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Olkkola AM, Tapaninen T, Tornio A, Hauta-Aho M, Lapatto-Reiniluoto O, Neuvonen M, Kiiski JI, Neuvonen PJ, Niemi M, Backman JT. Posaconazole-ibrutinib interaction cannot be avoided by staggered dosing: How to optimize ibrutinib dose during posaconazole treatment. Br J Clin Pharmacol 2024; 90:557-567. [PMID: 37872104 DOI: 10.1111/bcp.15932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/25/2023] Open
Abstract
AIMS Ibrutinib is used in the treatment of certain B-cell malignancies. Due to its CYP3A4-mediated metabolism and highly variable pharmacokinetics, it is prone to potentially harmful drug-drug interactions. METHODS In a randomized, placebo-controlled, three-phase crossover study, we examined the effect of the CYP3A4-inhibiting antifungal posaconazole on ibrutinib pharmacokinetics. Eleven healthy participants ingested repeated doses of 300 mg of posaconazole either in the morning or in the evening, or placebo. A single dose of ibrutinib (30, 70 or 140 mg, respectively) was administered at 9 AM, 1 or 12 h after the preceding posaconazole/placebo dose. RESULTS On average, morning posaconazole increased the dose-adjusted geometric mean area under the plasma concentration-time curve from zero to infinity (AUC0-∞ ) and peak plasma concentration (Cmax ) of ibrutinib 9.5-fold (90% confidence interval [CI] 6.3-14.3, P < 0.001) and 8.5-fold (90% CI 5.7-12.8, P < 0.001), respectively, while evening posaconazole increased those 10.3-fold (90% CI 6.7-16.0, P < 0.001) and 8.2-fold (90% CI 5.2-13.2, P < 0.001), respectively. Posaconazole had no significant effect on the half-life of ibrutinib, but substantially reduced the metabolite PCI-45227 to ibrutinib AUC0-∞ ratio. There were no significant differences in ibrutinib pharmacokinetics between morning and evening posaconazole phases. CONCLUSIONS Posaconazole increases ibrutinib exposure substantially, by about 10-fold. This interaction cannot be avoided by dosing the drugs 12 h apart. In general, a 70-mg daily dose of ibrutinib should not be exceeded during posaconazole treatment to avoid potentially toxic systemic ibrutinib concentrations.
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Affiliation(s)
- Aleksi M Olkkola
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tuija Tapaninen
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
- Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland
| | - Aleksi Tornio
- Institute of Biomedicine, Faculty of Medicine, University of Turku, Turku, Finland
- Unit of Clinical Pharmacology, Turku University Hospital, Turku, Finland
| | - Milka Hauta-Aho
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Outi Lapatto-Reiniluoto
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Mikko Neuvonen
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Johanna I Kiiski
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Pertti J Neuvonen
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Mikko Niemi
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Janne T Backman
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
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Small BG, Hatley O, Jamei M, Gardner I, Johnson TN. Incorporation and Performance Verification of Hepatic Portal Blood Flow Shunting in Minimal and Full PBPK Models of Liver Cirrhosis. Clin Pharmacol Ther 2023; 114:1264-1273. [PMID: 37620290 DOI: 10.1002/cpt.3032] [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: 06/01/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023]
Abstract
Patho-physiological changes in liver cirrhosis create portacaval shunts that allow blood flow to bypass the hepatic portal vein into the systemic circulation affecting drug pharmacokinetics (PKs). The objectives of this work were to implement a physiologically-based pharmacokinetic (PBPK) framework describing shunted blood flows in virtual patients with differing degrees of liver cirrhosis; and to assess the minimal and full PBPK model's performance using drugs with intermediate to high hepatic extraction. Single dose concentration-time profiles and PK parameters for oral ibrutinib, midazolam, propranolol, and buspirone were simulated in healthy volunteers (HVs) and subjects with cirrhosis (Child-Pugh severity score (CP-A, CP-B, or CP-C)). Model performance was verified by comparing predicted to observed fold-changes in PK parameters between HVs and cirrhotic subjects. The verified model was used to simulate the PK changes for simvastatin in patients with cirrhosis. The predicted area under the curve ratios (AUCCirr :AUCHV ) for ibrutinib were 3.38, 6.87, and 11.46 using the minimal PBPK model with shunt and 1.61, 2.58, and 4.33 without the shunt, these compared with observed values of 4.33, 8.14, and 9.04, respectively. For ibrutinib, propranolol, and buspirone, including a shunt in the PBPK model improved the prediction of the AUCCirr :AUCHV and maximum plasma concentration ratios (CmaxCirr :CmaxHV ). For midazolam, an intermediate extraction drug, the differences were less clear. Simulated simvastatin dose adjustments in cirrhosis suggested that 20 mg in CP-A and 10 mg in CP-B could be used clinically. A mechanistic model-informed understanding of the anatomic and pathophysiology of cirrhosis will facilitate improved dose prediction and adjustment in this vulnerable population.
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Affiliation(s)
- Ben G Small
- Certara UK Limited (Simcyp Division), Sheffield, UK
| | | | - Masoud Jamei
- Certara UK Limited (Simcyp Division), Sheffield, UK
| | - Iain Gardner
- Certara UK Limited (Simcyp Division), Sheffield, UK
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El Zein S, Mendoza MA, Wilson JW. Nontuberculous mycobacterial infections in patients with hematologic malignancies and recipients of hematopoietic stem cell transplantation. Transpl Infect Dis 2023; 25 Suppl 1:e14127. [PMID: 37594211 DOI: 10.1111/tid.14127] [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: 05/09/2023] [Revised: 07/17/2023] [Accepted: 08/08/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND The incidence of mycobacterial infections in patients with hematologic malignancies and hematopoietic stem cell transplant (HSCT) recipients is increasing, contributing to significant mortality and morbidity. This review explores the epidemiology, risk factors, clinical presentation, diagnosis, and treatment of nontuberculous mycobacteria (NTM) in this population. METHODS A literature search was performed using PubMed with keywords and MeSH terms pertaining to the topics of nontuberculous mycobacteria, hematologic malignancies, hematopoietic stem cell transplant, cellular therapies, chimeric antigen therapies, epidemiology, diagnosis, and treatment. Additionally, we examined the reference lists of the included articles to identify other pertinent studies. RESULTS Diagnosing mycobacterial disease among patients with hematologic disease and treatment-associated immunosuppressive conditions is challenging due to the lack of distinctive clinical, radiographic, and laboratory markers, as well as the atypical manifestations compared to immunocompetent patients. Treatment involves using a combination of antibiotics for extended durations, coupled with strategies to achieve source control and reduce immunosuppression when feasible. This is complicated by the absence of clear data correlating in-vitro drug susceptibility and clinical outcome for many antimicrobials use to treat NTM, adverse drug-drug interactions, and the frequent challenges related to poor medication tolerability and toxicities. CONCLUSION The rising incidence and corresponding clinical challenges of mycobacterial infections in this unique patient population necessitate a heightened awareness and familiarity of NTM disease by clinicians to achieve timely diagnosis and favorable treatment outcomes.
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Affiliation(s)
- Said El Zein
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria A Mendoza
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - John W Wilson
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
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Gomez-Mantilla JD, Huang F, Peters SA. Can Mechanistic Static Models for Drug-Drug Interactions Support Regulatory Filing for Study Waivers and Label Recommendations? Clin Pharmacokinet 2023; 62:457-480. [PMID: 36752991 PMCID: PMC10042977 DOI: 10.1007/s40262-022-01204-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND AND OBJECTIVE Mechanistic static and dynamic physiologically based pharmacokinetic models are used in clinical drug development to assess the risk of drug-drug interactions (DDIs). Currently, the use of mechanistic static models is restricted to screening DDI risk for an investigational drug, while dynamic physiologically based pharmacokinetic models are used for quantitative predictions of DDIs to support regulatory filing. As physiologically based pharmacokinetic model development by sponsors as well as a review of models by regulators require considerable resources, we explored the possibility of using mechanistic static models to support regulatory filing, using representative cases of successful physiologically based pharmacokinetic submissions to the US Food and Drug Administration under different classes of applications. METHODS Drug-drug interaction predictions with mechanistic static models were done for representative cases in the different classes of applications using the same data and modelling workflow as described in the Food and Drug Administration clinical pharmacology reviews. We investigated the hypothesis that the use of unbound average steady-state concentrations of modulators as driver concentrations in the mechanistic static models should lead to the same conclusions as those from physiologically based pharmacokinetic modelling for non-dynamic measures of DDI risk assessment such as the area under the plasma concentration-time curve ratio, provided the same input data are employed for the interacting drugs. RESULTS Drug-drug interaction predictions of area under the plasma concentration-time curve ratios using mechanistic static models were mostly comparable to those reported in the Food and Drug Administration reviews using physiologically based pharmacokinetic models for all representative cases in the different classes of applications. CONCLUSIONS The results reported in this study should encourage the use of models that best fit an intended purpose, limiting the use of physiologically based pharmacokinetic models to those applications that leverage its unique strengths, such as what-if scenario testing to understand the effect of dose staggering, evaluating the role of uptake and efflux transporters, extrapolating DDI effects from studied to unstudied populations, or assessing the impact of DDIs on the exposure of a victim drug with concurrent mechanisms. With this first step, we hope to trigger a scientific discussion on the value of a routine comparison of the two methods for regulatory submissions to potentially create a best practice that could help identify examples where the use of dynamic changes in modulator concentrations could make a difference to DDI risk assessment.
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Affiliation(s)
- Jose David Gomez-Mantilla
- Boehringer Ingelheim Pharma GmbH & Co. KG, TMCP Therapeutic Areas, Binger Str. 173, 55218, Ingelheim am Rhein, Germany
| | | | - Sheila Annie Peters
- Boehringer Ingelheim Pharma GmbH & Co. KG, TMCP Therapeutic Areas, Binger Str. 173, 55218, Ingelheim am Rhein, Germany.
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Tariq B, Ou YC, Stern JC, Mundra V, Wong Doo N, Walker P, Lewis KL, Lin C, Novotny W, Sahasranaman S, Opat S. A phase 1, open-label, randomized drug-drug interaction study of zanubrutinib with moderate or strong CYP3A inhibitors in patients with B-cell malignancies. Leuk Lymphoma 2023; 64:329-338. [PMID: 36480811 DOI: 10.1080/10428194.2022.2150820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BTK inhibitor exposure increases significantly when coadministered with CYP3A inhibitors, which may lead to dose-related toxicities. This study explored the pharmacokinetics, efficacy, and safety of zanubrutinib when coadministered with moderate or strong CYP3A inhibitors in 26 patients with relapsed or refractory B-cell malignancies. Coadministration of zanubrutinib (80 mg BID) with moderate CYP3A inhibitors fluconazole and diltiazem or zanubrutinib (80 mg QD) with strong CYP3A inhibitor voriconazole resulted in comparable exposures to zanubrutinib (320 mg QD) with AUC0-24h geometric least squares mean ratios approaching 1 (0.94, 0.81, and 0.83, for fluconazole, diltiazem, and voriconazole, respectively). The most common treatment-emergent adverse events were contusion (26.9%), back pain (19.2%), constipation and neutropenia (15.4% each), and rash, diarrhea, and fall (11.5% each). This study supports current United States Prescribing Information dose recommendations for the coadministration of reduced-dose zanubrutinib with moderate or strong CYP3A inhibitors and confirms the favorable efficacy and safety profile of zanubrutinib.
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Affiliation(s)
- Bilal Tariq
- Clinical Pharmacology, BeiGene USA, Inc, Fulton, MD, USA
| | - Ying C Ou
- Clinical Pharmacology, BeiGene USA, Inc, San Mateo, CA, USA
| | | | - Vaibhav Mundra
- Clinical Pharmacology, BeiGene USA, Inc, San Mateo, CA, USA
| | - Nicole Wong Doo
- Department of Hematology, Concord Repatriation General Hospital, Concord, Australia.,Concord Clinical School, University of Sydney, Sydney, Australia
| | - Patricia Walker
- Department of Hematology, Peninsula Health and Peninsula Private Hospitals, Frankston, Australia
| | - Katharine L Lewis
- Department of Haematology, Sir Charles Gairdner Hospital and Linear Clinical Research, Nedlands, Australia
| | - Chester Lin
- Biostatistics, BeiGene, Ltd, Emeryville, CA, USA
| | - William Novotny
- Clinical Development, Hematology, BeiGene USA, Inc, San Mateo, CA, USA
| | | | - Stephen Opat
- Clinical Hematology, Monash Health and Monash University, Clayton, Australia
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Le Louedec F, Puisset F, Chatelut E, Tod M. Considering the Oral Bioavailability of Protein Kinase Inhibitors: Essential in Assessing the Extent of Drug-Drug Interaction and Improving Clinical Practice. Clin Pharmacokinet 2023; 62:55-66. [PMID: 36631685 DOI: 10.1007/s40262-022-01200-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2022] [Indexed: 01/13/2023]
Abstract
Protein kinase inhibitors share pharmacokinetic (PK) pathways among themselves. They are all metabolized by several cytochromes P450 (CYP). For most of them, CYP3A4 is the predominant metabolic pathway. However, their oral bioavailability differs. For example, the oral bioavailability of imatinib has been estimated at nearly 100%, but that of ibrutinib averages 3% due to its high hepatic first-pass effect. Overall, the smaller the oral bioavailability, the larger its interindividual PK variability. Indeed, for drugs with low oral bioavailability, the extent of their absorption is an additional cause (along with elimination variability) of differences in drug exposure among patients. The impact of drug-drug interaction (DDI) also differs between drugs with low or high oral bioavailability. We describe and explain why the impact of CYP3A4 inhibitors and inducers is much greater for protein kinase inhibitors with low oral bioavailability. The effect of food on protein kinase inhibitors and DDIs corresponding to plasma protein binding will also be considered. Finally, the benefits of these concepts in clinical practice (including therapeutic drug monitoring) will be discussed. Overall, our main objective was to apply fundamental PK concepts to understanding the main clinical issues of these oral anticancer drugs.
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Affiliation(s)
- Félicien Le Louedec
- Institut Claudius-Regaud, Institut Universitaire du Cancer Toulouse, Oncopole, 31059, Toulouse, France
- CRCT, Cancer Research Center of Toulouse, Inserm U1037, Université Paul Sabatier, Toulouse, France
| | - Florent Puisset
- Institut Claudius-Regaud, Institut Universitaire du Cancer Toulouse, Oncopole, 31059, Toulouse, France
- CRCT, Cancer Research Center of Toulouse, Inserm U1037, Université Paul Sabatier, Toulouse, France
| | - Etienne Chatelut
- Institut Claudius-Regaud, Institut Universitaire du Cancer Toulouse, Oncopole, 31059, Toulouse, France.
- CRCT, Cancer Research Center of Toulouse, Inserm U1037, Université Paul Sabatier, Toulouse, France.
| | - Michel Tod
- Hospices Civils de Lyon, GH Nord, Service de Pharmacie, 69004, Lyon, France
- Université Claude Bernard Lyon 1, UMR CNRS 5558, LBBE-Laboratoire de Biométrie et Biologie Évolutive, 69622, Villeurbanne, France
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Lemaitre F, Grégoire M, Monchaud C, Bouchet S, Saint-Salvi B, Polard E. Management of drug-drug interactions with nirmatrelvir/ritonavir in patients treated for Covid-19: Guidelines from the French Society of Pharmacology and Therapeutics (SFPT). Therapie 2022; 77:509-521. [PMID: 35618549 PMCID: PMC9020499 DOI: 10.1016/j.therap.2022.03.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 01/14/2023]
Abstract
Objectives Nirmatrelvir in association with ritonavir (PAXLOVID™, Pfizer) is an antiviral agent targeting the 3-chymotrypsin–like cysteine protease enzyme (3C-like protease or Mpro) which is a key enzyme of the viral cycle of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This combination with a well-known pharmacokinetic enhancer leads to a high risk for drug-drug interactions in a polymedicated elected population for treatment. The aim of this work was to provide recommendations on behalf of the national French society of pharmacology (French Society of Pharmacology and Therapeutics; SFPT), by suggesting optimal and pragmatic therapeutic strategies if nirmatrelvir/ritonavir is to be given together with drugs commonly used, in order to ensure secured physicians’ prescription. Methods Six clinical pharmacologists search the scientific literature to provide a first draft of recommendations. Thereafter, twelve other clinical pharmacologists verified the recommendations and proposed modifications. The final draft was then validated by all 18 participants. Results Five distinct recommendations were issued: i) contra-indications, ii) “PAXLOVID™ not recommended with the comedication”, iii) “PAXLOVID™ possible whether the comedication is discontinued”, iv) “PAXLOVID™ possible only after an expert advice” and v) “PAXLOVID™ possible without modification of the associated treatment”. The final document comprises recommendations for 171 drugs/therapeutic classes aiming to secure prescription. In complex situations, clinicians are advised to contact their pharmacology department to obtain specific recommendations on the management of drug-drug interactions with nirmatrelvir/ritonavir. Conclusion These recommendations intend to be a help for clinicians willing to prescribe nirmatrelvir/ritonavir and to prevent drug-drug interactions leading to adverse drug reactions or loss of efficacy. They constitute a guideline for primary care situations. Of course, some complex situations may require expert advices and here, again, clinical pharmacologists are at the forefront in providing therapeutic advice.
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Affiliation(s)
- Florian Lemaitre
- Université de Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France; Inserm, centre d'investigation clinique, CIC 1414, 35000 Rennes, France.
| | - Matthieu Grégoire
- Clinical pharmacology department, Nantes university hospital, 44000 Nantes, France; UMR Inserm 1235, The Enteric Nervous System in Gut and Brain Disorders, University of Nantes, 44000 Nantes, France
| | - Caroline Monchaud
- Department of pharmacology, toxicology and centre of pharmacovigilance, CHU de Limoges, 87000 Limoges, France; UMR-1248, Inserm, 87000 Limoges, France
| | - Stéphane Bouchet
- Laboratoire de pharmacologie et toxicologie, service de pharmacologie médicale, CHU Pellegrin, Inserm U1219, 33000 Bordeaux, France
| | - Béatrice Saint-Salvi
- Medical interactions unit, Agence nationale de sécurité du médicaments et des produits de santé, 93200 Saint-Denis, France
| | - Elisabeth Polard
- Université de Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France; Inserm, centre d'investigation clinique, CIC 1414, 35000 Rennes, France
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Determining drug dose in the era of targeted therapies: playing it (un)safe? Blood Cancer J 2022; 12:123. [PMID: 35999205 PMCID: PMC9399108 DOI: 10.1038/s41408-022-00720-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/15/2022] [Accepted: 08/11/2022] [Indexed: 11/26/2022] Open
Abstract
Targeted therapies against phosphatidylinositol 3-kinase (PI3K), Bruton’s tyrosine kinase (BTK), and B-cell lymphoma-2 (BCL-2) are approved for chronic lymphocytic leukemia (CLL). Since approval of the first-in-class drugs, next-generation agents have become available and are continuously under development. While these therapies act on well-characterized molecular targets, this knowledge is only to some extent taken into consideration when determining their dose in phase I trials. For example, BTK occupancy has been assessed in dose-finding studies of various BTK inhibitors, but the minimum doses that result in full BTK occupancy were not determined. Although targeted agents have a different dose–response relationship than cytotoxic agents, which are more effective near the maximum tolerated dose, the traditional 3 + 3 toxicity-driven trial design remains heavily used in the era of targeted therapies. If pharmacodynamic biomarkers were more stringently used to guide dose selection, the recommended phase II dose would likely be lower as compared to the toxicity-driven selection. Reduced drug doses may lower toxicity, which in some cases is severe for these agents, and are supported by retrospective studies demonstrating non-inferior outcomes for patients with clinically indicated dose reductions. Here, we review strategies that were used for dose selection in phase I studies of currently approved and select investigational targeted therapies in CLL, and discuss how our initial clinical experience with targeted therapies have pointed to dose reductions, intermittent dosing, and drug combinations as strategies to overcome treatment intolerance and resistance.
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Cytochrome P450 3A2 and PGP-MDR1-Mediated Pharmacokinetic Interaction of Sinapic Acid with Ibrutinib in Rats: Potential Food/Herb–Drug Interaction. Processes (Basel) 2022. [DOI: 10.3390/pr10061066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
Ibrutinib (IBR) metabolism (primarily by CYP3A enzyme) is the main route of excretion for IBR, which could lead to drug–drug/herb–drug interactions with herbal medicines, nutritional supplements, and other foods. Sinapic acid (SA) is a bioactive phytonutrient that is used as a dietary supplement to treat a variety of illnesses. Pharmacokinetic interactions may occur when IBR interacts with SA, which influences the pharmacokinetic processes such as absorption, distribution, metabolism, and excretion. Therefore, it is obligatory to investigate the safety apprehensions of such parallel usage and to evaluate the possible impact of SA on the pharmacokinetics of IBR and propose a possible interaction mechanism in an animal model. The IBR concentration in plasma samples was determined using a validated UHPLC-MS/MS method after administration of a single oral dosage of IBR (50 mg/kg) in rats with or without SA pretreatment (40 mg/kg p.o. each day for 7 days, n = 6). The co-administration of IBR with SA displayed significant increases in Cmax ~18.77%, AUC0–T ~28.07%, MRT ~16.87%, and Kel ~24.76%, and a significant decrease in the volume of distribution Vz/F_obs ~37.66%, the rate of clearance (Cl/F) ~21.81%, and T½ ~20.43%, respectively, were observed as compared to rats that were administered IBR alone, which may result in increased bioavailability of IBR. The metabolism of IBR in the liver and intestines is significantly inhibited when SA is given, which may lead to an increase in the absorption rate of IBR. These findings need to be investigated further before they can be used in clinical practice.
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Weis TM, Gutierrez J, Kabel CC, King AC, Daley RJ, Stump SE. Real-world management of targeted therapies in chronic lymphocytic leukemia. J Oncol Pharm Pract 2022; 28:1411-1433. [PMID: 35350909 DOI: 10.1177/10781552221090869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The advent of novel targeted therapies, including B-cell receptor (BCR) pathway and B-cell lymphoma 2 (BCL2) inhibitors, has substantially changed the treatment paradigm for chronic lymphocytic leukemia (CLL). Although targeted therapies have improved outcomes compared to traditional chemoimmunotherapy in the front-line and relapsed or refractory settings, they are associated with resistance mutations and suboptimal outcomes in certain high-risk patients. Additionally, targeted therapies are associated with drug interactions and unique adverse effect profiles which can be challenging for patients and clinicians to manage. Ongoing studies continue to address questions regarding optimal sequencing of therapies, the role of treatment combinations, and the efficacy of next-generation novel agents. This review provides a comprehensive overview regarding the clinical management of targeted therapies for CLL and applies current literature to clinical practice.
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Affiliation(s)
- Taylor M Weis
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Jillian Gutierrez
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Charlene C Kabel
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Amber C King
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Ryan J Daley
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Sarah E Stump
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
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Eisenmann ED, Talebi Z, Sparreboom A, Baker SD. Boosting the oral bioavailability of anticancer drugs through intentional drug-drug interactions. Basic Clin Pharmacol Toxicol 2022; 130 Suppl 1:23-35. [PMID: 34117715 PMCID: PMC8665934 DOI: 10.1111/bcpt.13623] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/23/2021] [Accepted: 06/07/2021] [Indexed: 11/28/2022]
Abstract
Oral anticancer drugs suffer from significant variability in pharmacokinetics and pharmacodynamics partially due to limited bioavailability. The limited bioavailability of anticancer drugs is due to both pharmaceutical limitations and physiological barriers. Pharmacokinetic boosting is a strategy to enhance the oral bioavailability of a therapeutic drug by inhibiting physiological barriers through an intentional drug-drug interaction (DDI). This type of strategy has proven effective across several therapeutic indications including anticancer treatment. Pharmacokinetic boosting could improve anticancer drugs lacking or with otherwise unacceptable oral formulations through logistic, economic, pharmacodynamic and pharmacokinetic benefits. Despite these benefits, pharmacokinetic boosting strategies could result in unintended DDIs and are only likely to benefit a limited number of targets. Highlighting this concern, pharmacokinetic boosting has mixed results depending on the boosted drug. While pharmacokinetic boosting did not significantly improve certain drugs, it has resulted in the commercial approval of boosted oral formulations for other drugs. Pharmacokinetic boosting to improve oral anticancer therapy is an expanding area of research that is likely to improve treatment options for cancer patients.
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Affiliation(s)
- Eric D. Eisenmann
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH, USA
| | - Zahra Talebi
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH, USA
| | - Alex Sparreboom
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH, USA
| | - Sharyn D. Baker
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH, USA
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Zhang H, Ou YC, Su D, Wang F, Wang L, Sahasranaman S, Tang Z. In vitro investigations into the roles of CYP450 enzymes and drug transporters in the drug interactions of zanubrutinib, a covalent Bruton's tyrosine kinase inhibitor. Pharmacol Res Perspect 2021; 9:e00870. [PMID: 34664792 PMCID: PMC8524670 DOI: 10.1002/prp2.870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/25/2021] [Indexed: 11/27/2022] Open
Abstract
Zanubrutinib is a highly selective, potent, orally available, targeted covalent inhibitor (TCI) of Bruton's tyrosine kinase (BTK). This work investigated the in vitro drug metabolism and transport of zanubrutinib, and its potential for clinical drug-drug interactions (DDIs). Phenotyping studies indicated cytochrome P450 (CYP) 3A are the major CYP isoform responsible for zanubrutinib metabolism, which was confirmed by a clinical DDI study with itraconazole and rifampin. Zanubrutinib showed mild reversible inhibition with half maximal inhibitory concentration (IC50 ) of 4.03, 5.69, and 7.80 μM for CYP2C8, CYP2C9, and CYP2C19, respectively. Data in human hepatocytes disclosed induction potential for CYP3A4, CYP2B6, and CYP2C enzymes. Transport assays demonstrated that zanubrutinib is not a substrate of human breast cancer resistance protein (BCRP), organic anion transporting polypeptide (OATP)1B1/1B3, organic cation transporter (OCT)2, or organic anion transporter (OAT)1/3 but is a potential substrate of the efflux transporter P-glycoprotein (P-gp). Additionally, zanubrutinib is neither an inhibitor of P-gp at concentrations up to 10.0 μM nor an inhibitor of BCRP, OATP1B1, OATP1B3, OAT1, and OAT3 at concentrations up to 5.0 μM. The in vitro results with CYPs and transporters were correlated with the available clinical DDIs using basic models and mechanistic static models. Zanubrutinib is not likely to be involved in transporter-mediated DDIs. CYP3A inhibitors and inducers may impact systemic exposure of zanubrutinib. Dose adjustments may be warranted depending on the potency of CYP3A modulators.
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Affiliation(s)
| | | | - Dan Su
- BeiGene (Beijing) Co., LtdBeijingChina
| | - Fan Wang
- BeiGene (Beijing) Co., LtdBeijingChina
| | - Lai Wang
- BeiGene (Beijing) Co., LtdBeijingChina
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13
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Eisenmann ED, Fu Q, Muhowski EM, Jin Y, Uddin ME, Garrison DA, Weber RH, Woyach JA, Byrd JC, Sparreboom A, Baker SD. Intentional Modulation of Ibrutinib Pharmacokinetics through CYP3A Inhibition. CANCER RESEARCH COMMUNICATIONS 2021; 1:79-89. [PMID: 34950932 PMCID: PMC8691714 DOI: 10.1158/2767-9764.crc-21-0076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Ibrutinib (Imbruvica; PCI-32765) is an orally administered inhibitor of Bruton's tyrosine kinase that has transformed the treatment of B-cell malignancies. However, ibrutinib has very low oral bioavailability that contributes to significant variability in systemic exposure between patients, and this has the potential to affect both efficacy and toxicity. We hypothesized that the oral bioavailability of ibrutinib is limited by CYP3A isoform-mediated metabolism, and that this pathway can be inhibited to improve the pharmacokinetic properties of ibrutinib. Pharmacokinetic studies were performed in wild-type mice and mice genetically engineered to lack all CYP3A isoforms [CYP3A(-/-)] that received ibrutinib alone or in combination with CYP3A inhibitors cobicistat or ketoconazole. Computational modeling was performed to derive doses of ibrutinib that, when given after a CYP3A inhibitor, results in therapeutically-relevant drug levels. Deficiency of CYP3A in mice was associated with a ~10-fold increase in the area under the curve of ibrutinib. This result could be phenocopied by administration of cobicistat before ibrutinib in wild-type mice, but cobicistat did not influence levels of ibrutinib in CYP3A(-/-) mice. Population pharmacokinetic and prospectively validated physiologically-based pharmacokinetic models established preclinical and clinical doses of ibrutinib that could be given safely in combination with cobicistat without negatively affecting anti-leukemic properties. These findings signify a dominant role for CYP3A-mediated metabolism in the elimination of ibrutinib, and suggest a role for pharmacological inhibitors of this pathway to intentionally modulate the plasma levels and improve the therapeutic use of this clinically important agent.
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Affiliation(s)
- Eric D. Eisenmann
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Qiang Fu
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Elizabeth M. Muhowski
- Division of Hematology, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Yan Jin
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Muhammad Erfan Uddin
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Dominique A. Garrison
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Robert H. Weber
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Jennifer A. Woyach
- Division of Hematology, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
| | - John C. Byrd
- Division of Hematology, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Alex Sparreboom
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Sharyn D. Baker
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio.,Corresponding Author: Sharyn D. Baker, Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, 500 W. 12th Avenue, Columbus, OH 43210. E-mail:
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14
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Tang CPS, Lip GYH, McCormack T, Lyon AR, Hillmen P, Iyengar S, Martinez-Calle N, Parry-Jones N, Patten PEM, Schuh A, Walewska R. Management of cardiovascular complications of bruton tyrosine kinase inhibitors. Br J Haematol 2021; 196:70-78. [PMID: 34498258 DOI: 10.1111/bjh.17788] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/04/2021] [Accepted: 08/07/2021] [Indexed: 12/01/2022]
Affiliation(s)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | | | | | | | | | | | - Anna Schuh
- Oxford University Hospitals NHS Trust, Oxford, UK
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15
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Tam CS, Ou YC, Trotman J, Opat S. Clinical pharmacology and PK/PD translation of the second-generation Bruton's tyrosine kinase inhibitor, zanubrutinib. Expert Rev Clin Pharmacol 2021; 14:1329-1344. [PMID: 34491123 DOI: 10.1080/17512433.2021.1978288] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Introduction: Bruton's tyrosine kinase (BTK) inhibitors have revolutionized the treatment of B-cell lymphomas. Zanubrutinib was designed to achieve improved therapeutic concentrations and minimize off-target activities putatively accounting, in part, for the adverse effects seen with other BTK inhibitors.Areas covered: This drug profile covers zanubrutinib clinical pharmacology and the translation of pharmacokinetics (PK) and pharmacodynamics (PD) to clinical efficacy and safety profiles, by highlighting key differences between zanubrutinib and other BTK inhibitors. We discuss PK, sustained BTK occupancy, and potential factors affecting PK of zanubrutinib, including food effects, hepatic impairment, and drug-drug interactions. These data, along with exposure-response analyses, were used to support the recommended dose of 320 mg, either once daily or as 160 mg twice daily. Translation of PK/PD attributes into clinical effects was demonstrated in a randomized, phase 3 head-to-head study comparing it with ibrutinib in patients with Waldenström macroglobulinemia.Expert opinion: Among the approved BTK inhibitors, zanubrutinib is less prone to PK modulation by intrinsic and extrinsic factors, leading to more consistent, sustained therapeutic exposures and improved dosing convenience. Zanubrutinib PK/PD has translated into durable responses and improved safety, representing an important new treatment option for patients who benefit from BTK therapy.
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Affiliation(s)
- Constantine S Tam
- Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Department of Haematology, St Vincent's Hospital, Fitzroy, VIC, Australia.,Department of Haematology, University of Melbourne, Parkville, VIC, Australia.,Department of Haematology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Ying C Ou
- Sr. Director, Clinical Pharmacology, BeiGene USA Inc., San Mateo, CA, USA
| | - Judith Trotman
- Department of Haematology, Concord Repatriation Hospital, Concord, NSW, Australia.,Department of Haematology, The University of Sydney, Concord, NSW, Australia
| | - Stephen Opat
- Director, Clinical Haematology, Monash Health, Clayton, VIC, Australia.,Director, Clinical Haematology, Monash University, Clayton, VIC, Australia
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16
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Migkou M, Fotiou D, Gavriatopoulou M, Dimopoulos MA. Ibrutinib plus rituximab for the treatment of adult patients with Waldenström's macroglobulinemia: a safety evaluation. Expert Opin Drug Saf 2021; 20:987-995. [PMID: 34137347 DOI: 10.1080/14740338.2021.1945031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Introduction: Waldenström's macroglobulinemia (WM), an orphan disease, is a rare low-grade B-cell lymphoplasmacytic lymphoma with unique clinical features and monoclonal IgM production. Rituximab remains to this date the backbone of most commonly used treatment combinations. The FDA/EMA approval of Ibrutinib, the first-in-class BTK inhibitor, either as monotherapy or in combination with rituximab, changed the treatment landscape of the disease.Areas covered: Clinical trial data that demonstrate mode of action, efficacy, and the safety profile of each agent will be covered. A safety analysis of the combination treatment will also be performed to point out its high efficacy and overall favorable toxicity profile. The disadvantages and treatment gaps that still exist in the treatment of WM which relate to the need for long-term ibrutinib administration and the lack of deep remissions and subsequent disease relapse, will also be reviewed.Expert opinion: The ibrutinib-rituximab combination is both effective and safe, in the newly-diagnosed and relapsed-refractory disease setting. The optimal therapeutic approach for WM patients remains however to be established. The question of which combinatory (or synergistic) regimen can allow for a fixed-treatment duration, deep and durable responses with a safe toxicity profile is being addressed in ongoing clinical trials.
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Affiliation(s)
- Magdalini Migkou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Despina Fotiou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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17
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Model-based comparative analysis of rifampicin and rifabutin drug-drug interaction profile. Antimicrob Agents Chemother 2021; 65:e0104321. [PMID: 34228545 DOI: 10.1128/aac.01043-21] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rifamycins are widely used for treating mycobacterial and staphylococcal infections. Drug-drug interactions (DDI) caused by rifampicin (RIF) is a major issue. We used a model-based approach to predict the magnitude of DDI with RIF and rifabutin (RBT) for 217 cytochrome P450 (CYP) substrates. On average, DDI caused by low-dose RIF were twice more potent than those caused by RBT. Contrary to RIF, RBT appears unlikely to cause severe DDI, even with sensitive CYP substrates.
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18
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Zanubrutinib (BGB-3111) plus obinutuzumab in patients with chronic lymphocytic leukemia and follicular lymphoma. Blood Adv 2021; 4:4802-4811. [PMID: 33022066 DOI: 10.1182/bloodadvances.2020002183] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/07/2020] [Indexed: 12/14/2022] Open
Abstract
Zanubrutinib (BGB-3111) is a next-generation Bruton tyrosine kinase inhibitor designed to be more selective with fewer off-target effects. We conducted a phase 1 study to assess the safety of its combination with obinutuzumab and evaluate early efficacy in 81 patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) or relapsed/refractory (R/R) follicular lymphoma (FL). In this phase 1b study, zanubrutinib was tolerable at 160 mg twice daily or 320 mg once daily combined with IV obinutuzumab in patients with CLL/SLL (n = 45) and FL (n = 36). Common adverse events (AEs) included upper respiratory tract infection (51%; n = 23), neutropenia (44%; n = 20), contusion (33%; n = 15), cough, diarrhea, or fatigue (27%; n = 12 each), and pyrexia (22%; n = 10) in CLL/SLL patients and upper respiratory tract infection (39%; n = 14), contusion (28%; n = 10), fatigue (25%; n = 9), and cough (22%; n = 8) in FL patients. Neutropenia was the most common grade 3/4 AE (CLL/SLL, 31% [n = 14]; FL, 14% [n = 5]). Five patients required temporary dose reductions, and 5 discontinued the study drug because of AEs. Overall response rate (ORR) was 100% (n = 20) in treatment-naïve CLL patients and 92% (n = 23) in R/R CLL patients. ORR in 36 R/R FL patients was 72% (n = 26), with 14 complete and 12 partial responses. Median follow-up was 29 months (range, 8-37) for CLL patients and 20 months (range, 2-37) for FL patients. Zanubrutinib and obinutuzumab combination therapy was generally well tolerated. This trial was registered at www.clinicaltrials.gov as #NCT02569476.
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19
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Tank M, Franz K, Cereda E, Norman K. Dietary supplement use in ambulatory cancer patients: a survey on prevalence, motivation and attitudes. J Cancer Res Clin Oncol 2021; 147:1917-1925. [PMID: 33825025 PMCID: PMC8164602 DOI: 10.1007/s00432-021-03594-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/10/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE Patients with cancer often believe dietary supplements (DS) such as micronutrients and botanical products to be health supporting and non-toxic despite growing concerns regarding potential pharmacological interactions. Studies on the prevalence of DS use among patients with cancer are heterogeneous and mainly conducted at university-based cancer centers. This survey focused on a particular cancer patient group treated in an ambulatory setting without regular access to professional nutritional counselling. METHODS Patients with a history of cancer or hematological malignancy were included in this survey. A self-reported questionnaire was used to evaluate the different aspects of DS use, changes in dietary habits and patients' demographic characteristics. RESULTS Almost every second patient reported using DS (47.2%). Women (56.3%), patients with an academic degree (56.0%) and non-smokers (84.8%) were more inclined to use DS. Along with magnesium (16.6%), calcium (14.3%), multivitamins (12.0%) and vitamin C (9.4%), use of herbal supplements (12.6%) was common. Women (84.8% vs. 74.9% of men, p = < 0.001) and patients younger than 65 years (84.4% vs. 77.2% of patients > 65 y, p = 0.002) sought dietary advice more often. Support of the immune system was the main reason for DS use (26.4%) and a relevant number of patients (49.6%) reported to have changed their dietary habits following cancer diagnosis. CONCLUSION DS use is common among patients with cancer treated in an ambulatory setting. This finding should encourage oncologists to implement detailed questioning about DS use and dietary habits to prevent potential interactions and offer substantial advice.
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Affiliation(s)
- Maja Tank
- Medizinisches Versorgungszentrum Tempelhof Oncology, Berlin, Germany.,Department of Geriatrics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Reinickendorfer Str. 61, 13347, Berlin, Germany
| | - Kristina Franz
- Department of Geriatrics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Reinickendorfer Str. 61, 13347, Berlin, Germany.,Institute of Nutritional Science, University of Potsdam, Potsdam, Germany
| | - Emanuele Cereda
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Kristina Norman
- Department of Geriatrics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Reinickendorfer Str. 61, 13347, Berlin, Germany. .,Institute of Nutritional Science, University of Potsdam, Potsdam, Germany. .,Department of Nutrition and Gerontology, German Institute of Human Nutrition Potsdam-Rehbrücke, Nuthetal, Germany.
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20
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Pilla Reddy V, Jo H, Neuhoff S. Food constituent- and herb-drug interactions in oncology: Influence of quantitative modelling on Drug labelling. Br J Clin Pharmacol 2021; 87:3988-4000. [PMID: 33733472 DOI: 10.1111/bcp.14822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/22/2021] [Accepted: 03/05/2021] [Indexed: 12/13/2022] Open
Abstract
AIMS Herbal products, spices and/or fruits are perceived as inherently healthy; for instance, St. John's wort (SJW) is marketed as a natural antidepressant and patients often self-administer it concomitantly with oncology medications. However, food constituents/herbs can interfere with drug pharmacokinetics, with risk of altering pharmacodynamics and efficacy. The objective of this work was to develop a strategy to prioritize herb- or food constituent-drug interactions (FC-DIs) to better assess oncology drug clinical risk. METHODS Physiologically based pharmacokinetic (PBPK) models were developed by integrating in vitro parameters with the clinical pharmacokinetics of food constituents in grapefruit juice (bergamottin), turmeric (curcumin) or SJW (hyperforin). Perpetrator files were linked to verified victim PBPK models through appropriate interaction mechanisms (cytochrome P450 3A, breast cancer resistance protein, P-glycoprotein) and applied in prospective PBPK simulations to inform the likelihood and magnitude of changes in exposure to osimertinib, olaparib or acalabrutinib. RESULTS Reported FC-DIs with oncology drugs were well recovered, with absolute average fold error values of 1.10 (bergamottin), 1.05 (curcumin) and 1.01 (hyperforin). Prospective simulations with grapefruit juice and turmeric showed clinically minor to insignificant changes in exposure (<1.50-fold) to acalabrutinib, osimertinib and olaparib, but predicted 1.57-fold FC-DI risk between acalabrutinib and curcumin. Moderate DDI risk was expected when acalabrutinib, osimertinib or olaparib were dosed with SJW. CONCLUSIONS A model-informed decision tree based on mechanistic understanding of transporter and/or enzyme-mediated FC-DI is proposed based on bergamottin, curcumin and hyperforin FC-DI clinical data. Adopting this quantitative modelling approach should streamline herbal product safety assessments, assist in FC-DI management, and ultimately promote safe clinical use of oncology drugs.
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Affiliation(s)
- Venkatesh Pilla Reddy
- Modelling and Simulation, Early Oncology, Oncology R&D, AstraZeneca, Cambridge, UK.,Clinical Pharmacology and Quantitative Pharmacology, Biopharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Heeseung Jo
- Modelling and Simulation, Early Oncology, Oncology R&D, AstraZeneca, Cambridge, UK.,Certara UK Ltd, Simcyp Division, Sheffield, UK
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21
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Sarosiek S, Treon SP, Castillo JJ. Reducing treatment toxicity in Waldenström macroglobulinemia. Expert Opin Drug Saf 2021; 20:669-676. [PMID: 33645373 DOI: 10.1080/14740338.2021.1897565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Waldenström macroglobulinemia (WM) is a rare subtype of non-Hodgkin lymphoma characterized by the presence of IgM-secreting clonal lymphocytes, plasma cells, and lymphoplasmacytic cells. Many well-established treatment options are available for patients with WM. However, a unique array of side effects may occur in patients during therapy related to the underlying disease, as well as the chosen treatment regimen.Areas covered: This review summarizes the most common adverse effects that occur during treatment of WM, as well as potential strategies to decrease the risk of toxicity.Expert opinion: There are multiple highly effective treatment options for patients with WM. All these treatment options, however, can be associated with a variety of adverse events. For example, chemotherapy has been associated with the development of myeloid neoplasms, anti-CD20 monoclonal antibodies with paradoxical IgM flares and infusion reactions, proteasome inhibitors with neuropathy, and BTK inhibitors with bleeding and cardiac arrhythmias. Dose reductions, lower number of cycles and changes in route of administration are some of the tools a clinician has available for managing and minimizing toxicity. Future research will focus on improving patient safety without sacrificing the efficacy of treatment.
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Affiliation(s)
- Shayna Sarosiek
- Harvard Medical School, Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Steven P Treon
- Harvard Medical School, Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jorge J Castillo
- Harvard Medical School, Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA
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22
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von Hundelshausen P, Siess W. Bleeding by Bruton Tyrosine Kinase-Inhibitors: Dependency on Drug Type and Disease. Cancers (Basel) 2021; 13:1103. [PMID: 33806595 PMCID: PMC7961939 DOI: 10.3390/cancers13051103] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 12/13/2022] Open
Abstract
Bruton tyrosine kinase (Btk) is expressed in B-lymphocytes, myeloid cells and platelets, and Btk-inhibitors (BTKi) are used to treat patients with B-cell malignancies, developed against autoimmune diseases, have been proposed as novel antithrombotic drugs, and been tested in patients with severe COVID-19. However, mild bleeding is frequent in patients with B-cell malignancies treated with the irreversible BTKi ibrutinib and the recently approved 2nd generation BTKi acalabrutinib, zanubrutinib and tirabrutinib, and also in volunteers receiving in a phase-1 study the novel irreversible BTKi BI-705564. In contrast, no bleeding has been reported in clinical trials of other BTKi. These include the brain-penetrant irreversible tolebrutinib and evobrutinib (against multiple sclerosis), the irreversible branebrutinib, the reversible BMS-986142 and fenebrutinib (targeting rheumatoid arthritis and lupus erythematodes), and the reversible covalent rilzabrutinib (against pemphigus and immune thrombocytopenia). Remibrutinib, a novel highly selective covalent BTKi, is currently in clinical studies of autoimmune dermatological disorders. This review describes twelve BTKi approved or in clinical trials. By focusing on their pharmacological properties, targeted disease, bleeding side effects and actions on platelets it attempts to clarify the mechanisms underlying bleeding. Specific platelet function tests in blood might help to estimate the probability of bleeding of newly developed BTKi.
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Affiliation(s)
- Philipp von Hundelshausen
- Institute for Cardiovascular Prevention, Ludwig-Maximilians University (LMU), 80336 Munich, Germany;
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, 80336 Munich, Germany
| | - Wolfgang Siess
- Institute for Cardiovascular Prevention, Ludwig-Maximilians University (LMU), 80336 Munich, Germany;
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, 80336 Munich, Germany
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23
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Ntanasis-Stathopoulos I, Gavriatopoulou M, Fotiou D, Dimopoulos MA. Current and novel BTK inhibitors in Waldenström's macroglobulinemia. Ther Adv Hematol 2021; 12:2040620721989586. [PMID: 33613931 PMCID: PMC7874350 DOI: 10.1177/2040620721989586] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/04/2021] [Indexed: 01/28/2023] Open
Abstract
The current therapeutic approach in Waldenström’s macroglobulinemia (WM) is being driven by insights in disease biology and genomic landscape. Bruton’s tyrosine kinase (BTK) plays a key role in signaling pathways for the survival of WM clone. BTK inhibition has changed the treatment landscape of the disease. Ibrutinib has resulted in deep and durable responses both as an upfront and salvage treatment with a manageable toxicity profile. However, the need for fewer off-target effects and deeper responses has resulted in the clinical development of second-generation BTK inhibitors. Zanubrutinib has resulted in clinically meaningful antitumor activity, including deep and durable responses, with a low discontinuation rate due to treatment-related toxicities. Cardiovascular adverse events seem to be milder compared with ibrutinib. Interestingly, the efficacy of zanubrutinib in WM is significant both for MYD88L265P and MYD88WT patients. Although the randomized, phase III ASPEN clinical trial did not meet its primary endpoint in terms of showing a superiority of zanubrutinib in deep responses compared with ibrutinib, secondary efficacy and safety endpoints underscore the potential clinical role of zanubrutinib in the treatment algorithm of WM independent of the MYD88 mutational status. Combination regimens and non-covalent BTK inhibitors are emerging as promising treatment strategies. Long-term data will determine whether next-generation BTK inhibitors are more potent and safer compared with ibrutinib, and whether they are able to overcome resistance to ibrutinib, either alone or in combination with inhibitors of other interrelated molecular pathways.
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Affiliation(s)
- Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Despina Fotiou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, 80 Vas. Sofias Avenue, Athens 11528, Greece
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24
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Danilov AV, Persky DO. Incorporating acalabrutinib, a selective next-generation Bruton tyrosine kinase inhibitor, into clinical practice for the treatment of haematological malignancies. Br J Haematol 2020; 193:15-25. [PMID: 33216986 DOI: 10.1111/bjh.17184] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/20/2020] [Accepted: 08/25/2020] [Indexed: 01/15/2023]
Abstract
Greater understanding of the mechanisms involved in the disease progression of haematological malignancies has led to the introduction of novel targeted therapies with reduced toxicity compared with chemotherapy-based regimens, which has expanded the treatment options for patients with mantle cell lymphoma (MCL) and chronic lymphocytic leukaemia/small lymphocytic lymphoma (CLL/SLL). Ibrutinib is a first-in-class Bruton tyrosine kinase (BTK) inhibitor indicated for the treatment of patients with CLL/SLL or relapsed/refractory MCL. However, next-generation BTK inhibitors have been developed with improved specificity and the potential to reduce the off-target toxicity observed with ibrutinib. Acalabrutinib is a highly selective, next-generation BTK inhibitor, which was granted accelerated approval by the US Food and Drug Administration in 2017 for the treatment of adult patients with MCL who have received at least one prior therapy. In November 2019, it was also granted approval for the treatment of adult patients with CLL/SLL on the basis of two phase 3 clinical trials. This review describes the current understanding of acalabrutinib according to clinical study data for the treatment of MCL and CLL/SLL and shares recommendations from our practice on how it should be used when treating patients in the clinic, including dosing, administration and management of adverse events.
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Despina F, Meletios Athanasios D, Efstathios K. Emerging drugs for the treatment of Waldenström macroglobulinemia. Expert Opin Emerg Drugs 2020; 25:433-444. [PMID: 32955949 DOI: 10.1080/14728214.2020.1822816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Waldenström's Macroglobulinemia (WM) is an indolent lymphoma with uniquely distinct and heterogenous clinical and genomic profiles. Clonal lymphoplasmacytic cells secrete monoclonal IgM. More than 90% of patients harbor a mutation in MYD88 gene, leading to the constitutive activation of downstream pathways, involving BTK-mediated signaling. The use of BTK inhibitors has changed the treatment landscape of WM and has paved the way for new approaches to therapy. AREAS COVERED WM is an orphan disease and ibrutinib is the only FDA/EMA approved agent. Currently established agent combinations will be reviewed with a focus on emerging therapeutic options. These include second generation inhibitors, agents that target other molecules in the BCR signaling pathway, CXCR4 inhibitors, proteasome inhibitors and anti-CD38 antibodies. The current research goal is to establish a combination that can induce deep and durable responses with minimal associated toxicity. In addition, agents that can overcome ibrutinib resistance or act in a synergistic manner with BTKi are under investigation. EXPERT OPINION The optimal therapeutic approach for WM patients is not currently established. The question of whether a combinatory (or synergistic) regimen to overcome resistance and allow for fixed- duration treatment will allow for deep/durable responses is being addressed in ongoing clinical trials.
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Affiliation(s)
- Fotiou Despina
- Plasma Cell Dyscrasia Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens , Athens, Greece
| | - Dimopoulos Meletios Athanasios
- Plasma Cell Dyscrasia Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens , Athens, Greece
| | - Kastritis Efstathios
- Plasma Cell Dyscrasia Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens , Athens, Greece
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de Jong J, Mitselos A, Jurczak W, Cordoba R, Panizo C, Wrobel T, Dlugosz-Danecka M, Jiao J, Sukbuntherng J, Ouellet D, Hellemans P. Ibrutinib does not have clinically relevant interactions with oral contraceptives or substrates of CYP3A and CYP2B6. Pharmacol Res Perspect 2020; 8:e00649. [PMID: 32945596 PMCID: PMC7506988 DOI: 10.1002/prp2.649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 11/11/2022] Open
Abstract
Ibrutinib may inhibit intestinal CYP3A4 and induce CYP2B6 and/or CYP3A. Secondary to potential induction, ibrutinib may reduce the exposure and effectiveness of oral contraceptives (OCs). This phase I study evaluated the effect of ibrutinib on the pharmacokinetics of the CYP2B6 substrate bupropion, CYP3A substrate midazolam, and OCs ethinylestradiol (EE) and levonorgestrel (LN). Female patients (N = 22) with B‐cell malignancies received single doses of EE/LN (30/150 μg) and bupropion/midazolam (75/2 mg) during a pretreatment phase on days 1 and 3, respectively (before starting ibrutinib on day 8), and again after ibrutinib 560 mg/day for ≥ 2 weeks. Intestinal CYP3A inhibition was assessed on day 8 (single‐dose ibrutinib plus single‐dose midazolam). Systemic induction was assessed at steady‐state on days 22 (EE/LN plus ibrutinib) and 24 (bupropion/midazolam plus ibrutinib). The geometric mean ratios (GMRs; test/reference) for maximum plasma concentration (Cmax) and area under the plasma concentration‐time curve (AUC) were derived using linear mixed‐effects models (90% confidence interval within 80%‐125% indicated no interaction). On day 8, the GMR for midazolam exposure with ibrutinib coadministration was ≤ 20% lower than the reference, indicating lack of intestinal CYP3A4 inhibition. At ibrutinib steady‐state, the Cmax and AUC of EE were 33% higher than the reference, which was not considered clinically relevant. No substantial changes were noted for LN, midazolam, or bupropion. No unexpected safety findings were observed. A single dose of ibrutinib did not inhibit intestinal CYP3A4, and repeated administration did not induce CYP3A4/2B6, as assessed using EE, LN, midazolam, and bupropion.
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Affiliation(s)
- Jan de Jong
- Clinical Pharmacology, Janssen Research & Development LLC, San Diego, CA, USA
| | - Anna Mitselos
- Clinical Research Oncology, Janssen Research & Development LLC, Beerse, Belgium
| | - Wojciech Jurczak
- Maria Sklodowska-Curie National Institute of Oncology, Krakow, Poland
| | - Raul Cordoba
- Lymphoma Unit, Department of Hematology, Fundacion Jimenez Diaz University Hospital, Madrid, Spain.,Health Research Institute IIS-FJD, Madrid, Spain.,START Madrid, Phase 1 Clinical Trials Unit, Madrid, Spain
| | - Carlos Panizo
- Department of Hematology, Clínica Universidad de Navarra, Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Tomasz Wrobel
- Department and Clinic of Hematology, Blood Neoplasms, and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | | | - James Jiao
- Clinical Pharmacology, Janssen Research & Development LLC, Raritan, NJ, USA
| | | | - Daniele Ouellet
- Clinical Pharmacology, Janssen Research & Development LLC, Spring House, PA, USA
| | - Peter Hellemans
- Clinical Research Oncology, Janssen Research & Development LLC, Beerse, Belgium
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Garrison DA, Talebi Z, Eisenmann ED, Sparreboom A, Baker SD. Role of OATP1B1 and OATP1B3 in Drug-Drug Interactions Mediated by Tyrosine Kinase Inhibitors. Pharmaceutics 2020; 12:E856. [PMID: 32916864 PMCID: PMC7559291 DOI: 10.3390/pharmaceutics12090856] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 12/20/2022] Open
Abstract
Failure to recognize important features of a drug's pharmacokinetic characteristics is a key cause of inappropriate dose and schedule selection, and can lead to reduced efficacy and increased rate of adverse drug reactions requiring medical intervention. As oral chemotherapeutic agents, tyrosine kinase inhibitors (TKIs) are particularly prone to cause drug-drug interactions as many drugs in this class are known or suspected to potently inhibit the hepatic uptake transporters OATP1B1 and OATP1B3. In this article, we provide a comprehensive overview of the published literature and publicly-available regulatory documents in this rapidly emerging field. Our findings indicate that, while many TKIs can potentially inhibit the function of OATP1B1 and/or OATP1B3 and cause clinically-relevant drug-drug interactions, there are many inconsistencies between regulatory documents and the published literature. Potential explanations for these discrepant observations are provided in order to assist prescribing clinicians in designing safe and effective polypharmacy regimens, and to provide researchers with insights into refining experimental strategies to further predict and define the translational significance of TKI-mediated drug-drug interactions.
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Affiliation(s)
| | | | | | - Alex Sparreboom
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA; (D.A.G.); (Z.T.); (E.D.E.)
| | - Sharyn D. Baker
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA; (D.A.G.); (Z.T.); (E.D.E.)
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Gavriatopoulou M, Fotiou D, Ntanasis-Stathopoulos I, Dimopoulos MA. The current role of BTK inhibitors in the treatment of Waldenstrom's Macroglobulinemia. Expert Rev Anticancer Ther 2020; 20:663-674. [PMID: 32631091 DOI: 10.1080/14737140.2020.1791705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Waldenstrom's Macroglobulinemia (WM) is a rare, indolent lymphoplasmacytic lymphoma characterized by heterogeneous clinical and genomic profile. Bruton's tyrosine kinase (BTK) is central to the signaling pathways required for clonal WM cell survival, and BTK inhibitors currently have an imperative role in the treatment of WM. AREAS COVERED The central role of BTK in WM will be described, and the rationale behind the development of BTKi. Clinical trial data that led to the approval of ibrutinib (the first-in-class BTKi) will be reviewed. Despite its potency and safe toxicity profile, ibrutinib does not induce deep remissions, and responses are mutational-status dependent. The mechanisms that lead to resistance to this agent are being investigated. Ibrutinib treatment has to be continuous; consequently, patients face the effects of long-term toxicity. In that context, second-generation inhibitors are in clinical development with fewer off-target effects and an efficacy profile, which will be determined based on long-term follow-up data. EXPERT OPINION The optimal therapeutic approach for WM patients remains to be established. The question of whether a combinatory (or synergistic) regimen to overcome resistance and allow for a fixed treatment duration will allow for deep and durable response is being addressed in ongoing clinical trials.
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Affiliation(s)
- Maria Gavriatopoulou
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens , Athens, Greece
| | - Despina Fotiou
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens , Athens, Greece
| | - Ioannis Ntanasis-Stathopoulos
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens , Athens, Greece
| | - Meletios Athanasios Dimopoulos
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens , Athens, Greece
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Xu W, Yang S, Zhou K, Pan L, Li Z, Zhou J, Gao S, Zhou D, Hu J, Feng R, Huang H, Ji M, Guo H, Huang J, Novotny W, Feng S, Li J. Treatment of relapsed/refractory chronic lymphocytic leukemia/small lymphocytic lymphoma with the BTK inhibitor zanubrutinib: phase 2, single-arm, multicenter study. J Hematol Oncol 2020; 13:48. [PMID: 32393328 PMCID: PMC7216400 DOI: 10.1186/s13045-020-00884-4] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/23/2020] [Indexed: 02/05/2023] Open
Abstract
Background Bruton tyrosine kinase (BTK) inhibitors have demonstrated a high degree of efficacy in the treatment of B cell malignancies characterized by constitutive B cell receptor activation, including chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). Methods The efficacy and safety of zanubrutinib, an investigational highly selective BTK inhibitor, was evaluated in this single-arm, phase 2 study of Chinese patients with relapsed/refractory CLL/SLL. The primary endpoint was overall response rate as assessed by an independent review committee. Results Of the 91 evaluable patients, 77 (84.6%) achieved a response, with three (3.3%), 54 (59.3%), and 20 (22%) patients achieving a complete response, partial response, and partial response with lymphocytosis, respectively, after a median follow-up of 15.1 months. The estimated 12-month event-free rate for duration of response was 92.9%. The most commonly reported grade ≥ 3 adverse events (AEs) were neutropenia (44%), thrombocytopenia (15.4%), lung infection/pneumonia (13.2%), upper respiratory tract infection (9.9%), and anemia (8.8%). The 12-month overall survival rate was 96%. Eight (9.0%) patients discontinued zanubrutinib due to AEs, and seven (8.0%) patients required at least one dose reduction. Conclusion Treatment of patients with relapsed/refractory CLL/SLL with zanubrutinib was generally well tolerated and resulted in a high overall response rate, thereby conferring a favorable benefit-risk profile. Trial registration Prospectively registered in China public registry (CTR20160890) on December 7, 2016: http://www.chinadrugtrials.org.cn/. Retrospectively registered in ClinicalTrials.gov (NCT03206918) on July 2, 2017.
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Affiliation(s)
- Wei Xu
- Department of Hematology, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Shenmiao Yang
- Peking University Peoples Hospital, Peking University Institute of Hematology, Beijing, China
| | - Keshu Zhou
- Henan Cancer Hospital, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Ling Pan
- West China Hospital of Sichuan University, Chengdu, China
| | - Zengjun Li
- Blood Disease Hospital, Chinese Academy of Medical Science, Tianjin, China
| | - Jianfeng Zhou
- Tongji Hospital, Tongji Medical College, Wuhan, China
| | - Sujun Gao
- The First Hospital of Jilin University, Changchun, China
| | - Daobin Zhou
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jianda Hu
- Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ru Feng
- Nanfang Hospital of Southern Medical University, Guangzhou, China
| | - Haiwen Huang
- The 1st Hospital of Soochow University, Suzhou, China
| | - Meng Ji
- BeiGene (Beijing) Co., Ltd., Beijing, China.,BeiGene USA, Inc., San Mateo, CA, USA
| | - Haiyi Guo
- BeiGene (Beijing) Co., Ltd., Beijing, China.,BeiGene USA, Inc., San Mateo, CA, USA
| | - Jane Huang
- BeiGene (Beijing) Co., Ltd., Beijing, China.,BeiGene USA, Inc., San Mateo, CA, USA
| | - William Novotny
- BeiGene (Beijing) Co., Ltd., Beijing, China.,BeiGene USA, Inc., San Mateo, CA, USA
| | - Shibao Feng
- BeiGene (Beijing) Co., Ltd., Beijing, China.,BeiGene USA, Inc., San Mateo, CA, USA
| | - Jianyong Li
- Department of Hematology, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China.
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30
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Antifungal and Oral Anticancer Therapy Drug Interactions. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00386-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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31
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Gallais F, Ysebaert L, Despas F, De Barros S, Dupré L, Quillet-Mary A, Protin C, Thomas F, Obéric L, Allal B, Chatelut E, White-Koning M. Population Pharmacokinetics of Ibrutinib and Its Dihydrodiol Metabolite in Patients with Lymphoid Malignancies. Clin Pharmacokinet 2020; 59:1171-1183. [DOI: 10.1007/s40262-020-00884-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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32
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Stühlinger MC, Weltermann A, Staber P, Heintel D, Nösslinger T, Steurer M. Recommendations for ibrutinib treatment in patients with atrial fibrillation and/or elevated cardiovascular risk. Wien Klin Wochenschr 2020; 132:97-109. [PMID: 31414181 PMCID: PMC7035304 DOI: 10.1007/s00508-019-1534-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 07/09/2019] [Indexed: 12/12/2022]
Abstract
Ibrutinib is the first clinically approved inhibitor of Bruton's tyrosine kinase, an enzyme that is essential for survival and proliferation of B‑cells by activating the B‑cell receptor signalling pathway. Ibrutinib has been shown to be highly effective in B‑cell malignancies in clinical trials and is recommended in current international guidelines as a first and/or second line treatment of chronic lymphocytic leukemia. The drug has a favorable tolerability and safety profile but the occurrence of specific side effects (e.g. atrial fibrillation, bleeding and hypertension) may complicate or be of concern for doctors and patients considering the use of this treatment. In many cases, however, it is not necessary to withhold this effective therapy. In contrast, ibrutinib treatment can be initiated or continued, if certain recommendations are followed. The possibilities of prevention, diagnosis and management of specific clinical situations are discussed in detail and recommendations are derived, which should facilitate ibrutinib use.
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Affiliation(s)
- Markus C. Stühlinger
- University Clinic of Internal Medicine III/Cardiology and Angiology, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | | | - Philipp Staber
- University Clinic of Internal Medicine I, Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Daniel Heintel
- 1st Medical Department, Center for Oncology and Hematology, Wilhelminenspital Vienna, Vienna, Austria
| | - Thomas Nösslinger
- 3rd Medical Department, Hematology and Oncology, Hanusch Hospital Vienna, Vienna, Austria
| | - Michael Steurer
- University Clinic of Internal Medicine V, Hematology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
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Mu S, Tang Z, Novotny W, Tawashi M, Li TK, Ou Y, Sahasranaman S. Effect of rifampin and itraconazole on the pharmacokinetics of zanubrutinib (a Bruton's tyrosine kinase inhibitor) in Asian and non-Asian healthy subjects. Cancer Chemother Pharmacol 2019; 85:391-399. [PMID: 31875923 PMCID: PMC7015960 DOI: 10.1007/s00280-019-04015-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/14/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Zanubrutinib (BGB-3111) is a potent Bruton's tyrosine kinase inhibitor with promising clinical activity in B-cell malignancies. Zanubrutinib was shown to be mainly metabolized through cytochrome P450 3A (CYP3A) in vitro. We evaluated the effect of steady-state rifampin (a strong CYP3A inducer) and steady-state itraconazole (a strong CYP3A inhibitor) on the pharmacokinetics (PK), safety, and tolerability of zanubrutinib in healthy Asian and non-Asian subjects. METHODS In this open-label, two-part clinical study, 20 participants received a single oral dose of zanubrutinib (320 mg) and oral rifampin (600 mg) in Part A, and 18 participants received a single oral dose of zanubrutinib (20 mg) and oral itraconazole (200 mg) in Part B. Serial blood samples were collected after administration of zanubrutinib alone and zanubrutinib in combination with rifampin or itraconazole for the measurement of PK parameters. RESULTS Coadministration with rifampin decreased AUC0-∞ of zanubrutinib by 13.5-fold and Cmax by 12.6-fold. Coadministration with itraconazole increased the AUC0-∞ of zanubrutinib by 3.8-fold and Cmax by 2.6-fold. The PK of zanubrutinib was consistent between Asian and non-Asian subjects, and zanubrutinib was well tolerated in this study. CONCLUSIONS These results confirm that zanubrutinib is primarily metabolized by CYP3A in humans. The PK of zanubrutinib was comparable between Asian and non-Asian subjects and, therefore, no dose modifications are necessary for zanubrutinib in these ethnic populations.
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Affiliation(s)
- Song Mu
- Clinical Pharmacology, BeiGene USA, 2955 Campus Drive, Suite 300, San Mateo, CA, 94403, USA
| | - Zhiyu Tang
- Clinical Pharmacology, BeiGene USA, 2955 Campus Drive, Suite 300, San Mateo, CA, 94403, USA
| | | | - Manal Tawashi
- Clinical Operations, BeiGene USA, San Mateo, CA, USA
| | - Ta-Kai Li
- Drug Safety and Pharmacovigilance, BeiGene USA, San Mateo, CA, USA
| | - Ying Ou
- Clinical Pharmacology, BeiGene USA, 2955 Campus Drive, Suite 300, San Mateo, CA, 94403, USA
| | - Srikumar Sahasranaman
- Clinical Pharmacology, BeiGene USA, 2955 Campus Drive, Suite 300, San Mateo, CA, 94403, USA.
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Tapaninen T, Olkkola AM, Tornio A, Neuvonen M, Elonen E, Neuvonen PJ, Niemi M, Backman JT. Itraconazole Increases Ibrutinib Exposure 10-Fold and Reduces Interindividual Variation-A Potentially Beneficial Drug-Drug Interaction. Clin Transl Sci 2019; 13:345-351. [PMID: 31664782 PMCID: PMC7070818 DOI: 10.1111/cts.12716] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/10/2019] [Indexed: 12/31/2022] Open
Abstract
The oral bioavailability of ibrutinib is low and variable, mainly due to extensive first‐pass metabolism by cytochrome P450 (CYP) 3A4. The unpredictable exposure can compromise its safe and effective dosing. We examined the impact of itraconazole on ibrutinib pharmacokinetics. In a randomized crossover study, 11 healthy subjects were administered itraconazole 200 mg or placebo twice on day 1, and once on days 2–4. On day 3, 1 hour after itraconazole (placebo) and breakfast, ibrutinib (140 mg during placebo; 15 mg during itraconazole) was administered. Itraconazole increased the dose‐adjusted geometric mean area under the concentration‐time curve from zero to infinity (AUC0–∞) of ibrutinib 10.0‐fold (90% confidence interval (CI) 7.2–13.9; P < 0.001) and peak plasma concentration (Cmax) 8.8‐fold (90% CI 6.3–12.1; P < 0.001). During itraconazole, the intersubject variation for the AUC0–∞ (55%) and Cmax (53%) was around half of that during placebo (104%; 99%). In conclusion, itraconazole markedly increases ibrutinib bioavailability and decreases its interindividual variability, offering a possibility to improved dosing accuracy and cost savings.
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Affiliation(s)
- Tuija Tapaninen
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Aleksi M Olkkola
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Aleksi Tornio
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Mikko Neuvonen
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Erkki Elonen
- Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center, University of Helsinki, Helsinki, Finland
| | - Pertti J Neuvonen
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko Niemi
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Janne T Backman
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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Harnessing the therapeutic potential of anticancer drugs through amorphous solid dispersions. Biochim Biophys Acta Rev Cancer 2019; 1873:188319. [PMID: 31678141 DOI: 10.1016/j.bbcan.2019.188319] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/28/2019] [Accepted: 10/28/2019] [Indexed: 12/19/2022]
Abstract
The treatment of cancer is still a major challenge. But tremendous progress in anticancer drug discovery and development has occurred in the last few decades. However, this progress has resulted in few effective oncology products due to challenges associated with anticancer drug delivery. Oral administration is the most preferred route for anticancer drug delivery, but the majority of anticancer drugs currently in product pipelines and the majority of those that have been commercially approved have inherently poor water solubility, and this cannot be mitigated without compromising their potency and stability. The poor water solubility of anticancer drugs, in conjunction with other factors, leads to suboptimal pharmacokinetic performance. Thus, these drugs have limited efficacy and safety when administered orally. The amorphous solid dispersion (ASD) is a promising formulation technology that primarily enhances the aqueous solubility of poorly water-soluble drugs. In this review, we discuss the challenges associated with the oral administration of anticancer drugs and the use of ASD technology in alleviating these challenges. We emphasize the ability of ASDs to improve not only the pharmacokinetics of poorly water-soluble anticancer drugs, but also their efficacy and safety. The goal of this paper is to rationalize the application of ASD technology in the formulation of anticancer drugs, thereby creating superior oncology products that lead to improved therapeutic outcomes.
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Blosser N, Jupp J, Yau P, Stewart D. Clinical Pharmacokinetic and Pharmacodynamic Considerations in Treating Non-Hodgkin Lymphoma. Clin Pharmacokinet 2019; 59:7-23. [PMID: 31385204 DOI: 10.1007/s40262-019-00807-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Non-Hodgkin lymphoma (NHL) includes a variety of closely related malignancies that originate from lymphoid precursors. The majority of NHLs are of B-cell lineage, for which traditional therapy involves chemotherapy in combination with the anti-CD20 monoclonal antibody rituximab. Ongoing research into the pathogenesis of NHL subtypes has given rise to the use of novel agents that target specific molecular pathways. While the incidence of NHL extends over a range of ages from pediatric to elderly settings, the majority of diagnoses occur over age 60 years. Increasing the use of concomitant medication coupled with declining organ function among this group of patients creates pharmacokinetic (PK) challenges in administering a number of agents involved in the treatment of NHL. In addition, since many of the new agents are administered orally, there are a number of added PK factors that must be taken into consideration with their prescribing and administration. This article will review the available literature on the PK and pharmacodynamic properties of agents commonly used in the treatment of NHL, and intends to provide information that can assist with properly using these drugs in this setting.
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Affiliation(s)
- Nikki Blosser
- Pharmacy Services, Tom Baker Cancer Centre, Alberta Health Services, Edmonton, AB, Canada
| | - Jennifer Jupp
- Pharmacy Services, Tom Baker Cancer Centre, Alberta Health Services, Edmonton, AB, Canada
| | - Patrick Yau
- Pharmacy Services, Tom Baker Cancer Centre, Alberta Health Services, Edmonton, AB, Canada
| | - Douglas Stewart
- Departments of Oncology and Medicine, University of Calgary and Tom Baker Cancer Centre, Alberta Health Services, 1331-29th Street NW, Calgary, AB, T2N4N2, Canada.
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Dmitriev AV, Lagunin AA, Karasev DА, Rudik AV, Pogodin PV, Filimonov DA, Poroikov VV. Prediction of Drug-Drug Interactions Related to Inhibition or Induction of Drug-Metabolizing Enzymes. Curr Top Med Chem 2019; 19:319-336. [PMID: 30674264 DOI: 10.2174/1568026619666190123160406] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/02/2019] [Accepted: 01/07/2019] [Indexed: 02/07/2023]
Abstract
Drug-drug interaction (DDI) is the phenomenon of alteration of the pharmacological activity of a drug(s) when another drug(s) is co-administered in cases of so-called polypharmacy. There are three types of DDIs: pharmacokinetic (PK), pharmacodynamic, and pharmaceutical. PK is the most frequent type of DDI, which often appears as a result of the inhibition or induction of drug-metabolising enzymes (DME). In this review, we summarise in silico methods that may be applied for the prediction of the inhibition or induction of DMEs and describe appropriate computational methods for DDI prediction, showing the current situation and perspectives of these approaches in medicinal and pharmaceutical chemistry. We review sources of information on DDI, which can be used in pharmaceutical investigations and medicinal practice and/or for the creation of computational models. The problem of the inaccuracy and redundancy of these data are discussed. We provide information on the state-of-the-art physiologically- based pharmacokinetic modelling (PBPK) approaches and DME-based in silico methods. In the section on ligand-based methods, we describe pharmacophore models, molecular field analysis, quantitative structure-activity relationships (QSAR), and similarity analysis applied to the prediction of DDI related to the inhibition or induction of DME. In conclusion, we discuss the problems of DDI severity assessment, mention factors that influence severity, and highlight the issues, perspectives and practical using of in silico methods.
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Affiliation(s)
| | - Alexey A Lagunin
- Institute of Biomedical Chemistry, Moscow, Russian Federation.,Pirogov Russian National Research Medical University, Moscow, RussiaN Federation
| | | | | | - Pavel V Pogodin
- Institute of Biomedical Chemistry, Moscow, Russian Federation
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Wen J, Bao SS, Zhang BW, Liu TH, Ou-Yang QG, Cai JP, Zhou HY. Inhibitory effect of resveratrol on the pharmacokinetic of ibrutinib by UPLC-MS/MS. Drug Dev Ind Pharm 2019; 45:27-31. [PMID: 30156133 DOI: 10.1080/03639045.2018.1514044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To investigate the impact of resveratrol on the metabolism of ibrutinib in vitro and in vivo. METHODS In vitro, rat liver microsomes (RLM) and human liver microsomes (HLM) were used to study. In vivo, 18 male SD rats were randomly divided into three groups (n = 6): ibrutinib and the multiple dose of 100 mg/kg resveratrol for consecutive 7 days (Group A), ibrutinib and the single dose of 100 mg/kg resveratrol (Group B), ibrutinib (Group C). Processed samples were analyzed by UPLC-MS/MS. RESULTS Resveratrol showed inhibition on RLM and HLM in vitro. The IC50 of resveratrol was 8.745 µM in RLM and 7.789 µM in HLM. Furthermore, Groups A and B both increased the AUC and reduced the CLz/F. The Cmax of Group A and the MRT(0-t) of Group B were significantly improved. CONCLUSIONS Resveratrol inhibits the pharmacokinetic of ibrutinib in vitro and in vivo. It is necessary to pay more attention to adjust the dose of the drug when resveratrol is used in combination with ibrutinib.
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Affiliation(s)
- Jian Wen
- a School of Pharmaceutical Sciences , Wenzhou Medical University , Wenzhou , Zhejiang , China
| | - Su-Su Bao
- a School of Pharmaceutical Sciences , Wenzhou Medical University , Wenzhou , Zhejiang , China
| | - Bo-Wen Zhang
- a School of Pharmaceutical Sciences , Wenzhou Medical University , Wenzhou , Zhejiang , China
| | - Teng-Hui Liu
- a School of Pharmaceutical Sciences , Wenzhou Medical University , Wenzhou , Zhejiang , China
| | - Qiu-Geng Ou-Yang
- a School of Pharmaceutical Sciences , Wenzhou Medical University , Wenzhou , Zhejiang , China
| | - Jian-Ping Cai
- a School of Pharmaceutical Sciences , Wenzhou Medical University , Wenzhou , Zhejiang , China
| | - Hong-Yu Zhou
- a School of Pharmaceutical Sciences , Wenzhou Medical University , Wenzhou , Zhejiang , China
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Tornio A, Filppula AM, Niemi M, Backman JT. Clinical Studies on Drug-Drug Interactions Involving Metabolism and Transport: Methodology, Pitfalls, and Interpretation. Clin Pharmacol Ther 2019; 105:1345-1361. [PMID: 30916389 PMCID: PMC6563007 DOI: 10.1002/cpt.1435] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 03/22/2019] [Indexed: 12/15/2022]
Abstract
Many drug-drug interactions (DDIs) are based on alterations of the plasma concentrations of a victim drug due to another drug causing inhibition and/or induction of the metabolism or transporter-mediated disposition of the victim drug. In the worst case, such interactions cause more than tenfold increases or decreases in victim drug exposure, with potentially life-threatening consequences. There has been tremendous progress in the predictability and modeling of DDIs. Accordingly, the combination of modeling approaches and clinical studies is the current mainstay in evaluation of the pharmacokinetic DDI risks of drugs. In this paper, we focus on the methodology of clinical studies on DDIs involving drug metabolism or transport. We specifically present considerations related to general DDI study designs, recommended enzyme and transporter index substrates and inhibitors, pharmacogenetic perspectives, index drug cocktails, endogenous substrates, limited sampling strategies, physiologically-based pharmacokinetic modeling, complex DDIs, methodological pitfalls, and interpretation of DDI information.
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Affiliation(s)
- Aleksi Tornio
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anne M Filppula
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko Niemi
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Janne T Backman
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Deodato M, Frustaci AM, Zamprogna G, Cairoli R, Montillo M, Tedeschi A. Ibrutinib for the treatment of chronic lymphocytic leukemia. Expert Rev Hematol 2019; 12:273-284. [PMID: 30916599 DOI: 10.1080/17474086.2019.1597703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Chemoimmunotherapy has improved outcomes in chronic lymphocytic leukemia, yet it is not curative, with very high relapse rates, and is associated with a significant risk of toxicities. Moreover, patients with higher-risk genetic abnormalities continue to experience poorer outcomes and lower survival. Recently, novel targeted therapies have been developed to increase efficacy and reduce toxicity. Areas covered: Ibrutinib is an oral irreversible inhibitor of Bruton's tyrosine kinase, a mediator of B-cell receptor signaling, which plays a vital role in various B-cell neoplasms. The drug has been approved for the treatment of several hematological malignancies, including chronic lymphocytic leukemia/small lymphocytic lymphoma, where large trials have shown outcomes never seen before even in high-risk patients. The safety profile appeared furthermore favorable, even in elderly and unfit patients. Expert opinion: Therapy with ibrutinib rarely provides MRD-negative complete remission; an indefinite maintenance is therefore needed, with the risk of developing adverse events (AE) or resistance resulting in treatment interruption or discontinuation. Novel, extremely promising, combination strategies, based on the association of ibrutinib with chemoimmunotherapy, anti-CD20 monoclonal antibody or other targeted agents, are currently being investigated, with the goal of achieving greater depth of remission, especially MRD-negativity, and removing the need for indefinite treatment.
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Affiliation(s)
- Marina Deodato
- a Department of Hematology , Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda , Milano , Italy
| | - Anna Maria Frustaci
- a Department of Hematology , Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda , Milano , Italy
| | - Giulia Zamprogna
- a Department of Hematology , Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda , Milano , Italy
| | - Roberto Cairoli
- a Department of Hematology , Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda , Milano , Italy
| | - Marco Montillo
- a Department of Hematology , Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda , Milano , Italy
| | - Alessandra Tedeschi
- a Department of Hematology , Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda , Milano , Italy
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41
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Spaner DE, McCaw L, Wang G, Tsui H, Shi Y. Persistent janus kinase-signaling in chronic lymphocytic leukemia patients on ibrutinib: Results of a phase I trial. Cancer Med 2019; 8:1540-1550. [PMID: 30843659 PMCID: PMC6488147 DOI: 10.1002/cam4.2042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/20/2019] [Accepted: 02/04/2019] [Indexed: 12/13/2022] Open
Abstract
Methods to deepen clinical responses to ibrutinib are needed to improve outcomes for patients with chronic lymphocytic leukemia (CLL). This study aimed to determine the safety and efficacy of combining a janus kinase (JAK)‐inhibitor with ibrutinib because JAK‐mediated cytokine‐signals support CLL cells and may not be inhibited by ibrutinib. The JAK1/2 inhibitor ruxolitinib was prescribed to 12 CLL patients with abnormal serum beta‐2 microglobulin levels after 6 months or persistent lymphadenopathy or splenomegaly after 12 months on ibrutinib using a 3 + 3 phase 1 trial design (NCT02912754). Ibrutinib was continued at 420 mg daily and ruxolitinib was added at 5, 10, 15, or 20 mg BID for 3 weeks out of five for seven cycles. The break was mandated to avoid anemia and thrombocytopenia observed with ruxolitinib as a single agent in CLL. The combination was well‐tolerated without dose‐limiting toxicities. Cyclic changes in platelets, lymphocytes, and associated chemokines and thrombopoietic factors were observed and partial response criteria were met in 2 of 12 patients. The results suggest that JAK‐signaling helps CLL cells persist in the presence of ibrutinib and ruxolitinib with ibrutinib is well‐tolerated and may be a useful regiment to use in combination therapies for CLL.
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Affiliation(s)
- David E Spaner
- Biology Platform, Sunnybrook Research Institute, Toronto, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Canada.,Sunnybrook Odette Cancer Center, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,Department of Immunology, University of Toronto, Toronto, Canada
| | - Lindsay McCaw
- Biology Platform, Sunnybrook Research Institute, Toronto, Canada
| | - Guizhei Wang
- Biology Platform, Sunnybrook Research Institute, Toronto, Canada
| | - Hubert Tsui
- Department of Immunology, University of Toronto, Toronto, Canada.,Division of Hematopathology, Sunnybrook Health Sciences Center, Toronto, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Yonghong Shi
- Biology Platform, Sunnybrook Research Institute, Toronto, Canada
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Management of adverse effects/toxicity of ibrutinib. Crit Rev Oncol Hematol 2019; 136:56-63. [PMID: 30878129 DOI: 10.1016/j.critrevonc.2019.02.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 01/27/2019] [Accepted: 02/04/2019] [Indexed: 12/18/2022] Open
Abstract
Bruton tyrosine kinase signaling (BTK) is critical step for B-cell development and immunoglobulin synthesis. Ibrutinib is an orally bioavailable bruton tyrosine kinase inhibitor (BTKi) and forms an irreversible covalent bound to BTK at the Cysteine-481 residue. Ibrutinib has been approved by FDA for the treatment of mantle cell lymphoma, chronic lymphocytic leukemia, Waldenstrom's macroglobulinemia, marginal zone lymphoma and chronic graft-versus-host disease in allogeneic stem cell transplantation. Ibrutinib is generally well tolerated drug with rapid and durable responses but has some side events. The most common side effects are diarrhea, upper respiratory tract infection, bleeding, fatigue and cardiac side effects. These events are generally mild (grade I-II). However atrial fibrillation (AF) and bleeding are important and may be grade III or higher side effects require strict monitoring. Here side effects of ibrutinib have been summarized and important considerations in the management of these adverse events have been reviewed.
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Hussaarts KGAM, Veerman GDM, Jansman FGA, van Gelder T, Mathijssen RHJ, van Leeuwen RWF. Clinically relevant drug interactions with multikinase inhibitors: a review. Ther Adv Med Oncol 2019; 11:1758835918818347. [PMID: 30643582 PMCID: PMC6322107 DOI: 10.1177/1758835918818347] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/17/2018] [Indexed: 12/11/2022] Open
Abstract
Multikinase inhibitors (MKIs), including the tyrosine kinase inhibitors (TKIs), have rapidly become an established factor in daily (hemato)-oncology practice. Although the oral route of administration offers improved flexibility and convenience for the patient, challenges arise in the use of MKIs. As MKIs are prescribed extensively, patients are at increased risk for (severe) drug–drug interactions (DDIs). As a result of these DDIs, plasma pharmacokinetics of MKIs may vary significantly, thereby leading to high interpatient variability and subsequent risk for increased toxicity or a diminished therapeutic outcome. Most clinically relevant DDIs with MKIs concern altered absorption and metabolism. The absorption of MKIs may be decreased by concomitant use of gastric acid-suppressive agents (e.g. proton pump inhibitors) as many kinase inhibitors show pH-dependent solubility. In addition, DDIs concerning drug (uptake and efflux) transporters may be of significant clinical relevance during MKI therapy. Furthermore, since many MKIs are substrates for cytochrome P450 isoenzymes (CYPs), induction or inhibition with strong CYP inhibitors or inducers may lead to significant alterations in MKI exposure. In conclusion, DDIs are of major concern during MKI therapy and need to be monitored closely in clinical practice. Based on the current knowledge and available literature, practical recommendations for management of these DDIs in clinical practice are presented in this review.
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Affiliation(s)
- Koen G A M Hussaarts
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - G D Marijn Veerman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Frank G A Jansman
- Department of Clinical Pharmacy, Deventer Hospital, Deventer, The Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Dousa KM, Babiker A, Van Aartsen D, Shah N, Bonomo RA, Johnson JL, Skalweit MJ. Ibrutinib Therapy and Mycobacterium chelonae Skin and Soft Tissue Infection. Open Forum Infect Dis 2018; 5:ofy168. [PMID: 30090839 PMCID: PMC6065501 DOI: 10.1093/ofid/ofy168] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 07/12/2018] [Indexed: 12/25/2022] Open
Abstract
Ibrutinib is an irreversible inhibitor of Bruton’s tyrosine kinase approved for the treatment of B-cell malignancies. There is growing concern about the risk of opportunistic infections following ibrutinib therapy. Herein, we describe the first case of Mycobacterium chelonae skin and soft tissue infection in a patient receiving ibrutinib and recount the challenges in treating this infection.
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Affiliation(s)
- Khalid M Dousa
- Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Ahmed Babiker
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Ohio
| | - Daniel Van Aartsen
- Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Neel Shah
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Ohio
| | - Robert A Bonomo
- Infectious Diseases Section, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio.,Departments of Medicine, Pharmacology, Molecular Biology and Microbiology, Biochemistry, Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio.,CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, Ohio
| | - John L Johnson
- Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Marion J Skalweit
- Infectious Diseases Section, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio
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de Jong J, Hellemans P, De Wilde S, Patricia D, Masterson T, Manikhas G, Myasnikov A, Osmanov D, Córdoba R, Panizo C, de Zwart L, Snoeys J, Chauhan V, Jiao J, Sukbuntherng J, Ouellet D. A drug-drug interaction study of ibrutinib with moderate/strong CYP3A inhibitors in patients with B-cell malignancies. Leuk Lymphoma 2018; 59:2888-2895. [PMID: 29846137 DOI: 10.1080/10428194.2018.1460474] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
This was an open-label, multicenter, phase-1 study to evaluate the drug interaction between steady-state ibrutinib and moderate (erythromycin) and strong (voriconazole) CYP3A inhibitors in patients with B-cell malignancies and to confirm dosing recommendations. During cycle 1, patients received oral ibrutinib 560 mg qd alone (Days 1-4 and 14-18), and ibrutinib 140 mg (Days 5-13; 19-27) plus erythromycin 500 mg tid (Days 5-11) and voriconazole 200 mg bid (Days 19-25). Twenty-six patients (median [range] age: 64.5 [50-88] years) were enrolled. Geometric mean ratio (90% confidence intervals) after co-administration of ibrutinib 140 mg with erythromycin and voriconazole was 74.7 (53.97-103.51) and 143.3 (107.77-190.42), respectively, versus ibrutinib 560 mg alone. The most common (≥20%) adverse events were diarrhea (27%) and neutropenia (23%). The results demonstrate that ibrutinib 140 mg with voriconazole or erythromycin provides exposure within the clinical range for patients with B-cell malignancies.
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Affiliation(s)
- Jan de Jong
- a Janssen Research & Development , San Diego , CA , USA
| | | | | | | | - Tara Masterson
- c Janssen Research & Development , Spring House , PA , USA
| | - Georgii Manikhas
- d St. Petersburg City Oncology Hospital , St. Petersburg , Russian Federation
| | | | - Dzhelil Osmanov
- f N.N. Blokhin Russian Academy of Medical Sciences , Moscow , Russian Federation
| | - Raúl Córdoba
- g START Madrid, University Hospital Fundacion Jimenez Diaz, Health Research Institute IIS-FJD , Madrid , Spain
| | | | | | - Jan Snoeys
- b Janssen Research & Development , Beerse , Belgium
| | - Vijay Chauhan
- i Janssen Research & Development , Raritan , NJ , USA
| | - James Jiao
- i Janssen Research & Development , Raritan , NJ , USA
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Gordon MJ, Churnetski M, Alqahtani H, Rivera X, Kittai A, Amrock SM, James S, Hoff S, Manda S, Spurgeon SE, Choi M, Cohen JB, Persky D, Danilov AV. Comorbidities predict inferior outcomes in chronic lymphocytic leukemia treated with ibrutinib. Cancer 2018; 124:3192-3200. [DOI: 10.1002/cncr.31554] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/13/2018] [Accepted: 04/26/2018] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Hamood Alqahtani
- Moores Cancer CenterUniversity of California San DiegoSan Diego California
| | | | - Adam Kittai
- Oregon Health and Science UniversityPortland Oregon
| | | | - Spencer James
- Dartmouth‐Hitchcock Medical CenterLebanon New Hampshire
| | - Sheila Hoff
- Moores Cancer CenterUniversity of California San DiegoSan Diego California
| | - Sudhir Manda
- Dartmouth‐Hitchcock Medical CenterLebanon New Hampshire
| | | | - Michael Choi
- Moores Cancer CenterUniversity of California San DiegoSan Diego California
| | | | | | - Alexey V. Danilov
- Oregon Health and Science UniversityPortland Oregon
- Dartmouth‐Hitchcock Medical CenterLebanon New Hampshire
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Abstract
Abnormal B-cell receptor (BCR) signalling is a key mechanism of disease progression in B-cell malignancy. Bruton's tyrosine kinase (BTK) has a pivotal role in BCR signalling. Ibrutinib (PCI-32765) is a small molecule which serves as a covalent irreversible inhibitor of BTK. It is characterized by high selectivity for BTK and high potency. Ibrutinib is currently approved by the FDA and EMA for use in chronic lymphocytic leukaemia in any line of treatment, for treatment of Waldenstrom macroglobulinemia in patients who have received previous treatments or are not suitable to receive immunochemotherapy as well as for second line treatment of mantle cell lymphoma and for patients with marginal zone lymphoma who have received at least one prior anti-CD20-based therapy. In addition, there is emerging clinical data on its efficacy in ABC subtype diffuse large B-cell lymphoma, multiple myeloma and primary central nervous system lymphoma. Ibrutinib has opened new options for treatment of those patients that have relapsed or have been refractory to more classical modes of treatment. Moreover, Ibrutinib has been shown to be effective in patients that have been known to have little sensitivity to classical immunochemotherapy. Having a favourable risk profile, the substance is, unlike conventional immunochemotherapy, also suitable for the less physical fit patients. Cases of primary and secondary resistance to Ibrutinib have emerged and there is an ongoing effort to identify their mechanism and develop strategies to overcome them. Beyond its direct effects on survival and apoptosis of malignant B-cells, there is increasing evidence that Ibrutinib is able to modulate the tumour microenvironment to overcome mechanisms of immune evasion. This has sparked interest in use of the substance beyond lymphoid malignancy. This chapter discusses structure, mechanism of action and toxicities of Ibrutinib and also presents important preclinical and clinical data as well as mechanisms of Ibrutinib resistance. Combination strategies with immunotherapeutic strategies such as immune checkpoint blockade and CAR T-cell therapy may be synergistic and are currently under investigation.
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Affiliation(s)
| | - Mark-Alexander Schwarzbich
- Barts Cancer Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
- Department of Haematology, Oncology and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Mathias Witzens-Harig
- Department of Haematology, Oncology and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
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Xu RA, Wen J, Tang P, Wang C, Xie S, Zhang BW, Zhou Q, Cai JP, Hu GX. Functional Characterization of 22 CYP3A4 Protein Variants to Metabolize Ibrutinib In Vitro. Basic Clin Pharmacol Toxicol 2017; 122:383-387. [PMID: 29117640 DOI: 10.1111/bcpt.12934] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 10/26/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Ren-ai Xu
- The First Affiliated Hospital of Wenzhou Medical University; Wenzhou China
| | - Jian Wen
- Department of Pharmacology; School of Pharmaceutical Sciences; Wenzhou Medical University; Wenzhou China
| | - Pengfei Tang
- Department of Pharmacology; School of Pharmaceutical Sciences; Wenzhou Medical University; Wenzhou China
| | - Chenchen Wang
- Department of Pharmacology; School of Pharmaceutical Sciences; Wenzhou Medical University; Wenzhou China
| | - Saili Xie
- The First Affiliated Hospital of Wenzhou Medical University; Wenzhou China
| | - Bo-wen Zhang
- Department of Pharmacology; School of Pharmaceutical Sciences; Wenzhou Medical University; Wenzhou China
| | - Quan Zhou
- Department of Pharmacology; School of Pharmaceutical Sciences; Wenzhou Medical University; Wenzhou China
| | - Jian-ping Cai
- The Ministry of Health (MOH) Key Laboratory of Geriatrics; Beijing Hospital; National Center of Gerontology; Beijing China
| | - Guo-xin Hu
- Department of Pharmacology; School of Pharmaceutical Sciences; Wenzhou Medical University; Wenzhou China
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Ibrutinib does not prolong the corrected QT interval in healthy subjects: results from a thorough QT study. Cancer Chemother Pharmacol 2017; 80:1227-1237. [DOI: 10.1007/s00280-017-3471-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 10/16/2017] [Indexed: 10/18/2022]
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50
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Abstract
The development of bruton tyrosine kinase inhibitors (BTKi) has been a significant advancement in the treatment of chronic lymphocytic leukemia and related B-cell malignancies. As experience in using ibrutinib increased, the first drug to be licensed in its class, atrial fibrillation (AF) emerged as an important side effect. The intersection between BTKi therapy for B-cell malignancies and AF represents a complex area of management with scant evidence for guidance. Consideration needs to be taken regarding the interplay of increased bleeding risk versus thromboembolic complications of AF, drug interactions between ibrutinib and anticoagulants and antiarrhythmic agents, and the potential for other, as yet seldom reported cardiac side effects. This review describes the current knowledge regarding BTKi and potential pathophysiologic mechanisms of AF and discusses the management of BTKi-associated AF. Finally, a review of the second generation BTKi is provided and gaps in knowledge in this evolving field are highlighted.
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Affiliation(s)
- Chloe Pek Sang Tang
- a Department of Haematology , St Vincent's Hospital Melbourne , Fitzroy , Australia
| | - Julie McMullen
- b Baker IDI Heart and Diabetes Institute , Melbourne , Australia
| | - Constantine Tam
- a Department of Haematology , St Vincent's Hospital Melbourne , Fitzroy , Australia
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