| The Imiquimod
II./ El Imiquimod II.
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****** DATA-MEDICOS *********
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EL IMIQUIMOD II / THE IMIQUIMOD II
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***** DERMAGIC-EXPRESS No 8 *****
****** 22 OCTUBRE DE 1.998 *******
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EDITORIAL
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Hola de nuevo amigos Dermágicos, Ell Dr Gustavo Beltran (Peru) , me envía una excelente MONOGRAFIA del producto IMIQUIMOD, que la libero hoy para complementar los conocimientos sobre este nuevo producto.
Saludos a todos...
Proxima edicion: LA TALIDOMIDA, EL REGRESO...
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DERMAGIC/EXPRESS(8)
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E L I M I Q U I M O D II / THE IMIQUIMOD II
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DRUG EVALUATION MONOGRAPHS
Topic: IMIQUIMOD
0.0 OVERVIEW
A. Imiquimod is an immune response modifier.
B. DOSING INFORMATION: For the treatment of external
genital/perianal warts (venereal warts; condyloma
acuminata), a thin layer of imiquimod 5% cream is applied
to the warts 3 times a week until there is total
clearance of the lesions or for a maximum of 16 weeks.
C. PHARMACOKINETICS: The pharmacokinetics of imiquimod have
not been extensively studied; percutaneous absorption is
minimal. Less than 0.9% of a radiolabeled dose of
imiquimod is excreted in the urine and feces after
topical application. It is not known whether topically
applied imiquimod is excreted into breast milk.
D. CAUTIONS: Local skin reactions including erythema,
erosion, excoriation, flaking, and edema are the most
common adverse effects of topical imiquimod; therapy
should be temporarily discontinued until local effects
subside. Imiquimod has not been evaluated for the
treatment of urethral, intravaginal, cervical, rectal, or
intraanal human papillomavirus disease and is not
recommended for these conditions. The safety and
efficacy of imiquimod has not been determined in
pediatric or pregnant patients. Topical imiquimod is not
for ophthalmic use.
E. CLINICAL APPLICATIONS: Imiquimod 5% topical cream is
useful for the treatment of external genital and perianal
warts (condyloma acuminata) in adults. However,
comparative data are needed. Oral imiquimod has been
used for the treatment of HIV disease or cancer; more
safety and efficacy data are needed.
1.0 DOSING INFORMATION
1.1 DOSAGE FORMS
A. Information on specific dosage forms can be obtained by
entering a brand name or trade name at the "Type In
Topic" screen or by choosing "ProdIndx".
B. Imiquimod is manufactured in the US by 3M
Pharmaceuticals as a 5% topical cream (Aldara(R)).
C. SYNONYMS
1. R-837
2. S26308
1.2 STORAGE AND STABILITY
A. TOPICAL
1. Imiquimod 5% topical cream should not be stored above
30 degrees Centigrade; the product should not be
allowed to freeze (Prod Info Aldara(R), 1997).
1.3 ADULT DOSAGE
1.3.1 NORMAL DOSE
A. ADMINISTRATION TECHNIQUE
1. Proper administration technique should be demonstrated
DRUG EVALUATION MONOGRAPHS
Topic: IMIQUIMOD
by the prescriber to maximize the benefit of imiquimod
therapy. Handwashing before and after application is
recommended. Aldara(R) cream is packaged in single-use
packets which contain sufficient cream to cover a wart
area of up to 20 square centimeters; use of excessive
cream should be avoided. Patients should be instructed
to apply a thin layer of cream to the warts, and to rub
in the cream until it is no longer visible. The
application site is not to be occluded (Prod Info
Aldara(R), 1997).
B. TOPICAL
1. In the treatment of external genital or perianal warts
(VENEREAL WARTS; CONDYLOMA ACUMINATA) in patients
18 years of age or older, topical imiquimod 5 percent
cream (Aldara(R)) is to be applied 3 times a week,
prior to normal sleeping hours, and left on the skin
for 6 to 10 hours. Following each treatment period,
the cream should be removed by washing the treated area
with soap and water. Examples of 3 times per week
application schedules are: Monday, Wednesday, Friday
or Tuesday, Thursday, Saturday. Treatment should
continue until there is total clearance of the
genital/perianal warts, or for a maximum of 16 weeks
(Prod Info Aldara(R), 1997).
2. This topical regimen has shown efficacy in a controlled
trial (Beutner et al, 1994).
3. Local skin reactions (erythema) are common; a rest
period of several days may be taken if needed due to
patient discomfort or the severity of the local skin
reaction. Treatment may resume once the reaction
subsides. Nonocclusive dressings such as cotton gauze
or cotton underwear may be used in the management of
skin reactions (Prod Info Aldara(R), 1997).
1.4 PEDIATRIC DOSAGE
1.4.1 NORMAL DOSE
A. The safety and efficacy of imiquimod in patients below
the age of 18 have not been studied (Prod Info
Aldara(R), 1997).
2.0 PHARMACOKINETICS
2.3 ADME
2.3.1 ABSORPTION
A. TOPICAL, minimal (Prod Info Aldara(R), 1997).
1. No radioactivity was detected in the serum (lower limit
of quantitation: 1 ng/mL) (Prod Info Aldara(R), 1997).
2.3.4 EXCRETION
2.3.4.1 BREAST MILK
A. BREASTFEEDING: Unknown (Prod Info Aldara(R), 1997).
2.3.4.2 KIDNEY
A. RENAL EXCRETION: Less than 0.9% (Prod Info Aldara(R),
DRUG EVALUATION MONOGRAPHS
Topic: IMIQUIMOD
1997).
2.3.4.3 OTHER
A. FECES: Less than 0.9% (Prod Info Aldara(R), 1997).
3.0 CAUTIONS
3.1 CONTRAINDICATIONS
A. Previous hypersensitivity to imiquimod
3.2 PRECAUTIONS
A. Imiquimod has not been evaluated for the treatment of
urethral, intravaginal, cervical, rectal, or intraanal
human papillomavirus disease and is not recommended for
these conditions.
B. Pediatric patients (the safety and efficacy of imiquimod
in patients below the age of 18 have not been studied)
C. Topical imiquimod is not for ophthalmic use.
D. Local skin reactions, including erythema, erosion,
excoriation, flaking, and edema are common. If severe
local skin reactions occur, the cream should be removed
by washing the treatment area with soap and water.
Treatment can be resumed after the reaction has
subsided.
E. There is no clinical experience with topical imiquimod
therapy immediately following treatment with other
cutaneously applied drugs; therefore, topical imiquimod
administration is not recommended until genital/perianal
tissue is healed from any previous drug or surgical
treatment.
F. Topical imiquimod has the potential to exacerbate
inflammatory conditions of the skin.
3.3 ADVERSE REACTIONS
3.3.3 CENTRAL NERVOUS SYSTEM
A. CENTRAL NERVOUS SYSTEM EFFECTS
1. HEADACHE has been reported in patients receiving
topical imiquimod (Prod Info Aldara(R), 1997); however,
a causal relationship has not been determined.
3.3.5 GASTROINTESTINAL
A. GASTROINTESTINAL EFFECTS
1. DIARRHEA has been reported with topical imiquimod (Prod
Info Aldara(R), 1997); however, a causal relationship
has not been determined.
3.3.10 SKIN
A. DERMATOLOGIC EFFECTS
1. SUMMARY: Local skin reactions including ERYTHEMA,
EROSION, EXCORIATION, FLAKING, and EDEMA are common
with imiquimod 5% cream (Prod Info Aldara(R), 1997).
but the incidence of systemic reactions was similar to
that observed with placebo (Beutner et al, 1994; Prod
Info Aldara(R), 1997).
3.3.11 MUSCULOSKELETAL
A. MUSCULOSKELETAL EFFECTS
DRUG EVALUATION MONOGRAPHS
Topic: IMIQUIMOD
1. MYALGIAS and FLU-LIKE SYMPTOMS have been reported with
topical imiquimod (Prod Info Aldara(R), 1997); however,
a causal relationship has not been determined.
3.3.12 OTHER
A. ADVERSE EFFECTS - GENERAL
1. Fatigue, malaise, vomiting, mood changes, and
hypotension were dose-limiting toxicities in AIDS
patients treated with weekly oral doses of imiquimod
200 to 500 milligrams. Four of 12 patients who entered
into a maintenance treatment phase withdrew because of
malaise (2 patients) or grade 3 hepatotoxicity
(2 patients) (Goldstein et al, 1994).
2. In another trial, administration of oral imiquimod
100 to 500 milligrams once a week or 200 or 300 mg
twice a week resulted in dose-limiting toxicities
including fatigue, vomiting, chills and headache (Witt
et al, 1993).
B. CARCINOGENIC EFFECTS
1. Rodent carcinogenicity data are not available.
Imiquimod had no effect in a series of 8 different
mutagenicity assays including Ames, mouse lymphoma,
Chinese hamster ovary chromosome aberration, SHE cell
transformation, rat and hamster bone marrow
cytogenetics, and mouse dominant lethal test. Daily
oral administration of imiquimod in rats at doses up to
8 times the recommended human dose on a mg/m(2) basis
throughout mating, gestation, parturition, and
lactation demonstrated no impairment of reproduction
(Prod Info Aldara(R), 1997).
3.4 TERATOGENICITY/EFFECTS IN PREGNANCY
A. TERATOGENICITY
1. Imiquimod 5% topical cream is classified as FDA Pregnancy
Category B by the manufacturer (Prod Info Aldara(R),
1997).
See Drug Consult reference: "PREGNANCY RISK CATEGORIES"
2. There are no studies of topical imiquimod in pregnant
women. Imiquimod was not found to be rat or rabbit
teratology studies. In rats at high maternally toxic
doses (28 times the human dose on a mg/m(2) basis),
reduced pup weights and delayed ossification were
observed. In developmental studies with offspring of
pregnant rats treated with imiquimod (8 times human
dose), no adverse effects were demonstrated (Prod Info
Aldara(R), 1997).
4.0 CLINICAL APPLICATIONS
4.1 MONITORING PARAMETERS
4.1.1 THERAPEUTIC
A. PHYSICAL EXAMINATION
1. Reduction in wart size is indicative of a therapeutic
DRUG EVALUATION MONOGRAPHS
Topic: IMIQUIMOD
response to imiquimod.
4.1.2 TOXIC
A. PHYSICAL EXAMINATION
1. Patients receiving topical imiquimod should be
monitored for signs and symptoms of hypersensitivity to
it.
4.2 PATIENT INSTRUCTIONS
IMIQUIMOD (i-mi-KWI-mod) (For the skin):
- Treats genital warts.
BRAND NAME(S): Aldara(R)
WHEN YOU SHOULD NOT TAKE THIS MEDICINE:
- Do not use this medicine if you have had an allergic
reaction to imiquimod.
HOW TO TAKE AND STORE THIS MEDICINE
Cream:
- Your doctor will tell you how much medicine to use
and how often. You may be told to use the cream 3
times each week (Monday-Wednesday- Friday OR Tuesday-
Thursday-Saturday) right before you go to bed.
- Keep using the cream until the warts are gone or up
to 16 weeks. If you still have the warts after 16
weeks, talk with your doctor.
- Use the cream only on your skin. Do not get the
medicine in your eyes. Do not use the medicine inside
your vagina or anus.
- Wash your hands with soap and water before and after
you use this medicine.
- Put a thin layer of cream over the warts and gently
rub the cream into your skin.
- Do not bandage or tightly wrap the area so that air
cannot get to it. You may use gauze over the area, or
wear cotton underwear.
- Leave the cream on for 6-to-10 hours. Then wash the
cream off using a mild soap and water.
- Store the cream at room temperature away from heat
and moisture. Do not freeze.
- Keep all medicine out of the reach of children.
If you miss a dose:
- Use the medicine as soon as possible, unless it is
almost time for your next dose.
- Skip the missed dose if it is almost time for your
next regular dose.
- Do not put on two doses at the same time.
DRUGS AND FOODS TO AVOID:
Ask your doctor or pharmacist before taking any other
medicine, including over-the counter products.
WARNINGS:
- If you are pregnant or breastfeeding, talk to your
DRUG EVALUATION MONOGRAPHS
Topic: IMIQUIMOD
doctor before using this medicine.
- Do not have sex while being treated for warts, even
if you or your partner are using a condom. The cream
can weaken condoms and diaphragms, so you and your
partner may be unprotected during sex.
- Imiquimod is not a cure for genital or anal warts, so
you may develop new warts while using the cream.
SIDE EFFECTS
Call your doctor right away if you have any of these side
effects:
- Severe skin burning, pain, or peeling
- Open sores where you use the medicine
If you have problems with these less serious side effects,
talk with your doctor:
- Mild skin redness, swelling, flaking, or dryness
- Itching
- Headache, muscle pain, or feeling like you have the
flu
IF YOU HAVE OTHER SIDE EFFECTS THAT YOU THINK ARE CAUSED
BY THIS MEDICINE, TELL YOUR DOCTOR
4.3 PLACE IN THERAPY
A. Imiquimod topical cream appears to be safe and effective
for the treatment of condyloma acuminata. As an immune
response modifier, imiquimod represents a new
therapeutic approach to the treatment of this disease.
Other available treatments for genital warts have
included chemical burn, loop electrocautery excision,
surgery, laser excision, cryotherapy, intralesional
interferon, and tissue-destructive drugs such as
podofilox and podophyllin. Imiquimod may offer
increased patient comfort and compliance, and may
encourage the patient to seek medical treatment.
However, more comparative data are needed to assess the
place of imiquimod in therapy.
B. Imiquimod has been used in early clinical trials for the
treatment of cancer and AIDS. However, data are
extremely limited, and more clinical trials are needed.
Phase I trials have reported little or no antineoplastic
activity, and significant toxicity, of oral imiquimod.
4.4 MECHANISM OF ACTION/PHARMACOLOGY
A. MECHANISM OF ACTION
1. The mechanism of action of imiquimod in the treatment
of genital and perianal warts is unknown. Imiquimod
has no direct antiviral activity in cell culture.
Mouse skin studies suggest that imiquimod induces
cytokines including interferon-alpha. However, the
clinical relevance of these findings is unknown (Prod
Info Aldara(R), 1997).
2. In one study, serum interferon-alpha levels were
DRUG EVALUATION MONOGRAPHS
Topic: IMIQUIMOD
induced after oral administration of imiquimod
100 to 500mg once a week and 200 or 300 mg twice a week
to patients with cancer. Significant increases in
serum beta-2 microglobulin, serum neopterin, and 2-5A
synthetase activity in peripheral blood mononuclear
cells were also observed (Witt et al, 1993).
B. PRECLINICAL PHARMACOLOGY
1. Oral treatment of mice with imiquimod 30 mg/kg every
3 days significantly inhibited the growth of MC-26
colon carcinoma. An antiserum to murine
interferon-alpha significantly inhibited the antitumor
effects of imiquimod, suggesting that these effects
were mediated by interferon induction. Imiquimod also
significantly reduced the number of lung colonies in
mice inoculated with MC-26 tumor cells. Imiquimod plus
cyclophosphamide resulted in significantly better
responses than either drug alone and led to cures in
some of the mice inoculated with either subcutaneous or
intravenous MC-26 cells. Imiquimod treatment also
resulted in tumor growth inhibition in mice with RIF-1
sarcoma and Lewis lung carcinoma, but was not effective
in P388 leukemia (Sidky et al, 1992).
2. Imiquimod has been shown to be a direct B cell mitogen
in vitro. In one study, it induced the proliferation
of murine B cells in a dose-dependent manner; it also
induced IgM secretion from resting B cells. This
effect was enhanced by the addition of interferon-gamma
(Tygrett et al, 1996).
3. Other studies have shown imiquimod to be an inducer of
several cytokines, including interferons and tumor
necrosis factor in human lymphocytes, monocytes, and
keratinocytes in vitro (Testerman et al, 1995; Gibson
et al, 1995; Kono et al, 1994; Megyeri et al, 1995;
Weeks & Gibson, 1994).
C. REVIEW ARTICLES
1. A review of various approaches to immunomodulation,
including imiquimod, is available (Johnson, 1994).
2. A review of antiviral agents in dermatology, including
imiquimod, is provided (Memar & Tyring, 1995).
4.5 THERAPEUTIC USES
A. AIDS
1. OVERVIEW
FDA APPROVAL: Adult, no; pediatric, no
EFFICACY: Adult, possibly effective
DOCUMENTATION: Adult, poor
2. SUMMARY: Oral imiquimod has not been extensively
studied in the treatment of HUMAN IMMUNODEFICIENCY
VIRUS INFECTION.
3. ADULT:
DRUG EVALUATION MONOGRAPHS
Topic: IMIQUIMOD
a. Significant rises in serum interferon, beta-2
microglobulin, and neopterin levels were observed with
weekly oral doses of imiquimod of more than 100
milligrams in a phase I study of 12 patients with
asymptomatic HIV INFECTION. CD4 counts increased by a
median of 13% at week 1 and 20% at week 9. Fatigue,
malaise, vomiting, mood changes, and hypotension were
dose-limiting toxicities in patients treated with
weekly doses of 200 to 500 milligrams. Four of 12
patients who entered into a maintenance treatment
phase withdrew because of malaise (2 patients) or
grade 3 hepatotoxicity (2 patients) (Goldstein et al,
1994).
B. CANCER
1. OVERVIEW
FDA APPROVAL: Adult, no; pediatric, no
EFFICACY: Adult, possibly effective
DOCUMENTATION: Adult, poor
2. SUMMARY: Oral imiquimod has not been extensively
studied in the treatment of cancer. Small trials have
achieved little or no beneficial activity with oral
imiquimod.
3. ADULT:
a. No antitumor activity was observed in one phase I
study involving 14 patients with cancer who received
oral imiquimod 100 to 500 milligrams (mg) once a week
or 200 or 300 mg twice a week. Dose-limiting
toxicities included fatigue, vomiting, chills and
headache (Witt et al, 1993).
b. A mixed response was observed in 1 of 21 patients with
refractory cancer in a phase I trial. Patients
received oral imiquimod 25, 50, 100 or 200 mg once
daily for a projected 112-day course. Only 3 patients
completed the course, all receiving 50 mg day.
Toxicity was dose- related, and consisted primarily of
flu-like symptoms, nausea, and lymphopenia. In the
patient with a mixed response, biological activity was
confirmed by significant and sustained elevations in
peripheral blood mononuclear cell 2-5 synthetase
levels at all doses, and elevations in neopterin,
beta-2-microglobulin, and interferon levels (Savage et
al, 1996).
C. CONDYLOMA ACUMINATA
FDA Labeled Indication
1. OVERVIEW
FDA APPROVAL: Adult, yes; pediatric, no
EFFICACY: Adult, effective
DOCUMENTATION: Adult, excellent
2. SUMMARY: Imiquimod 5% topical cream is effective for
DRUG EVALUATION MONOGRAPHS
Topic: IMIQUIMOD
the treatment of external genital and perianal warts
(VENEREAL WARTS) in adults, with a 40% to 56% complete
clearance of warts, a reduction in the recurrence rate.
Topical imiquimod 5% cream is to be applied 3 times a
week and left on the skin for 6 to 10 hours (Prod Info
Aldara(R), 1997).
3. ADULT:
a. Imiquimod 5% cream is more effective than placebo in
108 patients with genital or perianal warts due to
HUMAN PAPILLOMAVIRUS INFECTION. In this randomized,
double-blind study, patients received either imiquimod
cream or placebo 3 times weekly for up to 8 weeks.
Median wart area was reduced by 90% with a 40%
complete wart clearance in patients receiving
imiquimod, compared to no patients receiving placebo.
During a 10-week follow-up period, 81% of patients
receiving imiquimod had no recurrence of disease
(Beutner et al, 1994).
b. In another randomized, multicenter, double-blind study
of 311 patients with genital or perianal warts, warts
cleared in 56% of patients receiving imiquimod 5%
cream, in 27% patients receiving imiquimod 1%, and in
14% of patients receiving placebo. Clearance rates
for imiquimod 5% cream were 77% in females and 40% in
males; there were no significant differences in
recurrence rates (Edwards et al, 1995).
c. In another trial, patients receiving 5% topical
imiquimod cream experienced a 90% reduction in wart
area; 40% of patients receiving imiquimod had complete
clearance of warts, compared to no patients receiving
placebo (vehicle). Although imiquimod caused more
local skin irritation than placebo, no systemic
effects were reported (Spruance et al, 1993).
6.0 REFERENCES
1. Beutner K, Spruance S, Douglas J et al: Double-blind,
vehicle controlled, randomized, multicenter trial of 5%
imiquimod cream for the treatment of genital and perianal
warts (abstract). Second Int Cong Papillomavirus Human
Pathol 1994; 93.
2. Edwards L, Ferenczy A, Eron L et al: Multi-center safety
and efficacy trial evaluating three times per week
application of 1% and 5% topical imiquimod for the
treatment of genital/perianal warts (abstract).
Antiviral Research 1995; 26:A244.
3. Gibson SJ, Imbertson LM, Wagner TL et al: Cellular
requirements for cytokine production in response to the
immunomodulators imiquimod and S-27609. J Interferon
Cytokine Res 1995; 15:537-545.
4. Goldstein D, Tomkinson E, Couldwell D et al: Phase I A/B
DRUG EVALUATION MONOGRAPHS
Topic: IMIQUIMOD
trial of imiquimod, an oral interferon inducer in
asymptomatic HIV positive individuals (abstract). AIDS
1994; 8(Suppl):14.
5. Johnson AG: Molecular adjuvants and immunomodulators:
new approaches to immunization. Clin Microbiol Reviews
1994; 7:277-289.
6. Kono T, Kondo S, Pastore S et al: Effects of a novel
topical immunomodulator, imiquimod, on keratinocyte
cytokine gene expression. Lymphokine Cytokine Res 1994;
13:71-76.
7. Megyeri K, Au WC, Rosztoczy I et al: Stimulation of
interferon and cytokine gene expression by imiquimod and
stimulation by Sendai virus utilize similar signal
transduction pathways. Molec Cell Biol 1995;
15:2207-2218.
8. Memar OM & Tyring SK: Antiviral agents in dermatology:
current status and future prospects. Int J Dermatol
1995; 14:597-606.
9. Product Information: Aldara(R), imiquimod 5% cream. 3M
Pharmaceuticals, Northridge, CA, 1997.
10. Savage P, Horton V, Moore J et al: A phase I clinical
trial of imiquimod, an oral interferon inducer,
administered daily. Br J Cancer 1996; 74:1482-1486.
11. Sidky YA, Borden EC, Weeks CE et al: Inhibition of
murine tumor growth by an interferon-inducing
imidazoquinolinamine. Cancer Res, 1992; 52:3528-3533.
12. Spruance S, Douglas J, Hougham A et al: Multicenter
trial of 5% imiquimod (IQ) cream for treatment of
genital and perianal warts (abstract). Prog Abstr 33rd
Intersci Conf Antimicrob Agents and Chemother (ICAAC),
Oct 17-20, 1993, New Orleans, LA, American Society of
Microbiology, session 131, abstract 1432.
13. Testerman TL, Gerster JF, Imbertson LM et al: Cytokine
induction by the immunomodulators imiquimod and S-27609.
J Leukocyte Biol 1995; 58:365-372.
14. Tygrett LT, Li X, Tomai MA et al:
Imidazoquinolinamines, a new class of immunomodulating
drugs, are direct B cell mitogens (abstract). FASEB J
1996; 10:A1461.
15. Weeks CE & Gibson SJ: Induction of interferon and other
cytokines by imiquimod and its hydroxylated metabolite
R-842 in human blood cells in vitro. J Interferon Res
1994; 14:81-85.
16. Witt PL, Ritch PS, Reding D et al: Phase I trial of an
oral immunomodulator and interferon inducer in cancer
patients. Cancer Res 1993; 53: 5176-5180.
7.0 AUTHOR INFORMATION
Original publication: 03/97
Most recent revision: 12/97
DRUG EVALUATION MONOGRAPHS
Topic: IMIQUIMOD
List of contributors:
1. DRUGDEX(R) Editorial Staff
For further information on contributing authors,
see editorial board listings.
(c)1974-1998 Micromedex Inc. - All rights reserved - Vol. 96 Exp. 30/06/98
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DATA-MEDICOS/DERMAGIC-EXPRESS No (8) 25/10/98 DR. JOSE LAPENTA R. DERMATOLOGO
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Dr. Jose Lapenta R.
Maracay Venezuela
[email protected]
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