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Tamir S, Dye TJ, Witt RM. Sleep and Circadian Disturbances in Children With Neurodevelopmental Disorders. Semin Pediatr Neurol 2023; 48:101090. [PMID: 38065637 DOI: 10.1016/j.spen.2023.101090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 12/18/2023]
Abstract
Sleep problems are highly prevalent in those with neurodevelopmental disorders (NDDs). We propose this is secondary to multiple factors that directly and indirectly negatively impact sleep and circadian processes in those with NDDs, which in turn, further perturbs development, resulting in a "developmental and sleep/circadian-related encephalopathy." In this review, we discuss select NDDs with known or suspected sleep and circadian phenotypes. We also highlight important considerations when evaluating and treating sleep and circadian disorders in these populations.
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Affiliation(s)
- Sharon Tamir
- University of Cincinnati College of Medicine, Cincinnati, OH; Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Thomas J Dye
- Division of Child Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Pulmonary Medicine and the Sleep Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Center for Circadian Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Rochelle M Witt
- Division of Child Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Pulmonary Medicine and the Sleep Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Center for Circadian Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
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2
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Muehlan C, Roch C, Vaillant C, Dingemanse J. The orexin story and orexin receptor antagonists for the treatment of insomnia. J Sleep Res 2023; 32:e13902. [PMID: 37086045 DOI: 10.1111/jsr.13902] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/22/2023] [Accepted: 03/22/2023] [Indexed: 04/23/2023]
Abstract
Insomnia is present in up to one third of the adult population worldwide, and it can present independently or with other medical conditions such as mental, metabolic, or cardiovascular diseases, which highlights the importance of treating this multifaceted disorder. Insomnia is associated with an abnormal state of hyperarousal (increased somatic, cognitive, and cortical activation) and orexin has been identified as a key promotor of arousal and vigilance. The current standards of care for the treatment of insomnia recommend non-pharmacological interventions (cognitive behavioural therapy) as first-line treatment and, if behavioural interventions are not effective or available, pharmacotherapy. In contrast to most sleep medications used for decades (benzodiazepines and 'Z-drugs'), the new orexin receptor antagonists do not modulate the activity of γ-aminobutyric acid receptors, the main inhibitory mechanism of the central nervous system. Instead, they temporarily block the orexin pathway, causing a different pattern of effects, e.g., less morning or next-day effects, motor dyscoordination, and cognitive impairment. The pharmacokinetic/pharmacodynamic properties of these drugs are the basis of the different characteristics explained in the package inserts, including the recommended starting dose. Orexin receptor antagonists seem to be devoid of any dependence and tolerance-inducing effects, rendering them a viable option for longer-term treatment. Safety studies did not show exacerbation of existing respiratory problems, but more real-world safety and pharmacovigilance experience is needed. This review provides an overview of the orexin history, the mechanism of action, the relation to insomnia, and key features of available drugs mediating orexin signalling.
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Darpo B, Leishman DJ. The New S7B/E14 Q&A Document Provides Additional Opportunities to Replace the Thorough QT Study. J Clin Pharmacol 2023; 63:1256-1274. [PMID: 37455487 DOI: 10.1002/jcph.2309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
Since 2015, concentration-QTc (C-QTc) analysis has been used to exclude the possibility that a drug has a concerning effect on the QTc interval. This has enabled the replacement of the designated thorough QT (TQT) study with serial electrocardiograms (ECGs) in routine clinical pharmacology studies, such as the first-in-human (FIH) study. The E14 revision has led to an increased proportion of FIH studies with the added objective of QT evaluation, with the intention of replacing the TQT study. With the more recent revision of the S7B/E14 Q&A document in February 2022, nonclinical assays/studies can be brought into the process of regulatory decisions at the time of marketing application. If the hERG (human ether-a-go-go-related gene) and the non-rodent in vivo study are conducted according to the described best practices and are negative, the previous requirement that a QTc effect of >10 milliseconds must be excluded in healthy subjects at plasma concentrations 2-fold above what can be seen in patients can be reduced to covering the concentrations seen in patients. For drugs that cannot be safely given in high doses to healthy subjects, ECG evaluation is often performed at the therapeutic dose in patients. If a QTc effect of >10 milliseconds can be excluded, an argument can be made that the drug should be considered as having a low likelihood of proarrhythmic effects due to delayedrepolarization, if supported by negative best practices hERG and in vivo studies. In this article, we describe what clinicians involved in early clinical development need to understand in terms of the hERG and in vivo studies to determine whether these meet best practices and therefore can be used in an integrated clinical/nonclinical QT/QTc risk assessment.
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Mogavero MP, Silvani A, Lanza G, DelRosso LM, Ferini-Strambi L, Ferri R. Targeting Orexin Receptors for the Treatment of Insomnia: From Physiological Mechanisms to Current Clinical Evidence and Recommendations. Nat Sci Sleep 2023; 15:17-38. [PMID: 36713640 PMCID: PMC9879039 DOI: 10.2147/nss.s201994] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/08/2023] [Indexed: 01/23/2023] Open
Abstract
After a detailed description of orexins and their roles in sleep and other medical disorders, we discuss here the current clinical evidence on the effects of dual (DORAs) or selective (SORAs) orexin receptor antagonists on insomnia with the aim to provide recommendations for their further assessment in a context of personalized and precision medicine. In the last decade, many trials have been conducted with orexin receptor antagonists, which represent an innovative and valid therapeutic option based on the multiple mechanisms of action of orexins on different biological circuits, both centrally and peripherally, and their role in a wide range of medical conditions which are often associated with insomnia. A very interesting aspect of this new category of drugs is that they have limited abuse liability and their discontinuation does not seem associated with significant rebound effects. Further studies on the efficacy of DORAs are required, especially on children and adolescents and in particular conditions, such as menopause. Which DORA is most suitable for each patient, based on comorbidities and/or concomitant treatments, should be the focus of further careful research. On the contrary, studies on SORAs, some of which seem to be appropriate also in insomnia in patients with psychiatric diseases, are still at an early stage and, therefore, do not allow to draw definite conclusions.
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Affiliation(s)
- Maria P Mogavero
- Vita-Salute San Raffaele University, Milan, Italy.,Sleep Disorders Center, Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Silvani
- PRISM Lab, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Giuseppe Lanza
- Sleep Research Centre, Oasi Research Institute - IRCCS, Troina, Italy.,Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Lourdes M DelRosso
- Pulmonary and Sleep Medicine, University of California San Francisco-Fresno, Fresno, CA, USA
| | - Luigi Ferini-Strambi
- Vita-Salute San Raffaele University, Milan, Italy.,Sleep Disorders Center, Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy
| | - Raffaele Ferri
- Sleep Research Centre, Oasi Research Institute - IRCCS, Troina, Italy
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5
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Darpo B, Borin M, Ferber G, Galluppi GR, Hopkins SC, Landry I, Lo A, Rege B, Reyderman L, Sun L, Watanabe T, Xue H, Yasuda S. ECG Evaluation as Part of the Clinical Pharmacology Strategy in the Development of New Drugs: A Review of Current Practices and Opportunities Based on Five Case Studies. J Clin Pharmacol 2022; 62:1480-1500. [PMID: 35665514 PMCID: PMC9796926 DOI: 10.1002/jcph.2095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/26/2022] [Indexed: 01/07/2023]
Abstract
The International Conference on Harmonization (ICH) E14 document was revised in 2015 to allow concentration-corrected QT interval (C-QTc) analysis to be applied to data from early clinical pharmacology studies to exclude a small drug-induced effect on QTc. Provided sufficiently high concentrations of the drug are obtained in the first-in-human (FIH) study, this approach can be used to obviate the need for a designated thorough QT (TQT) study. The E14 revision has resulted in a steady reduction in the number of TQT studies and an increased use of FIH studies to evaluate electrocardiogram (ECG) effects of drugs in development. In this review, five examples from different sponsors are shared in which C-QTc analysis was performed on data from FIH studies. Case 1 illustrates a clearly negative C-QTc evaluation, despite observations of QTc prolongation at high concentrations in nonclinical studies. In case 2 C-QTc analysis of FIH data was performed prior to full pharmacokinetic characterization in patients, and the role of nonclinical assays in an integrated risk assessment is discussed. Case 3 illustrates a positive clinical C-QTc relationship, despite negative nonclinical assays. Case 4 demonstrates a strategy for characterizing the C-QTc relationship for a nonracemic therapy and formulation optimization, and case 5 highlights an approach to perform a preliminary C-QTc analysis early in development and postpone the definitive analysis until proof of efficacy is demonstrated. The strategy of collecting and storing ECG data from FIH studies to enable an informed decision on whether and when to apply C-QTc analysis to obviate the need for a TQT study is described.
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Affiliation(s)
| | - Marie Borin
- Clinical and Translational PharmacologyTheravance Biopharma US, Inc.South San FranciscoCaliforniaUSA
| | | | | | | | - Ishani Landry
- Clinical Pharmacology and Translational MedicineEisaiNutleyNew JerseyUSA
| | - Arthur Lo
- Clinical and Translational PharmacologyTheravance Biopharma US, Inc.South San FranciscoCaliforniaUSA
| | | | - Larisa Reyderman
- Clinical Pharmacology and Translational MedicineEisaiNutleyNew JerseyUSA
| | - Lei Sun
- Alkermes, Inc.WalthamMassachusettsUSA
| | - Takao Watanabe
- Sunovion Pharmaceuticals, Inc.MarlboroughMassachusettsUSA
| | | | - Sally Yasuda
- Clinical Pharmacology and Translational MedicineEisaiNutleyNew JerseyUSA
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Landry IS, Boyd P, Aluri J, Darpo B, Xue H, Brown R, Reyderman L, Lai R. E2027 Cardiac Safety Evaluation With Concentration-Response Modeling of ECG Data to Inform Dose Selection in Studies in Patients With Dementia With Lewy Bodies. Alzheimer Dis Assoc Disord 2022; 36:208-214. [PMID: 35622456 DOI: 10.1097/wad.0000000000000510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 03/08/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND E2027 is a novel, highly selective and potent inhibitor of phosphodiesterase 9 in development for dementia with Lewy bodies. Cardiac safety assessments for emerging agents are essential to avoid drug-induced QT interval prolongation, which may predispose individuals to potentially fatal ventricular arrhythmias. To evaluate the cardiac safety of E2027 and to inform dose selection for the phase 2 study of E2027 in dementia with Lewy bodies, we evaluated concentration-response modeling of pooled electrocardiogram data. PATIENTS AND METHODS A post hoc concentration-QTc analysis evaluated potential QT effects using data from 2 randomized, double-blind studies in healthy subjects: a single ascending dose (SAD) study and a multiple ascending dose (MAD) study. Daily E2027 doses ranged from 5 to 1200 mg. RESULTS A linear mixed-effects model was used to establish the relationship between plasma concentrations of E2027 and change from the baseline of QTcF (ΔQTcF). A significant but shallow relationship was observed in the estimated slope of the concentration-ΔQTcF: 0.002 ms/ng/mL (90% confidence interval: 0.0007-0.0031) with a small, nonsignificant treatment effect-specific intercept of -0.6 ms. Based on this pooled concentration-QTc analysis, an effect on the QTcF interval >10 ms can be excluded up to E2027 plasma concentrations of ∼3579 ng/mL, corresponding to a dose at least 4-fold larger than the 50 mg phase 2 dose. CONCLUSION This pooled post hoc analysis evaluating cardiac safety of E2027 demonstrated that clinically concerning QTcF prolongation and related cardiac complications are highly unlikely with proposed E2027 doses planned for phase 2.
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Schilling U, Henrich A, Muehlan C, Krause A, Dingemanse J, Ufer M. Impact of Daridorexant, a Dual Orexin Receptor Antagonist, on Cardiac Repolarization Following Bedtime Dosing: Results from a Thorough QT Study Using Concentration-QT Analysis. Clin Drug Investig 2021; 41:711-721. [PMID: 34331678 DOI: 10.1007/s40261-021-01062-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Daridorexant is a new dual orexin receptor antagonist currently in late-stage clinical development for the treatment of insomnia. This randomized, double-blind, placebo-controlled, four-period crossover study investigated the effect of daridorexant at a therapeutic and supratherapeutic dose on QT interval duration. METHODS Thirty-six healthy subjects received single oral doses of daridorexant (50 mg; 200 mg), moxifloxacin (400 mg; open label), and placebo. All treatments were administered at bedtime to mimic therapeutic practice. The primary analysis was based on linear mixed-effects concentration-QT modelling. Triplicate ECG data were extracted from Holter recordings at baseline and until 24 h post dosing at time points matching those for pharmacokinetic sampling. Plasma concentrations of daridorexant were determined over 24 h. RESULTS Assay sensitivity was demonstrated based on mean baseline- and placebo-corrected QT interval using Fridericia's formula (ΔΔQTcF) > 5 ms following moxifloxacin administration (p < 0.01). Following daridorexant administration, mean (90% confidence interval, CI) ΔΔQTcF was 1.40 ms (0.48; 2.32 ms) and 1.84 ms (-0.12; 3.79 ms) at the Cmax of 747 ng/mL (50 mg dose) and 1809 ng/mL (200 mg dose), respectively, i.e., the upper bounds of the CIs were < 10 ms defined as threshold of regulatory concern. Lack of relevant QT prolongation was confirmed by secondary by-time point analysis and absence of relevant findings in the categorical outlier analysis. Daridorexant was safe and well tolerated and its pharmacokinetics were consistent with previous data. CONCLUSION Daridorexant does not impair cardiac repolarization evidenced by absence of relevant QT prolongation at therapeutic and supratherapeutic doses. Clinical Trials Registration ID: NCT04250506.
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Affiliation(s)
- Uta Schilling
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
| | - Andrea Henrich
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
| | - Clemens Muehlan
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
| | - Andreas Krause
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland.
| | - Mike Ufer
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
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Darpo B, Ferber G. The New S7B/E14 Question and Answer Draft Guidance for Industry: Contents and Commentary. J Clin Pharmacol 2021; 61:1261-1273. [PMID: 33896027 PMCID: PMC9290990 DOI: 10.1002/jcph.1880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/20/2021] [Indexed: 11/10/2022]
Abstract
In August 2020, the International Council on Harmonisation (ICH) released a new draft document, which for the first time combined nonclinical (S7B) and clinical (E14) Questions and Answers (Q&As) into 1 document. FDA describes the revision as a “value proposition”: if the human ether‐à‐go‐go assay and the in vivo study are performed in a standardized way, the number of dedicated thorough QT (TQT) studies can be reduced. In this article, we describe and discuss the Q&As that relate to clinical ECG evaluation. If supported by negative standardized nonclinical assays, Q&A 5.1 will obviate the need for a TQT study in the case that a >2‐fold exposure margin vs high clinical scenario cannot be obtained. Q&A 6.1 addresses drugs that are poorly tolerated in healthy subjects and cannot be studied at high doses or in placebo‐controlled studies; it therefore mainly applies to oncology drugs. It will enable sponsors to claim that a new drug has a “low likelihood of proarrhythmic effects” in the case that the mean corrected QT effect is <10 milliseconds at the time of market application. The E14 2015 revision allowed application of concentration–corrected QT analysis on data from routinely performed clinical pharmacology studies, for example, the first‐in‐human study and the proportion of dedicated TQT studies has since steadily decreased. It can be foreseen that the proposed new revision will further reduce the number of TQT studies. To achieve harmonization across regulatory regions, it seems important to reach consensus within the International Council on Harmonisation group on the new threshold proposed in 6.1. For this purpose, the Implementation Working Group has asked for public comments.
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Affiliation(s)
- Borje Darpo
- Cardiac Safety, ERT, Rochester, New York, USA.,Cardiology, Karolinska Institute, Stockholm, Sweden
| | - Georg Ferber
- Statistik Georg Ferber GmbH, Riehen, Switzerland
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Abstract
Lemborexant (DAYVIGO™) is an orally administered, dual orexin receptor (OXR) antagonist that exhibits reversible competitive antagonism at OXR1 and OXR2 (> affinity at OXR2) that was discovered and developed by Eisai Inc. for the treatment of adult patients with insomnia. In December 2019, lemborexant received its first approval (with final interim scheduling) in the USA for the treatment of adult patients with insomnia, characterized by difficulties with sleep onset and/or sleep maintenance. In January 2020, lemborexant also received approval in Japan for the treatment of insomnia. It is also being investigated for the treatment of irregular sleep-wake rhythm disorder (ISWRD) associated with mild to moderate Alzheimer's disease. This article summarizes the milestones in the development of lemborexant leading to its first global approval.
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Muehlan C, Vaillant C, Zenklusen I, Kraehenbuehl S, Dingemanse J. Clinical pharmacology, efficacy, and safety of orexin receptor antagonists for the treatment of insomnia disorders. Expert Opin Drug Metab Toxicol 2020; 16:1063-1078. [DOI: 10.1080/17425255.2020.1817380] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Clemens Muehlan
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Cedric Vaillant
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Isabelle Zenklusen
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Stephan Kraehenbuehl
- Department of Clinical Pharmacology and Toxicology, University Hospital Basel, Basel, Switzerland
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
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Lemborexant in insomnia disorder: a profile of its use. DRUGS & THERAPY PERSPECTIVES 2020. [DOI: 10.1007/s40267-020-00771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Vormfelde SV, Pezous N, Lefèvre G, Kolly C, Neumann U, Jordaan P, Ufer M, Legangneux E. A Pooled Analysis of Three Randomized Phase I/IIa Clinical Trials Confirms Absence of a Clinically Relevant Effect on the QTc Interval by Umibecestat. Clin Transl Sci 2020; 13:1316-1326. [PMID: 32583957 PMCID: PMC7719381 DOI: 10.1111/cts.12832] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/01/2020] [Indexed: 01/17/2023] Open
Abstract
Umibecestat, an orally active β‐secretase inhibitor, reduces the production of amyloid beta‐peptide that accumulates in the brain of patients with Alzheimer’s disease. The echocardiogram effects of umibecestat, on QTcF (Fridericia‐corrected QT), on PR and QRS and heart rate (HR), were estimated by concentration‐effect modeling. Three phase I/II studies with durations up to 3 months, with 372 healthy subjects over a wide age range, including both sexes and 2 ethnicities, were pooled, providing a large data set with good statistical power. No clinically relevant effect on QTcF, PR interval, QRS duration, or HR were observed up to supratherapeutic doses. The upper bound of 90% confidence intervals of the ∆QTcF was below the 10 ms threshold of regulatory concern for all concentrations measured. Prespecified sensitivity analysis confirmed the results in both sexes, in those over and below 60 years, and in Japanese subjects. All conclusions were endorsed by the US Food and Drug Administration (FDA).
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Affiliation(s)
- Stefan Viktor Vormfelde
- Department of Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Nicole Pezous
- Department of Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Gilbert Lefèvre
- Department of Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Carine Kolly
- Department of Preclinical Safety, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Ulf Neumann
- Department of Neuroscience, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Pierre Jordaan
- Cardiovascular Safety Expert - CMO and Patient Safety - Oncology, Novartis Pharma, Basel, Switzerland
| | - Mike Ufer
- Department of Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Eric Legangneux
- Department of Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
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Jaminion F, Bentley D, Wang K, Wandel C, Derks M, Diack C. PKPD and cardiac single cell modeling of a DDI study with a CYP3A4 substrate and itraconazole to quantify the effects on QT interval duration. J Pharmacokinet Pharmacodyn 2020; 47:447-459. [DOI: 10.1007/s10928-020-09696-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/16/2020] [Indexed: 01/14/2023]
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Landry I, Nakai K, Ferry J, Aluri J, Hall N, Lalovic B, Moline ML. Pharmacokinetics, Pharmacodynamics, and Safety of the Dual Orexin Receptor Antagonist Lemborexant: Findings From Single-Dose and Multiple-Ascending-Dose Phase 1 Studies in Healthy Adults. Clin Pharmacol Drug Dev 2020; 10:153-165. [PMID: 32468649 PMCID: PMC7891412 DOI: 10.1002/cpdd.817] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 04/20/2020] [Indexed: 12/30/2022]
Abstract
Lemborexant, a dual orexin receptor antagonist, is approved for the treatment of insomnia and is under investigation for treating other sleep disorders. Here we summarize pharmacokinetic, pharmacodynamic, and safety data from 3 randomized, double‐blind, placebo‐controlled phase 1 studies: single ascending doses in healthy adults (Study 001; 1‐200 mg; N = 64), multiple ascending doses in healthy and elderly adults (Study 002; 2.5‐75 mg; N = 55), and multiple doses in healthy white and Japanese adults (Study 003; 2.5‐25 mg; N = 32). Lemborexant exposure increased with increasing dose. The time to maximum concentration ranged from approximately 1 to 3 hours for the 5‐ and 10‐mg doses. The mean effective half‐life was 17 hours for lemborexant 5 mg and 19 hours for lemborexant 10 mg. The plasma concentration at 9 hours postdose was 27% of the maximum concentration following multiple dosing with lemborexant 10 mg. There were no clinically relevant effects on next‐morning residual sleepiness (Karolinska Sleepiness Scale, Digital Symbol Substitution Test, Psychomotor Vigilance Test) for doses through 10 mg/day, indicating no effect of residual plasma concentrations on next‐day residual effects. Lemborexant was well tolerated across the doses tested. There were no clinically relevant effects of age, sex, or race on lemborexant pharmacokinetics, pharmacodynamics, or safety. These results suggest that lemborexant at doses through 25 mg provides an overall pharmacokinetic, pharmacodynamic, and safety profile suitable for obtaining the target pharmacologic effect supporting treatment of insomnia while minimizing residual effects during wake time.
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Affiliation(s)
| | | | - Jim Ferry
- Eisai Inc, Woodcliff Lake, New Jersey, USA
| | | | - Nancy Hall
- Eisai Inc, Woodcliff Lake, New Jersey, USA
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Vermeeren A, Jongen S, Murphy P, Moline M, Filippov G, Pinner K, Perdomo C, Landry I, Majid O, Van Oers ACM, Van Leeuwen CJ, Ramaekers JG, Vuurman EFPM. On-the-road driving performance the morning after bedtime administration of lemborexant in healthy adult and elderly volunteers. Sleep 2020; 42:5267834. [PMID: 30597112 PMCID: PMC6448281 DOI: 10.1093/sleep/zsy260] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 11/16/2018] [Indexed: 01/03/2023] Open
Abstract
Study Objectives To assess potential effects of lemborexant on next-morning driving performance in adult and elderly healthy volunteers. Methods Randomized, double-blind, double-dummy, placebo and active-controlled, four period incomplete crossover study in 48 healthy volunteers (22 females), 23–78 years old. Participants were treated at bedtime for eight consecutive nights with two of three dose levels of lemborexant (2.5, 5, or 10 mg), zopiclone 7.5 mg (on the first and last night with placebo on intervening nights), or placebo. Driving performance was assessed in the morning on days 2 and 9 using a standardized highway driving test in normal traffic, measuring standard deviation of lateral position (SDLP). Drug–placebo differences in SDLP >2.4 cm were considered to reflect clinically meaningful driving impairment. Results Mean drug–placebo differences in SDLP following lemborexant 2.5, 5, and 10 mg on days 2 and 9 were 0.74 cm or less. The upper bound of the 95% confidence intervals (CIs) for lemborexant treatment groups were all below 2.4 cm and the 95% CIs included zero, indicating that the effects were neither clinically meaningful nor statistically significant. Symmetry analysis further supported the lack of clinically meaningful impairment with lemborexant. Conclusions When assessed starting ~9 h after lemborexant administration at bedtime the previous night, there was no statistically significant or clinically meaningful effect on driving performance in healthy adults and elderly, as assessed by either mean differences in SDLP relative to placebo or symmetry analysis. In this study, lemborexant at doses up to 10 mg was well-tolerated. Clinical Trial Registration clinicaltrials.gov, NCT02583451. https://clinicaltrials.gov/ct2/show/NCT02583451.
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Affiliation(s)
- Annemiek Vermeeren
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Stefan Jongen
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | | | | | - Gleb Filippov
- Neurology Business Group, Eisai, Inc., Woodcliff Lake, NJ
| | - Kate Pinner
- Neurology Business Group, Eisai Ltd., Hatfield, UK
| | - Carlos Perdomo
- Neurology Business Group, Eisai, Inc., Woodcliff Lake, NJ
| | - Ishani Landry
- Neurology Business Group, Eisai, Inc., Woodcliff Lake, NJ
| | - Oneeb Majid
- Neurology Business Group, Eisai Ltd., Hatfield, UK
| | - Anita C M Van Oers
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Cees J Van Leeuwen
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Johannes G Ramaekers
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Eric F P M Vuurman
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
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17
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Gong X, Darpo B, Xue H, Punwani N, He K, Barbour AM, Epstein N, Landman R, Chen X, Yeleswaram S. Evaluation of Clinical Cardiac Safety of Itacitinib, a JAK1 Inhibitor, in Healthy Participants. Clin Pharmacol Drug Dev 2019; 9:677-688. [DOI: 10.1002/cpdd.758] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/06/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Xiaohua Gong
- Incyte Research Institute Wilmington Delaware USA
| | - Borje Darpo
- eRT/iCardiac Technologies Rochester New York USA
| | - Hongqi Xue
- eRT/iCardiac Technologies Rochester New York USA
| | | | - Kevin He
- Incyte Corporation Wilmington Delaware USA
| | | | - Noam Epstein
- Incyte Research Institute Wilmington Delaware USA
| | | | - Xuejun Chen
- Incyte Research Institute Wilmington Delaware USA
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18
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Gaitonde P, Huh Y, Darpo B, Ferber G, Heimann G, Li J, Lu K, Sebastien B, Tsai K, Riley S. Cardiac risk assessment based on early Phase I data and PK-QTc analysis is concordant with the outcome of thorough QTc trials: an assessment based on eleven drug candidates. J Pharmacokinet Pharmacodyn 2019; 46:617-626. [DOI: 10.1007/s10928-019-09662-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 10/17/2019] [Indexed: 11/27/2022]
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19
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Herring WJ, Roth T, Krystal AD, Michelson D. Orexin receptor antagonists for the treatment of insomnia and potential treatment of other neuropsychiatric indications. J Sleep Res 2018; 28:e12782. [DOI: 10.1111/jsr.12782] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/06/2018] [Accepted: 09/22/2018] [Indexed: 01/06/2023]
Affiliation(s)
| | - Thomas Roth
- Sleep Disorders and Research Center Henry Ford Hospital Detroit MI USA
| | - Andrew D. Krystal
- Department of Psychiatry University of California San Francisco California USA
| | - David Michelson
- Clinical ResearchMerck & Co., Inc. Kenilworth New Jersey USA
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20
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CiPA challenges and opportunities from a non-clinical, clinical and regulatory perspectives. An overview of the safety pharmacology scientific discussion. J Pharmacol Toxicol Methods 2018; 93:15-25. [DOI: 10.1016/j.vascn.2018.06.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 05/23/2018] [Accepted: 06/19/2018] [Indexed: 01/22/2023]
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21
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Darpo B, Couderc JP. Challenges in implementing and obtaining acceptance for J-Tpeak assessment as the clinical component of CiPA. J Pharmacol Toxicol Methods 2018; 93:75-79. [PMID: 29879475 DOI: 10.1016/j.vascn.2018.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/13/2018] [Accepted: 05/30/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION This paper is based on a presentation held at the Annual Safety Pharmacology Society meeting in September 2017, at which challenges for the clinical component of CiPA were presented. FDA has published an automated algorithm for measurement of the J-Tpeak interval on a median beat from a vector magnitude lead derived from a 12-lead ECG. CiPA proposes that J-Tpeak prolongation < 10 ms can be used for drugs with a QTc effect < 20 ms to differentiate between safe and unsafe delayed repolarization and to reduce the level of ECG monitoring in late stage clinical trials. METHODS We applied FDA's algorithm, complemented with iCOMPAS, to moxifloxacin and dolasetron data from the IQ-CSRC study with 9 subjects on active and 6 on placebo. The effect on QTcF and corrected J-Tpeak (J-Tpeak_c) was analyzed using concentration-effect modeling. RESULTS There was a good correlation between QTcF and J-Tpeak_c prolongation after oral dosing of 400 mg moxifloxacin with placebo-adjusted, change-from-baseline (ΔΔ) J-Tpeak_c of ~12 ms at concentrations that caused ΔΔQTcF of ~20 ms. On dolasetron, J-Tpeak_c was highly variable, no prolongation was seen and an effect on ΔΔJ-Tpeak_c > 10 ms could be excluded across the observed plasma concentration range. DISCUSSION In this limited analysis performed on the IQ-CSRC study waveforms using FDA's automated algorithm, J-Tpeak prolongation was observed on moxifloxacin, but not on dolasetron, despite clinical observations of proarrhythmias with both drugs. Challenges for the implementation of the J-Tpeak interval as a replacement or complement to the QTc interval, include to demonstrate that the proposed clinical algorithm using a J-Tpeak threshold of 10 ms, can be used to categorize drugs with a QT effect up to ~20 ms as having low pro-arrhythmic risk.
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Affiliation(s)
- Borje Darpo
- iCardiac Technologies, Inc., Rochester, NY, USA.
| | - Jean-Philippe Couderc
- iCardiac Technologies, Inc., Rochester, NY, USA; Heart Research Follow-up Program, University of Rochester Medical Center, Rochester, NY, USA
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22
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Tsuneki H, Wada T, Sasaoka T. Chronopathophysiological implications of orexin in sleep disturbances and lifestyle-related disorders. Pharmacol Ther 2018; 186:25-44. [DOI: 10.1016/j.pharmthera.2017.12.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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23
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Spiegelstein O, Mimrod D, Rabinovich L, Eyal E, Sprenger C, Elgart A, Samara E, Morganroth J. A Thorough QT/QTc Study With Laquinimod, a Novel Immunomodulator in Development for Multiple Sclerosis and Huntington Disease. Clin Pharmacol Drug Dev 2018; 8:49-59. [DOI: 10.1002/cpdd.442] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 12/20/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Ofer Spiegelstein
- Clinical Pharmacology and Pharmacometrics; Teva Pharmaceutical Industries Ltd; Netanya Israel
| | - Dorit Mimrod
- Project Leadership; Teva Pharmaceutical Industries Ltd; Netanya Israel
| | - Laura Rabinovich
- Clinical Pharmacology and Pharmacometrics; Teva Pharmaceutical Industries Ltd; Frazer PA USA
| | - Eli Eyal
- Global Biostatistics Unit; TEVA Pharmaceutical Industries Ltd; Netanya Israel
| | | | - Anna Elgart
- Clinical Pharmacology and Pharmacometrics; Teva Pharmaceutical Industries Ltd; Netanya Israel
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24
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Panicker GK, Kadam P, Chakraborty S, Kothari S, Turner JR, Karnad DR. Individual-Specific QT Interval Correction for Drugs With Substantial Heart Rate Effect Using Holter ECGs Extracted Over a Wide Range of Heart Rates. J Clin Pharmacol 2018; 58:1013-1019. [PMID: 29775213 DOI: 10.1002/jcph.1258] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/13/2018] [Indexed: 12/11/2022]
Abstract
Although fixed QT correction methods are typically used to adjust for the effect of heart rate on the QT interval in thorough QT/QTc studies, individual-specific QT correction (QTcI = QT/RRI ) is advisable for drugs that increase the heart rate by >5 to 10 beats/minute (bpm). QTcI is traditionally derived using resting drug-free electrocardiograms (ECGs) collected at prespecified times. However, the resting heart rate range in healthy individuals is narrow, and extrapolation of inferences from these data to higher heart rates could be inappropriate. Accordingly, the QTcI derived from triplicate ECGs extracted at prespecified times (the traditional [T] method, yielding QTcIT) was compared with QTcIs obtained using ECGs with a wider heart rate range (alternative Holter [H] method, yielding QTcIH) from 24-hour Holter recordings from 40 healthy individuals selected from a central ECG laboratory database. For QTcIH, 10-second ECGs were extracted at stable heart rates in the ranges of 51-60, 61-70, 71-80, and 81-90 bpm (9 ECGs in each bin = 36 ECGs). An independent set of 40 ECGs with heart rates from 51 to 90 bpm was extracted from each individual to validate the accuracy of QTcI by the 2 methods. For the validation set, the QTcIH was a better QT correction method (slope of QTc vs heart rate closer to zero) than QTcIT. The mean difference between QTcIT and QTcIH increased from 3.1 milliseconds at 65 bpm to 10.0 milliseconds at 90 bpm (P < 0.01). The QTcIT exceeded QTcIH at heart rates > 60 bpm. Employment of the QTcIH may be more appropriate for studies involving drugs that increase heart rate.
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Affiliation(s)
| | | | | | | | - J Rick Turner
- Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, USA
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25
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Turner JR, Rodriguez I, Mantovani E, Gintant G, Kowey PR, Klotzbaugh RJ, Prasad K, Sager PT, Stockbridge N, Strnadova C. Drug-induced Proarrhythmia and Torsade de Pointes: A Primer for Students and Practitioners of Medicine and Pharmacy. J Clin Pharmacol 2018; 58:997-1012. [PMID: 29672845 DOI: 10.1002/jcph.1129] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/05/2018] [Indexed: 12/11/2022]
Abstract
Multiple marketing withdrawals due to proarrhythmic concerns occurred in the United States, Canada, and the United Kingdom in the late 1980s to early 2000s. This primer reviews the clinical implications of a drug's identified proarrhythmic liability, the issues associated with these safety-related withdrawals, and the actions taken by the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) and by regulatory agencies in terms of changing drug development practices and introducing new nonclinical and clinical tests to asses proarrhythmic liability. ICH Guidelines S7B and E14 were released in 2005. Since then, they have been adopted by many regional regulatory authorities and have guided nonclinical and clinical proarrhythmic cardiac safety assessments during drug development. While this regulatory paradigm has been successful in preventing drugs with unanticipated potential for inducing the rare but potentially fatal polymorphic ventricular arrhythmia torsade de pointes from entering the market, it has led to the termination of drug development programs for other potentially useful medicines because of isolated results from studies with limited predictive value. Research efforts are now exploring alternative approaches to better predict potential proarrhythmic liabilities. For example, in the domain of human electrocardiographic assessments, concentration-response modeling conducted during phase 1 clinical development has recently become an accepted alternate primary methodology to the ICH E14 "thorough QT/QTc" study for defining a drug's corrected QT interval prolongation liability under certain conditions. When a drug's therapeutic benefit is considered important at a public health level but there is also an identified proarrhythmic liability that may result from administration of the single drug in certain individuals and/or drug-drug interactions, marketing approval will be accompanied by appropriate directions in the drug's prescribing information. Health-care professionals in the fields of medicine and pharmacy need to consider the prescribing information in conjunction with individual patients' clinical characteristics and concomitant medications when prescribing and dispensing such drugs.
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Affiliation(s)
- J Rick Turner
- Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, USA
| | - Ignacio Rodriguez
- Cardiac Safety Research Consortium, Roche TCRC, Inc., New York, NY, USA
| | - Emily Mantovani
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
| | | | - Peter R Kowey
- Lankenau Heart Institute and Jefferson Medical College, Philadelphia, PA, USA
| | - Ralph J Klotzbaugh
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Krishna Prasad
- Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Philip T Sager
- Sager Consulting and Stanford University, San Francisco, CA, USA
| | - Norman Stockbridge
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Colette Strnadova
- Therapeutic Products Directorate, Health Canada, Ottawa, Ontario, Canada
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26
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Matsukura S, Nakamura Y, Hoshiai K, Hayashi T, Koga T, Goto A, Chiba K, Lubna NJ, Hagiwara-Nagasawa M, Izumi-Nakaseko H, Ando K, Naito AT, Sugiyama A. Effects of moxifloxacin on the proarrhythmic surrogate markers in healthy Filipino subjects: Exposure-response modeling using ECG data of thorough QT/QTc study. J Pharmacol Sci 2018; 136:234-241. [DOI: 10.1016/j.jphs.2018.01.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 01/08/2018] [Accepted: 01/19/2018] [Indexed: 12/01/2022] Open
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27
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Lu J, Li J, Helmlinger G, Al-Huniti N. Assessing QT/QTc interval prolongation with concentration-QT modeling for Phase I studies: impact of computational platforms, model structures and confidence interval calculation methods. J Pharmacokinet Pharmacodyn 2018; 45:469-482. [PMID: 29556866 DOI: 10.1007/s10928-018-9582-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 03/09/2018] [Indexed: 01/10/2023]
Abstract
Modeling the relationship between drug concentrations and heart rate corrected QT interval (QTc) change from baseline (C-∆QTc), based on Phase I single ascending dose (SAD) or multiple ascending dose (MAD) studies, has been proposed as an alternative to thorough QT studies (TQT), in assessing drug-induced QT prolongation risk. The present analysis used clinical SAD, MAD and TQT study data of an experimental compound, AZD5672, to evaluate the performance of: (i) three computational platforms (linear mixed-effects modeling implemented via PROC MIXED in SAS, as well as in R using LME4 package and linear quantile mixed models (LQMM) implemented via LQMM package; (ii) different model structures with and without treatment- or time-specific intercepts; and (iii) three methods for calculating the confidence interval (CI) of QTc prolongation (analytical and bootstrap methods with fixed or varied geometric mean concentrations). We show that treatment- and time-specific intercepts may need to be included into C-∆QTc modeling through PROC MIXED or LME4, regardless of their statistical significance. With the intersection union test (IUT) in the TQT study as a reference for comparison, inclusion of these intercepts increased the feasibility for C-∆QTc modelling of SAD or MAD to reach the same conclusion as the IUT analysis based on TQT study. Compared to PROC MIXED or LME4, the LQMM method is less dependent on inclusion of treatment- or time-specific intercepts, and the bootstrap CI calculation methods provided higher likelihood for C-∆QTc modeling of SAD and MAD studies to reach the same conclusion as the IUT based on the TQT study.
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Affiliation(s)
- Jingtao Lu
- Quantitative Clinical Pharmacology, IMED Biotech Unit, AstraZeneca Pharmaceuticals, Gatehouse Park, 35 Gatehouse Drive, Waltham, MA, 02451, USA
| | - Jianguo Li
- Quantitative Clinical Pharmacology, IMED Biotech Unit, AstraZeneca Pharmaceuticals, Gatehouse Park, 35 Gatehouse Drive, Waltham, MA, 02451, USA
| | - Gabriel Helmlinger
- Quantitative Clinical Pharmacology, IMED Biotech Unit, AstraZeneca Pharmaceuticals, Gatehouse Park, 35 Gatehouse Drive, Waltham, MA, 02451, USA
| | - Nidal Al-Huniti
- Quantitative Clinical Pharmacology, IMED Biotech Unit, AstraZeneca Pharmaceuticals, Gatehouse Park, 35 Gatehouse Drive, Waltham, MA, 02451, USA.
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28
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Timmers M, Sinha V, Darpo B, Smith B, Brown R, Xue H, Ferber G, Streffer J, Russu A, Tritsmans L, Solanki B, Bogert J, Van Nueten L, Salvadore G, Nandy P. Evaluating Potential QT Effects of JNJ-54861911, a BACE Inhibitor in Single- and Multiple-Ascending Dose Studies, and a Thorough QT Trial With Additional Retrospective Confirmation, Using Concentration-QTc Analysis. J Clin Pharmacol 2018; 58:952-964. [PMID: 29505101 DOI: 10.1002/jcph.1087] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 01/05/2018] [Indexed: 11/10/2022]
Abstract
Nonclinical assays with JNJ-54861911, a β-secretase 1 inhibitor have indicated that at high concentrations, it may delay cardiac repolarization. A 4-way crossover thorough QT (TQT) study was performed in 64 healthy subjects with 50 and 150 mg JNJ-54861911 once daily for 7 days, placebo, and 400 mg moxifloxacin. Retrospective high-precision QT (HPQT) analysis was performed on serial elecrocardiograms extracted from first-in-human single-ascending dose (SAD) and multiple-ascending dose (MAD) studies to evaluate if early studies could detect and predict QT effect. In the TQT study, a high therapeutic 50 mg dose did not cause QT prolongation, and an effect >10 milliseconds could be excluded at all postdose timepoints. QT prolongation with peak effect on placebo-corrected change from baseline QTcF of 15.5 milliseconds (90%CI, 12.9-18.1 milliseconds) was observed following a supratherapeutic dose (150 mg). No clinically relevant QT changes were observed in earlier studies. However, with SAD/MAD findings by HPQT, the slope of the exposure-response (ER) relationship in the SAD study (doses up to 150 mg) was similar to the TQT study slope, and the estimated QT effect was comparable at high plasma levels. In the MAD study, doses up to 90 mg once daily for 7 days resulted in JNJ-54861911 peak plasma concentrations (Cmax ) comparable to those in the SAD study (∼750 ng/mL), but ER by HPQT failed to detect a QT effect and resulted in negative estimations. Adding a higher dose cohort (150 mg; Cmax , 1125 ng/mL) demonstrated a QT effect, with a slightly lower ER slope than the TQT study. JNJ-54861911 (up to 50 mg) did not cause QT prolongation at clinically relevant plasma concentrations in any studies. Provided sufficiently high plasma concentrations were captured, mild QT prolongation observed postdose with a supratherapeutic dose could be detected (TQT study) and estimated in SAD/MAD studies. Based on population pharmacokinetic modeling and simulation, 5 and 25 mg doses are currently considered for further phase 3 studies and are expected not to cause any relevant QT prolongation.
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Affiliation(s)
- Maarten Timmers
- Janssen Research & Development, a Division of Janssen Pharmaceutica N.V., Beerse, Belgium.,Reference Center for Biological Markers of Dementia (BIODEM), Institute Born-Bunge, University of Antwerp, Antwerp, Belgium
| | - Vikash Sinha
- Janssen Research & Development LLC, Titusville, NJ, USA
| | - Borje Darpo
- Karolinska Institute, Stockholm, Sweden.,iCardiac Technologies, Rochester, NY, USA
| | | | | | - Hongqi Xue
- iCardiac Technologies, Rochester, NY, USA
| | - Georg Ferber
- Statistik Georg Ferber GmbH, Riehen, Switzerland
| | - Johannes Streffer
- Janssen Research & Development, a Division of Janssen Pharmaceutica N.V., Beerse, Belgium.,Reference Center for Biological Markers of Dementia (BIODEM), Institute Born-Bunge, University of Antwerp, Antwerp, Belgium
| | - Alberto Russu
- Janssen Research & Development, a Division of Janssen Pharmaceutica N.V., Beerse, Belgium
| | - Luc Tritsmans
- Janssen Research & Development, a Division of Janssen Pharmaceutica N.V., Beerse, Belgium
| | | | | | - Luc Van Nueten
- Janssen Research & Development, a Division of Janssen Pharmaceutica N.V., Beerse, Belgium
| | - Giacomo Salvadore
- Janssen Research & Development, a Division of Janssen Pharmaceutica N.V., Beerse, Belgium
| | - Partha Nandy
- Janssen Research & Development, a Division of Janssen Pharmaceutica N.V., Beerse, Belgium
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29
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Ferber G, Sun Y, Darpo B, Garnett C, Liu J. Study Design Parameters Affecting Exposure Response Analysis of QT Data: Results From Simulation Studies. J Clin Pharmacol 2018; 58:674-685. [PMID: 29420838 DOI: 10.1002/jcph.1065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 11/20/2017] [Indexed: 11/05/2022]
Abstract
The operating characteristics of dose-escalating studies in terms of false-negative predictions of the QT effect and the power to exclude clinically relevant QT effects are not quantitatively established. One thousand single-ascending-dose (SAD) studies with 7 dose groups with 6/2 subjects on active drug/placebo were generated through simulation for each of 32 scenarios with (1) 8 different QT effects of the study drug and (2) achieved plasma concentration 2- or 4-fold above therapeutic levels. For each subject, drug-free QT data from a thorough QT study were subsampled to capture the circadian profile, on which a drug effect was added. The percentage of false-negative studies was between 4% and 9% when the drug's QT effect was set to 10 milliseconds. If a somewhat lower effect of 6.7 milliseconds was set at therapeutic concentrations, the fraction of negative studies was higher, 40% to 60% when the variability of the QT data was well controlled. When the QT effect was set to 5 milliseconds at therapeutic plasma concentrations, the power of SAD studies to exclude 10 milliseconds QT effect was generally above 70% (74% to 94%) with well-controlled QT variability, whereas the power was reduced to 36% to 69% if supratherapeutic plasma concentrations were not achieved. The rate of false-negative studies was acceptably low in placebo-controlled SAD studies. With a drug with no or a small QT effect, supratherapeutic plasma concentrations, and well-controlled variability of QT data, the power of SAD studies to exclude a relevant effect was above 70%.
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Affiliation(s)
- Georg Ferber
- Statistik Georg Ferber GmbH, Riehen, Switzerland
| | - Yaning Sun
- Division of Pharmacometrics, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Borje Darpo
- Karolinska Institutet, Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd's Hospital, Stockholm, Sweden.,iCardiac Technologies Inc., Rochester, NY, USA
| | - Christine Garnett
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Jiang Liu
- Division of Pharmacometrics, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
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30
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Faucette S, Wagh S, Trivedi A, Venkatakrishnan K, Gupta N. Reverse Translation of US Food and Drug Administration Reviews of Oncology New Molecular Entities Approved in 2011-2017: Lessons Learned for Anticancer Drug Development. Clin Transl Sci 2017; 11:123-146. [PMID: 29266809 PMCID: PMC5867000 DOI: 10.1111/cts.12527] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 11/06/2017] [Indexed: 12/29/2022] Open
Affiliation(s)
- Stephanie Faucette
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, Massachusetts, USA
| | - Santosh Wagh
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, Massachusetts, USA
| | - Ashit Trivedi
- Clinical Pharmacology, Amgen Inc., Thousand Oaks, California, USA
| | - Karthik Venkatakrishnan
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, Massachusetts, USA
| | - Neeraj Gupta
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, Massachusetts, USA
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