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Elmeliegy M, Chen J, Dontabhaktuni A, Gaudy A, Kapitanov GI, Li J, Mim SR, Sharma S, Sun Q, Ait-Oudhia S. Dosing Strategies and Quantitative Clinical Pharmacology for Bispecific T-Cell Engagers Development in Oncology. Clin Pharmacol Ther 2024. [PMID: 38962850 DOI: 10.1002/cpt.3361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 06/09/2024] [Indexed: 07/05/2024]
Abstract
Bispecific T-cell Engagers (TCEs) are promising anti-cancer treatments that bind to both the CD3 receptors on T cells and an antigen on the surface of tumor cells, creating an immune synapse, leading to killing of malignant tumor cells. These novel therapies have unique development challenges, with specific safety risks of cytokine release syndrome. These on-target adverse events fortunately can be mitigated and deconvoluted from efficacy via innovative dosing strategies, making clinical pharmacology key in the development of these therapies. This review assesses dose selection and the role of quantitative clinical pharmacology in the development of the first eight approved TCEs. Model informed drug development (MIDD) strategies can be used at every stage to guide TCE development. Mechanistic modeling approaches allow for (1) efficacious yet safe first-in-human dose selection as compared with in vitro minimum anticipated biological effect level (MABEL) approach; (2) rapid escalation and reducing number of patients with subtherapeutic doses through model-based adaptive design; (3) virtual testing of different step-up dosing regimens that may not be feasible to be evaluated in the clinic; and (4) selection and justification of the optimal clinical step-up and full treatment doses. As the knowledge base around TCEs continues to grow, the relevance and utilization of MIDD strategies for supporting the development and dose optimization of these molecules are expected to advance, optimizing the benefit-risk profile for cancer patients.
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Affiliation(s)
- Mohamed Elmeliegy
- Oncology Research and Development, Pfizer Inc, San Diego, California, USA
| | - Joseph Chen
- Genentech Inc, South San Francisco, California, USA
| | | | | | | | - Junyi Li
- Genentech Inc, South San Francisco, California, USA
| | - Sabiha R Mim
- PharmaPro Consulting Inc, Hillsborough, New Jersey, USA
| | - Sharad Sharma
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, USA
| | - Qin Sun
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sihem Ait-Oudhia
- Quantitative Pharmacology and Pharmacometrics (QP2), Merck & Co., Rahway, New Jersey, USA
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2
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Lim K, Zhu XS, Zhou D, Ren S, Phipps A. Clinical Pharmacology Strategies for Bispecific Antibody Development: Learnings from FDA-Approved Bispecific Antibodies in Oncology. Clin Pharmacol Ther 2024. [PMID: 38825990 DOI: 10.1002/cpt.3308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/03/2024] [Indexed: 06/04/2024]
Abstract
Bispecific antibodies, by enabling the targeting of more than one disease-associated antigen or engaging immune effector cells, have both advantages and challenges compared with a combination of two different biological products. As of December 2023, there are 11 U.S. Food and Drug Administration-approved BsAb products on the market. Among these, 9 have been approved for oncology indications, and 8 of these are CD3 T-cell engagers. Clinical pharmacology strategies, including dose-related strategies, are critical for bispecific antibody development. This analysis reviewed clinical studies of all approved bispecific antibodies in oncology and identified dose-related perspectives to support clinical dose optimization and regulatory approvals, particularly in the context of the Food and Drug Administration's Project Optimus: (1) starting doses and dose ranges in first-in-human studies; (2) dose strategies including step-up doses or full doses for recommended phase 2 doses or dose level(s) used for registrational intent; (3) restarting therapy after dose delay; (4) considerations for the introduction of subcutaneous doses; (5) body weight vs. flat dosing strategy; and (6) management of immunogenicity. The learnings arising from this review are intended to inform successful strategies for future bispecific antibody development.
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Affiliation(s)
- KyoungSoo Lim
- Clinical Pharmacology & Quantitative Pharmacology, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - Xu Sue Zhu
- Clinical Pharmacology & Quantitative Pharmacology, BioPharmaceuticals R&D, AstraZeneca, Waltham, Massachusetts, USA
| | - Diansong Zhou
- Clinical Pharmacology & Quantitative Pharmacology, BioPharmaceuticals R&D, AstraZeneca, Waltham, Massachusetts, USA
| | - Song Ren
- Clinical Pharmacology & Quantitative Pharmacology, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - Alex Phipps
- Clinical Pharmacology & Quantitative Pharmacology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
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Qi T, Liao X, Cao Y. Development of bispecific T cell engagers: harnessing quantitative systems pharmacology. Trends Pharmacol Sci 2023; 44:880-890. [PMID: 37852906 PMCID: PMC10843027 DOI: 10.1016/j.tips.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/20/2023]
Abstract
Bispecific T cell engagers (bsTCEs) have emerged as a promising class of cancer immunotherapy. Several bsTCEs have achieved marketing approval; dozens more are under clinical investigation. However, the clinical development of bsTCEs remains rife with challenges, including nuanced pharmacology, limited translatability of preclinical findings, frequent on-target toxicity, and convoluted dosing regimens. In this opinion article we present a distinct perspective on how quantitative systems pharmacology (QSP) can serve as a powerful tool for overcoming these obstacles. Recent advances in QSP modeling have empowered developers of bsTCEs to gain a deeper understanding of their context-dependent pharmacology, bridge gaps in experimental data, guide first-in-human (FIH) dose selection, design dosing regimens with expanded therapeutic windows, and improve long-term treatment outcomes. We use recent case studies to exemplify the potential of QSP techniques to support future bsTCE development.
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Affiliation(s)
- Timothy Qi
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Xiaozhi Liao
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Yanguang Cao
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
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Pandiella A, Calvo E, Moreno V, Amir E, Templeton A, Ocana A. Considerations for the clinical development of immuno-oncology agents in cancer. Front Immunol 2023; 14:1229575. [PMID: 37638048 PMCID: PMC10451075 DOI: 10.3389/fimmu.2023.1229575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/26/2023] [Indexed: 08/29/2023] Open
Abstract
Targeting of the immune system has shown to be a successful therapeutic approach in cancer, with the development of check point inhibitors (ICI) or T-cell engagers (TCE). As immuno-oncology agents modulate the immune system to attack cancer cells and do not act directly on oncogenic vulnerabilities, specific characteristics of these compounds should be taken in consideration during clinical development. In this review we will discuss relevant concepts including limitations of preclinical models, special pharmacologic boundaries, clinical development strategies such as the selection of clinical indication, line of treatment and backbone partner, as well as the endpoints and expected magnitude of benefit required at different stages of the drug development. In addition, future directions for early and late trial designs will be reviewed. Examples from approved drugs or those currently in clinical development will be discussed and options to overcome these limitations will be provided.
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Affiliation(s)
- Atanasio Pandiella
- Centro de Investigación del Cáncer, CIC-CSIC, Salamanca, Spain
- Centro de Investigación Biomédica en Red en Oncología (CIBERONC), Madrid, Spain
| | - Emiliano Calvo
- START Madrid-HM Centro Integral Oncológico Clara Campal (CIOCC), Early Phase Program, HM Sanchinarro University Hospital, Madrid, Spain
| | - Victor Moreno
- START Madrid-Fundación Jiménez Díaz (FJD) Early Phase Program, Fundación Jiménez Díaz Hospital, Madrid, Spain
| | - Eitan Amir
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada
| | - Arnoud Templeton
- Department of Medical Oncology, St. Claraspital, Basel, Switzerland
| | - Alberto Ocana
- Centro de Investigación Biomédica en Red en Oncología (CIBERONC), Madrid, Spain
- START Madrid-Fundación Jiménez Díaz (FJD) Early Phase Program, Fundación Jiménez Díaz Hospital, Madrid, Spain
- Experimental Therapeutics Unit, Medical Oncology Department, Hospital Clínico San Carlos (HCSC), Instituto de Investigación Sanitaria (IdISSC), Madrid, Spain
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Niu J, Wang W, Ouellet D. Mechanism-based pharmacokinetic and pharmacodynamic modeling for bispecific antibodies: challenges and opportunities. Expert Rev Clin Pharmacol 2023; 16:977-990. [PMID: 37743720 DOI: 10.1080/17512433.2023.2257136] [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: 06/15/2023] [Accepted: 09/06/2023] [Indexed: 09/26/2023]
Abstract
INTRODUCTION Unlike conventional antibodies, bispecific antibodies (bsAbs) are engineered antibody- or antibody fragment-based molecules that can simultaneously recognize two different epitopes or antigens. Over the past decade, there has been an explosion of bsAbs being developed across therapeutic areas. Development of bsAbs presents unique challenges and mechanism-based pharmacokinetic/pharmacodynamic (PK/PD) modeling has served as a powerful tool to optimize their development and realize their clinical utility. AREAS COVERED In this review, the guiding principles and case examples of how fit-for-purpose, mechanism-based PK/PD models have been applied to answer questions commonly encountered in bsAb development are presented. Such models characterize the key pharmacological elements of bsAbs, and they can be utilized for model-informed drug development. We also include the discussion of challenges, knowledge gaps and future direction for such models. EXPERT OPINION Mechanistic PK/PD modeling is a powerful tool to support the development of bsAbs. These models can be extrapolated to predict treatment outcomes based on mechanisms of action (MoA) and clinical observations to form positive learn-and-confirm cycles during drug development, due to their abilities to differentiate system- and drug-specific parameters. Meanwhile, the models should keep being adapted according to novel drug design and MoA, providing continuous opportunities for model-informed drug development.
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Affiliation(s)
- Jin Niu
- Clinical Pharmacology and Pharmacometrics, Janssen Research & Development, Spring House, PA, USA
| | - Weirong Wang
- Clinical Pharmacology and Pharmacometrics, Janssen Research & Development, Spring House, PA, USA
| | - Daniele Ouellet
- Clinical Pharmacology and Pharmacometrics, Janssen Research & Development, Spring House, PA, USA
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Marcinek A, Brauchle B, Rohrbacher L, Hänel G, Philipp N, Märkl F, Strzalkowski T, Lacher SM, Udiljak D, Spiekermann K, Theurich S, Kobold S, Kischel R, James JR, Bücklein VL, Subklewe M. CD33 BiTE ® molecule-mediated immune synapse formation and subsequent T-cell activation is determined by the expression profile of activating and inhibitory checkpoint molecules on AML cells. Cancer Immunol Immunother 2023:10.1007/s00262-023-03439-x. [PMID: 37041225 DOI: 10.1007/s00262-023-03439-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 03/27/2023] [Indexed: 04/13/2023]
Abstract
Bispecific T-cell engager (BiTE®) molecules recruit T cells to cancer cells through CD3ε binding, independently of T-cell receptor (TCR) specificity. Whereas physiological T-cell activation is dependent on signal 1 (TCR engagement) and signal 2 (co-stimulation), BiTE molecule-mediated T-cell activation occurs without additional co-stimulation. As co-stimulatory and inhibitory molecules modulate the strength and nature of T-cell responses, we studied the impact of the expression profile of those molecules on target cells for BiTE molecule-mediated T-cell activation in the context of acute myeloid leukemia (AML). Accordingly, we created a novel in vitro model system using murine Ba/F3 cells transduced with human CD33 ± CD86 ± PD-L1. T-cell fitness was assessed by T-cell function assays in co-cultures and immune synapse formation by applying a CD33 BiTE molecule (AMG 330). Using our cell-based model platform, we found that the expression of positive co-stimulatory molecules on target cells markedly enhanced BiTE molecule-mediated T-cell activation. The initiation and stability of the immune synapse between T cells and target cells were significantly increased through the expression of CD86 on target cells. By contrast, the co-inhibitory molecule PD-L1 impaired the stability of BiTE molecule-induced immune synapses and subsequent T-cell responses. We validated our findings in primary T-cell-AML co-cultures, demonstrating a PD-L1-mediated reduction in redirected T-cell activation. The addition of the immunomodulatory drug (IMiD) lenalidomide to co-cultures led to stabilization of immune synapses and improved subsequent T-cell responses. We conclude that target cells modulate CD33 BiTE molecule-dependent T-cell activation and hence, combinatorial strategies might contribute to enhanced efficacy.
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Affiliation(s)
- Anetta Marcinek
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Bettina Brauchle
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Lisa Rohrbacher
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Gerulf Hänel
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Nora Philipp
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Florian Märkl
- Division of Clinical Pharmacology, Department of Medicine IV; Member of the German Center for Lung Research (DZL), University Hospital, LMU, Munich, Germany
| | - Thaddäus Strzalkowski
- Division of Clinical Pharmacology, Department of Medicine IV; Member of the German Center for Lung Research (DZL), University Hospital, LMU, Munich, Germany
| | - Sonja M Lacher
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Dragica Udiljak
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Karsten Spiekermann
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Experimental Leukemia and Lymphoma Research (ELLF), Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Theurich
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Cancer-and Immunometabolism Research Group, LMU Gene Center, Munich, Germany
| | - Sebastian Kobold
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Division of Clinical Pharmacology, Department of Medicine IV; Member of the German Center for Lung Research (DZL), University Hospital, LMU, Munich, Germany
| | - Roman Kischel
- AMGEN Research Munich GmbH, Munich, Germany
- AMGEN Inc., Thousand Oaks, CA, USA
| | - John R James
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Veit L Bücklein
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany
| | - Marion Subklewe
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany.
- Laboratory for Translational Cancer Immunology, LMU Gene Center, Munich, Germany.
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany.
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Ball K, Dovedi SJ, Vajjah P, Phipps A. Strategies for clinical dose optimization of T cell-engaging therapies in oncology. MAbs 2023; 15:2181016. [PMID: 36823042 PMCID: PMC9980545 DOI: 10.1080/19420862.2023.2181016] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/07/2023] [Accepted: 02/13/2023] [Indexed: 02/25/2023] Open
Abstract
Innovative approaches in the design of T cell-engaging (TCE) molecules are ushering in a new wave of promising immunotherapies for the treatment of cancer. Their mechanism of action, which generates an in trans interaction to create a synthetic immune synapse, leads to complex and interconnected relationships between the exposure, efficacy, and toxicity of these drugs. Challenges thus arise when designing optimal clinical dose regimens for TCEs with narrow therapeutic windows, with a variety of dosing strategies being evaluated to mitigate key side effects such as cytokine release syndrome, neurotoxicity, and on-target off-tumor toxicities. This review evaluates the current approaches to dose optimization throughout the preclinical and clinical development of TCEs, along with perspectives for improvement of these strategies. Quantitative approaches used to aid the understanding of dose-exposure-response relationships are highlighted, along with opportunities to guide the rational design of next-generation TCE molecules, and optimize their dose regimens in patients.
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Affiliation(s)
- Kathryn Ball
- Clinical Pharmacology and Quantitative Pharmacology, Biopharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | | | - Pavan Vajjah
- Clinical Pharmacology and Quantitative Pharmacology, Biopharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Alex Phipps
- Clinical Pharmacology and Quantitative Pharmacology, Biopharmaceuticals R&D, AstraZeneca, Cambridge, UK
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Pasquiers B, Benamara S, Felices M, Nguyen L, Declèves X. Review of the Existing Translational Pharmacokinetics Modeling Approaches Specific to Monoclonal Antibodies (mAbs) to Support the First-In-Human (FIH) Dose Selection. Int J Mol Sci 2022; 23:12754. [PMID: 36361546 PMCID: PMC9657028 DOI: 10.3390/ijms232112754] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 08/27/2023] Open
Abstract
The interest in therapeutic monoclonal antibodies (mAbs) has continuously growing in several diseases. However, their pharmacokinetics (PK) is complex due to their target-mediated drug disposition (TMDD) profiles which can induce a non-linear PK. This point is particularly challenging during the pre-clinical and translational development of a new mAb. This article reviews and describes the existing PK modeling approaches used to translate the mAbs PK from animal to human for intravenous (IV) and subcutaneous (SC) administration routes. Several approaches are presented, from the most empirical models to full physiologically based pharmacokinetic (PBPK) models, with a focus on the population PK methods (compartmental and minimal PBPK models). They include the translational approaches for the linear part of the PK and the TMDD mechanism of mAbs. The objective of this article is to provide an up-to-date overview and future perspectives of the translational PK approaches for mAbs during a model-informed drug development (MIDD), since the field of PK modeling has gained recently significant interest for guiding mAbs drug development.
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Affiliation(s)
- Blaise Pasquiers
- PhinC Development, 91300 Massy, France
- Université Paris Cité, Inserm UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, 75006 Paris, France
| | | | | | | | - Xavier Declèves
- Université Paris Cité, Inserm UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, 75006 Paris, France
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Haraya K, Tsutsui H, Komori Y, Tachibana T. Recent Advances in Translational Pharmacokinetics and Pharmacodynamics Prediction of Therapeutic Antibodies Using Modeling and Simulation. Pharmaceuticals (Basel) 2022; 15:ph15050508. [PMID: 35631335 PMCID: PMC9145563 DOI: 10.3390/ph15050508] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 02/05/2023] Open
Abstract
Therapeutic monoclonal antibodies (mAbs) have been a promising therapeutic approach for several diseases and a wide variety of mAbs are being evaluated in clinical trials. To accelerate clinical development and improve the probability of success, pharmacokinetics and pharmacodynamics (PKPD) in humans must be predicted before clinical trials can begin. Traditionally, empirical-approach-based PKPD prediction has been applied for a long time. Recently, modeling and simulation (M&S) methods have also become valuable for quantitatively predicting PKPD in humans. Although several models (e.g., the compartment model, Michaelis–Menten model, target-mediated drug disposition model, and physiologically based pharmacokinetic model) have been established and used to predict the PKPD of mAbs in humans, more complex mechanistic models, such as the quantitative systemics pharmacology model, have been recently developed. This review summarizes the recent advances and future direction of M&S-based approaches to the quantitative prediction of human PKPD for mAbs.
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Affiliation(s)
- Kenta Haraya
- Discovery Biologics Department, Research Division, Chugai Pharmaceutical Co., Ltd., 1-135 Komakado, Gotemba 412-8513, Japan;
- Correspondence:
| | - Haruka Tsutsui
- Discovery Biologics Department, Research Division, Chugai Pharmaceutical Co., Ltd., 1-135 Komakado, Gotemba 412-8513, Japan;
| | - Yasunori Komori
- Pharmaceutical Science Department, Translational Research Division, Chugai Pharmaceutical Co., Ltd., 1-135 Komakado, Gotemba 412-8513, Japan; (Y.K.); (T.T.)
| | - Tatsuhiko Tachibana
- Pharmaceutical Science Department, Translational Research Division, Chugai Pharmaceutical Co., Ltd., 1-135 Komakado, Gotemba 412-8513, Japan; (Y.K.); (T.T.)
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