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Deodato M, Frustaci AM, Zamprogna G, Cairoli R, Montillo M, Tedeschi A. Ibrutinib for the treatment of chronic lymphocytic leukemia. Expert Rev Hematol 2019; 12:273-284. [PMID: 30916599 DOI: 10.1080/17474086.2019.1597703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Chemoimmunotherapy has improved outcomes in chronic lymphocytic leukemia, yet it is not curative, with very high relapse rates, and is associated with a significant risk of toxicities. Moreover, patients with higher-risk genetic abnormalities continue to experience poorer outcomes and lower survival. Recently, novel targeted therapies have been developed to increase efficacy and reduce toxicity. Areas covered: Ibrutinib is an oral irreversible inhibitor of Bruton's tyrosine kinase, a mediator of B-cell receptor signaling, which plays a vital role in various B-cell neoplasms. The drug has been approved for the treatment of several hematological malignancies, including chronic lymphocytic leukemia/small lymphocytic lymphoma, where large trials have shown outcomes never seen before even in high-risk patients. The safety profile appeared furthermore favorable, even in elderly and unfit patients. Expert opinion: Therapy with ibrutinib rarely provides MRD-negative complete remission; an indefinite maintenance is therefore needed, with the risk of developing adverse events (AE) or resistance resulting in treatment interruption or discontinuation. Novel, extremely promising, combination strategies, based on the association of ibrutinib with chemoimmunotherapy, anti-CD20 monoclonal antibody or other targeted agents, are currently being investigated, with the goal of achieving greater depth of remission, especially MRD-negativity, and removing the need for indefinite treatment.
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Affiliation(s)
- Marina Deodato
- a Department of Hematology , Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda , Milano , Italy
| | - Anna Maria Frustaci
- a Department of Hematology , Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda , Milano , Italy
| | - Giulia Zamprogna
- a Department of Hematology , Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda , Milano , Italy
| | - Roberto Cairoli
- a Department of Hematology , Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda , Milano , Italy
| | - Marco Montillo
- a Department of Hematology , Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda , Milano , Italy
| | - Alessandra Tedeschi
- a Department of Hematology , Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda , Milano , Italy
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Rhea IB, Lyon AR, Fradley MG. Anticoagulation of Cardiovascular Conditions in the Cancer Patient: Review of Old and New Therapies. Curr Oncol Rep 2019; 21:45. [DOI: 10.1007/s11912-019-0797-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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153
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Goyal RK, Nagar SP, Kabadi S, Kaye JA, Seal B, Mato AR. Adverse events, resource use, and economic burden associated with mantle cell lymphoma: a real-world assessment of privately insured patients in the United States. Leuk Lymphoma 2019; 60:955-963. [PMID: 30277099 PMCID: PMC7564890 DOI: 10.1080/10428194.2018.1509320] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/02/2018] [Accepted: 08/04/2018] [Indexed: 10/28/2022]
Abstract
In view of recent therapeutic advances in mantle cell lymphoma (MCL), the aim of this retrospective cohort analysis was to assess treatment patterns, adverse events (AEs), resource utilization, and health care costs in patients with MCL in a US-based commercial claims database. A total of 783 patients with MCL (median age = 65 years) were selected. Among patients receiving systemic therapy (n = 457), the most common treatment regimens were bendamustine/rituximab (BR) (41.1%), rituximab/cyclophosphamide/doxorubicin/vincristine (RCHOP) (26.7%), rituximab monotherapy (20.4%), and ibrutinib monotherapy (14.2%). Mean monthly costs during treatments with BR, RCHOP, rituximab, and ibrutinib were $12,958, $24,719, $13,153, and $21,690, respectively. Mean monthly cost during follow-up was $13,650 among patients with ≥6 AEs versus $5131 among those without AEs. The costs of MCL varied considerably by treatment regimen and care setting. The overall economic burden of managing patients with MCL can be substantially affected by costs associated with managing AEs occurring during treatment.
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Affiliation(s)
- Ravi K. Goyal
- RTI Health Solutions, 300 Park Offices Drive, Research Triangle Park, Durham, NC 27709, USA
| | - Saurabh P. Nagar
- RTI Health Solutions, 300 Park Offices Drive, Research Triangle Park, Durham, NC 27709, USA
| | - Shaum Kabadi
- AstraZeneca, 101 Orchard Ridge Drive, Gaithersburg, MD 20878, USA
| | - James A. Kaye
- RTI Health Solutions, 307 Waverley Oaks Road, Suite 101, Waltham, MA 02452-8413 USA
| | - Brian Seal
- AstraZeneca, 101 Orchard Ridge Drive, Gaithersburg, MD 20878, USA
| | - Anthony R. Mato
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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154
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Fraser G, Cramer P, Demirkan F, Silva RS, Grosicki S, Pristupa A, Janssens A, Mayer J, Bartlett NL, Dilhuydy MS, Pylypenko H, Loscertales J, Avigdor A, Rule S, Villa D, Samoilova O, Panagiotidis P, Goy A, Pavlovsky MA, Karlsson C, Hallek M, Mahler M, Salman M, Sun S, Phelps C, Balasubramanian S, Howes A, Chanan-Khan A. Updated results from the phase 3 HELIOS study of ibrutinib, bendamustine, and rituximab in relapsed chronic lymphocytic leukemia/small lymphocytic lymphoma. Leukemia 2019; 33:969-980. [PMID: 30315239 PMCID: PMC6484712 DOI: 10.1038/s41375-018-0276-9] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/09/2018] [Accepted: 08/28/2018] [Indexed: 12/21/2022]
Abstract
We report follow-up results from the randomized, placebo-controlled, phase 3 HELIOS trial of ibrutinib+bendamustine and rituximab (BR) for previously treated chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) without deletion 17p. Overall, 578 patients were randomized 1:1 to either ibrutinib (420 mg daily) or placebo, in combination with 6 cycles of BR, followed by ibrutinib or placebo alone. Median follow-up was 34.8 months (range: 0.1-45.8). Investigator-assessed median progression-free survival (PFS) was not reached for ibrutinib+BR, versus 14.3 months for placebo+BR (hazard ratio [HR] [95% CI], 0.206 [0.159-0.265]; P < 0.0001); 36-month PFS rates were 68.0% versus 13.9%, respectively. The results are consistent with the primary analysis findings (HR = 0.203, as assessed by independent review committee, with 17-month median follow-up). Median overall survival was not reached in either arm; HR (95% CI) for ibrutinib+BR versus placebo: 0.652 (0.454-0.935; P = 0.019). Minimal residual disease (MRD)-negative response rates were 26.3% for ibrutinib+BR and 6.2% for placebo+BR (P < 0.0001). Incidence of treatment-emergent adverse events (including grades 3-4) were generally consistent with the initial HELIOS report. These long-term data support improved survival outcomes and deepening responses with ibrutinib+BR compared with BR in relapsed CLL/SLL.
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Affiliation(s)
- G Fraser
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada.
| | - P Cramer
- Department of Internal Medicine, Center of Integrated Oncology and German CLL Study Group, University of Cologne, Cologne, Germany
| | - F Demirkan
- Division of Hematology, Dokuz Eylul University, Izmir, Turkey
| | - R Santucci Silva
- IEP São Lucas/Hemomed Oncologia e Hematologia, São Paulo, Brazil
| | - S Grosicki
- Department of Cancer Prevention, Faculty of Public Health, Silesian Medical University, Katowice, Poland
| | - A Pristupa
- Regional Clinical Hospital, Ryazan, Russia
| | - A Janssens
- Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - J Mayer
- Department of Internal Medicine, Hematology and Oncology, Masaryk University Hospital Brno, Jihlavska, Brno, Czech Republic
| | - N L Bartlett
- Siteman Cancer Center, Washington University School of Medicine, St Louis, MO, USA
| | | | - H Pylypenko
- Department of Hematology, Cherkassy Regional Oncological Center, Cherkassy, Ukraine
| | - J Loscertales
- Hematology Department, Hospital Universitario La Princesa, IIS-IP, Madrid, Spain
| | - A Avigdor
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer and Sackler School of Medicine, University of Tel-Aviv, Tel-Aviv, Israel
| | - S Rule
- Department of Haematology, Plymouth University Medical School, Plymouth, UK
| | - D Villa
- Division of Medical Oncology, British Columbia Cancer Agency, Vancouver, BC, Canada
| | - O Samoilova
- Nizhny Novogorod Regional Clinical Hospital, Nizhny Novogorod, Russia
| | - P Panagiotidis
- 1st Department of Propedeutic Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - A Goy
- John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, NJ, USA
| | - M A Pavlovsky
- Department of Hematology, Fundaleu, Buenos Aires, Argentina
| | - C Karlsson
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - M Hallek
- Department I of Internal Medicine, University of Cologne, Cologne, Germany
| | - M Mahler
- Janssen Research & Development, Raritan, NJ, USA
| | - M Salman
- Janssen Research & Development, Raritan, NJ, USA
| | - S Sun
- Janssen Research & Development, Raritan, NJ, USA
| | - C Phelps
- Janssen Research & Development, Raritan, NJ, USA
| | | | - A Howes
- Janssen Research & Development, High Wycombe, UK
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Younes A, Sehn LH, Johnson P, Zinzani PL, Hong X, Zhu J, Patti C, Belada D, Samoilova O, Suh C, Leppä S, Rai S, Turgut M, Jurczak W, Cheung MC, Gurion R, Yeh SP, Lopez-Hernandez A, Dührsen U, Thieblemont C, Chiattone CS, Balasubramanian S, Carey J, Liu G, Shreeve SM, Sun S, Zhuang SH, Vermeulen J, Staudt LM, Wilson W. Randomized Phase III Trial of Ibrutinib and Rituximab Plus Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone in Non-Germinal Center B-Cell Diffuse Large B-Cell Lymphoma. J Clin Oncol 2019; 37:1285-1295. [PMID: 30901302 DOI: 10.1200/jco.18.02403] [Citation(s) in RCA: 343] [Impact Index Per Article: 68.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Ibrutinib has shown activity in non-germinal center B-cell diffuse large B-cell lymphoma (DLBCL). This double-blind phase III study evaluated ibrutinib and rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in untreated non-germinal center B-cell DLBCL. PATIENTS AND METHODS Patients were randomly assigned at a one-to-one ratio to ibrutinib (560 mg per day orally) plus R-CHOP or placebo plus R-CHOP. The primary end point was event-free survival (EFS) in the intent-to-treat (ITT) population and the activated B-cell (ABC) DLBCL subgroup. Secondary end points included progression-free survival (PFS), overall survival (OS), and safety. RESULTS A total of 838 patients were randomly assigned to ibrutinib plus R-CHOP (n = 419) or placebo plus R-CHOP (n = 419). Median age was 62.0 years; 75.9% of evaluable patients had ABC subtype disease, and baseline characteristics were balanced. Ibrutinib plus R-CHOP did not improve EFS in the ITT (hazard ratio [HR], 0.934) or ABC (HR, 0.949) population. A preplanned analysis showed a significant interaction between treatment and age. In patients age younger than 60 years, ibrutinib plus R-CHOP improved EFS (HR, 0.579), PFS (HR, 0.556), and OS (HR, 0.330) and slightly increased serious adverse events (35.7% v 28.6%), but the proportion of patients receiving at least six cycles of R-CHOP was similar between treatment arms (92.9% v 93.0%). In patients age 60 years or older, ibrutinib plus R-CHOP worsened EFS, PFS, and OS, increased serious adverse events (63.4% v 38.2%), and decreased the proportion of patients receiving at least six cycles of R-CHOP (73.7% v 88.8%). CONCLUSION The study did not meet its primary end point in the ITT or ABC population. However, in patients age younger than 60 years, ibrutinib plus R-CHOP improved EFS, PFS, and OS with manageable safety. In patients age 60 years or older, ibrutinib plus R-CHOP was associated with increased toxicity, leading to compromised R-CHOP administration and worse outcomes. Further investigation is warranted.
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Affiliation(s)
- Anas Younes
- 1 Memorial Sloan Kettering Cancer Center, New York, NY
| | - Laurie H Sehn
- 2 BC Cancer Agency, Vancouver, British Columbia, Canada
| | - Peter Johnson
- 3 University of Southampton, Southampton, United Kingdom
| | | | - Xiaonan Hong
- 5 Fudan University, Shanghai, People's Republic of China
| | - Jun Zhu
- 6 Peking University Cancer Hospital, Beijing, People's Republic of China
| | - Caterina Patti
- 7 Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - David Belada
- 8 Charles University, Hradec Králové, Czech Republic.,9 University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Olga Samoilova
- 10 Regional Clinical Hospital, Nizhny Novgorod, Russian Federation
| | - Cheolwon Suh
- 11 University of Ulsan, Seoul, Republic of Korea
| | - Sirpa Leppä
- 12 Helsinki University Hospital, Helsinki, Finland.,13 University of Helsinki, Helsinki, Finland
| | - Shinya Rai
- 14 Kindai University, Osakasayama, Japan
| | | | | | | | - Ronit Gurion
- 18 Rabin Medical Center, Petah Tikva, Israel.,19 Tel Aviv University, Tel Aviv, Israel
| | - Su-Peng Yeh
- 20 China Medical University Hospital, Taichung, Republic of China
| | | | | | - Catherine Thieblemont
- 23 Hôpital Saint-Louis, Paris, France.,24 Diderot University, Sorbonne Paris-Cité, Paris, France
| | | | | | - Jodi Carey
- 27 Janssen Research and Development, Spring House, PA
| | - Grace Liu
- 28 Janssen Research and Development, Raritan, NJ
| | | | - Steven Sun
- 28 Janssen Research and Development, Raritan, NJ
| | | | | | - Louis M Staudt
- 30 National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Wyndham Wilson
- 30 National Cancer Institute, National Institutes of Health, Bethesda, MD
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156
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Caldeira D, Alves D, Costa J, Ferreira JJ, Pinto FJ. Ibrutinib increases the risk of hypertension and atrial fibrillation: Systematic review and meta-analysis. PLoS One 2019; 14:e0211228. [PMID: 30785921 PMCID: PMC6382095 DOI: 10.1371/journal.pone.0211228] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 01/09/2019] [Indexed: 12/30/2022] Open
Abstract
Introduction Ibrutinib is an oral covalent inhibitor of Bruton's tyrosine kinase approved for the treatment of patients with chronic lymphocytic leukemia (CLL), mantle cell lymphoma and Waldenstrӧm’s macroglobulinemia. Ibrutinib has an increased risk of atrial fibrillation but the mechanism is unknown, and hypertension may play a role in the pathogenesis of this adverse drug reaction. Methods We aimed to review the risk of hypertension and atrial fibrillation as adverse events associated with ibrutinib through a systematic review with meta-analysis of randomized controlled trials (RCTs) retrieved in December 2018 on MEDLINE, EMBASE, CENTRAL and ClinicalTrials.gov. The data were pooled using random-effects meta-analyses using the risk ratio (RR) with the 95% confidence interval (95%CI). The confidence on the pooled estimates was ascertained through the grading of recommendations assessment, development, and evaluation (GRADE) approach. Results There were 8 eligible RCTs (2580 patients), all reporting safety data of interest. Ibrutinib was associated with a significant increase in the risk of hypertension with a RR of 2.82 (95%CI 1.52–5.23) with moderate quality evidence. Ibrutinib increased significantly the risk of atrial fibrillation with a RR of 4.69 (95%CI 2.17–7.64) with high quality evidence. Conclusions Ibrutinib was associated with significantly increased risks of both hypertension and atrial fibrillation.
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Affiliation(s)
- Daniel Caldeira
- Serviço de Cardiologia, Hospital Universitário de Santa Maria (CHLN), CAML, Centro Cardiovascular da Universidade de Lisboa—CCUL, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, Lisboa, Portugal
- Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, Lisboa, Portugal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, Lisboa, Portugal
- * E-mail:
| | - Daniela Alves
- Hematology Department, Faculdade de Medicina, Universidade de Lisboa, Santa Maria University Hospital (CHLN), Lisbon, Portugal
| | - João Costa
- Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, Lisboa, Portugal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, Lisboa, Portugal
| | - Joaquim J. Ferreira
- Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, Lisboa, Portugal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, Lisboa, Portugal
| | - Fausto J. Pinto
- Serviço de Cardiologia, Hospital Universitário de Santa Maria (CHLN), CAML, Centro Cardiovascular da Universidade de Lisboa—CCUL, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, Lisboa, Portugal
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157
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Management of adverse effects/toxicity of ibrutinib. Crit Rev Oncol Hematol 2019; 136:56-63. [PMID: 30878129 DOI: 10.1016/j.critrevonc.2019.02.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 01/27/2019] [Accepted: 02/04/2019] [Indexed: 12/18/2022] Open
Abstract
Bruton tyrosine kinase signaling (BTK) is critical step for B-cell development and immunoglobulin synthesis. Ibrutinib is an orally bioavailable bruton tyrosine kinase inhibitor (BTKi) and forms an irreversible covalent bound to BTK at the Cysteine-481 residue. Ibrutinib has been approved by FDA for the treatment of mantle cell lymphoma, chronic lymphocytic leukemia, Waldenstrom's macroglobulinemia, marginal zone lymphoma and chronic graft-versus-host disease in allogeneic stem cell transplantation. Ibrutinib is generally well tolerated drug with rapid and durable responses but has some side events. The most common side effects are diarrhea, upper respiratory tract infection, bleeding, fatigue and cardiac side effects. These events are generally mild (grade I-II). However atrial fibrillation (AF) and bleeding are important and may be grade III or higher side effects require strict monitoring. Here side effects of ibrutinib have been summarized and important considerations in the management of these adverse events have been reviewed.
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158
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Lentz R, Feinglass J, Ma S, Akhter N. Risk factors for the development of atrial fibrillation on ibrutinib treatment. Leuk Lymphoma 2019; 60:1447-1453. [DOI: 10.1080/10428194.2018.1533129] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Robert Lentz
- Department of Internal Medicine, Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joseph Feinglass
- Department of Internal Medicine, Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Shuo Ma
- Department of Internal Medicine, Division of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nausheen Akhter
- Department of Internal Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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159
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Brown JR, Moslehi J, Ewer MS, O'Brien SM, Ghia P, Cymbalista F, Shanafelt TD, Fraser G, Rule S, Coutre SE, Dilhuydy M, Cramer P, Jaeger U, Dreyling M, Byrd JC, Treon S, Liu EY, Chang S, Bista A, Vempati R, Boornazian L, Valentino R, Reddy V, Mahler M, Yang H, Graef T, Burger JA. Incidence of and risk factors for major haemorrhage in patients treated with ibrutinib: An integrated analysis. Br J Haematol 2019; 184:558-569. [PMID: 30506764 PMCID: PMC6587776 DOI: 10.1111/bjh.15690] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/15/2018] [Indexed: 01/16/2023]
Abstract
Ibrutinib, a Bruton tyrosine kinase inhibitor, is approved for treatment of various B-cell malignancies. In ibrutinib clinical studies, low-grade haemorrhage was common, whereas major haemorrhage (MH) was infrequent. We analysed the incidence of and risk factors for MH from 15 ibrutinib clinical studies (N = 1768), including 4 randomised controlled trials (RCTs). Rates of any-grade bleeding were similar for single-agent ibrutinib and ibrutinib combinations (39% and 40%). Low-grade bleeding was more common in ibrutinib-treated than comparator-treated patients (35% and 15%), and early low-grade bleeding was not associated with MH. The proportion of MH in RCTs was higher with ibrutinib than comparators (4.4% vs. 2.8%), but after adjusting for longer exposure with ibrutinib (median 13 months vs. 6 months), the incidence of MH was similar (3.2 vs. 3.1 per 1000 person-months). MH led to treatment discontinuation in 1% of all ibrutinib-treated patients. Use of anticoagulants and/or antiplatelets (AC/AP) during the study was common (~50% of patients) and had an increased exposure-adjusted relative risk for MH in both the total ibrutinib-treated population (1.9; 95% confidence interval, 1.2-3.0) and RCT comparator-treated patients (2.4; 95% confidence interval, 1.0-5.6), indicating that ibrutinib may not alter the effect of AC/AP on the risk of MH in B-cell malignancies.
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Affiliation(s)
- Jennifer R. Brown
- Chronic Lymphocytic Leukemia CenterDana‐Farber Cancer InstituteBostonMAUSA
| | | | - Michael S. Ewer
- The University of Texas MD Anderson Cancer CenterHoustonTXUSA
| | - Susan M. O'Brien
- Chao Family Comprehensive Cancer CenterUniversity of California IrvineOrangeCAUSA
| | - Paolo Ghia
- Strategic Research Program on CLLUniversità Vita‐Salute San Raffaele Milano and IRCCS Istituto Scientifico San RaffaeleMilanItaly
| | | | | | - Graeme Fraser
- Juravinski Cancer CentreMcMaster UniversityHamiltonONCanada
| | - Simon Rule
- Plymouth University Peninsula Schools of Medicine and DentistryPlymouthUK
| | | | | | - Paula Cramer
- German CLL Study GroupUniversity of CologneCologneGermany
| | | | | | - John C. Byrd
- The Ohio State University Comprehensive Cancer CenterColumbusOHUSA
| | | | - Emily Y. Liu
- Pharmacyclics LLC, an AbbVie CompanySunnyvaleCAUSA
| | | | - Amulya Bista
- Pharmacyclics LLC, an AbbVie CompanySunnyvaleCAUSA
| | - Rama Vempati
- Pharmacyclics LLC, an AbbVie CompanySunnyvaleCAUSA
| | | | | | - Vijay Reddy
- Pharmacyclics LLC, an AbbVie CompanySunnyvaleCAUSA
| | | | - Huiying Yang
- Pharmacyclics LLC, an AbbVie CompanySunnyvaleCAUSA
| | | | - Jan A. Burger
- The University of Texas MD Anderson Cancer CenterHoustonTXUSA
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Totzeck M, Schuler M, Stuschke M, Heusch G, Rassaf T. Cardio-oncology - strategies for management of cancer-therapy related cardiovascular disease. Int J Cardiol 2019; 280:163-175. [PMID: 30661849 DOI: 10.1016/j.ijcard.2019.01.038] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 12/15/2018] [Accepted: 01/10/2019] [Indexed: 02/07/2023]
Abstract
Current therapy of advanced cancers is based on several modalities including radiotherapy, cytotoxic chemotherapy, molecularly targeted inhibitors and antibodies targeting immune checkpoints. All of those these modalities can negatively impact the cardiovascular system, and there is considerable experience in relation to radiotherapy and chemotherapy. In contrast, the knowledge base on cardiovascular toxicities of novel agents targeting signal transduction pathways and immune regulation is quite limited. In particular, potential late effects are of concern as cardiovascular pathology can negatively impact quality of life and prognosis in cancer survivors, particularly when additional cardiovascular risk factors are present. Treatment-associated adverse events include hypertension, venous thromboembolism, coronary artery disease, valvular heart disease, heart failure and arrhythmias. Early diagnosis of subclinical cardiotoxic effects of cancer therapies remains challenging. Integrated care, as provided by multidisciplinary cardio-oncology teams is the best option for prevention, diagnosis and treatment of cardiovascular diseases associated with cancer therapy. This review considers the cardiotoxic effects of specific cancer therapies and discusses novel diagnostic and therapeutic approaches as a reference for optimizing the care of cancer patients receiving novel cancer therapies.
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Affiliation(s)
- Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Martin Schuler
- Department of Medical Oncology, West German Cancer Center, Medical Faculty, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany; German Cancer Consortium (DKTK), Partner site University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Martin Stuschke
- Department of Radiation Oncology, West German Cancer Center, Medical Faculty, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany; German Cancer Consortium (DKTK), Partner site University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany.
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161
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Guha A, Armanious M, Fradley MG. Update on cardio-oncology: Novel cancer therapeutics and associated cardiotoxicities. Trends Cardiovasc Med 2019; 29:29-39. [DOI: 10.1016/j.tcm.2018.06.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 05/22/2018] [Accepted: 06/03/2018] [Indexed: 02/08/2023]
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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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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: 16] [Impact Index Per Article: 2.7] [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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Blaes AH, Thavendiranathan P, Moslehi J. Cardiac Toxicities in the Era of Precision Medicine: Underlying Risk Factors, Targeted Therapies, and Cardiac Biomarkers. Am Soc Clin Oncol Educ Book 2018; 38:764-774. [PMID: 30231407 DOI: 10.1200/edbk_208509] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Cancer therapies can cause a variety of cardiac toxicities, including ischemia, cardiomyopathy, heart failure, myocarditis, arrhythmias, vascular disease, hypertension, and hyperlipidemia. Addressing cardiovascular risk at baseline, before initiating therapy, during cancer treatment, and in the survivorship period is imperative. It may be useful to risk stratify individuals with cardiovascular risk factors using biomarkers or imaging before they receive potentially cardiotoxic therapies. Additionally, new guidelines recommend cardiac imaging with echocardiography in the survivorship period 6 to 12 months after completing cancer therapy for these high-risk individuals. Close collaboration between cardiology and oncology in both clinical practice and future research is essential.
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Affiliation(s)
- Anne H Blaes
- From the Division of Hematology/Oncology, University of Minnesota, Minneapolis, MN; Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Division of Cardiology, University of Toronto, Toronto, ON, Canada; Division of Cardiology, Vanderbilt University, Nashville, TN
| | - Paaladinesh Thavendiranathan
- From the Division of Hematology/Oncology, University of Minnesota, Minneapolis, MN; Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Division of Cardiology, University of Toronto, Toronto, ON, Canada; Division of Cardiology, Vanderbilt University, Nashville, TN
| | - Javid Moslehi
- From the Division of Hematology/Oncology, University of Minnesota, Minneapolis, MN; Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Division of Cardiology, University of Toronto, Toronto, ON, Canada; Division of Cardiology, Vanderbilt University, Nashville, TN
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165
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Treon SP, Gustine J, Meid K, Yang G, Xu L, Liu X, Demos M, Kofides A, Tsakmaklis N, Chen JG, Munshi M, Chan G, Dubeau T, Raje N, Yee A, O’Donnell E, Hunter ZR, Castillo JJ. Ibrutinib Monotherapy in Symptomatic, Treatment-Naïve Patients With Waldenström Macroglobulinemia. J Clin Oncol 2018; 36:2755-2761. [DOI: 10.1200/jco.2018.78.6426] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Purpose Ibrutinib is active in previously treated Waldenström macroglobulinemia (WM). MYD88 mutations ( MYD88MUT) and CXCR4 mutations ( CXCR4MUT) affect ibrutinib response. We report on a prospective study of ibrutinib monotherapy in symptomatic, untreated patients with WM, and the effect of CXCR4MUT status on outcome. Patients and Methods Symptomatic, treatment-naïve patients with WM were eligible. Ibrutinib (420 mg) was administered daily until progression or unacceptable toxicity. All tumors were genotyped for MYD88MUT and CXCR4MUT. Results A total of 30 patients with WM received ibrutinib. All carried MYD88MUT, and 14 (47%) carried a CXCR4MUT. After ibrutinib treatment, median serum IgM levels declined from 4,370 to 1,513 mg/dL, bone marrow involvement declined from 65% to 20%, and hemoglobin level rose from 10.3 to 13.9 g/dL ( P < .001 for all comparisons). Overall (minor or more than minor) and major (partial or greater than partial) responses for all patients were 100% and 83%, respectively. Rates of major (94% v 71%) and very good partial (31 v 7%) responses were higher and time to major responses more rapid (1.8 v 7.3 months; P = 0.01) in patients with wild-type CXCR4 versus those with CXCR4MUT, respectively. With a median follow-up of 14.6 months, disease in two patients (both with CXCR4MUT) progressed. The 18-month, estimated progression-free survival is 92% (95% CI, 73% to 98%). All patients are alive. Grade 2/3 treatment-related toxicities in > 5% of patients included arthralgia (7%), bruising (7%), neutropenia (7%), upper respiratory tract infection (7%), urinary tract infection (7%), atrial fibrillation (10%), and hypertension (13%). There were no grade 4 or unexpected toxicities. Conclusion Ibrutinib is highly active, produces durable responses, and is safe as primary therapy in patients with symptomatic WM. CXCR4MUT status affects responses to ibrutinib.
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Affiliation(s)
- Steven P. Treon
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Joshua Gustine
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Kirsten Meid
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Guang Yang
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Lian Xu
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Xia Liu
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Maria Demos
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Amanda Kofides
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Nicholas Tsakmaklis
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Jiaji G. Chen
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Manit Munshi
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Gloria Chan
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Toni Dubeau
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Noopur Raje
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Andrew Yee
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Elizabeth O’Donnell
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Zachary R. Hunter
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
| | - Jorge J. Castillo
- Steven P. Treon, Joshua Gustine, Kirsten Meid, Guang Yang, Lian Xu, Xia Liu, Maria Demos, Amanda Kofides, Nicholas Tsakmaklis, Jiaji G. Chen, Manit Munshi, Gloria Chan, Toni Dubeau, Zachary R. Hunter, and Jorge J. Castillo, Dana-Farber Cancer Institute; Steven P. Treon, Guang Yang, Xia Liu, Noopur Raje, Andrew Yee, Elizabeth O’Donnell, Zachary R. Hunter, and Jorge J. Castillo, Harvard Medical School; and Noopur Raje, Andrew Yee, and Elizabeth O’Donnell, Massachusetts General Hospital, Boston, MA
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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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167
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Tam CS, Brown JR. Vigilance for ibrutinib-associated ventricular arrhythmias: rare but be aware. Leuk Lymphoma 2018; 59:2767-2768. [PMID: 30032684 DOI: 10.1080/10428194.2018.1482546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Constantine S Tam
- a Peter MacCallum Cancer Center, St Vincent's Hospital and University of Melbourne , Melbourne , Australia
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168
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Mauro FR, Caputo MD, Rosati S, Pepe S, De Benedittis D, De Luca ML, Foà R. Balancing efficacy and toxicity of targeted agents currently used for the treatment of patients with chronic lymphocytic leukemia. Expert Rev Hematol 2018; 11:601-611. [PMID: 29969322 DOI: 10.1080/17474086.2018.1495557] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION In recent years, innovative mechanism-based drugs have enriched the therapeutic armamentarium for patients with chronic lymphocytic leukemia (CLL) and are widely used in the clinical practice. These small molecules targeting the B-cell receptor signaling pathway and the BCL-2 anti-apoptotic protein offer new chemo-free options to both unfit patients and high-risk patients who show a poor response to chemoimmunotherapy. Nonetheless, treatment with ibrutinib, idelalisib and venetoclax is associated with unique side effects. Awareness, prevention and the appropriate management of these specific toxicities are of crucial importance for a successful treatment. Areas covered: The purpose of this review is to discuss the most relevant studies on small molecules in CLL, with particular attention to the emerging toxicity profile of these agents and to the factors that should be considered to address the most appropriate treatment approach for each patient. Expert opinion: The increased knowledge on the biology of CLL has translated into the development of targeted agents that are highly effective and produce deep responses. Toxicities potentially associated with these agents should be known for an optimal management of CLL patients.
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Affiliation(s)
- Francesca R Mauro
- a Hematology, Department of Cellular Biotechnologies and Hematology , Sapienza University and Policlinico Umberto 1 , Rome , Italy
| | - Maria D Caputo
- a Hematology, Department of Cellular Biotechnologies and Hematology , Sapienza University and Policlinico Umberto 1 , Rome , Italy
| | - Serena Rosati
- a Hematology, Department of Cellular Biotechnologies and Hematology , Sapienza University and Policlinico Umberto 1 , Rome , Italy
| | - Sara Pepe
- a Hematology, Department of Cellular Biotechnologies and Hematology , Sapienza University and Policlinico Umberto 1 , Rome , Italy
| | - Daniela De Benedittis
- a Hematology, Department of Cellular Biotechnologies and Hematology , Sapienza University and Policlinico Umberto 1 , Rome , Italy
| | - Maria L De Luca
- a Hematology, Department of Cellular Biotechnologies and Hematology , Sapienza University and Policlinico Umberto 1 , Rome , Italy
| | - Robin Foà
- a Hematology, Department of Cellular Biotechnologies and Hematology , Sapienza University and Policlinico Umberto 1 , Rome , Italy
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169
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O'Brien S, Hillmen P, Coutre S, Barr PM, Fraser G, Tedeschi A, Burger JA, Dilhuydy MS, Hess G, Moreno C, Cramer P, Liu E, Chang S, Vermeulen J, Styles L, Howes A, James DF, Patel K, Graef T, Valentino R. Safety Analysis of Four Randomized Controlled Studies of Ibrutinib in Patients With Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma or Mantle Cell Lymphoma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:648-657.e15. [PMID: 30061088 DOI: 10.1016/j.clml.2018.06.016] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/16/2018] [Accepted: 06/19/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Multiple studies have demonstrated the efficacy and safety of ibrutinib for chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and mantle cell lymphoma (MCL). This first-in-class inhibitor of Bruton's tyrosine kinase has become a standard treatment for patients with CLL and MCL. PATIENTS AND METHODS We conducted an integrated safety analysis to characterize the frequency, severity, natural history, and outcomes of adverse events (AEs) with ibrutinib versus comparators. Data were pooled from 4 completed randomized controlled studies that had included 756 ibrutinib-treated and 749 comparator-treated patients with CLL/SLL or relapsed/refractory MCL. Safety analyses included reporting of AEs using crude and exposure-adjusted incidence rates. RESULTS The median treatment duration was 13.3 months (maximum, 28.2 months) for ibrutinib and 5.8 months (maximum, 27.3 months) for comparators. When adjusted for exposure, diarrhea, atrial fibrillation, and hypertension were the only common grade ≥ 3 AEs more often reported with ibrutinib than with the comparators. Dose reductions (7% vs. 14%) and discontinuation (12% vs. 16%) because of AEs occurred less often with ibrutinib, and deaths due to AEs occurred at similar rates (6% vs. 7%). When adjusted for exposure, the corresponding data were all lower with ibrutinib than with the comparators (0.06 vs. 0.22, 0.11 vs. 0.22, and 0.06 vs. 0.09 patient-exposure-years, respectively). The prevalence of common grade 3/4 AEs with ibrutinib generally decreased over time, with the exception of hypertension. CONCLUSION These results from an integrated analysis support a favorable benefit/risk profile of ibrutinib in patients with CLL/SLL and MCL.
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Affiliation(s)
- Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California, Irvine, Orange, CA.
| | - Peter Hillmen
- The Leeds Teaching Hospitals, St. James University Hospital, Leeds, United Kingdom
| | - Steven Coutre
- Stanford University School of Medicine, Stanford, CA
| | - Paul M Barr
- Wilmot Cancer Institute, University of Rochester Cancer Center, Rochester, NY
| | - Graeme Fraser
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | - Jan A Burger
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Georg Hess
- Universitats Medizin Mainz, Mainz, Germany
| | - Carol Moreno
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Paula Cramer
- University of Cologne, German CLL Study Group, Cologne, Germany
| | - Emily Liu
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA
| | | | | | - Lori Styles
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA
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Reda G, Fattizzo B, Cassin R, Mattiello V, Tonella T, Giannarelli D, Massari F, Cortelezzi A. Predictors of atrial fibrillation in ibrutinib-treated CLL patients: a prospective study. J Hematol Oncol 2018; 11:79. [PMID: 29891001 PMCID: PMC5996546 DOI: 10.1186/s13045-018-0626-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 06/01/2018] [Indexed: 01/04/2023] Open
Abstract
Background Ibrutinib is an oral irreversible inhibitor of Bruton’s tyrosine kinase, indicated for the treatment of chronic lymphocytic leukaemia. The drug is generally well tolerated; however, not infrequent side effects are reported, with the major two being bleeding and ibrutinib-related atrial fibrillation. Atrial fibrillation pathogenesis in this setting is not completely clear, and no prospective studies have evaluated the impact of previous cardiologic history and baseline characteristics. Methods We prospectively performed cardiologic assessment in 43 CLL patients before starting ibrutinib therapy. Cardiologic workup included comorbidity collection and electrocardiographic and echocardiographic baseline evaluation. Results After a median observation of 8 months, seven patients developed atrial fibrillation (16.3%). Cases developing atrial fibrillation were all elderly males (p = 0.04), and mostly with a history of previous arterial hypertension (p = 0.009). Atrial fibrillation occurrence also correlated with the presence of one or more pre-existent cardiologic comorbidities (p = 0.03), with a higher atrial fibrillation risk score (calculated with comorbidities and cardiologic risk factor evaluation p < 0.001), and with higher left atrial diameter (p = 0.02) and area (p = 0.03) by echocardiography. The occurrence of atrial fibrillation was managed after an integrated cardio-oncologic evaluation: anticoagulation was started in 4 (57.1%) patients and beta-blockers or amiodarone in 5 (71.4%). One patient underwent electric cardioversion and another patient pacemaker positioning to normalise heart rate in order to continue ibrutinib. Conclusion Our data show that echocardiography is a highly informative and reproducible tool that should be included in pre-treatment workup for patients who are candidates for ibrutinib therapy. Electronic supplementary material The online version of this article (10.1186/s13045-018-0626-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gianluigi Reda
- UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, via Francesco Sforza 35, 20135, Milan, Italy.
| | - Bruno Fattizzo
- UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Università degli Studi di Milano, via Francesco Sforza 35, 20135, Milan, Italy
| | - Ramona Cassin
- UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, via Francesco Sforza 35, 20135, Milan, Italy
| | - Veronica Mattiello
- UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Università degli Studi di Milano, via Francesco Sforza 35, 20135, Milan, Italy
| | - Tatiana Tonella
- UOC Malattie Cardiovascolari, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Università degli Studi di Milano, via Francesco Sforza 35, 20135, Milan, Italy
| | - Diana Giannarelli
- Bio-statistical Unit, Regina Elena National Cancer Institute, via Elio Chianesi 53, 00144, Roma, Italy
| | - Ferdinando Massari
- UOC Malattie Cardiovascolari, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Università degli Studi di Milano, via Francesco Sforza 35, 20135, Milan, Italy
| | - Agostino Cortelezzi
- UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Università degli Studi di Milano, via Francesco Sforza 35, 20135, Milan, Italy
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171
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Barr PM, Robak T, Owen C, Tedeschi A, Bairey O, Bartlett NL, Burger JA, Hillmen P, Coutre S, Devereux S, Grosicki S, McCarthy H, Li J, Simpson D, Offner F, Moreno C, Zhou C, Styles L, James D, Kipps TJ, Ghia P. Sustained efficacy and detailed clinical follow-up of first-line ibrutinib treatment in older patients with chronic lymphocytic leukemia: extended phase 3 results from RESONATE-2. Haematologica 2018; 103:1502-1510. [PMID: 29880603 PMCID: PMC6119145 DOI: 10.3324/haematol.2018.192328] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 06/04/2018] [Indexed: 12/15/2022] Open
Abstract
Results of RESONATE-2 (PCYC-1115/1116) supported approval of ibrutinib for first-line treatment of chronic lymphocytic leukemia. Extended analysis of RESONATE-2 was conducted to determine long-term efficacy and safety of ibrutinib in older patients with chronic lymphocytic leukemia. A total of 269 patients aged ≥65 years with previously untreated chronic lymphocytic leukemia without del(17p) were randomized 1:1 to ibrutinib (n=136) or chlorambucil (n=133) on days 1 and 15 of a 28-day cycle for 12 cycles. Median ibrutinib treatment duration was 28.5 months. Ibrutinib significantly prolonged progression-free survival versus chlorambucil (median, not reached vs. 15 months; hazard ratio, 0.12; 95% confidence interval, 0.07-0.20; P<0.0001). The 24-month progression-free survival was 89% with ibrutinib (97% and 89% in patients with del[11q] and unmutated immunoglobulin heavy chain variable region gene, respectively). Progression-free survival rates at 24 months were also similar regardless of age (<75 years [88%], ≥75 years [89%]). Overall response rate was 92% (125/136). Rate of complete response increased substantially from 7% at 12 months to 18% with extended follow up. Greater quality of life improvements occurred with ibrutinib versus chlorambucil in Functional Assessment of Chronic Illness Therapy-Fatigue (P=0.0013). The most frequent grade ≥3 adverse events were neutropenia (12%), anemia (7%), and hypertension (5%). Rate of discontinuations due to adverse events was 12%. Results demonstrated that first-line ibrutinib for elderly patients with chronic lymphocytic leukemia provides sustained response and progression-free survival benefits over chemotherapy, with depth of response improving over time without new toxicity concerns. This trial was registered at clinicaltrials.gov identifier 01722487 and 01724346.
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Affiliation(s)
| | | | | | | | - Osnat Bairey
- Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | | | - Jan A Burger
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter Hillmen
- The Leeds Teaching Hospitals, St. James Institute of Oncology, UK
| | | | | | | | | | | | | | | | - Carol Moreno
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Cathy Zhou
- Pharmacyclics, LLC, an AbbVie Company, Sunnyvale, CA, USA
| | - Lori Styles
- Pharmacyclics, LLC, an AbbVie Company, Sunnyvale, CA, USA
| | - Danelle James
- Pharmacyclics, LLC, an AbbVie Company, Sunnyvale, CA, USA
| | - Thomas J Kipps
- University of California, San Diego, Moores Cancer Center, La Jolla, CA, USA
| | - Paolo Ghia
- Università Vita-Salute San Raffaele and IRCCS Istituto Scientifico San Raffaele, Milan, Italy
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172
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Awan FT, Jurczak W. Use of acalabrutinib in patients with mantle cell lymphoma. Expert Rev Hematol 2018; 11:495-502. [DOI: 10.1080/17474086.2018.1473030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Farrukh T. Awan
- Department of Internal Medicine, Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Wojciech Jurczak
- Department of Hematology, Jagiellonian University, Krakow, Poland
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173
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O'Brien S, Furman RR, Coutre S, Flinn IW, Burger JA, Blum K, Sharman J, Wierda W, Jones J, Zhao W, Heerema NA, Johnson AJ, Luan Y, James DF, Chu AD, Byrd JC. Single-agent ibrutinib in treatment-naïve and relapsed/refractory chronic lymphocytic leukemia: a 5-year experience. Blood 2018; 131:1910-1919. [PMID: 29437592 PMCID: PMC5921964 DOI: 10.1182/blood-2017-10-810044] [Citation(s) in RCA: 307] [Impact Index Per Article: 51.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 01/24/2018] [Indexed: 12/25/2022] Open
Abstract
We previously reported durable responses and manageable safety of ibrutinib from a 3-year follow-up of treatment-naïve (TN) older patients (≥65 years of age) and relapsed/refractory (R/R) patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). We now report on long-term efficacy and safety with median follow-up of 5 years in this patient population with TN (N = 31) and R/R (N = 101) CLL/SLL. With the current 5-year follow-up, ibrutinib continues to yield a high overall response rate of 89%, with complete response rates increasing over time to 29% in TN patients and 10% in R/R patients. The median progression-free survival (PFS) was not reached in TN patients. The 5-year PFS rate was 92% in TN patients and 44% in R/R patients. Median PFS in R/R patients was 51 months; in those with del(11q), del(17p), and unmutated IGHV, it was 51, 26, and 43 months, respectively, demonstrating long-term efficacy of ibrutinib in some high-risk subgroups. Survival outcomes were less robust for R/R patients with del(17p) and those who received more prior therapies. The onset of grade ≥3 cytopenias, such as neutropenia and thrombocytopenia, decreased over time. Treatment--limiting adverse events were more frequent during the first year compared with subsequent periods. These results demonstrate sustained efficacy and acceptable tolerability of ibrutinib over an extended time, providing the longest experience for Bruton tyrosine kinase inhibitor treatment in patients with CLL/SLL. These trials were registered at www.clinicaltrials.gov as #NCT01105247 and #NCT01109069.
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MESH Headings
- Adenine/analogs & derivatives
- Adult
- Aged
- Aged, 80 and over
- Disease-Free Survival
- Female
- Follow-Up Studies
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Male
- Middle Aged
- Piperidines
- Pyrazoles/administration & dosage
- Pyrazoles/adverse effects
- Pyrimidines/administration & dosage
- Pyrimidines/adverse effects
- Survival Rate
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Affiliation(s)
- Susan O'Brien
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA
| | - Richard R Furman
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Steven Coutre
- Stanford Cancer Center, Stanford University School of Medicine, Stanford, CA
| | - Ian W Flinn
- Sarah Cannon Research Institute, Nashville, TN
| | - Jan A Burger
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kristie Blum
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Jeff Sharman
- Willamette Valley Cancer Institute and Research Center, Springfield, OR; and
| | - William Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey Jones
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Weiqiang Zhao
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Nyla A Heerema
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Amy J Johnson
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Ying Luan
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA
| | | | - Alvina D Chu
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA
| | - John C Byrd
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
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174
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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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175
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176
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Depth and durability of response to ibrutinib in CLL: 5-year follow-up of a phase 2 study. Blood 2018; 131:2357-2366. [PMID: 29483101 DOI: 10.1182/blood-2017-12-820910] [Citation(s) in RCA: 147] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 02/14/2018] [Indexed: 12/13/2022] Open
Abstract
The safety and efficacy of ibrutinib (420 mg) in chronic lymphocytic leukemia (CLL) were evaluated in a phase 2 study; 51 patients had TP53 aberration (TP53 cohort) and 35 were enrolled because of age 65 years or older (elderly cohort). Both cohorts included patients with treatment-naive (TN) and relapsed/refractory (RR) CLL. With the median follow-up of 4.8 years, 49 (57.0%) of 86 patients remain on study. Treatment was discontinued for progressive disease in 20 (23.3%) patients and for adverse events in 5 (5.8%). Atrial fibrillation occurred in 18 (20.9%) patients for a rate of 6.4 per 100 patient-years. No serious bleeding occurred. The overall response rate at 6 months, the primary study endpoint, was 95.8% for the TP53 cohort (95% confidence interval, 85.7%-99.5%) and 93.9% for the elderly cohort (95% confidence interval, 79.8%-99.3%). Depth of response improved with time: at best response, 14 (29.2%) of 48 patients in the TP53 cohort and 9 (27.3%) of 33 in the elderly cohort achieved a complete response. Median minimal residual disease (MRD) in peripheral blood was 3.8 × 10-2 at 4 years, with MRD-negative (<10-4) remissions in 5 (10.2%) patients. In the TP53 cohort, the estimated 5-year progression-free survival (PFS) was 74.4% in TN-CLL compared with 19.4% in RR-CLL (P = .0002), and overall survival (OS) was 85.3% vs 53.7%, respectively (P = .023). In the elderly cohort, the estimated 5-year PFS and OS in RR-CLL were 64.8% and 71.6%, respectively, and no event occurred in TN-CLL. Long-term administration of ibrutinib was well tolerated and provided durable disease control for most patients. This trial was registered at www.clinicaltrials.gov as #NCT01500733.
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177
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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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178
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Itchaki G, Brown JR. Experience with ibrutinib for first-line use in patients with chronic lymphocytic leukemia. Ther Adv Hematol 2018; 9:3-19. [PMID: 29317997 PMCID: PMC5753924 DOI: 10.1177/2040620717741861] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 10/17/2017] [Indexed: 01/17/2023] Open
Abstract
Ibrutinib is the first in-class, orally administered, Bruton's tyrosine kinase (BTK) inhibitor that abrogates the critical signaling downstream of the B-cell receptor (BCR). This signaling is required for B-cell survival, proliferation and interaction with the microenvironment. Ibrutinib proved active in preclinical models of lymphoproliferative diseases and achieved impressive response rates in heavily pretreated relapsed and refractory (R/R) patients with chronic lymphocytic leukemia (CLL). Ibrutinib prolonged survival compared to standard therapy and mitigated the effect of most poor prognostic factors in CLL, thus becoming the main therapeutic option in high-risk populations. Moreover, compared with standard chemoimmunotherapy (CIT) for adults, ibrutinib causes fewer cytopenias and infections, while having its own unique toxicity profile. Its efficacy in relapsed patients as well as its tolerability have led to its increased use in previously untreated patients, especially in those with poor prognostic markers and/or the elderly. This review elaborates on ibrutinib's unique toxicity profile and the mechanisms of acquired resistance leading to progression on ibrutinib, since both are critical for understanding the obstacles to its first-line use. We will further evaluate the data from ongoing clinical trials in this setting and explore future options for combination therapy.
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179
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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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180
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Aw A, Brown JR. Current Status of Bruton's Tyrosine Kinase Inhibitor Development and Use in B-Cell Malignancies. Drugs Aging 2017; 34:509-527. [PMID: 28536906 DOI: 10.1007/s40266-017-0468-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The B-cell receptor (BCR) pathway plays an important role in the survival, proliferation and trafficking of cancer cells in a variety of B-cell malignancies. Recently, a number of agents have been developed to target various components of the BCR pathway. One such target is Bruton's tyrosine kinase (BTK), a Tec family kinase member found near the cell membrane that is involved in upstream BCR signaling. The biological function of BTK in several B-cell lymphoid malignancies has led to the development of the oral BTK inhibitor ibrutinib. In chronic lymphocytic leukemia (CLL), ibrutinib has demonstrated durable clinical responses in relapsed/refractory (R/R) patients, including those with the high-risk del(17p) cytogenetic abnormality. These findings have paved the way for trials evaluating ibrutinib in previously untreated CLL patients, and also in combination with chemoimmunotherapy or other novel agents. Durable clinical responses have also been demonstrated in mantle cell lymphoma (MCL) and Waldenström's macroglobulinemia (WM) patients treated with ibrutinib. Ibrutinib is generally well tolerated, although current follow-up remains short and patients of advanced age are more likely to discontinue treatment for toxicity. Treatment-specific side effects such as bleeding and atrial fibrillation may, at least partly, be related to off-target inhibition of non-BTK kinases. Studies evaluating other potential indications for BTK inhibition are ongoing, including in post-allogeneic hematopoietic stem cell transplant patients for whom ibrutinib may be effective in modulating graft-versus-host disease. Combination trials of ibrutinib with venetoclax, a Bcl-2 inhibitor, are underway and are supported by sound preclinical rationale. Several next-generation BTK inhibitors are under development with the goal of decreasing treatment-related toxicity and resistance.
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Affiliation(s)
- Andrew Aw
- Division of Hematology, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Jennifer R Brown
- CLL Center and Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA.
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