1
|
Makary MS, Zane K, Hwang GL, Kim CY, Ahmed O, Knavel Koepsel EM, Monroe EJ, Scheidt MJ, Smolock AR, Stewart EA, Wasnik AP, Pinchot JW. ACR Appropriateness Criteria® Management of Uterine Fibroids: 2023 Update. J Am Coll Radiol 2024; 21:S203-S218. [PMID: 38823944 DOI: 10.1016/j.jacr.2024.02.022] [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: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
Uterine fibroids are the most common benign tumor in women of reproductive age and can present with symptoms including bleeding, bulk related symptoms, and infertility. Several treatment options are available for the management of uterine fibroids, including medical management, minimally invasive therapies such as uterine artery embolization and MR-guided focused ultrasound ablation, and surgical interventions ranging from laparoscopic myomectomy to open hysterectomy. Given this wide range of therapeutic interventions, it is important to understand the data supporting these interventions and to be able to apply it in different clinical settings. This document provides a summary of recent trials supporting various therapies for uterine fibroids, including recent evidence for MR-guided focused ultrasound ablation and a detailed discussion of fertility outcomes in myomectomy and uterine fibroid embolization. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
Collapse
Affiliation(s)
- Mina S Makary
- Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - Kylie Zane
- Research Author, University of Chicago Hospitals, Chicago, Illinois
| | - Gloria L Hwang
- Stanford University School of Medicine, Stanford, California
| | - Charles Y Kim
- Panel Chair, Duke University Medical Center, Durham, North Carolina
| | | | | | | | | | - Amanda R Smolock
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Elizabeth A Stewart
- Mayo Clinic and Mayo Clinic Alix School of Medicine; American College of Obstetricians and Gynecologists
| | | | - Jason W Pinchot
- Specialty Chair, University of Wisconsin, Madison, Wisconsin
| |
Collapse
|
2
|
Song W, Ma M, Zhang W, Feng R, Lu C, Zhang HY, Zhang Y, Zhao J. Visible-light-induced C(sp 3)-H bromination of 4-methylthiophene derivatives with HBr/H 2O 2. Org Biomol Chem 2024; 22:4145-4152. [PMID: 38713051 DOI: 10.1039/d4ob00547c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
A convenient method to synthesize ethyl 4-(bromomethyl)thiophene-3-carboxylate derivatives has been developed via a visible-light-induced radical process in good yields and with wide functional group tolerance under air conditions and at ambient temperature. The present protocol has the advantages of a high atom economy, easy purification, and environmental friendliness as it employs HBr as the bromine source and the cheap and low-toxic H2O2 as the oxidant. The synthetic utility of this method is demonstrated by a gram scale reaction and its application in the innovative synthesis of the clinical drug relugolix.
Collapse
Affiliation(s)
- Wenbo Song
- School of Chemical Engineering and Technology, Hebei University of Technology, Tianjin 300131, China.
- Hebei Provincial Key Laboratory of Green Chemical Technology and High Efficient Energy Saving, Tianjin 300131, China
| | - Ming Ma
- School of Chemical Engineering and Technology, Hebei University of Technology, Tianjin 300131, China.
- Hebei Provincial Key Laboratory of Green Chemical Technology and High Efficient Energy Saving, Tianjin 300131, China
| | - Wenjing Zhang
- School of Chemical Engineering and Technology, Hebei University of Technology, Tianjin 300131, China.
- Hebei Provincial Key Laboratory of Green Chemical Technology and High Efficient Energy Saving, Tianjin 300131, China
| | - Ranran Feng
- School of Chemical Engineering and Technology, Hebei University of Technology, Tianjin 300131, China.
- Hebei Provincial Key Laboratory of Green Chemical Technology and High Efficient Energy Saving, Tianjin 300131, China
| | - Congcong Lu
- School of Chemical Engineering and Technology, Hebei University of Technology, Tianjin 300131, China.
- Hebei Provincial Key Laboratory of Green Chemical Technology and High Efficient Energy Saving, Tianjin 300131, China
| | - Hong-Yu Zhang
- School of Chemical Engineering and Technology, Hebei University of Technology, Tianjin 300131, China.
- Hebei Provincial Key Laboratory of Green Chemical Technology and High Efficient Energy Saving, Tianjin 300131, China
| | - Yuecheng Zhang
- School of Chemical Engineering and Technology, Hebei University of Technology, Tianjin 300131, China.
- National-Local Joint Engineering Laboratory for Energy Conservation of Chemical Process Integration and Resources Utilization, Hebei University of Technology, Tianjin 300130, China
| | - Jiquan Zhao
- School of Chemical Engineering and Technology, Hebei University of Technology, Tianjin 300131, China.
- Hebei Provincial Key Laboratory of Green Chemical Technology and High Efficient Energy Saving, Tianjin 300131, China
| |
Collapse
|
3
|
Venturella R, Lukes AS, Wu R, McLean R, Rakov VG, Al-Hendy A. Quality of life improvements in women with uterine fibroids treated with relugolix combination therapy during the LIBERTY long-term extension study: A descriptive subgroup analysis in women with anemia at baseline. Int J Gynaecol Obstet 2024; 165:431-441. [PMID: 38576220 DOI: 10.1002/ijgo.15505] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/13/2024] [Accepted: 03/13/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVE To investigate the effects of 52 weeks of treatment with relugolix combination therapy (relugolix 40 mg, estradiol 1 mg, norethindrone acetate 0.5 mg) on symptoms of uterine fibroids (UF) and quality of life (QoL) in women with heavy menstrual bleeding associated with UF and anemia (hemoglobin ≤10.5 g/dL) at baseline. METHODS This post hoc analysis included women from the LIBERTY long-term extension study with anemia (hemoglobin concentration ≤10.5 g/dL) at pivotal study baseline and documented hemoglobin values at week 52 (anemia-evaluable population). Treatment responders: women achieving a menstrual blood loss volume of <80 mL and a ≥50% reduction over the last 35 days of treatment. Anemia responders were women achieving a hemoglobin increase of >2 g/dL from baseline to week 52. Least squares (LS) mean changes from baseline in uterine fibroid symptom (UFS)-QoL symptom severity, fatigue, and health-related QoL total (HR-QoL) and (sub)scale scores were calculated. RESULTS In total, 115 women were included in the anemia-evaluable population. Of 39 anemia-evaluable women who received continuous treatment with relugolix combination therapy for 52 weeks, 34 (87.2%) met treatment responder criteria and 23 (59.0%) were anemia responders. LS mean hemoglobin concentration increased by 29.4% at week 52. LS mean UFS-QoL symptom severity and fatigue scores decreased by 38.5 and 31.9 points, respectively, and HR-QoL total score increased by 41.6 points. CONCLUSION In women with UF and a high disease burden due to anemia, relugolix combination therapy substantially improved hemoglobin levels, decreased distress due to symptoms, especially fatigue, over 52 weeks.
Collapse
Affiliation(s)
- Roberta Venturella
- Department of Experimental and Clinical Medicine, Magna Græcia University of Catanzaro, Catanzaro, Italy
| | - Andrea S Lukes
- Carolina Women's Research and Wellness Center, Durham, North Carolina, USA
| | - Rui Wu
- Data Science, Sumitomo Pharma America, Inc., Cambridge, Massachusetts, USA
| | - Rachel McLean
- Clinical Research, Sumitomo Pharma America, Inc., Cambridge, Massachusetts, USA
| | | | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois, USA
| |
Collapse
|
4
|
Kawahara N, Kawaguchi R, Yamamoto K, Nishikawa K, Matsuoka M, Maehana T, Fukui Y, Yamanaka S, Sugimoto S, Iwai K, Yamada Y, Kurakami H, Hirata T, Takashima R, Suzuki S, Asada K, Kasahara M, Kimura F. The clinical trial of alternative relugolix administration for uterine leiomyoma prior to surgically treatment: a study protocol for Non-Adverse Relugolix Administration (NARA) trial. Trials 2024; 25:68. [PMID: 38243317 PMCID: PMC10799434 DOI: 10.1186/s13063-024-07923-2] [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: 09/23/2023] [Accepted: 01/09/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Uterine leiomyomas are common for reproductive-aged women and affect women's quality of life due to heavy menstrual bleeding or dysmenorrhea. Leiomyomas grow according to estradiol exposure and decrease after post-menopause. In case serious symptoms are caused by leiomyomas, pharmacotherapy or surgical treatment is proposed. Prior to surgical treatment, pharmacotherapies aimed at the reduction of leiomyoma and uterine volume or improvement of anemia are introduced to conduct minimum invasive surgery (i.e., to reduce blood loss or surgical duration). Recently, relugolix (40 mg orally once daily) as a gonadotropin-releasing hormone (GnRH) receptor antagonist has proved its sufficient efficacy in suppressing estradiol levels without the transient estradiol flare-up compared with GnRH agonist. However, long-term administration should not be permitted liable to for climacteric disorder or osteoporosis, and evidence is lacking on the actual efficacy and extent of adverse effects of the every-other-day dosing regimen. This trial aimed to prove non-inferiority in volume reduction effect on leiomyoma and safety (i.e., reduction of adverse effects) by every-other-day administration after 2 months of everyday administration compared to daily administration throughout the duration. METHODS A minimization adaptive randomized control trial (RCT) will be conducted. Patients (over 20 years old) harboring leiomyoma who will be undergoing surgical treatment will be invited to participate. Patients who are enrolled in the intervention group will receive every-other-day administration for 16 weeks after 8 weeks of daily administration. Patients who are enrolled in the control group will receive daily throughout the 24 weeks. The primary outcome is the leiomyoma volume reduction, and the secondary endpoints are the reduction of uterine volume, the occurrence of the climacteric disorder, genital bleeding days, change rate of serum hormone or bone turnover markers, and bone mineral density after 24 weeks compared to before administration. DISCUSSION This study aims to prove both the non-inferiority in leiomyoma volume reduction and superiority in adverse effects occurrence reduction, which will provide a novel method to escape adverse effects while maintaining the effect of leiomyoma reduction. TRIAL REGISTRATION Japan Registry of Clinical Trials jRCTs051230078. Registered on 26 July 2023.
Collapse
Affiliation(s)
- Naoki Kawahara
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, 634-8522, Japan.
| | - Ryuji Kawaguchi
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, 634-8522, Japan
| | - Konosuke Yamamoto
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, 634-8522, Japan
| | - Kyohei Nishikawa
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, 634-8522, Japan
| | - Motoki Matsuoka
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, 634-8522, Japan
| | - Tomoka Maehana
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, 634-8522, Japan
| | - Yosuke Fukui
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, 634-8522, Japan
| | - Shoichiro Yamanaka
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, 634-8522, Japan
| | - Sumire Sugimoto
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, 634-8522, Japan
| | - Kana Iwai
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, 634-8522, Japan
| | - Yuki Yamada
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, 634-8522, Japan
| | - Hiroyuki Kurakami
- Institute for Clinical and Translational Science, Nara Medical University, Kashihara, 634-8522, Japan
| | - Takumi Hirata
- Institute for Clinical and Translational Science, Nara Medical University, Kashihara, 634-8522, Japan
| | - Ryuzo Takashima
- Institute for Clinical and Translational Science, Nara Medical University, Kashihara, 634-8522, Japan
| | - Shota Suzuki
- Institute for Clinical and Translational Science, Nara Medical University, Kashihara, 634-8522, Japan
| | - Kiyoshi Asada
- Institute for Clinical and Translational Science, Nara Medical University, Kashihara, 634-8522, Japan
| | - Masato Kasahara
- Institute for Clinical and Translational Science, Nara Medical University, Kashihara, 634-8522, Japan
| | - Fuminori Kimura
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, 634-8522, Japan
| |
Collapse
|
5
|
Ali M, Ciebiera M, Wlodarczyk M, Alkhrait S, Maajid E, Yang Q, Hsia SM, Al-Hendy A. Current and Emerging Treatment Options for Uterine Fibroids. Drugs 2023; 83:1649-1675. [PMID: 37922098 DOI: 10.1007/s40265-023-01958-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/05/2023]
Abstract
Uterine fibroids are the most common benign neoplasm of the female reproductive tract in reproductive age women. Their prevalence is age dependent and can be detected in up to 80% of women by the age of 50 years. Patients affected by uterine fibroids may experience a significant physical, emotional, social, and financial toll as well as losses in their quality of life. Unfortunately, curative hysterectomy abolishes future pregnancy potential, while uterine-sparing surgical and radiologic alternatives are variously associated with reduced long-term reproductive function and/or high tumor recurrence rates. Recently, pharmacological treatment against uterine fibroids have been widely considered by patients to limit uterine fibroid-associated symptoms such as heavy menstrual bleeding. This hormonal therapy seemed effective through blocking the stimulatory effects of gonadal steroid hormones on uterine fibroid growth. However, they are contraindicated in women actively pursuing pregnancy and otherwise effective only during use, which is limited because of long-term safety and other concerns. Accordingly, there is an urgent unmet need for safe, durable, and fertility-compatible non-surgical treatment options for uterine fibroids. In this review article, we cover the current pharmacological treatments for uterine fibroids including their comparable efficacy and side effects as well as emerging safe natural compounds with promising anti-uterine fibroid effects.
Collapse
Affiliation(s)
- Mohamed Ali
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
- Clinical Pharmacy Department, Faculty of Pharmacy, Ain Shams University, Cairo, 11566, Egypt
| | - Michał Ciebiera
- Second Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, Warsaw, 00-189, Poland
| | - Marta Wlodarczyk
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
- Department of Biochemistry and Pharmacogenomics, Faculty of Pharmacy, Medical University of Warsaw, Banacha 1B, Warsaw, 02-097, Poland
- Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Samar Alkhrait
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
| | - Elise Maajid
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
| | - Qiwei Yang
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
| | - Shih-Min Hsia
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, 11031, Taiwan
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL, 60637, USA.
| |
Collapse
|
6
|
Marquardt RM, Tran DN, Lessey BA, Rahman MS, Jeong JW. Epigenetic Dysregulation in Endometriosis: Implications for Pathophysiology and Therapeutics. Endocr Rev 2023; 44:1074-1095. [PMID: 37409951 PMCID: PMC10638603 DOI: 10.1210/endrev/bnad020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 02/15/2023] [Accepted: 07/05/2023] [Indexed: 07/07/2023]
Abstract
Endometriosis is a prevalent gynecological condition associated with pelvic pain and infertility. Despite more than a century of research, the etiology of endometriosis still eludes scientific consensus. This lack of clarity has resulted in suboptimal prevention, diagnosis, and treatment options. Evidence of genetic contributors to endometriosis is interesting but limited; however, significant progress has been made in recent years in identifying an epigenetic role in the pathogenesis of endometriosis through clinical studies, in vitro cell culture experiments, and in vivo animal models. The predominant findings include endometriosis-related differential expression of DNA methyltransferases and demethylases, histone deacetylases, methyltransferases, and demethylases, and regulators of chromatin architecture. There is also an emerging role for miRNAs in controlling epigenetic regulators in the endometrium and endometriosis. Changes in these epigenetic regulators result in differential chromatin organization and DNA methylation, with consequences for gene expression independent of a genetic sequence. Epigenetically altered expression of genes related to steroid hormone production and signaling, immune regulation, and endometrial cell identity and function have all been identified and appear to play into the pathophysiological mechanisms of endometriosis and resulting infertility. This review summarizes and critically discusses early seminal findings, the ever-growing recent evidence of epigenetic contributions to the pathophysiology of endometriosis, and implications for proposed epigenetically targeted therapeutics.
Collapse
Affiliation(s)
- Ryan M Marquardt
- Department of Obstetrics, Gynecology & Reproductive Biology, Michigan State University, Grand Rapids, MI, USA
| | - Dinh Nam Tran
- Department of Obstetrics, Gynecology and Women's Health, University of Missouri, Columbia, MO, USA
| | - Bruce A Lessey
- Department of Obstetrics and Gynecology, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Md Saidur Rahman
- Department of Obstetrics, Gynecology and Women's Health, University of Missouri, Columbia, MO, USA
| | - Jae-Wook Jeong
- Department of Obstetrics, Gynecology and Women's Health, University of Missouri, Columbia, MO, USA
| |
Collapse
|
7
|
Ciebiera M, Madueke-Laveaux OS, Feduniw S, Ulin M, Spaczyński R, Zgliczyńska M, Bączkowska M, Zarychta E, Łoziński T, Ali M, Al-Hendy A. GnRH agonists and antagonists in therapy of symptomatic uterine fibroids - current roles and future perspectives. Expert Opin Pharmacother 2023; 24:1799-1809. [PMID: 37602464 DOI: 10.1080/14656566.2023.2248890] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/12/2023] [Accepted: 08/14/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION Uterine fibroids are the most common noncancerous tumors in women of childbearing age. This review was developed to evaluate the current role of gonadotropin-releasing hormone (GnRH) agonists and antagonists in the therapy of symptomatic uterine fibroids. AREAS COVERED There is a great need for alternative methods for surgical treatment of uterine fibroids. Hormonal therapy remains the first-line treatment option for most patients. GnRH analogs (agonists and antagonists) modulate the pulsatile release of GnRH. This review summarizes the available literature concerning pharmacologic principles underlying the mechanism of action of GnRH and its analogs, as well as individual therapeutic applications to which these drugs have been applied. EXPERT OPINION In many cases, it is possible to try to treat uterine fibroids pharmacologically. Both groups of GnRH analogs are used in therapy, agonists instead as a preparation for surgery, and antagonists as a drug for long-term use. It is essential to develop this path further and look for at least long-term-release systems or new methods of administering these drugs. It is also important from the patient's perspective to search for possible drugs that may have an additive effect of decreasing side effects when combined with GnRH analogs.
Collapse
Affiliation(s)
- Michał Ciebiera
- Second Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
- Warsaw Institute of Women's Health, Warsaw, Poland
- Development and Research Center of Non-Invasive Therapies, Pro-Familia Hospital, Rzeszów, Poland
| | | | - Stepan Feduniw
- Department of Gynecology, University Hospital Zurich, Zurich, Switzerland
| | - Mara Ulin
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Chicago, IL, USA
| | - Robert Spaczyński
- Obstetrics and Infertility Treatment Pastelova, Center for Gynecology, Poznan, Poland
| | - Magdalena Zgliczyńska
- Department of Obstetrics, Perinatology and Neonatology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Monika Bączkowska
- Second Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Elżbieta Zarychta
- Second Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Tomasz Łoziński
- Department of Obstetrics and Gynecology, Pro-Familia Hospital, Rzeszow, Poland
- Department of Gynecology and Obstetrics, College of Medical Sciences, Institute of Medical Sciences, University of Rzeszow, Rzeszow, Poland
| | - Mohamed Ali
- Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL, USA
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL, USA
| |
Collapse
|
8
|
Lukes A, Migoya E, Johnson B, Lee TY, Li Y, Arjona Ferreira JC. A Randomized Open-Label Study of Relugolix Alone or Relugolix Combination Therapy in Premenopausal Women. Clin Pharmacokinet 2023; 62:1169-1182. [PMID: 37365436 PMCID: PMC10386916 DOI: 10.1007/s40262-023-01269-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND AND OBJECTIVE Relugolix is a gonadotropin-releasing hormone receptor antagonist. Relugolix 40-mg monotherapy is associated with vasomotor symptoms and long-term bone mineral density loss due to hypoestrogenism. This study assessed whether the addition of estradiol (E2) 1 mg and norethindrone acetate (NETA) 0.5 mg to relugolix 40 mg (relugolix combination therapy) provides systemic E2 concentrations in the 20-50 pg/mL range to minimize these undesirable effects. METHODS This was a randomized, open-label, parallel-group study to assess the pharmacokinetics, pharmacodynamics, safety, and tolerability of relugolix 40 mg alone or in combination with E2 1 mg and NETA 0.5 mg in healthy premenopausal women. Eligible women were randomized 1:1 to receive relugolix alone or relugolix plus E2/NETA for 6 weeks. Study assessments included pharmacokinetic parameters of E2, estrone, and relugolix in both treatment groups, and norethindrone in the relugolix plus E2/NETA treatment group at weeks 3 and 6. RESULTS Median E2 24 h average concentrations with the relugolix plus E2/NETA group (N = 23) were 31.5 pg/mL, 26 pg/mL higher compared with the relugolix-alone group (6.2 pg/mL) (N = 25). There were 86.4% of participants in the relugolix plus E2/NETA group who had E2 average concentrations exceeding 20 pg/mL, the threshold expected to minimize bone mineral density loss, compared with 21.1% in the relugolix-alone group. Both treatments were generally safe and well tolerated. CONCLUSIONS Relugolix 40 mg in combination with E2 1 mg and NETA 0.5 mg provided systemic E2 concentrations within a range expected to minimize the risk of undesirable effects of hypoestrogenism associated with the administration of relugolix alone. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov identifier no. NCT04978688. Trial registration date: 27 July, 2021; retrospectively registered.
Collapse
Affiliation(s)
- Andrea Lukes
- Carolina Women's Research and Wellness Center, Durham, NC, USA
| | - Elizabeth Migoya
- Myovant Sciences, Inc., 2000 Sierra Point Parkway, 9th Floor, Brisbane, CA, 94005-1852, USA.
| | | | - Tien-Yi Lee
- Myovant Sciences, Inc., 2000 Sierra Point Parkway, 9th Floor, Brisbane, CA, 94005-1852, USA
| | - Yulan Li
- Myovant Sciences, Inc., 2000 Sierra Point Parkway, 9th Floor, Brisbane, CA, 94005-1852, USA
| | | |
Collapse
|
9
|
Haimovich Segal S, Moratalla Bartolome E, Ross Cerro C, Vidal Mazo C, Pérez Sagaseta C. Conceptos actuales en cirugía histeroscópica: superando barreras y ampliando límites. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2023. [DOI: 10.1016/j.gine.2023.100853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
|
10
|
Singh S, Kumar P, Rathore SS, Singh Y, Garg N. Contemporary approaches in the management of uterine leiomyomas. Eur J Obstet Gynecol Reprod Biol 2023; 287:195-210. [PMID: 37385088 DOI: 10.1016/j.ejogrb.2023.06.021] [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: 11/02/2022] [Revised: 04/24/2023] [Accepted: 06/20/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Leiomyomas (fibroids), the most common benign solid tumours in females, originate from the myometrium and are associated with poor quality of life for patients. The current management of uterine leiomyomas mainly includes surgical interventions such as hysterectomy and myomectomy, either by laparoscopy or laparotomy, which have several complications and are not ideal for preserving fertility. Therefore, there is a need to develop or repurpose medical treatments that do not require surgical intervention. OBJECTIVE Many drugs are used to treat the symptoms associated with uterine fibroids. The main objective of this systematic review is to give an up-to-date account of potential pharmacological agents (non-surgical methods) for the management of uterine leiomyomas. SEARCH STRATEGY PubMed was searched for scientific and clinical literature using the keyword 'uterine fibroids' along with the drug names described in each section. For example, 'uterine fibroids' and 'ulipristal acetate' were the keywords used to search for literature on ulipristal acetate (UPA). RESULTS Various preclinical and clinical studies have shown that some drugs and herbal formulations exhibit activity in the management of uterine leiomyomas. Recent studies found that drugs such as UPA, elagolix, EC313, asoprisnol, nutritional supplements and herbal preparations were helpful in treating the symptoms associated with uterine leiomyomas. CONCLUSION Many drugs show efficacy in patients with symptomatic uterine fibroids. UPA is one of the most studied and prescribed medicines for uterine fibroids; however, its usage has been restricted due to a few recent incidences of hepatic toxicity. Herbal drugs and natural supplements have also shown promising effects on uterine fibroids. The synergistic effects of nutritional and herbal supplements have been reported in certain cases, and should be studied in detail. Further research is warranted to identify the mode of action of the drugs, and to determine the precise conditions that would explain the causes of toxicity in some patients.
Collapse
Affiliation(s)
- Shikha Singh
- Department of Prasuti Tantra, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Praveen Kumar
- Department of Medicinal Chemistry, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Saurabh Singh Rathore
- Department of Biotechnology, Mahatma Gandhi Central University, Raghunathpur, Motihari, East Champaran, Bihar, India
| | - Yashasvi Singh
- Department of Urology, CSSB, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Neha Garg
- Department of Medicinal Chemistry, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.
| |
Collapse
|
11
|
Neblett MF, Stewart EA. Oral Gonadotropin-Releasing Hormone Antagonists for the Treatment of Uterine Leiomyomas. Obstet Gynecol 2023; 141:901-910. [PMID: 37103532 DOI: 10.1097/aog.0000000000005145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/27/2022] [Indexed: 04/28/2023]
Abstract
Uterine leiomyomas are common hormone-responsive neoplasms that frequently cause heavy menstrual bleeding, anemia, pelvic pressure, pain, and adverse reproductive outcomes. In this overview, the efficacy and safety of oral gonadotropin-releasing hormone (GnRH) antagonists, co-administered with menopausal replacement-level steroid hormones or used at doses to avoid complete hypothalamic suppression, are reviewed for the management of uterine leiomyomas. Oral GnRH antagonists provide rapid suppression of sex steroids and avoid the initial steroidal flare and resultant temporary worsening of symptoms typically seen with parenteral GnRH agonists. Oral GnRH antagonists are effective in reducing leiomyoma-associated heavy menstrual bleeding, with high rates of amenorrhea and improved anemia and leiomyoma-associated pain, and providing modest reduction in uterine volume when used in combination with menopausal replacement-level steroid hormones. This add-back therapy can reduce hypogonadal side effects, including hot flushes and bone mineral density loss, close to levels seen with placebo therapy. Currently, both elagolix 300 mg twice daily with once-daily estradiol (1 mg) and norethindrone (0.5 mg) and relugolix 40 mg once daily with estradiol (1 mg) and norethindrone (0.5 mg) combination therapy are approved for leiomyoma treatment by the U.S. Food and Drug Administration. Linzagolix is under investigation in the United States but approved at two does with and without steroid hormones in the European Union. The efficacy of these agents appears to be robust over a wide spectrum of clinical presentations, demonstrating that worse disease parameters at baseline do not appear to inhibit efficacy. Across clinical trials, participants largely reflected the population of individuals affected by uterine leiomyomas.
Collapse
Affiliation(s)
- Michael F Neblett
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, the Department of Physiology and Biomedical Engineering, the Division of Endocrinology, Department of Medicine, the Department of Surgery, and the Women's Health Research Center, Mayo Clinic, and Mayo Clinic Alix School of Medicine, Rochester, Minnesota
| | | |
Collapse
|
12
|
Wada Y, Takei Y, Minezumi T, Hirashima H, Fujiwara H. Characteristics of submucosal leiomyomas that could cause severe hemorrhage with relugolix: an observational study. BMC Womens Health 2023; 23:110. [PMID: 36922784 PMCID: PMC10015954 DOI: 10.1186/s12905-023-02241-2] [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: 08/27/2022] [Accepted: 02/23/2023] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND Relugolix, an oral gonadotrophin-releasing hormone receptor antagonist, was launched in Japan in 2019. Although there have been several studies on relugolix for leiomyomas, few have focused on submucosal leiomyomas. Submucosal leiomyomas cause bleeding more frequently than leiomyomas in other locations. There is only one case report described a patient treated for a submucosal leiomyoma with relugolix who developed severe hemorrhage. However, it remains unclear which characteristics of submucosal leiomyomas can lead to severe hemorrhage. Thus, the aim of this study was to investigate the characteristics of submucosal leiomyomas that would cause severe hemorrhage when treated with relugolix. METHODS We retrospectively reviewed records of patients who underwent treatment for submucosal leiomyoma with relugolix (40 mg once daily for up to 6 months) in our institute between December 2019 and September 2021. We evaluated the clinical course and characteristics of submucosal leiomyoma in patients who developed severe hemorrhage. RESULTS A total of 17 patients were treated for submucosal leiomyoma with relugolix. Two patients developed severe hemorrhage and required emergent surgery and blood transfusions. Only those two of the 17 patients had a submucosal leiomyoma of the International Federation of Gynecology and Obstetrics (FIGO) type 0, which has a stalk. In the remaining 15 patients who had FIGO type 1 or 2 leiomyoma, hemorrhage did not occur. CONCLUSIONS Our study suggests that the use of relugolix for FIGO type 0 leiomyomas may be associated with a risk of hemorrhage. However, relugolix may be a safe and effective treatment option for patients with FIGO type 1 or 2 leiomyomas.
Collapse
Affiliation(s)
- Yoshimitsu Wada
- Department of Obstetrics and Gynecology, Sano Kosei General Hospital, 1728 Horigome, Sano, Tochigi, 327-8511, Japan
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Yuji Takei
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Takumi Minezumi
- Department of Obstetrics and Gynecology, Sano Kosei General Hospital, 1728 Horigome, Sano, Tochigi, 327-8511, Japan
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Hiroto Hirashima
- Department of Obstetrics and Gynecology, Sano Kosei General Hospital, 1728 Horigome, Sano, Tochigi, 327-8511, Japan
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Hiroyuki Fujiwara
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| |
Collapse
|
13
|
Behandlung symptomatischer uteriner Myome mit oral aktiven Gonadotropin-Releasing-Hormon-Antagonisten und Add-back-Therapie. GYNAKOLOGISCHE ENDOKRINOLOGIE 2023. [DOI: 10.1007/s10304-023-00505-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
|
14
|
Nagai K, Asano R, Sekiguchi F, Asai-Sato M, Miyagi Y, Miyagi E. MED12 mutations in uterine leiomyomas: prediction of volume reduction by gonadotropin-releasing hormone agonists. Am J Obstet Gynecol 2023; 228:207.e1-207.e9. [PMID: 36150519 DOI: 10.1016/j.ajog.2022.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/11/2022] [Accepted: 09/09/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Gonadotropin-releasing hormone agonists are used to treat premenopausal uterine leiomyomas; however, leiomyoma volume reduction is not always achieved. The reduction rate after this treatment varies for each leiomyoma, even in the same patient. Therefore, an effective method for predicting uterine leiomyoma volume reduction is required to reduce the adverse hypoestrogenic effects and drug-related economic burden related to gonadotropin-releasing hormone agonists. OBJECTIVE This study aimed to determine the predictive use of MED12 mutations for evaluating the effect of gonadotropin-releasing hormone agonist treatment concerning reducing uterine leiomyoma volume and to predict the MED12 mutation status based on the findings of magnetic resonance imaging performed before treatment. STUDY DESIGN MED12 exon 2 mutation and erythropoietin expression in uterine leiomyomas were evaluated concerning volume reduction, as measured using magnetic resonance imaging. We developed a system for classifying leiomyomas according to T2-weighted magnetic resonance imaging signals to noninvasively predict the presence or absence of MED12 mutations in leiomyomas. Leiomyoma samples (>5 cm) were obtained from 168 patients during surgery (hysterectomy or myomectomy) between 2005 and 2021 at Yokohama City University Hospital. To analyze the rate of leiomyoma volume reduction, 41 patients had been preoperatively administered the gonadotropin-releasing hormone agonist (leuprorelin acetate 3.75 mg, monthly subcutaneous injection) for 3 months; magnetic resonance imaging was performed before and after treatment without contrast material. RESULTS Patients with MED12 exon 2 mutations had smaller volume reduction after treatment with the gonadotropin-releasing hormone agonist (P<.001, Mann-Whitney U test) and displayed lower signal intensity on T2-weighted images than those with leiomyomas expressing wild-type MED12 exon 2. The newly proposed magnetic resonance imaging-based classification system showed that MED12 exon 2 mutations were more frequent in the low-signal group than in the high-signal group, with nearly equal proportions of mutated and wild-type MED12 exon 2 leiomyomas noted in the intermediate group. The low-signal group had significantly lower erythropoietin expression levels than the high-signal group (P<.001, Kruskal-Wallis test with the Dunn posthoc analysis). CONCLUSION MED12 mutation status can be a candidate marker for predicting the effect of gonadotropin-releasing hormone agonists on uterine leiomyoma reduction. Magnetic resonance imaging findings can be used to determine MED12 mutation status as a noninvasive strategy to select patients who will most likely benefit from gonadotropin-releasing hormone agonist treatment.
Collapse
Affiliation(s)
- Koichi Nagai
- Department of Obstetrics, Gynecology and Molecular Reproductive Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ryoko Asano
- Department of Obstetrics, Gynecology and Molecular Reproductive Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan; Department of Gynecology, Yokohama City University Medical Center, Yokohama, Japan.
| | - Futoshi Sekiguchi
- Department of Obstetrics, Gynecology and Molecular Reproductive Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Mikiko Asai-Sato
- Department of Obstetrics and Gynecology, Nihon University School of Medicine, Tokyo, Japan
| | - Yohei Miyagi
- Molecular Pathology and Genetics Division, Kanagawa Cancer Center Research Institute, Yokohama, Japan
| | - Etsuko Miyagi
- Department of Obstetrics, Gynecology and Molecular Reproductive Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| |
Collapse
|
15
|
Efficacy and Safety of Oral GnRh Antagonists in Patients With Uterine Fibroids: A Systematic Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:1279-1288. [PMID: 36368594 DOI: 10.1016/j.jogc.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE This review aimed to assess the efficacy and safety of GnRH antagonists in patients with symptomatic uterine fibroids. DATA SOURCES A literature search was performed on PubMed, Web of Science, Embase, Cochrane, and ClinicalTrials.gov using the MeSH and Emtree terms "leiomyoma" and "gonadotropin-releasing hormone." STUDY SELECTION All clinical trials that provided efficacy and safety data in clinical terms (i.e., reduction in menstrual bleeding and discomfort, changes in the size of leiomyoma and uterine volume, etc.) were included. We excluded all preclinical studies, case reports, meta-analyses, review articles, and clinical studies irrelevant to the study question. DATA EXTRACTION AND SYNTHESIS Two authors extracted data from 9 clinical studies. The extracted data included the study's characteristics, participants' baseline characteristics, treatment drugs, efficacy measures, and toxicity. CONCLUSION Among oral GnRH antagonists, relugolix, elagolix, and linzagolix were safe in patients with uterine fibroids. These drugs, alone and in combination with E2/NETA (estradiol/norethindrone acetate), showed significantly better efficacy than placebo in improving bleeding, discomfort, uterine/leiomyoma sizes, and quality of life in premenopausal patients with symptomatic uterine fibroids. However, more randomized, double-blind, multicentre clinical trials are needed to confirm these results and to see long-term benefits.
Collapse
|
16
|
Ito M, Yoshino O, Hiraoka T, Ono Y, Tanaka K, Iwahata S, Honda M, Furue A, Nishijima J, Shimoda T, Iwase H, Miki A, Tagaya H, Hirata S, Unno N. Oral Gonadotropin-Releasing Hormone Antagonist Relugolix Has the Same Effect as Gonadotropin-Releasing Hormone Agonist Injections in Terms of Preparation for Transcervical Resection Myomectomy. Gynecol Minim Invasive Ther 2022; 11:238-241. [PMID: 36660323 PMCID: PMC9844050 DOI: 10.4103/gmit.gmit_9_22] [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: 01/08/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 11/09/2022] Open
Abstract
For preparing the optimal condition in transcervical resection (TCR) surgery, gonadotropin-releasing hormone (GnRH) agonist has been utilized. Recently, an oral GnRH antagonist (relugolix) is available and acts directly on GnRH receptor, avoiding flare up and reducing blood E2 levels rapidly. We retrospectively compared the oral GnRH antagonist (n = 14) effect to that of subcutaneous GnRH agonist (n = 19) for the pretreatment of endometrium in TCR myomectomy. Endometrial thickening was determined by intraoperative videos. The color tone of the endometrium in the normal part was assessed by digital image processing. The median duration of the first GnRH agonist injection and the surgery was 67 days (21-136 days), which is significantly longer than that of the oral GnRH antagonist group, 18.5 days (7-157 days P < 0.01). Both the GnRH agonist and antagonist groups did not exhibit prominence in the endometrium. The GnRH antagonist group showed the same degree of whiteness in the normal endometrium as the GnRH agonist group. The oral GnRH antagonist administration could rapidly atrophy the endometrium and create an optimal surgical field for TCR in a short period.
Collapse
Affiliation(s)
- Mika Ito
- Department of Obstetrics and Gynecology, Kitasato University School of Medicine, Sagamihara, Japan,Department of Obstetrics and Gynecology, Kitasato University Medical Center, School of Medicine, Kitamoto, Japan
| | - Osamu Yoshino
- Department of Obstetrics and Gynecology, Kitasato University School of Medicine, Sagamihara, Japan,Department of Obstetrics and Gynecology, University of Yamanashi, Kofu, Japan,Address for correspondence: Dr. Osamu Yoshino, Department of Obstetrics and Gynecology, University of Yamanashi, 1110 Shimokato, Chuo-Shi, Zip: 409-3898, Yamanashi, Japan. E-mail:
| | - Takehiro Hiraoka
- Department of Obstetrics and Gynecology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yosuke Ono
- Department of Obstetrics and Gynecology, University of Yamanashi, Kofu, Japan
| | - Kouta Tanaka
- Department of Obstetrics and Gynecology, University of Yamanashi, Kofu, Japan
| | - Shunsuke Iwahata
- Department of Obstetrics and Gynecology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Masako Honda
- Department of Obstetrics and Gynecology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Akiko Furue
- Department of Obstetrics and Gynecology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Junichi Nishijima
- Department of Obstetrics and Gynecology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Takahito Shimoda
- Department of Obstetrics and Gynecology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Haruko Iwase
- Department of Obstetrics and Gynecology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Akinori Miki
- Department of Obstetrics and Gynecology, Kitasato University Medical Center, School of Medicine, Kitamoto, Japan
| | - Hikaru Tagaya
- Department of Obstetrics and Gynecology, University of Yamanashi, Kofu, Japan
| | - Shuji Hirata
- Department of Obstetrics and Gynecology, University of Yamanashi, Kofu, Japan
| | - Nobuya Unno
- Department of Obstetrics and Gynecology, Kitasato University School of Medicine, Sagamihara, Japan
| |
Collapse
|
17
|
Syed YY. Relugolix/Estradiol/Norethisterone (Norethindrone) Acetate: A Review in Symptomatic Uterine Fibroids. Drugs 2022; 82:1549-1556. [DOI: 10.1007/s40265-022-01790-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
|
18
|
Clemenza S, Vannuccini S, Ruotolo A, Capezzuoli T, Petraglia F. Advances in targeting estrogen synthesis and receptors in patients with endometriosis. Expert Opin Investig Drugs 2022; 31:1227-1238. [PMID: 36529967 DOI: 10.1080/13543784.2022.2152325] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Endometriosis is an estrogen-dependent disease on the background of progesterone resistance. Increased estrogen production, low estrogen metabolization, and altered estrogen receptors (ERs) expression contribute to the hyperestrogenic milieu within endometriotic lesions. Since estrogens play a crucial role in the pathogenesis of the disease, inhibition of estrogen production is one of the main targets of available and emerging drugs. AREAS COVERED Firstly, we described the molecular alterations responsible for estrogen dependence. Secondly, we reviewed available and emerging treatments that interfere, through central (gonadotropin-releasing hormone analogs (GnRH-a), GnRH antagonists) or local mechanisms (aromatase inhibitors (AIs), inhibitors of steroid sulfatase (STS) and hydroxysteroid dehydrogenase type 1 (17β-HSD1)), with estrogen dependence. Finally, we focused on emerging treatments targeting ERs (selective estrogen receptor modulators (SERMs), estrogen receptors agonists, and antagonists). EXPERT OPINION Available treatments interfering with estrogen pathways exert a contraceptive effect, have hypoestrogenic side effects, and cannot prevent or definitively treat the disease. Preclinical and animal studies are focusing on emerging drugs targeting ERs in order to overcome limitations of available treatments. These treatments may represent a promising option, as they may produce a more specific inhibition of disease activity within endometriotic implants, avoiding prolonged hypoestrogenic status and limiting systemic side effects.
Collapse
Affiliation(s)
- Sara Clemenza
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Silvia Vannuccini
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Agostino Ruotolo
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Tommaso Capezzuoli
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Felice Petraglia
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| |
Collapse
|
19
|
Zou F, Wang Y, Yu D, Liu C, Lu J, Zhao M, Ma M, Wang W, Jiang W, Gao Y, Zhang R, Zhang J, Ye L, Tian J. Discovery of the thieno[2,3-d]pyrimidine-2,4-dione derivative 21a: A potent and orally bioavailable gonadotropin-releasing hormone receptor antagonist. Eur J Med Chem 2022; 242:114679. [PMID: 35998545 DOI: 10.1016/j.ejmech.2022.114679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/05/2022] [Accepted: 08/10/2022] [Indexed: 11/26/2022]
Abstract
The gonadotropin releasing hormone receptor (GnRH-R) is a G protein-coupled receptor (GPCR) belonging to the rhodopsin family. GnRH-R antagonists suppress testosterone to castrate level more rapidly than gonadotropin releasing hormone agonists but lack the flare phenomenon often seen during the early period of GnRH-R agonist treatment. Recently orgovyx (relugolix) was approved as the first oral GnRH-R antagonist for the treatment of advanced prostate cancer. However, orgovyx has demonstrated poor pharmacokinetic profile with low oral bioavailability and high efflux. Here, we rationally designed and synthesized a series of derivatives (13a-m, 21a-i) through the modification and structure-activity relationship study of relugolix, which led to the discovery of 21a as a highly potent GnRH-R antagonist (IC50 = 2.18 nM) with improved membrane permeability (Papp, A-B = 0.98 × 10-6 cm/s) and oral bioavailability (F % = 44.7). Compound 21a showed high binding affinity (IC50 = 0.57 nM) and potent in vitro antagonistic activity (IC50 = 2.18 nM) at GnRH-R. 21a was well tolerated and efficacious in preclinical studies to suppress blood testosterone levels, which merits further investigation as a candidate novel GnRH-R antagonist for clinical studies.
Collapse
Affiliation(s)
- Fangxia Zou
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China
| | - Yao Wang
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China
| | - Dawei Yu
- Medicinal Chemistry Research Department, R & D Center (Luye Pharma Group Ltd.), Yantai, 264003, PR China
| | - Chunjiao Liu
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China
| | - Jing Lu
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China
| | - Min Zhao
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China
| | - Mingxu Ma
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China
| | - Wenyan Wang
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China
| | - Wanglin Jiang
- School of Public Health and Management, Binzhou Medical University, Yantai, PR China
| | - Yonglin Gao
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China
| | - Rui Zhang
- Medicinal Chemistry Research Department, R & D Center (Luye Pharma Group Ltd.), Yantai, 264003, PR China
| | - Jianzhao Zhang
- College of Life Sciences, Yantai University, Yantai, Shangdong, 264005, PR China.
| | - Liang Ye
- School of Public Health and Management, Binzhou Medical University, Yantai, PR China.
| | - Jingwei Tian
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China.
| |
Collapse
|
20
|
Evangelisti G, Barra F, Perrone U, Di Donato N, Bogliolo S, Ceccaroni M, Ferrero S. Comparing the pharmacokinetic and pharmacodynamic qualities of current and future therapies for uterine fibroids. Expert Opin Drug Metab Toxicol 2022; 18:441-457. [DOI: 10.1080/17425255.2022.2113381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Giulio Evangelisti
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Southern Endometriosis Centre, Queen Alexandra Hospital, Portsmouth, UK
- Department of Obstetrics and Gynecology, Gynecology Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy (ISSA), IRCCS Ospedale Sacro Cuore - Don Calabria, Via Don A. Sempreboni, 5, 37024, Negrar (Verona), Italy
| | - Umberto Perrone
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Nadine Di Donato
- Southern Endometriosis Centre, Queen Alexandra Hospital, Portsmouth, UK
| | - Stefano Bogliolo
- Department of Obstetrics and Gynecology, “P.O del Tigullio” Hospital-ASL4, Metropolitan Area of Genoa, Genoa, Italy
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecology Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy (ISSA), IRCCS Ospedale Sacro Cuore - Don Calabria, Via Don A. Sempreboni, 5, 37024, Negrar (Verona), Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| |
Collapse
|
21
|
Jiang L, Yu JW, Yang MJ, Zhong Q, Chen JY. Ultrasound-guided HIFU for uterine fibroids of hyperintense on T2-weighted MR imaging with or without GnRH-analogue-pretreated: A propensity score matched cohort study. Front Surg 2022; 9:975839. [PMID: 35990089 PMCID: PMC9386137 DOI: 10.3389/fsurg.2022.975839] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To compare the therapeutic effect of high-intensity focused ultrasound (HIFU) ablation and HIFU pretreated with gonadotropin-releasing hormone analogue (GnRH-a) in the treatment of hyperintense uterine fibroids on T2-weighted magnetic resonance imaging (T2WI) by using propensity score matching. Materials and methods 339 women with 368 hyperintense uterine fibroids on T2WI who underwent single-session HIFU ablation were enrolled, including 283 patients with 303 fibroids in the single-session HIFU (sHIFU) group and 56 patients with 65 fibroids in the HIFU pretreated with GnRH-a (Gn-HIFU) group. The signal intensity (SI) value and standard deviation (SD) value were measured based on T2WI, and the fibroids were further subdivided into heterogeneous hyperintense fibroids, slightly homogeneous hyperintense fibroids and markedly homogeneous hyperintense fibroids as 3 subgroups (HHF, sHHF and mHHF group respectively). Treatment time, sonication time, dose, non-perfused volume (NPV), NPV per sonication time, non-perfused volume ratio (NPVR), energy effect ratio (EEF) and adverse events were recorded. Results Out of 339 patients, the median NPVR was 75.2% (interquartile range,31.5%). After propensity score matching, the matched cohort included 91 (64.5%) patients in the sHIFU group and 48 (34.5%) patients in the Gn-HIFU group. The NPVR of sHHF in the Gn-HIFU group had significantly smaller than that in the sHIFU group (60.2% versus 74.9%, p = 0.005), and the NPVR of HHF in the Gn-HIFU group was higher than those in the sHIFU group (87.4% versus 72.9%, p = 0.002). Conclusions Compared with HIFU alone, the therapeutic efficacy of the heterogeneous hyperintense fibroids may be enhanced by GnRH-a pretreated with HIFU, however it is important to rule out the slightly homogeneous hyperintense fibroids.
Collapse
Affiliation(s)
- Li Jiang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Jing-Wen Yu
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Mei-Jie Yang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
- College of Medical Informatics, Chongqing Medical University, Chongqing, China
| | - Qiao Zhong
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Jin-Yun Chen
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
- Ultrasound Ablation Center, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Correspondence: Jin-Yun Chen
| |
Collapse
|
22
|
Wright D, Britten J, Malik M, Catherino WH. Relugolix and elagolix directly inhibit leiomyoma extracellular matrix production in 2-dimesnional and 3-dimensional cell cultures. F&S SCIENCE 2022; 3:299-308. [PMID: 35977805 DOI: 10.1016/j.xfss.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To determine the effect relugolix and elagolix have on the production of extracellular matrix (ECM) proteins in human leiomyoma cells. DESIGN Laboratory study. SETTING University hospital. PATIENT(S) OR ANIMALS None. January 5, 2022 Cell culture, protein analysis, immunohistochemistry. MAIN OUTCOME MEASURE(S) Production of GnRHR, COL1A1, FN1, VCAN, p-ERK, & ERK in treated/untreated leiomyoma cells. RESULTS 100 nM relugolix resulted in decreased production of COL1A1 at 24 (1.78 0.06-fold; P < .05) and 48 hours (1.92 0.14-fold; P < .05). Elagolix treatment resulted in a decrease in COL1A1 production at 24 but not 48 hours. In 2D and 3D, 100 nM relugolix resulted in decreased production of FN1 at 24 (1.7 ± 0.07-fold; P < .05) and 48 hours (1.8 ± 0.07-fold; P < .05); 100 nM elagolix resulted in decreased production of FN1 at 24 (1.7 ± 0.14-fold; P < .05) and 48 hours (2.0 ± 0.09-fold; P < .05). For cells treated with relugolix 100 nM resulted in decreased VCAN production by 48 hours (0.66 ± 0.07-fold; P < .05). Contrary to our 3D data, 2D elagolix-treated cells demonstrated a decrease in VCAN production that was identified only at 24 hours. For GnRHR, no significant difference between the drugs was seen at 24 hours; at 48 hours production was only significantly decreased for relugolix (P < .05). Comparing both drugs, there was a significant difference in the concentration of p-ERK to ERK at 24 hours (P < .05); there was no difference by 48 hours. CONCLUSIONS Our findings demonstrated that treatment with either drug can 1) decrease ECM protein production and 2) inhibit the MAPK pathway.
Collapse
Affiliation(s)
- Danielle Wright
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Joy Britten
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Minnie Malik
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - William H Catherino
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
| |
Collapse
|
23
|
Tezuka M, Tamai Y, Kuramochi Y, Kobayashi K, Fushimi N, Kiguchi S. Pharmacological characterization of linzagolix, a novel, orally active, non-peptide antagonist of gonadotropin-releasing hormone receptors. Clin Exp Pharmacol Physiol 2022; 49:1082-1093. [PMID: 35690889 DOI: 10.1111/1440-1681.13688] [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: 09/10/2021] [Revised: 03/23/2022] [Accepted: 06/08/2022] [Indexed: 11/28/2022]
Abstract
Control of gonadotropin-releasing hormone (GnRH) signaling is an effective strategy for the treatment of sex hormone-dependent diseases. GnRH analogs have been widely used for treating these diseases; however, initial stimulation or complete suppression of GnRH signaling by GnRH analogs results in the occurrence of several distinct adverse effects. Accordingly, we aimed to discover small molecule GnRH antagonists with superior pharmacokinetic (PK) and pharmacodynamic profiles. Linzagolix is a potent, orally available, and selective GnRH antagonist. Herein, we reported the pharmacological characterization of linzagolix in vitro and in vivo. Linzagolix selectively binds to the GnRH receptor and inhibits GnRH-stimulated signaling, in a manner comparable to cetrorelix, a peptide GnRH antagonist. Since the inhibitory effect of the gonad axis is useful for the treatment of gynecological conditions such as endometriosis and uterine fibroids, we investigated the effect of orally administered linzagolix on the gonadal axis in ovariectomized and intact cynomolgus monkeys. In ovariectomized monkeys, linzagolix immediately suppressed the serum luteinizing hormone concentration at doses over 1 mg/kg, indicating dose-dependent inhibition that correlated with serum linzagolix concentrations. In intact female monkeys, repeated linzagolix administration suppressed hormone surges and ceased or prolonged menstrual cycles. Furthermore, all animals presenting arrested menstrual cycles following linzagolix treatment showed recovery of hormone secretion and regular menstrual cycles after administration periods ended. Our results demonstrated that linzagolix has potential as a novel agent for reproductive-aged women suffering from sex hormone-dependent diseases. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Motohiro Tezuka
- Central Research Laboratories, Kissei Pharmaceutical Co., Ltd., 4365-1, Hotaka Kashiwabara, Azumino, Nagano, Japan
| | - Yasuaki Tamai
- Central Research Laboratories, Kissei Pharmaceutical Co., Ltd., 4365-1, Hotaka Kashiwabara, Azumino, Nagano, Japan
| | - Yu Kuramochi
- Central Research Laboratories, Kissei Pharmaceutical Co., Ltd., 4365-1, Hotaka Kashiwabara, Azumino, Nagano, Japan
| | - Kaoru Kobayashi
- Central Research Laboratories, Kissei Pharmaceutical Co., Ltd., 4365-1, Hotaka Kashiwabara, Azumino, Nagano, Japan
| | - Nobuhiko Fushimi
- Central Research Laboratories, Kissei Pharmaceutical Co., Ltd., 4365-1, Hotaka Kashiwabara, Azumino, Nagano, Japan
| | - Sumiyoshi Kiguchi
- Central Research Laboratories, Kissei Pharmaceutical Co., Ltd., 4365-1, Hotaka Kashiwabara, Azumino, Nagano, Japan
| |
Collapse
|
24
|
Stewart EA, Lukes AS, Venturella R, Arjona Ferreira JC, Li Y, Hunsche E, Wagman RB, Al-Hendy A. Relugolix Combination Therapy for Uterine Leiomyoma-Associated Pain in the LIBERTY Randomized Trials. Obstet Gynecol 2022; 139:1070-1081. [PMID: 35675604 DOI: 10.1097/aog.0000000000004787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/17/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess the effect of once-daily relugolix combination therapy (relugolix-CT: relugolix 40 mg, estradiol 1 mg, and norethindrone acetate 0.5 mg) compared with placebo on moderate-to-severe pain in women with uterine leiomyomas and heavy menstrual bleeding. METHODS Two replicate, multinational, double-blind, 24-week, randomized, phase 3 studies (LIBERTY 1 and 2) were conducted in premenopausal women with uterine leiomyoma-associated heavy menstrual bleeding (80 mL or greater per cycle for two cycles or 160 mL or greater during one cycle). A predefined secondary objective was to determine the effect of relugolix-CT on moderate-to-severe uterine leiomyoma-associated pain in the pain subpopulation (women with maximum pain scores of 4 or higher on the 0-10 numerical rating scale at baseline, with pain score reporting compliance of 80% (ie, 28 days or more over the last 35 days of treatment). This key secondary endpoint was defined as the proportion of women achieving minimal-to-no uterine leiomyoma-associated pain (maximum numerical rating scale score 1 or lower) at week 24; menstrual and nonmenstrual pain were evaluated in prespecified secondary analyses. Treatment comparisons were performed in the pooled LIBERTY 1 and 2 pain subpopulation using the Cochran-Mantel-Haenszel test stratified by baseline menstrual blood loss volume. RESULTS Across both trials, 509 women were randomized to relugolix-CT or placebo (April 2017-December 2018). Of these, 277 (54.4%) met pain subpopulation requirements. With relugolix-CT, 45.2% (95% CI 36.4-54.3) of women achieved minimal-to-no pain compared with 13.9% (95% CI 8.8-20.5) with placebo (nominal P<.001). The proportions of women with minimal-to-no pain during menstrual days and during nonmenstrual days were significantly higher with relugolix-CT (65.0% [95% CI 55.6-73.5] and 44.6% [95% CI 32.3-57.5], respectively) compared with placebo (19.3% [95% CI 13.2-26.7], nominal P<.001, and 21.6% [95% CI 12.9-32.7], nominal P=.004, respectively). CONCLUSION Over 24 weeks, relugolix-CT significantly reduced moderate-to-severe uterine leiomyoma-associated pain with a more pronounced effect on menstrual pain. These data support that relugolix-CT had clinically meaningful effects on women's experience of uterine leiomyoma-associated pain. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov: LIBERTY 1, NCT03049735; LIBERTY 2, NCT03103087. FUNDING SOURCE Myovant Sciences GmbH.
Collapse
Affiliation(s)
- Elizabeth A Stewart
- Mayo Clinic, Rochester, Minnesota; the Carolina Woman's Research and Wellness Center, Durham, North Carolina; the Department of Clinical and Experimental Medicine, Unit of Obstetrics and Gynecology, Magna Graecia University of Catanzaro, Catanzaro, Italy; Myovant Sciences, Inc., Brisbane, California; Myovant Sciences GmbH, Basel, Switzerland; and the Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Telek SB, Gurbuz Z, Kalafat E, Ata B. Oral Gonadotropin-Releasing Hormone Antagonists in the Treatment of Uterine Myomas: A Systematic Review and Network Meta-analysis of Efficacy Parameters and Adverse Effects. J Minim Invasive Gynecol 2022; 29:613-625. [PMID: 34942350 DOI: 10.1016/j.jmig.2021.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/12/2021] [Accepted: 12/17/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of this systematic review is to gather and synthesize evidence regarding the use of oral gonadotrophin-releasing hormone (GnRH) antagonist for the treatment of bleeding associated with uterine myomas. DATA SOURCES Web of Science, and MEDLINE databases were searched electronically on March 5, 2021, using combinations of the relevant Medical Subject Headings terms and keywords. The search was restricted to the English language and to human studies. METHODS OF STUDY SELECTION Only randomized controlled trials involving patients with heavy menstrual bleeding associated with uterine myomas treated with different doses of oral nonpeptide GnRH antagonists with or without add-back therapy were included. Studies comparing oral nonpeptide GnRH antagonists with treatments other than placebo were also excluded. TABULATION, INTEGRATION, AND RESULTS A total of 5 randomized trials including 2463 women were included in the analyses. Included studies were found to be at low risk of bias. When treatments were compared against placebo, the top 3 treatments for bleeding suppression were elagolix 600 mg, 400 mg, and 200 mg without add-back. Elagolix 600 mg without add-back therapy had a significantly higher risk of amenorrhea than lower doses of elagolix with and without add-back and relugolix as well. Uterine volume changes were more pronounced in therapies without add-back. All treatments were associated with significantly improved quality of life scores, both for myoma symptom-related and overall health-related scores. With the exception of relugolix with high-dose add-back, all treatments significantly increased low-density lipoprotein (LDL) levels. Again, all treatment modalities except for elagolix 200 mg without add-back significantly increased LDL-to-HDL ratio. The increase was highest for treatment without add-back therapy. CONCLUSION Oral GnRH antagonists seem to be effective for myoma-associated bleeding and for improving quality of life. The safety profile is acceptable for short-term use, but lipid metabolism is affected.
Collapse
Affiliation(s)
- Savci Bekir Telek
- Department of Obstetrics and Gynecology, Faculty of Medicine, Istanbul University (Dr. Telek), Istanbul, Turkey
| | - Zeynep Gurbuz
- School of Medicine, Koc University (Ms. Gurbuz), Istanbul, Turkey; Department of Statistics, Faculty of Arts and Sciences, Middle East Technical University (Dr. Kalafat), Ankara, Turkey
| | - Erkan Kalafat
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, School of Medicine, Koc University (Drs. Kalafat and Ata), Istanbul, Turkey
| | - Baris Ata
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, School of Medicine, Koc University (Drs. Kalafat and Ata), Istanbul, Turkey; ART Fertility Clinics (Dr. Ata), Dubai, UAE.
| |
Collapse
|
26
|
Takeda A. Short-term administration of oral relugolix before single-port laparoscopic-assisted vaginal hysterectomy for symptomatic uterine myomas: A retrospective comparative study with leuprorelin injection. J Obstet Gynaecol Res 2022; 48:1921-1929. [PMID: 35460303 DOI: 10.1111/jog.15269] [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: 02/27/2022] [Revised: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 11/27/2022]
Abstract
AIM To investigate the efficacy of short-term administration of relugolix, a novel orally active gonadotropin-releasing hormone (GnRH) antagonist, before single-port laparoscopic-assisted vaginal hysterectomy (LAVH) for symptomatic uterine myomas, retrospectively compared with injection of leuprorelin, a GnRH agonist. METHODS A retrospective comparative study of each 35 women with symptomatic myomas in the relugolix and leuprorelin groups. RESULTS Before administration of relugolix and leuprorelin, the median uterine volume did not differ significantly between the two groups (p = 0.53). Median uterine volume change from baseline after short-term administration of relugolix and leuprorelin did not differ significantly (p = 0.17). Surgical duration (p = 0.84) and estimated blood loss (p = 0.48) were not different between the two groups. According to a patient questionnaire, the side effects of the drugs were not different between the two groups (p = 0.27). When patients were was asked if they wanted to have either of these drugs again, some relugolix users preferred leuprorelin due to concern about forgetting daily medication, while some leuprorelin users preferred relugolix to avoid pain at injection. CONCLUSION Oral relugolix medication or leuprorelin injection administered before single-port LAVH for uterine myomas yielded an equivalent reduction of uterine volume and perioperative outcomes with no significant adverse events. Patient preference for either oral daily relugolix or a monthly injection of leuprorelin could be considered when preoperative management is determined.
Collapse
Affiliation(s)
- Akihiro Takeda
- Department of Obstetrics and Gynecology, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan
| |
Collapse
|
27
|
Daniels J, Middleton LJ, Cheed V, McKinnon W, Rana D, Sirkeci F, Manyonda I, Belli AM, Lumsden MA, Moss J, Wu O, McPherson K. Uterine artery embolisation versus myomectomy for premenopausal women with uterine fibroids wishing to avoid hysterectomy: the FEMME RCT. Health Technol Assess 2022; 26:1-74. [PMID: 35435818 PMCID: PMC9082260 DOI: 10.3310/zdeg6110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Uterine fibroids are the most common tumour in women of reproductive age and are associated with heavy menstrual bleeding, abdominal discomfort, subfertility and reduced quality of life. For women wishing to retain their uterus and who do not respond to medical treatment, myomectomy and uterine artery embolisation are therapeutic options. OBJECTIVES We examined the clinical effectiveness and cost-effectiveness of uterine artery embolisation compared with myomectomy in the treatment of symptomatic fibroids. DESIGN A multicentre, open, randomised trial with a parallel economic evaluation. SETTING Twenty-nine UK hospitals. PARTICIPANTS Premenopausal women who had symptomatic uterine fibroids amenable to myomectomy or uterine artery embolisation were recruited. Women were excluded if they had significant adenomyosis, any malignancy or pelvic inflammatory disease or if they had already had a previous open myomectomy or uterine artery embolisation. INTERVENTIONS Participants were randomised to myomectomy or embolisation in a 1 : 1 ratio using a minimisation algorithm. Myomectomy could be open abdominal, laparoscopic or hysteroscopic. Embolisation of the uterine arteries was performed under fluoroscopic guidance. MAIN OUTCOME MEASURES The primary outcome was the Uterine Fibroid Symptom Quality of Life questionnaire (with scores ranging from 0 to 100 and a higher score indicating better quality of life) at 2 years, adjusted for baseline score. The economic evaluation estimated quality-adjusted life-years (derived from EuroQol-5 Dimensions, three-level version, and costs from the NHS perspective). RESULTS A total of 254 women were randomised - 127 to myomectomy (105 underwent myomectomy) and 127 to uterine artery embolisation (98 underwent embolisation). Information on the primary outcome at 2 years was available for 81% (n = 206) of women. Primary outcome scores at 2 years were 84.6 (standard deviation 21.5) in the myomectomy group and 80.0 (standard deviation 22.0) in the uterine artery embolisation group (intention-to-treat complete-case analysis mean adjusted difference 8.0, 95% confidence interval 1.8 to 14.1, p = 0.01; mean adjusted difference using multiple imputation for missing responses 6.5, 95% confidence interval 1.1 to 11.9). The mean difference in the primary outcome at the 4-year follow-up time point was 5.0 (95% CI -1.4 to 11.5; p = 0.13) in favour of myomectomy. Perioperative and postoperative complications from all initial procedures occurred in similar percentages of women in both groups (29% in the myomectomy group vs. 24% in the UAE group). Twelve women in the uterine embolisation group and six women in the myomectomy group reported pregnancies over 4 years, resulting in seven and five live births, respectively (hazard ratio 0.48, 95% confidence interval 0.18 to 1.28). Over a 2-year time horizon, uterine artery embolisation was associated with higher costs than myomectomy (mean cost £7958, 95% confidence interval £6304 to £9612, vs. mean cost £7314, 95% confidence interval £5854 to £8773), but with fewer quality-adjusted life-years gained (0.74, 95% confidence interval 0.70 to 0.78, vs. 0.83, 95% confidence interval 0.79 to 0.87). The differences in costs (difference £645, 95% confidence interval -£1381 to £2580) and quality-adjusted life-years (difference -0.09, 95% confidence interval -0.11 to -0.04) were small. Similar results were observed over the 4-year time horizon. At a threshold of willingness to pay for a gain of 1 QALY of £20,000, the probability of myomectomy being cost-effective is 98% at 2 years and 96% at 4 years. LIMITATIONS There were a substantial number of women who were not recruited because of their preference for a particular treatment option. CONCLUSIONS Among women with symptomatic uterine fibroids, myomectomy resulted in greater improvement in quality of life than did uterine artery embolisation. The differences in costs and quality-adjusted life-years are very small. Future research should involve women who are desiring pregnancy. TRIAL REGISTRATION This trial is registered as ISRCTN70772394. FUNDING This study was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme, and will be published in full in Health Technology Assessment; Vol. 26, No. 22. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lee J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Versha Cheed
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - William McKinnon
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Dikshyanta Rana
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Fusun Sirkeci
- Department of Obstetrics and Gynaecology, Whipps Cross Hospital, London, UK
| | - Isaac Manyonda
- Department of Gynaecology, St George's Hospital and Medical School, London, UK
| | - Anna-Maria Belli
- Department of Radiology, St George's Hospital and Medical School, London, UK
| | | | - Jonathan Moss
- School of Medicine, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Klim McPherson
- Department of Primary Care, University of Oxford, Oxford, UK
| |
Collapse
|
28
|
Ali M, Chen HY, Chiang YF, Badary OA, Hsia SM, Al-Hendy A. An evaluation of relugolix/estradiol/norethindrone acetate for the treatment of heavy menstrual bleeding associated with uterine fibroids in premenopausal women. Expert Opin Pharmacother 2022; 23:421-429. [PMID: 35068291 PMCID: PMC8866208 DOI: 10.1080/14656566.2022.2030705] [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: 12/30/2022]
Abstract
INTRODUCTION Uterine Fibroids (UFs) are the most predominant benign tumor in women who are coming of reproductive age, and causes intense economic load priced in billions of US dollars. Historically, surgery has been the main definitive treatment, albeit less attractive nowadays, especially for women with future fertility plans. Therefore, studies to explore the pharmacological treatment options are increasing especially as those that are currently available are limited for short-term use only. AREAS COVERED This drug evaluation features the clinical results from previous and ongoing studies of relugolix, in combination with the add back therapy of estradiol (E2) and norethindrone acetate (NETA), as a novel, orally administered, nonpeptide antagonist of gonadotropin-releasing hormone (GnRH) for the management of heavy menstrual bleeding (HMB) in premenopausal women with UFs. EXPERT OPINION The combination of relugolix/E2/NETA is an encouraging, well-tolerated and noninvasive pharmacological option for UFs patients. Relugolix induced a concentration-dependent decrease in HMB. However, it should be used with hormonal add-back therapy (E2+ NETA) to avoid induced hypoestrogenic side effects, importantly bone mineral density loss. Moreover, symptoms will likely resume shortly after the termination of the relugolix combination administration.
Collapse
Affiliation(s)
- Mohamed Ali
- Clinical Pharmacy Department, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt.,Center of Drug Discovery Research and Development, Ain Shams University, Cairo, Egypt
| | - Hsin-Yuan Chen
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei 11031, Taiwan
| | - Yi-Fen Chiang
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei 11031, Taiwan
| | - Osama A Badary
- Clinical Pharmacy Practice Department, Faculty of Pharmacy, The British University in Egypt, Cairo, Egypt
| | - Shih-Min Hsia
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei 11031, Taiwan.,Graduate Institute of Metabolism and Obesity Sciences, College of Nutrition, Taipei Medical University, Taipei 11031, Taiwan.,School of Food and Safety, Taipei Medical University, Taipei 11031, Taiwan.,Nutrition Research Center, Taipei Medical University Hospital, Taipei 11031, Taiwan
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, USA
| |
Collapse
|
29
|
Systematic review of oral pharmacotherapeutic options for the management of uterine fibroids. J Am Pharm Assoc (2003) 2022; 62:674-682.e5. [DOI: 10.1016/j.japh.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 11/24/2022]
|
30
|
Hamada M, Horikawa M, Ensaka C, Enomoto M, Ishii R, Toriumi R, Tachibana N, Taketani Y. A novel orally active gonadotropin-releasing hormone antagonist, relugolix, is a potential substitute for injectable GnRH antagonists in controlled ovarian stimulation in assisted reproductive technology. Reprod Med Biol 2021; 21:e12424. [PMID: 34938148 PMCID: PMC8658872 DOI: 10.1002/rmb2.12424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/17/2021] [Accepted: 10/25/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose To evaluate the efficacy of an oral gonadotropin‐releasing hormone antagonist (GnRH Ant), relugolix (R), for assisted reproductive technology (ART). Methods We enrolled women undergoing ART using a GnRH Ant for controlled ovarian stimulation. We compared R; 20 mg/day with cetrorelix acetate (C); 0.125 mg. C was administered to 88 women in 2019, and R to 93 women in 2020. Clinical outcomes associated with ART were assessed in both groups. Results The luteinizing hormone levels on the day of human chorionic gonadotropin injection in the R group (1.26 ± 0.93 IU/L) were significantly lower than those in the C group (2.85 ± 3.02 IU/L). There were no cases in which egg retrieval was canceled in both groups. The total doses of gonadotropins administered were greater in the R group compared with the C group. The number of days of GnRH Ant administration in the R group (1.71 ± 0.57 days) was significantly longer compared with the C group (1.48 ± 0.58 days). The number of oocytes collected, fertilization rates, and pregnancy rates (R; 47.1% vs C; 45.8%) did not differ between the two groups. Conclusion An orally active GnRH Ant, relugolix, when used in controlled ovarian stimulation for ART, showed comparable clinical outcomes with cetrorelix.
Collapse
Affiliation(s)
- Michiko Hamada
- Women's Clinic Oizumigakuen Lenia Medical Corporation Tokyo Japan
| | - Michiharu Horikawa
- Women's Clinic Oizumigakuen Lenia Medical Corporation Tokyo Japan.,Artemis Women's Hospital Lenia Medical Corporation Tokyo Japan
| | - Chie Ensaka
- Women's Clinic Oizumigakuen Lenia Medical Corporation Tokyo Japan
| | - Megumi Enomoto
- Women's Clinic Oizumigakuen Lenia Medical Corporation Tokyo Japan
| | - Rena Ishii
- Women's Clinic Oizumigakuen Lenia Medical Corporation Tokyo Japan
| | - Rena Toriumi
- Women's Clinic Oizumigakuen Lenia Medical Corporation Tokyo Japan
| | | | - Yuji Taketani
- Women's Clinic Oizumigakuen Lenia Medical Corporation Tokyo Japan.,Artemis Women's Hospital Lenia Medical Corporation Tokyo Japan
| |
Collapse
|
31
|
Harada T, Osuga Y, Suzuki Y, Fujisawa M, Fukui M, Kitawaki J. Relugolix, an oral gonadotropin-releasing hormone receptor antagonist, reduces endometriosis-associated pain compared with leuprorelin in Japanese women: a phase 3, randomized, double-blind, noninferiority study. Fertil Steril 2021; 117:583-592. [PMID: 34895700 DOI: 10.1016/j.fertnstert.2021.11.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/04/2021] [Accepted: 11/04/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of 40-mg relugolix (REL) compared with those of leuprorelin (LEU) in women with endometriosis-associated pain. DESIGN Phase 3, multicenter, randomized, double-blind, double-dummy, active-controlled study in Japanese patients. SETTING Hospitals and clinics. PATIENT(S) Women aged ≥20 years with regular menstrual cycles (25-38 days) experiencing endometriosis or ovarian endometrioma and reporting pelvic pain. INTERVENTION(S) In the REL group, 40 mg of REL was orally administered once a day for 24 weeks. In the LEU group, 3.75 or 1.88 mg of LEU was subcutaneously injected every 4 weeks for 24 weeks. MAIN OUTCOME MEASURE(S) The primary endpoint was the change in the maximum visual analog scale score for pelvic pain from baseline until 28 days before the end of treatment. RESULT(S) Changes in the maximum visual analog scale score were -52.6 ± 1.3 for REL and -57.5 ± 1.4 for LEU. Ovarian endometrioma decreased by 12.26 ± 17.52 cm3 for REL and 14.10 ± 18.81 cm3 for LEU. Drug-related treatment emergent adverse events with an incidence of >10% for both groups were hot flush, metrorrhagia, headache, and genital hemorrhage. Discontinuations from treatment emergent adverse events were 2.9% for REL and 4.3% for LEU. CONCLUSION(S) Relugolix was noninferior to LEU for treating endometriosis-associated pelvic pain. Safety profiles of both medications were comparable, although menses returned earlier in patients taking REL, a huge benefit for women who plan to conceive after treatment. CLINICAL TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT03931915.
Collapse
Affiliation(s)
- Tasuku Harada
- Department of Obstetrics and Gynecology, Tottori University Faculty of Medicine, Yonago, Japan
| | - Yutaka Osuga
- Obstetrics and Gynecology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yusuke Suzuki
- Clinical Development Department, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Masaki Fujisawa
- Clinical Development Department, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Motoko Fukui
- Medical Affairs Department, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan.
| | - Jo Kitawaki
- Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| |
Collapse
|
32
|
Relugolix for oral treatment of uterine leiomyomas: a dose-finding, randomized, controlled trial. BMC WOMENS HEALTH 2021; 21:375. [PMID: 34711224 PMCID: PMC8555132 DOI: 10.1186/s12905-021-01475-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 09/08/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Uterine leiomyomas are the most common neoplasm affecting women and frequently cause heavy menstrual bleeding and pain. Gonadotropin-releasing hormone (GnRH) receptor antagonists provide fast symptom relief and show promise as a medical (non-surgical) treatment option and as a presurgical treatment to reduce leiomyoma size. The aim of this study was to evaluate the efficacy and safety of three dose levels of oral relugolix, a small molecule GnRH receptor antagonist, in Japanese women with uterine leiomyomas and heavy menstrual bleeding. METHODS This phase 2, multicenter, double-blind, parallel-group study was conducted at 36 sites in Japan in women with uterine leiomyomas and heavy menstrual bleeding, defined as a pictorial blood loss assessment chart (PBAC) score of ≥ 120 in one menstrual cycle. Patients were randomized 1:1:1:1 to relugolix 10, 20, or 40 mg, or placebo, orally once daily for 12 weeks. The primary endpoint was the proportion of patients with a total PBAC score of < 10 from week 6 to 12. A sample size of 50 patients per group was estimated to provide ≥ 95% power, based on the comparison of relugolix 40 mg with placebo using a chi-square test with a significance level of 5% (two-sided). RESULTS From November 2011 to September 2012, 216 patients were randomized and 214 patients (99.1%) were analyzed. The proportion (difference vs. placebo) of patients that achieved the primary endpoint in the placebo and 10-, 20-, and 40-mg relugolix groups were 0%, 20.8% (95% confidence interval [CI]: 9.3-32.3, P < .001), 42.6% (95% CI: 29.4-55.8, P < .001), and 83.3% (95% CI: 73.4-93.3, P < .001), respectively. Though treatment-emergent adverse events were similar between the 20- and 40-mg groups, the incidence rates were more frequent compared with the placebo group. Most of these adverse events were mild or moderate in intensity. CONCLUSIONS Relugolix decreased menstrual blood loss in women with uterine leiomyomas in a dose-response manner, and was generally well tolerated. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, https://clinicaltrials.gov/ct2/show/NCT01452659 , NCT01452659 (registered 17/10/2011); JAPIC Clinical Trial Information, https://www.clinicaltrials.jp , JapicCTI-111590 (registered 31/08/2011).
Collapse
|
33
|
Ali M, Raslan M, Ciebiera M, Zaręba K, Al-Hendy A. Current approaches to overcome the side effects of GnRH analogs in the treatment of patients with uterine fibroids. Expert Opin Drug Saf 2021; 21:477-486. [PMID: 34612122 DOI: 10.1080/14740338.2022.1989409] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Uterine fibroids (UFs) are the most prevalent benign neoplastic threat originating from myometria of reproductive age women, with a profound financial load valued in hundreds of billions of dollars. Unfortunately, there is no curative treatment so far except surgery and available pharmacological treatments are restricted for short-term treatment options. Thus, there is a large unmet need in the UF space for noninvasive therapeutics.Areas covered: The authors reviewed the literature available for the utility of gonadotropin-releasing hormone (GnRH) analogs in women with UFs. We also focused on clinical studies exploring the therapeutic benefits of novel oral non-peptide GnRH antagonists that were recently approved by the U.S. Food and Drug Administration (FDA) in combination with estradiol/norethindrone acetate for the management of heavy menstrual bleeding associated with UFs in premenopausal women.Expert opinion: The results regarding the efficacy of new-generation oral GnRH-antagonists, such as elagolix, relugolix and linzagolix, are promising and offer potential prospect for the future therapy of UFs. However, these antagonists must be combined with hormonal add-back therapy to minimize the resultant hypoestrogenic side effects such as bone loss.
Collapse
Affiliation(s)
- Mohamed Ali
- Clinical Pharmacy Department, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
| | | | - Michał Ciebiera
- Second Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, Cegłowska, Warsaw, Poland
| | - Kornelia Zaręba
- First Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, Żelazna, Warsaw, Poland
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, USA
| |
Collapse
|
34
|
Sasamori Y, Takehara K, Terashima T, Onodera T, Yatsuki K, Nakagawa I, Takahashi Y, Nishida H, Ichinose T, Hiraike H, Nagasaka K. A case of adenomyosis with leiomyoma that was effectively treated with relugolix and kamishoyosan add-on therapy. BMC Womens Health 2021; 21:306. [PMID: 34412607 PMCID: PMC8375059 DOI: 10.1186/s12905-021-01442-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 08/02/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Recently, relugolix, an oral gonadotropin-releasing hormone receptor antagonist, has been considered an effective therapy for leiomyoma based on a phase 3 study in Japanese women. Leiomyoma combined with severe adenomyosis occasionally occurs in perimenopausal women; however, little information on the effectiveness of relugolix against severe adenomyosis exists. CASE PRESENTATION A 49-year-old woman was referred to our hospital with acute lower abdominal pain and abnormal uterine bleeding. Magnetic resonance imaging revealed multiple leiomyomas with diffuse adenomyosis. Left hydrosalpinx was also observed. The patient refused surgical treatment and preferred oral relugolix. Since she experienced a hot flush and headache induced by relugolix, a traditional Japanese Kampo, kamishoyosan, was added to improve the side effects of relugolix. The patient was asymptomatic at the time of this report and experienced a significant shrinkage in uterine volume. Ultimately, she avoided hysterectomy as desired. CONCLUSIONS To our knowledge, this is the first report of co-occurring adenomyosis and leiomyoma, which was effectively treated with relugolix. Although the management of adverse side effects, including hot flush and headache by relugolix, has recently attracted attention and controversy, relugolix add-on therapy with kamishoyosan may help treat menopausal symptoms.
Collapse
Affiliation(s)
- Yukifumi Sasamori
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Kohei Takehara
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Tsuyoshi Terashima
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Takako Onodera
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Keita Yatsuki
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Ippei Nakagawa
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Yuko Takahashi
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Haruka Nishida
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Takayuki Ichinose
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Haruko Hiraike
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Kazunori Nagasaka
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan.
| |
Collapse
|
35
|
Dababou S, Garzon S, Laganà AS, Ferrero S, Evangelisti G, Noventa M, D'Alterio MN, Palomba S, Uccella S, Franchi M, Barra F. Linzagolix: a new GnRH-antagonist under investigation for the treatment of endometriosis and uterine myomas. Expert Opin Investig Drugs 2021; 30:903-911. [PMID: 34278887 DOI: 10.1080/13543784.2021.1957830] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Uterine myomas and endometriosis are benign hormone-dependent diseases affecting women of reproductive age. Substantial efforts have been made to develop innovative medical options for treating these gynecologic diseases. Elagolix and relugolix have been approved in some countries for treating endometriosis and myomas, respectively; however, linzagolix (OBE 2109, KLH 2109) is a new oral gonadotropin-releasing hormone (GnRH) antagonist in phase II-III trials. Treatment options for women with contraindications for hormonal therapies or who refuse particular options, are the driving force behind the development of new drugs in this area. AREA COVERED This drug evaluation highlights definitive and preliminary results from previous and ongoing studies of linzagolix for the treatment of endometriosis and myomas. EXPERT OPINION Linzagolix showed a dose-dependent and rapidly reversible action on the pituitary-gonadal axis. In a recent phase II trial (EDELWEISS), linzagolix significantly reduced pain related to endometriosis and improved quality of life at single daily doses of 75-200 mg. The preliminary results of international, double-blind phase III trials (PRIMROSE 1 and 2) reported its efficacy in treating heavy menstrual bleeding related to myomas with a good safety profile. Further studies will determine the necessity of add-back therapy during long-term use of linzagolix.
Collapse
Affiliation(s)
- Susan Dababou
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese (VA), Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova, Italy.,Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Giulio Evangelisti
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova, Italy.,Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Marco Noventa
- Department of Women and Children's Health, Clinic of Gynecology and Obstetrics, University of Padua, Padua, Italy
| | - Maurizio Nicola D'Alterio
- Department of Surgical Sciences, Section of Obstetrics & Gynecology, University of Cagliari, Monserrato, Italy
| | - Stefano Palomba
- Department of Experimental and Clinical Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Stefano Uccella
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Fabio Barra
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova, Italy.,Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| |
Collapse
|
36
|
Relugolix, an oral gonadotropin-releasing hormone (GnRH) receptor antagonist, in women with endometriosis-associated pain: phase 2 safety and efficacy 24-week results. BMC WOMENS HEALTH 2021; 21:250. [PMID: 34154590 PMCID: PMC8218467 DOI: 10.1186/s12905-021-01393-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/09/2021] [Indexed: 11/24/2022]
Abstract
Background Relugolix is a once-daily, oral, nonpeptide, gonadotropin-releasing hormone receptor antagonist. The aim of this study was to evaluate safety of relugolix over 24 weeks in women with endometriosis-associated pain. Methods This phase 2, randomized, open-label, parallel-group extension study was conducted in 101 clinics in Japan. Patients (premenopausal females ≥ 20 years) who completed the preceding 12-week relugolix phase 2 study continued to receive relugolix (10 mg, 20 mg, or 40 mg), placebo, or leuprorelin (3.75 mg) for an additional 12 weeks. Relugolix was administered orally once daily, and leuprorelin subcutaneously once every 4 weeks. The primary outcome was safety, including bone mineral density (BMD) and treatment-emergent adverse events (TEAEs). Secondary endpoints included visual analog scale (VAS) scores for endometriosis-associated pain. Analysis sets were defined as all patients who were administered the study drug. Results Of 487 randomized patients in the preceding study, 397 enrolled in this extension study and continued to receive placebo (n = 77), relugolix 10 mg (n = 84), relugolix 20 mg (n = 78), relugolix 40 mg (n = 89), or leuprorelin (n = 69). Baseline characteristics were similar between extension study patients and patients in the preceding study. Frequency of TEAEs including metrorrhagia, menorrhagia, and hot flush was similar in the relugolix 40-mg and leuprorelin groups. Mean (SD) change in BMD from baseline at Week 24 was − 0.2 (1.99)% for placebo; − 1.6 (2.34)%, − 2.6 (2.94)%, and − 4.9 (2.91)% for the relugolix 10-mg, 20-mg, and 40-mg groups, respectively; and − 4.4 (2.16)% for leuprorelin. Mean ± SD change from baseline in mean VAS score (mm) for pelvic pain at end of treatment was − 3.2 ± 12.16 for placebo; − 6.8 ± 10.56, − 9.0 ± 11.84, and − 11.9 ± 11.26 for the relugolix 10-mg, 20-mg, and 40-mg groups, respectively; and − 12.7 ± 12.57 for leuprorelin. Estradiol levels decreased with increasing relugolix dose and remained below postmenopausal levels throughout the 24-week relugolix 40-mg treatment period. Conclusions Treatment with relugolix for 24 weeks was generally well tolerated and demonstrated similar pain reduction to leuprorelin in women with endometriosis. The dose-dependent loss in BMD observed with relugolix treatment was expected due to an induced hypoestrogenic state. Relugolix demonstrated a similar benefit/risk profile to injectable therapy in this phase 2 study. Trial registration NCT01452685 (ClinicalTrials.gov, registered 17/10/2011). Supplementary Information The online version contains supplementary material available at 10.1186/s12905-021-01393-3.
Collapse
|
37
|
Ali M, A R S, Al Hendy A. Elagolix in the treatment of heavy menstrual bleeding associated with uterine fibroids in premenopausal women. Expert Rev Clin Pharmacol 2021; 14:427-437. [PMID: 33682578 DOI: 10.1080/17512433.2021.1900726] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Uterine fibroids (UFs) are the most common benign tumor arising from myometrium of reproductive age women, with significant financial burden estimated in hundreds of billions of dollars. Unfortunately, there are limitations in available long-term treatment options. Thus, there is a large unmet need in the UF space for noninvasive therapeutics. AREAS COVERED Authors reviewed the literature available for elagolix; an orally bioavailable, second-generation, non-peptide gonadotropin-releasing hormone (GnRH) antagonist recently approved by the US Food and Drug Administration (FDA) in combination with estradiol/norethindrone acetate for the management of heavy menstrual bleeding associated with UFs in premenopausal women. EXPERT OPINION The utility of new-generation oral GnRH-antagonists, such as elagolix, relugolix and linzagolix, is offering a new potential opportunity for the future therapy of UFs: elagolix has been the most studied drug of this class for treating benign gynecological diseases, including endometriosis and UFs, for which it has been US FDA-approved in 2018 and 2020, respectively.
Collapse
Affiliation(s)
- Mohamed Ali
- Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
| | - Sara A R
- Al-Galaa Military Hospital, Cairo, Egypt, Drug Research Center (DRC), Cairo, Egypt
| | - Ayman Al Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, USA
| |
Collapse
|
38
|
Al-Hendy A, Lukes AS, Poindexter AN, Venturella R, Villarroel C, Critchley HOD, Li Y, McKain L, Arjona Ferreira JC, Langenberg AGM, Wagman RB, Stewart EA. Treatment of Uterine Fibroid Symptoms with Relugolix Combination Therapy. N Engl J Med 2021; 384:630-642. [PMID: 33596357 PMCID: PMC8262231 DOI: 10.1056/nejmoa2008283] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Uterine fibroids are a common cause of heavy menstrual bleeding and pain. Treatment with the combination of relugolix (an oral gonadotropin-releasing hormone-receptor antagonist), estradiol, and norethindrone acetate, administered once daily, may have efficacy in women with uterine fibroids and heavy bleeding while avoiding hypoestrogenic effects. METHODS We conducted two replicate international, double-blind, 24-week, phase 3 trials involving women with fibroid-associated heavy menstrual bleeding. Participants were randomly assigned in a 1:1:1 ratio to receive once-daily placebo, relugolix combination therapy (40 mg of relugolix, 1 mg of estradiol, and 0.5 mg of norethindrone acetate), or delayed relugolix combination therapy (40 mg of relugolix monotherapy, followed by relugolix combination therapy, each for 12 weeks). The primary efficacy end point in each trial was the percentage of participants with a response (volume of menstrual blood loss <80 ml and a ≥50% reduction in volume from baseline) in the relugolix combination therapy group, as compared with the placebo group. Key secondary end points were amenorrhea, volume of menstrual blood loss, distress from bleeding and pelvic discomfort, anemia, pain, fibroid volume, and uterine volume. Safety and bone mineral density were assessed. RESULTS A total of 388 women in trial L1 and 382 in trial L2 underwent randomization. A total of 73% of the participants in the relugolix combination therapy group in trial L1 and 71% of those in trial L2 had a response (primary end point), as compared with 19% and 15%, respectively, of those in the placebo groups (P<0.001 for both comparisons). Both relugolix combination therapy groups had significant improvements, as compared with the placebo groups, in six of seven key secondary end points, including measures of menstrual blood loss (including amenorrhea), pain, distress from bleeding and pelvic discomfort, anemia, and uterine volume, but not fibroid volume. The incidence of adverse events was similar with relugolix combination therapy and placebo. Bone mineral density was similar with relugolix combination therapy and placebo but decreased with relugolix monotherapy. CONCLUSIONS Once-daily relugolix combination therapy resulted in a significant reduction in menstrual bleeding, as compared with placebo, and preserved bone mineral density in women with uterine fibroids. (Funded by Myovant Sciences; LIBERTY 1 [L1] and LIBERTY 2 [L2] ClinicalTrials.gov numbers, NCT03049735 and NCT03103087, respectively.).
Collapse
Affiliation(s)
- Ayman Al-Hendy
- From the Department of Obstetrics and Gynecology, University of Chicago, Chicago (A.A.-H.); Carolina Women's Research and Wellness Center, Durham, NC (A.S.L.); Advances in Health, Houston (A.N.P.); the Department of Clinical and Experimental Medicine, Unit of Obstetrics and Gynecology, Magna Graecia University of Catanzaro, Catanzaro, Italy (R.V.); the Institute for Mother and Child Research, Faculty of Medicine, University of Chile, Santiago, Chile (C.V.); the Medical Research Council Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom (H.O.D.C.); Myovant Sciences, Brisbane, CA (Y.L., L.M., J.C.A.F., A.G.M.L., R.B.W.); and the Department of Obstetrics and Gynecology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S)
| | - Andrea S Lukes
- From the Department of Obstetrics and Gynecology, University of Chicago, Chicago (A.A.-H.); Carolina Women's Research and Wellness Center, Durham, NC (A.S.L.); Advances in Health, Houston (A.N.P.); the Department of Clinical and Experimental Medicine, Unit of Obstetrics and Gynecology, Magna Graecia University of Catanzaro, Catanzaro, Italy (R.V.); the Institute for Mother and Child Research, Faculty of Medicine, University of Chile, Santiago, Chile (C.V.); the Medical Research Council Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom (H.O.D.C.); Myovant Sciences, Brisbane, CA (Y.L., L.M., J.C.A.F., A.G.M.L., R.B.W.); and the Department of Obstetrics and Gynecology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S)
| | - Alfred N Poindexter
- From the Department of Obstetrics and Gynecology, University of Chicago, Chicago (A.A.-H.); Carolina Women's Research and Wellness Center, Durham, NC (A.S.L.); Advances in Health, Houston (A.N.P.); the Department of Clinical and Experimental Medicine, Unit of Obstetrics and Gynecology, Magna Graecia University of Catanzaro, Catanzaro, Italy (R.V.); the Institute for Mother and Child Research, Faculty of Medicine, University of Chile, Santiago, Chile (C.V.); the Medical Research Council Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom (H.O.D.C.); Myovant Sciences, Brisbane, CA (Y.L., L.M., J.C.A.F., A.G.M.L., R.B.W.); and the Department of Obstetrics and Gynecology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S)
| | - Roberta Venturella
- From the Department of Obstetrics and Gynecology, University of Chicago, Chicago (A.A.-H.); Carolina Women's Research and Wellness Center, Durham, NC (A.S.L.); Advances in Health, Houston (A.N.P.); the Department of Clinical and Experimental Medicine, Unit of Obstetrics and Gynecology, Magna Graecia University of Catanzaro, Catanzaro, Italy (R.V.); the Institute for Mother and Child Research, Faculty of Medicine, University of Chile, Santiago, Chile (C.V.); the Medical Research Council Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom (H.O.D.C.); Myovant Sciences, Brisbane, CA (Y.L., L.M., J.C.A.F., A.G.M.L., R.B.W.); and the Department of Obstetrics and Gynecology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S)
| | - Claudio Villarroel
- From the Department of Obstetrics and Gynecology, University of Chicago, Chicago (A.A.-H.); Carolina Women's Research and Wellness Center, Durham, NC (A.S.L.); Advances in Health, Houston (A.N.P.); the Department of Clinical and Experimental Medicine, Unit of Obstetrics and Gynecology, Magna Graecia University of Catanzaro, Catanzaro, Italy (R.V.); the Institute for Mother and Child Research, Faculty of Medicine, University of Chile, Santiago, Chile (C.V.); the Medical Research Council Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom (H.O.D.C.); Myovant Sciences, Brisbane, CA (Y.L., L.M., J.C.A.F., A.G.M.L., R.B.W.); and the Department of Obstetrics and Gynecology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S)
| | - Hilary O D Critchley
- From the Department of Obstetrics and Gynecology, University of Chicago, Chicago (A.A.-H.); Carolina Women's Research and Wellness Center, Durham, NC (A.S.L.); Advances in Health, Houston (A.N.P.); the Department of Clinical and Experimental Medicine, Unit of Obstetrics and Gynecology, Magna Graecia University of Catanzaro, Catanzaro, Italy (R.V.); the Institute for Mother and Child Research, Faculty of Medicine, University of Chile, Santiago, Chile (C.V.); the Medical Research Council Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom (H.O.D.C.); Myovant Sciences, Brisbane, CA (Y.L., L.M., J.C.A.F., A.G.M.L., R.B.W.); and the Department of Obstetrics and Gynecology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S)
| | - Yulan Li
- From the Department of Obstetrics and Gynecology, University of Chicago, Chicago (A.A.-H.); Carolina Women's Research and Wellness Center, Durham, NC (A.S.L.); Advances in Health, Houston (A.N.P.); the Department of Clinical and Experimental Medicine, Unit of Obstetrics and Gynecology, Magna Graecia University of Catanzaro, Catanzaro, Italy (R.V.); the Institute for Mother and Child Research, Faculty of Medicine, University of Chile, Santiago, Chile (C.V.); the Medical Research Council Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom (H.O.D.C.); Myovant Sciences, Brisbane, CA (Y.L., L.M., J.C.A.F., A.G.M.L., R.B.W.); and the Department of Obstetrics and Gynecology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S)
| | - Laura McKain
- From the Department of Obstetrics and Gynecology, University of Chicago, Chicago (A.A.-H.); Carolina Women's Research and Wellness Center, Durham, NC (A.S.L.); Advances in Health, Houston (A.N.P.); the Department of Clinical and Experimental Medicine, Unit of Obstetrics and Gynecology, Magna Graecia University of Catanzaro, Catanzaro, Italy (R.V.); the Institute for Mother and Child Research, Faculty of Medicine, University of Chile, Santiago, Chile (C.V.); the Medical Research Council Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom (H.O.D.C.); Myovant Sciences, Brisbane, CA (Y.L., L.M., J.C.A.F., A.G.M.L., R.B.W.); and the Department of Obstetrics and Gynecology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S)
| | - Juan C Arjona Ferreira
- From the Department of Obstetrics and Gynecology, University of Chicago, Chicago (A.A.-H.); Carolina Women's Research and Wellness Center, Durham, NC (A.S.L.); Advances in Health, Houston (A.N.P.); the Department of Clinical and Experimental Medicine, Unit of Obstetrics and Gynecology, Magna Graecia University of Catanzaro, Catanzaro, Italy (R.V.); the Institute for Mother and Child Research, Faculty of Medicine, University of Chile, Santiago, Chile (C.V.); the Medical Research Council Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom (H.O.D.C.); Myovant Sciences, Brisbane, CA (Y.L., L.M., J.C.A.F., A.G.M.L., R.B.W.); and the Department of Obstetrics and Gynecology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S)
| | - Andria G M Langenberg
- From the Department of Obstetrics and Gynecology, University of Chicago, Chicago (A.A.-H.); Carolina Women's Research and Wellness Center, Durham, NC (A.S.L.); Advances in Health, Houston (A.N.P.); the Department of Clinical and Experimental Medicine, Unit of Obstetrics and Gynecology, Magna Graecia University of Catanzaro, Catanzaro, Italy (R.V.); the Institute for Mother and Child Research, Faculty of Medicine, University of Chile, Santiago, Chile (C.V.); the Medical Research Council Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom (H.O.D.C.); Myovant Sciences, Brisbane, CA (Y.L., L.M., J.C.A.F., A.G.M.L., R.B.W.); and the Department of Obstetrics and Gynecology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S)
| | - Rachel B Wagman
- From the Department of Obstetrics and Gynecology, University of Chicago, Chicago (A.A.-H.); Carolina Women's Research and Wellness Center, Durham, NC (A.S.L.); Advances in Health, Houston (A.N.P.); the Department of Clinical and Experimental Medicine, Unit of Obstetrics and Gynecology, Magna Graecia University of Catanzaro, Catanzaro, Italy (R.V.); the Institute for Mother and Child Research, Faculty of Medicine, University of Chile, Santiago, Chile (C.V.); the Medical Research Council Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom (H.O.D.C.); Myovant Sciences, Brisbane, CA (Y.L., L.M., J.C.A.F., A.G.M.L., R.B.W.); and the Department of Obstetrics and Gynecology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S)
| | - Elizabeth A Stewart
- From the Department of Obstetrics and Gynecology, University of Chicago, Chicago (A.A.-H.); Carolina Women's Research and Wellness Center, Durham, NC (A.S.L.); Advances in Health, Houston (A.N.P.); the Department of Clinical and Experimental Medicine, Unit of Obstetrics and Gynecology, Magna Graecia University of Catanzaro, Catanzaro, Italy (R.V.); the Institute for Mother and Child Research, Faculty of Medicine, University of Chile, Santiago, Chile (C.V.); the Medical Research Council Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom (H.O.D.C.); Myovant Sciences, Brisbane, CA (Y.L., L.M., J.C.A.F., A.G.M.L., R.B.W.); and the Department of Obstetrics and Gynecology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S)
| |
Collapse
|
39
|
Wu HM, Chang HM, Leung PCK. Gonadotropin-releasing hormone analogs: Mechanisms of action and clinical applications in female reproduction. Front Neuroendocrinol 2021; 60:100876. [PMID: 33045257 DOI: 10.1016/j.yfrne.2020.100876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/23/2020] [Accepted: 10/04/2020] [Indexed: 12/15/2022]
Abstract
Extra-hypothalamic GnRH and extra-pituitary GnRH receptors exist in multiple human reproductive tissues, including the ovary, endometrium and myometrium. Recently, new analogs (agonists and antagonists) and modes of GnRH have been developed for clinical application during controlled ovarian hyperstimulation for assisted reproductive technology (ART). Additionally, the analogs and upstream regulators of GnRH suppress gonadotropin secretion and regulate the functions of the reproductive axis. GnRH signaling is primarily involved in the direct control of female reproduction. The cellular mechanisms and action of the GnRH/GnRH receptor system have been clinically applied for the treatment of reproductive disorders and have widely been introduced in ART. New GnRH analogs, such as long-acting GnRH analogs and oral nonpeptide GnRH antagonists, are being continuously developed for clinical application. The identification of the upstream regulators of GnRH, such as kisspeptin and neurokinin B, provides promising potential to develop these upstream regulator-related analogs to control the hypothalamus-pituitary-ovarian axis.
Collapse
Affiliation(s)
- Hsien-Ming Wu
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University School of Medicine, Taoyuan 333, Taiwan, ROC
| | - Hsun-Ming Chang
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia V6H 3V5, Canada
| | - Peter C K Leung
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia V6H 3V5, Canada.
| |
Collapse
|
40
|
Shon J, Zou P, Tran D, Seo SK, Lu Y. Clinical Pharmacology at the Intersection of Women's Health and Regulation: Drug Development Considerations for Uterine Fibroids. J Clin Pharmacol 2020; 60 Suppl 2:S39-S48. [PMID: 33274511 DOI: 10.1002/jcph.1736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/03/2020] [Accepted: 08/12/2020] [Indexed: 01/14/2023]
Affiliation(s)
- Jihong Shon
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Peng Zou
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Doanh Tran
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Shirley K Seo
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Yanhui Lu
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| |
Collapse
|
41
|
Ishizawa C, Hirota Y, Urata Y, Morishima K, Fujii T, Osuga Y. Prolapse of a pedunculated uterine leiomyoma through the cervix during GnRH antagonist treatment: Case report and literature review. J Obstet Gynaecol Res 2020; 46:2679-2683. [PMID: 32911575 DOI: 10.1111/jog.14479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/28/2020] [Accepted: 08/30/2020] [Indexed: 11/30/2022]
Abstract
We here describe a case of the prolapse of pedunculated submucosal leiomyoma through the cervix during the treatment of a gonadotropin-releasing hormone (GnRH) antagonist relugolix. We also present the literature review of the cases of leiomyoma prolapse during GnRH modulators. A 55-year-old woman with atypical vaginal bleeding diagnosed submucosal uterine fibroid 6 cm in diameter, and daily oral administration of relugolix was conducted. On the 35th day of the administration, heavy vaginal bleeding suddenly occurred due to leiomyoma prolapse. Finally, she underwent abdominal hysterectomy to treat heavy bleeding. To date, six cases of leiomyoma prolapse during GnRH modulators have been reported, in which all the previous cases were treated with GnRH agonists. This is the first case report of leiomyoma prolapse during GnRH antagonist treatment. Notably, leiomyoma prolapse is a possible common adverse effect of GnRH modulators for the treatment of submucosal leiomyoma, which is caused by rapid decrease in its volume.
Collapse
Affiliation(s)
- Chihiro Ishizawa
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasushi Hirota
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoko Urata
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kaoru Morishima
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomoyuki Fujii
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
42
|
Panknin O, Wagenfeld A, Bone W, Bender E, Nowak-Reppel K, Fernández-Montalván AE, Nubbemeyer R, Bäurle S, Ring S, Schmees N, Prien O, Schäfer M, Friedrich C, Zollner TM, Steinmeyer A, Mueller T, Langer G. Discovery and Characterization of BAY 1214784, an Orally Available Spiroindoline Derivative Acting as a Potent and Selective Antagonist of the Human Gonadotropin-Releasing Hormone Receptor as Proven in a First-In-Human Study in Postmenopausal Women. J Med Chem 2020; 63:11854-11881. [PMID: 32960053 DOI: 10.1021/acs.jmedchem.0c01076] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The growth of uterine fibroids is sex hormone-dependent and commonly associated with highly incapacitating symptoms. Most treatment options consist of the control of these hormonal effects, ultimately blocking proliferative estrogen signaling (i.e., oral contraceptives/antagonization of human gonadotropin-releasing hormone receptor [hGnRH-R] activity). Full hGnRH-R blockade, however, results in menopausal symptoms and affects bone mineralization, thus limiting treatment duration or demanding estrogen add-back approaches. To overcome such issues, we aimed to identify novel, small-molecule hGnRH-R antagonists. This led to the discovery of compound BAY 1214784, an orally available, potent, and selective hGnRH-R antagonist. Altering the geminal dimethylindoline core of the initial hit compound to a spiroindoline system significantly improved GnRH-R antagonist potencies across several species, mandatory for a successful compound optimization in vivo. In a first-in-human study in postmenopausal women, once daily treatment with BAY 1214784 effectively lowered plasma luteinizing hormone levels by up to 49%, at the same time being associated with low pharmacokinetic variability and good tolerability.
Collapse
Affiliation(s)
- Olaf Panknin
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Andrea Wagenfeld
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Wilhelm Bone
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Eckhard Bender
- Research & Development, Pharmaceuticals, Bayer AG, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Katrin Nowak-Reppel
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | | | - Reinhard Nubbemeyer
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Stefan Bäurle
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Sven Ring
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Norbert Schmees
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Olaf Prien
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Martina Schäfer
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Christian Friedrich
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Thomas M Zollner
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Andreas Steinmeyer
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Thomas Mueller
- Research & Development, Pharmaceuticals, Bayer AG, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Gernot Langer
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| |
Collapse
|
43
|
Osuga Y, Seki Y, Tanimoto M, Kusumoto T, Kudou K, Terakawa N. Relugolix, an oral gonadotropin-releasing hormone receptor antagonist, reduces endometriosis-associated pain in a dose-response manner: a randomized, double-blind, placebo-controlled study. Fertil Steril 2020; 115:397-405. [PMID: 32912633 DOI: 10.1016/j.fertnstert.2020.07.055] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/21/2020] [Accepted: 07/29/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of three dose levels of relugolix, a gonadotropin-releasing hormone receptor antagonist, compared with placebo and leuprorelin in women with endometriosis-associated pain. DESIGN Phase 2, multicenter, randomized, double-blind, placebo-controlled study. SETTING Hospitals and clinics. PATIENT(S) Adult premenopausal women with endometriosis who had dysmenorrhea and endometriosis-associated pelvic pain. INTERVENTION(S) During a 12-week treatment period, patients received relugolix 10 mg (n = 103), 20 mg (n = 100), or 40 mg (n = 103) as a daily oral dose; placebo (n = 97) as a daily oral dose; or leuprorelin 3.75 mg (n = 80) as a monthly subcutaneous injection. MAIN OUTCOME MEASURE(S) Primary endpoint was the change from baseline in mean visual analog scale score for pelvic pain during 28 days before the end of treatment. RESULT(S) The mean changes in mean visual analog scale score for pelvic pain were -3.8 mm in the placebo group; -6.2, -8.1, and -10.4 mm in the relugolix 10-mg, 20-mg, and 40-mg groups; respectively; and -10.6 mm in the leuprorelin group. The major adverse events with relugolix were hot flush, metrorrhagia, menorrhagia, and irregular menstruation, and bone mineral density decrease in a dose-response manner, which were also observed in the leuprorelin group with a frequency comparable with that in the relugolix 40-mg group. CONCLUSION(S) Oral administration of relugolix alleviated endometriosis-associated pain in a dose-response manner and was generally well tolerated. Relugolix 40 mg demonstrated efficacy and safety comparable with those of leuprorelin. CLINICAL TRIAL REGISTRATION NUMBER NCT01458301.
Collapse
Affiliation(s)
- Yutaka Osuga
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Yoshifumi Seki
- Takeda Development Center Japan, Takeda Pharmaceutical Company Limited, Osaka, Japan
| | - Masataka Tanimoto
- Takeda Development Center Japan, Takeda Pharmaceutical Company Limited, Osaka, Japan
| | - Takeru Kusumoto
- Takeda Development Center Japan, Takeda Pharmaceutical Company Limited, Osaka, Japan
| | - Kentarou Kudou
- Takeda Development Center Japan, Takeda Pharmaceutical Company Limited, Osaka, Japan
| | - Naoki Terakawa
- Department of Obstetrics and Gynecology, Tottori University Faculty of Medicine, Yonago, Japan
| |
Collapse
|
44
|
Küpker W, Plathow D, Bullerdiek J, Felberbaum R. Neue Behandlungsoptionen mit GnRH-Antagonisten bei Endometriose und Uterus myomatosus. GYNAKOLOGISCHE ENDOKRINOLOGIE 2020. [DOI: 10.1007/s10304-020-00329-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
45
|
Relugolix: Early Promise for a Novel Oral Androgen Deprivation Therapy with Radiation Therapy for Prostate Cancer. Eur Urol 2020; 78:193-194. [DOI: 10.1016/j.eururo.2020.03.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 03/30/2020] [Indexed: 02/08/2023]
|
46
|
Barra F, Vitale SG, Seca M, Scala C, Leone Roberti Maggiore U, Cianci A, Ferrero S. The potential role of elagolix for treating uterine bleeding associated to uterine myomas. Expert Opin Pharmacother 2020; 21:1419-1430. [PMID: 32401547 DOI: 10.1080/14656566.2020.1755254] [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: 01/01/2023]
Abstract
INTRODUCTION Uterine myomas represents a widespread gynecological disease of women in reproductive age. Although surgery remains the first choice for treating most patients, in the last years, new medical approaches have been considered in order to ameliorate heavy menstrual bleeding (HMB) related to their presence. Elagolix is a second-generation gonadotropin-releasing hormone (GnRH) antagonist under investigation for the long-term treatment of uterine myomas. AREAS COVERED The aim of this drug evaluation is to give a complete overview of pharmacokinetic and pharmacodynamic data on elagolix for treating HMB related to uterine myomas and to report the results of the current clinical trials in this setting. EXPERT OPINION In two previous phase II studies, this drug succeeded in ameliorating blood loss and quality of life of patients affected by uterine myomas with a good safety profile. Three phase III trials (ELARIS UF-I, UF-II, and EXTEND) investigated the efficacy, tolerability, and safety of elagolix at 300 mg twice daily with add-back therapy. The primary endpoint, consisting in the reduction in HMB compared to placebo, was met in the majority of patients under treatment. Currently, elagolix is under investigation in two other ongoing multicenter phase III clinical studies.
Collapse
Affiliation(s)
- Fabio Barra
- Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino , Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova , Italy
| | - Salvatore Giovanni Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania , Catania, Italy
| | - Marta Seca
- Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino , Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova , Italy
| | - Carolina Scala
- Unit of Obstetrics and Gynecology, Gaslini Institute , Genova, Italy
| | | | - Antonio Cianci
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania , Catania, Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino , Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova , Italy
| |
Collapse
|
47
|
Short-term relugolix treatment for fibroid-related pain: where do we go from here? Fertil Steril 2019; 112:819-820. [PMID: 31731943 DOI: 10.1016/j.fertnstert.2019.08.062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 08/20/2019] [Indexed: 11/21/2022]
|