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Chen LS, Bose P, Cruz ND, Jiang Y, Wu Q, Thompson PA, Feng S, Kroll MH, Qiao W, Huang X, Jain N, Wierda WG, Keating MJ, Gandhi V. A pilot study of lower doses of ibrutinib in patients with chronic lymphocytic leukemia. Blood 2018; 132:2249-2259. [PMID: 30254130 PMCID: PMC6251009 DOI: 10.1182/blood-2018-06-860593] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/18/2018] [Indexed: 01/27/2023] Open
Abstract
Ibrutinib is highly efficacious and used at 420 mg/d for treatment of chronic lymphocytic leukemia (CLL). We previously demonstrated a decline in Bruton's tyrosine kinase (BTK) protein levels in CLL cells after 1 cycle of ibrutinib, suggesting ibrutinib dose could be lowered after the first cycle without loss of biological effect. To test this postulate, a pilot study (NCT02801578) was designed to systematically reduce ibrutinib dosing within the same patient with CLL over the course of three 28-day cycles. After an initial cycle of 420 mg/d, the dose was reduced to 280 mg/d in cycle 2, and then to 140 mg/d in cycle 3. Eleven patients began study treatment, and 9 completed the 3 cycles. Plasma and intracellular pharmacokinetics (PK), BTK occupancy, and pharmacodynamic (PD) response at different doses of ibrutinib were compared. Plasma and intracellular levels of ibrutinib were dose-dependent, and even the lowest dose was sufficient to occupy, on average, more than 95% of BTK protein. In concert, BTK downstream signaling inhibition was maintained with 140 mg/d ibrutinib in cycle 3, and there were comparable reductions in total and phospho-BTK (Tyr223) protein levels across 3 cycles. Reductions of plasma chemokine CCL3 and CCL4 levels, considered to be biomarkers of ibrutinib response, were similar during the 3 cycles. These PK/PD data demonstrate that after 1 cycle of ibrutinib at the standard 420 mg/d dose, the dose can be reduced without losing biological activity. Clinical efficacy of lower doses needs to be systematically evaluated. Such dose reductions would lower drug cost, lessen untoward toxicity, and facilitate rationale-based combinations. This trial was registered at www.clinicaltrials.gov as #NCT02801578.
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Affiliation(s)
| | | | | | | | - Qi Wu
- Institute for Applied Cancer Science
| | | | | | | | - Wei Qiao
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Varsha Gandhi
- Department of Experimental Therapeutics
- Department of Leukemia
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152
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Ibrutinib-related bleeding: pathogenesis, clinical implications and management. Blood Coagul Fibrinolysis 2018; 29:481-487. [PMID: 29995658 DOI: 10.1097/mbc.0000000000000749] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
: Ibrutinib is the first drug of a new family of Bruton's tyrosine kinases (Btk)-inhibiting agents, which have proved to be useful for the treatment of several B-cell lymphoid malignancies. This drug is associated to an increased bleeding risk from initial clinical trials especially in association with warfarin. Although Btk plays an important role in platelet signalling, increased bleeding tendency in patients on ibrutinib is more complex than Btk inhibition alone and is because of several antiplatelet mechanisms, namely inhibition of Btk and Tec kinases, which play a key role in platelet activation downstream of the collagen GPVI and Glycoprotein Ib. This risk is increased by concomitant antiplatelet and anticoagulant therapy; both dual antiplatelet therapy and vitamin K antagonists are contraindicated in these patients. Potential ibrutinib users often have age-associated cardiovascular risk factors or conditions and the drug itself may trigger atrial fibrillation requiring antithrombotic therapy. Aspirin and direct oral anticoagulants can be regarded as the antithrombotic therapies of choice if required. Heparin and fondaparinux have also been used in clinical trials. Therefore, the need and duration of antithrombotic therapy must be carefully evaluated and treatment individualized according to clinical circumstances. Ibrutinib withdrawal and platelet transfusion are key for the management of major bleeding not involving the central nervous system.
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153
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Mock J, Kunk PR, Palkimas S, Sen JM, Devitt M, Horton B, Portell CA, Williams ME, Maitland H. Risk of Major Bleeding with Ibrutinib. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:755-761. [DOI: 10.1016/j.clml.2018.07.287] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/30/2018] [Accepted: 07/09/2018] [Indexed: 10/28/2022]
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154
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Tullemans BME, Nagy M, Sabrkhany S, Griffioen AW, Oude Egbrink MGA, Aarts M, Heemskerk JWM, Kuijpers MJE. Tyrosine Kinase Inhibitor Pazopanib Inhibits Platelet Procoagulant Activity in Renal Cell Carcinoma Patients. Front Cardiovasc Med 2018; 5:142. [PMID: 30460241 PMCID: PMC6232667 DOI: 10.3389/fcvm.2018.00142] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 09/24/2018] [Indexed: 01/03/2023] Open
Abstract
Pazopanib is an angiostatic tyrosine kinase inhibitor (TKI) presently used for cancer treatment, particularly in patients with renal cell carcinoma (RCC). This treatment can be accompanied by mild bleeding as an adverse effect. Given the role of protein tyrosine kinases in platelet activation processes, we investigated whether and how pazopanib can affect platelet functions in purified systems and during treatment of advanced RCC patients. In isolated platelets from healthy volunteers, pazopanib dose-dependently reduced collagen-induced integrin activation and secretion, as well as platelet aggregation. Pazopanib addition diminished glycoprotein (GP) VI-dependent tyrosine phosphorylation of multiple platelet proteins, including the tyrosine kinase Syk. Furthermore, pazopanib inhibited GPVI-induced Ca2+ elevation, resulting in reduced exposure of the procoagulant phospholipid phosphatidylserine (PS). Upon perfusion of control blood over a collagen surface, pazopanib inhibited thrombus size as well as PS exposure. Blood samples from 10 RCC patients were also analyzed before and after 14 days of pazopanib treatment as monotherapy. This treatment caused an overall lowering in platelet count, with 3 out of 10 patients experiencing mild bleeding. Platelets isolated from pazopanib-treated patients showed a significant lowering of PS exposure upon activation. In addition, platelet procoagulant activity was inhibited in thrombi formed under flow conditions. Control experiments indicated that higher pazopanib concentrations were required to inhibit GPVI-mediated PS exposure in the presence of plasma. Together, these results indicated that pazopanib suppresses GPVI-induced platelet activation responses in a way partly antagonized by the presence of plasma. In treated cancer patients, pazopanib effects were confined to a reduction in GPVI-dependent PS exposure. Together with the reduced platelet count, this may explain the mild bleeding tendency observed in pazopanib-treated patients.
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Affiliation(s)
- Bibian M E Tullemans
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Magdolna Nagy
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Siamack Sabrkhany
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Arjan W Griffioen
- Angiogenesis Laboratory, Department of Medical Oncology, VU Medical Center, Amsterdam, Netherlands
| | - Mirjam G A Oude Egbrink
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Maureen Aarts
- Department of Medical Oncology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Johan W M Heemskerk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Marijke J E Kuijpers
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
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155
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Visentin A, Campello E, Scomazzon E, Spiezia L, Imbergamo S, Pravato S, Piazza F, Semenzato G, Simioni P, Trentin L. Dabigatran in ibrutinib-treated patients with atrial fibrillation and lymphoproliferative diseases: Experience of 4 cases. Hematol Oncol 2018; 36:801-803. [PMID: 30110712 DOI: 10.1002/hon.2545] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/02/2018] [Accepted: 08/02/2018] [Indexed: 01/16/2023]
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
| | - Elena Campello
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Edoardo Scomazzon
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Luca Spiezia
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Silvia Imbergamo
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Stefano Pravato
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, 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
| | - 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
| | - Paolo Simioni
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University of Padua, 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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156
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Tullemans BME, Heemskerk JWM, Kuijpers MJE. Acquired platelet antagonism: off-target antiplatelet effects of malignancy treatment with tyrosine kinase inhibitors. J Thromb Haemost 2018; 16:1686-1699. [PMID: 29975003 DOI: 10.1111/jth.14225] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Indexed: 12/26/2022]
Abstract
Platelets can contribute to tumor progression and metastasis. Cancer patients are at increased risk of thrombosis, and advanced stages of cancer are associated with thrombocytosis or increased platelet reactivity. Tyrosine kinase inhibitors (TKIs) are widely used as a targeted strategy for cancer treatment, with the aim of prolonging progression-free survival of the patients. Because of their broad kinase target spectrum, most TKIs inevitably have off-target effects. Platelets rely on tyrosine kinase activity for their activation. Frequently observed side effects are lowering of platelet count and inhibition of platelet functions, whether or not accompanied by an increased bleeding risk. In this review, we aim to give insights into: (i) 38 TKIs that are currently used for the treatment of different types of cancer, either on the market or in clinical trials; (ii) how distinct TKIs can inhibit activation mechanisms in platelets; and (iii) the clinical consequences of the antiplatelet effects of TKI treatment. For several TKIs, the knowledge on affinity for their targets does not align with the published effects on platelets and reported bleeding events. This review should raise awareness of the potential antiplatelet effects of several TKIs, which will be enhanced in the presence of antithrombotic drugs.
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Affiliation(s)
- B M E Tullemans
- Cardiovascular Research Institute Maastricht, Department of Biochemistry, Maastricht University, Maastricht, the Netherlands
| | - J W M Heemskerk
- Cardiovascular Research Institute Maastricht, Department of Biochemistry, Maastricht University, Maastricht, the Netherlands
| | - M J E Kuijpers
- Cardiovascular Research Institute Maastricht, Department of Biochemistry, Maastricht University, Maastricht, the Netherlands
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157
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Schuh AH, Parry-Jones N, Appleby N, Bloor A, Dearden CE, Fegan C, Follows G, Fox CP, Iyengar S, Kennedy B, McCarthy H, Parry HM, Patten P, Pettitt AR, Ringshausen I, Walewska R, Hillmen P. Guideline for the treatment of chronic lymphocytic leukaemia: A British Society for Haematology Guideline. Br J Haematol 2018; 182:344-359. [PMID: 30009455 DOI: 10.1111/bjh.15460] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Anna H Schuh
- NIHR BRC Oxford Molecular Diagnostic Centre, Oxford University Hospitals NHS Trust and Department of Oncology, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Nilima Parry-Jones
- Department of Haematology, Aneurin Bevan University Health Board, Abergavenny, UK
| | - Niamh Appleby
- NIHR BRC Oxford Molecular Diagnostic Centre, Oxford University Hospitals NHS Trust and Department of Oncology, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | | | | | | | - Christopher P Fox
- Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Ben Kennedy
- Department of Haematology, University Hospital Leicester, Leicester, UK
| | - Helen McCarthy
- Haematology, Bournemouth and Christchurch Hospitals, Bournemouth, UK
| | - Helen M Parry
- NIHR-ACL Haematology, University of Birmingham, Birmingham, UK
| | | | | | | | - Renata Walewska
- Haematology, Bournemouth and Christchurch Hospitals, Bournemouth, UK
| | - Peter Hillmen
- Haematology, Leeds Teaching Hospital NHS Trust, Leeds, UK
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158
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Chen J, Kinoshita T, Gururaja T, Sukbuntherng J, James D, Lu D, Whang J, Versele M, Chang BY. The effect of Bruton's tyrosine kinase (BTK) inhibitors on collagen-induced platelet aggregation, BTK, and tyrosine kinase expressed in hepatocellular carcinoma (TEC). Eur J Haematol 2018; 101:604-612. [PMID: 30030853 DOI: 10.1111/ejh.13148] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/03/2018] [Accepted: 07/04/2018] [Indexed: 02/28/2024]
Abstract
OBJECTIVES Bruton's tyrosine kinase (BTK) and tyrosine kinase expressed in hepatocellular carcinoma (TEC) are expressed by human platelets. These kinases participate in platelet activation through the collagen receptor glycoprotein VI and may perform overlapping functions. In clinical studies, BTK inhibitors (ibrutinib, acalabrutinib, tirabrutinib, zanubrutinib) have been associated with increased bleeding risk, which may result from inhibition of BTK alone or of both BTK and TEC, although the role of TEC in bleeding risk remains unclear. METHODS Here, in vitro catalytic and binding activities of ibrutinib and acalabrutinib were determined with four assay systems. Platelet aggregation assays determined inhibitor potency and its relationship to selectivity between BTK and TEC. RESULTS Neither inhibitor was substantially more selective for BTK over TEC. The potencies at which BTK inhibitors suppressed platelet aggregation correlated with the potencies in on-target BTK assays, including those in cells. At clinically relevant plasma concentration, ibrutinib, acalabrutinib, and tirabrutinib inhibited collagen-induced platelet aggregation to a similar extent, despite differing in vitro IC50 s. CONCLUSIONS Our results suggest BTK inhibition is the primary driver for inhibition of platelet aggregation. The subtle differences between these inhibitors suggest only randomized, double-blind, placebo-controlled clinical studies can fully address the bleeding risks of different BTK inhibitors.
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Affiliation(s)
- Jun Chen
- Pharmacyclics, LLC, an AbbVie Company, Sunnyvale, CA, USA
| | | | | | | | - Danelle James
- Pharmacyclics, LLC, an AbbVie Company, Sunnyvale, CA, USA
| | - Daniel Lu
- Pharmacyclics, LLC, an AbbVie Company, Sunnyvale, CA, USA
| | - Jennifer Whang
- Pharmacyclics, LLC, an AbbVie Company, Sunnyvale, CA, USA
| | | | - Betty Y Chang
- Pharmacyclics, LLC, an AbbVie Company, Sunnyvale, CA, USA
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159
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Anquetil T, Payrastre B, Gratacap MP, Viaud J. The lipid products of phosphoinositide 3-kinase isoforms in cancer and thrombosis. Cancer Metastasis Rev 2018; 37:477-489. [DOI: 10.1007/s10555-018-9735-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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160
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Gordon MJ, Churnetski M, Alqahtani H, Rivera X, Kittai A, Amrock SM, James S, Hoff S, Manda S, Spurgeon SE, Choi M, Cohen JB, Persky D, Danilov AV. Comorbidities predict inferior outcomes in chronic lymphocytic leukemia treated with ibrutinib. Cancer 2018; 124:3192-3200. [DOI: 10.1002/cncr.31554] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/13/2018] [Accepted: 04/26/2018] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Hamood Alqahtani
- Moores Cancer CenterUniversity of California San DiegoSan Diego California
| | | | - Adam Kittai
- Oregon Health and Science UniversityPortland Oregon
| | | | - Spencer James
- Dartmouth‐Hitchcock Medical CenterLebanon New Hampshire
| | - Sheila Hoff
- Moores Cancer CenterUniversity of California San DiegoSan Diego California
| | - Sudhir Manda
- Dartmouth‐Hitchcock Medical CenterLebanon New Hampshire
| | | | - Michael Choi
- Moores Cancer CenterUniversity of California San DiegoSan Diego California
| | | | | | - Alexey V. Danilov
- Oregon Health and Science UniversityPortland Oregon
- Dartmouth‐Hitchcock Medical CenterLebanon New Hampshire
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161
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Alexandre J, Moslehi JJ, Bersell KR, Funck-Brentano C, Roden DM, Salem JE. Anticancer drug-induced cardiac rhythm disorders: Current knowledge and basic underlying mechanisms. Pharmacol Ther 2018; 189:89-103. [PMID: 29698683 DOI: 10.1016/j.pharmthera.2018.04.009] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Significant advances in cancer treatment have resulted in decreased cancer related mortality for many malignancies with some cancer types now considered chronic diseases. Despite these improvements, there is increasing recognition that many cancer patients or cancer survivors can develop cardiovascular diseases, either due to the cancer itself or as a result of anticancer therapy. Much attention has focused on heart failure; however, other cardiotoxicities, notably cardiac rhythm disorders, can occur without underlying cardiomyopathy. Supraventricular tachycardias occur in cancer patients treated with cytotoxic chemotherapy (anthracyclines, gemcitabine, cisplatin and alkylating-agents) or kinase-inhibitors (KIs) such as ibrutinib. Ventricular arrhythmias, with a subset of them being torsades-de-pointes (TdP) favored by QTc prolongation have been reported: this may be the result of direct hERG-channel inhibition or a more recently-described mechanism of phosphoinositide-3-kinase inhibition. The major anticancer drugs responsible for QTc prolongation in this context are KIs, arsenic trioxide, anthracyclines, histone deacetylase inhibitors, and selective estrogen receptor modulators. Anticancer drug-induced cardiac rhythm disorders remain an underappreciated complication even by experienced clinicians. Moreover, the causal relationship of a particular anticancer drug with cardiac arrhythmia occurrence remains challenging due in part to patient comorbidities and complex treatment regimens. For example, any cancer patient may also be diagnosed with common diseases such as hypertension, diabetes or heart failure which increase an individual's arrhythmia susceptibility. Further, anticancer drugs are generally usually used in combination, increasing the challenge around establishing causation. Thus, arrhythmias appear to be an underappreciated adverse effect of anticancer agents and the incidence, significance and underlying mechanisms are now being investigated.
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Affiliation(s)
- Joachim Alexandre
- CHU Caen, PICARO Cardio-oncology Program, Department of Pharmacology, F-14033 Caen, France; Normandie Univ, UNICAEN, CHU Caen, EA 4650, Signalisation, Électrophysiologie et Imagerie des Lésions d'Ischémie-Reperfusion Myocardique, 14000 Caen, France
| | - Javid J Moslehi
- Vanderbilt University Medical Center, Cardio-oncology Program, Department of Medicine, Nashville, Tennessee, USA
| | - Kevin R Bersell
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christian Funck-Brentano
- Sorbonne Université, INSERM CIC Paris-Est, AP-HP, ICAN, Pitié-Salpêtrière Hospital, Department of Pharmacology, F-75013 Paris, France
| | - Dan M Roden
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joe-Elie Salem
- Vanderbilt University Medical Center, Cardio-oncology Program, Department of Medicine, Nashville, Tennessee, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA; Sorbonne Université, INSERM CIC Paris-Est, AP-HP, ICAN, Pitié-Salpêtrière Hospital, Department of Pharmacology, F-75013 Paris, France.
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162
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163
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Boriani G, Corradini P, Cuneo A, Falanga A, Foà R, Gaidano G, Ghia PP, Martelli M, Marasca R, Massaia M, Mauro FR, Minotti G, Molica S, Montillo M, Pinto A, Tedeschi A, Vitolo U, Zinzani PL. Practical management of ibrutinib in the real life: Focus on atrial fibrillation and bleeding. Hematol Oncol 2018; 36:624-632. [PMID: 29512173 DOI: 10.1002/hon.2503] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 01/23/2018] [Accepted: 01/24/2018] [Indexed: 12/15/2022]
Abstract
The Bruton tyrosine kinase inhibitor ibrutinib (IB) has attained an important role in the treatment of patients with chronic lymphocytic leukaemia, mantle cell lymphoma, and Waldenström macroglobulinemia, significantly improving clinical outcomes. However, IB therapy has been associated with an increased risk of atrial fibrillation (AF) and bleeding. We report on the expert opinion that a group of Italian haematologists, cardiologists, and pharmacologists jointly released to improve the practical management of patients at risk for AF and bleeding during treatment with IB. A proper pretreatment assessment to identify patients who are at a higher risk, careful choice of concomitant drugs, regular monitoring, and multispecialist approach were characterized as the main principles of clinical management of these patients. For patients developing AF, anticoagulant and antiarrhythmic therapy must be guided by considerations about efficacy, safety, and risk of pharmacokinetic interactions with IB. For patients experiencing bleeding or requiring procedures that increase the risk of bleeding, considerations about platelet turnover, IB-related platelet dysfunctions, and bleeding worsening by concomitant anticoagulants or antiplatelet agents provide clues to manage bleeding. Overall, AF and bleeding are manageable clinical events in patients receiving IB, not requiring drug interruption in most cases. Preexisting AF should not represent an absolute contraindication to IB therapy. For each patient candidate for IB, strategies of risk assessment and mitigation may allow to exploit the life-saving effects of in chronic lymphocytic leukaemia and mantle cell lymphoma.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Paolo Corradini
- Dipartimento di Oncologia ed Emato-oncologia, Universita' degli Studi di Milano, Milan, Italy
| | - Antonio Cuneo
- Hematology Section, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, "Papa Giovanni XXIII" Hospital, Bergamo, Italy
| | - Robin Foà
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University, Policlinico Umberto I, Rome, Italy
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Paolo Prospero Ghia
- Università Vita-Salute San Raffaele and IRCCS Istituto Scientifico San Raffaele, Milano, Italy
| | - Maurizio Martelli
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University, Policlinico Umberto I, Rome, Italy
| | - Roberto Marasca
- Hematology Division, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Massimo Massaia
- Division of Hematology, Department of Molecular Biotechnologies and Health Sciences, University of Torino, Torino, Italy
| | - Francesca Romana Mauro
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University, Policlinico Umberto I, Rome, Italy
| | - Giorgio Minotti
- Department of Medicine and Center for Drug Sciences, University Campus Bio-Medico, Rome, Italy
| | - Stefano Molica
- Department of Hematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy
| | - Marco Montillo
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Milan, Italy
| | - Antonio Pinto
- Hematology-Oncology and Stem Cell Transplantation Unit, National Cancer Institute, Fondazione "G. Pascale" IRCCS, Naples, Italy
| | | | - Umberto Vitolo
- Città della Salute e della Scienza Hospital and University, on behalf of FIL, Turin, Italy
| | - Pier Luigi Zinzani
- Institute of Hematology and Medical Oncology "Seragnoli", University of Bologna, Bologna, Italy
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164
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Gribben JG, Bosch F, Cymbalista F, Geisler CH, Ghia P, Hillmen P, Moreno C, Stilgenbauer S. Optimising outcomes for patients with chronic lymphocytic leukaemia on ibrutinib therapy: European recommendations for clinical practice. Br J Haematol 2018; 180:666-679. [DOI: 10.1111/bjh.15080] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 10/23/2017] [Indexed: 02/06/2023]
Affiliation(s)
- John G. Gribben
- Barts Cancer Institute; Queen Mary University of London; London UK
| | - Francesc Bosch
- Department of Haematology; Vall d'Hebron University Hospital; Barcelona Spain
| | - Florence Cymbalista
- U978 Institut National de la Santé et de la Recherche Médicale; Bobigny France
- Labex Inflamex; Université Paris 13; Sorbonne Paris Cité; Bobigny France
- Hôpital Avicenne; Assistance Publique-Hôpitaux de Paris; Bobigny France
| | | | - Paolo Ghia
- Strategic Research Programme on CLL; IRCCS San Raffaele Hospital; Milan Italy
- Università Vita-Salute San Raffaele; Milan Italy
| | - Peter Hillmen
- St James' Institute of Oncology; University of Leeds; Leeds UK
| | - Carol Moreno
- Department of Haematology; Hospital de la Santa Creu Sant Pau; Autonomous University of Barcelona; Barcelona Spain
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165
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Reda G, Cassin R, Artoni A, Fattizzo B, Lecchi A, La Marca S, Bucciarelli P, Levati GV, Peyvandi F, Cortelezzi A. Idelalisib rapidly improves platelet function tests in patients with chronic lymphocytic leukaemia. Br J Haematol 2018; 183:825-828. [PMID: 29315493 DOI: 10.1111/bjh.15052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Gianluigi Reda
- Haematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy
| | - Ramona Cassin
- Haematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy
| | - Andrea Artoni
- A. Bianchi Bonomi Haemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda Ospedale, Maggiore Policlinico of Milan, Milan, Italy
| | - Bruno Fattizzo
- Haematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy.,University of Milan, Milan, Italy
| | - Anna Lecchi
- A. Bianchi Bonomi Haemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda Ospedale, Maggiore Policlinico of Milan, Milan, Italy
| | - Silvia La Marca
- A. Bianchi Bonomi Haemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda Ospedale, Maggiore Policlinico of Milan, Milan, Italy
| | - Paolo Bucciarelli
- A. Bianchi Bonomi Haemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda Ospedale, Maggiore Policlinico of Milan, Milan, Italy
| | - Giorgia V Levati
- Haematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy.,University of Milan, Milan, Italy
| | - Flora Peyvandi
- A. Bianchi Bonomi Haemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda Ospedale, Maggiore Policlinico of Milan, Milan, Italy.,University of Milan, Milan, Italy
| | - Agostino Cortelezzi
- Haematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy.,University of Milan, Milan, Italy
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166
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Abstract
Ibrutinib is a transformative therapy for high-risk and relapsed refractory chronic lymphocytic leukemia (CLL) patients. In clinical trials in relatively healthy younger patients, ibrutinib has been well tolerated. As its use has become more widespread in the community, however, its full adverse event profile has emerged and proven more challenging than was initially anticipated. Reports of community-based use have estimated discontinuation rates as high as 40% in the first year of therapy. This article therefore reviews my approach to the evaluation and management of a CLL patient starting on ibrutinib, with the goal of minimizing and managing toxicity to maintain patients on ibrutinib. Key topics discussed include bleeding risk; cardiac complications, particularly atrial fibrillation; drug interactions; and infections.
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167
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Alberelli MA, Innocenti I, Autore F, Laurenti L, De Candia E. Ibrutinib does not affect ristocetin-induced platelet aggregation evaluated by light transmission aggregometry in chronic lymphocytic leukemia patients. Haematologica 2017; 103:e119-e122. [PMID: 29242303 DOI: 10.3324/haematol.2017.179044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Maria Adele Alberelli
- Servizio Malattie Emorragiche e Trombotiche, Polo Oncologia ed Ematologia, Istituto di Medicina Interna, Rome, Italy
| | - Idanna Innocenti
- Dipartimento di Ematologia, Polo Oncologia e Ematologia, Istituto di Ematologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Francesco Autore
- Dipartimento di Ematologia, Polo Oncologia e Ematologia, Istituto di Ematologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Luca Laurenti
- Dipartimento di Ematologia, Polo Oncologia e Ematologia, Istituto di Ematologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Erica De Candia
- Servizio Malattie Emorragiche e Trombotiche, Polo Oncologia ed Ematologia, Istituto di Medicina Interna, Rome, Italy
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168
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Severe platelet dysfunction in NHL patients receiving ibrutinib is absent in patients receiving acalabrutinib. Blood Adv 2017; 1:2610-2623. [PMID: 29296914 DOI: 10.1182/bloodadvances.2017011999] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 11/07/2017] [Indexed: 01/22/2023] Open
Abstract
The Bruton tyrosine kinase (Btk) inhibitor ibrutinib induces platelet dysfunction and causes increased risk of bleeding. Off-target inhibition of Tec is believed to contribute to platelet dysfunction and other side effects of ibrutinib. The second-generation Btk inhibitor acalabrutinib was developed with improved specificity for Btk over Tec. We investigated platelet function in patients with non-Hodgkin lymphoma (NHL) receiving ibrutinib or acalabrutinib by aggregometry and by measuring thrombus formation on collagen under arterial shear. Both patient groups had similarly dysfunctional aggregation responses to collagen and collagen-related peptide, and comparison with mechanistic experiments in which platelets from healthy donors were treated with the Btk inhibitors suggested that both drugs inhibit platelet Btk and Tec at physiological concentrations. Only ibrutinib caused dysfunctional thrombus formation, whereas size and morphology of thrombi following acalabrutinib treatment were of normal size and morphology. We found that ibrutinib but not acalabrutinib inhibited Src family kinases, which have a critical role in platelet adhesion to collagen that is likely to underpin unstable thrombus formation observed in ibrutinib patients. We found that platelet function was enhanced by increasing levels of von Willebrand factor (VWF) and factor VIII (FVIII) ex vivo by addition of intermediate purity FVIII (Haemate P) to blood from patients, resulting in consistently larger thrombi. We conclude that acalabrutinib avoids major platelet dysfunction associated with ibrutinib therapy, and platelet function may be enhanced in patients with B-cell NHL by increasing plasma VWF and FVIII.
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169
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Barf T, Covey T, Izumi R, van de Kar B, Gulrajani M, van Lith B, van Hoek M, de Zwart E, Mittag D, Demont D, Verkaik S, Krantz F, Pearson PG, Ulrich R, Kaptein A. Acalabrutinib (ACP-196): A Covalent Bruton Tyrosine Kinase Inhibitor with a Differentiated Selectivity and In Vivo Potency Profile. J Pharmacol Exp Ther 2017; 363:240-252. [PMID: 28882879 DOI: 10.1124/jpet.117.242909] [Citation(s) in RCA: 255] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 08/31/2017] [Indexed: 12/16/2022] Open
Abstract
Several small-molecule Bruton tyrosine kinase (BTK) inhibitors are in development for B cell malignancies and autoimmune disorders, each characterized by distinct potency and selectivity patterns. Herein we describe the pharmacologic characterization of BTK inhibitor acalabrutinib [compound 1, ACP-196 (4-[8-amino-3-[(2S)-1-but-2-ynoylpyrrolidin-2-yl]imidazo[1,5-a]pyrazin-1-yl]-N-(2-pyridyl)benzamide)]. Acalabrutinib possesses a reactive butynamide group that binds covalently to Cys481 in BTK. Relative to the other BTK inhibitors described here, the reduced intrinsic reactivity of acalabrutinib helps to limit inhibition of off-target kinases having cysteine-mediated covalent binding potential. Acalabrutinib demonstrated higher biochemical and cellular selectivity than ibrutinib and spebrutinib (compounds 2 and 3, respectively). Importantly, off-target kinases, such as epidermal growth factor receptor (EGFR) and interleukin 2-inducible T cell kinase (ITK), were not inhibited. Determination of the inhibitory potential of anti-immunoglobulin M-induced CD69 expression in human peripheral blood mononuclear cells and whole blood demonstrated that acalabrutinib is a potent functional BTK inhibitor. In vivo evaluation in mice revealed that acalabrutinib is more potent than ibrutinib and spebrutinib. Preclinical and clinical studies showed that the level and duration of BTK occupancy correlates with in vivo efficacy. Evaluation of the pharmacokinetic properties of acalabrutinib in healthy adult volunteers demonstrated rapid absorption and fast elimination. In these healthy individuals, a single oral dose of 100 mg showed approximately 99% median target coverage at 3 and 12 hours and around 90% at 24 hours in peripheral B cells. In conclusion, acalabrutinib is a BTK inhibitor with key pharmacologic differentiators versus ibrutinib and spebrutinib and is currently being evaluated in clinical trials.
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