HIGH OVERALL RESPONSE RATE WITH THE BTK INHIBITOR BGB-3111 IN PATIENTS WITH CHRONIC LYMPHOCYTIC LEUKEMIA/SMALL LYMPHOCYTIC LYMPHOMA: AN UPDATE ON SAFETY AND ACTIVITY

The Safety of Bruton's Tyrosine Kinase Inhibitors in B-cell Malignancies: A Systematic Review

B-cell malignancies, most notably lymphomas, make up most of the non-Hodgkin lymphomas in the United States. There is limited randomized data comparing 1^st and 2^nd generation Bruton Tyrosine Kinase inhibitors. Our aim was to compare the safety profiles of 1^st versus 2^nd generation Bruton Tyrosine Kinase inhibitors. A systematic search was performed from database inception to January 13, 2020. Studies with Bruton Tyrosine Kinase inhibitor monotherapy for the treatment of B-cell malignancies in the adult population (> 18 years old) were utilized and the adverse events were extracted. Fifty-five studies that met the inclusion criteria were included in the systematic review with forty-one studies with 1^st generation and fourteen studies with 2^nd generation. The review included both clinical trials and retrospective studies with average time of follow-up of 2 years for the 1^st generation group and 18 months for the 2^nd generation group. We found that the incidence of cardiovascular adverse events was significantly higher in the 1^st generation group (20.8%) as compared to the 2^nd generation group (6.3%). However, there was a higher incidence of hematologic/oncologic and gastrointestinal side effects in the 2^nd generation group compared to the 1^st (62.3% compared to 39.2% and 36.9% compare to 28.9%). The number of Grade 5 cardiovascular events (death) were same in the 1^st generation group compared to the 2^nd generation. Further research is needed to develop highly selective Bruton Tyrosine Kinase inhibitors to avoid unwanted adverse events by minimizing off-targets. This article is protected by copyright. All rights reserved.

Major hemorrhage in chronic lymphocytic leukemia patients in the US Veterans Health Administration system in the pre-ibrutinib era: Incidence and risk factors

Chronic lymphocytic leukemia (CLL) patients are at increased risk for major hemorrhage (MH). We examined incidence of and risk factors for MH in CLL patients before introduction of newer CLL therapies such as ibrutinib, which includes bleeding risk. This study included 24 198 CLL patients treated in the VA system before FDA approval of ibrutinib as CLL therapy. Data came from VA databases from 1999 to 2013. MH incidence was 1.9/100 person-years (95% CI: 1.8-1.9), with cumulative incidences of 2.3%, 5.2%, and 7.3% by year 1, 3, and 5, respectively. Median time from CLL diagnosis to MH was 2.8 years (range: 0-15.7 years). In multivariate analyses, concurrent anticoagulant and antiplatelet use (HR: 4.2; 95% CI: 3.2-5.6), anticoagulant use only (HR: 2.6; 95% CI: 2.3-3.1), and antiplatelet use only (HR: 1.5; 95% CI: 1.3-1.7) increased MH risk vs not receiving those medications; being nonwhite, male, having MH history, renal impairment, anemia, thrombocytopenia, and alcohol abuse were associated with increased MH risk. These pre-ibrutinib data are important for providing context for interpreting MH risk in ibrutinib-treated patients. As ibrutinib clinical use is increasing, updated analyses of MH risk among ibrutinib-treated VA patients with CLL may provide additional useful insight.

Retrospective pharmaceutical financial benefits and cost avoidance analysis of clinical trial participation in the Australian haematology setting

BACKGROUND

Clinical trial participants receiving investigational new drugs, which subsequently become approved by a medicines regulatory authority for its trialled indication, effectively gain free early access to efficacious treatment. Participants may also benefit from receiving approved, but unsubsidised medicines. These financial benefits of clinical trial participation have not previously been defined or quantified. Additionally, there are limited Australian pharmaceutical cost avoidance studies quantifying government savings through sponsored clinical trials.

AIMS

To calculate pharmaceutical financial benefits and cost avoidance of clinical trial participation at a single Clinical Research Unit.

METHODS

Recruiting clinical trials between 1 January 2006 and 31 December 2017 conducted at the Haematology Clinical Research Unit, Concord Repatriation General Hospital, Sydney were reviewed. Dispensing records were used to quantitate the pharmaceuticals dispensed to every participant. Financial calculations were based on Pharmaceutical Benefits Scheme (PBS) pricing, or from UpToDate for non-PBS listed agents.

RESULTS

Thirty-six eligible clinical trials involving 245 participants accrued AU$3 971 357 in financial benefit from early access to subsequently approved investigational new drugs, AU$12 209 538 in financial benefit from accessing approved medications not PBS listed, and AU$6 728 576 in government cost avoidance. These findings totalled AU$22 909 471, 89% of which was derived in the past 5 years.

CONCLUSION

Pharmaceutical financial benefit is a previously unquantified aspect of clinical trial participation, its assigned value reflecting a measure of the quality and quantity of life delivered to patients. These data, albeit from a single discipline and institution, suggest that financial benefit represents a greater value than cost avoidance, and that its inclusion in cost-analyses may better reflect the monetary benefits of accessing efficacious pharmaceutical agents through clinical trials.

Incidence of and risk factors for major haemorrhage in patients treated with ibrutinib: An integrated analysis

Ibrutinib, a Bruton tyrosine kinase inhibitor, is approved for treatment of various B‐cell malignancies. In ibrutinib clinical studies, low‐grade haemorrhage was common, whereas major haemorrhage (MH) was infrequent. We analysed the incidence of and risk factors for MH from 15 ibrutinib clinical studies (N = 1768), including 4 randomised controlled trials (RCTs). Rates of any‐grade bleeding were similar for single‐agent ibrutinib and ibrutinib combinations (39% and 40%). Low‐grade bleeding was more common in ibrutinib‐treated than comparator‐treated patients (35% and 15%), and early low‐grade bleeding was not associated with MH. The proportion of MH in RCTs was higher with ibrutinib than comparators (4.4% vs. 2.8%), but after adjusting for longer exposure with ibrutinib (median 13 months vs. 6 months), the incidence of MH was similar (3.2 vs. 3.1 per 1000 person‐months). MH led to treatment discontinuation in 1% of all ibrutinib‐treated patients. Use of anticoagulants and/or antiplatelets (AC/AP) during the study was common (~50% of patients) and had an increased exposure‐adjusted relative risk for MH in both the total ibrutinib‐treated population (1.9; 95% confidence interval, 1.2–3.0) and RCT comparator‐treated patients (2.4; 95% confidence interval, 1.0–5.6), indicating that ibrutinib may not alter the effect of AC/AP on the risk of MH in B‐cell malignancies.