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Valentin JP, Hoffmann P, Ortemann-Renon C, Koerner J, Pierson J, Gintant G, Willard J, Garnett C, Skinner M, Vargas HM, Wisialowski T, Pugsley MK. The Challenges of Predicting Drug-Induced QTc Prolongation in Humans. Toxicol Sci 2022; 187:3-24. [PMID: 35148401 PMCID: PMC9041548 DOI: 10.1093/toxsci/kfac013] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The content of this article derives from a Health and Environmental Sciences Institute (HESI) consortium with a focus to improve cardiac safety during drug development. A detailed literature review was conducted to evaluate the concordance between nonclinical repolarization assays and the clinical thorough QT (TQT) study. Food and Drug Administration and HESI developed a joint database of nonclinical and clinical data, and a retrospective analysis of 150 anonymized drug candidates was reviewed to compare the performance of 3 standard nonclinical assays with clinical TQT study findings as well as investigate mechanism(s) potentially responsible for apparent discrepancies identified. The nonclinical assays were functional (IKr) current block (Human ether-a-go-go related gene), action potential duration, and corrected QT interval in animals (in vivo corrected QT). Although these nonclinical assays demonstrated good specificity for predicting negative clinical QT prolongation, they had relatively poor sensitivity for predicting positive clinical QT prolongation. After review, 28 discordant TQT-positive drugs were identified. This article provides an overview of direct and indirect mechanisms responsible for QT prolongation and theoretical reasons for lack of concordance between clinical TQT studies and nonclinical assays. We examine 6 specific and discordant TQT-positive drugs as case examples. These were derived from the unique HESI/Food and Drug Administration database. We would like to emphasize some reasons for discordant data including, insufficient or inadequate nonclinical data, effects of the drug on other cardiac ion channels, and indirect and/or nonelectrophysiological effects of drugs, including altered heart rate. We also outline best practices that were developed based upon our evaluation.
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Affiliation(s)
- Jean-Pierre Valentin
- Department of Investigative Toxicology, UCB Biopharma SRL, Braine-l’Alleud B-1420, Belgium
| | | | | | - John Koerner
- Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland 20993, USA
| | - Jennifer Pierson
- Health and Environmental Sciences Institute, Washington, District of Columbia 20005, USA
| | | | - James Willard
- Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland 20993, USA
| | - Christine Garnett
- Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland 20993, USA
| | | | - Hugo M Vargas
- Department of Safety Pharmacology & Animal Research Center, Amgen, Thousand Oaks, California 91320, USA
| | - Todd Wisialowski
- Department of Safety Pharmacology, Pfizer, Groton, Connecticut 06340, USA
| | - Michael K Pugsley
- Department of Toxicology, Cytokinetics, South San Francisco, California 94080, USA
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Khan F, Ismail M, Khan Q, Ali Z. Moxifloxacin-induced QT interval prolongation and torsades de pointes: a narrative review. Expert Opin Drug Saf 2018; 17:1029-1039. [PMID: 30193085 DOI: 10.1080/14740338.2018.1520837] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Moxifloxacin is widely used for the treatment of a number of infectious diseases because of its favorable pharmacological profile and high clinical success rate. However, it is often criticized for its higher risk of QTc interval prolongation (QTIP) and torsades de pointes (TdP). AREAS COVERED A review of published literature on moxifloxacin-related QTIP and TdP. Readers will be provided with a comprehensive overview of the prevalence, cellular mechanism, risk factors, and magnitude of QTIP of moxifloxacin. EXPERT OPINION In healthy subjects, moxifloxacin prolongs the QTc interval by 11.5-19.5 ms, it binds at the Tyr652 residue in the S6 pore domain of the human ether a-go-go gene related potassium channel. Considerable QTIP (30-60 ms) have also been reported in some patients, for instance the incidence of QTIP (30-60 ms) in elderly pneumonia patients was 15.5%. Moxifloxacin-induced QTIP may be of little clinical importance in healthy individuals. However, marked QTIP (>60 ms) and TdP have been reported in high-risk patients (patients who have multiple QT prolonging risk factors). Patients must be thoroughly assessed prior to the use of moxifloxacin and high-risk patients must be identified using risk assessment tools to ensure safe use of moxifloxacin and to safeguard patients' health.
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Affiliation(s)
- Fahadullah Khan
- a Department of Pharmacy , University of Peshawar , Peshawar , Khyber Pakhtunkhwa , Pakistan
| | - Mohammad Ismail
- a Department of Pharmacy , University of Peshawar , Peshawar , Khyber Pakhtunkhwa , Pakistan
| | - Qasim Khan
- a Department of Pharmacy , University of Peshawar , Peshawar , Khyber Pakhtunkhwa , Pakistan.,b Department of Pharmacy , COMSATS Institute of Information Technology , Abbottabad , Khyber Pakhtunkhwa , Pakistan
| | - Zahid Ali
- a Department of Pharmacy , University of Peshawar , Peshawar , Khyber Pakhtunkhwa , Pakistan
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Fossa AA. Beat-to-beat ECG restitution: A review and proposal for a new biomarker to assess cardiac stress and ventricular tachyarrhythmia vulnerability. Ann Noninvasive Electrocardiol 2017; 22. [PMID: 28497858 DOI: 10.1111/anec.12460] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 04/06/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Cardiac restitution is the ability of the heart to recover from one beat to the next. Ventricular arrhythmia vulnerability can occur when the heart does not properly adjust to sudden changes in rate or in hemodynamics leading to excessive temporal and/or spatial heterogeneity in conduction or repolarization. Restitution has historically been used to study, by invasive means, the dynamics of the relationship between action potential duration (APD) and diastolic interval (DI) in sedated subjects using various pacing protocols. Even though the analogous measures of APD and DI can be obtained using the surface ECG to acquire the respective QT and TQ intervals for ECG restitution, this methodology has not been widely adopted for a number of reasons. METHODS Recent development of more advanced software algorithms enables ECG intervals to be measured accurately, on a continuous beat-to-beat basis, in an automated manner, and under highly dynamic conditions (i.e., ambulatory or exercise) providing information beyond that available in the typical resting state. RESULTS Current breakthroughs in ECG technology will allow ECG restitution measures to become a practical approach for providing quantitative measures of the risks for ventricular arrhythmias as well as cardiac stress in general. CONCLUSIONS In addition to a review of the underlying principles and caveats of ECG restitution, a new approach toward an advancement of more integrated restitution biomarkers is proposed.
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Abstract
With the adoption of the ICH E14 guidance, the thorough QT/QTc (TQT) study has become the focus of clinical assessment of an NCE's effects on ECG parameters. The TQT study is used as a guide to the liability of a drug to cause proarrhythmias on the basis of delayed cardiac repolarization. Around 300 TQT studies have been performed since 2005 and through interactions between sponsors and regulators, especially FDA's Interdisciplinary Review Team (IRT) for QT studies. These studies can today be performed more effectively and with great confidence in the generated data. This chapter will discuss technical features and the design and analysis of TQT studies, how assay sensitivity is demonstrated, and examples from recently conducted studies. ECG assessment for drugs that cannot be safely given to healthy volunteers is also addressed, and examples from studies in cancer patients and in healthy volunteers with tyrosine kinase inhibitors are discussed. The TQT study is resource intensive and designed to solely evaluate whether an NCE prolongs the QTc interval. If data with similar confidence can be generated from other studies that are routinely performed as part of the clinical development, this would represent a more optimal use of human resources. Methods and approaches to increase the confidence in ECG data derived from "early QT assessment" in single-ascending/multiple-ascending dose studies are therefore discussed, and a path toward replacing the TQT study using these approaches will be outlined.
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Affiliation(s)
- Borje Darpo
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd's Hospital, Stockholm, Sweden,
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Darpo B, Garnett C, Benson CT, Keirns J, Leishman D, Malik M, Mehrotra N, Prasad K, Riley S, Rodriguez I, Sager P, Sarapa N, Wallis R. Cardiac Safety Research Consortium: can the thorough QT/QTc study be replaced by early QT assessment in routine clinical pharmacology studies? Scientific update and a research proposal for a path forward. Am Heart J 2014; 168:262-72. [PMID: 25173536 DOI: 10.1016/j.ahj.2014.06.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 06/03/2014] [Indexed: 11/29/2022]
Abstract
The International Conference on Harmonization E14 guidance for the clinical evaluation of QT/QTc interval prolongation requires almost all new drugs to undergo a dedicated clinical study, primarily in healthy volunteers, the so-called TQT study. Since 2005, when the E14 guidance was implemented in United States and Europe, close to 400 TQT studies have been conducted. In February 2012, the Cardiac Safety Research Consortium held a think tank meeting at Food and Drug Administration's White Oak campus to discuss whether "QT assessment" can be performed as part of routine phase 1 studies. Based on these discussions, a group of experts convened to discuss how to improve the confidence in QT data from early clinical studies, for example, the First-Time-in-Human trial, through collection of serial electrocardiograms and pharmacokinetic samples and the use of exposure response analysis. Recommendations are given on how to design such "early electrocardiogram assessment," and the limitation of not having a pharmacologic-positive control in these studies is discussed. A research path is identified toward collecting evidence to replace or provide an alternative to the dedicated TQT study.
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Affiliation(s)
- Borje Darpo
- Karolinska Institutet, Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd's Hospital, Stockholm, Sweden; iCardiac Technologies, Rochester, NY.
| | | | | | - James Keirns
- Global Clinical Pharmacology & Exploratory Development, Astellas Pharma Global, Development, Inc, Northbrook, IL
| | - Derek Leishman
- Global PK/PD & Pharmacometrics, Lilly Research Laboratories, Eli Lilly & Co, Indianapolis, IN
| | - Marek Malik
- St Paul's Cardiac Electrophysiology, University of London, and Imperial College, London, United Kingdom
| | - Nitin Mehrotra
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD
| | - Krishna Prasad
- Medicines and Healthcare products Regulatory Agency, DoH, London, United Kingdom
| | - Steve Riley
- Clinical Pharmacology, Global Innovative Pharma Business, Pfizer Inc, Groton, CT
| | - Ignacio Rodriguez
- Pharma Development Safety Risk Management, Roche TCRC, Inc, New York, NY
| | | | - Nenad Sarapa
- Clinical Sciences, Bayer Healthcare, Inc. Whippany, NJ
| | - Robert Wallis
- Safety Pharmacology Consultant, Sandwich, United Kingdom
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Townsend C, Brown BS. Predicting drug-induced QT prolongation and torsades de pointes: a review of preclinical endpoint measures. ACTA ACUST UNITED AC 2013; Chapter 10:Unit 10.16. [PMID: 23744708 DOI: 10.1002/0471141755.ph1016s61] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Compound-induced prolongation of the cardiac QT interval is a major concern in drug development and this unit discusses approaches that can predict QT effects prior to undertaking clinical trials. The majority of compounds that prolong the QT interval block the cardiac rapid delayed rectifier potassium current, IKr (hERG). Described in this overview are different ways to measure hERG, from recent advances in automated electrophysiology to the quantification of channel protein trafficking and binding. The contribution of other cardiac ion channels to hERG data interpretation is also discussed. In addition, endpoint measures of the integrated activity of cardiac ion channels at the single-cell, tissue, and whole-animal level, including for example the well-established action potential to the more recent beat-to-beat variability, transmural dispersion of repolarization, and field potential duration, are described in the context of their ability to predict QT prolongation and torsadogenicity in humans.
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Affiliation(s)
- Claire Townsend
- GlaxoSmithKline Biological Reagents and Assay Development, Research Triangle Park, NC, USA
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Barbey JT. Vardenafil-associated QTc changes: not merely a normal autonomic process. Clin Pharmacol Ther 2012; 91:580; author reply 580-1. [PMID: 22378160 DOI: 10.1038/clpt.2011.294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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