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RAHWAY, N.J.--(BUSINESS WIRE)-- Merck (NYSE: MRK), known as MSD outside of the United States and Canada, today announced the discontinuation of the vibostolimab and pembrolizumab coformulation arm of the Phase 3 KeyVibe-010 trial. The trial is evaluating the investigational coformulation of vibostolimab, an anti-TIGIT antibody, and pembrolizumab (KEYTRUDA®), Merck’s anti-PD-1 therapy, compared to KEYTRUDA alone, as adjuvant treatment for patients with resected high-risk melanoma (Stage IIB-IV). At a pre-planned analysis, data showed that the primary endpoint of recurrence-free survival (RFS) met the pre-specified futility criteria. A higher rate of discontinuation of all adjuvant therapy by patients in the coformulation arm versus the KEYTRUDA-only arm, primarily due to immune-mediated adverse experiences, rendered it highly unlikely that the trial could achieve a statistically significant improvement in RFS. Based on the recommendation of an independent Data Monitoring Committee (DMC), Merck is unblinding the study and recommends that patients receiving the vibostolimab and pembrolizumab coformulation be offered the option to be treated with KEYTRUDA monotherapy. Data analysis from this study is ongoing. Results will be shared with the scientific community and communicated to regulatory agencies. “Through our clinical development program, we continue to ask the tough questions in an effort to fully explore the potential of novel coformulations and combinations that build on the foundation of KEYTRUDA, with a goal to improve upon current standards of care and help even more patients with cancer,” said Dr. Marjorie Green, senior vice president and head of oncology, global clinical development, Merck Research Laboratories. “We are grateful to the patients and investigators for their participation and will leverage insights from this trial as we rapidly advance our diverse pipeline of novel mechanisms, including further study of this coformulation in lung cancer.” Merck is committed to the development of new treatment options for patients with melanoma, including in earlier stages of disease, which build upon the current standard of care. The program includes the ongoing Phase 3 V940-001 study, in collaboration with Moderna, evaluating V940 (mRNA-4157), an investigational individualized neoantigen therapy (INT), in combination with KEYTRUDA as adjuvant treatment in patients with resected high-risk (Stage IIB-IV) melanoma. In the U.S., KEYTRUDA has two approved indications in melanoma: for the treatment of patients with unresectable or metastatic melanoma, and for the adjuvant treatment of adult and pediatric (12 years and older) patients with stage IIB, IIC, or III melanoma following complete resection. Vibostolimab is Merck’s investigational anti-TIGIT antibody that restores antitumor activity by blocking the TIGIT receptor from binding to its ligands (CD112 and CD155), thereby activating T lymphocytes that help destroy tumor cells. Merck has an extensive clinical development program evaluating the safety and efficacy of the vibostolimab and pembrolizumab coformulation alone and in combination with other agents in over 3,000 patients. Ongoing Phase 3 studies evaluating the vibostolimab and pembrolizumab coformulation in lung cancer, which are routinely monitored by external data monitoring committees, include KeyVibe-003, KeyVibe-006, KeyVibe-007 and KeyVibe-008. Interim external data monitoring committee safety reviews have not resulted in any safety-related study modifications to date. No changes to these studies are anticipated based on the KeyVibe-010 findings. About KeyVibe-010 KeyVibe-010 is a randomized, double-blind, active comparator-controlled Phase 3 trial (ClinicalTrials.gov, NCT05665595) evaluating a coformulation of vibostolimab and pembrolizumab (MK-7684A) versus KEYTRUDA alone as adjuvant treatment for patients with resected high-risk Stage IIB-IV melanoma. The trial’s primary endpoint is RFS. Key secondary endpoints include distant metastasis-free survival (DMFS) and overall survival (OS). The study enrolled 1594 patients who were randomly assigned (1:1) to receive: Vibostolimab/pembrolizumab coformulation (pembrolizumab 200 mg/20 mL and vibostolimab 200 mg intravenously [IV] every 3 three weeks [Q3W] for up to 17 cycles); or Pembrolizumab (adult patients receive 200 mg and adolescent patients ≥40 kg receive 2 mg/kg [up to a maximum of 200 mg] IV Q3W for up to 17 cycles). About melanoma Melanoma, the most serious form of skin cancer, is characterized by the uncontrolled growth of pigment-producing cells. The rates of melanoma have been rising over the past few decades, with more than 330,000 new cases diagnosed worldwide in 2022. In the U.S., skin cancer is one of the most common types of cancer diagnosed, and melanoma accounts for a large majority of skin cancer deaths. It is estimated there will be more than 100,000 new cases of melanoma diagnosed and more than 8,000 deaths resulting from the disease in the U.S. in 2024. About Merck’s early-stage cancer clinical program Finding cancer at an earlier stage may give patients a greater chance of long-term survival. Many cancers are considered most treatable and potentially curable in their earliest stage of disease. Building on the strong understanding of the role of KEYTRUDA in later-stage cancers, Merck is studying KEYTRUDA in earlier disease states, with more than 25 ongoing registrational studies across multiple types of cancer. About vibostolimab Vibostolimab (MK-7684) is an investigational humanized anti-TIGIT antibody discovered and developed by Merck. Vibostolimab restores antitumor activity by blocking the TIGIT receptor from binding to its ligands (CD112 and CD155), thereby activating T lymphocytes that help destroy tumor cells. The coformulation of vibostolimab and pembrolizumab and is being evaluated in a wide range of cancers, including lung, other solid tumors and blood cancers. About KEYTRUDA® (pembrolizumab) injection, 100 mg KEYTRUDA is an anti-programmed death receptor-1 (PD-1) therapy that works by increasing the ability of the body’s immune system to help detect and fight tumor cells. KEYTRUDA is a humanized monoclonal antibody that blocks the interaction between PD-1 and its ligands, PD- L1 and PD-L2, thereby activating T lymphocytes which may affect both tumor cells and healthy cells. Merck has the industry’s largest immuno-oncology clinical research program. There are currently more than 1,600 trials studying KEYTRUDA across a wide variety of cancers and treatment settings. The KEYTRUDA clinical program seeks to understand the role of KEYTRUDA across cancers and the factors that may predict a patient's likelihood of benefitting from treatment with KEYTRUDA, including exploring several different biomarkers. Selected KEYTRUDA® (pembrolizumab) Indications in the U.S. Melanoma KEYTRUDA is indicated for the treatment of patients with unresectable or metastatic melanoma. KEYTRUDA is indicated for the adjuvant treatment of adult and pediatric (12 years and older) patients with stage IIB, IIC, or III melanoma following complete resection. See additional selected KEYTRUDA indications in the U.S. after the Selected Important Safety Information. Selected Important Safety Information for KEYTRUDA Severe and Fatal Immune-Mediated Adverse Reactions KEYTRUDA is a monoclonal antibody that belongs to a class of drugs that bind to either the PD-1 or the PD-L1, blocking the PD-1/PD-L1 pathway, thereby removing inhibition of the immune response, potentially breaking peripheral tolerance and inducing immune-mediated adverse reactions. Immune-mediated adverse reactions, which may be severe or fatal, can occur in any organ system or tissue, can affect more than one body system simultaneously, and can occur at any time after starting treatment or after discontinuation of treatment. Important immune-mediated adverse reactions listed here may not include all possible severe and fatal immune-mediated adverse reactions. Monitor patients closely for symptoms and signs that may be clinical manifestations of underlying immune-mediated adverse reactions. Early identification and management are essential to ensure safe use of anti–PD-1/PD-L1 treatments. Evaluate liver enzymes, creatinine, and thyroid function at baseline and periodically during treatment. For patients with TNBC treated with KEYTRUDA in the neoadjuvant setting, monitor blood cortisol at baseline, prior to surgery, and as clinically indicated. In cases of suspected immune-mediated adverse reactions, initiate appropriate workup to exclude alternative etiologies, including infection. Institute medical management promptly, including specialty consultation as appropriate. Withhold or permanently discontinue KEYTRUDA depending on severity of the immune-mediated adverse reaction. In general, if KEYTRUDA requires interruption or discontinuation, administer systemic corticosteroid therapy (1 to 2 mg/kg/day prednisone or equivalent) until improvement to Grade 1 or less. Upon improvement to Grade 1 or less, initiate corticosteroid taper and continue to taper over at least 1 month. Consider administration of other systemic immunosuppressants in patients whose adverse reactions are not controlled with corticosteroid therapy. Immune-Mediated Pneumonitis KEYTRUDA can cause immune-mediated pneumonitis. The incidence is higher in patients who have received prior thoracic radiation. Immune-mediated pneumonitis occurred in 3.4% (94/2799) of patients receiving KEYTRUDA, including fatal (0.1%), Grade 4 (0.3%), Grade 3 (0.9%), and Grade 2 (1.3%) reactions. Systemic corticosteroids were required in 67% (63/94) of patients. Pneumonitis led to permanent discontinuation of KEYTRUDA in 1.3% (36) and withholding in 0.9% (26) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement; of these, 23% had recurrence. Pneumonitis resolved in 59% of the 94 patients. Pneumonitis occurred in 8% (31/389) of adult patients with cHL receiving KEYTRUDA as a single agent, including Grades 3-4 in 2.3% of patients. Patients received high-dose corticosteroids for a median duration of 10 days (range: 2 days to 53 months). Pneumonitis rates were similar in patients with and without prior thoracic radiation. Pneumonitis led to discontinuation of KEYTRUDA in 5.4% (21) of patients. Of the patients who developed pneumonitis, 42% interrupted KEYTRUDA, 68% discontinued KEYTRUDA, and 77% had resolution. Pneumonitis occurred in 7% (41/580) of adult patients with resected NSCLC who received KEYTRUDA as a single agent for adjuvant treatment of NSCLC, including fatal (0.2%), Grade 4 (0.3%), and Grade 3 (1%) adverse reactions. Patients received high-dose corticosteroids for a median duration of 10 days (range: 1 day to 2.3 months). Pneumonitis led to discontinuation of KEYTRUDA in 26 (4.5%) of patients. Of the patients who developed pneumonitis, 54% interrupted KEYTRUDA, 63% discontinued KEYTRUDA, and 71% had resolution. Immune-Mediated Colitis KEYTRUDA can cause immune-mediated colitis, which may present with diarrhea. Cytomegalovirus infection/reactivation has been reported in patients with corticosteroid-refractory immune-mediated colitis. In cases of corticosteroid-refractory colitis, consider repeating infectious workup to exclude alternative etiologies. Immune-mediated colitis occurred in 1.7% (48/2799) of patients receiving KEYTRUDA, including Grade 4 (<0.1%), Grade 3 (1.1%), and Grade 2 (0.4%) reactions. Systemic corticosteroids were required in 69% (33/48); additional immunosuppressant therapy was required in 4.2% of patients. Colitis led to permanent discontinuation of KEYTRUDA in 0.5% (15) and withholding in 0.5% (13) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement; of these, 23% had recurrence. Colitis resolved in 85% of the 48 patients. Hepatotoxicity and Immune-Mediated Hepatitis KEYTRUDA as a Single Agent KEYTRUDA can cause immune-mediated hepatitis. Immune-mediated hepatitis occurred in 0.7% (19/2799) of patients receiving KEYTRUDA, including Grade 4 (<0.1%), Grade 3 (0.4%), and Grade 2 (0.1%) reactions. Systemic corticosteroids were required in 68% (13/19) of patients; additional immunosuppressant therapy was required in 11% of patients. Hepatitis led to permanent discontinuation of KEYTRUDA in 0.2% (6) and withholding in 0.3% (9) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement; of these, none had recurrence. Hepatitis resolved in 79% of the 19 patients. KEYTRUDA With Axitinib KEYTRUDA in combination with axitinib can cause hepatic toxicity. Monitor liver enzymes before initiation of and periodically throughout treatment. Consider monitoring more frequently as compared to when the drugs are administered as single agents. For elevated liver enzymes, interrupt KEYTRUDA and axitinib, and consider administering corticosteroids as needed. With the combination of KEYTRUDA and axitinib, Grades 3 and 4 increased alanine aminotransferase (ALT) (20%) and increased aspartate aminotransferase (AST) (13%) were seen at a higher frequency compared to KEYTRUDA alone. Fifty-nine percent of the patients with increased ALT received systemic corticosteroids. In patients with ALT ≥3 times upper limit of normal (ULN) (Grades 2-4, n=116), ALT resolved to Grades 0-1 in 94%. Among the 92 patients who were rechallenged with either KEYTRUDA (n=3) or axitinib (n=34) administered as a single agent or with both (n=55), recurrence of ALT ≥3 times ULN was observed in 1 patient receiving KEYTRUDA, 16 patients receiving axitinib, and 24 patients receiving both. All patients with a recurrence of ALT ≥3 ULN subsequently recovered from the event. Immune-Mediated Endocrinopathies Adrenal Insufficiency KEYTRUDA can cause primary or secondary adrenal insufficiency. For Grade 2 or higher, initiate symptomatic treatment, including hormone replacement as clinically indicated. Withhold KEYTRUDA depending on severity. Adrenal insufficiency occurred in 0.8% (22/2799) of patients receiving KEYTRUDA, including Grade 4 (<0.1%), Grade 3 (0.3%), and Grade 2 (0.3%) reactions. Systemic corticosteroids were required in 77% (17/22) of patients; of these, the majority remained on systemic corticosteroids. Adrenal insufficiency led to permanent discontinuation of KEYTRUDA in <0.1% (1) and withholding in 0.3% (8) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement. Hypophysitis KEYTRUDA can cause immune-mediated hypophysitis. Hypophysitis can present with acute symptoms associated with mass effect such as headache, photophobia, or visual field defects. Hypophysitis can cause hypopituitarism. Initiate hormone replacement as indicated. Withhold or permanently discontinue KEYTRUDA depending on severity. Hypophysitis occurred in 0.6% (17/2799) of patients receiving KEYTRUDA, including Grade 4 (<0.1%), Grade 3 (0.3%), and Grade 2 (0.2%) reactions. Systemic corticosteroids were required in 94% (16/17) of patients; of these, the majority remained on systemic corticosteroids. Hypophysitis led to permanent discontinuation of KEYTRUDA in 0.1% (4) and withholding in 0.3% (7) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement. Thyroid Disorders KEYTRUDA can cause immune-mediated thyroid disorders. Thyroiditis can present with or without endocrinopathy. Hypothyroidism can follow hyperthyroidism. Initiate hormone replacement for hypothyroidism or institute medical management of hyperthyroidism as clinically indicated. Withhold or permanently discontinue KEYTRUDA depending on severity. Thyroiditis occurred in 0.6% (16/2799) of patients receiving KEYTRUDA, including Grade 2 (0.3%). None discontinued, but KEYTRUDA was withheld in <0.1% (1) of patients. Hyperthyroidism occurred in 3.4% (96/2799) of patients receiving KEYTRUDA, including Grade 3 (0.1%) and Grade 2 (0.8%). It led to permanent discontinuation of KEYTRUDA in <0.1% (2) and withholding in 0.3% (7) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement. Hypothyroidism occurred in 8% (237/2799) of patients receiving KEYTRUDA, including Grade 3 (0.1%) and Grade 2 (6.2%). It led to permanent discontinuation of KEYTRUDA in <0.1% (1) and withholding in 0.5% (14) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement. The majority of patients with hypothyroidism required long-term thyroid hormone replacement. The incidence of new or worsening hypothyroidism was higher in 1185 patients with HNSCC, occurring in 16% of patients receiving KEYTRUDA as a single agent or in combination with platinum and FU, including Grade 3 (0.3%) hypothyroidism. The incidence of new or worsening hypothyroidism was higher in 389 adult patients with cHL (17%) receiving KEYTRUDA as a single agent, including Grade 1 (6.2%) and Grade 2 (10.8%) hypothyroidism. The incidence of new or worsening hyperthyroidism was higher in 580 patients with resected NSCLC, occurring in 11% of patients receiving KEYTRUDA as a single agent as adjuvant treatment, including Grade 3 (0.2%) hyperthyroidism. The incidence of new or worsening hypothyroidism was higher in 580 patients with resected NSCLC, occurring in 22% of patients receiving KEYTRUDA as a single agent as adjuvant treatment (KEYNOTE-091), including Grade 3 (0.3%) hypothyroidism. Type 1 Diabetes Mellitus (DM), Which Can Present With Diabetic Ketoacidosis Monitor patients for hyperglycemia or other signs and symptoms of diabetes. Initiate treatment with insulin as clinically indicated. Withhold KEYTRUDA depending on severity. Type 1 DM occurred in 0.2% (6/2799) of patients receiving KEYTRUDA. It led to permanent discontinuation in <0.1% (1) and withholding of KEYTRUDA in <0.1% (1) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement. Immune-Mediated Nephritis With Renal Dysfunction KEYTRUDA can cause immune-mediated nephritis. Immune-mediated nephritis occurred in 0.3% (9/2799) of patients receiving KEYTRUDA, including Grade 4 (<0.1%), Grade 3 (0.1%), and Grade 2 (0.1%) reactions. Systemic corticosteroids were required in 89% (8/9) of patients. Nephritis led to permanent discontinuation of KEYTRUDA in 0.1% (3) and withholding in 0.1% (3) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement; of these, none had recurrence. Nephritis resolved in 56% of the 9 patients. Immune-Mediated Dermatologic Adverse Reactions KEYTRUDA can cause immune-mediated rash or dermatitis. Exfoliative dermatitis, including Stevens-Johnson syndrome, drug rash with eosinophilia and systemic symptoms, and toxic epidermal necrolysis, has occurred with anti–PD-1/PD-L1 treatments. Topical emollients and/or topical corticosteroids may be adequate to treat mild to moderate nonexfoliative rashes. Withhold or permanently discontinue KEYTRUDA depending on severity. Immune-mediated dermatologic adverse reactions occurred in 1.4% (38/2799) of patients receiving KEYTRUDA, including Grade 3 (1%) and Grade 2 (0.1%) reactions. Systemic corticosteroids were required in 40% (15/38) of patients. These reactions led to permanent discontinuation in 0.1% (2) and withholding of KEYTRUDA in 0.6% (16) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement; of these, 6% had recurrence. The reactions resolved in 79% of the 38 patients. Other Immune-Mediated Adverse Reactions The following clinically significant immune-mediated adverse reactions occurred at an incidence of <1% (unless otherwise noted) in patients who received KEYTRUDA or were reported with the use of other anti–PD-1/PD-L1 treatments. Severe or fatal cases have been reported for some of these adverse reactions. Cardiac/Vascular: Myocarditis, pericarditis, vasculitis; Nervous System: Meningitis, encephalitis, myelitis and demyelination, myasthenic syndrome/myasthenia gravis (including exacerbation), Guillain-Barré syndrome, nerve paresis, autoimmune neuropathy; Ocular: Uveitis, iritis and other ocular inflammatory toxicities can occur. Some cases can be associated with retinal detachment. Various grades of visual impairment, including blindness, can occur. If uveitis occurs in combination with other immune-mediated adverse reactions, consider a Vogt-Koyanagi-Harada-like syndrome, as this may require treatment with systemic steroids to reduce the risk of permanent vision loss; Gastrointestinal: Pancreatitis, to include increases in serum amylase and lipase levels, gastritis, duodenitis; Musculoskeletal and Connective Tissue: Myositis/polymyositis, rhabdomyolysis (and associated sequelae, including renal failure), arthritis (1.5%), polymyalgia rheumatica; Endocrine: Hypoparathyroidism; Hematologic/Immune: Hemolytic anemia, aplastic anemia, hemophagocytic lymphohistiocytosis, systemic inflammatory response syndrome, histiocytic necrotizing lymphadenitis (Kikuchi lymphadenitis), sarcoidosis, immune thrombocytopenic purpura, solid organ transplant rejection, other transplant (including corneal graft) rejection. Infusion-Related Reactions KEYTRUDA can cause severe or life-threatening infusion-related reactions, including hypersensitivity and anaphylaxis, which have been reported in 0.2% of 2799 patients receiving KEYTRUDA. Monitor for signs and symptoms of infusion-related reactions. Interrupt or slow the rate of infusion for Grade 1 or Grade 2 reactions. For Grade 3 or Grade 4 reactions, stop infusion and permanently discontinue KEYTRUDA. Complications of Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) Fatal and other serious complications can occur in patients who receive allogeneic HSCT before or after anti–PD-1/PD-L1 treatments. Transplant-related complications include hyperacute graft-versus-host disease (GVHD), acute and chronic GVHD, hepatic veno-occlusive disease after reduced intensity conditioning, and steroid-requiring febrile syndrome (without an identified infectious cause). These complications may occur despite intervening therapy between anti–PD-1/PD-L1 treatment and allogeneic HSCT. Follow patients closely for evidence of these complications and intervene promptly. Consider the benefit vs risks of using anti–PD-1/PD-L1 treatments prior to or after an allogeneic HSCT. Increased Mortality in Patients With Multiple Myeloma In trials in patients with multiple myeloma, the addition of KEYTRUDA to a thalidomide analogue plus dexamethasone resulted in increased mortality. Treatment of these patients with an anti–PD-1/PD-L1 treatment in this combination is not recommended outside of controlled trials. Embryofetal Toxicity Based on its mechanism of action, KEYTRUDA can cause fetal harm when administered to a pregnant woman. Advise women of this potential risk. In females of reproductive potential, verify pregnancy status prior to initiating KEYTRUDA and advise them to use effective contraception during treatment and for 4 months after the last dose. Adverse Reactions In KEYNOTE-006, KEYTRUDA was discontinued due to adverse reactions in 9% of 555 patients with advanced melanoma; adverse reactions leading to permanent discontinuation in more than one patient were colitis (1.4%), autoimmune hepatitis (0.7%), allergic reaction (0.4%), polyneuropathy (0.4%), and cardiac failure (0.4%). The most common adverse reactions (≥20%) with KEYTRUDA were fatigue (28%), diarrhea (26%), rash (24%), and nausea (21%). In KEYNOTE-054, when KEYTRUDA was administered as a single agent to patients with stage III melanoma, KEYTRUDA was permanently discontinued due to adverse reactions in 14% of 509 patients; the most common (≥1%) were pneumonitis (1.4%), colitis (1.2%), and diarrhea (1%). Serious adverse reactions occurred in 25% of patients receiving KEYTRUDA. The most common adverse reaction (≥20%) with KEYTRUDA was diarrhea (28%). In KEYNOTE-716, when KEYTRUDA was administered as a single agent to patients with stage IIB or IIC melanoma, adverse reactions occurring in patients with stage IIB or IIC melanoma were similar to those occurring in 1011 patients with stage III melanoma from KEYNOTE-054. In KEYNOTE-189, when KEYTRUDA was administered with pemetrexed and platinum chemotherapy in metastatic nonsquamous NSCLC, KEYTRUDA was discontinued due to adverse reactions in 20% of 405 patients. The most common adverse reactions resulting in permanent discontinuation of KEYTRUDA were pneumonitis (3%) and acute kidney injury (2%). The most common adverse reactions (≥20%) with KEYTRUDA were nausea (56%), fatigue (56%), constipation (35%), diarrhea (31%), decreased appetite (28%), rash (25%), vomiting (24%), cough (21%), dyspnea (21%), and pyrexia (20%). In KEYNOTE-407, when KEYTRUDA was administered with carboplatin and either paclitaxel or paclitaxel protein-bound in metastatic squamous NSCLC, KEYTRUDA was discontinued due to adverse reactions in 15% of 101 patients. The most frequent serious adverse reactions reported in at least 2% of patients were febrile neutropenia, pneumonia, and urinary tract infection. Adverse reactions observed in KEYNOTE-407 were similar to those observed in KEYNOTE-189 with the exception that increased incidences of alopecia (47% vs 36%) and peripheral neuropathy (31% vs 25%) were observed in the KEYTRUDA and chemotherapy arm compared to the placebo and chemotherapy arm in KEYNOTE-407. In KEYNOTE-042, KEYTRUDA was discontinued due to adverse reactions in 19% of 636 patients with advanced NSCLC; the most common were pneumonitis (3%), death due to unknown cause (1.6%), and pneumonia (1.4%). The most frequent serious adverse reactions reported in at least 2% of patients were pneumonia (7%), pneumonitis (3.9%), pulmonary embolism (2.4%), and pleural effusion (2.2%). The most common adverse reaction (≥20%) was fatigue (25%). In KEYNOTE-010, KEYTRUDA monotherapy was discontinued due to adverse reactions in 8% of 682 patients with metastatic NSCLC; the most common was pneumonitis (1.8%). The most common adverse reactions (≥20%) were decreased appetite (25%), fatigue (25%), dyspnea (23%), and nausea (20%). In KEYNOTE-671, adverse reactions occurring in patients with resectable NSCLC receiving KEYTRUDA in combination with platinum-containing chemotherapy, given as neoadjuvant treatment and continued as single-agent adjuvant treatment, were generally similar to those occurring in patients in other clinical trials across tumor types receiving KEYTRUDA in combination with chemotherapy. The most common adverse reactions (reported in ≥20%) in patients receiving KEYTRUDA in combination with chemotherapy were fatigue/asthenia, nausea, constipation, diarrhea, decreased appetite, rash, vomiting, cough, dyspnea, pyrexia, alopecia, peripheral neuropathy, mucosal inflammation, stomatitis, headache, weight loss, abdominal pain, arthralgia, myalgia, insomnia, palmar-plantar erythrodysesthesia, urinary tract infection, and hypothyroidism. In the neoadjuvant phase of KEYNOTE-671, when KEYTRUDA was administered in combination with platinum-containing chemotherapy as neoadjuvant treatment, serious adverse reactions occurred in 34% of 396 patients. The most frequent (≥2%) serious adverse reactions were pneumonia (4.8%), venous thromboembolism (3.3%), and anemia (2%). Fatal adverse reactions occurred in 1.3% of patients, including death due to unknown cause (0.8%), sepsis (0.3%), and immune-mediated lung disease (0.3%). Permanent discontinuation of any study drug due to an adverse reaction occurred in 18% of patients who received KEYTRUDA in combination with platinum-containing chemotherapy; the most frequent adverse reactions (≥1%) that led to permanent discontinuation of any study drug were acute kidney injury (1.8%), interstitial lung disease (1.8%), anemia (1.5%), neutropenia (1.5%) and pneumonia (1.3%). Of the KEYTRUDA-treated patients who received neoadjuvant treatment, 6% of 396 patients did not receive surgery due to adverse reactions. The most frequent (≥1%) adverse reaction that led to cancellation of surgery in the KEYTRUDA arm was interstitial lung disease (1%). In the adjuvant phase of KEYNOTE-671, when KEYTRUDA was administered as a single agent as adjuvant treatment, serious adverse reactions occurred in 14% of 290 patients. The most frequent serious adverse reaction was pneumonia (3.4%). One fatal adverse reaction of pulmonary hemorrhage occurred. Permanent discontinuation of KEYTRUDA due to an adverse reaction occurred in 12% of patients who received KEYTRUDA as a single agent, given as adjuvant treatment; the most frequent adverse reactions (≥1%) that led to permanent discontinuation of KEYTRUDA were diarrhea (1.7%), interstitial lung disease (1.4%), increased aspartate aminotransferase (1%), and musculoskeletal pain (1%). Adverse reactions observed in KEYNOTE-091 were generally similar to those occurring in other patients with NSCLC receiving KEYTRUDA as a single agent, with the exception of hypothyroidism (22%), hyperthyroidism (11%), and pneumonitis (7%). Two fatal adverse reactions of myocarditis occurred. In KEYNOTE-048, KEYTRUDA monotherapy was discontinued due to adverse events in 12% of 300 patients with HNSCC; the most common adverse reactions leading to permanent discontinuation were sepsis (1.7%) and pneumonia (1.3%). The most common adverse reactions (≥20%) were fatigue (33%), constipation (20%), and rash (20%). In KEYNOTE-048, when KEYTRUDA was administered in combination with platinum (cisplatin or carboplatin) and FU chemotherapy, KEYTRUDA was discontinued due to adverse reactions in 16% of 276 patients with HNSCC. The most common adverse reactions resulting in permanent discontinuation of KEYTRUDA were pneumonia (2.5%), pneumonitis (1.8%), and septic shock (1.4%). The most common adverse reactions (≥20%) were nausea (51%), fatigue (49%), constipation (37%), vomiting (32%), mucosal inflammation (31%), diarrhea (29%), decreased appetite (29%), stomatitis (26%), and cough (22%). In KEYNOTE-012, KEYTRUDA was discontinued due to adverse reactions in 17% of 192 patients with HNSCC. Serious adverse reactions occurred in 45% of patients. The most frequent serious adverse reactions reported in at least 2% of patients were pneumonia, dyspnea, confusional state, vomiting, pleural effusion, and respiratory failure. The most common adverse reactions (≥20%) were fatigue, decreased appetite, and dyspnea. Adverse reactions occurring in patients with HNSCC were generally similar to those occurring in patients with melanoma or NSCLC who received KEYTRUDA as a monotherapy, with the exception of increased incidences of facial edema and new or worsening hypothyroidism. In KEYNOTE-204, KEYTRUDA was discontinued due to adverse reactions in 14% of 148 patients with cHL. Serious adverse reactions occurred in 30% of patients receiving KEYTRUDA; those ≥1% were pneumonitis, pneumonia, pyrexia, myocarditis, acute kidney injury, febrile neutropenia, and sepsis. Three patients died from causes other than disease progression: 2 from complications after allogeneic HSCT and 1 from unknown cause. The most common adverse reactions (≥20%) were upper respiratory tract infection (41%), musculoskeletal pain (32%), diarrhea (22%), and pyrexia, fatigue, rash, and cough (20% each). In KEYNOTE-087, KEYTRUDA was discontinued due to adverse reactions in 5% of 210 patients with cHL. Serious adverse reactions occurred in 16% of patients; those ≥1% were pneumonia, pneumonitis, pyrexia, dyspnea, GVHD, and herpes zoster. Two patients died from causes other than disease progression: 1 from GVHD after subsequent allogeneic HSCT and 1 from septic shock. The most common adverse reactions (≥20%) were fatigue (26%), pyrexia (24%), cough (24%), musculoskeletal pain (21%), diarrhea (20%), and rash (20%). In KEYNOTE-170, KEYTRUDA was discontinued due to adverse reactions in 8% of 53 patients with PMBCL. Serious adverse reactions occurred in 26% of patients and included arrhythmia (4%), cardiac tamponade (2%), myocardial infarction (2%), pericardial effusion (2%), and pericarditis (2%). Six (11%) patients died within 30 days of start of treatment. The most common adverse reactions (≥20%) were musculoskeletal pain (30%), upper respiratory tract infection and pyrexia (28% each), cough (26%), fatigue (23%), and dyspnea (21%). In KEYNOTE-A39, when KEYTRUDA was administered in combination with enfortumab vedotin to patients with locally advanced or metastatic urothelial cancer (n=440), fatal adverse reactions occurred in 3.9% of patients, including acute respiratory failure (0.7%), pneumonia (0.5%), and pneumonitis/ILD (0.2%). Serious adverse reactions occurred in 50% of patients receiving KEYTRUDA in combination with enfortumab vedotin; the serious adverse reactions in ≥2% of patients were rash (6%), acute kidney injury (5%), pneumonitis/ILD (4.5%), urinary tract infection (3.6%), diarrhea (3.2%), pneumonia (2.3%), pyrexia (2%), and hyperglycemia (2%). Permanent discontinuation of KEYTRUDA occurred in 27% of patients. The most common adverse reactions (≥2%) resulting in permanent discontinuation of KEYTRUDA were pneumonitis/ILD (4.8%) and rash (3.4%). The most common adverse reactions (≥20%) occurring in patients treated with KEYTRUDA in combination with enfortumab vedotin were rash (68%), peripheral neuropathy (67%), fatigue (51%), pruritus (41%), diarrhea (38%), alopecia (35%), weight loss (33%), decreased appetite (33%), nausea (26%), constipation (26%), dry eye (24%), dysgeusia (21%), and urinary tract infection (21%). In KEYNOTE-052, KEYTRUDA was discontinued due to adverse reactions in 11% of 370 patients with locally advanced or mUC. Serious adverse reactions occurred in 42% of patients; those ≥2% were urinary tract infection, hematuria, acute kidney injury, pneumonia, and urosepsis. The most common adverse reactions (≥20%) were fatigue (38%), musculoskeletal pain (24%), decreased appetite (22%), constipation (21%), rash (21%), and diarrhea (20%). In KEYNOTE-045, KEYTRUDA was discontinued due to adverse reactions in 8% of 266 patients with locally advanced or mUC. The most common adverse reaction resulting in permanent discontinuation of KEYTRUDA was pneumonitis (1.9%). Serious adverse reactions occurred in 39% of KEYTRUDA-treated patients; those ≥2% were urinary tract infection, pneumonia, anemia, and pneumonitis. The most common adverse reactions (≥20%) in patients who received KEYTRUDA were fatigue (38%), musculoskeletal pain (32%), pruritus (23%), decreased appetite (21%), nausea (21%), and rash (20%). In KEYNOTE-057, KEYTRUDA was discontinued due to adverse reactions in 11% of 148 patients with high-risk NMIBC. The most common adverse reaction resulting in permanent discontinuation of KEYTRUDA was pneumonitis (1.4%). Serious adverse reactions occurred in 28% of patients; those ≥2% were pneumonia (3%), cardiac ischemia (2%), colitis (2%), pulmonary embolism (2%), sepsis (2%), and urinary tract infection (2%). The most common adverse reactions (≥20%) were fatigue (29%), diarrhea (24%), and rash (24%). Adverse reactions occurring in patients with MSI-H or dMMR CRC were similar to those occurring in patients with melanoma or NSCLC who received KEYTRUDA as a monotherapy. In KEYNOTE-158 and KEYNOTE-164, adverse reactions occurring in patients with MSI-H or dMMR cancer were similar to those occurring in patients with other solid tumors who received KEYTRUDA as a single agent. In KEYNOTE-811, when KEYTRUDA was administered in combination with trastuzumab, fluoropyrimidine- and platinum-containing chemotherapy, KEYTRUDA was discontinued due to adverse reactions in 6% of 217 patients with locally advanced unresectable or metastatic HER2+ gastric or GEJ adenocarcinoma. The most common adverse reaction resulting in permanent discontinuation was pneumonitis (1.4%). In the KEYTRUDA arm versus placebo, there was a difference of ≥5% incidence between patients treated with KEYTRUDA versus standard of care for diarrhea (53% vs 44%) and nausea (49% vs 44%). In KEYNOTE-859, when KEYTRUDA was administered in combination with fluoropyrimidine- and platinum-containing chemotherapy, serious adverse reactions occurred in 45% of 785 patients. Serious adverse reactions in >2% of patients included pneumonia (4.1%), diarrhea (3.9%), hemorrhage (3.9%), and vomiting (2.4%). Fatal adverse reactions occurred in 8% of patients who received KEYTRUDA including infection (2.3%) and thromboembolism (1.3%). KEYTRUDA was discontinued due to adverse reactions in 15% of patients. The most common adverse reaction resulting in permanent discontinuation of KEYTRUDA (≥1%) were infections (1.8%) and diarrhea (1%). The most common adverse reactions (reported in ≥20%) in patients receiving KEYTRUDA in combination with chemotherapy were peripheral neuropathy (47%), nausea (46%), fatigue (40%), diarrhea (36%), vomiting (34%), decreased appetite (29%), abdominal pain (26%), palmar-plantar erythrodysesthesia syndrome (25%), constipation (22%), and weight loss (20%). In KEYNOTE-590, when KEYTRUDA was administered with cisplatin and fluorouracil to patients with metastatic or locally advanced esophageal or GEJ (tumors with epicenter 1 to 5 centimeters above the GEJ) carcinoma who were not candidates for surgical resection or definitive chemoradiation, KEYTRUDA was discontinued due to adverse reactions in 15% of 370 patients. The most common adverse reactions resulting in permanent discontinuation of KEYTRUDA (≥1%) were pneumonitis (1.6%), acute kidney injury (1.1%), and pneumonia (1.1%). The most common adverse reactions (≥20%) with KEYTRUDA in combination with chemotherapy were nausea (67%), fatigue (57%), decreased appetite (44%), constipation (40%), diarrhea (36%), vomiting (34%), stomatitis (27%), and weight loss (24%). Adverse reactions occurring in patients with esophageal cancer who received KEYTRUDA as a monotherapy were similar to those occurring in patients with melanoma or NSCLC who received KEYTRUDA as a monotherapy. In KEYNOTE-A18, when KEYTRUDA was administered with CRT (cisplatin plus external beam radiation therapy [EBRT] followed by brachytherapy [BT]) to patients with FIGO 2014 Stage III-IVA cervical cancer, fatal adverse reactions occurred in 1.4% of 292 patients, including 1 case each (0.3%) of large intestinal perforation, urosepsis, sepsis, and vaginal hemorrhage. Serious adverse reactions occurred in 30% of patients; those ≥1% included urinary tract infection (2.7%), urosepsis (1.4%), and sepsis (1%). KEYTRUDA was discontinued for adverse reactions in 7% of patients. The most common adverse reaction (≥1%) resulting in permanent discontinuation was diarrhea (1%). For patients treated with KEYTRUDA in combination with CRT, the most common adverse reactions (≥10%) were nausea (56%), diarrhea (50%), vomiting (33%), urinary tract infection (32%), fatigue (26%), hypothyroidism (20%), constipation (18%), decreased appetite and weight loss (17% each), abdominal pain and pyrexia (12% each), hyperthyroidism, dysuria, rash (11% each), and pelvic pain (10%). In KEYNOTE-826, when KEYTRUDA was administered in combination with paclitaxel and cisplatin or paclitaxel and carboplatin, with or without bevacizumab (n=307), to patients with persistent, recurrent, or first-line metastatic cervical cancer regardless of tumor PD-L1 expression who had not been treated with chemotherapy except when used concurrently as a radio-sensitizing agent, fatal adverse reactions occurred in 4.6% of patients, including 3 cases of hemorrhage, 2 cases each of sepsis and due to unknown causes, and 1 case each of acute myocardial infarction, autoimmune encephalitis, cardiac arrest, cerebrovascular accident, femur fracture with perioperative pulmonary embolus, intestinal perforation, and pelvic infection. Serious adverse reactions occurred in 50% of patients receiving KEYTRUDA in combination with chemotherapy with or without bevacizumab; those ≥3% were febrile neutropenia (6.8%), urinary tract infection (5.2%), anemia (4.6%), and acute kidney injury and sepsis (3.3% each). KEYTRUDA was discontinued in 15% of patients due to adverse reactions. The most common adverse reaction resulting in permanent discontinuation (≥1%) was colitis (1%). For patients treated with KEYTRUDA, chemotherapy, and bevacizumab (n=196), the most common adverse reactions (≥20%) were peripheral neuropathy (62%), alopecia (58%), anemia (55%), fatigue/asthenia (53%), nausea and neutropenia (41% each), diarrhea (39%), hypertension and thrombocytopenia (35% each), constipation and arthralgia (31% each), vomiting (30%), urinary tract infection (27%), rash (26%), leukopenia (24%), hypothyroidism (22%), and decreased appetite (21%). For patients treated with KEYTRUDA in combination with chemotherapy with or without bevacizumab, the most common adverse reactions (≥20%) were peripheral neuropathy (58%), alopecia (56%), fatigue (47%), nausea (40%), diarrhea (36%), constipation (28%), arthralgia (27%), vomiting (26%), hypertension and urinary tract infection (24% each), and rash (22%). In KEYNOTE-158, KEYTRUDA was discontinued due to adverse reactions in 8% of 98 patients with previously treated recurrent or metastatic cervical cancer. Serious adverse reactions occurred in 39% of patients receiving KEYTRUDA; the most frequent included anemia (7%), fistula, hemorrhage, and infections [except urinary tract infections] (4.1% each). The most common adverse reactions (≥20%) were fatigue (43%), musculoskeletal pain (27%), diarrhea (23%), pain and abdominal pain (22% each), and decreased appetite (21%). In KEYNOTE-394, KEYTRUDA was discontinued due to adverse reactions in 13% of 299 patients with previously treated hepatocellular carcinoma. The most common adverse reaction resulting in permanent discontinuation of KEYTRUDA was ascites (2.3%). The most common adverse reactions in patients receiving KEYTRUDA (≥10%) were pyrexia (18%), rash (18%), diarrhea (16%), decreased appetite (15%), pruritis (12%), upper respiratory tract infection (11%), cough (11%), and hypothyroidism (10%). In KEYNOTE-966, when KEYTRUDA was administered in combination with gemcitabine and cisplatin, KEYTRUDA was discontinued for adverse reactions in 15% of 529 patients with locally advanced unresectable or metastatic biliary tract cancer. The most common adverse reaction resulting in permanent discontinuation of KEYTRUDA (≥1%) was pneumonitis (1.3%). Adverse reactions leading to the interruption of KEYTRUDA occurred in 55% of patients. The most common adverse reactions or laboratory abnormalities leading to interruption of KEYTRUDA (≥2%) were decreased neutrophil count (18%), decreased platelet count (10%), anemia (6%), decreased white blood cell count (4%), pyrexia (3.8%), fatigue (3.0%), cholangitis (2.8%), increased ALT (2.6%), increased AST (2.5%), and biliary obstruction (2.3%). In KEYNOTE-017 and KEYNOTE-913, adverse reactions occurring in patients with MCC (n=105) were generally similar to those occurring in patients with melanoma or NSCLC who received KEYTRUDA as a single agent. In KEYNOTE-426, when KEYTRUDA was administered in combination with axitinib, fatal adverse reactions occurred in 3.3% of 429 patients. Serious adverse reactions occurred in 40% of patients, the most frequent (≥1%) were hepatotoxicity (7%), diarrhea (4.2%), acute kidney injury (2.3%), dehydration (1%), and pneumonitis (1%). Permanent discontinuation due to an adverse reaction occurred in 31% of patients; KEYTRUDA only (13%), axitinib only (13%), and the combination (8%); the most common were hepatotoxicity (13%), diarrhea/colitis (1.9%), acute kidney injury (1.6%), and cerebrovascular accident (1.2%). The most common adverse reactions (≥20%) were diarrhea (56%), fatigue/asthenia (52%), hypertension (48%), hepatotoxicity (39%), hypothyroidism (35%), decreased appetite (30%), palmar-plantar erythrodysesthesia (28%), nausea (28%), stomatitis/mucosal inflammation (27%), dysphonia (25%), rash (25%), cough (21%), and constipation (21%). In KEYNOTE-564, when KEYTRUDA was administered as a single agent for the adjuvant treatment of renal cell carcinoma, serious adverse reactions occurred in 20% of patients receiving KEYTRUDA; the serious adverse reactions (≥1%) were acute kidney injury, adrenal insufficiency, pneumonia, colitis, and diabetic ketoacidosis (1% each). Fatal adverse reactions occurred in 0.2% including 1 case of pneumonia. Discontinuation of KEYTRUDA due to adverse reactions occurred in 21% of 488 patients; the most common (≥1%) were increased ALT (1.6%), colitis (1%), and adrenal insufficiency (1%). The most common adverse reactions (≥20%) were musculoskeletal pain (41%), fatigue (40%), rash (30%), diarrhea (27%), pruritus (23%), and hypothyroidism (21%). Adverse reactions occurring in patients with MSI-H or dMMR endometrial carcinoma who received KEYTRUDA as a single agent were similar to those occurring in patients with melanoma or NSCLC who received KEYTRUDA as a single agent. Adverse reactions occurring in patients with TMB-H cancer were similar to those occurring in patients with other solid tumors who received KEYTRUDA as a single agent. Adverse reactions occurring in patients with recurrent or metastatic cSCC or locally advanced cSCC were similar to those occurring in patients with melanoma or NSCLC who received KEYTRUDA as a monotherapy. In KEYNOTE-522, when KEYTRUDA was administered with neoadjuvant chemotherapy (carboplatin and paclitaxel followed by doxorubicin or epirubicin and cyclophosphamide) followed by surgery and continued adjuvant treatment with KEYTRUDA as a single agent (n=778) to patients with newly diagnosed, previously untreated, high-risk early-stage TNBC, fatal adverse reactions occurred in 0.9% of patients, including 1 each of adrenal crisis, autoimmune encephalitis, hepatitis, pneumonia, pneumonitis, pulmonary embolism, and sepsis in association with multiple organ dysfunction syndrome and myocardial infarction. Serious adverse reactions occurred in 44% of patients receiving KEYTRUDA; those ≥2% were febrile neutropenia (15%), pyrexia (3.7%), anemia (2.6%), and neutropenia (2.2%). KEYTRUDA was discontinued in 20% of patients due to adverse reactions. The most common reactions (≥1%) resulting in permanent discontinuation were increased ALT (2.7%), increased AST (1.5%), and rash (1%). The most common adverse reactions (≥20%) in patients receiving KEYTRUDA were fatigue (70%), nausea (67%), alopecia (61%), rash (52%), constipation (42%), diarrhea and peripheral neuropathy (41% each), stomatitis (34%), vomiting (31%), headache (30%), arthralgia (29%), pyrexia (28%), cough (26%), abdominal pain (24%), decreased appetite (23%), insomnia (21%), and myalgia (20%). In KEYNOTE-355, when KEYTRUDA and chemotherapy (paclitaxel, paclitaxel protein-bound, or gemcitabine and carboplatin) were administered to patients with locally recurrent unresectable or metastatic TNBC who had not been previously treated with chemotherapy in the metastatic setting (n=596), fatal adverse reactions occurred in 2.5% of patients, including cardio-respiratory arrest (0.7%) and septic shock (0.3%). Serious adverse reactions occurred in 30% of patients receiving KEYTRUDA in combination with chemotherapy; the serious reactions in ≥2% were pneumonia (2.9%), anemia (2.2%), and thrombocytopenia (2%). KEYTRUDA was discontinued in 11% of patients due to adverse reactions. The most common reactions resulting in permanent discontinuation (≥1%) were increased ALT (2.2%), increased AST (1.5%), and pneumonitis (1.2%). The most common adverse reactions (≥20%) in patients receiving KEYTRUDA in combination with chemotherapy were fatigue (48%), nausea (44%), alopecia (34%), diarrhea and constipation (28% each), vomiting and rash (26% each), cough (23%), decreased appetite (21%), and headache (20%). Lactation Because of the potential for serious adverse reactions in breastfed children, advise women not to breastfeed during treatment and for 4 months after the last dose. Pediatric Use In KEYNOTE-051, 173 pediatric patients (65 pediatric patients aged 6 months to younger than 12 years and 108 pediatric patients aged 12 years to 17 years) were administered KEYTRUDA 2 mg/kg every 3 weeks. The median duration of exposure was 2.1 months (range: 1 day to 25 months). Adverse reactions that occurred at a ≥10% higher rate in pediatric patients when compared to adults were pyrexia (33%), leukopenia (31%), vomiting (30%), neutropenia (29%), headache (25%), abdominal pain (23%), thrombocytopenia (22%), Grade 3 anemia (17%), decreased lymphocyte count (13%), and decreased white blood cell count (11%). Geriatric Use Of the 564 patients with locally advanced or metastatic urothelial cancer treated with KEYTRUDA in combination with enfortumab vedotin, 44% (n=247) were 65-74 years and 26% (n=144) were 75 years or older. No overall differences in safety or effectiveness were observed between patients 65 years of age or older and younger patients. Patients 75 years of age or older treated with KEYTRUDA in combination with enfortumab vedotin experienced a higher incidence of fatal adverse reactions than younger patients. The incidence of fatal adverse reactions was 4% in patients younger than 75 and 7% in patients 75 years or older. Additional Selected KEYTRUDA Indications in the U.S. Non-Small Cell Lung Cancer KEYTRUDA, in combination with pemetrexed and platinum chemotherapy, is indicated for the first-line treatment of patients with metastatic nonsquamous non-small cell lung cancer (NSCLC), with no EGFR or ALK genomic tumor aberrations. KEYTRUDA, in combination with carboplatin and either paclitaxel or paclitaxel protein-bound, is indicated for the first-line treatment of patients with metastatic squamous NSCLC. KEYTRUDA, as a single agent, is indicated for the first-line treatment of patients with NSCLC expressing PD-L1 [tumor proportion score (TPS) ≥1%] as determined by an FDA-approved test, with no EGFR or ALK genomic tumor aberrations, and is: stage III where patients are not candidates for surgical resection or definitive chemoradiation, or metastatic. KEYTRUDA, as a single agent, is indicated for the treatment of patients with metastatic NSCLC whose tumors express PD-L1 (TPS ≥1%) as determined by an FDA-approved test, with disease progression on or after platinum-containing chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving KEYTRUDA. KEYTRUDA is indicated for the treatment of patients with resectable (tumors ≥4 cm or node positive) NSCLC in combination with platinum-containing chemotherapy as neoadjuvant treatment, and then continued as a single agent as adjuvant treatment after surgery. KEYTRUDA, as a single agent, is indicated as adjuvant treatment following resection and platinum-based chemotherapy for adult patients with Stage IB (T2a ≥4 cm), II, or IIIA NSCLC. Head and Neck Squamous Cell Cancer KEYTRUDA, in combination with platinum and fluorouracil (FU), is indicated for the first-line treatment of patients with metastatic or with unresectable, recurrent head and neck squamous cell carcinoma (HNSCC). KEYTRUDA, as a single agent, is indicated for the first-line treatment of patients with metastatic or with unresectable, recurrent HNSCC whose tumors express PD-L1 [Combined Positive Score (CPS) ≥1] as determined by an FDA-approved test. KEYTRUDA, as a single agent, is indicated for the treatment of patients with recurrent or metastatic HNSCC with disease progression on or after platinum-containing chemotherapy. Classical Hodgkin Lymphoma KEYTRUDA is indicated for the treatment of adult patients with relapsed or refractory classical Hodgkin lymphoma (cHL). KEYTRUDA is indicated for the treatment of pediatric patients with refractory cHL, or cHL that has relapsed after 2 or more lines of therapy. Primary Mediastinal Large B-Cell Lymphoma KEYTRUDA is indicated for the treatment of adult and pediatric patients with refractory primary mediastinal large B-cell lymphoma (PMBCL), or who have relapsed after 2 or more prior lines of therapy. KEYTRUDA is not recommended for treatment of patients with PMBCL who require urgent cytoreductive therapy. Urothelial Carcinoma KEYTRUDA, in combination with enfortumab vedotin, is indicated for the treatment of adult patients with locally advanced or metastatic urothelial cancer. KEYTRUDA, as a single agent, is indicated for the treatment of patients with locally advanced or metastatic urothelial carcinoma: who are not eligible for any platinum-containing chemotherapy, or who have disease progression during or following platinum-containing chemotherapy or within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy. KEYTRUDA, as a single agent, is indicated for the treatment of patients with Bacillus Calmette-Guerin (BCG)-unresponsive, high-risk, non-muscle invasive bladder cancer (NMIBC) with carcinoma in situ (CIS) with or without papillary tumors who are ineligible for or have elected not to undergo cystectomy. Microsatellite Instability-High or Mismatch Repair Deficient Cancer KEYTRUDA is indicated for the treatment of adult and pediatric patients with unresectable or metastatic microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) solid tumors, as determined by an FDA-approved test, that have progressed following prior treatment and who have no satisfactory alternative treatment options. Microsatellite Instability-High or Mismatch Repair Deficient Colorectal Cancer KEYTRUDA is indicated for the treatment of patients with unresectable or metastatic MSI-H or dMMR colorectal cancer (CRC) as determined by an FDA-approved test. Gastric Cancer KEYTRUDA, in combination with trastuzumab, fluoropyrimidine- and platinum-containing chemotherapy, is indicated for the first-line treatment of adults with locally advanced unresectable or metastatic HER2-positive gastric or gastroesophageal junction (GEJ) adenocarcinoma whose tumors express PD-L1 (CPS ≥1) as determined by an FDA-approved test. This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval of this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials. KEYTRUDA, in combination with fluoropyrimidine- and platinum-containing chemotherapy, is indicated for the first-line treatment of adults with locally advanced unresectable or metastatic HER2-negative gastric or gastroesophageal junction (GEJ) adenocarcinoma. Esophageal Cancer KEYTRUDA is indicated for the treatment of patients with locally advanced or metastatic esophageal or gastroesophageal junction (GEJ) (tumors with epicenter 1 to 5 centimeters above the GEJ) carcinoma that is not amenable to surgical resection or definitive chemoradiation either: in combination with platinum- and fluoropyrimidine-based chemotherapy, or as a single agent after one or more prior lines of systemic therapy for patients with tumors of squamous cell histology that express PD-L1 (CPS ≥10) as determined by an FDA-approved test. Cervical Cancer KEYTRUDA, in combination with chemoradiotherapy (CRT), is indicated for the treatment of patients with FIGO 2014 Stage III-IVA cervical cancer. KEYTRUDA, in combination with chemotherapy, with or without bevacizumab, is indicated for the treatment of patients with persistent, recurrent, or metastatic cervical cancer whose tumors express PD-L1 (CPS ≥1) as determined by an FDA-approved test. KEYTRUDA, as a single agent, is indicated for the treatment of patients with recurrent or metastatic cervical cancer with disease progression on or after chemotherapy whose tumors express PD-L1 (CPS ≥1) as determined by an FDA-approved test. Hepatocellular Carcinoma KEYTRUDA is indicated for the treatment of patients with hepatocellular carcinoma (HCC) secondary to hepatitis B who have received prior systemic therapy other than a PD-1/PD-L1-containing regimen. Biliary Tract Cancer KEYTRUDA, in combination with gemcitabine and cisplatin, is indicated for the treatment of patients with locally advanced unresectable or metastatic biliary tract carcinoma (BTC). Merkel Cell Carcinoma KEYTRUDA is indicated for the treatment of adult and pediatric patients with recurrent locally advanced or metastatic Merkel cell carcinoma (MCC). Renal Cell Carcinoma KEYTRUDA, in combination with axitinib, is indicated for the first-line treatment of adult patients with advanced renal cell carcinoma (RCC). KEYTRUDA is indicated for the adjuvant treatment of patients with RCC at intermediate-high or high risk of recurrence following nephrectomy, or following nephrectomy and resection of metastatic lesions. Endometrial Carcinoma KEYTRUDA, as a single agent, is indicated for the treatment of patients with advanced endometrial carcinoma that is MSI-H or dMMR, as determined by an FDA-approved test, who have disease progression following prior systemic therapy in any setting and are not candidates for curative surgery or radiation. Tumor Mutational Burden-High Cancer KEYTRUDA is indicated for the treatment of adult and pediatric patients with unresectable or metastatic tumor mutational burden-high (TMB-H) [≥10 mutations/megabase (mut/Mb)] solid tumors, as determined by an FDA-approved test, that have progressed following prior treatment and who have no satisfactory alternative treatment options. This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials. The safety and effectiveness of KEYTRUDA in pediatric patients with TMB-H central nervous system cancers have not been established. Cutaneous Squamous Cell Carcinoma KEYTRUDA is indicated for the treatment of patients with recurrent or metastatic cutaneous squamous cell carcinoma (cSCC) or locally advanced cSCC that is not curable by surgery or radiation. Triple-Negative Breast Cancer KEYTRUDA is indicated for the treatment of patients with high-risk early-stage triple-negative breast cancer (TNBC) in combination with chemotherapy as neoadjuvant treatment, and then continued as a single agent as adjuvant treatment after surgery. KEYTRUDA, in combination with chemotherapy, is indicated for the treatment of patients with locally recurrent unresectable or metastatic TNBC whose tumors express PD-L1 (CPS ≥10) as determined by an FDA-approved test. Merck’s focus on cancer Our goal is to translate breakthrough science into innovative oncology medicines to help people with cancer worldwide. At Merck, the potential to bring new hope to people with cancer drives our purpose and supporting accessibility to our cancer medicines is our commitment. As part of our focus on cancer, Merck is committed to exploring the potential of immuno-oncology with one of the largest development programs in the industry across more than 30 tumor types. We also continue to strengthen our portfolio through strategic acquisitions and are prioritizing the development of several promising oncology candidates with the potential to improve the treatment of advanced cancers. For more information about our oncology clinical trials, visit . About Merck At Merck, known as MSD outside of the United States and Canada, we are unified around our purpose: We use the power of leading-edge science to save and improve lives around the world. For more than 130 years, we have brought hope to humanity through the development of important medicines and vaccines. We aspire to be the premier research-intensive biopharmaceutical company in the world – and today, we are at the forefront of research to deliver innovative health solutions that advance the prevention and treatment of diseases in people and animals. We foster a diverse and inclusive global workforce and operate responsibly every day to enable a safe, sustainable and healthy future for all people and communities. For more information, visit and connect with us X (formerly Twitter), Facebook, Instagram, YouTube and LinkedIn. Forward-Looking Statement of Merck & Co., Inc., Rahway, N.J., USA This news release of Merck & Co., Inc., Rahway, N.J., USA (the “company”) includes “forward-looking statements” within the meaning of the safe harbor provisions of the U.S. Private Securities Litigation Reform Act of 1995. These statements are based upon the current beliefs and expectations of the company’s management and are subject to significant risks and uncertainties. There can be no guarantees with respect to pipeline candidates that the candidates will receive the necessary regulatory approvals or that they will prove to be commercially successful. If underlying assumptions prove inaccurate or risks or uncertainties materialize, actual results may differ materially from those set forth in the forward-looking statements. Risks and uncertainties include but are not limited to, general industry conditions and competition; general economic factors, including interest rate and currency exchange rate fluctuations; the impact of pharmaceutical industry regulation and health care legislation in the United States and internationally; global trends toward health care cost containment; technological advances, new products and patents attained by competitors; challenges inherent in new product development, including obtaining regulatory approval; the company’s ability to accurately predict future market conditions; manufacturing difficulties or delays; financial instability of international economies and sovereign risk; dependence on the effectiveness of the company’s patents and other protections for innovative products; and the exposure to litigation, including patent litigation, and/or regulatory actions. 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摘  要癌症是全球第二大常见的死亡原因，仅次于心血管疾病。癌症的特征之一是不受控制的细胞分裂和对细胞死亡的抵抗。已经开发了多种方法来应对这种疾病，包括手术、放疗和化疗。尽管化疗主要用于控制细胞分裂和诱导细胞死亡，但一些癌细胞能够抵抗细胞凋亡，并对这些药物产生耐受性。化疗的副作用往往是患者很难承受得起的，患者可能会经历更多的不良反应而不是收益。此外，用于化疗的药物的生物利用度和稳定性是必须解决的关键问题，因此对确保快速和准确的靶向治疗的可靠输送系统有很高的需求。在本文中，我们讨论了不同类型的纳米载体、它们的特性和配方的最新进展，以及每种载体的相关优点和缺点。前  言纳米医学是一个新出现的领域，已经在世界范围内获得了极大的关注。该领域的技术可以深入探索细胞隔室，并可能有助于治疗包括癌症在内的多种疾病（Mushtaq，2021）。治疗性纳米医学递送系统的开发对全世界的研究团体来说都是一个挑战（Bamburowicz-Klimkowska，2019；Bastiancich，2019），人们对将活性成分药物与高效递送载体相结合的系统有很高的要求。传统的化疗递送策略有几个问题，包括潜在的多药耐药性的发展，这损害了这些药物的可靠使用（Karpkird，2020；Ruman，2020）。此外，经典的纳米载体的临床反应往往与抗癌治疗的预期不同。因此，人们开发了对刺激有反应的新材料和智能药物输送平台（Elzoghby，2020；Heinrich，2020；Parayath，2020）。一些临床试验表明，与游离药物相比，这些智能药物输送系统提高了几种癌症的治疗效率（Vergallo, 2021）。因此，需要开发新的纳米载体，能够有效地将特定的药物输送到其目标部位（Ruman，2020）。药物输送系统是改善抗癌药物治疗特性的一种重大策略（图1）。它们有助于克服药物的难溶性和生物利用度问题，这些问题会限制药物的治疗作用（He，2020；Laffleur and Keckeis，2020；Güven，2021；Mitchell，2021）。抗癌药物有几个主要的限制，其中包括（但不限于）：非特异性、广泛的生物分布、短半衰期和全身毒性（Taghizadeh，2015）。使用纳米载体可以帮助最大限度地减少这些与药物有关的障碍，并通过允许在特定的目标部位进行传递和控制释放来改善药物的治疗作用（Sharma & Bhatia，2021；Wang，2021）。图1 用于递送药物的不同类型的纳米载体因此，基于纳米技术的药物递送系统在开发合适的载体方面有很大的潜力，能够有效地、高效地递送药物来对抗包括癌症在内的一些疾病。此外，这些递送系统可以为其他药物的相关问题提供解决方案，包括副作用和疗效（Zheng，2020；Aranda-Lara，2021）。药物输送系统主要是指药理学载体。它们包括纳米乳剂、纳米脂质体、纳米水凝胶、纳米颗粒（nanoparticles，NPs）和纳米纤维，这些分子能够夹带或承载药物并将其运送到目标部位，引起了医学领域的关注（Zheng，2020；Tomeh & Zhao，2020；Baveloni，2021；Hasani，2021）。一般来说，包裹在纳米胶囊内的货物是纳米颗粒（尺寸小于100纳米）。它们的小尺寸使它们能够到达特定的细胞区，在那里沉积装载物（Güngör & Kahraman，2021；Martinelli，2021）。封装的聚合物也可以成功地用作递送系统，并且能够保护药物不受可能导致在胃肠道（gastrointestinal，GI）降解的环境因素的影响（Al-Hashimi, 2021; Calvino, 2021）。天然多糖（natural polysaccharides，NPLS）是最广泛使用的聚合物，其多样化的特性使其比合成聚合物更具优势（Niu，2021）。NPLS也被认为是安全的，因为它有几个独特的特性，包括无毒性、无反应性和生物相容性（Shah，2020；Chen，2021）。因此，NPLS通常被用作纳米载体递送药物的制药配方中的辅料。它们的物理和化学结构可以方便地修饰，以适应不同的应用，而且有些能够抵抗目标细胞经常拥有的酶降解过程。(Chakka and Zhou，2020；Guo，2020；Meneguin，2021；Shokri，2021）。由NPLS输送的药物能够与外层结合，使其具有增加稳定性和可溶性的优势（Salapa，2020；Torres-Pérez，2020）。用于制造纳米涂层药物的最常见的有效NPLS是果胶、淀粉、树胶、壳聚糖、海藻酸盐和纤维素（Niu，2021；Shah，2020）。它们的独特治疗效果在治疗包括癌症在内的几种疾病中是很显著的。本综述阐述了使用纳米载体递送抗癌药物的挑战，并指出了这一前景广阔的研究领域的未来远景。1 天然多糖的合成在形状、大小、结构和合成过程方面，NPs之间存在相当大的差异。存在两种主要的NP合成方法，被称为自上而下和自下而上的方法。下面将讨论这些方法。2 自上而下的方法自上而下的方法也被称为破坏性方法，即在生成所需的NPs之前，将大部分材料降解成小块（Shafey, 2020）。这种方法涉及几种技术，如激光烧蚀、热分解和机械研磨。在NP合成过程中，通过改变反应条件可以很容易地改变尺寸、形状和电荷（Lassalle & Ferreira，2007）。3 自下而上的方法在这种方法中，NPs由较小的结构（如原子）构建，最终生成所需的NPs（Yang，2014）。这种方法通常采用的一种方法是化学气相沉积旋转激光热解法。4 以癌细胞为目标的药物输送系统靶向药物递送系统是最近开发的一种向靶向肿瘤细胞有效递送特定药物的方法（Alshememry，2017；Bokan，2019），具有一些优点和缺点。优点包括由于特异性靶向癌细胞而保护正常细胞不受药物作用的影响，可大幅减少药物副作用，并降低一些肿瘤细胞的耐药率（Ahlawat，2018；Ajithkumar & Pramod，2016）。至关重要的是，药物要以足够的数量传递到其目标部位以发挥其作用，在选择和设计药物传递系统时应考虑这一点。细胞核是大多数药物的主要目标部位。尽管NPs的设计允许它们进入细胞膜，但不能保证它们能够到达细胞核。因此，有两种目标定位的方法，如下所述。5 主动靶向在主动药物靶向中，药物可以利用非常独到的结构，如抗体或肽，来进入受体和靶点。主动靶向包括超声能量和磁场等技术。主动靶向系统由三部分组成：作为靶向分子的配体、作为载体的聚合物和特定的活性药物。抗原拥有作为主动靶向系统的功能，因为它只在肿瘤细胞上表达。这允许该系统通过受体介导的内吞作用内化（Kumar Khanna，2012）。主动药物靶向方法不仅对于药物，而且对于将基因、蛋白质和治疗方法输送到其目标部位都至关重要，使正常细胞免于接触，从而减少潜在的副作用。与普通的药物递送系统相比，该系统还能增加药物递送的数量。当药物积聚在肿瘤细胞周围的间隙中时，可以被细胞的活性机制包裹。这种情况的发生是由于在纳米系统上修饰了独特的转录因子，这些转录因子附着在肿瘤细胞表面过度表达的蛋白质上。这种修饰提高了纳米系统对癌细胞表面的化学和物理亲和力（Attia，2019）。靶点是纳米系统在进入细胞之前所附着的分子。其中包括用于到达脑瘤微环境的转铁蛋白受体，转铁蛋白配体已经通过加载到固体脂质NPs（Jain，2013）、树枝状物（He，2011）、胶束（Zhang，2012）和超顺磁性氧化铁NPs（Jiang，2012）而被用于靶向胶质瘤细胞。6 被动靶向将药物直接注射到血液中是被动药物靶向（也称为物理靶向）的典型例子。在这种机制中，药物是通过身体机制（如代谢、排泄、调理和吞噬）来最大限度地减少其清除的。有充分的证据表明，在某些条件下，包括缺氧和炎症，血管会变得更具渗透性（Torchilin，2011）。肿瘤细胞通常在活跃分裂时通过血管生成过程建立新的血管。这使得新形成的血管更具渗透性，并允许大于40kDa的大分子（包括纳米系统）通过。因此，将小型药物封装成纳米形式可以增强其药代动力学并减少潜在的副作用。这种类型的靶向被称为被动靶向，因为它依赖于纳米载体的使用（Maeda，2001；Fang，2011年）。然而，应该注意的是，发生在肿瘤核心部分的缺氧和坏死病变可以阻止纳米载体和纳米药物进入整个肿瘤。这些坏死性病变是由于与主要肿瘤血液供应距离较远而导致氧气和营养物质输送不足。此外，作用在肿瘤核心部分血管上的间质压力使其渗透性低于外围血管（Fang，2011；Kobayashi，2013）。7 药物纳米递送系统有趣的是，NPLS是一种功能性大分子生物聚合物，通常从几种来源分离，包括植物（果胶和纤维素）、动物（壳聚糖）、细菌（黄原胶、树胶和葡聚糖）和藻类（藻酸盐）。这些多糖通常由十多个单糖单元组成，这些单糖单元通过糖苷以直链或支链连接，具有高度的安全性、稳定性和生物相容性。它们可以根据所需的设计和结构进行简单的修改和操作，以进一步应用于许多领域，包括生物医学和药物研究。NPLS由于其多种生物学特性，包括降血糖、抗癌和抗凝血作用，在生物医学研究中得到了有效的应用。由于存在与靶细胞受体结合的特异性配体，NPLS被用作药物纳米递送系统的候选赋形剂。这些配体参与药物的受控和靶向转运以供递送。此外，NPLS通常是可生物降解的、生物相容的，并且具有较低的毒性水平（图2）。图2 携带药物的纳米粒子与细胞膜之间的相互作用NPLS可以很容易地进行化学或生物化学修饰，以产生多种具有多种功能的活性形式，因为它们的表面结构含有羧基、羟基和氨基等官能团。特别是，这些衍生基团在与活体肌肉相关的非共价键的形成中发挥着重要作用，包括参与生物对接的粘膜和上皮。例如，NPLS海藻酸盐、果胶、淀粉和壳聚糖是有效的生物粘合剂（图3）。图3 细胞膜上的活性位点和靶向药物内化到癌症细胞中当生物粘合剂被用作药物递送系统时，细胞/药物摄取被成功地增强。NPLS的这些突出优点使其成为化疗药物，尤其是癌症治疗药物的首选方法。最近，人们对NPLS进行了广泛的研究，以深入了解其在各种纳米载体制剂中作为稳定剂的用途（Rehman，2020；Gheorghita-Puscaselu，2020；Pejin，2014）。生物聚合物（如多糖）因其高生物相容性和低免疫原性而被用作药物递送的有效纳米载体（Alsheemry，2017）。8 壳聚糖壳聚糖是一种被人熟知的线性阳离子杂多糖，由β-1,4-连接的2-氨基-2-脱氧-吡喃糖和2-乙酰氨基-2-脱氧残基-b-D-吡喃糖组成。它是最突出的天然多糖之一，由于其生物相容性和生物可降解性，被广泛用于纳米药物递送系统（Jhaveri，2021；Narmani & Jafari，2021）。壳聚糖具有多种特性，使其成为一种有效的纳米载体，包括血清中的高稳定性、低免疫原性、长循环时间、生物相容性和高生物利用度（Mushtaq，2021；Narmani & Jafari，2021；Pejin，2014）。壳聚糖是从甲壳类动物中提取的，用于各种药物和临床应用，包括作为纳米药物递送系统。壳聚糖结构中的氨基官能团使其可溶于酸性介质，对药物纳米递送系统中的生物化学适应和静电相互作用至关重要。此外，带正电荷的氨基可以提供具有免疫原性的壳聚糖，从而使其可以用作能够附着到粘膜细胞表面的生物粘合剂材料。壳聚糖的正电荷还能够打开上皮紧密连接，拓宽通过相邻细胞通路的通道，支持含有亲水性化合物的药物转运到靶组织中。壳聚糖已被广泛用作制备纳米载体的载体剂，用于治疗包括癌症在内的各种疾病的药物纳米系统。Akolade等人（2017）进行的一项研究发现，将姜黄素掺入壳聚糖中显示出包封效率的提高，负载能力达到64~76%（Akolade et al，2017）。姜黄素也被封装在壳聚糖纳米脂质体中，与阴道用传统药物结构相比，姜黄素显示出显著的负载量（Saesoo，2016）。其他药物已被掺入壳聚糖包被的藻酸钙纳米颗粒中，包括利拉鲁肽，其包封效率超过925，对糖尿病的治疗非常有效（Shamekhi，2018）。基于壳聚糖的纳米颗粒已被用于对抗几种细菌（Rashki，2021；Abd-El-Hack，2020）和病毒的感染，如冠状病毒（CoVs）（Rasul，2020）。当负载乙二醇时，研究者发现他们会在肿瘤细胞内积聚，这表明它们除了药物递送外，还可以用于其他应用（Ryu，2020）。此外，将壳聚糖与程序性死亡配体1（PD-L1）结合，以使这种参与程序性细胞死亡的蛋白质能够有效地跨粘膜递送（Jin，2021），并与碳量子点和DNA适体结合，用于在乳腺癌细胞中特异性递送5-氟尿嘧啶（5-FU）。这种方法的成功是通过测量不同凋亡相关基因（如BAX和BCL-2）的高表达谱来确定的（Zavareh，2020）。壳聚糖雷洛昔芬是Mohammadi等人首次引入的一种新型靶向治疗乳腺癌的药物，能够携带阿霉素。该制剂被发现具有近95%的载药能力（如果药物以高稳定性释放，则为60%）（Mohammadi，2020）。壳聚糖还与pluronic P123聚合物缀合以靶向肺癌细胞，并且由于修饰的脂质体与肿瘤细胞之间的高亲和力，这种缀合的配方显著增强了癌细胞的摄取。在肺癌小鼠模型中观察到了相同的情况，其中将紫杉醇负载到壳聚糖脂质体上导致84%的肿瘤生长抑制（Miao，2021）。壳聚糖作为纳米载体的使用具有许多优点，包括增强药物吸收、膜相互作用、抵抗迁移、刺激免疫反应和延长药物释放（Nandgude & Pagar，2021）。9 纤维素纤维素是最广泛存在的天然多糖元素之一。这种生物化合物主要从细菌、真菌、植物和藻类中获得（Hemmati，2018）。纤维素的结构由以特定方式排列的D-吡喃葡萄糖环组成（Bajpai，2019）。纤维素被认为是一种生物相容的生物大分子，具有低毒性，具有独特的化学和物理特性，使其在医学上有广泛的应用，包括将药物运送到目标部位。然而，这种生物大分子的原始形式不溶于水，这限制了其应用。各种类型的改性纤维素已经被创造出来以解决这个问题并增加其应用。其中有几种，如纳米纤维素、纤维素醚、甲基纤维素和羟丙基纤维素，可作为治疗各种疾病的纳米药物包装和输送。由于其功能特点，重组形式的纤维素被用作增稠剂、稳定剂，并用于制造特定药物的纳米载体。用聚乙烯吸附的纤维素已被用来制造以植物为基础的蛋白质负载的纳米脂质体，它在胃肠道中提供了磷脂蛋白的控制释放（Patel，2020）。在类风湿性关节炎中，纤维素纳米粒子已经与钠结合，在该疾病的小鼠模型中作为外用软膏递送氯喹进行治疗。使用这种递送系统的结果显示，明显比药物本身的效果好（Bhalekar，2015）。纤维素是自然界中最常见的多糖之一，其惰性和生物相容性使其成为新型纳米载体的有力候选材料。基于纤维素诱导的复合材料、涂层和薄膜，已经开发了几种配方，并以纳米形式使用。这些基于纤维素的配方被用于各个领域，包括医学、生物学，甚至电子和能源（Carvalho，2021）。纤维素可以被配制成一种细长的生物基纳米结构，称为纤维素纳米晶体。它拥有新颖的特性，可以治疗各种疾病，包括癌症（Pinto, 2021）。10 淀粉环境友好的纳米复合材料已经被开发出来，作为安全和可生物降解的纳米载体应用。这些纳米载体包括淀粉（Li，2019），一种有前途的天然多糖，由大分子量的葡萄糖长链的生物聚合物制成（Duan，2020）。最近，为了不同的应用，淀粉被进行了各种修饰，包括附着L-丙氨酸、L-赖氨酸和L-苯丙氨酸。这种修饰形成的球形分子适合作为包括萘普生在内的几种药物的纳米载体（Namazi & Abdollahzadeh, 2018）。一般来说，天然淀粉由于具有几个显著的优点，包括生物相容性、低毒性、不敏感和增加药物溶解度，已经被用来实现药物的控制释放。淀粉的一个局限性是它的乳化能力低，可以通过改性来提高胃肠道的吸收。这些修饰包括酶解、化学和物理活化（BravoNúñez，2019年）。在化学上，原生淀粉被乙酰化、氧化或羟丙基化，以获得能够显著给药的改性分子（Bai & Shi，2016；Zhu，2017）。近年来，纳米技术的发展拓宽了包括淀粉在内的几种生物聚合物的应用。为了优化使用这些改性聚合物，有必要在纳米尺度上更深入地了解其结构（Torres，2019）。与姜黄素偶联的淀粉最近在纳米尺度上被用来有效地输送前者的生物制剂。这种成分被发现具有很高的药物装载能力，增强了胶体稳定性和对酸敏感的释放曲线。此外，与游离的姜黄素相比，这种纳米配方大大增加了姜黄素的溶解度，并在暴露于紫外线和高温时保护其不被降解。这种配方已被用于治疗几种疾病，包括癌症（Chen，2020）。胆固醇和咪唑是用于氧化淀粉的生物大分子。最终产品是与胆固醇和咪唑相连的氧化淀粉，通过透析转化为纳米颗粒。这种配方被用来有效地将姜黄素送入癌细胞，其中加载的姜黄素在pH值7.4时被释放（相比之下，单独使用姜黄素时的pH值为5.5）（Zhu, 2017）。淀粉也被用来封装氧化铜纳米颗粒，并促进其在乳腺癌细胞（MDAMB-231）中的目标释放。数据显示，这种纳米配方在细胞中诱发了细胞毒性，其IC50接近21 μg/mL。细胞毒性是由活性氧（ROS）的产生和线粒体膜电位的降低引起的（Mariadoss，2020）。同样，甘露糖与5-FU偶联并加载到淀粉纳米粒子上，以锁定肝癌细胞。当加载时，发现5-FU的药物吸收效率在64.2和82.3%之间。体内研究表明，与NPs共轭的甘露糖延长了5-FU的血浆水平。此外，血浆分析显示肝脏中的5-FU水平升高，表明这种纳米载体将药物输送到目标部位的效率（Jain, 2021）。表观遗传药物（如组蛋白去乙酰化酶抑制剂CG-1521）也被封装在淀粉纳米颗粒中，以提高其生物利用度和可溶性。数据显示，CG-1521的封装降低了释放率，增加了药物在乳腺癌细胞MFC-7中的细胞毒性。这种纳米配方诱导了细胞周期停滞和细胞凋亡，表明将这种药物封装在淀粉纳米载体中可以大大改善其传递（Alp, 2019）。11 果胶果胶是一种天然存在的生物聚合物，具有由α-(1-4)-D-半乳糖醛酸组成的线性多糖，并显示出用于不同应用的前景，包括药物输送（Rehman, 2019）。果胶在胃肠道中不能被消化，其溶解度会降低。然而，通过共生细菌产生的果胶分解酶的作用，它可以在结肠中被吸收（Shishir，2019）。果胶的特点是疏水性，这一特性使它可以作为纳米载体使用，因此它已被用于一些药物的透皮给药。果胶还被用来合成纳米颗粒、纳米乳剂和纳米脂质体形式的药物负载纳米载体。一些药物已经被加载到果胶纳米载体上，包括姜黄素（Alippilakkotte & Sreejith，2018）、头孢唑啉（Shahzad，2019）和二甲双胍（Chinnaiyan，2019）。癌细胞的抗性限制了化疗药物的疗效。这个问题可以通过使用精油来解决，尽管生物利用度低仍然是一个关键因素。因此，纳米乳化剂代表了克服这一障碍的一个有前途的工具。一项研究将柑橘黄酮与多花紫草精油结合起来，以确定其抗增殖特性。该制剂被发现通过触发ROS的激活、线粒体膜电位的丧失和细胞周期在G2/M期的停滞来诱导乳腺癌细胞凋亡（Salehi，2020）。由于其自愈性，用氧化果胶、壳聚糖和γ-Fe2O3合成了复合水凝胶，将药物送入目标细胞。该配方被发现具有高溶解性和生物相容性，以及自愈性和抗增殖性，特别是当加载5-FU时，该复合材料能够在12小时内持续释放（Li, 2020）。果胶还可以与壳聚糖偶联以提高输送效率。一项研究开发了加载西妥昔单抗的果胶-壳聚糖纳米颗粒，并发现这种配方在结肠癌细胞中的细胞摄取得到了加强。这导致了癌细胞繁殖的减少和细胞周期在G2/M期的停滞，表明这种纳米配方具有抗增殖的特性（Sabra，2019）。除了其改性形式，果胶还显示了肿瘤靶向药物输送的前景。一些研究已经调查了果胶纳米颗粒与不同金属（如金）的纳米颗粒的组合，作为乳腺癌细胞的抗癌治疗（Suganya，2016）。细胞凋亡的增加和彗星试验的结果表明，这种组合作为一种抗增殖的纳米配方是有效的（Suganya，2016）。12 藻酸盐藻酸盐是线性阴离子水溶性多糖，通常天然存在于褐色海藻中。海藻酸盐具有二价阳离子，这在合成纳米药物输送系统中是很有利的。它们的安全性和生物相容性使它们对几种药物的封装很有用。阳离子（如钙离子）的存在使藻酸盐成为良好的纳米载体，并使它们可以用于制造水凝胶。利用水凝胶运输药物的过程主要依赖于pH值，由藻酸盐封装的药物在胃的酸性环境中不会释放。当化合物到达肠道，pH值增加时，药物就会被允许开始释放。由于藻酸盐的低毒性、高生物相容性和生物降解性，可以作为抗癌药物的传递工具（Jayapal & Dhanaraj，2017）。它们还可以与其他天然多糖，如壳聚糖和果胶相结合。许多研究表明，基于海藻酸盐的NPs平台有可能用于成功传递一些抗肿瘤药物（He，2020）。在一项研究中，姜黄素被加载到磁性海藻酸盐/壳聚糖NPs上，以提高其在乳腺癌细胞中的生物利用率和细胞毒性。结果表明，用负载的姜黄素处理的细胞对药物的吸收效率提高了3~6倍，表明这种纳米载体提供了一种可靠的药物输送方法（Song, 2018）。在另一项研究中，多柔比星（一种常见的化疗药物）被加载到海藻酸盐纳米水凝胶上，发现这种配方能在肿瘤细胞中使得多柔比星得到持续的释放（Zhou，2018）。其他研究人员将胰岛素加载到海藻酸盐纳米颗粒上以治疗糖尿病大鼠，发现它能使葡萄糖水平降低40%，持续时间超过18小时（Sarmento, 2007）。为了评估作为乳腺癌的治疗，口服化疗药物依西美坦被加载到海藻酸盐NPs上。体外实验的结果表明，海藻酸盐纳米颗粒（ALGNPs）作为一种可靠的药物输送系统用于乳腺癌（Jayapal & Dhanaraj，2017）。在另一项研究中，顺铂被胶结在海藻酸盐水凝胶和金NPs上进行传递；发现这种组合产生了更高的肿瘤抑制水平（Mirrahimi，2020）。研究人员还表明，儿茶酚功能化的海藻酸盐NPs可用于治疗膀胱癌。这种纳米配方是用耦合化学法制造的，体内分析显示，与未改性的形式相比，它在猪膀胱组织粘膜中的保留率有所提高。此外，这种组合还显示出较高的装载效率和容量。因此，这种纳米配方可以作为治疗膀胱癌的粘附性纳米剂（Sahatsapan，2020）。姜黄素戊二酸是活性形式姜黄素的前体，与活性形式相比，它的特点是高溶解度。为了加强这些特性，姜黄素戊二酸被封装在壳聚糖/海藻酸盐纳米粒中。这种纳米配方在结直肠癌细胞中显示出很高的细胞摄取率，与游离形式相比具有更好的抗增殖活性。因此，口服这种纳米形式可用于治疗一些癌症类型（Sorasitthiyanukarn，2018）。一项研究根据油包水乳化原理，将多柔比星以纳米形式装入海藻酸/壳聚糖中。在小鼠乳腺癌细胞中评估了这种新配方的功效，结果显示，与游离多柔比星（0.13 lg/mL）相比，纳米形式的IC50为0.15 μg/mL，表明纳米配方在传递细胞毒性药物方面更有效率（Rosch，2019）。13 透明质酸透明质酸（Hyaluronic acid，HA）是一种天然存在的多糖，存在于动物和人类的所有结缔组织中。研究人员将喜树碱与HA外壳偶联，发现这种配方能够消除小鼠的原发性乳腺癌细胞（Sun，2019）。另一项调查治疗CD44-表达的乳腺癌细胞的研究准备了HA、壳聚糖和硫辛酸NPs的组合。使用MTT、TUNEL、CASP3和罗丹明123检测确定这些组合NPs的有效性。该组合显示了持续释放、高细胞内化和在乳腺癌细胞（MCF-7）内快速释放药物。这些数据表明，这种纳米配方可能是一个有希望的平台，用于靶向输送治疗癌症的药物（Rezaei，2020）。基于HA的聚合物NPs也被用来封装IR780，用于乳腺癌治疗。这种纳米配方与多柔比星共包，以增强其治疗活性。二维和体外分析表明，与非恶性细胞相比，乳腺癌细胞对该纳米配方的细胞内化程度更高。这些结果证明了这种纳米配方在输送治疗癌症的药物方面的有效性（Alves，2019年）。多西他赛是一种常用的化疗药物，在CYP1B1的作用下失活，CYP1B1是一种由MDR乳腺癌细胞过度表达的酶。HA与纳米形式的聚乙烯亚胺相结合，加载多西他赛和a-萘酮（CYP1B1的抑制剂），以克服乳腺癌细胞中CYP1B1引起的MDR。该配方可以通过下调癌细胞中的CYP1B1来逆转MDR，从而提高多西他赛的治疗活性（Zhang，2019）。化疗药物的输送遇到了一些障碍，包括对目标细胞缺乏特异性，细胞内化率低，肝脏累积率较高。为了解决这个问题，研究人员准备了一种HA-紫杉醇-甲氧基聚乙二醇的复合纳米配方，并在表达CD44的肺癌细胞中进行了测试。结果发现，与游离药物形式相比，这种配方减少了肝脏蓄积，并在体内增强了抗肿瘤活性。因此，这种复合纳米配方可以直接应用于改善癌症治疗药物在体外和体内的传递（Luo，2020）。5-FU是一种常用的抗癌药物，其生物利用度有限。在他们的研究中，Mansoori等人开发了HA修饰的脂质体，将5-FU送入表达CD44的乳腺癌和结直肠癌细胞。凋亡试验表明，经处理的细胞在细胞周期的G0/G1期被逮捕。此外，他们的结果显示，与游离药物相比，给予5-FU-HA和5-FU-lipo时，菌落形成减少（Mansoori，2020）。HA也被用来修改Au-Ag合金NPs，以专门针对表达CD44的4T1乳腺癌细胞。该合金的过氧化物酶样活性有助于在肿瘤部位产生更多的OH并释放Ag+，从而导致该合金的高效治疗作用（Chong, 2020）。奎纳克林主要用于治疗疟疾，但也被发现具有抗癌特性。奎纳克林的主要挑战是它的肝毒性；为了克服这个问题，利用HA和乳铁蛋白制备了一种纳米复合材料，以胰腺癌细胞（PANC-1）为目标。该复合材料的IC50下降了3倍，表明其具有强大的抗癌活性。体内研究表明，该复合材料减少了肿瘤体积，提高了大鼠的生存率，对重要器官没有任何不利影响（Etman，2020）。最近，雷洛昔芬已被用于治疗肺癌和预防肝癌。雷洛昔芬耐药性仍然是使用这种药物的一个重要障碍。为了解决这个问题，研究人员将雷洛昔芬装入HA和壳聚糖纳米颗粒中，以增加药物的半衰期并增强其释放。这种配方在非小细胞肺癌（A549）和肝细胞癌（HCC）细胞上进行了测试，结果显示，它的药物吸收能力高于单独的自由药物。这是首次评估雷洛昔芬在HA和壳聚糖NPs中的装载效率的研究（Almutairi等人，2019）。在制备多西他赛时，HA与金纳米粒子（AuNPs）的组合已被证明是有用的，用于治疗癌细胞。与游离的多西他赛相比，这种组合在肿瘤模型中表现出更大的细胞毒性和对癌症生长的抑制作用（Gotov，2018)。研究人员通过在磷酸锆NPs中加入HA，将磷酸锆的药物装载特性和HA的癌细胞靶向能力结合起来。然后，该系统被加载了紫杉醇作为抗增殖药物来靶向肺癌细胞。与单独的自由药物相比，加载的药物显示出在目标细胞内的积累增加，体内分析表明抗癌活性增加（Li，2017）。14 右旋糖酐研究人员将葡聚糖与壳聚糖NPs相结合，并将其与NIK/STAT3特异性siRNA和BV6加载，以诱导不同癌症的细胞死亡，包括乳腺癌和结直肠癌。结果表明，这种组合诱导细胞凋亡，抑制细胞增殖，减少细胞迁移、血管生成和肿瘤细胞的集落形成（Nikkhoo，2020）。抗HER2抗体是一种有前途的靶向分子，用于肿瘤特异性癌症治疗。在一项研究中，这种抗体以纳米形式与葡聚糖和精胺偶联，并评估了这种配方对癌细胞的效率。结果表明，该偶联抗体对SKBR3和人类成纤维细胞没有毒性作用。当用于热疗时，发现偶联的抗HER2-精胺-葡聚糖NPs能够靶向并诱导所研究细胞的凋亡（Avazzadeh，2017）。为了提高5-FU和紫杉醇的效率，研究人员将这些分子加载到壳聚糖/葡聚糖NPs上，以促进双重药物输送。体外分析显示，该配方表现出可控的药物释放。评估了这种纳米配方对肝细胞癌细胞（HepG2）的细胞毒性作用，结果显示，这种双重药物抑制了细胞增殖并诱导细胞凋亡。此外，细胞摄取分析表明，紫杉醇和5-FU在肝癌细胞中的药物内化率很高（Wang，2020）。在另一项研究中，研究人员将甲氨蝶呤加载到葡聚糖-姜黄素纳米系统上，以促进有效输送到乳腺癌细胞（MCF-7）。他们的研究结果表明，该纳米系统能够控制甲氨蝶呤的释放，并在这些细胞中产生较高的药物内化率（Curcio, 2019）。已进行了进一步的研究，调查使用葡聚糖来改善药物输送。葡聚糖和叶酸包被的超顺磁性氧化铁的组合被用来提高长春花碱在胰腺癌细胞中的靶向效率和药物摄取。合成的纳米载体呈球形，发现该系统可以激活胰腺癌细胞中的PDL1、Casp3和NF-1，进而诱导细胞凋亡并减少细胞增殖（Albukhaty，2020）。为了克服癌细胞（尤其是乳腺癌）普遍获得的对多柔比星的抗性，多柔比星被封装在葡聚糖-壳聚糖NPs中。这种配方在癌细胞中显示出更高的细胞毒性，而对正常细胞不产生影响。此外，这种纳米配方通过增加Bax/Bcl-xL的比例以及上调p53和p21，增强了药物的吸收和诱导细胞凋亡（Siddharth, 2017）。葡聚糖还与聚乙胺和氧化铁NPs结合使用，作为磁性基因载体的一部分，将miR-320b送入骨肉瘤细胞。磁场的产生使这种纳米配方能够进入裸鼠的OS细胞，并揭示了miR-320b的抗骨肉瘤作用，它可能通过YOD1调节Hippo途径而减少增殖（Gong，2020）。葡聚糖包裹的磁性NPs也被用来高效和选择性地传递miR-29a到乳腺癌细胞中，它导致了几个抗凋亡基因的下调（Yalcin, 2019）。卡培他滨是一种抗肿瘤药物，可以加载到阳离子葡聚糖-丝氨酸聚合物上，有效地输送到胶质母细胞瘤细胞中。细胞毒性数据显示，与游离药物相比，负载药物的毒性增加，胶质母细胞瘤的吸收增强（Ghadiri, 2017）。通过将5-FU加载到结肠酶反应性的葡聚糖基寡糖NPs上，已经证明了5-FU的可控药物释放。葡聚糖酶触发了封装药物的释放，这种酶的作用可能是导致治疗结肠直肠癌的纳米配方的生物利用度增加和毒性升高的原因（Abid，2020）。右旋糖酐也被涂上Goldman NPs，用于将多柔比星送入肝癌细胞。该纳米配方表现出较高的延长多柔比星释放的能力，从而增强了药物的治疗作用。它还减少了多柔比星的不良反应，并抑制了肝癌细胞的生长和增殖。因此，该配方代表了通过改善药物输送来治疗癌症的一个有希望的步骤（Li，2018）。硫酸葡聚糖-壳聚糖NPs已被用于将拉帕替尼送入癌细胞，细胞毒性实验表明，与单独的药物相比，加载的拉帕替尼在治疗48小时后表现出强大的抗癌活性。这些结果表明，纳米载体以可控的方式有效地释放疏水药物（Mobasseri，2017）。紫杉醇最主要的问题是其低溶解度和生物利用率。Bakrania等人（2018）证明，当紫杉醇以DEAE-葡聚糖纳米配方输送到三阴性乳腺癌细胞时，这些问题可以得到解决。他们的结果显示，封装的紫杉醇通过β-干扰素诱导抑制ROS的作用更强。此外，该纳米配方还被发现可以抑制血管内皮生长因子和NOTCH1的过度表达。因此，该配方显示了对TNBC的全面抗癌活性（Bakrania，2018）。结  论使用纳米载体进行药物输送为治疗包括癌症在内的一些长期被认为无法治疗的疾病提供了可能性。这些纳米制剂提高了药物的生物利用度、溶解度和吸收率，从而在增加细胞毒性的同时减少了治疗副作用。这篇评论揭示了几种类型的纳米载体，特别是生物聚合物及其在癌症治疗中的药物输送潜力。未来的研究应集中在开发新一代的纳米载体，以促进越来越多的针对不同疾病（包括癌症）的药物的输送。参考文献Jhaveri, 2021. 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