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Hydroxyurea: an overview.

Hydroxyurea has been a compound of scientific and clinical interest for over 100 years. A small molecule with many biological properties, hydroxyurea is used in a number of myeloproliferative, neoplastic, and non-hematological diseases. Recently, the agent has been investigated for use in the treatment of Human Immunodeficiency Virus (HIV) disease. Hydroxyurea is associated with dose related bone marrow suppression, crosses the placenta, and is excreted in breast milk. Toxicity is often managed through dose titration. Although adequate attention must be paid to the drug's use in pregnancy and during breast feeding, hydroxyurea's ease of administration, multiplicity of clinical effects, and low cost ensure the drug a place in therapy for years to come.

Animals↗

Mechanisms of human immunodeficiency virus type 1 inhibition by hydroxyurea.

Virus life cycles depend on cellular factors. Therefore, targeting cellular in combination with viral enzymes could be an effective control in virus replication. In contrast to viral proteins, cellular proteins are not prone to mutations; therefore, viral escape is not expected from drugs inhibiting cellular factors. Hydroxyurea inhibits the cellular enzyme ribonucleotide reductase, thus reducing DNA synthesis. Furthermore, this drug potentiates the activity of nucleoside analogues, inhibits the escape of A-analogue resistant mutants, and increases the phosphorylation of T-analogues. Besides its antiviral activity, hydroxyurea effects the immune system by decreasing immune activation, inhibiting the expansion of CD8 cells and the depletion of CD4 cells. Hydroxyurea has been used in medicine for 40 years, is well tolerated, and it is the least expensive available anti-HIV-1 drug. These characteristics make hydroxyurea a primary candidate for use in combination therapies for the treatment of HIV-1 infection.

Anti-HIV Agents↗

Longitudinal melanonychia associated with hydroxyurea therapy in a patient with essential thrombocytosis.

Occurrence of skin lesions during long-term therapy with hydroxyurea are well described, but there have been only a few case reports of longitudinal melanonychia associated with hydroxyurea treatment. We report herein longitudinal melanonychia associated with hydroxyurea therapy in a subject with essential thrombocytosis. The prolonged time lapse (1 year) between initiation of hydroxyurea therapy and the onset of the longitudinal melanonychia should be noted.

Aged↗

Didanosine plus stavudine with or without hydroxyurea in HIV-1-infected patients: 1 year follow-up. Swiss HIV Cohort Study.

A total of 144 human immunodeficiency virus (HIV)-infected patients (mean CD4 cell count, 367 cells/mm3) were included in a double-blind placebo-controlled trial testing the efficacy on surrogate markers of HIV progression of the combination didanosine (2',3'-dideoxyinosine or DDI) plus stavudine (2',3'-didehydro-2',3'-dideoxythymidine or D4T) with or without hydroxyurea. The primary end point was a reduction of HIV RNA levels to below 200 copies/ml after 12 weeks of treatment. The results showed that the triple combination was associated with a more profound decrease in HIV RNA with an increased proportion of patients with viraemia < 200 copies/ml. This effect persisted for the majority of the patients after a 48 week follow-up. In contrast, the increase in CD4 cell counts was less in patients treated with hydroxyurea because of lymphopenia, and adverse events were more frequent in hydroxyurea-treated patients. In conclusion, the addition of hydroxyurea consistently improved the antiviral activity of the didanosine/stavudine combination over a 48 week follow-up. Increased toxicity and decreased effect on CD4 cell counts might inspire caution.

Anti-HIV Agents↗

[The role of hydroxyurea in globin gene expression and cell differentiation of human erythroleukemia cell line].

The HEL cells, a human erythroleukemia cell line, express mainly the fetal globin gene and small amount of the embryonic (epsilon) globin gene, but not the adult (beta) globin gene. Hydroxyurea, a small organic compound, has been successfully used to treat sickle cell anemia and beta-thalessaemia. Our data demonstrated that the growth rate of HEL cell proliferation was inhibited by different doses of hydroxyurea (from 50 mumol/L to 200 mumol/L). Using both routine RT-PCR and quantitative PCR analyses, we revealed that the expression of beta-globin gene was sharply activated and alpha-globin gene was almost completely silenced when HEL cells were induced for 3 or 5 days. Meanwhile, gamma-globin gene was expressed with no much difference between induced and uninduced HEL cells. We also demonstrated that the expression of GATA-1 and NF-E 2, which were two of the most important transcription factors in erythrocyte development, was activated about 3 folds in the induced cells. We suggested that the induction of GATA-1 and NF-E 2 expression by hydroxyurea might lead to activation of the adult beta-globin gene through some pathways of signal transduction, therefore, hydroxyurea might play a role to induce HEL cells to terminal differentiation.

Antineoplastic Agents↗

Short-term anti-HIV activity of the combination of didanosine and hydroxyurea.

The synergistic action of hydroxyurea with some other antiretroviral drugs led us to evaluate the effect of therapy with the combination of didanosine and hydroxyurea in HIV-1-infected patients. We aimed to assess the anti-HIV activity of therapy with this combination by measuring variations in viral load and in CD4 cell counts. We also evaluated the potential side effects of this drug combination in HIV-1-positive patients with advanced disease. A total of 15 HIV-1-seropositive homosexual men with a mean baseline CD4 cell count of 149 cells/mm3 (range: 1-430 cells/mm3) were recruited to the study, and received didanosine (200 mg) plus hydroxyurea (500 mg) twice daily for 12 weeks. Ten patients were didanosine naive and five had previously received didanosine (for > 3 months). The combination therapy was well tolerated, although grade 2-3 alopecia appeared in four patients who had very low CD4 cell counts (< 50 cells/mm3). No significant variation in renal, hepatic and pancreatic functions occurred. A significant reduction in the plasma HIV-1 RNA (> 0.5 logs) was observed in seven of ten patients naive to didanosine after weeks 4 and 12 of the study; five of these patients had a decrease in plasma HIV-1 RNA of > 1.5 logs, with two having a decrease of > 2.0 logs. The viral load became undetectable (below 200 copies/ml) in three patients. The patients whose plasma HIV-1 RNA levels were not significantly reduced by the combination therapy had a higher baseline viral load. CD4 cell counts did not increase significantly in most patients. We observed a better response in those patients who had virus of the non-syncytium-inducing phenotype. In conclusion, hydroxyurea in combination with didanosine was well tolerated and led to a reduction in viral load mainly in patients who were initially naive to didanosine.

Acquired Immunodeficiency Syndrome↗

Hydroxyurea for treatment of polycythemia secondary to right-to-left shunting patent ductus arteriosus in 4 dogs.

Four adult dogs with polycythemia secondary to reversed patent ductus arteriosus (rPDA) were treated with hydroxyurea, a myelosuppressive agent, for 6-22 months. Regardless of initial hematocrit, clinical signs attributed to the presence of polycythemia improved with hydroxyurea treatment. Chronic hydroxyurea therapy (40-50 mg/kg PO q48h) was well tolerated in this group of animals; mild, clinically silent thrombocytopenia and leukopenia were detected in some animals but resolved with decreased dosage or dose frequency. Chronic hydroxyurea therapy may provide an alternative to repeated phlebotomy for therapy of polycythemia secondary to rPDA.

Animals↗

Hydroxyurea in sickle cell disease patients from Eastern Saudi Arabia.

OBJECTIVE: To assess the efficiency and safety of hydroxyurea in patients with sickle cell disease from the Eastern Province, Kingdom of Saudi Arabia. METHODS: The study was an open-label and uncontrolled trial. Patients older than 10 years of age with sickle cell disease who suffered 4 or more episodes of painful vaso-occlusive crises requiring admissions per year were included, 36 patients (23 males and 13 females) were included between June 1994 and June 1998. Patients were started on hydroxyurea at a dose of 8-10mg/kg per day and the dose was escalated to a maximum tolerated dose or a dose of 35 mg/kg per day. Blood count, renal and liver functions, and hemoglobin F levels were monitored regulary. Clinical response was assessed by record of number of vaso-occlusive crises, requirement for hospital admission and self scoring at the end of each year of treatment. RESULTS: Thirty-six patients were enrolled in the study until the time of analysis of the data. The data of the first 27 patients (18 males and 9 females) who completed 12 months of therapy were analyzed and presented. There was significant reduction in leukocyte, platelet counts and rise in total hemoglobin and hemoglobin F. Hemoglobin F rose by 1.2-13 folds, from the baseline. Seventy-four percent of patients had at least 2 fold rise of maximum hemoglobin F. The mean maximum tolerated dose of hydroxyurea was 16.4 mg/kg. There was significant reduction in hospital admissions and hospital stay. No major side effects had occured. CONCLUSION: Hydroxyurea seems to be effective in decreasing the frequency of vasooclusive crises in patient with sickle cell disease from Eastern Saudi Arabia. In this preliminary analysis no major side effects were observed. Long term side effects need to be monitored.

Adolescent↗

Effect of hydroxyurea on the protein content and synthesis in normal and tumorous tobacco tissues cultured in vitro.

An over 9 per cent increase was found in the protein content of callus and tumorous tissues of Nicotiana tabacum cultured for 39 days in a medium with an addition of hydroxyurea at a concentration of 100 mg/l. The inhibitory effect of this compound on incorporation of [14C]leucine was demonstrated, differences in the intensity of labelling between the nucleus and cytoplasm being present only in the tumorous tissue. These differences may indicate either disturbances in the migration of proteins from cytoplasm to nuclei or a specific blockade of histone synthesis. Hydroxyurea inhibits incorporation of [3H]arginine in callus tissues, whereas in tumorous tissues, apart from inhibition (at 75 and 100 mg HU/1), the stimulation of incorporation of this amino acid was observed (at 10 and 50 mg HU/1). The inhibitory effect of hydroxyurea on incorporation of [3H] lysine was demonstrated in both tissues examined, but it was stronger in the callus tissue. On the basis of the results concerning the influence of hydroxyurea on the content and synthesis of nucleic acids [4, 5] and the results of the present study it may be supposed that this compound induces unbalanced growth of cells of both tissues (inhibition of DNA and RNA synthesis and simultaneous accumulation of proteins), thus leading to their death.

Arginine↗

[Ulcers on the legs and feet: a seldom recognised side effect of hydroxyurea].

Three male patients aged 52, 49 and 74 years who were treated with hydroxyurea for chronic myeloid leukaemia (CML) or essential thrombocytosis developed severely painful ulcers on the lower legs and feet after an interval varying from 4 months to 2.5 years. These ulcers only healed after discontinuation of the drug. This is an adverse effect of hydroxyurea that is not infrequently seen but is difficult to recognise. The precise pathogenesis is still unclear but micro-circulatory disorders and a direct cytostatic effect on the epidermal cells probably play a role. Often, the drug has already been used for several years before the ulcers develop. They are resistant to treatment unless the hydroxyurea is stopped. Alternatives to hydroxyurea are imatinib for the treatment of CML and interferon alpha-2a or anagrelide for essential thrombocytosis.

Aged↗

Cutaneous ulcerations on hands and heels secondary to long-term hydroxyurea treatment.

Hydroxyurea is a chemotherapeutic agent used to treat myeloproliferative disorders and other non-neoplastic conditions. Cutaneous side-effects have been described in long-term therapy with hydroxyurea and include xerosis, hyperpigmentation, skin atrophy, erythema, alopecia, skin tumours and ulceration of the skin, particularly of the legs. We present a 71-year old patient with chronic myelocytic leukemia (CML) who developed extremely painful ulcers on the hands and heels as well as skin tumours while on long-term therapy with hydroxyurea. The ulcers were resistant to therapy but healed three months after discontinuation of hydroxyurea therapy.

Aged↗

Treatment of colon cancer based on biochemical modulation of fluoropyrimidines by hydroxyurea.

Preclinical studies have indicated that hydroxyurea leads to enhancement of 5-fluorouracil (5-FU) activity when given after 5-FU. This is presumably due to hydroxyurea's actions resulting in maintaining low levels of deoxyuridine monophosphate pools. The combination of hydroxyurea and 5-FU has been tested in several inconclusive clinical trials in patients with advanced colorectal cancer. However, pharmacodynamic studies have been lacking, and the schedules tested have not usually tried to follow preclinical findings. With the current renewed interest in 5-FU, a role for hydroxyurea as part of its biochemical modulation is worthy of further study.

Animals↗

Hydroxyurea as treatment for sickle cell anemia.

Hydroxyurea may be the most promising drug suggested thus far as a treatment for patients with sickle cell anemia, but its safety and efficacy remain unproved, and it probably will not be evaluable for several years. It is not "the answer" for the disease, it seems likely that crises will not be eliminated by treatment, and at this time its use should be reserved for seriously affected adult patients who can participate in a controlled clinical trial. Every hematologist, internist, or pediatrician sees a few patients who are so severely afflicted by sickle cell anemia that their lives seem totally blighted. It is very tempting to consider treating them with hydroxyurea, because the drug is available in any pharmacy, but it is equally important to consider whether the treatment would accomplish any more than treating the physician's own sense of futility, or making the patient feel that "something was being done." If hydroxyurea were as safe as folic acid, treatment for these purposes would be reasonable. It is not, but its use may still be appropriate (although illegal unless used under an Investigational New Drug Agreement, because its use for this purpose is not approved by the FDA). Whether or not it is legal, prescription of hydroxyurea for patients with sickle cell anemia would be ethical or proper only if the potential risks, the variability of the Hb F response, and the lack of proof of clinical efficacy were clearly explained to potential recipients.

Anemia, Sickle Cell↗

Pharmacokinetics of hydroxyurea 1,000 mg coated breakable tablets and 500 mg capsules in pediatric and adult patients with sickle cell disease.

Little is known about the pharmacokinetics of hydroxyurea in patients with sickle cell disease (SCD). Our aims were to evaluate bioequivalence between standard hydroxyurea capsules and a new formulation of 1,000 mg coated breakable tablets in adults and to compare pharmacokinetic parameters in adults and children with SCD. Fifteen adults received hydroxyurea capsules and tablets in a randomized cross-over study. Eleven children received hydroxyurea tablets. The results showed bioequivalence between capsules and tablets in adults. Pharmacokinetic parameters were not significantly different between adults and children. Considerable inter-individual variability was noted.

Adolescent↗

Cooperative enhancement of F-cell formation in baboons treated with erythropoietin and hydroxyurea.

Chronically anemic baboons on a continuous hydroxyurea regimen were treated with pulsed doses of recombinant human erythropoietin (rHuEpo) to test whether the combination of these two compounds, which individually induce F-cell production, can enhance further F-cell output. A low-F-cell-responding animal under chronic hydroxyurea treatment was given three separate pulses of Epo and responded with F-reticulocyte increments that were similar to the sum increments caused by either hydroxyurea alone or rHuEpo alone. The same results were obtained in a high-F-responding animal similarly treated. These findings suggest that rHuEpo and hydroxyurea can increase F cell numbers in an additive fashion. It is speculated that both compounds act through perturbation of erythroid differentiation kinetics.

Animals↗

Hydroxyurea in the prevention of the effects of leukostasis in acute leukemia.

Hydroxyurea was administered orally to prevent the effects of leukostasis in adults with acute leukemia who had peripheral blast cell counts greater than 100,000/cu mm. A single oral dose of 50 to 100 mg/kg was given daily until the absolute blast cell count decreased to less than 100,000/cu mm. Hydroxyurea was effective in rapidly lowering the blast cell count by an average of 50% after one dose in each of ten episodes. No patient developed symptoms or signs of the leukostasis syndrome, and no side effects directly attributable to hydroxyurea were observed. The leukostasis syndrome associated with very high blast cell counts in adults with acute leukemia can be avoided by the use of hydroxyurea in the manner described. This treatment can be particularly useful in the interval before consultation or referral and prior to the cytotoxic effect of definitive induction chemotherapy.

Acute Disease↗

Molecular mechanisms of drug resistance involving ribonucleotide reductase: hydroxyurea resistance in a series of clonally related mouse cell lines selected in the presence of increasing drug concentrations.

Mammalian ribonucleotide reductase is a highly regulated, rate-limiting activity responsible for converting ribonucleoside diphosphates to the deoxyribonucleotide precursors of DNA. The enzyme consists of two nonidentical proteins often called M1 and M2, both of which are required for activity. Hydroxyurea is an antitumor agent which inhibits ribonucleotide reductase by interacting with the M2 component specifically at a unique tyrosyl free radical. To obtain further information about drug resistance mechanisms, we have used M1 and M2 complementary DNAs and monoclonal antibodies to investigate the properties of a series of clonally related drug-resistant mouse cell lines, selected by a step-wise procedure for increasing levels of resistance to the cytotoxic effects of hydroxyurea. Several interesting mechanisms have been identified. Each successive drug selection step leading to the isolation of highly resistant cells was accompanied by stable elevations in cellular resistance and ribonucleotide reductase activities. The changes that occurred at each step involved the M2 component. A very early event, occurring at the first step in the selection process, was the amplification of the M2 gene accompanied by an increase in M2 messenger RNA. Although cellular resistance and M2 protein levels increased significantly during drug selection, only a modest change in M2 gene copy number was observed after the initial selection step. Analysis of wild type, moderately resistant, and highly resistant cells indicated that, in addition to M2 gene amplification, posttranscriptional modification also occurred during drug selection. This second mechanism was not due to alterations in protein M2 half-life, but involved an increase in translational efficiency. By increasing the rate of M2 synthesis, without altering degradation rates, resistant cells were able to accumulate high levels of this key regulatory protein. Cells selected for the ability to proliferate in concentrations of drug as high as 4 mM exhibited changes that involved M2, without detectable changes to M1. These results provide further evidence that M1 and M2 levels are controlled by different mechanisms in mammalian cells. Eventually, however, cells required an elevation in the M1 protein, as well as the M2 protein, to survive in a hydroxyurea concentration of 5 mM. These results illustrate the complexity of the drug-resistant phenotype and provide further information about the molecular processes that lead to the development of cells resistant to low, intermediate, and high concentrations of hydroxyurea.

Animals↗

Disappearance of haemopoietic stem cells from blood after hydroxyurea.

Haemopoietic stem cells were examined in the blood of mice which had been injected with hydroxyurea. It was observed that the amount of CFU in the blood quickly decreased and after higher doses of hydroxyurea CFU completely disappeared from blood. Since CFU are rather resistant to the killing effect of hydroxyurea, it is assumed that the observed effect is caused either by an interference of hydroxyurea (due to its effect on the blood-forming tissues) with the migration of CFU into blood or by stimulating the removal og CFU from blood.

Animals↗