1
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Feld J, Tremblay D, Navada SC, Silverman LR. Ascertaining QUAZARs: slow-motion and light-speed development of oral azacitidine and decitabine. Leuk Lymphoma 2023; 64:525-539. [PMID: 36370098 DOI: 10.1080/10428194.2022.2142051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) are devastating diseases that frequently rely on the use of parenteral hypomethylating agents (HMAs), either as monotherapy or in combination, as first-line treatment for many patients. Two new oral HMAs, decitabine/cedazuridine (DC) for use in place of azacitidine or decitabine in MDS, and azacitidine (CC-486) for use as maintenance treatment in AML, were recently approved by the FDA. We will discuss the development of these oral HMAs, including the advantages/disadvantages in transitioning to oral HMAs and an in depth look at the pivotal phase III trials that led to their FDA approval - ASCERTAIN for DC and QUAZAR-AML-001 for CC-486. We also review how these agents have been and are being studied in other malignancies, and examine the future role that these exciting novel agents will play in both MDS and AML.
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Affiliation(s)
- Jonathan Feld
- Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Douglas Tremblay
- Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shyamala C Navada
- Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lewis R Silverman
- Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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2
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Jen EY, Wang X, Li M, Li H, Lee SL, Ni N, Przepiorka D, Vallejo J, Leong R, Ma L, Gehrke BJ, McLamore S, Theoret MR, de Claro RA. FDA Approval Summary: Oral Azacitidine for Continued Treatment of Adults with Acute Myeloid Leukemia Unable to Complete Intensive Curative Therapy. Clin Cancer Res 2022; 28:2989-2993. [PMID: 35325108 PMCID: PMC9288471 DOI: 10.1158/1078-0432.ccr-21-4525] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/03/2022] [Accepted: 03/10/2022] [Indexed: 01/17/2023]
Abstract
On September 1, 2020, the FDA granted approval for oral azacitidine (Onureg, CC-486) for continued treatment of adult patients with acute myeloid leukemia (AML) who achieved complete remission (CR) or complete remission with incomplete blood count recovery (CRi) following intensive induction chemotherapy and who are not able to complete intensive curative therapy. Approval was based on improvement in overall survival using CC-486 300 mg daily in a 2 weeks on/2 weeks off schedule in comparison with placebo (HR, 0.69; 95% confidence interval, 0.55-0.86; P = 0.0009) in the randomized trial CC-486-AML-001 (QUAZAR) in adults ≥ 55 years old with AML in CR/CRi who did not complete standard intensive induction and postremission therapy. Of note, the study was not designed to test CC-486 as maintenance after standard postremission therapy or as an alternative to standard postremission therapy. Gastrointestinal toxicities, fatigue, and pneumonia were more common in patients treated with CC-486 compared with placebo. Additional studies are needed to establish safe dosing for patients with hepatic impairment. The pharmacokinetic parameters, recommended dose, and recommended schedule of CC-486 differ substantially from those of other azacitidine formulations; therefore, inappropriate substitutions between formulations pose a considerable risk for harm.
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Affiliation(s)
- Emily Y. Jen
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration
| | - Xin Wang
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration
| | - Meng Li
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration
| | - Hongshan Li
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration
| | - Shwu-Luan Lee
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration
| | - Nina Ni
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration
| | - Donna Przepiorka
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration
| | - Jonathon Vallejo
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration
| | - Ruby Leong
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration
| | - Lian Ma
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration
| | - Brenda J. Gehrke
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration
| | - Sherita McLamore
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration
| | - Marc R. Theoret
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration,Oncology Center of Excellence, U.S. Food and Drug Administration
| | - R. Angelo de Claro
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration
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3
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Owens K, Argon S, Yu J, Yang X, Wu F, Lee SC, Sun WJ, Ramamoorthy A, Zhang L, Ragueneau-Majlessi I. Exploring the Relationship of Drug BCS Classification, Food Effect, and Gastric pH-Dependent Drug Interactions. AAPS J 2021; 24:16. [PMID: 34961909 DOI: 10.1208/s12248-021-00667-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/16/2021] [Indexed: 01/16/2023] Open
Abstract
Food effect (FE) and gastric pH-dependent drug-drug interactions (DDIs) are both absorption-related. Here, we evaluated if Biopharmaceutics Classification System (BCS) classes may be correlated with FE or pH-dependent DDIs. Trends in FE data were investigated for 170 drugs with clinical FE studies from the literature and new drugs approved from 2013 to 2019 by US Food and Drug Administration. A subset of 38 drugs was also evaluated to determine whether FE results can inform the need for a gastric pH-dependent DDI study. The results of FE studies were defined as no effect (AUC ratio 0.80-1.25), increased exposure (AUC ratio ≥1.25), or decreased exposure (AUC ratio ≤0.8). Drugs with significantly increased exposure FE (AUC ratio ≥2.0; N=14) were BCS Class 2 or 4, while drugs with significantly decreased exposure FE (AUC ratio ≤0.5; N=2) were BCS Class 1/3 or 3. The lack of FE was aligned with the lack of a pH-dependent DDI for all 7 BCS Class 1 or 3 drugs as expected. For the 13 BCS Class 2 or 4 weak base drugs with an increased exposure FE, 6 had a pH-dependent DDI (AUC ratio ≤0.8). Among the 16 BCS Class 2 or 4 weak base drugs with no FE, 6 had a pH-dependent DDI (AUC ratio ≤0.8). FE appears to have limited correlation with BCS classes except for BCS Class 1 drugs, confirming that multiple physiological mechanisms can impact FE. Lack of FE does not indicate absence of pH-dependent DDI for BCS Class 2 or 4 drugs. Graphical Abstract.
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Affiliation(s)
- Katie Owens
- Department of Pharmaceutics, University of Washington, H-272 Health Sciences Building, Box 357610, Seattle, Washington, 98195, USA.
| | - Sophie Argon
- Department of Pharmaceutics, University of Washington, H-272 Health Sciences Building, Box 357610, Seattle, Washington, 98195, USA
| | - Jingjing Yu
- Department of Pharmaceutics, University of Washington, H-272 Health Sciences Building, Box 357610, Seattle, Washington, 98195, USA
| | - Xinning Yang
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Fang Wu
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sue-Chih Lee
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Wei-Jhe Sun
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Anuradha Ramamoorthy
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lei Zhang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Isabelle Ragueneau-Majlessi
- Department of Pharmaceutics, University of Washington, H-272 Health Sciences Building, Box 357610, Seattle, Washington, 98195, USA
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4
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Griffiths EA. Oral hypomethylating agents: beyond convenience in MDS. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:439-447. [PMID: 34889435 PMCID: PMC8791154 DOI: 10.1182/hematology.2021000278] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Oral hypomethylating agents (HMAs) represent a substantial potential boon for patients with myelodysplastic syndrome (MDS) who have previously required between 5 and 7 visits per month to an infusion clinic to receive therapy. For patients who respond to treatment, ongoing monthly maintenance visits represent a considerable burden to quality of life, and for those who are early in therapy, these sequential visits may tax transportation and financial resources that would be optimally distributed over the treatment cycle to facilitate transfusion support. The availability of oral HMAs may support the optimal application of these agents by contributing to adherence and lessening the burden of therapy, potentially encouraging patients to stay on longer-term treatment. Distinct pharmacokinetic profiles for the recently approved oral HMAs (oral azacitidine and decitabine-cedazuridine) result in differential toxicity profiles and have prompted their clinical trial development in lower- and higher-risk MDS, respectively.
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Affiliation(s)
- Elizabeth A. Griffiths
- Correspondence Elizabeth A. Griffiths, Roswell Park Comprehensive Cancer Center, Elm and Carlton St, Buffalo, NY 14263; e-mail:
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5
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Garcia-Manero G, Döhner H, Wei AH, La Torre I, Skikne B, Beach CL, Santini V. Oral Azacitidine (CC-486) for the Treatment of Myeloid Malignancies. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:236-250. [PMID: 34758945 DOI: 10.1016/j.clml.2021.09.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 02/07/2023]
Abstract
Epigenetic dysregulation leads to aberrant DNA hypermethylation and is common in acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS). A large number of clinical trials in AML, MDS, and other hematologic malignancies have assessed hypomethylating agents (HMAs), used alone or in combination with other drugs, in the frontline, maintenance, relapsed/refractory, and peritransplant settings. Effective maintenance therapy has long been a goal for patients with AML in remission. Previous large, randomized clinical trials of maintenance with HMAs or other agents had not shown meaningful improvement in overall survival. Oral azacitidine (Oral-AZA [CC-486]) is approved in the United States, Canada, and European Union for treatment of adult patients with AML in first complete remission (CR) or CR with incomplete blood count recovery (CRi) following intensive induction chemotherapy who are ineligible for hematopoietic cell transplant. Regulatory approvals of Oral-AZA were based on outcomes from the randomized, phase III QUAZAR AML-001 trial, which showed a median overall survival advantage of 9.9 months with Oral-AZA versus placebo. Oral-AZA allows convenient extended AZA dosing for 14 days per 28-day treatment cycle, which is not feasible with injectable AZA. Focusing on AML and MDS, this report reviews the rationale for the use of orally bioavailable AZA and its potential use in all-oral combination therapy regimens; the unique pharmacokinetic and pharmacodynamic profile of Oral-AZA compared with injectable AZA; the clinical safety and efficacy of Oral-AZA maintenance therapy in patients with AML in first remission and for treatment of patients with active MDS; and ongoing Oral-AZA clinical trials.
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Affiliation(s)
| | - Hartmut Döhner
- Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany
| | - Andrew H Wei
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia; Monash University, Australian Centre for Blood Diseases, Melbourne, Australia
| | | | - Barry Skikne
- Bristol-Myers Squibb Company, Princeton, NJ; Department of Hematology, University of Kansas Medical Center, Kansas City, KS
| | - C L Beach
- Bristol-Myers Squibb Company, Princeton, NJ
| | - Valeria Santini
- MDS Unit, Hematology, AOU Careggi, University of Florence, Florence, Italy
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6
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Ravandi F, Roboz GJ, Wei AH, Döhner H, Pocock C, Selleslag D, Montesinos P, Sayar H, Musso M, Figuera-Alvarez A, Safah H, Tse W, Sohn SK, Hiwase D, Chevassut T, Pierdomenico F, La Torre I, Skikne B, Bailey R, Zhong J, Beach CL, Dombret H. Management of adverse events in patients with acute myeloid leukemia in remission receiving oral azacitidine: experience from the phase 3 randomized QUAZAR AML-001 trial. J Hematol Oncol 2021; 14:133. [PMID: 34454540 PMCID: PMC8401338 DOI: 10.1186/s13045-021-01142-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/17/2021] [Indexed: 02/08/2023] Open
Abstract
Background Most older patients with acute myeloid leukemia (AML) who attain morphologic remission with intensive chemotherapy (IC) will eventually relapse and post-relapse prognosis is dismal. In the pivotal QUAZAR AML-001 trial, oral azacitidine maintenance therapy significantly prolonged overall survival by 9.9 months (P < 0.001) and relapse-free survival by 5.3 months (P < 0.001) compared with placebo in patients with AML in first remission after IC who were not candidates for transplant. Currently, the QUAZAR AML-001 trial provides the most comprehensive safety information associated with oral azacitidine maintenance therapy. Reviewed here are common adverse events (AEs) during oral azacitidine treatment in QUAZAR AML-001, and practical recommendations for AE management based on guidance from international cancer consortiums, regulatory authorities, and the authors’ clinical experience treating patients in the trial. Methods QUAZAR AML-001 is an international, placebo-controlled randomized phase 3 study. Patients aged ≥ 55 years with AML and intermediate- or poor-risk cytogenetics at diagnosis, who had attained first complete remission (CR) or CR with incomplete blood count recovery (CRi) within 4 months before study entry, were randomized 1:1 to receive oral azacitidine 300 mg or placebo once-daily for 14 days in repeated 28-day cycles. Safety was assessed in all patients who received ≥ 1 dose of study drug. Results A total of 469 patients received oral azacitidine (n = 236) or placebo (n = 233). Median age was 68 years. Patients received a median of 12 (range 1–80) oral azacitidine treatment cycles or 6 (1–73) placebo cycles. Gastrointestinal AEs were common and typically low-grade. The most frequent grade 3–4 AEs during oral azacitidine therapy were hematologic events. AEs infrequently required permanent discontinuation of oral azacitidine (13%), suggesting they were effectively managed with use of concomitant medications and oral azacitidine dosing modifications. Conclusion Oral azacitidine maintenance had a generally favorable safety profile. Prophylaxis with antiemetic agents, and blood count monitoring every other week, are recommended for at least the first 2 oral azacitidine treatment cycles, and as needed thereafter. Awareness of the type, onset, and duration of common AEs, and implementation of effective AE management, may maximize treatment adherence and optimize the survival benefits of oral azacitidine AML remission maintenance therapy. Trial registration This trial is registered on clinicaltrials.gov: NCT01757535 as of December 2012. Supplementary Information The online version contains supplementary material available at 10.1186/s13045-021-01142-x.
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Affiliation(s)
- Farhad Ravandi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
| | - Gail J Roboz
- Weill Cornell Medicine, New York, NY, USA.,New York Presbyterian Hospital, New York, NY, USA
| | - Andrew H Wei
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia.,Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Hartmut Döhner
- Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany
| | | | | | - Pau Montesinos
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Hamid Sayar
- Indiana University Cancer Center, Indianapolis, IN, USA
| | | | | | - Hana Safah
- Tulane University Health Science Center, New Orleans, LA, USA
| | - William Tse
- University of Louisville School of Medicine, Louisville, KY, USA
| | | | | | | | | | | | - Barry Skikne
- University of Kansas Medical Center, Kansas City, KS, USA.,Bristol Myers Squibb, Princeton, NJ, USA
| | | | | | - C L Beach
- Bristol Myers Squibb, Princeton, NJ, USA
| | - Herve Dombret
- Hôpital Saint-Louis, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France.,Institut de Recherche Saint-Louis, Université de Paris, Paris, France
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7
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Kipp D, H Wei A. The path to approval for oral hypomethylating agents in acute myeloid leukemia and myelodysplastic syndromes. Future Oncol 2021; 17:2563-2571. [PMID: 33769069 DOI: 10.2217/fon-2020-1318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Two oral hypomethylating agents, oral azacitidine (CC-486) and decitabine/cedazuridine (ASTX727), have recently entered the clinical domain. CC-486 has been shown to improve overall survival as maintenance therapy for older patients with acute myeloid leukemia in complete remission, whereas the combination of decitabine with cedazuridine, a cytidine deaminase inhibitor, is indicated for the treatment of adult patients with myelodysplastic syndromes and chronic myelomonocytic leukemia with intermediate-1, or higher, International Prognostic Scoring System risk. This article briefly summarizes the clinical development of both drugs, the pivotal studies that led to their approval and some of the issues faced in extending the use of these drugs to other indications.
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Affiliation(s)
- David Kipp
- Department of Haematology, University Hospital Geelong, Geelong, 3220, Australia.,Australian Centre for Blood Diseases, Monash University, Melbourne, 3004, Australia
| | - Andrew H Wei
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, 3004, Australia.,Australian Centre for Blood Diseases, Monash University, Melbourne, 3004, Australia
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8
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Khouri J, Faiman BM, Grabowski D, Mahfouz RZ, Khan SN, Wei W, Valent J, Dean R, Samaras C, Jha BK, Lazarus H, Campagnaro EL, Malek E, Reed J, Karam MA, Hamilton K, Fada S, Kalaycio M, Liu H, Sobecks R, Saunthararajah Y, Chew Y, Orloff M, Reu FJ. DNA methylation inhibition in myeloma: Experience from a phase 1b study of low-dose continuous azacitidine in combination with lenalidomide and low-dose dexamethasone in relapsed or refractory multiple myeloma. Semin Hematol 2020; 58:45-55. [PMID: 33509443 DOI: 10.1053/j.seminhematol.2020.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 01/08/2023]
Abstract
The DNA methyltransferase inhibitor azacytidine (aza) may reactivate pathways associated with plasma cell differentiation, cell cycle control, apoptosis, and immune recognition and thereby restore sensitivity to lenalidomide (len) and dexamethasone (dex) in relapsed and/or refractory multiple myeloma (RRMM). We aimed to develop an aza regimen that reaches epigenetically active levels 8 times in 28 days with less bone marrow toxicity than the myeloid malignancy standard of 7 consecutive doses to enable safe combination with len. Aza was escalated from 30 mg/m2 once a week up to a predefined maximum of 50 mg/m2 twice a week in combination with GFR-adjusted len (≥ 60 mL/min: 25 mg, 3059 mL/min: 10 mg) day 1 to 21 every 28 days and dex 40 mg once a week followed by a limited expansion study to a total N of 23 at the highest tolerated dose. Fifty-one patients (pts) with RRMM were screened, 42 were treated and 41 were evaluable for response based on at least 1 response assessment or progression after treatment start. The median number of prior lines of therapy was 5 (1-11) and 81% (34) were refractory to len and/or pomalidomide (pom). Two DLTs occurred in different cohorts, 1 neutropenic fever in 1/6 pts on the aza 40 mg/m2 twice a week GFR ≥ 60 mL/min cohort and 1 GGT elevation in 1/6 pts on the aza 50 mg/m2 GFR 30-59 mL/min cohort. An MTD was not reached and aza 50 mg/m2 SC twice a week was chosen for the expansion study. At least possibly related Grade 3/4 AEs occurred in 28 pts (67%) with the following in > 1 pt: neutropenia (N = 16, 38%), anemia (N = 6, 14%), lymphopenia (N = 5, 12%), thrombocytopenia (N = 4, 10%), leukopenia (N = 4, 10%), febrile neutropenia (N = 4, 10%), fatigue (N = 3, 7%), fever (N = 2, 5%), and infection (N = 2, 5%). At a median follow up time for alive pts of 60.2 months (range: 36.1-82.5 months), the overall response rate (≥ partial response) and clinical benefit response rate (≥ minor response) was 22 and 32%, respectively, with 4 very good partial responses (10%), 5 partial responses (12%), and 4 minor responses (10%). The median PFS was 3.1 months (95% confidence interval [CI]: 2.1-5.1 months), median TTP 2.7 months (95% CI: 2.1-7.5 months), and median OS 18.6 months (95% CI: 12.9-33.0 months). Achieving at least minor response and reaching TTP > 6 months was associated with approximately 35% lower median plasma levels of the enzyme that inactivates aza, plasma cytidine deaminase (CDA, P< .0001). Two of the len refractory pts achieved longer disease control than with any prior regimen and 1 responded immediately after progression on len, bortezomib, and prednisone. Analyses of the methylation state of over 480,000 CpG sites in purified myeloma cells at screening were possible in 11 pts and on day 28 in 8 of them. As in other studies, the majority of differentially methylated CpGs compared to normal plasma cells were hypomethylated in myeloma. Treatment decreased the number of CpGs that were differentially methylated in normal plasma cells by > 0.5% in 6 and by > 5% in 3 of the 8 pts, most pronounced in 2 pts with clinically convincing aza contribution who achieved a reduction in overall differentially methylated CpGs by 23 and 68%, respectively, associated with increased expression of immunoglobulin genes. The study demonstrated tolerability of twice a week SC aza at 50 mg/m2 with len and dex in RRMM and suggested aza may help overcome the len/pom refractory state, possibly by activating differentiation pathways. Relatively low response rates and association of clinical benefit with low plasma levels of the aza inactivating enzyme CDA suggest the aza regimen will need to be optimized further and pt selection may be required to maximize benefit.
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Affiliation(s)
- Jack Khouri
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH
| | - Beth M Faiman
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH
| | - Dale Grabowski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Reda Z Mahfouz
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Department of Clinical Pathology, Menoufia University, Shebin-Elkom, Egypt
| | - Shahper N Khan
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Interdisciplinary Nanotechnology Centre, Aligarh Muslim University, Aligarh, India
| | - Wei Wei
- Taussig Cancer Institute, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Jason Valent
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH
| | - Robert Dean
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH
| | - Christy Samaras
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH
| | - Babal K Jha
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Hillard Lazarus
- Case Comprehensive Cancer Center, Cleveland, OH; Department of Hematology and Oncology, Seidman Cancer Center, University Hospitals, Cleveland, OH
| | - Erica L Campagnaro
- Case Comprehensive Cancer Center, Cleveland, OH; Department of Hematology and Oncology, Seidman Cancer Center, University Hospitals, Cleveland, OH; University of Michigan Comprehensive Cancer Center, Ann Arbor, MI
| | - Ehsan Malek
- Case Comprehensive Cancer Center, Cleveland, OH; Department of Hematology and Oncology, Seidman Cancer Center, University Hospitals, Cleveland, OH
| | - Janice Reed
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Mary Ann Karam
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Kimberly Hamilton
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Sherry Fada
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Matt Kalaycio
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH
| | - Hien Liu
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Ronald Sobecks
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH
| | - Yogen Saunthararajah
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH; Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | | | - Mohammed Orloff
- Lerner Research Institute, Genomic Core Facility, Cleveland Clinic, Cleveland, OH; Department of Epidemiology, University of Arkansas for Medical Sciences, Little Rock, AR; Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Frederic J Reu
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH; Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Morsani College of Medicine, University of South Florida, Tampa, FL.
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9
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DNA Methylation as a Therapeutic Target for Bladder Cancer. Cells 2020; 9:cells9081850. [PMID: 32784599 PMCID: PMC7463638 DOI: 10.3390/cells9081850] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 02/06/2023] Open
Abstract
Bladder cancer (BC) is the tenth most frequent cancer worldwide and is associated with high mortality when diagnosed in its most aggressive form, which is not reverted by the current treatment options. Thus, the development of new therapeutic strategies, either alternative or complementary to the current ones, is of major importance. The disruption of normal epigenetic mechanisms, namely, DNA methylation, is a known early event in cancer development. Consequently, DNA methyltransferase (DNMT) inhibitors constitute a promising therapeutic target for the treatment of BC. Although these inhibitors, mainly nucleoside analogues such as 5-azacytidine (5-aza) and decitabine (DAC), cause re-expression of tumor suppressor genes, inhibition of tumor cell growth, and increased apoptosis in BC experimental models and clinical trials, they also show important drawbacks that prevent their use as a valuable option for the treatment of BC. However, their combination with chemotherapy and/or immune-checkpoint inhibitors could aid in their implementation in the clinical practice. Here, we provide a comprehensive review of the studies exploring the effects of DNA methylation inhibition using DNMTs inhibitors in BC, from in vitro and in vivo studies to clinical trials.
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10
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McCullough KB, Patnaik MM. Myelodysplastic syndrome/myeloproliferative neoplasm overlap syndromes - Advances in treatment. Best Pract Res Clin Haematol 2020; 33:101130. [PMID: 32460984 DOI: 10.1016/j.beha.2019.101130] [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: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 10/25/2022]
Abstract
Optimal treatment for myelodysplastic syndrome/myeloproliferative neoplasm (MDS/MPN) overlap syndromes remain to be defined and are currently extrapolated from MDS and MPN. The heterogeneity of these diseases and their rare occurrences add to this void. Supportive care therapies such as erythropoiesis stimulating agents, iron chelation and cytoreductive therapy do not have prospective evidence in these disorders and the only approved treatments, hypomethylating agents, are based on the inclusion of a small number of chronic myelomonocytic leukaemia patients in MDS predominant trials. While allogeneic stem cell transplant remains the only curative option, the median age at presentation (7th decade), comorbidities, risk of disease relapse, and transplant related morbidity and mortality, make this option accessible to < 10% of patients. The advent of next generation sequencing has better defined the genomic landscape and opened the doors for personalized medicine. Herein we focus on recent therapeutic advances and options in MDS/MPN overlap syndromes.
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Affiliation(s)
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
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11
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Kuehl PJ, Tellez CS, Grimes MJ, March TH, Tessema M, Revelli DA, Mallis LM, Dye WW, Sniegowski T, Badenoch A, Burke M, Dubose D, Vodak DT, Picchi MA, Belinsky SA. 5-Azacytidine inhaled dry powder formulation profoundly improves pharmacokinetics and efficacy for lung cancer therapy through genome reprogramming. Br J Cancer 2020; 122:1194-1204. [PMID: 32103148 PMCID: PMC7156464 DOI: 10.1038/s41416-020-0765-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/06/2020] [Indexed: 12/31/2022] Open
Abstract
Background Epigenetic therapy through demethylation of 5-methylcytosine has been largely ineffective in treating lung cancer, most likely due to poor tissue distribution with oral or subcutaneous delivery of drugs such as 5-azacytidine (5AZA). An inhalable, stable dry powder formulation of 5AZA was developed. Methods Pharmacokinetics of inhaled dry powder and aqueous formulations of 5AZA were compared to an injected formulation. Efficacy studies and effect of therapy on the epigenome were conducted in an orthotopic rat lung cancer model for inhaled formulations. Results Inhaled dry powder 5AZA showed superior pharmacokinetic properties in lung, liver, brain and blood compared to the injected formulation and for all tissues except lung compared to an inhaled aqueous formulation. Only dry powder 5AZA was detected in brain (~4-h half-life). Inhaled dry powder was superior to inhaled aqueous 5AZA in reducing tumour burden 70–95%. Superiority of inhaled 5AZA dry powder was linked to effectively reprogramming the cancer genome through demethylation and gene expression changes in cancer signalling and immune pathways. Conclusions These findings could lead to widespread use of this drug as the first inhaled dry powder therapeutic for treating local and metastatic lung cancer, for adjuvant therapy, and in combination with immunotherapy to improve patient survival.
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Affiliation(s)
- Philip J Kuehl
- Lung Cancer Program, Lovelace Respiratory Research Institute, Albuquerque, NM, USA
| | - Carmen S Tellez
- Lung Cancer Program, Lovelace Respiratory Research Institute, Albuquerque, NM, USA
| | - Marcie J Grimes
- Lung Cancer Program, Lovelace Respiratory Research Institute, Albuquerque, NM, USA
| | - Thomas H March
- Lung Cancer Program, Lovelace Respiratory Research Institute, Albuquerque, NM, USA
| | - Mathewos Tessema
- Lung Cancer Program, Lovelace Respiratory Research Institute, Albuquerque, NM, USA
| | - David A Revelli
- Lung Cancer Program, Lovelace Respiratory Research Institute, Albuquerque, NM, USA
| | - Larry M Mallis
- Lung Cancer Program, Lovelace Respiratory Research Institute, Albuquerque, NM, USA
| | - Wendy W Dye
- Lung Cancer Program, Lovelace Respiratory Research Institute, Albuquerque, NM, USA
| | - Tyler Sniegowski
- Lung Cancer Program, Lovelace Respiratory Research Institute, Albuquerque, NM, USA
| | | | | | | | | | - Maria A Picchi
- Lung Cancer Program, Lovelace Respiratory Research Institute, Albuquerque, NM, USA
| | - Steven A Belinsky
- Lung Cancer Program, Lovelace Respiratory Research Institute, Albuquerque, NM, USA.
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12
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Babiker HM, Milhem M, Aisner J, Edenfield W, Shepard D, Savona M, Iyer S, Abdelrahim M, Beach CL, Skikne B, Laille E, Tsai KT, Ho T. Evaluation of the bioequivalence and food effect on the bioavailability of CC-486 (oral azacitidine) tablets in adult patients with cancer. Cancer Chemother Pharmacol 2020; 85:621-626. [PMID: 32036412 PMCID: PMC7036073 DOI: 10.1007/s00280-020-04037-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 01/22/2020] [Indexed: 12/04/2022]
Abstract
Purpose CC-486 is an oral formulation of azacitidine that allows for extended dosing schedules to prolong azacitidine exposure to malignant cells and maximize clinical activity. CC-486 300 mg daily, administered for 14 or 21 days of 28-day treatment cycles, is currently under investigation in two ongoing phase III trials. The 300-mg daily dose in these studies is administered as two 150-mg tablets (Formulation A). Methods We evaluated the bioequivalence of one 300-mg CC-486 tablet (Formulation B) with Formulation A and food effect on Formulation B, in adult patients with cancer in a 2-stage crossover design study. Results The ratios of the geometric means of the maximum azacitidine plasma concentration (Cmax) and of the area under the plasma concentration–time curve from time 0 extrapolated to infinity (AUC∞) were 101.5% and 105.7%, demonstrating the bioequivalence of Formulations A and B. Formulation B was rapidly absorbed under fasted and fed conditions. The geometric mean of Cmax was significantly decreased by ~ 21% in the fed state. Median Tmax was reached at 2 h and 1 h post-dose in fed and fasted states, respectively (P < 0.001). Nevertheless, systemic drug exposure (AUC) in fed and fasted states was within the 80–125% boundaries of bioequivalence and differences in Cmax and Tmax are not expected to have a clinical impact. Conclusion The single 300-mg CC-486 tablet was bioequivalent to two 150-mg tablets, which have shown to be efficacious and generally well-tolerated in clinical trials, and can be taken with or without food. Electronic supplementary material The online version of this article (10.1007/s00280-020-04037-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hani M Babiker
- University of Arizona Comprehensive Cancer Center, Tucson, AZ, USA.
| | | | - Joseph Aisner
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | | | | | - Michael Savona
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - C L Beach
- Celgene Corporation, Summit, NJ, USA
| | - Barry Skikne
- Celgene Corporation, Summit, NJ, USA.,University of Kansas Medical Center, Kansas City, KS, USA
| | | | | | - Thai Ho
- Mayo Clinic, Phoenix, AZ, USA
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13
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Hobson CA, Bonacorsi S, Hocquet D, Baruchel A, Fahd M, Storme T, Tang R, Doit C, Tenaillon O, Birgy A. Impact of anticancer chemotherapy on the extension of beta-lactamase spectrum: an example with KPC-type carbapenemase activity towards ceftazidime-avibactam. Sci Rep 2020; 10:589. [PMID: 31953453 PMCID: PMC6969056 DOI: 10.1038/s41598-020-57505-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 12/19/2019] [Indexed: 01/05/2023] Open
Abstract
Through their action on DNA replication, anticancer chemotherapies could increase the basal mutation rate in bacteria and increase the risk of selecting antibiotic resistant mutants. We investigated the impact of several drugs on a beta-lactamase model using KPC-type carbapenemase-producing Enterobacteriaceae. We studied the impact of anticancer chemotherapies used in pediatric hematologic malignancies on 7 clinical isolates of Enterobacteriaceae producing KPC-type carbapenemases. We compared the mutation rates from cultures with/without chemotherapy on ceftazidime-avibactam, rifampicin and ceftazidime-avibactam combined with meropenem media. Mechanisms of ceftazidime-avibactam resistance were explored on a subset of mutants. After exposure to some cytotoxic molecules, the bacterial mutation rates leading to ceftazidime-avibactam and to rifampicin resistance increased up to 104-fold while we observed no emergence of resistant mutants (frequency of <10-10) on a meropenem combined with ceftazidime-avibactam media. Compared to the parental strains, an increased susceptibility to meropenem was observed in the ceftazidime-avibactam resistant mutants. The blaKPC genes of ceftazidime-avibactam mutants harbored either mutations, deletions or insertions, especially in the region encoding the Ω-loop of the KPC-type carbapenemase. Anticancer chemotherapy can increase the mutation rates of bacteria accelerating the extension of KPC-type carbapenemases towards ceftazidime-avibactam, one of the last resort antimicrobial chemotherapy.
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Affiliation(s)
| | - Stéphane Bonacorsi
- Université de Paris, IAME, INSERM, F-75018, Paris, France
- AP-HP, Hôpital Robert Debré, Service de Microbiologie, F-75019, Paris, France
| | - Didier Hocquet
- Hygiène Hospitalière, UMR CNRS 6249, Université de Bourgogne Franche-Comté, Besançon, France
| | - André Baruchel
- Service d'Immuno-Hématologie Pédiatrique, Hôpital Robert Debré, AP-HP, Paris, France
| | - Mony Fahd
- Service d'Immuno-Hématologie Pédiatrique, Hôpital Robert Debré, AP-HP, Paris, France
| | - Thomas Storme
- Pharmacie Hospitalière, Hôpital Robert Debré, AP-HP, Paris, France
| | - Raksamy Tang
- Pharmacie Hospitalière, Hôpital Robert Debré, AP-HP, Paris, France
| | - Catherine Doit
- Université de Paris, IAME, INSERM, F-75018, Paris, France
- AP-HP, Hôpital Robert Debré, Service de Microbiologie, F-75019, Paris, France
| | | | - André Birgy
- Université de Paris, IAME, INSERM, F-75018, Paris, France.
- AP-HP, Hôpital Robert Debré, Service de Microbiologie, F-75019, Paris, France.
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14
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Hattori N, Sako M, Kimura K, Iida N, Takeshima H, Nakata Y, Kono Y, Ushijima T. Novel prodrugs of decitabine with greater metabolic stability and less toxicity. Clin Epigenetics 2019; 11:111. [PMID: 31370878 PMCID: PMC6670186 DOI: 10.1186/s13148-019-0709-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 07/22/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND DNA demethylation therapy is now used in practice for hematological tumors and is being developed for solid tumors. Nevertheless, it is difficult to achieve stable pharmacokinetics with the current DNA-demethylating agents, azacitidine (AZA) and decitabine (DAC), because of their rapid deamination by cytidine deaminase in vivo and spontaneous hydrolytic cleavage. Here, we aimed to develop metabolically stable prodrugs of AZA and DAC as novel DNA-demethylating agents. RESULTS Thirty-five 5'-O-trialkylsilylated AZAs/DACs were synthesized with potential resistance to deamination. Out of these, 11 compounds exhibited demethylating activity similar to that of DAC and guadecitabine, and a suitable aqueous solubility. Pharmacokinetic analysis in mice showed that OR-2003 displayed the highest serum concentration and the area under the curve in an intraperitoneal experiment, whereas OR-2100 exhibited high stability to cytidine deaminase. Treatment of cells with OR-2003 and OR-2100 depleted DNA methyltransferase 1 completely and induced both gene-specific and genome-wide demethylation. The treatment suppressed the growth of multiple types of cancer cells and induced re-expression of tumor suppressor genes. The anti-tumor effect and DNA demethylation effect of OR-2003 and OR-2100 were comparable to that of DAC with fewer adverse effects in vivo. CONCLUSIONS We developed two novel prodrugs of DAC that exhibited greater stability, comparable DNA demethylation activity, and less toxicity. These compounds are expected to overcome the difficulty in achieving stable pharmacokinetics in patients, leading to maximum DNA demethylation activity with minimum adverse effects.
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Affiliation(s)
- Naoko Hattori
- Division of Epigenomics, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Magoichi Sako
- Research and Development Division, Pharmaceutical Research Center, OHARA Pharmaceutical Co., Ltd., Koga, Japan
| | - Kana Kimura
- Division of Epigenomics, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Naoko Iida
- Division of Epigenomics, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Hideyuki Takeshima
- Division of Epigenomics, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Yoshitaka Nakata
- Research and Development Division, Pharmaceutical Research Center, OHARA Pharmaceutical Co., Ltd., Koga, Japan
| | - Yutaka Kono
- Research and Development Division, Pharmaceutical Research Center, OHARA Pharmaceutical Co., Ltd., Koga, Japan
| | - Toshikazu Ushijima
- Division of Epigenomics, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan.
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15
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Meunier A, Nerich V, Fagnoni-Legat C, Richard M, Mazel D, Adotevi O, Bertrand X, Hocquet D. Enhanced emergence of antibiotic-resistant pathogenic bacteria after in vitro induction with cancer chemotherapy drugs. J Antimicrob Chemother 2019; 74:1572-1577. [PMID: 30789224 DOI: 10.1093/jac/dkz070] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 01/09/2019] [Accepted: 01/25/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Infections with antibiotic-resistant pathogens in cancer patients are a leading cause of mortality. Cancer patients are treated with compounds that can damage bacterial DNA, potentially triggering the SOS response, which in turn enhances the bacterial mutation rate. Antibiotic resistance readily occurs after mutation of bacterial core genes. Thus, we tested whether cancer chemotherapy drugs enhance the emergence of resistant mutants in commensal bacteria. METHODS Induction of the SOS response was tested after the incubation of Escherichia coli biosensors with 39 chemotherapeutic drugs at therapeutic concentrations. The mutation frequency was assessed after induction with the SOS-inducing chemotherapeutic drugs. We then tested the ability of the three most highly inducing drugs to drive the emergence of resistant mutants of major bacterial pathogens to first-line antibiotics. RESULTS Ten chemotherapeutic drugs activated the SOS response. Among them, eight accelerated the evolution of the major commensal E. coli, mostly through activation of the SOS response, with dacarbazine, azacitidine and streptozotocin enhancing the mutation rate 21.3-fold (P < 0.001), 101.7-fold (P = 0.01) and 1158.7-fold (P = 0.02), respectively. These three compounds also spurred the emergence of imipenem-resistant Pseudomonas aeruginosa (up to 6.21-fold; P = 0.05), ciprofloxacin-resistant Staphylococcus aureus (up to 57.72-fold; P = 0.016) and cefotaxime-resistant Enterobacteria cloacae (up to 4.57-fold; P = 0.018). CONCLUSIONS Our results suggest that chemotherapy could accelerate evolution of the microbiota and drive the emergence of antibiotic-resistant mutants from bacterial commensals in patients. This reveals an additional level of complexity of the interactions between cancer, chemotherapy and the gut microbiota.
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Affiliation(s)
- Alexandre Meunier
- CNRS UMR6249, Université de Bourgogne-Franche-Comté, Besançon, France.,Hygiène hospitalière, Centre Hospitalier Universitaire, Besançon, France
| | - Virginie Nerich
- INSERM UMR1098, Université de Bourgogne-Franche-Comté, Besançon, France.,Pharmacie centrale, Centre Hospitalier Universitaire, Besançon, France
| | - Christine Fagnoni-Legat
- INSERM UMR1098, Université de Bourgogne-Franche-Comté, Besançon, France.,Pharmacie centrale, Centre Hospitalier Universitaire, Besançon, France
| | - Marion Richard
- Hygiène hospitalière, Centre Hospitalier Universitaire, Besançon, France
| | - Didier Mazel
- Institut Pasteur, Unité Plasticité du Génome Bactérien, CNRS UMR3525, Département Génomes et Génétique, Paris, France
| | - Olivier Adotevi
- INSERM UMR1098, Université de Bourgogne-Franche-Comté, Besançon, France.,Oncologie médicale, Centre Hospitalier Universitaire, Besançon, France
| | - Xavier Bertrand
- CNRS UMR6249, Université de Bourgogne-Franche-Comté, Besançon, France.,Hygiène hospitalière, Centre Hospitalier Universitaire, Besançon, France
| | - Didier Hocquet
- CNRS UMR6249, Université de Bourgogne-Franche-Comté, Besançon, France.,Hygiène hospitalière, Centre Hospitalier Universitaire, Besançon, France
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16
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Savona MR, Kolibaba K, Conkling P, Kingsley EC, Becerra C, Morris JC, Rifkin RM, Laille E, Kellerman A, Ukrainskyj SM, Dong Q, Skikne BS. Extended dosing with CC-486 (oral azacitidine) in patients with myeloid malignancies. Am J Hematol 2018; 93:1199-1206. [PMID: 30016552 PMCID: PMC6221082 DOI: 10.1002/ajh.25216] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/10/2018] [Indexed: 12/17/2022]
Abstract
CC‐486 (oral azacitidine) is an epigenetic modifier in clinical development for treatment of hematological cancers. This study of extended CC‐486 dosing included patients with myelodysplastic syndromes (MDSs), chronic myelomonocytic leukemia (CMML), or acute myeloid leukemia (AML). After a pharmacokinetic assessment period, 31 patients (MDS n = 18, CMML n = 4, and AML n = 9) entered a clinical phase in which they received CC‐486 300 mg once‐daily for 21 days of repeated 28‐day cycles. Median age was 71 years (range: 53‐93); 42% of patients were aged ≥75 years. A total of 5 patients with AML (63%) had prior MDS. Median number of CC‐486 treatment cycles was 4 (range: 1‐32). The most common treatment‐emergent adverse events (TEAEs) were gastrointestinal (84% of patients) and hematologic (81%). Most common grade 3‐4 TEAEs were neutropenia (n = 13, 42%) and anemia (n = 9, 29%). Ten patients experienced grade 4 neutropenia. Infrequently, CC‐486 dose was interrupted or reduced due to gastrointestinal (n = 5, 16%) or hematologic (n = 6, 19%) TEAEs. Overall response rate (complete remission [CR], CR with incomplete hematological recovery [CRi], partial remission [PR], marrow CR) in the MDS/CMML subgroups was 32% and in the AML subgroup (CR/CRi/PR) was 22%. Red blood cell transfusion independence rates in the MDS/CMML and AML subgroups were 33% and 25%, respectively, and 2 MDS/CMML patients attained hematologic improvement as a best response on‐study. No baseline gene mutation was predictive of response/nonresponse. CC‐486 allows flexible dosing and schedules to improve tolerability or response. Neutropenia in early treatment cycles deserves scrutiny and may warrant initiation of prophylactic antibiotics. KEY POINTS The safety profile of oral CC‐486 was comparable to that of injectable azacitidine; most adverse events were hematological and gastrointestinal. Extended (21‐day/cycle) CC‐486 dosing induced responses in patients with hematological malignancies, many of whom had prior DNMTi failure.
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Affiliation(s)
| | - Kathryn Kolibaba
- US Oncology Research; Woodlands Texas
- Northwest Cancer Specialists; Vancouver Western Australia
| | - Paul Conkling
- US Oncology Research; Woodlands Texas
- Virginia Oncology Associates; Norfolk Virginia
| | - Edwin C. Kingsley
- US Oncology Research; Woodlands Texas
- Comprehensive Cancer Centers of Nevada; Las Vegas Nevada
| | - Carlos Becerra
- US Oncology Research; Woodlands Texas
- Texas Oncology, PA (North), Sammons Cancer Center; Dallas Texas
| | - John C. Morris
- University of Cincinnati Cancer Institute; Cincinnati Ohio
| | - Robert M. Rifkin
- US Oncology Research; Woodlands Texas
- Rocky Mountain Cancer Centers; Denver Colorado
| | | | | | | | - Qian Dong
- Celgene Corporation; Summit New Jersey
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17
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Garcia-Manero G, Scott BL, Cogle CR, Boyd TE, Kambhampati S, Hetzer J, Dong Q, Kumar K, Ukrainskyj SM, Beach CL, Skikne BS. CC-486 (oral azacitidine) in patients with myelodysplastic syndromes with pretreatment thrombocytopenia. Leuk Res 2018; 72:79-85. [PMID: 30114559 DOI: 10.1016/j.leukres.2018.08.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/18/2018] [Accepted: 08/02/2018] [Indexed: 11/24/2022]
Abstract
Thrombocytopenia is among the strongest predictors of decreased survival for patients with myelodysplastic syndromes (MDS) across all prognostic risk groups. The safety and efficacy of CC-486 (oral azacitidine) was investigated in early-phase studies; we assessed clinical outcomes among subgroups of MDS patients from these studies, defined by presence or lack of pretreatment thrombocytopenia (≤75 × 109/L platelet count). Patients received CC-486 300 mg once-daily for 14 or 21 days of repeated 28-day cycles. Overall, 81 patients with MDS, median age 72 years, comprised the Low Platelets (n = 45) and High Platelets (n = 36) cohorts. Pretreatment median platelet counts were 34 × 109/L and 198 × 109/L, respectively. Grade 3-4 bleeding events occurred in 2 patients in the Low Platelets and 1 patient in the High Platelets groups; events resolved without sequelae. Treatment-related mortality was reported for 7 patients, 5 of whom had pretreatment platelet values <25 × 109/L. Overall response rates were 38% and 46% in the Low Platelets and High Platelets groups, respectively. Five thrombocytopenic patients attained complete remission and 9 attained platelet hematologic improvement. In both cohorts, platelet counts dropped during the first CC-486 treatment cycle, then increased thereafter. Extended CC-486 dosing was generally well tolerated and induced hematologic responses in these patients regardless of pretreatment thrombocytopenia.
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Affiliation(s)
- Guillermo Garcia-Manero
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Bart L Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Christopher R Cogle
- Medicine/Hematology & Oncology, University of Florida, Gainesville, FL, United States
| | - Thomas E Boyd
- Willamette Valley Cancer Institute, Eugene, OR, United States
| | - Suman Kambhampati
- University of Kansas Medical Center, Kansas City, KS, United States; Sarah Cannon at Research Medical Center, Kansas City, MO, United States
| | - Joel Hetzer
- Celgene Corporation, Summit, NJ, United States
| | - Qian Dong
- Celgene Corporation, Summit, NJ, United States
| | | | | | - C L Beach
- Celgene Corporation, Summit, NJ, United States
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18
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Nucleosidic DNA demethylating epigenetic drugs – A comprehensive review from discovery to clinic. Pharmacol Ther 2018; 188:45-79. [DOI: 10.1016/j.pharmthera.2018.02.006] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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19
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Shamliyan TA, Middleton M, Borst C. Patient-centered Outcomes with Concomitant Use of Proton Pump Inhibitors and Other Drugs. Clin Ther 2017; 39:404-427.e36. [PMID: 28189362 DOI: 10.1016/j.clinthera.2017.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/19/2016] [Accepted: 01/06/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE We performed a systematic review of patient-centered outcomes after the concomitant use of proton pump inhibitors (PPIs) and other drugs. METHODS We searched 4 databases in July 2016 to find studies that reported mortality and morbidity after the concomitant use of PPIs and other drugs. We conducted direct meta-analyses using a random-effects model and graded the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation working group approach. FINDINGS We included data from 17 systematic reviews and meta-analyses, 16 randomized controlled trials, and 16 observational studies that examined the concomitant use of PPIs with medications from 10 drug classes. Low-quality evidence suggests that the use of PPIs is associated with greater morbidity when administered with antiplatelet drugs, bisphosphonates, antibiotics, anticoagulants, metformin, mycophenolate mofetil, or nelfinavir. Concomitant PPIs reduce drug-induced gastrointestinal bleeding and are associated with greater docetaxel and cisplatin response rates in patients with metastatic breast cancer. For demonstrated statistically significant relative risks and benefits from concomitant PPIs, the magnitudes of the effects are small, with <100 attributable events per 1000 patients treated, and the effects are inconsistent among specific drugs. Among individual PPIs, the concomitant use of pantoprazole or esomeprazole, but not omeprazole or lansoprazole, is associated with an increased risk for all-cause mortality, nonfatal myocardial infarction, or stroke. Clopidogrel is associated with a greater risk for myocardial infarction compared with prasugrel. Conflicting results between randomized controlled trials and observational studies and high risk for bias in the body of evidence lessened our confidence in the results. IMPLICATIONS Available evidence suggests a greater risk for adverse patient outcomes after the concomitant use of PPIs and medications from 9 drug classes and warns against inappropriate drug combinations.
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Affiliation(s)
- Tatyana A Shamliyan
- Evidence-Based Medicine Center, Quality Assurance, Elsevier, Philadelphia, Pennsylvania.
| | - Maria Middleton
- Evidence-Based Medicine Center, Elsevier, Philadelphia, Pennsylvania
| | - Clarissa Borst
- Clinical Drug Information, Elsevier, Philadelphia, Pennsylvania
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20
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Chou WC, Yeh SP, Hsiao LT, Lin SF, Chen YC, Chen TY, Laille E, Galettis A, Dong Q, Songer S, Beach CL. Efficacy, safety, and pharmacokinetics of subcutaneous azacitidine in Taiwanese patients with higher-risk myelodysplastic syndromes. Asia Pac J Clin Oncol 2017; 13:e430-e439. [PMID: 28124500 DOI: 10.1111/ajco.12659] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/27/2016] [Accepted: 10/03/2016] [Indexed: 11/29/2022]
Abstract
AIM Clinical and pharmacokinetic effects of azacitidine in higher-risk myelodysplastic syndromes were established in mainly Caucasian populations. Because of inter-ethnic genotype variability of drug-metabolizing enzymes, it is important to evaluate azacitidine in populations expected to use the drug. METHODS In this single-arm study, Taiwanese patients with higher-risk myelodysplastic syndromes received azacitidine 75 mg/m2 /day for 7 days/28-day cycle for up to six cycles. Response-evaluable patients had baseline and cycle 6 marrow assessments. Clinical outcomes are compared descriptively with those from a phase 3 study comprising mainly Caucasian patients (N = 179). Pharmacokinetics in a subgroup of Taiwanese patients are descriptively compared with a historical control of North American patients (N = 45). RESULTS Median age of Taiwanese patients (N = 44) was 64 years (range 36-90), and 46% had poor cytogenetics. Median number of azacitidine cycles was six (1-6). No response-evaluable patient (n = 33) achieved complete or partial remission; however, 22 patients (50%) achieved hematologic improvement, 12 of 32 patients attained RBC transfusion independence and 7 of 18 attained platelet transfusion independence. Most common grade 3-4 treatment-emergent adverse events were neutropenia (52%) and leukopenia (39%). Pharmacokinetic profiles were similar for Taiwanese (N = 12) and North American (N = 45) patients. Maximum plasma concentration was higher in Taiwanese patients; however, mean azacitidine exposure was within the range for North American patients. CONCLUSION These data confirm the safety and efficacy of azacitidine in Taiwanese patients with higher-risk myelodysplastic syndromes. Clinical outcomes were generally comparable with those for Caucasian patients. No meaningful differences in azacitidine pharmacokinetics were observed for Taiwanese patients, and no initial dose adjustment is necessary.
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Affiliation(s)
| | - Su-Peng Yeh
- China Medical University Hospital, Taichung City, Taiwan
| | - Liang-Tsai Hsiao
- Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Sheng-Fung Lin
- Kaohsiung Medical University Hospital and Kaohsiung Medical University, School of Medicine, Kaohsiung, Taiwan
| | - Yeu-Chin Chen
- Tri-Service General Hospital, National Defense Medical Center, Taipei City, Taiwan
| | - Tsai-Yun Chen
- National Cheng-Kung University Hospital, Tainan, Taiwan
| | - Eric Laille
- Celgene Corporation, Summit, New Jersey, USA
| | | | - Qian Dong
- Celgene Corporation, Summit, New Jersey, USA
| | | | - C L Beach
- Celgene Corporation, Summit, New Jersey, USA
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21
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Tenti E, Papayannidis C, Marconi G, Parisi S, Simonetti G, Paolini S, Sartor C, Ottaviani E, Testoni N, Martinelli G. Efficacy of Azacitidine in the treatment of adult patients aged 65 years or older with AML. Expert Opin Pharmacother 2016; 17:2479-2486. [PMID: 27829292 DOI: 10.1080/14656566.2016.1258056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Therapy for acute myeloid leukemia (AML) in elderly populations (>65 years) is still a challenge for scientists and hematologists worldwide, and represents an urgent medical need. Notably, the identification and the recognition of molecular and epigenetic mechanisms involved in the pathogenesis of such a heterogeneous disease, are providing new tools for a more successful and 'targeted' approach. Azacitidine is a hypomethylating agent (HMA) with relevant activity in patients affected by myelodysplastic syndrome (MDS) and AML with low blast cells percentage (>30%), in terms of reduction of transfusion dependence, and improvement of quality of life. Areas covered: This review summarizes the mechanism of action, safety profile and efficacy of azacitidine in the field of elderly AML populations, providing up-to-date references on this subset of high-risk patients. Expert opinion: HMAs are the first successful treatment for elderly patients with high-risk MDS and are effective for some AML subtypes. Translational studies based on gene expression profiling and molecular sequencing, would be able to identify, in the near future, patients with a favorable profile of response to these compounds suggesting new potential treatment combinations also.
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Affiliation(s)
- Elena Tenti
- a Institute of Hematology L. e A. Seràgnoli , Universita degli Studi di Bologna Azienda Ospedaliera Sant\'Orsola-Malpighi Ringgold standard institution , Bologna , Italy
| | - Cristina Papayannidis
- a Institute of Hematology L. e A. Seràgnoli , Universita degli Studi di Bologna Azienda Ospedaliera Sant\'Orsola-Malpighi Ringgold standard institution , Bologna , Italy
| | - Giovanni Marconi
- a Institute of Hematology L. e A. Seràgnoli , Universita degli Studi di Bologna Azienda Ospedaliera Sant\'Orsola-Malpighi Ringgold standard institution , Bologna , Italy
| | - Sarah Parisi
- a Institute of Hematology L. e A. Seràgnoli , Universita degli Studi di Bologna Azienda Ospedaliera Sant\'Orsola-Malpighi Ringgold standard institution , Bologna , Italy
| | - Giorgia Simonetti
- a Institute of Hematology L. e A. Seràgnoli , Universita degli Studi di Bologna Azienda Ospedaliera Sant\'Orsola-Malpighi Ringgold standard institution , Bologna , Italy
| | - Stefania Paolini
- a Institute of Hematology L. e A. Seràgnoli , Universita degli Studi di Bologna Azienda Ospedaliera Sant\'Orsola-Malpighi Ringgold standard institution , Bologna , Italy
| | - Chiara Sartor
- a Institute of Hematology L. e A. Seràgnoli , Universita degli Studi di Bologna Azienda Ospedaliera Sant\'Orsola-Malpighi Ringgold standard institution , Bologna , Italy
| | - Emanuela Ottaviani
- a Institute of Hematology L. e A. Seràgnoli , Universita degli Studi di Bologna Azienda Ospedaliera Sant\'Orsola-Malpighi Ringgold standard institution , Bologna , Italy
| | - Nicoletta Testoni
- b Dept Hematol & Oncol Sci, St Orsola Malpighi Hospital , Univ Bologna , Bologna , Italy
| | - Giovanni Martinelli
- a Institute of Hematology L. e A. Seràgnoli , Universita degli Studi di Bologna Azienda Ospedaliera Sant\'Orsola-Malpighi Ringgold standard institution , Bologna , Italy
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22
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Duenas-Gonzalez A, Medina-Franco JL, Chavez-Blanco A, Dominguez-Gomez G, Fernández-de Gortari E. Developmental DNA methyltransferase inhibitors in the treatment of gynecologic cancers. Expert Opin Pharmacother 2015; 17:323-38. [PMID: 26559668 DOI: 10.1517/14656566.2016.1118053] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION DNA methylation has become an attractive target for the treatment of cancer. DNA methyltransferase inhibitors have proven useful for the treatment of myelodysplastic syndrome and are being evaluated in gynecological neoplasias. AREAS COVERED We provide an overview of the current knowledge on DNA methylation and cancer and the role of DNA methylation in cervical, ovarian and endometrial carcinomas. The results of recent clinical trials with demethylating agents for cervical and ovarian cancer treatment are also discussed. EXPERT OPINION There are few studies of DNA demethylating agents for cervical and ovarian cancer treatment; nevertheless, the results are promising. To accelerate these advances, there are at least two actions that can be simultaneously pursued. One is to greatly increase the number of small clinical exploratory trials with existing demethylating drugs and using methylome analyses to identify predictive factors for response and/or toxicity. The second is finding out epigenetic 'drivers' unique to gynecological cancers and their subtypes, and then proceed to clinical trials in a highly selected population of patients. It is expected that in the future, DNA demethylation could have a role in the treatment of gynecologic cancers.
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Affiliation(s)
- Alfonso Duenas-Gonzalez
- a Instituto de Investigaciones Biomédicas , Universidad Nacional Autónoma de México/Instituto Nacional de Cancerología , Mexico City , Mexico
| | - José L Medina-Franco
- b Facultad de Química, Departamento de Farmacia , Universidad Nacional Autónoma de México , México City , México
| | - Alma Chavez-Blanco
- c Division of Basic Research , Instituto Nacional de Cancerología , Mexico City , México
| | | | - Eli Fernández-de Gortari
- b Facultad de Química, Departamento de Farmacia , Universidad Nacional Autónoma de México , México City , México
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23
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Cogle CR, Scott BL, Boyd T, Garcia-Manero G. Oral Azacitidine (CC-486) for the Treatment of Myelodysplastic Syndromes and Acute Myeloid Leukemia. Oncologist 2015; 20:1404-12. [PMID: 26463870 PMCID: PMC4679081 DOI: 10.1634/theoncologist.2015-0165] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 08/21/2015] [Indexed: 12/22/2022] Open
Abstract
The myelodysplastic syndromes (MDS) comprise a heterogeneous group of clonal myeloid malignancies characterized by multilineage cytopenias, recurrent cytogenetic abnormalities, and risk of progression to acute myeloid leukemia (AML). AML, which can occur de novo as well as secondary to MDS, is characterized by malignant clones of myeloid lineage in the bone marrow and peripheral blood, with dissemination into tissues. The cytidine nucleoside analog and epigenetic modifier azacitidine is approved in the U.S. for the treatment of all French-American-British subtypes of MDS and in many countries for the treatment of AML with 20%-30% blasts and multilineage dysplasia according to the World Health Organization classification. Benefits of azacitidine treatment of patients with AML with >30% blasts have also been shown in a recent phase III trial. Oral administration of azacitidine may enhance patient convenience, eliminate injection-site reactions, allow for alternative dosing and scheduling, and enable long-term treatment. Phase I studies with oral azacitidine (CC-486) have shown biological activity, clinical responses, and tolerability in patients with MDS and AML. Extended dosing schedules of oral azacitidine (for 14 or 21 days of 28-day cycles) are currently under investigation as frontline therapy in patients with lower risk MDS, as maintenance therapy for patients with AML not eligible for stem cell transplant, and as maintenance therapy for patients with MDS or AML following stem cell transplant. This review presents clinical data supporting the use of injectable azacitidine in MDS and AML and examines the rationale for and results of the clinical development of oral azacitidine.
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Affiliation(s)
- Christopher R Cogle
- Division of Hematology and Oncology, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Bart L Scott
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Thomas Boyd
- North Star Lodge Cancer Center, Yakima, Washington, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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24
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Lowder JN, Taverna P, Issa JPJ. Will next-generation agents deliver on the promise of epigenetic hypomethylation therapy? Epigenomics 2015; 7:1083-8. [PMID: 26541345 DOI: 10.2217/epi.15.66] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- James N Lowder
- Astex Pharmaceuticals, 4420 Rosewood Drive, Suite 200, Pleasanton, CA 92488, USA
| | - Pietro Taverna
- Astex Pharmaceuticals, 4420 Rosewood Drive, Suite 200, Pleasanton, CA 92488, USA
| | - Jean-Pierre J Issa
- Fels Institute, Temple University School of Medicine & Cancer Epigenetics Program, Fox Chase Cancer Center, Temple Health, 3307 North Broad Street, Room 154, Philadelphia, PA 19140, USA
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25
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Garcia-Manero G, Gore SD, Kambhampati S, Scott B, Tefferi A, Cogle CR, Edenfield WJ, Hetzer J, Kumar K, Laille E, Shi T, MacBeth KJ, Skikne B. Efficacy and safety of extended dosing schedules of CC-486 (oral azacitidine) in patients with lower-risk myelodysplastic syndromes. Leukemia 2015; 30:889-96. [PMID: 26442612 PMCID: PMC4832070 DOI: 10.1038/leu.2015.265] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/02/2015] [Accepted: 09/16/2015] [Indexed: 11/18/2022]
Abstract
CC-486, the oral formulation of azacitidine (AZA), is an epigenetic modifier and DNA methyltransferase inhibitor in clinical development for treatment of hematologic malignancies. CC-486 administered for 7 days per 28-day treatment cycle was evaluated in a phase 1 dose-finding study. AZA has a short plasma half-life and DNA incorporation is S-phase-restricted; extending CC-486 exposure may increase the number of AZA-affected diseased target cells and maximize therapeutic effects. Patients with lower-risk myelodysplastic syndromes (MDS) received 300 mg CC-486 once daily for 14 days (n=28) or 21 days (n=27) of repeated 28-day cycles. Median patient age was 72 years (range 31–87) and 75% of patients had International Prognostic Scoring System Intermediate-1 risk MDS. Median number of CC-486 treatment cycles was 7 (range 2–24) for the 14-day dosing schedule and 6 (1–24) for the 21-day schedule. Overall response (complete or partial remission, red blood cell (RBC) or platelet transfusion independence (TI), or hematologic improvement) (International Working Group 2006) was attained by 36% of patients receiving 14-day dosing and 41% receiving 21-day dosing. RBC TI rates were similar with both dosing schedules (31% and 38%, respectively). CC-486 was generally well-tolerated. Extended dosing schedules of oral CC-486 may provide effective long-term treatment for patients with lower-risk MDS.
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Affiliation(s)
- G Garcia-Manero
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S D Gore
- Yale Cancer Center, New Haven, CT, USA
| | - S Kambhampati
- Division of Hematology/Oncology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - B Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - A Tefferi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - C R Cogle
- Medicine/Hematology & Oncology, University of Florida, Gainesville, FL, USA
| | - W J Edenfield
- Cancer Centers of The Carolinas, Greenville, SC, USA
| | - J Hetzer
- Celgene Corporation, Summit, NJ, USA
| | - K Kumar
- Celgene Corporation, Summit, NJ, USA
| | - E Laille
- Celgene Corporation, Summit, NJ, USA
| | - T Shi
- Celgene Corporation, Summit, NJ, USA
| | | | - B Skikne
- Celgene Corporation, Summit, NJ, USA
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26
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Abstract
Cancer genome sequencing has created an opportunity for precision medicine. Thus far, genetic alterations can only be used to guide treatment for small subsets of certain cancer types with these key alterations. Similar to mutations, epigenetic events are equally suitable for personalized medicine. DNA methylation alterations have been used to identify tumor-specific drug responsive markers. Methylation of MGMT sensitizes gliomas to alkylating agents is an example of epigenetic personalized medicine. Recent studies have revealed that 5-azacytidine and decitabine show activity in myelodysplasia, lung and other cancers. There are currently at least 20 kinds of histone deacetylase inhibitors in clinical testing. Inhibitors targeting other epigenetic regulators are being clinically tested, such as EZH2 inhibitor EPZ-6438.
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Affiliation(s)
- Wenji Yan
- Department of Gastroenterology & Hepatology, Chinese PLA General Hospital, #28 Fuxing Road, Beijing 100853, China
| | - James G Herman
- The Hillman Cancer Center, University of Pittsburgh Cancer Institute, 5117 Centre Avenue, Suite 2.18/Research, Pittsburgh, PA 15213, USA
| | - Mingzhou Guo
- Department of Gastroenterology & Hepatology, Chinese PLA General Hospital, #28 Fuxing Road, Beijing 100853, China
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27
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Anders NM, Wanjiku TM, He P, Azad NS, Rudek MA. A robust and rapid liquid chromatography tandem mass spectrometric method for the quantitative analysis of 5-azacytidine. Biomed Chromatogr 2015; 30:494-6. [PMID: 26174363 DOI: 10.1002/bmc.3562] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 06/25/2015] [Accepted: 07/06/2015] [Indexed: 11/09/2022]
Abstract
The DNA methyltransferase inhibitor 5-azacytidine is being evaluated clinically as an oral formulation to treat various solid tumors. A sensitive, reliable method was developed to quantitate 5-azacytidine using LC-MS/MS to perform detailed pharmacokinetic studies. The drug of interest was extracted from plasma using Oasis MCX ion exchange solid-phase extraction 96-well plates. Chromatographic separation was achieved with a YMC J'sphere M80 C18 column and isocratic elution with a methanol-water-formic acid (15:85:0.1, v/v/v) mobile phase over a 7 min total analytical run time. An AB Sciex 5500 triple quadrupole mass spectrometer operated in positive electrospray ionization mode was used for the detection of 5-azacytidine. The assay range was 5-500 ng/mL and proved to be accurate (97.8-109.1%) and precise (CV ≤ 9.8%). Tetrahydrouridine was used to stabilize 5-azacytidine in blood/plasma samples. With the addition of tetrahydrouridine, long-term frozen plasma stability for 5-azacytidine at -70°C has been determined for at least 323 days. The method was applied for the measurement of total plasma concentrations of 5-azacytidine in a cancer patient receiving a 300 mg oral daily dose.
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Affiliation(s)
- Nicole M Anders
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - Teresia M Wanjiku
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - Ping He
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - Nilofer S Azad
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - Michelle A Rudek
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
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28
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Hamm CA, Costa FF. Epigenomes as therapeutic targets. Pharmacol Ther 2015; 151:72-86. [PMID: 25797698 DOI: 10.1016/j.pharmthera.2015.03.003] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 03/06/2015] [Indexed: 12/19/2022]
Abstract
Epigenetics is a molecular phenomenon that pertains to heritable changes in gene expression that do not involve changes in the DNA sequence. Epigenetic modifications in a whole genome, known as the epigenome, play an essential role in the regulation of gene expression in both normal development and disease. Traditional epigenetic changes include DNA methylation and histone modifications. Recent evidence reveals that other players, such as non-coding RNAs, may have an epigenetic regulatory role. Aberrant epigenetic signaling is becoming to be known as a central component of human disease, and the reversible nature of the epigenetic modifications provides an exciting opportunity for the development of clinically relevant therapeutics. Current epigenetic therapies provide a clinical benefit through disrupting DNA methyltransferases or histone deacetylases. However, the emergence of next-generation epigenetic therapies provides an opportunity to more effectively disrupt epigenetic disease states. Novel epigenetic therapies may improve drug targeting and drug delivery, optimize dosing schedules, and improve the efficacy of preexisting treatment modalities (chemotherapy, radiation, and immunotherapy). This review discusses the epigenetic mechanisms that contribute to the disease, available epigenetic therapies, epigenetic therapies currently in development, and the potential future use of epigenetic therapeutics in a clinical setting.
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Affiliation(s)
- Christopher A Hamm
- Cancer Biology and Epigenomics Program, Ann & Robert H Lurie Children's Hospital of Chicago Research Center and Department of Pediatrics, Northwestern University's Feinberg School of Medicine, 225 E. Chicago Avenue, Box 220, Chicago, IL 60611-2605, USA.
| | - Fabricio F Costa
- Cancer Biology and Epigenomics Program, Ann & Robert H Lurie Children's Hospital of Chicago Research Center and Department of Pediatrics, Northwestern University's Feinberg School of Medicine, 225 E. Chicago Avenue, Box 220, Chicago, IL 60611-2605, USA; StartUp Health Academy, 2000 Broadway St, 18th Floor, New York, NY 10.023, USA; Genomic Enterprise, 2405 N. Sheffield Av., # 14088, Chicago, IL 60.614, USA; Genomic Sciences and Biotechnology Program, UCB - Brasilia, SGAN 916 Modulo B, Bloco C, 70.790-160 Brasilia, Brazil.
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29
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Erdmann A, Halby L, Fahy J, Arimondo PB. Targeting DNA Methylation with Small Molecules: What’s Next? J Med Chem 2014; 58:2569-83. [DOI: 10.1021/jm500843d] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Alexandre Erdmann
- Epigenetic Targeting of Cancer,
USR3388 ETaC, CNRS-Pierre Fabre, 3 Avenue H. Curien, 31035 Toulouse Cedex 01, France
| | - Ludovic Halby
- Epigenetic Targeting of Cancer,
USR3388 ETaC, CNRS-Pierre Fabre, 3 Avenue H. Curien, 31035 Toulouse Cedex 01, France
| | - Jacques Fahy
- Epigenetic Targeting of Cancer,
USR3388 ETaC, CNRS-Pierre Fabre, 3 Avenue H. Curien, 31035 Toulouse Cedex 01, France
| | - Paola B Arimondo
- Epigenetic Targeting of Cancer,
USR3388 ETaC, CNRS-Pierre Fabre, 3 Avenue H. Curien, 31035 Toulouse Cedex 01, France
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30
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Stopping higher-risk myelodysplastic syndrome in its tracks. Curr Hematol Malig Rep 2014; 9:421-31. [PMID: 25208927 DOI: 10.1007/s11899-014-0234-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Higher-risk myelodysplastic syndromes (MDS) are a collection of diseases associated with poor outcomes from complications related to bone marrow failure and evolution to acute myeloid leukemia. While most patients receive epigenetic therapies, intensive chemotherapy or allogeneic stem cell transplantation, more tolerable and effective treatments are necessary to realize the goal of stopping this disease in its tracks. Recent efforts, building on decades of research exploring the pathogenesis of this disease, have revealed exciting clues that elucidate critical biological features that drive or contribute to MDS, and may serve as targets for selective and well-tolerated future therapies. Here, we review the current diagnostic, prognostic, and therapeutic approaches to higher-risk MDS.
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