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Rodgers GM, Gilreath JA. Will Prolyl Hydroxylase Inhibitors Supplant Erythropoiesis-Stimulating Agents and IV Iron in the Treatment of Chemotherapy-Induced Anemia? J Clin Oncol 2024:JCO2401694. [PMID: 39353167 DOI: 10.1200/jco-24-01694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Revised: 08/08/2024] [Accepted: 08/13/2024] [Indexed: 10/04/2024] Open
Affiliation(s)
- George M Rodgers
- Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT
| | - Jeffrey A Gilreath
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT
- Department of Pharmacy, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
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2
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Shen ZW, Yang XY, Han L, Yang X, Xie J, Liu XQ, Mao JH, Dai HR, Kong WW, Wu XY, Qiu YQ, Huang HF, Lou Y. Optimizing the dosing regimen of roxadustat in kidney transplant recipients with early post-transplant anemia. J Pharm Sci 2024:S0022-3549(24)00409-X. [PMID: 39251067 DOI: 10.1016/j.xphs.2024.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 09/04/2024] [Accepted: 09/05/2024] [Indexed: 09/11/2024]
Abstract
INTRODUCTION Roxadustat, an oral inhibitor of hypoxia-inducible factor prolyl hydroxylase domain enzymes, has been approved for the treatment of renal anemia. However, there is a lack of study on its pharmacokinetics in kidney transplant recipients (KTRs) with early posttransplant anemia (PTA). Therefore, the aim of this study is to elucidate the pharmacokinetic characteristics of roxadustat in KTRs with early PTA and optimize the dosing regimen. METHODS A population pharmacokinetic (PopPK) analysis was performed based on 72-hour full concentration-time profiles collected from 52 Chinese KTRs. Covariates influencing exposure were assessed using stepwise covariate modelling. Monte Carlo simulations were conducted to recommend the dosing regimen for patients with different levels of covariates. RESULTS PopPK analysis showed that the concentration-time data can be fully described by a two-compartment model. Body weight (BW) and direct bilirubin (DBIL) levels significant affected the apparent clearance of roxadustat. Based on the established model and the estimated exposures of roxadustat by Monte Carlo simulations, a recommended dosing regimen for KTRs with early PTA at varying BW and DBIL levels were developed. Roxadustat at 100 mg three times weekly were suitable for the majority of KTRs with a DBIL level around 3 μmol/L and BW between 50 and 75 kg. The required dose may need to be increased with higher BW and lower DBIL levels, while decreased with lower BW and higher DBIL levels. CONCLUSIONS It was the first PopPK analysis of roxadustat in KTRs with early PTA, which provide a research basis for optimizing the dosing regimen.
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Affiliation(s)
- Zhuo-Wei Shen
- Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Zhejiang Provincial Key Laboratory for Drug Clinical Research and Evaluation, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.; Clinical Pharmacy Center, Department of Pharmacy, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310014, China
| | - Xiu-Yan Yang
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.; Zhejiang Provincial Hospital of Chinese Medicine, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, China
| | - Lu Han
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Xi Yang
- Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Zhejiang Provincial Key Laboratory for Drug Clinical Research and Evaluation, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Jiao Xie
- Department of Pharmacy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, China
| | - Xiao-Qin Liu
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Jue-Hui Mao
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 21009, China
| | - Hao-Ran Dai
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Wei-Wei Kong
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Xiao-Ying Wu
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Yun-Qing Qiu
- Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Zhejiang Provincial Key Laboratory for Drug Clinical Research and Evaluation, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Hong-Feng Huang
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China..
| | - Yan Lou
- Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Zhejiang Provincial Key Laboratory for Drug Clinical Research and Evaluation, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China..
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3
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Yasuoka Y, Izumi Y, Sands JM, Kawahara K, Nonoguchi H. Progress in the Detection of Erythropoietin in Blood, Urine, and Tissue. Molecules 2023; 28:molecules28114446. [PMID: 37298922 DOI: 10.3390/molecules28114446] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/22/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
Detection of erythropoietin (Epo) was difficult until a method was developed by the World Anti-Doping Agency (WADA). WADA recommended the Western blot technique using isoelectric focusing (IEF)-PAGE to show that natural Epo and injected erythropoiesis-stimulating agents (ESAs) appear in different pH areas. Next, they used sodium N-lauroylsarcosinate (SAR)-PAGE for better differentiation of pegylated proteins, such as epoetin β pegol. Although WADA has recommended the use of pre-purification of samples, we developed a simple Western blotting method without pre-purification of samples. Instead of pre-purification, we used deglycosylation of samples before SDS-PAGE. The double detection of glycosylated and deglycosylated Epo bands increases the reliability of the detection of Epo protein. All of the endogenous Epo and exogenous ESAs shift to 22 kDa, except for Peg-bound epoetin β pegol. All endogenous Epo and exogenous ESAs were detected as 22 kDa deglycosylated Epo by liquid chromatography/mass spectrum (LC/MS) analysis. The most important factor for the detection of Epo is the selection of the antibody against Epo. WADA recommended clone AE7A5, and we used sc-9620. Both antibodies are useful for the detection of Epo protein by Western blotting.
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Affiliation(s)
- Yukiko Yasuoka
- Department of Physiology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara 252-0374, Japan
| | - Yuichiro Izumi
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, 1-1-1 Honjo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Jeff M Sands
- Renal Division, Department of Medicine, Emory University School of Medicine, 1639 Pierce Drive, WMB Room 3313, Atlanta, GA 30322, USA
| | - Katsumasa Kawahara
- Department of Physiology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara 252-0374, Japan
| | - Hiroshi Nonoguchi
- Division of Internal Medicine, Kitasato University Medical Center, 6-100 Arai, Kitamoto 364-8501, Japan
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Zhu X, Jiang L, Wei X, Long M, Du Y. Roxadustat: Not just for anemia. Front Pharmacol 2022; 13:971795. [PMID: 36105189 PMCID: PMC9465375 DOI: 10.3389/fphar.2022.971795] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/12/2022] [Indexed: 11/13/2022] Open
Abstract
Roxadustat is a recently approved hypoxia-inducible factor prolyl hydroxylase inhibitor that has demonstrated favorable safety and efficacy in the treatment of renal anemia. Recent studies found it also has potential for the treatment of other hypoxia-related diseases. Although clinical studies have not yet found significant adverse or off-target effects of roxadustat, clinicians must be vigilant about these possible effects. Hypoxia-inducible factor regulates the expression of many genes and physiological processes in response to a decreased level of oxygen, but its role in the pathogenesis of different diseases is complex and controversial. In addition to increasing the expression of hypoxia-inducible factor, roxadustat also has some effects that may be HIF-independent, indicating some potential off-target effects. This article reviews the pharmacological characteristics of roxadustat, its current status in the treatment of renal anemia, and its possible effects on other pathological mechanisms.
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Affiliation(s)
- Xiaoyu Zhu
- Department of Nephrology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Lili Jiang
- Physical Examination Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xuejiao Wei
- Department of Nephrology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Mengtuan Long
- Department of Nephrology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yujun Du
- Department of Nephrology, The First Hospital of Jilin University, Changchun, Jilin, China
- *Correspondence: Yujun Du,
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Abdelazeem B, Shehata J, Abbas KS, El-Shahat NA, Malik B, Savarapu P, Eltobgy M, Kunadi A. The efficacy and safety of roxadustat for the treatment of anemia in non-dialysis dependent chronic kidney disease patients: An updated systematic review and meta-analysis of randomized clinical trials. PLoS One 2022; 17:e0266243. [PMID: 35363823 PMCID: PMC8974992 DOI: 10.1371/journal.pone.0266243] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/16/2022] [Indexed: 12/18/2022] Open
Abstract
Background Roxadustat (ROX) is a new medication for anemia as a complication of chronic kidney disease (CKD). Our meta-analysis aims to evaluate the efficacy and safety of ROX, especially on the cardiovascular risks, for anemia in NDD-CKD patients. Methods Electronic databases were searched systematically from inception to July 2021 to look for randomized control trials (RCTs) that evaluated ROX NDD-CKD patients. Hemoglobin level and iron utilization parameters, including ferritin, serum iron, transferrin saturation (TSAT), total iron-binding capacity (TIBC), transferrin, and hepcidin were analyzed for efficacy. Pooled risk ratios (RRs) and standardized mean differences (SMDs) were calculated and presented with their 95% confidential intervals (CIs). Results Nine RCTs included a total of 3,175 patients in the ROX group and 2,446 patients in the control group. When compared the control group, ROX increased Hb level significantly (SMD: 1.65; 95% CI: 1.08, 2.22; P< 0.00001) and improved iron utilization parameters by decreasing ferritin (SMD: -0.32; 95% CI: -0.51, -0.14; P = 0.0006), TSAT (SMD: -0.19; 95% CI: -0.32, -0.07; P = 0.003), and hepcidin (SMD: -0.74; 95% CI: -1.09, -0.39; P< 0.0001) and increasing TIBC (SMD: 0.99; 95% CI: 0.76, 1.22; P< 0.00001) and transferrin (SMD: 1.20; 95% CI: 0.70, 1.71; P< 0.00001). As for safety, ROX was associated with higher serious adverse effects (RR: 1.07; 95% CI: 1.01, 1.13; P = 0.01), deep venous thrombosis (DVT) (RR: 3.80; 95% CI: 1.5, 9.64; P = 0.08), and hypertension (HTN) (RR: 1.37; 95% CI: 1.13, 1.65; P = 0.001). Conclusion We concluded that ROX increased Hb level and improved iron utilization parameters in NDD-CKD patients, but ROX was associated with higher serious adverse effects, especially DVT and HTN. Our results support the use of ROX for NDD-CKD patients with anemia. However, higher-quality RCTs are still needed to ensure its safety and risk of thrombosis.
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Affiliation(s)
- Basel Abdelazeem
- McLaren Health Care, Flint, Michigan, United States of America
- Michigan State University, East Lansing, Michigan, United States of America
| | | | | | | | - Bilal Malik
- McLaren Health Care, Flint, Michigan, United States of America
- Michigan State University, East Lansing, Michigan, United States of America
| | - Pramod Savarapu
- Louisiana State University Health Sciences Center, Monroe, Louisiana, United States of America
| | - Mostafa Eltobgy
- The Ohio State University, Columbus, Ohio, United States of America
- * E-mail:
| | - Arvind Kunadi
- McLaren Health Care, Flint, Michigan, United States of America
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Groenendaal-van de Meent D, den Adel M, Kerbusch V, van Dijk J, Shibata T, Kato K, Schaddelee M. Effect of Roxadustat on the Pharmacokinetics of Simvastatin, Rosuvastatin, and Atorvastatin in Healthy Subjects: Results From 3 Phase 1, Open-Label, 1-Sequence, Crossover Studies. Clin Pharmacol Drug Dev 2022; 11:486-501. [PMID: 35182045 PMCID: PMC9306950 DOI: 10.1002/cpdd.1076] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 12/27/2021] [Indexed: 12/17/2022]
Abstract
Roxadustat inhibits breast cancer resistance protein and organic anion transporting polypeptide 1B1, which can affect coadministered statin concentrations. Three open‐label, 1‐sequence crossover phase 1 studies in healthy subjects were conducted to assess effects from steady‐state 200‐mg roxadustat on pharmacokinetics and tolerability of 40‐mg simvastatin (CL‐0537 and CL‐0541), 40‐mg atorvastatin (CL‐0538), or 10‐mg rosuvastatin (CL‐0537). Statins were dosed concomitantly with roxadustat in 28 (CL‐0537) and 24 (CL‐0538) healthy subjects, resulting in increases of maximum plasma concentration (Cmax) and area under the plasma concentration–time curve from the time of dosing extrapolated to infinity (AUCinf) 1.87‐ and 1.75‐fold for simvastatin, 2.76‐ and 1.85‐fold for simvastatin acid, 4.47‐ and 2.93‐fold for rosuvastatin, and 1.34‐ and 1.96‐fold for atorvastatin, respectively. Additionally, simvastatin dosed 2 hours before, and 4 and 10 hours after roxadustat in 28 (CL‐0541) healthy subjects, resulted in increases of Cmax and AUCinf 2.32‐ to 3.10‐fold and 1.56‐ to 1.74‐fold for simvastatin and 2.34‐ to 5.98‐fold and 1.89‐ to 3.42‐fold for simvastatin acid, respectively. These increases were not attenuated by time‐separated statin dosing. No clinically relevant differences were observed for terminal elimination half‐life. Concomitant 200‐mg roxadustat and a statin was generally well tolerated during the study period. Roxadustat effects on statin Cmax and AUCinf were statin and administration time dependent. When coadministered with roxadustat, statin‐associated adverse reactions and the need for statin dose reduction should be evaluated.
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Affiliation(s)
| | | | | | - Jan van Dijk
- Astellas Pharma Europe B.V., Leiden, The Netherlands
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7
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Yasuoka Y, Izumi Y, Fukuyama T, Omiya H, Pham TD, Inoue H, Oshima T, Yamazaki T, Uematsu T, Kobayashi N, Shimada Y, Nagaba Y, Yamashita T, Mukoyama M, Sato Y, Wall SM, Sands JM, Takahashi N, Kawahara K, Nonoguchi H. Effects of Roxadustat on Erythropoietin Production in the Rat Body. Molecules 2022; 27:1119. [PMID: 35164384 PMCID: PMC8838165 DOI: 10.3390/molecules27031119] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/04/2022] [Accepted: 02/04/2022] [Indexed: 12/19/2022] Open
Abstract
Anemia is a major complication of chronic renal failure. To treat this anemia, prolylhydroxylase domain enzyme (PHD) inhibitors as well as erythropoiesis-stimulating agents (ESAs) have been used. Although PHD inhibitors rapidly stimulate erythropoietin (Epo) production, the precise sites of Epo production following the administration of these drugs have not been identified. We developed a novel method for the detection of the Epo protein that employs deglycosylation-coupled Western blotting. With protein deglycosylation, tissue Epo contents can be quantified over an extremely wide range. Using this method, we examined the effects of the PHD inhibitor, Roxadustat (ROX), and severe hypoxia on Epo production in various tissues in rats. We observed that ROX increased Epo mRNA expression in both the kidneys and liver. However, Epo protein was detected in the kidneys but not in the liver. Epo protein was also detected in the salivary glands, spleen, epididymis and ovaries. However, both PHD inhibitors (ROX) and severe hypoxia increased the Epo protein abundance only in the kidneys. These data show that, while Epo is produced in many tissues, PHD inhibitors as well as severe hypoxia regulate Epo production only in the kidneys.
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Affiliation(s)
- Yukiko Yasuoka
- Department of Physiology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara 252-0374, Kanagawa, Japan; (Y.Y.); (T.O.); (N.T.); (K.K.)
| | - Yuichiro Izumi
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, 1-1-1 Honjo, Chuo-ku, Kumamoto 860-8556, Kumamoto, Japan; (Y.I.); (H.I.); (M.M.)
| | - Takashi Fukuyama
- Division of Biomedical Research, Kitasato University Medical Center, 6-100 Arai, Kitamoto 364-8501, Saitama, Japan; (T.F.); (T.Y.); (T.U.); (N.K.)
| | - Haruki Omiya
- Department of Biological Chemistry and Food Sciences, Faculty of Agriculture, Iwate University, 3-18-8 Ueda, Morioka 020-8550, Iwate, Japan; (H.O.); (T.Y.)
| | - Truyen D. Pham
- Renal Division, Department of Medicine, Emory University School of Medicine, 1639 Pierce Drive, WMB Room 3313, Atlanta, GA 30322, USA; (T.D.P.); (S.M.W.); (J.M.S.)
| | - Hideki Inoue
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, 1-1-1 Honjo, Chuo-ku, Kumamoto 860-8556, Kumamoto, Japan; (Y.I.); (H.I.); (M.M.)
| | - Tomomi Oshima
- Department of Physiology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara 252-0374, Kanagawa, Japan; (Y.Y.); (T.O.); (N.T.); (K.K.)
| | - Taiga Yamazaki
- Division of Biomedical Research, Kitasato University Medical Center, 6-100 Arai, Kitamoto 364-8501, Saitama, Japan; (T.F.); (T.Y.); (T.U.); (N.K.)
| | - Takayuki Uematsu
- Division of Biomedical Research, Kitasato University Medical Center, 6-100 Arai, Kitamoto 364-8501, Saitama, Japan; (T.F.); (T.Y.); (T.U.); (N.K.)
| | - Noritada Kobayashi
- Division of Biomedical Research, Kitasato University Medical Center, 6-100 Arai, Kitamoto 364-8501, Saitama, Japan; (T.F.); (T.Y.); (T.U.); (N.K.)
| | - Yoshitaka Shimada
- Division of Internal Medicine, Kitasato University Medical Center, 6-100 Arai, Kitamoto 364-8501, Saitama, Japan; (Y.S.); (Y.N.)
| | - Yasushi Nagaba
- Division of Internal Medicine, Kitasato University Medical Center, 6-100 Arai, Kitamoto 364-8501, Saitama, Japan; (Y.S.); (Y.N.)
| | - Tetsuro Yamashita
- Department of Biological Chemistry and Food Sciences, Faculty of Agriculture, Iwate University, 3-18-8 Ueda, Morioka 020-8550, Iwate, Japan; (H.O.); (T.Y.)
| | - Masashi Mukoyama
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, 1-1-1 Honjo, Chuo-ku, Kumamoto 860-8556, Kumamoto, Japan; (Y.I.); (H.I.); (M.M.)
| | - Yuichi Sato
- Department of Molecular Diagnostics, Kitasato University School of Allied Health Sciences, Sagamihara 252-0373, Kanagawa, Japan;
| | - Susan M. Wall
- Renal Division, Department of Medicine, Emory University School of Medicine, 1639 Pierce Drive, WMB Room 3313, Atlanta, GA 30322, USA; (T.D.P.); (S.M.W.); (J.M.S.)
| | - Jeff M. Sands
- Renal Division, Department of Medicine, Emory University School of Medicine, 1639 Pierce Drive, WMB Room 3313, Atlanta, GA 30322, USA; (T.D.P.); (S.M.W.); (J.M.S.)
| | - Noriko Takahashi
- Department of Physiology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara 252-0374, Kanagawa, Japan; (Y.Y.); (T.O.); (N.T.); (K.K.)
| | - Katsumasa Kawahara
- Department of Physiology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara 252-0374, Kanagawa, Japan; (Y.Y.); (T.O.); (N.T.); (K.K.)
| | - Hiroshi Nonoguchi
- Division of Internal Medicine, Kitasato University Medical Center, 6-100 Arai, Kitamoto 364-8501, Saitama, Japan; (Y.S.); (Y.N.)
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8
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Nakai T, Saigusa D, Iwamura Y, Matsumoto Y, Umeda K, Kato K, Yamaki H, Tomioka Y, Hirano I, Koshiba S, Yamamoto M, Suzuki N. Esterification promotes the intracellular accumulation of roxadustat, an activator of hypoxia-inducible factors, to extend its effective duration. Biochem Pharmacol 2022; 197:114939. [PMID: 35114188 DOI: 10.1016/j.bcp.2022.114939] [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: 12/06/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/02/2022]
Abstract
Kidney injury often causes anemia due to a lack of production of the erythroid growth factor erythropoietin (EPO) in the kidneys. Roxadustat is one of the first oral medicines inducing EPO production in patients with renal anemia by activating hypoxia-inducible factors (HIFs), which are activators of EPO gene expression. In this study, to develop prodrugs of roxadustat with improved permeability through cell membrane, we investigated the effects of 8 types of esterification on the pharmacokinetics and bioactivity of roxadustat using Hep3B hepatoma cells that HIF-dependently produce EPO. Mass spectrometry of cells incubated with the esterified roxadustat derivatives revealed that the designed compounds were deesterified after being taken up by cells and showed low cytotoxicity compared to the original compound. Esterification prolonged the effective duration of roxadustat with respect to EPO gene induction and HIF activation in cells transiently exposed to the compounds. In the kidneys and livers of mice, both of which are unique sites of EPO production, a majority of the methyl-esterified roxadustat was deesterified within 6 h after drug administration. The deesterified roxadustat derivative was continuously detectable in plasma and urine for at least 48 h after administration, while the administered compound became undetectable 24 h after administration. Additionally, we confirmed that methyl-esterified roxadustat activated erythropoiesis in mice by inducing Epo mRNA expression exclusively in renal interstitial cells, which have intrinsic EPO-producing potential. These data suggest that esterification could lead to the development of roxadustat prodrugs with improvements in cell membrane permeability, effective duration and cytotoxicity.
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Affiliation(s)
- Taku Nakai
- Division of Oxygen Biology, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Daisuke Saigusa
- Department of Integrative Genomics, Tohoku Medical Megabank Organization, Tohoku University, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan; Laboratory of Biomedical and Analytical Sciences, Faculty of Pharma-Science, Teikyo University, Kaga 2-11-1, Itabashi-ku, Tokyo 173-8605, Japan
| | - Yuma Iwamura
- Division of Oxygen Biology, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Yotaro Matsumoto
- Laboratory of Oncology, Pharmacy Practice and Sciences, Tohoku University Graduate School of Pharmaceutical Sciences, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Keiko Umeda
- Department of Integrative Genomics, Tohoku Medical Megabank Organization, Tohoku University, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Koichiro Kato
- Division of Oxygen Biology, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Hayato Yamaki
- Division of Oxygen Biology, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Yoshihisa Tomioka
- Laboratory of Oncology, Pharmacy Practice and Sciences, Tohoku University Graduate School of Pharmaceutical Sciences, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Ikuo Hirano
- Department of Medical Biochemistry, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Seizo Koshiba
- Department of Integrative Genomics, Tohoku Medical Megabank Organization, Tohoku University, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Masayuki Yamamoto
- Department of Integrative Genomics, Tohoku Medical Megabank Organization, Tohoku University, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan; Department of Medical Biochemistry, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Norio Suzuki
- Division of Oxygen Biology, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan; Applied Oxygen Physiology Project, New Industry Creation Hatchery Center, Tohoku University, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan.
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9
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Abstract
The pharmacokinetics of roxadustat are well characterized, with an apparent volume of distribution after oral administration of 22–57 L, apparent clearance of 1.2–2.65 L/h, and renal clearance of 0.030–0.026 L/h in healthy volunteers; the elimination half-life is 9.6–16 h. Plasma binding is 99% and the fraction eliminated by hemodialysis is 2.34%. As an interpretation of the pharmacodynamics of roxadustat, we proposed a concept with a hypothetical cascade of two subsequent effects, first on erythropoetin (EPO) and second on hemoglobin (delta Hb). The primary effect on EPO is observed within a few hours after roxadustat administration and can be modeled using the sigmoidal Hill equation. The concentration at half-maximum effect can be inferred at 10–36 µg/mL, the Hill coefficient at 3.3, and the effect bisection time at 10–17 h, corresponding to EPO half-life. The subsequent effect on hemoglobin (delta Hb) is observed after several weeks and can be interpreted as an irreversible, dose proportional, unsaturable effect, continuing in agreement with the lifespan of red blood cells of 63–112 days.
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Crugliano G, Serra R, Ielapi N, Battaglia Y, Coppolino G, Bolignano D, Bracale UM, Pisani A, Faga T, Michael A, Provenzano M, Andreucci M. Hypoxia-Inducible Factor Stabilizers in End Stage Kidney Disease: "Can the Promise Be Kept?". Int J Mol Sci 2021; 22:12590. [PMID: 34830468 PMCID: PMC8618724 DOI: 10.3390/ijms222212590] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/12/2021] [Accepted: 11/19/2021] [Indexed: 12/13/2022] Open
Abstract
Anemia is a common complication of chronic kidney disease (CKD). The prevalence of anemia in CKD strongly increases as the estimated Glomerular Filtration Rate (eGFR) decreases. The pathophysiology of anemia in CKD is complex. The main causes are erythropoietin (EPO) deficiency and functional iron deficiency (FID). The administration of injectable preparations of recombinant erythropoiesis-stimulating agents (ESAs), especially epoetin and darbepoetin, coupled with oral or intravenous(iv) iron supplementation, is the current treatment for anemia in CKD for both dialysis and non-dialysis patients. This approach reduces patients' dependence on transfusion, ensuring the achievement of optimal hemoglobin target levels. However, there is still no evidence that treating anemia with ESAs can significantly reduce the risk of cardiovascular events. Meanwhile, iv iron supplementation causes an increased risk of allergic reactions, gastrointestinal side effects, infection, and cardiovascular events. Currently, there are no studies defining the best strategy for using ESAs to minimize possible risks. One class of agents under evaluation, known as prolyl hydroxylase inhibitors (PHIs), acts to stabilize hypoxia-inducible factor (HIF) by inhibiting prolyl hydroxylase (PH) enzymes. Several randomized controlled trials showed that HIF-PHIs are almost comparable to ESAs. In the era of personalized medicine, it is possible to envisage and investigate specific contexts of the application of HIF stabilizers based on the individual risk profile and mechanism of action.
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Affiliation(s)
- Giuseppina Crugliano
- Department of Health Sciences, “Magna Graecia” University, I-88100 Catanzaro, Italy; (G.C.); (G.C.); (D.B.); (T.F.); (A.M.)
| | - Raffaele Serra
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, I-88100 Catanzaro, Italy;
- Interuniversity Center of Phlebolymphology (CIFL), “Magna Graecia” University, I-88100 Catanzaro, Italy
| | - Nicola Ielapi
- Department of Public Health and Infectious Disease, “Sapienza” University of Rome, I-00185 Roma, Italy;
| | - Yuri Battaglia
- Division of Nephrology and Dialysis, St. Anna University-Hospital, I-44121 Ferrara, Italy;
| | - Giuseppe Coppolino
- Department of Health Sciences, “Magna Graecia” University, I-88100 Catanzaro, Italy; (G.C.); (G.C.); (D.B.); (T.F.); (A.M.)
| | - Davide Bolignano
- Department of Health Sciences, “Magna Graecia” University, I-88100 Catanzaro, Italy; (G.C.); (G.C.); (D.B.); (T.F.); (A.M.)
| | - Umberto Marcello Bracale
- Vascular Surgery Unit, Department of Public Health, University Federico II of Naples, I-80131 Naples, Italy;
| | - Antonio Pisani
- Department of Public Health, University Federico II of Naples, I-80131 Naples, Italy;
| | - Teresa Faga
- Department of Health Sciences, “Magna Graecia” University, I-88100 Catanzaro, Italy; (G.C.); (G.C.); (D.B.); (T.F.); (A.M.)
| | - Ashour Michael
- Department of Health Sciences, “Magna Graecia” University, I-88100 Catanzaro, Italy; (G.C.); (G.C.); (D.B.); (T.F.); (A.M.)
| | - Michele Provenzano
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, I-88100 Catanzaro, Italy;
| | - Michele Andreucci
- Department of Health Sciences, “Magna Graecia” University, I-88100 Catanzaro, Italy; (G.C.); (G.C.); (D.B.); (T.F.); (A.M.)
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Kurata Y, Tanaka T, Nangaku M. An evaluation of roxadustat for the treatment of anemia associated with chronic kidney disease. Expert Opin Pharmacother 2021; 23:19-28. [PMID: 34686069 DOI: 10.1080/14656566.2021.1993821] [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] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Anemia is one of the major complications of chronic kidney disease (CKD). Erythropoiesis-stimulating agents (ESAs) have been the mainstay of renal anemia treatment. However, there are several safety drawbacks, and a safer and more effective alternative treatment has been sought. AREAS COVERED Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) have been developed as a novel orally active therapeutic agent for renal anemia. HIF-PHIs stimulate endogenous EPO and optimize iron utilization. Roxadustat is a first-in-class HIF-PHI for the treatment of anemia in CKD patients approved in China, Japan, South Korea, and Chile. The authors herein evaluate the pharmacology of roxadustat and give their expert perspectives on its use. EXPERT OPINION Phase 3 clinical trials have demonstrated that roxadustat effectively increases and maintains hemoglobin (Hb) levels in both nondialysis-dependent and dialysis-dependent CKD patients. Roxadustat also improved iron metabolism and reduced intravenous (IV) iron requirements. However, pooled analyses of phase 3 studies have revealed frequent thromboembolic events in the roxadustat group, which might be attributed to rapid changes in Hb and inadequate iron supplementation. Roxadustat is an attractive alternative treatment especially for patients with ESA hyporesponsive due to impaired iron utilization, and so appropriate selection of target patients and its proper use are crucially important.
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Affiliation(s)
- Yu Kurata
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Tetsuhiro Tanaka
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
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Burmakin M, Fasching A, Kobayashi H, Urrutia AA, Damdimopoulos A, Palm F, Haase VH. Pharmacological HIF-PHD inhibition reduces renovascular resistance and increases glomerular filtration by stimulating nitric oxide generation. Acta Physiol (Oxf) 2021; 233:e13668. [PMID: 33900001 DOI: 10.1111/apha.13668] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
AIM Hypoxia-inducible factors (HIFs) are O2 -sensitive transcription factors that regulate multiple biological processes which are essential for cellular adaptation to hypoxia. Small molecule inhibitors of HIF-prolyl hydroxylase domain (PHD) dioxygenases (HIF-PHIs) activate HIF-dependent transcriptional programs and have broad clinical potential. HIF-PHIs are currently in global late-stage clinical development for the treatment of anaemia associated with chronic kidney disease. Although the effects of hypoxia on renal haemodynamics and function have been studied in animal models and in humans living at high altitude, the effects of pharmacological HIF activation on renal haemodynamics, O2 metabolism and metabolic efficiency are not well understood. METHODS Using a cross-sectional study design, we investigated renal haemodynamics, O2 metabolism, gene expression and NO production in healthy rats treated with different doses of HIF-PHIs roxadustat or molidustat compared to vehicle control. RESULTS Systemic administration of roxadustat or molidustat resulted in a dose-dependent reduction in renovascular resistance (RVR). This was associated with increased glomerular filtration rate (GFR), urine flow and tubular sodium transport rate (TNa ). Although both total O2 delivery and TNa were increased, more O2 was extracted per transported sodium in rats treated with high-doses of HIF-PHIs, suggesting a reduction in metabolic efficiency. Changes in RVR and GFR were associated with increased nitric oxide (NO) generation and substantially suppressed by pharmacological inhibition of NO synthesis. CONCLUSIONS Our data provide mechanistic insights into dose-dependent effects of short-term pharmacological HIF activation on renal haemodynamics, glomerular filtration and O2 metabolism and identify NO as a major mediator of these effects.
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Affiliation(s)
- Mikhail Burmakin
- Section of Integrative Physiology Department of Medical Cell Biology Uppsala University Uppsala Sweden
| | - Angelica Fasching
- Section of Integrative Physiology Department of Medical Cell Biology Uppsala University Uppsala Sweden
| | - Hanako Kobayashi
- Department of Medicine Vanderbilt University Medical Center and Vanderbilt University School of Medicine Nashville TN USA
| | - Andrés A. Urrutia
- Unidad de Investigación Hospital de Santa CristinaInstituto de Investigación del Hospital Universitario La PrincesaUniversidad Autónoma de Madrid Madrid Spain
| | - Anastasios Damdimopoulos
- Bioinformatics and Expression Analysis Core Facility Department of Biosciences and Nutrition Karolinska Institute Stockholm Sweden
| | - Fredrik Palm
- Section of Integrative Physiology Department of Medical Cell Biology Uppsala University Uppsala Sweden
| | - Volker H. Haase
- Section of Integrative Physiology Department of Medical Cell Biology Uppsala University Uppsala Sweden
- Department of Medicine Vanderbilt University Medical Center and Vanderbilt University School of Medicine Nashville TN USA
- Department of Molecular Physiology and Biophysics Vanderbilt University School of Medicine Nashville TN USA
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Takada A, Shibata T, Shiga T, Groenendaal-van de Meent D, Komatsu K. Population pharmacokinetics of roxadustat in Japanese dialysis-dependent chronic kidney disease patients with anaemia. Br J Clin Pharmacol 2021; 88:787-797. [PMID: 34350625 PMCID: PMC9292185 DOI: 10.1111/bcp.15023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/16/2021] [Accepted: 07/06/2021] [Indexed: 12/11/2022] Open
Abstract
Aims Our objective was to develop a population pharmacokinetic (PK) model to describe roxadustat plasma concentrations in Japanese dialysis‐dependent chronic kidney disease (DD‐CKD) patients with renal anaemia and to identify the covariate factors that affect exposure of roxadustat. Methods In total, 367 patients (male, 256; female, 111) contributing 1285 concentration values from 4 clinical studies were analysed using a nonlinear mixed‐effects modelling approach. Candidate covariates included clinical characteristics hypothesized to affect roxadustat clearance and bioavailability, such as demographics, hepatic parameters and concomitant drugs. Results The roxadustat PK data in Japanese DD‐CKD patients with renal anaemia were well described by a 2‐compartment disposition model with first‐order absorption and interindividual variability on clearance, central volume of distribution and absorption rate constant. Age was identified as a significant covariate on clearance. PK profiles of haemodialysis and peritoneal dialysis patients were comparable. Eighty‐two percent of patients were administered at least 1 phosphate binder (PB). The effect of PBs on roxadustat concentration was modelled as a decrease in bioavailability. Staggered administration of PBs reduced the effect on roxadustat bioavailability. The clinical impact of all covariates on roxadustat PK was mild and manageable as the roxadustat dose was titrated based on haemoglobin level and administered starting from a low dose. Conclusion Roxadustat PK in Japanese DD‐CKD patients were successfully described by a population PK model. The identified key covariates included coadministration of PBs on the roxadustat bioavailability and age on clearance of roxadustat.
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Groenendaal-van de Meent D, Kerbusch V, Barroso-Fernandez B, den Adel M, van Dijk J, Golor G, Schaddelee M. Effect of the Phosphate Binders Sevelamer Carbonate and Calcium Acetate on the Pharmacokinetics of Roxadustat After Concomitant or Time-Separated Administration in Healthy Individuals. Clin Ther 2021; 43:1079-1091. [PMID: 33962762 DOI: 10.1016/j.clinthera.2021.03.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 03/23/2021] [Accepted: 03/31/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE Roxadustat, a hypoxia-inducible factor prolyl hydroxylase inhibitor, treats anemia in chronic kidney disease. Hyperphosphatemia, a common complication in chronic kidney disease, is treated with phosphate binders (PBs). This study in healthy individuals investigated the effect of 2 PBs, sevelamer carbonate and calcium acetate, on the pharmacokinetic properties of a single oral dose of roxadustat administered concomitantly or with a time lag. METHODS This 2-part, Phase I study was conducted with an open-label, randomized, 3-way (part 1) or 5-way (part 2) crossover design, with 5-day treatment periods. On day 1 of each period, participants received 200 mg roxadustat administered alone or (1) concomitantly with sevelamer carbonate (2400 mg) or calcium acetate (1900 mg) (part 1) or (2) 1 hour before or 1, 2, or 3 hours after sevelamer carbonate (part 2A) or calcium acetate (part 2B); 5 additional PB doses were administered during 2 days. In both parts, PBs were administered with meals. Primary pharmacokinetic variables were AUC0-∞ and Cmax. FINDINGS: Twenty-four individuals were randomized in part 1; 60 individuals were randomized in part 2 (part 2A, n = 30; part 2B, n = 30). All participants completed the study in part 1; 28 and 27 individuals completed the study in part 2A and part 2B, respectively. Compared with roxadustat alone, concomitant sevelamer carbonate and calcium acetate administration reduced roxadustat's AUC0-∞ by 67% (90% CI, 63.5%-69.3%) and 46% (90% CI, 41.7%-50.9%), respectively, and reduced roxadustat's Cmax by 66% (90% CI, 61.6%-69.4%) and 52% (90% CI, 46.2%-57.2%), respectively. This effect was attenuated when roxadustat and PB administration occurred with a time lag. Roxadustat's AUC0-∞ was reduced by 41% and 22% to 25%, respectively, when roxadustat was administered 1 hour before or 1 to 3 hours after sevelamer carbonate and by 31% and 14% to 18%, respectively, when administered 1 hour before or 1 to 3 hours after calcium acetate. Roxadustat's Cmax was reduced by 26% and 12%, respectively, when roxadustat was administered 1 hour before and 1 hour after sevelamer carbonate; it was reduced by 19% when administered 1 hour before calcium acetate and was not affected when administered 1 hour after. Roxadustat was well tolerated. IMPLICATIONS Concomitant administration of roxadustat with sevelamer carbonate or calcium acetate reduced exposure to roxadustat in healthy individuals. This effect was attenuated when roxadustat was administered ≥1 hour before or after either PB. Results from this study helped inform dosing and administration guidelines aimed at reducing interactions between roxadustat and these PBs. (Clin Ther. 2021;XX:XXX-XXX) © 2021 Elsevier HS Journals, Inc.
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Affiliation(s)
| | | | - Begona Barroso-Fernandez
- Department of Drug Discovery Research and Bioanalysis, Astellas Pharma Europe B.V., Leiden, the Netherlands
| | - Martin den Adel
- Department of Clinical Pharmacology and Exploratory Development, Astellas Pharma Europe B.V., Leiden, the Netherlands
| | - Jan van Dijk
- Department of Clinical Pharmacology and Exploratory Development, Astellas Pharma Europe B.V., Leiden, the Netherlands
| | - Georg Golor
- Department of Clinical Operations, Parexel GmbH, Berlin, Germany
| | - Marloes Schaddelee
- Department of Clinical Pharmacology and Exploratory Development, Astellas Pharma Europe B.V., Leiden, the Netherlands
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Whether Prolyl Hydroxylase Blocker-Roxadustat-In the Treatment of Anemia in Patients with Chronic Kidney Disease Is the Future? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041612. [PMID: 33567688 PMCID: PMC7914880 DOI: 10.3390/ijerph18041612] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 12/19/2022]
Abstract
In patients with chronic kidney disease (CKD), anemia develops gradually, which is primarily due to an inadequate synthesis of erythropoietin by the kidneys, as well as to iron disorders in the body, blood loss, shortened erythrocyte survival and inflammation. The currently accepted treatment employs iron, vitamin B12, folic acid supplementation and the use of erythropoiesis stimulants, which are administered only parenterally. Research is currently underway on the new erythropoiesis drugs that can be orally administered, i.e., hypoxia-inducible factor-propyl hydroxylase inhibitor (HIF-PHI) inhibitors which temporarily block propyl hydroxylase [PHD] catalysis and promote a transient increase in the expression of genes regulated by HIF, including kidney and liver erythropoietin [EPO]. Roxadustat is the first oral drug in this class and a potent HIF-PHD inhibitor, exerted to treat anemia in patients with CKD. In phase 1, 2 and 3 studies with CKD-affected patients, roxadustat was more effective to stimulate erythropoiesis for anemia correction than previously used drugs. Roxadustat can be orally given, unlike other erythropoiesis drugs with parenteral administration only, which grants roxadustat a considerable advantage. Our paper presents the results of studies with roxadustat applied for the treatment of anemia in CKD patients with or without dialysis. We are currently not yet able to know the exact role of roxadustat in the treatment of anemia in patients with CKD, but time will tell. It is possible that roxadustat has benefits an iron metabolism and cardiovascular risk.
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Rekić D, Kerbusch-Herben V, Någård M, Chou J, Huang J, Bradley C, Åstrand M, Tannenbaum S, Hamrén B. Pharmacokinetics of Roxadustat: A Population Analysis of 2855 Dialysis- and Non-Dialysis-Dependent Patients with Chronic Kidney Disease. Clin Pharmacokinet 2021; 60:759-773. [PMID: 33486718 DOI: 10.1007/s40262-020-00974-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Roxadustat is a novel, small-molecule, first-in-class therapeutic that stimulates erythropoiesis by inhibiting hypoxia-inducible factor prolyl hydroxylase enzymes. This agent (roxadustat) is in clinical development for the treatment of anemia in patients with non-dialysis-dependent (NDD) and dialysis-dependent (DD) chronic kidney disease. A population pharmacokinetic analysis was undertaken to evaluate the effect of intrinsic and extrinsic factors on roxadustat pharmacokinetics. METHODS Non-linear mixed-effects models implemented in NONMEM software were fitted to 8209 pharmacokinetic samples from 2855 DD and NDD subjects enrolled in four phase III studies with roxadustat dose concentrations of 20-400 mg as orally administered tablets. Effects of intrinsic and extrinsic factors were evaluated using a stepwise covariate modeling procedure in combination with the full covariate approach, and defined no-effect boundaries for exposure were based on the difference in exposure between 70 and 100 mg of roxadustat (i.e., - 30%, + 43%). RESULTS A two-compartment model with first-order absorption adequately described roxadustat pharmacokinetics, with parameter estimates (relative standard error) for apparent clearance of 1.1 (0.0223) L/h in NDD subjects, and apparent central and peripheral volumes of distribution of 14.9 (0.0278) L and 9.5 (0.0872) L, respectively. Stepwise covariate modeling identified bodyweight, dialysis status, race, and dose as statistically significant covariates on apparent clearance, and bodyweight, sex, and albumin as statistically significant covariates on apparent central volume of distribution. However, the effects of these covariates did not result in roxadustat area under the curve or maximum plasma concentration changes outside of the defined no-effect boundaries. The effects of concomitant oral iron, clopidogrel, and staggered sevelamer, calcium carbonate, or calcium acetate were investigated using a full covariate approach but did not result in roxadustat area under the curve or maximum plasma concentration changes outside of the defined no-effect boundaries. CONCLUSIONS A population pharmacokinetic model was developed for the pharmacokinetics of roxadustat in the target population. None of the investigated intrinsic or extrinsic factors resulted in a significant change in roxadustat exposure outside of the defined no-effect boundaries.
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Affiliation(s)
- Dinko Rekić
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, Research and Development, AstraZeneca AB, Pepparedsleden 1, Mölndal, 431 50, Gothenburg, Sweden.
| | | | - Mats Någård
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, Research and Development, AstraZeneca, Gaithersburg, MD, USA
| | - James Chou
- Clinical Development, FibroGen, San Francisco, CA, USA
| | - Jiayin Huang
- Astellas Pharma Global Development, Northbrook, IL, USA
| | | | - Magnus Åstrand
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, Research and Development, AstraZeneca AB, Pepparedsleden 1, Mölndal, 431 50, Gothenburg, Sweden
| | | | - Bengt Hamrén
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, Research and Development, AstraZeneca AB, Pepparedsleden 1, Mölndal, 431 50, Gothenburg, Sweden
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Hanna RM, Streja E, Kalantar-Zadeh K. Burden of Anemia in Chronic Kidney Disease: Beyond Erythropoietin. Adv Ther 2021; 38:52-75. [PMID: 33123967 PMCID: PMC7854472 DOI: 10.1007/s12325-020-01524-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/03/2020] [Indexed: 02/08/2023]
Abstract
Anemia is a frequent comorbidity of chronic kidney disease (CKD) and is associated with a considerable burden because of decreased patient health-related quality of life and increased healthcare resource utilization. Based on observational data, anemia is associated with an increased risk of CKD progression, cardiovascular events, and all-cause mortality. The current standard of care includes oral or intravenous iron supplementation, erythropoiesis-stimulating agents, and red blood cell transfusion. However, each of these therapies has its own set of population-specific patient concerns, including increased risk of cardiovascular disease, thrombosis, and mortality. Patients receiving dialysis or those who have concurrent diabetes or high blood pressure may be at greater risk of developing these complications. In particular, treatment with high doses of erythropoiesis-stimulating agents has been associated with increased rates of hospitalization, cardiovascular events, and mortality. Resistance to erythropoiesis-stimulating agents remains a therapeutic challenge in a subset of patients. Hypoxia-inducible factor transcription factors, which regulate several genes involved in erythropoiesis and iron metabolism, can be stabilized by a new class of drugs that act as inhibitors of hypoxia-inducible factor prolyl-hydroxylase enzymes to promote erythropoiesis and elevate hemoglobin levels. Here, we review the burden of anemia of chronic kidney disease, the shortcomings of current standard of care, and the potential practical advantages of hypoxia-inducible factor prolyl-hydroxylase inhibitors in the treatment of patients with anemia of CKD.
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Affiliation(s)
- Ramy M Hanna
- Division of Nephrology, Hypertension and Kidney Transplantation, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California, Irvine School of Medicine, Orange, CA, USA
| | - Elani Streja
- Division of Nephrology and Hypertension, University of California, Irvine School of Medicine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California, Irvine School of Medicine, Orange, CA, USA.
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Eleftheriadis T, Pissas G, Mavropoulos A, Nikolaou E, Filippidis G, Liakopoulos V, Stefanidis I. In Mixed Lymphocyte Reaction, the Hypoxia-Inducible Factor Prolyl-Hydroxylase Inhibitor Roxadustat Suppresses Cellular and Humoral Alloimmunity. Arch Immunol Ther Exp (Warsz) 2020; 68:31. [PMID: 33011826 DOI: 10.1007/s00005-020-00596-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 09/18/2020] [Indexed: 12/13/2022]
Abstract
Hypoxia-inducible factor (HIF) prolyl-hydroxylase inhibitors are currently used for the treatment of renal anemia. Since HIF affects immune cells, we evaluated the effect of such a drug, the roxadustat, on adaptive immunity. Cell proliferation was assessed in a two-way mixed lymphocyte reaction (MLR) with BrdU assay. In CD4+ T cells isolated from the two-way MLRs, western blotting was performed to detect the impact of roxadustat on HIF-1α and HIF-2α, the apoptotic marker cleaved caspase-3, and the master transcription factors of CD4+ T cells differentiation towards Th1, Th2, Th17, Treg and Tfh subsets. The signature cytokines of the above CD4+ T-cell subsets IFN-γ, IL-4, IL-17, IL-10, and IL-21 were measured in the supernatants. For assessing humoral immunity, we developed a suitable antibody-mediated complement-dependent cytotoxicity assay. Roxadustat stabilized HIF-1α and HIF-2α, suppressed cell proliferation, inhibited CD4+ T-cell differentiation into Th1 and Th17 subsets, while it favored differentiation towards Th2, Treg and Tfh. Roxadustat suppressed humoral immunity too. These immunosuppressive properties of roxadustat indicate that the recently introduced HIF prolyl-hydroxylase inhibitors in medical therapeutics may render the patients vulnerable to infections. This possibility should be further evaluated in clinical trials.
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Affiliation(s)
- Theodoros Eleftheriadis
- Department of Nephrology, Faculty of Medicine, University of Thessaly, Biopolis, Mezourlo Hill, 41110, Larissa, Greece.
| | - Georgios Pissas
- Department of Nephrology, Faculty of Medicine, University of Thessaly, Biopolis, Mezourlo Hill, 41110, Larissa, Greece
| | - Athanasios Mavropoulos
- Department of Nephrology, Faculty of Medicine, University of Thessaly, Biopolis, Mezourlo Hill, 41110, Larissa, Greece
| | - Evdokia Nikolaou
- Department of Nephrology, Faculty of Medicine, University of Thessaly, Biopolis, Mezourlo Hill, 41110, Larissa, Greece
| | - Georgios Filippidis
- Department of Nephrology, Faculty of Medicine, University of Thessaly, Biopolis, Mezourlo Hill, 41110, Larissa, Greece
| | - Vassilios Liakopoulos
- Department of Nephrology, Faculty of Medicine, University of Thessaly, Biopolis, Mezourlo Hill, 41110, Larissa, Greece
| | - Ioannis Stefanidis
- Department of Nephrology, Faculty of Medicine, University of Thessaly, Biopolis, Mezourlo Hill, 41110, Larissa, Greece
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The prolyl hydroxylase inhibitor roxadustat: Paradigm in drug discovery and prospects for clinical application beyond anemia. Drug Discov Today 2020; 25:1262-1269. [PMID: 32380083 DOI: 10.1016/j.drudis.2020.04.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/12/2020] [Accepted: 04/23/2020] [Indexed: 12/17/2022]
Abstract
Prolyl hydroxylase (PHD) inhibitors, such as roxadustat, can stabilize hypoxia-inducible factor (HIF)-2α and induce erythropoietin (EPO) production under normal conditions. Roxadustat was recently approved as a first-in-class orally active drug for the treatment of renal anemia. In addition, it has garnered growing therapeutic interest for use against various diseases, such as carcinoma, neurological diseases, ocular diseases, and tissue and organ injuries. In this review, we systemically review target validation, hit identification, and further key clinical trials of roxadustat. The prospective clinical applications of PHD inhibitors are then discussed based on this marketed drug.
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Messa P, Cappellini MD. A new approach for anemia in kidney disease. Eur J Intern Med 2020; 71:1-3. [PMID: 31784191 DOI: 10.1016/j.ejim.2019.10.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 10/28/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Piergiorgio Messa
- Nephrology, Dialysis and Renal transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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Kabei K, Tateishi Y, Shiota M, Osada-Oka M, Nishide S, Uchida J, Nakatani T, Matsunaga S, Yamaguchi T, Tomita S, Miura K. Effects of orally active hypoxia inducible factor alpha prolyl hydroxylase inhibitor, FG4592 on renal fibrogenic potential in mouse unilateral ureteral obstruction model. J Pharmacol Sci 2019; 142:93-100. [PMID: 31866051 DOI: 10.1016/j.jphs.2019.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/13/2019] [Accepted: 11/27/2019] [Indexed: 12/19/2022] Open
Abstract
Orally active hypoxia-inducible factor (HIF) prolyl hydroxylase inhibitors that stabilize HIF protein and stimulate the production of erythropoietin have been approved to treat renal anemia. Our previous report suggested that HIF-1α dependent fibrogenic mechanisms are operating at the early onset of renal fibrosis and its contribution declines with the progression in mouse unilateral ureteral obstruction (UUO) model. The aim of the study is to evaluate the renal fibrogenic potential of FG4592, a recently approved orally active HIF prolyl hydroxylase inhibitor in mouse UUO model. Male C57BL/6J mice orally given FG-4592 (12.5 mg/kg/day and 50 mg/kg/day) were subjected to UUO. Neither dose of FG-4592 affected renal fibrosis or macrophage infiltration. FG-4592 had no effects on increased mRNA of collagen I, collagen III or transforming growth factor-β1. At 3 days after UUO, higher dose of FG-4592 potentiated the increased mRNA expression of profibrogenic molecules, plasminogen activator inhibitor 1 (Pai-1) and connective tissue growth factor (Ctgf) but such potentiation disappeared at 7 days after UUO. It is suggested that FG-4592 used in the present study had little effects on renal fibrosis even though high dose of FG-4592 used in the present study transiently potentiated gene expression of Pai-1 and Ctgf in the UUO kidney.
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Affiliation(s)
- Kazuya Kabei
- Department of Applied Pharmacology and Therapeutics, Osaka City University Graduate School of Medicine, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan; Department of Urology, Osaka City University Graduate School of Medicine, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan; Minami-Osaka Hospital, Higashikagaya, Suminoe-ku, Osaka, 559-0012, Japan
| | - Yu Tateishi
- Ishikiri Seiki Hospital, Yayoi-cho, Higashiosaka, Osaka, 579-8026, Japan
| | - Masayuki Shiota
- Department of Research Support Platform, Osaka City University Graduate School of Medicine, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Mayuko Osada-Oka
- Food Hygiene and Environmental Health Division of Applied Life Science, Graduate School of Life and Environmental Sciences, Kyoto Prefectural University, Sakyo-ku, Kyoto, 606-8522, Japan
| | - Shunji Nishide
- Department of Urology, Osaka City University Graduate School of Medicine, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan; Department of Pharmacology, Osaka City University Graduate School of Medicine, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Junji Uchida
- Department of Urology, Osaka City University Graduate School of Medicine, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Tatsuya Nakatani
- Department of Urology, Osaka City University Graduate School of Medicine, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Shinji Matsunaga
- Department of Pharmacology, Osaka City University Graduate School of Medicine, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Takehiro Yamaguchi
- Department of Pharmacology, Osaka City University Graduate School of Medicine, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Shuhei Tomita
- Department of Pharmacology, Osaka City University Graduate School of Medicine, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Katsuyuki Miura
- Department of Applied Pharmacology and Therapeutics, Osaka City University Graduate School of Medicine, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan; Ishikiri Seiki Hospital, Yayoi-cho, Higashiosaka, Osaka, 579-8026, Japan; Department of Pharmacology, Osaka City University Graduate School of Medicine, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan.
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Jiang C, Wang Q, Song M, Wang M, Zhao L, Huang Y. Coronarin D affects TNF-α induced proliferation and osteogenic differentiation of human periodontal ligament stem cells. Arch Oral Biol 2019; 108:104519. [DOI: 10.1016/j.archoralbio.2019.104519] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/01/2019] [Accepted: 08/08/2019] [Indexed: 02/08/2023]
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Abstract
Roxadustat (Ai Rui Zhuo® in China) is an orally administered, small molecule hypoxia-inducible factor (HIF) prolyl hydroxylase inhibitor that is being developed by FibroGen, in collaboration with Astellas and AstraZeneca, for the treatment of anaemia in patients with dialysis-dependent chronic kidney disease (CKD), non-dialysis-dependent CKD and in patients with myelodysplastic syndromes. The drug reversibly binds to and inhibits HIF-prolyl hydroxylase enzymes that are responsible for the degradation of transcription factors in the HIF family under normal oxygen conditions. Inhibition of these enzymes reduces HIF breakdown and promotes HIF activity, leading to an increase in endogenous erythropoietin production, thereby enhancing erythropoiesis. It also reduces the expression of the peptide hormone hepcidin, improves iron availability and increases haemoglobin levels. HIF regulates the expression of genes in response to reduced oxygen levels, including genes required for erythropoiesis and iron metabolism. Roxadustat is approved in China and is under regulatory review in Japan for the treatment of anaemia in patients with dialysis-dependent CKD. Studies are underway to investigate long-term cardiovascular outcomes with roxadustat versus placebo (for non-dialysis-dependent CKD) or standard of care (for dialysis-dependent CKD). This article summarizes the milestones in the development of roxadustat leading to this first approval.
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Affiliation(s)
- Sohita Dhillon
- Springer, Private Bag 65901, Mairangi Bay, 0754, Auckland, New Zealand.
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Sanghani NS, Haase VH. Hypoxia-Inducible Factor Activators in Renal Anemia: Current Clinical Experience. Adv Chronic Kidney Dis 2019; 26:253-266. [PMID: 31477256 PMCID: PMC7318915 DOI: 10.1053/j.ackd.2019.04.004] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/26/2019] [Accepted: 04/30/2019] [Indexed: 12/14/2022]
Abstract
Prolyl hydroxylase domain oxygen sensors are dioxygenases that regulate the activity of hypoxia-inducible factor (HIF), which controls renal and hepatic erythropoietin production and coordinates erythropoiesis with iron metabolism. Small molecule inhibitors of prolyl hydroxylase domain dioxygenases (HIF-PHI [prolyl hydroxylase inhibitor]) stimulate the production of endogenous erythropoietin and improve iron metabolism resulting in efficacious anemia management in patients with CKD. Three oral HIF-PHIs-daprodustat, roxadustat, and vadadustat-have now advanced to global phase III clinical development culminating in the recent licensing of roxadustat for oral anemia therapy in China. Here, we survey current clinical experience with HIF-PHIs, discuss potential therapeutic advantages, and deliberate over safety concerns regarding long-term administration in patients with renal anemia.
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Affiliation(s)
- Neil S Sanghani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Volker H Haase
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Department of Medical Cell Biology, Uppsala Universitet, Uppsala, Sweden; Department of Molecular Physiology & Biophysics and Program in Cancer Biology, Vanderbilt University School of Medicine, Nashville, TN.
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Liver Zonation in Health and Disease: Hypoxia and Hypoxia-Inducible Transcription Factors as Concert Masters. Int J Mol Sci 2019; 20:ijms20092347. [PMID: 31083568 PMCID: PMC6540308 DOI: 10.3390/ijms20092347] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/06/2019] [Accepted: 05/08/2019] [Indexed: 02/06/2023] Open
Abstract
The liver and its zonation contribute to whole body homeostasis. Acute and chronic, not always liver, diseases impair proper metabolic zonation. Various underlying pathways, such as β-catenin, hedgehog signaling, and the Hippo pathway, along with the physiologically occurring oxygen gradient, appear to be contributors. Interestingly, hypoxia and hypoxia-inducible transcription factors can orchestrate those pathways. In the current review, we connect novel findings of liver zonation in health and disease and provide a view about the dynamic interplay between these different pathways and cell-types to drive liver zonation and systemic homeostasis.
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Effect of Multiple Doses of Omeprazole on the Pharmacokinetics, Safety, and Tolerability of Roxadustat in Healthy Subjects. Eur J Drug Metab Pharmacokinet 2019; 43:685-692. [PMID: 29752643 PMCID: PMC6244714 DOI: 10.1007/s13318-018-0480-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Roxadustat is an orally active hypoxia-inducible factor prolyl hydroxylase inhibitor for the treatment of anemia in chronic kidney disease. This study investigated the effect of multiple daily oral doses of omeprazole on the pharmacokinetics, safety, and tolerability of a single oral dose of roxadustat. METHODS This phase 1, open-label, two-period, one-sequence, crossover study enrolled healthy subjects. During Period 1, subjects received a single oral dose of 100 mg roxadustat. After a ≥ 7-day washout, subjects started Period 2 and received daily oral doses of 40 mg omeprazole on Days 1-9, and a single oral dose of 100 mg roxadustat on Day 7. Roxadustat pharmacokinetics were assessed on Days 1-4 in Period 1 and on Days 7-10 in Period 2. Primary endpoints were area under the concentration-time profile from the time of dosing extrapolated to infinity (AUCinf) and maximum concentration (Cmax). Safety was assessed by vital signs, laboratory tests, electrocardiograms, and nature, frequency, and severity of treatment-emergent adverse events (TEAEs). RESULTS Eighteen subjects were enrolled. The geometric least squares mean ratio for both AUCinf and Cmax of roxadustat (with omeprazole/alone) was 104.5%; 90% confidence intervals were within the no-effect boundaries of 80.0 and 125.0%, indicating no significant effect of omeprazole on the pharmacokinetics of roxadustat. No serious TEAEs were reported. CONCLUSION Multiple daily oral doses of 40 mg omeprazole had no significant effect on the pharmacokinetics of a single oral dose of 100 mg roxadustat. Roxadustat was considered safe and well tolerated when administered alone or in combination with multiple daily oral doses of 40 mg omeprazole in healthy subjects.
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Hypoxia-Inducible Factor Prolyl 4-Hydroxylases and Metabolism. Trends Mol Med 2018; 24:1021-1035. [DOI: 10.1016/j.molmed.2018.10.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 10/09/2018] [Accepted: 10/10/2018] [Indexed: 12/17/2022]
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Shibata T, Nomura Y, Takada A, Aoki S, Katashima M, Murakami H. Evaluation of the effect of lanthanum carbonate hydrate on the pharmacokinetics of roxadustat in non‐elderly healthy adult male subjects. J Clin Pharm Ther 2018; 43:633-639. [DOI: 10.1111/jcpt.12729] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/31/2018] [Indexed: 12/17/2022]
Affiliation(s)
| | | | | | - S. Aoki
- Astellas Pharma Inc. Tokyo Japan
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Shibata T, Nomura Y, Takada A, Ueno M, Katashima M, Yazawa R, Furihata K. Evaluation of Food and Spherical Carbon Adsorbent Effects on the Pharmacokinetics of Roxadustat in Healthy Nonelderly Adult Male Japanese Subjects. Clin Pharmacol Drug Dev 2018; 8:304-313. [PMID: 29966038 PMCID: PMC6585706 DOI: 10.1002/cpdd.597] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/28/2018] [Indexed: 12/15/2022]
Abstract
Roxadustat is a hypoxia‐inducible factor prolyl hydroxylase inhibitor in late‐stage clinical development for the treatment of anemia in chronic kidney disease. Spherical carbon adsorbent (SCA) is used in patients with chronic kidney disease and has been shown to impact absorption of certain concomitant drugs. Two phase 1, open‐label, randomized, crossover studies were conducted in healthy adult Japanese males to investigate the effect of food and SCA on the pharmacokinetics of a single oral dose of roxadustat. Subjects in the food effect study received a single dose of 100‐mg roxadustat under fed and fasted conditions. Subjects in the SCA/roxadustat drug‐drug interaction study received a single dose of 100‐mg roxadustat alone, concomitantly with SCA, and 1 and 2 hours before and after SCA to consider the real‐world clinical situation and assess any potential impact of a lag time on the pharmacokinetics of roxadustat. Primary outcomes for both studies were area under the concentration‐time curve from the time of dosing extrapolated to infinity and maximum concentration of drug in blood plasma. In the food effect study (N = 16), the geometric mean ratio (fed/fasted) and 90% confidence interval for area under the concentration‐time curve from the time of dosing extrapolated to infinity and maximum concentration of roxadustat were 94.44 (89.93‐99.18) and 79.88 (72.09‐88.52), respectively. In the SCA/roxadustat drug‐drug interaction study, all geometric mean ratios and 90% confidence intervals (roxadustat + SCA/roxadustat) were within the no‐effect boundaries of 80% and 125%. Roxadustat was generally well tolerated. The effect of food on the pharmacokinetics of roxadustat and the drug‐drug interaction between roxadustat and SCA do not appear to be clinically relevant and support the safe use of roxadustat under these conditions.
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Affiliation(s)
- Tomohisa Shibata
- Clinical Pharmacology, Development, Astellas Pharma Inc., Tokyo, Japan
| | - Yuki Nomura
- Research Program Management, Drug Discovery Research, Astellas Pharma Inc., Tokyo, Japan
| | - Akitsugu Takada
- Clinical Pharmacology, Development, Astellas Pharma Inc., Tokyo, Japan
| | - Mai Ueno
- Japan-Asia Data Science, Development, Astellas Pharma Inc., Tokyo, Japan
| | | | - Rie Yazawa
- Medical Co. LTA Sumida Hospital, Tokyo, Japan
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Discovery of novel 2-[(4-hydroxy-6-oxo-2,3-dihydro-1H-pyridine-5-carbonyl)amino]acetic acid derivatives as HIF prolyl hydroxylase inhibitors for treatment of renal anemia. Bioorg Med Chem Lett 2018; 28:1725-1730. [DOI: 10.1016/j.bmcl.2018.04.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 04/14/2018] [Indexed: 12/20/2022]
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Zhong H, Zhou T, Li H, Zhong Z. The role of hypoxia-inducible factor stabilizers in the treatment of anemia in patients with chronic kidney disease. Drug Des Devel Ther 2018; 12:3003-3011. [PMID: 30271115 PMCID: PMC6151102 DOI: 10.2147/dddt.s175887] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION The purpose of this study was to analyze the effects of hypoxia-inducible factor (HIF) stabilizers on anemia in non-dialysis-dependent (NDD) and dialysis-dependent (DD) chronic kidney disease (CKD) patients. METHODS Published studies were extracted from PubMed, China Biological Medicine Database (CBM), Wanfang database, and Cochrane Library on March 10, 2018, and relevant studies were pooled and included in a meta-analysis. Data on hemoglobin (Hb), ferritin, and hepcidin levels, total iron-binding capacity (TIBC), and incidence of adverse events (AEs) were extracted and pooled using Review Manager Version 5.3. RESULTS Data from nine selected studies were extracted. Meta-analysis of the included studies showed that HIF stabilizers reduced ferritin and hepcidin levels and increased Hb level and TIBC in NDD-CKD patients. However, HIF stabilizers only increased TIBC, and did not affect ferritin, hepcidin, and Hb levels in DD-CKD patients. Furthermore, no notable differences in AEs and severe AEs between NDD-CKD and DD-CKD patients were detected. CONCLUSION HIF stabilizers are effective for the treatment of anemia in NDD-CKD patients and safe for short-term use.
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Affiliation(s)
- Hongzhen Zhong
- Department of Nephrology, The Second Affiliated Hospital, Shantou University Medical College, Shantou, China,
| | - Tianbiao Zhou
- Department of Nephrology, The Second Affiliated Hospital, Shantou University Medical College, Shantou, China,
| | - Hongyan Li
- Department of Nephrology, Huadu District People's Hospital of Guangzhou, Southern Medical University, Guangzhou, China
| | - Zhiqing Zhong
- Department of Nephrology, The Second Affiliated Hospital, Shantou University Medical College, Shantou, China,
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Del Vecchio L, Locatelli F. Roxadustat in the treatment of anaemia in chronic kidney disease. Expert Opin Investig Drugs 2017; 27:125-133. [PMID: 29254377 DOI: 10.1080/13543784.2018.1417386] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Anaemia is one of the hallmarks of advanced chronic kidney disease (CKD); it correlates with a lower quality of life and increased cardiovascular risk. Currently its management is based on iron and erythropoiesis-stimulating agents (ESAs) therapy. Given safety issues on ESA therapy and excessive iron use, anaemia management is still suboptimal. Areas covered: The inhibitors of the prolyl-hydroxylases domain (PHD) are oral drugs which activate the hypoxia-inducible factors (HIF) and stimulate the production of endogenous erythropoietin. Roxadustat (FG-4592) is a second-generation PHD inhibitor; it is undergoing now phase-III clinical development. Expert opinion: Phase-II clinical trials have shown that roxadustat is effective and save in the short term in either non-dialysis or dialysis CKD patients. Roxadustat is a chemical drug and thus has the potential of being cheaper than traditional ESAs. Given that the peaks of endogenous EPO are much lower than those observed with traditional ESA, it is possible to speculate the roxadustat (and more in general PHD inhibitors) will be safer than ESA on cardiovascular safety end-points. Considering that HIFs are involved in different pathways, with possible promotion of relevant side effects, their safety must be proven in long-term studies.
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Affiliation(s)
- Lucia Del Vecchio
- a Department of Nephrology and Dialysis , A. Manzoni Hospital , Lecco , Italy
| | - Francesco Locatelli
- a Department of Nephrology and Dialysis , A. Manzoni Hospital , Lecco , Italy
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Gupta N, Wish JB. Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitors: A Potential New Treatment for Anemia in Patients With CKD. Am J Kidney Dis 2017; 69:815-826. [PMID: 28242135 DOI: 10.1053/j.ajkd.2016.12.011] [Citation(s) in RCA: 293] [Impact Index Per Article: 41.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 12/11/2016] [Indexed: 12/15/2022]
Abstract
Erythropoiesis-stimulating agents (ESAs) increase hemoglobin levels, reduce transfusion requirements, and have been the standard of treatment for anemia in patients with chronic kidney disease (CKD) since 1989. Many safety concerns have emerged regarding the use of ESAs, including an increased occurrence of cardiovascular events and vascular access thrombosis. Hypoxia-inducible factor (HIF) prolyl hydroxylase (PH) enzyme inhibitors are a new class of agents for the treatment of anemia in CKD. These agents work by stabilizing the HIF complex and stimulating endogenous erythropoietin production even in patients with end-stage kidney disease. HIF-PH inhibitors improve iron mobilization to the bone marrow. They are administered orally, which may be a more favorable route for patients not undergoing hemodialysis. By inducing considerably lower but more consistent blood erythropoietin levels than ESAs, HIF-PH inhibitors may be associated with fewer adverse cardiovascular effects at comparable hemoglobin levels, although this has yet to be proved in long-term clinical trials. One significant concern regarding the long-term use of these agents is their possible effect on tumor growth. There are 4 such agents undergoing phase 2 and 3 clinical trials in the United States; this report provides a focused review of HIF-PH inhibitors and their potential clinical utility in the management of anemia of CKD.
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Affiliation(s)
| | - Jay B Wish
- Indiana University Health, Indianapolis, IN.
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