1
|
Pugsley MK, Winters BR, Koshman YE, Authier S, Foley CM, Hayes ES, Curtis MJ. Innovative approaches to cardiovascular safety pharmacology assessment. J Pharmacol Toxicol Methods 2024; 128:107533. [PMID: 38945308 DOI: 10.1016/j.vascn.2024.107533] [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: 06/09/2024] [Accepted: 06/27/2024] [Indexed: 07/02/2024]
Abstract
This editorial prefaces the annual themed issue on safety pharmacology (SP) methods which has been published since 2004 in the Journal of Pharmacological and Toxicological Methods (JPTM). Here we highlight content derived from the 2023 Safety Pharmacology Society (SPS) meeting held in Brussels, Belgium. The meeting generated 138 abstracts, reproduced in the current volume of JPTM. As in prior years, the manuscripts reflect various areas of innovation in SP including in silico modeling of stroke volume, cardiac output and systemic vascular resistance, computational approaches that compare drug-induced proarrhythmic sensitivity of human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs), an evaluation of the utility of the corrected J-Tpeak and Tpeak-to-Tend parameters from the ECG as potential proarrhythmia biomarkers, and the applicability of nonclinical concentration-QTc (C-QTc) modeling of data derived from the conduct of the in vivo QTc study as a component of the core battery of safety pharmacology studies.
Collapse
Affiliation(s)
- Michael K Pugsley
- Toxicology & Safety Pharmacology, Cytokinetics, South San Francisco, CA 94080, United States of America.
| | - Brett R Winters
- Toxicology & Safety Pharmacology, Cytokinetics, South San Francisco, CA 94080, United States of America
| | - Yevgeniya E Koshman
- Safety Pharmacology, Abbvie, North Chicago, IL 60064, United States of America
| | - Simon Authier
- Charles River Laboratories, Laval, QC H7V 4B3, Canada
| | - C Michael Foley
- Safety Pharmacology, Abbvie, North Chicago, IL 60064, United States of America
| | - Eric S Hayes
- BioCurate Pty Ltd, Carlton, Victoria 3053, Australia
| | - Michael J Curtis
- Cardiovascular Division, King's College London, Rayne Institute, St Thomas' Hospital, London SE17EH, UK
| |
Collapse
|
2
|
Bartko TM, Lutgen SM, Ross RA, Walisser JA, Garske EP, Kopelke KR, Ashcroft-Hawley K, Tang HM, Kremer JJ, Friedrichs GS, Nichols JV. Optimized J to T peak and T peak to T end measurements in nonclinical species administered moxifloxacin and amiodarone. J Pharmacol Toxicol Methods 2024; 128:107527. [PMID: 38852685 DOI: 10.1016/j.vascn.2024.107527] [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: 03/01/2024] [Revised: 05/08/2024] [Accepted: 06/05/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION Cardiovascular safety and the risk of developing the potentially fatal ventricular tachyarrhythmia, Torsades de Pointes (TdP), have long been major concerns of drug development. TdP is associated with a delayed ventricular repolarization represented by QT interval prolongation in the electrocardiogram (ECG), typically due to block of the potassium channel encoded by the human ether-a-go-go related gene (hERG). Importantly however, not all drugs that prolong the QT interval are torsadagenic and not all hERG blockers prolong the QT interval. Recent clinical reports suggest that partitioning the QT interval into early (J to T peak; JTp) and late repolarization (T peak to T end; TpTe) components may be valuable for distinguishing low-risk mixed ion channel blockers (hERG plus calcium and/or late sodium currents) from high-risk pure hERG channel blockers. This strategy, if true for nonclinical animal models, could be used to de-risk QT prolonging compounds earlier in the drug development process. METHODS To explore this, we investigated JTp and TpTe in ECG data collected from telemetered dogs and/or monkeys administered moxifloxacin or amiodarone at doses targeting relevant clinical exposures. An optimized placement of the Tpeak fiducial mark was utilized, and all intervals were corrected for heart rate (QTc, JTpc, TpTec). RESULTS Increases in QTc and JTpc intervals with administration of the pure hERG blocker moxifloxacin and an initial QTc and JTpc shortening followed by prolongation with the mixed ion channel blocker amiodarone were detected as expected, aligning with clinical data. However, anticipated increases in TpTec by both standard agents were not detected. DISCUSSION The inability to detect changes in TpTec reduces the utility of these subintervals for prediction of arrhythmias using continuous single‑lead ECGs collected from freely moving dogs and monkeys.
Collapse
Affiliation(s)
- Theresa M Bartko
- Labcorp Early Development Laboratories Inc., Madison, WI, United States of America.
| | - Stephen M Lutgen
- Labcorp Early Development Laboratories Inc., Madison, WI, United States of America
| | - Rebecca A Ross
- Labcorp Early Development Laboratories Inc., Madison, WI, United States of America
| | | | - Eric P Garske
- Labcorp Early Development Laboratories Inc., Madison, WI, United States of America
| | - Kerry R Kopelke
- Labcorp Early Development Laboratories Inc., Madison, WI, United States of America
| | | | - Hai-Ming Tang
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States of America
| | - John J Kremer
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States of America
| | - Gregory S Friedrichs
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States of America
| | - Jill V Nichols
- Labcorp Early Development Laboratories Inc., Madison, WI, United States of America
| |
Collapse
|
3
|
Bhatt LK, Shah CR, Patel SD, Patel SR, Patel VA, Patel RJ, Joshi NM, Shah NA, Patel JH, Dwivedi P, Sundar R, Jain MR. A Retrospective Comparison of Electrocardiographic Parameters in Ketamine and Tiletamine-Zolazepam Anesthetized Indian Rhesus Monkeys ( Macaca mulatta). Int J Toxicol 2024; 43:184-195. [PMID: 38108647 DOI: 10.1177/10915818231221276] [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: 12/19/2023]
Abstract
Electrocardiographic evaluation is performed in rhesus monkeys to establish the cardiovascular safety of candidate molecules before progressing to clinical trials. These animals are usually immobilized chemically by ketamine (KTM) and tiletamine-zolazepam (TZ) to obtain a steady-state heart rate and to ensure adequate human safety. The present study aimed to evaluate the effect of these anesthetic regimens on different electrocardiographic parameters. Statistically significant lower HR and higher P-wave duration, RR, QRS, and QT intervals were observed in the KTM-anesthetized group in comparison to TZ-anesthetized animals. No significant changes were noticed in the PR interval and p-wave amplitude. Sex-based significance amongst these parameters was observed in male and female animals of TZ- and KTM-anesthetized groups. Regression analysis of four QTc formulas in TZ-anesthetized rhesus monkeys revealed that QTcNAK (Nakayama) better corrected the QT interval than QTcHAS (Hassimoto), QTcBZT (Bazett), and QTcFRD (Fridericia) formulas. QTcNAK exhibited the least correlation with the RR interval (slope closest to zero and r = .01) and displayed no statistical significance between male and female animals. These data will prove useful in the selection of anesthetic regimens for chemical restraint of rhesus monkeys in nonclinical safety evaluation studies.
Collapse
|
4
|
Pharmacological characterisation of electrocardiogram J-T peak interval in conscious Guinea pigs. Eur J Pharmacol 2022; 927:175065. [PMID: 35640715 DOI: 10.1016/j.ejphar.2022.175065] [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: 02/15/2022] [Revised: 05/13/2022] [Accepted: 05/23/2022] [Indexed: 11/24/2022]
Abstract
Drug-induced human ether-à-go-go-related gene (hERG) channel block and QT interval prolongation increase torsade de pointes (TdP) risk. However, some drugs block hERG channels and prolong QT interval with low TdP risk, likely because they block additional inward currents. We investigated the utility of J-Tpeak interval, a novel biomarker of inward current block and TdP risk, in conscious telemetered guinea pigs. Electrocardiogram parameters were analysed in Hartley guinea pigs orally administered one of eight test compounds (dofetilide, flecainide, nifedipine, quinidine, quinine, ranolazine, sotalol, verapamil) or vehicle alone as controls. Heart rate-corrected QT (QTcX) and J-Tpeak (J-TpeakcX) were calculated to evaluate the relations of QT-RR and J-Tpeak-RR. Dofetilide and sotalol significantly increased ΔQTcX and ΔJ-TpeakcX intervals to similar degrees. Quinidine, quinine and flecainide also increased ΔQTcX and ΔJ-TpeakcX intervals, but the degrees of ΔJ-TpeakcX interval prolongation were shorter than those of ΔQTcX interval prolongation. Ranolazine showed slight increasing trends in ΔQTcX and ΔJ-TpeakcX intervals, but the differences were not significant. Verapamil and nifedipine did not increase the ΔQTcX or ΔJ-TpeakcX intervals. Based on the relations of ΔΔJ-TpeakcX and ΔΔQTcX intervals, dofetilide, sotalol and quinidine were classified as high risk for TdP, quinine, flecainide and ranolazine were classified as intermediate risk and verapamil and nifedipine were classified as low risk. These results supported the usefulness of J-Tpeak interval assessment in conscious guinea pigs for predicting drug-induced balanced block of inward currents and TdP risk in early-stage preclinical studies.
Collapse
|
5
|
Midei MG, Darpo B, Ayers G, Brown R, Couderc JP, Daly W, Ferber G, Sager PT, Camm AJ. Electrophysiological and ECG Effects of Perhexiline, a Mixed Cardiac Ion Channel Inhibitor, Evaluated in Nonclinical Assays and in Healthy Subjects. J Clin Pharmacol 2021; 61:1606-1617. [PMID: 34214210 DOI: 10.1002/jcph.1934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 06/28/2021] [Indexed: 11/10/2022]
Abstract
Perhexiline has been used to treat hypertrophic cardiomyopathy. In addition to its effect on carnitine-palmitoyltransferase-1, it has mixed ion channel effects through inhibition of several cardiac ion currents. Effects on cardiac ion channels expressed in mammalian cells were assayed using a manual patch-clamp technique, action potential duration (APD) was measured in ventricular trabeculae of human donor hearts, and electrocardiogram effects were evaluated in healthy subjects in a thorough QT (TQT) study. Perhexiline blocked several cardiac ion currents at concentrations within the therapeutic range (150-600 ng/mL) with IC50 for hCav1.2 ∼ hERG < late hNav1.5. A significant APD shortening was observed in perhexiline-treated cardiomyocytes. The TQT study was conducted with a pilot part in 9 subjects to evaluate a dosing schedule that would achieve therapeutic and supratherapeutic perhexiline plasma concentrations on days 4 and 6, respectively. Guided by the results from the pilot, 104 subjects were enrolled in a parallel-designed part with a nested crossover comparison for the positive control. Perhexiline caused QTc prolongation, with the largest effect on ΔΔQTcF, 14.7 milliseconds at therapeutic concentrations and 25.6 milliseconds at supratherapeutic concentrations and a positive and statistically significant slope of the concentration-ΔΔQTcF relationship (0.018 milliseconds per ng/mL; 90%CI, 0.0119-0.0237 milliseconds per ng/mL). In contrast, the JTpeak interval was shortened with a negative concentration-JTpeak relationship, a pattern consistent with multichannel block. Further studies are needed to evaluate whether this results in a low proarrhythmic risk.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Georg Ferber
- Statistik Georg Ferber GmbH, Riehen, Switzerland
| | - Philip T Sager
- Department of Medicine, Cardiovascular Research Institute, Stanford University, Palo Alto, California, USA
| | - A John Camm
- Division of Clinical Sciences, Cardiovascular and Cell Sciences Research Institute, St George's University of London, London, UK
| |
Collapse
|
6
|
Darpo B, Ferber G. The New S7B/E14 Question and Answer Draft Guidance for Industry: Contents and Commentary. J Clin Pharmacol 2021; 61:1261-1273. [PMID: 33896027 PMCID: PMC9290990 DOI: 10.1002/jcph.1880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/20/2021] [Indexed: 11/10/2022]
Abstract
In August 2020, the International Council on Harmonisation (ICH) released a new draft document, which for the first time combined nonclinical (S7B) and clinical (E14) Questions and Answers (Q&As) into 1 document. FDA describes the revision as a “value proposition”: if the human ether‐à‐go‐go assay and the in vivo study are performed in a standardized way, the number of dedicated thorough QT (TQT) studies can be reduced. In this article, we describe and discuss the Q&As that relate to clinical ECG evaluation. If supported by negative standardized nonclinical assays, Q&A 5.1 will obviate the need for a TQT study in the case that a >2‐fold exposure margin vs high clinical scenario cannot be obtained. Q&A 6.1 addresses drugs that are poorly tolerated in healthy subjects and cannot be studied at high doses or in placebo‐controlled studies; it therefore mainly applies to oncology drugs. It will enable sponsors to claim that a new drug has a “low likelihood of proarrhythmic effects” in the case that the mean corrected QT effect is <10 milliseconds at the time of market application. The E14 2015 revision allowed application of concentration–corrected QT analysis on data from routinely performed clinical pharmacology studies, for example, the first‐in‐human study and the proportion of dedicated TQT studies has since steadily decreased. It can be foreseen that the proposed new revision will further reduce the number of TQT studies. To achieve harmonization across regulatory regions, it seems important to reach consensus within the International Council on Harmonisation group on the new threshold proposed in 6.1. For this purpose, the Implementation Working Group has asked for public comments.
Collapse
Affiliation(s)
- Borje Darpo
- Cardiac Safety, ERT, Rochester, New York, USA.,Cardiology, Karolinska Institute, Stockholm, Sweden
| | - Georg Ferber
- Statistik Georg Ferber GmbH, Riehen, Switzerland
| |
Collapse
|
7
|
Andršová I, Hnatkova K, Šišáková M, Toman O, Smetana P, Huster KM, Barthel P, Novotný T, Schmidt G, Malik M. Heart Rate Dependency and Inter-Lead Variability of the T Peak - T End Intervals. Front Physiol 2021; 11:595815. [PMID: 33384609 PMCID: PMC7769826 DOI: 10.3389/fphys.2020.595815] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/14/2020] [Indexed: 11/24/2022] Open
Abstract
The electrocardiographic (ECG) assessment of the T peak–T end (Tpe) intervals has been used in many clinical studies, but several related physiological aspects have not been reported. Specifically, the sources of the Tpe differences between different ECG leads have not been systematically researched, the relationship of Tpe duration to underlying heart rate has not been firmly established, and little is known about the mutual correspondence of Tpe intervals measured in different ECG leads. This study evaluated 796,620 10-s 12-lead ECGs obtained from long-term Holters recorded in 639 healthy subjects (311 female) aged 33.8 ± 9.4 years. For each ECG, transformation to orthogonal XYZ lead was used to measure Tpe in the orthogonal vector magnitude (used as a reference for lead-to-lead comparisons) and to construct a three-dimensional T wave loop. The loop roundness was expressed by a ratio between its circumference and length. These ratios were significantly related to the standard deviation of Tpe durations in different ECG leads. At the underlying heart rate of 60 beats per minute, Tpe intervals were shorter in female than in male individuals (82.5 ± 5.6 vs 90.0 ± 6.5 ms, p < 0.0001). When studying linear slopes between Tpe intervals measured in different leads and the underlying heart rate, we found only minimal heart rate dependency, which was not systematic across the ECG leads and/or across the population. For any ECG lead, positive Tpe/RR slope was found in some subjects (e.g., 79 and 25% of subjects for V2 and V4 measurements, respectively) and a negative Tpe/RR slope in other subjects (e.g., 40 and 65% for V6 and V5, respectively). The steepest positive and negative Tpe/RR slopes were found for measurements in lead V2 and V4, respectively. In all leads, the Tpe/RR slope values were close to zero, indicating, on average, Tpe changes well below 2 ms for RR interval changes of 100 ms. On average, longest Tpe intervals were measured in lead V2, the shortest in lead III. The study concludes that the Tpe intervals measured in different leads cannot be combined. Irrespective of the measured ECG lead, the Tpe interval is not systematically heart rate dependent, and no heart rate correction should be used in clinical Tpe investigations.
Collapse
Affiliation(s)
- Irena Andršová
- Department of Internal Medicine and Cardiology, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Katerina Hnatkova
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Martina Šišáková
- Department of Internal Medicine and Cardiology, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Ondřej Toman
- Department of Internal Medicine and Cardiology, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | | | - Katharina M Huster
- Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Petra Barthel
- Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Tomáš Novotný
- Department of Internal Medicine and Cardiology, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Georg Schmidt
- Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Marek Malik
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| |
Collapse
|
8
|
Abstract
Drug-induced changes of the J to T peak (JTp) and J to the median of area under the T wave (JT50) were reported to differentiate QT prolonging drugs that are predominant blockers of the delayed potassium rectifier current from those with multiple ion channel effects. Studies of drug-induced JTp/JT50 interval changes might therefore facilitate cardiac safety evaluation of new pharmaceuticals. It is not known whether formulas for QT heart rate correction are applicable to JTp and JT50 intervals. QT/RR, JTp/RR, and JT50/RR profiles were studied in 523 healthy subjects aged 33.5 ± 8.4 years (254 females). In individual subjects, 1,256 ± 220 electrocardiographic measurements of QT, JTp, and JT50 intervals were available including a 5-minute history of RR intervals preceding each measurement. Curvilinear, linear and log-linear regression models were used to characterize individual QT/RR, JTp/RR, and JT50/RR profiles both without and with correction for heart rate hysteresis. JTp/RR and JT50/RR hysteresis correction needs to be included but the generic universal correction for QT/RR hysteresis is also applicable to JTp/RR and JT50/RR profiles. Once this is incorporated, median regression coefficients of the investigated population suggest linear correction formulas JTpc = JTp + 0.150(1-RR) and JT50c = JT50 + 0.117(1-RR) where RR intervals of the underlying heart rate are hysteresis-corrected, and all measurements expressed in seconds. The established correction formulas can be proposed for future clinical pharmacology studies that show drug-induced heart rate changes of up to approximately 10 beats per minute.
Collapse
|
9
|
Hnatkova K, Vicente J, Johannesen L, Garnett C, Strauss DG, Stockbridge N, Malik M. Detection of T Wave Peak for Serial Comparisons of JTp Interval. Front Physiol 2019; 10:934. [PMID: 31402872 PMCID: PMC6670189 DOI: 10.3389/fphys.2019.00934] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/09/2019] [Indexed: 11/17/2022] Open
Abstract
Electrocardiogram (ECG) studies of drug-induced prolongation of the interval between the J point and the peak of the T wave (JTp interval) distinguished QT prolonging drugs that predominantly block the delayed potassium rectifier current from those affecting multiple cardiac repolarisation ion channel currents. Since the peak of the T wave depends on ECG lead, a “global” T peak requires to combine ECG leads into one-dimensional signal in which the T wave peak can be measured. This study aimed at finding the optimum one-dimensional representation of 12-lead ECGs for the most stable JTp measurements. Seven different one-dimensional representations were investigated including the vector magnitude of the orthogonal XYZ transformation, root mean square of all 12 ECG leads, and the vector magnitude of the 3 dominant orthogonal leads derived by singular value decomposition. All representations were applied to the median waveforms of 660,657 separate 10-s 12-lead ECGs taken from repeated day-time Holter recordings in 523 healthy subjects aged 33.5 ± 8.4 years (254 women). The JTp measurements were compared with the QT intervals and with the intervals between the J point and the median point of the area under the T wave one-dimensional representation (JT50 intervals) by means of calculating the residuals of the subject-specific curvilinear regression models relating the measured interval to the hysteresis-corrected RR interval of the underlying heart rate. The residuals of the regression models (equal to the intra-subject standard deviations of individually heart rate corrected intervals) expressed intra-subject stability of interval measurements. For both the JTp intervals and the JT50 intervals, the curvilinear regression residuals of measurements derived from the orthogonal XYZ representation were marginally but statistically significantly lower compared to the other representations. Using the XYZ representation, the residuals of the QT/RR, JTp/RR and JT50/RR regressions were 5.6 ± 1.1 ms, 7.2 ± 2.2 ms, and 4.9 ± 1.2 ms, respectively (all statistically significantly different; p < 0.0001). The study concludes that the orthogonal XYZ ECG representation might be proposed for future investigations of JTp and JT50 intervals. If the ability of classifying QT prolonging drugs is further confirmed for the JT50 interval, it might be appropriate to replace the JTp interval since with JT50 it appears more stable.
Collapse
Affiliation(s)
- Katerina Hnatkova
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Jose Vicente
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food & Drug Administration, Silver Spring, MD, United States
| | - Lars Johannesen
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food & Drug Administration, Silver Spring, MD, United States
| | - Christine Garnett
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food & Drug Administration, Silver Spring, MD, United States
| | - David G Strauss
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food & Drug Administration, Silver Spring, MD, United States
| | - Marek Malik
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| |
Collapse
|
10
|
Darpo B, Benson C, Brown R, Dota C, Ferber G, Ferry J, Jarugula V, Keirns J, Ortemann‐Renon C, Pham T, Riley S, Sarapa N, Ticktin M, Zareba W, Couderc J. Evaluation of the Effect of 5 QT‐Positive Drugs on the JTpeak Interval — An Analysis of ECGs From the IQ‐CSRC Study. J Clin Pharmacol 2019; 60:125-139. [DOI: 10.1002/jcph.1502] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 07/16/2019] [Indexed: 12/30/2022]
Affiliation(s)
| | | | | | | | | | - Jim Ferry
- Clinical PharmacologyEisai Woodcliff Lake New Jersey USA
| | | | - James Keirns
- Retired; at the time of the IQ‐CSRC study at Astellas Northbrook Illinois USA
| | | | | | | | - Nenad Sarapa
- Sarah Cannon Research Institute Nashville Tennessee USA
| | | | - Wojciech Zareba
- Cardiovascular Clinical Research CenterUniversity of Rochester New York USA
| | - Jean‐Philippe Couderc
- ERT Rochester New York USA
- Cardiovascular Clinical Research CenterUniversity of Rochester New York USA
| |
Collapse
|
11
|
Deep Learning-Based Proarrhythmia Analysis Using Field Potentials Recorded From Human Pluripotent Stem Cells Derived Cardiomyocytes. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE-JTEHM 2019. [PMCID: PMC6570462 DOI: 10.1109/jtehm.2019.2907945] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
12
|
CiPA challenges and opportunities from a non-clinical, clinical and regulatory perspectives. An overview of the safety pharmacology scientific discussion. J Pharmacol Toxicol Methods 2018; 93:15-25. [DOI: 10.1016/j.vascn.2018.06.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 05/23/2018] [Accepted: 06/19/2018] [Indexed: 01/22/2023]
|
13
|
Darpo B, Couderc JP. Challenges in implementing and obtaining acceptance for J-Tpeak assessment as the clinical component of CiPA. J Pharmacol Toxicol Methods 2018; 93:75-79. [PMID: 29879475 DOI: 10.1016/j.vascn.2018.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/13/2018] [Accepted: 05/30/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION This paper is based on a presentation held at the Annual Safety Pharmacology Society meeting in September 2017, at which challenges for the clinical component of CiPA were presented. FDA has published an automated algorithm for measurement of the J-Tpeak interval on a median beat from a vector magnitude lead derived from a 12-lead ECG. CiPA proposes that J-Tpeak prolongation < 10 ms can be used for drugs with a QTc effect < 20 ms to differentiate between safe and unsafe delayed repolarization and to reduce the level of ECG monitoring in late stage clinical trials. METHODS We applied FDA's algorithm, complemented with iCOMPAS, to moxifloxacin and dolasetron data from the IQ-CSRC study with 9 subjects on active and 6 on placebo. The effect on QTcF and corrected J-Tpeak (J-Tpeak_c) was analyzed using concentration-effect modeling. RESULTS There was a good correlation between QTcF and J-Tpeak_c prolongation after oral dosing of 400 mg moxifloxacin with placebo-adjusted, change-from-baseline (ΔΔ) J-Tpeak_c of ~12 ms at concentrations that caused ΔΔQTcF of ~20 ms. On dolasetron, J-Tpeak_c was highly variable, no prolongation was seen and an effect on ΔΔJ-Tpeak_c > 10 ms could be excluded across the observed plasma concentration range. DISCUSSION In this limited analysis performed on the IQ-CSRC study waveforms using FDA's automated algorithm, J-Tpeak prolongation was observed on moxifloxacin, but not on dolasetron, despite clinical observations of proarrhythmias with both drugs. Challenges for the implementation of the J-Tpeak interval as a replacement or complement to the QTc interval, include to demonstrate that the proposed clinical algorithm using a J-Tpeak threshold of 10 ms, can be used to categorize drugs with a QT effect up to ~20 ms as having low pro-arrhythmic risk.
Collapse
Affiliation(s)
- Borje Darpo
- iCardiac Technologies, Inc., Rochester, NY, USA.
| | - Jean-Philippe Couderc
- iCardiac Technologies, Inc., Rochester, NY, USA; Heart Research Follow-up Program, University of Rochester Medical Center, Rochester, NY, USA
| |
Collapse
|
14
|
Turner JR, Rodriguez I, Mantovani E, Gintant G, Kowey PR, Klotzbaugh RJ, Prasad K, Sager PT, Stockbridge N, Strnadova C. Drug-induced Proarrhythmia and Torsade de Pointes: A Primer for Students and Practitioners of Medicine and Pharmacy. J Clin Pharmacol 2018; 58:997-1012. [PMID: 29672845 DOI: 10.1002/jcph.1129] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/05/2018] [Indexed: 12/11/2022]
Abstract
Multiple marketing withdrawals due to proarrhythmic concerns occurred in the United States, Canada, and the United Kingdom in the late 1980s to early 2000s. This primer reviews the clinical implications of a drug's identified proarrhythmic liability, the issues associated with these safety-related withdrawals, and the actions taken by the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) and by regulatory agencies in terms of changing drug development practices and introducing new nonclinical and clinical tests to asses proarrhythmic liability. ICH Guidelines S7B and E14 were released in 2005. Since then, they have been adopted by many regional regulatory authorities and have guided nonclinical and clinical proarrhythmic cardiac safety assessments during drug development. While this regulatory paradigm has been successful in preventing drugs with unanticipated potential for inducing the rare but potentially fatal polymorphic ventricular arrhythmia torsade de pointes from entering the market, it has led to the termination of drug development programs for other potentially useful medicines because of isolated results from studies with limited predictive value. Research efforts are now exploring alternative approaches to better predict potential proarrhythmic liabilities. For example, in the domain of human electrocardiographic assessments, concentration-response modeling conducted during phase 1 clinical development has recently become an accepted alternate primary methodology to the ICH E14 "thorough QT/QTc" study for defining a drug's corrected QT interval prolongation liability under certain conditions. When a drug's therapeutic benefit is considered important at a public health level but there is also an identified proarrhythmic liability that may result from administration of the single drug in certain individuals and/or drug-drug interactions, marketing approval will be accompanied by appropriate directions in the drug's prescribing information. Health-care professionals in the fields of medicine and pharmacy need to consider the prescribing information in conjunction with individual patients' clinical characteristics and concomitant medications when prescribing and dispensing such drugs.
Collapse
Affiliation(s)
- J Rick Turner
- Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, USA
| | - Ignacio Rodriguez
- Cardiac Safety Research Consortium, Roche TCRC, Inc., New York, NY, USA
| | - Emily Mantovani
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
| | | | - Peter R Kowey
- Lankenau Heart Institute and Jefferson Medical College, Philadelphia, PA, USA
| | - Ralph J Klotzbaugh
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Krishna Prasad
- Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Philip T Sager
- Sager Consulting and Stanford University, San Francisco, CA, USA
| | - Norman Stockbridge
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Colette Strnadova
- Therapeutic Products Directorate, Health Canada, Ottawa, Ontario, Canada
| | | |
Collapse
|
15
|
Vicente J, Zusterzeel R, Johannesen L, Mason J, Sager P, Patel V, Matta MK, Li Z, Liu J, Garnett C, Stockbridge N, Zineh I, Strauss DG. Mechanistic Model-Informed Proarrhythmic Risk Assessment of Drugs: Review of the "CiPA" Initiative and Design of a Prospective Clinical Validation Study. Clin Pharmacol Ther 2018; 103:54-66. [PMID: 28986934 DOI: 10.1002/cpt.v103.110.1002/cpt.896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 09/20/2017] [Accepted: 10/01/2017] [Indexed: 05/26/2023]
Abstract
The Comprehensive in vitro Proarrhythmia Assay (CiPA) initiative is developing and validating a mechanistic-based assessment of the proarrhythmic risk of drugs. CiPA proposes to assess a drug's effect on multiple ion channels and integrate the effects in a computer model of the human cardiomyocyte to predict proarrhythmic risk. Unanticipated or missed effects will be assessed with human stem cell-derived cardiomyocytes and electrocardiogram (ECG) analysis in early phase I clinical trials. This article provides an overview of CiPA and the rationale and design of the CiPA phase I ECG validation clinical trial, which involves assessing an additional ECG biomarker (J-Tpeak) for QT prolonging drugs. If successful, CiPA will 1) create a pathway for drugs with hERG block / QT prolongation to advance without intensive ECG monitoring in phase III trials if they have low proarrhythmic risk; and 2) enable updating drug labels to be more informative about proarrhythmic risk, not just QT prolongation.
Collapse
Affiliation(s)
- Jose Vicente
- Office of New Drugs, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robbert Zusterzeel
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lars Johannesen
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jay Mason
- Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City, Utah, USA
- Spaulding Clinical Research, West Bend, Wisconsin, USA
| | | | - Vikram Patel
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Murali K Matta
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Zhihua Li
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jiang Liu
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Christine Garnett
- Office of New Drugs, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Norman Stockbridge
- Office of New Drugs, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Issam Zineh
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - David G Strauss
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| |
Collapse
|
16
|
Vicente J, Zusterzeel R, Johannesen L, Mason J, Sager P, Patel V, Matta MK, Li Z, Liu J, Garnett C, Stockbridge N, Zineh I, Strauss DG. Mechanistic Model-Informed Proarrhythmic Risk Assessment of Drugs: Review of the "CiPA" Initiative and Design of a Prospective Clinical Validation Study. Clin Pharmacol Ther 2018; 103:54-66. [PMID: 28986934 PMCID: PMC5765372 DOI: 10.1002/cpt.896] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 09/20/2017] [Accepted: 10/01/2017] [Indexed: 12/19/2022]
Abstract
The Comprehensive in vitro Proarrhythmia Assay (CiPA) initiative is developing and validating a mechanistic-based assessment of the proarrhythmic risk of drugs. CiPA proposes to assess a drug's effect on multiple ion channels and integrate the effects in a computer model of the human cardiomyocyte to predict proarrhythmic risk. Unanticipated or missed effects will be assessed with human stem cell-derived cardiomyocytes and electrocardiogram (ECG) analysis in early phase I clinical trials. This article provides an overview of CiPA and the rationale and design of the CiPA phase I ECG validation clinical trial, which involves assessing an additional ECG biomarker (J-Tpeak) for QT prolonging drugs. If successful, CiPA will 1) create a pathway for drugs with hERG block / QT prolongation to advance without intensive ECG monitoring in phase III trials if they have low proarrhythmic risk; and 2) enable updating drug labels to be more informative about proarrhythmic risk, not just QT prolongation.
Collapse
Affiliation(s)
- Jose Vicente
- Office of New Drugs, Center for Drug Evaluation and ResearchUnited States Food and Drug AdministrationSilver SpringMarylandUSA
| | - Robbert Zusterzeel
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and ResearchUnited States Food and Drug AdministrationSilver SpringMarylandUSA
| | - Lars Johannesen
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and ResearchUnited States Food and Drug AdministrationSilver SpringMarylandUSA
| | - Jay Mason
- Department of Medicine, Division of CardiologyUniversity of UtahSalt Lake CityUtahUSA
- Spaulding Clinical ResearchWest BendWisconsinUSA
| | | | - Vikram Patel
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and ResearchUnited States Food and Drug AdministrationSilver SpringMarylandUSA
| | - Murali K. Matta
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and ResearchUnited States Food and Drug AdministrationSilver SpringMarylandUSA
| | - Zhihua Li
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and ResearchUnited States Food and Drug AdministrationSilver SpringMarylandUSA
| | - Jiang Liu
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and ResearchUnited States Food and Drug AdministrationSilver SpringMarylandUSA
| | - Christine Garnett
- Office of New Drugs, Center for Drug Evaluation and ResearchUnited States Food and Drug AdministrationSilver SpringMarylandUSA
| | - Norman Stockbridge
- Office of New Drugs, Center for Drug Evaluation and ResearchUnited States Food and Drug AdministrationSilver SpringMarylandUSA
| | - Issam Zineh
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and ResearchUnited States Food and Drug AdministrationSilver SpringMarylandUSA
| | - David G. Strauss
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and ResearchUnited States Food and Drug AdministrationSilver SpringMarylandUSA
| |
Collapse
|