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Elshony H, Alzahrani M, Khafaji S, Almuhanna R, Khalil K, Mudassir R. Ischemic stroke as the initial presentation in acute myeloid leukemia vs. myelodysplastic syndrome: a case report and literature review with pathophysiological and clinical exploration. Neurol Sci 2024; 45:3297-3304. [PMID: 38351359 DOI: 10.1007/s10072-024-07367-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/25/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) present intricate challenges due to their diverse clinical manifestations and thrombotic complications. Thromboembolism (TE) incidence in newly diagnosed AML patients is noteworthy, with arterial TE linked to poorer overall survival. Ischemic strokes, although relatively low in prevalence, carry significant clinical implications. CASE DESCRIPTION We report the case of an 84-year-old male with Type 2 Diabetes, Hypertension, and Chronic Kidney Disease, presenting with seizures, focal neurological deficits, and pancytopenia. An unexpected diagnosis of AML or MDS emerged during the investigation. Despite interventions, the patient's condition deteriorated, leading to a fatal outcome weeks later. CONCLUSION This case underscores the intricate relationship between hematologic malignancies and ischemic stroke. The rarity of this complication emphasizes the importance of understanding the multifaceted mechanisms at play, including hyperleukocytosis, pro-inflammatory cytokine release, coagulation cascade activation, and direct interactions with endothelial cells. In our literature review, analysis of 15 cases, including ours, revealed a wide age range (3-87 years) and a gender bias towards females. AML diagnosis was predominant, with uniformly low platelet counts. Cortical infarctions, especially in the anterior circulation, were common. Hyperleukocytosis, disseminated intravascular coagulation (DIC), and fatal outcomes were observed in a subset of cases. Despite the grim statistics and often poor prognosis, the identification of specific risk factors, such as thrombocytopenia and cytogenetic abnormalities, offers avenues for targeted prevention and management.
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Affiliation(s)
- Hosna Elshony
- Department of Neuropsychiatry, Faculty of Medicine, Menoufiya University, Shebin El-kom, Egypt.
| | - Meshari Alzahrani
- Department of Neurology/Internal Medicine, Security Forces Hospital, Almashaer Street, Altaif road, Makkah, Saudi Arabia
| | - Salah Khafaji
- Department of Neurology/Internal Medicine, Security Forces Hospital, Almashaer Street, Altaif road, Makkah, Saudi Arabia
| | - Rakan Almuhanna
- Department of Neurology/Internal Medicine, Security Forces Hospital, Almashaer Street, Altaif road, Makkah, Saudi Arabia
| | - Khalid Khalil
- Department of Internal Medicine/Hematology, Security Forces Hospital, Makkah, Saudi Arabia
| | - Rabia Mudassir
- Department of Neurology/Internal Medicine, Security Forces Hospital, Almashaer Street, Altaif road, Makkah, Saudi Arabia
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Algarra-Sahuquillo J, Pestana-Eliche M, Markthaler M, Martín-Neda FG. Tranexamic Acid for Postoperative Bleeding in a Patient Treated With Ibrutinib. Dermatol Surg 2024:00042728-990000000-00827. [PMID: 38833410 DOI: 10.1097/dss.0000000000004266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Affiliation(s)
| | - María Pestana-Eliche
- Dermatology Department, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
| | - Marcella Markthaler
- Dermatology Department, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
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Tawfiq RK, Abeykoon JP, Kapoor P. Bruton Tyrosine Kinase Inhibition: an Effective Strategy to Manage Waldenström Macroglobulinemia. Curr Hematol Malig Rep 2024; 19:120-137. [PMID: 38536576 DOI: 10.1007/s11899-024-00731-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2024] [Indexed: 05/26/2024]
Abstract
PURPOSE OF REVIEW The treatment of Waldenström macroglobulinemia (WM) has evolved over the past decade. With the seminal discoveries of MYD88 and CXCR warts, hypogammaglobulinemia, infections, and myelokathexis (WHIM) mutations in WM cells, our understanding of the disease biology and treatment has improved. The development of a new class of agents, Bruton tyrosine kinase inhibitors (BTKi), has substantially impacted the treatment paradigm of WM. Herein, we review the current and emerging BTKi and the evidence for their use in WM. RECENT FINDINGS Clinical trials have established the role of covalent BTKi in the treatment of WM. Their efficacy is compromised among patients who harbor CXCR4WHIM mutation or MYD88WT genotype. The development of BTKC481 mutation-mediated resistance to covalent BTKi may lead to disease refractoriness. Novel, non-covalent, next-generation BTKi are emerging, and preliminary results of the early phase clinical trials show promising activity in WM, even among patients refractory to a covalent BTKi. Covalent BTK inhibitors have demonstrated meaningful outcomes in treatment-naïve (TN) and relapsed refractory (R/R) WM, particularly among those harboring the MYD88L265P mutation. The next-generation BTKi demonstrate improved selectivity, resulting in a more favorable toxicity profile. In WM, BTKi are administered until progression or the development of intolerable toxicity. Consequently, the potential for acquired resistance, the emergence of cumulative toxicities, and treatment-related financial burden are critical challenges associated with the continuous therapy approach. By circumventing BTK C481 mutations that alter the binding site to covalent BTKi, the non-covalent BTKi serve as alternative agents in the event of acquired resistance. Head-to-head comparative trials with the conventional chemoimmunotherapies are lacking. The findings of the RAINBOW trial (NCT046152), comparing the dexamethasone, rituximab, and cyclophosphamide (DRC) regimen to the first-generation, ibrutinib are awaited, but more studies are needed to draw definitive conclusions on the comparative efficacy of chemoimmunotherapy and BTKi. Complete response is elusive with BTKi, and combination regimens to improve upon the efficacy and limit the treatment duration are also under evaluation in WM.
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Affiliation(s)
- Reema K Tawfiq
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Jithma P Abeykoon
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Prashant Kapoor
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Huang Y, Qin Y, He Y, Qiu D, Zheng Y, Wei J, Zhang L, Yang DH, Li Y. Advances in molecular targeted drugs in combination with CAR-T cell therapy for hematologic malignancies. Drug Resist Updat 2024; 74:101082. [PMID: 38569225 DOI: 10.1016/j.drup.2024.101082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/03/2024] [Accepted: 03/22/2024] [Indexed: 04/05/2024]
Abstract
Molecular targeted drugs and chimeric antigen receptor (CAR) T cell therapy represent specific biological treatments that have significantly improved the efficacy of treating hematologic malignancies. However, they face challenges such as drug resistance and recurrence after treatment. Combining molecular targeted drugs and CAR-T cells could regulate immunity, improve tumor microenvironment (TME), promote cell apoptosis, and enhance sensitivity to tumor cell killing. This approach might provide a dual coordinated attack on cancer cells, effectively eliminating minimal residual disease and overcoming therapy resistance. Moreover, molecular targeted drugs can directly or indirectly enhance the anti-tumor effect of CAR-T cells by inducing tumor target antigen expression, reversing CAR-T cell exhaustion, and reducing CAR-T cell associated toxic side effects. Therefore, combining molecular targeted drugs with CAR-T cells is a promising and novel tactic for treating hematologic malignancies. In this review article, we focus on analyzing the mechanism of therapy resistance and its reversal of CAR-T cell therapy resistance, as well as the synergistic mechanism, safety, and future challenges in CAR-T cell therapy in combination with molecular targeted drugs. We aim to explore the benefits of this combination therapy for patients with hematologic malignancies and provide a rationale for subsequent clinical studies.
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Affiliation(s)
- Yuxian Huang
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, Guangdong, China.
| | - Yinjie Qin
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, Guangdong, China
| | - Yingzhi He
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, Guangdong, China
| | - Dezhi Qiu
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, Guangdong, China
| | - Yeqin Zheng
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, Guangdong, China
| | - Jiayue Wei
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, Guangdong, China
| | - Lenghe Zhang
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, Guangdong, China
| | - Dong-Hua Yang
- New York College of Traditional Chinese Medicine, Mineola, NY, USA.
| | - Yuhua Li
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, Guangdong, China.
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Airas L, Bermel RA, Chitnis T, Hartung HP, Nakahara J, Stuve O, Williams MJ, Kieseier BC, Wiendl H. A review of Bruton's tyrosine kinase inhibitors in multiple sclerosis. Ther Adv Neurol Disord 2024; 17:17562864241233041. [PMID: 38638671 PMCID: PMC11025433 DOI: 10.1177/17562864241233041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 01/29/2024] [Indexed: 04/20/2024] Open
Abstract
Bruton's tyrosine kinase (BTK) inhibitors are an emerging class of therapeutics in multiple sclerosis (MS). BTK is expressed in B-cells and myeloid cells, key progenitors of which include dendritic cells, microglia and macrophages, integral effectors of MS pathogenesis, along with mast cells, establishing the relevance of BTK inhibitors to diverse autoimmune conditions. First-generation BTK inhibitors are currently utilized in the treatment of B-cell malignancies and show efficacy in B-cell modulation. B-cell depleting therapies have shown success as disease-modifying treatments (DMTs) in MS, highlighting the potential of BTK inhibitors for this indication; however, first-generation BTK inhibitors exhibit a challenging safety profile that is unsuitable for chronic use, as required for MS DMTs. A second generation of highly selective BTK inhibitors has shown efficacy in modulating MS-relevant mechanisms of pathogenesis in preclinical as well as clinical studies. Six of these BTK inhibitors are undergoing clinical development for MS, three of which are also under investigation for chronic spontaneous urticaria (CSU), rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Phase II trials of selected BTK inhibitors for MS showed reductions in new gadolinium-enhancing lesions on magnetic resonance imaging scans; however, the safety profile is yet to be ascertained in chronic use. Understanding of the safety profile is developing by combining safety insights from the ongoing phase II and III trials of second-generation BTK inhibitors for MS, CSU, RA and SLE. This narrative review investigates the potential of BTK inhibitors as an MS DMT, the improved selectivity of second-generation inhibitors, comparative safety insights established thus far through clinical development programmes and proposed implications in female reproductive health and in long-term administration.
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Affiliation(s)
- Laura Airas
- Division of Clinical Neurosciences, University of Turku, Turku, Finland
- Neurocenter, Turku University Hospital, Turku, Finland
| | - Robert A. Bermel
- Mellen Center for MS, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tanuja Chitnis
- Brigham Multiple Sclerosis Center, Harvard Medical School, Boston, MA, USA
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
- Brain and Mind Center, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Palacký University Olomouc, Olomouc, Czech Republic
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Olaf Stuve
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Neurology Section, VA North Texas Health Care System, Dallas, TX, USA
- Peter O’Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Bernd C. Kieseier
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
- Novartis Pharma AG, Basel, Switzerland
| | - Heinz Wiendl
- Department of Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A 1, Muenster 48149, Germany
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Li X, Shang N, Yan Q, Yue X, Liu Y, Zheng X. Investigating bleeding adverse events associated with BTK inhibitors in the food and drug administration adverse event reporting system (FAERS). Expert Opin Drug Saf 2024:1-10. [PMID: 38568245 DOI: 10.1080/14740338.2024.2339448] [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: 02/14/2024] [Accepted: 03/28/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND This study analyzed the bleeding adverse events (AEs) resulting from the treatment of B-cell lymphoma with Bruton tyrosine kinase (BTK) inhibitors, according to reports in the US Food and Drug Administration's Adverse Event Reporting System (FAERS). METHODS Bleeding AEs associated with BTK inhibitors (including ibrutinib, zanubrutinib, and acalabrutinib) from the first quarter of 2013 to the third quarter of 2023 were extracted. Reporting odds ratio (ROR) and proportional reporting ratio (PRR) were reported. Preferred Terms (PTs) of Medical Dictionary for Regulatory Activities (MedDRA) terms were mapped to System Organ Class terms (SOC) terms and analyzed bleeding AEs associated with three BTK inhibitors. RESULTS A total of 463 cases of bleeding AEs were included. Contusion, subcutaneous hemorrhage, hematuria, and cerebral hemorrhage were included in PTs. Blood urine was present and subdural hematoma were also reported. The incidence of bleeding AEs was higher with ibrutinib (Case number = 10,696) than with zanubrutinib (Case number = 213) and acalabrutinib (Case number = 314). CONCLUSION Our findings indicate that bleeding AEs linked to BTK inhibitors in various conditions underscore the need for cautious clinical decision-making, particularly in nervous system disorders, injuries, poisoning, surgical complications, vascular disorders, and others.
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Affiliation(s)
- Xianlin Li
- Department of Pharmacy, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Nan Shang
- Department of Pharmacy, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Qianci Yan
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xiunan Yue
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yang Liu
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xiaojun Zheng
- Department of Pharmacy, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
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Parviz M, Agius R, Rotbain EC, Vainer N, Aarup K, Niemann CU. Identifying CLL patients at high risk of atrial fibrillation on treatment using machine learning. Leuk Lymphoma 2024; 65:449-459. [PMID: 38179708 DOI: 10.1080/10428194.2023.2299737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/21/2023] [Indexed: 01/06/2024]
Abstract
An increased risk of developing atrial fibrillation (AF) has been observed in patients with chronic lymphocytic leukemia (CLL) who were treated with ibrutinib and other BTK inhibitors. Previous studies have explored the prevalence of AF in CLL and the risk of developing AF at time of diagnosis. However, the interaction between treatment type with other risk factors on risk of developing atrial fibrillation at the time of treatment initiation has not been investigated. This becomes particularly crucial in CLL, as there is often a substantial time gap between diagnosis and treatment, unlike many other cancers. We propose a treatment-aware approach using predictive modeling to identify the risk factors associated with AF at time of treatment initiation. Moreover, the model provides treatment-dependent risk factors by including the interaction between the treatment types and other risk factors. The results demonstrated that the treatment-aware modeling including interactions outperformed currentrisk scores.
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Affiliation(s)
- Mehdi Parviz
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Rudi Agius
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | - Noomi Vainer
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Kathrine Aarup
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Carsten U Niemann
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
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8
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Patel R, Singh A, Meng Z, Baldridge AS, Addison D, Akhter N. The risk vs. benefit calculus of anticoagulation in patients with ibrutinib-related atrial fibrillation. Leuk Lymphoma 2024; 65:168-174. [PMID: 37953609 PMCID: PMC10952122 DOI: 10.1080/10428194.2023.2278433] [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: 08/11/2023] [Accepted: 10/29/2023] [Indexed: 11/14/2023]
Abstract
For ibrutinib-related atrial fibrillation (IRAF), guidelines for anticoagulation do not exist. We sought to describe stroke, bleeding, and anticoagulation rates among patients with IRAF. We performed a single-center retrospective review of 168 patients treated with ibrutinib followed from 2013 to 2022. Over a median follow-up of 6.4 years, 44 (26.0%) patients developed IRAF of which 38 (86.4%) had a CHA2DS2-VASc ≥2 and 7 (15.9%) had a HAS-BLED ≥3. Anticoagulation was initiated in 20 (45.5%) without a clear pattern in scores, risk factors, or cumulative dose, besides having another reason for anticoagulation. Few patients with IRAF developed non-hemorrhagic CVA (n = 3, 6.8%) or significant bleeding (n = 3, 6.8%). Among those with each adverse outcome, 2 in each group were anticoagulated and all were older than 65 years old. In conclusion, decisions for anticoagulation vary widely and patients who are elderly or with HTN may be most at risk for CVA or significant bleed.
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Affiliation(s)
- Ruchi Patel
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Arushi Singh
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Zhiying Meng
- Department of Medicine, Division of Cardiovascular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Abigail S. Baldridge
- Department of Medicine, Division of Cardiovascular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Daniel Addison
- Division of Cardiology, CardioOncology Program, The Ohio State University Medical Center, Columbus, OH
- Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH
| | - Nausheen Akhter
- Department of Medicine, Division of Cardiovascular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Wang Y, Xu J, Li P, Xu Y, Xue H, Liu P. Zanubrutinib-lenalidomide-rituximab (ZR 2) in unfit diffuse large B-cell lymphoma: efficient and tolerant. Ann Hematol 2024; 103:499-510. [PMID: 37957370 DOI: 10.1007/s00277-023-05498-7] [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: 07/05/2023] [Accepted: 10/06/2023] [Indexed: 11/15/2023]
Abstract
The objective of this study is to examine the effectiveness and safety of zanubrutinib, rituximab, and lenalidomide (ZR2) in unfit patients with diffuse large B-cell lymphoma (DLBCL). Thrombosis or bleeding risk of ZR2 regimen, especially when antiplatelet agents were co-prescribed, was also evaluated. We retrospectively reviewed unfit newly diagnosed (ND) and refractory or relapsed (R/R) patients with DLBCL who were administered with ZR2 regimen in two medical centers between December 2019 and February 2022. Response rates, progression-free survival (PFS), overall survival (OS), bleeding adverse events (AEs), and thrombosis episodes were analyzed. Furthermore, we investigated the effects of zanubrutinib alone or in combination with lenalidomide on platelet functions in vitro and in vivo. A total of 30 unfit patients (13 ND DLBCL and 17 R/R DLBCL patients) who received ZR2 regimen were enrolled in the study (median age: 69.5 years). The ultimate ORRs for the ND DLBCL and R/R DLBCL were 77.0% and 50.1%, respectively. The median follow-up was 16.6 months. The median PFS and OS were not achieved during the follow-up time. Subcutaneous hemorrhage AEs occurred in four cases, three cases suffered severe bleeding events, and thrombosis events were observed in two patients. ZR2 regimen inhibited platelet functions (aggregation, clot retraction, spreading and activation) in vitro and in vivo function testing especially in response to collagen. ZR2 is an efficient treatment option for unfit patients with DLBCL and could be well tolerated. Notably, this regimen inhibited platelet functions. Antiplatelet agents should be used with caution in patients treated with this regimen.
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Affiliation(s)
- Yawen Wang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Hematology, the Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Jiadai Xu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Panpan Li
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yanyan Xu
- Department of Biochemistry and Molecular Cell Biology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongwei Xue
- Department of Hematology, the Affiliated Hospital of Qingdao University, Qingdao, Shandong, China.
| | - Peng Liu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China.
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China.
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Kueffer LE, Lin DYW, Amatya N, Serrenho J, Joseph RE, Courtney AH, Andreotti AH. Screening and Characterization of Allosteric Small Molecules Targeting Bruton's Tyrosine Kinase. Biochemistry 2024; 63:94-106. [PMID: 38091504 DOI: 10.1021/acs.biochem.3c00362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Bruton's Tyrosine Kinase (BTK) is a nonreceptor tyrosine kinase that belongs to the TEC family. Mutations in the BTK gene cause X-linked agammaglobulinemia (XLA) leading to an arrest in B-cell development. BTK is also a drug target for B-cell lymphomas that rely on an intact B-cell receptor signaling cascade for survival. All FDA approved drugs for BTK target the ATP binding site of the catalytic kinase domain, leading to potential adverse events due to off-target inhibition. In addition, acquired resistance mutations occur in a subset of patients, rendering available BTK inhibitors ineffective. Therefore, allosteric sites on BTK should be explored for drug development to target BTK more specifically and in combination with active site inhibitors. Virtual screening against nonactive site pockets and in vitro experiments resulted in a series of small molecules that bind to BTK outside of the active site. We characterized these compounds using biochemical and biophysical techniques and narrowed our focus to compound "C2". C2 activates full-length BTK and smaller multidomain BTK fragments but not the isolated kinase domain, consistent with an allosteric mode of action. Kinetic experiments reveal a C2-mediated decrease in Km and an increase in kcat leading to an overall increase in the catalytic efficiency of BTK. C2 is also capable of activating the BTK XLA mutants. These proof-of-principle data reveal that BTK can be targeted allosterically with small molecules, providing an alternative to active site BTK inhibitors.
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Affiliation(s)
- Lauren E Kueffer
- Roy J. Carver Department of Biochemistry, Biophysics, and Molecular Biology, Iowa State University, Ames, Iowa 50011, United States
| | - David Yin-Wei Lin
- Roy J. Carver Department of Biochemistry, Biophysics, and Molecular Biology, Iowa State University, Ames, Iowa 50011, United States
| | - Neha Amatya
- Roy J. Carver Department of Biochemistry, Biophysics, and Molecular Biology, Iowa State University, Ames, Iowa 50011, United States
| | - Joseph Serrenho
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Raji E Joseph
- Roy J. Carver Department of Biochemistry, Biophysics, and Molecular Biology, Iowa State University, Ames, Iowa 50011, United States
| | - Adam H Courtney
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Amy H Andreotti
- Roy J. Carver Department of Biochemistry, Biophysics, and Molecular Biology, Iowa State University, Ames, Iowa 50011, United States
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Dhopeshwarkar N, Yang W, Hennessy S, Rhodes JM, Cuker A, Leonard CE. Combining Super Learner with high-dimensional propensity score to improve confounding adjustment: A real-world application in chronic lymphocytic leukemia. Pharmacoepidemiol Drug Saf 2024; 33:e5678. [PMID: 37609668 PMCID: PMC10841179 DOI: 10.1002/pds.5678] [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: 04/15/2023] [Revised: 07/28/2023] [Accepted: 08/02/2023] [Indexed: 08/24/2023]
Abstract
PURPOSE High-dimensional propensity score (hdPS) is a semiautomated method that leverages a vast number of covariates available in healthcare databases to improve confounding adjustment. A novel combined Super Learner (SL)-hdPS approach was proposed to assist with selecting the number of covariates for propensity score inclusion, and was found in plasmode simulation studies to improve bias reduction and precision compared to hdPS alone. However, the approach has not been examined in the applied setting. METHODS We compared SL-hdPS's performance with that of several hdPS models, each with prespecified covariates and a different number of empirically-identified covariates, using a cohort study comparing real-world bleeding rates between ibrutinib- and bendamustine-rituximab (BR)-treated individuals with chronic lymphocytic leukemia in Optum's de-identified Clinformatics® Data Mart commercial claims database (2013-2020). We used inverse probability of treatment weighting for confounding adjustment and Cox proportional hazards regression to estimate hazard ratios (HRs) for bleeding outcomes. Parameters of interest included prespecified and empirically-identified covariate balance (absolute standardized difference [ASD] thresholds of <0.10 and <0.05) and outcome HR precision (95% confidence intervals). RESULTS We identified 2423 ibrutinib- and 1102 BR-treated individuals. Including >200 empirically-identified covariates in the hdPS model compromised covariate balance at both ASD thresholds. SL-hdPS balanced more covariates than all individual hdPS models at both ASD thresholds. The bleeding HR 95% confidence intervals were generally narrower with SL-hdPS than with individual hdPS models. CONCLUSION In a real-world application, hdPS was sensitive to the number of covariates included, while use of SL for covariate selection resulted in improved covariate balance and possibly improved precision.
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Affiliation(s)
- Neil Dhopeshwarkar
- Center for Real-World Effectiveness and Safety of Therapeutics and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
| | - Wei Yang
- Center for Real-World Effectiveness and Safety of Therapeutics and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
| | - Sean Hennessy
- Center for Real-World Effectiveness and Safety of Therapeutics and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
| | - Joanna M. Rhodes
- Division of Hematology/Medical Oncology, Department of Medicine, Northwell Health (New Hyde Park, New York, US)
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
| | - Charles E. Leonard
- Center for Real-World Effectiveness and Safety of Therapeutics and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
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12
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Sindt JE, Fitzgerald LA, Kuznicki J, Prelewicz S, Odell DW, Brogan SE. Antiplatelet and Wound Healing Implications of Immunotherapy and Targeted Cancer Therapies in the Perioperative Period. Anesthesiology 2023; 139:511-522. [PMID: 37698434 DOI: 10.1097/aln.0000000000004669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
The traditional paradigm of oncologic treatment centered on cytotoxic chemotherapy has undergone tremendous advancement during the last 15 yr with the advent of immunotherapy and targeted cancer therapies. These agents, including small molecule inhibitors, monoclonal antibodies, and immune-checkpoint inhibitors, are highly specific to individual tumor characteristics and can prevent cell growth and tumorigenesis by inhibiting specific molecular targets or single oncogenes. While generally better tolerated than traditional chemotherapy, these therapies are associated with unique constellations of adverse effects. Of particular importance in the perioperative and periprocedural settings are hematologic abnormalities, particularly antiplatelet effects with increased risk of bleeding, and implications for wound healing. This narrative review discusses targeted cancer therapies and provides recommendations for physicians managing these patients' care as it relates to procedural or surgical interventions.
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Affiliation(s)
- Jill E Sindt
- Division of Pain Medicine, Department of Anesthesiology, University of Utah-Huntsman Cancer Institute, Salt Lake City, Utah
| | - Lindsey A Fitzgerald
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah-Huntsman Cancer Institute, Salt Lake City, Utah
| | - Joanne Kuznicki
- Department of Pharmacy, University of Utah-Huntsman Cancer Institute, Salt Lake City, Utah
| | - Stacy Prelewicz
- Department of Pharmacy, University of Utah-Huntsman Cancer Institute, Salt Lake City, Utah
| | - Daniel W Odell
- Division of Pain Medicine, Department of Anesthesiology, University of Utah-Huntsman Cancer Institute, Salt Lake City, Utah
| | - Shane E Brogan
- Division of Pain Medicine, Department of Anesthesiology, University of Utah-Huntsman Cancer Institute, Salt Lake City, Utah
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13
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Easaw S, Ezzati S, Coombs CC. SOHO State of the Art Updates and Next Questions: Updates on BTK Inhibitors for the Treatment of Chronic Lymphocytic Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:697-704. [PMID: 37544810 DOI: 10.1016/j.clml.2023.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/24/2023] [Indexed: 08/08/2023]
Abstract
Over the last decade, targeted inhibition of Bruton's tyrosine kinase (BTK) has led to a paradigm shift in the way chronic lymphocytic leukemia (CLL) is managed. BTK inhibitors (BTKi) are broadly classified as covalent BTKI and noncovalent BTKi (cBTKi and ncBTK) Ibrutinib, as the first approved cBTKi, vastly improved outcomes for patients with CLL over prior chemoimmunotherapy regimens. However, long-term use is limited by both intolerance and resistance. The second generation of more selective BTKi were developed to improve tolerability. While these agents have led to an improved safety profile in comparison to Ibrutinib (both acalabrutinib and zanubrutinib), and improved efficacy (zanubrutinib), intolerance occasionally occurs, and resistance remains a challenge. The third generation of BTKi, which noncovalently or reversibly inhibits BTK, has shown promising results in early phase trials and are being evaluated in the phase 3 setting. These drugs could be an effective treatment option in patients with either resistance and intolerance to cBTKi. The most recent development in therapeutic agents targeting BTK is the development of BTK degraders. By removing BTK, as opposed to inhibiting it, these drugs could remain efficacious irrespective of BTK resistance mutations, however clinical data are limited at this time. This review summarizes the evolution and ongoing development of newer BTKi and BTK degraders in the management of CLL, with a focus of future directions in this field, including how emerging clinical data could inform therapeutic sequencing in CLL management.
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Affiliation(s)
| | - Shawyon Ezzati
- California Northstate University College of Medicine, Elk Grove, CA
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14
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Tazoe K, Nishimoto M, Yamamoto A, Makuuchi Y, Kuno M, Okamura H, Nakashima Y, Tanaka S, Ohsawa M, Hino M, Nakamae H. Ibrutinib Induces a Dramatic Improvement for Idiopathic Refractory Ascites Following Allogeneic Hematopoietic Cell Transplantation. Intern Med 2023; 62:2737-2741. [PMID: 36754405 PMCID: PMC10569935 DOI: 10.2169/internalmedicine.1139-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/27/2022] [Indexed: 02/10/2023] Open
Abstract
We herein report a case of idiopathic refractory ascites following allogeneic hematopoietic cell transplantation that was successfully treated with ibrutinib. A 39-year-old man presented with massive transudative ascites. Despite a high portal venous pressure, the liver histology showed traces of alloreactivity inconsistent with veno-occlusive disease/sinusoidal obstructive syndrome. Ibrutinib was administered for ascites possibly secondary to portal hypertension associated with the alloreactivity. The ascites dramatically improved, and the portal venous pressure was reduced. This case may help clarify the mechanism through which refractory ascites develops after allogeneic hematopoietic cell transplantation and establish appropriate treatment protocols.
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Affiliation(s)
- Kumiyo Tazoe
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Mitsutaka Nishimoto
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Yosuke Makuuchi
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Masatomo Kuno
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Hiroshi Okamura
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Yasuhiro Nakashima
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Sayaka Tanaka
- Department of Diagnostic Pathology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Masahiko Ohsawa
- Department of Diagnostic Pathology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Masayuki Hino
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Hirohisa Nakamae
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Japan
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15
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Tam CS, Muñoz JL, Seymour JF, Opat S. Zanubrutinib: past, present, and future. Blood Cancer J 2023; 13:141. [PMID: 37696810 PMCID: PMC10495438 DOI: 10.1038/s41408-023-00902-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/01/2023] [Accepted: 08/14/2023] [Indexed: 09/13/2023] Open
Abstract
In recent years, Bruton tyrosine kinase (BTK) inhibitors have provided significant advances in the treatment of patients with B-cell malignancies. Ibrutinib was the first BTK inhibitor to be approved, and it changed the standard-of-care treatment for diseases such as chronic lymphocytic leukemia, mantle cell lymphoma, marginal zone lymphoma, and Waldenström macroglobulinemia, improving efficacy outcomes and safety compared to chemotherapy. In this article, we review the development of zanubrutinib, a next-generation BTK inhibitor, from molecular design to patient-related outcomes. We start this journey by providing insights into the discovery of BTK and the physiologic, genetic, and molecular characterization of patients lacking this kinase, together with the brief treatment landscape in the era of chemo-immunotherapies. Zanubrutinib was originally developed by applying a structure-activity strategy to enhance the specificity as well as enzymatic and pharmacokinetic properties. Preclinical studies confirmed greater specificity and better bioavailability of zanubrutinib compared with that of ibrutinib, which supported the initiation of clinical trials in humans. Preliminary clinical results indicated activity in B-cell malignancies together with an improved safety profile, in line with less off-target effects described in the preclinical studies. The clinical program of zanubrutinib has since expanded significantly, with ongoing studies in a wide range of hemato-oncological diseases and in combination with many other therapies. Zanubrutinib currently is approved for various B-cell malignancies in multiple countries. This story highlights the importance of multidisciplinary collaborative research, from bench to bedside, and provides an example of how the commitment to finding improved treatment options should always run parallel to patient care.
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Affiliation(s)
| | | | - John F Seymour
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital & University of Melbourne, Melbourne, VIC, Australia
| | - Stephen Opat
- Monash Health and Monash University, Clayton, VIC, Australia
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16
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Kwok C, Nolan M. Cardiotoxicity of anti-cancer drugs: cellular mechanisms and clinical implications. Front Cardiovasc Med 2023; 10:1150569. [PMID: 37745115 PMCID: PMC10516301 DOI: 10.3389/fcvm.2023.1150569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 07/17/2023] [Indexed: 09/26/2023] Open
Abstract
Cardio-oncology is an emerging field that seeks to enhance quality of life and longevity of cancer survivors. It is pertinent for clinicians to understand the cellular mechanisms of prescribed therapies, as this contributes to robust understanding of complex treatments and off-target effects, improved communication with patients, and guides long term care with the goal to minimise or prevent cardiovascular complications. Our aim is to review the cellular mechanisms of cardiotoxicity involved in commonly used anti-cancer treatments and identify gaps in literature and strategies to mitigate cardiotoxicity effects and guide future research endeavours.
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Affiliation(s)
- Cecilia Kwok
- Department of Medicine, Western Health, Melbourne, VIC, Australia
| | - Mark Nolan
- Department of Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Cardiovascular Imaging, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
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17
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Aghel N, Baro Vila RC, Lui M, Hillis C, Leong DP. Diagnosis and Management of Cardiovascular Effects of Bruton's Tyrosine Kinase Inhibitors. Curr Cardiol Rep 2023; 25:941-958. [PMID: 37498449 DOI: 10.1007/s11886-023-01916-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 07/28/2023]
Abstract
PURPOSE OF REVIEW Bruton's tyrosine kinase inhibitors (BTKis) have changed the treatment and prognosis of several B-cell malignancies. However, since the approval of the first BTKi, ibrutinib, reports of cardiovascular adverse events especially atrial fibrillation have arisen. In this review, we discuss the cardiovascular side effects of BTKis and the management of these toxicities in clinical practice. RECENT FINDINGS BTKIs increase the risks of atrial fibrillation, bleeding, hypertension, heart failure, and potentially ventricular arrhythmia. Newer second and third-generation BTKis appear to have a lower risk of cardiovascular adverse events; however, long-term follow-up data are not available for these new BTKis. BTKis are an effective treatment for some B-cell malignancies; however, they can cause cardiovascular side effects. The best preventive strategies to minimize cardiovascular complications remain undefined. Currently, a practical approach for managing patients receiving BTKis includes the management of cardiovascular risk factors and side effects of BTKis to prevent interruption of cancer treatment.
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Affiliation(s)
- Nazanin Aghel
- The Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
- McMaster University, Hamilton, ON, Canada.
| | - Rocio C Baro Vila
- McMaster University, Hamilton, ON, Canada
- Division of Cardiology, Instituto Cardiovascular de Buenos Aires ICBA, Buenos Aires, Argentina
| | | | | | - Darryl P Leong
- The Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- McMaster University, Hamilton, ON, Canada
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18
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Bruzzese A, Martino EA, Labanca C, Mendicino F, Lucia E, Olivito V, Neri A, Morabito F, Vigna E, Gentile M. Zanubrutinib for the treatment of chronic lymphocytic leukemia. Expert Opin Pharmacother 2023; 24:1409-1413. [PMID: 37350553 DOI: 10.1080/14656566.2023.2229734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/22/2023] [Indexed: 06/24/2023]
Affiliation(s)
| | | | | | | | - Eugenio Lucia
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | | | - Antonino Neri
- Scientific Directorate IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | | | - Ernesto Vigna
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, Rende, Italy
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19
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Mascolo A, Di Napoli R, Balzano N, D’Alessio E, Izzo I, Rossi F, Paolisso G, Capuano A, Sportiello L. Which is the top player for the cardiovascular safety? ibrutinib vs. obinutuzumab in CLL. Front Pharmacol 2023; 14:1229304. [PMID: 37654615 PMCID: PMC10467285 DOI: 10.3389/fphar.2023.1229304] [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: 05/26/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023] Open
Abstract
Introduction: Ibrutinib, a Bruton's tyrosine kinase (BTK) inhibitor, is authorized for the treatment of chronic lymphocytic leukemia (CLL). This study aims to explore the cardiac safety profile of ibrutinib in comparison with obinutuzumab. Methods: A retrospective pharmacovigilance study was conducted on data retrieved from the European pharmacovigilance database (Eudravigilance) from 1 January 2014 to 30 September 2022. To compare the reporting frequency of cardiovascular events among ibrutinib, obinutuzumab, and the combination of both. Results: A total of 2 291 CV cases were retrieved, of which 1965 were related to ibrutinib, 312 to obinutuzumab, and 14 to the combination. Most cases referred to patients aged ≥65 years (N = 1,454; 63.47%) and male (N = 1,497; 65.34%). Most cases were serious (N = 2,131; 93.02%). The most reported events were: atrial fibrillation (N = 913; 31.31%) and haemorrhage (N = 201; 6.89%). A higher reporting frequency of CV events was found when ibrutinib was compared to obinutuzumab (ROR, 3.22; 95% CI, 2.89-3.60) or combination (ROR, 1.77; 95% CI, 1.11-2.83). A lower reporting was observed when obinutuzumab was compared to combination (ROR, 0.55; 95% CI, 0.34-0.88). Discussion: A higher reporting frequency of CV events in patients exposed to ibrutinib in comparison with obinutuzumab was found. Further studies are needed to better explore the safety of ibrutinib.
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Affiliation(s)
- Annamaria Mascolo
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
- Department of Experimental Medicine—Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Raffaella Di Napoli
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
- Department of Experimental Medicine—Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Nunzia Balzano
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
- Department of Experimental Medicine—Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Elena D’Alessio
- Pharmacy Unit, Ospedale del Mare—A.S.L. Na1-Centro, Naples, Italy
| | - Imma Izzo
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
- Department of Experimental Medicine—Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Francesco Rossi
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
- Department of Experimental Medicine—Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Giuseppe Paolisso
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Annalisa Capuano
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
- Department of Experimental Medicine—Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Liberata Sportiello
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Napoli, Italy
- Department of Experimental Medicine—Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Napoli, Italy
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20
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Takeuchi T, Tanaka S, Murata M, Tanaka Y. Irreversible covalent Bruton's tyrosine kinase inhibitor, TAS5315 versus placebo in rheumatoid arthritis patients with inadequate response to methotrexate: a randomised, double-blind, phase IIa trial. Ann Rheum Dis 2023; 82:1025-1034. [PMID: 37217273 PMCID: PMC10359550 DOI: 10.1136/ard-2022-223759] [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: 12/13/2022] [Accepted: 05/03/2023] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To examine the efficacy and safety of TAS5315, an irreversible covalent Bruton's tyrosine kinase inhibitor, in Japanese patients with rheumatoid arthritis (RA) refractory to methotrexate. METHODS In part A of this phase IIa double-blind study, patients were randomised to TAS5315 4 or 2 mg or placebo once daily for 12 weeks; in part B, all patients received TAS5315 for another 24 weeks. The proportion of patients meeting American College of Rheumatology criteria for 20% improvement (ACR20) at week 12 was assessed (primary endpoint). RESULTS Ninety-one patients were randomised in part A, and 84 entered part B. At week 12, 78.9% of patients achieved ACR20 in the TAS5315 combined group vs 60.0% with placebo (p=0.053), 33.3% vs 13.3% achieved ACR50 (p=0.072) and 7.0% vs 0.0% achieved ACR70 (p=0.294), respectively. More patients receiving TAS5315 than placebo had low disease activity or remission at week 12. Clinical and biomarker improvements were maintained during part B. Adverse event (AE) incidence in TAS5315 was similar to placebo in part A; common AEs with TAS5315 were nasopharyngitis (10.3%), pruritus (6.9%) and cystitis (5.2%). Over 36 weeks, nine patients experienced bleeding events of whom four and two patients recovered with drug continuation and interruption, respectively. Three patients recovered after TAS5315 discontinuation. CONCLUSIONS The primary endpoint was not achieved. TAS5315 appears to have some bleeding risks, but nevertheless demonstrated numerical differences, compared with placebo, in the improvement rates of all measures of RA disease activity. Future analysis of the risk-benefit of TAS5315 should be considered. TRIAL REGISTRATION NUMBERS NCT03605251, JapicCTI-184020, jRCT2080223962.
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Affiliation(s)
- Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
- Saitama Medical University, Saitama, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, The University of Tokyo, Tokyo, Japan
| | - Mitsuru Murata
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
- Clinical Research Center for Medicine, International University of Health and Welfare, Tokyo, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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21
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Shyam Sunder S, Sharma UC, Pokharel S. Adverse effects of tyrosine kinase inhibitors in cancer therapy: pathophysiology, mechanisms and clinical management. Signal Transduct Target Ther 2023; 8:262. [PMID: 37414756 PMCID: PMC10326056 DOI: 10.1038/s41392-023-01469-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/06/2023] [Accepted: 04/23/2023] [Indexed: 07/08/2023] Open
Abstract
Since their invention in the early 2000s, tyrosine kinase inhibitors (TKIs) have gained prominence as the most effective pathway-directed anti-cancer agents. TKIs have shown significant utility in the treatment of multiple hematological malignancies and solid tumors, including chronic myelogenous leukemia, non-small cell lung cancers, gastrointestinal stromal tumors, and HER2-positive breast cancers. Given their widespread applications, an increasing frequency of TKI-induced adverse effects has been reported. Although TKIs are known to affect multiple organs in the body including the lungs, liver, gastrointestinal tract, kidneys, thyroid, blood, and skin, cardiac involvement accounts for some of the most serious complications. The most frequently reported cardiovascular side effects range from hypertension, atrial fibrillation, reduced cardiac function, and heart failure to sudden death. The potential mechanisms of these side effects are unclear, leading to critical knowledge gaps in the development of effective therapy and treatment guidelines. There are limited data to infer the best clinical approaches for the early detection and therapeutic modulation of TKI-induced side effects, and universal consensus regarding various management guidelines is yet to be reached. In this state-of-the-art review, we examine multiple pre-clinical and clinical studies and curate evidence on the pathophysiology, mechanisms, and clinical management of these adverse reactions. We expect that this review will provide researchers and allied healthcare providers with the most up-to-date information on the pathophysiology, natural history, risk stratification, and management of emerging TKI-induced side effects in cancer patients.
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Affiliation(s)
- Sunitha Shyam Sunder
- Cardio-Oncology Research Group, Department of Pathology and Laboratory Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Umesh C Sharma
- Division of Cardiovascular Medicine, Jacob's School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Saraswati Pokharel
- Cardio-Oncology Research Group, Department of Pathology and Laboratory Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.
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22
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Gomez EB, Ebata K, Randeria HS, Rosendahl MS, Cedervall EP, Morales TH, Hanson LM, Brown NE, Gong X, Stephens J, Wu W, Lippincott I, Ku KS, Walgren RA, Abada PB, Ballard JA, Allerston CK, Brandhuber BJ. Preclinical characterization of pirtobrutinib, a highly selective, noncovalent (reversible) BTK inhibitor. Blood 2023; 142:62-72. [PMID: 36796019 PMCID: PMC10651869 DOI: 10.1182/blood.2022018674] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/23/2023] [Accepted: 01/31/2023] [Indexed: 02/18/2023] Open
Abstract
Bruton tyrosine kinase (BTK), a nonreceptor tyrosine kinase, is a major therapeutic target for B-cell-driven malignancies. However, approved covalent BTK inhibitors (cBTKis) are associated with treatment limitations because of off-target side effects, suboptimal oral pharmacology, and development of resistance mutations (eg, C481) that prevent inhibitor binding. Here, we describe the preclinical profile of pirtobrutinib, a potent, highly selective, noncovalent (reversible) BTK inhibitor. Pirtobrutinib binds BTK with an extensive network of interactions to BTK and water molecules in the adenosine triphosphate binding region and shows no direct interaction with C481. Consequently, pirtobrutinib inhibits both BTK and BTK C481 substitution mutants in enzymatic and cell-based assays with similar potencies. In differential scanning fluorimetry studies, BTK bound to pirtobrutinib exhibited a higher melting temperature than cBTKi-bound BTK. Pirtobrutinib, but not cBTKis, prevented Y551 phosphorylation in the activation loop. These data suggest that pirtobrutinib uniquely stabilizes BTK in a closed, inactive conformation. Pirtobrutinib inhibits BTK signaling and cell proliferation in multiple B-cell lymphoma cell lines, and significantly inhibits tumor growth in human lymphoma xenografts in vivo. Enzymatic profiling showed that pirtobrutinib was highly selective for BTK in >98% of the human kinome, and in follow-up cellular studies pirtobrutinib retained >100-fold selectivity over other tested kinases. Collectively, these findings suggest that pirtobrutinib represents a novel BTK inhibitor with improved selectivity and unique pharmacologic, biophysical, and structural attributes with the potential to treat B-cell-driven cancers with improved precision and tolerability. Pirtobrutinib is being tested in phase 3 clinical studies for a variety of B-cell malignancies.
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23
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Johnson G, Baviriseaty N, Massanet N, Kooper J. Serositis causing pericardial and pleural effusions after eight years of maintenance ibrutinib for Waldenstrom's macroglobulinemia. J Oncol Pharm Pract 2023:10781552231171925. [PMID: 37097903 DOI: 10.1177/10781552231171925] [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: 04/26/2023]
Abstract
INTRODUCTION Ibrutinib is a tyrosine kinase inhibitor approved for multiple B-cell malignancies, including Waldenstrom's macroglobulinemia in 2014. Although the drug portends favorable outcomes, it also bears a profile of side effects. Current literature describes only two cases of nonhemorrhagic pericardial effusion associated with ibrutinib use, and here we present the third. This case recounts an episode of serositis causing pericardial and pleural effusions and diffuse edema after eight years of maintenance ibrutinib for Waldenstrom's macroglobulinemia (WM). CASE REPORT A 90-year-old male with WM and atrial fibrillation presented to the emergency department for a week of progressive periorbital and upper and lower extremity edema, dyspnea, and gross hematuria, despite increasing at-home diuretic dose. The patient was on 140 mg ibrutinib twice daily. Labs showed stable creatinine, serum IgMs of 97, and negative serum and urine protein electrophoresis. Imaging revealed bilateral pleural effusions and pericardial effusion with impending tamponade. All other workup was unrevealing, diuretics were ceased, pericardial effusion was monitored with serial echocardiograms, and ibrutinib was exchanged for low-dose prednisone. MANAGEMENT AND OUTCOME After five days, the effusions and edema dissipated, hematuria resolved, and patient was discharged. Resumption of lower dose ibrutinib one month later led to a subsequent return of edema, which again subsided with cessation. Reevaluation of maintenance therapy continues outpatient. CONCLUSION Patients on ibrutinib presenting with dyspnea and edema should be monitored for pericardial effusion; the drug should be held in exchange for anti-inflammatory therapy, and future management should involve cautious, low-dose resumption, or exchange for alternative therapy.
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Affiliation(s)
- Grace Johnson
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | | | - Nicholas Massanet
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Jeffrey Kooper
- James A Haley Veteran's Affairs Hospital, Tampa, FL, USA
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24
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Nixon S, Duquette D, Doucette S, Larouche JF. How We Manage Patients with Indolent B-Cell Malignancies on Bruton's Tyrosine Kinase Inhibitors: Practical Considerations for Nurses and Pharmacists. Curr Oncol 2023; 30:4222-4245. [PMID: 37185435 PMCID: PMC10137400 DOI: 10.3390/curroncol30040322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/05/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
The most common forms of B-cell malignancy, non-Hodgkin lymphoma (NHL) and chronic lymphocytic leukemia (CLL), have seen a drastic shift in the treatment landscape over the last two decades with the introduction of targeted agents. Among them are Bruton's tyrosine kinase (BTK) inhibitors, which have demonstrated excellent efficacy in indolent B-cell NHLs and CLL. Although BTK inhibitors are generally thought to be more tolerable than chemoimmunotherapy, they are associated with a unique safety profile including varying rates of rash, diarrhea, musculoskeletal events, cardiovascular events, and bleeding. Ibrutinib was the first BTK inhibitor to gain a Health Canada indication, followed by second-generation BTK inhibitors acalabrutinib and zanubrutinib, which have better safety profiles compared to ibrutinib, likely due to their improved selectivity for BTK. As BTK inhibitors are oral agents given continuously until disease progression, long-term adverse event (AE) monitoring and management as well as polypharmacy considerations are important for maintaining patient quality of life. This paper intends to serve as a reference for Canadian nurses and pharmacists on dosing, co-administration, and AE management strategies when caring for patients with indolent B-cell NHL or CLL being treated with BTK inhibitors.
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Affiliation(s)
- Shannon Nixon
- Malignant Hematology, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
| | - Dominic Duquette
- Department of Pharmacy, Hôpital de l'Enfant-Jésus, CHU de Québec-Université Laval, Quebec City, QC G1J 1Z4, Canada
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Diamond A, Bensken WP, Vu L, Dong W, Koroukian SM, Caimi P. Ibrutinib Is Associated With Increased Cardiovascular Events and Major Bleeding in Older CLL Patients. JACC CardioOncol 2023; 5:233-243. [PMID: 37144107 PMCID: PMC10152196 DOI: 10.1016/j.jaccao.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 01/25/2023] [Accepted: 02/07/2023] [Indexed: 05/06/2023] Open
Abstract
Background Early ibrutinib trials showed an association between ibrutinib use and risk of bleeding and atrial fibrillation (AF) in younger chronic lymphocytic leukemia (CLL) patients. Little is known about these adverse events in older CLL patients and whether increased AF rates are associated with increased stroke risk. Objectives To compare the incidence of stroke, AF, myocardial infarction, and bleeding in CLL patients treated with ibrutinib with those who were treated without ibrutinib in a linked SEER-Medicare database. Methods The incidence rate of each adverse event for treated and untreated patients was calculated. Among those treated, inverse probability weighted Cox proportional hazards regression models were used to calculate HRs and 95% CIs for the association between ibrutinib treatment and each adverse event. Results Among 4,958 CLL patients, 50% were treated without ibrutinib and 6% received ibrutinib. The median age at first treatment was 77 (IQR: 73-83) years. Compared with those treated without ibrutinib, those treated with ibrutinib had a 1.91-fold increased risk of stroke (95% CI: 1.06-3.45), 3.65-fold increased risk of AF (95% CI: 2.42-5.49), a 4.92-fold increased risk of bleeding (95% CI: 3.46-7.01) and a 7.49-fold increased risk of major bleeding (95% CI: 4.32-12.99). Conclusions In patients a decade older than those in the initial clinical trials, treatment with ibrutinib was associated with an increased risk of stroke, AF, and bleeding. The risk of major bleeding is higher than previously reported and underscores the importance of surveillance registries to identify new safety signals.
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Affiliation(s)
- Akiva Diamond
- Dan L Duncan Comprehensive Cancer Center at Baylor St. Luke's Medical Center, Houston, Texas, USA
- Address for correspondence: Dr. Akiva Diamond, Dan L Duncan Comprehensive Cancer Center, 7200 Cambridge Street, Suite 7B, MS: BCM904, Houston, Texas 77030, USA. @Akiva.Diamond
| | - Wyatt P. Bensken
- Population Cancer Analytics Shared Resource, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Long Vu
- Population Cancer Analytics Shared Resource, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Weichuan Dong
- Population Cancer Analytics Shared Resource, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Siran M. Koroukian
- Population Cancer Analytics Shared Resource, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Paolo Caimi
- Cleveland Clinic Taussig Cancer Center, Cleveland, Ohio, USA
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Wolska-Washer A, Robak T. Zanubrutinib for the treatment of lymphoid malignancies: Current status and future directions. Front Oncol 2023; 13:1130595. [PMID: 37035197 PMCID: PMC10076791 DOI: 10.3389/fonc.2023.1130595] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/06/2023] [Indexed: 04/11/2023] Open
Abstract
Zanubrutinib (BGB-3111, Brukinsa®, BeiGene) is a next-generation irreversible inhibitor of Bruton's tyrosine kinase (BTK), developed by BeiGene in 2012 for the treatment of B-cell malignancies. It was designed to minimize off-target inhibition of TEC- and EGFR-family kinases. Zanubrutinib is more selective than ibrutinib for BTK versus EGFR, FGR, FRK, HER2, HER4, ITK, JAK3, LCK, BLK and TEC. In addition, compared to ibrutinib, zanubrutinib has improved oral absorption and better target occupancy. Zanubrutinib demonstrated a lower incidence of off-target toxicities and reduced severity than ibrutinib. Moreover, zanubrutinib is similar to acalabrutinib, with less activity against TEC and ITK. The preliminary phase 1 results suggest that zanubrutinib has clinical activity and the drug is well tolerated in patients with B-cell lymphoid malignancies. Recent clinical trials have found it to demonstrate excellent efficacy and good tolerability in patients with chronic lymphocytic leukemia (CLL), Waldenstrom macroglobulinemia (WM) and mantle cell lymphoma (MCL). In recent phase 3 studies, zanubrutinib was compared with ibrutinib in patients with relapsed/refractory (R/R) MW and RR CLL. In both trials, zanubrutinib was found to demonstrate clinically meaningful advantages in safety and tolerability over ibrutinib; in particular, it was associated with a lower risk of atrial fibrillation/flutter and major bleeding events. In the recent SEQUOIA study, comparing zanubrutinib with bendamustine and rituximab (BR) in patients with previously untreated CLL, zanubrutinib significantly improved progression-free survival versus BR, with an acceptable safety profile consistent with previous studies. Zanubrutinib also demonstrated good activity and tolerability in patients with R/R MCL, marginal zone lymphoma and follicular lymphoma. Trials examining the efficacy and safety of the combination of zanubrutinib with obinutuzumab venetoclax and other drugs are ongoing. This review summarizes the clinical efficacy and safety of zanubrutinib in lymphoid malignancies.
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Affiliation(s)
- Anna Wolska-Washer
- Department of Experimental Hematology, Medical University of Lodz, Lodz, Poland
- Department of Hematooncology, Copernicus Memorial Hospital, Lodz, Poland
| | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Lodz, Poland
- Department of General Hematology, Copernicus Memorial Hospital, Lodz, Poland
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Evaluation of bleeding events in patients receiving acalabrutinib therapy. Leukemia 2023:10.1038/s41375-023-01869-1. [PMID: 36932166 DOI: 10.1038/s41375-023-01869-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/22/2023] [Accepted: 03/01/2023] [Indexed: 03/19/2023]
Abstract
Acalabrutinib is a next-generation, more selective, covalent Bruton tyrosine kinase inhibitor (BTKi), designed to have less toxicity, including bleeding, than the first-generation covalent BTKi ibrutinib. We performed a retrospective medical record review of 289 patients with B-cell malignancies treated with acalabrutinib to evaluate and describe bleeding events. Median acalabrutinib exposure was 40.8 months (range 0-81.6) with 83% of patients experiencing at least one bleeding event. Of these patients, 59%, 35%, and 6% had a clinically non-relevant minor, clinically relevant minor, or major bleed as their first, most severe event per ISTH criteria, respectively. For all bleed events, 24% were clinically relevant minor/major and 2.5% were CTCAE grade ≥3. Age >65, prior bleed history, and longer time on acalabrutinib therapy were found to be independent risk factors for clinically relevant minor/major bleeds. Additionally, 1263 procedures were identified, and the incidence of clinically non-relevant and clinically relevant minor/major bleeds related to procedures was 0.95% and 1.3%, respectively. In conclusion, with a long median exposure time, most bleeds were clinically non-relevant per ISTH criteria and CTCAE grade <3 for patients with B-cell malignancies treated with acalabrutinib.
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Cao X, Jin X, Zhang X, Utsav P, Zhang Y, Guo R, Lu W, Zhao M. Small-Molecule Compounds Boost CAR-T Cell Therapy in Hematological Malignancies. Curr Treat Options Oncol 2023; 24:184-211. [PMID: 36701037 PMCID: PMC9992085 DOI: 10.1007/s11864-023-01049-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2022] [Indexed: 01/27/2023]
Abstract
OPINION STATEMENT Although chimeric antigen receptor T cell immunotherapy has been successfully applied in patients with hematological malignancies, several obstacles still need to be overcome, such as high relapse rates and side effects. Overcoming the limitations of CAR-T cell therapy and boosting the efficacy of CAR-T cell therapy are urgent issues that must be addressed. The exploration of small-molecule compounds in combination with CAR-T cell therapies has achieved promising success in pre-clinical and clinical studies in recent years. Protein kinase inhibitors, demethylating drugs, HDAC inhibitors, PI3K inhibitors, immunomodulatory drugs, Akt inhibitors, mTOR inhibitors, and Bcl-2 inhibitors exhibited potential synergy in combination with CAR-T cell therapy. In this review, we will discuss the recent application of these combination therapies for improved outcomes of CAR-T cell therapy.
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Affiliation(s)
- Xinping Cao
- First Center Clinic College of Tianjin Medical University, Tianjin, 300192, China
| | - Xin Jin
- Department of Hematology, Tianjin First Central Hospital, Tianjin, 300192, China
| | - Xiaomei Zhang
- School of Medicine, Nankai University, Tianjin, 300071, China
| | - Paudel Utsav
- First Center Clinic College of Tianjin Medical University, Tianjin, 300192, China
| | - Yi Zhang
- First Center Clinic College of Tianjin Medical University, Tianjin, 300192, China
| | - Ruiting Guo
- First Center Clinic College of Tianjin Medical University, Tianjin, 300192, China
| | - Wenyi Lu
- Department of Hematology, Tianjin First Central Hospital, Tianjin, 300192, China.
| | - Mingfeng Zhao
- Department of Hematology, Tianjin First Central Hospital, Tianjin, 300192, China.
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Pratz KW, Kaplan J, Levy M, Bixby D, Burke PW, Erba H, Wise-Draper TM, Roboz GJ, Papadantonakis N, Rajkhowa T, Hernandez D, Dobler I, Gregory RC, Li C, Wang S, Stumpo K, Kannan K, Miao H, Levis M. A phase Ib trial of mivavotinib (TAK-659), a dual SYK/FLT3 inhibitor, in patients with relapsed/refractory acute myeloid leukemia. Haematologica 2023; 108:705-716. [PMID: 36226495 PMCID: PMC9973464 DOI: 10.3324/haematol.2022.281216] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Indexed: 11/09/2022] Open
Abstract
Mivavotinib (TAK-659) is an investigational type 1 tyrosine kinase inhibitor with dual activity against spleen tyrosine kinase (SYK) and FMS-like tyrosine kinase 3 (FLT3). We conducted a phase Ib study to investigate the safety, tolerability, and efficacy of mivavotinib in patients with refractory and/or relapsed (R/R) acute myeloid leukemia (AML). Both daily (QD) and twice daily (BID) dosing regimens were evaluated. A total of 43 patients were enrolled, and there were 5 complete responses (4 with incomplete count recovery). In the QD dosing regimen, the maximum tolerated dose (MTD) was not reached up to 160 mg QD per protocol; 140 mg QD was identified as the recommended phase II dose. In the BID dosing regimen, the MTD was 60 mg BID. Thirty patients (70%) experienced a bleeding event on study; the majority were grades 1 or 2, were resolved without mivavotinib modification, and were not considered related to study treatment. Eleven patients (26%) experienced grade ≥3 bleeding events, which were observed most frequently with the 80 mg BID dose. We conducted platelet aggregation studies to investigate the potential role of mivavotinib-mediated SYK inhibition on platelet function. The bleeding events observed may have been the result of several confounding factors, including AML disease status, associated thrombocytopenia, and high doses of mivavotinib. Overall, these findings indicate that the activity of mivavotinib in R/R AML is modest. Furthermore, any future clinical investigation of this agent should be undertaken with caution, particularly in thrombocytopenic patients, due to the potential bleeding risk of SYK inhibition. ClinicalTrials.gov: NCT02323113.
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Affiliation(s)
- Keith W Pratz
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA
| | - Jason Kaplan
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL
| | - Moshe Levy
- Baylor University Medical Center, Dallas, TX
| | - Dale Bixby
- University of Michigan Rogel Cancer Center, Ann Arbor, MI
| | | | - Harry Erba
- Duke University School of Medicine, Durham, NC
| | | | | | | | - Trivikram Rajkhowa
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Daniela Hernandez
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Iwona Dobler
- Takeda Development Center Americas, Inc. (TDCA), Cambridge, MA
| | | | - Cheryl Li
- Takeda Development Center Americas, Inc. (TDCA), Cambridge, MA
| | - Shining Wang
- Takeda Development Center Americas, Inc. (TDCA), Cambridge, MA
| | - Kate Stumpo
- Takeda Development Center Americas, Inc. (TDCA), Cambridge, MA
| | | | - Harry Miao
- Takeda Development Center Americas, Inc. (TDCA), Cambridge, MA
| | - Mark Levis
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD.
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Ali MA, Anwar MY, Aiman W, Dhanesar G, Omar Z, Hamza M, Zafar M, Rengarajan HK, Maroules M. Safety and Efficacy of Tyrosine Kinase Inhibitors in Immune Thrombocytopenic Purpura: A Systematic Review of Clinical Trials. J Xenobiot 2023; 13:29-41. [PMID: 36810430 PMCID: PMC9944448 DOI: 10.3390/jox13010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 02/03/2023] Open
Abstract
Immune thrombocytopenic purpura (ITP) is an acquired antibody or cell-mediated platelet damage or decreased platelet production. Steroids, IV immunoglobulins (IVIG), and Rho-anti-D antibodies are the commonly used initial treatments for ITP. However, many ITP patients either do not respond or do not maintain a response to initial therapy. Splenectomy, rituximab, and thrombomimetics are the commonly used second-line treatment. More treatment options include tyrosine kinases inhibitors (TKI), including spleen tyrosine kinase (Syk) and Bruton's tyrosine kinase (BTK) inhibitors. This review aims to assess the safety and efficacy of TKIs. Methods: Literature was searched on PubMed, Embase, WOS, and clinicaltrials.gov using keywords, "tyrosine kinase" and "idiopathic thrombocytopenic purpura". PRISMA guidelines were followed. Results: In total, 4 clinical trials were included with 255 adult patients with relapsed/refractory ITP. In all, 101 (39.6%) patients were treated with fostamatinib, 60 (23%) patients with rilzabrutinib, and 34 (13%) with HMPL-523. Patients treated with fostamatinib achieved a stable response (SR) and overall response (OR) in 18/101 (17.8%) and 43/101 (42.5%) of the patients, respectively, while SR and OR were achieved in 1/49 (2%) and 7/49 (14%) of the patients, respectively, in the placebo group. Patients treated with HMPL-523 (300 mg dose expansion) achieved an SR and OR in 5/20 (25%) and 11/20 (55%) of the patients, respectively, while SR and OR were achieved in 1/11 (9%) of the patients treated with the placebo. Patients treated with rilzabrutinib achieved an SR in 17/60 (28%) patients. Dizziness (1%), hypertension (2%), diarrhea (1%), and neutropenia (1%) were serious adverse events in fostamatinib patients. Rilzabrutinib or HMPL-523 patients did not require a dose reduction due to drug-related adverse effects. Conclusions: Rilzabrutinib, fostamatinib, and HMPL-523 were safe and effective in the treatment of relapsed/refractory ITP.
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Affiliation(s)
- Muhammad Ashar Ali
- Department of Internal Medicine, St. Mary’s and St. Clare’s Hospitals, New York Medical College, Denville, NJ 07834, USA
- Correspondence:
| | - Muhammad Yasir Anwar
- Department of Internal Medicine, BronxCare Hospital, Icahn School of Medicine, Bronx, NY 10457, USA
| | - Wajeeha Aiman
- Department of Internal Medicine, Saint Michael’s Medical Center, New York Medical College, Newark, NJ 07102, USA
| | - Gurneel Dhanesar
- Department of Internal Medicine, St. Mary’s and St. Clare’s Hospitals, New York Medical College, Denville, NJ 07834, USA
| | - Zainab Omar
- Department of Pediatrics, Dubai Medical College for Girls, Dubai 20170, United Arab Emirates
| | - Mohammad Hamza
- Department of Internal Medicine, Albany Medical Center Hospital, Albany, NY 12208, USA
| | - Maha Zafar
- Department of Internal Medicine, Mercy Hospital Fort Smith, Arkansas College of Osteopathic Medicine, Fort Smith, AR 72903, USA
| | - Harish Kumar Rengarajan
- Department of Internal Medicine, St. Mary’s and St. Clare’s Hospitals, New York Medical College, Denville, NJ 07834, USA
| | - Michael Maroules
- Department of Hematology/Oncology, St. Mary’s General Hospital, New York Medical College, Passaic, NJ 07102, USA
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Zheng Y, Guo X, Chen C, Chi L, Guo Z, Liang J, Wei L, Chen X, Ye X, He J. Cardiovascular Toxicities of Ibrutinib: A Pharmacovigilance Study Based on the United States Food and Drug Administration Adverse Event Reporting System Database. Pharmaceuticals (Basel) 2023; 16:ph16010098. [PMID: 36678594 PMCID: PMC9863914 DOI: 10.3390/ph16010098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/29/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023] Open
Abstract
Background: Although ibrutinib has been widely used to treat haematological malignancies, many studies have reported associated cardiovascular events. These studies were primarily animal experiments and clinical trials. For more rational clinical drug use, a study based on post-marketing data is necessary. Aim: Based on post-marketing data, we investigated the clinical features, time to onset, and outcomes of potential cardiovascular toxicities of ibrutinib. Methods: This disproportionality study utilised data from the 2014−2021 United States Food and Drug Administration Adverse Event Reporting System (FAERS) database. We used two disproportionality methods information component (IC) and reporting odds ratio (ROR)) to detect the potential cardiovascular toxicities of ibrutinib. Positive signals were defined as IC025 > 0 and ROR025 > 1. Results: A total of 10 cardiovascular events showed positive signals: supraventricular tachyarrhythmias, haemorrhagic central nervous system vascular conditions, ventricular tachyarrhythmias, cardiac failure, ischaemic central nervous system vascular conditions, cardiomyopathy, conduction defects, myocardial infarction, myocardial infarction disorders of sinus node function, and torsade de pointes/QT prolongation. Cardiomyopathy and supraventricular tachyarrhythmias were the two most common signals. Disorders of sinus node function were observed for the first time, which may be a new adverse effect of ibrutinib. Conclusions: This pharmacovigilance study systematically explored the adverse cardiovascular events of ibrutinib and provided new safety signals based on past safety information. Attention should be paid to some high-risk signals.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Xiaofei Ye
- Correspondence: (X.Y.); (J.H.); Tel.: +86-138-1626-2536 (X.Y.); +86-133-8627-7040 (J.H.)
| | - Jia He
- Correspondence: (X.Y.); (J.H.); Tel.: +86-138-1626-2536 (X.Y.); +86-133-8627-7040 (J.H.)
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Buske C, Jurczak W, Salem JE, Dimopoulos MA. Managing Waldenström's macroglobulinemia with BTK inhibitors. Leukemia 2023; 37:35-46. [PMID: 36402930 PMCID: PMC9883164 DOI: 10.1038/s41375-022-01732-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/09/2022] [Accepted: 10/13/2022] [Indexed: 11/21/2022]
Abstract
Bruton's tyrosine kinase (BTK) inhibition is one of the treatment standards for patients with relapsed/refractory Waldenström's macroglobulinemia (WM) and for patients with WM who are unsuitable for immunochemotherapy (ICT). It offers deep and durable responses with a manageable safety profile that is generally favorable compared with ICT regimens. However, the limitations of the first approved BTK inhibitor (BTKi), ibrutinib, include reduced efficacy in patients lacking the characteristic WM mutation (MYD88L265P) and toxicities related to off-target activity. The risk of atrial fibrillation (AF) and other cardiovascular side effects are a notable feature of ibrutinib therapy. Several next-generation covalent BTKis with greater selectivity for BTK are at various stages of development. In November 2021, zanubrutinib became the first of these agents to be approved by the European Medicines Agency for the treatment of WM. Head-to-head trial data indicate that it has comparable efficacy to ibrutinib for patients with WM overall, although it may be more effective in patients with CXCR4 mutations or wild-type MYD88. In the clinical trial setting, its greater selectivity translates into a reduced risk of cardiovascular side effects, including AF. Acalabrutinib, which is pre-approval in WM, appears to offer similar advantages over ibrutinib in terms of its safety profile. Beyond the next-generation covalent BTKis, non-covalent BTKis are an emerging class with the potential to provide a therapeutic option for patients who relapse on covalent BTKis. In the future, BTKis may be increasingly utilized within combination regimens. Several ongoing trials in WM are investigating the potential for BTKi use in combination with established and novel targeted agents.
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Affiliation(s)
- Christian Buske
- Institute of Experimental Cancer Research, Comprehensive Cancer Center, University Hospital of Ulm, Ulm, Germany.
| | - Wojciech Jurczak
- Department of Clinical Oncology, Maria Skłodowska-Curie National Research Institute of Oncology, Kraków, Poland
| | - Joe-Elie Salem
- Sorbonne University, AP-HP, INSERM CIC-1901, Paris, France
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
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33
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Severe Postoperative Bleeding Secondary to Ibrutinib Intake. Dermatol Surg 2023; 49:106-108. [DOI: 10.1097/dss.0000000000003650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Platelet recovery with ibrutinib therapy in patient with treatment-refractory immune thrombocytopenia. Ann Hematol 2023; 102:237-238. [PMID: 36441261 DOI: 10.1007/s00277-022-05031-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/04/2022] [Indexed: 11/29/2022]
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35
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Wallace DJ, Dörner T, Pisetsky DS, Sanchez‐Guerrero J, Patel AC, Parsons‐Rich D, Le Bolay C, Drouin EE, Kao AH, Guehring H, Dall'Era M. Efficacy and Safety of the Bruton's Tyrosine Kinase Inhibitor Evobrutinib in Systemic Lupus Erythematosus: Results of a Phase II, Randomized, Double-Blind, Placebo-Controlled Dose-Ranging Trial. ACR Open Rheumatol 2022; 5:38-48. [PMID: 36530019 PMCID: PMC9837396 DOI: 10.1002/acr2.11511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Evobrutinib is a highly selective, orally administered Bruton's tyrosine kinase (BTK) inhibitor. The objective of this phase II, multicenter, randomized, double-blind, placebo-controlled trial was to evaluate the efficacy and safety of evobrutinib in patients with active autoantibody-positive systemic lupus erythematosus (SLE). METHODS Patients were diagnosed with SLE by either the Systemic Lupus International Collaborating Clinics criteria or at least four American College of Rheumatology criteria 6 months or more prior to screening, had an SLE Disease Activity Index-2000 score of 6 or more, were autoantibody-positive and on standard-of-care therapy. Randomization was 1:1:1:1 to oral evobrutinib 25 mg once daily (QD), 75 mg QD, 50 mg twice daily, or placebo. Primary efficacy endpoints were SLE responder index (SRI)-4 response at week 52 and SRI-6 response at week 52 in the high disease activity subpopulation. Safety endpoints included treatment-emergent adverse events (TEAEs). RESULTS A total of 469 patients were randomized and received at least one dose of evobrutinib or placebo at the time of primary analysis. Mean (SD) age at baseline was 40.7 (±12.3) years; 94.9% of patients were female. Neither primary efficacy endpoint was met. All doses of evobrutinib were well tolerated, and there was no clear dose effect on the incidence of reported TEAEs, or serious TEAEs, including severe infections. CONCLUSION This phase II, dose-ranging trial in SLE failed to show a treatment effect of evobrutinib versus placebo at any dose. Evobrutinib was generally well tolerated, with no dose effect observed for TEAEs. These results suggest that BTK inhibition does not appear to be an effective therapeutic intervention for patients with SLE.
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Affiliation(s)
- Daniel J. Wallace
- Cedars‐Sinai Medical Center and David Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
| | - Thomas Dörner
- Dept. Medicine/Rheumatology and Clinical ImmunologyCharité UniversitätsmedizinBerlinGermany
| | - David S. Pisetsky
- Division of Rheumatology and Immunology at Duke University Medical CenterDurhamNorth CarolinaUSA,Medical Research Service, Durham VAMCDurhamNorth CarolinaUSA
| | | | - Anand C. Patel
- Pioneering Medicines, Flagship Pioneering, Cambridge, Massachusetts, USA; ECD‐Early Clinical Development, Pfizer, Cambridge, Massachusetts, USA; EMD SeronoBillericaMassachusettsUSA
| | - Dana Parsons‐Rich
- Pioneering Medicines, Flagship Pioneering, Cambridge, Massachusetts, USA; ECD‐Early Clinical Development, Pfizer, Cambridge, Massachusetts, USA; EMD SeronoBillericaMassachusettsUSA
| | | | - Elise E. Drouin
- Pioneering Medicines, Flagship Pioneering, Cambridge, Massachusetts, USA; ECD‐Early Clinical Development, Pfizer, Cambridge, Massachusetts, USA; EMD SeronoBillericaMassachusettsUSA
| | - Amy H. Kao
- Pioneering Medicines, Flagship Pioneering, Cambridge, Massachusetts, USA; ECD‐Early Clinical Development, Pfizer, Cambridge, Massachusetts, USA; EMD SeronoBillericaMassachusettsUSA
| | - Hans Guehring
- The healthcare business of Merck KGaADarmstadtGermany
| | - Maria Dall'Era
- Division of RheumatologyRussell/Engleman Rheumatology Research Center, University of CaliforniaSan FranciscoCaliforniaUSA
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Kuss B, Nagarajan C, Hsieh WS, Cheah CY. Practical management of chronic lymphocytic leukemia with acalabrutinib. Leuk Lymphoma 2022; 63:2785-2794. [PMID: 35852229 DOI: 10.1080/10428194.2022.2098289] [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: 12/14/2022]
Abstract
Treatment of chronic lymphocytic leukemia (CLL) has been transformed in the past two decades. The introduction of targeted therapies has improved patient outcomes and the deliverability of effective therapies. Making the best use of the next wave of Bruton's tyrosine kinase (BTK) inhibitors requires an understanding of the nuances that separate the drugs in this class of agents. This paper reviews the newer BTK inhibitors and provides practical guidance on the management of CLL using acalabrutinib. Acalabrutinib is a safe and efficacious BTKi in the treatment of CLL. While some side effects appear to be an "on-target" effect of BTK inhibition, the selectivity of second-generation covalent BTK inhibitors such as acalabrutinib may result in a favorable safety profile due to less off-target kinase inhibition. Acalabrutinib represents a well-tolerated and effective alternative to ibrutinib in the management of CLL.
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Affiliation(s)
- Bryone Kuss
- Molecular Medicine and Genetics, Flinders University, Adelaide, SA, Australia.,Haematology Department, Flinders Medical Centre and SA Pathology, Adelaide, SA, Australia
| | - Chandramouli Nagarajan
- Department of Haematology, Singapore General Hospital, 1 Outram Rd, Block 3 Basement, Singapore 169608, Singapore.,SingHealth DUKE-NUS Blood Cancer Center and Duke-NUS Medical School, 8 College Road, Singapore 169857, Singapore
| | - Wen Son Hsieh
- ICON Cancer Centre, 1 Farrer Park Station Rd, Singapore 217562, Singapore.,Division of Hematologic Malignancies, The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland, USA
| | - Chan Yoon Cheah
- University of Western Australia Medical School, University of Western Australia, Perth, WA, Australia.,Haematology Department, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
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Elaskalani O, Gilmore G, Hagger M, Baker RI, Metharom P. Adenosine 2A Receptor Activation Amplifies Ibrutinib Antiplatelet Effect; Implications in Chronic Lymphocytic Leukemia. Cancers (Basel) 2022; 14:cancers14235750. [PMID: 36497231 PMCID: PMC9741389 DOI: 10.3390/cancers14235750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022] Open
Abstract
Chronic lymphocytic leukemia patients have an increased bleeding risk with the introduction of Bruton tyrosine kinase (BTK) inhibitors. BTK is a signaling effector downstream of the platelet GPVI receptor. Innate platelet dysfunction in CLL patients and the contribution of the leukemia microenvironment to the anti-platelet effect of BTK inhibitors are still not well defined. Herein, we investigated platelet function in stable, untreated CLL patients in comparison to age-matched healthy subjects as control. Secondly, we proposed a novel mechanism of platelet dysfunction via the adenosinergic pathway during BTK inhibitor therapy. Our data indicate that the nucleotidase that produces adenosine, CD73, was expressed on one-third of B-cells in CLL patients. Inhibition of CD73 improved platelet response to ADP in the blood of CLL patients ex vivo. Using healthy platelets, we show that adenosine 2A (A2A) receptor activation amplifies the anti-platelet effect of ibrutinib (10 nM). Ibrutinib plus an A2A agonist-but not ibrutinib as a single agent-significantly inhibited collagen (10 µg/mL)-induced platelet aggregation. Mechanistically, A2A activation attenuated collagen-mediated inhibition of p-VASP and synergized with ibrutinib to inhibit the phosphorylation of AKT, ERK and SYK kinases. This manuscript highlights the potential role of adenosine generated by the microenvironment in ibrutinib-associated bleeding in CLL patients.
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Affiliation(s)
- Omar Elaskalani
- Telethon Kids Institute, Cancer Centre, Nedlands, WA 6009, Australia
- Centre for Child Health Research, University of Western Australia, Crawley, WA 6009, Australia
| | - Grace Gilmore
- Perth Blood Institute (PBI), Perth, WA 6005, Australia
- Western Australian Centre for Thrombosis and Haemostasis (WACTH), Health Futures Institute, Murdoch University, Murdoch, WA 6150, Australia
| | - Madison Hagger
- Platelet Research Laboratory, School of Pharmacy and Biomedical Sciences, Curtin Health and Innovation Research Institute (CHIRI), Faculty of Health Sciences, Curtin University, Bentley, WA 6102, Australia
| | - Ross I. Baker
- Perth Blood Institute (PBI), Perth, WA 6005, Australia
- Western Australian Centre for Thrombosis and Haemostasis (WACTH), Health Futures Institute, Murdoch University, Murdoch, WA 6150, Australia
- Correspondence: (R.I.B.); (P.M.)
| | - Pat Metharom
- Platelet Research Laboratory, School of Pharmacy and Biomedical Sciences, Curtin Health and Innovation Research Institute (CHIRI), Faculty of Health Sciences, Curtin University, Bentley, WA 6102, Australia
- Correspondence: (R.I.B.); (P.M.)
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38
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Rao H, Song X, Lei J, Lu P, Zhao G, Kang X, Zhang D, Zhang T, Ren Y, Peng C, Li Y, Pei J, Cao Z. Ibrutinib Prevents Acute Lung Injury via Multi-Targeting BTK, FLT3 and EGFR in Mice. Int J Mol Sci 2022; 23:13478. [PMID: 36362264 PMCID: PMC9657648 DOI: 10.3390/ijms232113478] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/28/2022] [Accepted: 10/28/2022] [Indexed: 09/12/2023] Open
Abstract
Ibrutinib has potential therapeutic or protective effects against viral- and bacterial-induced acute lung injury (ALI), likely by modulating the Bruton tyrosine kinase (BTK) signaling pathway. However, ibrutinib has multi-target effects. Moreover, immunity and inflammation targets in ALI treatment are poorly defined. We investigated whether the BTK-, FLT3-, and EGFR-related signaling pathways mediated the protective effects of ibrutinib on ALI. The intratracheal administration of poly I:C or LPS after ibrutinib administration in mice was performed by gavage. The pathological conditions of the lungs were assessed by micro-CT and HE staining. The levels of neutrophils, lymphocytes, and related inflammatory factors in the lungs were evaluated by ELISA, flow cytometry, immunohistochemistry, and immunofluorescence. Finally, the expression of proteins associated with the BTK-, FLT3-, and EGFR-related signaling pathways were evaluated by Western blotting. Ibrutinib (10 mg/kg) protected against poly I:C-induced (5 mg/kg) and LPS-induced (5 mg/kg) lung inflammation. The wet/dry weight ratio (W/D) and total proteins in the bronchoalveolar lavage fluid (BALF) were markedly reduced after ibrutinib (10 mg/kg) treatment, relative to the poly I:C- and LPS-treated groups. The levels of ALI indicators (NFκB, IL-1β, IL-6, TNF-α, IFN-γ, neutrophils, and lymphocytes) were significantly reduced after treatment. Accordingly, ibrutinib inhibited the poly I:C- and LPS-induced BTK-, FLT3-, and EGFR-related pathway activations. Ibrutinib inhibited poly I:C- and LPS-induced acute lung injury, and this may be due to its ability to suppress the BTK-, FLT3-, and EGFR-related signaling pathways. Therefore, ibrutinib is a potential protective agent for regulating immunity and inflammation in poly I:C- and LPS-induced ALI.
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Affiliation(s)
- Huanan Rao
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Xiaominting Song
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Jieting Lei
- Basic Medical College, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Peng Lu
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Guiying Zhao
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Xin Kang
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Duanna Zhang
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Tingrui Zhang
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Yali Ren
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Cheng Peng
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Yuzhi Li
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Jin Pei
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Zhixing Cao
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
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Wong JSY, Sadullah S. Acute haemothorax secondary to ibrutinib: A case report. EJHAEM 2022; 3:1365-1366. [PMID: 36467786 PMCID: PMC9713043 DOI: 10.1002/jha2.367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/25/2021] [Accepted: 11/29/2021] [Indexed: 06/17/2023]
Affiliation(s)
- Jessica Sue Yi Wong
- Department of HaematologyJames Paget University Hospitals NHS Foundation TrustGreat YarmouthUK
| | - Shalal Sadullah
- Department of HaematologyJames Paget University Hospitals NHS Foundation TrustGreat YarmouthUK
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Perioperative Bleeding Associated With Ibrutinib in Dermatologic Surgery: A Case-Control Study. Dermatol Surg 2022; 48:1166-1170. [PMID: 36095288 DOI: 10.1097/dss.0000000000003590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Ibrutinib, an irreversible Bruton tyrosine kinase inhibitor, has been associated with an increased risk of bleeding. There is a paucity of data on the risk of bleeding in patients on ibrutinib undergoing dermatologic surgery. OBJECTIVE To determine the frequency of bleeding complications associated with ibrutinib in patients undergoing dermatologic surgery. MATERIALS AND METHODS A retrospective, single-center, case-control study of patients on ibrutinib undergoing skin surgery between January 2013 and March 2020 compared with sex, disease, and age-matched control patients undergoing cutaneous surgeries. RESULTS A total of 75 surgeries performed on 37 case patients and 116 surgeries performed on 64 control patients were included. Ibrutinib was associated with a statistically significant increased rate of bleeding events (6/75 [8%] vs 1/116 [0.8%], p -value = .02). Compared with ibrutinib patients who did not have a bleeding event, those on ibrutinib who suffered bleeding were all men, older (mean age 82.7 vs 73.0, p -value= .01), and had lower mean platelet counts (104.0 vs 150.5 K/μL, p -value = .03). CONCLUSION Ibrutinib may be associated with increased risk of bleeding in patients with hematologic malignancies, particularly older men with lower platelet levels and on multiple anticoagulants. Transient discontinuation of ibrutinib should be considered for dermatologic surgeries.
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Munoz JL, Wang Y, Jain P, Wang M. BTK Inhibitors and CAR T-Cell Therapy in Treating Mantle Cell Lymphoma-Finding a Dancing Partner. Curr Oncol Rep 2022; 24:1299-1311. [PMID: 35596920 PMCID: PMC9474429 DOI: 10.1007/s11912-022-01286-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW This review focuses on the feasibility of combining Bruton's tyrosine kinase (BTK) inhibitors (BTKis) with chimeric antigen receptor (CAR) T-cell therapy in patients with relapsed or refractory (R/R) mantle cell lymphoma (MCL). Potential scenarios for combination treatment with these agents are presented. RECENT FINDINGS BTKis and CAR T-cell therapy have revolutionized the treatment paradigm for R/R MCL. Ibrutinib, acalabrutinib, and zanubrutinib are covalent irreversible BTKis approved for R/R MCL. Brexucabtagene autoleucel was the first CAR T-cell therapy approved for R/R MCL based on findings from the ZUMA-2 trial. There is evidence to suggest that combination treatment with BTKis and CAR T-cell therapy may improve CAR T-cell efficacy. As BTKis and CAR T-cell therapy become mainstays in R/R MCL therapy, combination treatment strategies should be evaluated for their potential benefit in R/R MCL.
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Affiliation(s)
| | | | - Preetesh Jain
- Department of Lymphoma-Myeloma, Division of Cancer Medicine, MD Anderson Cancer Center, University of Texas, Houston, TX, USA.
| | - Michael Wang
- Department of Lymphoma-Myeloma, Division of Cancer Medicine, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
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42
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Leitinger DE, Kaplan DZ. BTK Inhibitors in Haematology: Beyond B Cell Malignancies. Transfus Med Rev 2022; 36:239-245. [DOI: 10.1016/j.tmrv.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/25/2022] [Indexed: 11/27/2022]
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Antic D, Milic N, Chatzikonstantinou T, Scarfò L, Otasevic V, Rajovic N, Allsup D, Alonso Cabrero A, Andres M, Baile Gonzales M, Capasso A, Collado R, Cordoba R, Cuéllar-García C, Correa JG, De Paoli L, De Paolis MR, Del Poeta G, Dimou M, Doubek M, Efstathopoulou M, El-Ashwah S, Enrico A, Espinet B, Farina L, Ferrari A, Foglietta M, Lopez-Garcia A, García-Marco JA, García-Serra R, Gentile M, Gimeno E, da Silva MG, Gutwein O, Hakobyan YK, Herishanu Y, Hernández-Rivas JÁ, Herold T, Itchaki G, Jaksic O, Janssens A, Kalashnikova OB, Kalicińska E, Kater AP, Kersting S, Koren-Michowitz M, Labrador J, Lad D, Laurenti L, Fresa A, Levin MD, Mayor Bastida C, Malerba L, Marasca R, Marchetti M, Marquet J, Mihaljevic B, Milosevic I, Mirás F, Morawska M, Motta M, Munir T, Murru R, Nunes R, Olivieri J, Pavlovsky MA, Piskunova I, Popov VM, Quaglia FM, Quaresmini G, Reda G, Rigolin GM, Shrestha A, Šimkovič M, Smirnova S, Špaček M, Sportoletti P, Stanca O, Stavroyianni N, Te Raa D, Tomic K, Tonino S, Trentin L, Van Der Spek E, van Gelder M, Varettoni M, Visentin A, Vitale C, Vukovic V, Wasik-Szczepanek E, Wróbel T, Segundo LYS, Yassin M, Coscia M, Rambaldi A, Montserrat E, Foà R, Cuneo A, Carrier M, Ghia P, Stamatopoulos K. Thrombotic and bleeding complications in patients with chronic lymphocytic leukemia and severe COVID-19: a study of ERIC, the European Research Initiative on CLL. J Hematol Oncol 2022; 15:116. [PMID: 36028857 PMCID: PMC9415249 DOI: 10.1186/s13045-022-01333-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/08/2022] [Indexed: 12/03/2022] Open
Abstract
Background Patients with chronic lymphocytic leukemia (CLL) may be more susceptible to COVID-19 related poor outcomes, including thrombosis and death, due to the advanced age, the presence of comorbidities, and the disease and treatment-related immune deficiency. The aim of this study was to assess the risk of thrombosis and bleeding in patients with CLL affected by severe COVID-19. Methods This is a retrospective multicenter study conducted by ERIC, the European Research Initiative on CLL, including patients from 79 centers across 22 countries. Data collection was conducted between April and May 2021. The COVID-19 diagnosis was confirmed by the real-time polymerase chain reaction (RT-PCR) assay for SARS-CoV-2 on nasal or pharyngeal swabs. Severe cases of COVID-19 were defined by hospitalization and the need of oxygen or admission into ICU. Development and type of thrombotic events, presence and severity of bleeding complications were reported during treatment for COVID-19. Bleeding events were classified using ISTH definition. STROBE recommendations were used in order to enhance reporting. Results A total of 793 patients from 79 centers were included in the study with 593 being hospitalized (74.8%). Among these, 511 were defined as having severe COVID: 162 were admitted to the ICU while 349 received oxygen supplementation outside the ICU. Most patients (90.5%) were receiving thromboprophylaxis. During COVID-19 treatment, 11.1% developed a thromboembolic event, while 5.0% experienced bleeding. Thrombosis developed in 21.6% of patients who were not receiving thromboprophylaxis, in contrast to 10.6% of patients who were on thromboprophylaxis. Bleeding episodes were more frequent in patients receiving intermediate/therapeutic versus prophylactic doses of low-molecular-weight heparin (LWMH) (8.1% vs. 3.8%, respectively) and in elderly. In multivariate analysis, peak D-dimer level and C-reactive protein to albumin ratio were poor prognostic factors for thrombosis occurrence (OR = 1.022, 95%CI 1.007‒1.038 and OR = 1.025, 95%CI 1.001‒1.051, respectively), while thromboprophylaxis use was protective (OR = 0.199, 95%CI 0.061‒0.645). Age and LMWH intermediate/therapeutic dose administration were prognostic factors in multivariate model for bleeding (OR = 1.062, 95%CI 1.017–1.109 and OR = 2.438, 95%CI 1.023–5.813, respectively). Conclusions Patients with CLL affected by severe COVID-19 are at a high risk of thrombosis if thromboprophylaxis is not used, but also at increased risk of bleeding under the LMWH intermediate/therapeutic dose administration.
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Affiliation(s)
- Darko Antic
- Lymphoma Center, Clinic for Hematology, University Clinical Center of Serbia, Belgrade, Serbia. .,Faculty of Medicine, University of Belgrade, Belgrade, Serbia.
| | - Natasa Milic
- Department of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Thomas Chatzikonstantinou
- Hematology Department and HCT Unit, G. Papanicolaou Hospital, Thessaloniki, Greece.,Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki, Greece
| | - Lydia Scarfò
- Università Vita-Salute San Raffaele and IRCC Ospedale San Raffaele, Milan, Italy
| | - Vladimir Otasevic
- Lymphoma Center, Clinic for Hematology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Nina Rajovic
- Department of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - David Allsup
- Centre for Atherothrombosis and Metabolic Disease, Hull York Medical School, Hull, UK
| | | | - Martin Andres
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | - Rosa Collado
- Department of Hematology, Hospital General Universitario, Valencia, Spain.,Fundación de Investigación del Hospital General Universitario, Valencia, Spain
| | - Raul Cordoba
- Department of Hematology, Health Research Institute IIS-FJD, Fundacion Jimenez Diaz University Hospital, Madrid, Spain
| | | | | | - Lorenzo De Paoli
- Division of Internal Medicine, Hematology Unit, ASL Vercelli, Vercelli, Italy
| | | | - Giovanni Del Poeta
- Department of Biomedicine and Prevention Hematology, University Tor Vergata, Rome, Italy
| | - Maria Dimou
- 1st Internal Medicine Department, Propaedeutic, Hematology Clinical Trial Unit, National and Kapodistrian University of Athens, Athens, Greece
| | - Michael Doubek
- Department of Internal Medicine - Hematology and Oncology, University Hospital, Brno, Czechia.,Department of Medical Genetics and Genomics, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Maria Efstathopoulou
- Department of Haematology Athens Medical Center-Psychikon Branch, Athens, Greece
| | - Shaimaa El-Ashwah
- Clinical Hematology Unit, Oncology Center, Faculty of Medicine, Mansoura University, Mansoura, 35516, Egypt
| | | | - Blanca Espinet
- Department of Hematology, Hospital del Mar, Barcelona, Spain
| | - Lucia Farina
- Hematology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Angela Ferrari
- Hematology Unit, Azienda Unità Sanitaria Locale - IRCCS, Reggio Emilia, Italy
| | | | - Alberto Lopez-Garcia
- Department of Hematology, Health Research Institute IIS-FJD, Fundacion Jimenez Diaz University Hospital, Madrid, Spain
| | - José A García-Marco
- Hematology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Rocío García-Serra
- Department of Hematology, Hospital General Universitario, Valencia, Spain.,Fundación de Investigación del Hospital General Universitario, Valencia, Spain
| | | | - Eva Gimeno
- Department of Hematology, Hospital del Mar, Barcelona, Spain
| | - Maria Gomes da Silva
- Hematology Department, Portuguese Institute of Oncology Lisbon, Lisbon, Portugal
| | - Odit Gutwein
- Department of Hematology, Shamir Medical Center, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Yair Herishanu
- Department of Hematology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Tobias Herold
- Laboratory for Leukemia Diagnostics, Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Gilad Itchaki
- Division of Hematology, Rabin Medical Center, Petah Tikva, and the Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ozren Jaksic
- Department of Hematology, University Hospital Dubrava, Zagreb, Croatia
| | - Ann Janssens
- Department of Hematology, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Olga B Kalashnikova
- Federal State Budgetary Educational Institution of Higher Education Academician I.P. Pavlov, First St. Petersburg State Medical University of the Ministry of Healthcare of Russian Federation, St. Petersburg, Russia
| | - Elżbieta Kalicińska
- Department and Clinic of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Pasteura Street 4, 50-367, Wrocław, Poland
| | - Arnon P Kater
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Sabina Kersting
- Department of Hematology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Maya Koren-Michowitz
- Department of Hematology, Shamir Medical Center, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jorge Labrador
- Hematology Department, Unit Research, Complejo Asistencial Universitario de Burgos, Burgos, Spain
| | - Deepesh Lad
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Luca Laurenti
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy.,Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alberto Fresa
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy.,Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Mark-David Levin
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Carlota Mayor Bastida
- Haematology Department, Hospital Universitario de La Princesa, Madrid, Spain.,Spanish Society of Haematology and Hemotherapy (SEHH: Sociedad Española de Hematología y Hemoterapia), Madrid, Spain
| | - Lara Malerba
- Hematology and Stem Cell Transplant Center Marche Nord Hospital, Pesaro, Italy
| | - Roberto Marasca
- Section of Hematology, Department of Medical Sciences, University of Modena and Reggio E., Modena, Italy
| | - Monia Marchetti
- Hematology Unit & TMO Center, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Juan Marquet
- Hematology Department, Ramón y Cajal University Hospital, Madrid, Spain
| | - Biljana Mihaljevic
- Lymphoma Center, Clinic for Hematology, University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivana Milosevic
- Clinical Centre of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Fatima Mirás
- Hematology Department, Hospital Universitario 12de Octubre, Madrid, Spain
| | - Marta Morawska
- Experimental Hematooncology Department, Medical University of Lublin, Lublin, Poland.,Hematology Department, St. John's Cancer Center, Lublin, Poland
| | - Marina Motta
- S.C. Ematologia ASST Spedali Civili Brescia, Brescia, Italy
| | - Talha Munir
- Consultant Haematologist, St James's Hospital, Leeds, LS9 7TF, UK
| | - Roberta Murru
- Hematology and Stem Cell Transplantation Unit, Ospedale Oncologico A. Businco, ARNAS "G. Brotzu", Cagliari, Italy
| | - Raquel Nunes
- Hematology Department, Portuguese Institute of Oncology Lisbon, Lisbon, Portugal
| | | | | | - Inga Piskunova
- Consultative Hematology Department with a Day Hospital for Intensive High-Dose Chemotherapy, National Research Center for Hematology, Moscow, Russia
| | - Viola Maria Popov
- Hematology Department, Colentina Clinical Hospital, Bucharest, Romania
| | | | | | - Gianluigi Reda
- Hematology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy
| | | | - Amit Shrestha
- Hematology Unit, Nepal Cancer Hospital and Research Center, Lalitpur, Nepal
| | - Martin Šimkovič
- 4th Department of Internal Medicine - Haematology, Faculty of Medicine in Hradec Králové, University Hospital and Charles University in Prague, Hradec Kralove, Czech Republic
| | - Svetlana Smirnova
- Consultative Hematology Department with a Day Hospital for Intensive High-Dose Chemotherapy, National Research Center for Hematology, Moscow, Russia
| | - Martin Špaček
- 1st Department of Medicine - Hematology, First Faculty of Medicine, Charles University and General Hospital in Prague, Prague, Czech Republic
| | - Paolo Sportoletti
- Department of Medicine and Surgery, Institute of Hematology and Center for Hemato-Oncological Research, Ospedale S. Maria della Misericordia, Perugia, Italy
| | - Oana Stanca
- Hematology Department from Coltea Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Niki Stavroyianni
- Hematology Department and HCT Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - Doreen Te Raa
- Department of Hematology, Gelderse Vallei Ede, Ede, The Netherlands
| | - Kristina Tomic
- Lymphoma Center, Clinic for Hematology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Sanne Tonino
- Department of Hematology, Lymmcare, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Livio Trentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, Padua, Italy
| | - Ellen Van Der Spek
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Michel van Gelder
- Department Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marzia Varettoni
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, Padua, Italy
| | - Candida Vitale
- Division of Hematology, A.O.U. Cittàdella Salute e della Scienza di Torino and Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin, Italy
| | - Vojin Vukovic
- Lymphoma Center, Clinic for Hematology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Ewa Wasik-Szczepanek
- Department Hematooncology and Bone Marrow Transplantation, Medical University in Lublin, Lublin, Poland
| | - Tomasz Wróbel
- Department and Clinic of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Pasteura Street 4, 50-367, Wrocław, Poland
| | | | - Mohamed Yassin
- Hematology Section, Department of Medical Oncology, National Center for Cancer Care and Research, Doha, Qatar
| | - Marta Coscia
- Division of Hematology, A.O.U. Cittàdella Salute e della Scienza di Torino and Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin, Italy
| | | | | | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | | | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, K1H 8L6, Canada
| | - Paolo Ghia
- Università Vita-Salute San Raffaele and IRCC Ospedale San Raffaele, Milan, Italy
| | - Kostas Stamatopoulos
- Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki, Greece
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44
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Lovell AR, Jammal N, Bose P. Selecting the optimal BTK inhibitor therapy in CLL: rationale and practical considerations. Ther Adv Hematol 2022; 13:20406207221116577. [PMID: 35966045 PMCID: PMC9373150 DOI: 10.1177/20406207221116577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Bruton’s tyrosine kinase (BTK) inhibitors have dramatically changed the treatment
of newly diagnosed and relapsed/refractory chronic lymphocytic leukemia (CLL).
Ibrutinib, acalabrutinib, and zanubrutinib are Food and Drug Administration
(FDA)-approved BTK inhibitors that have all demonstrated progression-free
survival (PFS) benefit compared with chemoimmunotherapy. The efficacy of these
agents compared to one another is under study; however, current data suggest
they provide similar efficacy. Selectivity for BTK confers different adverse
effect profiles, and longer follow-up and real-world use have characterized side
effects over time. The choice of BTK inhibitor is largely patient-specific, and
this review aims to highlight the differences among the agents and guide the
choice of BTK inhibitor in clinical practice.
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Affiliation(s)
- Alexandra R Lovell
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nadya Jammal
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
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45
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Gonçalves-Teixeira P, Costa T, Fragoso I, Ferreira D, Brandão M, Leite-Moreira A, Sampaio F, Ribeiro J, Fontes-Carvalho R. Screening, Diagnosis and Management of Atrial Fibrillation in Cancer Patients: Current Evidence and Future Perspectives. Arq Bras Cardiol 2022; 119:328-341. [PMID: 35946695 PMCID: PMC9363048 DOI: 10.36660/abc.20201362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/12/2021] [Indexed: 11/18/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the general population, carrying a high morbimortality burden, and this also holds true in cancer patients. The association between AF and cancer goes even further, with some studies suggesting that AF can be a marker of occult cancer. There is, however, a remarkable paucity of data concerning specific challenges of AF management in cancer patients. AF prompt recognition and management in this special population can lessen the arrhythmia-related morbidity and have an important prognostic benefit. This review will focus on current AF diagnosis and management challenges in cancer patients, with special emphasis on AF screening strategies and devices, and anticoagulation therapy with non-vitamin K antagonist oral anti-coagulants (NOACs) for thromboembolic prevention in these patients. Some insights concerning future perspectives for AF prevention, diagnosis, and treatment in this special population will also be addressed.
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Affiliation(s)
- Pedro Gonçalves-Teixeira
- Departamento de Cardiologia, Vila Nova de Gaia Hospital Center, Gaia - Portugal.,Departamento de Fisiologia, Faculdade de Medicina, Universidade do Porto, Porto - Portugal.,Clínica Cardio-Oncológica, Centro Hospitalar Vila Nova de Gaia, Gaia - Portugal
| | - Telma Costa
- Clínica Cardio-Oncológica, Centro Hospitalar Vila Nova de Gaia, Gaia - Portugal.,Departamento de Oncologia, Centro Hospitalar Vila Nova de Gaia, Gaia - Portugal
| | - Isabel Fragoso
- Unidade de Atenção Primária à Saúde Aracetti, Arazede - Portugal
| | - Diogo Ferreira
- Departamento de Cardiologia, Vila Nova de Gaia Hospital Center, Gaia - Portugal.,Departamento de Fisiologia, Faculdade de Medicina, Universidade do Porto, Porto - Portugal
| | - Mariana Brandão
- Departamento de Cardiologia, Vila Nova de Gaia Hospital Center, Gaia - Portugal
| | - Adelino Leite-Moreira
- Departamento de Fisiologia, Faculdade de Medicina, Universidade do Porto, Porto - Portugal.,Departamento de Cirurgia Cardiotorácica, Hospital Universitário São João, Porto - Portugal.,Unidade de Pesquisa Cardiovascular (UnIC), Faculdade de Medicina, Universidade do Porto, Porto - Portugal
| | - Francisco Sampaio
- Departamento de Cardiologia, Vila Nova de Gaia Hospital Center, Gaia - Portugal.,Departamento de Fisiologia, Faculdade de Medicina, Universidade do Porto, Porto - Portugal
| | - José Ribeiro
- Departamento de Cardiologia, Vila Nova de Gaia Hospital Center, Gaia - Portugal.,Clínica Cardio-Oncológica, Centro Hospitalar Vila Nova de Gaia, Gaia - Portugal
| | - Ricardo Fontes-Carvalho
- Departamento de Cardiologia, Vila Nova de Gaia Hospital Center, Gaia - Portugal.,Departamento de Fisiologia, Faculdade de Medicina, Universidade do Porto, Porto - Portugal
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46
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Jiang D, Song Z, Hu Y, Dong F, Zhao R. Risk of bleeding associated with BTK inhibitor monotherapy: a systematic review and meta-analysis of randomized controlled trials. Expert Rev Clin Pharmacol 2022; 15:987-996. [PMID: 35892246 DOI: 10.1080/17512433.2022.2106968] [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: 11/04/2022]
Abstract
BACKGROUND The risk of bleeding associated with Bruton's tyrosine kinase inhibitor (BTKi) monotherapy remains to be understood. This systematic review aims to evaluate BTKi monotherapy related bleeding risk. RESEARCH DESIGN AND METHODS PubMed, Embase, and CENTRAL were searched up to December 5, 2021. We included randomized controlled trials (RCTs) comparing BTKi monotherapy with control drugs or placebo, or comparing different BTKi monotherapies. The risk ratios (RR) with 95% confidence intervals (95% CI) were calculated. RESULTS 10 studies with 3139 patients were included. Ibrutinib (vs. control drugs or placebo) significantly increased the risk of overall bleeding and major bleeding (RR=2.22, 95% CI 1.80-2.75, P<0.00001; RR=1.80, 95% CI 1.02-3.18, P=0.04, respectively). Acalabrutinib (vs. control drugs) had a significantly increased overall bleeding risk (RR=3.45, 95% CI 2.39-4.99, p<0.00001). A significant difference was found in overall bleeding between ibrutinib and acalabrutinib (RR=1.35, 95% CI 1.11-1.64, P=0.002). Compared to zanubrutinib, ibrutinib tended to increase the risk of major bleeding (RR=1.55, 95% CI 0.57-4.18, P=0.39). CONCLUSIONS Ibrutinib and acalabrutinib (vs. control drugs or placebo) have a higher risk of bleeding and overall bleeding, respectively. Limited evidence suggests that ibrutinib (vs. acalabrutinib) significantly increases overall bleeding risk, but the differences are not observed in other comparisons.
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Affiliation(s)
- Dan Jiang
- Department of Pharmacy, Peking University Third Hospital, Beijing 100191, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing 100191, China.,Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing 100191, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Zaiwei Song
- Department of Pharmacy, Peking University Third Hospital, Beijing 100191, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing 100191, China.,Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing 100191, China
| | - Yang Hu
- Department of Pharmacy, Peking University Third Hospital, Beijing 100191, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing 100191, China.,Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing 100191, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Fei Dong
- Department of Hematology, Peking University Third Hospital, Beijing 100191, China
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, Beijing 100191, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing 100191, China.,Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing 100191, China
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47
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Rice WG, Howell SB, Zhang H, Rastgoo N, Local A, Kurtz SE, Lo P, Bottomly D, Wilmot B, McWeeney SK, Druker BJ, Tyner JW. Luxeptinib (CG-806) Targets FLT3 and Clusters of Kinases Operative in Acute Myeloid Leukemia. Mol Cancer Ther 2022; 21:1125-1135. [PMID: 35499387 PMCID: PMC9256809 DOI: 10.1158/1535-7163.mct-21-0832] [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: 10/11/2021] [Revised: 01/25/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022]
Abstract
Luxeptinib (CG-806) simultaneously targets FLT3 and select other kinase pathways operative in myeloid malignancies. We investigated the range of kinases it inhibits, its cytotoxicity landscape ex vivo with acute myeloid leukemia (AML) patient samples, and its efficacy in xenograft models. Luxeptinib inhibits wild-type (WT) and many of the clinically relevant mutant forms of FLT3 at low nanomolar concentrations. It is a more potent inhibitor of the activity of FLT3-internal tandem duplication, FLT3 kinase domain and gatekeeper mutants than against WT FLT3. Broad kinase screens disclosed that it also inhibits other kinases that can drive oncogenic signaling and rescue pathways, but spares kinases known to be associated with clinical toxicity. In vitro profiling of luxeptinib against 186 AML fresh patient samples demonstrated greater potency relative to other FLT3 inhibitors, including cases with mutations in FLT3, isocitrate dehydrogenase-1/2, ASXL1, NPM1, SRSF2, TP53, or RAS, and activity was documented in a xenograft AML model. Luxeptinib administered continuously orally every 12 hours at a dose that yielded a mean Cmin plasma concentration of 1.0 ± 0.3 μmol/L (SEM) demonstrated strong antitumor activity but no myelosuppression or evidence of tissue damage in mice or dogs in acute toxicology studies. On the basis of these studies, luxeptinib was advanced into a phase I trial for patients with AML and myelodysplastic/myeloproliferative neoplasms.
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Affiliation(s)
| | - Stephen B. Howell
- Department of Medicine and the Moores Cancer Center, University of California, San Diego, California
| | | | | | | | - Stephen E. Kurtz
- Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon.,Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon
| | - Pierrette Lo
- Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon.,Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon
| | - Daniel Bottomly
- Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon.,Division of Bioinformatics and Computational Biology, Oregon Health & Science University, Portland, Oregon
| | - Beth Wilmot
- Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon.,Division of Bioinformatics and Computational Biology, Oregon Health & Science University, Portland, Oregon
| | - Shannon K. McWeeney
- Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon.,Division of Bioinformatics and Computational Biology, Oregon Health & Science University, Portland, Oregon
| | - Brian J. Druker
- Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon.,Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon.,Corresponding Author: Brian J. Druker, Oregon Health & Science University, 3181 SW Sam Jackson Park Road CR 145 & L592, Portland, OR 97239. Phone: 503-494-5596; Fax: 503-494-3688; E-mail:
| | - Jeffrey W. Tyner
- Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon.,Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon.,Department of Cell, Developmental & Cancer Biology, Oregon Health & Science University, Portland, Oregon
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48
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St-Pierre F, Ma S. Use of BTK Inhibitors in Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL): A Practical Guidance. Blood Lymphat Cancer 2022; 12:81-98. [PMID: 35911566 PMCID: PMC9325877 DOI: 10.2147/blctt.s326627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/01/2022] [Indexed: 11/23/2022] Open
Abstract
The treatment landscape of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) has changed significantly since the development of oral Bruton’s tyrosine kinase (BTK) inhibitors. While chemoimmunotherapy was previously the standard of care for first-line treatment, BTK inhibitors have proven to be a highly effective and safe therapeutic option for CLL/SLL, and now constitute one of the preferred first-line options. Ibrutinib, the first approved covalent BTK inhibitor in CLL/SLL, has the most long-term data supporting its efficacy in CLL/SLL treatment although is associated with increased risk of cardiovascular and hemorrhage adverse events due to off-target kinase inhibition. The second-generation covalent BTK inhibitors, including acalabrutinib and zanubrutinib, are more selective to BTK with less off-target effects. Resistance to covalent BTK inhibitors may emerge over time due to mutations in BTK and downstream kinases. Novel non-covalent BTK inhibitors currently being studied are showing promising activities to overcome such resistance. In this review, we discuss the role of BTK inhibitors in treatment of CLL/SLL, review the data that led to approval of BTK inhibitors in CLL/SLL, outline the toxicity profile of each approved BTK inhibitor and management, and give practical guidance on how to select the most appropriate agent for treatment.
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Affiliation(s)
- Frédérique St-Pierre
- Department of Medicine, Division of Hematology/Oncology and the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Shuo Ma
- Department of Medicine, Division of Hematology/Oncology and the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
- Department of Medicine, Division of Hematology/Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Correspondence: Shuo Ma, Division of Hematology-Oncology, Department of Medicine, Feinberg School of Medicine and the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Tel +1 312-695-0990, Email
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49
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Jensen JL, Mato AR, Pena C, Roeker LE, Coombs CC. The potential of pirtobrutinib in multiple B-cell malignancies. Ther Adv Hematol 2022; 13:20406207221101697. [PMID: 35747462 PMCID: PMC9210100 DOI: 10.1177/20406207221101697] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/29/2022] [Indexed: 12/30/2022] Open
Abstract
Bruton’s tyrosine kinase (BTK) is a critical downstream signaling element from the B-cell receptor (BCR) that has been effectively inhibited in B-cell cancers by irreversible, covalent inhibitors including ibrutinib and acalabrutinib. All FDA-approved covalent BTK inhibitors rely on binding to the cysteine 481 (C481) amino acid within the active site of BTK, thus rendering it inert. While covalent BTK inhibitors have been very successful in multiple B-cell malignancies, improving both overall survival and progression-free survival relative to chemoimmunotherapy in phase 3 trials, they can be limited by intolerance and disease progression. Pirtobrutinib is a novel, highly selective, and non-covalent BTK inhibitor that binds independently of C481, and in a recent, first-in-human phase 1/2 clinical trial was shown to be extremely well tolerated and lead to remissions in relapsed/refractory patients with multiple B-cell malignancies. Here, we review the pharmacologic rationale for pursuing non-covalent BTK inhibitors, the clinical need for such inhibitors, existing safety, and resistance mechanism data for pirtobrutinib, and the forthcoming clinical trials that seek to define the clinical utility of pirtobrutinib, which has the potential to fulfill multiple areas of unmet clinical need for patients with B-cell malignancies.
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Affiliation(s)
- Jeffrey L Jensen
- Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anthony R Mato
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Camila Pena
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Catherine C Coombs
- Division of Hematology, Department of Medicine, The University of North Carolina at Chapel Hill, 170 Manning Drive, Chapel Hill, NC 27599, USA
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50
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Ababneh O, Abushukair H, Qarqash A, Syaj S, Al Hadidi S. The Use of Bruton Tyrosine Kinase Inhibitors in Waldenström’s Macroglobulinemia. Clin Hematol Int 2022; 4:21-29. [PMID: 35950210 PMCID: PMC9358782 DOI: 10.1007/s44228-022-00007-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/15/2022] [Indexed: 01/04/2023] Open
Abstract
The use of Bruton Tyrosine Kinase (BTK) inhibitors in Waldenström’s Macroglobulinemia (WM) is evolving. Ibrutinib, a first-generation BTK inhibitor, is currently approved for use in frontline and relapsed/refractory disease. Second-generation BTK inhibitors are being used and studied to improve clinical outcomes and/or safety profile. Zanubrutinib, one such second-generation inhibitor, was recently approved in treatment-naive and refractory/relapsed patients. Here, we review the use of BTK inhibitors in WM in front-line and refractory or relapsed settings. We also highlight common adverse events, the emergence of BTK inhibitors resistance, and future directions of their use.
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Affiliation(s)
- Obada Ababneh
- Faculty of Medicine, Jordan University of Science and Technology, P.O. 22110, Irbid, Jordan
| | - Hassan Abushukair
- Faculty of Medicine, Jordan University of Science and Technology, P.O. 22110, Irbid, Jordan
| | - Aref Qarqash
- Faculty of Medicine, Jordan University of Science and Technology, P.O. 22110, Irbid, Jordan
| | - Sebawe Syaj
- Faculty of Medicine, Jordan University of Science and Technology, P.O. 22110, Irbid, Jordan
| | - Samer Al Hadidi
- Myeloma Center, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR USA
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