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Meertens M, Giraud EL, van der Kleij MBA, Westerdijk K, Guchelaar NAD, Bleckman RF, Rieborn A, Imholz ALT, Otten HM, Vulink A, Los M, Hamberg P, van der Graaf WTA, Gelderblom H, Moes DJAR, Broekman KE, Touw DJ, Koolen SLW, Mathijssen RHJ, Huitema ADR, van Erp NP, Desar IME, Steeghs N. Evaluating the Clinical Impact and Feasibility of Therapeutic Drug Monitoring of Pazopanib in a Real-World Soft-Tissue Sarcoma Cohort. Clin Pharmacokinet 2024; 63:1045-1054. [PMID: 39012619 PMCID: PMC11271328 DOI: 10.1007/s40262-024-01399-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2024] [Indexed: 07/17/2024]
Abstract
INTRODUCTION AND OBJECTIVE Pazopanib is registered for metastatic renal cell carcinoma and soft-tissue sarcoma (STS). Its variable pharmacokinetic (PK) characteristics and narrow therapeutic range provide a strong rationale for therapeutic drug monitoring (TDM). Prior studies have defined target levels of drug exposure (≥ 20.5 mg/L) linked to prolonged progression-free survival (PFS), but the added value of using TDM remains unclear. This study investigates the effect of TDM of pazopanib in patients with STS on survival outcomes and dose-limiting toxicities (DLTs) and evaluates the feasibility of TDM-guided dosing. METHODS A TDM-guided cohort was compared to a non-TDM-guided cohort for PFS, overall survival (OS) and DLTs. PK samples were available from all patients, though not acted upon in the non-TDM-guided cohort. We evaluated the feasibility of TDM by comparing the proportion of underdosed patients in our TDM cohort with data from previous publications. RESULTS A total of 122 STS patients were included in the TDM-guided cohort (n = 95) and non-TDM-guided cohort (n = 27). The average exposure in the overall population was 30.5 mg/L and was similar in both groups. Median PFS and OS did not differ between the TDM-guided cohort and non-TDM-guided cohort (respectively 5.5 vs 4.4 months, p = 0.3, and 12.6 vs 10.1 months, p = 0.8). Slightly more patients in the non-TDM-guided cohort experienced DLTs (54%) compared to the TDM-guided cohort (44%). The proportion of underdosed patients (13.3%) was halved compared to historical data (26.7%). CONCLUSION TDM reduced the proportion of patients with subtherapeutic exposure levels by ~ 50%. Nonetheless, the added value of TDM for achieving target trough levels of ≥ 20.5 mg/L for pazopanib on survival outcomes could not be confirmed in STS patients.
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Affiliation(s)
- Marinda Meertens
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Eline L Giraud
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Maud B A van der Kleij
- Department of Medical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Kim Westerdijk
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Niels A D Guchelaar
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Roos F Bleckman
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Amy Rieborn
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Alex L T Imholz
- Department of Medical Oncology, Deventer Hospital, Deventer, The Netherlands
| | - Hans-Martin Otten
- Department of Medical Oncology, Meander Medical Centre, Amersfoort, The Netherlands
| | - Annelie Vulink
- Department of Medical Oncology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Maartje Los
- Department of Medical Oncology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Paul Hamberg
- Department of Medical Oncology, Franciscus Gasthuis & Vlietland, Schiedam, The Netherlands
| | - Winette T A van der Graaf
- Department of Medical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Dirk Jan A R Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - K Esther Broekman
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
- Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, Utrecht University Medical Centre, Utrecht, The Netherlands
- Department of Pharmacology, Princess Máxima Centre for Pediatric Oncology, Utrecht, The Netherlands
| | - Nielka P van Erp
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ingrid M E Desar
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Neeltje Steeghs
- Department of Medical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
- Department of Medical Oncology, Utrecht University Medical Centre, Utrecht, The Netherlands.
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2
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Del Re M, Crucitta S, Brighi N, Kinspergher S, Mercinelli C, Rizzo M, Conteduca V, Rebuzzi SE, Beninato T, Venturi G, Doni L, Verzoni E, Puglisi S, Landriscina M, Porta C, Manfredi F, Caffo O, De Giorgi U, Fogli S, Danesi R. Concomitant Administration of VEGFR Tyrosine Kinase and Proton Pump Inhibitors May Impair Clinical Outcome of Patients With Metastatic Renal Cancer. Clin Genitourin Cancer 2024:102147. [PMID: 39030142 DOI: 10.1016/j.clgc.2024.102147] [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: 12/08/2023] [Accepted: 06/23/2024] [Indexed: 07/21/2024]
Abstract
INTRODUCTION The administration of proton pump inhibitors (PPIs) is a common practice to reduce gastro-esophageal adverse events associated with drug treatments but may impair absorption and exposure to oncology drugs. This study investigated the effect of concomitant administration of PPIs and pazopanib, sunitinib and cabozantinib on survival of patients with metastatic clear cell renal carcinoma (mRCC). PATIENTS AND METHODS Total 451 patients receiving pazopanib, sunitinib and cabozantinib as first line treatment were enrolled in this retrospective study. Patients were defined as "no concomitant PPIs (PPI-)" if no PPIs were administered during TKIs, and as "concomitant PPIs (PPI+)" if the administration of PPIs was at least 75% of the time during which TKIs were given. RESULTS Eighty patients administered pazopanib were PPI- and 86 PPI+; no difference in PFS was observed (10.7 vs. 11.9 months, P = .79). If patients were stratified as short (n = 89) and long (n = 77) responders, there was a significant difference in terms of PFS in PPI+ (n = 47) versus PPI- (n = 30) in long responders, being 24.7 versus 38 months (P = .04), respectively. In the sunitinib cohort, no significant difference of PFS in PPI+ (n = 102) versus PPI- (n = 131) was found, being 11.3 versus 18.1 months, respectively (P=0.15). In the cabozantinib cohort, there was a statistically significant difference in PFS of PPI+ versus PPI- (6 months vs. not reached, P = .04). No correlation with adverse events was found. CONCLUSIONS This study demonstrates an association between PPIs and impaired PFS in mRCC patients given pazopanib and cabozantinib and recommends caution on their concomitant use.
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Affiliation(s)
- Marzia Del Re
- Department of Clinical and Experimental Medicine, Unit of Clinical Pharmacology and Pharmacogenetics, University of Pisa, Pisa, Italy
| | - Stefania Crucitta
- Department of Clinical and Experimental Medicine, Unit of Clinical Pharmacology and Pharmacogenetics, University of Pisa, Pisa, Italy
| | - Nicole Brighi
- Oncology Department, IRCCS Istituto Scientifico Romagnolo per lo Studio dei Tumori "Dino Amadori", Meldola, Italy
| | | | - Chiara Mercinelli
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Mimma Rizzo
- Division of Medical Oncology, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
| | - Vincenza Conteduca
- Unit of Medical Oncology and Biomolecular Therapy, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Sara Elena Rebuzzi
- Unit of Medical Oncology 1, Department of Internal Medicine and Medical Specialties, University of Genova, IRCCS Ospedale San Martino, Genova, Italy
| | - Teresa Beninato
- Department of Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Giulia Venturi
- Department of Oncology, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Laura Doni
- Department of Oncology, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Elena Verzoni
- Department of Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Silvia Puglisi
- Unit of Medical Oncology 1, Department of Internal Medicine and Medical Specialties, University of Genova, IRCCS Ospedale San Martino, Genova, Italy
| | - Matteo Landriscina
- Unit of Medical Oncology and Biomolecular Therapy, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Camillo Porta
- Division of Medical Oncology, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy; Interdisciplinary Department of Medicine, University of Bari "A. Moro", Bari, Italy
| | - Fiorella Manfredi
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Orazio Caffo
- Department of Medical Oncology, Santa Chiara Hospital, Trento, Italy
| | - Ugo De Giorgi
- Oncology Department, IRCCS Istituto Scientifico Romagnolo per lo Studio dei Tumori "Dino Amadori", Meldola, Italy
| | - Stefano Fogli
- Department of Clinical and Experimental Medicine, Unit of Clinical Pharmacology and Pharmacogenetics, University of Pisa, Pisa, Italy
| | - Romano Danesi
- Department of Oncology and Hemato-Oncology, University of Milano, Milano, Italy.
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Turjap M, Pelcová M, Gregorová J, Šmak P, Martin H, Štingl J, Peš O, Juřica J. Therapeutic Drug Monitoring of Pazopanib in Renal Cell Carcinoma and Soft Tissue Sarcoma: A Systematic Review. Ther Drug Monit 2024; 46:321-331. [PMID: 38723115 DOI: 10.1097/ftd.0000000000001206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 01/28/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Pazopanib, an anti-angiogenic multitarget tyrosine kinase inhibitor, has been approved for the treatment of metastatic renal cell carcinoma and soft tissue sarcoma. However, its recommended dose does not always produce consistent outcomes, with some patients experiencing adverse effects or toxicity. This variability is due to differences in the systemic exposure to pazopanib. This review aimed to establish whether sufficient evidence exists for the routine or selective therapeutic drug monitoring of pazopanib in adult patients with approved indications. METHODS A systematic search of the PubMed and Web of Science databases using search terms related to pazopanib and therapeutic drug monitoring yielded 186 and 275 articles, respectively. Ten articles associated with treatment outcomes or toxicity due to drug exposure were selected for review. RESULTS The included studies were evaluated to determine the significance of the relationship between drug exposure/Ctrough and treatment outcomes and between drug exposure and toxicity. A relationship between exposure and treatment outcomes was observed in 5 studies, whereas the trend was nonsignificant in 4 studies. A relationship between exposure and toxicity was observed in 6 studies, whereas 2 studies did not find a significant relationship; significance was not reported in 3 studies. CONCLUSIONS Sufficient evidence supports the therapeutic drug monitoring of pazopanib in adult patients to improve its efficacy and/or safety in the approved indications.
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Affiliation(s)
- Miroslav Turjap
- Department of Clinical Pharmacy, University Hospital Ostrava, Ostrava, Czech Republic
| | - Marta Pelcová
- Department of Biochemistry, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Jana Gregorová
- Department of Biochemistry, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Pavel Šmak
- Department of Biochemistry, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Hiroko Martin
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jan Štingl
- Department of Biochemistry, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ondřej Peš
- Department of Biochemistry, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jan Juřica
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Masaryk Memorial Cancer Institute, Brno, Czech Republic; and
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Masaryk University, Brno, Czech Republic
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Kato M, Maruyama S, Watanabe N, Yamada R, Suzaki Y, Ishida M, Kanno H. Preliminary Investigation of a Rapid and Feasible Therapeutic Drug Monitoring Method for the Real-Time Estimation of Blood Pazopanib Concentrations. AAPS J 2024; 26:48. [PMID: 38622446 DOI: 10.1208/s12248-024-00918-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/25/2024] [Indexed: 04/17/2024] Open
Abstract
Pazopanib is a multi-kinase inhibitor used to treat advanced/metastatic renal cell carcinoma and advanced soft tissue tumors; however, side effects such as diarrhea and hypertension have been reported, and dosage adjustment based on drug concentration in the blood is necessary. However, measuring pazopanib concentrations in blood using the existing methods is time-consuming; and current dosage adjustments are made using the results of blood samples taken at the patient's previous hospital visit (approximately a month prior). If the concentration of pazopanib could be measured during the waiting period for a doctor's examination at the hospital (in approximately 30 min), the dosage could be adjusted according to the patient's condition on that day. Therefore, we aimed to develop a method for rapidly measuring blood pazopanib concentrations (in approximately 25 min) using common analytical devices (a tabletop centrifuge and a spectrometer). This method allowed for pazopanib quantification in the therapeutic concentration range (25-50 μg/mL). Additionally, eight popular concomitant medications taken simultaneously with pazopanib did not interfere with the measurements. We used the developed method to measure blood concentration in two patients and obtained similar results to those measured using the previously reported HPLC method. By integrating it with the point of care and sample collection by finger pick, this method can be used for measurements in pharmacies and patients' homes. This method can maximize the therapeutic effects of pazopanib by dose adjustment to control adverse events.
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Affiliation(s)
- Masaru Kato
- Department of Bioanalytical Chemistry, Showa University Graduate School of Pharmacy, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan.
| | - Shinichi Maruyama
- Department of Bioanalytical Chemistry, Showa University Graduate School of Pharmacy, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
- Department of Pharmacy, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi Tsurumi-ku, Yokohama, Kanagawa, 230-8765, Japan
| | - Noriko Watanabe
- Department of Bioanalytical Chemistry, Showa University Graduate School of Pharmacy, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Risa Yamada
- Department of Bioanalytical Chemistry, School of Pharmacy, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Yuki Suzaki
- Department of Bioanalytical Chemistry, School of Pharmacy, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Masaru Ishida
- Department of Urology, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi Tsurumi-ku, Yokohama, Kanagawa, 230-8765, Japan
| | - Hiroshi Kanno
- Department of Pharmacy, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi Tsurumi-ku, Yokohama, Kanagawa, 230-8765, Japan
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Henriksen JN, Andersen CU, Fristrup N. Therapeutic Drug Monitoring for Tyrosine Kinase Inhibitors in Metastatic Renal Cell Carcinoma. Clin Genitourin Cancer 2024; 22:102064. [PMID: 38555681 DOI: 10.1016/j.clgc.2024.102064] [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: 12/22/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 04/02/2024]
Abstract
Inter-individual variability in drug response pose significant challenges to treatment with tyrosine kinase inhibitors (TKIs) in patients with metastatic renal cell carcinoma (mRCC). TKIs meet traditional criteria for using therapeutic drug monitoring (TDM), but research is still limited. Understanding the role of TDM in individualizing treatment strategies could help optimize treatment. Here we review the state of knowledge of TDM for TKIs in mRCC treatment. A comprehensive literature review of original research studies focusing on TDM of TKIs in mRCC treatment, clinical in vivo studies reporting on pharmacokinetics-pharmacodynamics, therapeutic ranges, drug concentrations, dose adjustments, clinical outcomes, or other relevant aspects related to TDM. We reviewed studies involving human subjects published in peer-reviewed journals. A narrative synthesis approach was employed to summarize the findings. Key themes and trends related to TDM of TKIs in mRCC treatment were identified and synthesized to provide a comprehensive overview of the current state of knowledge. Our search yielded 25 articles. Most were observational. The most consistently reported association between plasma concentration and effect was pazopanib Ctrough >20 µg/mL, but this concentration was not significant across all studies. We found inconsistent evidence for sunitinib and cabozantinib. For axitinib, we found a clear exposure-response relationship, but research was too diverse to conclude on a therapeutic window to use for TDM. We found much heterogeneity between recommended time of measurement (minimum plasma concentration [Cmin], maximal plasma concentration [Cmax], area under the curve [AUC]) and large variation in plasma concentration associated with clinical outcomes, which makes it difficult to recommend specific concentration intervals based on 1 or more of these measurements. Results were more consistent with TKIs continuously administered. Further research is needed to elucidate the long-term impact of TDM to possibly establish standardized therapeutic intervals. Prospective studies are suggested. The application of TDM in TKI-combination therapy is warranted in future research.
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Affiliation(s)
- Jakob N Henriksen
- Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus N, Denmark; Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark.
| | - Charlotte U Andersen
- Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus N, Denmark; Department of Forensic Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Niels Fristrup
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
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Tardy C, Puszkiel A, Boudou-Rouquette P, De Percin S, Alexandre J, Berge M, Ulmann G, Blanchet B, Batista R, Goldwasser F, Thomas Schoemann A. Pazopanib pharmacokinetically guided dose optimization in three cancer patients with gastrointestinal resection. Cancer Chemother Pharmacol 2024; 93:169-175. [PMID: 37620675 DOI: 10.1007/s00280-023-04574-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE Pazopanib is approved in advanced renal cell carcinoma (RCC) and soft-tissue sarcoma at a flat-fixed dose despite a large pharmacokinetics interindividual variability and a narrow therapeutic index. To our knowledge, pazopanib exposure in patients with gastrointestinal resections (GIR) has not been described. This report focuses on feasibility of pharmacokinetics-guided dose escalation in these patients and clinical implications for their management. METHOD A retrospective data collection was performed for three patients with GIR treated with pazopanib, including pazopanib plasma concentrations (high-performance liquid chromatography with UV detection) and treatment adherence (Girerd score). CASE PRESENTATION First patient (55-year-old man, RCC, gastric bypass surgery) pazopanib Cmin,ss at day 39 was 4.1 mg/L. Dose escalation to 1800 mg/day fractionated allowed to reach Cmin,ss of 18.5 mg/L (target threshold in RCC patients: 20.5 mg/L). Patient 2 (50-year-old woman, metastatic myxofibrosarcoma, gastric band) showed Cmin,ss of 4.0 mg/L at day 13. In patient 3 (49-year-old man, gastric malignant peripheral nerve sheath tumor, gastrectomy), Cmin,ss at day 13 was 2.7 mg/L. For these two patients, intake with food and dose fractioning only slightly increased pazopanib Cmin,ss to 12.0 mg/L and 6.5 mg/L, respectively (therapeutic threshold in sarcoma patients: 27 mg/L). Treatment adherence was good in all patients. CONCLUSION Optimal pazopanib exposure cannot be achieved in patients with GIR, and thus, other therapeutic strategies should be encouraged. Pretherapeutic assessment seems crucial to evaluate factors as bariatric surgery that may impact pazopanib concentrations. Therapeutic drug monitoring could be helpful to optimize pazopanib response in these patients.
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Affiliation(s)
- Cléa Tardy
- Pharmacy Department, Cochin Hospital (AP-HP), CARPEM, Paris, France.
| | - Alicja Puszkiel
- Biologie du Médicament-Toxicologie, Cochin Hospital (AP-HP), Paris, France
- INSERM UMR-S1144, Université Paris Cité, Paris, France
| | | | | | - Jérôme Alexandre
- Oncology Department, Cochin Hospital (AP-HP), CARPEM, Paris, France
- Centre de Recherche des Cordeliers, Université Paris-Sorbonne, INSERM, 75005, Paris, France
| | - Marion Berge
- Pharmacy Department, Cochin Hospital (AP-HP), CARPEM, Paris, France
| | | | - Benoit Blanchet
- Biologie du Médicament-Toxicologie, Cochin Hospital (AP-HP), Paris, France
| | - Rui Batista
- Pharmacy Department, Cochin Hospital (AP-HP), CARPEM, Paris, France
| | | | - Audrey Thomas Schoemann
- Pharmacy Department, Cochin Hospital (AP-HP), CARPEM, Paris, France
- Université Paris Cité, UMR 8038 CNRS, CiTCom, INSERM U1268, 75006, Paris, France
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7
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Giraud EL, Te Brake LMH, van den Hombergh ECA, Desar IME, Kweekel DM, van Erp NP. Results of the first international quality control programme for oral targeted oncolytics. Br J Clin Pharmacol 2024; 90:336-343. [PMID: 37776845 DOI: 10.1111/bcp.15918] [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: 06/22/2023] [Revised: 09/20/2023] [Accepted: 09/22/2023] [Indexed: 10/02/2023] Open
Abstract
AIMS With the rising number of oral targeted oncolytics and growing awareness of the benefits of therapeutic drug monitoring (TDM) within the field of oncology, it is expected that the requests for quantifying concentrations of these drugs will increase. It is important to (cross-)validate available assays and ensure its quality, as results may lead to altered dosing recommendations. Therefore, we aimed to evaluate the performance of laboratories measuring concentrations of targeted oral oncolytics in a one-time international quality control (QC) programme. METHODS Participating laboratories received a set of plasma samples containing low, medium and high concentrations of imatinib, sunitinib, desethylsunitinib, pazopanib, cabozantinib, olaparib, enzalutamide, desmethylenzalutamide and abiraterone, with the request to report their results back within five weeks after shipment. Accuracy was defined acceptable if measurements where within 85%-115% from the weighed-in reference concentrations. Besides descriptive statistics, an exploratory ANOVA was performed. RESULTS Seventeen laboratories from six countries reported 243 results. Overall, 80.7% of all measurements were within the predefined range of acceptable accuracy. Laboratories performed best in quantifying imatinib and poorest in quantifying desethylsunitinib (median absolute inaccuracy respectively 4.0% (interquartile range (IQR) 1.8%-6.5%) and 15.5% (IQR 8.8%-34.9%)). The poorest performance of desethylsunitinib might be caused by using the stable-isotope-labelled sunitinib instead of desethylsunitinib as an internal standard, or due to the light-induced cis(Z)/trans(E) isomerization of (desethyl)sunitinib. Overall, drug substance and performing laboratory seemed to influence the absolute inaccuracy (F = 16.4; p < 0.001 and F = 35.5; p < 0.001, respectively). CONCLUSION Considering this is the first evaluation of an international QC programme for oral targeted oncolytics, an impressive high percentage of measurements were within the predefined range of accuracy. Cross-validation of assays that are used for dose optimization of oncolytics will secure the performance and will protect patients from incorrect advices.
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Affiliation(s)
- Eline L Giraud
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lindsey M H Te Brake
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Erik C A van den Hombergh
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ingrid M E Desar
- Department of Medical Oncology, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Dina M Kweekel
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, The Netherlands
- Drug Analysis and Toxicology division (KKGT) of the Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Utrecht, The Netherlands
| | - Nielka P van Erp
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
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8
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Westerdijk K, Steeghs N, Tacke CSJ, van der Graaf WTA, van Erp NP, van Oortmerssen G, Hermens RPMG, Desar IME. Therapeutic drug monitoring to personalize dosing of imatinib, sunitinib, and pazopanib: A mixed methods study on barriers and facilitators. Cancer Med 2023; 12:21041-21056. [PMID: 37902257 PMCID: PMC10709747 DOI: 10.1002/cam4.6663] [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: 03/28/2023] [Revised: 08/20/2023] [Accepted: 10/03/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND Personalized dosing based on measurement of individual drug levels and adjusting the dose accordingly can improve efficacy and decrease unnecessary toxicity of oncological treatment. For imatinib, sunitinib, and pazopanib, this therapeutic drug monitoring (TDM)-guided dosing is, however, not routinely used, despite accumulating evidence favoring individualized dosing. Therefore, we aimed to identify and quantify (potential) barriers and facilitators in TDM-guided dosing for imatinib, sunitinib, and pazopanib. METHODS We performed a mixed methods study among all stakeholders involved: patients, healthcare professionals (HCPs), pharmaceutical companies, and health insurance companies. During the first qualitative part of this study, we performed semi-structured individual interviews and one focus group interview to identify all (potential) barriers and facilitators, and during the second quantitative part of this study, we used a web-based survey to quantify these findings. The interviews addressed the six domains of the implementation of change model of Grol and Wensing: (1) the innovation itself; (2) the HCP; (3) the patient; (4) social context; (5) organizational context; and (6) finances, law, and governance. RESULTS In the qualitative study, we interviewed 20 patients, 18 HCPs and 10 representatives of pharmaceutical and health insurance companies and identified 72 barriers and 90 facilitators. In the quantitative study, the survey was responded by 66 HCPs and 58 patients. Important barriers were on the domain of the HCP, such as a lack of experience with TDM (36.4%), on the domain of the patient, such as lack of awareness of TDM (39.7%), and the processing time for measurement and interpretation of the TDM result (40.9%) (organizational domain). Important facilitators were education of HCPs (95.5%), education of patients (87.9%) and facilitating an overview of when and where TDM measurements are being performed (86.4%). CONCLUSION We identified and quantified important barriers and facilitators for the implementation of TDM-guided dosing for imatinib, sunitinib, and pazopanib. Based on our results, the implementation strategy should mainly focus on educating both HCPs and patients and on the organizational aspect of TDM.
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Affiliation(s)
- Kim Westerdijk
- Department of Medical OncologyResearch Institute for Medical Innovation, Radboud University Medical CenterNijmegenThe Netherlands
| | - Neeltje Steeghs
- Department of Medical OncologyNetherlands Cancer Institute, Antoni van LeeuwenhoekAmsterdamThe Netherlands
| | - Casper S. J. Tacke
- Department of Medical OncologyResearch Institute for Medical Innovation, Radboud University Medical CenterNijmegenThe Netherlands
| | - Winette T. A. van der Graaf
- Department of Medical OncologyNetherlands Cancer Institute, Antoni van LeeuwenhoekAmsterdamThe Netherlands
- Department of Medical OncologyErasmus MC Cancer Institute, Erasmus Medical Center RotterdamRotterdamThe Netherlands
| | - Nielka P. van Erp
- Department of PharmacyResearch Institute for Medical Innovation, Radboud University Medical CenterNijmegenThe Netherlands
| | | | | | - Ingrid M. E. Desar
- Department of Medical OncologyResearch Institute for Medical Innovation, Radboud University Medical CenterNijmegenThe Netherlands
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9
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van der Kleij MBA, Guchelaar NAD, Mathijssen RHJ, Versluis J, Huitema ADR, Koolen SLW, Steeghs N. Therapeutic Drug Monitoring of Kinase Inhibitors in Oncology. Clin Pharmacokinet 2023; 62:1333-1364. [PMID: 37584840 PMCID: PMC10519871 DOI: 10.1007/s40262-023-01293-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/17/2023]
Abstract
Although kinase inhibitors (KI) frequently portray large interpatient variability, a 'one size fits all' regimen is still often used. In the meantime, relationships between exposure-response and exposure-toxicity have been established for several KIs, so this regimen could lead to unnecessary toxicity and suboptimal efficacy. Dose adjustments based on measured systemic pharmacokinetic levels-i.e., therapeutic drug monitoring (TDM)-could therefore improve treatment efficacy and reduce the incidence of toxicities. Therefore, the aim of this comprehensive review is to give an overview of the available evidence for TDM for the 77 FDA/EMA kinase inhibitors currently approved (as of July 1st, 2023) used in hematology and oncology. We elaborate on exposure-response and exposure-toxicity relationships for these kinase inhibitors and provide practical recommendations for TDM and discuss corresponding pharmacokinetic targets when possible.
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Affiliation(s)
- Maud B A van der Kleij
- Division of Medical Oncology, Department of Clinical Pharmacology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Niels A D Guchelaar
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jurjen Versluis
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
- Department of Pharmacy, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Neeltje Steeghs
- Division of Medical Oncology, Department of Clinical Pharmacology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
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10
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van Eerden RAG, IJzerman NS, van Meekeren M, Oomen-de Hoop E, Guchelaar NAD, Visser AMW, Matic M, van Schaik RHN, de Bruijn P, Moes DJAR, Jobse PA, Gelderblom H, Huitema ADR, Steeghs N, Mathijssen RHJ, Koolen SLW. CYP3A4*22 Genotype-Guided Dosing of Kinase Inhibitors in Cancer Patients. Clin Pharmacokinet 2023; 62:1129-1139. [PMID: 37310647 PMCID: PMC10386914 DOI: 10.1007/s40262-023-01260-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 06/14/2023]
Abstract
INTRODUCTION A genetic variant explaining a part of the exposure of many kinase inhibitors (KIs) is the single nucleotide polymorphism (SNP) CYP3A4*22, resulting in less CYP3A4 enzyme activity. The primary aim of this study was to investigate if the systemic exposure is non-inferior after a dose reduction of KIs metabolized by CYP3A4 in CYP3A4*22 carriers compared to patients without this SNP (i.e., wildtype patients) receiving the standard dose. METHODS In this multicenter, prospective, non-inferiority study, patients were screened for the presence of CYP3A4*22. Patients with the CYP3A4*22 SNP received a 20-33% dose reduction. At steady state, a pharmacokinetic (PK) analysis was performed and compared to the PK results from wildtype patients treated with the registered dose using a two-stage individual patient data meta-analysis approach. RESULTS In total, 207 patients were included in the final analysis. The CYP3A4*22 SNP was found in 16% of the patients in the final analysis (n = 34). Most of the included patients received imatinib (37%) or pazopanib (22%) treatment. The overall geometric mean ratio (GMR) comparing the exposure of the CYP3A4*22 carriers to the exposure of the wildtype CYP3A4 patients was 0.89 (90% confidence interval: 0.77-1.03). CONCLUSION Non-inferiority could not be proven for dose reduction of KIs metabolized by CYP3A4 in CYP3A4*22 carriers compared to the registered dose in wildtype patients. Therefore, an up-front dose reduction based upon the CYP3A4*22 SNP for all KIs does not seem an eligible new way of personalized therapy. TRIAL REGISTRATION International Clinical Trials Registry Platform Search Portal; number NL7514; registered 11/02/2019.
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Affiliation(s)
- Ruben A G van Eerden
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, PO box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Nikki S IJzerman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, PO box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Milan van Meekeren
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther Oomen-de Hoop
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, PO box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Niels A D Guchelaar
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, PO box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Andrea M W Visser
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, PO box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Maja Matic
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Peter de Bruijn
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, PO box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Dirk-Jan A R Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Pieter A Jobse
- Department of Internal Medicine, ADRZ, Goes, The Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Neeltje Steeghs
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, PO box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, PO box 2040, 3000 CA, Rotterdam, The Netherlands.
- Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands.
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11
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van Leuven J, Evans S, Kichenadasse G, Steeghs N, Bonevski B, Mikus G, van Dyk M. Framework for Implementing Individualised Dosing of Anti-Cancer Drugs in Routine Care: Overcoming the Logistical Challenges. Cancers (Basel) 2023; 15:3293. [PMID: 37444404 DOI: 10.3390/cancers15133293] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/26/2022] [Accepted: 12/26/2022] [Indexed: 07/15/2023] Open
Abstract
Precision medicine in oncology involves identifying the 'right drug', at the 'right dose', for the right person. Currently, many orally administered anti-cancer drugs, particularly kinase inhibitors (KIs), are prescribed at a standard fixed dose. Identifying the right dose remains one of the biggest challenges to optimal patient care. Recently the Precision Dosing Group established the Accurate Dosing of Anti-cancer Patient-centred Therapies (ADAPT) Program to address individualised dosing; thus, use existing anti-cancer drugs more safely and efficiently. In this paper, we outline our framework, based on the Medical Research Council (MRC) framework, with a simple 6-step process and strategies which have led to the successful implementation of the ADAPT program in South Australia. Implementation strategies in our 6-step process involve: (1) Evaluate the evidence and identify the cancer drugs: Literature review, shadowing other experts, establishing academic partnerships, adaptability/flexibility; (2) Establishment of analytical equipment for drug assays for clinical purposes: assessment for readiness, accreditation, feasibility, obtaining formal commitments, quality assurance to all stakeholders; (3) Clinical preparation and education: educational material, conducted educational meetings, involve opinion leaders, use of mass media, promote network weaving, conduct ongoing training; (4) Blood collection, sample preparation and analyses: goods received procedures, critical control points (transport time); (5) Interpret and release results with recommendations: facilitate the relay of clinical data to providers; (6) Clinical application: providing ongoing consultation, identify early adopters, identify, and prepare champions. These strategies were selected from the 73 implementation strategies outlined in the Expert Recommendations for Implementing Change (ERIC) study. The ADAPT program currently provides routine plasma concentrations for patients on several orally administered drugs in South Australia and is currently in its evaluation phase soon to be published. Our newly established framework could provide great potential and opportunities to advance individualised dosing of oral anti-cancer drugs in routine clinical care.
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Affiliation(s)
- Jason van Leuven
- College of Medicine and Public Health, Flinders University, Adelaide 5042, Australia
- Medical Oncology, Flinders Medical Centre, Adelaide 5042, Australia
| | - Simon Evans
- Implementation Science Unit, Department for Health and Wellbeing, Adelaide 5042, Australia
| | - Ganessan Kichenadasse
- College of Medicine and Public Health, Flinders University, Adelaide 5042, Australia
- Medical Oncology, Flinders Medical Centre, Adelaide 5042, Australia
| | - Neeltje Steeghs
- Antoni van Leeuwenhoek Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
- Department of Medical Oncology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Billie Bonevski
- College of Medicine and Public Health, Flinders University, Adelaide 5042, Australia
| | - Gerd Mikus
- College of Medicine and Public Health, Flinders University, Adelaide 5042, Australia
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Madelé van Dyk
- College of Medicine and Public Health, Flinders University, Adelaide 5042, Australia
- Medical Oncology, Flinders Medical Centre, Adelaide 5042, Australia
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12
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Zhong Q, Xiao X, Qiu Y, Xu Z, Chen C, Chong B, Zhao X, Hai S, Li S, An Z, Dai L. Protein posttranslational modifications in health and diseases: Functions, regulatory mechanisms, and therapeutic implications. MedComm (Beijing) 2023; 4:e261. [PMID: 37143582 PMCID: PMC10152985 DOI: 10.1002/mco2.261] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 03/26/2023] [Accepted: 03/27/2023] [Indexed: 05/06/2023] Open
Abstract
Protein posttranslational modifications (PTMs) refer to the breaking or generation of covalent bonds on the backbones or amino acid side chains of proteins and expand the diversity of proteins, which provides the basis for the emergence of organismal complexity. To date, more than 650 types of protein modifications, such as the most well-known phosphorylation, ubiquitination, glycosylation, methylation, SUMOylation, short-chain and long-chain acylation modifications, redox modifications, and irreversible modifications, have been described, and the inventory is still increasing. By changing the protein conformation, localization, activity, stability, charges, and interactions with other biomolecules, PTMs ultimately alter the phenotypes and biological processes of cells. The homeostasis of protein modifications is important to human health. Abnormal PTMs may cause changes in protein properties and loss of protein functions, which are closely related to the occurrence and development of various diseases. In this review, we systematically introduce the characteristics, regulatory mechanisms, and functions of various PTMs in health and diseases. In addition, the therapeutic prospects in various diseases by targeting PTMs and associated regulatory enzymes are also summarized. This work will deepen the understanding of protein modifications in health and diseases and promote the discovery of diagnostic and prognostic markers and drug targets for diseases.
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Affiliation(s)
- Qian Zhong
- Department of Endocrinology and MetabolismGeneral Practice Ward/International Medical Center WardGeneral Practice Medical Center and National Clinical Research Center for GeriatricsState Key Laboratory of BiotherapyWest China Hospital, Sichuan UniversityChengduChina
| | - Xina Xiao
- Department of Endocrinology and MetabolismGeneral Practice Ward/International Medical Center WardGeneral Practice Medical Center and National Clinical Research Center for GeriatricsState Key Laboratory of BiotherapyWest China Hospital, Sichuan UniversityChengduChina
| | - Yijie Qiu
- Department of Endocrinology and MetabolismGeneral Practice Ward/International Medical Center WardGeneral Practice Medical Center and National Clinical Research Center for GeriatricsState Key Laboratory of BiotherapyWest China Hospital, Sichuan UniversityChengduChina
| | - Zhiqiang Xu
- Department of Endocrinology and MetabolismGeneral Practice Ward/International Medical Center WardGeneral Practice Medical Center and National Clinical Research Center for GeriatricsState Key Laboratory of BiotherapyWest China Hospital, Sichuan UniversityChengduChina
| | - Chunyu Chen
- Department of Endocrinology and MetabolismGeneral Practice Ward/International Medical Center WardGeneral Practice Medical Center and National Clinical Research Center for GeriatricsState Key Laboratory of BiotherapyWest China Hospital, Sichuan UniversityChengduChina
| | - Baochen Chong
- Department of Endocrinology and MetabolismGeneral Practice Ward/International Medical Center WardGeneral Practice Medical Center and National Clinical Research Center for GeriatricsState Key Laboratory of BiotherapyWest China Hospital, Sichuan UniversityChengduChina
| | - Xinjun Zhao
- Department of Endocrinology and MetabolismGeneral Practice Ward/International Medical Center WardGeneral Practice Medical Center and National Clinical Research Center for GeriatricsState Key Laboratory of BiotherapyWest China Hospital, Sichuan UniversityChengduChina
| | - Shan Hai
- Department of Endocrinology and MetabolismGeneral Practice Ward/International Medical Center WardGeneral Practice Medical Center and National Clinical Research Center for GeriatricsState Key Laboratory of BiotherapyWest China Hospital, Sichuan UniversityChengduChina
| | - Shuangqing Li
- Department of Endocrinology and MetabolismGeneral Practice Ward/International Medical Center WardGeneral Practice Medical Center and National Clinical Research Center for GeriatricsState Key Laboratory of BiotherapyWest China Hospital, Sichuan UniversityChengduChina
| | - Zhenmei An
- Department of Endocrinology and MetabolismGeneral Practice Ward/International Medical Center WardGeneral Practice Medical Center and National Clinical Research Center for GeriatricsState Key Laboratory of BiotherapyWest China Hospital, Sichuan UniversityChengduChina
| | - Lunzhi Dai
- Department of Endocrinology and MetabolismGeneral Practice Ward/International Medical Center WardGeneral Practice Medical Center and National Clinical Research Center for GeriatricsState Key Laboratory of BiotherapyWest China Hospital, Sichuan UniversityChengduChina
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13
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Maruyama S, Kato M, Hiraga T, Ishida M, Kanno H. Quantitative determination of plasma cabozantinib concentration using HPLC-UV and its application to patients with renal cell carcinoma. Biomed Chromatogr 2023; 37:e5599. [PMID: 36760165 DOI: 10.1002/bmc.5599] [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: 12/24/2022] [Revised: 02/03/2023] [Accepted: 02/07/2023] [Indexed: 02/11/2023]
Abstract
Cabozantinib is an oral small-molecule tyrosine kinase inhibitor that has become a standard of care for advanced renal cell carcinoma (RCC). However, cabozantinib is associated with a high rate of adverse events. Therefore, individualised cabozantinib administration and monitoring could help maximise its therapeutic efficacy and avoid serious adverse events. This study developed and validated a method to determine cabozantinib concentration in plasma using HPLC-UV. Sorafenib, an internal standard, was added to the plasma sample containing cabozantinib. A calibration curve for cabozantinib showed good linearity (R2 = 1.00), between 25 and 4,000 ng/ml. The recovery rate was above 92.1%, and the intra- and inter-day coefficients of variation were smaller than 5.2 and 6.8%, respectively. Then, we applied the method for monitoring cabozantinib blood levels in three patients with advanced RCC who were taking cabozantinib at a dose of 20, 40 or 60 mg/day. Grade 3 adverse events were more likely to occur in patients with high dosing and blood level of cabozantinib. Owing to its simplicity, the developed method can be used in general hospitals, and is expected to help maximise drug efficacy and minimise serious adverse events in many patients with RCC undergoing cabozantinib treatment.
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Affiliation(s)
- Shinichi Maruyama
- Department of Pharmacy, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Kanagawa, Japan.,Division of Bioanalytical Chemistry, Graduate School of Pharmacy, Tokyo, Japan
| | - Masaru Kato
- Division of Bioanalytical Chemistry, Graduate School of Pharmacy, Tokyo, Japan
| | - Tatsuru Hiraga
- Department of Pharmacy, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Kanagawa, Japan
| | - Masaru Ishida
- Department of Urology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Kanagawa, Japan
| | - Hiroshi Kanno
- Department of Pharmacy, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Kanagawa, Japan
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14
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Association between pazopanib exposure and safety in Japanese patients with renal cell carcinoma or soft tissue sarcoma. Sci Rep 2023; 13:2099. [PMID: 36746987 PMCID: PMC9902386 DOI: 10.1038/s41598-023-28688-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 01/23/2023] [Indexed: 02/08/2023] Open
Abstract
The safety and effectiveness of pazopanib are related to plasma trough concentrations in renal cell carcinoma (RCC); however, data on pazopanib plasma trough concentrations with soft tissue sarcoma (STS) are limited. This study investigated the relationship between plasma trough concentrations and pazopanib safety in 45 Japanese patients with RCC or STS. Among the 33 patients included, the median pazopanib trough concentration was 37.5 (range, 12.1-67.6) µg/mL, which was not significantly different between Japanese RCC and STS patients. The plasma trough concentrations showed significant and positive correlations with aspartate aminotransferase and alanine aminotransferase values in blood samples taken for pharmacokinetic measurements after the administration. The incidence of pazopanib treatment discontinuation were significantly higher in RCC patients (p = 0.027). The primary reason for treatment discontinuation was hepatic dysfunction (5/6, 83.3%). Furthermore, this study revealed that pazopanib trough concentration was affected significantly by proton pump inhibitors but not by histamine 2-receptor blockers. In conclusion, the observed pazopanib trough levels and their safety in the Japanese RCC and STS populations in this study were similar to those of the global population. This is the first study to correlate the hepatotoxicity and pharmacokinetic property of pazopanib plasma trough levels by comparing Japanese patients with RCC or STS.
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15
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Puisset F, Mseddi M, Mourey L, Pouessel D, Blanchet B, Chatelut E, Chevreau C. Therapeutic Drug Monitoring of Tyrosine Kinase Inhibitors in the Treatment of Advanced Renal Cancer. Cancers (Basel) 2023; 15:cancers15010313. [PMID: 36612311 PMCID: PMC9818258 DOI: 10.3390/cancers15010313] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/28/2022] [Accepted: 12/30/2022] [Indexed: 01/05/2023] Open
Abstract
Seven tyrosine kinase inhibitor compounds with anti-angiogenic properties remain key drugs to treat advanced renal cell carcinoma. There is a strong rationale to develop therapeutic drug monitoring for these drugs. General considerations of such monitoring of the several groups of anticancer drugs are given, with a focus on oral therapy. Pharmacokinetics and the factors of inter- and intraindividual variabilities of these tyrosine kinase inhibitors are described together with an exhaustive presentation of their pharmacokinetic/pharmacodynamic relationships. The latter was observed in studies where every patient was treated with the same dose, and the results of several prospective studies based on dose individualization support the practice of increasing individual dosage in case of low observed plasma drug concentrations. Finally, the benefits and limits of therapeutic drug monitoring as a routine practice are discussed.
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Affiliation(s)
- Florent Puisset
- Institut Claudius-Regaud, Institut Universitaire du Cancer de Toulouse–Oncopole, 31059 Toulouse, France
- CRCT, Cancer Research Center of Toulouse, Inserm U1037, Université Paul Sabatier, 31037 Toulouse, France
| | - Mourad Mseddi
- Department of Pharmacokinetics and Pharmacochemistry, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris, CARPEM, 75014 Paris, France
| | - Loïc Mourey
- Institut Claudius-Regaud, Institut Universitaire du Cancer de Toulouse–Oncopole, 31059 Toulouse, France
| | - Damien Pouessel
- Institut Claudius-Regaud, Institut Universitaire du Cancer de Toulouse–Oncopole, 31059 Toulouse, France
| | - Benoit Blanchet
- Department of Pharmacokinetics and Pharmacochemistry, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris, CARPEM, 75014 Paris, France
- UMR8038 CNRS, U1268 INSERM, Faculté de Pharmacie, Université Paris Cité, PRES Sorbonne Paris Cité, CARPEM, 75006 Paris, France
| | - Etienne Chatelut
- Institut Claudius-Regaud, Institut Universitaire du Cancer de Toulouse–Oncopole, 31059 Toulouse, France
- CRCT, Cancer Research Center of Toulouse, Inserm U1037, Université Paul Sabatier, 31037 Toulouse, France
- Correspondence: ; Tel.: +33-5-3115-5250
| | - Christine Chevreau
- Institut Claudius-Regaud, Institut Universitaire du Cancer de Toulouse–Oncopole, 31059 Toulouse, France
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Muacevic A, Adler JR, Watanabe T, Usui K, Ito J, Kaiho Y, Sato M, Okada K. Pazopanib-Induced Liver Injury in Patients With Metastatic Renal Cell Carcinoma: A Report of Two Cases. Cureus 2022; 14:e32474. [PMID: 36644081 PMCID: PMC9835853 DOI: 10.7759/cureus.32474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2022] [Indexed: 12/15/2022] Open
Abstract
We report two cases of pazopanib (PAZ)-induced liver injury in patients with metastatic renal cell carcinoma. The first patient was a 70-year-old female who was diagnosed with right renal cell carcinoma and showed tumor embolism in the inferior vena cava. PAZ was started but discontinued after about one month due to a grade four liver injury. The second patient was a 60-year-old male who was diagnosed with left renal cell carcinoma and suspected multiple lung metastases. PAZ was started following a laparoscopic left radical nephrectomy but was stopped after about a month due to a grade three liver injury. We analyzed the plasma PAZ concentrations for treatment evaluation. High plasma PAZ concentrations were observed in both patients after PAZ treatment began. Severe liver injury after PAZ administration may be associated with high plasma PAZ concentrations; hence, we should reduce PAZ dosage early. We also recommend monitoring plasma PAZ concentrations, if possible, so that physicians can either reduce the dosage or discontinue treatment to avoid further liver damage.
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17
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Effect of Concomitant Proton Pump Inhibitors with Pazopanib on Cancer Patients: A Retrospective Analysis. Cancers (Basel) 2022; 14:cancers14194721. [PMID: 36230642 PMCID: PMC9564055 DOI: 10.3390/cancers14194721] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 09/22/2022] [Accepted: 09/24/2022] [Indexed: 11/17/2022] Open
Abstract
The absorption of pazopanib depends on gastric pH. PPIs are frequently prescribed for cancer patients to modify gastric acidity, decreasing pazopanib absorption. The aim of our study was, retrospectively, to investigate the impact of PPIs on the clinical efficacy and safety of pazopanib in a cohort of patients treated in our health center. Of the 147 patients who were included retrospectively, 79 (54%) did not take PPIs concomitantly with pazopanib (cohort 1), while 68 (46%) patients did take PPIs concomitantly with pazopanib (cohort 2). The efficacy parameters were lower in patients taking pazopanib and PPIs: the i/tumor response was statistically different between the two cohorts (p = 0.008), in particular, with 19% vs. 3% of the objective response and 24% vs. 43% of progression in cohorts 1 and 2, respectively; ii/median overall survival was 17.6 (95% CI: 12.5−32.8) months in cohort 1 and 8.6 months (95% CI: 5.9−18.6) in cohort 2 (HR = 1.7 [95% CI: 1.2−2.5]; p < 0.006); on multivariable analysis, overall survival was associated with performance status, PPI intake, tumor location, hemoglobin, and PMN/lymphocyte ratio. In contrast, the dose reduction for toxicity and severe adverse events were (non-significantly) less frequent in cohort 1. To conclude, our study shows that combining PPIs with pazopanib has an adverse effect on overall survival. The clinical modifications that were observed are in line with a decrease in pazopanib absorption due to PPIs. This co-medication should be avoided.
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Amaro F, Pisoeiro C, Valente MJ, Bastos MDL, Guedes de Pinho P, Carvalho M, Pinto J. Sunitinib versus Pazopanib Dilemma in Renal Cell Carcinoma: New Insights into the In Vitro Metabolic Impact, Efficacy, and Safety. Int J Mol Sci 2022; 23:ijms23179898. [PMID: 36077297 PMCID: PMC9456255 DOI: 10.3390/ijms23179898] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/26/2022] [Accepted: 08/26/2022] [Indexed: 11/30/2022] Open
Abstract
Sunitinib and pazopanib are tyrosine kinase inhibitors (TKIs) used as first-line therapy for metastatic renal cell carcinoma (RCC). Although these TKIs are associated with similar survival outcomes, some differences have been reported in their safety profiles. In this work, traditional toxicological endpoints (cell viability and growth, oxidative stress, and nuclear morphology) and 1H NMR spectroscopy-based metabolomics analysis were used to provide new insights into the cytotoxicity and metabolic mechanisms underlying sunitinib and pazopanib treatments. Tumoral (Caki-1) and non-tumoral (HK-2) human renal cells were exposed to clinically relevant concentrations of sunitinib (2 µM) or pazopanib (50 µM). Sunitinib showed selectivity for cancer cells, inhibiting proliferation, and inducing apoptotic death of Caki-1 cells, whereas pazopanib had a similar cytotoxic effect in both tumoral and non-tumoral cells. 1H-NMR metabolomics unveiled a higher impact of sunitinib on the levels of intracellular metabolites of Caki-1 cells (seven dysregulated metabolites), suggesting dysregulations on amino acid, glutathione and glycerophospholipid metabolisms. In contrast, pazopanib had a higher impact on the levels of extracellular metabolites of Caki-1 cells (seven dysregulated metabolites in culture medium), unveiling alterations on amino acid and energetic metabolisms. In HK-2 cells, sunitinib caused only a minor increase in intracellular isoleucine levels, whereas pazopanib induced several alterations on the intracellular (three dysregulated metabolites) and extracellular (three dysregulated metabolites) compartments suggesting changes on amino acid, glycerophospholipid, and energy metabolisms. Our results demonstrate that these TKIs elicit distinct cellular and metabolic responses, with sunitinib showing better in vitro efficacy against target RCC cells and lesser nephrotoxic potential than pazopanib.
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Affiliation(s)
- Filipa Amaro
- Associate Laboratory i4HB, Department of Biological Sciences, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- UCIBIO-REQUIMTE, Department of Biological Sciences, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- Correspondence: (F.A.); (J.P.); Tel.: +351-220428796 (F.A. & J.P.)
| | - Carolina Pisoeiro
- Associate Laboratory i4HB, Department of Biological Sciences, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- UCIBIO-REQUIMTE, Department of Biological Sciences, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
| | - Maria João Valente
- National Food Institute, Technical University of Denmark, Kongens Lyngby, 2800 Copenhagen, Denmark
| | - Maria de Lourdes Bastos
- Associate Laboratory i4HB, Department of Biological Sciences, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- UCIBIO-REQUIMTE, Department of Biological Sciences, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
| | - Paula Guedes de Pinho
- Associate Laboratory i4HB, Department of Biological Sciences, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- UCIBIO-REQUIMTE, Department of Biological Sciences, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
| | - Márcia Carvalho
- Associate Laboratory i4HB, Department of Biological Sciences, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- UCIBIO-REQUIMTE, Department of Biological Sciences, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- FP-I3ID, FP-BHS, University Fernando Pessoa, 4200-150 Porto, Portugal
- Faculty of Health Sciences, University Fernando Pessoa, 4200-150 Porto, Portugal
| | - Joana Pinto
- Associate Laboratory i4HB, Department of Biological Sciences, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- UCIBIO-REQUIMTE, Department of Biological Sciences, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- Correspondence: (F.A.); (J.P.); Tel.: +351-220428796 (F.A. & J.P.)
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Noda S, Morita SY, Terada T. Dose Individualization of Oral Multi-Kinase Inhibitors for the Implementation of Therapeutic Drug Monitoring. Biol Pharm Bull 2022; 45:814-823. [PMID: 35786588 DOI: 10.1248/bpb.b21-01098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Oral multi-kinase inhibitors have transformed the treatment landscape for various cancer types and provided significant improvements in clinical outcomes. These agents are mainly approved at fixed doses, but the large inter-individual variability in pharmacokinetics and pharmacodynamics (efficacy and safety) has been an unsolved clinical issue. For example, certain patients treated with oral multi-kinase inhibitors at standard doses have severe adverse effects and require dose reduction and discontinuation, yet other patients have a suboptimal response to these drugs. Consequently, optimizing the dosing of oral multi-kinase inhibitors is important to prevent over-dosing or under-dosing. To date, multiple studies on the exposure-efficacy/toxicity relationship of molecular targeted therapy have been attempted for the implementation of therapeutic drug monitoring (TDM) strategies. In this milieu, we recently conducted research on several multi-kinase inhibitors, such as sunitinib, pazopanib, sorafenib, and lenvatinib, with the aim to optimize their treatment efficacy using a pharmacokinetic/pharmacodynamic approach. Among them, sunitinib use is an example of successful TDM implementation. Sunitinib demonstrated a significant correlation between drug exposure and treatment efficacy or toxicities. As a result, TDM services for sunitinib has been covered by the National Health Insurance program in Japan since April 2018. Additionally, other multi-kinase targeted anticancer drugs have promising data regarding the exposure-efficacy/toxicity relationship, suggesting the possibility of personalization of drug dosage. In this review, we provide a comprehensive summary of the clinical evidence for dose individualization of multi-kinase inhibitors and discuss the utility of TDM of multi-kinase inhibitors, especially sunitinib, pazopanib, sorafenib, and lenvatinib.
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Affiliation(s)
- Satoshi Noda
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | - Shin-Ya Morita
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | - Tomohiro Terada
- Department of Pharmacy, Shiga University of Medical Science Hospital.,Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital
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Minot-This MS, Boudou-Rouquette P, Jouinot A, de Percin S, Balakirouchenane D, Khoudour N, Tlemsani C, Chauvin J, Thomas-Schoemann A, Goldwasser F, Blanchet B, Alexandre J. Relation between Plasma Trough Concentration of Pazopanib and Progression-Free Survival in Metastatic Soft Tissue Sarcoma Patients. Pharmaceutics 2022; 14:pharmaceutics14061224. [PMID: 35745797 PMCID: PMC9231369 DOI: 10.3390/pharmaceutics14061224] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/04/2022] [Accepted: 06/07/2022] [Indexed: 12/20/2022] Open
Abstract
Background: Pazopanib (PAZ) is an oral angiogenesis inhibitor approved to treat soft tissue sarcoma (STS) but associated with a large interpatient pharmacokinetic (PK) variability and narrow therapeutic index. We aimed to define the specific threshold of PAZ trough concentration (Cmin) associated with better progression-free survival (PFS) in STS patients. Methods: In this observational study, PAZ Cmin was monitored over the treatment course. For the primary endpoint, the 3-month PFS in STS was analyzed with logistic regression. Second, we performed exposure−overall survival (OS) (Cox model plus Kaplan−Meier analysis/log-rank test) and exposure−toxicity analyses. Results: Ninety-five STS patients were eligible for pharmacokinetic/pharmacodynamic (PK/PD) assessment. In the multivariable analysis, PAZ Cmin < 27 mg/L was independently associated with a risk of progression at 3 months (odds ratio (OR) 4.21, 95% confidence interval (CI) (1.47−12.12), p = 0.008). A higher average of PAZ Cmin over the first 3 months was associated with a higher risk of grade 3−4 toxicities according to the NCI-CTCAE version 5.0 (OR 1.07 per 1 mg/L increase, CI95 (1.02−1.13), p = 0.007). Conclusion: PAZ Cmin ≥ 27 mg/L was independently associated with improved 3-month PFS in STS patients. Pharmacokinetically-guided dosing could be helpful to optimize the clinical management of STS patients in daily clinical practice.
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Affiliation(s)
- Marie-Sophie Minot-This
- Institut du Cancer Paris CARPEM, AP-HP, APHP.Centre, Department of Medical Oncology, ARIANE, Cochin Hospital, 75014 Paris, France; (M.-S.M.-T.); (A.J.); (S.d.P.); (C.T.); (F.G.); (J.A.)
| | - Pascaline Boudou-Rouquette
- Institut du Cancer Paris CARPEM, AP-HP, APHP.Centre, Department of Medical Oncology, ARIANE, Cochin Hospital, 75014 Paris, France; (M.-S.M.-T.); (A.J.); (S.d.P.); (C.T.); (F.G.); (J.A.)
- Correspondence:
| | - Anne Jouinot
- Institut du Cancer Paris CARPEM, AP-HP, APHP.Centre, Department of Medical Oncology, ARIANE, Cochin Hospital, 75014 Paris, France; (M.-S.M.-T.); (A.J.); (S.d.P.); (C.T.); (F.G.); (J.A.)
- INSERM U-1016, CNRS UMR-8104, University of Paris, Institut Cochin, 75014 Paris, France
| | - Sixtine de Percin
- Institut du Cancer Paris CARPEM, AP-HP, APHP.Centre, Department of Medical Oncology, ARIANE, Cochin Hospital, 75014 Paris, France; (M.-S.M.-T.); (A.J.); (S.d.P.); (C.T.); (F.G.); (J.A.)
| | - David Balakirouchenane
- Department of Pharmacokinetics and Pharmacochemistry, AP-HP, CARPEM, Cochin Hospital, 75014 Paris, France; (D.B.); (N.K.); (A.T.-S.); (B.B.)
- UMR8038 CNRS, U1268 INSERM, Faculty of Pharmacy, University of Paris, PRES Sorbonne Paris Cité, CARPEM, 75006 Paris, France
| | - Nihel Khoudour
- Department of Pharmacokinetics and Pharmacochemistry, AP-HP, CARPEM, Cochin Hospital, 75014 Paris, France; (D.B.); (N.K.); (A.T.-S.); (B.B.)
| | - Camille Tlemsani
- Institut du Cancer Paris CARPEM, AP-HP, APHP.Centre, Department of Medical Oncology, ARIANE, Cochin Hospital, 75014 Paris, France; (M.-S.M.-T.); (A.J.); (S.d.P.); (C.T.); (F.G.); (J.A.)
| | | | - Audrey Thomas-Schoemann
- Department of Pharmacokinetics and Pharmacochemistry, AP-HP, CARPEM, Cochin Hospital, 75014 Paris, France; (D.B.); (N.K.); (A.T.-S.); (B.B.)
- UMR8038 CNRS, U1268 INSERM, Faculty of Pharmacy, University of Paris, PRES Sorbonne Paris Cité, CARPEM, 75006 Paris, France
| | - François Goldwasser
- Institut du Cancer Paris CARPEM, AP-HP, APHP.Centre, Department of Medical Oncology, ARIANE, Cochin Hospital, 75014 Paris, France; (M.-S.M.-T.); (A.J.); (S.d.P.); (C.T.); (F.G.); (J.A.)
- Lixoft, 92160 Antony, France;
| | - Benoit Blanchet
- Department of Pharmacokinetics and Pharmacochemistry, AP-HP, CARPEM, Cochin Hospital, 75014 Paris, France; (D.B.); (N.K.); (A.T.-S.); (B.B.)
- UMR8038 CNRS, U1268 INSERM, Faculty of Pharmacy, University of Paris, PRES Sorbonne Paris Cité, CARPEM, 75006 Paris, France
| | - Jérôme Alexandre
- Institut du Cancer Paris CARPEM, AP-HP, APHP.Centre, Department of Medical Oncology, ARIANE, Cochin Hospital, 75014 Paris, France; (M.-S.M.-T.); (A.J.); (S.d.P.); (C.T.); (F.G.); (J.A.)
- Centre de Recherche des Cordeliers, Université Paris-Sorbonne, INSERM, 75005 Paris, France
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Krens SD, van Erp NP, Groenland SL, Moes DJAR, Mulder SF, Desar IME, van der Hulle T, Steeghs N, van Herpen CML. Exposure-response analyses of cabozantinib in patients with metastatic renal cell cancer. BMC Cancer 2022; 22:228. [PMID: 35236333 PMCID: PMC8892746 DOI: 10.1186/s12885-022-09338-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/17/2022] [Indexed: 11/10/2022] Open
Abstract
Aim In the registration trial, cabozantinib exposure ≥ 750 ng/mL correlated to improved tumor size reduction, response rate and progression free survival (PFS) in patients with metastatic renal cell cancer (mRCC). Because patients in routine care often differ from patients in clinical trials, we explored the cabozantinib exposure–response relationship in patients with mRCC treated in routine care. Methods Cabozantinib trough concentrations (Cmin) were collected and average exposure was calculated per individual. Exposure–response analyses were performed using the earlier identified target of Cmin > 750 ng/mL and median Cmin. In addition, the effect of dose reductions on response was explored. PFS was used as measure of response. Results In total, 59 patients were included:10% were classified as favourable, 61% as intermediate and 29% as poor IMDC risk group, respectively. Median number of prior treatment lines was 2 (0–5). Starting dose was 60 mg in 46%, 40 mg in 42% and 20 mg in 12% of patients. Dose reductions were needed in 58% of patients. Median Cmin was 572 ng/mL (IQR: 496–701). Only 17% of patients had an average Cmin ≥ 750 ng/mL. Median PFS was 52 weeks (95% CI: 40–64). No improved PFS was observed for patients with Cmin ≥ 750 ng/mL or ≥ 572 ng/ml. A longer PFS was observed for patients with a dose reduction vs. those without (65 vs. 31 weeks, p = .001). After incorporating known covariates (IMDC risk group and prior treatment lines (< 2 vs. ≥ 2)) in the multivariable analysis, the need for dose reduction remained significantly associated with improved PFS (HR 0.32, 95% CI:0.14–0.70, p = .004). Conclusion In these explorative analyses, no clear relationship between increased cabozantinib exposure and improved PFS was observed. Average cabozantinib exposure was below the previously proposed target in 83% of patients. Future studies should focus on validating the cabozantinib exposure required for long term efficacy. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09338-1.
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Affiliation(s)
- Stefanie D Krens
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - Nielka P van Erp
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Stefanie L Groenland
- Division of Medical Oncology, Department of Clinical Pharmacology, The Netherlands Cancer Institute-Antoni Van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Dirk Jan A R Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Sasja F Mulder
- Department of Medical Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Ingrid M E Desar
- Department of Medical Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Tom van der Hulle
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Neeltje Steeghs
- Division of Medical Oncology, Department of Clinical Pharmacology, The Netherlands Cancer Institute-Antoni Van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Carla M L van Herpen
- Department of Medical Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
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22
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Studentova H, Volakova J, Spisarova M, Zemankova A, Aiglova K, Szotkowski T, Melichar B. Severe tyrosine-kinase inhibitor induced liver injury in metastatic renal cell carcinoma patients: two case reports assessed for causality using the updated RUCAM and review of the literature. BMC Gastroenterol 2022; 22:49. [PMID: 35123392 PMCID: PMC8818210 DOI: 10.1186/s12876-022-02121-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 01/25/2022] [Indexed: 11/24/2022] Open
Abstract
Background Sunitinib and pazopanib are both oral small molecule multityrosine kinase inhibitors (MTKI) used in the treatment of renal cell carcinoma (RCC). Hepatotoxicity or “liver injury” is the most important adverse effect of pazopanib administration, but little is known about the underlying mechanism. Liver injury may also occur in patients treated with sunitinib, but severe toxicity is extremely rare. Herein we report two new cases of severe liver injury induced by MTKI. Both cases are unique and exceptional. We assessed both cases for drug-induced liver injury (DILI) using the updated score Roussel Uclaf causality assessment method (RUCAM). The literature on potential pathogenic mechanisms and precautionary measures is reviewed.
Case presentation A case of a metastatic RCC (mRCC) patient treated with pazopanib who had manifestation of severe liver injury is presented. These manifestations consisted of grade 4 alanine aminotransferase (ALT) increase and grade 4 hyperbilirubinemia. Alternate causes of acute or chronic liver disease were excluded. The patient gradually recovered from the liver injury and refused any further therapy for mRCC. The patient was diagnosed with acute myeloid leukemia (AML) two years later and eventually succumbed to the disease. The second case describes a mRCC patient treated with sunitinib for 3,5 years and fatal liver failure after 2 weeks of clarithromycin co-medication for acute bronchitis. Conclusions Liver injury has been commonly observed in TKI-treated patients with unpredictable course. Management requires regular routine liver enzyme-monitoring and the collaboration of medical oncologist and hepatologist. There is an unmet medical need for a risk stratification and definition of predictive biomarkers to identify potential genetic polymorphisms or other factors associated with TKI-induced liver injury. Any potential unrecommended concomitant therapy has to be avoided.
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Pazopanib in Patients with Osteosarcoma Metastatic to the Lung: Phase 2 Study Results and the Lessons for Tumor Measurement. JOURNAL OF ONCOLOGY 2022; 2022:3691025. [PMID: 35075361 PMCID: PMC8783732 DOI: 10.1155/2022/3691025] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 12/28/2021] [Indexed: 11/17/2022]
Abstract
Background. This single-arm, multicenter, phase 2 study evaluated the safety and antitumor activity of pazopanib in patients with unresectable, pulmonary metastatic osteosarcoma. Patients and Methods. Patients with pulmonary metastatic osteosarcoma unresponsive to chemotherapy were eligible. Patients who received prior tyrosine kinase inhibitor therapy were excluded. Pazopanib at 800 mg once daily was administered for 28-day cycles. Tumor responses were evaluated by local radiology assessment 1 month prior to and after initiation of treatment to calculate tumor doubling time and after every even numbered cycle. The primary endpoints were progression-free survival at 4 months, concomitant with a demonstrated 30% increase in tumor doubling time relative to the pretreatment growth rate. Results. 12 patients (7 female) were enrolled. The study was terminated prematurely due to withdrawal of financial support by the sponsor. 8 subjects were eligible for the primary analysis, whereas 4 patients were in a predefined exploratory “slow-growing” cohort. In the “fast-growing” cohort, 3 of the 8 patients (37.5%) eligible for first-stage analysis were deemed “success” by the preplanned criteria, adequate to proceed to second-stage accrual. In addition, 1 of the 4 patients in the “slow-growing” cohort experienced a partial remission. Grade 1-2 diarrhea was the most common adverse event, and grade 3 events were infrequent. Conclusion. This study illustrates a novel method of demonstrating positive drug activity in osteosarcoma by increasing tumor doubling time, and this is further supported by a partial response in a patient with “slow-growing” disease. This trial is registered with NCT01759303.
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Groenland SL, Verheijen RB, Joerger M, Mathijssen RHJ, Sparreboom A, Beijnen JH, Beumer JH, Steeghs N, Huitema ADR. Precision Dosing of Targeted Therapies Is Ready for Prime Time. Clin Cancer Res 2021; 27:6644-6652. [PMID: 34548319 PMCID: PMC8934568 DOI: 10.1158/1078-0432.ccr-20-4555] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/19/2021] [Accepted: 09/13/2021] [Indexed: 12/16/2022]
Abstract
Fixed dosing of oral targeted therapies is inadequate in the era of precision medicine. Personalized dosing, based on pharmacokinetic (PK) exposure, known as therapeutic drug monitoring (TDM), is rational and supported by increasing evidence. The purpose of this perspective is to discuss whether randomized studies are needed to confirm the clinical value of precision dosing in oncology. PK-based dose adjustments are routinely made for many drugs and are recommended by health authorities, for example, for patients with renal impairment or for drug-drug interaction management strategies. Personalized dosing simply extrapolates this paradigm from selected patient populations to each individual patient with suboptimal exposure, irrespective of the underlying cause. If it has been demonstrated that exposure is related to a relevant clinical outcome, such as efficacy or toxicity, and that exposure can be optimized by PK-guided dosing, it could be logically assumed that PK-guided dosing would result in better treatment outcomes without the need for randomized confirmatory trials. We propose a path forward to demonstrate the clinical relevance of individualized dosing of molecularly-targeted anticancer drugs.
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Affiliation(s)
- Stefanie L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Remy B Verheijen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Markus Joerger
- Department of Medical Oncology and Hematology, Cantonal Hospital, St. Gallen, Switzerland
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Alex Sparreboom
- Division of Pharmaceutics and Pharmacology, College of Pharmacy and Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Jan H Beumer
- Cancer Therapeutics Program, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Neeltje Steeghs
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.
- Department of Clinical Pharmacy, Utrecht University Medical Center, Utrecht, the Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
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Association of cabozantinib pharmacokinetics, progression and toxicity in metastatic renal cell carcinoma patients: results from a pharmacokinetics/pharmacodynamics study. ESMO Open 2021; 6:100312. [PMID: 34864351 PMCID: PMC8645912 DOI: 10.1016/j.esmoop.2021.100312] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/13/2021] [Accepted: 10/25/2021] [Indexed: 11/26/2022] Open
Abstract
Background Cabozantinib is a tyrosine kinase inhibitor with a substantial efficacy in metastatic renal cell carcinoma, and is associated with a challenging toxicity profile leading to frequent drug discontinuations. Whereas an exposure/safety relationship was demonstrated for this drug, an exposure/efficacy relationship is still unknown. Patients and methods We carried out a monocentric, observational, pharmacokinetics/pharmacodynamics (PK/PD) study in patients with metastatic renal cell carcinoma (INDS MR 5612140520). We used measured blood concentrations of cabozantinib (Cmeas) to determine the area under the curve (AUC), apparent clearance (Cl/F) and residual blood concentration (Ctrough). Best overall response according to RECIST 1.1 and relevant toxicity (adverse event grade 3-4 or grade 2 requiring dose reduction or discontinuation) were assessed according to Cmeas, Ctrough, AUC and Cl/F. Results We enrolled 76 patients, including 35 who experienced disease progression and 30 with grade 3-4 toxicity. Patients with progressive disease had a significantly lower median Ctrough (406 versus 634 ng/ml, P = 0.001), Cl/F (2 versus 2.9 l/h, P = 0.002) and AUC (16 versus 20 μg h/ml, P = 0.037) compared with patients who had disease control as best response. Patients with relevant toxicity had a significantly higher Cmeas (732 versus 531 ng/ml, P = 0.006), Ctrough (693 versus 521 ng/ml, P = 0.005) and AUC (21 versus 16 μg h/ml, P = 0.046) compared with patients who did not experience any grade relevant toxicity. Receiver operating characteristic curves obtained from our study defined a threshold for drug efficacy of 536.8 ng/ml and of 617.7 ng/ml for toxicity. Conclusion We first demonstrate the PK/PD relationship for cabozantinib. Severe toxicities are associated with a higher drug exposure, whereas inefficacy is associated with a lower drug exposure. Cabozantinib plasma drug monitoring may be useful to optimize clinical practice. Cabozantinib is a widely used TKI for mRCC for which there is no clearly noted pharmacokinetics/pharmacodynamics relationship. We demonstrated that a lower Ctrough AUC and a higher drug apparent clearance (Cl/F) are associated with progressive disease. We demonstrated that a dose-limiting toxicity is associated with a higher Ctrough and a lower clearance.
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Krens SD, Mulder SF, van Erp NP. Lost in third space: altered tyrosine-kinase inhibitor pharmacokinetics in a patient with malignant ascites. Cancer Chemother Pharmacol 2021; 89:271-274. [PMID: 34853912 DOI: 10.1007/s00280-021-04377-0] [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: 10/18/2021] [Accepted: 11/20/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pazopanib and sunitinib are oral tyrosine kinase inhibitors (TKI) approved for the treatment of renal cell carcinoma. For both oncolytics, a clear target trough concentration level in plasma has been defined above which improved clinical efficacy can be expected. However, many factors can alter TKI exposure, including disease characteristics. CASE A 79-year old male with metastatic papillary renal cell carcinoma and malignant ascites was treated with pazopanib. Initially, treatment with pazopanib at adequate trough concentrations resulted in regression of ascites. After a 6-month puncture-free interval, paracenteses were again required and the plasma trough concentration of pazopanib had decreased to 5 mg/L without any dose adjustments. Despite a dose increase, pazopanib levels remained subtherapeutic and could not prevent new paracenteses. Pazopanib concentrations in the drained ascites fluid were comparable to plasma concentrations and remained high also after treatment discontinuation. This observation suggests that the ascites compartment may act as a third space in which pazopanib accumulates. During subsequent treatment with sunitinib, a similar distribution over ascites fluid was observed. CONCLUSION Presence of ascites or pleural effusion in patients treated with TKIs may lead to subtherapeutic plasma exposure, which may hamper treatment efficacy. Measuring TKIs plasma concentrations regularly during treatment is essential to identify patients with subtherapeutic exposure.
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Affiliation(s)
- Stefanie D Krens
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - Sasja F Mulder
- Department of Medical Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Nielka P van Erp
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
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Kummar S, Srivastava AK, Navas T, Cecchi F, Lee YH, Bottaro DP, Park SR, Do KT, Jeong W, Johnson BC, Voth AR, Rubinstein L, Wright JJ, Parchment RE, Doroshow JH, Chen AP. Combination therapy with pazopanib and tivantinib modulates VEGF and c-MET levels in refractory advanced solid tumors. Invest New Drugs 2021; 39:1577-1586. [PMID: 34180036 PMCID: PMC8541958 DOI: 10.1007/s10637-021-01138-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/10/2021] [Indexed: 11/26/2022]
Abstract
The vascular endothelial growth factor (VEGF)/VEGFR and hepatocyte growth factor (HGF)/c-MET signaling pathways act synergistically to promote angiogenesis. Studies indicate VEGF inhibition leads to increased levels of phosphorylated c-MET, bypassing VEGF-mediated angiogenesis and leading to chemoresistance. We conducted a phase 1 clinical trial with 32 patients with refractory solid tumors to evaluate the safety, pharmacokinetics, and pharmacodynamics of combinations of VEGF-targeting pazopanib and the putative c-MET inhibitor ARQ197 (tivantinib) at 5 dose levels (DLs). Patients either took pazopanib and tivantinib from treatment initiation (escalation phase) or pazopanib alone for 7 days, with paired tumor sampling, prior to starting combination treatment (expansion phase). Hypertension was the most common adverse event. No more than 1 dose limiting toxicity (DLT) occurred at any DL, so the maximum tolerated dose (MTD) was not determined; DL5 (800 mg pazopanib daily and 360 mg tivantinib BID) was used during the expansion phase. Twenty of 31 evaluable patients achieved stable disease lasting up to 22 cycles. Circulating VEGF, VEGFR2, HGF, and c-MET levels were assessed, and only VEGF levels increased. Tumor c-MET levels (total and phosphorylated) were determined in paired biopsies before and after 7 days of pazopanib treatment. Total intact c-MET decreased in 6 of 7 biopsy pairs, in contrast to previously reported c-MET elevation in response to VEGF inhibition. These results are discussed in the context of our previously reported analysis of epithelial-mesenchymal transition in these tumors.
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Affiliation(s)
- Shivaani Kummar
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, 20892, USA
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Apurva K Srivastava
- Clinical Pharmacodynamics Biomarkers Program, Applied/Developmental Research Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, 21702, USA
| | - Tony Navas
- Clinical Pharmacodynamics Biomarkers Program, Applied/Developmental Research Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, 21702, USA
- Pfizer Inc, Groton, CT, 06340, USA
| | - Fabiola Cecchi
- Urologic Oncology Branch, NCI, Bethesda, NIH, 20892, USA
- AstraZeneca, Inc, Gaithersburg, MD, 20878, USA
| | - Young H Lee
- Urologic Oncology Branch, NCI, Bethesda, NIH, 20892, USA
- Altimmune, Inc, Gaithersburg, MD, 20878, USA
| | | | - Sook Ryun Park
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, 20892, USA
- Department of Oncology, University of Ulsan College of Medicine, Seoul, 138-736, South Korea
| | - Khanh T Do
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, 20892, USA
- Moderna Therapeutics, Inc, Cambridge, MA, 02139, USA
| | - Woondong Jeong
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, 20892, USA
- Millennium Physicians, Tomball, TX, 77375, USA
| | - Barry C Johnson
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, 20892, USA
| | - Andrea R Voth
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, 20892, USA
| | - Larry Rubinstein
- Biostatistics Branch, National Cancer Institute, Bethesda, MD, 20892, USA
| | - John J Wright
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, 20892, USA
| | - Ralph E Parchment
- Clinical Pharmacodynamics Biomarkers Program, Applied/Developmental Research Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, 21702, USA
| | - James H Doroshow
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, 20892, USA
- Center for Cancer Research, National Cancer Institute, Bethesda, MD, 20892, USA
| | - Alice P Chen
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, 20892, USA.
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28
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Matsumoto A, Shiraiwa K, Suzuki Y, Tanaka K, Kawano M, Iwasaki T, Tanaka R, Tatsuta R, Tsumura H, Itoh H. Sensitive quantification of free pazopanib using ultra-high performance liquid chromatography coupled to tandem mass spectrometry and assessment of clinical application. J Pharm Biomed Anal 2021; 206:114348. [PMID: 34509660 DOI: 10.1016/j.jpba.2021.114348] [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: 05/24/2021] [Revised: 08/25/2021] [Accepted: 08/27/2021] [Indexed: 10/20/2022]
Abstract
Pazopanib is widely used to treat renal cell carcinomas and soft tissue tumors in Japan. Although several reports demonstrated the usefulness of therapeutic drug monitoring (TDM) of pazopanib, those studies measured only total pazopanib concentration. For drugs with high protein binding rates such as pazopanib, measuring free concentrations may be clinically more useful than measuring total concentrations. In this study, we aimed to develop a high-throughput method for quantification of free pazopanib in human plasma using ultra-high performance liquid chromatography coupled to tandem mass spectrometry (UHPLC-MS/MS). Free pazopanib was separated by ultrafiltration. After a simple solid-phase extraction step using a 96-well plate, pazopanib was analyzed by UHPLC-MS/MS in positive electrospray ionization mode. The novel method fulfilled the requirements of the US Food and Drug Administration guidelines for assay validation, and the lower limit of quantification was 0.05 ng/mL. The calibration curve was linear over the concentration range of 0.05-50 ng/mL. The average recovery rate was 66.9 ± 2.1% (mean ± SD). The precision was below 7.02%, and accuracy was within 10.60% across all quality control levels. Matrix effect varied between 44.4% and 60.4%. This assay was successfully applied to measure trough free pazopanib concentrations in three patients treated with pazopanib for soft tissue tumors. We succeeded to develop a novel high-throughput UHPLC-MS/MS method for quantification of free pazopanib in human plasma. This method can be applied to TDM for patients receiving pazopanib in the clinical setting.
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Affiliation(s)
- Asami Matsumoto
- Department of Clinical Pharmacy, Oita University Hospital, Yufu-shi, Oita, Japan
| | - Ken Shiraiwa
- Department of Clinical Pharmacy, Oita University Hospital, Yufu-shi, Oita, Japan.
| | - Yosuke Suzuki
- Department of Clinical Pharmacy, Oita University Hospital, Yufu-shi, Oita, Japan
| | - Kazuhiro Tanaka
- Department of Orthopaedic Surgery, Oita University Faculty of Medicine, Yufu-shi, Oita, Japan
| | - Masanori Kawano
- Department of Orthopaedic Surgery, Oita University Faculty of Medicine, Yufu-shi, Oita, Japan
| | - Tatsuya Iwasaki
- Department of Orthopaedic Surgery, Oita University Faculty of Medicine, Yufu-shi, Oita, Japan
| | - Ryota Tanaka
- Department of Clinical Pharmacy, Oita University Hospital, Yufu-shi, Oita, Japan
| | - Ryosuke Tatsuta
- Department of Clinical Pharmacy, Oita University Hospital, Yufu-shi, Oita, Japan
| | - Hiroshi Tsumura
- Department of Orthopaedic Surgery, Oita University Faculty of Medicine, Yufu-shi, Oita, Japan
| | - Hiroki Itoh
- Department of Clinical Pharmacy, Oita University Hospital, Yufu-shi, Oita, Japan
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Molenaar-Kuijsten L, van Meekeren M, Verheijen RB, Bovée JVMG, Fiocco M, Thijssen B, Rosing H, Huitema ADR, Miah AB, Gelderblom H, Haas RLM, Steeghs N. Intra-Tumoral Pharmacokinetics of Pazopanib in Combination with Radiotherapy in Patients with Non-Metastatic Soft-Tissue Sarcoma. Cancers (Basel) 2021; 13:cancers13225780. [PMID: 34830931 PMCID: PMC8616484 DOI: 10.3390/cancers13225780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/05/2021] [Accepted: 11/15/2021] [Indexed: 01/15/2023] Open
Abstract
There is a lack of understanding whether plasma levels of anticancer drugs (such as pazopanib) correlate with intra-tumoral levels and whether the plasma compartment is the best surrogate for pharmacokinetic and pharmacodynamic evaluation. Therefore, we aimed to quantify pazopanib concentrations in tumor tissue, to assess the correlation between tumor concentrations and plasma concentrations and between tumor concentrations and efficacy. In this clinical trial, non-metastatic STS patients were treated with neo-adjuvant concurrent radiotherapy and pazopanib. Plasma samples and tumor biopsies were collected, and pazopanib concentrations were measured using liquid chromatography-tandem mass spectrometry. Twenty-four evaluable patients were included. The median pazopanib tumor concentration was 19.2 µg/g (range 0.149-200 µg/g). A modest correlation was found between tumor concentrations and plasma levels of pazopanib (ρ = 0.41, p = 0.049). No correlation was found between tumor concentrations and percentage of viable tumor cells (p > 0.05); however, a trend towards less viable tumor cells in patients with high pazopanib concentrations in tumor tissue was observed in a categorical analysis. Possible explanations for the lack of correlation might be heterogeneity of the tumors and timing of the biopsy procedure.
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Affiliation(s)
- Laura Molenaar-Kuijsten
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; (L.M.-K.); (R.B.V.); (B.T.); (H.R.); (A.D.R.H.)
| | - Milan van Meekeren
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (M.v.M.); (H.G.)
| | - Remy B. Verheijen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; (L.M.-K.); (R.B.V.); (B.T.); (H.R.); (A.D.R.H.)
| | - Judith V. M. G. Bovée
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands;
| | - Marta Fiocco
- Mathematical Institute Leiden University, Niels Bohrweg 1, 2333 CA Leiden, The Netherlands;
- Department of Biomedical Data Science, Section Medical Statistics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Bas Thijssen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; (L.M.-K.); (R.B.V.); (B.T.); (H.R.); (A.D.R.H.)
| | - Hilde Rosing
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; (L.M.-K.); (R.B.V.); (B.T.); (H.R.); (A.D.R.H.)
| | - Alwin D. R. Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; (L.M.-K.); (R.B.V.); (B.T.); (H.R.); (A.D.R.H.)
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 EA Utrecht, The Netherlands
| | - Aisha B. Miah
- Department of Clinical Oncology, The Royal Marsden Hospital and The Institute of Cancer Research, 15 Cotswold Rd, London SM2 5NG, UK;
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (M.v.M.); (H.G.)
| | - Rick L. M. Haas
- Department of Radiotherapy, The Netherlands Cancer Institute—Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands;
- Department of Radiotherapy, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Neeltje Steeghs
- Department of Medical Oncology and Clinical Pharmacology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-(0)20-512-2532
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30
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Krens SD, van Boxtel W, Uijen MJM, Jansman FGA, Desar IME, Mulder SF, van Herpen CML, van Erp NP. Exposure-toxicity relationship of cabozantinib in patients with renal cell cancer and salivary gland cancer. Int J Cancer 2021; 150:308-316. [PMID: 34494665 PMCID: PMC9291492 DOI: 10.1002/ijc.33797] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 07/23/2021] [Accepted: 08/17/2021] [Indexed: 01/18/2023]
Abstract
Cabozantinib is registered in fixed 60 mg dose. However, 46% to 62% of patients in the registration studies needed a dose reduction due to toxicity. Improved clinical efficacy has been observed in renal cell carcinoma patients (RCC) with a cabozantinib exposure greater than 750 μg/L. In our study we explored the cabozantinib exposure in patients with different tumour types. We included RCC patients from routine care and salivary gland carcinoma (SGC) patients from a phase II study with ≥1 measured Cmin at steady‐state. The geometric mean (GM) Cmin at the starting dose, at 40 mg and at best tolerated dose (BTD) were compared between both tumour types. Forty‐seven patients were included. All SGC patients (n = 22) started with 60 mg, while 52% of RCC patients started with 40 mg. GM Cmin at the start dose was 1456 μg/L (95% CI: 1185‐1789) vs 682 μg/L (95% CI: 572‐812) (P < .001) for SGC and RCC patients, respectively. When dose‐normalised to 40 mg, SGC patients had a significantly higher cabozantinib exposure compared to RCC patients (Cmin 971 μg/L [95% CI: 790‐1193] vs 669 μg/L [95% CI: 568‐788]) (P = .005). Dose reductions due to toxicity were needed in 91% and 60% of SGC and RCC patients, respectively. Median BTD was between 20 to 30 mg for SGC and 40 mg for RCC patients. GM Cmin at BTD were comparable between the SGC and the RCC group, 694 μg/L (95% CI: 584‐824) vs 583 μg/L (95% CI: 496‐671) (P = .1). The observed cabozantinib exposure at BTD of approximately 600 μg/L is below the previously proposed target. Surprisingly, a comparable exposure at BTD was reached at different dosages of cabozantinib for SGC patients compared to RCC patients Further research is warranted to identify the optimal exposure and starting dose to balance efficacy and toxicity.
What's new?
Cabozantinib, a potent tyrosine kinase inhibitor that targets multiple signaling pathways, is approved for use against advanced renal cell carcinoma (RCC). Variations in cabozantinib clearance, however, warrant further investigation. Here, the authors evaluated cabozantinib exposure in RCC patients and in patients with salivary gland cancer (SGC). SGC patients were found to have significantly higher cabozantinib exposure compared to RCC patients following a 40 mg dose. However, the best‐tolerated cabozantinib exposure was equivalent (~600 μg/L) for both tumor types and was substantially below the previously proposed target. The findings offer insight on exposure, dose, and the balance between efficacy and toxicity for cabozantinib.
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Affiliation(s)
- Stefanie D Krens
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wim van Boxtel
- Department of Medical Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maike J M Uijen
- Department of Medical Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank G A Jansman
- Department of Clinical Pharmacy, Deventer Hospital, Deventer, The Netherlands.,Unit of Pharmacotherapy, Pharmacoepidemiology and Pharmacoeconomics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Ingrid M E Desar
- Department of Medical Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sasja F Mulder
- Department of Medical Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carla M L van Herpen
- Department of Medical Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nielka P van Erp
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Just MA, Van Mater D, Wagner LM. Receptor tyrosine kinase inhibitors for the treatment of osteosarcoma and Ewing sarcoma. Pediatr Blood Cancer 2021; 68:e29084. [PMID: 33894051 PMCID: PMC8238849 DOI: 10.1002/pbc.29084] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/24/2021] [Accepted: 04/05/2021] [Indexed: 12/24/2022]
Abstract
Adjuvant chemotherapy for osteosarcoma and Ewing sarcoma consists of conventional cytotoxic regimens that have changed little over the past decades. There is an urgent need for agents that are more effective and have less long-term toxicity. Receptor tyrosine kinases regulate cell growth and proliferation of these tumors, and small-molecule inhibitors for many of these kinases are now available. In this article, we review published phase II trials for patients with recurrent disease and highlight the pathways targeted by available agents, as well as the toxicity and efficacy results seen to date. We also discuss the difficulties in identifying biomarkers to facilitate rational patient selection, as well as published and proposed strategies for how these inhibitors can be combined with conventional chemotherapy or other targeted agents. It is hoped future trials can capitalize on this growing experience to optimize the use of this exciting class of agents.
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Affiliation(s)
- Marissa A Just
- Duke University Medical Center, Durham, North Carolina, USA
| | | | - Lars M Wagner
- Duke University Medical Center, Durham, North Carolina, USA
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Fahmy A, Hopkins AM, Sorich MJ, Rowland A. Evaluating the utility of therapeutic drug monitoring in the clinical use of small molecule kinase inhibitors: a review of the literature. Expert Opin Drug Metab Toxicol 2021; 17:803-821. [PMID: 34278936 DOI: 10.1080/17425255.2021.1943357] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Orally administered small molecule kinase inhibitors (KI) are a key class of targeted anti-cancer medicines that have contributed substantially to improved survival outcomes in patients with advanced disease. Since the introduction of KIs in 2001, there has been a building body of evidence that the benefit derived from these drugs may be further enhanced by individualizing dosing on the basis of concentration.Areas covered: This review considers the rationale for individualized KI dosing and the requirements for robust therapeutic drug monitoring (TDM). Current evidence supporting TDM-guided KI dosing is presented and critically evaluated, and finally potential approaches to address translational challenges for TDM-guided KI dosing and alternate approaches to support individualization of KI dosing are discussed.Expert opinion: Intuitively, the individualization of KI dosing through an approach such as TDM-guided dosing has great potential to enhance the effectiveness and tolerability of these drugs. However, based on current literature evidence it is unrealistic to propose that TDM-guided KI dosing should be routinely implemented into clinical practice.
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Affiliation(s)
- Alia Fahmy
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Ashley M Hopkins
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Michael J Sorich
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Andrew Rowland
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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Bellantoni AJ, Wagner LM. Pursuing Precision: Receptor Tyrosine Kinase Inhibitors for Treatment of Pediatric Solid Tumors. Cancers (Basel) 2021; 13:3531. [PMID: 34298746 PMCID: PMC8303693 DOI: 10.3390/cancers13143531] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/05/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
Receptor tyrosine kinases are critical for the growth and proliferation of many different cancers and therefore represent a potential vulnerability that can be therapeutically exploited with small molecule inhibitors. Over forty small molecule inhibitors are currently approved for the treatment of adult solid tumors. Their use has been more limited in pediatric solid tumors, although an increasing number of single-agent and combination studies are now being performed. These agents have been quite successful in certain clinical contexts, such as the treatment of pediatric tumors driven by kinase fusions or activating mutations. By contrast, only modest activity has been observed when inhibitors are used as single agents for solid tumors that do not have genetically defined alterations in the target genes. The absence of predictive biomarkers has limited the wider applicability of these drugs and much work remains to define the appropriate patient population and clinical situation in which receptor tyrosine kinase inhibitors are most beneficial. In this manuscript, we discuss these issues by highlighting past trials and identifying future strategies that may help add precision to the use of these agents for pediatric extracranial solid tumors.
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Affiliation(s)
| | - Lars M. Wagner
- Division of Pediatric Hematology/Oncology, Duke University, Durham, NC 27710, USA;
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High-Trough Plasma Concentration of Afatinib Is Associated with Dose Reduction. Cancers (Basel) 2021; 13:cancers13143425. [PMID: 34298637 PMCID: PMC8305619 DOI: 10.3390/cancers13143425] [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: 05/22/2021] [Revised: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 12/20/2022] Open
Abstract
Afatinib is used to treat non-small-cell lung cancer (NSCLC) harboring epidermal growth factor receptor (EGFR) mutation as a second-generation EGFR-tyrosine kinase inhibitor (TKI). Early prediction of adverse effects based on the pharmacokinetics of afatinib enables support for quality of life (QOL) in patients with no change in efficacy. We examined the pharmacokinetic relationship between trough plasma concentration and adverse effects and evaluated the utility of measuring the trough plasma concentration of afatinib as the first EGFR-TKI treatment for NSCLC in a prospective multicenter study. Twenty-four patients treated with afatinib were enrolled in this study. All blood samples were collected at the trough point, and plasma concentrations were measured using high-performance liquid chromatography-tandem mass spectrometry. Logistic regression analysis for the dose reduction of afatinib was performed, and the receiver operating characteristic (ROC) curve was plotted. Although all patients started afatinib at 40 mg/day, plasma concentrations were variable, and mean and median trough plasma concentrations were 32.9 ng/mL and 32.5 ng/mL in this study, respectively. Minimum and maximum trough plasma concentrations were 10.4 ng/mL and 72.7 ng/mL, respectively. This variability was speculated to involve personal parameters such as laboratory data. However, no patient characteristics or laboratory data examined correlated with the trough plasma concentration of afatinib, except albumin. Albumin showed a weak correlation with plasma concentration (r = 0.60, p = 0.009). The trough plasma concentration of afatinib was significantly associated with the dose reduction of afatinib (p = 0.047). The area under the ROC curve (AUC) for the trough plasma concentration of afatinib was 0.81. The cut-off value was 21.4 ng/mL. The sensitivity and specificity of the cut-off as a risk factor were 0.80 and 0.75. In summary, the trough plasma concentration of afatinib was associated with continued or reduced dosage because of the onset of several adverse effects, and a threshold was seen. Adverse effects not only lower QOL but also hinder continued treatment. Measuring plasma concentrations of afatinib appears valuable to predict adverse effects and continue effective therapy.
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35
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Mulder TAM, van Eerden RAG, de With M, Elens L, Hesselink DA, Matic M, Bins S, Mathijssen RHJ, van Schaik RHN. CYP3A4∗22 Genotyping in Clinical Practice: Ready for Implementation? Front Genet 2021; 12:711943. [PMID: 34306041 PMCID: PMC8296839 DOI: 10.3389/fgene.2021.711943] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/17/2021] [Indexed: 12/26/2022] Open
Abstract
Cytochrome P450 3A4 (CYP3A4) is the most important drug metabolizing enzyme in the liver, responsible for the oxidative metabolism of ∼50% of clinically prescribed drugs. Therefore, genetic variation in CYP3A4 could potentially affect the pharmacokinetics, toxicity and clinical outcome of drug treatment. Thus far, pharmacogenetics for CYP3A4 has not received much attention. However, the recent discovery of the intron 6 single-nucleotide polymorphism (SNP) rs35599367C > T, encoding the CYP3A4∗22 allele, led to several studies into the pharmacogenetic effect of CYP3A4∗22 on different drugs. This allele has a relatively minor allele frequency of 3-5% and an effect on CYP3A4 enzymatic activity. Thus far, no review summarizing the data published on several drugs is available yet. This article therefore addresses the current knowledge on CYP3A4∗22. This information may help in deciding if, and for which drugs, CYP3A4∗22 genotype-based dosing could be helpful in improving drug therapy. CYP3A4∗22 was shown to significantly influence the pharmacokinetics of several drugs, with currently being most thoroughly investigated tacrolimus, cyclosporine, and statins. Additional studies, focusing on toxicity and clinical outcome, are warranted to demonstrate clinical utility of CYP3A4∗22 genotype-based dosing.
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Affiliation(s)
- Tessa A M Mulder
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ruben A G van Eerden
- Department of Medical Oncology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Mirjam de With
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Department of Medical Oncology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Laure Elens
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium.,Louvain Centre for Toxicology and Applied Pharmacology, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Dennis A Hesselink
- Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Erasmus MC Transplant Institute, Rotterdam, Netherlands
| | - Maja Matic
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Sander Bins
- Department of Medical Oncology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, Netherlands
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36
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Meriggi F. Controversial link between proton pump inhibitors and anticancer agents: review of the literature. TUMORI JOURNAL 2021; 108:204-212. [PMID: 34159850 DOI: 10.1177/03008916211025091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Drug-drug interactions represent a topic of great interest, not only due to the risk of unexpected adverse events but also due to the possibility of altering the effectiveness of a specific treatment. Inappropriate or concomitant use of drugs can often lead to changes in the bioavailability of various compounds, resulting in pharmacokinetic alterations. A recent example is the concomitant administration of proton pump inhibitors (PPIs) and anticancer agents. PPIs are overused beyond their classic indications, resulting in a high risk of interactions with other drugs, such as anticancer agents, both PO and intravenous. However, the real clinical impact of concomitant acid suppression therapy and anticancer therapies remains controversial and is not yet fully understood. Certainly, the gut microbiota plays a key role in regulating the response of the immune system, and PPIs can significantly alter the gut microbiome, resulting in gut dysbiosis. Indeed, while the link sometimes appears to lead to negative outcomes, as in the case of immunotherapy, oral capecitabine, or tyrosine kinase inhibitors, in other cases, it seems to enhance the effectiveness of intravenous chemotherapy. In this review, I analyse the possible drug interactions between PPIs and the main classes of anticancer drugs.
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Affiliation(s)
- Fausto Meriggi
- Oncology Department, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
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37
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Zhang Z, Xiong L, Wu Z, Liu H, Ning K, Peng Y, Yu C, Ding Y, Weng D, Xia J, Jiang L, Guo S, Han H, Zhou F, Dong P. Neoadjuvant combination of pazopanib or axitinib and programmed cell death protein-1-activated dendritic cell-cytokine-induced killer cells immunotherapy may facilitate surgery in patients with renal cell carcinoma. Transl Androl Urol 2021; 10:2091-2102. [PMID: 34159090 PMCID: PMC8185689 DOI: 10.21037/tau-21-406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Radical/cytoreductive nephrectomy or nephron-sparing surgery may be thought to be not safe or unfeasible in some renal cell carcinoma (RCC) patients in which tumor is locally advanced or highly complicated. Neoadjuvant therapy may reduce the volume of the tumor, thus facilitates surgery. The aim the study is to evaluate the efficacy and safety of neoadjuvant combination of pazopanib or axitinib and PD-1-activated dendritic cell-cytokine-induced killer (PD-1/DC-CIK) cell immunotherapy in those patients. Methods Data from 16 RCC patients who received neoadjuvant pazopanib (Group P, n=9) or axitinib (Group A, n=7) plus PD-1/DC-CIK cells immunotherapy were reviewed retrospectively. A total of 9 participants that were potential candidates for radical/cytoreductive nephrectomy (RN/CN) had locally advanced tumor and 5 participants with partial nephrectomy (PN) absolute indications had highly complicated tumors. The efficacy outcomes were based on volume changes of the primary tumor, lymph nodes, and tumor thrombus in 13 participants with complete computed tomography (CT) imaging. The treatment-related toxicities and surgical complications were also reported. Results With a median of 2.1 months treatment, the overall volume of the tumors decreased by a median of 42.30% [interquartile range (IQR): 19.37–66.78%]. Specifically, the median reduction of tumor volume was 88.77 and 15.50 cm3 in group P and group A, respectively (P=0.014). However, participants in Group P were more likely to experience grade 3 or 4 treatment-related adverse events (AEs) than those in Group A (44.4% vs. 0). Finally, all participants were candidates for appropriate surgery after neoadjuvant therapy (as assessed by the surgeon), and 10 participants accepted surgery, including 5 PN, 4 RN/CN, and 1 lymph node dissection. A solitary participant had Clavien grade IV acute renal failure required dialysis and another had grade II lymphatic leakage. Conclusions Neoadjuvant combination of pazopanib or axitinib and PD-1/DC-CIK cells immunotherapy was well-tolerated and could effectively reduce the volume of tumors in locally advanced or highly complicated RCC patients.
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Affiliation(s)
- Zhiling Zhang
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Longbin Xiong
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Zeshen Wu
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Huiming Liu
- State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Radiology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Kang Ning
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yulu Peng
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Chunping Yu
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Ya Ding
- State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Biotherapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Desheng Weng
- State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Biotherapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jianchuan Xia
- State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Biotherapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Lijuan Jiang
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Shengjie Guo
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Hui Han
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Fangjian Zhou
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Pei Dong
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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Noda S, Iida H, Fujimoto T, Wakasugi Y, Yabuta N, Sudou M, Hira D, Tani M, Andoh A, Morita SY, Terada T. Exploratory analysis of target concentration of lenvatinib in the treatment of hepatocellular carcinoma. Cancer Chemother Pharmacol 2021; 88:281-288. [PMID: 33928425 DOI: 10.1007/s00280-021-04286-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/19/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE We aimed to evaluate exposure-toxicity/efficacy relationship of lenvatinib by determining its target trough concentration for patients with hepatocellular carcinoma (HCC). METHODS In this retrospective, observational study, 28 HCC patients who had been treated with lenvatinib were enrolled between August 2018 and April 2020. We evaluated the association between the trough lenvatinib concentration and occurrence of grade ≥ 3 toxicities. Additionally, we estimated the association of the trough lenvatinib concentration with responder status (disease control; complete response, partial response, or stable disease), and progression-free survival (PFS). RESULTS The mean trough lenvatinib concentration was significantly higher in the group with grade ≥ 3 toxicity (n = 15) than in the group with grade ≤ 2 toxicity (n = 13). Based on the receiver operating characteristic curve, the threshold values of the trough lenvatinib concentrations for predicting grade ≥ 3 toxicities and responder status were 71.4 ng/mL [area under the curve (AUC) 0.86, 95% confidence interval (CI) 0.71-1.00; p < 0.05] and 36.8 ng/mL (AUC 0.95, 95% CI 0.85-1.00; p < 0.05), respectively. Lenvatinib concentrations of 36.8-71.4 ng/mL resulted in longer PFS than concentrations < 36.8 ng/mL and ≥ 71.4 ng /mL [median 13.3 months (36.8-71.4 ng/mL) vs. 3.5 months (< 36.8 ng/mL) and 7.8 months (≥ 71.4 ng /mL), respectively]. CONCLUSIONS Considering these results, we propose that the target trough concentration of lenvatinib could be 36.8-71.4 ng/mL for maintaining disease control status and reducing grade ≥ 3 toxicity in the treatment of HCC.
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Affiliation(s)
- Satoshi Noda
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu City, Shiga, 520-2192, Japan.
| | - Hiroya Iida
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Takehide Fujimoto
- Department of Gastroenterology, Shiga University of Medical Science, Otsu, Japan
| | - Yoshinori Wakasugi
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu City, Shiga, 520-2192, Japan
| | - Naoki Yabuta
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu City, Shiga, 520-2192, Japan
| | - Masatomo Sudou
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu City, Shiga, 520-2192, Japan
| | - Daiki Hira
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu City, Shiga, 520-2192, Japan.,College of Pharmaceutical Sciences, Ritsumeikan University, Kusatsu, Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Akira Andoh
- Department of Gastroenterology, Shiga University of Medical Science, Otsu, Japan
| | - Shin-Ya Morita
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu City, Shiga, 520-2192, Japan
| | - Tomohiro Terada
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu City, Shiga, 520-2192, Japan
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Zhan C, Wang Z, Xu C, Huang X, Su J, Chen B, Wang M, Qi Z, Bai P. Development and Validation of a Prognostic Gene Signature in Clear Cell Renal Cell Carcinoma. Front Mol Biosci 2021; 8:609865. [PMID: 33968978 PMCID: PMC8098777 DOI: 10.3389/fmolb.2021.609865] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 01/19/2021] [Indexed: 12/14/2022] Open
Abstract
Clear cell renal cell carcinoma (ccRCC), one of the most common urologic cancer types, has a relatively good prognosis. However, clinical diagnoses are mostly done during the medium or late stages, when mortality and recurrence rates are quite high. Therefore, it is important to perform real-time information tracking and dynamic prognosis analysis for these patients. We downloaded the RNA-seq data and corresponding clinical information of ccRCC from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) databases. A total of 3,238 differentially expressed genes were identified between normal and ccRCC tissues. Through a series of Weighted Gene Co-expression Network, overall survival, immunohistochemical and the least absolute shrinkage selection operator (LASSO) analyses, seven prognosis-associated genes (AURKB, FOXM1, PTTG1, TOP2A, TACC3, CCNA2, and MELK) were screened. Their risk score signature was then constructed. Survival analysis showed that high-risk scores exhibited significantly worse overall survival outcomes than low-risk patients. Accuracy of this prognostic signature was confirmed by the receiver operating characteristic curve and was further validated using another cohort. Gene set enrichment analysis showed that some cancer-associated phenotypes were significantly prevalent in the high-risk group. Overall, these findings prove that this risk model can potentially improve individualized diagnostic and therapeutic strategies.
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Affiliation(s)
| | - Zichu Wang
- Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Chao Xu
- Shaoxing people's Hospital, Shaoxing, China
| | - Xiao Huang
- Nanchang Five Elements Bio-Technology Co., Ltd, Nanchang, China
| | - Junzhou Su
- Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Bisheng Chen
- Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Mingshan Wang
- Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Zhihong Qi
- Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Peiming Bai
- Zhongshan Hospital, Xiamen University, Xiamen, China
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40
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Mueller-Schoell A, Groenland SL, Scherf-Clavel O, van Dyk M, Huisinga W, Michelet R, Jaehde U, Steeghs N, Huitema ADR, Kloft C. Therapeutic drug monitoring of oral targeted antineoplastic drugs. Eur J Clin Pharmacol 2021; 77:441-464. [PMID: 33165648 PMCID: PMC7935845 DOI: 10.1007/s00228-020-03014-8] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/01/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE This review provides an overview of the current challenges in oral targeted antineoplastic drug (OAD) dosing and outlines the unexploited value of therapeutic drug monitoring (TDM). Factors influencing the pharmacokinetic exposure in OAD therapy are depicted together with an overview of different TDM approaches. Finally, current evidence for TDM for all approved OADs is reviewed. METHODS A comprehensive literature search (covering literature published until April 2020), including primary and secondary scientific literature on pharmacokinetics and dose individualisation strategies for OADs, together with US FDA Clinical Pharmacology and Biopharmaceutics Reviews and the Committee for Medicinal Products for Human Use European Public Assessment Reports was conducted. RESULTS OADs are highly potent drugs, which have substantially changed treatment options for cancer patients. Nevertheless, high pharmacokinetic variability and low treatment adherence are risk factors for treatment failure. TDM is a powerful tool to individualise drug dosing, ensure drug concentrations within the therapeutic window and increase treatment success rates. After reviewing the literature for 71 approved OADs, we show that exposure-response and/or exposure-toxicity relationships have been established for the majority. Moreover, TDM has been proven to be feasible for individualised dosing of abiraterone, everolimus, imatinib, pazopanib, sunitinib and tamoxifen in prospective studies. There is a lack of experience in how to best implement TDM as part of clinical routine in OAD cancer therapy. CONCLUSION Sub-therapeutic concentrations and severe adverse events are current challenges in OAD treatment, which can both be addressed by the application of TDM-guided dosing, ensuring concentrations within the therapeutic window.
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Affiliation(s)
- Anna Mueller-Schoell
- Dept. of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
- Graduate Research Training Program, PharMetrX, Berlin/Potsdam, Germany
| | - Stefanie L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Oliver Scherf-Clavel
- Institute of Pharmacy and Food Chemistry, Julius-Maximilians-Universität Würzburg, Würzburg, Germany
| | - Madelé van Dyk
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Robin Michelet
- Dept. of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Ulrich Jaehde
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany
| | - Neeltje Steeghs
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Charlotte Kloft
- Dept. of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany.
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41
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Nelson RS, Seligson ND, Bottiglieri S, Carballido E, Cueto AD, Imanirad I, Levine R, Parker AS, Swain SM, Tillman EM, Hicks JK. UGT1A1 Guided Cancer Therapy: Review of the Evidence and Considerations for Clinical Implementation. Cancers (Basel) 2021; 13:cancers13071566. [PMID: 33805415 PMCID: PMC8036652 DOI: 10.3390/cancers13071566] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/18/2021] [Accepted: 03/19/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary The use of multi-gene testing platforms to individualize treatment is rapidly expanding into routine oncology practice. UGT1A1, which encodes for the uridine diphosphate glucuronosyltransferase (UGT) 1A1 enzyme, is commonly included on multi-gene molecular testing assays. UGT1A1 polymorphisms may influence drug-induced toxicities of numerous medications used in oncology. However, guidance for incorporating UGT1A1 results into therapeutic decision-making is sparse and can differ depending on the referenced resource. We summarize the literature describing associations between UGT1A1 polymorphisms and toxicity risk with irinotecan, belinostat, pazopanib, and nilotinib. Resources that provide recommendations for UGT1A1-guided drug prescribing are reviewed, and considerations for implementation into patient care are provided. Abstract Multi-gene assays often include UGT1A1 and, in certain instances, may report associated toxicity risks for irinotecan, belinostat, pazopanib, and nilotinib. However, guidance for incorporating UGT1A1 results into therapeutic decision-making is mostly lacking for these anticancer drugs. We summarized meta-analyses, genome-wide association studies, clinical trials, drug labels, and guidelines relating to the impact of UGT1A1 polymorphisms on irinotecan, belinostat, pazopanib, or nilotinib toxicities. For irinotecan, UGT1A1*28 was significantly associated with neutropenia and diarrhea, particularly with doses ≥ 180 mg/m2, supporting the use of UGT1A1 to guide irinotecan prescribing. The drug label for belinostat recommends a reduced starting dose of 750 mg/m2 for UGT1A1*28 homozygotes, though published studies supporting this recommendation are sparse. There was a correlation between UGT1A1 polymorphisms and pazopanib-induced hepatotoxicity, though further studies are needed to elucidate the role of UGT1A1-guided pazopanib dose adjustments. Limited studies have investigated the association between UGT1A1 polymorphisms and nilotinib-induced hepatotoxicity, with data currently insufficient for UGT1A1-guided nilotinib dose adjustments.
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Affiliation(s)
- Ryan S. Nelson
- Department of Consultative Services, ARUP Laboratories, Salt Lake City, UT 84108, USA;
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL 33612, USA;
| | - Nathan D. Seligson
- Department of Pharmacotherapy and Translational Research, The University of Florida, Jacksonville, FL 32610, USA;
- Department of Hematology and Oncology, Nemours Children’s Specialty Care, Jacksonville, FL 32207, USA
| | - Sal Bottiglieri
- Department of Pharmacy, Moffitt Cancer Center, Tampa, FL 33612, USA;
| | - Estrella Carballido
- Department of Oncological Sciences, University of South Florida, Tampa, FL 33612, USA; (E.C.); (I.I.); (R.L.)
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Alex Del Cueto
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL 33612, USA;
| | - Iman Imanirad
- Department of Oncological Sciences, University of South Florida, Tampa, FL 33612, USA; (E.C.); (I.I.); (R.L.)
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Richard Levine
- Department of Oncological Sciences, University of South Florida, Tampa, FL 33612, USA; (E.C.); (I.I.); (R.L.)
- Department of Satellite and Community Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | | | - Sandra M. Swain
- Georgetown University Medical Center, MedStar Health, Washington, DC 20007, USA;
| | - Emma M. Tillman
- Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - J. Kevin Hicks
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL 33612, USA;
- Department of Oncological Sciences, University of South Florida, Tampa, FL 33612, USA; (E.C.); (I.I.); (R.L.)
- Correspondence: ; Tel.: +1-(813)-745-4668
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Sadeghi S, Kargar M. Is there association between clinically relevant toxicities of pazopanib and sunitinib with the use of weak CYP3A4 and P-gp inhibitors? Eur J Clin Pharmacol 2021; 77:1427-1428. [PMID: 33723657 DOI: 10.1007/s00228-021-03118-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/02/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Setayesh Sadeghi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mona Kargar
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran.
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43
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Mourey L, Le Louedec F, Ravaud A, Paludetto MN, Digue L, Gomez-Roca CA, Valentin T, Balardy L, Olivier P, Cabarrou B, Filleron T, Chatelut E. VOTRAGE study: Phase I dose-escalation study of pazopanib in unfit older patients. J Geriatr Oncol 2021; 12:759-764. [PMID: 33715996 DOI: 10.1016/j.jgo.2021.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/18/2020] [Accepted: 02/05/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pazopanib is a tyrosine kinase inhibitor given at the approved dose of 800 mg orally once daily (OD), but often requiring individual dose adjustment due to toxicity. Limited data is available to guide prescription in older patients especially the unfit according to geriatric assessment. PATIENTS AND METHODS VOTRAGE is a 3 + 3 dose-escalation, open-label phase I trial of continuous OD oral administration of pazopanib to evaluate safety, PK and PD data in unfit older patients with advanced solid tumors. The primary objective was to determine the maximum tolerated dose (MTD). PK data were compared with those obtained in younger adult patients in a population PK analysis. RESULTS Eighteen patients with a median age of 82.5 years (range 75-91) were included in three dosing cohorts (400, 600, and 800 mg daily). Three dose-limiting toxicities (DLT) were observed in five patients at 800 mg and one DLT at 600 mg in six evaluable patients. MTD was defined as level 2 dose (600 mg). Individual oral clearance was not correlated with age. A relationship was observed between the occurrence of DLT and pazopanib plasma exposure. Decreased oral bioavailability of pazopanib when given with proton-pump inhibitors was confirmed in this group of patients. CONCLUSION We recommend performing geriatric assessment in patients older than 75 and starting pazopanib at 600 mg per day in unfit older patients. Therapeutic drug monitoring appears very helpful in this population.
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Affiliation(s)
- Loïc Mourey
- Department of Medical Oncology, Institut Claudius Regaud, IUCT-Oncopole, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France.
| | - Félicien Le Louedec
- Laboratory of Phamacology, Institut Claudius Regaud, IUCT-Oncopole, and CRCT, Université de Toulouse, Inserm, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - Alain Ravaud
- Department of Medical Oncology, Saint André CHU Hospital, 1, rue Jean Burguet, 33000 Bordeaux, France
| | - Marie-Noëlle Paludetto
- Pharmacy Department, Institut Claudius Regaud, IUCT-Oncopole, Toulouse, France et Cancer Research Center of Toulouse (CRCT), INSERM UMR1037, University of Toulouse, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - Laurence Digue
- Department of Medical Oncology, Saint André CHU Hospital, 1, rue Jean Burguet, 33000 Bordeaux, France
| | - Carlos Alberto Gomez-Roca
- Department of Medical Oncology, Institut Claudius Regaud, IUCT-Oncopole, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - Thibaud Valentin
- Department of Medical Oncology, Institut Claudius Regaud, IUCT-Oncopole, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - Laurent Balardy
- Geriatric Department, Internal Medicine and Oncogeriatry Unit, Toulouse University Hospital Purpan, place du Docteur Joseph Baylac, 31300 Toulouse, France
| | - Pascale Olivier
- Department of Clinical and Medical Pharmacology and regional pharmacovigilance center, Toulouse University Hospital, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - Bastien Cabarrou
- Department of Biostatistics, Institut Claudius Regaud, IUCT-Oncopole, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - Thomas Filleron
- Department of Biostatistics, Institut Claudius Regaud, IUCT-Oncopole, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - Etienne Chatelut
- Laboratory of Phamacology, Institut Claudius Regaud, IUCT-Oncopole, and CRCT, Université de Toulouse, Inserm, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France
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44
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Groenland SL, Ratain MJ, Chen LS, Gandhi V. The Right Dose: From Phase I to Clinical Practice. Am Soc Clin Oncol Educ Book 2021; 41:92-106. [PMID: 34010057 DOI: 10.1200/edbk_319567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To realize the full potential of promising new anticancer drugs, it is of paramount importance to administer them at the right dose. The aim of this educational article is to provide several opportunities to optimize anticancer drug dosing, focusing on oral targeted therapies. First, therapeutic drug monitoring can optimize exposure in individual patients, if the optimal concentration is known. This approach is of particular interest in regard to oral kinase inhibitors with high interindividual pharmacokinetic variability. If exposure is related to response, then therapeutic drug monitoring is potentially feasible, although the clinical utility of this approach has not yet been established. Other approaches to reduce variability include administration of more frequent, smaller doses and administration under optimal prandial conditions. However, for many drugs, the labeled dose has not been demonstrated to be the optimal dose; for such agents, the vast majority of patients may be receiving excessive doses, which results in excessive toxicity. Furthermore, administration of lower off-label doses may reduce both medical and financial toxicity. These strategies should be applied from registration studies to clinical practice, with the goal of better optimizing anticancer treatment.
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Affiliation(s)
- Stefanie L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, the Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL
| | - Lisa S Chen
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Varsha Gandhi
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX.,Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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Limited Sampling Strategy for Determination of Ibrutinib Plasma Exposure: Joint Analyses with Metabolite Data. Pharmaceuticals (Basel) 2021; 14:ph14020162. [PMID: 33670575 PMCID: PMC7922501 DOI: 10.3390/ph14020162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/09/2021] [Accepted: 02/11/2021] [Indexed: 12/30/2022] Open
Abstract
Therapeutic drug monitoring of ibrutinib is based on the area under the curve of concentration vs. time (AUCIBRU) instead of trough concentration (Cmin,ss) because of a limited accumulation in plasma. Our objective was to identify a limited sampling strategy (LSS) to estimate AUCIBRU associated with Bayesian estimation. The actual AUCIBRU of 85 patients was determined by the Bayesian analysis of the full pharmacokinetic profile of ibrutinib concentrations (pre-dose T0 and 0.5, 1, 2, 4 and 6 h post-dose) and experimental AUCIBRU were derived considering combinations of one to four sampling times. The T0–1–2–4 design was the most accurate LSS (root-mean-square error RMSE = 11.0%), and three-point strategies removing the 1 h or 2 h points (RMSE = 22.7% and 14.5%, respectively) also showed good accuracy. The correlation between the actual AUCIBRU and Cmin,ss was poor (r2 = 0.25). The joint analysis of dihydrodiol-ibrutinib metabolite concentrations did not improve the predictive performance of AUCIBRU. These results were confirmed in a prospective validation cohort (n = 27 patients). At least three samples, within the pre-dose and 4 h post-dose period, are necessary to estimate ibrutinib exposure accurately.
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Krens SD, Lubberman FJE, van Egmond M, Jansman FGA, Burger DM, Hamberg P, Vervenne WL, Gelderblom H, van der Graaf WTA, Desar IME, van Herpen CML, van Erp NP. The impact of a 1-hour time interval between pazopanib and subsequent intake of gastric acid suppressants on pazopanib exposure. Int J Cancer 2021; 148:2799-2806. [PMID: 33428771 PMCID: PMC8048885 DOI: 10.1002/ijc.33469] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/16/2020] [Accepted: 12/17/2020] [Indexed: 01/01/2023]
Abstract
Co‐treatment with gastric acid suppressants (GAS) in patients taking anticancer drugs that exhibit pH‐dependant absorption may lead to decreased drug exposure and may hamper drug efficacy. In our study, we investigated whether a 1‐hour time interval between subsequent intake of pazopanib and GAS could mitigate this negative effect on drug exposure. We performed an observational study in which we collected the first steady‐state pazopanib trough concentration (Cmin) levels from patients treated with pazopanib 800 mg once daily (OD) taken fasted or pazopanib 600 mg OD taken with food. All patients were advised to take GAS 1 hour after pazopanib. Patients were grouped based on the use of GAS and the geometric (GM) Cmin levels were compared between groups for each dose regimen. Additionally, the percentage of patients with exposure below the target threshold of 20.5 mg/L and the effect of the type of PPI was explored. The GM Cmin levels were lower in GAS users vs non‐GAS users for both the 800 and 600 mg cohorts (23.7 mg/L [95% confidence interval [CI]: 21.1‐26.7] vs 28.2 mg/L [95% CI: 25.9‐30.5], P = .015 and 26.0 mg/L [95% CI: 22.4‐30.3] vs 33.5 mg/L [95% CI: 30.3‐37.1], P = .006). Subtherapeutic exposure was more prevalent in GAS users vs non‐GAS users (33.3% vs 19.5% and 29.6% vs 14%). Sub‐analysis showed lower GM pazopanib Cmin in patients who received omeprazole, while minimal difference was observed in those receiving pantoprazole compared to non‐users. Our research showed that a 1‐hour time interval between intake of pazopanib and GAS did not mitigate the negative effect of GAS on pazopanib exposure and may hamper pazopanib efficacy.
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Affiliation(s)
- Stefanie D. Krens
- Department of PharmacyRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenThe Netherlands
| | | | - Marthe van Egmond
- Department of Clinical PharmacyRadboud University Medical CenterNijmegenThe Netherlands
| | - Frank G. A. Jansman
- Department of PharmacyDeventer HospitalDeventerThe Netherlands
- PharmacoTherapy, ‐Epidemiology & ‐EconomicsUniversity of Groningen, Groningen Research Institute of PharmacyGroningenThe Netherlands
| | - David M. Burger
- Department of PharmacyRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenThe Netherlands
| | - Paul Hamberg
- Department of Medical OncologyFranciscus Gasthuis & VlietlandRotterdamThe Netherlands
| | | | - Hans Gelderblom
- Department of Medical OncologyLeiden University Medical CenterLeidenThe Netherlands
| | - Winette T. A. van der Graaf
- Department of Medical OncologyRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenThe Netherlands
| | - Ingrid M. E. Desar
- Department of Medical OncologyRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenThe Netherlands
| | - Carla M. L. van Herpen
- Department of Medical OncologyRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenThe Netherlands
| | - Nielka P. van Erp
- Department of Clinical PharmacyRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenThe Netherlands
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Association of lenvatinib plasma concentration with clinical efficacy and adverse events in patients with hepatocellular carcinoma. Cancer Chemother Pharmacol 2020; 86:803-813. [PMID: 33095285 DOI: 10.1007/s00280-020-04178-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/10/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE This study aimed to examine the association between the trough plasma concentration of lenvatinib with the objective response rate (ORR) and adverse events in patients with hepatocellular carcinoma (HCC). METHODS Twenty-one patients with HCC who received lenvatinib were enrolled. We examined the median trough concentration (Ctrough median) of plasma lenvatinib until the first clinical response evaluation. The receiver-operating characteristic curve was drawn to show the discrimination potential of the Ctrough median for the ORR, using the modified Response Evaluation Criteria in Solid Tumors. Adverse events were graded based on the Common Terminology Criteria for Adverse Events (ver. 5.0). RESULTS The Ctrough median values in the complete response and partial response group were significantly higher than those in the stable disease and progressive disease groups. The ORR was significantly higher in the high-Ctrough median group (≥ 42.68 ng/mL) than in the low-Ctrough median group (< 42.68 ng/mL) (80.0% vs. 18.2%; p = 0.0089). Although there was no difference in the occurrence of most adverse events between the high- and low-Ctrough median groups, the occurrence of any grade anorexia (100.0% vs. 45.5%; p = 0.0124) and grade 3 serious hypertension (70.0% vs. 18.2%; p = 0.0300) was significantly higher in the high-Ctrough median group than in the low-Ctrough median group. Multivariate analysis showed that high-Ctrough median was significantly associated with ORR development (odds ratio, 15.00; 95% confidence interval, 1.63-138.16; p = 0.0168). CONCLUSION Maintaining Ctrough median above 42.68 ng/mL was crucial for achieving the ORR in patients with HCC.
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Xiang L, He B, Liu Q, Hu D, Liao W, Li R, Peng X, Wang Q, Zhao G. Antitumor effects of curcumin on the proliferation, migration and apoptosis of human colorectal carcinoma HCT‑116 cells. Oncol Rep 2020; 44:1997-2008. [PMID: 33000266 PMCID: PMC7550984 DOI: 10.3892/or.2020.7765] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 08/13/2020] [Indexed: 12/22/2022] Open
Abstract
Curcumin is the main component of the Chinese herbal plant turmeric, which has been demonstrated to possess antitumor and other pharmacological properties. The aim of the present study was to investigate the effects of curcumin on the viability, migration and apoptosis of human colorectal carcinoma HCT-116 cells, and to explore the underlying molecular mechanisms. In addition, it was investigated whether the antitumor effect of curcumin on HCT-116 cells could match that of the chemotherapeutic drug 5-fluorouracil (5-FU). HCT-116 cells were treated with curcumin (10, 20 and 30 µM) and 5-FU (500 µM), and cell viability and proliferation were detected by Cell Counting Kit-8 and colony formation assays, respectively. The migration and invasion of treated cells were determined using Transwell and carboxyfluorescein succinimidyl amino ester fluorescent labeling assays. Cell cycle distribution and apoptosis rates were detected by flow cytometry. Furthermore, cell morphology changes associated with apoptosis were observed by fluorescence microscopy with acridine orange/ethidium bromide dual staining. To investigate the possible underlying molecular mechanisms, the gene and protein levels of Fas, Fas-associated via death domain (FADD), caspase-8, caspase-3, matrix metalloproteinase (MMP)-9, nuclear factor (NF)-κB, E-cadherin and claudin-3 were detected using quantitative PCR analysis, zymography and western blotting. The results revealed that curcumin markedly inhibited the viability and proliferation of HCT-116 cells in a dose- and time-dependent manner. The migration, aggregation and invasion of HCT-116 cells into the lungs of mice were decreased by curcumin treatment in a dose-dependent manner. S-phase arrest and gradually increased apoptotic rates of HCT-116 cells were observed with increasing curcumin concentrations. Additionally, the mRNA and protein levels of apoptosis-associated proteins (Fas, FADD, caspase-8 and caspase-3) and E-cadherin in HCT-116 cells were upregulated following treatment with curcumin in a dose-dependent manner. By contrast, the expression of migration-associated proteins, including MMP-9, NF-κB and claudin-3, was downregulated with increasing curcumin concentrations. These data suggested that the inhibitory effect of curcumin on HCT-116 cells may match that of 5-FU. Therefore, curcumin induced cell apoptosis and inhibited tumor cell metastasis by regulating the NF-κB signaling pathway, and its therapeutic effect may be comparable to that of 5-FU.
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Affiliation(s)
- Lei Xiang
- Department of Medical Biology, School of Basic Medical Sciences, Hubei University of Chinese Medicine, Wuhan, Hubei 430065, P.R. China
| | - Bin He
- Department of Medical Biology, School of Basic Medical Sciences, Hubei University of Chinese Medicine, Wuhan, Hubei 430065, P.R. China
| | - Qiang Liu
- Department of Medical Biology, School of Basic Medical Sciences, Hubei University of Chinese Medicine, Wuhan, Hubei 430065, P.R. China
| | - Dongdong Hu
- Department of Medical Biology, School of Basic Medical Sciences, Hubei University of Chinese Medicine, Wuhan, Hubei 430065, P.R. China
| | - Wenjing Liao
- Department of Medical Biology, School of Basic Medical Sciences, Hubei University of Chinese Medicine, Wuhan, Hubei 430065, P.R. China
| | - Ruochan Li
- Department of Medical Biology, School of Basic Medical Sciences, Hubei University of Chinese Medicine, Wuhan, Hubei 430065, P.R. China
| | - Xinyi Peng
- Department of Medical Biology, School of Basic Medical Sciences, Hubei University of Chinese Medicine, Wuhan, Hubei 430065, P.R. China
| | - Qian Wang
- Department of Pathogen Biology, School of Basic Medical Sciences, Hubei University of Chinese Medicine, Wuhan, Hubei 430065, P.R. China
| | - Gang Zhao
- Department of Medical Biology, School of Basic Medical Sciences, Hubei University of Chinese Medicine, Wuhan, Hubei 430065, P.R. China
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Lyashchenko AK, Cremers S. On precision dosing of oral small molecule drugs in oncology. Br J Clin Pharmacol 2020; 87:263-270. [PMID: 32621551 DOI: 10.1111/bcp.14454] [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: 04/16/2020] [Revised: 06/06/2020] [Accepted: 06/17/2020] [Indexed: 12/17/2022] Open
Abstract
Personalization of oral small molecule anticancer drug doses based on individual patient blood drug levels, also known as therapeutic drug monitoring (TDM), has the potential to significantly improve the effectiveness of treatment by maximizing drug efficacy and minimize toxicity. However, this option has not yet been widely embraced by the oncology community. Some reasons for this include increased logistical complexity of dose individualization, the lack of clinical laboratories that measure small molecule drug concentrations in support of patient care, and the lack of reimbursement of costs. However, the main obstacle may be the lack of studies clearly demonstrating that monitoring of oral small molecule anticancer drug levels actually improves clinical outcomes. Without unequivocal evidence in support of TDM-guided dose individualization, especially demonstration of improved survival with TDM in randomized controlled trials, wide acceptance of this approach by oncologists and reimbursement by insurance companies is unlikely, and patients may continue to suffer as a result of receiving incorrect drug doses. This article reviews the current status of TDM of oral small molecule drugs in oncology and intends to provide strategic insights into the design of studies for evaluating the utility of TDM in this clinical context.
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Affiliation(s)
- Alex K Lyashchenko
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Serge Cremers
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Abstract
BACKGROUND AND OBJECTIVE As pazopanib plasma trough concentrations are correlated with treatment outcome, we explored whether single nucleotide polymorphisms in the elimination pathway of pazopanib affect systemic pazopanib concentrations. METHODS The decreased function alleles CYP3A4 15389 C > T (*22), ABCB1 3435 C >T, ABCG2 421 C >A, and ABCG2 34G >A were analyzed within a recently developed population-pharmacokinetic model. RESULTS Incorporation of CYP3A4*22 in the model resulted in a 35% lower clearance for variant carriers (0.18 vs. 0.27 L/h; difference in objective function value: - 9.7; p < 0.005). Simulated median trough concentrations of cancer patients with CYP3A4*22 with 600 mg once daily or 800 mg once daily were 31 and 35 mg/L, respectively. The simulated trough concentrations for the population excluding the CYP3A4*22 carriers after 600 mg once daily or 800 mg once daily were 18 and 20 mg/L, respectively. CONCLUSION This analysis shows that CYP3A4*22 heterozygotes have a substantial lower pazopanib clearance and that dose adjustments based on CYP3A4*22 status could be considered.
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