|Drug class||Epidermal growth factor receptor (EGFR) inhibitor|
|Main uses||Colorectal cancer, head and neck cancer|
|Side effects||Rash, low magnesium, mouth inflammation, liver problems|
|Elimination half-life||114 hrs|
|Chemical and physical data|
|Molar mass||145781.92 g·mol−1|
Cetuximab, sold under the brand name Erbitux, is a medication used to treat colorectal cancer and head and neck cancer. For colon cancer it is for metastatic disease that is EGFR positive and without RAS gene mutation. It is given by injection into a vein.
Common side effects include rash, low magnesium, mouth inflammation, and liver problems. Other side effects include infusion reactions. Use in pregnancy may harm the baby. It is a monoclonal antibody and epidermal growth factor receptor (EGFR) inhibitor.
Cetuximab was approved for medical use in Europe and the United States in 2004. In the United Kingdom 500 mg costs the NHS about £890 as of 2021. In the United States this amount is about 3,600 USD.
A diagnostic immunohistochemistry assay (EGFR pharmDx) can be used to detect EGFR expression in the tumor material. Approximately 75% of patients with metastatic colorectal cancer have an EGFR-expressing tumor and are therefore considered eligible for treatment with cetuximab or panitumumab, according to FDA guidelines. Unfortunately, there is evidence that immunohistochemical EGFR receptor testing does not predict response to either cetuximab or panitumumab, so that this has been called a "misleading biomarker" that has nevertheless caused insurers and even health systems to deny payment for EGFR antibody treatment for patients who lack a positive tumor EGFR histochemical test.
Head and neck cancer
Cetuximab was approved by the FDA in 2006 for use in combination with radiation therapy for treating squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in people who have had prior platinum-based therapy.
In July 2009, the US Food and Drug Administration (FDA) updated the labels of two anti-EGFR monoclonal antibody drugs (panitumumab and cetuximab) indicated for treatment of metastatic colorectal cancer to include information about KRAS mutations.
Studies have indicated that detection of KRAS gene mutations helps physicians identify patients that are unlikely to respond to treatment with targeted EGFR inhibitors, including cetuximab and panitumumab. Accordingly, genetic testing to confirm the absence of KRAS mutations (and so the presence of the KRAS wild-type gene), is now clinically routine before the start of treatment with EGFR inhibitors. mCRC patients with wild-type KRAS tumors have been shown to benefit from a response rate of over 60% and a decreased risk for progression of over 40% when treated with Erbitux as 1st-line therapy.[medical citation needed] Around 65% of mCRC patients have the KRAS wild-type gene.[medical citation needed]
It is used at an initial dose of 400 mg/m2 which is followed by 250 mg/m2 every week.
Further severe infusion reactions include but are not limited to: fevers, chills, rigors, urticaria, itchiness, rash, hypotension, nausea, vomiting, headache, shortness of breath, wheezing, angioedema, dizziness, anaphylaxis, and cardiac arrest. Therefore, pretreatment with diphenhydramine (30 to 60) min before administration is standard of care. Other common side effects include photosensitivity, hypomagnesemia due to magnesium wasting, and less commonly pulmonary and cardiac toxicity. 
Certain geographic regions have a high rate of anaphylactic reactions to cetuximab upon the first exposure to the medication. This is unusual because exposure to the allergen must occur before the development of an allergy. Fewer than 1% of people in the northeast United States reacted, while greater than 20% in the southeast did. The alpha-gal allergy is believed to result from tick bites. Lone star ticks are native to the regions of the US where reactions occurred and were found to be the vector. Cetuximab is produced in the mouse myeloma cell line SP2/0, and contains the alpha-gal oligosaccharide on the Fab portion of the heavy chain.
Mechanism of action
Cetuximab is a chimeric (mouse/human) monoclonal antibody which binds to and inhibits EGFR.
Michael Sela, Ester Hurwitz and co-workers published observations on EGFR inhibition in 1988. Yeda Research, on behalf of the Weizmann Institute of Science in Israel, challenged the Aventis-owned patent, licensed by Imclone, for the use of anti-epidermal growth factor receptor antibodies in combination with chemotherapy, to slow the growth of certain tumors which was filed in 1989 by Rhone-Poulenc-Rorer. The court ruled that Yeda is sole owner of the patent in the U.S., while Yeda and Sanofi-Aventis co-own the patent's foreign counterparts.
Society and culture
- Eli Lilly and Company is responsible for the manufacture and supply of Erbitux in bulk-form active pharmaceutical ingredient (API) for clinical and commercial use in the U.S. and Canada.
- Merck KGaA manufactures Erbitux for supply in its territory (outside the U.S. and Canada) as well as for Japan.
- Erbitux is marketed in the U.S. and Canada by Eli Lilly.
- Outside the U.S. and Canada, Erbitux is commercialized by Merck KGaA. Eli Lilly receives royalties from Merck KGaA.
- A separate agreement grants co-exclusive rights among Merck, Bristol-Myers Squibb and Eli Lilly in Japan and expires in 2032.
Merck KGaA had 887 million euros ($1.15 billion) in Erbitux sales in 2012, from head and neck as well as bowel cancer, while Bristol-Myers Squibb generated $702 million in sales from the drug.
Erbitux was the eighth best-selling cancer drug of 2013, with sales of $1.87 billion.
Erbitux had 2013 worldwide sales of US$1.9 billion making it a lucrative target for biosimilars developers. Additionally the patent protection for Erbitux in Europe expired in June 2014, and in the U.S. and in Japan the protection will expire in 2016. However biosimilars of Erbitux are not expected until 2018.
Cetuximab failed to get FDA approval in 2001, which caused the stock price of the developer ImClone to drop dramatically. Prior to the announcement, several executives sold stock, and the SEC launched an investigation into insider trading. This resulted in a widely publicized criminal case, which resulted in prison terms for media celebrity Martha Stewart, ImClone chief executive officer Samuel D. Waksal and Stewart's broker at Merrill Lynch, Peter Bacanovic.
A 2020 phase 3 multicentre randomized controlled trial headed by University College London showed that adding cetuximab to perioperative chemotherapy worsened survival for colorectal cancer patients with operable liver metastases. With over 5 years of follow-up, median overall survival (OS) dropped from 81 months for patients treated with chemotherapy alone before and after liver resection, to 55.4 months for those that also received cetuximab.
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