DNA alkylating medications

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DNA alkylating medications

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Questions

USMLE® Step 1 style questions USMLE

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USMLE® Step 2 style questions USMLE

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A 72-year-old man presents to the emergency room with incoherent speech. He is accompanied by his spouse, who states the patient has had a headache for two weeks and that he appeared confused this morning. His medical history includes atrial fibrillation, hypertension, and diabetes. His current medications include warfarin, lisinopril, and metformin. Family history is noncontributory. He returned from a trip to India a month ago. His temperature is 37.0°C (98.6°F), pulse is 90/min, respirations are 18/min, blood pressure is 115/75 mmHg, and SpO2 is 98%. Pupils are equal and reactive to light. Extraocular movements are within normal limits. His speech is intangible, but he can pick up a pen and copy a picture of a matchstick when prompted. Axial MRI scan reveals a butterfly-shaped intracranial mass crossing the corpus callosum. Following a biopsy, he is initiated on procarbazine, lomustine, and vincristine regimen. Which of the following adverse effects can be expected in this patient?

External References

First Aid

2024

2023

2022

2021

Alkylating agents p. 445

as carcinogens p. 221

in cell cycle p. 443

targets of p. 443

teratogenicity of p. 632

Myelosuppression

alkylating agents p. 445

Transcript

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DNA alkylating medications are a class of drugs that are mainly used as anticancer agents. They disrupt the structure of DNA by adding an alkyl group to the guanine base and can affect all phases of the cell cycle.

Alright, the cell cycle refers to the events that somatic cells, which includes all of the cells in our bodies except the reproductive cells, go through from the moment they’re formed until the moment they divide into two identical daughter cells. This cycle varies in length depending on the type of cell. For rapidly dividing cells, like skin cells, it takes less than a day, whereas for other cells, like liver cells, the cell cycle can last years.

Now, the cell cycle can be divided in two phases: interphase and mitosis. Interphase comprises of the G1 phase, during which the cell grows and performs its cell functions, the S phase, during which DNA is replicated, and the G2 phase, during which the cell grows again before entering mitosis. Mitosis can be broken down into prophase, metaphase, anaphase, and telophase, during which the replicated DNA divides equally for the two daughter cells, and ends with cytokinesis, which is when the cell membrane actually divides to form the two new cells. There’s also a G0 phase which is an extended G1 phase where the cell is resting and not actively preparing to divide.

Alright, now imagine a cancer cell. This cell is going through the phases of the cell cycle without regulation, and its DNA also replicates more frequently and with less error-correcting than healthy cells. Therefore, it’s more sensitive to DNA damage.

Here’s a DNA base, guanine. Alkylating agents attach an alkyl group at the number 7 nitrogen atom of guanine. Based on their mechanism of action, alkylating agents are characterized as monofunctional, or bifunctional. When monofunctional alkylating agents attach an alkyl group to guanine, repair enzymes recognize there’s something wrong, so they attempt to replace the alkylated bases and cause fragmentation of the DNA, or DNA strand breakage. When this section of the DNA is repaired, abnormal base pairing could result, like having a thymine paired up with guanine instead of the usual cytosine. Eventually, the DNA damage, that is caused by the monofunctional alkylating agents, can potentially lead to carcinogenesis, or development of cancer cells, or it can result in cell death.

Summary

Alkylating medications are a type of chemotherapy drugs used against cancer, which work by damaging the DNA of cancer cells. They disrupt the structure of DNA by adding an alkyl group to the guanine base, which prevents cancer cells from growing and dividing. There are many different alkylating agents which can be given alone or in combination with other drugs. Examples of DNA alkylating medications include Cyclophosphamide, Busulfan, and Melphalan.

Sources

  1. "Katzung & Trevor's Pharmacology Examination and Board Review,12th Edition" McGraw-Hill Education / Medical (2018)
  2. "Rang and Dale's Pharmacology" Elsevier (2019)
  3. "Goodman and Gilman's The Pharmacological Basis of Therapeutics, 13th Edition" McGraw-Hill Education / Medical (2017)
  4. "Nomograms" D. Nicoll , C. Mark Lu, S.J. McPhee (Eds.), Guide to Diagnostic Tests, 7e. McGraw-Hill (2017)
  5. "Overview of hemostasis" J.C. Aster, H. Bunn (Eds.), Pathophysiology of Blood Disorders, 2e. McGraw-Hill. (2016)
  6. "Cyclophosphamide for the treatment of acute lymphoblastic leukemia" Medicine (2019)
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