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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.
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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
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Strauss DG, Wu WW, Li Z, Koerner J, Garnett C. Translational Models and Tools to Reduce Clinical Trials and Improve Regulatory Decision Making for QTc and Proarrhythmia Risk (ICH E14/S7B Updates). Clin Pharmacol Ther 2021; 109:319-333. [PMID: 33332579 PMCID: PMC7898549 DOI: 10.1002/cpt.2137] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 01/06/2023]
Abstract
After multiple drugs were removed from the market secondary to drug-induced torsade de pointes (TdP) risk, the International Council for Harmonisation (ICH) released guidelines in 2005 that focused on the nonclinical (S7B) and clinical (E14) assessment of surrogate biomarkers for TdP. Recently, Vargas et al. published a pharmaceutical-industry perspective making the case that "double-negative" nonclinical data (negative in vitro hERG and in vivo heart-rate corrected QT (QTc) assays) are associated with such low probability of clinical QTc prolongation and TdP that potentially all double-negative drugs would not need detailed clinical QTc evaluation. Subsequently, the ICH released a new E14/S7B Draft Guideline containing Questions and Answers (Q&As) that defined ways that double-negative nonclinical data could be used to reduce the number of "Thorough QT" (TQT) studies and reach a low-risk determination when a TQT or equivalent could not be performed. We review the Vargas et al. proposal in the context of what was contained in the ICH E14/S7B Draft Guideline and what was proposed by the ICH E14/S7B working group for a "stage 2" of updates (potential expanded roles for nonclinical data and details for assessing TdP risk of QTc-prolonging drugs). Although we do not agree with the exact probability statistics in the Vargas et al. paper because of limitations in the underlying datasets, we show how more modest predictive value of individual assays could still result in low probability for TdP with double-negative findings. Furthermore, we expect that the predictive value of the nonclinical assays will improve with implementation of the new ICH E14/S7B Draft Guideline.
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Affiliation(s)
- David G. Strauss
- Division of Applied Regulatory ScienceOffice of Clinical PharmacologyOffice of Translational SciencesCenter for Drug Evaluation and ResearchUS Food and Drug AdministrationSilver SpringMarylandUSA
| | - Wendy W. Wu
- Division of Applied Regulatory ScienceOffice of Clinical PharmacologyOffice of Translational SciencesCenter for Drug Evaluation and ResearchUS Food and Drug AdministrationSilver SpringMarylandUSA
| | - Zhihua Li
- Division of Applied Regulatory ScienceOffice of Clinical PharmacologyOffice of Translational SciencesCenter for Drug Evaluation and ResearchUS Food and Drug AdministrationSilver SpringMarylandUSA
| | - John Koerner
- Division of Pharm/Tox for Cardiology, Hematology, Endocrinology and NephrologyOffice of Cardiology, Hematology, Endocrinology and NephrologyOffice of New DrugsCenter for Drug Evaluation and ResearchUS Food and Drug AdministrationSilver SpringMarylandUSA
| | - Christine Garnett
- Division of Cardiology and NephrologyOffice of Cardiology, Hematology, Endocrinology and NephrologyOffice of New DrugsCenter for Drug Evaluation and ResearchUS Food and Drug AdministrationSilver SpringMarylandUSA
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Corino VDA, Rivolta MW, Mainardi LT, Sassi R. Assessment of spatial heterogeneity of ventricular repolarization after multi-channel blocker drugs in healthy subjects. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 189:105291. [PMID: 31935579 DOI: 10.1016/j.cmpb.2019.105291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 12/18/2019] [Accepted: 12/20/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVES In contrast to potassium channel blockers, drugs affecting multiple channels seem to reduce torsadogenic risks. However, their effect on spatial heterogeneity of ventricular repolarization (SHVR) is still matter of investigation. Aim of this work is to assess the effect of four drugs blocking the human ether-à-go-go-related gene (hERG) potassium channel, alone or in combination with other ionic channel blocks, on SHVR, as estimated by the V-index on short triplicate 10 s ECG. METHODS The V-index is an estimate of the standard deviation of the repolarization times of the myocytes across the entire myocardium, obtained from multi-lead surface electrocardiograms. Twenty-two healthy subjects received a pure hERG potassium channel blocker (dofetilide) and 3 other drugs with additional varying degrees of sodium and calcium (L-type) channel block (quinidine, ranolazine, and verapamil), as well as placebo. A one-way repeated-measures Friedman test was performed to compare the V-index over time. RESULTS Computer simulations and Bland-Altman analysis supported the reliability of the estimates of V-index on triplicate 10 s ECG. Ranolazine, verapamil and placebo did not affect the V-index. On the contrary, after quinidine and dofetilide administration, an increase of V-index from predose to its peak value was observed (ΔΔV-index values were 19 ms and 27 ms, respectively, p < 0.05). CONCLUSIONS High torsadogenic drugs (dofetilide and quinidine) affected significantly the SHVR, as quantified by the V-index. The metric has therefore a potential in assessing drug arrhythmogenicity.
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Affiliation(s)
- Valentina D A Corino
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, via Golgi 39, 20133 Milan, Italy.
| | - Massimo W Rivolta
- Dipartimento di Informatica, Università degli Studi di Milano, Via Celoria 18, 20133 Milan, Italy
| | - Luca T Mainardi
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, via Golgi 39, 20133 Milan, Italy
| | - Roberto Sassi
- Dipartimento di Informatica, Università degli Studi di Milano, Via Celoria 18, 20133 Milan, Italy
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Cruces PD, Torkar D, Arini PD. Biomarkers of pre-existing risk of Torsade de Pointes under Sotalol treatment. J Electrocardiol 2020; 60:177-183. [PMID: 32464371 DOI: 10.1016/j.jelectrocard.2020.04.011] [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: 02/27/2020] [Revised: 04/09/2020] [Accepted: 04/15/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Antiarrhythmic drugs therapies are currently going through a turning point. The high risk that exists during the treatments has led to an ongoing search for new non-invasive toxicity risk biomarkers. METHODS We propose the use of spatial biomarkers obtained through the quaternion algebra, evaluating the dynamics of the cardiac electrical vector in a non-invasive way in order to detect abnormal changes in ventricular heterogeneity. In groups of patients with and without history of Torsade de Pointes undergoing a Sotalol challenge, we compute the radius and the linear and angular velocities of QRS complex and T-wave loops. From these signals we extract significant features in order to compute a risk patient classifier. RESULTS Using machine learning techniques and statistical analysis, the combinations of few indices reach a pair of sensitivity/specificity of 100%/100% when separating patients with arrhythmogenic substrate. Several biomarkers not only measure drug-induced changes significantly but also observe differences in at-risk patients outperforming current standards. DISCUSSION Alternative biomarkers were able to describe pre-existing risk of patients. Given the high levels of significance and performance, these results could contribute to a better understanding of the torsadogenic substrate and to the safe development of drug therapies.
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Affiliation(s)
- Pablo Daniel Cruces
- Instituto de Ingeniería Biomédica, UBA, Paseo Colón 850 (C1063ACV), Buenos Aires, Argentina; Instituto Argentino de Matemática 'Alberto P. Calderón', CONICET, Saavedra 15 (C1083ACA), Buenos Aires, Argentina.
| | - Drago Torkar
- Institut 'Jožef Stefan', Department of Computer Systems, Jamova cesta 39 (SI-1000), Ljubljana, Slovenia
| | - Pedro David Arini
- Instituto de Ingeniería Biomédica, UBA, Paseo Colón 850 (C1063ACV), Buenos Aires, Argentina; Instituto Argentino de Matemática 'Alberto P. Calderón', CONICET, Saavedra 15 (C1083ACA), Buenos Aires, Argentina
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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
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Vicente J, Strauss DG, Upreti VV, Fossler MJ, Sager PT, Noveck R. The Potential Role of the J‐T
peak
Interval in Proarrhythmic Cardiac Safety: Current State of the Science From the American College of Clinical Pharmacology and the Cardiac Safety Research Consortium. J Clin Pharmacol 2019; 59:909-914. [DOI: 10.1002/jcph.1411] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Jose Vicente
- Division of Cardiovascular and Renal Products, Office of Drug Evaluation I, Office of New Drugs, Center for Drug Evaluation and ResearchUS Food and Drug Administration Silver Spring MD USA
| | - David G. Strauss
- Division of Applied Regulatory ScienceUS Food and Drug Administration Silver Spring MD USA
| | - Vijay V. Upreti
- Clinical Pharmacology Oncology Therapeutic Area HeadClinical Pharmacology Modeling and SimulationAmgen South San Francisco CA USA
| | - Michael J. Fossler
- Clinical Operations & Quantitative SciencesTrevena, Inc. Chesterbrook PA USA
| | | | - Robert Noveck
- Duke Early Phase 1 Clinical Research Unit Durham NC USA
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Lester RM, Paglialunga S, Johnson IA. QT Assessment in Early Drug Development: The Long and the Short of It. Int J Mol Sci 2019; 20:ijms20061324. [PMID: 30884748 PMCID: PMC6471571 DOI: 10.3390/ijms20061324] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/01/2019] [Accepted: 03/05/2019] [Indexed: 11/16/2022] Open
Abstract
The QT interval occupies a pivotal role in drug development as a surface biomarker of ventricular repolarization. The electrophysiologic substrate for QT prolongation coupled with reports of non-cardiac drugs producing lethal arrhythmias captured worldwide attention from government regulators eventuating in a series of guidance documents that require virtually all new chemical compounds to undergo rigorous preclinical and clinical testing to profile their QT liability. While prolongation or shortening of the QT interval may herald the appearance of serious cardiac arrhythmias, the positive predictive value of an abnormal QT measurement for these arrhythmias is modest, especially in the absence of confounding clinical features or a congenital predisposition that increases the risk of syncope and sudden death. Consequently, there has been a paradigm shift to assess a compound's cardiac risk of arrhythmias centered on a mechanistic approach to arrhythmogenesis rather than focusing solely on the QT interval. This entails both robust preclinical and clinical assays along with the emergence of concentration QT modeling as a primary analysis tool to determine whether delayed ventricular repolarization is present. The purpose of this review is to provide a comprehensive understanding of the QT interval and highlight its central role in early drug development.
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Affiliation(s)
- Robert M Lester
- Cardiac Safety Services, Celerion, 2420 W Baseline Rd, Tempe, AZ 85283, USA.
| | | | - Ian A Johnson
- Cardiac Safety Services, Celerion, 2420 W Baseline Rd, Tempe, AZ 85283, USA.
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Vicente J. Update on the ECG component of the CiPA initiative. J Electrocardiol 2018; 51:S98-S102. [PMID: 30121123 DOI: 10.1016/j.jelectrocard.2018.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/23/2018] [Accepted: 08/07/2018] [Indexed: 10/28/2022]
Abstract
The Comprehensive in vitro Proarrhythmia Assay (CiPA) initiative is validating a new paradigm for assessing proarrhythmic potential of drugs that goes beyond hERG block and QT prolongation. Based on in vitro data of the drug's effects on multiple cardiac ion channel currents, CiPA's in silico model of the human cardiomyocyte will classify drugs as low, intermediate or high risk for torsade de pointes. Under CiPA, early phase 1 ECG data will be used to determine if there are unexpected ion channel effects in humans compared to the in vitro ion channel data. CiPA's ECG biomarker working group identified the heart rate corrected J-Tpeak interval (J-Tpeakc, from the end of the QRS to the peak of the T-wave) as the best of 12 ECG biomarkers to detect late sodium current block in presence of hERG block. While predominant hERG blockers prolonged QTc and J-Tpeakc, "balanced" ion channel blocking drugs (hERG + late sodium and/or calcium block) prolonged QTc without prolonging J-Tpeakc. This manuscript reviews the ECG component of CiPA and provides a description of the ECG methods used in the CiPA ECG validation clinical study.
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Affiliation(s)
- Jose Vicente
- Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA.
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Zusterzeel R, Vicente J, Ochoa-Jimenez R, Zhu J, Couderc JP, Akinnagbe-Zusterzeel E, Strauss DG. The 43rd International Society for Computerized Electrocardiology ECG initiative for the automated detection of strict left bundle branch block. J Electrocardiol 2018; 51:S25-S30. [PMID: 30082088 DOI: 10.1016/j.jelectrocard.2018.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/26/2018] [Accepted: 08/01/2018] [Indexed: 10/28/2022]
Abstract
The presence of left bundle branch block (LBBB) is an important predictor of benefit from cardiac resynchronization therapy (CRT). New "strict" electrocardiographic (ECG) criteria for LBBB have been shown to better predict benefit from CRT. The "strict" LBBB criteria include: QRS duration ≥140 ms (men) or ≥130 ms (women), QS- or rS-configurations of the QRS complex in leads V1 and V2, and mid-QRS notching or slurring in ≥2 of leads V1, V2, V5, V6, I and aVL. The "strict" LBBB criteria are not regularly used and most hospital automated ECG systems and physicians still use more conventional LBBB criteria. As part of the 43rd International Society for Computerized Electrocardiology (ISCE) meeting, we conducted an initiative on the automated detection of "strict" LBBB where industry and academic investigators could present their algorithm results on digital 12-lead ECGs with varying QRS morphologies from the MADIT-CRT trial (300 training and 302 test set ECGs that were manually adjudicated for "strict" LBBB presence). The results revealed a 64-82% accuracy, 48-76% sensitivity and 46-87% specificity for automated "strict" LBBB detection from 7 participants. Most mismatches were likely attributed to differences in detection and absence of specific definitions for notches and slurs while differences in QRS duration and S-waves in leads V1 and V2 were less problematic. The full unblinded training and test datasets including all ECG signals are being made available through the Telemetric and Holter ECG Warehouse (THEW) for further exploration.
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Affiliation(s)
| | - Jose Vicente
- U.S. Food and Drug Administration, Silver Spring, MD, USA
| | | | - Jun Zhu
- U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Jean-Philippe Couderc
- Telemetric and Holter ECG Warehouse, University of Rochester Medical Center, Rochester, NY, USA
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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.
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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
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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.
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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
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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.
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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
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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.
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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
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