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Ravenstijn P, Chetty M, Manchandani P, Elmeliegy M, Qosa H, Younis I. Design and conduct considerations for studies in patients with hepatic impairment. Clin Transl Sci 2022; 16:50-61. [PMID: 36176049 PMCID: PMC9841300 DOI: 10.1111/cts.13428] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 02/06/2023] Open
Abstract
Despite the liver being the primary site for clearance of xenobiotics utilizing a myriad of mechanisms ranging from cytochrome P450 enzyme pathways, glucuronidation, and biliary excretion, there is a dearth of information available as to how the severity of hepatic impairment (HI) can alter drug absorption and disposition (i.e., pharmacokinetics [PK]) as well as their efficacy and safety or pharmacodynamics (PD). In general, regulatory agencies recommend conducting PK studies in subjects with HI when hepatic metabolism/excretion accounts for more than 20% of drug elimination or if the drug has a narrow therapeutic range. In this tutorial, we provide an overview of the global regulatory landscape, clinical measures for hepatic function assessment, methods to stage HI severity, and consequently the impact on labeling. In addition, we provide an in-depth practical guidance for designing and conducting clinical trials for patients with HI and on the application of modeling and simulation strategies in lieu of dedicated trials for dosing recommendations in patients with HI.
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Affiliation(s)
| | - Manoranjenni Chetty
- Discipline of Pharmaceutical SciencesCollege of Health SciencesUniversity of KwaZulu NatalBereaSouth Africa
| | - Pooja Manchandani
- Clinical Pharmacology and Exploratory DevelopmentAstellas Pharma US Inc.NorthbrookIllinoisUSA
| | - Mohamed Elmeliegy
- Clinical PharmacologyGlobal Product DevelopmentPfizer Inc.San DiegoCaliforniaUSA
| | - Hisham Qosa
- Clinical Pharmacology and PharmacometricsBristol Myers SquibbPrincetonNew JerseyUSA
| | - Islam Younis
- Clinical PharmacologyGilead SciencesFoster CityCaliforniaUSA
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2
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Abstract
Background and Objective Dacomitinib is a kinase inhibitor indicated for the first-line treatment of patients with metastatic non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR)-activating mutations. To evaluate the effect of hepatic impairment on the pharmacokinetics of dacomitinib, two dedicated studies were conducted to inform optimal dosing. Methods Study 1 (NCT01571388) evaluated the effect of mild and moderate hepatic impairment on the plasma pharmacokinetics, safety, and tolerability after a single oral dose of dacomitinib 30 mg, and Study 2 (NCT03865446) evaluated the same endpoints in a severe hepatic impairment population. Both studies were phase I, open-label, parallel-group studies. A one-way analysis of variance (ANOVA) with unequal variance assumption and hepatic impairment group as a fixed effect was used to compare the natural log of area under the plasma concentration-time curve extrapolated to infinite time (AUCinf), AUC from time zero to the last quantifiable concentration (AUClast), and maximum plasma concentration (Cmax) for each hepatic impairment group to the respective normal hepatic function group. Since dacomitinib is a cytochrome P450 (CYP) 2D6 substrate, only participants with extensive or intermediate CYP2D6 phenotypes were included in the primary analysis. Results The AUCinf for participants with mild, moderate, or severe hepatic impairment decreased by 6%, decreased by 23%, and increased by 4%, respectively, compared with normal hepatic function, while the Cmax for participants with mild, moderate, or severe hepatic impairment increased by 3%, decreased by 20%, and increased by 31%, respectively, compared with normal hepatic function. A single oral dose of dacomitinib 30 mg was well tolerated in all participants. Conclusion Based on these pharmacokinetic results, dacomitinib pharmacokinetics of participants with mild, moderate, or severe hepatic impairment were not statistically different relative to participants with normal hepatic function based on the ANOVA analysis. No dacomitinib dose adjustments for patients with hepatic impairment are recommended. Clinical Trial Registration ClinicalTrials.gov NCT01571388, registered 5 April 2012; ClinicalTrials.gov NCT03865446, registered 6 March 2019. Supplementary Information The online version contains supplementary material available at 10.1007/s40261-022-01125-x.
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Palmieri C, Macpherson IR. A review of the evidence base for utilizing Child-Pugh criteria for guiding dosing of anticancer drugs in patients with cancer and liver impairment. ESMO Open 2021; 6:100162. [PMID: 34098229 PMCID: PMC8190488 DOI: 10.1016/j.esmoop.2021.100162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 04/12/2021] [Accepted: 05/05/2021] [Indexed: 12/24/2022] Open
Abstract
As the liver is vital for the metabolism of many anticancer drugs, determining the correct starting doses in cancer patients with liver impairment is key to safe prescription and prevention of unnecessary adverse effects. Clinicians typically use liver function tests when evaluating patients; however, prescribing information and summaries of product characteristics often suggest dosing of anticancer drugs in patients with liver impairment based on the Child-Pugh criteria, even though the criteria were not developed for this purpose. In this review, we assessed all the oncological small molecule and cytotoxic drugs approved by the United States Food and Drug Administration (FDA) over a 5-year period from 2014 to 2018. The various entry criteria related to these drugs—with respect to hepatic function—in key pivotal studies were compared with their approved dosing recommendations found in prescribing information and summaries of product characteristics. We found that 46% of drugs have dosing recommendations based on Child-Pugh criteria alone, despite the fact that only 8% of these drugs were tested within studies that used the Child-Pugh criteria as entry criteria. Moreover, we note that the data used to make recommendations based on Child-Pugh criteria are typically from small studies that may lack an appropriate patient population. We propose that these findings, along with details surrounding the development of the Child-Pugh criteria, call into question the validity and appropriateness of using Child-Pugh criteria for dosing recommendations of anticancer drugs. Dosing information for anticancer drugs in patients with liver impairment is often based on the Child-Pugh criteria. Clinical trials and clinicians typically use liver function tests when evaluating patients. Of the 39 oncologic drugs examined, almost half (46%) had dosing recommendations based on Child-Pugh criteria alone. We question whether using Child-Pugh criteria for dosing recommendations of anticancer drugs is the best approach.
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Affiliation(s)
- C Palmieri
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK; Academic Department of Medical Oncology, The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK.
| | - I R Macpherson
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
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Macpherson IR, He Y, Palmieri C. Eribulin, Child-Pugh score, and liver-function tests: lessons from pivotal breast cancer studies 301 and 305. Breast Cancer Res 2021; 23:33. [PMID: 33736675 PMCID: PMC7977154 DOI: 10.1186/s13058-021-01407-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 02/17/2021] [Indexed: 11/12/2022] Open
Abstract
Background The recommended starting dose of eribulin in patients with hepatic impairment is based on the Child-Pugh score, largely informed by a pharmacokinetic study of 18 patients. In the pivotal studies of eribulin in metastatic breast cancer (Study 301 and Study 305 [EMBRACE]), entry criteria and dose modifications were based on liver-function test (LFT) results rather than Child-Pugh score. In populations such as patients with metastatic breast cancer, in which metastatic infiltration is the predominant cause of hepatic impairment, using Child-Pugh score may be problematic; in clinical practice, it has been more common for oncologists to make dosing decisions based on LFTs. To address this, the effects of abnormal baseline LFT results on eribulin efficacy and safety were investigated. Methods In this pooled post hoc analysis, 1062 patients who were randomized to receive eribulin in Studies 301 and 305 were divided into 4 groups: (A) no elevated LFT results (no liver impairment); (B) increased levels of aspartate aminotransferase and/or alanine aminotransferase; (C) decreased albumin and/or increased levels of aspartate aminotransferase and/or alanine aminotransferase but not increased bilirubin; and (D) increased bilirubin. Patients were subcategorized by presence of liver metastasis. Drug exposure, dose intensity, and treatment-emergent adverse events (TEAEs) were analyzed. Results Eribulin mesylate mean dosage was 0.82 (group A)–0.65 mg/m2/week (group D). Group D had shorter treatment, more dose reductions/delays, more TEAEs leading to dose modifications, and numerically lower objective response rates and clinical benefit rates versus groups A–C. TEAE rates leading to dose modification were similar between group D (45.5%) and groups A–C (range, 43.5–54.9%) in the absence of liver metastases, but higher in group D (91.3%) compared with groups A–C (range, 41.7–54.3%) if liver metastases were present. Conclusions Mild elevations in bilirubin levels were associated with increased toxicity and a greater requirement for dose modifications. Based both on these study data and existing recommendations, we propose a novel scheme to guide initial dose selection in patients with metastatic breast cancer and hepatic impairment that is based on LFTs rather than Child-Pugh score. Supplementary Information The online version contains supplementary material available at 10.1186/s13058-021-01407-w.
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Affiliation(s)
- Iain R Macpherson
- Institute of Cancer Sciences, CR-UK Beatson Institute, University of Glasgow, Glasgow, UK
| | - Yaohua He
- Formerly of Eisai Inc., Woodcliff Lake, NJ, USA
| | - Carlo Palmieri
- Department of Molecular and Clinical Cancer Medicine, The Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Ashton Street, Liverpool, L69 3GE, UK. .,Academic Department of Medical Oncology, The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK.
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5
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Maesaka K, Sakamori R, Yamada R, Urabe A, Tahata Y, Oshita M, Ohkawa K, Mita E, Hagiwara H, Tamura S, Ito T, Yakushijin T, Iio S, Kodama T, Hikita H, Tatsumi T, Takehara T. Therapeutic efficacy of lenvatinib in hepatocellular carcinoma patients with portal hypertension. Hepatol Res 2020; 50:1091-1100. [PMID: 32559342 DOI: 10.1111/hepr.13537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/09/2020] [Accepted: 06/14/2020] [Indexed: 02/08/2023]
Abstract
AIM Preserved liver function may be an important factor affecting therapeutic efficacy in hepatocellular carcinoma patients treated with lenvatinib, but not all patients can be treated while preserving liver function. This study evaluated the therapeutic efficacy of lenvatinib in patients with poor liver function with and without portal hypertension. METHODS This prospectively registered multicenter study analyzed 93 patients treated with lenvatinib. Progression-free survival was compared between patients with and without advanced portal hypertension according to baseline liver function. Advanced portal hypertension was defined as having both splenomegaly and any portosystemic collaterals. RESULTS A total of 37 patients (40.7%) had advanced portal hypertension. Progression-free survival did not differ between patients with and without advanced portal hypertension in the entire cohort (median 7.6 vs. 4.1 months, respectively; P = 0.148), but was significantly longer in patients with advanced portal hypertension than in those without advanced portal hypertension in the albumin-bilirubin grade 2 or 3 group (median 7.6 vs. 2.1 months, respectively; P = 0.016). In a multivariate analysis, the presence of advanced portal hypertension was identified as the only significant predictor associated with prolonged progression-free survival in the albumin-bilirubin grade 2 or 3 group. CONCLUSIONS Advanced portal hypertension was associated with the therapeutic efficacy of lenvatinib in controlling the progression of hepatocellular carcinoma in patients with poor liver function.
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Affiliation(s)
- Kazuki Maesaka
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Ryotaro Sakamori
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Ryoko Yamada
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Ayako Urabe
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yuki Tahata
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | | | | | - Eiji Mita
- National Hospital Organization Osaka Medical Center, Osaka, Osaka, Japan
| | | | | | - Toshifumi Ito
- Japan Community Healthcare Organization, Osaka Hospital, Osaka, Osaka, Japan
| | | | - Sadaharu Iio
- Hyogo Prefectural Nishinomiya Hospital, Nishinomiya, Hyogo, Japan
| | - Takahiro Kodama
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hayato Hikita
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tomohide Tatsumi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Krens SD, Lassche G, Jansman FGA, Desar IME, Lankheet NAG, Burger DM, van Herpen CML, van Erp NP. Dose recommendations for anticancer drugs in patients with renal or hepatic impairment. Lancet Oncol 2020; 20:e200-e207. [PMID: 30942181 DOI: 10.1016/s1470-2045(19)30145-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/19/2019] [Accepted: 02/19/2019] [Indexed: 01/22/2023]
Abstract
Renal or hepatic impairment is a common comorbidity for patients with cancer either because of the disease itself, toxicity of previous anticancer treatments, or because of other factors affecting organ function, such as increased age. Because renal and hepatic function are among the main determinants of drug exposure, the pharmacokinetic profile might be altered for patients with cancer who have renal or hepatic impairment, necessitating dose adjustments. Most anticancer drugs are dosed near their maximum tolerated dose and are characterised by a narrow therapeutic index. Consequently, selecting an adequate dose for patients who have either hepatic or renal impairment, or both, is challenging and definitive recommendations on dose adjustments are scarce. In this Review, we discuss the effect of renal and hepatic impairment on the pharmacokinetics of anticancer drugs. To guide clinicians in selecting appropriate dose adjustments, information from available drug labels and from the published literature were combined to provide a practical set of recommendations for dose adjustments of 160 anticancer drugs for patients with hepatic and renal impairment.
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Affiliation(s)
- Stefanie D Krens
- Department of Clinical Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Gerben Lassche
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Frank G A Jansman
- Department of Pharmacy, Deventer Hospital, Deventer, Netherlands; PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands
| | - Ingrid M E Desar
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nienke A G Lankheet
- Department of Clinical Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands; Department of Clinical Pharmacy, Medisch Spectrum Twente, Enschede, Netherlands
| | - David M Burger
- Department of Clinical Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Carla M L van Herpen
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nielka P van Erp
- Department of Clinical Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands.
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Palmieri C, Macpherson I. Use of the Child-Pugh score in anticancer drug dosing decision making: proceed with caution. Lancet Oncol 2020; 20:e289. [PMID: 31162096 DOI: 10.1016/s1470-2045(19)30296-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 05/02/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Carlo Palmieri
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, Liverpool, L69 3GE, UK.
| | - Iain Macpherson
- Institute of Cancer Sciences, University of Glasgow, Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, Bearsden, UK
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8
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Sakamoto S, Sato K, Takita Y, Izumiya Y, Kumagai N, Sudo K, Hasegawa Y, Yokota H, Akamine Y, Okuda Y, Asano M, Takeda M, Sano M, Miura M, Nakayama K. ABCG2 C421A polymorphisms affect exposure of the epidermal growth factor receptor inhibitor gefitinib. Invest New Drugs 2020; 38:1687-1695. [PMID: 32436059 DOI: 10.1007/s10637-020-00946-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/06/2020] [Indexed: 01/05/2023]
Abstract
ATP-binding castle protein G2 (ABCG2) is thought to inhibit the activities of certain gefitinib transporters, thereby affecting drug pharmacokinetics. The C421A polymorphism affects the function and expression of ABCG2 on the cell membrane. Previous studies have shown that proton-pump inhibitors (PPIs) inhibit gefitinib absorption, as well as the function of ABCG2. We evaluated the plasma concentrations of gefitinib in patients with and without the ABCG2 C421A polymorphism, who were or were not taking PPIs. In total, 61 patients with advanced epidermal-growth-factor-positive non-small-cell lung cancer were enrolled in this study. They were treated with gefitinib at a dose of 250 mg per day. Plasma gefitinib concentration and ABCG2 C421A status were determined after 2 weeks. The patients were divided into CC- and CA/AA genotype groups. We compared the trough and peak gefitinib levels and the area under the curve (AUC) values for 24-h gefitinib concentrations. We also compared these parameters among four groups distinguished according to the presence or absence of the polymorphism and PPI use. The mean trough gefitinib level and AUC value for 24-h gefitinib concentration were significantly lower in the CA/AA group compared to the CC group (mean trough level: 333.2 vs. 454.5 ng/mL, respectively, P = 0.021; AUC: 9949.9 vs. 13,085.4 ng・h/mL, respectively, P = 0.034). Among patients taking PPIs, the mean trough gefitinib level was significantly lower in the CA/AA group than the CC group (220.1 vs. 340.5 ng/mL, respectively, P = 0.033). The CA/AA-type of ABCG2 C421A polymorphism may be associated with lower gefitinib plasma concentrations.
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Affiliation(s)
- Sho Sakamoto
- Department of Respiratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Kazuhiro Sato
- Department of Respiratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Yuri Takita
- Department of Respiratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Yuka Izumiya
- Department of Respiratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Naho Kumagai
- Department of Respiratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Kazuhisa Sudo
- Department of Respiratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Yukiyasu Hasegawa
- Department of Respiratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Hayato Yokota
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Yumiko Akamine
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Yuji Okuda
- Department of Respiratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Mariko Asano
- Department of Respiratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Masahide Takeda
- Department of Respiratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Masaaki Sano
- Department of Respiratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Masatomo Miura
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Katsutoshi Nakayama
- Department of Respiratory Medicine, Akita University Graduate School of Medicine, Akita, Japan.
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9
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Bile Duct Obstruction Leads to Increased Intestinal Expression of Breast Cancer Resistance Protein With Reduced Gastrointestinal Absorption of Imatinib. J Pharm Sci 2019; 108:3130-3137. [DOI: 10.1016/j.xphs.2019.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/04/2019] [Accepted: 05/14/2019] [Indexed: 12/12/2022]
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Nguyen L, Chapel S, Tran BD, Lacy S. Updated Population Pharmacokinetic Model of Cabozantinib Integrating Various Cancer Types Including Hepatocellular Carcinoma. J Clin Pharmacol 2019; 59:1551-1561. [PMID: 31187515 PMCID: PMC6790584 DOI: 10.1002/jcph.1467] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 05/22/2019] [Indexed: 12/14/2022]
Abstract
An integrated population pharmacokinetic (PPK) model was used to evaluate the effects of liver dysfunction on the pharmacokinetics (PK) of cabozantinib in patients with hepatocellular carcinoma and to determine whether clinical dosage adjustment may be necessary in this population. An integrated PPK model previously developed in healthy volunteers and patients with various cancer types was updated with cabozantinib concentration data from hepatocellular carcinoma patients in phase 2 and 3 studies (total 2023; hepatocellular carcinoma 489 patients). Covariate effects of cancer type including hepatocellular carcinoma population and liver dysfunction per the National Cancer Institute Organ Dysfunction Working Group criteria were evaluated (normal 1425; mild liver dysfunction 558; moderate/severe liver dysfunction 15/1 patients). With hepatocellular carcinoma patients, PK parameter estimates and covariate effects were similar to the previous PPK model (2 compartments with first‐ and zero‐order absorption and first‐order elimination). Only medullary thyroid cancer had appreciable PK differences from healthy volunteers. PK parameter estimates were similar with and without addition of liver dysfunction covariates. Patients with mild liver dysfunction were predicted to have minimal differences in apparent clearance of cabozantinib relative to patients with normal liver function. Therefore, no initial cabozantinib dosage adjustment is recommended for cancer patients with mild liver dysfunction. The small sample size for patients with moderate and severe liver dysfunction limited dosing recommendations in these subpopulations. The results from this PPK analysis were different from those of the single‐dose hepatic impairment study in healthy volunteers and more reflective of exposure in cancer patients following daily cabozantinib dosing.
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Affiliation(s)
| | - Sunny Chapel
- Ann Arbor Pharmacometrics Group, Inc, Ann Arbor, MI, USA
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11
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Lucas CJ, Martin JH. Pharmacokinetic-Guided Dosing of New Oral Cancer Agents. J Clin Pharmacol 2017; 57 Suppl 10:S78-S98. [DOI: 10.1002/jcph.937] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 04/10/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Catherine J. Lucas
- Discipline of Clinical Pharmacology, School of Medicine and Public Health; University of Newcastle; New South Wales Australia
| | - Jennifer H. Martin
- Discipline of Clinical Pharmacology, School of Medicine and Public Health; University of Newcastle; New South Wales Australia
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12
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Wang TF, Chu SC, Lee JJ, Yang GG, Huang WH, Chang ET, Low T, Wu YF, Kao RH, Lin CB. Presence of pleural effusion is associated with a poor prognosis in patients with epidermal growth factor receptor-mutated lung cancer receiving tyrosine kinase inhibitors as first-line treatment. Asia Pac J Clin Oncol 2017; 13:304-313. [PMID: 28124437 DOI: 10.1111/ajco.12658] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 11/10/2016] [Accepted: 11/16/2016] [Indexed: 11/27/2022]
Abstract
AIM This study was conducted to evaluate the effect of clinical factors on the treatment outcomes of lung cancer patients with active epidermal growth factor receptor (EGFR) mutations treated by first-line tyrosine kinase inhibitors (TKIs). METHODS Patients of stage IIIb or IV lung adenocarcinoma harboring mutated EGFR were enrolled between March 2010 and June 2014 and followed up until December 2015. The effects of various clinical features, such as age, sex, smoking history, EGFR mutation types, TKIs used, presence of pleural effusion, metastatic sites on progression-free survival (PFS) and overall survival (OS), were analyzed retrospectively. RESULTS A total of 104 patients were included in this study. Patients with pleural effusion at initial diagnosis had significantly shorter PFS and OS than those without pleural effusion (median PFS: 8.2 months vs 15.3 months, P = 0.0004; median OS: 16.3 months vs 28.2 months, P = 0.0003). Univariate analysis revealed that being male or a smoker was associated with short PFS, whereas smoking history, bony metastasis and malignant pleural effusion were associated with poor OS. Stepwise multivariate Cox regression analysis showed that the presence of pleural effusion and different TKI use were independent prognostic factors for PFS [hazard ratio [HR] = 2.50 (95% confidence interval [CI], 1.53-4.10), P = 0.0003 and HR = 0.55 (95% CI, 0.31-0.97), P = 0.0396, respectively], whereas the presence of pleural effusion and liver metastasis were associated with poor OS [HR = 2.79 (95% CI: 1.46-5.30), P = 0.0018 and HR = 2.12 (95% CI, 1.02-4.40), P = 0.0440, respectively]. CONCLUSION The presence of pleural effusion predicts poor PFS and OS in lung adenocarcinoma patients receiving TKIs as the first-line treatment. Additional studies are warranted to elucidate the underlying mechanisms and determine novel strategies for improving the outcome of these patients.
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Affiliation(s)
- Tso-Fu Wang
- Departments of Hematology and Oncology, Buddhist Tzu-Chi General Hospital, Hualien, Taiwan.,College of Medicine, Tzu-Chi University, Hualien, Taiwan
| | - Sung-Chao Chu
- Departments of Hematology and Oncology, Buddhist Tzu-Chi General Hospital, Hualien, Taiwan.,College of Medicine, Tzu-Chi University, Hualien, Taiwan
| | - Jen-Jyh Lee
- Division of Chest Medicine, Department of Internal Medicine, Buddhist Tzu-Chi General Hospital, Hualien, Taiwan.,College of Medicine, Tzu-Chi University, Hualien, Taiwan
| | - Gee-Gwo Yang
- Division of Chest Medicine, Department of Internal Medicine, Buddhist Tzu-Chi General Hospital, Hualien, Taiwan.,College of Medicine, Tzu-Chi University, Hualien, Taiwan
| | - Wei-Han Huang
- Departments of Hematology and Oncology, Buddhist Tzu-Chi General Hospital, Hualien, Taiwan.,Division of Clinical Pathology, Department of Laboratory Medicine, Buddhist Tzu-Chi General Hospital, Hualien, Taiwan
| | - En-Ting Chang
- Division of Chest Medicine, Department of Internal Medicine, Buddhist Tzu-Chi General Hospital, Hualien, Taiwan.,College of Medicine, Tzu-Chi University, Hualien, Taiwan
| | - Tissot Low
- Division of Chest Medicine, Department of Internal Medicine, Buddhist Tzu-Chi General Hospital, Hualien, Taiwan
| | - Yi-Feng Wu
- Departments of Hematology and Oncology, Buddhist Tzu-Chi General Hospital, Hualien, Taiwan
| | - Ruey-Ho Kao
- Departments of Hematology and Oncology, Buddhist Tzu-Chi General Hospital, Hualien, Taiwan.,College of Medicine, Tzu-Chi University, Hualien, Taiwan
| | - Chih-Bin Lin
- Division of Chest Medicine, Department of Internal Medicine, Buddhist Tzu-Chi General Hospital, Hualien, Taiwan.,College of Medicine, Tzu-Chi University, Hualien, Taiwan
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Ikeda M, Okusaka T, Mitsunaga S, Ueno H, Tamai T, Suzuki T, Hayato S, Kadowaki T, Okita K, Kumada H. Safety and Pharmacokinetics of Lenvatinib in Patients with Advanced Hepatocellular Carcinoma. Clin Cancer Res 2015; 22:1385-94. [PMID: 26500236 DOI: 10.1158/1078-0432.ccr-15-1354] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 10/13/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE To determine the maximum tolerable dose (MTD), safety, pharmacokinetics, pharmacodynamics, and preliminary efficacy of lenvatinib in patients with advanced hepatocellular carcinoma (HCC). EXPERIMENTAL DESIGN This multicenter, open-label, phase I, dose-escalation study included patients aged 20 to 80 years, refractory to standard therapy, and stratified by hepatic function measured using Child-Pugh (CP) scores: CP-A (score, 5-6) and CP-B (score, 7-8). Lenvatinib was administered continually once daily for 4-week cycles. MTD was defined as the maximum dose associated with ≤ 1 dose-limiting toxicity (DLT) occurring in cycle 1 among 6 patients. RESULTS In total, 20 patients (9 in CP-A and 11 in CP-B) were enrolled. The MTD was 12 and 8 mg once daily in CP-A and CP-B, respectively; DLTs included proteinuria, hepatic encephalopathy, and hyperbilirubinemia. The most common grade 3 toxicities included hypertension in CP-A and hyperbilirubinemia in CP-B. Lenvatinib plasma concentration at 24 hours after administration (C24 h) for 12 mg once daily was higher in patients with HCC than in patients with other solid tumors shown in a previous phase I study, but C24 h for 25 mg once daily lenvatinib was comparable. After lenvatinib treatment, the number of circulating endothelial and c-Kit(+) cells decreased and the levels of interleukin (IL)-6, IL10, granulocyte-colony stimulating factor, and vascular endothelial growth factor increased (P < 0.05). Partial responses were observed in 3 patients and tumor shrinkage occurred in 14 patients. CONCLUSIONS Lenvatinib (12 mg once daily) demonstrated preliminary efficacy with manageable toxicity and is the recommended dose for phase II studies in patients with HCC and CP-A.
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Affiliation(s)
| | | | | | - Hideki Ueno
- National Cancer Center Hospital, Tokyo, Japan
| | | | | | | | - Tadashi Kadowaki
- Biomarkers and Personalized Medicine Core Function Unit, Eisai Co., Ltd., Tsukuba, Japan
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Giri N, Masters JC, Plotka A, Liang Y, Boutros T, Pardo P, O'Connell J, Bello C. Investigation of the impact of hepatic impairment on the pharmacokinetics of dacomitinib. Invest New Drugs 2015; 33:931-41. [PMID: 26048096 DOI: 10.1007/s10637-015-0256-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 05/25/2015] [Indexed: 12/21/2022]
Abstract
Dacomitinib (PF-00299804) is a small-molecule inhibitor of the tyrosine kinases human epidermal growth factor receptor-1 (HER1; epidermal growth factor receptor, EGFR), HER2, and HER4 currently being developed for the treatment of lung cancer with sensitizing mutations in EGFR or refractory to EGFR-directed treatment. Dacomitinib is largely metabolized by the liver through oxidative and conjugative metabolism; therefore, determination of the impact of varying degrees of hepatic impairment on the pharmacokinetics (PK) of dacomitinib was warranted to ensure patient safety. In this phase I, open-label, parallel-group study, a single dose of dacomitinib was administered to healthy volunteers and to subjects with mild or moderate liver dysfunction, as determined by Child-Pugh classification. The primary goal of this study was to evaluate the effects of mild and moderate hepatic impairment on the single-dose PK profile of dacomitinib, as well as to assess the safety and tolerability in these subjects. Plasma protein binding and impact of hepatic function on the PK of the active metabolite PF-05199265 was also investigated. Twenty-five male subjects received dacomitinib 30 mg, with 8 subjects in the healthy- and mild-impairment cohorts and 9 subjects in the moderate-impairment cohort. Compared with healthy volunteers, there was no significant change in dacomitinib exposure in subjects with mild or moderate liver dysfunction and no observed alteration in plasma protein binding. No serious treatment-related adverse events were reported in any group, and dacomitinib was well tolerated. A dose adjustment does not appear necessary when administering dacomitinib to patients with mild or moderate hepatic impairment.
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Affiliation(s)
- Nagdeep Giri
- Pfizer Inc, 10646 Science Center Drive, La Jolla, CA, 92121, USA,
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15
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Wu KL, Tsai MJ, Yang CJ, Chang WA, Hung JY, Yen CJ, Shen CH, Kuo TY, Lee JY, Chou SH, Liu TC, Chong IW, Huang MS. Liver metastasis predicts poorer prognosis in stage IV lung adenocarcinoma patients receiving first-line gefitinib. Lung Cancer 2015; 88:187-94. [PMID: 25747806 DOI: 10.1016/j.lungcan.2015.02.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 02/01/2015] [Accepted: 02/13/2015] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Gefitinib is currently used as a first-line therapy in patients of advanced non-small cell lung cancer (NSCLC) with susceptible epidermal growth factor receptor (EGFR) mutations. However, treatment outcomes of these patients vary. This study was conducted to evaluate the impact of specific metastatic sites on treatment outcomes of patients with stage IV lung adenocarcinoma with susceptible EGFR mutations receiving first-line gefitinib, focusing on the impact of liver metastasis. MATERIALS AND METHODS Between October 2009 and April 2014, patients of stage IV lung adenocarcinoma harboring EGFR mutation in exon 19 or 21, who received first-line gefitinib treatment, were enrolled in two hospitals and followed until December 22, 2014. The impacts of various clinical features, including sex, age, smoking history, performance status, EGFR mutation site, metastatic sites, etc., on progression-free survival (PFS) and overall survival (OS) were analyzed. RESULTS A total of 148 patients were eligible for analysis. Patients with liver metastasis on initial diagnosis (n=19) had shorter PFS and OS than those without liver metastasis did (median of PFS, 6.7 vs. 11.2 months, p<0.0001; median of OS, 9.2 vs. 17.5 months, p<0.0001). Multivariable Cox regression analysis showed liver metastasis was an independent poor prognostic factor for PFS (HR=2.939 [95% CI: 1.729-4.997], p<0.0001) and OS (HR=3.300 [95% CI: 1.708-6.373], p=0.0004). CONCLUSION Liver metastasis predicts poorer PFS and OS in stage IV lung adenocarcinoma patients with susceptible gene mutations receiving first-line gefitinib. Further study is warranted to elucidate the underlying mechanisms and find treatment modalities to improve prognosis of these patients.
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Affiliation(s)
- Kuan-Li Wu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Tz-You 1st Road, 807 Kaohsiung, Taiwan; Department of Internal Medicine, Pingtung Hospital, Ministry of Health and Welfare, Pingtung, Taiwan
| | - Ming-Ju Tsai
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Tz-You 1st Road, 807 Kaohsiung, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Jen Yang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Tz-You 1st Road, 807 Kaohsiung, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-An Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Tz-You 1st Road, 807 Kaohsiung, Taiwan; Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jen-Yu Hung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Tz-You 1st Road, 807 Kaohsiung, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chun-Ju Yen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Tz-You 1st Road, 807 Kaohsiung, Taiwan; Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chi-Hsiang Shen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Tz-You 1st Road, 807 Kaohsiung, Taiwan; Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzu-Yu Kuo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Tz-You 1st Road, 807 Kaohsiung, Taiwan
| | - Jui-Ying Lee
- Division of Chest Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shah-Hwa Chou
- Division of Chest Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Respiratory Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ta-Chih Liu
- Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Hematology and Oncology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Inn-Wen Chong
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Tz-You 1st Road, 807 Kaohsiung, Taiwan; Department of Respiratory Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Shyan Huang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Tz-You 1st Road, 807 Kaohsiung, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Individualized dosing of tyrosine kinase inhibitors: are we there yet? Drug Discov Today 2015; 20:18-36. [DOI: 10.1016/j.drudis.2014.09.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 07/25/2014] [Accepted: 09/12/2014] [Indexed: 12/11/2022]
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Shumaker R, Aluri J, Fan J, Martinez G, Pentikis H, Ren M. Influence of hepatic impairment on lenvatinib pharmacokinetics following single-dose oral administration. J Clin Pharmacol 2014; 55:317-27. [PMID: 25204557 DOI: 10.1002/jcph.398] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 09/07/2014] [Indexed: 11/07/2022]
Abstract
This open-label, single-dose study assessed lenvatinib pharmacokinetics (PK) in subjects with normal hepatic function (n = 8) and mild, moderate, or severe hepatic impairment (n = 6 each). Subjects received 10 mg oral lenvatinib, except those with severe hepatic impairment (5 mg). Plasma and urine samples were collected over 14 days; free and total lenvatinib and its metabolites were analyzed using validated chromatography/spectrometry. PK parameters were estimated using noncompartmental analysis. There were no clinically meaningful effects of mild or moderate hepatic impairment on lenvatinib PK. Dose-normalized Cmax for free lenvatinib was 7.0, 3.7, 5.7, and 5.6 ng/mL in subjects with normal hepatic function, mild, moderate, and severe hepatic impairment, respectively. There was no consistent trend, although dose-normalized Cmax was lower for all subjects with hepatic impairment. AUCs increased 170% and t1/2 increased (37 versus 23 hours) in subjects with severe hepatic impairment. Changes in exposure based on total plasma concentrations were generally less than those based on free concentrations, suggesting changes in plasma protein binding in subjects with severe hepatic impairment. Lenvatinib was generally well tolerated. Subjects with severe hepatic impairment should begin lenvatinib treatment at a reduced dose of 14 mg versus 24 mg for subjects with normal liver function and subjects with mild or moderate hepatic impairment.
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Affiliation(s)
| | | | - Jean Fan
- Eisai Inc., Woodcliff Lake, NJ, USA
| | | | | | - Min Ren
- Eisai Inc., Woodcliff Lake, NJ, USA
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Oral epidermal growth factor receptor tyrosine kinase inhibitors for the treatment of non-small cell lung cancer: Comparative pharmacokinetics and drug–drug interactions. Cancer Treat Rev 2014; 40:917-26. [DOI: 10.1016/j.ctrv.2014.06.010] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 06/17/2014] [Accepted: 06/21/2014] [Indexed: 12/23/2022]
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A limited sampling strategy for estimation of the area under the plasma concentration-time curve of gefitinib. Ther Drug Monit 2014; 36:24-9. [PMID: 24413624 DOI: 10.1097/ftd.0b013e31829dabbc] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study was to develop a limited sampling strategy (LSS) to estimate the area under the concentration-time curve (AUC) of gefitinib using data from 18 patients with non-small-cell lung cancer. METHODS On day 14 after beginning daily therapy with 250 mg of gefitinib, plasma samples were collected just before (C(0h), 24 hours after the 13th administration) and 1, 2, 4, 6, 8, 12, and 24 hours (C(nh)) after gefitinib administration and were analyzed by high-performance liquid chromatography. RESULTS The predicted AUC from 0 to 24 hours (AUC₀₋₂₄) from the single time point of C(12h) showed the highest correlation with the measured AUC₀₋₂₄ of gefitinib (AUC₀₋₂₄ = 20.0 · C(12h) + 1348.0; r² = 0.9623; P , 0.0001). The 95% confidence intervals of the slopes and intercepts of the formulae obtained by bootstrap analysis indicated acceptable accuracy and robustness in the prediction of AUC₀₋₂₄ using C(0h), C(1h), C(12h), and C(1h) + C(12h). The median AUC₀₋₂₄ and C(0h) of gefitinib in patients with diarrhea (n = 8) were higher than those without diarrhea (n = 10) (15,043 versus 8918 ng·h·mL⁻¹, respectively, P = 0.0164 and 542 versus 261 ng/mL, respectively, P = 0.0263). The area under the receiver operator curve was 0.813, giving the best sensitivity (75%) and specificity (90%) at a C(0h) threshold of 398 ng/mL. CONCLUSIONS Use of the C(12h) single time point is recommended for the gefitinib AUC₀₋₂₄ predictive equation; however, total estimation of the AUC₀₋₂₄ of gefitinib at the single point of C(0h) was also precise. C(0h) monitoring of gefitinib might be beneficial during gefitinib therapy, because of a high variability in gefitinib exposure among patients taking 250 mg. Further examination of the correlation between clinical evaluation and the gefitinib exposure is necessary.
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Widmer N, Bardin C, Chatelut E, Paci A, Beijnen J, Levêque D, Veal G, Astier A. Review of therapeutic drug monitoring of anticancer drugs part two – Targeted therapies. Eur J Cancer 2014; 50:2020-36. [DOI: 10.1016/j.ejca.2014.04.015] [Citation(s) in RCA: 217] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 04/11/2014] [Indexed: 02/06/2023]
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Durand M, Logerot S, Fonrose X, Schir E. Traitement par erlotinib après une toxicité hépatique induite par le géfitinib : revue de la littérature à propos d’une observation. Therapie 2014; 69:163-8. [DOI: 10.2515/therapie/2014017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 10/15/2013] [Indexed: 11/20/2022]
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Practical Guidelines for Therapeutic Drug Monitoring of Anticancer Tyrosine Kinase Inhibitors: Focus on the Pharmacokinetic Targets. Clin Pharmacokinet 2014; 53:305-25. [DOI: 10.1007/s40262-014-0137-2] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Pharmacokinetics of the novel PAR-1 antagonist vorapaxar in patients with hepatic impairment. Eur J Clin Pharmacol 2012; 68:1501-8. [PMID: 22527342 DOI: 10.1007/s00228-012-1269-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 03/07/2012] [Indexed: 12/29/2022]
Abstract
PURPOSE To determine whether hepatic impairment has an effect on the pharmacokinetics (PK) of vorapaxar or M20, its main pharmacologically active metabolite. METHODS This was an open-label study in which a single 40-mg oral dose of vorapaxar was administered to patients with mild (n = 6), moderate (n = 6), and severe (n = 4) hepatic impairment and healthy controls (n = 16) matched for age, gender, weight, and height. Blood samples for vorapaxar and M20 assay were collected predose and at frequent intervals up to 8 weeks postdose. RESULTS Plasma vorapaxar and M20 PK profiles were similar between patients with impaired liver function and healthy controls. Group mean values for vorapaxar C(max) and AUC(tf) were 206-279 ng/mL and 14,200-18,200 ng·h/mL, respectively, with the lowest values observed in patients with severe impairment. Vorapaxar median T(max) and mean t(1/2) values were 1.00-1.75 h and 298-366 h, respectively. There was no apparent correlation between vorapaxar or M20 exposure or t(1/2) values and disease severity. Vorapaxar was generally well tolerated; one serious adverse event (gastrointestinal bleeding secondary to ruptured esophageal varices) was reported in a patient with severe hepatic impairment. CONCLUSIONS Hepatic impairment had no clinically relevant effect on the PK of vorapaxar and M20. No dose or dosage adjustment of vorapaxar will be required in patients with mild to moderate hepatic impairment. Although systemic exposure to vorapaxar does not appear to increase in patients with severe hepatic impairment, administration of vorapaxar to such patients is not recommended given their bleeding diathesis.
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