Nonlinear blending: a useful general concept for the assessment of combination drug synergy

Human diseases may involve cellular signaling networks that contain redundant pathways, so that blocking a single pathway in the system cannot achieve the desired effect. As such, the use of drugs in combination are particularly effective interventions in networked systems. However, common synergy measures are often inadequate to quantify the effect of two different drugs in complex cellular systems. This article proposes a general approach to quantifying the synergy of two drugs in combination. This approach is called strong nonlinear blending. Drugs with different relative potencies, different effect maxima, or situations of potentiation or coalism pose no problem for strong nonlinear blending as a way to assess the increased response benefit to be gained by combining two drugs. This is important as testing drug combinations in complex biological systems are likely to produce a wide variety of possible response surfaces. It is also shown that for monotone increasing (or decreasing) dose response surfaces that strong nonlinear blending is equivalent to improved potency along a ray of constant dose ratio. This is important because fixed dose ratios form the basis for many preclinical and clinical combination drug experiments. Two examples are given involving HIV and cancer chemotherapy combination drug experiments.