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Introduction

Ribavirin, a synthetic nucleoside analogue (1-β-D-ribofuranosyl-1,2,4-triazole-3-carboxamide) is a widely used drug whose antiviral activity was described almost 40 years (1). Currently, ribavirin is almost solely used for hepatitis C infection (HCV) in combination with interferon. This combination significantly increases sustained virological response rates even in patients with interferon resistance arising from HCV-related factors (2). The knowledge gained on the molecular pathogenesis of cancer has led to considerable interest in repurposing non-cancer drugs against several malignancies (3). It was previously demonstrated that ribavirin and mycophenolic acid inhibit inosine 5′-phosphate dehydrogenase (IMPDH), the first enzyme specific for the de novo synthesis of guanosine monophosphate (GMP) (4). IMPDH encodes the rate-limiting enzyme in de novo guanine nucleotide biosynthesis, which is necessary for DNA and RNA synthesis. IMPDH has been linked to cell growth, differentiation and malignant transformation (5,6). Two isoforms of IMPDH have been described: Type I is constitutively expressed in normal cells, whereas type II activity has been shown to be increased in proliferating and particularly malignant cells (7,8). Thus, IMPDH has been considered an attractive target for cancer therapy (9).

On the other hand, Kentsis et al (10), demonstrated the direct binding of ribavirin to eIF4E in vitro at micromolar concentrations and an efficient competition with eIF4E:m7G mRNA cap binding in vitro and in vivo, which disrupts eIF4E:m7G functions in the transport and translation of eIF4E-regulated genes. These effects lead to downregulation of the oncogenic proteins, cell cycle arrest and suppression of the eIF4E-mediated transformation in vitro and in vivo (10). eIF4E is overexpressed in many human malignancies where it is typically a marker of poor prognosis. The function of this factor is controlled by interactions with protein cofactors together with many signaling pathways, including Ras, Mnk, Erk, MAPK, PI3K, mTOR and Akt. Borden and Culjkovic-Kraljacic suggest that ~30% of cancer types have elevated eIF4E (11). In a recent proof-of-principle study on relapsed or refractory acute myeloid patients with subtypes M4 and M5 or other subtypes with high eIF4E levels, administered oral ribavirin at daily doses ranging from 1,000 to 1,800 mg led to plasma ribavirin between 5 and 36 μM, produced 1 complete, 2 partial remissions, 2 blast response, and four stable diseases out of 11 evaluable patients. Best responses were observed at ~28 days (12). These results clearly support investigations on ribavirin as a cancer treatment.

Beyond DNA methylation and histone deacetylase inhibitors, drugs able to block histone methylation are currently pursued as epigenetic anticancer drugs (13). Enhancer of zeste homolog 2 (EZH2), a core component of polycomb repressive complex 2 (PRC2), plays a role in transcriptional repression through H3K27 trimethylation, and is involved in various biological processes (14). It is well known that 3-deazaneplanocin A (DZNep), an inhibitor of S-adenosylmethionine-dependent methyltransferase targets the degradation of EZH2, leading to apoptosis in various malignancies, suggesting that EZH2 may be a new target for epigenetic treatment (15). The results of the present study showed that ribavirin is also an EZH2 inhibitor and that its antitumor effects stem from the inhibition of the IMPDH, eIF4E and EZH2 targets.

Materials and methods

Cell culture and ribavirin treatment

The breast (MCF-7, MDA-231 and MDA-436), brain (D54), cervical (HeLa), colon (SW-480) and prostate (PC3 and DU-145) cancer cell lines were obtained from the ATCC (Manassas, VA, USA) and cultured in Dulbecco’s modified Eagle’s medium (DMEM)/F12 medium supplemented with 10% fetal bovine serum (FBS) (both from Invitrogen Life Technologies, Carlsbad, CA, USA), and penicillin-streptomycin at 37°C in a humidified 5% CO2 atmosphere. Ribavirin was obtained from Sigma (St. Louis, MO, USA), and dissolved in dimethyl sulfoxide (DMSO), stored at −20°C and thawed prior to use. Stock solutions were thawed/frozen ≤3 times. Cell lines employed for the proliferation assay were treated with 10, 15, 20, 25 and 50 μM for 96 h. For the mRNA expression, and protein immunodetection, ribavirin treatment with 25 μM was maintained for 72 h.

Cell proliferation assay

Cells were seeded in 96-well microplates (Corning) at a density of 2×5103 cells/well in 0.1 ml of complete medium for 24 h, and then treated for 96 h with ribavirin at concentrations of 10, 15, 20, 25 and 50 μM with changes of medium containing ribavirin on alternate days. After 96 h, the medium was aspirated and replaced for 10 min with 50 μl of 0.75% crystal violet in 50% ethanol, 0.25% NaCl and 1.75% formaldehyde solution. The cells were then washed with water, air-dried, and the dye was eluted with PBS + 1% sodium dodecyl sulfate (SDS) solution. The absorbance of crystal violet is proportional to the cell number and was assessed by dye absorbance measured at 570 nm on an automated microplate reader. All assays were performed in triplicate. The cytotoxic effect of each treatment was expressed as a percentage of cell proliferation relative to the untreated control cells (percentage of control) and was defined as (A570 nm treated cells/A570 nm non-treated cells) × 100.

Computational search of approved drugs with a high structural similarity to DZNep

To identify in a systematic manner approved drugs with similar activity as DZNep, we carried out a rapid computational search of DrugBank, a database listing approved drugs (16). Using the well-established principles of similarity searching by two-dimensional fingerprints (17), we used the chemical structure of DZNep as a query and computed the similarity of each of 1,491 compounds listed in DrugBank using the Molecular Access System (MACCS) keys and the Tanimoto coefficientREF as implemented in Molecular Operating Environment (MOE), version 2011.10 (18,19). In general, compounds in DrugBank had an extremely low molecular similarity with DZNep (median and mean similarity values of 0.35 with a standard deviation of 0.12).

Flexible alignment in silico

The chemical structures of ribavirin and DZNep were constructed in MOE, version 2011.10 (18). The alignment of the two compounds was performed following the flexible alignment protocol implemented in MOE for small molecules. In this tool, the alignment is based on the internal strain and overlap of molecular features (20). For the flexible alignment we used default parameters including an iteration limit of 200, failure limit of 20, and an energy cut-off of 15. Prior to the search, the charges were computed using the MMFF94x force field. The search was performed with the stochastic conformation search enabled. The top-ranked solution was used for analysis.

RNA isolation and quantitative expression assay

Total RNA was isolated using the PureLink RNA kit (Ambion-Life Technologies) according to the manufacturer’s instructions. RNA purity and integrity were assessed by spectrophotometric analysis (NanoDrop 2000c; Thermo Scientific) and denaturing agarose gel. Total RNA (1 μg) was used for cDNA synthesis with the SuperScript III First-Strand Synthesis SuperMix according to the manufacturer’s instructions (Invitrogen Life Technologies). Quantitative PCR for amplification and detection of DNA was performed on the CFX96 thermocycler (Bio-Rad, Hercules, CA, USA). PCR was carried out in triplicate in a 10 μl reaction volume with the SYBR-Green qPCR master mix (Bio-Rad), 0.35 nM forward primer, and 0.35 nM reverse primer. Data were analyzed using the 2−ΔΔCT method and reported as the fold-change in gene expression normalized to the endogenous control gene (GUSB) and relative to cells without treatment. The primers used were: GUSB, forward: 5′-CCTGTGACCTTTGTGAGCAA-3′ and reverse: 5′-AAACCCTGCAATCGTTTCTG-3′; EZH2, forward: 5′-CAACACCAAGCAGTGCCCGTGC-3′ and reverse: 5′-CCTGCCACGTCAGATGGTGCC-3′; G9a, forward: 5′-CTCCGCTGATTTTCGAGTGTAA-3′ and reverse: 5′-GTCGAAGAGGTAAGAATCATCC-3′; LSD1, forward: 5′-GTGTCTCGTTGGCGTGCT-3′ and reverse: 5′-CCCGCAAAGAAGAGTCGTG-3′; HDAC1, forward: 5′-GTTACACCATTCGTAACGTTGC-3′ and reverse: 5′-CAGTCGCTGTTTGATCTTCTC-3; eif4E, forward: 5′-GCTTTGGTTAAAAATGGCTCA-3′ and reverse: 5′-GAGACTGCCTTGCAATAAGAAG-3; Dnmt1, forward: 5′-TACCTGGACGACCCTGACCTC-3′ and reverse: 5′-CGTTGGCATCAAAGATGGACA-3′; Dnmt3a, forward: 5′-TATT GATGAGCGCACAAGAGAGC-3′ and reverse: 5′-GGGTGTTCCAGGGTAACATTGAG-3′; Dnmt3b, forward: 5′-GGCAAGTTCTCCGAGGTCTCTG-3′ and reverse: 5′-TGGTACATGGCTTTTCGATAGGA-3′.

Protein extraction and immunoblot analysis

Whole-cell extraction was performed with lysis buffer containing 50 mM Tris-HCl pH 7.4, 150 mM NaCl, 0.5% Nonidet P-40, 1 mM EDTA, 1 mM phenylmethylsulfonyl fluoride (PMSF), 0.2 mM Na3VO4 and a protease inhibitor cocktail (Sigma). Histones proteins were obtained by sulfuric acid extraction. Briefly, the nuclear pellet was resuspended in 0.4 M H2SO4 for 4 h, and acid-soluble proteins in a postcentrifugation supernatant (10,000 × g for 20 min) were recovered by overnight precipitation with 20% trichloroacetic acid and centrifugation (16,000 × g for 30 min). The pellets containing the histone proteins were washed once in ice-cold acetone containing 1% HCl and then washed once with ice-cold acetone. The pellet was dried under vacuum and stored at −80°C. The protein concentration was determined by the Bradford method, and the integrity of the histone proteins in the acid soluble extract was evaluated with Coomassie staining. Proteins were separated in an SDS-PAGE gel 10–18% according to the molecular weight of the studied protein, and transferred to a PVDF membrane (Bio-Rad). The membrane was incubated for 1 h with blocking solution (TBS/Tween-20, 5% of non-fat milk), and incubated overnight with the specific primary antibody in blocking solution (dilution 1:1,000). The membranes were washed with TBS-T, and incubated 1 h with a peroxidase secondary antibody at a dilution of 1:1,000 and developed with chemiluminescence substrate cat. no. WBLUR0100 (Millipore, Billerica, MA, USA). Antibodies for EZH2 (cat. no. 36–6300) Invitrogen, G9a (cat. 07-551), histone 3 (cat. no. 06-755), H3K4me2 (cat. no. 07-030), H3K9me2 (cat. no. 07-212) and H3K27me3 (cat. no. 07-449) were obtained from Millipore.

Inhibition of the histone methyltranferase activity

Histone methyltransferase activity/inhibition assay kit (Epigentek, New York, NY, USA) was employed to determine the inhibitory activity of ribavirin with HMT that specifically target histone H3 at lysine 27. Briefly, the nuclear extract was prepared from the MCF-7 cell line using the EpiQuik Nuclear Extraction kit (Epigentek), and incubated with ribavirin at 5, 10 and 15 μM. The percentage of ribavirin inhibition was calculated according to the level of H3K27 obtained in the control assay in the presence of 10 μg of nuclear protein plus DMSO.

siRNA transfection assay

MCF-7 cells were seeded in 24-well microplate (Corning) at a density of 1.5×105 cells/well into 0.2 ml of DMEM/F12 medium supplemented with 10% FBS. After 24 h, cells were transfected with the Lipofectamine RNAimax transfection reagent (Invitrogen-Life Technologies) and siRNA directed to EZH2 (4392420), eiF4E (4390771), IMPDH1 (4390771) and IMPDH2 (4390824) (Applied Biosystems-Life Technologies). Negative control was included as siRNA scramble (4390844) (Applied Biosystems-Life Technologies). Transfected cells were employed for the cytotoxicity assay as described above, and analyzed after 72 h with ribavirin treatment.

Results

Ribavirin inhibits cell growth

To investigate the growth inhibitory effects of ribavirin, the cell lines were exposed to different concentrations of ribavirin (10–50 μM) and cell viability was analyzed at 72 h. The results showed that the cell lines were inhibited in a dose-dependent manner although the extent of inhibition was cell line-dependent. The MCF-7 and MDA-436 breast cancer, DU145 prostate carcinoma and D54 glioma cell lines showed increased inhibition whereas the SW480 colon cancer, prostate PC3 and breast MDA-231 cells were less inhibited. HeLa cells showed minimal inhibition even at the highest dose of ribavirin (Fig. 1).

Figure 1 Growth inhibition by ribavirin. (A) Breast, (B) cervical, colon, and brain, and (C) prostate cancer cell lines were treated with different concentrations of ribavirin for 72 h. Growth inhibition occurred in a cell line-dependent manner. Three independent experiments were performed (mean ± SD). Errors bars show SD.

Ribavirin has a high structural similarity to DZNep

The search for similarity using DZNep as a query and after visual inspection of the 32 top-ranked compounds with a significantly increased similarity value compared to the observed mean value [i.e., mean plus 2 standard deviations (0.59)], ribavirin (similarity value of 0.70) was selected for additional three-dimensional comparisons using flexible alignment. Following the ‘principle of molecular similarity’ (21) which states that, similar compounds have similar properties (with the exception of the so-called activity cliffs) (22) we performed a comparison in silico of the chemical structures of ribavirin and DZNep. Fig. 2A shows the two-dimensional chemical structures of the two molecules and the result of the top-ranked solution of the flexible alignment of both compounds obtained with Molecular Operating Environment software. Fig. 2B shows the almost perfect overlay of the pentose ring of ribavirin with the cyclopenten ring of DZNep. Furthermore, there was an excellent overlay in three dimensions of the 1,2,4-triazole carboxamide moiety of ribavirin with the 4-aminoimidazo[4,5-c]pyridine ring of DZNep leading to a perfect match of several nitrogen atoms, including the amino groups of the two molecules. The comparison of the two compounds clearly demonstrated that ribavirin has a high structural similarity to DZNep in the two- and three-dimensions. This analysis in silico further supported the hypothesis that the antiviral compound ribavirin has similar biological properties as DZNep.

Figure 2 High structural similarity of ribavirin and DZNep. (A) Chemical structures of DZNep and ribavirin. (B) Result of the flexible alignment of the two compounds obtained with MOE. The image clearly shows the high structural similarity of ribavirin to DZNep in two- and three-dimensions. DZNep, 3-deazaneplanocin A; MOE, Molecular Operating Environment.

Effects of ribavirin on epigenetic enzymes

To determine whether ribavirin exerts similar epigenetic effects compared to DZNep, quantitative RT-PCR was performed on MCF-7, PC3 and D54 cell lines to evaluate the effect of ribavirin upon several epigenetic enzymes. In MCF-7 cells ribavirin at 25 μM led to a profound decrease in the level of EZH2 expression, while the effect was minor in PC3 cells and absent in D54 cells (Fig. 3A). Notably, a similar effect was observed for G9A histone methyltransferase expression. This downregulation was observed at the protein level as shown in Fig. 3B in MCF-7 cells treated with ribavirin at 25 μM for 72 h and the effect appeared as early as 24 h (Fig. 3C). These data suggested that ribavirin inhibits histone methylation targets. Thus, the methylation levels of H3K27, H3K9 and H3K4 were analyzed by western blotting. Results in Fig. 4A shows that while ribavirin clearly decreased trimethylation of H3K27, no inhibition of methylation was observed for H3K9 and H3K4. To confirm these findings, an in vitro histone methyltransferase assay was performed in MCF-7 cells treated with ribavirin. As shown in Fig. 4B, ribavirin at concentrations starting at 10 μM showed a clear inhibition of the histone methyltransferase activity following H3K27. The expression of DNA methyltransferases was also evaluated following treatment with ribavirin. Fig. 5A shows that DNMT1 was inhibited only in MCF-7 cells, had no effect on D54 cells but was increased in PC3 cells. By contrast, DNMT3a was decreased to almost the same extent in the three cell lines, while DNMT3b was also decreased in three cell lines, although an increase was observed in MCF-7 cells. To explore other epigenetic enzymes that could be modified by ribavirin, we analyzed HDAC1, which was decreased in MCF-7 and D54 but not in PC3. Ribavirin did not induce changes in the expression of histone lysine demethylase 1 (LSD1) in these cell lines (Fig. 5B).

Figure 3 Inhibition of HMTs EZH2 and G9a. (A) Inhibition of EZH2 and G9a mRNA expression in breast and prostate cancer cell lines treated with ribavirin (25 μM). (B) Western blotting of EZH2, and G9a methyltransferases (data were normalized according to GUS-B expression or β-actin protein levels, respectively). (C) Time-response curve of EZH2 protein in the MCF-7 cell line with ribavirin treatment. Errors bars show SD. EZH2, zeste homolog 2.

Figure 4 In vitro and in vivo dose-dependent inhibition of the repressive histone mark H3K27me3. (A) Immunoblot of H3K27me3 levels in MCF-7 cells treated with different doses of ribavirin. (B) In vitro histone methyltransferase activity (H3K27me3) in nuclear extracts from the MCF-7 cell line in the presence of DMSO (CT) or ribavirin (R). Error bars show SD.

Figure 5 Downregulation of DNA methyltranferases by ribavirin treatment. Expression of DNA methyltranferases, and enzymes associated with histone modification was analyzed by RT-qPCR in breast, brain and prostate cancer cell lines treated with 25 μM ribavirin. Data were normalized according to GUSB expression. (A) DNMT1 was inhibited only in MCF-7 cells, had no effect on D54 cells but was increased in PC3 cells. (B) Ribavirin did not induce changes in the expression of histone lysine demethylase 1. Errors bars show SD.

Target inhibition by ribavirin

To determine the extent that each ribavirin target contributed to the growth inhibitory effects of this drug on the cancer cell lines investigated, siRNA assays were used to downregulate eIF4E, EZH2 and both IMPDH1 and IMPDH2. As shown in Fig. 6A, each of the target genes were downregulated by >50%. Downregulation of EZH2 and eIF4E reduced cell viability almost to the same extent, with an ~40% reduction as compared to the control. The extent of growth inhibition was slightly higher, reaching almost 50% reduction for IMPDH1 and IMPDH2. No attempt was made to knock the targets down simultaneously, however, each individual target downregulation led to higher growth inhibition as compared to ribavirin at 25 μM. Notably, no significant further reduction in viability was observed when siRNA-transfected cells were treated with ribavirin.

Figure 6 Downregulation of eIF4E, EZH2, MPDH1 and MPDH2 leads to growth inhibition. (A) siRNA transfection for EZH2, eIF4E and IMPDH1 and 2 in MCF-7 induced a decrease of >60% in each gene. A scrambled sequence was the negative control. (B) Decreased expression of each of the targets led to reduced cell proliferation at the same or to a higher extent than ribavirin alone at 25 μM, which was not further increased when ribavirin was added. Errors bars show SD.

Discussion

The results of the present study demonstrate that ribavirin at clinically achievable concentrations had growth inhibitory effects in vitro on a number of malignant cancer cell lines. Besides inhibiting eIF4E and IMPDH (4,10) ribavirin led to downregulation of EZH2 at RNA and protein levels and inhibition of EZH2 enzyme activity and reduction of H3K27 methylation. These data support the repositioning of ribavirin as an antitumor drug, specifically in neoplasias whose growth is associated with alterations in these targets.

The realization that genetic alterations in histone methyltransferases occur in different types of tumor (23–25) has led to the development of epigenetic drugs beyond DNA methyltransferase (DNMTi) and histone deacetylase (HDACi) inhibitors. Concerning EZH2 histone methyltransferase, gain-of-function heterozygous point mutations in the SET-coding domain of the gene have shown to lead transcriptional repression via trimethylation of H3K27. In addition, the elevated levels of EZH2 have been associated with silencing of EZH2 target genes and poor prognosis in solid tumors such as breast, kidney and lung carcinomas (26–28). A number of EZH2 small-molecule inhibitors are in preclinical development, with E7438 already being in a phase I-II trial (unpublished data). Due to the proven tolerability and extensive use of ribavirin, the results from the present study suggest its rapid introduction into clinical trials for neoplasias with alterations at this oncogene.

DZNep is a potent inhibitor of S-adenosylhomocysteine (AdoHcy) hydrolase, which results in the accumulation of AdoHyc, which in turn causes by-product inhibition of S-adenosyl-L-methionine-dependent MTases (29). Initial studies have demonstrated a selective depletion of methylation targets on H3K27 and H3K20 (15). However, subsequent studies have shown that according to its proposed mechanism of action as a global inhibitor of SAM-dependent MTAses, DZNep inhibits histone methylation in a non-selective manner (30). Nevertheless, our results, although limited as only two additional methylation targets were analyzed, suggest that ribavirin is a potential selective histone methylation inhibitor. In particular, ribavirin induced a decrease in the trimethylation of H3K27. However, ribavirin did not induce changes in the methylation targets H3K9 and H3K20. A comprehensive analysis of histone methylation targets is needed to confirm whether ribavirin may be selected with H3K27 target.

As previously reported for DZNep, ribavirin also leads to the depletion of EZH2 RNA in MCF-7 although this effect is cell line-dependent as it was not observed in D54 glioma cells and prostate cancer PC3 cells. Of note, ribavirin also depletes H3K9 methyltransferase G9A in MCF-7 cells but not or only slightly in D54 and PC3, respectively. In this sense, DZNep has been shown to downregulate another H3K9 methyltransferase, SETDB1, in lung cancer cells (31). To demonstrate that ribavirin inhibits the methylation reaction at H3K27, nuclear extracts of MCF-7 cells treated with or without ribavirin between 10 and 15 μM were assayed with a kit containing the substrate, the enzyme and adomet. The results in show an almost 50% reduction in activity. As in mammals, EZH2 is the only enzyme that catalyzes di- and trimethylation at H3K27 (32). Our results suggest that ribavirin inhibits EZH2 in a similar manner to DZNep. Ribavirin treatment also affected the expression of some elements of epigenetic machinery in a variable manner depending on the cell line. In particular, the majority of changes were identified in MCF-7 cells, such as the reduction of DNMT1, DNMT3a, DNMT3b and HDAC1 but not LSD1. Notably, DNMT3b was consistently decreased in the three cell lines whereas LSD1 was not affected. To the best of our knowledge, no information exists on the effect of any EZH2 inhibitor on the expression of these enzymes. Since DZNep depleted cell proteins of the core PRC2 complex, as well as several other interacting proteins of this complex, such as Jarid2, HDAC1/2, Aebp2, Phf1, MTF2 and Phf19, it is suggested that significant interactions between polycomb proteins and other chromatin regulators may exist (33). In this sense, if DNMTs and HDACs also interact with the complex, then it is expected that they may be downregulated by ribavirin as a consequence of its depleting effect on EZH2; however, this remains to be demonstrated. Even for highly selective drugs, off-target effects are common. Thus, alternatively, the inhibition of IMPDH and eIF4E by ribavirin affects the expression of epigenetic machinery components by unknown mechanisms.

The present study on the antitumor effects of ribavirin as a tri-targeted therapy has some limitations. It is clear that growth inhibition while dose-dependent is also dependent on the cell line. Of the eight lines tested, MCF-7, MDA-436, D54 and DU-145 were the most sensitive. However, we have no information on the expression level of each of these putative targets on the model system. In a model of K562 leukemia cells, ribavirin induces differentiation and apoptosis while modulating the expression of ~60 out of 85 genes having roles in cell proliferation, purine biosynthesis, translation initiation, oncogenic signaling and cell survival (34). These effects are mediated through the modulation of key molecular and metabolic pathways but most likely result from the composed action of ribavirin on these three targets. In a study of 6 breast cancer cell lines investigating the antitumor effects of ribavirin as an eIF4E antagonist, it was shown that while ribavirin induces growth inhibition in all the cell lines, the variability in growth response observed did not correlate with eIF4E expression level (35). Our results on the individual downregulation of EZH2, eIF4E and IMPDH1 and IMPDH2 by siRNAs showed growth inhibition that varied between 36 and 55%, being lower for eIF4E and higher for IMPDH2, which suggests that in this cell line viability is dependent on IMPDH2. Notably, in all the cases, the depletion of each of these genes led to higher growth inhibition as compared to ribavirin alone at 25 μM. However, ribavirin did not significantly increase the growth inhibition already achieved by downregulating the mRNA of the gene in any of the cases, suggesting that ribavirin is a tri-targeted agent. Other potential antitumor effects of ribavirin were not investigated in the present study. Recently, Kosaka et al, using an early transposon Oct4 and Sox2 enhancer (EOS) system to select human prostate cancer cells expressing high levels of OCT4, a transcription factor that induces pluripotency in somatic cells, found that ribavirin reverses docetaxel resistance in prostatic cancer cells most likely by reprogramming cancer stem cells by downregulating OCT4 expression (36).

Our results are of relevance in the field of drug repositioning for cancer therapy as these three targets are commonly altered in cancers, supporting the current shift of drug identification from single- to multi-target drug development (37). It is necessary however, to investigate which and what proportion of tumors share alterations in these targets and the manner in which their status correlates with sensitivity to ribavirin. However, a preclinical study to investigate whether non-Hodgkin lymphoma models with gain-of-function mutations in EZH2 are as sensitive to ribavirin as they are to the highly selective EZH2 inhibitor E7438 should be conducted. If these results are yielded a follow-up clinical study should be performed taking into account the known safety of ribavirin.

In conclusion, highly potent and selective small-molecule inhibitors of EZH2 are currently being investigated under the vision of ‘rational drug design’. However, ‘promiscuous’ drugs that act on more than one relevant target for cancer biology such as ribavirin, should be studied to increase therapeutic armamentarium for cancer patients.

Acknowledgments

This study was supported by Fonsec CONACyT grant 161915, and UNAM PAPIIT grant IT206611.

References