Review
Doxil® — The first FDA-approved nano-drug: Lessons learned

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Abstract

Doxil®, the first FDA-approved nano-drug (1995), is based on three unrelated principles: (i) prolonged drug circulation time and avoidance of the RES due to the use of PEGylated nano-liposomes; (ii) high and stable remote loading of doxorubicin driven by a transmembrane ammonium sulfate gradient, which also allows for drug release at the tumor; and (iii) having the liposome lipid bilayer in a “liquid ordered” phase composed of the high-Tm (53 °C) phosphatidylcholine, and cholesterol. Due to the EPR effect, Doxil is “passively targeted” to tumors and its doxorubicin is released and becomes available to tumor cells by as yet unknown means. This review summarizes historical and scientific perspectives of Doxil development and lessons learned from its development and 20 years of its use. It demonstrates the obligatory need for applying an understanding of the cross talk between physicochemical, nano-technological, and biological principles. However, in spite of the large reward, ~ 2 years after Doxil-related patents expired, there is still no FDA-approved generic “Doxil” available.

Graphical abstract

Doxil vial as sold by Sequus Pharmaceuticals (starting 1996)

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Section snippets

What led to Doxil® development: OLV-DOX

Development of Doxil was initiated in Israel and the USA ~ 14 years ago when it became evident in a “first in man” (FIM) clinical trial by Gabizon and Barenholz that a “first generation” liposomal doxorubicin did not justify further clinical development despite an elevation of drug MTD (rev. in [1]). In this FIM trial we used negatively charged, medium-size oligolamellar liposomes (OLV) composed of two low-Tm (fluid) phospholipids [the zwitterionic egg-derived phosphatidylcholine (EPC), the

Liposomal doxorubicin: the desired product profile

We decided that in order for the liposomal doxorubicin product to become an anticancer FDA and EMA approved drug the product should be characterized by the following features:

  • The liposomes used should be at the nano-scale (nano-liposomes) so they will be able to take advantage of the EPR effect and extravasate from the blood vessels at the tumor into the tumor tissue. Such liposomes can be considered as a “Nano-Drug”.

    However going nano imposes a major challenge of achieving a sufficient level

Pharmacokinetics and passive targeting to tumors

In our Jerusalem 1991–1994 “first in man Doxil clinical trial” Doxil demonstrated high and selective tumor localization, published in Cancer Research [50]. The data (presented in Fig. 5) are the first proof for the EPR effect induced in tumors by passive targeting in humans [50]. The accumulation of Doxil in humans' tumors was further supported by direct fluorescence microscopy of patient biopsies by Gabizon and coworkers [96].

The above-cited Jerusalem pilot study includes 53 courses of Doxil

Doxil take home lessons and what will next-generation Doxil-like liposomes look like?

In summary, the anticancer nano-drug Doxil shows superiority to free doxorubicin (standard of care) clinical performance in a variety of neoplastic conditions due to its unique EPR-related pharmacokinetics and bio-distribution, which reduce side effects (especially important is the large reduction in cardiac toxicity) and improve overall patient compliance and quality of life. These, when combined with the way the doxorubicin is remote loaded into the long-circulating nano-liposomes, improve

Doxil historical perspectives

Pre-Doxil era (liver passively targeted by liposomal doxorubicin referred to as OLV-DOX)

1979Gabizon and Barenholz started their basic research on liposomal doxorubicin
1984First clinical trials with liposomal doxorubicin (OLV-DOX which differs to a large extent from Doxil)
1985LTI licensed the OLV-DOX technology and Barenholz and Gabizon 1990, 1991 I.P. on OLV-DOX
1987Clinical trial of OLV-DOX failed
1988Barenholz developed and Yissum, R&D Company of the Hebrew University of Jerusalem, Israel

Doxil I.P. aspects

It is important to note that Doxil® was based on two families of patents. However, there is no direct patent on Doxil. One family covers the transmembrane-driven remote loading of amphipathic weak bases such as doxorubicin [55], [56], while the second deals with contribution of the lipopolymer PEG-DSPE as a lipid component of liposome membrane for prolongation liposome circulation time and RES avoidance [78].

It took ~ 7 1/2 years from the submission of these two families of patent applications in

Generic doxorubicin in liposomes (Doxil-like)

The patent protection of Doxil® in the USA has been over since March 2010, and Doxil/Caelyx is selling well (over $600 million annually), so how come there is still no generic PEGylated liposomal doxorubicin (PLD)-like product approved by the FDA or EMA?

In addition to the complexity of FDA approval of generic Doxil, the current situation is even more complex. Ben Venue Laboratories (the sole supplier) has stopped Doxil production because of FDA-cited GMP deficiencies at their facilities. A

Personal touch

I cannot end this Doxil review without a personal touch. The road to the development of Doxil® covers a major part of my professional career. I have been working on the development of liposomal drugs since 1979. However, I could not perform all my applied multidisciplinary work without the many research years and major efforts I dedicated to basic research in the fields of lipid biochemistry and biophysics. I started to study phospholipid and sphingolipid enzymology when I was a second-year

Special acknowledgments

Professionally, I have a very long list of people to thank, in large part described above. Here, however I would like to thank by name only those people with whom I interacted on Doxil-related matters. Alberto Gabizon, for a 32-year partnership in exciting research including Doxil development, and friendship — the many shared papers and patents with him are excellent evidence of our highly productive collaborative interaction; the late Demetrios (Dimitri) Papahadjopoulos, for his friendship and

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