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Lim KJC, Tam CS. Zanubrutinib for the treatment of Waldenström Macroglobulinemia. Expert Rev Hematol 2020; 13:1303-1310. [PMID: 33297772 DOI: 10.1080/17474086.2020.1851184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Waldenström Macroglobulinaemia (WM) is a heterogeneous, incurable condition which often relapses after chemoimmunotherapy. Novel therapies such as Bruton tyrosine-kinase (BTK) inhibitors have shown to be efficacious in treating WM but with an established, significant toxicity profile seen in the first-generation inhibitor Ibrutinib. Zanubrutinib is a selective, potent BTK inhibitor with the potential to reduce toxicity and improve efficacy. Areas covered: This review examines the activity of Zanubrutinib in treating treatment-naïve and relapsed refractory WM and it's toxicity profile when compared to Ibrutinib. Outcomes from the AU003 and ASPEN studies will be examined in detail including a particular focus on MYD88WT and CXCR4WHIM disease. Strengths and weaknesses of this treatment approach will be highlighted and future directions for research will be identified. Expert opinion: Zanubrutinib induces deeper responses and have greater activity in MYD88WT and CXCR4WHIM WM. Zanubrutinib also has a favorable toxicity profile when compared to Ibrutinib. This may potentially translate to lower discontinuation rates, improved quality of life and ultimately longer progression-free survival in patients with WM.
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Affiliation(s)
- Kenneth J C Lim
- Department of Haematology, St Vincent's Hospital , Melbourne, Australia
| | - Constantine S Tam
- Department of Haematology, Peter MacCallum Cancer Centre , Melbourne, Australia.,Department of Medicine, University of Melbourne , Melbourne, Australia
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102
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Rhodes JM, Barrientos JC. Chemotherapy-free frontline therapy for CLL: is it worth it? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:24-32. [PMID: 33275668 PMCID: PMC7727503 DOI: 10.1182/hematology.2020000085] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The treatment of chronic lymphocytic leukemia (CLL) embodies one of the great success stories in translational research, with the development of therapies aimed at disrupting crucial pathways that allow for the survival and proliferation of the malignant clone. The arrival of targeted agents into our armamentarium, along with the advent of novel monoclonal antibodies that can achieve deeper remissions, has steered the field to a new treatment paradigm. Given the panoply of therapeutic options available, the question arises whether chemotherapy still has a role in the management of CLL. The novel targeted agents, which include the Bruton's tyrosine kinase inhibitors, ibrutinib and acalabrutinib, along with the B-cell lymphoma-2 inhibitor, venetoclax, are highly effective in achieving a response with improved remission duration and survival, particularly in high-risk patients. Despite this major progress, the new agents bring a unique set of toxicities unlike those associated with cytotoxic chemotherapy. There is a paucity of head-to-head comparisons among all of the novel agents, because their approval was based on randomization against traditional chemoimmunotherapeutic regimens. Parallel to the increase in the number of available targeted agents, there has been a significant improvement in quality of life and life expectancy of the patients with a CLL diagnosis over the last decade. Our review will examine whether "chemotherapy-free" frontline treatment approaches are worth the associated risks. Our goal is to help identify optimal treatment strategies tailored to the individual by reviewing available data on monotherapy vs combination strategies, depth of response, treatment duration, and potential toxicities.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Benzamides/therapeutic use
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Male
- Middle Aged
- Pyrazines/therapeutic use
- Rituximab/therapeutic use
- Sulfonamides/therapeutic use
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Affiliation(s)
- Joanna M Rhodes
- CLL Research and Treatment Center, Division of Hematology-Oncology, Department of Medicine at Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY
| | - Jacqueline C Barrientos
- CLL Research and Treatment Center, Division of Hematology-Oncology, Department of Medicine at Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY
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103
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Zamorano JL, Gottfridsson C, Asteggiano R, Atar D, Badimon L, Bax JJ, Cardinale D, Cardone A, Feijen EA, Ferdinandy P, López-Fernández T, Gale CP, Maduro JH, Moslehi J, Omland T, Plana Gomez JC, Scott J, Suter TM, Minotti G. The cancer patient and cardiology. Eur J Heart Fail 2020; 22:2290-2309. [PMID: 32809231 PMCID: PMC8278961 DOI: 10.1002/ejhf.1985] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/12/2020] [Accepted: 08/14/2020] [Indexed: 02/06/2023] Open
Abstract
Advances in cancer treatments have improved clinical outcomes, leading to an increasing population of cancer survivors. However, this success is associated with high rates of short- and long-term cardiovascular (CV) toxicities. The number and variety of cancer drugs and CV toxicity types make long-term care a complex undertaking. This requires a multidisciplinary approach that includes expertise in oncology, cardiology and other related specialties, and has led to the development of the cardio-oncology subspecialty. This paper aims to provide an overview of the main adverse events, risk assessment and risk mitigation strategies, early diagnosis, medical and complementary strategies for prevention and management, and long-term follow-up strategies for patients at risk of cancer therapy-related cardiotoxicities. Research to better define strategies for early identification, follow-up and management is highly necessary. Although the academic cardio-oncology community may be the best vehicle to foster awareness and research in this field, additional stakeholders (industry, government agencies and patient organizations) must be involved to facilitate cross-discipline interactions and help in the design and funding of cardio-oncology trials. The overarching goals of cardio-oncology are to assist clinicians in providing optimal care for patients with cancer and cancer survivors, to provide insight into future areas of research and to search for collaborations with industry, funding bodies and patient advocates. However, many unmet needs remain. This document is the product of brainstorming presentations and active discussions held at the Cardiovascular Round Table workshop organized in January 2020 by the European Society of Cardiology.
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Affiliation(s)
- José Luis Zamorano
- Department of Cardiology, University Hospital Ramón y Cajal, CiberCV, Madrid, Spain
| | - Christer Gottfridsson
- Cardiovascular Safety Centre of Excellence, Patient Safety, CMO Organization, AstraZeneca, Gothenburg, Sweden
| | - Riccardo Asteggiano
- ESC Council of Cardio-Oncology, Insubria University of Medicine, Varese, Italy
- LARC (Laboratorio Analisi Ricerca Clinica), Turin, Italy
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Lina Badimon
- ESC Advocacy Committee 2018–2020, Director Cardiovascular Programme (ICCC)-IR Hospital de la Santa Creu I Sant Pau, CiberCV, Barcelona, Spain
| | - Jeroen J. Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Daniela Cardinale
- Cardio-Oncology Unit, European Institute of Oncology, IRCCS, Milan, Italy
| | | | | | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | | | - Chris P. Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - John H. Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Javid Moslehi
- Cardio-Oncology Program, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, University of Oslo, Oslo, Norway
| | - Juan Carlos Plana Gomez
- Department of Cardiology, Texas Heart Institute and Baylor College of Medicine, Houston, TX, USA
| | - Jessica Scott
- Exercise Oncology Research Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Thomas M. Suter
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Giorgio Minotti
- Campus Bio-Medico University School of Medicine, Rome, Italy
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104
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Danilov AV, Persky DO. Incorporating acalabrutinib, a selective next-generation Bruton tyrosine kinase inhibitor, into clinical practice for the treatment of haematological malignancies. Br J Haematol 2020; 193:15-25. [PMID: 33216986 DOI: 10.1111/bjh.17184] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/20/2020] [Accepted: 08/25/2020] [Indexed: 01/15/2023]
Abstract
Greater understanding of the mechanisms involved in the disease progression of haematological malignancies has led to the introduction of novel targeted therapies with reduced toxicity compared with chemotherapy-based regimens, which has expanded the treatment options for patients with mantle cell lymphoma (MCL) and chronic lymphocytic leukaemia/small lymphocytic lymphoma (CLL/SLL). Ibrutinib is a first-in-class Bruton tyrosine kinase (BTK) inhibitor indicated for the treatment of patients with CLL/SLL or relapsed/refractory MCL. However, next-generation BTK inhibitors have been developed with improved specificity and the potential to reduce the off-target toxicity observed with ibrutinib. Acalabrutinib is a highly selective, next-generation BTK inhibitor, which was granted accelerated approval by the US Food and Drug Administration in 2017 for the treatment of adult patients with MCL who have received at least one prior therapy. In November 2019, it was also granted approval for the treatment of adult patients with CLL/SLL on the basis of two phase 3 clinical trials. This review describes the current understanding of acalabrutinib according to clinical study data for the treatment of MCL and CLL/SLL and shares recommendations from our practice on how it should be used when treating patients in the clinic, including dosing, administration and management of adverse events.
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105
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Awan FT, Al-Sawaf O, Fischer K, Woyach JA. Current Perspectives on Therapy for Chronic Lymphocytic Leukemia. Am Soc Clin Oncol Educ Book 2020; 40:1-10. [PMID: 32239979 DOI: 10.1200/edbk_279099] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Therapy for chronic lymphocytic leukemia has improved dramatically over the past decade with the introduction of new targeted therapies and a paradigm shift toward targeted therapies for the majority of patients. Better understanding of prognostic factors has helped tailor therapy for individual patients, and work continues to identify optimal therapy for each patient. When therapy is required, most patients will be treated with targeted therapies, either the Bruton tyrosine kinase (BTK) inhibitors ibrutinib or acalabrutinib or the BCL-2 inhibitor venetoclax in combination with obinutuzumab. Without head-to-head comparisons showing differential efficacy among these options, considerations regarding safety, patient preference, and ability to sequence therapy currently influence treatment decisions. Also, clinical trials investigating combinations of these therapies have the potential to further change the standard of care. In this review, we cover the currently available options for the frontline treatment of chronic lymphocytic leukemia (CLL) and discuss safety considerations and toxicity management with each agent as well as novel combination strategies currently under investigation.
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Affiliation(s)
- Farrukh T Awan
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX
| | - Othman Al-Sawaf
- Department of Internal Medicine and Center of Integrated Oncology Cologne Bonn, University Hospital, Cologne, Germany
| | - Kirsten Fischer
- Department of Internal Medicine and Center of Integrated Oncology Cologne Bonn, University Hospital, Cologne, Germany
| | - Jennifer A Woyach
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH
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106
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Acalabrutinib monotherapy in patients with relapsed/refractory chronic lymphocytic leukemia: updated phase 2 results. Blood 2020; 135:1204-1213. [PMID: 31876911 DOI: 10.1182/blood.2018884940] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 10/23/2019] [Indexed: 12/31/2022] Open
Abstract
Therapeutic targeting of Bruton tyrosine kinase (BTK) has dramatically improved survival outcomes for patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). Acalabrutinib is an oral, highly selective BTK inhibitor that allows for twice-daily dosing due to its selectivity. In this phase 1b/2 study, 134 patients with relapsed/refractory CLL or SLL (median age, 66 years [range, 42-85 years]; median prior therapies, 2 [range, 1-13]) received acalabrutinib 100 mg twice daily for a median of 41 months (range, 0.2-58 months). Median trough BTK occupancy at steady state was 97%. Most adverse events (AEs) were mild or moderate, and were most commonly diarrhea (52%) and headache (51%). Grade ≥3 AEs (occurring in ≥5% of patients) were neutropenia (14%), pneumonia (11%), hypertension (7%), anemia (7%), and diarrhea (5%). Atrial fibrillation and major bleeding AEs (all grades) occurred in 7% and 5% of patients, respectively. Most patients (56%) remain on treatment; the primary reasons for discontinuation were progressive disease (21%) and AEs (11%). The overall response rate, including partial response with lymphocytosis, with acalabrutinib was 94%; responses were similar regardless of genomic features (presence of del(11)(q22.3), del(17)(p13.1), complex karyotype, or immunoglobulin variable region heavy chain mutation status). Median duration of response and progression-free survival (PFS) have not been reached; the estimated 45-month PFS was 62% (95% confidence interval, 51% to 71%). BTK mutation was detected in 6 of 9 patients (67%) at relapse. This updated and expanded study confirms the efficacy, durability of response, and long-term safety of acalabrutinib, justifying its further investigation in previously untreated and treated patients with CLL/SLL. This trial was registered at www.clinicaltrials.gov as #NCT02029443.
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107
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Tam CS, Opat S, D'Sa S, Jurczak W, Lee HP, Cull G, Owen RG, Marlton P, Wahlin BE, Sanz RG, McCarthy H, Mulligan S, Tedeschi A, Castillo JJ, Czyz J, Fernández de Larrea C, Belada D, Libby E, Matous JV, Motta M, Siddiqi T, Tani M, Trneny M, Minnema MC, Buske C, Leblond V, Trotman J, Chan WY, Schneider J, Ro S, Cohen A, Huang J, Dimopoulos M. A randomized phase 3 trial of zanubrutinib vs ibrutinib in symptomatic Waldenström macroglobulinemia: the ASPEN study. Blood 2020; 136:2038-2050. [PMID: 32731259 PMCID: PMC7596850 DOI: 10.1182/blood.2020006844] [Citation(s) in RCA: 280] [Impact Index Per Article: 70.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/26/2020] [Indexed: 12/23/2022] Open
Abstract
Bruton tyrosine kinase (BTK) inhibition is an effective treatment approach for patients with Waldenström macroglobulinemia (WM). The phase 3 ASPEN study compared the efficacy and safety of ibrutinib, a first-generation BTK inhibitor, with zanubrutinib, a novel highly selective BTK inhibitor, in patients with WM. Patients with MYD88L265P disease were randomly assigned 1:1 to treatment with ibrutinib or zanubrutinib. The primary end point was the proportion of patients achieving a complete response (CR) or a very good partial response (VGPR) by independent review. Key secondary end points included major response rate (MRR), progression-free survival (PFS), duration of response (DOR), disease burden, and safety. A total of 201 patients were randomized, and 199 received ≥1 dose of study treatment. No patient achieved a CR. Twenty-nine (28%) zanubrutinib patients and 19 (19%) ibrutinib patients achieved a VGPR, a nonstatistically significant difference (P = .09). MRRs were 77% and 78%, respectively. Median DOR and PFS were not reached; 84% and 85% of ibrutinib and zanubrutinib patients were progression free at 18 months. Atrial fibrillation, contusion, diarrhea, peripheral edema, hemorrhage, muscle spasms, and pneumonia, as well as adverse events leading to treatment discontinuation, were less common among zanubrutinib recipients. Incidence of neutropenia was higher with zanubrutinib, although grade ≥3 infection rates were similar in both arms (1.2 and 1.1 events per 100 person-months). These results demonstrate that zanubrutinib and ibrutinib are highly effective in the treatment of WM, but zanubrutinib treatment was associated with a trend toward better response quality and less toxicity, particularly cardiovascular toxicity.
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Affiliation(s)
- Constantine S Tam
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- St Vincent's Hospital, Fitzroy, VIC, Australia
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
- Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Stephen Opat
- Monash Health, Clayton, VIC, Australia
- Clinical Haematology Unit, Monash University, Clayton, VIC, Australia
| | - Shirley D'Sa
- University College London Hospital Foundation Trust, London, United Kingdom
| | - Wojciech Jurczak
- Maria Sklodowska-Curie National Institute of Oncology, Krakow, Poland
| | - Hui-Peng Lee
- Flinders Medical Centre, Adelaide, SA, Australia
| | - Gavin Cull
- Sir Charles Gairdner Hospital, Perth, WA, Australia
- Department of Lymphoma/Myeloma, University of Western Australia, Perth, WA, Australia
| | - Roger G Owen
- St James's University Hospital, Leeds, United Kingdom
| | - Paula Marlton
- Department of Haematology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Björn E Wahlin
- Unit of Hematology, Department of Medicine, Karolinska Universitetssjukhuset-Karolinska Institutet, Stockholm, Sweden
| | | | - Helen McCarthy
- Royal Bournemouth and Christchurch Hospital, Bournemouth, United Kingdom
| | | | | | - Jorge J Castillo
- Bing Center for Waldenstrom Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Jaroslaw Czyz
- Szpital Uniwersytecki No 2 im Dr Jana Biziela, Bydgoszcz, Poland
- Department of Hematology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Carlos Fernández de Larrea
- Amyloidosis and Myeloma Unit, Department of Hematology, Hospital Clinic of Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - David Belada
- Fourth Department of Internal Medicine - Haematology, Charles University Hospital and Faculty of Medicine, Hradec Králové, Czech Republic
| | - Edward Libby
- Department of Medicine, University of Washington and the Seattle Cancer Care Alliance, Seattle, WA
| | | | - Marina Motta
- ASST Spedali Civili di Brescia, Lombardia, Italy
| | | | - Monica Tani
- Ospedale Civile S Maria delle Croci, Azienda Unità Sanitaria Locale (AUSL), Ravenna, Italy
| | - Marek Trneny
- First Department of Medicine, First Faculty of Medicine, Charles University, General Hospital, Prague, Czech Republic
| | | | - Christian Buske
- Comprehensive Cancer Center Ulm-Universitätsklinikum Ulm, Ulm, Germany
| | - Veronique Leblond
- Service d'Hématologie Clinique, Sorbonne University, Pitié Salpêtrière Hospital, Paris, France
| | - Judith Trotman
- Haematology Department, University of Sydney, Concord, NSW, Australia
- Department of Haematology, Concord Repatriation General Hospital, Sydney, Concord, NSW, Australia
| | | | | | - Sunhee Ro
- BeiGene USA, Inc, San Mateo, CA; and
| | | | | | - Meletios Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
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108
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Xiao L, Salem JE, Clauss S, Hanley A, Bapat A, Hulsmans M, Iwamoto Y, Wojtkiewicz G, Cetinbas M, Schloss MJ, Tedeschi J, Lebrun-Vignes B, Lundby A, Sadreyev RI, Moslehi J, Nahrendorf M, Ellinor PT, Milan DJ. Ibrutinib-Mediated Atrial Fibrillation Attributable to Inhibition of C-Terminal Src Kinase. Circulation 2020; 142:2443-2455. [PMID: 33092403 DOI: 10.1161/circulationaha.120.049210] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Ibrutinib is a Bruton tyrosine kinase inhibitor with remarkable efficacy against B-cell cancers. Ibrutinib also increases the risk of atrial fibrillation (AF), which remains poorly understood. METHODS We performed electrophysiology studies on mice treated with ibrutinib to assess inducibility of AF. Chemoproteomic analysis of cardiac lysates identified candidate ibrutinib targets, which were further evaluated in genetic mouse models and additional pharmacological experiments. The pharmacovigilance database, VigiBase, was queried to determine whether drug inhibition of an identified candidate kinase was associated with increased reporting of AF. RESULTS We demonstrate that treatment of mice with ibrutinib for 4 weeks results in inducible AF, left atrial enlargement, myocardial fibrosis, and inflammation. This effect was reproduced in mice lacking Bruton tyrosine kinase, but not in mice treated with 4 weeks of acalabrutinib, a more specific Bruton tyrosine kinase inhibitor, demonstrating that AF is an off-target side effect. Chemoproteomic profiling identified a short list of candidate kinases that was narrowed by additional experimentation leaving CSK (C-terminal Src kinase) as the strongest candidate for ibrutinib-induced AF. Cardiac-specific Csk knockout in mice led to increased AF, left atrial enlargement, fibrosis, and inflammation, phenocopying ibrutinib treatment. Disproportionality analyses in VigiBase confirmed increased reporting of AF associated with kinase inhibitors blocking Csk versus non-Csk inhibitors, with a reporting odds ratio of 8.0 (95% CI, 7.3-8.7; P<0.0001). CONCLUSIONS These data identify Csk inhibition as the mechanism through which ibrutinib leads to AF. Registration: URL: https://ww.clinicaltrials.gov; Unique identifier: NCT03530215.
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Affiliation(s)
- Ling Xiao
- Cardiovascular Research Center (L.X., S.C., A.H., A.B., J.T., M.N., P.T.E., D.J.M.), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Joe-Elie Salem
- Clinical Pharmacology, Sorbonne University, INSERM, APHP, UNICO-GRECO Cardio-oncology Program (J-E.S., B.L-V.), Sorbonne University, ISERM, APHP, UNICO-GRECO Cardio-oncology Program, Hospital Pitié-Salpêtrière, Paris, France.,Clinical Investigation Center, Paris, France (J-E.S.).,Vanderbilt University Medical Center, Cardio-Oncology Program, Division of Cardiovascular Medicine, Nashville, TN (J-E.S., J.M.)
| | - Sebastian Clauss
- Cardiovascular Research Center (L.X., S.C., A.H., A.B., J.T., M.N., P.T.E., D.J.M.), Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Department of Medicine I, Klinikum Grosshadern, University of Munich, Germany (S.C.).,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance, Germany (S.C.)
| | - Alan Hanley
- Cardiovascular Research Center (L.X., S.C., A.H., A.B., J.T., M.N., P.T.E., D.J.M.), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Aneesh Bapat
- Cardiovascular Research Center (L.X., S.C., A.H., A.B., J.T., M.N., P.T.E., D.J.M.), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Maarten Hulsmans
- Center for Systems Biology, Department of Radiology (M.H., Y.I., G.W., M.J.S., M.N.), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Yoshiko Iwamoto
- Center for Systems Biology, Department of Radiology (M.H., Y.I., G.W., M.J.S., M.N.), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Gregory Wojtkiewicz
- Center for Systems Biology, Department of Radiology (M.H., Y.I., G.W., M.J.S., M.N.), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Murat Cetinbas
- Department of Molecular Biology(M.C.), Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Department of Genetics, Harvard Medical School, Boston, MA (M.C.)
| | - Maximilian J Schloss
- Center for Systems Biology, Department of Radiology (M.H., Y.I., G.W., M.J.S., M.N.), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Justin Tedeschi
- Cardiovascular Research Center (L.X., S.C., A.H., A.B., J.T., M.N., P.T.E., D.J.M.), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Bénédicte Lebrun-Vignes
- Clinical Pharmacology, Sorbonne University, INSERM, APHP, UNICO-GRECO Cardio-oncology Program (J-E.S., B.L-V.), Sorbonne University, ISERM, APHP, UNICO-GRECO Cardio-oncology Program, Hospital Pitié-Salpêtrière, Paris, France.,Clinical Pharmacology and Regional Pharmacovigilance Center (B.L-V.), Sorbonne University, ISERM, APHP, UNICO-GRECO Cardio-oncology Program, Hospital Pitié-Salpêtrière, Paris, France.,Université Paris Est (UPEC), IRMB- EA 7379 EpiDermE (Epidemiology in Dermatology and Evaluation of Therapeutics), F-94010, Créteil, France (B.L-V.)
| | - Alicia Lundby
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences and NNF Center for Protein Research, Københavns Universitet, Copenhagen, Denmark (A.L.)
| | - Ruslan I Sadreyev
- Department of Pathology (R.I.S.), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Javid Moslehi
- Vanderbilt University Medical Center, Cardio-Oncology Program, Division of Cardiovascular Medicine, Nashville, TN (J-E.S., J.M.)
| | - Matthias Nahrendorf
- Cardiovascular Research Center (L.X., S.C., A.H., A.B., J.T., M.N., P.T.E., D.J.M.), Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Center for Systems Biology, Department of Radiology (M.H., Y.I., G.W., M.J.S., M.N.), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Patrick T Ellinor
- Cardiovascular Research Center (L.X., S.C., A.H., A.B., J.T., M.N., P.T.E., D.J.M.), Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA (P.T.E.)
| | - David J Milan
- Cardiovascular Research Center (L.X., S.C., A.H., A.B., J.T., M.N., P.T.E., D.J.M.), Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Leducq Foundation, Boston, MA (D.J.M.)
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109
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Despina F, Meletios Athanasios D, Efstathios K. Emerging drugs for the treatment of Waldenström macroglobulinemia. Expert Opin Emerg Drugs 2020; 25:433-444. [PMID: 32955949 DOI: 10.1080/14728214.2020.1822816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Waldenström's Macroglobulinemia (WM) is an indolent lymphoma with uniquely distinct and heterogenous clinical and genomic profiles. Clonal lymphoplasmacytic cells secrete monoclonal IgM. More than 90% of patients harbor a mutation in MYD88 gene, leading to the constitutive activation of downstream pathways, involving BTK-mediated signaling. The use of BTK inhibitors has changed the treatment landscape of WM and has paved the way for new approaches to therapy. AREAS COVERED WM is an orphan disease and ibrutinib is the only FDA/EMA approved agent. Currently established agent combinations will be reviewed with a focus on emerging therapeutic options. These include second generation inhibitors, agents that target other molecules in the BCR signaling pathway, CXCR4 inhibitors, proteasome inhibitors and anti-CD38 antibodies. The current research goal is to establish a combination that can induce deep and durable responses with minimal associated toxicity. In addition, agents that can overcome ibrutinib resistance or act in a synergistic manner with BTKi are under investigation. EXPERT OPINION The optimal therapeutic approach for WM patients is not currently established. The question of whether a combinatory (or synergistic) regimen to overcome resistance and allow for fixed- duration treatment will allow for deep/durable responses is being addressed in ongoing clinical trials.
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Affiliation(s)
- Fotiou Despina
- Plasma Cell Dyscrasia Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens , Athens, Greece
| | - Dimopoulos Meletios Athanasios
- Plasma Cell Dyscrasia Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens , Athens, Greece
| | - Kastritis Efstathios
- Plasma Cell Dyscrasia Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens , Athens, Greece
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Treon SP, Meid K, Gustine J, Yang G, Xu L, Liu X, Patterson CJ, Hunter ZR, Branagan AR, Laubach JP, Ghobrial IM, Palomba ML, Advani R, Castillo JJ. Long-Term Follow-Up of Ibrutinib Monotherapy in Symptomatic, Previously Treated Patients With Waldenström Macroglobulinemia. J Clin Oncol 2020; 39:565-575. [PMID: 32931398 PMCID: PMC8078354 DOI: 10.1200/jco.20.00555] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
We report the long-term findings and final analysis of a pivotal multicenter trial of ibrutinib monotherapy in previously treated patients with Waldenström macroglobulinemia (WM).
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Affiliation(s)
- Steven P Treon
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA.,Department of Medicine, Harvard Medical School, Boston, MA
| | - Kirsten Meid
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Joshua Gustine
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Guang Yang
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Lian Xu
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Xia Liu
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | | | - Zachary R Hunter
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Andrew R Branagan
- Department of Medicine, Harvard Medical School, Boston, MA.,Massachusetts General Hospital, Boston, MA
| | - Jacob P Laubach
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA.,Department of Medicine, Harvard Medical School, Boston, MA
| | - Irene M Ghobrial
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA.,Department of Medicine, Harvard Medical School, Boston, MA
| | - M Lia Palomba
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Jorge J Castillo
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA.,Department of Medicine, Harvard Medical School, Boston, MA
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111
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Geethakumari PR, Awan F. An evaluation of zanubrutinib, a BTK inhibitor, for the treatment of chronic lymphocytic leukemia. Expert Rev Hematol 2020; 13:1039-1046. [PMID: 32869675 DOI: 10.1080/17474086.2020.1817735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Recent years have seen a tremendous increase in the availability of therapeutic options for the management of patients with chronic lymphocytic leukemia (CLL). Notable among those are Bruton's tyrosine kinase (BTK) and b-cell lymphoma-2 (bcl-2) inhibitors. AREAS COVERED The authors provide a brief overview of the BTK signaling pathway as well as available, approved BTK inhibitors for CLL. In addition, they review pre-clinical and clinical data related to zanubrutinib and its use and CLL and other lymphoid malignancies. EXPERT OPINION Two BTK inhibitors are currently Food and Drug Administration (FDA) approved for use in CLL, and multiple additional agents are in development. Zanubrutinib is currently approved for the treatment of patients with relapsed mantle cell lymphoma and has demonstrated an impressive safety and efficacy profile. The choice of a specific BTK inhibitor for clinical use is dependent on its efficacy and relative toxicity profile. In addition, drug interactions also influence this decision. Zanubrutinib therefore provides an exciting option to utilize a specific BTK inhibitor with potentially limited toxicities. Additional comparative studies are currently underway to establish its advantage over currently available BTK inhibitors. Combination strategies are also being pursued to increase the depth and durability of remissions.
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Affiliation(s)
- Praveen Ramakrishnan Geethakumari
- Division of Hematology/Oncology, Department of Internal Medicine, Harold C. Simmons Cancer Center, UT Southwestern Medical Center , Dallas, TX, USA
| | - Farrukh Awan
- Division of Hematology/Oncology, Department of Internal Medicine, Harold C. Simmons Cancer Center, UT Southwestern Medical Center , Dallas, TX, USA
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112
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Makita S, Hosoba R, Tobinai K. Safety considerations with targeted therapy drugs for B-cell non-Hodgkin lymphoma. Expert Opin Drug Saf 2020; 19:1105-1120. [PMID: 32715803 DOI: 10.1080/14740338.2020.1802424] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION B-cell non-Hodgkin lymphomas (B-NHLs) are the most frequent hematologic malignant cancers. Molecular targeted therapy is an important aspect of B-NHL treatment alongside cytotoxic chemotherapy, radiotherapy, and immunotherapy. AREAS COVERED Molecular targeted therapies have changed the landscape of treatment strategies for B-NHLs since the approval of rituximab, an anti-CD20 monoclonal antibody, by the US Food and Drug Administration in 1997. Currently, several targeted therapies have been approved or are in the later-phase of clinical trials including naked antibodies, antibody-drug conjugates, and small molecules, such as Bruton's tyrosine kinase (BTK) inhibitors, phosphatidylinositol 3-kinase (PI3 K) inhibitors, enhancer of zeste homolog 2 (EZH2) inhibitors, and B-cell lymphoma 2 (Bcl-2) inhibitors. These drugs have various toxicities because of their unique mechanisms of action. In this review, the available toxicity data of the targeted therapies for B-NHLs have been summarized. EXPERT OPINION Recent clinical developments of targeted therapies for B-NHLs have provided several useful effective therapeutic options for patients. However, there are unique toxicities that need to be resolved. It is necessary to find out the toxicity mechanism; optimal treatment strategy for these toxicities; and novel targeted therapies that might potentially overcome the toxicities of previously approved targeted therapies.
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Affiliation(s)
- Shinichi Makita
- Department of Hematology, National Cancer Center Hospital , Tokyo, Japan
| | - Rika Hosoba
- Department of Hematology, National Cancer Center Hospital , Tokyo, Japan
| | - Kensei Tobinai
- Department of Hematology, National Cancer Center Hospital , Tokyo, Japan
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Abstract
Bruton tyrosine kinase (BTK) is a nonreceptor tyrosine kinase that plays a central role in the signal transduction of the B-cell antigen receptor and other cell surface receptors, both in normal and malignant B lymphocytes. B-cell antigen receptor signaling is activated in secondary lymphatic organs and drives the proliferation of malignant B cells, including chronic lymphocytic leukemia (CLL) cells. During the last 10 years, BTK inhibitors (BTKis) are increasingly replacing chemotherapy-based regimen, especially in patients with CLL and mantle cell lymphoma (MCL). Bruton tyrosine kinase inhibitors are particularly active in patients with CLL and MCL, but also received approval for Waldenström macroglobulinemia, small lymphocytic lymphoma, marginal zone lymphoma, and chronic graft-versus-host disease. Current clinical practice is continuous long-term administration of BTKi, which can be complicated by adverse effects or the development of drug resistance. Alternatives to long-term use of BTKi are being developed, such as combination therapies, permitting for limited duration therapy. Second-generation BTKis are under development, which differ from ibrutinib, the first-in-class BTKi, in their specificity for BTK, and therefore may differentiate themselves from ibrutinib in terms of adverse effects or efficacy.
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114
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Bond DA, Maddocks KJ. Current Role and Emerging Evidence for Bruton Tyrosine Kinase Inhibitors in the Treatment of Mantle Cell Lymphoma. Hematol Oncol Clin North Am 2020; 34:903-921. [PMID: 32861286 DOI: 10.1016/j.hoc.2020.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The Bruton tyrosine kinase inhibitors (BTKi), acalabrutinib, ibrutinib, and zanubrutinib, are all approved in the United States for the treatment of relapsed mantle cell lymphoma (MCL). BTKi as a class have become the preferred therapy for most of the patients with relapsed MCL, and ongoing clinical trials are evaluating whether combining BTKi with other targeted agents may deepen response and further improve outcomes. Emerging evidence supports the efficacy of BTKi-containing combinations as frontline treatment, and clinical studies to define the role of this class of drugs for newly diagnosed patients with MCL are in progress.
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Affiliation(s)
- David A Bond
- Division of Hematology, The Ohio State University, 320 West 10th Avenue, A340 Starling Loving Hall, Columbus, OH 43210, USA.
| | - Kami J Maddocks
- Division of Hematology, The Ohio State University, 320 West 10th Street, A350C Starling Loving Hall, Columbus, OH 43210, USA. https://twitter.com/kmaddmd
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MESH Headings
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/history
- Antineoplastic Agents/therapeutic use
- Antineoplastic Agents, Immunological/therapeutic use
- Drug Resistance, Neoplasm
- Female
- History, 20th Century
- History, 21st Century
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Mutation
- Prognosis
- Receptors, Antigen, B-Cell/genetics
- Receptors, Antigen, B-Cell/metabolism
- Signal Transduction
- Survival Rate
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Affiliation(s)
- Jan A Burger
- From the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston
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Gavriatopoulou M, Fotiou D, Ntanasis-Stathopoulos I, Dimopoulos MA. The current role of BTK inhibitors in the treatment of Waldenstrom's Macroglobulinemia. Expert Rev Anticancer Ther 2020; 20:663-674. [PMID: 32631091 DOI: 10.1080/14737140.2020.1791705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Waldenstrom's Macroglobulinemia (WM) is a rare, indolent lymphoplasmacytic lymphoma characterized by heterogeneous clinical and genomic profile. Bruton's tyrosine kinase (BTK) is central to the signaling pathways required for clonal WM cell survival, and BTK inhibitors currently have an imperative role in the treatment of WM. AREAS COVERED The central role of BTK in WM will be described, and the rationale behind the development of BTKi. Clinical trial data that led to the approval of ibrutinib (the first-in-class BTKi) will be reviewed. Despite its potency and safe toxicity profile, ibrutinib does not induce deep remissions, and responses are mutational-status dependent. The mechanisms that lead to resistance to this agent are being investigated. Ibrutinib treatment has to be continuous; consequently, patients face the effects of long-term toxicity. In that context, second-generation inhibitors are in clinical development with fewer off-target effects and an efficacy profile, which will be determined based on long-term follow-up data. EXPERT OPINION The optimal therapeutic approach for WM patients remains to be established. The question of whether a combinatory (or synergistic) regimen to overcome resistance and allow for a fixed treatment duration will allow for deep and durable response is being addressed in ongoing clinical trials.
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Affiliation(s)
- Maria Gavriatopoulou
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens , Athens, Greece
| | - Despina Fotiou
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens , Athens, Greece
| | - Ioannis Ntanasis-Stathopoulos
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens , Athens, Greece
| | - Meletios Athanasios Dimopoulos
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens , Athens, Greece
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117
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Allouchery M, Tomowiak C, Guidez S, Delwail V, Delaunay P, Lafay-Chebassier C, Salvo F, Pérault-Pochat MC. Patterns of use and safety of ibrutinib in real-life practice. Br J Clin Pharmacol 2020; 87:895-904. [PMID: 32559327 DOI: 10.1111/bcp.14440] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS To provide real-life data on patterns of use and safety of ibrutinib. METHODS A cohort study including all patients initiating ibrutinib between 21 November 2014 and 21 November 2018, and followed for 1 year was conducted. Patient characteristics, ibrutinib use and adverse drug reactions (ADRs) were collected from medical records. Kaplan-Meier analysis estimated the probability of developing ibrutinib-associated serious ADRs (SADRs) with a 95% confidence interval (CI). A Cox proportional hazards model was used to investigate factors associated with SADR occurrence. RESULTS In total, 102 patients were included in the study. The median age was 70.3 years (interquartile range 64.7-75.6), the male/female gender ratio was 2.9. Almost half the patients (47.1%) were prescribed ibrutinib for chronic lymphocytic leukaemia (CLL). Forty-three patients (42.1%) permanently discontinued ibrutinib in the first year, mostly for progression (51.2%) or ADRs (32.6%). Forty-eight patients (47.1%) experienced at least one ibrutinib-associated SADR. Haematological, infectious and vascular disorders were the most frequent SADRs. The probability of developing ibrutinib-associated SADR was 35.1% (95% CI 26.3-45.7%) at 3 months, 44.8% (35.2%; 55.8%) at 6 months and 54.3% (44.0%; 65.2%) at 12 months. Age ≥80 years (hazard ratio [HR] 2.03; 95% CI 1.02-4.05) and CLL (HR 1.81; 95% CI 1.01-3.25) were significantly associated with a higher risk of SADR occurrence. CONCLUSION This study found a high cumulative incidence of ibrutinib-associated SADRs within the first year of treatment. In view of the risk of SADR, patients aged ≥80 years or treated for CLL deserve special attention.
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Affiliation(s)
- Marion Allouchery
- Pharmacologie Clinique et Vigilances, CHU de Poitiers, Poitiers, France
| | - Cécile Tomowiak
- Onco-Hématologie et Thérapie Cellulaire, CHU de Poitiers, Poitiers, France.,INSERM CIC 1402, CHU de Poitiers, Poitiers, France
| | - Stéphanie Guidez
- Onco-Hématologie et Thérapie Cellulaire, CHU de Poitiers, Poitiers, France.,INSERM CIC 1402, CHU de Poitiers, Poitiers, France
| | - Vincent Delwail
- Onco-Hématologie et Thérapie Cellulaire, CHU de Poitiers, Poitiers, France.,INSERM CIC 1402, CHU de Poitiers, Poitiers, France
| | - Paul Delaunay
- Pharmacologie Clinique et Vigilances, CHU de Poitiers, Poitiers, France
| | - Claire Lafay-Chebassier
- Pharmacologie Clinique et Vigilances, CHU de Poitiers, Poitiers, France.,Laboratoire de Neurosciences Expérimentales et Cliniques, INSERM U1084, Université de Poitiers, Poitiers, France
| | - Francesco Salvo
- Bordeaux Population Health Research Center, Pharmacoepidemiology research team, INSERM U1219, Université de Bordeaux, Bordeaux, France.,Pharmacologie Médicale, Pôle de Santé Publique, CHU de Bordeaux, Bordeaux, France
| | - Marie-Christine Pérault-Pochat
- Pharmacologie Clinique et Vigilances, CHU de Poitiers, Poitiers, France.,Laboratoire de Neurosciences Expérimentales et Cliniques, INSERM U1084, Université de Poitiers, Poitiers, France
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Abstract
PURPOSE OF REVIEW While the Bruton's tyrosine kinase inhibitor (BTKi) ibrutinib has revolutionized the treatment of chronic lymphocytic leukemia (CLL), current limitations include off-target toxicities and the development of resistance. In this review, we summarize the emerging data for alternative BTKi. RECENT FINDINGS Second-generation BTKi include acalabrutinib, zanubrutinib, and tirabrutinib which offer greater BTK selectivity. While these agents may limit off-target toxicity, they do not overcome common mechanisms of ibrutinib resistance. Reversible BTKi including vecabrutinib and LOXO-305 inhibit BTK in the presence of C481S mutation, and non-selective reversible BTKi, including ARQ-531, may retain activity despite mutations within PLCG2. Early-phase studies are underway to establish the clinical efficacy and toxicity of these agents. A randomized trial of ibrutinib versus acalabrutinib is ongoing, and acalabrutinib may be an option for ibrutinib-intolerant patients. Results from ongoing trials of alternate BTKi will help to define their role in CLL therapy as single agents or in combination therapy.
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119
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Pineda-Gayoso R, Alomar M, Lee DH, Fradley MG. Cardiovascular Toxicities of Bruton’s Tyrosine Kinase Inhibitors. Curr Treat Options Oncol 2020; 21:67. [DOI: 10.1007/s11864-020-00764-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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120
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Arthur R, Valle-Argos B, Steele AJ, Packham G. Development of PROTACs to address clinical limitations associated with BTK-targeted kinase inhibitors. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2020; 1:131-152. [PMID: 32924028 PMCID: PMC7116064 DOI: 10.37349/etat.2020.00009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/24/2020] [Indexed: 02/03/2023] Open
Abstract
Chronic lymphocytic leukemia is a common form of leukemia and is dependent on growth-promoting signaling via the B-cell receptor. The Bruton tyrosine kinase (BTK) is an important mediator of B-cell receptor signaling and the irreversible BTK inhibitor ibrutinib can trigger dramatic clinical responses in treated patients. However, emergence of resistance and toxicity are major limitations which lead to treatment discontinuation. There remains, therefore, a clear need for new therapeutic options. In this review, we discuss recent progress in the development of BTK-targeted proteolysis targeting chimeras (PROTACs) describing how such agents may provide advantages over ibrutinib and highlighting features of PROTACs that are important for the development of effective BTK degrading agents. Overall, PROTACs appear to be an exciting new approach to target BTK. However, development is at a very early stage and considerable progress is required to refine these agents and optimize their drug-like properties before progression to clinical testing.
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Affiliation(s)
- Rachael Arthur
- Cancer Research UK Centre, Cancer Sciences, Faculty of Medicine, University of Southampton, SO16 6YD Southampton, UK
| | - Beatriz Valle-Argos
- Cancer Research UK Centre, Cancer Sciences, Faculty of Medicine, University of Southampton, SO16 6YD Southampton, UK
| | - Andrew J. Steele
- Cancer Research UK Centre, Cancer Sciences, Faculty of Medicine, University of Southampton, SO16 6YD Southampton, UK
- Institute for Life Sciences, University of Southampton, University Road, Highfield Campus, SO17 1BJ, Southampton, UK
| | - Graham Packham
- Cancer Research UK Centre, Cancer Sciences, Faculty of Medicine, University of Southampton, SO16 6YD Southampton, UK
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121
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Gordon MJ, Huang J, Chan RJ, Bhargava P, Danilov AV. Medical comorbidities in patients with chronic lymphocytic leukaemia treated with idelalisib: analysis of two large randomised clinical trials. Br J Haematol 2020; 192:720-728. [PMID: 32599655 DOI: 10.1111/bjh.16879] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 12/18/2022]
Abstract
Comorbidities influence survival in patients with chronic lymphocytic leukaemia (CLL) treated with chemo-immunotherapy or ibrutinib. While idelalisib has been studied in patients with comorbidities, their impact has not been investigated. We analysed 481 patients treated with idelalisib on two randomised trials (NCT01659021 and NCT01539512). Comorbidities were assessed using the Cumulative Illness Risk Scale (CIRS). Patients received idelalisib + anti-CD20 (rituximab or ofatumumab; n = 284) or anti-CD20 alone (n = 197). The median age was 69 years. We found that comorbidities did not significantly affect outcomes of idelalisib therapy. The objective response rate (ORR) was 79·3% versus 85·8%, the median progression-free survival (PFS) was 16·3 versus 19·1 months, and the median overall survival (OS) was 39·8 versus 49·8 months in patients treated with idelalisib who had a CIRS score of >6 versus ≤6, correspondingly. Treatment with idelalisib + anti-CD20 was associated with superior PFS and ORR when compared to anti-CD20 monotherapy in patients who had high comorbidities (CIRS score of >6) or at least one severe comorbidity (median PFS 16·3 vs. 6·9 months and 16·6 vs. 6·5 months; odds ratio 20·1 and 33·2; P < 0·0001). Thus, comorbidities do not portend inferior outcomes in patients with CLL treated with idelalisib in combination with anti-CD20 therapy.
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Affiliation(s)
- Max J Gordon
- Oregon Health and Science University, Portland, OR, USA
| | | | | | | | - Alexey V Danilov
- Oregon Health and Science University, Portland, OR, USA.,City of Hope National Medical Center, Duarte, CA, USA
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122
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Jin Y, Xu Z, Yan H, He Q, Yang X, Luo P. A Comprehensive Review of Clinical Cardiotoxicity Incidence of FDA-Approved Small-Molecule Kinase Inhibitors. Front Pharmacol 2020; 11:891. [PMID: 32595510 PMCID: PMC7303342 DOI: 10.3389/fphar.2020.00891] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 05/29/2020] [Indexed: 11/24/2022] Open
Abstract
Numerous protein kinases encoded in the genome have become attractive targets for the treatment of different types of cancer. As of January 2020, a total of 52 small-molecule kinase inhibitors (SMKIs) have been approved by the FDA. With the numerous clinical trials and a heavy focus on drug safety, SMKI-induced cardiotoxicity, which is a life-threatening risk, has greatly attracted the attention of researchers. In this review, the SMKIs with cardiotoxicity incidence were described exhaustively. The data were collected from 42 clinical trials, 25 FDA-published documents, seven meta-analysis/systematic reviews, three case reports and more than 50 other types of articles. To date, 73% (38 of 52) of SMKIs have reported treatment-related cardiotoxicity. Among the 38 SMKIs with known cardiotoxicity, the rates of incidence of cardiac adverse events were QT prolongation: 47% (18 of 38), hypertension: 40% (15 of 38), left ventricular dysfunction: 34% (13 of 38), arrhythmia: 34% (13 of 38), heart failure: 26% (10 of 38) and ischemia or myocardial infarction: 29% (11 of 38). In the development process of novel SMKIs, more attention should be paid to balancing the treatment efficacy and the risk of cardiotoxicity. In preclinical drug studies, producing an accurate and reliable cardiotoxicity evaluation model is of key importance. To avoid the clinical potential cardiotoxicity risk and discontinuation of a highly effective drug, patients treated with SMKIs should be proactively monitored on the basis of a global standard. Moreover, the underlying mechanisms of SMKI-induced cardiotoxicity need to be further studied to develop new therapies for SMKI-induced cardiotoxicity.
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Affiliation(s)
| | | | | | | | - Xiaochun Yang
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Peihua Luo
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
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123
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Larsson K, Mattsson M, Ebrahim F, Glimelius I, Höglund M. High prevalence and incidence of cardiovascular disease in chronic lymphocytic leukaemia: a nationwide population-based study. Br J Haematol 2020; 190:e245-e248. [PMID: 32515008 DOI: 10.1111/bjh.16859] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Karin Larsson
- Institute of Medical Sciences, Uppsala University, Uppsala, Sweden.,Deptartment of Blood and Tumour Diseases, Uppsala University Hospital, Uppsala, Sweden
| | - Mattias Mattsson
- Deptartment of Blood and Tumour Diseases, Uppsala University Hospital, Uppsala, Sweden.,Institute of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Fereshte Ebrahim
- Regional Cancer Centre Stockholm-Gotland, Stockholm City Council, Stockholm, Sweden
| | - Ingrid Glimelius
- Deptartment of Blood and Tumour Diseases, Uppsala University Hospital, Uppsala, Sweden.,Institute of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Martin Höglund
- Institute of Medical Sciences, Uppsala University, Uppsala, Sweden.,Deptartment of Blood and Tumour Diseases, Uppsala University Hospital, Uppsala, Sweden
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124
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Archibald WJ, Rabe KG, Kabat BF, Herrmann J, Ding W, Kay NE, Kenderian SS, Muchtar E, Leis JF, Wang Y, Chanan-Khan AA, Schwager SM, Koehler AB, Fonder AL, Slager SL, Shanafelt TD, Call TG, Parikh SA. Atrial fibrillation in patients with chronic lymphocytic leukemia (CLL) treated with ibrutinib: risk prediction, management, and clinical outcomes. Ann Hematol 2020; 100:143-155. [PMID: 32488603 DOI: 10.1007/s00277-020-04094-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 05/17/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Ibrutinib therapy is associated with an increased risk of atrial fibrillation (AF) in chronic lymphocytic leukemia (CLL). Risk assessment tools and outcomes of AF in these patients are not well described. METHODS We performed a retrospective review of patients with CLL treated with ibrutinib at Mayo Clinic between October 2012 and November 2018. RESULTS Two hundred ninety-eight patients were identified with a median time on ibrutinib of 19 months (range 0.23-69.7 months). Fifty-one patients developed treatment-emergent AF; the risk of treatment-emergent AF at 6 months, 1 year, and 2 years was 9%, 12%, and 16%, respectively. The following were associated with an increased risk of treatment-emergent AF on multivariable analyses: past history of AF (hazard ratio [HR] 3.5, p = 0.0072) and heart failure (HR 3.4, p = 0.0028). Most patients are able to continue ibrutinib therapy (dose reduced in 43%). Development of treatment-emergent AF was associated with shorter event-free survival (EFS; HR 2.0, p = 0.02) and shorter overall survival (OS; HR 3.2, p = 0.001), after adjusting for age, prior treatment status, TP53 disruption, heart failure, valvular disease, and past history of AF. CONCLUSIONS Patient comorbidities, rather than CLL-related factors, predict risk of treatment-emergent AF in patients treated with ibrutinib. Although the vast majority of patients with treatment-emergent AF are able to continue ibrutinib (with dose reduction in 43%), treatment-emergent AF appears to be associated with worse outcomes, independent of other adverse prognostic factors.
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Affiliation(s)
- William J Archibald
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Kari G Rabe
- Division of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, MN, USA
| | - Brian F Kabat
- Division of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, MN, USA
| | | | - Wei Ding
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Neil E Kay
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Saad S Kenderian
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Eli Muchtar
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Jose F Leis
- Department of Hematology and Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Yucai Wang
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | | | - Susan M Schwager
- Division of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, MN, USA
| | - Amber B Koehler
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Amie L Fonder
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Susan L Slager
- Division of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, MN, USA
| | - Tait D Shanafelt
- Division of Hematology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Timothy G Call
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Sameer A Parikh
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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Lew TE, Anderson MA, Seymour JF. Promises and pitfalls of targeted agents in chronic lymphocytic leukemia. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2020; 3:415-444. [PMID: 35582452 PMCID: PMC8992498 DOI: 10.20517/cdr.2019.108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/19/2020] [Accepted: 02/05/2020] [Indexed: 11/12/2022]
Abstract
Targeted agents have significantly improved outcomes for patients with chronic lymphocytic leukemia, particularly high-risk subgroups for whom chemoimmunotherapy previously offered limited efficacy. Two classes of agent in particular, the Bruton tyrosine kinase inhibitors (e.g., ibrutinib) and the B-cell lymphoma 2 inhibitor, venetoclax, induce high response rates and durable remissions in the relapsed/refractory and frontline settings. However, maturing clinical data have revealed promises and pitfalls for both agents. These drugs induce remissions and disease control in the majority of patients, often in situations where modest efficacy would be expected with traditional chemoimmunotherapy approaches. Unfortunately, in the relapsed and refractory setting, both agents appear to be associated with an inevitable risk of disease relapse and progression. Emerging patterns of resistance are being described for both agents but a common theme appears to be multiple sub-clonal drivers of disease progression. Understanding these mechanisms and developing effective and safe methods to circumvent the emergence of resistance will determine the longer-term utility of these agents to improve patients' quality and length of life. Rational drug combinations, optimised scheduling and sequencing of therapy will likely hold the key to achieving these important goals.
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Affiliation(s)
- Thomas E. Lew
- Department of Clinical Haematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville 3050, Australia
- Blood Cells and Blood Cancer Division, Walter and Eliza Hall Institute of Medical Research, Parkville 3050, Australia
| | - Mary Ann Anderson
- Department of Clinical Haematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville 3050, Australia
- Blood Cells and Blood Cancer Division, Walter and Eliza Hall Institute of Medical Research, Parkville 3050, Australia
| | - John F. Seymour
- Department of Clinical Haematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville 3050, Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville 3050, Australia
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George B, Mullick Chowdhury S, Hart A, Sircar A, Singh SK, Nath UK, Mamgain M, Singhal NK, Sehgal L, Jain N. Ibrutinib Resistance Mechanisms and Treatment Strategies for B-Cell lymphomas. Cancers (Basel) 2020; 12:E1328. [PMID: 32455989 PMCID: PMC7281539 DOI: 10.3390/cancers12051328] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/17/2020] [Accepted: 05/19/2020] [Indexed: 02/03/2023] Open
Abstract
Chronic activation of B-cell receptor (BCR) signaling via Bruton tyrosine kinase (BTK) is largely considered to be one of the primary mechanisms driving disease progression in B-Cell lymphomas. Although the BTK-targeting agent ibrutinib has shown promising clinical responses, the presence of primary or acquired resistance is common and often leads to dismal clinical outcomes. Resistance to ibrutinib therapy can be mediated through genetic mutations, up-regulation of alternative survival pathways, or other unknown factors that are not targeted by ibrutinib therapy. Understanding the key determinants, including tumor heterogeneity and rewiring of the molecular networks during disease progression and therapy, will assist exploration of alternative therapeutic strategies. Towards the goal of overcoming ibrutinib resistance, multiple alternative therapeutic agents, including second- and third-generation BTK inhibitors and immunomodulatory drugs, have been discovered and tested in both pre-clinical and clinical settings. Although these agents have shown high response rates alone or in combination with ibrutinib in ibrutinib-treated relapsed/refractory(R/R) lymphoma patients, overall clinical outcomes have not been satisfactory due to drug-associated toxicities and incomplete remission. In this review, we discuss the mechanisms of ibrutinib resistance development in B-cell lymphoma including complexities associated with genomic alterations, non-genetic acquired resistance, cancer stem cells, and the tumor microenvironment. Furthermore, we focus our discussion on more comprehensive views of recent developments in therapeutic strategies to overcome ibrutinib resistance, including novel BTK inhibitors, clinical therapeutic agents, proteolysis-targeting chimeras and immunotherapy regimens.
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Affiliation(s)
- Bhawana George
- Department of Hematopathology, MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Sayan Mullick Chowdhury
- Department of Internal Medicine, the Ohio State University, Columbus, OH 43210, USA; (S.M.C.); (A.H.); (A.S.); (S.K.S.)
| | - Amber Hart
- Department of Internal Medicine, the Ohio State University, Columbus, OH 43210, USA; (S.M.C.); (A.H.); (A.S.); (S.K.S.)
| | - Anuvrat Sircar
- Department of Internal Medicine, the Ohio State University, Columbus, OH 43210, USA; (S.M.C.); (A.H.); (A.S.); (S.K.S.)
| | - Satish Kumar Singh
- Department of Internal Medicine, the Ohio State University, Columbus, OH 43210, USA; (S.M.C.); (A.H.); (A.S.); (S.K.S.)
| | - Uttam Kumar Nath
- Department of Medical Oncology & Hematology, All India Institute of Medical Sciences, Rishikesh 249203, India;
| | - Mukesh Mamgain
- Department of Biochemistry, All India Institute of Medical Sciences, Rishikesh 249203, India; (M.M.); (N.K.S.)
| | - Naveen Kumar Singhal
- Department of Biochemistry, All India Institute of Medical Sciences, Rishikesh 249203, India; (M.M.); (N.K.S.)
| | - Lalit Sehgal
- Department of Internal Medicine, the Ohio State University, Columbus, OH 43210, USA; (S.M.C.); (A.H.); (A.S.); (S.K.S.)
| | - Neeraj Jain
- Department of Medical Oncology & Hematology, All India Institute of Medical Sciences, Rishikesh 249203, India;
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Salem JE, Manouchehri A, Bretagne M, Lebrun-Vignes B, Groarke JD, Johnson DB, Yang T, Reddy NM, Funck-Brentano C, Brown JR, Roden DM, Moslehi JJ. Cardiovascular Toxicities Associated With Ibrutinib. J Am Coll Cardiol 2020; 74:1667-1678. [PMID: 31558250 DOI: 10.1016/j.jacc.2019.07.056] [Citation(s) in RCA: 168] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/05/2019] [Accepted: 07/07/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Ibrutinib has revolutionized treatment for several B-cell malignancies. However, a recent clinical trial where ibrutinib was used in a front-line setting showed increased mortality during treatment compared with conventional chemotherapy. Cardiovascular toxicities were suspected as the culprit but not directly assessed in the study. OBJECTIVES The purpose of this study was to identify and characterize cardiovascular adverse drug reactions (CV-ADR) associated with ibrutinib. METHODS This study utilized VigiBase (International pharmacovigilance database) and performed a disproportionality analysis using reporting odds ratios (ROR) and information component (IC) to determine whether CV-ADR and CV-ADR deaths were associated with ibrutinib. IC compares observed and expected values to find associations between drugs and adverse drug reactions using disproportionate Bayesian-reporting; IC025 (lower end of the IC 95% credibility interval) >0 is significant. RESULTS This study identified 303 ibrutinib-associated cardiovascular deaths. Ibrutinib was associated with higher reporting of supraventricular arrhythmias (SVAs) (ROR: 23.1; 95% confidence interval: 21.6 to 24.7; p < 0.0001; IC025: 3.97), central nervous system (CNS) hemorrhagic events (ROR: 3.7; 95% confidence interval: 3.4 to 4.1; p < 0.0001; IC025: 1.63), heart failure (ROR: 3.5; 95% confidence interval: 3.1 to 3.8; p < 0.0001; IC025: 1.46), ventricular arrhythmias (ROR: 4.7; 95% confidence interval: 3.7 to 5.9; p < 0.0001; IC025: 0.96), conduction disorders (ROR: 3.5; 95% confidence interval: 2.7 to 4.6; p < 0.0001; IC025: 0.76), CNS ischemic events (ROR: 2.2; 95% confidence interval: 2.0 to 2.5; p < 0.0001; IC025: 0.73), and hypertension (ROR: 1.7; 95% confidence interval: 1.5 to 1.9; p < 0.0001; IC025: 0.4). CV-ADR often occurred early after ibrutinib administration. Importantly, CV-ADR were associated with fatalities that ranged from ∼10% (SVAs and ventricular arrhythmias) to ∼20% (CNS events, heart failure, and conduction disorders). Ibrutinib-associated SVA portends poor prognosis when CNS events occur concomitantly, with 28.8% deaths (15 of 52 cases). CONCLUSIONS Severe and occasionally fatal cardiac events occur in patients exposed to ibrutinib. These events should be considered in patient care and in clinical trial designs. (Evaluation of Reporting of Cardio-vascular Adverse Events With Antineoplastic and Immunomodulating Agents [EROCA]; NCT03530215).
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Affiliation(s)
- Joe-Elie Salem
- Sorbonne Université, INSERM CIC-1421, AP-HP, Regional Pharmacovigilance Center, Pitié-Salpêtrière Hospital, UNICO-GRECO.6 Cardio-Oncology Program, Department of Pharmacology, Paris, France; Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Ali Manouchehri
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marie Bretagne
- Sorbonne Université, INSERM CIC-1421, AP-HP, Regional Pharmacovigilance Center, Pitié-Salpêtrière Hospital, UNICO-GRECO.6 Cardio-Oncology Program, Department of Pharmacology, Paris, France
| | - Bénédicte Lebrun-Vignes
- Sorbonne Université, INSERM CIC-1421, AP-HP, Regional Pharmacovigilance Center, Pitié-Salpêtrière Hospital, UNICO-GRECO.6 Cardio-Oncology Program, Department of Pharmacology, Paris, France
| | - John D Groarke
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Douglas B Johnson
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tao Yang
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nishitha M Reddy
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christian Funck-Brentano
- Sorbonne Université, INSERM CIC-1421, AP-HP, Regional Pharmacovigilance Center, Pitié-Salpêtrière Hospital, UNICO-GRECO.6 Cardio-Oncology Program, Department of Pharmacology, Paris, France
| | - Jennifer R Brown
- CLL Center, Dana-Farber Cancer Institute; Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Dan M Roden
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Javid J Moslehi
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee.
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Rasmussen KM, Patil V, Burningham Z, Yong C, Sauer BC, Halwani AS. Atrial Fibrillation and Bleeding in Patients With Chronic Lymphocytic Leukemia Treated with Ibrutinib in the Veterans Health Administration. Fed Pract 2020; 37:S44-S49. [PMID: 32952387 PMCID: PMC7497878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in adults. The introduction of novel oral agents, starting with ibrutinib in 2013, has revolutionized the therapeutic landscape; however, clinical trials have suggested an association between ibrutinib and the risk of bleeding-related adverse events and atrial fibrillation (Afib) in patients with CLL. METHODS Patients diagnosed and treated for CLL at the Veterans Health Administration (VHA) from 2010 to 2014 were followed until December 31, 2016, death, or lack of utilization of hematology/oncology services for ≥ 18 months; or until incidence of another cancer. Treatments dispensed, evidence of VHA system use, bleeding events, and Afib were determined from the administrative records, laboratory records, pharmacy dispensation records, and clinical notes in the electronic healthcare record. RESULTS From 2010 to 2014, 2,796 patients were diagnosed and received care for CLL within the VHA, of whom 172 patients received ibrutinib and 291 received bendamustine + rituximab (BR). The use of anticoagulants following induction therapy did not differ between BR and ibrutinib patients (9% vs 8%, respectively), nor did the use of antiplatelets agents (6% vs 2%, respectively). Of the 291 patients that received BR, 12 (4%) developed a bleeding event compared with 20 (12%) who received ibrutinib. Additionally, 13 (8%) ibrutinib patients developed Afib compared with 9 (3%) BR patients. CONCLUSIONS Real-world evidence from a nationwide cohort of patients with CLL suggests that while ibrutinib is associated with increased bleeding-related adverse events and Afib, the risk is comparable to those reported in previous clinical trials. These findings suggest that patients in real-world clinical care settings with higher levels of comorbidities may be at an increased risk for bleeding events and Afib.
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Affiliation(s)
- Kelli M Rasmussen
- is a Senior Research Analyst at the University of Utah School of Medicine and the George E. Wahlen Veterans Affairs Medical Center (GEWVAMC) in Salt Lake City, Utah; is a Senior Research Analyst at the University of Utah School of Medicine and GEWVAMC; is a Research Associate at GEWVAMC; is a Medical Writer at the University of Utah School of Medicine and GEWVAM; is an Associate Professor at the University of Utah School of Medicine and GEWVAMC; is an Assistant Professor of Medicine at the Huntsman Cancer Institute, University of Utah and GEWVAMC
| | - Vikas Patil
- is a Senior Research Analyst at the University of Utah School of Medicine and the George E. Wahlen Veterans Affairs Medical Center (GEWVAMC) in Salt Lake City, Utah; is a Senior Research Analyst at the University of Utah School of Medicine and GEWVAMC; is a Research Associate at GEWVAMC; is a Medical Writer at the University of Utah School of Medicine and GEWVAM; is an Associate Professor at the University of Utah School of Medicine and GEWVAMC; is an Assistant Professor of Medicine at the Huntsman Cancer Institute, University of Utah and GEWVAMC
| | - Zachary Burningham
- is a Senior Research Analyst at the University of Utah School of Medicine and the George E. Wahlen Veterans Affairs Medical Center (GEWVAMC) in Salt Lake City, Utah; is a Senior Research Analyst at the University of Utah School of Medicine and GEWVAMC; is a Research Associate at GEWVAMC; is a Medical Writer at the University of Utah School of Medicine and GEWVAM; is an Associate Professor at the University of Utah School of Medicine and GEWVAMC; is an Assistant Professor of Medicine at the Huntsman Cancer Institute, University of Utah and GEWVAMC
| | - Christina Yong
- is a Senior Research Analyst at the University of Utah School of Medicine and the George E. Wahlen Veterans Affairs Medical Center (GEWVAMC) in Salt Lake City, Utah; is a Senior Research Analyst at the University of Utah School of Medicine and GEWVAMC; is a Research Associate at GEWVAMC; is a Medical Writer at the University of Utah School of Medicine and GEWVAM; is an Associate Professor at the University of Utah School of Medicine and GEWVAMC; is an Assistant Professor of Medicine at the Huntsman Cancer Institute, University of Utah and GEWVAMC
| | - Brian C Sauer
- is a Senior Research Analyst at the University of Utah School of Medicine and the George E. Wahlen Veterans Affairs Medical Center (GEWVAMC) in Salt Lake City, Utah; is a Senior Research Analyst at the University of Utah School of Medicine and GEWVAMC; is a Research Associate at GEWVAMC; is a Medical Writer at the University of Utah School of Medicine and GEWVAM; is an Associate Professor at the University of Utah School of Medicine and GEWVAMC; is an Assistant Professor of Medicine at the Huntsman Cancer Institute, University of Utah and GEWVAMC
| | - Ahmad S Halwani
- is a Senior Research Analyst at the University of Utah School of Medicine and the George E. Wahlen Veterans Affairs Medical Center (GEWVAMC) in Salt Lake City, Utah; is a Senior Research Analyst at the University of Utah School of Medicine and GEWVAMC; is a Research Associate at GEWVAMC; is a Medical Writer at the University of Utah School of Medicine and GEWVAM; is an Associate Professor at the University of Utah School of Medicine and GEWVAMC; is an Assistant Professor of Medicine at the Huntsman Cancer Institute, University of Utah and GEWVAMC
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Byrd JC, Furman RR, Coutre SE, Flinn IW, Burger JA, Blum K, Sharman JP, Wierda W, Zhao W, Heerema NA, Luan Y, Liu EA, Dean JP, O'Brien S. Ibrutinib Treatment for First-Line and Relapsed/Refractory Chronic Lymphocytic Leukemia: Final Analysis of the Pivotal Phase Ib/II PCYC-1102 Study. Clin Cancer Res 2020; 26:3918-3927. [PMID: 32209572 DOI: 10.1158/1078-0432.ccr-19-2856] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/20/2019] [Accepted: 03/20/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE The safety and efficacy of ibrutinib, a once-daily Bruton's tyrosine kinase (BTK) inhibitor, in chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) was demonstrated in this phase Ib/II study. Extended follow-up up to 8 years is described, representing the longest follow-up for single-agent ibrutinib, or any BTK inhibitor, to date. PATIENTS AND METHODS Phase Ib/II PCYC-1102 (NCT01105247) and extension study PCYC-1103 (NCT01109069) included patients receiving single-agent ibrutinib in first-line or relapsed/refractory CLL/SLL. RESULTS Overall response rate was 89%, with similar rates in first-line (87%; complete response, 35%) and relapsed/refractory settings (89%; 10%). Estimated 7-year progression-free survival (PFS) rates were 83% in first-line and 34% in relapsed/refractory settings. Forty-one patients had CLL progression (n = 11 with Richter's transformation). Median PFS was not reached with first-line ibrutinib. In relapsed/refractory CLL/SLL, median PFS was 52 months overall, 26 months in patients with chromosome 17p deletion, 51 months with 11q deletion, not reached with trisomy 12 or 13q deletion, and 88 months in patients without these cytogenetic abnormalities. Estimated 7-year overall survival rates were 84% in first-line and 55% in relapsed/refractory settings. Grade ≥3 adverse events (AE) in >15% of patients were hypertension (28%), pneumonia (24%), and neutropenia (18%). These grade ≥3 AEs generally declined over time, except hypertension. AEs leading to discontinuation in ≥2 patients were observed only in the relapsed/refractory setting (sepsis, diarrhea, subdural hematoma, and Richter's transformation). CONCLUSIONS With up to 8 years of follow-up, sustained responses and long-term tolerability of single-agent ibrutinib were observed with treatment of first-line or relapsed/refractory CLL/SLL, including high-risk CLL/SLL.
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Affiliation(s)
- John C Byrd
- Department of Internal Medicine, The Ohio State University Medical Center, Columbus, Ohio.
| | - Richard R Furman
- Department of Medicine, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York
| | - Steven E Coutre
- Department of Medicine Hematology, Stanford Cancer Center, Stanford University School of Medicine, Stanford, California
| | - Ian W Flinn
- Hematology/Oncology, Sarah Cannon Research Institute/Tennessee Oncology, Nashville, Tennessee
| | - Jan A Burger
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristie Blum
- Department of Internal Medicine, The Ohio State University Medical Center, Columbus, Ohio
| | - Jeff P Sharman
- Medical Oncology Division, Willamette Valley Cancer Institute and Research Center/US Oncology Research, Eugene, Oregon
| | - William Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Weiqiang Zhao
- Department of Pathology, The Ohio State University, Columbus, Ohio
| | - Nyla A Heerema
- Department of Pathology, The Ohio State University, Columbus, Ohio
| | - Ying Luan
- Department of Biostatistics, Pharmacyclics LLC, an AbbVie Company, Sunnyvale, California
| | - Emily A Liu
- Department of Clinical Sciences, Pharmacyclics LLC, an AbbVie Company, Sunnyvale, California
| | - James P Dean
- Department of Clinical Sciences, Pharmacyclics LLC, an AbbVie Company, Sunnyvale, California
| | - Susan O'Brien
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Medicine, University of California, Irvine, Chao Family Comprehensive Cancer Center, Irvine, California
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Burger JA, Barr PM, Robak T, Owen C, Ghia P, Tedeschi A, Bairey O, Hillmen P, Coutre SE, Devereux S, Grosicki S, McCarthy H, Simpson D, Offner F, Moreno C, Dai S, Lal I, Dean JP, Kipps TJ. Long-term efficacy and safety of first-line ibrutinib treatment for patients with CLL/SLL: 5 years of follow-up from the phase 3 RESONATE-2 study. Leukemia 2020; 34:787-798. [PMID: 31628428 PMCID: PMC7214263 DOI: 10.1038/s41375-019-0602-x] [Citation(s) in RCA: 301] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 08/08/2019] [Accepted: 08/22/2019] [Indexed: 11/08/2022]
Abstract
RESONATE-2 is a phase 3 study of first-line ibrutinib versus chlorambucil in chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). Patients aged ≥65 years (n = 269) were randomized 1:1 to once-daily ibrutinib 420 mg continuously or chlorambucil 0.5-0.8 mg/kg for ≤12 cycles. With a median (range) follow-up of 60 months (0.1-66), progression-free survival (PFS) and overall survival (OS) benefits for ibrutinib versus chlorambucil were sustained (PFS estimates at 5 years: 70% vs 12%; HR [95% CI]: 0.146 [0.098-0.218]; OS estimates at 5 years: 83% vs 68%; HR [95% CI]: 0.450 [0.266-0.761]). Ibrutinib benefit was also consistent in patients with high prognostic risk (TP53 mutation, 11q deletion, and/or unmutated IGHV) (PFS: HR [95% CI]: 0.083 [0.047-0.145]; OS: HR [95% CI]: 0.366 [0.181-0.736]). Investigator-assessed overall response rate was 92% with ibrutinib (complete response, 30%; 11% at primary analysis). Common grade ≥3 adverse events (AEs) included neutropenia (13%), pneumonia (12%), hypertension (8%), anemia (7%), and hyponatremia (6%); occurrence of most events as well as discontinuations due to AEs decreased over time. Fifty-eight percent of patients continue to receive ibrutinib. Single-agent ibrutinib demonstrated sustained PFS and OS benefit versus chlorambucil and increased depth of response over time.
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Affiliation(s)
- Jan A Burger
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Paul M Barr
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Tadeusz Robak
- Medical University of Lodz, Copernicus Memorial Hospital, Lodz, Poland
| | - Carolyn Owen
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Paolo Ghia
- Università Vita-Salute San Raffaele and IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Osnat Bairey
- Rabin Medical Center, Petah Tikva, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Peter Hillmen
- The Leeds Teaching Hospitals, St. James Institute of Oncology, University of Leeds, Leeds, UK
| | - Steven E Coutre
- Stanford Cancer Center, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention, Silesiam Medical University, Katowice, Poland
| | | | | | | | - Carol Moreno
- Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Sandra Dai
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA, USA
| | - Indu Lal
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA, USA
| | - James P Dean
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA, USA
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Rhodes JM, LoRe VA, Mato AR, Chong EA, Barrientos JC, Gerson JN, Barta SK, Landsburg DJ, Nasta SD, Svoboda J, Loren AW, Schuster SJ. Ibrutinib-associated Arthralgias/Myalgias in Patients With Chronic Lymphocytic Leukemia: Incidence and Impact on Clinical Outcomes. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:438-444.e1. [PMID: 32197990 DOI: 10.1016/j.clml.2020.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/04/2020] [Accepted: 02/04/2020] [Indexed: 01/26/2023]
Abstract
INTRODUCTION The Bruton's tyrosine kinase (BTK) inhibitor ibrutinib has transformed the treatment of chronic lymphocytic leukemia (CLL), leading to unprecedented improvements in progression-free and overall survival for all patients, including those with poor prognostic features. The side effect profile of ibrutinib is unique compared with chemoimmunotherapy and includes atrial fibrillation, increased bleeding risk, and arthralgias/myalgias. Although common, arthralgias/myalgias and their management are poorly described. PATIENTS AND METHODS We identified 214 patients with CLL treated with ibrutinib (as a single agent or in combination) from 2011 to 2018 at the University of Pennsylvania. RESULTS In this cohort, 36% (76/214) of patients developed arthralgias/myalgias during follow-up with a median onset of 34.5 months. Most (79%) events were grade 1 or 2. Risk factors for developing arthralgias/myalgias included younger age at start of ibrutinib, female gender, and ibrutinib use as first treatment. Twenty-eight percent of patients with grade 1 or 2 toxicity continued ibrutinib and had resolution of symptoms. Dose holds were frequently used to manage this toxicity, and this strategy was more successful than dose reduction. Sixty-two percent of patients with grade 3 toxicity ultimately discontinued ibrutinib. Supportive care measures such as discontinuing statins or use of non-steroidal anti-inflammatory drugs, acetaminophen, or corticosteroids were not used frequently enough in this cohort to evaluate their efficacy. CONCLUSIONS Additional studies to determine the mechanism of ibrutinib-related arthralgias/myalgias are needed to develop optimal management strategies.
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Affiliation(s)
- Joanna M Rhodes
- Division of Hematology/Oncology, Northwell Health Cancer Institute, New Hyde Park, NY; Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA.
| | - Vincent A LoRe
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Anthony R Mato
- Chronic Lymphocytic Leukemia Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Elise A Chong
- Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | | | - James N Gerson
- Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Stefan K Barta
- Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Daniel J Landsburg
- Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Sunita Dwivedy Nasta
- Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Jakub Svoboda
- Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Alison W Loren
- Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Stephen J Schuster
- Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
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Yang X, An N, Zhong C, Guan M, Jiang Y, Li X, Zhang H, Wang L, Ruan Y, Gao Y, Liu N, Shang H, Xing Y. Enhanced cardiomyocyte reactive oxygen species signaling promotes ibrutinib-induced atrial fibrillation. Redox Biol 2020; 30:101432. [PMID: 31986467 PMCID: PMC6994714 DOI: 10.1016/j.redox.2020.101432] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/27/2019] [Accepted: 01/12/2020] [Indexed: 12/12/2022] Open
Abstract
Atrial fibrillation (AF) occurs in up to 11% of cancer patients treated with ibrutinib. The pathophysiology of ibrutinib promoted AF is complicated, as there are multiple interactions involved; the detailed molecular mechanisms underlying this are still unclear. Here, we aimed to determine the electrophysiological and molecular mechanisms of burst-pacing-induced AF in ibrutinib-treated mice. The results indicated differentially expressed proteins in ibrutinib-treated mice, identified through proteomic analysis, were found to play a role in oxidative stress-related pathways. Finally, treatment with an inhibitor of NADPH oxidase (NOX) prevented and reversed AF development in ibrutinib-treated mice. It was showed that the related protein expression of reactive oxygen species (ROS) in the ibrutinib group was significantly increased, including NOX2, NOX4, p22-phox, XO and TGF-β protein expression. It was interesting that ibrutinib group also significantly increased the expression of ox-CaMKII, p-CaMKII (Thr-286) and p-RyR2 (Ser2814), causing enhanced abnormal sarcoplasmic reticulum (SR) Ca2+ release and mitochondrial structures, as well as atrial fibrosis and atrial hypertrophy in ibrutinib-treated mice, and apocynin reduced the expression of these proteins. Ibrutinib-treated mice were also more likely to develop AF, and AF occurred over longer periods. In conclusion, our study has established a pathophysiological role for ROS signaling in atrial cardiomyocytes, and it may be that ox-CaMKII and p-CaMKII (Thr-286) are activated by ROS to increase AF susceptibility following ibrutinib treatment. We have also identified the inhibition of NOX as a potential novel AF therapy approach.
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Affiliation(s)
- Xinyu Yang
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China; Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Na An
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China; Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Changming Zhong
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Manke Guan
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Yuchen Jiang
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Xinye Li
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Hanlai Zhang
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Liqin Wang
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Yanfei Ruan
- Department of Cardiology, Beijing An Zhen Hospital of the Capital University of Medical Sciences, Beijing, 100853, PR China
| | - Yonghong Gao
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Nian Liu
- Department of Cardiology, Beijing An Zhen Hospital of the Capital University of Medical Sciences, Beijing, 100853, PR China.
| | - Hongcai Shang
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China.
| | - Yanwei Xing
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
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Abstract
Inhibitors of Bruton's tyrosine kinase (BTK), a major kinase in the B-cell receptor (BCR) signaling pathway, mediating B-cell proliferation and apoptosis, have substantially altered the management, clinical course, and outcome of patients with B-cell malignancies. This is especially true for patients with previously limited treatment options due to disease characteristics or coexisting diseases. Ibrutinib was the first orally available, nonselective and irreversible inhibitor of BTK approved for the treatment of patients with various B-cell malignancies. Newer and more selective BTK inhibitors are currently in clinical development, including acalabrutinib, which is currently US FDA approved for previously treated mantle cell lymphoma. Significant efforts are underway to investigate the optimal combinations, timing, and sequencing of BTK inhibitors with other regimens and targeted agents, and to capitalize on the immunomodulatory modes of action of BTK inhibitors to correct tumor-induced immune defects and to achieve long-lasting tumor control. This review describes the major milestones in the clinical development of BTK inhibitors in chronic lymphocytic leukemia and other B-cell malignancies, highlights the most recent long-term follow-up results, and evaluates the role of BTK inhibitors and their combination with other agents in B-cell malignancies and other indications.
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MESH Headings
- Agammaglobulinaemia Tyrosine Kinase/antagonists & inhibitors
- Antineoplastic Agents/therapeutic use
- Humans
- Leukemia, B-Cell/drug therapy
- Leukemia, B-Cell/enzymology
- Leukemia, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/enzymology
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Lymphoma, B-Cell/drug therapy
- Lymphoma, B-Cell/enzymology
- Lymphoma, B-Cell/pathology
- Prognosis
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Affiliation(s)
- Fabienne Lucas
- Division of Hematology, Department of Medicine, The Ohio State University College of Medicine, Comprehensive Cancer Center, 455D Wiseman Hall, 410 W 12th Ave, Columbus, OH, 43210, USA
| | - Jennifer A Woyach
- Division of Hematology, Department of Medicine, The Ohio State University College of Medicine, Comprehensive Cancer Center, 455D Wiseman Hall, 410 W 12th Ave, Columbus, OH, 43210, USA.
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, OH, USA.
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Munir T, Brown JR, O'Brien S, Barrientos JC, Barr PM, Reddy NM, Coutre S, Tam CS, Mulligan SP, Jaeger U, Kipps TJ, Moreno C, Montillo M, Burger JA, Byrd JC, Hillmen P, Dai S, Szoke A, Dean JP, Woyach JA. Final analysis from RESONATE: Up to six years of follow-up on ibrutinib in patients with previously treated chronic lymphocytic leukemia or small lymphocytic lymphoma. Am J Hematol 2019; 94:1353-1363. [PMID: 31512258 PMCID: PMC6899718 DOI: 10.1002/ajh.25638] [Citation(s) in RCA: 297] [Impact Index Per Article: 59.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/03/2019] [Accepted: 09/09/2019] [Indexed: 12/14/2022]
Abstract
Ibrutinib, a once-daily oral inhibitor of Bruton's tyrosine kinase, is approved in the United States and Europe for treatment of patients with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL). The phase 3 RESONATE study showed improved efficacy of single-agent ibrutinib over ofatumumab in patients with relapsed/refractory CLL/SLL, including those with high-risk features. Here we report the final analysis from RESONATE with median follow-up on study of 65.3 months (range, 0.3-71.6) in the ibrutinib arm. Median progression-free survival (PFS) remained significantly longer for patients randomized to ibrutinib vs ofatumumab (44.1 vs 8.1 months; hazard ratio [HR]: 0.148; 95% confidence interval [CI]: 0.113-0.196; P˂.001). The PFS benefit with ibrutinib vs ofatumumab was preserved in the genomic high-risk population with del(17p), TP53 mutation, del(11q), and/or unmutated IGHV status (median PFS 44.1 vs 8.0 months; HR: 0.110; 95% CI: 0.080-0.152), which represented 82% of patients. Overall response rate with ibrutinib was 91% (complete response/complete response with incomplete bone marrow recovery, 11%). Overall survival, censored for crossover, was better with ibrutinib than ofatumumab (HR: 0.639; 95% CI: 0.418-0.975). With up to 71 months (median 41 months) of ibrutinib therapy, the safety profile remained consistent with prior reports; cumulatively, all-grade (grade ≥3) hypertension and atrial fibrillation occurred in 21% (9%) and 12% (6%) of patients, respectively. Only 16% discontinued ibrutinib because of adverse events (AEs). These long-term results confirm the robust efficacy of ibrutinib in relapsed/refractory CLL/SLL irrespective of high-risk clinical or genomic features, with no unexpected AEs. This trial is registered at www.clinicaltrials.gov (NCT01578707).
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Affiliation(s)
- Talha Munir
- Department of Haematology St. James's University Hospital Leeds UK
| | | | - Susan O'Brien
- UC Irvine, Chao Family Comprehensive Cancer Center Irvine California
| | - Jacqueline C. Barrientos
- Division of Medical Oncology and Hematology Northwell Health Cancer Institute Lake Success New York
| | - Paul M. Barr
- Wilmot Cancer Institute University of Rochester Medical Center Rochester New York
| | | | - Steven Coutre
- Stanford Cancer Center Stanford University School of Medicine Stanford California
| | - Constantine S. Tam
- Peter MacCallum Cancer Centre St. Vincent's Hospital and University of Melbourne Melbourne Australia
| | | | - Ulrich Jaeger
- Division of Hematology and Hemostaseology Medical University of Vienna Wien Austria
| | | | - Carol Moreno
- Hospital de la Santa Creu i Sant Pau Autonomous University of Barcelona Barcelona Spain
| | | | - Jan A. Burger
- Department of Leukemia University of Texas MD Anderson Cancer Center Houston Texas
| | - John C. Byrd
- The Ohio State University Comprehensive Cancer Center Columbus Ohio
| | - Peter Hillmen
- The Leeds Teaching Hospitals St. James Institute of Oncology Leeds UK
| | - Sandra Dai
- Pharmacyclics LLC, an AbbVie Company Sunnyvale California
| | - Anita Szoke
- Pharmacyclics LLC, an AbbVie Company Sunnyvale California
| | - James P. Dean
- Pharmacyclics LLC, an AbbVie Company Sunnyvale California
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135
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Puła B, Gołos A, Górniak P, Jamroziak K. Overcoming Ibrutinib Resistance in Chronic Lymphocytic Leukemia. Cancers (Basel) 2019; 11:E1834. [PMID: 31766355 PMCID: PMC6966427 DOI: 10.3390/cancers11121834] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 11/15/2019] [Accepted: 11/19/2019] [Indexed: 12/11/2022] Open
Abstract
Ibrutinib is the first Bruton's tyrosine kinase (BTK) inhibitor, which showed significant clinical activity in chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) patients regardless of cytogenetic risk factors. Recent results of phase III clinical trials in treatment-naïve CLL patients shift the importance of the agent to frontline therapy. Nevertheless, beside its clinical efficacy, ibrutinib possesses some off-target activity resulting in ibrutinib-characteristic adverse events including bleeding diathesis and arrhythmias. Furthermore, acquired and primary resistance to the drug have been described. As the use of ibrutinib in clinical practice increases, the problem of resistance is becoming apparent, and new methods of overcoming this clinical problem arise. In this review, we summarize the mechanisms of BTK inhibitors' resistance and discuss the post-ibrutinib treatment options.
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Affiliation(s)
- Bartosz Puła
- Department of Hematology, Institute of Hematology and Transfusion Medicine, 02-776 Warsaw, Poland;
| | - Aleksandra Gołos
- Institute of Hematology and Transfusion Medicine, 02-776 Warsaw, Poland;
| | - Patryk Górniak
- Department of Experimental Hematology, Institute of Hematology and Transfusion Medicine, 02-776 Warsaw, Poland;
| | - Krzysztof Jamroziak
- Department of Hematology, Institute of Hematology and Transfusion Medicine, 02-776 Warsaw, Poland;
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136
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Scarfò L, Tedeschi A. Chemo-immunotherapy for Older Patients with Chronic Lymphocytic Leukemia - Time to Retire? Hemasphere 2019; 3:e278. [PMID: 31723848 PMCID: PMC6745920 DOI: 10.1097/hs9.0000000000000278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 06/02/2019] [Indexed: 11/25/2022] Open
Affiliation(s)
- Lydia Scarfò
- Strategic Research Program on CLL, Università Vita-Salute San Raffaele and IRCCS Ospedale San Raffaele, Milano, Italy
| | - Alessandra Tedeschi
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital Milano, Italy
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137
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Fürstenau M, Hallek M, Eichhorst B. Sequential and combination treatments with novel agents in chronic lymphocytic leukemia. Haematologica 2019; 104:2144-2154. [PMID: 31585959 PMCID: PMC6821614 DOI: 10.3324/haematol.2018.208603] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/22/2019] [Indexed: 12/14/2022] Open
Abstract
Chemoimmunotherapy has been the standard of care for patients with chronic lymphocytic leukemia for a long time. However, over the last few years, novel agents have produced unprecedented outcomes in treatment-naïve and relapsed/refractory chronic lymphocytic leukemia. With the advent of these targeted agents, treatment options have diversified very considerably and new questions have emerged. For example, it is unclear whether these novel agents should be used as sequential monotherapies until disease progression or whether they should preferably be combined in time-limited treatment regimens aimed at achieving deep and durable remissions. While both approaches yield high response rates and long progression-free and overall survival, it remains challenging to identify patients individually for the optimal concept. This review provides guidance in this decision process by presenting evidence on sequential and combined use of novel agents and discussing the advantages and drawbacks of these two approaches.
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Affiliation(s)
- Moritz Fürstenau
- University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German CLL Study Group, University Hospital Cologne
| | - Michael Hallek
- University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German CLL Study Group, University Hospital Cologne
- Cologne Cluster of Excellence in Cellular Stress Responses in Aging-associated Disease (CECAD), University of Cologne, Cologne, Germany
| | - Barbara Eichhorst
- University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German CLL Study Group, University Hospital Cologne
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138
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Alomar M, Fradley MG. Electrophysiology Translational Considerations in Cardio-Oncology: QT and Beyond. J Cardiovasc Transl Res 2019; 13:390-401. [DOI: 10.1007/s12265-019-09924-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/04/2019] [Indexed: 12/14/2022]
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139
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Abstract
AbstractPurposeThis article summarizes current targeted therapies that have received regulatory approval for the treatment of B- and T-cell lymphomas.SummaryOver the last 20 years, new drug therapies for lymphomas of B cells and T cells have expanded considerably. Targeted therapies for B-cell lymphomas include: (1) monoclonal antibodies directed at the CD20 lymphocyte antigen, examples of which are rituximab, ofatumumab, and obinutuzumab; (2) gene transfer therapy, an example of which is chimeric antigen receptor–modified T-cell (CAR-T) therapy directed at the CD19 antigen expressed on the cell surface of both immature and mature B cells; and (3) small-molecule inhibitors (ibrutinib, acalabrutinib, copanlisib, duvelisib, and idelalisib) that target the B-cell receptor signaling pathway. Of note, brentuximab vedotin is an antibody–drug conjugate that targets CD30, another lymphocyte antigen expressed on the cell surface of both Hodgkin lymphoma (a variant of B-cell lymphoma) and some T-cell lymphomas. Although aberrant epigenetic signaling pathways are present in both B- and T-cell lymphomas, epigenetic inhibitors (examples include belinostat, vorinostat, and romidepsin) are currently approved by the Food and Drug Administration for T-cell lymphomas only. In addition, therapies that target the tumor microenvironment have been developed. Examples include mogamulizumab, bortezomib, lenalidomide, nivolumab, and pembrolizumab. In summary, the efficacy of these agents has led to the development of supportive care to mitigate adverse effects, due to the presence of on- or off-target toxicities.ConclusionThe therapeutic landscape of lymphomas has continued to evolve. In turn, the efficacy of these agents has led to the development of supportive care to mitigate adverse effects, due to the presence of on- or off-target toxicities. Further opportunities are warranted to identify patients who are most likely to achieve durable response and reduce the risk of disease progression. Ongoing trials with current and investigational agents may further elucidate their place in therapy and therapeutic benefits.
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140
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Jiang L, Li L, Ruan Y, Zuo S, Wu X, Zhao Q, Xing Y, Zhao X, Xia S, Bai R, Du X, Liu N, Ma CS. Ibrutinib promotes atrial fibrillation by inducing structural remodeling and calcium dysregulation in the atrium. Heart Rhythm 2019; 16:1374-1382. [DOI: 10.1016/j.hrthm.2019.04.008] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Indexed: 12/14/2022]
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141
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Fradley MG, Gliksman M, Emole J, Viganego F, Rhea I, Welter-Frost A, Armanious M, Lee DH, Walko C, Shah B, Chavez JC, McLeod H, Pinilla-Ibarz J, Schabath MB. Rates and Risk of Atrial Arrhythmias in Patients Treated With Ibrutinib Compared With Cytotoxic Chemotherapy. Am J Cardiol 2019; 124:539-544. [PMID: 31208701 DOI: 10.1016/j.amjcard.2019.05.029] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 01/03/2023]
Abstract
There is increasing evidence that rates of atrial arrhythmias (AA), specifically atrial fibrillation and flutter are elevated in patients treated with the tyrosine kinase inhibitor, ibrutinib; however, the exact risk of ibrutinib-associated AA is not definitively established. We conducted a retrospective study of 137 patients diagnosed with B-cell malignancies treated with ibrutinib compared with 106 patients treated with chemotherapy for the same cancers in order to quantify the rates and risk of AA in a "real-world" sample of cancer patients. Fisher's exact test was used to evaluate for any statistically significant differences between groups. Logistic regression was used to generate odds ratios, adjusting for potential confounders. Incidence of AA was 14% (n = 17) in ibrutinib-treated patients compared with 3% (n = 3) in patients treated with chemotherapy (p = 0.009). Ibrutinib-treated patients were significantly older (mean age 67 vs 63 years, p = 0.003); however, there were no other significant differences in baseline characteristics. Ibrutinib use, age, hypertension, and previous use of ACE inhibitors, angiotensin receptor blocker use, β blocker use, and aspirin use were independently associated with incident arrhythmias. In multivariable analysis, patients treated with ibrutinib were associated with a 5-fold increased risk of developing AA (odds ratio = 5.18, 95% confidence interval 1.42 to 18.89). In conclusion, the rates and risk of AA are higher in patients treated with ibrutinib compared with chemotherapy, and this study provides strong evidence that ibrutinib itself is an independent risk factor for the development of incident AA.
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142
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Chemo-immunotherapy for Older Patients with Chronic Lymphocytic Leukemia - Passé Yet? Hemasphere 2019; 3:e275. [PMID: 31723845 PMCID: PMC6745924 DOI: 10.1097/hs9.0000000000000275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 05/24/2019] [Indexed: 11/26/2022] Open
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143
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Visentin A, Deodato M, Mauro FR, Autore F, Reda G, Vitale C, Molica S, Rigolin GM, Piazza F, Cesini L, Tedeschi A, Laurenti L, Cassin R, Coscia M, Cuneo A, Foà R, Semenzato G, Trentin L. A scoring system to predict the risk of atrial fibrillation in chronic lymphocytic leukemia. Hematol Oncol 2019; 37:508-512. [DOI: 10.1002/hon.2655] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine University of Padua Padua Italy
- Venetian Institute of Molecular Medicine Centro di Eccellenza per la Ricerca Biomedica Avanzata Padua Italy
| | - Marina Deodato
- Hematology Unit, Niguarda Cancer Center ASST Grande Ospedale Metropolitano Niguarda Milan Italy
| | - Francesca R. Mauro
- Hematology Unit, Department of Translational and Precision Medicine Sapienza University Rome Italy
| | - Francesco Autore
- Hematology Institute Fondazione Policlinico Universitario Agostino Gemelli IRCSS Rome Italy
| | - Gianluigi Reda
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore University of Milan Milan Italy
| | - Candida Vitale
- Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino University of Turin Turin Italy
| | - Stefano Molica
- Department Hematology‐Oncology Azienda Ospedaliera Pugliese‐Ciaccio Catanzaro Italy
| | - Gian Matteo Rigolin
- Hematology section, Department of Medical Sciences University of Ferrara—Azienda Ospedaliera‐Universitaria di Ferrara Ferrara Italy
| | - Francesco Piazza
- Hematology and Clinical Immunology Unit, Department of Medicine University of Padua Padua Italy
- Venetian Institute of Molecular Medicine Centro di Eccellenza per la Ricerca Biomedica Avanzata Padua Italy
| | - Laura Cesini
- Hematology Unit, Department of Translational and Precision Medicine Sapienza University Rome Italy
| | - Alessandra Tedeschi
- Hematology Unit, Niguarda Cancer Center ASST Grande Ospedale Metropolitano Niguarda Milan Italy
| | - Luca Laurenti
- Hematology Institute Fondazione Policlinico Universitario Agostino Gemelli IRCSS Rome Italy
| | - Ramona Cassin
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore University of Milan Milan Italy
| | - Marta Coscia
- Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino University of Turin Turin Italy
| | - Antonio Cuneo
- Hematology section, Department of Medical Sciences University of Ferrara—Azienda Ospedaliera‐Universitaria di Ferrara Ferrara Italy
| | - Robin Foà
- Hematology Unit, Department of Translational and Precision Medicine Sapienza University Rome Italy
| | - Gianpietro Semenzato
- Hematology and Clinical Immunology Unit, Department of Medicine University of Padua Padua Italy
- Venetian Institute of Molecular Medicine Centro di Eccellenza per la Ricerca Biomedica Avanzata Padua Italy
| | - Livio Trentin
- Hematology and Clinical Immunology Unit, Department of Medicine University of Padua Padua Italy
- Venetian Institute of Molecular Medicine Centro di Eccellenza per la Ricerca Biomedica Avanzata Padua Italy
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144
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Shanafelt TD, Wang XV, Kay NE, Hanson CA, O'Brien S, Barrientos J, Jelinek DF, Braggio E, Leis JF, Zhang CC, Coutre SE, Barr PM, Cashen AF, Mato AR, Singh AK, Mullane MP, Little RF, Erba H, Stone RM, Litzow M, Tallman M. Ibrutinib-Rituximab or Chemoimmunotherapy for Chronic Lymphocytic Leukemia. N Engl J Med 2019; 381:432-443. [PMID: 31365801 PMCID: PMC6908306 DOI: 10.1056/nejmoa1817073] [Citation(s) in RCA: 497] [Impact Index Per Article: 99.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Data regarding the efficacy of treatment with ibrutinib-rituximab, as compared with standard chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab, in patients with previously untreated chronic lymphocytic leukemia (CLL) have been limited. METHODS In a phase 3 trial, we randomly assigned (in a 2:1 ratio) patients 70 years of age or younger with previously untreated CLL to receive either ibrutinib and rituximab for six cycles (after a single cycle of ibrutinib alone), followed by ibrutinib until disease progression, or six cycles of chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab. The primary end point was progression-free survival, and overall survival was a secondary end point. We report the results of a planned interim analysis. RESULTS A total of 529 patients underwent randomization (354 patients to the ibrutinib-rituximab group, and 175 to the chemoimmunotherapy group). At a median follow-up of 33.6 months, the results of the analysis of progression-free survival favored ibrutinib-rituximab over chemoimmunotherapy (89.4% vs. 72.9% at 3 years; hazard ratio for progression or death, 0.35; 95% confidence interval [CI], 0.22 to 0.56; P<0.001), and the results met the protocol-defined efficacy threshold for the interim analysis. The results of the analysis of overall survival also favored ibrutinib-rituximab over chemoimmunotherapy (98.8% vs. 91.5% at 3 years; hazard ratio for death, 0.17; 95% CI, 0.05 to 0.54; P<0.001). In a subgroup analysis involving patients without immunoglobulin heavy-chain variable region (IGHV) mutation, ibrutinib-rituximab resulted in better progression-free survival than chemoimmunotherapy (90.7% vs. 62.5% at 3 years; hazard ratio for progression or death, 0.26; 95% CI, 0.14 to 0.50). The 3-year progression-free survival among patients with IGHV mutation was 87.7% in the ibrutinib-rituximab group and 88.0% in the chemoimmunotherapy group (hazard ratio for progression or death, 0.44; 95% CI, 0.14 to 1.36). The incidence of adverse events of grade 3 or higher (regardless of attribution) was similar in the two groups (in 282 of 352 patients [80.1%] who received ibrutinib-rituximab and in 126 of 158 [79.7%] who received chemoimmunotherapy), whereas infectious complications of grade 3 or higher were less common with ibrutinib-rituximab than with chemoimmunotherapy (in 37 patients [10.5%] vs. 32 [20.3%], P<0.001). CONCLUSIONS The ibrutinib-rituximab regimen resulted in progression-free survival and overall survival that were superior to those with a standard chemoimmunotherapy regimen among patients 70 years of age or younger with previously untreated CLL. (Funded by the National Cancer Institute and Pharmacyclics; E1912 ClinicalTrials.gov number, NCT02048813.).
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Affiliation(s)
- Tait D Shanafelt
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Xin V Wang
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Neil E Kay
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Curtis A Hanson
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Susan O'Brien
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Jacqueline Barrientos
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Diane F Jelinek
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Esteban Braggio
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Jose F Leis
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Cong C Zhang
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Steven E Coutre
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Paul M Barr
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Amanda F Cashen
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Anthony R Mato
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Avina K Singh
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Michael P Mullane
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Richard F Little
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Harry Erba
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Richard M Stone
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Mark Litzow
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
| | - Martin Tallman
- From Stanford University, Stanford (T.D.S., S.E.C.), the University of California, Irvine, Medical Center, Orange (S.O.), and Kaiser Permanente National Cancer Institute Community Oncology Research Program (NCORP)-Permanente Medical Group, Oakland (C.C.Z.) - all in California; Dana-Farber Cancer Institute, Boston (X.V.W., R.M.S.); Mayo Clinic, Rochester (N.E.K., C.A.H., J.F.L., M.L.), and Minnesota Oncology, Burnsville (A.K.S.) - both in Minnesota; Northwell Health Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lake Success (J.B.), and University of Rochester, Rochester (P.M.B.) - both in New York; Mayo Clinic, Phoenix, AZ (D.F.J., E.B.); Washington University School of Medicine, St. Louis (A.F.C.); Memorial Sloan Kettering Cancer Center, New York (A.R.M., M.T.); Aurora Cancer Care, West Allis, WI (M.P.M.); National Cancer Institute, Bethesda, MD (R.F.L.); and the University of Alabama, Tuscaloosa (H.E.)
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Delluc A, Wang TF, Yap ES, Ay C, Schaefer J, Carrier M, Noble S. Anticoagulation of cancer patients with non-valvular atrial fibrillation receiving chemotherapy: Guidance from the SSC of the ISTH. J Thromb Haemost 2019; 17:1247-1252. [PMID: 31207027 DOI: 10.1111/jth.14478] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 05/14/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Aurelien Delluc
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Tzu-Fei Wang
- Division of Hematology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Eng-Soo Yap
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Comprehensive Cancer Center Vienna, Vienna, Austria
| | - Jordan Schaefer
- Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, Wales, UK
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Jain N, Keating M, Thompson P, Ferrajoli A, Burger J, Borthakur G, Takahashi K, Estrov Z, Fowler N, Kadia T, Konopleva M, Alvarado Y, Yilmaz M, DiNardo C, Bose P, Ohanian M, Pemmaraju N, Jabbour E, Sasaki K, Kanagal-Shamanna R, Patel K, Jorgensen J, Garg N, Wang X, Sondermann K, Cruz N, Wei C, Ayala A, Plunkett W, Kantarjian H, Gandhi V, Wierda W. Ibrutinib and Venetoclax for First-Line Treatment of CLL. N Engl J Med 2019; 380:2095-2103. [PMID: 31141631 DOI: 10.1056/nejmoa1900574] [Citation(s) in RCA: 352] [Impact Index Per Article: 70.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Ibrutinib, an inhibitor of Bruton's tyrosine kinase, and venetoclax, an inhibitor of B-cell lymphoma 2 protein, have been approved for patients with chronic lymphocytic leukemia (CLL). Preclinical investigations have indicated potential synergistic interaction of their combination. METHODS We conducted an investigator-initiated phase 2 study of combined ibrutinib and venetoclax involving previously untreated high-risk and older patients with CLL. All patients had at least one of the following features: chromosome 17p deletion, mutated TP53, chromosome 11q deletion, unmutated IGHV, or an age of 65 years or older. Patients received ibrutinib monotherapy (420 mg once daily) for 3 cycles, followed by the addition of venetoclax (weekly dose escalation to 400 mg once daily). Combined therapy was administered for 24 cycles. Response assessments were performed according to International Workshop on Chronic Lymphocytic Leukemia 2008 criteria. Minimal residual disease was assessed by means of multicolor flow cytometry in bone marrow (sensitivity, 10-4). RESULTS A total of 80 patients were treated. The median age was 65 years (range, 26 to 83). A total of 30% of the patients were 70 years of age or older. Overall, 92% of the patients had unmutated IGHV, TP53 aberration, or chromosome 11q deletion. With combined treatment, the proportions of patients who had complete remission (with or without normal blood count recovery) and remission with undetectable minimal residual disease increased over time. After 12 cycles of combined treatment, 88% of the patients had complete remission or complete remission with incomplete count recovery, and 61% had remission with undetectable minimal residual disease. Responses were noted in older adults and across all high-risk subgroups. Three patients had laboratory evidence of tumor lysis syndrome. The adverse-event profile was similar to what has been reported with ibrutinib and venetoclax. CONCLUSIONS In this study, combined venetoclax and ibrutinib was an effective oral regimen for high-risk and older patients with CLL. (Funded by AbbVie and others; ClinicalTrials.gov number, NCT02756897.).
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MESH Headings
- Adenine/analogs & derivatives
- Administration, Oral
- Adult
- Aged
- Aged, 80 and over
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Atrial Fibrillation/chemically induced
- Bridged Bicyclo Compounds, Heterocyclic/administration & dosage
- Bridged Bicyclo Compounds, Heterocyclic/adverse effects
- Female
- Humans
- Induction Chemotherapy
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Lymphocyte Count
- Male
- Middle Aged
- Mutation
- Neoplasm, Residual
- Neutropenia/chemically induced
- Piperidines
- Pyrazoles/administration & dosage
- Pyrazoles/adverse effects
- Pyrimidines/administration & dosage
- Pyrimidines/adverse effects
- Remission Induction
- Sulfonamides/administration & dosage
- Sulfonamides/adverse effects
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Affiliation(s)
- Nitin Jain
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Michael Keating
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Philip Thompson
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Alessandra Ferrajoli
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Jan Burger
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Gautam Borthakur
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Koichi Takahashi
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Zeev Estrov
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Nathan Fowler
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Tapan Kadia
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Marina Konopleva
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Yesid Alvarado
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Musa Yilmaz
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Courtney DiNardo
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Prithviraj Bose
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Maro Ohanian
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Naveen Pemmaraju
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Elias Jabbour
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Koji Sasaki
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Rashmi Kanagal-Shamanna
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Keyur Patel
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Jeffrey Jorgensen
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Naveen Garg
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Xuemei Wang
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Katrina Sondermann
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Nichole Cruz
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Chongjuan Wei
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Ana Ayala
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - William Plunkett
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Hagop Kantarjian
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - Varsha Gandhi
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
| | - William Wierda
- From the Departments of Leukemia (N.J., M. Keating, P.T., A.F., J.B., G.B., K.T., Z.E., T.K., M. Konopleva, Y.A., M.Y., C.D., P.B., M.O., N.P., E.J., K. Sasaki, K. Sondermann, N.C., C.W., A.A., H.K., W.W.), Lymphoma and Myeloma (N.F.), Hematopathology (R.K.-S., K.P., J.J.), Diagnostic Radiology (N.G.), Biostatistics (X.W.), and Experimental Therapeutics (W.P., V.G.), University of Texas M.D. Anderson Cancer Center, Houston
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Abstract
PURPOSE OF REVIEW With the rapid development of novel cancer therapeutics and the growing number of cancer survivors, there is significant demand for cardio-oncology experts to care for these patients. As such, it has become increasingly necessary to develop formalized training in the field of cardio-oncology. This review will focus on the current state of cardio-oncology education, with recommendations for the development of dedicated cardio-oncology fellowships. RECENT FINDINGS Cardio-oncology fellowships should be affiliated with high-volume centers that have established cardio-oncology clinical and research programs with dedicated cardio-oncology faculty. Several recent publications have proposed recommendations to develop uniform cardio-oncology training standards, core curricula, and evaluation metrics. With the rapid evolution of the field and the support of various profession organizations, the number and quality of dedicated cardio-oncology fellowship programs is expected to increase significantly. The adoption of defined training requirements and evaluation standards to measure competency will be essential to ensure the legitimacy and success of the field.
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Affiliation(s)
- Michael G Fradley
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Morsani College of Medicine and H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, 12902 USF Magnolia Dr., MCB-CPT, Tampa, FL, 33612-9416, USA.
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149
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Byrd JC, Hillmen P, O'Brien S, Barrientos JC, Reddy NM, Coutre S, Tam CS, Mulligan SP, Jaeger U, Barr PM, Furman RR, Kipps TJ, Thornton P, Moreno C, Montillo M, Pagel JM, Burger JA, Woyach JA, Dai S, Vezan R, James DF, Brown JR. Long-term follow-up of the RESONATE phase 3 trial of ibrutinib vs ofatumumab. Blood 2019; 133:2031-2042. [PMID: 30842083 PMCID: PMC6509542 DOI: 10.1182/blood-2018-08-870238] [Citation(s) in RCA: 163] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 01/26/2019] [Indexed: 12/17/2022] Open
Abstract
Ibrutinib, a once-daily oral inhibitor of Bruton tyrosine kinase, has greatly improved outcomes for patients with chronic lymphocytic leukemia (CLL). The phase 3 RESONATE trial, which compared single-agent ibrutinib to ofatumumab in high-risk, relapsed patients with CLL, provided support for approval of ibrutinib in the United States and Europe. We describe long-term follow-up of patients treated in RESONATE, where continued superiority of progression-free survival (PFS) (hazard ratio [HR], 0.133; 95% confidence interval [CI], 0.099-0.178) was observed. Overall survival benefit continues (HR, 0.591; 95% CI, 0.378-0.926), although with decreased magnitude relative to that seen before crossover to ibrutinib was implemented for patients on ofatumumab (HR, 0.426; 95% CI, 0.220-0.823). Notably, overall response to ibrutinib increased over time, with 91% of patients attaining a response. The PFS benefit with ibrutinib was independent of baseline risk factors, although patients with ≥2 prior therapies had shorter PFS than those with <2 prior therapies, and the presence of TP53 or SF3B1 mutations showed a trend toward shorter PFS vs without these factors. Median duration of ibrutinib was 41 months, with 46% remaining on treatment at a median follow-up of 44 months. Grade ≥3 adverse events generally decreased over time, causing only a small proportion of patients to cease therapy. Ibrutinib was discontinued due to progressive disease in 27% of patients. This long-term study provides support for sustained efficacy and safety of ibrutinib in relapsed/refractory CLL and consideration of study provisions that allow crossover to investigational therapy when benefit has been clearly demonstrated. This trial was registered at www.clinicaltrials.gov as #NCT01578707.
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Affiliation(s)
- John C Byrd
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Peter Hillmen
- The Leeds Teaching Hospitals, St. James Institute of Oncology, Leeds, United Kingdom
| | - Susan O'Brien
- UC Irvine, Chao Family Comprehensive Cancer Center, Irvine, CA
| | | | | | - Steven Coutre
- Stanford University School of Medicine, Stanford, CA
| | - Constantine S Tam
- Department of Haematology, Peter MacCallum Cancer Centre and St. Vincent's Hospital, Melbourne, VIC, Australia
| | | | - Ulrich Jaeger
- Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Paul M Barr
- University of Rochester Medical Center, Rochester, NY
| | - Richard R Furman
- Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY
| | | | | | - Carol Moreno
- Hospital de la Santa Creu Sant Pau, Barcelona, Spain
| | | | - John M Pagel
- Swedish Cancer Institute Hematologic Malignancies Program, Seattle, WA
| | - Jan A Burger
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Sandra Dai
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA; and
| | - Remus Vezan
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA; and
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150
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Shafaattalab S, Lin E, Christidi E, Huang H, Nartiss Y, Garcia A, Lee J, Protze S, Keller G, Brunham L, Tibbits GF, Laksman Z. Ibrutinib Displays Atrial-Specific Toxicity in Human Stem Cell-Derived Cardiomyocytes. Stem Cell Reports 2019; 12:996-1006. [PMID: 31031187 PMCID: PMC6524928 DOI: 10.1016/j.stemcr.2019.03.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 01/08/2023] Open
Abstract
Ibrutinib (IB) is an oral Bruton's tyrosine kinase (BTK) inhibitor that has demonstrated benefit in B cell cancers, but is associated with a dramatic increase in atrial fibrillation (AF). We employed cell-specific differentiation protocols and optical mapping to investigate the effects of IB and other tyrosine kinase inhibitors (TKIs) on the voltage and calcium transients of atrial and ventricular human pluripotent stem cell-derived cardiomyocytes (hPSC-CMs). IB demonstrated direct cell-specific effects on atrial hPSC-CMs that would be predicted to predispose to AF. Second-generation BTK inhibitors did not have the same effect. Furthermore, IB exposure was associated with differential chamber-specific regulation of a number of regulatory pathways including the receptor tyrosine kinase pathway, which may be implicated in the pathogenesis of AF. Our study is the first to demonstrate cell-type-specific toxicity in hPSC-derived atrial and ventricular cardiomyocytes, which reliably reproduces the clinical cardiotoxicity observed. hPSCs can be differentiated into atrial and ventricular cardiomyocytes (CMs) Drug effects can be measured using optical mapping of voltage and calcium transients Ibrutinib demonstrates cell-specific toxicity on atrial hPSC-CMs Ibrutinib exposure is associated with chamber-specific effects on regulatory pathways
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Affiliation(s)
- Sanam Shafaattalab
- Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1A6, Canada; British Columbia Children's Hospital Research Institute, 950 West 28th Avenue, Vancouver, BC V5Z 4H4, Canada
| | - Eric Lin
- Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1A6, Canada
| | - Effimia Christidi
- University of British Columbia, 170-6371 Crescent Road, Vancouver, BC V6T 1Z2, Canada
| | - Haojun Huang
- University of British Columbia, 170-6371 Crescent Road, Vancouver, BC V6T 1Z2, Canada
| | - Yulia Nartiss
- McEwen Stem Cell Institute, University Health Network, Toronto, ON M5G 1L7, Canada
| | - Analucia Garcia
- McEwen Stem Cell Institute, University Health Network, Toronto, ON M5G 1L7, Canada
| | - Jeehon Lee
- McEwen Stem Cell Institute, University Health Network, Toronto, ON M5G 1L7, Canada
| | - Stephanie Protze
- McEwen Stem Cell Institute, University Health Network, Toronto, ON M5G 1L7, Canada; Department of Molecular Genetics, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Gordon Keller
- McEwen Stem Cell Institute, University Health Network, Toronto, ON M5G 1L7, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7, Canada
| | - Liam Brunham
- University of British Columbia, 170-6371 Crescent Road, Vancouver, BC V6T 1Z2, Canada
| | - Glen F Tibbits
- Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1A6, Canada; British Columbia Children's Hospital Research Institute, 950 West 28th Avenue, Vancouver, BC V5Z 4H4, Canada
| | - Zachary Laksman
- Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1A6, Canada; University of British Columbia, 170-6371 Crescent Road, Vancouver, BC V6T 1Z2, Canada.
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