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Donnez J, Becker C, Taylor H, Carmona Herrera F, Donnez O, Horne A, Paszkowski M, Petraglia F, Renner SP, Patel A, Boolell M, Bestel E, Dolmans MM. Linzagolix therapy versus a placebo in patients with endometriosis-associated pain: a prospective, randomized, double-blind, Phase 3 study (EDELWEISS 3). Hum Reprod 2024; 39:1208-1221. [PMID: 38648863 PMCID: PMC11144970 DOI: 10.1093/humrep/deae076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 03/07/2024] [Indexed: 04/25/2024] Open
Abstract
STUDY QUESTION Does linzagolix administered orally once daily for up to 3 months at a dose of 75 mg alone or 200 mg in combination with add-back therapy (ABT) (1.0 mg estradiol; 0.5 mg norethindrone acetate, also known as norethisterone acetate [NETA]) demonstrate better efficacy than placebo in the management of endometriosis-related dysmenorrhea and non-menstrual pelvic pain? SUMMARY ANSWER Combining 200 mg linzagolix with ABT was found to significantly reduce dysmenorrhea and non-menstrual pelvic pain at 3 months of therapy, while a daily dose of 75 mg linzagolix yielded a significant decrease only in dysmenorrhea at 3 months. WHAT IS KNOWN ALREADY? A previously published Phase 2, dose-finding study reported that at a dose of 200 mg daily, linzagolix promotes full suppression of estradiol secretion to serum levels below 20 pg/ml and noted that the addition of ABT may be needed to manage hypoestrogenic side effects. At lower doses (75 mg and 100 mg/day), linzagolix maintains estradiol values within the target range of 20-60 pg/ml, which could be ideal to alleviate symptoms linked to endometriosis. STUDY DESIGN, SIZE, DURATION EDELWEISS 3 was a multicenter, prospective, randomized, placebo-controlled, double-blind, double-dummy Phase 3 study to evaluate the safety and efficacy of linzagolix for the treatment of moderate-to-severe endometriosis-associated pain. Treatment was administered orally once daily for up to 6 months. PARTICIPANTS/MATERIALS, SETTING, METHODS In the EDELWEISS 3 trial, 486 subjects with moderate-to-severe endometriosis-associated pain were randomized at a 1:1:1 ratio to one of the three study groups: placebo, 75 mg linzagolix alone or 200 mg linzagolix in association with ABT. Pain was measured daily on a verbal rating scale and recorded in an electronic diary. MAIN RESULTS AND THE ROLE OF CHANCE At 3 months, the daily 200 mg linzagolix dose with ABT met the primary efficacy objective, showing clinically meaningful and statistically significant reductions in dysmenorrhea and non-menstrual pelvic pain, with stable or decreased use of analgesics. The proportion of responders for dysmenorrhea in the 200 mg linzagolix with ABT group was 72.9% compared with 23.5% in the placebo group (P < 0.001), while the rates of responders for non-menstrual pelvic pain were 47.3% and 30.9% (P = 0.007), respectively. The 75 mg linzagolix daily dose demonstrated a clinically meaningful and statistically significant reduction in dysmenorrhea versus placebo at 3 months. The proportion of responders for dysmenorrhea in the 75 mg linzagolix group was 44.0% compared with 23.5% in the placebo group (P < 0.001). Although the 75 mg dose showed a trend toward reduction in non-menstrual pelvic pain at 3 months relative to the placebo, it was not statistically significant (P = 0.279). Significant improvements in dyschezia and overall pelvic pain were observed in both linzagolix groups when compared to placebo. Small improvements in dyspareunia scores were observed in both linzagolix groups but they were not significant. In both groups, hypoestrogenic effects were mild, with low rates of hot flushes and bone density loss of <1%. A daily dose of 200 mg linzagolix with ABT or 75 mg linzagolix alone was found to significantly reduce dysmenorrhea and non-menstrual pelvic pain also at 6 months of therapy. LIMITATIONS, REASONS FOR CAUTION Efficacy was compared between linzagolix groups and placebo; however, it would be useful to have results from comparative studies with estro-progestogens or progestogens. It will be important to ascertain whether gonadotropin-releasing hormone antagonists have significant benefits over traditional first-line medications. WIDER IMPLICATIONS OF THE FINDINGS Linzagolix administered orally once daily at a dose of 200 mg in combination with add-back therapy (ABT) demonstrated better efficacy and safety than placebo in the management of moderate-to-severe endometriosis-associated pain. The quality of life was improved and the risks of bone loss and vasomotor symptoms were minimized due to the ABT. The 75 mg dose alone could be suitable for chronic treatment of endometriosis-associated pain without the need for concomitant hormonal ABT, but further research is needed to confirm this. If confirmed, it would offer a viable option for women who do not want to wish to have ABT or for whom it is contraindicated. STUDY FUNDING/COMPETING INTEREST(S) Funding for the EDELWEISS 3 study was provided by ObsEva (Geneva, Switzerland). Analysis of data and manuscript writing were partially supported by ObsEva (Geneva, Switzerland), Theramex (London, UK) and Kissei (Japan) and grant 5/4/150/5 was awarded to M.-M.D. by FNRS. J.D. was a member of the scientific advisory board of ObsEva until August 2022, a member of the scientific advisory board of PregLem, and received personal fees from Gedeon Richter, ObsEva and Theramex. J.D. received consulting fees, speakers' fees, and travel support from Gedeon Richter, Obseva and Theramex, which was paid to their institution. C.B. has received fees from Theramex, Gedeon Richter, and Myovant, and travel support from Gedeon Richter-all funds went to the University of Oxford. He was a member of the data monitoring board supervising the current study, and served at an advisory board for endometriosis studies of Myovant. H.T. has received grants from Abbvie and was past president of ASRM. F.C.H. has received fees from Gedeon Richter and Theramex. O.D. received fees for lectures from Gedeon Richter and ObsEva and research grants for clinical studies from Preglem and ObsEva independent from the current study. A.H. has received grants from NIHR, UKRI, CSO, Wellbeing of Women, and Roche Diagnostics; he has received fees from Theramex. A.H.'s institution has received honoraria for consultancy from Roche Diagnostics, Gesynta, and Joii. M.P. has nothing to declare. F.P. has received fees from Theramex. S.P.R. has been a member of the scientific advisory board of Gedeon Richter and received fees from Gedeon Richter. A.P. and M.B. are employees of Theramex. E.B. was an employee of ObsEva, sponsor chair of the data monitoring board supervising the current study, and has been working as a consultant for Theramex since December 2022; she owns stock options in ObsEva. M.-M.D. has received fees and travel support from Gedeon Richter and Theramex. TRIAL REGISTRATION NUMBER NCT03992846. TRIAL REGISTRATION DATE 20 June 2019. DATE OF FIRST PATIENT’S ENROLLMENT 13 June 2019.
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Affiliation(s)
- Jacques Donnez
- Department of Gynecology, Université Catholique de Louvain, Brussels, Belgium
- Department of Gynecology, Société de Recherche pour l’Infertilité (SRI), Brussels, Belgium
| | - Christian Becker
- Nuffield Department of Women’s & Reproductive Health, Endometriosis CaRe Centre, University of Oxford, Oxford, UK
| | - Hugh Taylor
- Department of Obstetrics, Gynecology and Reproductive sciences, Yale School of Medicine, New Haven, CT, USA
| | - Francisco Carmona Herrera
- Gynaecology Department, Clinic Institute of Gynaecology, Obstetrics and Neonatology (ICGON), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Olivier Donnez
- Département de Gynécologie, Centre de l’Endométriose Complexe, Chirurgie endoscopique pelvienne, Polyclinique Urbain V (ELSAN Group), Avignon, France
| | - Andrew Horne
- Department of Gynecology, EXPPECT and MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Maciej Paszkowski
- Third Chair and Department of Gynecology, Medical University of Lublin, Lublin, Poland
| | - Felice Petraglia
- Obstetrics and Gynecology Unit, Department of Clinical Experimental and Biomedical Sciences, University of Florence, Florence, Italy
| | - Stefan P Renner
- Department of Gynecology and Obstetrics, Hospital Böblingen, Klinikverbund-Suedwest, Sindelfingen 71065, Germany
| | - Amisha Patel
- Department of Medical Affairs, Theramex UK Ltd, London, UK
| | - Mitra Boolell
- Department of Medical Affairs, Theramex UK Ltd, London, UK
| | - Elke Bestel
- Department of Medical Affairs, Theramex UK Ltd, London, UK
| | - Marie-Madeleine Dolmans
- Gynecology Research Laboratory, Institut de Recherche Expérimentale et Clinique, Department of Gynecology, Université Catholique de Louvain, Brussels, Belgium
- Gynecology Department, Cliniques Universitaires St-Luc, Brussels, Belgium
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Evangelisti G, Ferrero S, Perrone U, Gustavino C, Volpi E, Izzotti A, Barra F. Experimental and new investigational drugs for the treatment of uterine fibroids. Expert Opin Investig Drugs 2024; 33:497-508. [PMID: 38618931 DOI: 10.1080/13543784.2024.2343786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 04/12/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Uterine fibroids, the most prevalent benign tumors among reproductive-age women, pose treatment challenges that range from surgical interventions to medical therapies for symptom control. Progestins and estroprogestins effectively manage uterine bleeding by suppressing dysfunctional endometrium over fibroids. While GnRH agonists represent a crucial milestone in symptom treatment, their prolonged use results in menopausal-like symptoms and irreversible bone mineral density loss. Advancements in understanding fibroid pathophysiology have prompted the exploration of new compounds to overcome current therapy limitations. AREAS COVERED This manuscript offers an updated overview of investigational drugs for symptomatic uterine fibroids. EXPERT OPINION Despite ulipristal acetate's well-established efficacy as a selective progesterone receptor modulator (SPRM) in fibroid treatment, its prescription has declined due to the rare but severe risk of liver damage. Oral GnRH antagonists, like elagolix, relugolix, and linzagolix, with their novel pharmacodynamic properties, are gaining traction in fibroid management, inducing a dose-dependent reduction in circulating sex hormone levels. Ongoing research on natural compounds, such as vitamin D and epigallocatechin gallate (EGCG), presents emerging options for treating uterine fibroids. This evolving landscape reflects the ongoing efforts to improve therapeutic outcomes for individuals with symptomatic uterine fibroids.
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Affiliation(s)
- Giulio Evangelisti
- Unit of Obstetrics and Gynecology, San Paolo Hospital - ASL2, Savona, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Umberto Perrone
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Claudio Gustavino
- Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Eugenio Volpi
- Unit of Obstetrics and Gynecology, San Paolo Hospital - ASL2, Savona, Italy
| | - Alberto Izzotti
- Unit of Mutagenesis and Cancer Prevention, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy
| | - Fabio Barra
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"- ASL4, Chiavari, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
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Goitia M, Estadella J. [Emerging therapies in the medical treatment of uterine fibroids]. Med Clin (Barc) 2023; 161 Suppl 1:S32-S37. [PMID: 37923512 DOI: 10.1016/j.medcli.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 05/29/2023] [Accepted: 06/15/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Mikel Goitia
- Servicio Ginecología y Obstetricia, Hospital Universitario Cruces, Barakaldo, Bizkaia, España.
| | - Josep Estadella
- Servicio de Ginecología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
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McInturff EL, France SP, Leverett CA, Flick AC, Lindsey EA, Berritt S, Carney DW, DeForest JC, Ding HX, Fink SJ, Gibson TS, Gray K, Hubbell AK, Johnson AM, Liu Y, Mahapatra S, McAlpine IJ, Watson RB, O'Donnell CJ. Synthetic Approaches to the New Drugs Approved During 2021. J Med Chem 2023; 66:10150-10201. [PMID: 37528515 DOI: 10.1021/acs.jmedchem.3c00501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
Each year, new drugs are introduced to the market, representing structures that have affinity for biological targets implicated in human diseases and conditions. These new chemical entities (NCEs), particularly small molecules and antibody-drug conjugates, provide insight into molecular recognition and serve as potential leads for the design of future medicines. This annual review is part of a continuing series highlighting the most likely process-scale synthetic approaches to 35 NCEs that were first approved anywhere in the world during 2021.
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Affiliation(s)
- Emma L McInturff
- Groton Laboratories, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Scott P France
- Process Research & Development, Merck & Co., Inc., Rahway, New Jersey 07065, United States
| | - Carolyn A Leverett
- Groton Laboratories, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Andrew C Flick
- Takeda Pharmaceuticals, 9625 Towne Centre Drive, San Diego, California 92121, United States
| | - Erick A Lindsey
- Takeda Pharmaceuticals, 9625 Towne Centre Drive, San Diego, California 92121, United States
| | - Simon Berritt
- Groton Laboratories, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Daniel W Carney
- Takeda Pharmaceuticals, 9625 Towne Centre Drive, San Diego, California 92121, United States
| | - Jacob C DeForest
- La Jolla Laboratories, Pfizer Worldwide Research and Development, 10777 Science Center Drive, San Diego, California 92121, United States
| | - Hong X Ding
- Pharmacodia (Beijing) Co. Ltd., Beijing, 100085, China
| | - Sarah J Fink
- Takeda Pharmaceuticals, 125 Binney Street, Cambridge, Massachusetts 02142, United States
| | - Tony S Gibson
- Takeda Pharmaceuticals, 9625 Towne Centre Drive, San Diego, California 92121, United States
| | - Kaitlyn Gray
- Groton Laboratories, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Aran K Hubbell
- Groton Laboratories, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Amber M Johnson
- Groton Laboratories, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Yiyang Liu
- Groton Laboratories, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Subham Mahapatra
- Groton Laboratories, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Indrawan J McAlpine
- Genesis Therapeutics, 11568 Sorrento Valley Road, Suite 8, San Diego, California 92121, United States
| | - Rebecca B Watson
- La Jolla Laboratories, Pfizer Worldwide Research and Development, 10777 Science Center Drive, San Diego, California 92121, United States
| | - Christopher J O'Donnell
- Groton Laboratories, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, Connecticut 06340, United States
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Casati L, Ciceri S, Maggi R, Bottai D. Physiological and Pharmacological overview of the Gonadotropin Releasing Hormone. Biochem Pharmacol 2023; 212:115553. [PMID: 37075816 DOI: 10.1016/j.bcp.2023.115553] [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: 02/22/2023] [Revised: 04/07/2023] [Accepted: 04/10/2023] [Indexed: 04/21/2023]
Abstract
Gonadotropin-releasing Hormone (GnRH) is a decapeptide responsible for the control of the reproductive functions. It shows C- and N-terminal aminoacid modifications and two other distinct isoforms have been so far identified. The biological effects of GnRH are mediated by binding to high-affinity G-protein couple receptors (GnRHR), showing characteristic very short C tail. In mammals, including humans, GnRH-producing neurons originate in the embryonic nasal compartment and during early embryogenesis they undergo rapid migration towards the hypothalamus; the increasing knowledge of such mechanisms improved diagnostic and therapeutic approaches to infertility. The pharmacological use of GnRH, or its synthetic peptide and non-peptide agonists or antagonists, provides a valid tool for reproductive disorders and assisted reproduction technology (ART). The presence of GnRHR in several organs and tissues indicates additional functions of the peptide. The identification of a GnRH/GnRHR system in the human endometrium, ovary, and prostate has extended the functions of the peptide to the physiology and tumor transformation of such tissues. Likely, the activity of a GnRH/GnRHR system at the level of the hippocampus, as well as its decreased expression in mice brain aging, raised interest in its possible involvement in neurogenesis and neuronal functions. In conclusion, GnRH/GnRHR appears to be a fascinating biological system that exerts several possibly integrated pleiotropic actions in the complex control of reproductive functions, tumor growth, neurogenesis, and neuroprotection. This review aims to provide an overview of the physiology of GnRH and the pharmacological applications of its synthetic analogs in the management of reproductive and non-reproductive diseases.
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Affiliation(s)
- Lavinia Casati
- Department of Health Sciences, Università degli Studi di Milano, Milano, Italy
| | - Samuele Ciceri
- Dept. of Pharmaceutical Sciences (DISFARM), Università degli Studi di Milano, Milano Italy
| | - Roberto Maggi
- Dept. of Pharmaceutical Sciences (DISFARM), Università degli Studi di Milano, Milano Italy.
| | - Daniele Bottai
- Dept. of Pharmaceutical Sciences (DISFARM), Università degli Studi di Milano, Milano Italy
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Donnez J, Cacciottola L, Squifflet JL, Dolmans MM. Profile of Linzagolix in the Management of Endometriosis, Including Design, Development and Potential Place in Therapy: A Narrative Review. Drug Des Devel Ther 2023; 17:369-380. [PMID: 36789095 PMCID: PMC9922511 DOI: 10.2147/dddt.s269976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/17/2023] [Indexed: 02/10/2023] Open
Abstract
Estrogens play a critical role in the pathogenesis of endometriosis and it is logical to assume that lowering estradiol levels with oral gonadotropin-releasing hormone (GnRH) antagonists may prove effective, especially in women who fail to respond to progestogens. Indeed, due to progesterone resistance, oral contraceptives and progestogens work well in two-thirds of women suffering from endometriosis, but are ineffective in 33% of women. Oral GnRH antagonists have therefore been evaluated for management of premenopausal women with endometriosis-associated pelvic pain. The first publication on these drugs reported the efficacy of elagolix. The present paper is a narrative review of linzagolix, which is an orally administered GnRH receptor antagonist with low pharmacokinetic/pharmacodynamic variability. It binds to and blocks the GnRH receptor in the pituitary gland, resulting in a dose-dependent drop in luteinizing hormone (LH) and follicle-stimulating hormone (FSH) production. This reduction in LH and FSH levels in turn leads to a dose-dependent decline in estrogen. Phase 2 and 3 trials are reviewed and discussed here. There is a place for GnRH antagonists in the management of symptomatic endometriosis, and linzagolix with or without add-back therapy (ABT) is one option that can be used at low doses, avoiding the need for ABT, which is contraindicated in some patients.
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Affiliation(s)
- Jacques Donnez
- Department of Gynaecology, Université Catholique de Louvain, Brussels, Belgium,Société de Recherche pour l’Infertilité (SRI), Brussels, Belgium
| | - Luciana Cacciottola
- Gynecology Research Laboratory, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Jean-Luc Squifflet
- Gynecology Department, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Gynecology Research Laboratory, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium,Gynecology Department, Cliniques Universitaires St-Luc, Brussels, Belgium,Correspondence: Marie-Madeleine Dolmans, Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte B1.52.02, Brussels, 1200, Belgium, Tel +32 02 764 5237, Fax +32 02 764 9507, Email
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Actualización sobre las posibilidades de tratamiento médico hormonal para el sangrado menstrual abundante. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2023. [DOI: 10.1016/j.gine.2022.100819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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8
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Dolmans MM, Donnez J. Emerging Drug Targets for Endometriosis. Biomolecules 2022; 12:biom12111654. [PMID: 36359004 PMCID: PMC9687824 DOI: 10.3390/biom12111654] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022] Open
Abstract
Endometriosis is a chronic inflammatory disease causing distressing symptoms and requiring a life-long management strategy. The objective of this review is to evaluate endometriosis-related pathways and identify novel therapies to treat it. We focused on the crucial role of inflammation and inflammatory molecules in order to define new perspectives for non-hormonal treatment of the disease by targeting inflammation, nuclear factor kappa B and cytokines, or reactive oxygen species, apoptotic and autophagic pathways, regulators of epithelial-mesenchymal transition, and angiogenesis and neuroangiogenesis. Novel non-steroidal therapies targeting these pathways for endometriosis were explored, but multiple challenges remain. While numerous agents have been investigated in preclinical trials, few have reached the clinical testing stage because of use of inappropriate animal models, with no proper study design or reporting of preclinical strategies. Targeting estrogens is still the best way to control endometriosis progression and inflammation.
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Affiliation(s)
- Marie-Madeleine Dolmans
- Gynecology Department, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
- Gynecology Research Laboratory, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte B1.52.02, 1200 Brussels, Belgium
| | - Jacques Donnez
- Department of Gynaecology, Université Catholique de Louvain, 1200 Brussels, Belgium
- Société de Recherche pour l’Infertilité (SRI), 143 Avenue Grandchamp, 1150 Brussels, Belgium
- Correspondence:
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Evangelisti G, Barra F, Perrone U, Di Donato N, Bogliolo S, Ceccaroni M, Ferrero S. Comparing the pharmacokinetic and pharmacodynamic qualities of current and future therapies for uterine fibroids. Expert Opin Drug Metab Toxicol 2022; 18:441-457. [DOI: 10.1080/17425255.2022.2113381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Giulio Evangelisti
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Southern Endometriosis Centre, Queen Alexandra Hospital, Portsmouth, UK
- Department of Obstetrics and Gynecology, Gynecology Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy (ISSA), IRCCS Ospedale Sacro Cuore - Don Calabria, Via Don A. Sempreboni, 5, 37024, Negrar (Verona), Italy
| | - Umberto Perrone
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Nadine Di Donato
- Southern Endometriosis Centre, Queen Alexandra Hospital, Portsmouth, UK
| | - Stefano Bogliolo
- Department of Obstetrics and Gynecology, “P.O del Tigullio” Hospital-ASL4, Metropolitan Area of Genoa, Genoa, Italy
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecology Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy (ISSA), IRCCS Ospedale Sacro Cuore - Don Calabria, Via Don A. Sempreboni, 5, 37024, Negrar (Verona), Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Xing L, Liu YN, Yao H, Wang T, Xie F, Luo S, Luo P, Tang S. An Efficient UPLC-MS/MS Method Established to Detect Relugolix Concentration in Rat Plasma. Front Pharmacol 2022; 13:874973. [PMID: 35784757 PMCID: PMC9243301 DOI: 10.3389/fphar.2022.874973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 05/17/2022] [Indexed: 12/18/2022] Open
Abstract
Relugolix, a gonadotropin-releasing hormone (GnRH) receptor antagonist, has been well studied in the treatment of endometriosis symptomatic. It is mainly metabolized by the CYP3A subfamily of P450 enzymes, while minorly metabolized by CYP2C8. Daidzein in different dose groups exhibited a certain induction on the mRNA expression level of CYP3A4 and resulted in the potent induction of CYP3A4. However, it is still unknown whether daidzein and relugolix interact. We developed an effective ultra-performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) method to study the effect of daidzein on the pharmacokinetics of relugolix in rats after oral administration of 12 mg/kg relugolix in a single or mixed of 50 mg/kg daidzein. The results showed that the method had respectable linearity (r2 > 0.999) on the scale of 0.7–1000 ng/mL. The intra-day precision was between 3.0% and 8.4% in this assay, and the inter-day was between 4.0% and 11.7%. The intra-day accuracy was from -4.3% to 6.1%, and the inter-day was 2.9% to 12.1%. Another three key indicators, including the stability, the recovery rate of extraction and the new technique’s matrix effect, were perfectly in accord with the test verification rule in the biological medium by the United States Food and Drug Administration. Meanwhile, treatment with daidzein led to a decrease in Cmax and AUC0–t of relugolix by about 15.56% and 21.36%, respectively. Although there was no statistical difference in pharmacokinetic parameters, it reflected the induction trend of daidzein on relugolix metabolism for food-drug interaction. It would provide reference and improvement value for subsequent experiments.
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Affiliation(s)
- Liying Xing
- The First People’s Hospital of Jiashan, Jiaxing, China
| | - Ya-nan Liu
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hongye Yao
- The First People’s Hospital of Jiashan, Jiaxing, China
| | - Tingting Wang
- The First People’s Hospital of Jiashan, Jiaxing, China
| | - Fuchen Xie
- The People’s Hospital of Lishui, Lishui, China
| | - Shunbin Luo
- The People’s Hospital of Lishui, Lishui, China
| | - Pingping Luo
- The People’s Hospital of Lishui, Lishui, China
- *Correspondence: Pingping Luo, ; Shengling Tang,
| | - Shengling Tang
- The People’s Hospital of Lishui, Lishui, China
- *Correspondence: Pingping Luo, ; Shengling Tang,
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Zhong M. Effect of Core Muscle Strength Training Combined with Taijiquan on Bone Mineral Density Measured by Quantitative CT Scanning in the Elderly. SCANNING 2022; 2022:6942081. [PMID: 35795616 PMCID: PMC9152348 DOI: 10.1155/2022/6942081] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/08/2022] [Accepted: 05/13/2022] [Indexed: 06/15/2023]
Abstract
Learn about the benefits of muscle strength training combined with tai chi for adult skeletal muscle in multiple CT scanning. The study included 182 people over the age of 60 with no long-term history of physical activity and exercise. They were divided into the Taijiquan group (52 people), student muscle strength group (45 people), student muscle group combined with Taijiquan group (45 people), and control group (40 people). The board of directors did not attend. The other three groups received tai chi (more than 4 times a week), muscle strength training, and muscle training combined with tai chi for 6 months. Lumbar spine (L1-4) BMD and Berg scores were approximately the same as those measured in adults before exercise and at 3 and 6 months after exercise. The results showed that there were significant differences in the scores of lumbar spine BMD and Berg Balance Scale between the Taijiquan group and students before and after exercise combined with muscle strength training (P < 0.05 or <0.01). The difference was statistically significant (P < 0.05). The scores of lumbar BMD and Berg Balance Scale in the core muscle strength training combined with Taijiquan group after 6 months of exercise were higher than those after 3 months of exercise (P < 0.05), and the CT value of lumbar vertebral bone calcium was significantly positively correlated with BMD (Pearson correlation coefficients of L5 vertebral body were r = 0.704, 0.683, 0.728, 0.673, and 0.686, P < 0.01). Single or combined training of core muscle strength or Taijiquan can improve lumbar bone mineral density and balance function in the elderly.
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Affiliation(s)
- Mingliang Zhong
- Zhengzhou Preschool Education College, Zhengzhou, Henan 450000, China
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Daniels J, Middleton LJ, Cheed V, McKinnon W, Rana D, Sirkeci F, Manyonda I, Belli AM, Lumsden MA, Moss J, Wu O, McPherson K. Uterine artery embolisation versus myomectomy for premenopausal women with uterine fibroids wishing to avoid hysterectomy: the FEMME RCT. Health Technol Assess 2022; 26:1-74. [PMID: 35435818 PMCID: PMC9082260 DOI: 10.3310/zdeg6110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Uterine fibroids are the most common tumour in women of reproductive age and are associated with heavy menstrual bleeding, abdominal discomfort, subfertility and reduced quality of life. For women wishing to retain their uterus and who do not respond to medical treatment, myomectomy and uterine artery embolisation are therapeutic options. OBJECTIVES We examined the clinical effectiveness and cost-effectiveness of uterine artery embolisation compared with myomectomy in the treatment of symptomatic fibroids. DESIGN A multicentre, open, randomised trial with a parallel economic evaluation. SETTING Twenty-nine UK hospitals. PARTICIPANTS Premenopausal women who had symptomatic uterine fibroids amenable to myomectomy or uterine artery embolisation were recruited. Women were excluded if they had significant adenomyosis, any malignancy or pelvic inflammatory disease or if they had already had a previous open myomectomy or uterine artery embolisation. INTERVENTIONS Participants were randomised to myomectomy or embolisation in a 1 : 1 ratio using a minimisation algorithm. Myomectomy could be open abdominal, laparoscopic or hysteroscopic. Embolisation of the uterine arteries was performed under fluoroscopic guidance. MAIN OUTCOME MEASURES The primary outcome was the Uterine Fibroid Symptom Quality of Life questionnaire (with scores ranging from 0 to 100 and a higher score indicating better quality of life) at 2 years, adjusted for baseline score. The economic evaluation estimated quality-adjusted life-years (derived from EuroQol-5 Dimensions, three-level version, and costs from the NHS perspective). RESULTS A total of 254 women were randomised - 127 to myomectomy (105 underwent myomectomy) and 127 to uterine artery embolisation (98 underwent embolisation). Information on the primary outcome at 2 years was available for 81% (n = 206) of women. Primary outcome scores at 2 years were 84.6 (standard deviation 21.5) in the myomectomy group and 80.0 (standard deviation 22.0) in the uterine artery embolisation group (intention-to-treat complete-case analysis mean adjusted difference 8.0, 95% confidence interval 1.8 to 14.1, p = 0.01; mean adjusted difference using multiple imputation for missing responses 6.5, 95% confidence interval 1.1 to 11.9). The mean difference in the primary outcome at the 4-year follow-up time point was 5.0 (95% CI -1.4 to 11.5; p = 0.13) in favour of myomectomy. Perioperative and postoperative complications from all initial procedures occurred in similar percentages of women in both groups (29% in the myomectomy group vs. 24% in the UAE group). Twelve women in the uterine embolisation group and six women in the myomectomy group reported pregnancies over 4 years, resulting in seven and five live births, respectively (hazard ratio 0.48, 95% confidence interval 0.18 to 1.28). Over a 2-year time horizon, uterine artery embolisation was associated with higher costs than myomectomy (mean cost £7958, 95% confidence interval £6304 to £9612, vs. mean cost £7314, 95% confidence interval £5854 to £8773), but with fewer quality-adjusted life-years gained (0.74, 95% confidence interval 0.70 to 0.78, vs. 0.83, 95% confidence interval 0.79 to 0.87). The differences in costs (difference £645, 95% confidence interval -£1381 to £2580) and quality-adjusted life-years (difference -0.09, 95% confidence interval -0.11 to -0.04) were small. Similar results were observed over the 4-year time horizon. At a threshold of willingness to pay for a gain of 1 QALY of £20,000, the probability of myomectomy being cost-effective is 98% at 2 years and 96% at 4 years. LIMITATIONS There were a substantial number of women who were not recruited because of their preference for a particular treatment option. CONCLUSIONS Among women with symptomatic uterine fibroids, myomectomy resulted in greater improvement in quality of life than did uterine artery embolisation. The differences in costs and quality-adjusted life-years are very small. Future research should involve women who are desiring pregnancy. TRIAL REGISTRATION This trial is registered as ISRCTN70772394. FUNDING This study was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme, and will be published in full in Health Technology Assessment; Vol. 26, No. 22. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lee J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Versha Cheed
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - William McKinnon
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Dikshyanta Rana
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Fusun Sirkeci
- Department of Obstetrics and Gynaecology, Whipps Cross Hospital, London, UK
| | - Isaac Manyonda
- Department of Gynaecology, St George's Hospital and Medical School, London, UK
| | - Anna-Maria Belli
- Department of Radiology, St George's Hospital and Medical School, London, UK
| | | | - Jonathan Moss
- School of Medicine, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Klim McPherson
- Department of Primary Care, University of Oxford, Oxford, UK
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Systematic review of oral pharmacotherapeutic options for the management of uterine fibroids. J Am Pharm Assoc (2003) 2022; 62:674-682.e5. [DOI: 10.1016/j.japh.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 11/24/2022]
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Pohl O, Baron K, Riggs M, French J, Garcia R, Gotteland JP. A model-based analysis to guide gonadotropin-releasing hormone receptor antagonist use for management of endometriosis. Br J Clin Pharmacol 2021; 88:2359-2371. [PMID: 34904270 PMCID: PMC9306723 DOI: 10.1111/bcp.15171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 10/25/2021] [Accepted: 11/21/2021] [Indexed: 12/05/2022] Open
Abstract
Aims To identify linzagolix doses, an oral GnRH receptor antagonist, that effectively lower oestradiol (E2) to relieve endometriosis‐related pelvic pain without compromising bone health. Methods Integrated statistical, pharmacokinetic–pharmacodynamic and systems pharmacology models were developed from Phase 1 and 2 clinical trial data in healthy volunteers and patients, receiving linzagolix 25–200 mg daily or placebo, and analysed simultaneously. The main outcome measures were pelvic pain scores for dysmenorrhoea, nonmenstrual pelvic pain (NMPP), uterine bleeding and lumbar spine bone mineral density (BMD). Results Linzagolix pharmacokinetics were described by a 2‐compartment model with sequential zero/first‐order absorption process (CL/F: 0.422 L/h). E2 changes over time were well described as a function of linzagolix 24‐hour AUC (AUC50: 1.68 × 105 ng h/mL). For a Caucasian reference patient, a change in E2 from 50–20 pg/mL at 24 weeks increased the odds of relief of dysmenorrhoea 1.33‐fold and NMPP 1.07‐fold (95% CI: 1.22–1.47 and 1.02–1.12, respectively) and decreased bleeding days by 1.55 (95% CI: 1.39–1.72). A previously validated quantitative systems pharmacology BMD model was adjusted to the clinical data. The mean week 24 lumbar spine BMD change from baseline ranged from −0.092% in the 50 mg dose, −1.30% in the 100 mg dose group and −2.67% in the 200 mg dose group. Discussion The previously‐reported E2 target range (20–50 pg/mL) to balance efficacy and safety endpoints was confirmed. Linzagolix once daily doses between 75–125 mg daily were expected to meet endometriosis‐associated pain, efficacy, and BMD loss targets in Caucasian patients.
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Ali M, Raslan M, Ciebiera M, Zaręba K, Al-Hendy A. Current approaches to overcome the side effects of GnRH analogs in the treatment of patients with uterine fibroids. Expert Opin Drug Saf 2021; 21:477-486. [PMID: 34612122 DOI: 10.1080/14740338.2022.1989409] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Uterine fibroids (UFs) are the most prevalent benign neoplastic threat originating from myometria of reproductive age women, with a profound financial load valued in hundreds of billions of dollars. Unfortunately, there is no curative treatment so far except surgery and available pharmacological treatments are restricted for short-term treatment options. Thus, there is a large unmet need in the UF space for noninvasive therapeutics.Areas covered: The authors reviewed the literature available for the utility of gonadotropin-releasing hormone (GnRH) analogs in women with UFs. We also focused on clinical studies exploring the therapeutic benefits of novel oral non-peptide GnRH antagonists that were recently approved by the U.S. Food and Drug Administration (FDA) in combination with estradiol/norethindrone acetate for the management of heavy menstrual bleeding associated with UFs in premenopausal women.Expert opinion: The results regarding the efficacy of new-generation oral GnRH-antagonists, such as elagolix, relugolix and linzagolix, are promising and offer potential prospect for the future therapy of UFs. However, these antagonists must be combined with hormonal add-back therapy to minimize the resultant hypoestrogenic side effects such as bone loss.
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Affiliation(s)
- Mohamed Ali
- Clinical Pharmacy Department, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
| | | | - Michał Ciebiera
- Second Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, Cegłowska, Warsaw, Poland
| | - Kornelia Zaręba
- First Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, Żelazna, Warsaw, Poland
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, USA
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GnRH Antagonists with or without Add-Back Therapy: A New Alternative in the Management of Endometriosis? Int J Mol Sci 2021; 22:ijms222111342. [PMID: 34768770 PMCID: PMC8583814 DOI: 10.3390/ijms222111342] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 12/15/2022] Open
Abstract
To evaluate the effectiveness of a new class of medical drugs, namely oral gonadotropin-releasing hormone (GnRH) antagonists, in the management of premenopausal women with endometriosis-associated pelvic pain. We reviewed the most relevant papers (n = 27) on the efficacy of new medical alternatives (oral GnRH antagonists) as therapy for endometriosis. We first briefly summarized the concept of progesterone resistance and established that oral contraceptives and progestogens work well in two-thirds of women suffering from endometriosis. Since clinical evidence shows that estrogens play a critical role in the pathogenesis of the disease, lowering their levels with oral GnRH antagonists may well prove effective, especially in women who fail to respond to progestogens. There is a need for reliable long-term oral treatment capable of managing endometriosis symptoms, taking into consideration both the main symptoms and phenotype of the disease. Published studies reviewed and discussed here confirm the efficacy of GnRH antagonists. There is a place for GnRH antagonists in the management of symptomatic endometriosis. Novel algorithms that take into account the different phenotypes are proposed.
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Dababou S, Garzon S, Laganà AS, Ferrero S, Evangelisti G, Noventa M, D'Alterio MN, Palomba S, Uccella S, Franchi M, Barra F. Linzagolix: a new GnRH-antagonist under investigation for the treatment of endometriosis and uterine myomas. Expert Opin Investig Drugs 2021; 30:903-911. [PMID: 34278887 DOI: 10.1080/13543784.2021.1957830] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Uterine myomas and endometriosis are benign hormone-dependent diseases affecting women of reproductive age. Substantial efforts have been made to develop innovative medical options for treating these gynecologic diseases. Elagolix and relugolix have been approved in some countries for treating endometriosis and myomas, respectively; however, linzagolix (OBE 2109, KLH 2109) is a new oral gonadotropin-releasing hormone (GnRH) antagonist in phase II-III trials. Treatment options for women with contraindications for hormonal therapies or who refuse particular options, are the driving force behind the development of new drugs in this area. AREA COVERED This drug evaluation highlights definitive and preliminary results from previous and ongoing studies of linzagolix for the treatment of endometriosis and myomas. EXPERT OPINION Linzagolix showed a dose-dependent and rapidly reversible action on the pituitary-gonadal axis. In a recent phase II trial (EDELWEISS), linzagolix significantly reduced pain related to endometriosis and improved quality of life at single daily doses of 75-200 mg. The preliminary results of international, double-blind phase III trials (PRIMROSE 1 and 2) reported its efficacy in treating heavy menstrual bleeding related to myomas with a good safety profile. Further studies will determine the necessity of add-back therapy during long-term use of linzagolix.
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Affiliation(s)
- Susan Dababou
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese (VA), Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova, Italy.,Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Giulio Evangelisti
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova, Italy.,Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Marco Noventa
- Department of Women and Children's Health, Clinic of Gynecology and Obstetrics, University of Padua, Padua, Italy
| | - Maurizio Nicola D'Alterio
- Department of Surgical Sciences, Section of Obstetrics & Gynecology, University of Cagliari, Monserrato, Italy
| | - Stefano Palomba
- Department of Experimental and Clinical Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Stefano Uccella
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Fabio Barra
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova, Italy.,Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Barnett C, Bauerfeind A, von Stockum S, Heinemann K. Thromboembolic safety profile of low-dose estradiol (valerate) in combined hormonal preparations: Implications for the development of new hormonal endometriosis and uterine fibroid therapies. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2021. [DOI: 10.1177/22840265211019546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Several promising new medications containing low-dose estradiol (E2) in combination with a progestin and an additional component, such as gonadotropin-releasing hormone antagonists, are currently being developed for use in pre-menopausal women. Objective: This pooled analysis was designed to estimate the thromboembolic safety profile of E2 and its ester, estradiol valerate (E2Val), when used in combined hormonal treatments in a pre-menopausal population. Methods: Data regarding users of combined oral contraceptives (COCs) and combined menopausal hormonal therapy (MHT) containing either E2/E2Val or ethinylestradiol (EE) ⩽ 30 µg were retrieved from five large prospective, non-interventional, cohort studies in Europe, US, and Canada with similar study design but differing medication cohorts. Propensity score sub-classification was applied to balance baseline parameters between cohorts and time-to-event analysis of venous thromboembolic events (VTE) was carried out based on the extended Cox model to calculate crude and adjusted hazard ratios (HR). Results: (1) Crude incidence rates of VTE were higher in MHT users compared to pre-menopausal COC users, (2) the VTE risk in menopausal users of E2/E2Val-norethindrone acetate was not higher than that in menopausal users of E2/E2Val-progestin (adjusted HR 0.71; 95% confidence interval, 0.41-1.26) and (3) the VTE risk in pre-menopausal users of E2/E2Val-progestin was similar, or lower, than pre-menopausal users of EE⩽30µg-progestin (adjusted HR 0.49; 95% confidence interval, 0.28–0.84). Conclusion: Our data presents a solid safety assessment of combined hormonal preparations containing E2/E2Val. We conclude that the risk of E2/E2Val-norethindrone acetate in pre-menopausal users is unlikely to be higher than the known risk of COCs containing EE ⩽ 30 µg-progestin.
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Affiliation(s)
- Clare Barnett
- ZEG - Berlin Center for Epidemiology and Health Research, Berlin, Germany
| | - Anja Bauerfeind
- ZEG - Berlin Center for Epidemiology and Health Research, Berlin, Germany
| | - Sophia von Stockum
- ZEG - Berlin Center for Epidemiology and Health Research, Berlin, Germany
| | - Klaas Heinemann
- ZEG - Berlin Center for Epidemiology and Health Research, Berlin, Germany
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Endometriosis and Medical Therapy: From Progestogens to Progesterone Resistance to GnRH Antagonists: A Review. J Clin Med 2021; 10:jcm10051085. [PMID: 33807739 PMCID: PMC7961981 DOI: 10.3390/jcm10051085] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 02/20/2021] [Accepted: 02/26/2021] [Indexed: 02/07/2023] Open
Abstract
Background: The first objective of this review was to present, based on recent literature, the most frequently applied medical options (oral contraceptive pills (OCPs) and progestogens) for the management of symptomatic endometriosis, and evaluate their effectiveness in treating premenopausal women with endometriosis-associated pelvic pain, dysmenorrhea, non-menstrual pelvic pain and dyspareunia. The second objective was to review the concept of progesterone resistance and newly available treatment options. Methods: We reviewed the most relevant papers (n = 73) on the efficacy of OCPs and progestogens as medical therapy for endometriosis, as well as those on progesterone resistance and new medical alternatives (oral gonadotropin-releasing hormone (GnRH) antagonist). Eleven papers, essentially reviews, were selected and scrutinized from among 94 papers discussing the concept of progesterone resistance. Results: Having reviewed the most significant papers, we can confirm that OCPs and progestogens are effective in two-thirds of women suffering from endometriosis, but that other options are required in case of failure (in one-third of women due to progesterone resistance) or intolerance to these compounds. It is clear that there is a need for effective long-term oral treatment capable of managing endometriosis symptoms, while mitigating the impact of side effects. Biochemical, histological and clinical evidence show that estrogens play a critical role in the pathogenesis of endometriosis, so lowering levels of circulating estrogens should be considered an effective medical approach. The efficacy of three oral GnRH antagonists is discussed on the basis of published studies. Conclusion: There is a place for GnRH antagonists in the management of symptomatic endometriosis and clinical trials should be conducted, taking into account the different phenotypes in order to propose novel algorithms.
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20
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Wu HM, Chang HM, Leung PCK. Gonadotropin-releasing hormone analogs: Mechanisms of action and clinical applications in female reproduction. Front Neuroendocrinol 2021; 60:100876. [PMID: 33045257 DOI: 10.1016/j.yfrne.2020.100876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/23/2020] [Accepted: 10/04/2020] [Indexed: 12/15/2022]
Abstract
Extra-hypothalamic GnRH and extra-pituitary GnRH receptors exist in multiple human reproductive tissues, including the ovary, endometrium and myometrium. Recently, new analogs (agonists and antagonists) and modes of GnRH have been developed for clinical application during controlled ovarian hyperstimulation for assisted reproductive technology (ART). Additionally, the analogs and upstream regulators of GnRH suppress gonadotropin secretion and regulate the functions of the reproductive axis. GnRH signaling is primarily involved in the direct control of female reproduction. The cellular mechanisms and action of the GnRH/GnRH receptor system have been clinically applied for the treatment of reproductive disorders and have widely been introduced in ART. New GnRH analogs, such as long-acting GnRH analogs and oral nonpeptide GnRH antagonists, are being continuously developed for clinical application. The identification of the upstream regulators of GnRH, such as kisspeptin and neurokinin B, provides promising potential to develop these upstream regulator-related analogs to control the hypothalamus-pituitary-ovarian axis.
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Affiliation(s)
- Hsien-Ming Wu
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University School of Medicine, Taoyuan 333, Taiwan, ROC
| | - Hsun-Ming Chang
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia V6H 3V5, Canada
| | - Peter C K Leung
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia V6H 3V5, Canada.
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21
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Panknin O, Wagenfeld A, Bone W, Bender E, Nowak-Reppel K, Fernández-Montalván AE, Nubbemeyer R, Bäurle S, Ring S, Schmees N, Prien O, Schäfer M, Friedrich C, Zollner TM, Steinmeyer A, Mueller T, Langer G. Discovery and Characterization of BAY 1214784, an Orally Available Spiroindoline Derivative Acting as a Potent and Selective Antagonist of the Human Gonadotropin-Releasing Hormone Receptor as Proven in a First-In-Human Study in Postmenopausal Women. J Med Chem 2020; 63:11854-11881. [PMID: 32960053 DOI: 10.1021/acs.jmedchem.0c01076] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The growth of uterine fibroids is sex hormone-dependent and commonly associated with highly incapacitating symptoms. Most treatment options consist of the control of these hormonal effects, ultimately blocking proliferative estrogen signaling (i.e., oral contraceptives/antagonization of human gonadotropin-releasing hormone receptor [hGnRH-R] activity). Full hGnRH-R blockade, however, results in menopausal symptoms and affects bone mineralization, thus limiting treatment duration or demanding estrogen add-back approaches. To overcome such issues, we aimed to identify novel, small-molecule hGnRH-R antagonists. This led to the discovery of compound BAY 1214784, an orally available, potent, and selective hGnRH-R antagonist. Altering the geminal dimethylindoline core of the initial hit compound to a spiroindoline system significantly improved GnRH-R antagonist potencies across several species, mandatory for a successful compound optimization in vivo. In a first-in-human study in postmenopausal women, once daily treatment with BAY 1214784 effectively lowered plasma luteinizing hormone levels by up to 49%, at the same time being associated with low pharmacokinetic variability and good tolerability.
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Affiliation(s)
- Olaf Panknin
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Andrea Wagenfeld
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Wilhelm Bone
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Eckhard Bender
- Research & Development, Pharmaceuticals, Bayer AG, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Katrin Nowak-Reppel
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | | | - Reinhard Nubbemeyer
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Stefan Bäurle
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Sven Ring
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Norbert Schmees
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Olaf Prien
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Martina Schäfer
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Christian Friedrich
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Thomas M Zollner
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Andreas Steinmeyer
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Thomas Mueller
- Research & Development, Pharmaceuticals, Bayer AG, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Gernot Langer
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
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Abstract
PURPOSE OF REVIEW Uterine fibroids are the most common benign neoplasms of the female reproductive tract and one of the major public health concerns. Although most women with uterine fibroids are asymptomatic, over 30% of them will present with varying symptoms. This review focuses on the role of non-hormonal mediators and pathways in uterine fibroid biology. Furthermore, it provides data regarding the most recent findings in the field of compounds, which use those non-hormonal pathways in the medical therapy of uterine fibroids. RECENT FINDINGS Complex signaling pathway alterations are crucial for uterine fibroid development. The topic of the pathophysiology of uterine fibroids focuses mostly on steroids and other hormones. However, other very important pathways exist, and some of them are independent of hormones. Some of the most important pathways, which are non-hormonal, but in some cases still hormone-depended, include growth factors, cytokines and inflammation, Smad proteins, wingless type/β-catenin and others. SUMMARY Much more is known about hormonal than about non-hormonal signaling in uterine fibroids. Growth factors, early life exposure and inflammation are key factors in uterine fibroid biology. Numerous agents depend on those pathways and may find their place in the current and future therapy of uterine fibroids.
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Affiliation(s)
- Esra Cetin
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ayman Al-Hendy
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
- Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Michał Ciebiera
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
- Second Department of Obstetrics and Gynecology, the Center of Postgraduate Medical Education, Warsaw, Poland
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23
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Küpker W, Plathow D, Bullerdiek J, Felberbaum R. Neue Behandlungsoptionen mit GnRH-Antagonisten bei Endometriose und Uterus myomatosus. GYNAKOLOGISCHE ENDOKRINOLOGIE 2020. [DOI: 10.1007/s10304-020-00329-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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24
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Ciebiera M, Ali M, Zgliczyńska M, Skrzypczak M, Al-Hendy A. Vitamins and Uterine Fibroids: Current Data on Pathophysiology and Possible Clinical Relevance. Int J Mol Sci 2020; 21:ijms21155528. [PMID: 32752274 PMCID: PMC7432695 DOI: 10.3390/ijms21155528] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 01/27/2023] Open
Abstract
Uterine fibroid (UF) is the most common benign tumor pathology of the female reproductive organs. UFs constitute the main reason for a hysterectomy and hospitalization due to gynecological conditions. UFs consist of uterine smooth muscle immersed in a large amount of extracellular matrix (ECM). Genetic studies have demonstrated that UFs are monoclonal tumors originating from the myometrial stem cells that have underwent specific molecular changes to tumor initiating stem cells which proliferate and differentiate later under the influence of steroid hormones. There is growing interest in the role of micronutrients, for example, vitamins, in UFs. This article is a comprehensive review of publications regarding the available data concerning the role of vitamins in the biology and management of UFs. In summary, the results showed that some vitamins are important in the biology and pathophysiology of UFs. For example, vitamins A and D deserve particular attention following studies of their influence on the treatment of UF tumors. Vitamins B3, C, and E have not been as widely studied as the abovementioned vitamins. However, more research could reveal their potential role in UF biology.
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Affiliation(s)
- Michał Ciebiera
- Second Department of Obstetrics and Gynecology, The Center of Postgraduate Medical Education, 01-809 Warsaw, Poland;
- Department of Surgery, University of Illinois at Chicago, Chicago, IL 60612, USA;
- Correspondence: (M.C.); (A.A.-H.); Tel.: +48-225690274 (M.C.); +1-312-996-7006 (A.A.-H.)
| | - Mohamed Ali
- Department of Surgery, University of Illinois at Chicago, Chicago, IL 60612, USA;
- Clinical Pharmacy Department, Faculty of Pharmacy, Ain Shams University, 11566 Cairo, Egypt
| | - Magdalena Zgliczyńska
- Second Department of Obstetrics and Gynecology, The Center of Postgraduate Medical Education, 01-809 Warsaw, Poland;
| | - Maciej Skrzypczak
- Second Department of Gynecology, Medical University of Lublin, 20-954 Lublin, Poland;
| | - Ayman Al-Hendy
- Department of Surgery, University of Illinois at Chicago, Chicago, IL 60612, USA;
- Correspondence: (M.C.); (A.A.-H.); Tel.: +48-225690274 (M.C.); +1-312-996-7006 (A.A.-H.)
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