title: Sunitinib-induced cardiotoxicity is mediated by off-target inhibition of AMP-activated protein kinase.
abstract: Tyrosine kinase inhibitors (TKIs) are transforming the treatment of patients with malignancies. One such agent, sunitinib (Sutent, Pfizer), has demonstrated activity against a variety of solid tumors. Sunitinib is "multi-targeted," inhibiting growth factor receptors that regulate both tumor angiogenesis and tumor cell survival. However cardiac dysfunction has been associated with its use. Identification of the target of sunitinib associated cardiac dysfunction could guide future drug design to reduce toxicity while preserving anti-cancer activity. Herein we identify severe mitochondrial structural abnormalities in the heart of a patient with sunitinib-induced heart failure. In cultured cardiomyocytes, sunitinib induces loss of mitochondrial membrane potential and energy rundown. Despite the latter, AMPK activity, which should be increased in the setting of energy compromise, is reduced in hearts of sunitinib-treated mice and cardiomyocytes in culture and this is due to direct inhibition of AMPK by sunitinib. Critically, we find that adenovirus-mediated gene transfer of an actived mutant of AMPK reduces sunitinib-induced cell death. Our findings suggest AMPK inhibition plays a central role in sunitinib cardiomyocyte toxicity, highlighting the potential of off-target effects of TKIs contributing to cardiotoxicity. While multi-targeting can enhance tumor cell killing, this must be balanced against the potential increased risk of cardiac dysfunction.
authors.affiliation: Center for Translational Medicine, Thomas Jefferson University, Philadelphia, PA, USA.
authors.forename: Risto
authors.initials: R
authors.lastname: Kerkela
authors.forename: Kathleen C
authors.initials: KC
authors.lastname: Woulfe
authors.forename: Jean-Bernard
authors.initials: JB
authors.lastname: Durand
authors.forename: Ronald
authors.initials: R
authors.lastname: Vagnozzi
authors.forename: David
authors.initials: D
authors.lastname: Kramer
authors.forename: Tammy F
authors.initials: TF
authors.lastname: Chu
authors.forename: Cara
authors.initials: C
authors.lastname: Beahm
authors.forename: Ming Hui
authors.initials: MH
authors.lastname: Chen
authors.forename: Thomas
authors.initials: T
authors.lastname: Force
mesh_terms: D055372:AMP-Activated Protein Kinases / Q000037:antagonists & inhibitors*; D000818:Animals; D001706:Biopsy; D002196:Capillaries / Q000187:drug effects; D002470:Cell Survival / Q000187:drug effects; D004452:Echocardiography; D006801:Humans; D007211:Indoles / Q000009:adverse effects / Q000494:pharmacology* / Q000633:toxicity*; D020128:Inhibitory Concentration 50; D000076222:Mechanistic Target of Rapamycin Complex 1; D053078:Membrane Potential, Mitochondrial / Q000187:drug effects; D051379:Mice; D008810:Mice, Inbred C57BL; D008928:Mitochondria / Q000187:drug effects / Q000473:pathology / Q000648:ultrastructure; D046912:Multiprotein Complexes; D009206:Myocardium / Q000473:pathology* / Q000648:ultrastructure; D032383:Myocytes, Cardiac / Q000187:drug effects / Q000473:pathology / Q000648:ultrastructure; D047428:Protein Kinase Inhibitors / Q000009:adverse effects / Q000494:pharmacology* / Q000633:toxicity*; D011506:Proteins; D011758:Pyrroles / Q000009:adverse effects / Q000494:pharmacology* / Q000633:toxicity*; D051381:Rats; D017207:Rats, Sprague-Dawley; D015398:Signal Transduction / Q000187:drug effects; D000077210:Sunitinib; D058570:TOR Serine-Threonine Kinases; D014157:Transcription Factors / Q000037:antagonists & inhibitors; D020257:Ventricular Remodeling / Q000187:drug effects
chemical_list: D007211:Indoles; D046912:Multiprotein Complexes; D047428:Protein Kinase Inhibitors; D011506:Proteins; D011758:Pyrroles; D014157:Transcription Factors; D000076222:Mechanistic Target of Rapamycin Complex 1; D058570:TOR Serine-Threonine Kinases; D055372:AMP-Activated Protein Kinases; D000077210:Sunitinib