1
|
Tang W, Tummala R, Almquist J, Hwang M, White WI, Boulton DW, MacDonald A. Clinical Pharmacokinetics, Pharmacodynamics, and Immunogenicity of Anifrolumab. Clin Pharmacokinet 2023; 62:655-671. [PMID: 37148484 PMCID: PMC10182164 DOI: 10.1007/s40262-023-01238-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 05/08/2023]
Abstract
The type I interferon (IFN) signaling pathway is implicated in the pathogenesis of systemic lupus erythematosus (SLE). Anifrolumab is a monoclonal antibody that targets the type I IFN receptor subunit 1. Anifrolumab is approved in several countries for patients with moderate to severe SLE receiving standard therapy. The approved dosing regimen of anifrolumab is a 300-mg dose administered intravenously every 4 weeks; this was initially based on the results of the Phase 2b MUSE and further confirmed in the Phase 3 TULIP-1 and TULIP-2 trials, in which anifrolumab 300-mg treatment was associated with clinically meaningful improvements in disease activity with an acceptable safety profile. There have been several published analyses of the pharmacokinetic and pharmacodynamic profile of anifrolumab, including a population-pharmacokinetic analysis of 5 clinical studies of healthy volunteers and patients with SLE, in which body weight and type I IFN gene expression were significant covariates identified for anifrolumab exposure and clearance. Additionally, the pooled Phase 3 SLE population has been used to evaluate how serum exposure may be related to clinical responses, safety risks, and pharmacodynamic effects of the 21-gene type I IFN gene signature (21-IFNGS). The relevance of 21-IFNGS with regard to clinical efficacy outcomes has also been analyzed. Herein, the clinical pharmacokinetics, pharmacodynamics, and immunogenicity of anifrolumab as well as results of population-pharmacokinetics and exposure-response analyses are reviewed.
Collapse
Affiliation(s)
- Weifeng Tang
- Clinical Pharmacology & Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Gaithersburg, MD, USA.
| | - Raj Tummala
- Clinical Development, Late Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Joachim Almquist
- Clinical Pharmacology & Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Michael Hwang
- Clinical Pharmacology & Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, South San Francisco, CA, USA
| | - Wendy I White
- Clinical Pharmacology & Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Gaithersburg, MD, USA
| | - David W Boulton
- Clinical Pharmacology & Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Alexander MacDonald
- Clinical Pharmacology & Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Cambridge, UK
| |
Collapse
|
2
|
Almquist J, Kuruvilla D, Mai T, Tummala R, White WI, Tang W, Roskos L, Chia YL. Nonlinear Population Pharmacokinetics of Anifrolumab in Healthy Volunteers and Patients With Systemic Lupus Erythematosus. J Clin Pharmacol 2022; 62:1106-1120. [PMID: 35383948 PMCID: PMC9540432 DOI: 10.1002/jcph.2055] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/27/2022] [Indexed: 12/03/2022]
Abstract
We characterized the population pharmacokinetics of anifrolumab, a type I interferon receptor–blocking antibody. Pharmacokinetic data were analyzed from the anifrolumab (intravenous [IV], every 4 weeks) arms from 5 clinical trials in patients with systemic lupus erythematosus (SLE) (n = 664) and healthy volunteers (n = 6). Population pharmacokinetic modeling was performed using a 2‐compartment model with parallel linear and nonlinear elimination pathways. The impact of covariates (demographics, interferon gene signature [IFNGS, high/low], disease characteristics, renal/hepatic function, SLE medications, and antidrug antibodies) on pharmacokinetics was evaluated. Time‐varying clearance (CL) was characterized using an empirical sigmoidal time‐dependent function. Anifrolumab exposure increased more than dose‐proportionally from 100 to 1000 mg IV every 4 weeks. Based on population pharmacokinetics modeling, the baseline median linear CL was 0.193 L/day in IFNGS‐high patients and 0.153 L/day in IFNGS‐low/healthy volunteers. After a year, median anifrolumab linear CL decreased by 8.4% from baseline. Body weight and IFNGS were significant pharmacokinetic covariates, whereas age, sex, race, disease activity, SLE medications, and presence of antidrug antibodies had no significant effect on anifrolumab pharmacokinetics. Anifrolumab at a concentration of 300 mg IV every 4 weeks was predicted to be below the lower limit of quantitation in 95% of patients ≈10 weeks after a single dose and ≈16 weeks after stopping dosing at steady state. To conclude, anifrolumab exhibited nonlinear pharmacokinetics and time‐varying linear CL; doses ≥300 mg IV every 4 weeks provided sustained anifrolumab concentrations. This study provides further evidence to support the use of anifrolumab 300 mg IV every 4 weeks in patients with moderate to severe SLE.
Collapse
Affiliation(s)
- Joachim Almquist
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Denison Kuruvilla
- BioPharmaceuticals R&D, AstraZeneca, South San Francisco, California, USA
| | - Tu Mai
- BioPharmaceuticals R&D, AstraZeneca, South San Francisco, California, USA
| | - Raj Tummala
- Clinical Development, Late Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland, United States
| | - Wendy I White
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland, United States
| | - Weifeng Tang
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland, United States
| | - Lorin Roskos
- BioPharmaceuticals R&D, AstraZeneca, South San Francisco, California, USA
| | - Yen Lin Chia
- BioPharmaceuticals R&D, AstraZeneca, South San Francisco, California, USA
| |
Collapse
|
3
|
Song X, Khan AA, Zhou D, Elgeioushi N, Walcott F, Ren S, Gibbs M. Pharmacokinetics and pharmacodynamics of MEDI0680, a fully human anti-PD-1 monoclonal antibody, in patients with advanced malignancies. Cancer Chemother Pharmacol 2022; 89:373-382. [PMID: 35133489 DOI: 10.1007/s00280-022-04396-5] [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: 10/01/2021] [Accepted: 01/10/2022] [Indexed: 12/01/2022]
Abstract
MEDI0680 is a humanized immunoglobulin monoclonal antibody that targets human programmed cell death protein 1 (PD-1) for the treatment of cancer. A population two-compartmental pharmacokinetic (PK) model and a sequential direct maximal effective drug concentration receptor occupancy (RO) model with baseline parameters were developed to quantify PK variability, identify significant covariates, and characterize the relationship between the PK and the RO of MEDI0680. A total of 58 patients with advanced malignancies received MEDI0680 by intravenous infusion at a dose of 0.1-20 mg/kg in a phase 1 study. The clearance was 0.27 L per day and the central volume of distribution (V1) was 3.14 L, with a modest between-subject variability of 30 and 19%, respectively. None of the evaluated covariates showed any impact on PK parameters except for a nonclinically meaningful relevant impact of body weight on V1. The estimated half-maximal effective concentration for MEDI0680 binding to the PD-1 antigen was approximately 1.88 µg/mL. Visual predictive check results demonstrated good predictability of the final population PK-RO model. PK-RO simulations demonstrated that > 90% RO could be maintained in all subjects after a 20-mg/kg dose every 2 weeks (Q2W). Therefore, 20 mg/kg Q2W and an equivalently fixed dose of 1500 mg was recommended for phase 2 studies.
Collapse
Affiliation(s)
- Xuyang Song
- AstraZeneca, One MedImmune Way, Gaithersburg, MD, 20878, USA.
| | - Anis A Khan
- AstraZeneca, One MedImmune Way, Gaithersburg, MD, 20878, USA
| | - Diansong Zhou
- AstraZeneca, One MedImmune Way, Gaithersburg, MD, 20878, USA
| | | | - Farzana Walcott
- AstraZeneca, One MedImmune Way, Gaithersburg, MD, 20878, USA
| | - Song Ren
- AstraZeneca, One MedImmune Way, Gaithersburg, MD, 20878, USA
| | - Megan Gibbs
- AstraZeneca, One MedImmune Way, Gaithersburg, MD, 20878, USA
| |
Collapse
|
4
|
Klavdianou K, Lazarini A, Fanouriakis A. Targeted Biologic Therapy for Systemic Lupus Erythematosus: Emerging Pathways and Drug Pipeline. BioDrugs 2021; 34:133-147. [PMID: 32002918 DOI: 10.1007/s40259-020-00405-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Following the approval of belimumab, the first drug to be approved for systemic lupus erythematosus (SLE) in over 50 years, advances in our understanding of the pathogenesis of the disease have led to a remarkable number of clinical trials for investigational drugs, each with a unique mechanism of action. These include, but are not limited to, antibodies targeting B or T cells or their interaction, dendritic cells, interferon, and other cytokines. Frustratingly, this boost of studies has not been accompanied by a corresponding success and subsequent approval of novel agents, for reasons only partly attributed to the efficacy of the drugs per se. Successful phase II trials are often followed by failed phase III studies, which typically require many more patients. Nevertheless, recent successes, such as the ustekinumab and baricitinib trials and the positive results from the phase III TULIP-2 study of anifrolumab, provide room for cautious optimism. In this review, we attempt to draw the current landscape of the drug pipeline in SLE, focusing on the rationale behind each drug development, its mechanism of action, and the available preclinical and clinical data. We also highlight lessons learned from failed attempts that have helped to optimize clinical trial design for this challenging disease. We conclude with a look into the future, commenting on the surge of studies in the field of biomarkers and the use of omics technologies in lupus, which aim to pinpoint different disease phenotypes and, ideally, identify subsets of patients with disease that will respond to different biologic drugs.
Collapse
Affiliation(s)
- Kalliopi Klavdianou
- Department of Rheumatology, "Asklepieion" General Hospital, 1 Vasileos Pavlou Str., Voula, 16673, Athens, Greece
| | - Argyro Lazarini
- Department of Rheumatology, "Asklepieion" General Hospital, 1 Vasileos Pavlou Str., Voula, 16673, Athens, Greece
| | - Antonis Fanouriakis
- Department of Rheumatology, "Asklepieion" General Hospital, 1 Vasileos Pavlou Str., Voula, 16673, Athens, Greece.
- Rheumatology and Clinical Immunology, 4th Department of Internal Medicine, "Attikon" University Hospital, Athens, Greece.
| |
Collapse
|
5
|
Yao Z, Loggia L, Fink D, Chevrier M, Marciniak S, Sharma A, Xu Z. Pharmacokinetics and Pharmacodynamics of JNJ-55920839, an Antibody Targeting Interferon α/ω, in Healthy Subjects and Subjects with Mild-to-Moderate Systemic Lupus Erythematosus. Clin Drug Investig 2020; 40:1127-1136. [PMID: 33085033 DOI: 10.1007/s40261-020-00978-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The interferon (IFN) pathway has been correlated with clinical and serological markers of disease activity in patients with systemic lupus erythematosus (SLE). OBJECTIVE The pharmacokinetics and pharmacodynamics of JNJ-55920839, a fully human immunoglobulin G1κ antibody targeting IFNα/ω, were investigated. METHODS In a double-blind, first-in-human study, Part A enrolled 48 healthy adults who received a single dose of placebo/JNJ-55920839 between 0.3 and 15 mg/kg intravenous (IV) or at 1 mg/kg subcutaneous (SC). Part B enrolled 26 adults with SLE who received placebo or JNJ-55920839 10 mg/kg IV 6 times biweekly. Pharmacokinetic parameters were calculated by noncompartmental analysis (NCA) and estimated by nonlinear mixed-effects modeling. RESULTS JNJ-55920839 pharmacokinetics following a single IV infusion exhibited a biphasic disposition in healthy subjects. Maximum plasma concentration (Cmax) and area under the concentration-time curve values increased dose-proportionally. Mean clearance (CL) after a single IV infusion ranged between 2.28 and 3.09 mL/kg/day. Absolute bioavailability after a single SC injection was ≥ 80.0%. Mean terminal elimination half-life (t1/2) was similar after IV (20.7 to 24.6 days) and SC administration (22.6 days). Steady state of JNJ-55920839 was achieved 6 weeks after multiple 10 mg/kg IV doses in subjects with SLE. Mean steady-state CL and t1/2 were 4.73 mL/kg/day and 14.8 days, respectively. A linear 2-compartment population pharmacokinetic model with 1st-order absorption and elimination adequately characterized the pharmacokinetics; parameters were consistent with NCA estimates. Higher CL was estimated in subjects with SLE compared with healthy subjects, after correcting for body weight. A trend of increased total IFNα/ω levels was observed after treatment with JNJ-55920839. CONCLUSION Pharmacokinetic and pharmacodynamic analyses of the data from this study demonstrated that there was biphasic disposition in both healthy subjects and subjects with SLE, CL was faster in subjects with SLE, and increases in total IFNα/ω levels were observed in both healthy subjects and subjects with SLE after treatment with JNJ-55920839, thus further development is supported. The study is registered at ClinicalTrials.gov NCT02609789.
Collapse
MESH Headings
- Administration, Intravenous
- Adult
- Antibodies, Monoclonal, Humanized/pharmacokinetics
- Antibodies, Monoclonal, Humanized/pharmacology
- Antibodies, Monoclonal, Humanized/therapeutic use
- Area Under Curve
- Biological Availability
- Double-Blind Method
- Female
- Healthy Volunteers
- Humans
- Infusions, Intravenous
- Injections, Subcutaneous
- Interferon-alpha/antagonists & inhibitors
- Lupus Erythematosus, Systemic/drug therapy
- Male
- Middle Aged
- Placebos
Collapse
Affiliation(s)
- Zhenling Yao
- Janssen Research and Development, LLC, Clin Pharm TA PA, SH32-10590, Welsh & McKean Road, Spring House, PA, 19477, USA
| | - Laura Loggia
- Janssen Research and Development, LLC, Clin Pharm TA PA, SH32-10590, Welsh & McKean Road, Spring House, PA, 19477, USA
| | - Damien Fink
- Janssen Research and Development, LLC, Clin Pharm TA PA, SH32-10590, Welsh & McKean Road, Spring House, PA, 19477, USA
| | - Marc Chevrier
- Janssen Research and Development, LLC, Clin Pharm TA PA, SH32-10590, Welsh & McKean Road, Spring House, PA, 19477, USA
| | - Stanley Marciniak
- Janssen Research and Development, LLC, Clin Pharm TA PA, SH32-10590, Welsh & McKean Road, Spring House, PA, 19477, USA
| | - Amarnath Sharma
- Janssen Research and Development, LLC, Clin Pharm TA PA, SH32-10590, Welsh & McKean Road, Spring House, PA, 19477, USA
| | - Zhenhua Xu
- Janssen Research and Development, LLC, Clin Pharm TA PA, SH32-10590, Welsh & McKean Road, Spring House, PA, 19477, USA.
| |
Collapse
|
6
|
Paredes JL, Niewold TB. Type I interferon antagonists in clinical development for lupus. Expert Opin Investig Drugs 2020; 29:1025-1041. [PMID: 32700979 PMCID: PMC7924012 DOI: 10.1080/13543784.2020.1797677] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/15/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is a severe chronic and incurable autoimmune disease. Treatment includes glucocorticoids and immunosuppressants which typically result in partial responses, and hence there is a great need for new therapies. The type I interferon (IFN) pathway is activated in more than 50% of SLE patients, and it is strongly implicated as a pathogenic factor in SLE. AREAS COVERED We searched the literature using 'SLE and interferon antagonists' as search terms. This identified a number of therapeutics that have entered clinical development targeting type I IFN in SLE. These include monoclonal antibodies against type I IFN cytokines and a kinoid vaccination strategy to induce anti-IFN antibodies. EXPERT OPINION Type I IFN antagonists have had some success, but many molecules have not progressed to phase III. These varied results are likely attributed to the multiple concurrent cytokine abnormalities present in SLE, the imprecise nature of the IFN signature as a readout for type I IFN and difficulties with clinical trials such as background medication use and diffuse composite disease activity measures. Despite these challenges, it seems likely that a type I IFN antagonist will come to clinical utility for SLE given the large unmet need and the recent phase III success with anifrolumab.
Collapse
Affiliation(s)
- Jacqueline L Paredes
- Colton Center for Autoimmunity, New York University School of Medicine , New York, NY, USA
| | - Timothy B Niewold
- Colton Center for Autoimmunity, New York University School of Medicine , New York, NY, USA
| |
Collapse
|
7
|
Li Z, Bai J, Wen A, Shen S, Duan M, Li X. Pharmacokinetic and Pharmacodynamic Analysis of Critically Ill Patients Undergoing Continuous Renal Replacement Therapy With Imipenem. Clin Ther 2020; 42:1564-1577.e8. [PMID: 32741646 DOI: 10.1016/j.clinthera.2020.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/12/2020] [Accepted: 06/21/2020] [Indexed: 01/30/2023]
Abstract
PURPOSE This study explores factors that affect behavior in critically ill patients receiving continuous renal replacement therapy (CRRT) with imipenem and provides dosing regimens for these patients. METHODS A prospective, open-label study was conducted in a clinical setting. Both blood and effluent samples were collected pairwise at the scheduled time points. Plasma and effluent imipenem concentrations were determined by HPLC-UV. A population pharmacokinetic model was developed using a nonlinear mixed-effects modeling method. The final model was evaluated by a bootstrap and visual predictive check. A population pharmacokinetic and pharmacodynamic analysis using Monte Carlo simulations was performed to explore the effects of empirically used dosing regimens (0.5 g q6h, 0.5 g q8h, 0.5 g q12h, 1 g q6h, 1 g q8h, and 1 g q12h) on the probability of target attainment. FINDINGS Thirty patients were included in the population model analysis. Imipenem concentration data were best described by a 3-compartment model (central, peripheral, and dialysis compartments). The clearance of the dialysis compartment (CLd) was used to characterize drug elimination from the dialyzer. Creatinine clearance (CrCl) was the covariate that influenced the central clearance (CLc), and the effects of dialysate flow (Qd) was significant for CLd. Model validation revealed that the final model had qualified stability and acceptable predictive properties. A pharmacokinetic and pharmacodynamic analysis was conducted by Monte Carlo simulation, and patients were categorized into 12 subgroups based on different CrCl values (<30, 31-60, 61-90, and >90 mL/min) and Qd values (300, 500, and 1000 mL/h). Under the same MIC value and administration regimen, probability of target attainment values decreased with an increase of CrCl and Qd. IMPLICATIONS CrCl and Qd had significant effects on CLc and CLd, respectively. The proposed final model may be used to guide practitioners in imipenem dosing in this specific patient population.
Collapse
Affiliation(s)
- Zhe Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jing Bai
- Department of Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Aiping Wen
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Su Shen
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Meili Duan
- Department of Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
| | - Xingang Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
8
|
Bensalem A, Ternant D. Pharmacokinetic Variability of Therapeutic Antibodies in Humans: A Comprehensive Review of Population Pharmacokinetic Modeling Publications. Clin Pharmacokinet 2020; 59:857-874. [DOI: 10.1007/s40262-020-00874-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
9
|
Understanding Inter-Individual Variability in Monoclonal Antibody Disposition. Antibodies (Basel) 2019; 8:antib8040056. [PMID: 31817205 PMCID: PMC6963779 DOI: 10.3390/antib8040056] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/22/2019] [Accepted: 11/27/2019] [Indexed: 12/29/2022] Open
Abstract
Monoclonal antibodies (mAbs) are currently the largest and most dominant class of therapeutic proteins. Inter-individual variability has been observed for several mAbs; however, an understanding of the underlying mechanisms and factors contributing to inter-subject differences in mAb disposition is still lacking. In this review, we analyze the mechanisms of antibody disposition and the putative mechanistic determinants of inter-individual variability. Results from in vitro, preclinical, and clinical studies were reviewed evaluate the role of the neonatal Fc receptor and Fc gamma receptors (expression and polymorphism), target properties (expression, shedding, turnover, internalization, heterogeneity, polymorphism), and the influence of anti-drug antibodies. Particular attention is given to the influence of co-administered drugs and disease, and to the physiological relevance of covariates identified by population pharmacokinetic modeling, as determinants of variability in mAb pharmacokinetics.
Collapse
|
10
|
Huo AX, Chen WH, Liu YH, Gao P, Li J. Efficacy of sifalimumab for treatment of skin injury caused by systemic lupus erythematosus. Medicine (Baltimore) 2019; 98:e17607. [PMID: 31651869 PMCID: PMC6824784 DOI: 10.1097/md.0000000000017607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND This study aims to provide the best possible evidence-based information on the efficacy and safety of sifalimumab for treatment of skin injury (SI) caused by systemic lupus erythematosus (SLE). METHODS In this study, electronic databases of MEDLINE, EMBASE, Cochrane Library, PsycINFO, CINAHL Plus, Global Health, WHO Global Index Medicus, Virtual Health Library, Social Care Online, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure will be searched comprehensively from inceptions to June 30, 2019 without language restrictions. We will include randomized controlled trials (RCTs) on evaluating the efficacy and safety of sifalimumab for SI caused by SLE. Two investigators will conduct study selection, data extraction, and risk of bias assessment independently. We will use RevMan 5.3 Software to perform statistical analysis. RESULTS This study will lie in the exhaustive and systematic nature of the literature search and its methods for evaluating quality and analyzing RCTs data. Considering the controversial efficacy of the treatment for sifalimumab, this study is responsible for improving the existing evidence on the efficacy and safety of sifalimumab for SI caused by SLE. CONCLUSION The results of this study will provide latest evidence for judging whether sifalimumab is an effective intervention for patients with SI caused by SLE or not. STUDY REGISTRATION CRD42019148225.
Collapse
Affiliation(s)
- Ai-xin Huo
- Department of Immunology and Rheumatology, Yanan University Affiliated Hospital, Yan’an
| | - Wen-hui Chen
- Department of Dermatology, Shaanxi Provincial Institute of Dermatology and Venereology, Xi’an, China
| | - Yu-hong Liu
- Department of Immunology and Rheumatology, Yanan University Affiliated Hospital, Yan’an
| | - Peng Gao
- Department of Immunology and Rheumatology, Yanan University Affiliated Hospital, Yan’an
| | - Jing Li
- Department of Immunology and Rheumatology, Yanan University Affiliated Hospital, Yan’an
| |
Collapse
|
11
|
Takeuchi T, Tanaka Y, Matsumura R, Saito K, Yoshimura M, Amano K, Atsumi T, Suematsu E, Hayashi N, Wang L, Tummala R. Safety and tolerability of sifalimumab, an anti-interferon-α monoclonal antibody, in Japanese patients with systemic lupus erythematosus: A multicenter, phase 2, open-label study. Mod Rheumatol 2019; 30:93-100. [PMID: 30791804 DOI: 10.1080/14397595.2019.1583832] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objectives: To evaluate the safety of sifalimumab in Japanese patients with systemic lupus erythematosus (SLE).Methods: This phase 2, open-label study consisted of a 52-week initial stage (Stage I) and a long-term extension (Stage II). In Stage I, sequential cohorts of patients received ascending doses of sifalimumab (intravenous [IV] 1.0, 3.0, and 10.0 mg/kg or subcutaneous 100 mg every 2 weeks; IV 600 and 1200 mg every 6 weeks). In Stage II, patients enrolled before June 2012 received the same dose of sifalimumab as during Stage I for up to 157 weeks or sifalimumab 600 mg IV every 4 weeks if they enrolled later. The safety of sifalimumab was assessed by adverse events (AEs).Results: Thirty patients enrolled in Stage I and 21 patients entered Stage II. The majority of patients experienced AEs (96.7% in Stage I and 100% in Stage II); most were mild or moderate in severity. Serious AEs occurred in 30.0% and 57.1% of patients in Stage I and II, respectively; most were instances of SLE flares. The proportion of patients in Stage I and II who had AEs leading to discontinuation was 10.0% and 28.6%, respectively.Conclusion: Sifalimumab was well tolerated in Japanese patients with SLE.
Collapse
Affiliation(s)
- Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiya Tanaka
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| | - Ryutaro Matsumura
- Department of Allergy, National Hospital Organization, Chiba-East Hospital, Chiba, Japan
| | - Kazuyoshi Saito
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| | - Mitsuhiro Yoshimura
- Department of Internal Medicine, National Hospital Organization, Kanazawa Medical Center, Ishikawa, Japan
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Hokkaido University Hospital, Hokkaido, Japan
| | - Eiichi Suematsu
- Department of Internal Medicine and Rheumatology, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan
| | - Nobuya Hayashi
- Department of Research and Development, AstraZeneca K.K, Osaka, Japan
| | | | | |
Collapse
|
12
|
A pre-clinical quantitative model predicts the pharmacokinetics/pharmacodynamics of an anti-BDCA2 monoclonal antibody in humans. J Pharmacokinet Pharmacodyn 2018; 45:817-827. [DOI: 10.1007/s10928-018-9609-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 10/20/2018] [Indexed: 12/12/2022]
|
13
|
Haraya K, Tachibana T, Nezu J. Quantitative prediction of therapeutic antibody pharmacokinetics after intravenous and subcutaneous injection in human. Drug Metab Pharmacokinet 2017; 32:208-217. [DOI: 10.1016/j.dmpk.2017.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 05/15/2017] [Accepted: 05/17/2017] [Indexed: 01/29/2023]
|
14
|
Yu T, Enioutina EY, Brunner HI, Vinks AA, Sherwin CM. Clinical Pharmacokinetics and Pharmacodynamics of Biologic Therapeutics for Treatment of Systemic Lupus Erythematosus. Clin Pharmacokinet 2017; 56:107-125. [PMID: 27384528 PMCID: PMC5575762 DOI: 10.1007/s40262-016-0426-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Systemic lupus erythematosus (SLE) is a multifactorial autoimmune disease with potentially severe clinical manifestation that mainly affects women of child-bearing age. Patients who do not respond to standard-of-care therapies, such as corticosteroids and immunosuppressants, require biologic therapeutics that specifically target a single or multiple SLE pathogenesis pathways. This review summarizes the clinical pharmacokinetic and pharmacodynamic characteristics of biologic agents that are approved, used off-label, or in the active pipeline of drug development for SLE patients. Depending on the type of target, the interacting biologics may exhibit linear (non-specific) or non-linear (target-mediated) disposition profiles, with terminal half-lives varying from approximately 1 week to 1 month. Biologics given by subcutaneous administration, which offers dosing flexibility over intravenous administration, demonstrated a relatively slow absorption with a time to maximum concentration of approximately 1 day to 2 weeks and a variable bioavailability of 30-82 %. The population pharmacokinetics of monoclonal antibodies were best described by a two-compartment model with central clearance and steady-state volume of distribution ranging from 0.176 to 0.215 L/day and 3.60-5.29 L, respectively. The between-subject variability in pharmacokinetic parameters were moderate (20-79 %) and could be partially explained by body size. The development of linked pharmacokinetic-pharmacodynamic models incorporating SLE disease biomarkers are an attractive strategy for use in dosing regimen simulation and optimization. The relationship between efficacy/adverse events and biologic concentration should be evaluated to improve clinical trial outcomes, especially for biologics in the advanced phase of drug development. New strategies, such as model-based precision dosing dashboards, could be utilized to incorporate information collected from therapeutic drug monitoring into pharmacokinetic/pharmacodynamic models to enable individualized dosing in real time.
Collapse
Affiliation(s)
- Tian Yu
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, SLC, Utah 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Elena Y Enioutina
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, SLC, Utah 295 Chipeta Way, Salt Lake City, UT, 84108, USA
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Hermine I Brunner
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Catherine M Sherwin
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, SLC, Utah 295 Chipeta Way, Salt Lake City, UT, 84108, USA.
- Department of Pediatrics, Clinical Trials Office, Salt Lake City, UT, USA.
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Utah, Salt Lake City, UT, USA.
| |
Collapse
|
15
|
Greth W, Robbie GJ, Brohawn P, Hultquist M, Yao B. Targeting the interferon pathway with sifalimumab for the treatment of systemic lupus erythematosus. Immunotherapy 2017; 9:57-70. [DOI: 10.2217/imt-2016-0090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Dysregulation of the type I interferon (IFN) system is associated with various immunologic diseases, such as systemic lupus erythematosus (SLE). Targeting this dysregulation presents an attractive approach for SLE therapy. Sifalimumab, a fully human immunoglobulin G1 κ monoclonal antibody that binds to and neutralizes most IFN-α subtypes, has been recently evaluated in a Phase IIb study in patients with moderate to severe SLE. Insights gained from earlier studies were used to inform design of the Phase IIb study, to provide a more comprehensive evaluation of sifalimumab. Sifalimumab demonstrated broad efficacy across composite and organ-specific end points, suggesting that targeting of IFN-α is a promising treatment option for SLE, particularly for those patients whose disease is refractory to current standard of care.
Collapse
Affiliation(s)
| | | | | | | | - Bing Yao
- MedImmune, Gaithersburg, MD, USA
| |
Collapse
|
16
|
Li X, Wu Y, Sun S, Zhao Z, Wang Q. Population Pharmacokinetics of Vancomycin in Postoperative Neurosurgical Patients and the Application in Dosing Recommendation. J Pharm Sci 2016; 105:3425-3431. [PMID: 27671237 DOI: 10.1016/j.xphs.2016.08.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/14/2016] [Accepted: 08/18/2016] [Indexed: 11/25/2022]
Abstract
Our previous study indicates that cerebrospinal fluid (CSF) albumin level is a determinant of CSF vancomycin concentration for postoperative neurosurgical patients. We aimed to develop an improved vancomycin population pharmacokinetic model with incorporation of more covariates, and to provide dosing guidance for clinicians. Vancomycin was administered intravenously to 20 patients with external ventricular drains after neurosurgical operation. Blood and CSF were collected and vancomycin concentrations were measured by HPLC. A separate CSF compartment was considered, and was linked to the central compartment by a first-order process (QCSF). The clearance of the CSF compartment (ClCSF) was used to characterize vancomycin elimination from CSF through external ventricular drain. Nonlinear mixed-effects modeling approach was used to develop the model. The CSF albumin level (mg/dL) was the covariate influencing QCSF: QCSF=0.0049+0.000021×(CSF albumin-279). The effect of body weight (BW, kg) was significant on central volume (VC): VC=27.84+0.96×(BW-69). All parameters were estimated with an acceptable precision (relative standard error: RSE% < 30.26). The performance of the final model was acceptable with our previous dataset. A simple to use dosage regimen table was created to guide clinicians with vancomycin dosing. This model incorporates variables of both CSF albumin and BW, which offers improvements to the previous pharmacokinetics model.
Collapse
Affiliation(s)
- Xingang Li
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; Precision Medicine Research Center for Neurological Disorders, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Yuanxing Wu
- Respiratory and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Shusen Sun
- College of Pharmacy, Western New England University, Springfield, Massachusetts 01119
| | - Zhigang Zhao
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; Precision Medicine Research Center for Neurological Disorders, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Qiang Wang
- Intensive Care Unit, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China.
| |
Collapse
|
17
|
Zheng B, Yu X, Greth W, Robbie GJ. Population pharmacokinetic analysis of sifalimumab from a clinical phase IIb trial in systemic lupus erythematosus patients. Br J Clin Pharmacol 2016; 81:918-28. [PMID: 26659791 PMCID: PMC4834601 DOI: 10.1111/bcp.12864] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 11/23/2015] [Accepted: 12/02/2015] [Indexed: 01/05/2023] Open
Abstract
AIMS Sifalimumab, a human immunoglobulin (Ig) G1 monoclonal antibody against INF-alpha, is being studied as a treatment for systemic lupus erythematosus (SLE). This analysis characterized population pharmacokinetics (PK) of sifalimumab following repeat fixed dose and evaluated the utility of fixed dosing vs. body weight normalized dosing in SLE patients. METHODS PK data were collected in a phase IIb study where 298 patients received multiple intravenous doses (200-1200 mg) of sifalimumab every 4 weeks for 52 weeks. A population pharmacokinetic model was developed using 3961 quantifiable serum concentrations and the impact of patient demographics, clinical indices and biomarkers on pharmacokinetic parameters was evaluated. The appropriateness of the final model was evaluated using visual predictive check and bootstrap. RESULTS A two compartment model with first order elimination adequately described sifalimumab serum PK. The estimated typical clearance (CL) and central volume of distribution (V1 ) were 184 ml day(-1) and 2.82 l with 24% and 16% between-subject variability (BSV), respectively. Body weight, dose, 21 INF gene signature baseline and concomitant steroid use were identified as statistically significant covariates for CL and V1 and accounted for <10% of PK variability in the final model. Typical values and BSV of PK parameters from the current analysis with fixed dosing were similar to previous population PK results with body weight normalized dosing. CONCLUSIONS The transition from body weight normalized dosing to fixed dosing did not impact sifalimumab PK. These findings support the use of fixed dosing for sifalimumab in future clinical studies evaluating it as a potential treatment for SLE.
Collapse
Affiliation(s)
- Bo Zheng
- Clinical Pharmacology and DMPK (CPD)MedImmune, LLC, One MedImmune WayGaithersburgMaryland20878
| | - Xiang‐Qing Yu
- Clinical Pharmacology and DMPK (CPD)MedImmune, LLC, One MedImmune WayGaithersburgMaryland20878
| | - Warren Greth
- Clinical DevelopmentMedImmune, LLC, One MedImmune WayGaithersburgMaryland20878USA
| | - Gabriel J. Robbie
- Clinical Pharmacology and DMPK (CPD)MedImmune, LLC, One MedImmune WayGaithersburgMaryland20878
| |
Collapse
|
18
|
Zhang H, Chambers W, Sciascia S, Cuadrado MJ. Emerging therapies in systemic lupus erythematous: from clinical trial to the real life. Expert Rev Clin Pharmacol 2016; 9:681-94. [DOI: 10.1586/17512433.2016.1155446] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
19
|
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease of unknown aetiology that can be debilitating and life threatening. As new insights are gained into the underlying pathology of SLE, there have been an unprecedented number of new agents under development to treat the disease via a diverse range of targets. One such class of emerging agents target interferon (IFN) signalling. In this article, we review the preclinical evidence that the inhibition of the secretion and downstream effectors of both IFN-α and IFN-γ may be effective for the treatment of SLE. The primary agents that are currently in clinical development to treat SLE via the targeting of interferon pathways are monoclonal neutralising antibodies (Mab) that bind to and neutralise IFN-γ (AMG 811), IFN-α (sifalimumab, rontalizumab and AGS-009) or its receptor (anifrolumab), and IFN-α kinoid, which is a drug composed of inactivated IFN-α molecules coupled to the keyhole limpet haemocyanin protein. Phase I and II trials have demonstrated acceptable short-term safety with no increase in severe viral infections or reactivation, favourable pharmacokinetic profiles and an inhibition of IFN-associated gene overexpression; however, the impact of these drugs on disease activity must still be assessed in phase III clinical trials. This review concludes with a summary of the challenges that are inherent to this approach to managing SLE.
Collapse
|
20
|
Marcuzzi A, Piscianz E, Valencic E, Monasta L, Vecchi Brumatti L, Tommasini A. To Extinguish the Fire from Outside the Cell or to Shutdown the Gas Valve Inside? Novel Trends in Anti-Inflammatory Therapies. Int J Mol Sci 2015; 16:21277-93. [PMID: 26370962 PMCID: PMC4613252 DOI: 10.3390/ijms160921277] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/19/2015] [Accepted: 08/31/2015] [Indexed: 12/26/2022] Open
Abstract
Cytokines are the most important soluble mediators of inflammation. Rare pediatric diseases provided exemplar conditions to study the anti-inflammatory efficacy of new generation therapies (biologics/biopharmaceuticals) selectively targeting single cytokines. Monoclonal antibodies and recombinant proteins have revolutionized anti-inflammatory therapies in the last two decades, allowing the specific targeting of single cytokines. They are very effective in extinguishing inflammation from outside the cell, even with the risk of an excessive and prolonged immunosuppression. Small molecules can enter the cell and shutdown the valve of inflammation by directly targeting signal proteins involved in cytokine release or in response to cytokines. They are orally-administrable drugs whose dosage can be easily adjusted to obtain the desired anti-inflammatory effect. This could make these drugs more suitable for a wide range of diseases as stroke, gout, or neurological impairment, where inflammatory activation plays a pivotal role as trigger. Autoinflammatory diseases, which have previously put anti-cytokine proteins in the limelight, can again provide a valuable model to measure the real potential of small inhibitors as anti-inflammatory agents.
Collapse
Affiliation(s)
- Annalisa Marcuzzi
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Piazzale Europa 1, Trieste 34128, Italy.
| | - Elisa Piscianz
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo" - , via dell'Istria, 65/1, Trieste 34137, Italy.
| | - Erica Valencic
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo" - , via dell'Istria, 65/1, Trieste 34137, Italy.
| | - Lorenzo Monasta
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo" - , via dell'Istria, 65/1, Trieste 34137, Italy.
| | - Liza Vecchi Brumatti
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo" - , via dell'Istria, 65/1, Trieste 34137, Italy.
| | - Alberto Tommasini
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo" - , via dell'Istria, 65/1, Trieste 34137, Italy.
| |
Collapse
|
21
|
Hansen CB, Callen JP. Current and future treatment options for cutaneous lupus erythematosus. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1048224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
22
|
Becerra CR, Conkling P, Vogelzang N, Wu H, Hong S, Narwal R, Liang M, Tavakkoli F, Pandya N. A phase I dose-escalation study of MEDI-575, a PDGFRα monoclonal antibody, in adults with advanced solid tumors. Cancer Chemother Pharmacol 2014; 74:917-25. [PMID: 25149088 PMCID: PMC4209236 DOI: 10.1007/s00280-014-2567-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 08/04/2014] [Indexed: 11/16/2022]
Abstract
Purpose The purpose of the study was to evaluate safety and determine the maximum tolerated dose (MTD) of MEDI-575, a fully human monoclonal antibody that selectively binds to platelet-derived growth factor receptor-α (PDGFRα), in patients with advanced solid tumors. Methods This phase I multicenter, open-label, single-arm study enrolled adults in a 3 + 3 dose escalation design to receive MEDI-575 (3, 6, 9, 12, or 15 mg/kg) once weekly (QW) until toxicity or disease progression occurred. One 0.5-mg/kg dose was given before the first dose in the 3-mg/kg cohort to determine pharmacokinetics (PK) and pharmacodynamics under unsaturated conditions. After completion of dose escalation in the QW cohorts, patients were enrolled in two additional cohorts and received MEDI-575 25 or 35 mg/kg every 3 weeks (Q3W). Secondary measures included assessments of PK, immunogenicity, and antitumor activity. Results A total of 35 patients received MEDI-575 QW (n = 23) or Q3W (n = 12). Most treatment-related adverse events were grade 1 or 2 in severity across all dose levels, with fatigue (n = 12) and nausea (n = 8) being reported most frequently. With no reports of dose-limiting toxicities (DLTs), the MTD was not reached. MEDI-575 exhibited a nonlinear PK profile and increased plasma platelet-derived growth factor-AA levels in a dose-dependent manner with limited immunogenicity. Stable disease was reported as the best tumor response in 9 of 29 evaluable patients; however, no objective responses were reported. Conclusion Administration of MEDI-575 QW or Q3W resulted in a favorable safety profile, including a lack of DLTs, but without evidence of antitumor activity in patients with refractory solid tumors.
Collapse
Affiliation(s)
- Carlos R Becerra
- Sammons Cancer Center, Texas Oncology P.A., 3410 Worth St., Suite 300, Dallas, TX, 75246, USA,
| | | | | | | | | | | | | | | | | |
Collapse
|
23
|
[Use of the simulation in the clinical investigation]. Med Clin (Barc) 2013; 141:550-5. [PMID: 24238627 DOI: 10.1016/j.medcli.2013.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 10/08/2013] [Accepted: 10/17/2013] [Indexed: 11/22/2022]
|