Dose recommendations for anticancer drugs in patients with renal or hepatic impairment

Incidence, risk factors, and management of bleeding in patients receiving anticoagulants for the treatment of cancer-associated thrombosis

Updated clinical practice guidelines recommend the long-term use of low-molecular-weight heparins or direct oral anticoagulants as the preferred option for the treatment of cancer-associated thrombosis (CAT), using a personalized approach matching the right drug to the right patient. In most cases, the benefit of anticoagulant therapy outweighs the risk. However, the long-term use of anticoagulants is associated with a non-negligible risk of bleeding, which constitutes a rare but serious adverse effect. Bleeding complications have been reported to be overall 2 to 3 times more frequent in cancer patients with CAT receiving anticoagulation than in non-cancer patients, with a reported incidence of major bleeding ranging from 2.4 to 16.0% in randomized controlled trials (RCT). In the absence of validated risk assessment model to predict the risk of bleeding in these patients, a careful evaluation of each individual profile, with adequate selection of the most appropriate anticoagulant for each individual patient, is warranted for overcoming management challenges, taking in account the numerous factors which may potentiate the overall bleeding risk in these complex patients, such as advanced or metastatic disease, older age, anemia, thrombocytopenia, renal impairment, liver dysfunction, and concomitant anticancer therapies. The purpose of this review is to call for awareness on bleeding complications as a major safety issue of CAT treatment and to summarize data from recent RCT and real-world studies on the incidence and risk factors for bleeding in this unique and challenging population to further help clinicians in decision-making.

Evidence to guide the optimal timing for pre-chemotherapy blood tests for early breast, colorectal cancer and diffuse large B-cell lymphoma

Background

Re‐designing services and processes to meet growing demands in chemotherapy services is necessary with increasing treatments. There is little evidence guiding the timing and thresholds to be attained of pre‐chemotherapy blood assessments, namely neutrophils.

Methods

A survey was developed and distributed to health professionals in the United Kingdom (UK) to examine current practice in timing and threshold values of neutrophils and platelets before treatment administration. This was followed by a retrospective cohort study, using data from electronic patient record systems; including patients initiating treatment between January 2013 and December 2018, to determine a safe timeframe for blood assessments; comparing neutrophil, platelet, creatinine and bilirubin levels at different time points.

Results

The survey captured 25% of hospitals in the UK and variations were apparent in both the timing of assessments and thresholds needed, particularly for neutrophils. 616 (6.5%) of 4007 patients included had neutrophil levels measured twice within 7 days of treatment (with the first level taken beyond 3 days and the second test being within 3 days of treatment‐ the UK standard). Of the patients that attained an acceptable neutrophil level at their first test, five of the 616 (0.8%) became ineligible for administration from the test 2 level. 23% of patients improved their grade and became eligible for treatment. Little difference was observed for platelets.

Conclusions

We have demonstrated that extending the timeframe for blood tests can be safe, however, this practice may cause unnecessary delays for patients if only an early test is relied on for eligibility.

Conventional Chemotherapy Nephrotoxicity

Conventional chemotherapies remain the mainstay of treatment for many malignancies. Kidney complications of these therapies are not infrequent and may have serious implications for future kidney function, cancer treatment options, eligibility for clinical trials, and overall survival. Kidney adverse effects may include acute kidney injury (via tubular injury, tubulointerstitial nephritis, glomerular disease and thrombotic microangiopathy), long-term kidney function loss and CKD, and electrolyte disturbances. In this review, we summarize the kidney complications of conventional forms of chemotherapy and, where possible, provide estimates of incidence, and identify risk factors and strategies for kidney risk mitigation. In addition, we provide recommendations regarding kidney dose modifications, recognizing that these adjustments may be limited by available supporting pharmacokinetic and clinical outcomes data. We discuss management strategies for kidney adverse effects associated with these therapies with drug-specific recommendations. We focus on frequently used anticancer agents with established kidney complications, including platinum-based chemotherapies (cisplatin, carboplatin, oxaliplatin), cyclophosphamide, gemcitabine, ifosfamide, methotrexate and pemetrexed, among others.

Safe use of radiopharmaceuticals in patients with chronic kidney disease: a systematic review

BACKGROUND

Patients with chronic kidney disease (CKD) may need to have their radiopharmaceutical dosage adjusted to prevent adverse effects and poor outcomes, but there are few recommendations on radiopharmaceutical dosing for this group of patients. The aim of this study is to provide an overview of the available information on radiopharmaceutical dose recommendations for patients with CKD.

METHODS

We performed a systematic literature review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We conducted a literature search in the MEDLINE (PubMed) and Embase databases and screened potentially relevant studies using inclusion and exclusion criteria. We independently assessed the included observational studies' methodologies and extracted relevant data.

RESULTS

Of the 5795 studies first identified, 34 were included in this systematic review. These studies described three radiopharmaceuticals: [131I]sodium iodine, [18F]fludeoxyglucose, and [131I]iobenguane. Twenty-nine studies (85.3%) reported data on patients with CKD stage 5, while only three studies mentioned CKD patients in other stages (8.8%).

CONCLUSION

We found no consistent recommendations for radiopharmaceutical dosing in patients with CKD. Although some studies do mention dosing difficulties in patients with CKD, information is available for only a few radiopharmaceuticals, and recommendations are sometimes contradictory. Further research on radiopharmaceutical dosing in patients with CKD is needed to determine whether these patients require specific dosing, especially for therapeutic radiopharmaceuticals where a non-optimised dose may lead to an increased risk of toxicity for non-targeted organs. Including patients with CKD in studies and providing specific information about dosing in these patients should be a priority for the radiopharmaceutical community.

Pharmacokinetics of Ipatasertib in Subjects With Hepatic Impairment Using Two Methods of Classification of Hepatic Function

Ipatasertib is a highly selective small-molecule pan-Akt inhibitor in clinical development. Ipatasertib is predominantly eliminated by the liver, and therefore the effect of hepatic impairment on ipatasertib pharmacokinetics (PK) was evaluated. In this Phase I open-label, parallel group study, the PK of ipatasertib was evaluated in subjects with hepatic impairment based on both, the Child-Pugh and the National Cancer Institute-Organ Dysfunction Working Group (NCI-ODWG) classification for hepatic impairment. A single dose of ipatasertib at 100 mg was administered and the PK was characterized in healthy subjects with normal hepatic function or mild, moderate and severe hepatic impairment. Based on Child-Pugh classification, subjects with moderate or severe hepatic impairment had an approximately 2- and 3-fold increase in systemic exposure (AUC_0-∞ ) to ipatasertib, respectively, compared to subjects with normal hepatic function. Systemic exposure (AUC_0-∞ ) to ipatasertib in subjects with mild hepatic impairment was comparable to that in subjects with normal hepatic function. In accordance with reduced clearance capacity, subjects with mild to severe hepatic impairment showed lower systemic exposure (AUC_0-∞ ) of ipatasertib metabolite M1 (G-037720). Overall results were comparable between Child-Pugh and NCI-ODWG classification criteria. Based upon the results from this study, no dosage adjustment is required for ipatasertib when treating patients with mild hepatic impairment, whereas a dose reduction would be recommended for subjects with moderate or severe hepatic impairment. Based on real world data analysis, ∼2% of intended patient population is expected to need a modified dose due to moderate or severe hepatic impairment. This article is protected by copyright. All rights reserved.

Pharmacokinetics and safety of niraparib in patients with moderate hepatic impairment

PURPOSE

The purpose of this study is to characterize niraparib pharmacokinetics (PK) and safety in patients with normal hepatic function (NHF) versus moderate hepatic impairment (MHI).

METHODS

Patients with advanced solid tumors were stratified by NHF or MHI (National Cancer Institute-Organ Dysfunction Working Group criteria [bilirubin > 1.5-3 × upper limit of normal and any aspartate aminotransferase elevation]). In the PK phase, all patients received one 300 mg dose of niraparib. In the extension phase, patients with MHI received niraparib 200 mg daily; patients with NHF received 200 or 300 mg based on weight (< 77 kg, ≥ 77 kg)/platelets (< 150,000/µL, ≥ 150,000/µL). PK parameters included maximum concentration (C_max), area under the curve to last measured concentration (AUC_last) and extrapolated to infinity (AUC_inf). Safety was assessed in both phases. Exposure-response (E-R) modeling was used to predict MHI effects on exposure and safety of niraparib doses ≤ 200 mg or 300/200 mg or 200/100 mg weight/platelet regimens.

RESULTS

In the PK phase (NHF, n = 9; MHI, n = 8), mean niraparib C_max was 7% lower in patients with MHI versus NHF. Mean exposure (AUC_last, AUC_inf) was increased by 45% and 56%, respectively, in patients with MHI without impacting tolerability. In the extension phase (NHF, n = 8; MHI, n = 7), the overall safety profile was consistent with previous trials. In patients with MHI, E-R modeling predicted niraparib 200 mg reduced Grade ≥ 3 thrombocytopenia incidence, whereas a 200/100 mg regimen yielded exposures below efficacy-associated levels in 15% of patients.

CONCLUSION

These findings support adjusting the 300 mg niraparib starting dose to 200 mg QD in patients with MHI.

TRIAL REGISTRATION

NCT03359850; registered December 2, 2017.

Safety and Survival Outcomes in Lung Cancer Patients Receiving Carboplatin: Impact of Uncapped Dosage

The prescription of carboplatin is commonly based on the Calvert formula, and low serum creatinine values can lead to an overestimation of the glomerular filtration rate and of the carboplatin dose. Limited data recommend to cap carboplatin dose at 800 mg, but the risk of suboptimal carboplatin dose is concerning. This study compared hematologic toxicity occurrence and survival outcomes in lung cancer patients receiving carboplatin > or <800 mg based on the Calvert formula (target area under the curve = 5 mg/mL min). Our results show more severe cytopenia in patients receiving carboplatin >800 mg with significant difference for all grades of thrombocytopenia in the uncapped group (37% patients vs. 3%, p = 0.02). For metastatic non-small-cell lung cancer patients, we also observed hematologic toxicity in the uncapped group with more severe anemia (30% of patients vs. 0%, p = 0.03) and all grades of thrombocytopenia (39 vs. 0%, p = 0.02) than the capped group. Concerning the secondary endpoint, we obtained a trend of lower progression-free survival and overall survival in patients receiving carboplatin >800 mg, but no significant difference appears for the both survival criteria. This study aims to improve the determination of carboplatin dosage to know the real impact of carboplatin capping and to find the optimum balance between excessive toxicity and substandard therapeutics outcomes.

Pharmacokinetics and Safety of Glasdegib in Participants With Moderate/Severe Hepatic Impairment: A Phase I, Single-Dose, Matched Case-Control Study

This phase I open-label trial (NCT03627754) assessed glasdegib pharmacokinetics and safety in otherwise healthy participants with moderate (Child-Pugh B) or severe (Child-Pugh C) hepatic impairment. Participants with hepatic impairment and age/weight-matched controls with normal hepatic function received a single oral 100-mg glasdegib dose under fasted conditions. The primary end points were area under the plasma concentration-time curve from time zero to infinity (AUCinf ) and maximum plasma concentration (Cmax ). Twenty-four participants (8/cohort) were enrolled. Glasdegib plasma exposures in moderate hepatic impairment were similar to controls, with adjusted geometric mean ratios (GMRs) of 110.8% (90% confidence interval [CI], 78.0-157.3) for AUCinf and 94.8% (69.9-128.4) for Cmax versus controls. In severe hepatic impairment, glasdegib plasma exposures were lower than controls (AUCinf GMR, 75.7%; 90%CI, 51.5-111.0; Cmax GMR, 58.0%; 90%CI, 37.8-89.0). Unbound glasdegib exposures were similar to controls for moderate (AUCinf,u GMR, 118.1%; 90%CI, 88.7-157.2; Cmax,u GMR, 101.1%; 90%CI, 78.4-130.3) and severe hepatic impairment (AUCinf,u GMR, 116.3%; 90%CI 81.8-165.5; Cmax,u GMR, 89.2%, 90%CI, 60.2-132.3). No treatment-related adverse events or clinically significant changes in laboratory values, vital signs, or electrocardiograms were observed. Together with previous findings, this suggests glasdegib dose modifications are not required based on hepatic impairment.

The effect of a Clinical Decision Support System on the frequency of dose adjustments of anticancer drugs in case of renal or hepatic dysfunction

INTRODUCTION

Dose adjustments in patients with renal or hepatic dysfunction using anticancer drugs are indicated according to guidelines. However, implementation depends on awareness of prescribing physicians. We implemented a Clinical Decision Support System (CDSS), recommending dose adjustments upon electronic prescriptions based on renal and hepatic function. The alert provides a dose adjustment proposal and recent laboratory results. Our objective was to determine the frequency of dose adjustments before and after implementation of this CDSS.

METHODS

We included all first orders for patients ≥18 years treated with parenteral antineoplastic agents, for whom dosage adjustment is necessary based on renal or hepatic function between February 2018 and January 2019. This study was performed at the department of Clinical Oncology and Hematology of the Amsterdam University Medical Center. We implemented the CDSS August first. All prescriptions were prescribed according to common practice. We analyzed the orders where a dose reduction based on renal or hepatic function was indicated.

RESULTS

We included 73 orders before implementation and 99 orders after implementation. Before implementation 21% of doses were reduced in line with the guidelines versus 34% after implementation (p = 0.048). For hepatic dysfunction the proportion changed from 11% to 46% p = 0.011, while there was no effect for renal dysfunction (24% vs. 26% p = 0.75).

CONCLUSION

Dosages are more frequently adjusted in concordance with guidelines in patients with hepatic dysfunction who are treated with parenteral antineoplastic agents after implementation of a CDSS. The change was not seen in patients with renal dysfunction.

A review of the evidence base for utilizing Child-Pugh criteria for guiding dosing of anticancer drugs in patients with cancer and liver impairment

As the liver is vital for the metabolism of many anticancer drugs, determining the correct starting doses in cancer patients with liver impairment is key to safe prescription and prevention of unnecessary adverse effects. Clinicians typically use liver function tests when evaluating patients; however, prescribing information and summaries of product characteristics often suggest dosing of anticancer drugs in patients with liver impairment based on the Child-Pugh criteria, even though the criteria were not developed for this purpose. In this review, we assessed all the oncological small molecule and cytotoxic drugs approved by the United States Food and Drug Administration (FDA) over a 5-year period from 2014 to 2018. The various entry criteria related to these drugs—with respect to hepatic function—in key pivotal studies were compared with their approved dosing recommendations found in prescribing information and summaries of product characteristics. We found that 46% of drugs have dosing recommendations based on Child-Pugh criteria alone, despite the fact that only 8% of these drugs were tested within studies that used the Child-Pugh criteria as entry criteria. Moreover, we note that the data used to make recommendations based on Child-Pugh criteria are typically from small studies that may lack an appropriate patient population. We propose that these findings, along with details surrounding the development of the Child-Pugh criteria, call into question the validity and appropriateness of using Child-Pugh criteria for dosing recommendations of anticancer drugs.

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Dosing information for anticancer drugs in patients with liver impairment is often based on the Child-Pugh criteria.

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Clinical trials and clinicians typically use liver function tests when evaluating patients.

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Of the 39 oncologic drugs examined, almost half (46%) had dosing recommendations based on Child-Pugh criteria alone.

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We question whether using Child-Pugh criteria for dosing recommendations of anticancer drugs is the best approach.

Identification of the key target profiles underlying the drugs of narrow therapeutic index for treating cancer and cardiovascular disease

An appropriate therapeutic index is crucial for drug discovery and development since narrow therapeutic index (NTI) drugs with slight dosage variation may induce severe adverse drug reactions or potential treatment failure. To date, the shared characteristics underlying the targets of NTI drugs have been explored by several studies, which have been applied to identify potential drug targets. However, the association between the drug therapeutic index and the related disease has not been dissected, which is important for revealing the NTI drug mechanism and optimizing drug design. Therefore, in this study, two classes of disease (cancers and cardiovascular disorders) with the largest number of NTI drugs were selected, and the target property of the corresponding NTI drugs was analyzed. By calculating the biological system profiles and human protein–protein interaction (PPI) network properties of drug targets and adopting an AI-based algorithm, differentiated features between two diseases were discovered to reveal the distinct underlying mechanisms of NTI drugs in different diseases. Consequently, ten shared features and four unique features were identified for both diseases to distinguish NTI from NNTI drug targets. These computational discoveries, as well as the newly found features, suggest that in the clinical study of avoiding narrow therapeutic index in those diseases, the ability of target to be a hub and the efficiency of target signaling in the human PPI network should be considered, and it could thus provide novel guidance in the drug discovery and clinical research process and help to estimate the drug safety of cancer and cardiovascular disease.

Eribulin, Child-Pugh score, and liver-function tests: lessons from pivotal breast cancer studies 301 and 305

Background

The recommended starting dose of eribulin in patients with hepatic impairment is based on the Child-Pugh score, largely informed by a pharmacokinetic study of 18 patients. In the pivotal studies of eribulin in metastatic breast cancer (Study 301 and Study 305 [EMBRACE]), entry criteria and dose modifications were based on liver-function test (LFT) results rather than Child-Pugh score. In populations such as patients with metastatic breast cancer, in which metastatic infiltration is the predominant cause of hepatic impairment, using Child-Pugh score may be problematic; in clinical practice, it has been more common for oncologists to make dosing decisions based on LFTs. To address this, the effects of abnormal baseline LFT results on eribulin efficacy and safety were investigated.

Methods

In this pooled post hoc analysis, 1062 patients who were randomized to receive eribulin in Studies 301 and 305 were divided into 4 groups: (A) no elevated LFT results (no liver impairment); (B) increased levels of aspartate aminotransferase and/or alanine aminotransferase; (C) decreased albumin and/or increased levels of aspartate aminotransferase and/or alanine aminotransferase but not increased bilirubin; and (D) increased bilirubin. Patients were subcategorized by presence of liver metastasis. Drug exposure, dose intensity, and treatment-emergent adverse events (TEAEs) were analyzed.

Results

Eribulin mesylate mean dosage was 0.82 (group A)–0.65 mg/m²/week (group D). Group D had shorter treatment, more dose reductions/delays, more TEAEs leading to dose modifications, and numerically lower objective response rates and clinical benefit rates versus groups A–C. TEAE rates leading to dose modification were similar between group D (45.5%) and groups A–C (range, 43.5–54.9%) in the absence of liver metastases, but higher in group D (91.3%) compared with groups A–C (range, 41.7–54.3%) if liver metastases were present.

Conclusions

Mild elevations in bilirubin levels were associated with increased toxicity and a greater requirement for dose modifications. Based both on these study data and existing recommendations, we propose a novel scheme to guide initial dose selection in patients with metastatic breast cancer and hepatic impairment that is based on LFTs rather than Child-Pugh score.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13058-021-01407-w.

DA-EPOCH-R therapy for high-grade B-cell lymphoma with MYC and BCL2 and/or BCL6 rearrangements in a patient with renal dysfunction

High-grade B-cell lymphoma with MYC and BCL2 and/or BCL6 rearrangements, also known as double-hit lymphoma, has been reported as refractory to R-CHOP therapy and requires more intensive regimens. However, intensive and safe regimens for patients with renal dysfunction are unknown. Herein, we report the successful use of DA-EPOCH-R therapy for double-hit lymphoma in a 64-year-old man with renal dysfunction. The patient had lymphoma-induced bilateral ureteral obstruction. Although renal dysfunction remained after removing the obstruction using R-CHOP therapy, we completed six cycles of DA-EPOCH-R therapy without any major adverse events. DA-EPOCH-R therapy may be a safe regimen for renal dysfunction patients.

Recent Advances in Photodynamic Therapy for Deep-Seated Tumors with the Aid of Nanomedicine

Photodynamic therapy (PDT) works through photoactivation of a specific photosensitizer (PS) in a tumor in the presence of oxygen. PDT is widely applied in oncology to treat various cancers as it has a minimally invasive procedure and high selectivity, does not interfere with other treatments, and can be repeated as needed. A large amount of reactive oxygen species (ROS) and singlet oxygen is generated in a cancer cell during PDT, which destroys the tumor effectively. However, the efficacy of PDT in treating a deep-seated tumor is limited due to three main reasons: Limited light penetration depth, low oxygen concentration in the hypoxic core, and poor PS accumulation inside a tumor. Thus, PDT treatments are only approved for superficial and thin tumors. With the advancement of nanotechnology, PDT to treat deep-seated or thick tumors is becoming a reachable goal. In this review, we provide an update on the strategies for improving PDT with nanomedicine using different sophisticated-design nanoparticles, including two-photon excitation, X-ray activation, targeting tumor cells with surface modification, alteration of tumor cell metabolism pathways, release of therapeutic gases, improvement of tumor hypoxia, and stimulation of host immunity. We focus on the difficult-to-treat pancreatic cancer as a model to demonstrate the influence of advanced nanomedicine in PDT. A bright future of PDT application in the treatment of deep-seated tumors is expected.

Dose Optimization in Kidney Disease: Opportunities for PBPK Modeling and Simulation

Kidney disease affects pharmacokinetic (PK) profiles of not only renally cleared drugs but also nonrenally cleared drugs. The impact of kidney disease on drug disposition has not been fully elucidated, but describing the extent of such impact is essential for conducting dose optimization in kidney disease. Accurate evaluation of kidney function has been a clinical interest for dose optimization, and more scientists pay attention and conduct research for clarifying the role of drug transporters, metabolic enzymes, and their interplay in drug disposition as kidney disease progresses. Physiologically based pharmacokinetic (PBPK) modeling and simulation can provide valuable insights for dose optimization in kidney disease. It is a powerful tool to integrate discrete knowledge from preclinical and clinical research and mechanistically investigate system- and drug-dependent factors that may contribute to the changes in PK profiles. PBPK-based prediction of drug exposures may be used a priori to adjust dosing regimens and thereby minimize the likelihood of drug-related toxicity. With real-time clinical studies, parameter estimation may be performed with PBPK approaches that can facilitate identification of sources of interindividual variability. PBPK modeling may also facilitate biomarker research that aids dose optimization in kidney disease. U.S. Food and Drug Administration guidances related to conduction of PK studies in kidney impairment and PBPK documentation provide the foundation for facilitating model-based dose-finding research in kidney disease.

Therapeutic efficacy of lenvatinib in hepatocellular carcinoma patients with portal hypertension

AIM

Preserved liver function may be an important factor affecting therapeutic efficacy in hepatocellular carcinoma patients treated with lenvatinib, but not all patients can be treated while preserving liver function. This study evaluated the therapeutic efficacy of lenvatinib in patients with poor liver function with and without portal hypertension.

METHODS

This prospectively registered multicenter study analyzed 93 patients treated with lenvatinib. Progression-free survival was compared between patients with and without advanced portal hypertension according to baseline liver function. Advanced portal hypertension was defined as having both splenomegaly and any portosystemic collaterals.

RESULTS

A total of 37 patients (40.7%) had advanced portal hypertension. Progression-free survival did not differ between patients with and without advanced portal hypertension in the entire cohort (median 7.6 vs. 4.1 months, respectively; P = 0.148), but was significantly longer in patients with advanced portal hypertension than in those without advanced portal hypertension in the albumin-bilirubin grade 2 or 3 group (median 7.6 vs. 2.1 months, respectively; P = 0.016). In a multivariate analysis, the presence of advanced portal hypertension was identified as the only significant predictor associated with prolonged progression-free survival in the albumin-bilirubin grade 2 or 3 group.

CONCLUSIONS

Advanced portal hypertension was associated with the therapeutic efficacy of lenvatinib in controlling the progression of hepatocellular carcinoma in patients with poor liver function.

The link between kidney disease and cancer: complications and treatment

Acute and chronic kidney disease encompasses a complex set of diseases that can both lead to, and result from, cancer. In particular, kidney disease can arise from the use of chemotherapeutic agents. Many of the current and newly developed cancer chemotherapeutic agents are nephrotoxic and can promote kidney dysfunction, which frequently manifests during the terminal stages of cancer. Given the link between kidney disease and cancer development and treatment, the aim of this Review is to highlight the importance of multidisciplinary collaboration between oncologists and nephrologists to predict and prevent chemotherapeutic-induced nephrotoxicity. As new therapies are introduced to treat cancer, new renal toxicities require proper diagnosis and management. We anticipate that multidisciplinary collaborations will lead to the development and implementation of guidelines for clinicians to improve the therapeutic management of patients with both cancer and renal impairment.

Pharmacokinetic-Based Drug-Drug Interactions with Anaplastic Lymphoma Kinase Inhibitors: A Review

Anaplastic lymphoma kinase (ALK) inhibitors are important treatment options for non-small-cell lung cancer (NSCLC), associated with ALK gene rearrangement. Patients with ALK gene rearrangement show sensitivity to and benefit clinically from treatment with ALK tyrosine kinase inhibitors (ALK-TKIs). To date, crizotinib, ceritinib, alectinib, brigatinib, lorlatinib, and entrectinib have received approval from the US Food and Drug Administration and/or the European Medicines Agency for use during the treatment of ALK-gene-rearrangement forms of NSCLC. Although the oral route of administration is convenient and results in good compliance among patients, oral administration can be affected by many factors, such as food, intragastric pH, cytochrome P450 enzymes, transporters, and p-glycoprotein. These factors can result in increased risks for serious adverse events or can lead to reduced therapeutic effects of ALK-TKIs. This review characterizes and summarizes the pharmacokinetic parameters and drug–-drug interactions associated with ALK-TKIs to provide specific recommendations for oncologists and clinical pharmacists when prescribing ALK-TKIs.

GFR Measurement and Chemotherapy Dosing in Patients with Kidney Disease and Cancer

Chemotherapeutic agents require precise dosing to ensure optimal efficacy and minimize complications. For those agents that are removed from the body by the kidney, accurate knowledge of GFR is critical. In addition, GFR needs to be determined rapidly, easily, and, if possible, with little additional cost. The ability to easily measure GFR also allows for rapid detection of nephrotoxicity. Current methodologies include direct clearance measurement of an indicator substance or estimation of creatinine clearance or GFR through regression equations that use a serum marker, such as creatinine or cystatin C. These methodologies all have shortfalls and limitations, some of which are specific to the patient with cancer. Newer methodologies that directly measure GFR are in clinical trials and offer the ability to rapidly and noninvasively provide accurate estimates of drug clearance as well as detection of nephrotoxicity. These methods offer the opportunity to refine drug dosing and improve outcomes.

Design, Synthesis, And Evaluation Of Cyanopyridines As Anti-Colorectal Cancer Agents Via Inhibiting STAT3 Pathway

Background

Colorectal cancer is one of the common malignant tumors. Cyanopyridine and aminocyanopyridine having a carbon-nitrogen bond have been shown to have significant anticancer effects. STAT3 is a promising therapeutic target in multiple cancers. However, there are currently no effective STAT3 inhibitors in clinical practice for the treatment of colorectal cancer.

Materials and methods

We screened 27 cyanopyridines for their anticancer activity by cell viability. The HCT-116, RKO, and DLD-1 cell lines were used to evaluate the anti-colorectal cancer effect of 3n. Scratch experiments and colony formation assays were used for the assessment of cell migration and proliferation capacity. Phosphorylated STAT3, STAT3, MCL-1, and Survivin levels were assessed by Western blot analysis.

Results

In this study, we synthesized 27 cyanopyridines and screened their anticancer activities in three human tumor cells, HCT-116, Hela229, and A375. We found that 2-amino-3-cyanopyridine 3n has better anticancer activity with IC50 values in the low micromolar range. Furthermore, 3n significantly inhibited the migration and colony formation of colorectal cancer cells. Mechanistically, 3n inhibited the expression of STAT3 phosphorylation in a dose- and time-dependent manner.

Conclusion

3n is worth of further investigations toward the discovery of STAT3 inhibitor as a drug candidate for cancer therapy.

Oral antineoplastic agents: assessment of safety and dose adjustments in clinical practice

Objectives: Although the safety profile of oral antineoplastic agents (OAAs) is better than that of classic chemotherapy, the rate of severe adverse events (AEs) is high. The objective was to assess the reasons for adjustments to treatment with OAAs during the first 100 days of treatment. Methods: The authors performed a prospective observational study of cancer outpatients who initiated OAAs between November 2015 and October 2017. Dose reductions and treatment interruptions were closely followed-up during the first 100 days after the beginning of treatment with an OAA. The authors described the different safety profile of different OAA classes. Results: The authors included 443 patients (31 different OAA assessed), of whom 53.0% required their OAA to be adjusted during the first 100 days of treatment. A total of 151 patients required dose reductions and/or interruptions of OAAs owing to AEs. The authors identified 203 AEs in these patients. Treatment with sorafenib, lower ECOG performance status, and first-line treatment were associated with a higher proportion of treatment adjustments due to AEs. Conclusion: These results in clinical practice could be a first approach to help healthcare professionals to design patient monitoring programs by identifying priority patients and drugs, and remarks the importance of pharmacovigilance in OAAs.