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Li X, Shang N, Yan Q, Yue X, Liu Y, Zheng X. Investigating bleeding adverse events associated with BTK inhibitors in the food and drug administration adverse event reporting system (FAERS). Expert Opin Drug Saf 2024:1-10. [PMID: 38568245 DOI: 10.1080/14740338.2024.2339448] [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: 02/14/2024] [Accepted: 03/28/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND This study analyzed the bleeding adverse events (AEs) resulting from the treatment of B-cell lymphoma with Bruton tyrosine kinase (BTK) inhibitors, according to reports in the US Food and Drug Administration's Adverse Event Reporting System (FAERS). METHODS Bleeding AEs associated with BTK inhibitors (including ibrutinib, zanubrutinib, and acalabrutinib) from the first quarter of 2013 to the third quarter of 2023 were extracted. Reporting odds ratio (ROR) and proportional reporting ratio (PRR) were reported. Preferred Terms (PTs) of Medical Dictionary for Regulatory Activities (MedDRA) terms were mapped to System Organ Class terms (SOC) terms and analyzed bleeding AEs associated with three BTK inhibitors. RESULTS A total of 463 cases of bleeding AEs were included. Contusion, subcutaneous hemorrhage, hematuria, and cerebral hemorrhage were included in PTs. Blood urine was present and subdural hematoma were also reported. The incidence of bleeding AEs was higher with ibrutinib (Case number = 10,696) than with zanubrutinib (Case number = 213) and acalabrutinib (Case number = 314). CONCLUSION Our findings indicate that bleeding AEs linked to BTK inhibitors in various conditions underscore the need for cautious clinical decision-making, particularly in nervous system disorders, injuries, poisoning, surgical complications, vascular disorders, and others.
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Affiliation(s)
- Xianlin Li
- Department of Pharmacy, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Nan Shang
- Department of Pharmacy, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Qianci Yan
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xiunan Yue
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yang Liu
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xiaojun Zheng
- Department of Pharmacy, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
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Tamargo J, Villacastín J, Caballero R, Delpón E. Drug-induced atrial fibrillation. A narrative review of a forgotten adverse effect. Pharmacol Res 2024; 200:107077. [PMID: 38244650 DOI: 10.1016/j.phrs.2024.107077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/22/2023] [Accepted: 01/12/2024] [Indexed: 01/22/2024]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with an increased morbidity and mortality. There is clinical evidence that an increasing number of cardiovascular and non-cardiovascular drugs, mainly anticancer drugs, can induce AF either in patients with or without pre-existing cardiac disorders, but drug-induced AF (DIAF) has not received the attention that it might deserve. In many cases DIAF is asymptomatic and paroxysmal and patients recover sinus rhythm spontaneously, but sometimes, DIAF persists, and it is necessary to perform a cardioversion. Furthermore, DIAF is not mentioned in clinical guidelines on the treatment of AF. The risk of DIAF increases in elderly and in patients treated with polypharmacy and with risk factors and comorbidities that commonly coexist with AF. This is the case of cancer patients. Under these circumstances ascribing causality of DIAF to a given drug often represents a clinical challenge. We review the incidence, the pathophysiological mechanisms, risk factors, clinical relevance, and treatment of DIAF. Because of the limited information presently available, further research is needed to obtain a deeper insight into DIAF. Meanwhile, it is important that clinicians are aware of the problem that DIAF represents, recognize which drugs may cause DIAF, and consider the possibility that a drug may be responsible for a new-onset AF episode.
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Affiliation(s)
- Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, 28040 Madrid, Spain
| | - Julián Villacastín
- Hospital Clínico San Carlos, CardioRed1, Universidad Complutense de Madrid, CIBERCV, 28040 Madrid, Spain
| | - Ricardo Caballero
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, 28040 Madrid, Spain.
| | - Eva Delpón
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, 28040 Madrid, Spain
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3
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Baucher L, Lemiale V, Joseph A, Wallet F, Pineton de Chambrun M, Ferré A, Lombardi R, Platon L, Contejean A, Fuseau C, Calvet L, Pène F, Kouatchet A, Mokart D, Azoulay E, Lafarge A. Severe infections requiring intensive care unit admission in patients receiving ibrutinib for hematological malignancies: a groupe de recherche respiratoire en réanimation onco-hématologique (GRRR-OH) study. Ann Intensive Care 2023; 13:123. [PMID: 38055081 DOI: 10.1186/s13613-023-01219-5] [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: 09/12/2023] [Accepted: 11/22/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND In the last decade, Ibrutinib has become the standard of care in the treatment of several lymphoproliferative diseases such as chronic lymphocytic leukemia (CLL) and several non-Hodgkin lymphoma. Beyond Bruton tyrosine kinase inhibition, Ibrutinib shows broad immunomodulatory effects that may promote the occurrence of infectious complications, including opportunistic infections. The infectious burden has been shown to vary by disease status, neutropenia, and prior therapy but data focusing on severe infections requiring intensive care unit (ICU) admission remain scarce. We sought to investigate features and outcomes of severe infections in a multicenter cohort of 69 patients receiving ibrutinib admitted to 10 French intensive care units (ICU) from 1 January 2015 to 31 December 2020. RESULTS Median time from ibrutinib initiation was 6.6 [3-18] months. Invasive fungal infections (IFI) accounted for 19% (n = 13/69) of severe infections, including 9 (69%; n = 9/13) invasive aspergillosis, 3 (23%; n = 3/13) Pneumocystis pneumonia, and 1 (8%; n = 1/13) cryptococcosis. Most common organ injury was acute respiratory failure (ARF) (71%; n = 49/69) and 41% (n = 28/69) of patients required mechanical ventilation. Twenty (29%; n = 20/69) patients died in the ICU while day-90 mortality reached 55% (n = 35/64). In comparison with survivors, decedents displayed more severe organ dysfunctions (SOFA 7 [5-11] vs. 4 [3-7], p = 0.004) and were more likely to undergo mechanical ventilation (68% vs. 31%, p = 0.010). Sixty-three ibrutinib-treated patients were matched based on age and underlying malignancy with 63 controls receiving conventional chemotherapy from an historic cohort. Despite a higher median number of prior chemotherapy lines (2 [1-2] vs. 0 [0-2]; p < 0.001) and higher rates of fungal [21% vs. 8%, p = 0.001] and viral [17% vs. 5%, p = 0.027] infections in patients receiving ibrutinib, ICU (27% vs. 38%, p = 0.254) and day-90 mortality (52% vs. 48%, p = 0.785) were similar between the two groups. CONCLUSION In ibrutinib-treated patients, severe infections requiring ICU admission were associated with a dismal prognosis, mostly impacted by initial organ failures. Opportunistic agents should be systematically screened by ICU clinicians in this immunocompromised population.
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Affiliation(s)
- Louise Baucher
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Université Paris Cité, Paris, France.
- Sorbonne Université, Paris, France.
| | - Virginie Lemiale
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Université Paris Cité, Paris, France
| | - Adrien Joseph
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Université Paris Cité, Paris, France
| | - Florent Wallet
- Médecine Intensive Réanimation, Hospices Civils de Lyon, Lyon, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital de La Pitié-Salpêtrière, Paris, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme Et Nutrition (ICAN), 75013, Paris, France
| | - Alexis Ferré
- Réanimation Médico-Chirurgicale, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Romain Lombardi
- Médecine Intensive Réanimation, Hôpital Pasteur, Nice, France
| | - Laura Platon
- Médecine Intensive Réanimation, Hôpital Lapeyronie, Montpellier, France
| | | | - Charline Fuseau
- Hématologie, Institut de Cancérologie (ICANS), Strasbourg, France
| | - Laure Calvet
- Médecine Intensive Réanimation, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | - Frédéric Pène
- Médecine Intensive Réanimation, Hôpital Cochin, Paris, France
| | | | - Djamel Mokart
- Anesthésie Réanimation, Institut Paoli Calmettes, Marseille, France
| | - Elie Azoulay
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Université Paris Cité, Paris, France
| | - Antoine Lafarge
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Université Paris Cité, Paris, France
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4
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Allouchery M, Tomowiak C, Singier A, Puyade M, Dari L, Pambrun E, Pariente A, Bezin J, Pérault-Pochat MC, Salvo F. Bleeding risk with concurrent use of anticoagulants and ibrutinib: A population-based nested case-control study. Br J Haematol 2023; 203:311-318. [PMID: 37485683 DOI: 10.1111/bjh.18995] [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: 05/04/2023] [Revised: 06/22/2023] [Accepted: 07/13/2023] [Indexed: 07/25/2023]
Abstract
Data regarding the safety of co-administration of ibrutinib with anticoagulants in real-life settings are scarce. Using a nationwide database, we conducted a nested case-control study in a cohort of new users of ibrutinib to assess the risk of clinically relevant bleeding (CRB) associated with anticoagulation. Cases were patients with a diagnosis of CRB, defined as hospitalization with a diagnosis of bleeding. The date of CRB constituted the index date. Up to four controls were matched on sex, age at index date and duration of follow-up. The risk of CRB associated with anticoagulation in patients receiving ibrutinib was estimated using conditional logistic regression models, providing odds ratios (OR) adjusted for risk factors of bleeding. Among 614 cases and 2407 matched controls, the risk of CRB was significantly higher in patients receiving both ibrutinib and anticoagulants (adjusted OR [aOR] 2.54, confidence interval [CI] 95% [1.94; 3.32]). When considering anticoagulant class, aOR was 1.99 (CI 95% [1.19; 3.33]) for VKA, 2.48 (CI 95% [1.76; 3.47]) for direct oral anticoagulants and 3.40 (CI 95% [2.01; 5.75]) for parenteral anticoagulants. In conclusion, this study found a 2.5-fold increased risk of CRB in patients receiving both ibrutinib and anticoagulants in real-life settings, and similar aOR among oral anticoagulants.
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Affiliation(s)
- Marion Allouchery
- Pharmacologie Clinique et Vigilances, CHU de Poitiers, Poitiers, France
- Faculté de Médecine, Université de Poitiers, Poitiers, France
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
| | - Cécile Tomowiak
- Onco-Hématologie et Thérapie Cellulaire, CHU de Poitiers, Poitiers, France
- INSERM CIC 1402, CHU de Poitiers, Poitiers, France
| | - Allison Singier
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
| | - Mathieu Puyade
- INSERM CIC 1402, CHU de Poitiers, Poitiers, France
- Médecine Interne et Maladies Infectieuses, CHU de Poitiers, Poitiers, France
| | - Loubna Dari
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
- Médecine Vasculaire, CHU de Bordeaux, Bordeaux, France
| | - Elodie Pambrun
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
| | - Antoine Pariente
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
| | - Julien Bezin
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
- CHU de Bordeaux, Pôle de Santé Publique, Service de Pharmacologie Médicale, Bordeaux, France
| | - Marie-Christine Pérault-Pochat
- Pharmacologie Clinique et Vigilances, CHU de Poitiers, Poitiers, France
- Laboratoire de Neurosciences Expérimentales et Cliniques, INSERM, UMR1084, Université de Poitiers, Poitiers, France
| | - Francesco Salvo
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
- CHU de Bordeaux, Pôle de Santé Publique, Service de Pharmacologie Médicale, Bordeaux, France
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5
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Quartermaine C, Ghazi SM, Yasin A, Awan FT, Fradley M, Wiczer T, Kalathoor S, Ferdousi M, Krishan S, Habib A, Shaaban A, Kola-Kehinde O, Kittai AS, Rogers KA, Grever M, Ruz P, Bhat S, Dickerson T, Byrd JC, Woyach J, Addison D. Cardiovascular Toxicities of BTK Inhibitors in Chronic Lymphocytic Leukemia: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2023; 5:570-590. [PMID: 37969643 PMCID: PMC10635896 DOI: 10.1016/j.jaccao.2023.09.002] [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: 06/09/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 11/17/2023] Open
Abstract
Over the past decade, the treatment landscape of chronic lymphocytic leukemia (CLL) has dramatically changed, shifting from cytotoxic chemotherapy to targeted therapies. Bruton's tyrosine kinase (BTK) inhibitors have revolutionized the treatment of CLL and are increasingly applied in many other malignancies. However, ibrutinib, the first BTK inhibitor approved, is associated with serious toxicities, including atrial fibrillation in up to 38% of patients, ventricular arrhythmias, and other cardiovascular toxicities. Emerging data suggest several newer BTK inhibitors (eg, acalabrutinib, zanubrutinib) are still associated with cardiotoxic risks. This review examines the current state of evidence, including incidence rates, risk factors, mechanisms, and management strategies of cardiovascular toxicities with BTK inhibitors and other CLL therapies. We specifically focus on atrial fibrillation, ventricular arrhythmias/sudden death, hypertension, heart failure, bleeding, and stroke. We also touch on other emerging BTK therapies (eg, pirtobrutinib). Finally, we highlight key unanswered questions and future directions of research.
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Affiliation(s)
- Cooper Quartermaine
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Sanam M Ghazi
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Aneeq Yasin
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Farrukh T Awan
- Division of Hematology, UT-Southwestern Medical Center, Dallas, Texas, USA
| | - Michael Fradley
- Cardio-Oncology Program, Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tracy Wiczer
- Department of Pharmacy, James Cancer Hospital and Solove Research Institute, Columbus, Ohio, USA
| | - Sujay Kalathoor
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Mussammat Ferdousi
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Satyam Krishan
- Department of Medicine, University of Oklahoma Medical Center, Oklahoma City, Oklahoma, USA
| | - Alma Habib
- Division of Hematology, The Ohio State University, Columbus, Ohio, USA
| | - Adnan Shaaban
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Onaopepo Kola-Kehinde
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Adam S Kittai
- Division of Hematology, The Ohio State University, Columbus, Ohio, USA
| | - Kerry A Rogers
- Division of Hematology, The Ohio State University, Columbus, Ohio, USA
| | - Michael Grever
- Division of Hematology, The Ohio State University, Columbus, Ohio, USA
| | - Patrick Ruz
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Seema Bhat
- Division of Hematology, The Ohio State University, Columbus, Ohio, USA
| | - Tyler Dickerson
- Department of Pharmacy, James Cancer Hospital and Solove Research Institute, Columbus, Ohio, USA
| | - John C Byrd
- Department of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jennifer Woyach
- Division of Hematology, The Ohio State University, Columbus, Ohio, USA
| | - Daniel Addison
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
- Division of Cancer Prevention and Control, The Ohio State University, Columbus, Ohio, USA
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6
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Aghel N, Baro Vila RC, Lui M, Hillis C, Leong DP. Diagnosis and Management of Cardiovascular Effects of Bruton's Tyrosine Kinase Inhibitors. Curr Cardiol Rep 2023; 25:941-958. [PMID: 37498449 DOI: 10.1007/s11886-023-01916-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 07/28/2023]
Abstract
PURPOSE OF REVIEW Bruton's tyrosine kinase inhibitors (BTKis) have changed the treatment and prognosis of several B-cell malignancies. However, since the approval of the first BTKi, ibrutinib, reports of cardiovascular adverse events especially atrial fibrillation have arisen. In this review, we discuss the cardiovascular side effects of BTKis and the management of these toxicities in clinical practice. RECENT FINDINGS BTKIs increase the risks of atrial fibrillation, bleeding, hypertension, heart failure, and potentially ventricular arrhythmia. Newer second and third-generation BTKis appear to have a lower risk of cardiovascular adverse events; however, long-term follow-up data are not available for these new BTKis. BTKis are an effective treatment for some B-cell malignancies; however, they can cause cardiovascular side effects. The best preventive strategies to minimize cardiovascular complications remain undefined. Currently, a practical approach for managing patients receiving BTKis includes the management of cardiovascular risk factors and side effects of BTKis to prevent interruption of cancer treatment.
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Affiliation(s)
- Nazanin Aghel
- The Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
- McMaster University, Hamilton, ON, Canada.
| | - Rocio C Baro Vila
- McMaster University, Hamilton, ON, Canada
- Division of Cardiology, Instituto Cardiovascular de Buenos Aires ICBA, Buenos Aires, Argentina
| | | | | | - Darryl P Leong
- The Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- McMaster University, Hamilton, ON, Canada
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7
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Shyam Sunder S, Sharma UC, Pokharel S. Adverse effects of tyrosine kinase inhibitors in cancer therapy: pathophysiology, mechanisms and clinical management. Signal Transduct Target Ther 2023; 8:262. [PMID: 37414756 PMCID: PMC10326056 DOI: 10.1038/s41392-023-01469-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/06/2023] [Accepted: 04/23/2023] [Indexed: 07/08/2023] Open
Abstract
Since their invention in the early 2000s, tyrosine kinase inhibitors (TKIs) have gained prominence as the most effective pathway-directed anti-cancer agents. TKIs have shown significant utility in the treatment of multiple hematological malignancies and solid tumors, including chronic myelogenous leukemia, non-small cell lung cancers, gastrointestinal stromal tumors, and HER2-positive breast cancers. Given their widespread applications, an increasing frequency of TKI-induced adverse effects has been reported. Although TKIs are known to affect multiple organs in the body including the lungs, liver, gastrointestinal tract, kidneys, thyroid, blood, and skin, cardiac involvement accounts for some of the most serious complications. The most frequently reported cardiovascular side effects range from hypertension, atrial fibrillation, reduced cardiac function, and heart failure to sudden death. The potential mechanisms of these side effects are unclear, leading to critical knowledge gaps in the development of effective therapy and treatment guidelines. There are limited data to infer the best clinical approaches for the early detection and therapeutic modulation of TKI-induced side effects, and universal consensus regarding various management guidelines is yet to be reached. In this state-of-the-art review, we examine multiple pre-clinical and clinical studies and curate evidence on the pathophysiology, mechanisms, and clinical management of these adverse reactions. We expect that this review will provide researchers and allied healthcare providers with the most up-to-date information on the pathophysiology, natural history, risk stratification, and management of emerging TKI-induced side effects in cancer patients.
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Affiliation(s)
- Sunitha Shyam Sunder
- Cardio-Oncology Research Group, Department of Pathology and Laboratory Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Umesh C Sharma
- Division of Cardiovascular Medicine, Jacob's School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Saraswati Pokharel
- Cardio-Oncology Research Group, Department of Pathology and Laboratory Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.
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8
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Nixon S, Duquette D, Doucette S, Larouche JF. How We Manage Patients with Indolent B-Cell Malignancies on Bruton's Tyrosine Kinase Inhibitors: Practical Considerations for Nurses and Pharmacists. Curr Oncol 2023; 30:4222-4245. [PMID: 37185435 PMCID: PMC10137400 DOI: 10.3390/curroncol30040322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/05/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
The most common forms of B-cell malignancy, non-Hodgkin lymphoma (NHL) and chronic lymphocytic leukemia (CLL), have seen a drastic shift in the treatment landscape over the last two decades with the introduction of targeted agents. Among them are Bruton's tyrosine kinase (BTK) inhibitors, which have demonstrated excellent efficacy in indolent B-cell NHLs and CLL. Although BTK inhibitors are generally thought to be more tolerable than chemoimmunotherapy, they are associated with a unique safety profile including varying rates of rash, diarrhea, musculoskeletal events, cardiovascular events, and bleeding. Ibrutinib was the first BTK inhibitor to gain a Health Canada indication, followed by second-generation BTK inhibitors acalabrutinib and zanubrutinib, which have better safety profiles compared to ibrutinib, likely due to their improved selectivity for BTK. As BTK inhibitors are oral agents given continuously until disease progression, long-term adverse event (AE) monitoring and management as well as polypharmacy considerations are important for maintaining patient quality of life. This paper intends to serve as a reference for Canadian nurses and pharmacists on dosing, co-administration, and AE management strategies when caring for patients with indolent B-cell NHL or CLL being treated with BTK inhibitors.
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Affiliation(s)
- Shannon Nixon
- Malignant Hematology, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
| | - Dominic Duquette
- Department of Pharmacy, Hôpital de l'Enfant-Jésus, CHU de Québec-Université Laval, Quebec City, QC G1J 1Z4, Canada
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9
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Diamond A, Bensken WP, Vu L, Dong W, Koroukian SM, Caimi P. Ibrutinib Is Associated With Increased Cardiovascular Events and Major Bleeding in Older CLL Patients. JACC CardioOncol 2023; 5:233-243. [PMID: 37144107 PMCID: PMC10152196 DOI: 10.1016/j.jaccao.2023.02.001] [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: 03/31/2022] [Revised: 01/25/2023] [Accepted: 02/07/2023] [Indexed: 05/06/2023] Open
Abstract
Background Early ibrutinib trials showed an association between ibrutinib use and risk of bleeding and atrial fibrillation (AF) in younger chronic lymphocytic leukemia (CLL) patients. Little is known about these adverse events in older CLL patients and whether increased AF rates are associated with increased stroke risk. Objectives To compare the incidence of stroke, AF, myocardial infarction, and bleeding in CLL patients treated with ibrutinib with those who were treated without ibrutinib in a linked SEER-Medicare database. Methods The incidence rate of each adverse event for treated and untreated patients was calculated. Among those treated, inverse probability weighted Cox proportional hazards regression models were used to calculate HRs and 95% CIs for the association between ibrutinib treatment and each adverse event. Results Among 4,958 CLL patients, 50% were treated without ibrutinib and 6% received ibrutinib. The median age at first treatment was 77 (IQR: 73-83) years. Compared with those treated without ibrutinib, those treated with ibrutinib had a 1.91-fold increased risk of stroke (95% CI: 1.06-3.45), 3.65-fold increased risk of AF (95% CI: 2.42-5.49), a 4.92-fold increased risk of bleeding (95% CI: 3.46-7.01) and a 7.49-fold increased risk of major bleeding (95% CI: 4.32-12.99). Conclusions In patients a decade older than those in the initial clinical trials, treatment with ibrutinib was associated with an increased risk of stroke, AF, and bleeding. The risk of major bleeding is higher than previously reported and underscores the importance of surveillance registries to identify new safety signals.
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Affiliation(s)
- Akiva Diamond
- Dan L Duncan Comprehensive Cancer Center at Baylor St. Luke's Medical Center, Houston, Texas, USA
- Address for correspondence: Dr. Akiva Diamond, Dan L Duncan Comprehensive Cancer Center, 7200 Cambridge Street, Suite 7B, MS: BCM904, Houston, Texas 77030, USA. @Akiva.Diamond
| | - Wyatt P. Bensken
- Population Cancer Analytics Shared Resource, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Long Vu
- Population Cancer Analytics Shared Resource, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Weichuan Dong
- Population Cancer Analytics Shared Resource, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Siran M. Koroukian
- Population Cancer Analytics Shared Resource, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Paolo Caimi
- Cleveland Clinic Taussig Cancer Center, Cleveland, Ohio, USA
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10
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Sayegh N, Yirerong J, Agarwal N, Addison D, Fradley M, Cortes J, Weintraub NL, Sayed N, Raval G, Guha A. Cardiovascular Toxicities Associated with Tyrosine Kinase Inhibitors. Curr Cardiol Rep 2023; 25:269-280. [PMID: 36795308 PMCID: PMC10392782 DOI: 10.1007/s11886-023-01845-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 02/17/2023]
Abstract
PURPOSE OF REVIEW To provide a detailed overview of cardiovascular adverse events associated with the use of tyrosine kinase inhibitors across different tumor types. RECENT FINDINGS Despite an undeniable survival advantage of tyrosine kinase inhibitors (TKIs) in patients with hematologic or solid malignancies, the accompanying off-target cardiovascular adverse events can be life-threatening. In patients with B cell malignancies, the use of Bruton tyrosine kinase inhibitors has been associated with atrial and ventricular arrhythmias, as well as hypertension. Cardiovascular toxic profiles are heterogeneous among the several approved breakpoint cluster region (BCR)-ABL TKIS. Notably, imatinib might be cardioprotective. Vascular endothelial growth factor TKIs, constituting the central axis in the treatment of several solid tumors, including renal cell carcinoma and hepatocellular carcinoma, have strongly been associated with hypertension and arterial ischemic events. Epidermal growth factor TKIs as therapy for advanced non-small cell lung cancer (NSCLC) have been reported to be infrequently associated with heart failure and QT prolongation. While tyrosine kinase inhibitors have been demonstrated to increase overall survival across different types of cancers, special consideration should be given to cardiovascular toxicities. High-risk patients can be identified by undergoing a comprehensive workup at baseline.
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Affiliation(s)
- Nicolas Sayegh
- Division of Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Juliet Yirerong
- Division of Cardiology, Department of Internal Medicine, Yale Bridgeport Hospital, Bridgeport, CT, USA
| | - Neeraj Agarwal
- Division of Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Daniel Addison
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH, USA
| | - Michael Fradley
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jorge Cortes
- Division of Hematology and Oncology, Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA.,Cardio-Oncology Program, Georgia Cancer Center, Medical College of Georgia, Augusta University, 1410 Laney Walker Blvd, CN 5313, Augusta, GA, 30912, USA
| | - Neal L Weintraub
- Division of Cardiology, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA.,Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Nazish Sayed
- Department of Vascular Surgery, Cardiovascular Research Institute, Stanford University, Palo Alto, CA, USA
| | - Girindra Raval
- Division of Hematology and Oncology, Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA.,Cardio-Oncology Program, Georgia Cancer Center, Medical College of Georgia, Augusta University, 1410 Laney Walker Blvd, CN 5313, Augusta, GA, 30912, USA
| | - Avirup Guha
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH, USA. .,Cardio-Oncology Program, Georgia Cancer Center, Medical College of Georgia, Augusta University, 1410 Laney Walker Blvd, CN 5313, Augusta, GA, 30912, USA. .,Division of Cardiology, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA.
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11
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Potter AS, Hulsukar MM, Wu L, Narasimhan B, Karimzad K, Koutroumpakis E, Palaskas N, Deswal A, Kantharia BK, Wehrens XH. Kinase Inhibitors and Atrial Fibrillation. JACC Clin Electrophysiol 2023; 9:591-602. [PMID: 37100538 DOI: 10.1016/j.jacep.2022.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/13/2022] [Accepted: 11/30/2022] [Indexed: 02/24/2023]
Abstract
Recent advances have significantly expanded the options of available therapeutics for cancer treatment, including novel targeted cancer therapies. Within this broad category of targeted therapies is the class of kinase inhibitors (KIs), which target kinases that have undergone aberrant activation in cancerous cells. Although KIs have shown a benefit in treating various forms of malignancy, they have also been shown to cause a wide array of cardiovascular toxicities, with cardiac arrhythmias, in particular atrial fibrillation (AF), being 1 of the predominant side effects. The occurrence of AF in patients undergoing cancer treatment can complicate the treatment approach and poses unique clinical challenges. The association of KIs and AF has led to new research aimed at trying to elucidate the underlying mechanisms. Furthermore, there are unique considerations to treating KI-induced AF because of the anticoagulant properties of some KIs as well as drug-drug interactions with KIs and some cardiovascular medications. Here, we review the current literature pertaining to KI-induced AF.
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12
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Shadman M, Flinn IW, Levy MY, Porter RF, Burke JM, Zafar SF, Misleh J, Kingsley EC, Yimer HA, Freeman B, Rao SS, Chaudhry A, Tumula PK, Gandhi MD, Manda S, Chen DY, By K, Xu L, Liu Y, Crescenzo R, Idoine A, Zhang X, Cohen A, Huang J, Sharman JP. Zanubrutinib in patients with previously treated B-cell malignancies intolerant of previous Bruton tyrosine kinase inhibitors in the USA: a phase 2, open-label, single-arm study. Lancet Haematol 2023; 10:e35-e45. [PMID: 36400069 DOI: 10.1016/s2352-3026(22)00320-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/09/2022] [Accepted: 09/15/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND We hypothesised that zanubrutinib, a highly selective next-generation Bruton tyrosine kinase (BTK) inhibitor, would be a safe and active treatment for patients intolerant of ibrutinib, acalabrutinib, or both. We aimed to assess whether zanubrutinib would prolong treatment duration by minimising treatment-related toxicities and discontinuations in patients with previously treated B-cell malignancies. METHODS This ongoing, phase 2, multicentre, open-label, single-arm study was done in 20 centres in the USA. Patients aged 18 or older with previously treated B-cell malignancies (chronic lymphocytic leukaemia, small lymphocytic lymphoma, mantle cell lymphoma, Waldenström macroglobulinaemia, or marginal zone lymphoma) who became intolerant of ibrutinib, acalabrutinib, or both, were orally administered zanubrutinib 160 mg twice daily or 320 mg once daily per investigator. The primary endpoint was recurrence and change in severity of ibrutinib or acalabrutinib intolerance events based on investigator-assessed adverse events. Secondary endpoints were investigator-assessed overall response rate; duration of response; disease control rate; and progression-free survival. Analyses included all patients who received any dose of the study drug. This study is registered with ClinicalTrials.gov, NCT04116437. FINDINGS Between Oct 14, 2019, and Sept 8, 2021, 67 patients (36 [54%] men and 31 [46%] women) who were intolerant of ibrutinib (n=57; cohort 1) or of acalabrutinib or acalabrutinib and ibrutinib (n=10; cohort 2) were enrolled. 63 (94%) patients were White, one (2%) had multiple ethnicities, and three (5%) had unreported or unknown ethnicity. Most intolerance events (81 [70%] of 115 for ibrutinib; 15 [83%] of 18 for acalabrutinib) did not recur with zanubrutinib. Of the recurring events, seven (21%) of 34 ibrutinib intolerance events and two (67%) of three acalabrutinib intolerance events recurred at the same severity with zanubrutinib; 27 (79%) ibrutinib intolerance events and one (33%) acalabrutinib intolerance event recurred at a lower severity with zanubrutinib. No events recurred at higher severity. No grade 4 intolerance events recurred. 64 (96%) of 67 patients had one or more adverse events with zanubrutinib; the most common adverse events were contusion (in 15 [22%] of 67 patients), fatigue (14 [21%]), myalgia (ten [15%]), arthralgia (nine [13%]), and diarrhoea (nine [13%]). Atrial fibrillation occurred in three (4%) patients (all grade 2). Eight (12%) of 67 patients had serious adverse events (anaemia, atrial fibrillation, bronchitis, COVID-19, COVID-19 pneumonia, febrile neutropenia, salmonella gastroenteritis, transfusion reaction, trigeminal nerve disorder, and urinary tract infection). No treatment-related deaths occurred. The median follow-up time was 12·0 months (IQR 8·2-15·6). Among the 64 efficacy-evaluable patients, disease control rate was 93·8% (60; 95% CI 84·8-98·3) and overall response rate was 64·1% (41; 95% CI 51·1-75·7). The median duration of response was not reached; the 12-month event-free duration of response rate was 95·0% (95% CI 69·5-99·3). Similarly, median progression-free survival was not reached; 18-month progression-free survival was 83·8% (95% CI 62·6-93·6). INTERPRETATION Patients intolerant of previous BTK inhibitors have limited treatment options. These results suggest that zanubrutinib, a safe and viable treatment for patients with B-cell malignancies, might fill that unmet need for those who exhibit intolerance to ibrutinib or acalabrutinib. FUNDING BeiGene.
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Affiliation(s)
- Mazyar Shadman
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Division of Medical Oncology, University of Washington, Seattle, WA, USA.
| | - Ian W Flinn
- Sarah Cannon Research Institute/Tennessee Oncology, Nashville, TN, USA
| | - Moshe Y Levy
- Texas Oncology-Baylor Charles A Sammons Cancer Center, Dallas, TX, USA
| | | | - John M Burke
- Rocky Mountain Cancer Centers, US Oncology Research, Aurora, CO, USA
| | - Syed F Zafar
- Florida Cancer Specialists & Research Institute, Fort Myers, FL, USA
| | - Jamal Misleh
- Medical Oncology Hematology Consultants, Newark, DE, USA
| | | | - Habte A Yimer
- Texas Oncology-Tyler, US Oncology Research, Tyler, TX, USA
| | | | - Subramanya S Rao
- Affiliated Oncologists, Alpha Med Physicians Group, Tinley Park, IL, USA
| | | | | | | | - Sudhir Manda
- Arizona Oncology/US Oncology Research, Tucson, AZ, USA
| | | | | | | | - Ye Liu
- BeiGene USA, San Mateo, CA, USA; BeiGene Beijing, Beijing, China
| | | | | | | | | | | | - Jeff P Sharman
- Willamette Valley Cancer Institute and Research Center, US Oncology Research, Eugene, OR, USA
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13
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Preparation and evaluation of ibrutinib lipid-based formulations. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2022.103912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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14
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Hatashima A, Karami M, Shadman M. Approved and emerging Bruton's tyrosine kinase inhibitors for the treatment of chronic lymphocytic leukemia. Expert Opin Pharmacother 2022; 23:1545-1557. [PMID: 35973973 DOI: 10.1080/14656566.2022.2113384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The Bruton's tyrosine kinase (BTK) pathway has proven to be an effective and transformative therapeutic target in the treatment of chronic lymphocytic leukemia (CLL), fueling the growth of BTK inhibitors (BTKis) and landmark approval of first-generation BTKi, ibrutinib. However, ibrutinib's side effect profile left an unmet need for BTKis with improved tolerability thus spurring the subsequent development of second-generation acalabrutinib and zanubrutinib. The treatment landscape continues to evolve with studies using BTKi combination therapies, notably with venetoclax, with and without an anti-CD20 monoclonal antibody as well as third generation BTKis aimed to overcome BTKi resistance. AREAS COVERED This article details the current literature highlighting the efficacy, toxicities, and potential therapeutic combinations of approved and preclinical BTKis. EXPERT OPINION BTKis have signaled the start of a new treatment paradigm in CLL and improved clinical outcomes especially for patients with high-risk disease. However, drug resistance, low CR rates, and indefinite treatment necessitate the development of novel BTKis and fixed duration combination therapy. The results from recently completed and ongoing clinical trials are eagerly awaited with the potential promise of reduced treatment durations and financial burden while achieving durable remissions.
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Affiliation(s)
| | | | - Mazyar Shadman
- Fred Hutch Cancer Center, Seattle WA.,University of Washington, Seattle WA
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15
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Up to 8-year follow-up from RESONATE-2: first-line ibrutinib treatment for patients with chronic lymphocytic leukemia. Blood Adv 2022; 6:3440-3450. [PMID: 35377947 PMCID: PMC9198904 DOI: 10.1182/bloodadvances.2021006434] [Citation(s) in RCA: 97] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/28/2022] [Indexed: 01/10/2023] Open
Abstract
We report long-term follow-up from the RESONATE-2 phase 3 study of the once-daily Bruton's tyrosine kinase inhibitor ibrutinib, which is the only targeted therapy with significant progression-free survival (PFS) and overall survival (OS) benefit in multiple randomized chronic lymphocytic leukemia (CLL) studies. Patients (≥65 years) with previously untreated CLL, without del(17p), were randomly assigned 1:1 to once-daily ibrutinib 420 mg until disease progression/unacceptable toxicity (n = 136) or chlorambucil 0.5-0.8 mg/kg ≤12 cycles (n = 133). With up to 8 years of follow-up (range, 0.1-96.6 months; median, 82.7 months), significant PFS benefit was sustained for ibrutinib vs chlorambucil (hazard ratio [HR], 0.154; 95% confidence interval [CI], 0.108-0.220). At 7 years, PFS was 59% for ibrutinib vs 9% for chlorambucil. PFS benefit was also observed for ibrutinib- vs chlorambucil-randomized patients with high-risk genomic features: del(11q) (HR, 0.033; 95% CI, 0.010-0.107) or unmutated immunoglobulin heavy chain variable region (HR, 0.112; 95% CI, 0.065-0.192). OS at 7 years was 78% with ibrutinib. Prevalence of adverse events (AEs) was consistent with previous 5-year follow-up. Ibrutinib dosing was held (≥7 days) for 79 patients and reduced for 31 patients because of AEs; these AEs resolved or improved in 85% (67 of 79) and 90% (28 of 31) of patients, respectively. With up to 8 years of follow-up, 42% of patients remain on ibrutinib. Long-term RESONATE-2 data demonstrate sustained benefit with first-line ibrutinib treatment for CLL, including for patients with high-risk genomic features. These trials were registered at www.clinicaltrials.gov as #NCT01722487 and #NCT01724346.
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16
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Evans MG, Shestakova A, Haghighi N, Zhao X, Nardi V, Pinter-Brown LC, Rezk SA. Rare case of leptomeningeal small lymphocytic lymphoma with TP53 mutation detected by deep next-generation sequencing. Leuk Lymphoma 2022; 63:2479-2483. [DOI: 10.1080/10428194.2022.2070911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Mark G. Evans
- Department of Hematopathology, Division of Pathology and Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anna Shestakova
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Nahideh Haghighi
- Department of Pathology, City of Hope National Medical Center, Duarte, CA, USA
| | - Xiaohui Zhao
- Department of Pathology and Laboratory Medicine, University of California Irvine (UCI) Medical Center, Orange, CA, USA
| | - Valentina Nardi
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lauren C. Pinter-Brown
- Department of Medicine, Hematology/Oncology Division, University of California Irvine (UCI) Medical Center, Orange, CA, USA
| | - Sherif A. Rezk
- Department of Pathology and Laboratory Medicine, University of California Irvine (UCI) Medical Center, Orange, CA, USA
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17
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Weis TM, Gutierrez J, Kabel CC, King AC, Daley RJ, Stump SE. Real-world management of targeted therapies in chronic lymphocytic leukemia. J Oncol Pharm Pract 2022; 28:1411-1433. [PMID: 35350909 DOI: 10.1177/10781552221090869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The advent of novel targeted therapies, including B-cell receptor (BCR) pathway and B-cell lymphoma 2 (BCL2) inhibitors, has substantially changed the treatment paradigm for chronic lymphocytic leukemia (CLL). Although targeted therapies have improved outcomes compared to traditional chemoimmunotherapy in the front-line and relapsed or refractory settings, they are associated with resistance mutations and suboptimal outcomes in certain high-risk patients. Additionally, targeted therapies are associated with drug interactions and unique adverse effect profiles which can be challenging for patients and clinicians to manage. Ongoing studies continue to address questions regarding optimal sequencing of therapies, the role of treatment combinations, and the efficacy of next-generation novel agents. This review provides a comprehensive overview regarding the clinical management of targeted therapies for CLL and applies current literature to clinical practice.
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Affiliation(s)
- Taylor M Weis
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Jillian Gutierrez
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Charlene C Kabel
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Amber C King
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Ryan J Daley
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Sarah E Stump
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
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18
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Lee DH, Hawk F, Seok K, Gliksman M, Emole J, Rhea IB, Viganego F, Welter-Frost A, Armanious M, Shah B, Chavez JC, Pinilla-Ibarz J, Schabath MB, Fradley M. Association between ibrutinib treatment and hypertension. Heart 2022; 108:445-450. [PMID: 34210750 PMCID: PMC9809112 DOI: 10.1136/heartjnl-2021-319110] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 06/03/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Ibrutinib is a tyrosine kinase inhibitor most commonly associated with atrial fibrillation. However, additional cardiotoxicities have been identified, including accelerated hypertension. The incidence and risk factors of new or worsening hypertension following ibrutinib treatment are not as well known. METHODS We conducted a retrospective study of 144 patients diagnosed with B cell malignancies treated with ibrutinib (n=93) versus conventional chemoimmunotherapy (n=51) and evaluated their effects on blood pressure at 1, 2, 3 and 6 months after treatment initiation. Descriptive statistics were used to compare baseline characteristics for each treatment group. Fisher's exact test was used to identify covariates significantly associated with the development of hypertension. Repeated measures analyses were conducted to analyse longitudinal blood pressure changes. RESULTS Both treatments had similar prevalence of baseline hypertension at 63.4% and 66.7%, respectively. There were no differences between treatments by age, sex and baseline cardiac comorbidities. Both systolic and diastolic blood pressure significantly increased over time with ibrutinib compared with baseline, whereas conventional chemoimmunotherapy was not associated with significant changes in blood pressure. Baseline hypertensive status did not affect the degree of blood pressure change over time. A significant increase in systolic blood pressure (defined as more than 10 mm Hg) was noted for ibrutinib (36.6%) compared with conventional chemoimmunotherapy (7.9%) at 1 month after treatment initiation. Despite being hypertensive at follow-up, 61.2% of patients who were treated with ibrutinib did not receive adequate blood pressure management (increase or addition of blood pressure medications). Within the ibrutinib group, of patients who developed more than 20 mm Hg increase in systolic blood pressure, only 52.9% had hypertension management changes. CONCLUSIONS Ibrutinib is associated with the development of hypertension and worsening of blood pressure. Cardiologists and oncologists must be aware of this cardiotoxicity to allow timely management of blood pressure elevations.
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Affiliation(s)
- Dae Hyun Lee
- Division of Cardiovascular Medicine, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Fahad Hawk
- Division of Cardiovascular Medicine, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Kieun Seok
- Department of Internal Medicine, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Matthew Gliksman
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Josephine Emole
- Department of Medical Oncology, Henry Ford Health System, Detroit, Michigan, USA
| | - Isaac B Rhea
- Cardio-Oncology Division, University of Tennessee Health Science Center Bookstore, Memphis, Tennessee, USA
| | - Federico Viganego
- Cardio-Oncology Program, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Allan Welter-Frost
- Division of Cardiovascular Medicine, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Merna Armanious
- Division of Cardiovascular Medicine, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Bijal Shah
- Malignant Hematology Program, Moffitt Cancer Center, Tampa, Florida, USA
| | - Juliio C Chavez
- Malignant Hematology Program, Moffitt Cancer Center, Tampa, Florida, USA
| | | | - Matthew B Schabath
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Michael Fradley
- Cardio-Oncology Center of Excellence, Division of Cardiology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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19
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Wu JJ, Wang WH, Dong M, Ma SS, Zhang XD, Zhu LN, Niu ST, Ding MJ, Zhang JM, Zhang L, Li X, Li L, Sun ZC, Wang XH, Fu XR, Li ZM, Chang Y, Nan FF, Yan JQ, Yu H, Wu XL, Zhou ZY, Zhang MZ. Orelabrutinib-bruton tyrosine kinase inhibitor-based regimens in the treatment of central nervous system lymphoma: a retrospective study. Invest New Drugs 2022; 40:650-659. [PMID: 35137332 DOI: 10.1007/s10637-022-01219-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/21/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND Central nervous system lymphoma (CNSL) is an aggressive lymphoma. Orelabrutinib, an oral Bruton tyrosine kinase inhibitor, is a new treatment strategy for CNSL. This study aims to evaluate the efficacy and safety of orelabrutinib-based regimens in the treatment of patients with CNSL. METHODS Twenty-three patients with CNSL were included in this retrospective study. All patients received the orelabrutinib-based regimen. Efficacy was evaluated based on investigators' assessment of overall response rate (ORR), complete response/unconfirmed complete response (CR/CRu), partial response (PR), stable disease (SD), progressive disease (PD), duration of response (DOR), progression-free survival (PFS) and overall survival (OS). The safety of orelabrutinib-based regimens has also been evaluated. RESULTS A total of 17.39% of patients received orelabrutinib-based regimens for consolidation therapy, and 82.61% of patients for induction therapy (4 newly diagnosed CNSL, 15 relapsed/refractory CNSL). In the newly diagnosed CNSL group, the ORR was 100% (1 CR, 1 CRu, 2 PR). The 6-month DOR rate, 6-month PFS rate, and 6-month OS rate were 100%, 100%, and 100%, respectively. Of the 15 relapsed/refractory CNSL patients, five therapy regimens were applied (orelabrutinib, n = 3; orelabrutinib/immunotherapy, n = 3; orelabrutinib/chemotherapy, n = 2; orelabrutinib/immunochemotherapy, n = 6; orelabrutinib/radiotherapy, n = 1). The ORR was 60.00% (4 CR, 5 PR). The 6-month DOR rate, 6-month PFS rate, and 6-month OS rate were 92.30%, 67.70%, and 70.00%, respectively. Twenty-one patients reported adverse events (AEs), and 6 patients experienced grade ≥ 3 AEs. CONCLUSION Orelabrutinib-based regimens were efficacious and well-tolerated in patients with CNSL. These combined therapies offer a new potential therapeutic strategy for patients with CNSL.
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Affiliation(s)
- Jing-Jing Wu
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Wen-Hua Wang
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Meng Dong
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Shan-Shan Ma
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Xu-Dong Zhang
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Li-Nan Zhu
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Song-Tao Niu
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Meng-Jie Ding
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Jie-Ming Zhang
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Lei Zhang
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Xin Li
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Ling Li
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Zhen-Chang Sun
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Xin-Hua Wang
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Xiao-Rui Fu
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Zhao-Ming Li
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Yu Chang
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Fei-Fei Nan
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Jia-Qin Yan
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Hui Yu
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Xiao-Long Wu
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Zhi-Yuan Zhou
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Ming-Zhi Zhang
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan, 450052, China.
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20
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Robak T, Witkowska M, Smolewski P. The Role of Bruton's Kinase Inhibitors in Chronic Lymphocytic Leukemia: Current Status and Future Directions. Cancers (Basel) 2022; 14:771. [PMID: 35159041 PMCID: PMC8833747 DOI: 10.3390/cancers14030771] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/24/2022] [Accepted: 01/31/2022] [Indexed: 12/20/2022] Open
Abstract
The use of Bruton's tyrosine kinase (BTK) inhibitors has changed the management and clinical history of patients with chronic lymphocytic leukemia (CLL). BTK is a critical molecule that interconnects B-cell antigen receptor (BCR) signaling. BTKis are classified into two categories: irreversible (covalent) inhibitors and reversible (non-covalent) inhibitors. Ibrutinib was the first irreversible BTK inhibitor approved by the U.S. Food and Drug Administration in 2013 as a breakthrough therapy in CLL patients. Subsequently, several studies have evaluated the efficacy and safety of new agents with reduced toxicity when compared with ibrutinib. Two other irreversible, second-generation BTK inhibitors, acalabrutinib and zanubrutinib, were developed to reduce ibrutinib-mediated adverse effects. Additionally, new reversible BTK inhibitors are currently under development in early-phase studies to improve their activity and to diminish adverse effects. This review summarizes the pharmacology, clinical efficacy, safety, dosing, and drug-drug interactions associated with the treatment of CLL with BTK inhibitors and examines their further implications.
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Affiliation(s)
- Tadeusz Robak
- Department of Hematology, Medical University of Lodz, 93-510 Lodz, Poland
| | - Magda Witkowska
- Department of Experimental Hematology, Medical University of Lodz, 93-510 Lodz, Poland; (M.W.); (P.S.)
| | - Piotr Smolewski
- Department of Experimental Hematology, Medical University of Lodz, 93-510 Lodz, Poland; (M.W.); (P.S.)
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21
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Alnassfan T, Cox‐Pridmore MJ, Taktak A, Till KJ. Mantle cell lymphoma treatment options for elderly/unfit patients: A systematic review. EJHAEM 2022; 3:276-290. [PMID: 35846186 PMCID: PMC9175944 DOI: 10.1002/jha2.311] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 09/21/2021] [Indexed: 12/23/2022]
Affiliation(s)
- Tahera Alnassfan
- Department of Molecular and Clinical Cancer Medicine University of Liverpool Liverpool UK
- Authors Tahera Alnassfan and Megan J. Cox‐Pridmore contributed equally to the review
| | - Megan J. Cox‐Pridmore
- Department of Molecular and Clinical Cancer Medicine University of Liverpool Liverpool UK
- Authors Tahera Alnassfan and Megan J. Cox‐Pridmore contributed equally to the review
| | - Azzam Taktak
- Medical Physics and Clinical Engineering Royal Liverpool University Hospital Liverpool UK
| | - Kathleen J Till
- Department of Molecular and Clinical Cancer Medicine University of Liverpool Liverpool UK
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22
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Abrisqueta P, Loscertales J, Terol MJ, Ramírez Payer Á, Ortiz M, Pérez I, Cuellar-García C, Fernández de la Mata M, Rodríguez A, Lario A, Delgado J, Godoy A, Arguiñano Pérez JM, Berruezo MJ, Oliveira A, Hernández-Rivas JÁ, García Malo MD, Medina Á, García Martin P, Osorio S, Baltasar P, Fernández-Zarzoso M, Marco F, Vidal Manceñido MJ, Smucler Simonovich A, López Rubio M, Jarque I, Suarez A, Fernández Álvarez R, Lancharro Anchel A, Ríos E, Losada Castillo MDC, Pérez Persona E, García Muñoz R, Ramos R, Yáñez L, Bello JL, Loriente C, Acha D, Villanueva M. Real-World Characteristics and Outcome of Patients Treated With Single-Agent Ibrutinib for Chronic Lymphocytic Leukemia in Spain (IBRORS-LLC Study). CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2021; 21:e985-e999. [PMID: 34511320 DOI: 10.1016/j.clml.2021.07.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/16/2021] [Accepted: 07/19/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Ibrutinib demonstrated remarkable efficacy and favorable tolerability in patients with untreated or relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL), including those with high-risk genetic alterations. The IBRORS-CLL study assessed the characteristics, clinical management and outcome of CLL patients receiving ibrutinib in routine clinical practice in Spain. PATIENTS Observational, retrospective, multicenter study in CLL patients who started single-agent ibrutinib as first-line treatment or at first or second relapse between January 2016 and January 2019. RESULTS A total of 269 patients were included (median age: 70.9 years; cardiovascular comorbidity: 55.4%, including hypertension [47.6%] and atrial fibrillation [AF] [7.1%]). Overall, 96.7% and 69% of patients underwent molecular testing for del(17p)/TP53 mutation and IGHV mutation status. High-risk genetic features included unmutated IGHV (79%) and del(17p)/TP53 mutation (first-line: 66.3%; second-line: 23.1%). Overall, 84 (31.2%) patients received ibrutinib as first-line treatment, and it was used as second- and third-line therapy in 121 (45.0%) and 64 (23.8%) patients. The median progression-free survival and overall survival were not reached irrespective of del(17p)/TP53, or unmutated IGHV. Common grade ≥3 adverse events were infections (12.2%) and bleeding (3%). Grade ≥3 AF occurred in 1.5% of patients. CONCLUSION This real-world study shows that single-agent ibrutinib is an effective therapy for CLL, regardless of age and high-risk molecular features, consistent with clinical trials. Additionally, single-agent ibrutinib was well tolerated, with a low rate of cardiovascular events. This study also emphasized a high molecular testing rate of del(17p)/TP53 mutation and IGHV mutation status in clinical practice according to guideline recommendations.
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Affiliation(s)
| | | | | | | | - Macarena Ortiz
- Hospital Regional Universitario de Málaga, Malaga, Spain
| | | | | | | | | | - Ana Lario
- Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Ana Godoy
- Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | | | - Ana Oliveira
- ICO L'Hospitalet, L'Hospitalet de Llobregat, Spain
| | | | | | | | | | - Santiago Osorio
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Fernando Marco
- Hospital Universitario de Basurto, Bilbo, Bizkaia, Spain
| | | | | | | | | | - Alexia Suarez
- Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Spain
| | | | | | - Eduardo Ríos
- Hospital Universitario Virgen de Valme, Sevilla, Spain
| | | | | | | | - Rafael Ramos
- Hospital Universitario de Badajoz, Badajoz, Spain
| | - Lucrecia Yáñez
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - José Luis Bello
- Hospital Clínico Universitario de Santiago-CHUS, Santiago de Compostela, A Coruña, Spain
| | | | - Daniel Acha
- Medical Department-Hematology Janssen-Cilag, S.A., Madrid, Spain
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23
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Pooled safety analysis of zanubrutinib monotherapy in patients with B-cell malignancies. Blood Adv 2021; 6:1296-1308. [PMID: 34724705 PMCID: PMC8864647 DOI: 10.1182/bloodadvances.2021005621] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/04/2021] [Indexed: 11/20/2022] Open
Abstract
Pooled safety data from zanubrutinib monotherapy studies in B-cell malignancies are consistent with the toxicity profile of BTK inhibitors. Zanubrutinib exhibits a lower incidence of atrial fibrillation and hypertension than previously reported with ibrutinib.
Zanubrutinib is a selective Bruton tyrosine kinase (BTK) inhibitor evaluated in multiple B-cell malignancy studies. We constructed a pooled safety analysis to better understand zanubrutinib-associated treatment-emergent adverse events (TEAEs) and identify treatment-limiting toxicities. Data were pooled from 6 studies (N = 779). Assessments included type, incidence, severity, and outcome of TEAEs. Median age was 65 years; 20% were ≥75 years old. Most patients had Waldenström macroglobulinemia (33%), chronic lymphocytic leukemia/small lymphocytic lymphoma (29%), or mantle-cell lymphoma (19%). Median treatment duration was 26 months (range, 0.1-65); 16% of patients were treated for ≥3 years. Common nonhematologic TEAEs were upper respiratory tract infection (URI, 39%), rash (27%), bruising (25%), musculoskeletal pain (24%), diarrhea (23%), cough (21%), pneumonia (21%), urinary tract infection (UTI), and fatigue (15% each). Most common grade ≥3 TEAEs were pneumonia (11%), hypertension (5%), URI, UTI, sepsis, diarrhea, and musculoskeletal pain (2% each). Atrial fibrillation and major hemorrhage occurred in 3% and 4% of patients, respectively. Atrial fibrillation, hypertension, and diarrhea occurred at lower rates than those reported historically for ibrutinib. Grade ≥3 adverse events included neutropenia (23%), thrombocytopenia (8%), and anemia (8%). Serious TEAEs included pneumonia (11%), sepsis (2%), and pyrexia (2%).Treatment discontinuations and dose reductions for adverse events occurred in 10% and 8% of patients, respectively. Thirty-nine patients (4%) had fatal TEAEs, including pneumonia (n = 9), sepsis (n = 4), unspecified cause (n = 4), and multiple organ dysfunction syndrome (n = 5). This analysis demonstrates that zanubrutinib is generally well tolerated with a safety profile consistent with known BTK inhibitor toxicities; these were manageable and mostly reversible.
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24
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Carda JP, Santos L, Mariz JM, Monteiro P, Gonçalves HM, Raposo J, Gomes da Silva M. Management of ibrutinib treatment in patients with B-cell malignancies: clinical practice in Portugal and multidisciplinary recommendations. ACTA ACUST UNITED AC 2021; 26:785-798. [PMID: 34605364 DOI: 10.1080/16078454.2021.1980690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Ibrutinib, a potent inhibitor of the Bruton tyrosine kinase, has revolutionized the treatment of many B-cell malignancies. Ibrutinib has an established favorable toxicity profile with up to 8 years of experience in clinical trials; however, despite ibrutinib's favorable toxicity profile, dose reductions and treatment discontinuations are becoming more evident in clinical practice, particularly in the setting of specific clinical contexts and patient characteristics. This manuscript is set to provide practical recommendations on the management of patients treated with this agent in daily practice. METHODS A group of multidisciplinary experts from Portugal met to discuss and highlight practical recommendations, supported on both literature and clinical insights, for the management of the treatment with ibrutinib. RESULTS/DISCUSSION Handling of both toxicities and drug-drug interactions during ibrutinib treatment poses several challenges to healthcare providers and can benefit from a multidisciplinary approach. The involvement of specialties, such as cardiology, infectiology and pharmacology, can bring an added value to patient care, not only in anticipating/managing safety issues and dose adjustments but also in enhancing adherence to treatment, ultimately improving the risk/benefit balance. CONCLUSION By involving a multidisciplinary group of experts, this work provides a set of key recommendations to optimize care and outcomes for ibrutinib-treated patients. Despite not being a fully comprehensive review on the topic, it is intended as a framework to hematologists and other healthcare professionals who manage these patients in their daily clinical practice.
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Affiliation(s)
- José Pedro Carda
- Serviço de Hematologia Clínica, Faculdade de Medicina da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal
| | - Lurdes Santos
- Centro Hospitalar Universitário de São João, Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,Nephrology and Infectious Diseases R&D, I3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - José Mário Mariz
- Onco-Haematology Clinic, Instituto Português de Oncologia do Porto, EPE/IPOFG - CRO, Porto, Portugal
| | - Pedro Monteiro
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Humberto Miguel Gonçalves
- Serviço Farmacêutico, Instituto Português de Oncologia de Lisboa, Francisco Gentil, Lisboa, Portugal
| | - João Raposo
- Centro Hospitalar Universitário Lisboa Norte, EPE, Lisboa, Portugal
| | - Maria Gomes da Silva
- Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisbon, Portugal
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25
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Ammad Ud Din M, Thakkar S, Patel H, Saeed H, Hussain SA, Liaqat H, Zafar A, Dani SS, Ganatra S, Anwer F. The Impact of Atrial Fibrillation on hospitalization Outcomes for Patients With Chronic Lymphocytic Leukemia Using the National Inpatient Sample Database. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2021; 22:98-104. [PMID: 34598909 DOI: 10.1016/j.clml.2021.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/15/2021] [Accepted: 08/23/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The incidence of atrial fibrillation (AF) in patients with chronic lymphocytic leukemia (CLL) has been on the rise. However, the excess burden added by AF to the morbidity and mortality of CLL patients especially in the hospitalized setting is undetermined. METHODS The National Inpatient Sample (NIS) database was accessed to gather data of hospitalized CLL patients with AF from 2009 to 2018. Propensity-score matching (PSM) and logistic regression model were performed to control for baseline patient factors to match 7265 CLL patient admissions with AF and 7265 CLL patient admissions without AF. The primary outcome was all-cause mortality (ACM), while the secondary outcomes included acute coronary syndrome (ACS), acute myocardial infarction (AMI), and the need for percutaneous coronary intervention (PCI), acute heart failure (AHF), acute hypoxic respiratory failure (AHRF), cardiac arrest (CA), cardiogenic shock (CS), stroke, and the total cost of hospitalization. RESULTS CLL patients with AF had a higher rate of ACM (6.06% vs 4.47%; odds ratio [OR] 1.39, 95% confidence interval [CI] 1.19-1.61; P =< .001). All other secondary outcomes including ACS, AMI, PCI, AHRF, CA, CS, and stroke were observed at a significantly higher rate in the AF group as well. The median total hospital cost was also higher in the AF group ($9097 vs. $7646; P value < .0001) CONCLUSION: CLL patients with AF are at a significantly increased risk of all-cause mortality, cardiac-related mortality, and stroke. For this population, a multidisciplinary approach should be orchestrated for better management and outcomes.
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Affiliation(s)
| | | | - Harsh Patel
- Department of Internal Medicine, Louis A. Weiss Memorial Hospital, Chicago, IL
| | - Hassan Saeed
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Syed Ather Hussain
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Hania Liaqat
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Aneeqa Zafar
- Department of Hospitalist Medicine, El Camino Health Mountain View Campus, Mountain View, CA
| | - Sourbha S Dani
- Department of Cardiology, Lahey Hospital & Medical Center, MA
| | - Sarju Ganatra
- Department of Cardiology, Lahey Hospital & Medical Center, MA
| | - Faiz Anwer
- Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
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26
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Tang CPS, Lip GYH, McCormack T, Lyon AR, Hillmen P, Iyengar S, Martinez-Calle N, Parry-Jones N, Patten PEM, Schuh A, Walewska R. Management of cardiovascular complications of bruton tyrosine kinase inhibitors. Br J Haematol 2021; 196:70-78. [PMID: 34498258 DOI: 10.1111/bjh.17788] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/04/2021] [Accepted: 08/07/2021] [Indexed: 12/01/2022]
Affiliation(s)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | | | | | | | | | | | - Anna Schuh
- Oxford University Hospitals NHS Trust, Oxford, UK
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27
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Cho HJ, Baek DW, Kim J, Lee JM, Moon JH, Sohn SK. Keeping a balance in chronic lymphocytic leukemia (CLL) patients taking ibrutinib: ibrutinib-associated adverse events and their management based on drug interactions. Expert Rev Hematol 2021; 14:819-830. [PMID: 34375536 DOI: 10.1080/17474086.2021.1967139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Ibrutinib is a highly effective drug for patients with chronic lymphocytic leukemia (CLL), and is well tolerated even by older patients and those unfit to receive conventional immuno-chemotherapy. AREAS COVERED The occurrence of adverse events was revealed as a major cause of ibrutinib failure in the real-world. Ibrutinib-induced lymphocytosis carries the risk of an untimely interruption of therapy because it may be misinterpreted as disease progression. In addition, drug interactions can worsen ibrutinib-associated toxicities by increasing the plasma concentration of ibrutinib. In this review, we present a case of major hemorrhage and atrial fibrillation (AF) during ibrutinib use and summarize the adverse events associated with ibrutinib. Furthermore, the practical management of ibrutinib-associated toxicities was covered with reference to a drug interaction mechanism. EXPERT OPINION Clinicians should examine the prescribed drugs prior to ibrutinib initiation and carefully monitor toxicities while taking ibrutinib. A reduced dose of ibrutinib with the concurrent use of CYP3A inhibitors such as antifungal agents could be an attractive strategy to reduce toxicities and may confer financial benefits. Reducing unexpected toxicities is as significant as achieving treatment response in the era of life-long therapy with ibrutinib in patients with CLL.
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Affiliation(s)
- Hee Jeong Cho
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Dong Won Baek
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Juhyung Kim
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jung Min Lee
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Joon Ho Moon
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Sang Kyun Sohn
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
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Bruton's tyrosine kinase Inhibitors and Cardiotoxicity: More Than Just Atrial Fibrillation. Curr Oncol Rep 2021; 23:113. [PMID: 34342738 PMCID: PMC8330192 DOI: 10.1007/s11912-021-01102-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 12/12/2022]
Abstract
Purpose of Review The purpose of this review is to summarize the epidemiology, mechanisms, and management of cardiovascular complications of Bruton’s Tyrosine Kinase inhibitors (BTKIs). Recent Findings Ibrutinib increases the risk of atrial fibrillation, bleeding, and hypertension compared with non-BTKI therapies. The evidence to support an association between ibrutinib and other cardiovascular complications including ventricular tachyarrhythmias or cardiomyopathy is limited. Ibrutinib metabolism can be inhibited by some medications used to treat cardiovascular complications. The cardiovascular effects of more selective BTKIs, such as acalabrutinib, remain to be determined. Summary Future research should address the mechanisms underlying the cardiovascular complications of BTKIs and how best to manage them. The risks and benefits of more selective BTKIs as compared with ibrutinib require further evaluation.
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29
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Wilkinson M, Yeung D, Limaye V. A case of inflammatory myopathy in graft vs host disease - A potential role for ibrutinib. Neuromuscul Disord 2021; 31:865-869. [PMID: 34334272 DOI: 10.1016/j.nmd.2021.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/19/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
Myositis is a known complication of chronic graft-vs-host disease (cGVHD) following allogeneic haematopoietic stem cell transplantation, but can be difficult to diagnose and manage. We present the case of a 57 year old man with cGVHD in whom the full manifestations of myositis were suppressed for some time, likely due to partial treatment of his condition with immunosuppression including ibrutinib. Though initial muscle biopsy showed necrotising myopathy without significant inflammation, on cessation of ibrutinib he developed increasing weakness and creatine kinase levels, with repeat muscle biopsy showing histological changes more in keeping with dermatomyositis. The close temporal correlation of his clinical course with commencement and cessation of ibrutinib suggests a potential role for ibrutinib in treating inflammatory myopathy in cGVHD.
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Affiliation(s)
- Michael Wilkinson
- Advanced Trainee, General and Acute Care Medicine, Royal Adelaide Hospital, Associate Clinical Lecturer, University of Adelaide, Australia.
| | - David Yeung
- Consultant Haematologist, Royal Adelaide Hospital, Postdoctoral Research Fellow, University of Adelaide, Australia
| | - Vidya Limaye
- Consultant Rheumatologist, Royal Adelaide Hospital, Associate Professor of Rheumatology, Discipline of Medicine, University of Adelaide, Australia
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30
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Mehraban Far P, Rullo J, Farmer J, Urton T. Recurrent Uveitis Related to Ibrutinib for Treatment of Chronic Lymphocytic Leukemia. Ocul Immunol Inflamm 2021; 30:1005-1008. [PMID: 33539715 DOI: 10.1080/09273948.2020.1841802] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose: We describe a case vision-threatening sclerouveitis as a probable adverse drug reaction to ibrutinib. Methods: Case report. Results: Ibrutinib is an inhibitor of Bruton's kinase which has shown success in the treatment of hematological malignancies such as chronic lymphocytic leukemia. Despite being generally well tolerated, recent studies have implicated ibrutinib in several adverse events affecting organs such as the heart, intestines, and the eyes. We present the case of a patient who developed severe sclerouveitis after approximately one year of ibrutinib therapy, and suggest this is a probable adverse drug reaction associated with ibrutinib in accordance with the Naranjo algorithm, highlighting the importance of prompt management of ocular symptoms in these patients.
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Affiliation(s)
- Parsa Mehraban Far
- Department of Ophthalmology, Queen's University, Kingston, Ontario, Canada
| | - Jacob Rullo
- Department of Ophthalmology, Queen's University, Kingston, Ontario, Canada
| | - James Farmer
- Department of Ophthalmology, Queen's University, Kingston, Ontario, Canada
| | - Todd Urton
- Department of Ophthalmology, Queen's University, Kingston, Ontario, Canada
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31
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Ghia P, Dlugosz-Danecka M, Scarfò L, Jurczak W. Acalabrutinib: a highly selective, potent Bruton tyrosine kinase inhibitor for the treatment of chronic lymphocytic leukemia. Leuk Lymphoma 2021; 62:1066-1076. [PMID: 33427570 DOI: 10.1080/10428194.2020.1864352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Inhibiting the activity of Bruton tyrosine kinase (BTK) prevents the activation of the B-cell receptor (BCR) signaling pathway, which in turn prevents both B-cell activation and BTK-mediated activation of downstream survival pathways. Acalabrutinib is an orally available, highly selective, next-generation inhibitor of BTK. Based on the results of two key phase 3 trials (ELEVATE-TN in patients with previously untreated chronic lymphocytic leukemia [CLL] and ASCEND in patients with relapsed or refractory CLL), which demonstrated superior progression-free survival while maintaining favorable tolerability, acalabrutinib was granted US Food and Drug Administration (FDA) approval in 2019 for the treatment of patients with CLL. Acalabrutinib appears to offer similar efficacy but a significantly improved tolerability profile to first-generation agents. Acalabrutinib is a good candidate to combine with other anti-cancer therapies, including B-cell lymphoma 2 inhibitors and monoclonal antibodies, a factor that may help to further improve clinical outcomes in CLL.
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Affiliation(s)
- Paolo Ghia
- Division of Experimental Oncology, Strategic Research Program on Chronic Lymphocytic Leukemia, IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | - Monika Dlugosz-Danecka
- Department of Lymphoid Malignancies, Maria Skłodowska-Curie National Research Institute of Oncology, Kraków, Poland
| | - Lydia Scarfò
- Division of Experimental Oncology, Strategic Research Program on Chronic Lymphocytic Leukemia, IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | - Wojciech Jurczak
- Department of Lymphoid Malignancies, Maria Skłodowska-Curie National Research Institute of Oncology, Kraków, Poland
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32
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Abstract
PURPOSE OF REVIEW Ibrutinib is a first-in-class, highly potent Bruton tyrosine kinase inhibitor which has become standard of care for patients with chronic lymphocytic leukaemia and other lymphoproliferative disorders. It requires indefinite administration which places emphasis on toxicity and long-term tolerance. RECENT FINDINGS Extensive use of ibrutinib in studies and clinical practice has better defined its full toxicity profile which has made its use more challenging than initially foreseen. In particular, dysrhythmias, bleeding, infections and constitutional symptoms have been reported and can result in dose reduction or discontinuation of ibrutinib. Herein, we review the common as well as rare but important toxicities and discuss approach and management on a practical level. We also highlight that patients should be regularly monitored for adverse events and proactively treated to minimise side effects and avoid disruption.
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Affiliation(s)
- Masa Lasica
- Department of Haematology, St Vincent's Hospital, Melbourne, Australia.,Department of Haematology, Eastern Health, Melbourne, Australia
| | - Constantine S Tam
- Department of Haematology, St Vincent's Hospital, Melbourne, Australia. .,Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, Australia. .,Department of Medicine, University of Melbourne, Melbourne, Australia.
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33
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Kojima K, Burger JA. Treatment algorithm for Japanese patients with chronic lymphocytic leukemia in the era of novel targeted therapies. J Clin Exp Hematop 2020; 60:130-137. [PMID: 32404571 PMCID: PMC7810251 DOI: 10.3960/jslrt.20002] [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] [Indexed: 12/12/2022] Open
Abstract
Treatment for patients with chronic lymphocytic leukemia (CLL) is becoming more individualized due to the recent introduction of novel molecularly targeted therapies into the therapeutic armamentarium. Genomic and molecular risk factors in CLL patients determine the individual risk for disease progression and response to therapy, and can impact survival. In this review article, we discuss current treatment strategies for CLL patients in Japan, where the novel targeted agents, the BTK inhibitor ibrutinib and BCL2 antagonist venetoclax, now are available and increasingly used in clinical practice. We also discuss the importance of CLL risk factors for making therapy decisions, focusing on immunoglobulin variable region heavy chain (IGHV) mutation status, 11q deletion, and 17p deletion. Treatment approaches for CLL have rapidly changed in the past few years because of these new targeted agents. They are highly effective, well tolerated, and have been demonstrated in a series of large randomized clinical trials to improve survival when compared with conventional chemotherapy-based treatment. Therefore, for most patients, especially high-risk CLL patients, BTK inhibitor and BCL2 antagonist therapies are preferred over chemo-immunotherapy. Currently ongoing studies seek to determine the best sequence for these new agents and whether a combination therapy approach is beneficial. With these developments, a new era of chemotherapy-free treatment for CLL patients is expected.
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Affiliation(s)
- Kensuke Kojima
- Department of Hematology, Kochi Medical School, Kochi University, Nankoku, Kochi, Japan
| | - Jan A Burger
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Moreno C. Standard treatment approaches for relapsed/refractory chronic lymphocytic leukemia after frontline chemoimmunotherapy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:33-40. [PMID: 33275679 PMCID: PMC7727531 DOI: 10.1182/hematology.2020000086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Despite the effectiveness of chemoimmunotherapy (CIT), in most cases the clinical course of chronic lymphocytic leukemia (CLL) is characterized by consecutive episodes of disease progression and need for therapy. Treatment possibilities for patients with CLL in whom CIT fails whose disease progresses after initial CIT include pathway inhibitors (PIs) and, for selected patients, cellular therapy (ie, allogeneic stem cell transplant, chimeric antigen receptor T cells). PIs (ie, Bruton tyrosine kinase inhibitors, phosphatidylinositol 3-kinase inhibitors, and BCL2 inhibitors) are revolutionizing the treatment of CLL. PIs have proved to be more effective than CIT, both as upfront therapy and for relapsed/refractory disease, largely because they may overcome the negative impact of adverse biomarkers (eg, TP53 aberrations, unmutated IGHV) on outcomes and because of their acceptable toxicity. In this article, the management of patients with relapsed/refractory CLL is discussed, with a particular emphasis on the role of PIs.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/metabolism
- Cyclophosphamide/administration & dosage
- Female
- Humans
- Immunotherapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Middle Aged
- Rituximab/administration & dosage
- Vidarabine/administration & dosage
- Vidarabine/analogs & derivatives
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Affiliation(s)
- Carol Moreno
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Lipsky A, Lamanna N. Managing toxicities of Bruton tyrosine kinase inhibitors. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:336-345. [PMID: 33275698 PMCID: PMC7727553 DOI: 10.1182/hematology.2020000118] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Inhibition of Bruton's tyrosine kinase (BTK) has revolutionized the treatment landscape for patients with chronic lymphocytic leukemia (CLL). By targeting this critical kinase in proximal B-cell receptor signaling, BTK inhibitors (BTKis) impair cell proliferation, migration, and activation of NF-κB. Clinically, because indefinite inhibition is a mainstay of therapy, there is an extended period of exposure in which adverse effects can develop. Given the impressive efficacy and activity of BTKis in the treatment of patients with CLL, appropriate management of treatment-emergent adverse events (AEs) is of paramount importance. Here we review the BTKi landscape and present the available toxicity and safety data for each agent. The long-term toxicity profile of ibrutinib, a first-in-class inhibitor, is well characterized and includes a clinically significant incidence of cardiac arrhythmias, bleeding, infection, diarrhea, arthralgias, and hypertension. Acalabrutinib, the initial second-generation BTKi to earn approval from the US Food and Drug Administration, demonstrates improved kinase selectivity for BTK, with commonly observed adverse reactions including infection, headache, and diarrhea. Mediated by both on-target inhibition of BTK and variable off-target inhibition of other kinases including interleukin-2-inducible T-cell kinase (ITK), tyrosine-protein kinase (TEC), and endothelial growth factor receptor (EGFR), the toxicity profile of BTKis is closely linked to their pattern of kinase binding. Other emerging BTKis include second-generation agents with variable degrees of kinase selectivity and third-generation agents that exhibit reversible noncovalent binding to BTK. We also highlight critical considerations for the prevention and monitoring of AEs and offer practical management strategies for treatment-emergent toxicities.
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Wang J, Zhao A, Zhou H, Zhu J, Niu T. Risk of Bleeding Associated With Ibrutinib in Patients With B-Cell Malignancies: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Front Pharmacol 2020; 11:580622. [PMID: 33658926 PMCID: PMC7919192 DOI: 10.3389/fphar.2020.580622] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/05/2020] [Indexed: 02/05/2023] Open
Abstract
Background: Ibrutinib is an oral covalent Bruton's tyrosine kinase inhibitor that has been approved for chronic lymphocytic leukemia (CLL)/small lymphocytic leukemia and some other B-cell malignancies. Some studies have found an increased risk of bleeding with ibrutinib. Some studies, however, found no significant differences in the risk of major bleeding between patients treated with ibrutinib and those with other regimens. So, a systematic review and meta-analysis of randomized controlled trials (RCTs) were performed to estimate the risk of bleeding associated with ibrutinib in patients with B-cell malignancies. Methods: A systematic search of PUBMED, EMBASE, Central Register of Controlled Trials, and ClinicalTrials.gov was conducted from January 2000 to February 2020 to identify RCTs by comparing ibrutinib with other agents or placebo in B-cell malignancies. The RevMan software (version 5.3) was used to carry out this analysis, and the analyzed data were represented by risk ratios (RR) and 95% confidence intervals (CI). Results: There were 11 eligible RCTs (4,288 patients). All studies reported major bleeding, and seven studies reported overall bleeding (any-grade bleeding). Ibrutinib was associated with a significantly increased risk of bleeding (overall bleeding and major bleeding) in patients with B-cell malignancies [RR = 2.56, 95% CI 1.68-3.90, p < 0.0001 and RR = 2.08, 95% CI 1.36-3.16, p = 0.0006, respectively]. The bleeding (overall bleeding and major bleeding) risk in patients with CLL was more obvious [RR = 3.08, 95% CI 2.07-4.58, p < 0.00001 and RR = 2.46, 95% CI 1.37-4.41, p = 0.003, respectively]. There were no statistically significant differences for risk of bleeding between the subgroups based on dose and treatment setting. Conclusion: Ibrutinib was associated with a significantly higher risk of bleeding (both overall bleeding and major bleeding) in patients with B-cell malignancies, especially in CLL.
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Affiliation(s)
| | | | | | | | - Ting Niu
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
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Traoré S, Roumila M, Eftekhari P, Farhat H, Merabet F, Guira O, Rousselot P, Azarian R, Besson C. Highlights on the risk of pulmonary tuberculosis in patients on ibrutinib treatment: Case report and literature review. EJHAEM 2020; 1:601-603. [PMID: 35844981 PMCID: PMC9176077 DOI: 10.1002/jha2.80] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/04/2020] [Accepted: 08/07/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Solo Traoré
- Training and Research Unit in Health Sciences Joseph Ki ZERBO University Ouagadougou Burkina Faso
- Department of Internal Medicine Yalgado Ouedraogo Teaching Hospital Ouagadougou Burkina Faso
- Department of Hematology‐Oncology Versailles Hospital Center Le Chesnay France
| | - Mehdi Roumila
- Department of Pneumology Versailles Hospital Center Le Chesnay France
- Faculty of Medicine University Paris‐Saclay UVSQ Montigny‐le‐Bretonneux France
| | - Pirayeh Eftekhari
- French Regional Pharmacovigilance Center Fernand‐Widal Hospital‐APHP Paris France
| | - Hassan Farhat
- Department of Hematology‐Oncology Versailles Hospital Center Le Chesnay France
| | - Fatiha Merabet
- Department of Hematology‐Oncology Versailles Hospital Center Le Chesnay France
| | - Oumar Guira
- Training and Research Unit in Health Sciences Joseph Ki ZERBO University Ouagadougou Burkina Faso
- Department of Internal Medicine Yalgado Ouedraogo Teaching Hospital Ouagadougou Burkina Faso
| | - Philippe Rousselot
- Department of Hematology‐Oncology Versailles Hospital Center Le Chesnay France
- Faculty of Medicine University Paris‐Saclay UVSQ Montigny‐le‐Bretonneux France
| | - Reza Azarian
- Department of Pneumology Versailles Hospital Center Le Chesnay France
| | - Caroline Besson
- Department of Hematology‐Oncology Versailles Hospital Center Le Chesnay France
- Faculty of Medicine University Paris‐Saclay UVSQ Montigny‐le‐Bretonneux France
- CESP, INSERM U1018 University Paris‐Saclay UVSQ Villejuif France
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Makita S, Hosoba R, Tobinai K. Safety considerations with targeted therapy drugs for B-cell non-Hodgkin lymphoma. Expert Opin Drug Saf 2020; 19:1105-1120. [PMID: 32715803 DOI: 10.1080/14740338.2020.1802424] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION B-cell non-Hodgkin lymphomas (B-NHLs) are the most frequent hematologic malignant cancers. Molecular targeted therapy is an important aspect of B-NHL treatment alongside cytotoxic chemotherapy, radiotherapy, and immunotherapy. AREAS COVERED Molecular targeted therapies have changed the landscape of treatment strategies for B-NHLs since the approval of rituximab, an anti-CD20 monoclonal antibody, by the US Food and Drug Administration in 1997. Currently, several targeted therapies have been approved or are in the later-phase of clinical trials including naked antibodies, antibody-drug conjugates, and small molecules, such as Bruton's tyrosine kinase (BTK) inhibitors, phosphatidylinositol 3-kinase (PI3 K) inhibitors, enhancer of zeste homolog 2 (EZH2) inhibitors, and B-cell lymphoma 2 (Bcl-2) inhibitors. These drugs have various toxicities because of their unique mechanisms of action. In this review, the available toxicity data of the targeted therapies for B-NHLs have been summarized. EXPERT OPINION Recent clinical developments of targeted therapies for B-NHLs have provided several useful effective therapeutic options for patients. However, there are unique toxicities that need to be resolved. It is necessary to find out the toxicity mechanism; optimal treatment strategy for these toxicities; and novel targeted therapies that might potentially overcome the toxicities of previously approved targeted therapies.
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Affiliation(s)
- Shinichi Makita
- Department of Hematology, National Cancer Center Hospital , Tokyo, Japan
| | - Rika Hosoba
- Department of Hematology, National Cancer Center Hospital , Tokyo, Japan
| | - Kensei Tobinai
- Department of Hematology, National Cancer Center Hospital , Tokyo, Japan
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Sawalha Y, Bond DA, Alinari L. Evaluating the Therapeutic Potential of Zanubrutinib in the Treatment of Relapsed/Refractory Mantle Cell Lymphoma: Evidence to Date. Onco Targets Ther 2020; 13:6573-6581. [PMID: 32753893 PMCID: PMC7351990 DOI: 10.2147/ott.s238832] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 06/26/2020] [Indexed: 12/27/2022] Open
Abstract
Mantle cell lymphoma (MCL) is an uncommon B-cell non-Hodgkin lymphoma characterized by an aggressive clinical course in the majority of patients. Despite recent improvements in outcomes, MCL remains incurable and a major therapeutic challenge. BTK inhibitors are the preferred treatment option for patients with relapsed/refractory MCL, including those unfit for chemotherapy or those with chemoresistant disease. In addition to ibrutinib and acalabrutinib, the FDA recently approved zanubrutinib for the treatment of patients with relapsed/refractory MCL based on the results of two Phase 2 clinical trials showing overall response rates of 85–87% with complete responses in 30–77% of patients. Compared with ibrutinib, zanubrutinib is more selective for BTK and has less off-target inhibition, which is thought to limit certain toxicities although direct comparative data are still lacking. This review article summarizes data from clinical trials of currently FDA-approved BTK inhibitors in MCL with a focus on zanubrutinib.
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Affiliation(s)
- Yazeed Sawalha
- Department of Internal Medicine, Division of Hematology, Arthur G. James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - David A Bond
- Department of Internal Medicine, Division of Hematology, Arthur G. James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lapo Alinari
- Department of Internal Medicine, Division of Hematology, Arthur G. James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Pineda-Gayoso R, Alomar M, Lee DH, Fradley MG. Cardiovascular Toxicities of Bruton’s Tyrosine Kinase Inhibitors. Curr Treat Options Oncol 2020; 21:67. [DOI: 10.1007/s11864-020-00764-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Archibald WJ, Rabe KG, Kabat BF, Herrmann J, Ding W, Kay NE, Kenderian SS, Muchtar E, Leis JF, Wang Y, Chanan-Khan AA, Schwager SM, Koehler AB, Fonder AL, Slager SL, Shanafelt TD, Call TG, Parikh SA. Atrial fibrillation in patients with chronic lymphocytic leukemia (CLL) treated with ibrutinib: risk prediction, management, and clinical outcomes. Ann Hematol 2020; 100:143-155. [PMID: 32488603 DOI: 10.1007/s00277-020-04094-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 05/17/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Ibrutinib therapy is associated with an increased risk of atrial fibrillation (AF) in chronic lymphocytic leukemia (CLL). Risk assessment tools and outcomes of AF in these patients are not well described. METHODS We performed a retrospective review of patients with CLL treated with ibrutinib at Mayo Clinic between October 2012 and November 2018. RESULTS Two hundred ninety-eight patients were identified with a median time on ibrutinib of 19 months (range 0.23-69.7 months). Fifty-one patients developed treatment-emergent AF; the risk of treatment-emergent AF at 6 months, 1 year, and 2 years was 9%, 12%, and 16%, respectively. The following were associated with an increased risk of treatment-emergent AF on multivariable analyses: past history of AF (hazard ratio [HR] 3.5, p = 0.0072) and heart failure (HR 3.4, p = 0.0028). Most patients are able to continue ibrutinib therapy (dose reduced in 43%). Development of treatment-emergent AF was associated with shorter event-free survival (EFS; HR 2.0, p = 0.02) and shorter overall survival (OS; HR 3.2, p = 0.001), after adjusting for age, prior treatment status, TP53 disruption, heart failure, valvular disease, and past history of AF. CONCLUSIONS Patient comorbidities, rather than CLL-related factors, predict risk of treatment-emergent AF in patients treated with ibrutinib. Although the vast majority of patients with treatment-emergent AF are able to continue ibrutinib (with dose reduction in 43%), treatment-emergent AF appears to be associated with worse outcomes, independent of other adverse prognostic factors.
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Affiliation(s)
- William J Archibald
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Kari G Rabe
- Division of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, MN, USA
| | - Brian F Kabat
- Division of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, MN, USA
| | | | - Wei Ding
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Neil E Kay
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Saad S Kenderian
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Eli Muchtar
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Jose F Leis
- Department of Hematology and Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Yucai Wang
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | | | - Susan M Schwager
- Division of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, MN, USA
| | - Amber B Koehler
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Amie L Fonder
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Susan L Slager
- Division of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, MN, USA
| | - Tait D Shanafelt
- Division of Hematology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Timothy G Call
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Sameer A Parikh
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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Salem JE, Manouchehri A, Bretagne M, Lebrun-Vignes B, Groarke JD, Johnson DB, Yang T, Reddy NM, Funck-Brentano C, Brown JR, Roden DM, Moslehi JJ. Cardiovascular Toxicities Associated With Ibrutinib. J Am Coll Cardiol 2020; 74:1667-1678. [PMID: 31558250 DOI: 10.1016/j.jacc.2019.07.056] [Citation(s) in RCA: 151] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/05/2019] [Accepted: 07/07/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Ibrutinib has revolutionized treatment for several B-cell malignancies. However, a recent clinical trial where ibrutinib was used in a front-line setting showed increased mortality during treatment compared with conventional chemotherapy. Cardiovascular toxicities were suspected as the culprit but not directly assessed in the study. OBJECTIVES The purpose of this study was to identify and characterize cardiovascular adverse drug reactions (CV-ADR) associated with ibrutinib. METHODS This study utilized VigiBase (International pharmacovigilance database) and performed a disproportionality analysis using reporting odds ratios (ROR) and information component (IC) to determine whether CV-ADR and CV-ADR deaths were associated with ibrutinib. IC compares observed and expected values to find associations between drugs and adverse drug reactions using disproportionate Bayesian-reporting; IC025 (lower end of the IC 95% credibility interval) >0 is significant. RESULTS This study identified 303 ibrutinib-associated cardiovascular deaths. Ibrutinib was associated with higher reporting of supraventricular arrhythmias (SVAs) (ROR: 23.1; 95% confidence interval: 21.6 to 24.7; p < 0.0001; IC025: 3.97), central nervous system (CNS) hemorrhagic events (ROR: 3.7; 95% confidence interval: 3.4 to 4.1; p < 0.0001; IC025: 1.63), heart failure (ROR: 3.5; 95% confidence interval: 3.1 to 3.8; p < 0.0001; IC025: 1.46), ventricular arrhythmias (ROR: 4.7; 95% confidence interval: 3.7 to 5.9; p < 0.0001; IC025: 0.96), conduction disorders (ROR: 3.5; 95% confidence interval: 2.7 to 4.6; p < 0.0001; IC025: 0.76), CNS ischemic events (ROR: 2.2; 95% confidence interval: 2.0 to 2.5; p < 0.0001; IC025: 0.73), and hypertension (ROR: 1.7; 95% confidence interval: 1.5 to 1.9; p < 0.0001; IC025: 0.4). CV-ADR often occurred early after ibrutinib administration. Importantly, CV-ADR were associated with fatalities that ranged from ∼10% (SVAs and ventricular arrhythmias) to ∼20% (CNS events, heart failure, and conduction disorders). Ibrutinib-associated SVA portends poor prognosis when CNS events occur concomitantly, with 28.8% deaths (15 of 52 cases). CONCLUSIONS Severe and occasionally fatal cardiac events occur in patients exposed to ibrutinib. These events should be considered in patient care and in clinical trial designs. (Evaluation of Reporting of Cardio-vascular Adverse Events With Antineoplastic and Immunomodulating Agents [EROCA]; NCT03530215).
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Affiliation(s)
- Joe-Elie Salem
- Sorbonne Université, INSERM CIC-1421, AP-HP, Regional Pharmacovigilance Center, Pitié-Salpêtrière Hospital, UNICO-GRECO.6 Cardio-Oncology Program, Department of Pharmacology, Paris, France; Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Ali Manouchehri
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marie Bretagne
- Sorbonne Université, INSERM CIC-1421, AP-HP, Regional Pharmacovigilance Center, Pitié-Salpêtrière Hospital, UNICO-GRECO.6 Cardio-Oncology Program, Department of Pharmacology, Paris, France
| | - Bénédicte Lebrun-Vignes
- Sorbonne Université, INSERM CIC-1421, AP-HP, Regional Pharmacovigilance Center, Pitié-Salpêtrière Hospital, UNICO-GRECO.6 Cardio-Oncology Program, Department of Pharmacology, Paris, France
| | - John D Groarke
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Douglas B Johnson
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tao Yang
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nishitha M Reddy
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christian Funck-Brentano
- Sorbonne Université, INSERM CIC-1421, AP-HP, Regional Pharmacovigilance Center, Pitié-Salpêtrière Hospital, UNICO-GRECO.6 Cardio-Oncology Program, Department of Pharmacology, Paris, France
| | - Jennifer R Brown
- CLL Center, Dana-Farber Cancer Institute; Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Dan M Roden
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Javid J Moslehi
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee.
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Yoon SE, Kim SJ, Yoon DH, Koh Y, Mun YC, Do YR, Choi YS, Yang DH, Kim MK, Lee GW, Suh C, Ko YH, Kim WS. A phase II study of ibrutinib in combination with rituximab-cyclophosphamide-doxorubicin hydrochloride-vincristine sulfate-prednisone therapy in Epstein-Barr virus-positive, diffuse large B cell lymphoma (54179060LYM2003: IVORY study): results of the final analysis. Ann Hematol 2020; 99:1283-1291. [PMID: 32333154 PMCID: PMC7237534 DOI: 10.1007/s00277-020-04005-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/12/2020] [Indexed: 12/11/2022]
Abstract
Epstein-Barr virus (EBV) positivity in diffuse large B cell lymphoma (DLBCL) provokes a critical oncogenic mechanism to activate intracellular signaling by LMP1. LMP1 specifically mimics the role of BTK-dependent B cell receptor. Therefore, a trial considering RCHOP therapy along with ibrutinib (I-RCHOP) in combination was conducted among patients with EBV-positive DLBCL. This study was an open-label, single-arm, prospective multicenter phase II clinical trial. Patients received 560 mg of ibrutinib with RCHOP every 3 weeks until 6 cycles were completed or progression or unacceptable toxicity was observed. The primary endpoint was objective response, while secondary endpoints included toxicity, progression-free survival, and overall survival. A matched case-control analysis was completed to compare the efficacy and toxicity of I-RCHOP and RCHOP, respectively, in EBV-positive DLBCL patients. From September 2016 to August 2019, 24 patients proven to have EBV-positive DLBCL in the tissue were enrolled and received I-RCHOP. Their median age was 58 years (range, 28-84 years). The objective overall response was 66.7%, including 16 patients who achieved complete response after 6 cycles. Patients aged younger than 65 years presented a superior OR (87.5%) as compared with those older than 65 years (25.0%; p = 0.01). In a matched case-control study, I-RCHOP therapy provoked a more favorable complete response rate (87.3%) than did RCHOP (68.8%) in those younger than 65 years. Treatment-related mortality was linked most frequently with I-RCHOP therapy (four patients presented with unusual infection without Gr3/4 neutropenia) in the older age group (age ≥ 65 years). In conclusion, in this phase II trial for EBV-positive DLBCL, I-RCHOP was effective but did not show a significant improvement in response and survival in comparison with RCHOP. Also, I-RCHOP promoted serious toxicity and treatment-related death in older patients.
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Affiliation(s)
- Sang Eun Yoon
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Seok Jin Kim
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Dok Hyun Yoon
- Department of Oncology, Asan Medical Center, Ulsan University College of Medicine, Seoul, South Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Yeung-Chul Mun
- Department of Hematology-Oncology, Ewha Womans University Mokdong Hospital, Seoul, South Korea
| | - Young Rok Do
- Department of Hematology-Oncology, Keimyung University School of Medicine, Daegu, South Korea
| | - Yoon Seok Choi
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, South Korea
| | - Deok Hwan Yang
- Division of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, South Korea
| | - Min Kyoung Kim
- Department of Internal Medicine, Yeungnam University College of medicine, Daegu, South Korea
| | - Gyeong-Won Lee
- Division of Hematology-Oncology, Department of Internal Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju, South Korea
| | - Cheolwon Suh
- Department of Oncology, Asan Medical Center, Ulsan University College of Medicine, Seoul, South Korea
| | - Young Hyeh Ko
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Won Seog Kim
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
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Risnik D, Elías EE, Keitelman I, Colado A, Podaza E, Cordini G, Vergara Rubio M, Fernández Grecco H, Bezares RF, Borge M, Trevani A, Giordano M, Jancic C, Gamberale R. The effect of ibrutinib on neutrophil and γδ T cell functions. Leuk Lymphoma 2020; 61:2409-2418. [PMID: 32306816 DOI: 10.1080/10428194.2020.1753043] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Ibrutinib is a BTK/ITK inhibitor with efficacy for the treatment of various lymphoid cancers, including CLL. Considering that innate and adaptative immune defects are a dominant feature of CLL patients, we evaluated whether in vitro ibrutinib affects the survival and function of neutrophils and γδ T cells, key players of the early immune response against microbes. Neutrophils and γδ T cells were obtained from peripheral blood of healthy donors and CLL patients. We found that ibrutinib reduces the production of reactive oxygen species (ROS) and bacteria killing capacity, and slightly impairs neutrophil extracellular traps (NETs) production without affecting bacteria-uptake and CD62L-downregulation induced by fMLP or aggregated IgG. In addition, ibrutinib reduces γδ T cell activation and CD107a degranulation induced by phosphoantigens or anti-CD3. These findings are in agreement with previous data suggesting that ibrutinib interferes with the protective immune response to pathogens, particularly Mycobacteria and Aspergillus.
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Affiliation(s)
- Denise Risnik
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-CONICET-Academia Nacional de Medicina (ANM), Buenos Aires, Argentina.,Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Argentina
| | - Esteban E Elías
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-CONICET-Academia Nacional de Medicina (ANM), Buenos Aires, Argentina
| | - Irene Keitelman
- Laboratorio de Inmunidad Innata, Instituto de Medicina Experimental (IMEX) - CONICET, Academia Nacional de Medicina (ANM), Buenos Aires, Argentina
| | - Ana Colado
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-CONICET-Academia Nacional de Medicina (ANM), Buenos Aires, Argentina
| | - Enrique Podaza
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-CONICET-Academia Nacional de Medicina (ANM), Buenos Aires, Argentina
| | - Gregorio Cordini
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-CONICET-Academia Nacional de Medicina (ANM), Buenos Aires, Argentina.,Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Argentina
| | - Maricef Vergara Rubio
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-CONICET-Academia Nacional de Medicina (ANM), Buenos Aires, Argentina.,Departamento de Biología, Facultad de Ciencias, Universidad de Los Andes, Mérida, Venezuela
| | | | | | - Mercedes Borge
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-CONICET-Academia Nacional de Medicina (ANM), Buenos Aires, Argentina.,Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Argentina
| | - Analía Trevani
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Argentina.,Laboratorio de Inmunidad Innata, Instituto de Medicina Experimental (IMEX) - CONICET, Academia Nacional de Medicina (ANM), Buenos Aires, Argentina
| | - Mirta Giordano
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-CONICET-Academia Nacional de Medicina (ANM), Buenos Aires, Argentina.,Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Argentina
| | - Carolina Jancic
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Argentina.,Laboratorio de Inmunidad Innata, Instituto de Medicina Experimental (IMEX) - CONICET, Academia Nacional de Medicina (ANM), Buenos Aires, Argentina
| | - Romina Gamberale
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-CONICET-Academia Nacional de Medicina (ANM), Buenos Aires, Argentina.,Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Argentina
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Pharmacists' Role in Managing Patients with Chronic Lymphocytic Leukemia. PHARMACY 2020; 8:pharmacy8020052. [PMID: 32230834 PMCID: PMC7355755 DOI: 10.3390/pharmacy8020052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 03/23/2020] [Accepted: 03/24/2020] [Indexed: 02/08/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is a hematologic malignancy that has seen significant advances in care over the last 5 years with the approval of oral agents such as ibrutinib and venetoclax for the treatment of this disease. As such, there has been a substantial shift away from the traditional chemotherapy infusions which have allowed patients greater autonomy with oral cancer therapies. This paradigm shift poses new challenges for the medical team, including drug-drug interactions, adherence counseling, and financial toxicity. Pharmacists are uniquely trained and equipped to help to manage the changing landscape of CLL care. From identifying common medications which may impair ibrutinib clearance to ensuring patients are on the appropriate anti-infective prophylaxis while receiving obinutuzumab, pharmacists can play a vital role in ensuring the highest quality of patient care. Furthermore, additional credentialing of clinical pharmacists in select states allows for independent visits with the pharmacists, allowing for greater involvement, particularly for initiation of venetoclax and management of ibrutinib-induced toxicities. Pharmacists are essential to both expanding and enhancing the care of patients with CLL and should be leveraged to improve patient outcomes whenever possible.
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Byrd JC, Furman RR, Coutre SE, Flinn IW, Burger JA, Blum K, Sharman JP, Wierda W, Zhao W, Heerema NA, Luan Y, Liu EA, Dean JP, O'Brien S. Ibrutinib Treatment for First-Line and Relapsed/Refractory Chronic Lymphocytic Leukemia: Final Analysis of the Pivotal Phase Ib/II PCYC-1102 Study. Clin Cancer Res 2020; 26:3918-3927. [PMID: 32209572 DOI: 10.1158/1078-0432.ccr-19-2856] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/20/2019] [Accepted: 03/20/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE The safety and efficacy of ibrutinib, a once-daily Bruton's tyrosine kinase (BTK) inhibitor, in chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) was demonstrated in this phase Ib/II study. Extended follow-up up to 8 years is described, representing the longest follow-up for single-agent ibrutinib, or any BTK inhibitor, to date. PATIENTS AND METHODS Phase Ib/II PCYC-1102 (NCT01105247) and extension study PCYC-1103 (NCT01109069) included patients receiving single-agent ibrutinib in first-line or relapsed/refractory CLL/SLL. RESULTS Overall response rate was 89%, with similar rates in first-line (87%; complete response, 35%) and relapsed/refractory settings (89%; 10%). Estimated 7-year progression-free survival (PFS) rates were 83% in first-line and 34% in relapsed/refractory settings. Forty-one patients had CLL progression (n = 11 with Richter's transformation). Median PFS was not reached with first-line ibrutinib. In relapsed/refractory CLL/SLL, median PFS was 52 months overall, 26 months in patients with chromosome 17p deletion, 51 months with 11q deletion, not reached with trisomy 12 or 13q deletion, and 88 months in patients without these cytogenetic abnormalities. Estimated 7-year overall survival rates were 84% in first-line and 55% in relapsed/refractory settings. Grade ≥3 adverse events (AE) in >15% of patients were hypertension (28%), pneumonia (24%), and neutropenia (18%). These grade ≥3 AEs generally declined over time, except hypertension. AEs leading to discontinuation in ≥2 patients were observed only in the relapsed/refractory setting (sepsis, diarrhea, subdural hematoma, and Richter's transformation). CONCLUSIONS With up to 8 years of follow-up, sustained responses and long-term tolerability of single-agent ibrutinib were observed with treatment of first-line or relapsed/refractory CLL/SLL, including high-risk CLL/SLL.
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Affiliation(s)
- John C Byrd
- Department of Internal Medicine, The Ohio State University Medical Center, Columbus, Ohio.
| | - Richard R Furman
- Department of Medicine, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York
| | - Steven E Coutre
- Department of Medicine Hematology, Stanford Cancer Center, Stanford University School of Medicine, Stanford, California
| | - Ian W Flinn
- Hematology/Oncology, Sarah Cannon Research Institute/Tennessee Oncology, Nashville, Tennessee
| | - Jan A Burger
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristie Blum
- Department of Internal Medicine, The Ohio State University Medical Center, Columbus, Ohio
| | - Jeff P Sharman
- Medical Oncology Division, Willamette Valley Cancer Institute and Research Center/US Oncology Research, Eugene, Oregon
| | - William Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Weiqiang Zhao
- Department of Pathology, The Ohio State University, Columbus, Ohio
| | - Nyla A Heerema
- Department of Pathology, The Ohio State University, Columbus, Ohio
| | - Ying Luan
- Department of Biostatistics, Pharmacyclics LLC, an AbbVie Company, Sunnyvale, California
| | - Emily A Liu
- Department of Clinical Sciences, Pharmacyclics LLC, an AbbVie Company, Sunnyvale, California
| | - James P Dean
- Department of Clinical Sciences, Pharmacyclics LLC, an AbbVie Company, Sunnyvale, California
| | - Susan O'Brien
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Medicine, University of California, Irvine, Chao Family Comprehensive Cancer Center, Irvine, California
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Hypertension and incident cardiovascular events following ibrutinib initiation. Blood 2020; 134:1919-1928. [PMID: 31582362 DOI: 10.1182/blood.2019000840] [Citation(s) in RCA: 143] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/26/2019] [Indexed: 12/12/2022] Open
Abstract
Ibrutinib is associated with dramatic efficacy against B-cell malignancies. Yet, it has been linked with potentially limiting cardiotoxicity, including emerging reports of profound hypertension (HTN). The long-term incidence, severity, and impact of HTN development with ibrutinib are unknown. Therefore, in 562 consecutive patients treated with ibrutinib for B-cell malignancies from 2009 through 2016, we assessed the new/incident or worsened HTN (systolic blood pressure [BP] cutoff, 130 mm Hg). Observed incident HTN rates were compared with Framingham-heart-predicted incident HTN rates. We also evaluated the relationship of HTN to the development of other major adverse cardiovascular events (MACEs), including arrhythmia, myocardial infarction, stroke, heart failure, and cardiovascular death. Further, we assessed the effects of different antihypertensive classes on ibrutinib-related HTN. Overall, 78.3% of ibrutinib users developed new or worsened HTN over a median of 30 months. New HTN developed in 71.6% of ibrutinib users, with a time to 50% cumulative incidence of 4.2 months. Among those without preceding HTN, 17.7% developed high-grade HTN (BP >160/100 mm Hg). In multivariate regression, new or worsened HTN was associated with increased MACEs (hazard ratio [HR], 2.17; 95% confidence interval [CI], 1.08-4.38). No single antihypertensive class was associated with prevention or control of ibrutinib-related HTN. However, antihypertensive initiation was associated with a lower risk of a MACE (HR, 0.40; 95% CI, 0.24-0.66). Collectively, these data suggest that ibrutinib is associated with a substantial increase in the incidence and severity of HTN, and that HTN development carries a higher risk of subsequent cardiotoxic events.
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Rhodes JM, LoRe VA, Mato AR, Chong EA, Barrientos JC, Gerson JN, Barta SK, Landsburg DJ, Nasta SD, Svoboda J, Loren AW, Schuster SJ. Ibrutinib-associated Arthralgias/Myalgias in Patients With Chronic Lymphocytic Leukemia: Incidence and Impact on Clinical Outcomes. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:438-444.e1. [PMID: 32197990 DOI: 10.1016/j.clml.2020.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/04/2020] [Accepted: 02/04/2020] [Indexed: 01/26/2023]
Abstract
INTRODUCTION The Bruton's tyrosine kinase (BTK) inhibitor ibrutinib has transformed the treatment of chronic lymphocytic leukemia (CLL), leading to unprecedented improvements in progression-free and overall survival for all patients, including those with poor prognostic features. The side effect profile of ibrutinib is unique compared with chemoimmunotherapy and includes atrial fibrillation, increased bleeding risk, and arthralgias/myalgias. Although common, arthralgias/myalgias and their management are poorly described. PATIENTS AND METHODS We identified 214 patients with CLL treated with ibrutinib (as a single agent or in combination) from 2011 to 2018 at the University of Pennsylvania. RESULTS In this cohort, 36% (76/214) of patients developed arthralgias/myalgias during follow-up with a median onset of 34.5 months. Most (79%) events were grade 1 or 2. Risk factors for developing arthralgias/myalgias included younger age at start of ibrutinib, female gender, and ibrutinib use as first treatment. Twenty-eight percent of patients with grade 1 or 2 toxicity continued ibrutinib and had resolution of symptoms. Dose holds were frequently used to manage this toxicity, and this strategy was more successful than dose reduction. Sixty-two percent of patients with grade 3 toxicity ultimately discontinued ibrutinib. Supportive care measures such as discontinuing statins or use of non-steroidal anti-inflammatory drugs, acetaminophen, or corticosteroids were not used frequently enough in this cohort to evaluate their efficacy. CONCLUSIONS Additional studies to determine the mechanism of ibrutinib-related arthralgias/myalgias are needed to develop optimal management strategies.
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Affiliation(s)
- Joanna M Rhodes
- Division of Hematology/Oncology, Northwell Health Cancer Institute, New Hyde Park, NY; Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA.
| | - Vincent A LoRe
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Anthony R Mato
- Chronic Lymphocytic Leukemia Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Elise A Chong
- Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | | | - James N Gerson
- Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Stefan K Barta
- Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Daniel J Landsburg
- Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Sunita Dwivedy Nasta
- Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Jakub Svoboda
- Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Alison W Loren
- Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Stephen J Schuster
- Division of Hematology/Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
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Morabito F, Recchia AG, Vigna E, Botta C, Skafi M, Abu-Rayyan M, Atrash M, Galimberti S, Morabito L, Al-Janazreh H, Martino M, Cutrona G, Gentile M. An in-depth evaluation of acalabrutinib for the treatment of mantle-cell lymphoma. Expert Opin Pharmacother 2019; 21:29-38. [DOI: 10.1080/14656566.2019.1689959] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Fortunato Morabito
- Hematology Department and Bone Marrow Transplant Unit, Cancer Care Center, Augusta Victoria Hospital, East Jerusalem, Israel
- Hematology and Oncology Department, Biotechnology Research Unit, Cosenza, Italy
| | - Anna Grazia Recchia
- Hematology and Oncology Department, Biotechnology Research Unit, Cosenza, Italy
| | - Ernesto Vigna
- Hematology and Oncology Department, Biotechnology Research Unit, Cosenza, Italy
- Hematology and Oncology Department, Hematology Unit, Cosenza, Italy
| | - Cirino Botta
- Hematology and Oncology Department, Biotechnology Research Unit, Cosenza, Italy
- Hematology and Oncology Department, Hematology Unit, Cosenza, Italy
| | - Mamdouh Skafi
- Hematology Department and Bone Marrow Transplant Unit, Cancer Care Center, Augusta Victoria Hospital, East Jerusalem, Israel
| | - Mohammed Abu-Rayyan
- Hematology Department and Bone Marrow Transplant Unit, Cancer Care Center, Augusta Victoria Hospital, East Jerusalem, Israel
| | - Moien Atrash
- Hematology Department and Bone Marrow Transplant Unit, Cancer Care Center, Augusta Victoria Hospital, East Jerusalem, Israel
| | | | - Lucio Morabito
- Humanitas Clinical and Research Center – IRCCS, Humanitas Cancer Center, Milan, Italy
| | - Hamdi Al-Janazreh
- Hematology Department and Bone Marrow Transplant Unit, Cancer Care Center, Augusta Victoria Hospital, East Jerusalem, Israel
| | - Massimo Martino
- Stem Cell Transplant Program, Clinical Section, Department of Hemato-Oncology and Radiotherapy, Grande Ospedale Metropolitano Bianchi-Melacrino-Morelli, Reggio, Italy
| | - Giovanna Cutrona
- Molecular Pathology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Massimo Gentile
- Hematology and Oncology Department, Biotechnology Research Unit, Cosenza, Italy
- Hematology and Oncology Department, Hematology Unit, Cosenza, Italy
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Abstract
AbstractPurposeThis article summarizes current targeted therapies that have received regulatory approval for the treatment of B- and T-cell lymphomas.SummaryOver the last 20 years, new drug therapies for lymphomas of B cells and T cells have expanded considerably. Targeted therapies for B-cell lymphomas include: (1) monoclonal antibodies directed at the CD20 lymphocyte antigen, examples of which are rituximab, ofatumumab, and obinutuzumab; (2) gene transfer therapy, an example of which is chimeric antigen receptor–modified T-cell (CAR-T) therapy directed at the CD19 antigen expressed on the cell surface of both immature and mature B cells; and (3) small-molecule inhibitors (ibrutinib, acalabrutinib, copanlisib, duvelisib, and idelalisib) that target the B-cell receptor signaling pathway. Of note, brentuximab vedotin is an antibody–drug conjugate that targets CD30, another lymphocyte antigen expressed on the cell surface of both Hodgkin lymphoma (a variant of B-cell lymphoma) and some T-cell lymphomas. Although aberrant epigenetic signaling pathways are present in both B- and T-cell lymphomas, epigenetic inhibitors (examples include belinostat, vorinostat, and romidepsin) are currently approved by the Food and Drug Administration for T-cell lymphomas only. In addition, therapies that target the tumor microenvironment have been developed. Examples include mogamulizumab, bortezomib, lenalidomide, nivolumab, and pembrolizumab. In summary, the efficacy of these agents has led to the development of supportive care to mitigate adverse effects, due to the presence of on- or off-target toxicities.ConclusionThe therapeutic landscape of lymphomas has continued to evolve. In turn, the efficacy of these agents has led to the development of supportive care to mitigate adverse effects, due to the presence of on- or off-target toxicities. Further opportunities are warranted to identify patients who are most likely to achieve durable response and reduce the risk of disease progression. Ongoing trials with current and investigational agents may further elucidate their place in therapy and therapeutic benefits.
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