1
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Hundal J, Curley T, Hamilton BK. Cardiovascular Considerations in Patients Undergoing Hematopoietic Cell Transplantation. Curr Treat Options Oncol 2024:10.1007/s11864-024-01240-1. [PMID: 39052206 DOI: 10.1007/s11864-024-01240-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2024] [Indexed: 07/27/2024]
Abstract
OPINION STATEMENT Cardiac dysfunction is a serious adverse effect of cancer therapies that can interfere with quality of life and impact long-term survival in patients with cancer. Hematopoietic cell transplantation is a potentially curative therapy for many advanced hematologic malignancies and bone marrow failure syndromes, however is associated with several short- and long-term adverse effects, including importantly, cardiovascular toxicities. The goal of this review article is to describe the cardiovascular events that may develop before, during, and after hematopoietic cell transplantation, review risk factors for short- and long-term cardiovascular toxicities, discuss approaches to cardiovascular risk stratification and evaluation, and highlight the research gaps in the consideration of cardiovascular disease in patients undergoing hematopoietic cell transplantation. Further understanding of cardiovascular events and the factors associated with cardiovascular disease will hopefully lead to novel interventions in managing and mitigating the significant long-term burden of late cardiovascular effects in transplant survivors.
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Affiliation(s)
- Jasmin Hundal
- Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Thomas Curley
- Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Betty K Hamilton
- Blood and Marrow Transplant Program, Hematology and Medical Oncology, Taussig Cancer Institute, 9500 Euclid Ave CA60, Cleveland, OH, 44195, USA.
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2
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Famta P, Shah S, Vambhurkar G, Srinivasarao DA, Jain N, Begum N, Sharma A, Shahrukh S, Kumar KC, Bagasariya D, Khatri DK, Singh SB, Srivastava S. Quality by design endorsed fabrication of Ibrutinib-loaded human serum albumin nanoparticles for the management of leukemia. Eur J Pharm Biopharm 2023; 190:94-106. [PMID: 37467865 DOI: 10.1016/j.ejpb.2023.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/03/2023] [Accepted: 07/16/2023] [Indexed: 07/21/2023]
Abstract
Ibrutinib (IB), a BCS class II drug suffers from limited aqueous solubility, short half-life and extensive first-pass metabolism. In this project, we aim to recruit the desirable properties of human serum albumin (HSA) as a biocompatible drug carrier to circumvent nanoparticle-associated drawbacks. Quality by design and multivariate analysis was used for the optimization of IB-NPs. Cell culture studies performed on the K562 cell line revealed that the Ibrutinib-loaded HSA NPs demonstrated improved cytotoxicity, drug uptake, and reactive oxygen species generation in the leukemic K562 cells. Cell cycle analysis revealed G2/M phase retention of the leukemia cells. In vitro protein corona and hemolysis studies revealed superior hematological stability compared to the free drug which showed greater than 40 % hemolysis. In vitro drug release studies showed prolonged release profile till 48 h. Pharmacokinetic studies demonstrated a 2.31-fold increase in AUC and an increase in half-life from 0.43 h to 2.887 h with a tremendous reduction in clearance and elimination rate indicating prolonged systemic circulation which is desirable in leukemia. Hence, we conclude that IB-loaded albumin nanoparticles could be a promising approach for the management of leukemia.
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Affiliation(s)
- Paras Famta
- Pharmaceutical Innovation and Translation Research Lab (PITRL), Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, India
| | - Saurabh Shah
- Pharmaceutical Innovation and Translation Research Lab (PITRL), Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, India
| | - Ganesh Vambhurkar
- Pharmaceutical Innovation and Translation Research Lab (PITRL), Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, India
| | - Dadi A Srinivasarao
- Pharmaceutical Innovation and Translation Research Lab (PITRL), Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, India
| | - Naitik Jain
- Pharmaceutical Innovation and Translation Research Lab (PITRL), Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, India
| | - Nusrat Begum
- Department of Biological Sciences, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, India
| | - Anamika Sharma
- Department of Biological Sciences, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, India
| | - Syed Shahrukh
- Pharmaceutical Innovation and Translation Research Lab (PITRL), Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, India
| | - Kondasingh Charan Kumar
- Pharmaceutical Innovation and Translation Research Lab (PITRL), Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, India
| | - Deepkumar Bagasariya
- Pharmaceutical Innovation and Translation Research Lab (PITRL), Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, India
| | - Dharmendra Kumar Khatri
- Department of Biological Sciences, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, India
| | - Shashi Bala Singh
- Department of Biological Sciences, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, India
| | - Saurabh Srivastava
- Pharmaceutical Innovation and Translation Research Lab (PITRL), Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, India.
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3
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Tannock IF, Bouche G, Goldstein DA, Goto Y, Lichter AS, Prabhash K, Ranganathan P, Saltz LB, Sonke GS, Strohbehn GW, von Moos R, Ratain MJ. Patient-centred, self-funding dose optimisation trials as a route to reduce toxicity, lower cost and improve access to cancer therapy. Ann Oncol 2023:S0923-7534(23)00687-7. [PMID: 37230253 DOI: 10.1016/j.annonc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 05/27/2023] Open
Affiliation(s)
- Ian F Tannock
- Division of Medical Oncology, Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada; Optimal Cancer Care Alliance, Ann Arbor, MI, USA.
| | - Gauthier Bouche
- Anticancer Fund, Meise, Belgium; Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Daniel A Goldstein
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yasushi Goto
- Department of Thoracic Oncology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | | | - Kumar Prabhash
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | - Leonard B Saltz
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gabe S Sonke
- Department of Medical Oncology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, & University of Amsterdam, Amsterdam, The Netherlands
| | - Garth W Strohbehn
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan; Section of Hematology Oncology, Veterans Affairs Ann Arbor Healthcare System; Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Roger von Moos
- Department of Oncology/Hematology, Kantonsspital Graubünden, Chur, Switzerland & SAKK Competence Center, Bern
| | - Mark J Ratain
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA
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4
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Araujo D, Greystoke A, Bates S, Bayle A, Calvo E, Castelo-Branco L, de Bono J, Drilon A, Garralda E, Ivy P, Kholmanskikh O, Melero I, Pentheroudakis G, Petrie J, Plummer R, Ponce S, Postel-Vinay S, Siu L, Spreafico A, Stathis A, Steeghs N, Yap C, Yap TA, Ratain M, Seymour L. Oncology phase I trial design and conduct: time for a change - MDICT Guidelines 2022. Ann Oncol 2023; 34:48-60. [PMID: 36182023 DOI: 10.1016/j.annonc.2022.09.158] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/18/2022] [Indexed: 02/03/2023] Open
Abstract
In 2021, the Food and Drug Administration Oncology Center of Excellence announced Project Optimus focusing on dose optimization for oncology drugs. The Methodology for the Development of Innovative Cancer Therapies (MDICT) Taskforce met to review and discuss the optimization of dosage for oncology trials and to develop a practical guide for oncology phase I trials. Defining a single recommended phase II dose based on toxicity may define doses that are neither the most effective nor the best tolerated. MDICT recommendations address the need for robust non-clinical data which are needed to inform trial design, as well as an expert team including statisticians and pharmacologists. The protocol must be flexible and adaptive, with clear definition of all endpoints. Health authorities should be consulted early and regularly. Strategies such as randomization, intrapatient dose escalation, and real-world eligibility criteria are encouraged whereas serial tumor sampling is discouraged in the absence of a strong rationale and appropriately validated assay. Endpoints should include consideration of all longitudinal toxicity. The phase I dose escalation trial should define the recommended dose range for later testing in randomized phase II trials, rather than a single recommended phase II dose, and consider scenarios where different populations may require different dosages. The adoption of these recommendations will improve dosage selection in early clinical trials of new anticancer treatments and ultimately, outcomes for patients.
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Affiliation(s)
- D Araujo
- Hospital de Base, Sao Jose do Rio Preto, Brazil
| | - A Greystoke
- Northern Centre for Cancer Care, Newcastle, UK
| | - S Bates
- Division of Hematology and Oncology, Department of Medicine, Columbia University, New York, USA
| | - A Bayle
- Institut Gustave Roussy, Paris, France
| | - E Calvo
- START Madrid-CIOCC, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - L Castelo-Branco
- European Society for Medical Oncology (ESMO), Lugano, Switzerland
| | - J de Bono
- Institute of Cancer Research, University of London, London; The Royal Marsden Hospital, London, UK
| | - A Drilon
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, USA
| | - E Garralda
- Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - P Ivy
- National Cancer Institute, USA Cancer Therapy Evaluation Program Investigational Drug Branch (NCI/CTEP/IDB), Bethesda, USA
| | - O Kholmanskikh
- European Medicines Agency, Amsterdam, Netherlands; Federal Agency for Medicines and Health Products, Brussels, Belgium
| | - I Melero
- CUN and CIMA, University of Navarra, Pamplona, Spain
| | - G Pentheroudakis
- European Society for Medical Oncology (ESMO), Lugano, Switzerland
| | - J Petrie
- Canadian Cancer Trials Group, Queen's University, Kingston
| | - R Plummer
- Northern Centre for Cancer Care, Newcastle, UK
| | - S Ponce
- Institut Gustave Roussy, Paris, France
| | | | - L Siu
- Princess Margaret Cancer Centre, Toronto, Canada
| | - A Spreafico
- Princess Margaret Cancer Centre, Toronto, Canada
| | - A Stathis
- Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
| | - N Steeghs
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - C Yap
- Institute of Cancer Research, University of London, London
| | - T A Yap
- Department of Investigational Cancer Therapeutics, University of Texas, MD Anderson Cancer Center, Houston
| | - M Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, USA
| | - L Seymour
- Canadian Cancer Trials Group, Queen's University, Kingston.
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5
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Cardiovascular Complications in Hematopoietic Stem Cell Transplanted Patients. J Pers Med 2022; 12:jpm12111797. [PMID: 36579521 PMCID: PMC9692512 DOI: 10.3390/jpm12111797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/16/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is the only curative treatment for many patients suffering from hematologic malignancies, solid tumors, inborn errors of metabolism or genetic disorders. Despite decades of successful HSCT, clinical outcomes are still far from satisfactory due to treatment-related complications, including graft-versus-host disease (GvHD) and cardiovascular complications (CVC). CVC may affect patients in the acute period post-HSCT; however, the occurrence is far higher among long-term survivors. Induction treatment using cardiotoxic treatments, e.g., anthracyclines and radiotherapy, conditioning regimens containing cyclophosphamide, and post-HSCT comorbidities, including GvHD, are factors contributing to CVC. Cardiac function evaluation prior to and post-transplantation is an important strategy for choosing the proper conditioning regimen, HSCT protocol and post-HSCT supportive care. Cardiac systolic function evaluation by echocardiography, in addition to serum cardiac biomarkers, such as troponins and brain natriuretic peptides, is recommended as a routine follow-up for HSCT patients. Angiotensin-converting enzyme inhibitors, angiotensin-II-receptor blockers, and beta-blockers, which are mostly used for the treatment of chemotherapy-induced cardiotoxicity, might be used as treatments for HSCT-related CVC. In summary, the present review reveals the urgent need for further investigations concerning HSCT-related CVC both at the preclinical and clinical levels due to the lack of knowledge about CVC and its underlying mechanisms.
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6
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The Dosing of Ibrutinib and Related Bruton's Tyrosine Kinase Inhibitors: Eliminating the Use of Brute Force. Blood Adv 2022; 6:5041-5044. [PMID: 35816636 PMCID: PMC9631621 DOI: 10.1182/bloodadvances.2022007793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/07/2022] [Indexed: 12/04/2022] Open
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7
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Schnog JJB, Samson MJ, Gans ROB, Duits AJ. An urgent call to raise the bar in oncology. Br J Cancer 2021; 125:1477-1485. [PMID: 34400802 PMCID: PMC8365561 DOI: 10.1038/s41416-021-01495-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 06/09/2021] [Accepted: 07/09/2021] [Indexed: 02/07/2023] Open
Abstract
Important breakthroughs in medical treatments have improved outcomes for patients suffering from several types of cancer. However, many oncological treatments approved by regulatory agencies are of low value and do not contribute significantly to cancer mortality reduction, but lead to unrealistic patient expectations and push even affluent societies to unsustainable health care costs. Several factors that contribute to approvals of low-value oncology treatments are addressed, including issues with clinical trials, bias in reporting, regulatory agency shortcomings and drug pricing. With the COVID-19 pandemic enforcing the elimination of low-value interventions in all fields of medicine, efforts should urgently be made by all involved in cancer care to select only high-value and sustainable interventions. Transformation of medical education, improvement in clinical trial design, quality, conduct and reporting, strict adherence to scientific norms by regulatory agencies and use of value-based scales can all contribute to raising the bar for oncology drug approvals and influence drug pricing and availability.
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Affiliation(s)
- John-John B. Schnog
- Department of Hematology-Medical Oncology, Curaçao Medical Center, Willemstad, Curaçao ,Curaçao Biomedical and Health Research Institute, Willemstad, Curaçao
| | - Michael J. Samson
- Department of Radiation Oncology, Curaçao Medical Center, Willemstad, Curaçao
| | - Rijk O. B. Gans
- grid.4494.d0000 0000 9558 4598Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ashley J. Duits
- Curaçao Biomedical and Health Research Institute, Willemstad, Curaçao ,grid.4494.d0000 0000 9558 4598Institute for Medical Education, University Medical Center Groningen, Groningen, The Netherlands ,Red Cross Blood Bank Foundation, Willemstad, Curaçao
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8
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Eisenmann ED, Fu Q, Muhowski EM, Jin Y, Uddin ME, Garrison DA, Weber RH, Woyach JA, Byrd JC, Sparreboom A, Baker SD. Intentional Modulation of Ibrutinib Pharmacokinetics through CYP3A Inhibition. CANCER RESEARCH COMMUNICATIONS 2021; 1:79-89. [PMID: 34950932 PMCID: PMC8691714 DOI: 10.1158/2767-9764.crc-21-0076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Ibrutinib (Imbruvica; PCI-32765) is an orally administered inhibitor of Bruton's tyrosine kinase that has transformed the treatment of B-cell malignancies. However, ibrutinib has very low oral bioavailability that contributes to significant variability in systemic exposure between patients, and this has the potential to affect both efficacy and toxicity. We hypothesized that the oral bioavailability of ibrutinib is limited by CYP3A isoform-mediated metabolism, and that this pathway can be inhibited to improve the pharmacokinetic properties of ibrutinib. Pharmacokinetic studies were performed in wild-type mice and mice genetically engineered to lack all CYP3A isoforms [CYP3A(-/-)] that received ibrutinib alone or in combination with CYP3A inhibitors cobicistat or ketoconazole. Computational modeling was performed to derive doses of ibrutinib that, when given after a CYP3A inhibitor, results in therapeutically-relevant drug levels. Deficiency of CYP3A in mice was associated with a ~10-fold increase in the area under the curve of ibrutinib. This result could be phenocopied by administration of cobicistat before ibrutinib in wild-type mice, but cobicistat did not influence levels of ibrutinib in CYP3A(-/-) mice. Population pharmacokinetic and prospectively validated physiologically-based pharmacokinetic models established preclinical and clinical doses of ibrutinib that could be given safely in combination with cobicistat without negatively affecting anti-leukemic properties. These findings signify a dominant role for CYP3A-mediated metabolism in the elimination of ibrutinib, and suggest a role for pharmacological inhibitors of this pathway to intentionally modulate the plasma levels and improve the therapeutic use of this clinically important agent.
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Affiliation(s)
- Eric D. Eisenmann
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Qiang Fu
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Elizabeth M. Muhowski
- Division of Hematology, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Yan Jin
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Muhammad Erfan Uddin
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Dominique A. Garrison
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Robert H. Weber
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Jennifer A. Woyach
- Division of Hematology, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
| | - John C. Byrd
- Division of Hematology, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Alex Sparreboom
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Sharyn D. Baker
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio.,Corresponding Author: Sharyn D. Baker, Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, 500 W. 12th Avenue, Columbus, OH 43210. E-mail:
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9
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Ratain MJ. Designing Dose-Finding Phase I Clinical Trials: Top Questions That Should Be Discussed With Your Clinical Pharmacologist. JCO Precis Oncol 2021; 5:935-936. [DOI: 10.1200/po.21.00065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Mark J. Ratain
- Mark J. Ratain, MD, The University of Chicago, Chicago, IL
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10
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Ratain MJ, Tannock IF, Lichter AS. Dose Optimization of Sotorasib: Is the US Food and Drug Administration Sending a Message? J Clin Oncol 2021; 39:3423-3426. [PMID: 34543056 DOI: 10.1200/jco.21.01371] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL.,Optimal Cancer Care Alliance, Ann Arbor, MI
| | - Ian F Tannock
- Optimal Cancer Care Alliance, Ann Arbor, MI.,Division of Medical Oncology, Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada
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11
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Zimmerman SM, Peer CJ, Figg WD. Ibrutinib's off-target mechanism: cause for dose optimization. Cancer Biol Ther 2021; 22:529-531. [PMID: 34632931 DOI: 10.1080/15384047.2021.1980313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Ibrutinib (Imbruvica®, 2013) is a Bruton's tyrosine kinase (BTK) inhibitor approved for multiple B-cell malignancies and cGVHD. Its treatment is associated with increased risk of cardiac adverse events. Atrial fibrillation is a common cause of therapy discontinuation and interruptions, which have been correlated with shorter progression-free survival in chronic lymphocyte leukemia (CLL) patients. Recently, Xiao et al. identified that ibrutinib-mediated atrial fibrillation is likely due to off-target CSK inhibition. Given promising in vitro and in vivo evidence of maintained biological activity in CLL at lower-than-labeled ibrutinib doses, this elucidated mechanism substantiates the case to investigate alternative dosing schedules. The potential to minimize ibrutinib's off-target effects while conserving response warrants further discussion and investigation of optimal ibrutinib dosing.
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Affiliation(s)
- Sara M Zimmerman
- Clinical Pharmacology Program, Office of the Clinical Director, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Cody J Peer
- Clinical Pharmacology Program, Office of the Clinical Director, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - William D Figg
- Clinical Pharmacology Program, Office of the Clinical Director, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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12
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Cardiac complications associated with hematopoietic stem-cell transplantation. Bone Marrow Transplant 2021; 56:2637-2643. [PMID: 34381168 DOI: 10.1038/s41409-021-01427-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/21/2021] [Accepted: 07/27/2021] [Indexed: 12/11/2022]
Abstract
Advances in chemotherapy and supportive therapy have resulted in improved clinical outcomes in patients with hematological malignancies undergoing hematopoietic stem-cell transplantation (HSCT). However, the association between HSCT and early- and late-onset cardiotoxicity remains controversial as these cardiac complications, including acute heart failure and arrhythmia, such as atrial fibrillation, can occasionally be lethal. Although the overall pathophysiology has not been elucidated, initial/salvage chemotherapy before HSCT, such as anthracycline-combined regimens, conditioning regimens, thoracic radiotherapy, and pre-existing personal risk factors, could be associated with an increased risk of cardiac events. Routine monitoring of cardiac function using global longitudinal strain or left ventricular ejection fraction in echocardiogram and serum biomarkers could be an option to detect early changes in cardiac status before irreversible cardiac complications develop. While beta-blockers and angiotensin-converting enzyme inhibitors are commonly used for cardioprotection, their clinical benefit has not been fully established in HSCT-associated cardiotoxicity. In the future, genetic analysis to reveal individual vulnerability to cardiotoxicity and prospective trials assessing the clinical benefit of early interventions, including novel agents such as angiotensin receptor-neprilysin inhibitor, are warranted. Collaboration between oncologists and cardiologists is crucial to establishing a strategy to prevent cardiac complications.
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13
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Feldman RC, Hyman DA, Price WN, Ratain MJ. Negative innovation: when patents are bad for patients. Nat Biotechnol 2021; 39:914-916. [PMID: 34376839 DOI: 10.1038/s41587-021-00999-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Robin C Feldman
- University of California Hastings College of the Law, San Francisco, CA, USA.
| | - David A Hyman
- Georgetown University Law Center, Washington, DC, USA
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14
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15
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Fleming MR, Xiao L, Jackson KD, Beckman JA, Barac A, Moslehi JJ. Vascular Impact of Cancer Therapies: The Case of BTK (Bruton Tyrosine Kinase) Inhibitors. Circ Res 2021; 128:1973-1987. [PMID: 34110908 PMCID: PMC10185355 DOI: 10.1161/circresaha.121.318259] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Novel targeted cancer therapies have revolutionized oncology therapies, but these treatments can have cardiovascular complications, which include heterogeneous cardiac, metabolic, and vascular sequelae. Vascular side effects have emerged as important considerations in both cancer patients undergoing active treatment and cancer survivors. Here, we provide an overview of vascular effects of cancer therapies, focusing on small-molecule kinase inhibitors and specifically inhibitors of BTK (Bruton tyrosine kinase), which have revolutionized treatment and prognosis for B-cell malignancies. Cardiovascular side effects of BTK inhibitors include atrial fibrillation, increased risk of bleeding, and hypertension, with the former 2 especially providing a treatment challenge for the clinician. Cardiovascular complications of small-molecule kinase inhibitors can occur through either on-target (targeting intended target kinase) or off-target kinase inhibition. We will review these concepts and focus on the case of BTK inhibitors, highlight the emerging data suggesting an off-target effect that may provide insights into development of arrhythmias, specifically atrial fibrillation. We believe that cardiac and vascular sequelae of novel targeted cancer therapies can provide insights into human cardiovascular biology.
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Affiliation(s)
- Matthew R Fleming
- Division of Cardiovascular Medicine (M.R.F., J.A.B., J.J.M.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ling Xiao
- Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School, Boston (L.X.)
| | - Klarissa D Jackson
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill (K.D.J.)
| | - Joshua A Beckman
- Division of Cardiovascular Medicine (M.R.F., J.A.B., J.J.M.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ana Barac
- Georgetown University and MedStar Heart and Vascular Institute, MedStar Washing Hospital Center, DC (A.B.)
| | - Javid J Moslehi
- Division of Cardiovascular Medicine (M.R.F., J.A.B., J.J.M.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.,Cardio-Oncology Program (J.J.M.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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16
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Groenland SL, Ratain MJ, Chen LS, Gandhi V. The Right Dose: From Phase I to Clinical Practice. Am Soc Clin Oncol Educ Book 2021; 41:92-106. [PMID: 34010057 DOI: 10.1200/edbk_319567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To realize the full potential of promising new anticancer drugs, it is of paramount importance to administer them at the right dose. The aim of this educational article is to provide several opportunities to optimize anticancer drug dosing, focusing on oral targeted therapies. First, therapeutic drug monitoring can optimize exposure in individual patients, if the optimal concentration is known. This approach is of particular interest in regard to oral kinase inhibitors with high interindividual pharmacokinetic variability. If exposure is related to response, then therapeutic drug monitoring is potentially feasible, although the clinical utility of this approach has not yet been established. Other approaches to reduce variability include administration of more frequent, smaller doses and administration under optimal prandial conditions. However, for many drugs, the labeled dose has not been demonstrated to be the optimal dose; for such agents, the vast majority of patients may be receiving excessive doses, which results in excessive toxicity. Furthermore, administration of lower off-label doses may reduce both medical and financial toxicity. These strategies should be applied from registration studies to clinical practice, with the goal of better optimizing anticancer treatment.
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Affiliation(s)
- Stefanie L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, the Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL
| | - Lisa S Chen
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Varsha Gandhi
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX.,Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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