itraconazole / PKM2 Cancer Research Results

itraC, itraconazole: Click to Expand ⟱
Features:

Itraconazole — a synthetic, highly lipophilic triazole antifungal drug with substantial drug-repurposing interest in oncology. Standard abbreviations include ITZ and ITRA; Sporanox is a major brand name. Its approved pharmacologic function is inhibition of fungal lanosterol 14α-demethylase, disrupting ergosterol synthesis. Its anticancer activity is mechanistically distinct and appears to be multitargeted, involving direct inhibition of NPC1-dependent lysosomal cholesterol export, VDAC1-dependent metabolic signaling, mTOR suppression, inhibition of VEGFR2 maturation/angiogenesis, and inhibition of Hedgehog signaling through SMO. Itraconazole remains an approved antifungal rather than an approved anticancer drug.

Primary mechanisms (ranked):

  1. ↓ NPC1-mediated lysosomal cholesterol export, causing endolysosomal cholesterol accumulation and downstream disruption of growth and angiogenic signaling.
  2. ↓ Hedgehog signaling through inhibition of SMO trafficking/activation and downstream GLI signaling, particularly relevant to Hedgehog-dependent tumors such as basal cell carcinoma.
  3. ↓ Angiogenesis through impaired VEGFR2 glycosylation, trafficking and signaling, with reduced endothelial proliferation.
  4. ↓ mTORC1 signaling through complementary NPC1/cholesterol-trafficking and VDAC1/AMPK mechanisms.
  5. ↓ VDAC1-dependent mitochondrial metabolite transport, producing an increased AMP:ATP ratio, ↑ AMPK and ↓ mTOR signaling in endothelial models.
  6. ↓ P-glycoprotein/BCRP transporter activity and MDR-associated drug efflux, potentially contributing to chemosensitization; this is also a clinically important source of pharmacokinetic drug interactions.
  7. ↓ Glycolysis through the CEBPB–ENO1 axis in colorectal-cancer models, with decreases in glycolytic enzymes, glucose utilization, ECAR and tumor growth; this appears tumor- and model-dependent rather than a universal itraconazole mechanism.
  8. ↑ Autophagy and growth arrest in selected tumor models, frequently downstream of impaired cholesterol trafficking and AKT/mTOR signaling.
  9. ↑ Apoptosis and cell-cycle arrest in responsive tumor models as downstream phenotypes rather than primary direct molecular targets.

Bioavailability / PK relevance: Itraconazole has nonlinear, formulation-dependent pharmacokinetics and very low aqueous solubility. Conventional capsule absolute oral bioavailability is approximately 55%, is maximal immediately after a full meal, and decreases with reduced gastric acidity or acid-suppressive therapy. Capsule and oral-solution formulations are not pharmacokinetically interchangeable; systemic exposure is generally greater with oral solution at the same dose. After repeated capsule dosing, reported steady-state Cmax values are approximately 0.5, 1.1 and 2.0 µg/mL after 100 mg once daily, 200 mg once daily and 200 mg twice daily, respectively. Itraconazole is approximately 99.8% plasma-protein bound, extensively tissue distributed, metabolized predominantly through CYP3A4, and has an active hydroxy-itraconazole metabolite. Strong CYP3A4, P-glycoprotein and BCRP inhibition produces a major drug–drug interaction burden.

In-vitro vs systemic exposure relevance: Several experimentally important anticancer effects occur around the low-micromolar range, which overlaps total plasma concentrations achievable with high-dose clinical regimens, but free circulating itraconazole is far lower because protein binding approaches 99.8%. Tissue accumulation can exceed plasma concentrations, while exposure varies markedly among patients and formulations. Consequently, mechanistic plausibility is relatively strong for NPC1, VDAC1/mTOR and endothelial targets, but translation of individual in-vitro concentration-response findings should not be assumed without pharmacokinetic confirmation.

Clinical evidence status: Approved antifungal; oncology repurposing remains investigational. Human anticancer evidence includes phase II studies in basal cell carcinoma and prostate cancer, window-of-opportunity studies in NSCLC, and small combination studies in several malignancies. A recent randomized double-blind placebo-controlled study in 60 patients with advanced epithelial ovarian cancer reported improved response and progression-free outcomes when itraconazole was added to paclitaxel/carboplatin, but this remains a small single-institution study and does not establish an approved oncology indication. A recent perioperative phase II BCC study also showed a modest reduction in tumor diameter together with decreased CD105-associated angiogenesis. Important translational limitations include substantial interpatient PK variability, CYP3A4-mediated oncology drug interactions, a boxed warning concerning congestive heart failure/negative inotropy, and rare serious hepatotoxicity.



Itraconazole Mechanistic Pathway Map

Rank Pathway / Axis Cancer Cells Normal Cells TSF Primary Effect Notes / Interpretation
1 NPC1 and lysosomal cholesterol trafficking ↓ NPC1 activity
↑ lysosomal cholesterol		 ↓ NPC1 activity
↑ lysosomal cholesterol		 R/G Disrupts cholesterol export and growth signaling Direct itraconazole binding to NPC1 is structurally and functionally supported. This mechanism can contribute to ↓ mTOR signaling and altered membrane-associated signaling. It is not intrinsically cancer-selective.
2 Hedgehog SMO GLI signaling ↓ SMO
↓ GLI1
↓ Hedgehog signaling		 ↓ (context-dependent) R/G Reduced Hedgehog-dependent proliferation One of the strongest tumor-directed repurposing mechanisms. Most relevant where Hedgehog signaling is oncogenic, particularly basal cell carcinoma. Clinical pharmacodynamic suppression has been demonstrated.
3 VEGFR2 maturation and angiogenesis ↓ vascular support ↓ VEGFR2 glycosylation
↓ VEGFR2 trafficking
↓ endothelial proliferation		 R/G Anti-angiogenic activity Itraconazole impairs VEGFR2 N-glycosylation and surface trafficking in endothelial cells. This is primarily an effect on tumor-supporting vasculature rather than direct killing of malignant cells.
4 VDAC1 AMPK mTOR axis ↑ AMPK
↓ mTOR (model-dependent)		 ↓ VDAC1 function
↑ AMP:ATP
↑ AMPK
↓ mTOR		 P/R Energetic stress and suppression of anabolic signaling VDAC1 is a direct itraconazole target in endothelial models. AMPK activation can occur within minutes and precedes mTOR inhibition.
5 mTORC1 growth signaling ↓ (model-dependent) ↓ (endothelium) R/G Reduced protein synthesis, proliferation and angiogenic signaling Mechanistically convergent downstream effect of both NPC1-mediated cholesterol sequestration and VDAC1-mediated AMPK activation.
6 P-glycoprotein and multidrug resistance ↓ P-gp activity
↓ drug efflux		 ↓ P-gp activity P/R Chemosensitization and altered drug disposition Itraconazole inhibits P-glycoprotein and can increase intracellular exposure to P-gp substrates. Therapeutically interesting for resistant tumors but clinically hazardous because the same transporter and CYP3A4 inhibition can markedly alter concomitant anticancer-drug exposure.
7 CEBPB ENO1 glycolysis axis ↓ CEBPB
↓ ENO1
↓ glycolysis
↓ ECAR		 Not established G Reduced glycolytic metabolism and tumor growth Demonstrated recently in colorectal-cancer models. ENO1, LDHA, PKM2 and GAPDH-related metabolic changes were reported, but this should currently be treated as tumor-specific rather than a universal itraconazole mechanism.
8 Autophagy and lysosomal stress ↑ autophagy (model-dependent) ↑ (stress-dependent) G Autophagic growth suppression or cell death Frequently follows cholesterol-trafficking and AKT/mTOR disruption. Biological outcome varies by tumor type and can be cytostatic or cytotoxic.
9 Cell cycle and apoptosis ↑ arrest
↑ apoptosis (model-dependent)		 ↔ / ↑ (high exposure) G Reduced proliferation and programmed cell death Downstream phenotype reported in multiple tumor systems rather than a single direct molecular target.
10 Clinical Translation Constraint ↓ usable therapeutic window ↓ tolerability margin G PK variability, DDIs and toxicity constrain oncology use Capsule absorption depends strongly on food and gastric acidity; exposure is formulation-dependent and variable. Itraconazole and hydroxy-itraconazole are potent CYP3A4 inhibitors and itraconazole inhibits P-gp/BCRP. Major concerns include numerous anticancer-drug interactions, negative inotropy/CHF risk and rare serious hepatotoxicity.

TSF legend: P: 0–30 min     R: 30 min–3 hr     G: >3 hr
PKM2, Pyruvate Kinase, Muscle 2: Click to Expand ⟱
Source:
Type: enzyme
PKM2 (Pyruvate Kinase, Muscle 2) is an enzyme that plays a crucial role in glycolysis, the process by which cells convert glucose into energy. PKM2 is a key regulatory enzyme in the glycolytic pathway, and it is primarily expressed in various tissues, including muscle, brain, and cancer cells.
-C-myc is a common oncogene that enhances aerobic glycolysis in the cancer cells by transcriptionally activating GLUT1, HK2, PKM2 and LDH-A
-PKM2 has been shown to be overexpressed in many types of tumors, including breast, lung, and colon cancer. This overexpression may contribute to the development and progression of cancer by promoting glycolysis and energy production in cancer cells.
-inhibition of PKM2 may cause ATP depletion and inhibiting glycolysis.
-PK exists in four isoforms: PKM1, PKM2, PKR, and PKL
-PKM2 plays a role in the regulation of glucose metabolism in diabetes.
-PKM2 is involved in the regulation of cell proliferation, apoptosis, and autophagy.
– Pyruvate kinase catalyzes the final, rate-limiting step of glycolysis, converting phosphoenolpyruvate (PEP) to pyruvate with the production of ATP.
– The PKM2 isoform is uniquely regulated and can exist in both highly active tetrameric and less active dimeric forms.
– Cancer cells often favor the dimeric form of PKM2 to slow pyruvate production, thereby accumulating upstream glycolytic intermediates that can be diverted into anabolic pathways to support cell growth and proliferation.
– Under low oxygen conditions, cancer cells rely on altered metabolic pathways in which PKM2 is a key player. – The shift to aerobic glycolysis (Warburg effect) orchestrated in part by PKM2 helps tumor cells survive and grow in hypoxic conditions.

– Elevated expression of PKM2 is frequently observed in many cancer types, including lung, breast, colorectal, and pancreatic cancers.
– High levels of PKM2 are often correlated with enhanced tumor aggressiveness, poor differentiation, and advanced clinical stage.

PKM2 in carcinogenesis and oncotherapy

Inhibitors of PKM2:
-Shikonin, Resveratrol, Baicalein, EGCG, Apigenin, Curcumin, Ursolic Acid, Citrate (best known as an allosteric inhibitor of phosphofructokinase-1 (PFK-1), a key rate-limiting enzyme in glycolysis) potential to directly inhibit or modulate PKM2 is less well established

Full List of PKM2 inhibitors from Database
-key connected observations: Glycolysis↓, lactateProd↓, ROS↑ in cancer cell, while some result for opposite effect on normal cells.
Tumor pyruvate kinase M2 modulators

Flavonoids effect on PKM2
Compounds name IC50/AC50uM Effect
Flavonols
1. Fisetin 0.90uM Inhibition
2. Rutin 7.80uM Inhibition
3. Galangin 8.27uM Inhibition
4. Quercetin 9.24uM Inhibition
5. Kaempferol 9.88uM Inhibition
6. Morin hydrate 37.20uM Inhibition
7. Myricetin 0.51uM Activation
8. Quercetin 3-b- D-glucoside 1.34uM Activation
9. Quercetin 3-D -galactoside 27-107uM Ineffective
Flavanons
10. Neoeriocitrin 0.65uM Inhibition
11. Neohesperidin 14.20uM Inhibition
12. Naringin 16.60uM Inhibition
13. Hesperidin 17.30uM Inhibition
14. Hesperitin 29.10uM Inhibition
15. Naringenin 70.80uM Activation
Flavanonols
16. (-)-Catechin gallateuM 0.85 Inhibition
17. (±)-Taxifolin 1.16uM Inhibition
18. (-)-Epicatechin 1.33uM Inhibition
19. (+)-Gallocatechin 4-16uM Ineffective
Phenolic acids
20. Ferulic 11.4uM Inhibition
21. Syringic and 13.8uM Inhibition
22. Caffeic acid 36.3uM Inhibition
23. 3,4-Dihydroxybenzoic acid 78.7uM Inhibition
24. Gallic acid 332.6uM Inhibition
25. Shikimic acid 990uM Inhibition
26. p-Coumaric acid 22.2uM Activation
27. Sinapinic acids 26.2uM Activation
28. Vanillic 607.9uM Activation


Scientific Papers found: Click to Expand⟱
2178- itraC,    Itraconazole inhibits tumor growth via CEBPB-mediated glycolysis in colorectal cancer
- in-vivo, CRC, HCT116
TumCG↓, Glycolysis↓, CEBPB?, ENO1↓, LDHA↓, PKM2↓, GAPDH↓, ECAR↓, OCR↓,

Showing Research Papers: 1 to 1 of 1

* indicates research on normal cells as opposed to diseased cells
Total Research Paper Matches: 1

Pathway results for Effect on Cancer / Diseased Cells:


Mitochondria & Bioenergetics(tgid=3) ⓘ

OCR↓, 1,  

Core Metabolism/Glycolysis(tgid=4) ⓘ

ECAR↓, 1,   ENO1↓, 1,   GAPDH↓, 1,   Glycolysis↓, 1,   LDHA↓, 1,   PKM2↓, 1,  

Proliferation, Differentiation & Cell State(tgid=12) ⓘ

CEBPB?, 1,   TumCG↓, 1,  
Total Targets: 9

Pathway results for Effect on Normal Cells:


Total Targets: 0

Scientific Paper Hit Count for: PKM2, Pyruvate Kinase, Muscle 2
Query results interpretion may depend on "conditions" listed in the research papers.
Such Conditions may include : 
  -low or high Dose
  -format for product, such as nano of lipid formations
  -different cell line effects
  -synergies with other products 
  -if effect was for normal or cancerous cells

Filter Conditions: Pro/AntiFlg:%  IllCat:%  CanType:%  Cells:%  prod#:312  Target#:772  State#:%  Dir#:%
  wNotes=0  sortOrder:rid,rpid

 

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