This research investigates a novel combination therapy to overcome the limitations of single-agent approaches in cancer treatment, which often fail due to toxicity or the activation of compensatory metabolism. Using metabolically distinct breast cancer cell lines, the study shows that repurposing FDA-approved mitochondrial-targeting agents—such as niclosamide, IMD-0354, and pyrvinium pamoate—disrupts mitochondrial respiration but triggers an unwanted surge in glycolysis. To counteract this adaptation, researchers combined these mitochondrial poisons with BAY-876, a selective GLUT1 inhibitor, successfully shutting down glucose uptake and the compensatory pathway. Ultimately, this dual-targeting strategy induces a fatal metabolic crisis in cancer cells, highlighting the therapeutic potential of tailoring treatment regimens to a tumor’s specific nutrient handling and bioenergetic profile.
In combination therapies, newly engineered niclosamide prodrugs (such as NIC-PS and SSL-0024) and nanoengineered formulations (such as Penetrium) act as potent chemo- and immuno-sensitizers. They overcome drug resistance by simultaneously suppressing parallel survival networks, reducing immune-checkpoint expression, and dismantling structural microenvironmental barriers that block drug access.
1. Combination with Sorafenib (Targeted Kinase Therapy)
Enhanced Sensitivity & Tumor Inhibition: Co-treatment of NIC-PS with sorafenib significantly increases the drug sensitivity of hepatocellular carcinoma (HCC) cells compared to sorafenib alone.
Overcoming Resistance via VASN/TGF-β Axis: Multi-kinase inhibitors like sorafenib often fail due to adaptive activation of compensatory survival pathways (e.g., PI3K/AKT or RAF/MEK/ERK). Prodrugs such as NIC-PS and SSL-0024 directly bind and downregulate Vasorin (VASN), blocking downstream TGF-β/SMAD2/3 signaling.
Multi-Pathway Network Suppression: In addition to VASN inhibition, SSL-0024 concurrently inhibits AKT, mTOR, STAT3, C-Raf, and Wnt/β-catenin signaling. This multi-target suppression prevents tumors from shifting to parallel pathways to escape sorafenib. In patient-derived organoids (PDOs), SSL-0024 alone achieved significantly greater cytotoxicity than sorafenib monotherapy, establishing a rationale for combined or follow-on treatment.
2. Combination with Immune Checkpoint Inhibitors (Anti-PD-1 / Anti-PD-L1)
Direct PD-L1 Downregulation: Both NIC-PS and SSL-0024 significantly suppress PD-L1 mRNA and protein expression in cancer cells, largely by shutting down STAT3, a key transcriptional driver of PD-L1.
Reversing TGF-β-Mediated Immune Escape: Elevated TGF-β in tumors acts as an immunosuppressive shield that restricts T-cell activity and impairs PD-L1 blockade. By inhibiting VASN and suppressing TGF-β signaling, NIC-PS re-sensitizes resistant HCC cells to anti-PD-L1 antibody treatment.
Overcoming Physical Immune Exclusion (Penetrium Nanohybrid): In aggressive, desmoplastic models like triple-negative breast cancer (TNBC), anti-PD-1 monotherapy fails because a dense extracellular matrix (ECM) creates an “immune-excluded” phenotype. The niclosamide nanohybrid Penetrium remodels the ECM and depletes cancer-associated fibroblasts (CAFs). This allows CD8+ T cells to infiltrate the tumor parenchyma, restoring anti-PD-1 responsiveness and achieving near-complete suppression of lung metastasis.
3. Combination with Chemotherapy & Anti-Angiogenic Agents
Paclitaxel (Chemotherapy): Combining Penetrium with paclitaxel in breast cancer models markedly reduces lung metastasis and reverses Epithelial-to-Mesenchymal Transition (EMT) by restoring E-cadherin and downregulating invasion markers like MMP-9 and S100A4.
Gemcitabine (Pancreatic Organoid/CAF Co-Culture): In pancreatic cancer organoid co-cultures, cancer-associated fibroblasts normally drive severe chemoresistance to gemcitabine. Pre-treatment with niclosamide or Penetrium selectively eliminates CAFs, dismantling the protective stromal shield and restoring gemcitabine chemosensitivity.
Bevacizumab (Anti-VEGF): Combining Penetrium with the anti-angiogenic agent bevacizumab synergistically downregulates both MMP-9 (matrix degradation) and VEGF (vascular formation), achieving up to 100% suppression of distant metastasis in lung carcinoma models.
GLUT1 Inhibitors (Metabolic Blockade): Combining niclosamide (a mitochondrial uncoupler) with the GLUT1 inhibitor BAY-876 blocks the compensatory spike in glycolysis that cancer cells use to survive mitochondrial disruption, triggering a fatal metabolic crisis.
Schumacher, T. J., Iyer, A. V., Rumbley, J., Ronayne, C. T., & Mereddy, V. R. (2024). Repurposing mitochondrial-targeting anthelmintic agents with GLUT1 inhibitor BAY-876 for cancer therapy [Preprint]. bioRxiv.
Tan, M., Ye, W., Liu, Y., Chen, X., Huttad, L., Chua, M.-S., & So, S. (2024). Niclosamide prodrug enhances oral bioavailability and targets vasorin-TGFβ signaling in hepatocellular carcinoma [Preprint]. bioRxiv.
Rejinold, N. S., Kim, S. J., Jin, G.-W., & Choy, J.-H. (2025). Penetrium nanodrug remodels the tumor ECM to overcome pseudo-resistance and enhance anticancer therapeutic synergy [Preprint]. bioRxiv.
Tan, M., Schow, S., Liu, Y., Lum, R., Massoudi, D., Dhanasekaran, R., So, S., & Chua, M.-S. (2026). A novel niclosamide sulfate prodrug with enhanced bioavailability suppresses hepatocellular carcinoma via inhibition of multiple signaling pathways [Preprint]. bioRxiv.