenia. In this setting, rhIL-11 has been shown to reduce the postchemotherapy platelet nadir and, thus, shorten the time required for platelet recovery, thereby enabling many patients to receive successive cycles of chemotherapy at full doses.[1]

The ability to attain these benefits, however, is dependent on the appropriate use of rhIL-11, particularly timing its administration within the framework of the patient’s expected platelet response to chemotherapy. These practical considerations, while seemingly simple, require an understanding of both the role of endogenous IL-11 in the process of megakaryocytopoiesis and the pharmacodynamic effects of rhIL-11. The purpose of this review is to provide an overview of the preclinical pharmacology of rhIL-11, the manufactured recombinant human form of IL-11, by providing a rationale for both its clinical efficacy and recommended dosing regimen. A brief background of the role of endogenous IL-11 in the regulation of megakaryocytopoiesis is provided as a prelude.

Role of Cytokines in the Regulation of Megakaryocytopoiesis and Biology of Endogenous IL-11

As reviewed by several authors,[2-5] a number of cytokines and growth factors are known to be involved in the regulation of megakaryocytopoiesis and platelet formation (Figure 1). IL-11 indirectly promotes thrombopoiesis either by stimulating the release of granulocyte-macrophage colony-stimulating factor (GM-CSF, sargramostim [Leukine]) and interleukin-6 (IL-6) or synergizing with interleukin-3 (IL-3).[5] IL-3 stimulates the proliferation of megakaryocyte progenitor cells in vitro and acts synergistically with stem-cell factor (SCF) to stimulate the growth of burst-forming unit–megakaryocytes (BFU-MKs) and colony-forming unit megakaryocytes (BFU-MKs); IL-3 acts synergistically with GM-CSF to stimulate BFU-MK growth. Therefore, the action of IL-3 occurs primarily on the proliferation of immature cells (the early phase of megakaryocytopoiesis).

IL-6 acts primarily on megakaryocytes at more advanced stages of maturity—a process that furthers their maturation. It does so by enhancing the diameter, ploidy, acetylcholinesterase activity, and protein synthesis of megakaryocytes.[2] Synergism with CSF (IL-3) is required for IL-6 to effect an increase in the number of megakaryocyte colonies.[4] In vivo, GM-CSF enhances proliferation of megakaryocytes, but not platelets. However, GM-CSF does not appear to act independently, but rather synergistically with other cytokines, including IL-3, IL-6, IL-11, thrombopoietin, and stem-cell factor. Stem-cell factor acts synergistically with IL-3, GM-CSF, and IL-6 to stimulate megakaryocytopoiesis. The action of stem-cell factor appears to be restricted to the proliferation of megakaryocyte progenitors. Thrombopoietin is a humoral-growth factor that directly promotes proliferation, growth, and maturation of megakaryocytes.[6]

Role of IL-11

IL-11 is a pleiotropic cytokine that is expressed in vivo in a variety of tissues, including the brain (specifically in hippocampal neurons), spinal cord, thymus, spleen, bone (osteoblasts, osteoclasts), bone marrow (megakaryocytes), heart, lung (mucosal epithelial cells), connective tissues (chondrocytes, synoviocytes), small and large intestines (mucosal epithelial cells), kidney, testes (spermatogonia), and uterus (endometrial tissues).[5,7,8] The gene expression and secretion of IL-11 is stimulated by interleukin-1a (IL-1a), transforming-growth factor (TGF)-b1 and TGF-b2, and low platelet count.[5]

The activity of IL-11 was initially identified in an immortalized primate bone marrow stromal cell line, called PU-34. IL-11 mediates its effects on bone marrow megakaryocytes through direct association between its unique IL-11 receptor and glycoprotein (gp)130. Once activated, the gp130 molecule transmits a signal to the target cell.[7] Receptors for IL-6 (as well as oncostatin M, leukemia-inhibitory factor, and ciliary-neurotrophic factor) also use the gp130–signal-transduction pathway, which may be a shared mechanism through which IL-11 and IL-6 enhance megakaryocyte proliferation.[7,9]

Mediation of thrombopoiesis by thrombopoietin via its receptor, cMpl (which does not utilize the gp130 signal transduction pathway), suggests the involvement of additional pathways (in addition to the pathway for IL-11) in the regulation of megakaryocytopoiesis.[10] IL-11 and thrombopoietin have been shown to act synergistically to stimulate megakaryocyte colony growth and polyploidization in vitro.[11] These data suggest mutual augmentation, but not interdependence (as discussed later)[8] of these two different pathways in promoting megakaryocytopoiesis. However, the clinical relevance of these in vitro findings is unknown.

The human IL-11 complementary DNA was cloned from a human, fetal lung-fibroblast cell line.[12] rhIL-11 is a protein produced in Escherichia coli by recombinant DNA methods. It differs from naturally occurring IL-11 sheerly by the absence of the amino-terminal proline residue. The following is a discussion of the preclinical pharmacologic profile of rhIL-11.

Megakaryocytopoietic Effects of rhIL-11

In Vitro Studies

Collectively, data from in vitro studies indicate that rhIL-11 promotes the proliferation, differentiation, and maturation of megakaryocytes and exerts a direct stimulatory action on cells at all phases of megakaryocytopoiesis—from primitive progenitors to mature megakaryocytes. In these studies, the effects of rhIL-11, itself a multifunctional cytokine, appeared to result from a synergistic action with other cytokines, primarily IL-3[8,13-14] and/or stem-cell factor,[8,13] rather than an independent effect.[8,14] This may reflect a complex interaction between endogenous cytokines that takes place within the bone marrow microenvironment in vivo.

rhIL-11 synergizes in vitro with IL-3 or stem-cell factor to stimulate primitive, multilineage hematopoietic progenitor cells and the proliferation of lineage-committed myeloid and erythroid progenitor cells from murine bone marrow.[13] In combination with IL-3 or stem-cell factor, rhIL-11 has been shown to stimulate a marked proliferative response in primitive, pluripotential progenitors (pre-CFCmulti)—a response that resulted in a tenfold increase in the number of multilineage (composed of erythroid, megakaryocytic, and other myeloid cells) hematopoietic, progenitor cells (CFCmulti). This response was dependent on the presence of IL-3, in whose presence rhIL-11 stimulated an increase in the number of pure erythroid BFU–erythroid (E)-derived colonies (regardless of the presence of erythropoietin) and also supported the maturation of late-stage erythroid progenitors (CFU-E).

Additionally, in studies in mouse or human bone marrow cells, rhIL-11 and IL-3 synergistically produced increases in the number and size of megakaryocyte colonies and in megakaryocyte ploidy.[14,15] By contrast, in cultured, human T–cell-depleted bone marrow mononuclear cells, rhIL-11 alone failed to stimulate the growth of megakaryocyte colonies. Yet, in the presence of IL-3, rhIL-11 produced a synergistic increase in the number and size of the megakaryocyte colonies.[14] This same response was observed in highly purified bone marrow CD34+ cells (ie, early progenitor cells).

The in vitro megakaryocytopoietic effects of rhIL-11 in human (and murine) bone marrow are not mediated through (or dependent on) input from thrombopoietin.[8] In human bone marrow cultures, the addition of an antibody to neutralize thrombopoietin activity did not prevent the synergistic stimulation by rhIL-11 in combination with IL-3 or SCF of the formation of colonies that were derived from BFU-MK (P < .01 for IL-3; P < .02 for SCF) and CFU-MK (P < .001 for IL-3; P < .05 for SCF) or the generation of CD41+ (megakaryocytes) from CD34+ cells in liquid cultures containing rhIL-11, with or without IL-3.[8] However, rhIL-11 can act synergistically with thrombopoietin to promote megakaryocyte colony formation from murine bone-marrow–derived mononuclear cells.

An important observation of this study was the expression of the IL-11 receptor in human bone–marrow–derived CD41+ CD14- cells and enhancement by rhIL-11 of phosphorylation of gp130 (the receptor signaling subunit) and STAT3 (a transcription factor that is part of the IL-11 signaling pathway[5] in human bone marrow megakaryocytes). No IL-11 receptors were detected on platelets. These combined data support a direct action of rhIL-11 on human megakaryocytes.

In Vivo Studies

rhIL-11 Promotes Differentiation and Proliferation of Progenitor Cells

rhIL-11 (in conjunction with other endogenous-growth factors) has the ability to promote the proliferation of primitive progenitor cells by provoking progenitor cells to leave the quiescent G0 stage and enter the active G1/S-phase of the cell cycle, thereby shortening cell-cycle time. Injection of mice with rhIL-11 resulted in a dose-dependent increase in absolute numbers of femoral bone marrow progenitor cells, including multipotential progenitor cells (CFU-GEMM [colony-forming unit–granulocyte-erythroid-macrophage-megakaryocyte]), CFU-BM (bone marrow), and BFU-E, that reached statistical significance at the 4- and 8-mg doses (P < .05 vs vehicle-treated controls).[16] A time-sequence study showed that rhIL-11 (8 mg) also increased the cycling rates of these progenitors, resulting in a significantly (P < .005) higher percentage of progenitors in S-phase compared with controls.

rhIL-11 Increases Platelet Count by Promoting Maturation of Megakaryocytes

Injection of rhIL-11 intraperitoneally for 5 days into healthy mice resulted in an increase in the peripheral platelet count,[17] thereby confirming in vitro evidence of the maturational effects of rhIL-11 on megakaryocytes.[14,15] In normal and splenectomized mice, increases in peripheral platelet count induced by treatment with rhIL-11 for 7 days was shown to correspond with an increase in megakaryocyte progenitors and in endoreduplication of bone marrow megakaryocytes (maturational effects).[18] Peripheral platelet counts were increased by 30% to 40%, and these increases were maintained throughout a 14-day dosing period.

In the latter study, increased endoreduplication was reflected by statistically significant increases (P < .01) in the percentage of megakaryocytes with a modal ploidy of 32N in normal and splenectomized mice on days 3 (28%) and 7 (26%) of treatment with rhIL-11, compared with the percentage in saline-treated control mice (day 3, 13%; day 7, 16%).[18] At baseline, 10% to 15% of megakaryocytes in the study population were at 32N. This shift in ploidy distribution was accompanied by corresponding decreases from baseline (15% to 20%) in the percentage of 8N megakaryocytes (9% in rhIL-11–treated mice vs 17% in controls). A similar shift in ploidy distribution was seen in splenectomized mice with similar relative increases in 32N megakaryocytes on days 3 and 7 of treatment.

With respect to the effect of rhIL-11 on megakaryocyte progenitors, bone marrow assay showed a threefold increase in megakaryocyte–colony-forming cells (MK-CFC) in normal mice on day 7 of rhIL-11 treatment, and a twofold increase in splenectomized mice on days 3 and 7 of treatment—relative to MK-CFC levels in controls.[18] No significant changes in red blood cell or white blood cell counts or white blood cell differential were observed, thereby suggesting that the predominant in vivo hematopoietic effect of rhIL-11 on normal bone marrow is stimulation of megakaryocytopoiesis and thrombopoiesis.

This study demonstrates that the administration of rhIL-11 alone stimulates early and later stages of megakaryocytopoiesis to produce an increase in platelet count—a process that requires several days to manifest itself.[18] The clinical implication is that to derive a maximum effect following the myelotoxic insult of chemotherapy, the timing of rhIL-11 administration must take into account the kinetics of the megakaryocytopoietic process. Additional data supporting the early postchemotherapy administration of rhIL-11 in clinical practice are provided below.

The study data indicated that splenic megakaryocytopoiesis does not contribute to the increase in peripheral platelet count induced by rhIL-11 treatment in vivo. However, observation of a more rapid decline in peripheral platelets to control levels in splenectomized mice compared with normal mice (day 10 vs day 15) suggests that following completion of rhIL-11 dosing, splenic megakaryocytopoiesis may help sustain the rhIL-11-induced platelet response.[18]

The maturational effect of rhIL-11 on megakaryocytopoiesis has also been demonstrated in larger animals. In normal dogs, subcutaneous injections of rhIL-11 at doses of 30, 60, 120, and 240 mg/kg/d for 14 days resulted in increases in posttreatment peripheral platelet counts by magnitudes ranging from 1.4- to 3.1-fold, compared with pretreatment levels (P = .01 vs baseline for peak platelet increases at doses of 120 and 240 mg/kg/d).[19] rhIL-11 treatment was associated with an increase in the proportion of megakaryocytes with a ploidy number of 32N/64N on day 7 and on day 14 of treatment compared with megakaryocytes from control dogs (P £ .01 for days 7 and 14). Peripheral blood neutrophil, total white blood cell or differential counts were not affected by rhIL-11 treatment. These observations in dogs confirm the prominent megakaryocytopoietic effects of rhIL-11 seen earlier in mice.[18]

In normal, nonhuman primates (cynomolgus monkeys), continuous intravenous infusion of rhIL-11 at doses of either 10, 30, or 100 mg/kg/d for 7 days produced a dose-dependent increase in the platelet count that was apparent on day 8 and peaked on days 12 to 14 (Figure 2).[20] The extent of the increases in platelet count from baseline ranged from 90% to 162%. Administration via the subcutaneous route (60 and 100 mg/kg/d for 7 days) resulted in similar platelet response profiles. The peak increase in peripheral platelet count was preceded by a peak increase in reticulated platelets, thereby confirming a maturational thrombopoietic effect.

This study also showed a trend toward improved platelet response with longer duration of treatment. By increasing the treatment duration (60 mg/kg/d subcutaneously) to 14 days, higher peak platelet counts were achieved. This platelet increase was also sustained for a longer period compared with the response achieved with shorter durations of treatment (4 or 7 days) (Figure 3). These data are consistent with the recommendation of a 10- to 21-day dosing period for rhIL-11 in humans (or until the post-nadir platelet count is ³ 50,000/µL for 2 consecutive days).

Bone marrow megakaryocyte counts taken from nonhuman primates treated with intravenous rhIL-11 100 mg/kg/d were significantly greater than those from untreated controls (P < .01). These megakaryocytes were also ultrastructurally normal. Maturation of normal megakaryocytes was evidenced by microscopic visualization of landmarks of normal maturation, including segmented, nuclei-containing, condensed chromatin; highly developed demarcation membrane systems; and mature granule formation.[20] In this species, platelets produced by treatment with rhIL-11 have also been shown to have a normal lifespan and to be structurally and functionally normal.[21]

The capacity of rhIL-11 to increase the megakaryocyte population in human bone marrow (when used for the FDA-approved indication of prophylaxis of chemotherapy-induced thrombocytopenia and in accordance with the recommended dose regimen) has been demonstrated in an immunohistologic and morphological study of bone marrow specimens. The specimens were taken from rhIL-11-treated women with advanced breast cancer who had no apparent bone marrow involvement.[22] Subcutaneous administration of rhIL-11 at doses of 50 or 75 mg/kg/d for 14 consecutive days during a prechemotherapy period resulted in a statistically significant twofold increase in the frequencies (numbers) of morphologically identified megakaryocytes (from 0.5 ± 0.1% to 1.0 ± 0.3%; P < .001), and a dose-related increase in peripheral blood-platelet counts. Increases in proliferation of marrow cells (P < .01) and ploidy of megakaryocytes (P < .012) were also observed. At the 75 mg/kg/d dose, rhIL-11 therapy induced a three- and tenfold increase in the number of CFU-MK progenitor cells in two patients, respectively. These data confirm that the in vivo megakaryocytopoietic effects of rhIL-11 shown in nonhuman species also occur in human patients with cancer.

Animal Models of Myelosuppression

In rodent and nonhuman primate animal models of chemotherapy-induced myelosuppression, intravenous or subcutaneous treatment with rhIL-11 alone for up to 14 days consistently produced increases in peripheral platelet counts compared to reference groups of animals (Table 1).[16,20,23,24] Multilineage hematopoietic effects, including increases in erythroid, granulocyte, and macrophage progenitors, were also reported; however, effects outside the megakaryocytopoietic lineage probably reflect synergism with ambient endogenous cytokines.[16,23]

In the nonhuman primate myelosuppression model, rhIL-11 was administered at a dose equivalent to the 50-µg/kg/d dose that is currently recommended in patients with cancer receiving chemotherapy.[20] Treatment with rhIL-11 was continued untilplatelet levels increased to ³ 50,000/µL for 2 consecutive days (as currently recommended during clinical use). In untreated controls, carboplatin (Paraplatin)-induced thrombocytopenia (platelet nadir of £ 20,000/µL) occurred at a median of 3 days following the last dose of chemotherapy in the cycle.

rhIL-11 treatment initiated within 24 hours after the end of chemotherapy significantly (P £ .05) reduced the depth of the platelet nadir and significantly (P £ .05) accelerated platelet recovery compared with standard-care controls (Figure 4). In animals started on treatment with rhIL-11 within 24 hours following chemotherapy, mean platelet counts were £ 50,000/µL for a median of only 2 days, compared with a median of 5.5 days in untreated controls, thus indicating accelerated platelet recovery.

Leonard et al demonstrated that the magnitude of platelet response is markedly affected by the time at which rhIL-11 treatment is instituted (Figure 5).[23] Only when rhIL-11 was begun within 24 hours after myelosuppressive treatment was the platelet nadir improved and optimal platelet recovery achieved; progressively lower responses were seen with longer delays between the time of ending chemotherapy and starting rhIL-11 dosing. These observations are not surprising, since the action of rhIL-11 begins in the early stages of megakaryocytopoiesis and the natural maturation time of platelets is 5 to 9 days.

These observations, taken together with the significant platelet responses observed in nonhuman primates (Figure 4), strongly support the prescribing guidelines for initiation of rhIL-11 within 6 to 24 hours after the completion of chemotherapy for the purpose of preventing chemotherapy-induced thrombocytopenia in patients with nonmyeloid malignancies. These data also suggest that rhIL-11 must be used prophylactically (with dosing of rhIL-11 starting well before the time period in which severe thrombocytopenia is expected to occur), rather than therapeutically as a rescue agent (ie, waiting until thrombocytopenia has occurred before initiating therapy).

Nonhematopoietic Effects

Preclinical Renal Effects

Studies performed in both experimental animals, as well as human volunteers, have found that treatment with rhIL-11 is associated with an increase in plasma volume (data on file, Genetics Institute, Inc.). Thus, conscious dogs receiving rhIL-11 show a rapid dilutional anemia and volume expansion that peaks on day 7. Likewise, dogs and controls receiving this agent do not excrete an acute salt load (100 mL of 1.35% sodium chloride) (data on file, Genetics Institute, Inc.).

 The volume-expanding effect of rhIL-11 has also been observed in human volunteers.[26] The mechanism of the sodium-retaining effect of the agent has not been fully explained to date. Studies in dogs suggest that both a cardiac and humoral mechanism may be operant (data on file, Genetics Institute, Inc.). In addition, echocardiographic studies reveal increments in left ventricular-end systolic and diastolic volumes, as well as some mitral and tricuspid regurgitation. These findings could be a consequence of volume expansion itself. Nonetheless, cardiac effects that could culminate in neuroendocrine reflexes leading to sodium retention have not been fully excluded.

The increase in total plasma volume is associated with an appropriate increase in atrial-natriuretic peptide (data on file, Genetics Institute, Inc.). It is of interest that the sodium retention occurs despite the elevation of the levels of this hormone, thus suggesting the presence of counterregulatory neurohormonal pathways leading to sodium conservation. However, levels of aldosterone were only marginally elevated in both dogs[28] and humans (data on file, Genetics Institute, Inc.) receiving IL-11, with hormone levels rising only in animals concomitantly receiving furosemide or in humans receiving triamterene/hydrochlorothiazide. The use of diuretics partially, but not completely, attenuated the sodium-retaining effect of rhIL-11. In none of the studies did the drug appear to have an adverse effect on glomerular filtration rate, thereby suggesting a possible direct tubular effect on sodium reabsorption.

Lack of Effect of rhIL-11 on Tumor Growth

Although some nonhematopoietic cancer cells express the signal transducer and receptor RNA for IL-11,[29,30] recent in vitro data suggest that rhIL-11 is unlikely to stimulate the growth of the most common solid tumors, including breast, ovarian, colon, and non–small-cell lung tumors. Soda et al evaluated the effect of rhIL-11 on the proliferation of tumor cells taken directly from patients with a variety of solid tumors.[31] After continuous exposure for 14 days to three different concentrations of rhIL-11 (1, 10, and 100 U/mL), no stimulation of cultured human-tumor, colony-forming units was observed. Rather, rhIL-11 inhibited the growth of 24% (16/66) of evaluable specimens, including 24% (4/17) of breast cancer specimens and 36% (5/14) of non–small-cell lung cancer specimens in a concentration-dependent manner. Although we do not suggest that rhIL-11 is an antineoplastic agent in itself, these data are reassuring and indicate that rhIL-11 does not stimulate tumor cell proliferation.

Preclinical Evidence Predictive of Potentially Beneficial Nonhematopoietic Effects

The observed efficacy of rhIL-11 in several preclinical models of epithelial damage predicts its potential clinical usefulness in chemotherapy-associated mucositis and possibly also in gastrointestinal-inflammatory disease states (Table 2).[32-38] Evidence suggests that an improvement in mucositis may occur independent of the hematopoietic effects of rhIL-11. This consists of observed mucosal improvement in myelosuppressed hamsters antecedent to maximum effects on platelets (by approximately 7 days) and in the absence of bone marrow changes.[33] Additionally, histologic improvement ofdamaged intestinal, mucosal morphology has been documented with rhIL-11 dosing in association with significantly (P < .01) increased crypt-cell proliferative activity.[39] rhIL–11–induced elevation of peripheral white blood cells may also have contributed to mucosal healing in these preclinical model systems.

rhIL-11 has been shown to inhibit the release of proinflammatory mediators from activated murine macrophages, thereby reducing circulating levels of tumor-necrosis factor (TNF)-a, IL-1b, interleukin-12 (IL-12), and interferon-g (IFN-g) in a murine model of endotoxemia.[40] Suppression of proinflammatory cytokine release was apparently mediated by inhibition of gene expression of these cytokines via an inhibitory effect on the function of nuclear factor-kB—a key transcription factor.[41] Downregulation of the expression of TNF-a, IL-1b and IFN-g by rhIL-11 has also been demonstrated in a human-lymphocyte antigen (HLA)-B27 rat model of inflammatory bowel disease.[36] This was accompanied by a significant reduction in myeloperoxidase activity in cecal tissue of the HLA-B27 rat model, thus indicating reduced intestinal inflammation.

This data, combined with the data presented in Table 2, suggest that rhIL-11 (potentially due to its effects as a multifunctional cytokine) facilitates the repair of damaged gastrointestinal mucosa in animals through anti-inflammatory and positive effects on epithelial integrity and regeneration. Findings in models of short-bowel syndrome also suggest a trophic effect on small-intestine enterocytes (Table 2), which could potentially facilitate an intestinal adaptation in patients with bowel resection.[34,35]

A gastrointestinal mucoprotective effect of rhIL-11 has also been demonstrated in animal models of gram-negative sepsis (Pseudomonas aeruginosa) associated with chemotherapy-induced neutropenia.[42,43] Treatment with rhIL-11 alone or in combination with recombinant human granulocyte colony-stimulating factor (rhG-CSF) prevented thinning and necrosis of intestinal mucosa and significantly improved survival rates (P < .01 vs controls).

Use of rhIL-11 with rhG-CSF produced an additive survival benefit.[43] An observed reduction in circulating TNF-a suggests a reduction in systemic-inflammatory response. These data suggest the potential for rhIL-11 to maintain an effective gastrointestinal mucosal barrier against the migration of bacteria into the systemic circulation.

rhIL-11 is currently in clinical trials for the treatment of cytotoxic-associated mucositis[44] and Crohn’s disease.[45]

Summary: Practical Application of Preclinical Data to Clinical Practice

The hematopoietic action of rhIL-11 in promoting production of megakaryocytes begins in the early stages of megakaryocytopoiesis. In synergy with endogenous cytokines and possibly other unknown humoral factors, rhIL-11 stimulates the proliferation and differentiation of megakaryocyte precursors and the maturation of megakaryocytes, ultimately producing an increase in peripheral platelet count.

This implies that rhIL-11 must be administered sufficiently in advance of the expected period of platelet nadir to allow enough time for megakaryocyte maturation and platelet formation, thereby reinforcing the appropriate clinical use of rhIL-11 as a preventative agent. Preclinical data indicate that the optimal time to begin rhIL-11 is within 24 hours following the final chemotherapy dose (reflected in the prescribing guidelines for rhIL-11). Ideally, the platelet response to rhIL-11 would begin approximately 1 week later. This corresponds to the time when the platelet nadir would normally be experienced.

Markedly better platelet responses were achieved in myelosuppressed, nonhuman primates with 14-day treatment courses of rhIL-11 than with shorter courses of dosing.[20] This implies that in myelosuppressed patients with cancer, treatment with rhIL-11 for an adequate duration is critical for optimal amelioration of myelosuppression and the ability to maintain the planned dosing regimen. In controlled clinical trials of rhIL-11 where efficacy was demonstrated, the duration of dosing was 10 to 21 days.[1,46]

In these trials, rhIL-11 produced a dose-dependent increase in peripheral platelet counts in myelosuppressed, nonhuman primates, thus indicating that adequate doses of rhIL-11 must be used for optimal outcome. In this model, administration of rhIL-11 at a dose equivalent to the 50-mg/kg/d dose recommended in myelosuppressed patients with cancer significantly blunted the platelet nadirs seen in untreated controls and significantly accelerated platelet recovery to 50,000/µL.

rhIL-11 causes plasma-volume expansion secondary to sodium and water retention in dogs and humans. During clinical use, patients treated with

rhIL-11 should be monitored for signs of edema, such as swelling of the extremities, possibly perceived by patients as a tightening of rings or subtle difficulty putting on their shoes. rhIL-11 should also be used cautiously in patients with underlying medical conditions that could be aggravated by plasma-volume expansion—cardiovascular disease, for example. A sodium-restriction diet may help reduce the extent of edema. It should also be noted that the occurrence of edema seen with rhIL-11 is usually easily managed and fully reversible.

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