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Tang Y, Rao P, Li S, Yu W, Wang R, Liu J. Individualized medication of venetoclax based on therapeutic drug monitoring in Chinese acute myeloid leukemia patients using an HPLC method. Anticancer Drugs 2024; 35:852-858. [PMID: 38995659 DOI: 10.1097/cad.0000000000001632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
OBJECTIVE The aim of this study was to establish a simple and sensitive high-performance liquid chromatography method for therapeutic drug monitoring of venetoclax (VEN) and optimize regimens. METHODS The analysis required the extraction of a 50 μl plasma sample and the precipitation of proteins using acetonitrile extraction. The chromatographic method employed a mobile phase of acetonitrile: 0.5% KH 2 PO 4 (pH 3.5) (60/40, v/v) on a Diamond C 18 (4.6 mm × 250 mm, 5 μm) column at a flow rate of 1.0 ml/min. The quantitative method was validated based on standards described in 'Bioanalytical Method Validation: Guidance for Industry' published by the US Food and Drug Administration (FDA). RESULTS The calibration curve was linear ( R2 = 0.9998) over the range of 75-4800 ng/ml, with limits of quantification of 25 ng/ml. The coefficients of intraday and interday validation, specificity, recovery, and stability all met the criteria of FDA guidance. The method was successfully applied to analyze VEN concentrations in 30 cases of acute myeloid leukemia patients. The peak concentration ( Cmax ) was 1881.19 ± 756.61 ng/ml, while the trough concentration ( Cmin ) was 1212.69 ± 767.92 ng/ml in acute myeloid leukemia patients. CONCLUSION Our study establishes a simple, precise, and sensitive high-performance liquid chromatography method for monitoring VEN and confirms its applicability for therapeutic drug monitoring of VEN in hematological cancers.
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Affiliation(s)
- Yue Tang
- School of Pharmacy, Anhui Medical University
- Department of Pharmacy, the First Affiliated Hospital of Anhui Medical University
| | - Peng Rao
- School of Pharmacy, Anhui Medical University
- Department of Pharmacy, the First Affiliated Hospital of Anhui Medical University
| | - Shuojiao Li
- Department of Pharmacy, Anhui University of Chinese Medicine, Hefei, Anhui Province, China
| | - Wenxian Yu
- School of Pharmacy, Anhui Medical University
- Department of Pharmacy, the First Affiliated Hospital of Anhui Medical University
| | - Ranran Wang
- School of Pharmacy, Anhui Medical University
- Department of Pharmacy, the First Affiliated Hospital of Anhui Medical University
| | - Jiatao Liu
- Department of Pharmacy, the First Affiliated Hospital of Anhui Medical University
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Ngo HX, Oh E, Li C, Yu J. Oncology Dose Selection in Subsequent Indications: What Can We Learn From FDA-approved Oncology Drugs? Clin Ther 2024:S0149-2918(24)00259-5. [PMID: 39304367 DOI: 10.1016/j.clinthera.2024.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 08/08/2024] [Accepted: 08/22/2024] [Indexed: 09/22/2024]
Abstract
PURPOSE The modern oncology drug development landscape has shifted away from traditional cytotoxic chemotherapies. Following their initial approvals, many oncology drugs have been approved in subsequent indications either as monotherapy or in combination to benefit a broader patient population. To date, dose selection strategies for subsequent indications have not been systematically reviewed. This review examines how approved dosing regimens were selected in subsequent indications for FDA-approved oncology drugs. METHODS The Drugs@FDA database was used to identify FDA-approved new molecular entities (NMEs) between 2010 and 2023. NMEs with more than 1 approved indication were included in the analysis. In total, the dosing regimens for 67 novel oncology drugs that obtained FDA approvals for multiple indications were evaluated. FINDINGS Overall, in subsequent indications, 72% of NMEs used the same or clinically equivalent alternative dosing regimens to those approved in the initial indications. Amongst the 28% of NMEs that used different dosing regimens, safety/tolerability was the leading cause of a dosing regimen changes in both monotherapy and combination therapy settings. Other factors leading to changes in dosing regimens include differences in tumor biology, disease burden, pharmacokinetics, and overall benefit-risk profiles obtained from dose-finding studies. IMPLICATIONS Our analysis highlighted the importance of selecting a safe, tolerable, and yet efficacious dosing regimen for the initial indication as a suboptimal initially approved regimen could lead to dosing regimen changes in later indications. Preclinical and clinical data could be leveraged to understand the pharmacology, pharmacokinetic, and pharmacodynamic differences between indications and thus support dose selection in subsequent indications.
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Affiliation(s)
- Huy X Ngo
- Department of Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA
| | - Elise Oh
- Department of Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA
| | - Chunze Li
- Department of Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA
| | - Jiajie Yu
- Department of Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA.
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3
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Kobayashi T, Sato H, Miura M, Fukushi Y, Kuroki W, Ito F, Teshima K, Watanabe A, Fujishima N, Kobayashi I, Kameoka Y, Takahashi N. Overexposure to venetoclax is associated with prolonged-duration of neutropenia during venetoclax and azacitidine therapy in Japanese patients with acute myeloid leukemia. Cancer Chemother Pharmacol 2024; 94:285-296. [PMID: 38782790 DOI: 10.1007/s00280-024-04673-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/01/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE An observational study was conducted to evaluate the pharmacokinetics of venetoclax and its impact on the efficacy and safety for Japanese patients with acute myeloid leukemia (AML) treated with venetoclax and azacitidine therapy. METHODS The association between the plasma concentration, after the first cycle of azacitidine and venetoclax therapy, and the efficacy and safety was evaluated in 33 patients with untreated or relapsed/refractory AML. RESULTS Full dose of venetoclax was administered to all patients. Venetoclax treatment was 28 day long in 82% of patients; the relative dose intensity of azacitidine was 82%. Trough concentration was significantly higher among patients with complete remission (CR) and CR with incomplete hematologic recovery (CRi) than those with the morphologic leukemia-free state and partial remission, and no response groups (P = 0.01). Median duration of grade 3 neutropenia was 28 days (range 8-46 days). Area under the concentration-time curve (AUC0-24) was significantly higher among patients with protracted grade 3 neutropenia (≥ 28 days) than those with a shorter duration (< 28 days) (P = 0.03); multivariate analysis revealed that a higher AUC0-24 was a significant predictor of a longer duration of neutropenia (odds ratio 54.3, P = 0.007). CONCLUSION Plasma concentrations of venetoclax were variable in Japanese patients with AML. Higher plasma concentrations were associated with CR/CRi and protracted grade 3 neutropenia. Therefore, it is essential to adjust the duration of venetoclax administration based on individual pharmacokinetic data to limit total drug exposure, reduce severe neutropenia, and achieve higher efficacy.
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Affiliation(s)
- Takahiro Kobayashi
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita City, Akita, Japan.
| | - Honami Sato
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita City, Akita, Japan
| | - Masatomo Miura
- Department of Pharmacokinetics, Akita University Graduate School of Medicine, Akita, Japan
| | - Yayoi Fukushi
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Wataru Kuroki
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita City, Akita, Japan
- Department of Internal Medicine, Yuri Kumiai General Hospital, Yurihonjo, Japan
| | - Fumiko Ito
- Department of Hematology, Akita City Hospital, Akita, Japan
| | - Kazuaki Teshima
- Department of Hematology, Hiraka General Hospital, Yokote, Japan
| | - Atsushi Watanabe
- Department of Hematology, Nephrology and Rheumatology, Omagari Kousei Medical Center, Daisen, Japan
| | - Naohito Fujishima
- Department of Hematology, Nephrology and Rheumatology, Noshiro Kousei Medical Center, Noshiro, Japan
| | - Isuzu Kobayashi
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita City, Akita, Japan
| | - Yoshihiro Kameoka
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita City, Akita, Japan
| | - Naoto Takahashi
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita City, Akita, Japan
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4
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Alaei S, Wang Y, Liu Y, Schiele J, Deng R, Shiller D, Marroum P, Menon R, Salem AH. Venetoclax Clinical Pharmacokinetics After Administration of Crushed, Ground or Whole Tablets. Clin Ther 2024:S0149-2918(24)00080-8. [PMID: 38782609 DOI: 10.1016/j.clinthera.2024.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/29/2024] [Accepted: 03/30/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE Venetoclax is a potent, orally bioavailable BCL-2 inhibitor used in the treatment of some hematological malignancies. Crushing tablets may be necessary to help with the administration of venetoclax to patients with swallowing difficulties or patients requiring nasogastric tube feeding. The study was conducted to assess the bioavailability of crushed and finely ground venetoclax tablets relative to whole tablets. METHODS An open-label, randomized, 3-way, crossover study in 15 healthy adult females was conducted. Venetoclax tablets were administered orally in a crushed, ground or intact form on Day 1 of each period with water following a high-fat breakfast. Pharmacokinetic samples were collected up to 72 hours postdosing. FINDINGS The crushed and ground tablets met the bioequivalence criteria (0.80-1.25) relative to the intact tablets with respect to area under the concentration-time curve to time of the last measurable concentration (AUCt) and to infinite time (AUCinf) but exhibited a slightly lower maximum plasma concentration (Cmax). This was not considered clinically significant as only venetoclax overall exposure (AUC) has been shown to correlate with clinical efficacy. There was no change in the physical appearance and the evaluated physicochemical properties of crushed and ground venetoclax tablets after 72 hours of storage at 25°C/60% relative humidity. IMPLICATIONS Crushing or grinding venetoclax tablets before administration could be considered as a viable alternative method of administration for patients who have difficulty swallowing whole venetoclax tablets or patients requiring nasogastric tube feeding. CLINICALTRIALS GOV IDENTIFIERS NCT05909553, registered June 12, 2023.
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Affiliation(s)
| | | | | | | | - Rong Deng
- Genentech Inc., South San Francisco, California
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Salem AH, Menon RM. Clinical pharmacokinetics and pharmacodynamics of venetoclax, a selective B-cell lymphoma-2 inhibitor. Clin Transl Sci 2024; 17:e13807. [PMID: 38778732 PMCID: PMC11112299 DOI: 10.1111/cts.13807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/29/2024] [Accepted: 03/22/2024] [Indexed: 05/25/2024] Open
Abstract
Venetoclax, a highly potent BCL-2 inhibitor, is indicated for treatment of some hematologic malignancies as monotherapy, and/or in combination with other agents. Venetoclax pharmacokinetics has been extensively characterized in patients and healthy participants. After oral dosing, the median time to reach maximum plasma concentration ranged from 5 to 8 h and harmonic mean half-life ranged from 14 to 18 h. Food increases venetoclax bioavailability by 3-5-fold and venetoclax should be administered with food to ensure adequate and consistent bioavailability. Venetoclax is eliminated via cytochrome P450 (CYP)3A metabolism, and a negligible amount of unchanged drug is excreted in urine. Strong CYP3A/P-glycoprotein inhibitors increased venetoclax exposures (AUC) by 1.44- to 6.90-fold while a significant decrease (71%) has been observed when dosed with strong CYP3 inducers. Venetoclax does not inhibit or induce CYP enzymes or transporters. Venetoclax pharmacokinetics is not appreciably altered by age, weight, sex, but the exposure is up to twofold higher in participants from Asian countries. Mild-to-severe renal impairment or end-stage renal disease do not alter venetoclax exposures, and venetoclax is not cleared by dialysis. Although mild-to-moderate hepatic impairment does not affect venetoclax exposures, twofold higher exposure was observed in subjects with severe hepatic impairment. Venetoclax exposure is comparable across patients with different hematologic malignancies and healthy participants. Overall, venetoclax exposure is only affected by food and CYP3A modulators and is only higher in Asian subjects and subjects with severe hepatic impairment. Venetoclax exposure-response relationships are malignancy-dependent and can be different between monotherapy and combination therapy.
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Affiliation(s)
- Ahmed Hamed Salem
- Faculty of PharmacyAin Shams UniversityCairoEgypt
- AbbVie Inc.North ChicagoIllinoisUSA
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Noorani B, Menon RM, Chen X, Marsh KC, Huang W, Gupta S, Dobkowska E, Marbury T, Salem AH. Venetoclax pharmacokinetics in participants with end-stage renal disease undergoing haemodialysis. Br J Clin Pharmacol 2024; 90:748-758. [PMID: 37855131 DOI: 10.1111/bcp.15935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/06/2023] [Accepted: 10/11/2023] [Indexed: 10/20/2023] Open
Abstract
AIMS Renal insufficiency is a common comorbidity in patients with haematological malignancies. This study aimed to assess how end-stage renal disease (ESRD) might affect the pharmacokinetics of venetoclax, a Bcl-2 inhibitor, in participants with ESRD undergoing haemodialysis. METHODS Venetoclax was administered as a single 100-mg dose to 6 female participants with ESRD (estimated glomerular filtration rate <15 mL/min) both prior to haemodialysis and between haemodialysis days and 7 healthy female participants with normal renal function (estimated glomerular filtration rate >90 mL/min). Intensive pharmacokinetic and protein binding samples were collected from all participants. Arterial and venous samples were collected from ESRD participants during haemodialysis to assess the effect of haemodialysis on venetoclax pharmacokinetics. Pharmacokinetic parameters were estimated using noncompartmental methods. RESULTS There was no difference in plasma venetoclax concentrations between arterial and venous samples, suggesting that haemodialysis did not affect the pharmacokinetics of venetoclax. The fraction unbound (fu ) of venetoclax was ~2-fold higher for participants with ESRD compared to participants with normal renal function. The unbound maximum plasma concentration and area under the plasma concentration-time curve from time 0 to 48 h were comparable between ESRD and normal function groups. The mean half-life ranged from 10.4 to 12.2 h across groups, demonstrating that ESRD did not affect the half-life of venetoclax. No new safety signals were observed during this study. CONCLUSION ESRD and dialysis do not alter unbound venetoclax plasma concentrations. No pharmacokinetics driven dose adjustment is needed for patients with renal insufficiency.
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Affiliation(s)
| | | | - Xin Chen
- AbbVie, Inc., North Chicago, Illinois, USA
| | | | - Weize Huang
- Genentech Inc., South San Francisco, California, USA
| | | | - Edyta Dobkowska
- Pharmacyclics, an AbbVie company in Switzerland, Schaffhausen, Switzerland
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7
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Philippe M, Guitton J, Goutelle S, Thoma Y, Favier B, Chtiba N, Michallet M, Belhabri A. Pharmacokinetic Consideration of Venetoclax in Acute Myeloid Leukemia Patients: A Potential Candidate for TDM? A Short Communication. Ther Drug Monit 2024; 46:127-131. [PMID: 37941111 DOI: 10.1097/ftd.0000000000001151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/05/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Venetoclax (VNX)-based regimens have demonstrated significantly favorable outcomes in patients with acute myeloid leukemia (AML) and are now becoming the standard treatment. Tyrosine kinase inhibitors are administered at a fixed dose, irrespective of body surface area or weight. For such orally targeted therapies, real-world data have highlighted a larger pharmacokinetic (PK) interindividual variability (IIV) than expected. Even if VNX PKs have been well characterized and described in the literature, only 1 clinical trial-based PK study has been conducted in patients with AML. This study aimed to evaluate the PK of VNX in AML patients. MATERIAL AND METHODS We retrospectively analyzed all patients treated with a combination of VNX-azacitidine between January and July 2022 at our center, using at least 1 available VNX blood sample. Based on a previously published population PK model, individual PK parameters were estimated to evaluate the exposure and IIV. RESULTS and Discussion. Twenty patients received VNX in combination with azacitidine, according to the PK data. A total of 93 plasma concentrations were collected. The dose of VNX was 400 mg, except in 7 patients who received concomitant posaconazole (VNX 70 mg). The patients' weight ranged from 49 kg to 108 kg (mean = 78 kg). Mean individual clearance was 13.5 ± 9.4 L/h with mean individual daily area under the concentration-time curves of 35.8 mg.h/L with significant IIV (coefficient of variation = 41.1%). Ten patients were still alive (8 in complete response), but all experienced at least 1 hematological toxicity of grade ≥ 3. CONCLUSIONS Based on the observed large PK variability in the data from our real-world AML patients, the risk of drug interactions and the recommended fixed-dosage regimen of VNX therapeutic drug monitoring may be useful.
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Affiliation(s)
| | - Jérôme Guitton
- Biochemistry and Pharmacology-Toxicology Laboratory, Lyon Sud Hospital, Pierre Benite, France
- ISPB, Faculté de Pharmacie de Lyon, Université Lyon 1, Lyon, France
| | - Sylvain Goutelle
- ISPB, Faculté de Pharmacie de Lyon, Université Lyon 1, Lyon, France
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France
- UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Université Lyon 1, Villeurbanne, France
| | - Yann Thoma
- School of Engineering and Management Vaud (HEIG-VD), HES-SO University of Applied Sciences and Arts Western Switzerland, Yverdon-les-Bains, Switzerland
| | | | - Nour Chtiba
- Faculty of Pharmacy of Monastir, University of Monastir, Monastir, Tunisia; and
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Zhao Y, Jiang S, Tang Y, Zhao L. Venetoclax with CAG regimen for early T-cell precursor acute lymphoblastic leukemia: a case report and literature review. Int J Hematol 2023; 118:483-488. [PMID: 37269505 DOI: 10.1007/s12185-023-03623-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/23/2023] [Accepted: 05/26/2023] [Indexed: 06/05/2023]
Abstract
This article describes a potential treatment for early T-cell precursor acute lymphoblastic leukemia (ETP-ALL), a relatively rare and highly aggressive hematologic malignancy. A 59-year-old woman admitted to our hospital with enlarged cervical lymph nodes, weight loss, abnormal count, and morphology of peripheral blood cells was diagnosed with ETP-ALL according to morphology, immunology, cytogenetics, and molecular biology. The patient initially received two cycles of the VICP regimen, including vincristine, idarubicin, cyclophosphamide, and prednisone, and had a response with positive minimal residual disease (MRD). The patient was then given venetoclax plus the CAG regimen, including aclarubicin, cytosine arabinoside, and granulocyte colony-stimulating factor. After one cycle, the patient achieved complete remission with negative MRD and was eligible for allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
- Yihan Zhao
- School of the First Clinical Medical, Henan University of Chinese Medicine, Longzihu University Park, Zhengdong New District, 156 Jinshui East Road, Zhengzhou, Henan, China
- Department of Hematology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, 528 Zhangheng Road, Shanghai, 200120, China
| | - Shiqing Jiang
- Department of Oncology, The First Affiliated Hospital of Henan University of Chinese Medicine, 19 Renmin Road, Zhengzhou, Henan, China
| | - Yujun Tang
- School of the First Clinical Medical, Henan University of Chinese Medicine, Longzihu University Park, Zhengdong New District, 156 Jinshui East Road, Zhengzhou, Henan, China
| | - Lin Zhao
- Department of Hematology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, 528 Zhangheng Road, Shanghai, 200120, China.
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Guarana M, Nucci M. Should patients with acute myeloid leukemia treated with venetoclax-based regimens receive antifungal prophylaxis? Leuk Res 2023; 131:107341. [PMID: 37327641 DOI: 10.1016/j.leukres.2023.107341] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 06/18/2023]
Abstract
Invasive fungal disease (IFD) is a major complication in patients with acute myeloid leukemia (AML) receiving intensive induction chemotherapy, and the use of anti-mold prophylaxis is considered standard of care. On the other hand, the use of anti-mold prophylaxis in AML patients receiving less-intensive venetoclax-based regimens is not well established, basically because the incidence of IFD may not be high enough to justify primary antifungal prophylaxis. Furthermore, dose adjustments in venetoclax are needed because of drug interactions with azoles. Finally, the use of azoles is associated with toxicity, including liver, gastrointestinal and cardiac (QT prolongation) toxicity. In a setting of low incidence of invasive fungal disease, the number needed to harm would be higher than the number needed to treat. In this paper we review the risk factors for IFD in AML patients receiving intensive chemotherapeutic regimens, the incidence and risk factors for IFD in patients receiving hypomethylating agents alone, and in patients receiving less-intensive venetoclax-based regimens. We also discuss potential problems with the concomitant use of azoles, and present our perspective on how to manage AML patients receiving venetoclax-based regimens without primary antifungal prophylaxis.
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Affiliation(s)
- Mariana Guarana
- University Hospital, Universidade Federal do Rio de Janeiro, Brazil
| | - Marcio Nucci
- University Hospital, Universidade Federal do Rio de Janeiro, Brazil; Grupo Oncoclínicas, Brazil.
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Laloi L, Billotey NC, Dumas P, Paul F, Villate A, Simand C, Fornecker L, Puisset F, Bertoli S, Simonet MB, Laribi K, Houyou D, Santagostino A, Michel C, Guepin GR, Guerineau E, Tabrizi R, Hunault M, Giltat A, Kaphan E, Bulabois C, Cartet E, Rocher C, Lachenal F, Morisset S, Récher C, Pigneux A, Belhabri A, Michallet M, Michallet A. Retrospective, real‐life study of venetoclax plus azacitidine or low‐dose cytarabine in French patients with acute myeloid leukemia ineligible for intensive chemotherapy. Cancer Med 2022; 12:7175-7181. [PMID: 36482507 PMCID: PMC10067034 DOI: 10.1002/cam4.5459] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/08/2022] [Accepted: 11/11/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Recently, the combination of venetoclax plus a hypomethylating agent (HMA; azacitidine ordecitabine) or low-dose cytarabine (LDAC) showed promise in Phase III trials in previously untreated AML. In France at the time of this study, venetoclax was not yet approved for AML and there were therefore no formal usage recommendations. Here we report the first study in a French cohort that assessed venetoclax in combination with existing treatments for AML under real-life conditions. METHOD This retrospective, real-life study collected data on venetoclax use and management in a French cohort with acute myeloid leukemia (AML) ineligible for intensive chemotherapy. RESULT Of 118 patients, 81 were in second line/beyond (71.6% also hypomethylating agent [HMA]; 23.5% lowdose cytarabine [LDAC]) and 37 in first line. For venetoclax initiation, 57.3% underwent ramp up and 74.6% were hospitalized. Median venetoclax duration was 2.5 months (range 0.03-16.2). With all treatment lines and regimens, most common grade 3/4 adverse events were hematologic (overall 96.4% of patients) and infections (57.1%). Dosage adjustments for drug interactions and safety varied between centers. In second-line/beyond, median progression-free survival was 4.0 months (95% confidence interval [CI] 2.7-12.8) with venetoclax-HMA and 3.4 months (1.3-8.9) with venetoclax-LDAC; overall response rate was 51.9% and 41.2%, respectively. Thus, we showed that venetoclax-based treatment yields promising findings in patients with AML, but to address treatment complexity, practice harmonization is needed.
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Affiliation(s)
- Louise Laloi
- Department of Pharmacy Centre Léon Bérard Lyon France
| | | | - Pierre‐Yves Dumas
- Department of Hematology University Hospital of Bordeaux Bordeaux France
| | - Franciane Paul
- Department of Hematology University Hospital of Montpellier Montpellier France
| | - Alban Villate
- Department of Hematology University Hospital of Tours Tours France
| | - Célestine Simand
- Department of Hematology University Hospital of Strasbourg Strasbourg France
| | - Luc Fornecker
- Department of Hematology University Hospital of Strasbourg Strasbourg France
| | - Florent Puisset
- Department of Pharmacy Institut Universitaire du Cancer Oncopole Toulouse France
| | - Sarah Bertoli
- Department of Hematology Institut Universitaire du Cancer Oncopole Toulouse France
| | | | - Kamel Laribi
- Department of Hematology Hospital of Le Mans Le Mans France
| | - Dyhia Houyou
- Department of Clinical Research Hospital of Troyes Troyes France
| | | | - Claire Michel
- Department of Hematology University Hospital of Nancy Nancy France
| | | | - Elodie Guerineau
- Department of Clinical Research Hospital of Mont de Marsan Mont de Marsan France
| | - Reza Tabrizi
- Department of Hematology Hospital of Mont de Marsan Mont de Marsan France
| | - Mathilde Hunault
- Department of Hematology University Hospital of Angers Angers France
| | - Aurélien Giltat
- Department of Hematology University Hospital of Angers Angers France
| | - Eléonore Kaphan
- Department of Hematology University Hospital of Grenoble Grenoble France
| | - Claude Bulabois
- Department of Hematology University Hospital of Grenoble Grenoble France
| | - Elodie Cartet
- Department of Pharmacy Hospital of Bourgoin‐Jallieu Bourgoin‐Jallieu France
| | - Clément Rocher
- Department of Hematology Hospital of Bourgoin‐Jallieu Bourgoin‐Jallieu France
| | - Florence Lachenal
- Department of Hematology Hospital of Bourgoin‐Jallieu Bourgoin‐Jallieu France
| | | | - Christian Récher
- Department of Hematology Institut Universitaire du Cancer Oncopole Toulouse France
| | - Arnaud Pigneux
- Department of Hematology University Hospital of Bordeaux Bordeaux France
| | - Amine Belhabri
- Department of Hematology and Medical Oncology Centre Léon Bérard Lyon France
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Badawi M, Chen X, Marroum P, Suleiman AA, Mensing S, Koenigsdorfer A, Schiele JT, Palenski T, Samineni D, Hoffman D, Menon R, Salem AH. Bioavailability Evaluation of Venetoclax Lower-Strength Tablets and Oral Powder Formulations to Establish Interchangeability with the 100 mg Tablet. Clin Drug Investig 2022; 42:657-668. [PMID: 35829925 PMCID: PMC9338003 DOI: 10.1007/s40261-022-01172-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE Venetoclax is an approved BCL-2 inhibitor, currently under evaluation in different hematological malignancies in adult and pediatric populations. Venetoclax is available as 10, 50, and 100 mg tablets. To provide an alternative to patients who find taking the commonly prescribed 100 mg tablet a challenge, the interchangeability of lower-strength tablets with the 100 mg tablet was investigated. Additionally, newly developed oral suspension powder formulations to facilitate dosing in pediatrics were evaluated. METHODS Pharmacokinetic data from 80 healthy female participants from three phase I studies were utilized to evaluate the bioavailability of (1) 10 and 50 mg tablets relative to a 100 mg tablet; (2) 0.72 and 7.2% (drug to total weight) oral powder formulations relative to the 100 mg tablet; and (3) oral powder formulations administered using different vehicles (apple juice, apple sauce, and yogurt) relative to water under fed conditions. RESULTS Bioavailability assessments at a 100 mg dose of venetoclax demonstrated bioequivalence across the 10, 50, and 100 mg tablet strengths. Oral powder formulations met the bioequivalence criteria (0.80-1.25) with respect to area under the concentration-time curve to time of the last measurable concentration (AUCt) and to infinite time (AUC∞) but exhibited a slightly lower maximum plasma concentration (Cmax). Exposure-response analyses were utilized to demonstrate that the lower Cmax observed with the powder formulations is not clinically meaningful. The delivery vehicles tested did not affect the bioavailability of venetoclax oral powder formulations. CONCLUSIONS The smaller-sized tablets (10 and 50 mg) and the newly developed oral powder formulations of venetoclax can be used interchangeably with the 100 mg tablets to improve the patients' experience, while maintaining adequate exposure. CLINICAL TRIALS IDENTIFIERS: NCT01682616, 11 September 2012; NCT02005471, 9 December 2013; NCT02242942, 17 September 2014; NCT02203773, 30 July 2014; NCT02287233, 10 November 2014; NCT02993523, 15 December 2016; NCT03069352, 3 March 2017.
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Affiliation(s)
- Mohamed Badawi
- Clinical Pharmacology and Pharmacometrics (R4PK/AP31), AbbVie Inc, 1 North Waukegan Road, North Chicago, IL, 60064-1802, USA
| | - Xin Chen
- Data and Statistical Sciences, AbbVie Inc, North Chicago, IL, USA
| | - Patrick Marroum
- Clinical Pharmacology and Pharmacometrics (R4PK/AP31), AbbVie Inc, 1 North Waukegan Road, North Chicago, IL, 60064-1802, USA
| | - Ahmed A Suleiman
- Clinical Pharmacology and Pharmacometrics, AbbVie Deutschland GmbH & Co. KG, Ludwigshafen am Rhein, Germany
| | - Sven Mensing
- Clinical Pharmacology and Pharmacometrics, AbbVie Deutschland GmbH & Co. KG, Ludwigshafen am Rhein, Germany
| | - Anette Koenigsdorfer
- Drug Product Development, AbbVie Deutschland GmbH & Co. KG, Ludwigshafen am Rhein, Germany
| | - Julia Teresa Schiele
- Drug Product Development, AbbVie Deutschland GmbH & Co. KG, Ludwigshafen am Rhein, Germany
| | - Tammy Palenski
- Clinical Development, AbbVie Inc, North Chicago, IL, USA
| | - Divya Samineni
- Clinical Pharmacology, Genentech, Inc, South San Francisco, CA, USA
| | - David Hoffman
- Data and Statistical Sciences, AbbVie Inc, North Chicago, IL, USA
| | - Rajeev Menon
- Clinical Pharmacology and Pharmacometrics (R4PK/AP31), AbbVie Inc, 1 North Waukegan Road, North Chicago, IL, 60064-1802, USA
| | - Ahmed Hamed Salem
- Clinical Pharmacology and Pharmacometrics (R4PK/AP31), AbbVie Inc, 1 North Waukegan Road, North Chicago, IL, 60064-1802, USA.
- Clinical Pharmacy, Ain Shams University, Cairo, Egypt.
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12
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On S, Rath CG, Lan M, Wu B, Lau KM, Cheung E, Alegria W, Young R, Tan M, Kim C, Phun J, Patel N, Mannis G, Logan AC, Kennedy V, Goodman A, Taplitz RA, Young PA, Wen R, Saunders IM. Characterisation of infections in patients with acute myeloid leukaemia receiving venetoclax and a hypomethylating agent. Br J Haematol 2022; 197:63-70. [DOI: 10.1111/bjh.18051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Sandy On
- Department of Pharmacy Stanford Health Care Stanford CA USA
| | - Carolyn G. Rath
- Department of Pharmaceutical Services University of California, San Francisco Health San Francisco CA USA
| | - Michelle Lan
- Department of Pharmacy University of California, San Diego Health San Francisco CA USA
| | - Bobby Wu
- Department of Pharmacy University of California, Los Angeles Health Los Angeles CA USA
| | | | - Edna Cheung
- Department of Pharmacy Stanford Health Care Stanford CA USA
| | - William Alegria
- Department of Quality, Patient Safety and Effectiveness Stanford Health Care Stanford CA USA
| | - Rebecca Young
- Department of Pharmaceutical Services University of California, San Francisco Health San Francisco CA USA
| | - Marisela Tan
- Department of Pharmaceutical Services University of California, San Francisco Health San Francisco CA USA
| | - Carrie Kim
- Department of Pharmacy University of California, Los Angeles Health Los Angeles CA USA
| | - Jennifer Phun
- Department of Pharmacy University of California, Los Angeles Health Los Angeles CA USA
| | - Nimish Patel
- Skaggs School of Pharmacy & Pharmaceutical Sciences University of California, San Diego La Jolla CA USA
| | - Gabriel Mannis
- Division of Hematology Stanford Cancer Institute, Stanford University Stanford CA USA
| | - Aaron C. Logan
- Division of Hematology and Oncology University of California, San Francisco Health San Francisco CA USA
| | - Vanessa Kennedy
- Division of Hematology and Oncology University of California, San Francisco Health San Francisco CA USA
| | - Aaron Goodman
- Division of Blood & Marrow Transplant, Department of Medicine University of California, San Diego Health La Jolla CA USA
| | - Randy A. Taplitz
- Department of Medicine City of Hope Medical Center Duarte CA USA
| | - Patricia A. Young
- Division of Hematology/Oncology University of California Los Angeles Medical Center Los Angeles CA USA
| | - Raymond Wen
- Skaggs School of Pharmacy & Pharmaceutical Sciences University of California, San Diego La Jolla CA USA
| | - Ila M. Saunders
- Skaggs School of Pharmacy & Pharmaceutical Sciences University of California, San Diego La Jolla CA USA
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13
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Brackman D, Eckert D, Menon R, Salem AH, Potluri J, Smith BD, Wei AH, Hayslip J, Miles D, Mensing S, Gopalakrishnan S, Zha J. Venetoclax Exposure-Efficacy and Exposure-Safety Relationships in Patients with Treatment-Naïve Acute Myeloid Leukemia Who Are Ineligible for Intensive Chemotherapy. Hematol Oncol 2022; 40:269-279. [PMID: 35043428 PMCID: PMC9303465 DOI: 10.1002/hon.2964] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/06/2021] [Accepted: 01/11/2022] [Indexed: 11/11/2022]
Abstract
This study evaluated venetoclax population pharmacokinetics (popPK) in patients with treatment‐naïve acute myeloid leukemia and assessed the relationship between venetoclax exposure and clinical response for venetoclax in combination with either a hypomethylating agent (HMA) or low‐dose cytarabine (LDAC). A total of 771 patients who received venetoclax from 5 Phase 1–3 studies were included in the popPK model. Exposure‐response analyses included data from 575 patients for venetoclax/placebo plus HMA and 279 patients for venetoclax/placebo plus LDAC. The popPK model successfully characterized venetoclax plasma concentrations over time and confirmed venetoclax exposure did not vary significantly with age, weight, sex, mild to moderate hepatic impairment, or mild to severe renal impairment. Asian patients had 67% higher mean relative bioavailability than non‐Asian patients, however the range of exposures in Asian patients was similar to non‐Asian patients. For all efficacy endpoints with both treatment combinations, efficacy was higher in the venetoclax treatment groups compared with the respective control arm of placebo plus azacitidine or LDAC. Within patients who received venetoclax, no significant exposure‐efficacy relationships were identified for either treatment combination, indicating that the beneficial effects of venetoclax were already maximized in the dose ranges studied. There was no apparent effect of venetoclax exposure on treatment‐emergent Grade ≥3 thrombocytopenia or infections for either combination. Rates of treatment‐emergent Grade ≥3 neutropenia were higher in the venetoclax treatment arms compared with the respective control arms; however, within patients who received venetoclax, there was only a shallow relationship or no apparent relationship with venetoclax exposure for venetoclax plus HMA or LDAC, respectively. Along with the efficacy and safety data previously published, the exposure‐response analyses support the venetoclax dose regimens of 400 mg once daily (QD) plus HMA and 600 mg QD plus LDAC in treatment‐naïve AML patients who are ineligible for intensive chemotherapy.
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Affiliation(s)
| | | | | | | | | | - B Douglas Smith
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Andrew H Wei
- The Alfred Hospital and Monash University, Melbourne, Australia
| | | | | | - Sven Mensing
- AbbVie Deutschland GmbH Co. KG, Ludwigshafen, Germany
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14
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Metronomic chemotherapy regimens and targeted therapies in non-Hodgkin lymphoma: The best of two worlds. Cancer Lett 2022; 524:144-150. [PMID: 34673128 DOI: 10.1016/j.canlet.2021.10.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/11/2021] [Accepted: 10/13/2021] [Indexed: 12/31/2022]
Abstract
Novel drugs are rapidly moving forward the treatment-paradigm of non-Hodgkin-lymphomas (NHLs). Notwithstanding, especially in aggressive subtypes, chemotherapy remains the pillar of treatment. Indeed, the combination of highly effective Maximum-Tolerated-Dose Chemotherapy (MTD-CHEMO) + "novel drugs", has so far, fallen short from expectations, often because it caused excessive toxicity. Metronomic chemotherapy (mCHEMO), which is the frequent, long-term administration of low dose cytotoxic drugs, may allow more effective and tolerable combinations. mCHEMO pharmacodynamics, has been described as pleiotropic. In fact, it may have different cellular and molecular targets, when drugs or their schedules are modified. Although mCHEMO has been little explored in NHLs, pre-clinical studies - in lymphoma models - which addressed the activity of mCHEMO in combination with novel drugs, have shown very promising results. These included inhibitors of histone deacetylase, mTOR and PI3K/mTOR, as well as the immune checkpoint inhibitor anti-PD-L1. Moreover, a few impressive reports have recently shown all-oral mCHEMO schedules, with or without rituximab, can effectively shrink both B and T-cell aggressive NHLs. Indeed, these regimens allowed elderly-frail patients to achieve sustained remission, while toxicity proved manageable. In our opinion, all-oral mCHEMO, is an active, easy-to start, well-tolerated, and inexpensive therapeutic approach, which deserves further investigation. Most importantly, mCHEMO, holds promise to empower the activity of novel targeted therapies, without causing excessive toxicity.
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15
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Samineni D, Huang W, Gibiansky L, Ding H, Zhang R, Li C, Sinha A, Rajwanshi R, Humphrey K, Bazeos A, Salem AH, Miles D. Population Pharmacokinetics and Exposure-Response Analyses for Venetoclax in Combination with R-CHOP in Relapsed/Refractory and Previously Untreated Patients with Diffuse Large B Cell Lymphoma. Adv Ther 2022; 39:598-618. [PMID: 34822104 PMCID: PMC8799559 DOI: 10.1007/s12325-021-01919-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/07/2021] [Indexed: 12/16/2022]
Abstract
Introduction Outcomes remain poor in patients with diffuse large B cell lymphoma (DLBCL) who overexpress BCL-2 protein. We present population pharmacokinetics (PopPK) and exposure–response (ER) analyses for venetoclax (a selective BCL-2 inhibitor) administered with rituximab-cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in patients with relapsed/refractory (R/R) and previously untreated (1L) non-Hodgkin lymphoma (NHL) from the phase 1b/2 CAVALLI study, to confirm dose selection for future studies. Methods Analyses included 216 patients with R/R or 1L NHL treated for eight 21-day cycles with 400–800 mg venetoclax (cycle 1: days 4–10; cycles 2–8: days 1–10) in combination with R for eight cycles and CHOP for 6–8 cycles. A legacy PopPK model for venetoclax was used to describe the observed data and provide post hoc PK parameters. Venetoclax steady-state exposure (AUCss) was used to predict clinical efficacy, safety, or tolerability. To isolate the effect of venetoclax, ER analyses referenced data from the R-CHOP arm of a historical control study, GOYA, in 1L DLBCL. Results There was no significant association between venetoclax AUCss and progression-free survival or complete response either for all-comers or the BCL-2-immunohistochemistry-positive subpopulation. No statistically significant trends were observed with venetoclax AUCss and the key grade ≥ 3 adverse events and serious adverse events. Similar dose intensities were observed for venetoclax and R-CHOP components across venetoclax exposures, suggesting venetoclax did not impact delivery of the R-CHOP backbone. Conclusions The PopPK and ER analyses, in addition to the positive benefit–risk observed in the clinical data, support the selection of 800 mg venetoclax given with R-CHOP for future studies in BCL-2-immunohistochemistry-positive patients with 1L DLBCL. Trial Registration ClinicalTrials.gov Identifier NCT02055820. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01919-z.
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Affiliation(s)
- Divya Samineni
- Genentech, Inc., 1 DNA Way, South San Francisco, CA, USA.
| | - Weize Huang
- Genentech, Inc., 1 DNA Way, South San Francisco, CA, USA
| | | | - Hao Ding
- Genentech, Inc., 1 DNA Way, South San Francisco, CA, USA
| | - Rong Zhang
- Genentech, Inc., 1 DNA Way, South San Francisco, CA, USA
| | - Chunze Li
- Genentech, Inc., 1 DNA Way, South San Francisco, CA, USA
| | | | | | | | | | - Ahmed Hamed Salem
- AbbVie Inc., North Chicago, IL, USA
- Ain Shams University, Cairo, Egypt
| | - Dale Miles
- Genentech, Inc., 1 DNA Way, South San Francisco, CA, USA
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16
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Alaarg A, Menon R, Rizzo D, Liu Y, Bien J, Elkinton T, Grieme T, Asmus LR, Salem AH. A microdosing framework for absolute bioavailability assessment of poorly soluble drugs: A case study on cold-labeled venetoclax, from chemistry to the clinic. Clin Transl Sci 2021; 15:244-254. [PMID: 34416076 PMCID: PMC8742638 DOI: 10.1111/cts.13144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/10/2021] [Accepted: 07/07/2021] [Indexed: 11/26/2022] Open
Abstract
This work presents an end‐to‐end approach for assessing the absolute bioavailability of highly hydrophobic, poorly water‐soluble compounds that exhibit high nonspecific binding using venetoclax as a model drug. The approach utilizes a stable labeled i.v. microdose and requires fewer resources compared with traditional approaches that use radioactive 14C‐labeled compounds. The stable labeled venetoclax and internal standard were synthesized, then an i.v. formulation was developed. In the clinical study, female subjects received a single oral dose of venetoclax 100 mg followed by a 100‐µg i.v. dose of cold‐labeled 13C‐venetoclax at the oral time of maximum concentration (Tmax). The i.v. microdose was prepared as an extemporaneous, sterile compounded solution on the dosing day by pharmacists at the clinical site. Several measures were taken to ensure the sterility and safety of the i.v. preparation. A sensitive liquid chromatography‐tandem mass spectrometry method was developed to allow the detection of plasma levels from the i.v. microdose. Plasma samples were collected through 72 h, and pharmacokinetic parameters were estimated using noncompartmental methods. Postdosing sample analysis demonstrated the consistency of the preparations and allowed the precise calculation of the pharmacokinetic parameters based on the actual injected dose. The absolute bioavailability of venetoclax was estimated at 5.4% under fasting conditions. Venetoclax extraction ratio was estimated to be 0.06 suggesting that the fraction transferred from the enterocytes into the liver is limiting venetoclax bioavailability. The proposed framework can be applied to other highly hydrophobic, poorly water‐soluble compounds that exhibit high nonspecific binding to support the understanding of their absorption and disposition mechanisms and guide formulation development.
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Affiliation(s)
- Amr Alaarg
- Drug Product Development, AbbVie Inc., North Chicago, Illinois, USA
| | - Rajeev Menon
- Clinical Pharmacology and Pharmacometrics, AbbVie, North Chicago, Illinois, USA
| | - David Rizzo
- DMPK-BA, AbbVie Inc, North Chicago, Illinois, USA
| | - Yemin Liu
- Development Sciences Analytical R&D, AbbVie Inc., North Chicago, Illinois, USA
| | - Jeffrey Bien
- Development Sciences Program Management & Sourcing, North Chicago, Illinois, USA
| | - Tricia Elkinton
- AbbVie Clinical Pharmacology Research Unit, Grayslake, Illinois, USA
| | | | - Lutz R Asmus
- Drug Product Development, AbbVie Deutschland GmbH & Co. KG, Ludwigshafen, Germany
| | - Ahmed Hamed Salem
- Clinical Pharmacology and Pharmacometrics, AbbVie, North Chicago, Illinois, USA.,Clinical Pharmacy, Ain Shams University, Cairo, Egypt
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17
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Taniguchi S, Yamauchi T, Choi I, Fukuhara N, Potluri J, Salem AH, Hong WJ, Honda H, Nishimura Y, Okubo S, Usuki K. Venetoclax in combination with azacitidine in Japanese patients with acute myeloid leukaemia: phase 1 trial findings. Jpn J Clin Oncol 2021; 51:857-864. [PMID: 33712849 DOI: 10.1093/jjco/hyab018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Venetoclax plus azacitidine is indicated in the USA for the treatment of newly diagnosed acute myeloid leukaemia in older patients (≥75 years) or those ineligible for induction chemotherapy due to co-morbidities. METHODS In this phase 1/2 study (NCT02265731), Japanese patients (≥60 years) with untreated (ineligible for induction chemotherapy) or relapsed/refractory acute myeloid leukaemia received oral venetoclax 400 mg/day (3-day ramp up in cycle 1) plus subcutaneous or intravenous azacitidine 75 mg/m2 on days 1-7 per 28-day cycle until disease progression or unacceptable toxicity. RESULTS As of 10 December 2019, six patients were enrolled (median age: 75 years; untreated: n = 5; relapsed/refractory: n = 1); median treatment duration: 10.3 months (range, 0.7-29.4). Most common grade ≥ 3 adverse events were lymphopaenia and febrile neutropaenia (n = 4 each). Four patients reported serious adverse events; only an event of grade 3 fungal pneumonia was considered possibly related to both study drugs, requiring dose interruption of venetoclax and delay of azacitidine. Five (83%) patients had responses (complete remission: n = 3). Median time to first response of complete remission/complete remission with incomplete count recovery was 1.0 month (range, 0.8-5.5); median overall survival: 15.7 months (95% confidence interval: 6.2, not reached). CONCLUSIONS Venetoclax plus azacitidine was well tolerated and showed high response rates in Japanese patients with acute myeloid leukaemia.
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Affiliation(s)
- Shuichi Taniguchi
- Department of Hematology, Toranomon Hospital, Minato-ku, Tokyo, Japan
| | - Takahiro Yamauchi
- Department of Hematology and Oncology, University of Fukui Hospital, Fukui, Japan
| | - Ilseung Choi
- Department of Hematology, National Hospital Organization, Kyushu Cancer Centerk, Fukuoka, Japan
| | - Noriko Fukuhara
- Department of Hematology and Rheumatology, Tohoku University Hospital, Sendai, Japan
| | | | - Ahmed Hamed Salem
- AbbVie Inc., North Chicago, IL, USA.,Department of Clinical Pharmacy, Ain Shams University, Cairo, Egypt
| | | | | | | | | | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan
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Othman TA, Azenkot T, Moskoff BN, Tenold ME, Jonas BA. Venetoclax-based combinations for the treatment of newly diagnosed acute myeloid leukemia. Future Oncol 2021; 17:2989-3005. [PMID: 34024158 DOI: 10.2217/fon-2021-0262] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Elderly and/or unfit patients with acute myeloid leukemia have historically been challenging to manage as they were ineligible for what was considered standard of care treatment with induction chemotherapy. The emergence of venetoclax with hypomethylating agents or low-dose cytarabine has substantially improved outcomes in the frontline setting with manageable toxicity. However, this regimen can be challenging to deliver given its differences from standard intensive chemotherapy. In this review, we summarize the landmark trials that established venetoclax-based combinations as a new standard of care for patients with acute myeloid leukemia not suitable for intense chemotherapy, provide practical clinical pearls for managing patients on these therapies, and offer a brief overview of modifications to these regimens under development to improve their efficacy and/or applicability.
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Affiliation(s)
- Tamer A Othman
- Department of Internal Medicine, Division of Hematology & Oncology, University of California Davis School of Medicine, Sacramento, CA 95817, USA
| | - Tali Azenkot
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA 95817, USA
| | - Benjamin N Moskoff
- Pharmacy Department, University of California Davis School of Medicine, Sacramento, CA 95817, USA
| | - Matthew E Tenold
- Department of Internal Medicine, Division of Hematology & Oncology, University of California Davis School of Medicine, Sacramento, CA 95817, USA
| | - Brian A Jonas
- Department of Internal Medicine, Division of Hematology & Oncology, University of California Davis School of Medicine, Sacramento, CA 95817, USA
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Abstract
The management of febrile neutropenia is a backbone of treating patients with hematologic malignancies and has evolved over the past decades. This article reviews my approach to the evaluation and treatment of febrile neutropenic patients. Key topics discussed include antibacterial and antifungal prophylaxis, the initial workup for fever, the choice of the empiric antibiotic regimen and its modifications, and criteria for discontinuation. For each of these questions, I review the literature and present my perspective.
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20
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Schuler E, Wagner-Drouet EM, Ajib S, Bug G, Crysandt M, Dressler S, Hausmann A, Heidenreich D, Hirschbühl K, Hoepting M, Jost E, Kaivers J, Klein S, Koldehoff M, Kordelas L, Kriege O, Müller LP, Rautenberg C, Schaffrath J, Schmid C, Wolff D, Haas R, Bornhäuser M, Schroeder T, Kobbe G. Treatment of myeloid malignancies relapsing after allogeneic hematopoietic stem cell transplantation with venetoclax and hypomethylating agents-a retrospective multicenter analysis on behalf of the German Cooperative Transplant Study Group. Ann Hematol 2020; 100:959-968. [PMID: 33191481 PMCID: PMC8448702 DOI: 10.1007/s00277-020-04321-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/26/2020] [Indexed: 02/07/2023]
Abstract
Treatment of relapse after allogeneic hematopoietic stem cell transplantation (alloHSCT) remains a great challenge. Aiming to evaluate the combination of venetoclax and hypomethylating agents (HMAClax) for the treatment of relapse of myeloid malignancies after alloHSCT, we retrospectively collected data from 32 patients treated at 11 German centers. Venetoclax was applied with azacitidine (n = 13) or decitabine (n = 19); 11 patients received DLI in addition. HMAClax was the first salvage therapy in 8 patients. The median number of cycles per patient was 2 (1–19). All but 1 patient had grade 3/4 neutropenia. Hospital admission for grade 3/4 infections was necessary in 23 patients (72%); 5 of these were fatal. In 30 evaluable patients, overall response rate (ORR) was 47% (14/30, 3 CR MRDneg, 5 CR, 2 CRi, 1 MLFS, 3 PR). ORR was 86% in first salvage patients versus 35% in later salvage patients (p = 0.03). In 6 patients with molecular relapse (MR), ORR was 67% versus 42% in patients with hematological relapse (HR) (n = 24, p = n.s.). After a median follow-up of 8.4 months, 25 patients (78%) had died and 7 were alive. Estimated median overall survival was 3.7 months. Median survival of patients with HMAClax for first versus later salvage therapy was 5.7 and 3.4 months (p = n.s.) and for patients with MR (not reached) compared to HR (3.4 months, p = 0.024). This retrospective case series shows that venetoclax is utilized in various different combinations, schedules, and doses. Toxicity is substantial and patients who receive venetoclax/HMA combinations for MR or as first salvage therapy derive the greatest benefit.
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Affiliation(s)
- Esther Schuler
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Eva-Maria Wagner-Drouet
- Department of Hematology, Oncology, Pneumology, Medical Clinic III, UCT Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Salem Ajib
- Department of Medicine II, Goethe University, Frankfurt am Main, Germany
| | - Gesine Bug
- Department of Medicine II, Goethe University, Frankfurt am Main, Germany
| | - Martina Crysandt
- Department of Hematology, Oncology, Hemostasiology and Stem Cell Transplantation, Medical Clinic IV, University Hospital RWTH Aachen, Aachen, Germany
| | - Sabine Dressler
- Bone Marrow Transplantation Unit, Medical Clinic 5, Nürnberg, Germany
| | - Andreas Hausmann
- Department of Hematology, Oncology, Immunology, Palliative Care, Munich Clinic Schwabing, Munich, Germany
| | | | - Klaus Hirschbühl
- Department of Hematology and Oncology, Medical Clinic II, University Hospital Augsburg, Augsburg, Germany
| | - Matthias Hoepting
- Medical Clinic III, University Medicine Regensburg, Regensburg, Germany
| | - Edgar Jost
- Department of Hematology, Oncology, Hemostasiology and Stem Cell Transplantation, Medical Clinic IV, University Hospital RWTH Aachen, Aachen, Germany
| | - Jennifer Kaivers
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Stefan Klein
- Medical Clinic III, University Medicine Mannheim, Mannheim, Germany
| | - Michael Koldehoff
- Clinic for Bone Marrow Transplantation, University Hospital Essen, Essen, Germany
| | - Lambros Kordelas
- Clinic for Bone Marrow Transplantation, University Hospital Essen, Essen, Germany
| | - Oliver Kriege
- Department of Hematology, Oncology, Pneumology, Medical Clinic III, UCT Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Lutz P Müller
- Department of Internal Medicine IV, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Christina Rautenberg
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Judith Schaffrath
- Department of Internal Medicine IV, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Christoph Schmid
- Department of Hematology and Oncology, Medical Clinic II, University Hospital Augsburg, Augsburg, Germany
| | - Daniel Wolff
- Medical Clinic III, University Medicine Regensburg, Regensburg, Germany
| | - Rainer Haas
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Martin Bornhäuser
- Department of Internal Medicine I, University Hospital Carl Gustav Carus at the Technische Universität, Dresden, Germany
| | - Thomas Schroeder
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Guido Kobbe
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
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21
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Bermúdez A, Colorado M. A glimmer of hope for older people with acute myeloid leukaemia. LANCET HAEMATOLOGY 2020; 7:e700-e701. [PMID: 32896300 DOI: 10.1016/s2352-3026(20)30279-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Arancha Bermúdez
- Hematology Department, University Hospital Marqués de Valdecilla, Research Institute of Marqués de Valdecilla (IDIVAL), Cantabria University, Santander 39008, Spain.
| | - Mercedes Colorado
- Hematology Department, University Hospital Marqués de Valdecilla, Research Institute of Marqués de Valdecilla (IDIVAL), Cantabria University, Santander 39008, Spain
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22
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Zhang N, Zhang Y, Zhang P, Lou S, Chen Y, Li H, Zeng H, Shen Y, Deng J. Overexpression of annexin A5 might guide the gemtuzumab ozogamicin treatment choice in patients with pediatric acute myeloid leukemia. Ther Adv Med Oncol 2020; 12:1758835920927635. [PMID: 32636939 PMCID: PMC7310896 DOI: 10.1177/1758835920927635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 04/27/2020] [Indexed: 12/27/2022] Open
Abstract
Background: Acute myeloid leukemia (AML) is a common hematological malignancy. Gemtuzumab
ozogamicin (GO), a humanized anti-CD33 antibody conjugated with the potent
anti-tumor antibiotic calicheamicin, represents a promising targeted therapy
for AML. Annexin A5 (ANXA5) is a proposed marker for the clinical prognosis
of AML to guide treatment choice. Methods: In total, 253 patients with pediatric AML were enrolled and divided into two
treatment groups: conventional chemotherapy alone and conventional
chemotherapy in combination with GO. Univariate, multivariate, and
Kaplan–Meier survival analyses were conducted to assess risk factors and
clinical outcomes, and to estimate hazard ratios (HRs) and their 95%
confidence interval. The level of statistical significance was set at
p < 0.05. Results: In the GO treatment group, high ANXA5 expression was
considered a favorable prognostic factor for overall survival (OS) and
event-free survival (EFS). Multivariate analysis showed that high
ANXA5 expression was an independent favorable factor
for OS (HR = 0.629, p = 0.084) and EFS (HR = 0.544,
p = 0.024) distinct from the curative effect of GO
treatment. When all patients were again divided into two groups, this time
based on the median expression of ANXA5, patients
undergoing chemotherapy combined with GO had significantly better OS
(p = 0.0012) and EFS (p = 0.0003) in
the ANXA5 high-expression group. Gene set enrichment
analysis identified a relevant series of pathways associated with
glutathione metabolism, leukocyte transendothelial migration, and
hematopoietic cell lineage. Conclusion: The expression level of ANXA5 can help optimize the
treatment regimen for individual patients, and patients with overexpression
of ANXA5 may circumvent poor outcomes from chemotherapy
combined with GO.
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Affiliation(s)
- Nan Zhang
- Department of Hematology, The Second Affiliated Hospital, Chongqing Medical University, Jiangnan, Chongqing, P.R. China
| | - Ying Zhang
- Department of Hematology, The Second Affiliated Hospital, Chongqing Medical University, Jiangnan, Chongqing, P.R. China
| | - Ping Zhang
- Hematology Laboratory, The Second Affiliated Hospital, Chongqing Medical University, Yuzhong, Chongqing, P.R. China
| | - Shifeng Lou
- Department of Hematology, The Second Affiliated Hospital, Chongqing Medical University, Jiangnan, Chongqing, P.R. China
| | - Ying Chen
- Department of Hematology, The Second Affiliated Hospital, Chongqing Medical University, Jiangnan, Chongqing, P.R. China
| | - Huan Li
- Department of Hematology, The Second Affiliated Hospital, Chongqing Medical University, Jiangnan, Chongqing, P.R. China
| | - Hanqing Zeng
- Department of Hematology, The Second Affiliated Hospital, Chongqing Medical University, Jiangnan, Chongqing, P.R. China
| | - Yan Shen
- Department of Hematology, The Second Affiliated Hospital, Chongqing Medical University, Jiangnan, Chongqing, P.R. China
| | - Jianchuan Deng
- Department of Hematology, The Second Affiliated Hospital, Chongqing Medical University, 76 Linjiang Road, Chongqing, 400010, P.R. China
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23
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Alhadab AA, Salem AH, Freise KJ. Semimechanistic Modeling to Guide Venetoclax Coadministration with Ritonavir and Digoxin. Clin Transl Sci 2020; 13:555-562. [PMID: 31961475 PMCID: PMC7214649 DOI: 10.1111/cts.12739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 11/01/2019] [Indexed: 12/25/2022] Open
Abstract
Venetoclax is a cytochrome P450, family 3, subfamily A (CYP3A) substrate and was shown to inhibit P-gp efflux transporters in vitro. To quantify the impact of CYP3A inhibition by ritonavir on venetoclax disposition and P-gp inhibition by venetoclax on digoxin pharmacokinetics, two semimechanistic drug-drug interaction (DDI) models of venetoclax were developed using clinical data from healthy volunteers who received subtherapeutic doses of venetoclax with ritonavir 50-100 mg or digoxin 0.5 mg. These models were then used to assess the magnitude of interaction at therapeutic venetoclax doses and to explore various clinical dosing strategies that maintain venetoclax and digoxin concentrations within their respective therapeutic windows. Simulations demonstrated that venetoclax dose reductions of at least 75% are needed when venetoclax is coadministered with ritonavir and administering digoxin at least 2 hours before venetoclax would minimize DDI. Semimechanistic modeling leveraging clinical data is a plausible approach to predict DDI and propose dose adjustments, and administration time of interacting drugs.
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Affiliation(s)
- Ali A Alhadab
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., North Chicago, Illinois, USA
| | - Ahmed Hamed Salem
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., North Chicago, Illinois, USA.,Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
| | - Kevin J Freise
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., North Chicago, Illinois, USA
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24
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Ferrara F. Venetoclax plus hypomethylating agents or low-dose cytarabine in acute myeloid leukemia: all that glitters is gold? Blood Cancer J 2020; 10:10. [PMID: 31992691 PMCID: PMC6987123 DOI: 10.1038/s41408-020-0281-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/06/2020] [Accepted: 01/14/2020] [Indexed: 11/09/2022] Open
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25
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Dave N, Gopalakrishnan S, Mensing S, Salem AH. Model-Informed Dosing of Venetoclax in Healthy Subjects: An Exposure-Response Analysis. Clin Transl Sci 2019; 12:625-632. [PMID: 31268229 PMCID: PMC6853148 DOI: 10.1111/cts.12665] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/13/2019] [Indexed: 12/27/2022] Open
Abstract
Venetoclax is an approved drug for the treatment of some hematological malignancies. Venetoclax can cause reduction in B-lymphocyte counts as an on-target effect. The purpose of this analysis is to quantify the relationship between venetoclax exposure and B-lymphocyte levels to inform dosing of venetoclax in healthy subjects. Data were pooled from 10 studies in healthy subjects with venetoclax doses ranging from 10 mg to 400 mg and food ranging from fasting to high-fat meals. Venetoclax pharmacokinetics (PK) was characterized in 203 subjects using a population approach, as implemented in NONMEM version 7.3 (Icon Development Solutions, Ellicott City, MD, USA). A semimechanistic pharmacodynamic (PD) model with a linear drug effect was fit to the B-lymphocyte data to determine the exposure-response relationship. The population PK and PD model described the observed data adequately. The 200 and 400 mg doses were shown to reduce the B-lymphocyte levels by 24% (15-35%) and 38% (25-54%), respectively. B-lymphocytes recovered to normal levels within an average of 48 (21-64) days and 59 (30-66) days, respectively, with 200 and 400 mg doses. Venetoclax can be safely administered in healthy subjects. The PK-PD model characterized the relationship between venetoclax exposure and reduction in B-lymphocytes and will help design future venetoclax studies in healthy subjects.
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Affiliation(s)
| | | | | | - Ahmed Hamed Salem
- AbbVie, North Chicago, Illinois, USA.,Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
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