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Wilbaux M, Yang S, Jullion A, Demanse D, Porta DG, Myers A, Meille C, Gu Y. Integration of Pharmacokinetics, Pharmacodynamics, Safety, and Efficacy into Model-Informed Dose Selection in Oncology First-in-Human Study: A Case of Roblitinib (FGF401). Clin Pharmacol Ther 2022; 112:1329-1339. [PMID: 36131557 DOI: 10.1002/cpt.2752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/09/2022] [Indexed: 01/31/2023]
Abstract
Model-informed dose selection has been drawing increasing interest in oncology early clinical development. The current paper describes the example of FGF401, a selective fibroblast growth factor receptor 4 (FGFR4) inhibitor, in which a comprehensive modeling and simulation (M&S) framework, using both pharmacometrics and statistical methods, was established during its first-in-human clinical development using the totality of pharmacokinetics (PK), pharmacodynamic (PD) biomarkers, and safety and efficacy data in patients with cancer. These M&S results were used to inform FGF401 dose selection for future development. A two-compartment population PK (PopPK) model with a delayed 0-order absorption and linear elimination adequately described FGF401 PK. Indirect PopPK/PD models including a precursor compartment were independently established for two biomarkers: circulating FGF19 and 7α-hydroxy-4-cholesten-3-one (C4). Model simulations indicated a close-to-maximal PD effect achieved at the clinical exposure range. Time-to-progression was analyzed by Kaplan-Meier method which favored a trough concentration (Ctrough )-driven efficacy requiring Ctrough above a threshold close to the drug concentration producing 90% inhibition of phospho-FGFR4. Clinical tumor growth inhibition was described by a PopPK/PD model that reproduced the dose-dependent effect on tumor growth. Exposure-safety analyses on the expected on-target adverse events, including elevation of aspartate aminotransferase and diarrhea, indicated a lack of clinically relevant relationship with FGF401 exposure. Simulations from an indirect PopPK/PD model established for alanine aminotransferase, including a chain of three precursor compartments, further supported that maximal target inhibition was achieved and there was a lack of safety-exposure relationship. This M&S framework supported a dose selection of 120 mg once daily fasted or with a low-fat meal and provides a practical example that might be applied broadly in oncology early clinical development.
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Affiliation(s)
| | - Shu Yang
- Pharmacometrics, Novartis, East Hanover, New Jersey, USA
| | - Astrid Jullion
- Early Development Analytics, Novartis, Basel, Switzerland
| | - David Demanse
- Early Development Analytics, Novartis, Basel, Switzerland
| | - Diana Graus Porta
- Oncology, Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Andrea Myers
- Global Drug Development, Novartis, East Hanover, New Jersey, USA
| | | | - Yi Gu
- Pharmacokinetic Sciences, Translational Medicine, Novartis, Cambridge, Massachusetts, USA
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2
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Mayawala K, de Alwis D. Dose Finding in Oncology: What is Impeding Coming of Age? Pharm Res 2022; 39:1817-1822. [PMID: 35474158 PMCID: PMC9314272 DOI: 10.1007/s11095-022-03263-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/11/2022] [Indexed: 11/30/2022]
Abstract
After a drug molecule enters clinical trials, there are primarily three levers to enhance probability of success: patient selection, dose selection and choice of combination agents. Of these, dose selection remains an under-appreciated aspect in oncology drug development despite numerous peer-reviewed publications. Here, we share practical challenges faced by the biopharmaceutical industry that reduce the willingness to invest in dose finding for oncology drugs. First, randomized dose finding admittedly slows down clinical development. To reduce the size of dose finding study, trend in exposure vs. tumor-size analysis can be assessed, instead of a statistical test for non-inferiority between multiple doses. Second, investment in testing a lower dose when benefit-risk at the higher dose is sufficient for regulatory approval (i.e., efficacy at the higher dose is better than standard of care and safety is acceptable) is perceived as low priority. Changing regulatory landscape must be considered to optimize dose in pre-marketing setting as post-marketing changes in dose can be commercially costly. Third, the risk of exposing patients to subtherapeutic exposures with a lower dose should be assessed scientifically instead of assuming a monotonic relationship between dose and efficacy. Only the doses which are expected to be at the plateau of dose/exposure-response curve should be investigated in Phase 1b/2. Overall, changing the perceptions that have been impeding investment in dose finding in oncology requires pragmatic discourse among biopharmaceutical industry, regulatory agencies and academia. These perceptions should also not deter dose finding for recently emerging modalities, including BITEs and CART cell therapies.
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Affiliation(s)
- Kapil Mayawala
- Oncology Early Development, Clinical Research, Merck and Co., Inc., NJ, Kenilworth, USA.
| | - Dinesh de Alwis
- Oncology Early Development, Clinical Research, Merck and Co., Inc., NJ, Kenilworth, USA
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Li TR, Chatterjee M, Lala M, Abraham AK, Freshwater T, Jain L, Sinha V, de Alwis DP, Mayawala K. Pivotal Dose of Pembrolizumab: A Dose-Finding Strategy for Immuno-Oncology. Clin Pharmacol Ther 2021; 110:200-209. [PMID: 33462831 DOI: 10.1002/cpt.2170] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/20/2020] [Indexed: 12/16/2022]
Abstract
Despite numerous publications emphasizing the value of dose finding, drug development in oncology is dominated by the mindset that higher dose provides higher efficacy. Examples of dose finding implemented by biopharmaceutical firms can change this mindset. The purpose of this article is to outline a pragmatic dose selection strategy for immuno-oncology (IO) and other targeted monoclonal antibodies (mAbs). The approach was implemented for pembrolizumab. Selecting a recommended phase II dose (RP2D) with a novel mechanism of action is often challenging due to uncertain relationships between pharmacodynamics measurements and clinical end points. Additionally, phase I efficacy and safety data are generally inadequate for RP2D selection for IO mAbs. Here, the RP2D was estimated based on phase I (clinical study KN001 A and A2) pharmacokinetics data as the dose required for target saturation, which represents a surrogate for maximal pharmacological effect for antagonist mAbs. Due to limitations associated with collecting and analyzing tumor biopsies, characterizing intratumoral target engagement (TE) is challenging. To overcome this gap, a physiologically-based pharmacokinetic model was implemented to predict intratumoral TE. As tumors are spatially heterogeneous, TE was predicted in well-vascularized and poorly vascularized tumor regions. Additionally, impact of differences in target expression, for example, due to interindividual variability and cancer type, was simulated. Simulations showed that 200 mg every 3 weeks can achieve ≥ 90% TE in clinically relevant scenarios, resulting in the recommendation of 200 mg every 3 weeks as the RP2D. Randomized dose comparison studies (KN001 B2 and D) showing similar efficacy over a fivefold dose/exposure range confirmed the RP2D as the pivotal dose.
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Affiliation(s)
- Tommy R Li
- Quantitative Pharmacology and Pharmacometrics, Merck & Co., Inc, Kenilworth, New Jersey, USA
| | - Manash Chatterjee
- Quantitative Pharmacology and Pharmacometrics, Merck & Co., Inc, Kenilworth, New Jersey, USA
| | - Mallika Lala
- Quantitative Pharmacology and Pharmacometrics, Merck & Co., Inc, Kenilworth, New Jersey, USA
| | - Anson K Abraham
- Quantitative Pharmacology and Pharmacometrics, Merck & Co., Inc, Kenilworth, New Jersey, USA
| | - Tomoko Freshwater
- Quantitative Pharmacology and Pharmacometrics, Merck & Co., Inc, Kenilworth, New Jersey, USA
| | - Lokesh Jain
- Quantitative Pharmacology and Pharmacometrics, Merck & Co., Inc, Kenilworth, New Jersey, USA
| | - Vikram Sinha
- Quantitative Pharmacology and Pharmacometrics, Merck & Co., Inc, Kenilworth, New Jersey, USA
| | - Dinesh P de Alwis
- Quantitative Pharmacology and Pharmacometrics, Merck & Co., Inc, Kenilworth, New Jersey, USA
| | - Kapil Mayawala
- Quantitative Pharmacology and Pharmacometrics, Merck & Co., Inc, Kenilworth, New Jersey, USA
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Kurtin SE, Taher R. Clinical Trial Design and Drug Approval in Oncology: A Primer for the Advanced Practitioner in Oncology. J Adv Pract Oncol 2021; 11:736-751. [PMID: 33575069 PMCID: PMC7646634 DOI: 10.6004/jadpro.2020.11.7.7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Evidenced-based practice requires timely and accurate integration of scientific advances. This presents a challenge for the oncology clinician given the robust pace of scientific discovery and the increasing number of new drug approvals and expanded indications for previously approved drugs. All currently available antineoplastic therapies have been developed through the clinical trials process. Advanced practitioners (APs) in oncology are often involved in the conduct of clinical trials as primary investigators, sub-investigators, study coordinators, or in the delivery and monitoring of care to patients enrolled in these trials. A prerequisite to evidenced-based practice is understanding how clinical trials are conducted and how to critically analyze published results of studies leading to U.S. Food & Drug Administration approval. Any AP involved in the clinical management and supportive care of patients receiving antineoplastic therapies should be able to critically review published data to glean findings that warrant a change in practice. The goals of this manuscript are to summarize key elements of the clinical trial process for oncology drug development and approval in the United States and to provide a primer for the interpretation of clinical data.
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Affiliation(s)
- Sandra E Kurtin
- The University of Arizona Cancer Center, Tucson, Arizona.,Lifespan Cancer Institute, Providence, Rhode Island
| | - Rashida Taher
- The University of Arizona Cancer Center, Tucson, Arizona.,Lifespan Cancer Institute, Providence, Rhode Island
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Lassman ME, Chappell DL, McAvoy T, Cheng A, de Alwis DP, Pruitt SK, Laterza OF, Li C, Stoch A, Mayawala K. Experimental Medicine Study to Measure Immune Checkpoint Receptors PD-1 and GITR Turnover Rates In Vivo in Humans. Clin Pharmacol Ther 2020; 109:1575-1582. [PMID: 33280089 DOI: 10.1002/cpt.2129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 11/12/2020] [Indexed: 11/12/2022]
Abstract
Development of monoclonal antibodies (mAbs) targeting immune-checkpoint receptors (IMRs) for the treatment of cancer is one of the most active areas of investment in the biopharmaceutical industry. A key decision in the clinical development of anti-IMR mAbs is dose selection. Dose selection can be challenging because the traditional oncology paradigm of administering the maximum tolerated dose is not applicable to anti-IMR mAbs. Instead, dose selection should be informed by the pharmacology of immune signaling. Engaging an IMR is a key initial step to triggering pharmacologic effects, and turnover (i.e., the rate of protein synthesis) of the IMR is a key property to determining the dose level needed to engage the IMR. Here, we applied the stable isotope labeling mass spectrometry technique using 13 C6 -leucine to measure the in vivo turnover rates of IMRs in humans. The 13 C6 -leucine was administered to 10 study participants over 15 hours to measure 13 C6 -leucine enrichment kinetics in 2 IMR targets that have been clinically pursued in oncology: GITR and PD-1. We report the first measurements of GITR and PD-1 median half-lives associated with turnover to be 55.6 and ≥ 49.5 hours, respectively. The approach outlined here can be applied to other IMRs and, more generally, to protein targets.
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Affiliation(s)
- Michael E Lassman
- Translational Molecular Biomarkers, Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Derek L Chappell
- Translational Molecular Biomarkers, Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Thomas McAvoy
- Translational Molecular Biomarkers, Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Amy Cheng
- Translational Medicine Clinical Operations, Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Dinesh P de Alwis
- Quantitative Pharmacology and Pharmacometrics, PPDM, Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Scott K Pruitt
- Oncology Clinical Research, Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Omar F Laterza
- Translational Molecular Biomarkers, Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Claire Li
- Quantitative Pharmacology and Pharmacometrics, PPDM, Merck & Co., Inc., Kenilworth, New Jersey, USA
| | | | - Kapil Mayawala
- Quantitative Pharmacology and Pharmacometrics, PPDM, Merck & Co., Inc., Kenilworth, New Jersey, USA
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Lee L, Lewis LD. Standing in the Shifting Sands of Molecular Targeting and Precision Medicine Is the Oasis of 21st-Century Oncology Therapeutics. J Clin Pharmacol 2017; 57 Suppl 10:S7-S10. [DOI: 10.1002/jcph.1011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 08/09/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Lucy Lee
- Clinical Pharmacology; Infinity Pharmaceuticals; Cambridge MA USA
| | - Lionel D. Lewis
- Section of Clinical Pharmacology; Department of Medicine; The Geisel School of Medicine at Dartmouth & Dartmouth-Hitchcock Medical Center; Lebanon NH USA
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