Repositioning of Quinacrine for Treatment of Acute Myeloid Leukemia
Authors: Eriksson Anna , Osterros Albin , Hassan Sadia , Gullbo Joachim , Rickardson Linda , Jarvius Malin , Nygren Peter , Fryknas Marten , Hoglund Martin , Larsson Rolf 
Published: November 2019

Abstract
Background: A promising strategy for new drug discovery is ‘repositioning’, in which a new indication for an existing drug is identified. Using this approach, known on-patent, off-patent, discontinued and withdrawn drugs with unrecognized cancer activity, can be rapidly advanced into clinical trials for the new indication. We here report findings from a library screen of pharmacologically active and mechanistically annotated compounds in leukemia cells from patients aiming at the identification of repositioning candidates.
Methods and results: The LOPAC®, 1280substance library (Sigma-Aldrich), with 1266 mechanistically annotated compounds, were investigated for cytotoxic activity by the fluorometric microculture cytotoxicity assay (FMCA) on tumor cells from 12 patients with leukemia (4 acute lymphocytic leukemia, 4 acute myeloid leukemia [AML], 4 chronic lymphocytic leukemia), as well as on peripheral blood mononuclear cells (PBMC) from 4 healthy donors. Sixty-eight compounds were identified as hits, defined as having a cytotoxic activity (less than 50% cell survival compared with controls) in all leukemia subgroups at the 10µM drug concentration used for screening. Only one of the hit compounds, quinacrine, showed higher activity in the leukemic cells than in normal PBMCs and was therefore selected for further preclinical evaluation focusing on AML. The aminoacridine quinacrine has a wide range of biological and therapeutical applications, and has been used for decades outside hemato-oncology, notably as an anti-protozoal and anti-rheumatic drug. Its side effects and toxicity are well characterized.
Quinacrine showed significant cytotoxic activity in all four AML cell lines tested (HL-60, Kasumi-1, KG1a and MV4-11). In tumor cells from another 9 patients with AML, the cytotoxic effect (IC50 median 1.8, range 0.8-4 µM) was significantly superior to that in normal lymphocytes and clearly dose-dependent.
Analysis of quinacrine data from the National Cancer Institute growth inhibitory screen in 60 cell lines (NCI 60 GI 50 data) was performed with the help of the NCI Cellminer database (http://discover.nci.nih.gov/cellminer/), and indicated leukemia sensitivity. To examine the ability of quinacrine to reverse diagnosis-specific gene expression, we utilized the Nextbio bioinformatics software, with its gene expression signatures of drug exposed myeloid leukemia cell cultures (HL60). These queries showed that myeloid leukemias had high reversibility scores. Moreover, gene enrichment and drug correlation data revealed a strong association to ribosomal biogenesis nucleoli. Translation initiation was observed including a high drug-drug correlation with ellipticine, a known inhibitor of RNA polymerase I (Pol-I).
To validate the latter results, gene expression analysis of HL-60 cells exposed to quinacrine were obtained using the protocol described by Lamb et al (Science, 2006, 313, 1929), showing down regulation of Pol-1 associated RNA. Supporting these findings, quinacrine induced early inhibition of protein synthesis.
Conclusions: The anti-protozoal and anti-rheumatic drug quinacrine has significant in vitro activity in AML. The anti-leukemic effect may be mediated by targeting ribosomal biogenesis. Considering its favorable and well-known safety profile, clinical studies of quinacrine in AML should be considered.

Disclosures
No relevant conflicts of interest to declare.