Emerging drugs for the treatment of myelofibrosis: phase II & III clinical trials

INTRODUCTION

Myelofibrosis is a clonal hematologic malignancy with clinical manifestations that include cytopenias, debilitating constitutional symptoms, splenomegaly, bone marrow fibrosis and a propensity toward leukemic progression. While allogeneic hematopoietic stem cell transplantation can be curative, this therapy is not available for the majority of patients. Ruxolitinib and fedratinib are approved JAK2 inhibitors that have produced meaningful benefits in terms of spleen reduction and symptom improvement, but there remain several unmet needs.

AREAS COVERED

We discuss novel therapies based upon published data from phase II or III clinical trials. Specifically, we cover novel JAK inhibitors (momelotinib and pacritinib), and agents that target bromodomain and extra-terminal domain (pelabresib), the antiapoptotic proteins BCL-2/BCL-xL (navitoclax), MDM2 (navtemadlin), phosphatidylinositol 3-kinase (parsaclisib), or telomerase (imetelstat).

EXPERT OPINION

Patients with disease related cytopenias are ineligible for currently approved JAK2 inhibitors. However, momelotinib and pacritinib may be able to fill this void. Novel therapies are being evaluated in the upfront setting to improve the depth and duration of responses with ruxolitinib. Future evaluation of agents must be judged on their potential to modify disease progression, which current JAK2 inhibitors lack. Combination therapy, possibly with an immunotherapeutic agent might serve as key components of future myelofibrosis treatment options.

Navigating the treatment landscape in multiple myeloma: which combinations to use and when?

Multiple myeloma is one of the most common hematological malignancies, affecting mainly elderly patients. The treatment landscape for the management of this disease has evolved significantly over the past 15 years, and a vast array of therapeutics is now available, including immunomodulatory drugs, proteasome inhibitors, histone deacetylase inhibitors, and monoclonal antibodies. As a result, deciding which drugs to use and when, and whether these should be used in a particular order or combination, can be challenging. Although combination regimens are often associated with deeper responses and better long-term outcomes than monotherapy, and are becoming the standard of care, they may result in significant incremental toxicity; hence, a sequential approach may be more appropriate for some patients. In particular, treatment choices can vary depending on whether the patient has newly diagnosed multiple myeloma, is eligible for transplant, has relapsed and/or refractory multiple myeloma, or is considered to have high-risk disease. In this review, we discuss factors to be taken into account when making treatment decisions in each of these settings. We also briefly discuss possible therapeutic strategies involving agents that may become available in the future.

Light-induced mechanisms for nanocarrier's cargo release

Nanomaterials have been the focus of attention in several fields, including biomedicine, electronics, or catalysis, mainly due to the novel properties of the materials at the nanoscale. In the field of diagnosis, nanomaterials have been contemplated as an opportunity to improve sensitivity and time of response, therefore, facilitating early treatment and monitoring of the disease. For therapeutic applications, new drug delivery nanosystems aiming to provide enhanced efficiency have been proposed often addressing selective or controlled delivery of therapeutic agents to particular cells to maximize treatment efficacy minimizing adverse effects. The therapeutic agents can be dissolved, adsorbed, entrapped, encapsulated or attached on the surface or inside the nanocarriers. Given the context of the different generations of nanocarriers and their wide range of applications, the present article aims to discuss the nature of external stimuli which will trigger the controlled release of different biomolecules. For each class, a brief description of the physical principle, basic concepts, as well as some examples, are reported. A final discussion focused on the real implications and needs for optimal drug delivery system is presented, altogether with some considerations and prospects in the trends that diagnostics applications could follow in the next years.

The emerging role of carfilzomib combination therapy in the management of multiple myeloma

Carfilzomib is a proteasome inhibitor that selectively and irreversibly binds to its target, resulting in sustained inhibition absent of off-target effects relative to bortezomib. Single-agent carfilzomib has produced robust and durable responses in clinical trials and it has been approved in the US for treating relapsed and refractory multiple myeloma (MM). Due to its favorable safety profile, carfilzomib is particularly suitable for use in combination strategies. Promising data have been reported from studies that investigated the use of carfilzomib in combination with immunomodulators, alkylating agents, glucocorticoids, histone deacetylase inhibitors and kinesin spindle protein inhibitors. Ongoing pivotal randomized Phase III studies are investigating the efficacy and safety of carfilzomib combinations in patients with relapsed MM and transplant ineligible patients.

A macromolecular prodrug strategy for combinatorial drug delivery

A novel macromolecular prodrug strategy was developed for the combinatorial delivery of two poorly water-soluble drugs, dexamethasone and doxorubicin. In this work, dexamethasone was firstly conjugated onto a water-soluble modified polysaccharide by an acid-labile hydrazone linkage. The resultant macromolecular prodrug had an amphiphilic character and could self-assemble into spherical polymeric micelles in aqueous system. With these micelles, doxorubicin was then encapsulated into their hydrophobic cores. For the conjugated dexamethasone and encapsulated doxorubicin, they could exhibit independent and acid-sensitive release characteristics. For the doxorubicin-loaded prodrug micelles, they were easily be internalized by living cells and showed obvious antitumor activity.