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İlhan B, Erdoğan T, Topinková E, Bahat G. Management of use of urinary antimuscarinics and alpha blockers for benign prostatic hyperplasia in older adults at risk of falls: a clinical review. Eur Geriatr Med 2023; 14:733-746. [PMID: 37245173 DOI: 10.1007/s41999-023-00798-7] [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: 10/07/2022] [Accepted: 05/10/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE We aimed to outline the existing information and the underlying mechanisms of risk of falls associated with the use of urinary antimuscarinics for overactive bladder (OAB) or alpha-blockers for benign prostatic hyperplasia (BPH) in older adults. In addition, we aimed to provide assistance to clinicians in decision-making about (de-)prescribing these drugs in older adults. METHODOLOGY Based on a literature search in PubMed and Google Scholar, we reviewed the literature, and identified additional relevant articles from reference lists, with an emphasis on the most commonly prescribed drugs in OAB and BPH in older patients. We discussed the use of bladder antimuscarinics and alpha-blockers, their potential side effects related to falls, and the deprescribing of these drugs in older adults. RESULTS Urinary urgency or incontinence and lower urinary tract symptoms due to untreated OAB and BPH contribute to fall risk. On the other hand, the use of bladder antimuscarinics and alpha-blockers is also related to fall risk. They contribute to (or cause) falling through dizziness, somnolence, visual impairment, and orthostatic hypotension while they differ in their side-effect profiles regarding these problems. Falls are common and can cause a remarkable amount of morbidity and mortality. Thus, preventive measures should be taken to lower the risk. If the clinical condition allows, withdrawal of bladder antimuscarinics and alpha-blockers is recommended in fall-prone older adults. There are practical resources and algorithms that guide and assist clinicians in deprescribing these drug groups. CONCLUSIONS The decision to prescribe or deprescribe these treatments in patients at high risk of falls should be individualized. In addition to explicit tools that are helpful for clinical decision-making in (de-)prescribing these drugs, STOPPFall (a recently developed expert-based decision aid specifically aiming to prevent falls) is present to assist prescribers in attaining decisions.
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Affiliation(s)
- Birkan İlhan
- Internal Medicine, and Geriatrics Clinic, Liv Hospital Vadi Istanbul, Istanbul, Turkey
| | - Tuğba Erdoğan
- Geriatrics Clinic, Tekirdağ Dr. Ismail Fehmi Cumalıoglu City Hospital, Tekirdağ, Turkey
| | - Eva Topinková
- Department of Geriatric Medicine, 1st Faculty of Medicine, Charles University and General University Hospital, Prague and Faculty of Health and Social Sciences, University of South Bohemia, České Budejovice, Czechia
| | - Gülistan Bahat
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Istanbul, Turkey.
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Goto A, Sakamoto K, Kambayashi R, Izumi-Nakaseko H, Kawai S, Takei Y, Matsumoto A, Kanda Y, Sugiyama A. Validation of risk-stratification method for the chronic atrioventricular block cynomolgus monkey model and its mechanistic interpretation using 6 drugs with pharmacologically-distinct profile. Toxicol Sci 2022; 190:99-109. [PMID: 35993620 DOI: 10.1093/toxsci/kfac088] [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: 11/13/2022] Open
Abstract
Validation of risk-stratification method for the chronic atrioventricular block cynomolgus monkey model and its mechanistic interpretation were performed using 6 pharmacologically-distinct drugs. The following drugs were orally administered in conscious state, astemizole: 1, 5 and 10 mg/kg (n = 6); haloperidol: 1, 10 and 30 mg/kg (n = 5); amiodarone: 30 mg/kg (n = 4); famotidine: 10 mg/kg (n = 4); levofloxacin: 100 mg/kg (n = 4); and tolterodine: 0.2, 1 and 4.5 mg/kg (n = 4). Astemizole of 5 and 10 mg/kg significantly prolonged ΔΔQTcF, whereas no significant change was observed by the others. Torsade de pointes (TdP) was induced by astemizole of 5 and 10 mg/kg in 3/6 and 6/6, and by haloperidol of 10 and 30 mg/kg in 1/5 and 1/5, respectively, which was not observed in the others. Torsadogenic risk of the drugs was quantified using the criteria for the monkey model specified in our previous study. Namely, high-risk drugs induced TdP at ≤ 3times of their maximum clinical daily dose. Intermediate-risk drugs did not induce TdP at this dose range, but induced it at higher doses. Low/no-risk drugs never induced TdP at any dose tested. The magnitude of risk was intermediate for astemizole and haloperidol, and low/no risk for the others. The pre-specified, risk-stratification method for the monkey model may solve the issue existing between non-clinical models and patients with labile repolarization, which can reinforce the regulatory decision-making and labelling at time of marketing application of non-double-negative drug candidate (hERG assay positive and/or in vivo QT study positive).
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Affiliation(s)
- Ai Goto
- Department of Pharmacology, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Kengo Sakamoto
- Ina Research Inc, 2148-188 Nishiminowa, Ina-shi, Nagano, 399-4501, Japan
| | - Ryuichi Kambayashi
- Department of Pharmacology, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Hiroko Izumi-Nakaseko
- Department of Pharmacology, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Shinichi Kawai
- Department of Inflammation & Pain Control Research, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Yoshinori Takei
- Department of Pharmacology, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Akio Matsumoto
- Department of Aging Pharmacology, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Yasunari Kanda
- Division of Pharmacology, National Institute of Health Sciences, 3-25-26 Tonomachi, Kawasaki-ku, Kawasaki, Kanagawa, 210-9501, Japan
| | - Atsushi Sugiyama
- Department of Pharmacology, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan.,Department of Inflammation & Pain Control Research, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan.,Department of Aging Pharmacology, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
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Functional human cell-based vascularised cardiac tissue model for biomedical research and testing. Sci Rep 2022; 12:13459. [PMID: 35931748 PMCID: PMC9355975 DOI: 10.1038/s41598-022-17498-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 07/26/2022] [Indexed: 12/01/2022] Open
Abstract
Cardiomyocytes derived from human induced pluripotent stem cells (hiPSC) are widely used in in vitro biomedical research and testing. However, fully matured, adult cardiomyocyte characteristics have not been achieved. To improve the maturity and physiological relevance of hiPSC-derived cardiomyocytes, we co-cultured them with preconstructed vascular-like networks to form a functional, human cell-based cardiac tissue model. The morphology and gene expression profiles indicated advanced maturation in the cardiac tissue model compared to those of a cardiomyocyte monoculture. The cardiac tissue model’s functionality was confirmed by measuring the effects of 32 compounds with multielectrode array and comparing results to human data. Our model predicted the cardiac effects with a predictive accuracy of 91%, sensitivity of 90% and specificity of 100%. The correlation between the effective concentration (EC50) and the reported clinical plasma concentrations was 0.952 (R2 = 0.905). The developed advanced human cell-based cardiac tissue model showed characteristics and functionality of human cardiac tissue enabling accurate transferability of gained in vitro data to human settings. The model is standardized and thus, it would be highly useful in biomedical research and cardiotoxicity testing.
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Kim Y, Kim A, Chung JY. Population pharmacokinetic/pharmacodynamic modeling of delayed effect of escitalopram-induced QT prolongation. J Affect Disord 2021; 285:120-126. [PMID: 33647579 DOI: 10.1016/j.jad.2021.02.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 02/14/2021] [Accepted: 02/17/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND A thorough QT study identified that escitalopram-induced QT prolongation was delayed. This study thus aimed to develop a population pharmacokinetic (PK)/pharmacodynamic (PD) model to characterize the relationship between escitalopram concentrations and the delayed effect on QT prolongation. METHODS The data of completed subjects who had placebo (n=36) and a single dose of 20 mg escitalopram (n=33) from a previous thorough QT study were used. Population PK/PD analysis was performed by nonlinear mixed-effects modeling. A escitalopram concentration-drug effect model was developed with estimated individual PK and baseline QT parameters. To explain the relationship between escitalopram concentrations and QT prolongation delay, an effect compartment model was utilized. RESULTS A two-compartment model with first-order absorption and lag time and first-order elimination adequately described the PK of escitalopram. The circadian rhythm of baseline QT interval was best explained by two harmonic cosine functions. A linear model properly characterized escitalopram-induced QT prolongation. The average estimated maximal QT prolongation was 5.4 ms (range: 1.9-7.6 ms). The equilibrium half-life of delayed QT prolongation was 1.9 h. The drug effect of QTc change compared with that at baseline remained relatively constant from 1.3 to 3.5 ms over 24 h, and the maximum QTc change occurred with a 3-h delay after the time to the maximum plasma concentration. LIMITATIONS We did not include genetic polymorphisms, such as CYP2C19, as potential covariates owing to limited information. CONCLUSIONS These results may provide useful information on when to monitor electrocardiogram in patients who require intensive care after drug administration.
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Affiliation(s)
- Yun Kim
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Anhye Kim
- Department of Clinical Pharmacology and Therapeutics, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Jae-Yong Chung
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Bundang Hospital, Seongnam, Republic of Korea.
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Wiśniowska B, Bielecka ZM, Polak S. How circadian variability of the heart rate and plasma electrolytes concentration influence the cardiac electrophysiology - model-based case study. J Pharmacokinet Pharmacodyn 2021; 48:387-399. [PMID: 33666801 PMCID: PMC8144092 DOI: 10.1007/s10928-021-09744-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/24/2021] [Indexed: 11/24/2022]
Abstract
The circadian rhythm of cardiac electrophysiology is dependent on many physiological and biochemical factors. Provided, that models describing the circadian patterns of cardiac activity and/or electrophysiology which have been verified to the acceptable level, modeling and simulation can give answers to many of heart chronotherapy questions. The aim of the study was to assess the performance of the circadian models implemented in Cardiac Safety Simulator v 2.2 (Certara, Sheffield, UK) (CSS), as well as investigate the influence ofcircadian rhythms on the simulation results in terms of cardiac safety. The simulations which were run in CSS accounted for inter-individual and intra-individual variability. Firstly, the diurnal variations in QT interval length in a healthy population were simulated accounting for heart rate (HR) circadian changes alone, or with concomitant diurnal variations of plasma ion concentrations. Next, tolterodine was chosen as an exemplary drug for PKPD modelling exercise to assess the role of circadian rhythmicity in the prediction of drug effects on QT interval. The results of the simulations were in line with clinical observations, what can serve as a verification of the circadian models implemented in CSS. Moreover, the results have suggested that the circadian variability of the electrolytes balance is the main factor influencing QT circadian pattern. The fluctuation of ion concentration increases the intra-subject variability of predicted drug-triggered QT corrected for HR (QTc) prolongation effect and, in case of modest drug effect on QTc interval length, allows to capture this effect.
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Affiliation(s)
- Barbara Wiśniowska
- Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Street, 30-688, Kraków, Poland.
| | - Zofia M Bielecka
- Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Street, 30-688, Kraków, Poland
- Simcyp Division, Certara UK Limited, Level 2-Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Sebastian Polak
- Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Street, 30-688, Kraków, Poland
- Simcyp Division, Certara UK Limited, Level 2-Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK
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Research implications of the FDA ECG warehouse and related resources. J Electrocardiol 2019; 57S:S27-S33. [PMID: 31627942 DOI: 10.1016/j.jelectrocard.2019.09.009] [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: 07/08/2019] [Revised: 09/01/2019] [Accepted: 09/05/2019] [Indexed: 11/22/2022]
Abstract
The electrocardiogram is often used as an efficacy endpoint for comparing new drugs or as an indicator for cardiovascular safety in both studies of arrhythmic and non-arrhythmic novel drugs. The FDA ECG Warehouse data are owned by the submitting entities, generally pharmaceutical company manufacturers. However, a subset of these ECG data was released with permission from the data owners to the CSRC for access by investigators, equipment manufacturers and algorithm developers for CSRC-approved research and development studies. This article provides an overview of the Cardiac Safety Research Consortium (CSRC) ECG Warehouse, including data availability, completed and ongoing projects, as well as future growth potential amidst an ever expanding FDA ECG Warehouse. Given that current ICH E14 guidelines request that sponsors submitting new drug applications assess the effects on the QT interval using a thorough QT (TQT) or dose-ranging study with concentration-QT analysis during early clinical development to assess cardiac risk, developing novel methods to determine cardiovascular safety, as well as understanding current ECG collection and analysis methods are prudent. The ability to utilize previously collected ECG data for secondary analyses improves cardiovascular safety by multiplying the scientific contribution of the original research.
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Patel N, Wisniowska B, Polak S. Virtual Thorough QT (TQT) Trial-Extrapolation of In Vitro Cardiac Safety Data to In Vivo Situation Using Multi-Scale Physiologically Based Ventricular Cell-wall Model Exemplified with Tolterodine and Fesoterodine. AAPS JOURNAL 2018; 20:83. [PMID: 29995258 DOI: 10.1208/s12248-018-0244-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 06/20/2018] [Indexed: 12/14/2022]
Abstract
QT interval prolongation typically assessed with dedicated clinical trials called thorough QT/QTc (TQT) studies is used as surrogate to identify the proarrhythmic risk of drugs albeit with criticism in terms of cost-effectiveness in establishing the actual risk of torsade de pointes (TdP). Quantitative systems toxicology and safety (QSTS) models have potential to quantitatively translate the in vitro cardiac safety data to clinical level including simulation of TQT trials. Virtual TQT simulations have been exemplified with use of two related drugs tolterodine and fesoterodine. The impact of bio-relevant concentration in plasma versus estimated heart tissue exposure on predictions was also assessed. Tolterodine and its therapeutically equipotent metabolite formed via CYP2D6 pathway, 5-HMT, inhibit multiple cardiac ion currents (IKr, INa, ICaL). The QSTS model was able to accurately simulate the QT prolongation at therapeutic and supra-therapeutic dose levels of tolterodine well within 95% confidence interval limits of observed data. The model was able to predict the QT prolongation difference between CYP2D6 extensive and poor metaboliser subject groups at both dose levels thus confirming the ability of the model to account for electrophysiologically active metabolite. The QSTS model was able to simulate the negligible QT prolongation observed with fesoterodine establishing that the 5-HMT does not prolong QT interval even though it is a blocker of hERG channel. With examples of TOL and FESO, we demonstrated the utility of the QSTS approaches to simulate virtual TQT trials, which in turn could complement and reduce the clinical studies or help optimise clinical trial designs.
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Affiliation(s)
- Nikunjkumar Patel
- Simcyp Division, Certara UK Limited, Level 2-Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK. .,Unit of Pharmacoepidemiology and Pharmacoeconomics, Faculty of Pharmacy, Jagiellonian University Medical College, Krakow, Poland.
| | - Barbara Wisniowska
- Unit of Pharmacoepidemiology and Pharmacoeconomics, Faculty of Pharmacy, Jagiellonian University Medical College, Krakow, Poland
| | - Sebastian Polak
- Simcyp Division, Certara UK Limited, Level 2-Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK.,Unit of Pharmacoepidemiology and Pharmacoeconomics, Faculty of Pharmacy, Jagiellonian University Medical College, Krakow, Poland
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Attia AK, Frag EY, Ahmed HE. Validated electroanalytical determination of flavoxate hydrochloride and tolterodine tartrate drugs in bulk, dosage forms and urine using modified carbon paste electrodes. ARAB J CHEM 2018. [DOI: 10.1016/j.arabjc.2016.07.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Qu Y, Page G, Abi-Gerges N, Miller PE, Ghetti A, Vargas HM. Action Potential Recording and Pro-arrhythmia Risk Analysis in Human Ventricular Trabeculae. Front Physiol 2018; 8:1109. [PMID: 29354071 PMCID: PMC5760531 DOI: 10.3389/fphys.2017.01109] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/14/2017] [Indexed: 01/20/2023] Open
Abstract
To assess drug-induced pro-arrhythmic risk, especially Torsades de Pointe (TdP), new models have been proposed, such as in-silico modeling of ventricular action potential (AP) and stem cell-derived cardiomyocytes (SC-CMs). Previously we evaluated the electrophysiological profile of 15 reference drugs in hESC-CMs and hiPSC-CMs for their effects on intracellular AP and extracellular field potential, respectively. Our findings indicated that SC-CMs exhibited immature phenotype and had the propensity to generate false positives in predicting TdP risk. To expand our knowledge with mature human cardiac tissues for drug-induced pro-arrhythmic risk assessment, human ventricular trabeculae (hVT) from ethically consented organ donors were used to evaluate the effects of the same 15 drugs (8 torsadogenic, 5 non-torsadogenic, and 2 discovery molecules) on AP parameters at 1 and 2 Hz. Each drug was tested blindly with 4 concentrations in duplicate trabeculae from 2 hearts. To identify the pro-arrhythmic risk of each drug, a pro-arrhythmic score was calculated as the weighted sum of percent drug-induced changes compared to baseline in various AP parameters, including AP duration and recognized pro-arrhythmia predictors such as triangulation, beat-to-beat variability and incidence of early-afterdepolarizations, at each concentration. In addition, to understand the translation of this preclinical hVT AP-based model to clinical studies, a ratio that relates each testing concentration to the human therapeutic unbound Cmax (Cmax) was calculated. At a ratio of 10, for the 8 torsadogenic drugs, 7 were correctly identified by the pro-arrhythmic score; 1 was mislabeled. For the 5 non-torsadogenic drugs, 4 were correctly identified as safe; 1 was mislabeled. Calculation of sensitivity, specificity, positive predictive value, and negative predictive value indicated excellent performance. For example, at a ratio of 10, scores for sensitivity, specificity, positive predictive value and negative predictive values were 0.88, 0.8, 0.88 and 0.8, respectively. Thus, the hVT AP-based model combined with the integrated analysis of pro-arrhythmic score can differentiate between torsadogenic and non-torsadogenic drugs, and has a greater predictive performance when compared to human SC-CM models.
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Affiliation(s)
- Yusheng Qu
- Integrated Discovery and Safety Pharmacology, Amgen Inc., Thousand Oaks, CA, United States
| | - Guy Page
- AnaBios Corporation, San Diego, CA, United States
| | | | | | - Andre Ghetti
- AnaBios Corporation, San Diego, CA, United States
| | - Hugo M. Vargas
- Integrated Discovery and Safety Pharmacology, Amgen Inc., Thousand Oaks, CA, United States
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Tammara BK, Plotka A, Shafer FE, Readett DRJ, Riley S, Korth-Bradley JM. Lack of Effect of Rivipansel on QTc Interval in Healthy Adult African American Male Subjects. J Clin Pharmacol 2017; 57:1315-1321. [PMID: 28510346 DOI: 10.1002/jcph.924] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 03/22/2017] [Indexed: 01/01/2023]
Abstract
Rivipansel is a pan-selectin inhibitor in phase 3 development for the treatment of vaso-occlusive crises in patients with sickle cell disease. This single-dose, randomized, 3-period, 3-treatment (400 mg moxifloxacin open-label, 4 g rivipansel-blinded, and placebo-blinded) crossover study evaluated the effect of rivipansel on the QT/QTc interval in 48 healthy male African American subjects (age, 21-53 years; weight, 60-115 kg). Time-matched, placebo-adjusted change from baseline QT interval using Fridericia's correction method (QTcF) was determined using a repeated-measures mixed-effects model. The highest upper bound of the 2-sided 90% confidence interval (CI) for QTcF change was 3.22 milliseconds 3 hours postdose. Moxifloxacin showed the anticipated QTcF effect, indicating that the study had adequate sensitivity to detect changes in the QTcF interval. The study concluded that no QTcF effect was demonstrated with rivipansel compared with placebo, as the upper bound of the 2-sided 90%CI was less than 10 milliseconds at all times. Exposure-response modeling for rivipansel concentrations and change from baseline in QTcF data corroborated a lack of effect with rivipansel compared with placebo. Single doses of rivipansel 4 g by intravenous infusion over 20 minutes were well tolerated in this study.
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Wiśniowska B, Tylutki Z, Polak S. Thorough QT (TQT) studies: concordance with torsadogenesis and an evolving cardiac safety testing paradigm. Drug Discov Today 2017; 22:1460-1465. [PMID: 28511997 DOI: 10.1016/j.drudis.2017.04.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 03/30/2017] [Accepted: 04/26/2017] [Indexed: 01/08/2023]
Abstract
Since 2005, when the International Conference on Harmonisation (ICH) E14 guideline was adopted, no drug has been withdrawn because of QTc prolongation or torsade de pointes arrhythmia. There are, however, costs associated with this success. In addition to the time and money invested, thorough QT (TQT) studies have limited the efficiency of the drug development pipeline. In this paper, we discuss the relevance of TQT trials as a tool for proarrhythmic risk prediction as a part of the debate regarding their usefulness.
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Affiliation(s)
- Barbara Wiśniowska
- Pharmacoepidemiology and Pharmacoeconomics Unit, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9, Str., 30-688 Krakow, Poland.
| | - Zofia Tylutki
- Pharmacoepidemiology and Pharmacoeconomics Unit, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9, Str., 30-688 Krakow, Poland
| | - Sebastian Polak
- Pharmacoepidemiology and Pharmacoeconomics Unit, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9, Str., 30-688 Krakow, Poland; Simcyp (part of Certara), Sheffield S2 4SU, UK
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Kitaguchi T, Moriyama Y, Taniguchi T, Maeda S, Ando H, Uda T, Otabe K, Oguchi M, Shimizu S, Saito H, Toratani A, Asayama M, Yamamoto W, Matsumoto E, Saji D, Ohnaka H, Miyamoto N. CSAHi study: Detection of drug-induced ion channel/receptor responses, QT prolongation, and arrhythmia using multi-electrode arrays in combination with human induced pluripotent stem cell-derived cardiomyocytes. J Pharmacol Toxicol Methods 2017; 85:73-81. [DOI: 10.1016/j.vascn.2017.02.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/05/2016] [Accepted: 02/01/2017] [Indexed: 12/20/2022]
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Nomura Y, Iitsuka H, Toyoshima J, Kuroishi K, Hatta T, Kaibara A, Katashima M, Moy S, Sawamoto T. Pharmacokinetic drug interaction study between overactive bladder drugs mirabegron and tolterodine in Japanese healthy postmenopausal females. Drug Metab Pharmacokinet 2016; 31:411-416. [PMID: 27829538 DOI: 10.1016/j.dmpk.2016.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 08/05/2016] [Accepted: 08/09/2016] [Indexed: 11/17/2022]
Abstract
Mirabegron, the first selective β3-adrenoceptor agonist for the treatment of overactive bladder (OAB), inhibits cytochrome P450 isozyme CYP2D6. This study was performed in Japanese healthy postmenopausal female volunteers to assess any pharmacokinetic drug interaction between mirabegron and tolterodine, another OAB drug and a sensitive substrate of CYP2D6. Tolterodine 4 mg was orally administered from Days 1-7 and co-administered with mirabegron 50 mg from Days 8-14. Mirabegron 50 mg increased maximum concentration (Cmax) and area under the concentration-time curve from zero to 24 h after dosing (AUC24h) of tolterodine by 2.06-fold (90% confidence interval [CI] 1.81, 2.34) and 1.86-fold (90% CI 1.60, 2.16), respectively, and increased Cmax and AUC24h of the metabolite 5-hydroxymethyl tolterodine by 1.36-fold (90% CI 1.26, 1.47) and 1.25-fold (90% CI 1.15, 1.37), respectively. This suggested a weak pharmacokinetic drug interaction between mirabegron and tolterodine. Mean change from baseline of Fridericia's QT correction formula (ΔQTcF) was slightly higher on Day 14 than on Day 7. No subject had QTcF >480 msec or ΔQTcF >60 msec. All the treatment-emergent adverse events were mild. Mirabegron 50 mg was considered to be safe and well tolerated when coadministered with tolterodine 4 mg in healthy postmenopausal female volunteers.
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Affiliation(s)
- Yuki Nomura
- Clinical Pharmacology, Development, Astellas Pharma Inc., 2-5-1, Nihonbashi-Honcho, Chuo-ku, Tokyo 103-8411, Japan.
| | - Hiromi Iitsuka
- Clinical Pharmacology, Development, Astellas Pharma Inc., 2-5-1, Nihonbashi-Honcho, Chuo-ku, Tokyo 103-8411, Japan
| | - Junko Toyoshima
- Clinical Pharmacology, Development, Astellas Pharma Inc., 2-5-1, Nihonbashi-Honcho, Chuo-ku, Tokyo 103-8411, Japan
| | - Kentaro Kuroishi
- Data Science, Development, Astellas Pharma Inc., 2-5-1, Nihonbashi-Honcho, Chuo-ku, Tokyo 103-8411, Japan
| | - Toshifumi Hatta
- Clinical Pharmacology, Development, Astellas Pharma Inc., 2-5-1, Nihonbashi-Honcho, Chuo-ku, Tokyo 103-8411, Japan
| | - Atsunori Kaibara
- Clinical Pharmacology, Development, Astellas Pharma Inc., 2-5-1, Nihonbashi-Honcho, Chuo-ku, Tokyo 103-8411, Japan
| | - Masataka Katashima
- Clinical Pharmacology, Development, Astellas Pharma Inc., 2-5-1, Nihonbashi-Honcho, Chuo-ku, Tokyo 103-8411, Japan
| | - Selina Moy
- Astellas Research Institute of America, 8045 Lamon Avenue, Skokie, IL 60077, United States
| | - Taiji Sawamoto
- Clinical Pharmacology, Development, Astellas Pharma Inc., 2-5-1, Nihonbashi-Honcho, Chuo-ku, Tokyo 103-8411, Japan
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Ruiz-Garcia A, Houk BE, Pithavala YK, Toh M, Sarapa N, Tortorici MA. Effect of axitinib on the QT interval in healthy volunteers. Cancer Chemother Pharmacol 2015; 75:619-28. [PMID: 25589220 DOI: 10.1007/s00280-015-2677-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 01/04/2015] [Indexed: 10/24/2022]
Abstract
PURPOSE Axitinib is a potent and selective inhibitor of vascular endothelial growth factor receptors 1-3, approved for second-line treatment of advanced renal cell carcinoma (RCC). Preclinical studies did not indicate potential for axitinib-induced delayed cardiac repolarization. METHODS The effect of axitinib on corrected QT (QTc) prolongation was evaluated with one-stage concentration-QTc response modeling using data from a definitive randomized crossover QT phase I study in healthy volunteers administered one single 5-mg axitinib dose alone or in the presence of steady-state ketoconazole (400 mg once daily). RESULTS Axitinib and ketoconazole had opposite effects on heart rate: Axitinib lowered it, ketoconazole raised it. The final analysis showed a flat relationship between QTc and axitinib concentration (slope -0.0314 ms·mL/ng) for axitinib alone. Mean highest placebo-matched change from baseline in QTc was -3.0 [90 % confidence interval (CI) -5.4, -0.6] ms. At supratherapeutic axitinib exposures achieved with potent cytochrome P450 3A4/5 inhibition by ketoconazole, the model predicted mean QTc change of 6.5 (90 % CI 4.4-8.5) ms. The slope population mean estimate was -0.331 (95 % CI -0.860, 0.198) ms·mL/µg for ketoconazole alone and 0.0725 (0.0445-0.1005) ms·mL/ng for axitinib in the presence of ketoconazole. The results were then compared with those obtained based on more widely used Fridericia's, Bazett's, and study-specific correction methods. CONCLUSIONS Since axitinib plasma concentrations observed in this study exceeded the range of concentrations observed in patients with RCC at the highest approved clinical dose (10 mg twice daily), axitinib was not associated with clinically significant QTc prolongation in target populations.
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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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Hizue M, Ochi Y, Imura M, Yamagami H. [Pharmacological profile and clinical findings of fesoterodine (Toviaz®Tablets )]. Nihon Yakurigaku Zasshi 2014; 143:203-213. [PMID: 24717610 DOI: 10.1254/fpj.143.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Beasley CM, Dmitrienko A, Mitchell MI. Design and analysis considerations for thorough QT studies employing conventional (10 s, 12-lead) ECG recordings. Expert Rev Clin Pharmacol 2014; 1:815-39. [PMID: 24410610 DOI: 10.1586/17512433.1.6.815] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The QT interval from the ECG cannot be measured precisely. The relationship of the QT interval to the RR interval within individuals across time and different RR values, and across individuals eludes complete understanding. Intrinsic beat-to-beat variability in QT interval corrected for heart rate (QTc interval) is not trivial. Therefore, it is difficult to determine a valid and reliable estimate of the time for ventricular repolarization based on the QTc interval. Yet, it must be demonstrated that a drug does not result in an increase in the QTc interval that exceeds 5 ms with some reasonable degree of certainty to be quite confident that the drug does not convey some risk of ventricular tachydysrhythmia due to delayed ventricular repolarization. This demonstration can be a Herculean task due to the magnitude of variability in the QTc interval. Design features and analytical methods that might be used in the thorough QT study to improve the chances of demonstrating the true relationship between a drug and QTc interval are reviewed.
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Mock S, Dmochowski RR. Evaluation of fesoterodine fumarate for the treatment of an overactive bladder. Expert Opin Drug Metab Toxicol 2013; 9:1659-66. [PMID: 24205892 DOI: 10.1517/17425255.2013.858118] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Fesoterodine fumarate is an approved drug for overactive bladder. The aim of this study is to review the preclinical and most up to date clinical data on fesoterodine, with a special emphasis on its unique pharmacokinetic features and its implications on safety and tolerability in various patient populations. AREAS COVERED In this review, the authors extensively reviewed available literature via PubMed search regarding fesoterodine, covering its mechanism of action, pharmacodynamics and pharmacokinetics, clinical efficacy, safety, and tolerability. EXPERT OPINION Fesoterodine is an anti-muscarinic agent with a unique pharmacokinetic profile. It is a prodrug that is rapidly metabolized to its active form by nonspecific plasma esterases. Its metabolism is independent of the cytochrome P450 enzyme system. This along with its dual excretion pathways and minimal central nervous system penetration leads to less variability in drug exposure and allowance of administration in those with mild to moderate renal and hepatic insufficiency and in the geriatric population.
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Affiliation(s)
- Stephen Mock
- Vanderbilt University Medical Center, Department of Urology , Room A 1302, Medical Center North, Nashville, TN 37232 , USA +1 615 343 5602 ; +1 615 322 8990 ;
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Elterman DS, Chughtai B, Kaplan SA, Barkin J. Tolterodine for the treatment of urge urinary incontinence. Expert Opin Pharmacother 2013; 14:1987-91. [PMID: 23885788 DOI: 10.1517/14656566.2013.823158] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Overactive bladder (OAB) and its resultant urge urinary incontinence (UUI) are significant problems that medically, psychologically and financially affect people. The constellation of symptoms comprising OAB affects ∼ 16% of the adult population and its prevalence increases with aging. The typical class of medications used to treat OAB is antimuscarinics. AREAS COVERED OAB medications, with a focus on tolterodine for the treatment of UUI are reviewed. A thorough review of English language literature using EMBASE/Medline and PubMed has been performed. EXPERT OPINION Tolterodine provides a reasonable starting point when treating patients with OAB and UUI. Efficacy and tolerability are generally comparable between tolterodine and other newer antimuscarinics. Tolterodine is a good option as part of the algorithm in the treatment of OAB and UUI.
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Affiliation(s)
- Dean S Elterman
- Weill Cornell Medical College of Cornell University, James Buchanan Brady Department of Urology , 425 East 61st Street, 12th floor, New York, NY 10065 , USA
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Rosa GM, Bauckneht M, Scala C, Tafi E, Leone Roberti Maggiore U, Ferrero S, Brunelli C. Cardiovascular effects of antimuscarinic agents in overactive bladder. Expert Opin Drug Saf 2013; 12:815-27. [PMID: 23800037 DOI: 10.1517/14740338.2013.813016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The potential impact of antimuscarinics (AMs) on cardiac function is a major concern in the treatment of overactive bladder (OAB) patients, especially in older ones who are likely to present cardiovascular (CV) comorbidities and other risk factors that may predispose them to the adverse cardiac effects of this therapy. AREAS COVERED This article aims to review the literature on the impact on the CV system of AMs used in the treatment of OAB, giving a comprehensive explanation of the pathogenetic mechanisms of AMs' effects on CV system and the impact of each AM drug on cardiac function. EXPERT OPINION Although the CV safety of AM drugs seems to be good, evidence provided in this manuscript does not allow to exclude an increase in HR, QT prolongation or an increase in the CV risk due to drug-drug interactions in OAB patients who are usually elderly and have comorbidities. Clinical and electrocardiographic monitoring may be necessary throughout the administration period in selected populations such as patients aged > 80 years, those with coronary heart disease or congestive heart failure. Further studies are needed to understand whether the most recently developed AM drugs, such as imidafenacin, are safer than the old ones.
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Affiliation(s)
- Gian Marco Rosa
- University of Genoa, San Martino Hospital and National Institute for Cancer Research, Department of Cardiology , Genoa , Italy
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Tyl B, Kabbaj M, Fassi B, De Jode P, Wheeler W. Comparison of Semiautomated and Fully Automated Methods for QT Measurement During a Thorough QT/QTc Study: Variability and Sample Size Considerations. J Clin Pharmacol 2013; 49:905-15. [DOI: 10.1177/0091270009337944] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Malik M, Hnatkova K, Schmidt A, Smetana P. Electrocardiographic QTc Changes Due to Moxifloxacin Infusion. J Clin Pharmacol 2013; 49:674-83. [DOI: 10.1177/0091270008330984] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ayalasomayajula S, Yeh CM, Vaidyanathan S, Flannery B, Dieterich HA, Howard D, Bedigian MP, Dole WP. Effects of Aliskiren, a Direct Renin Inhibitor, on Cardiac Repolarization and Conduction in Healthy Subjects. J Clin Pharmacol 2013; 48:799-811. [DOI: 10.1177/0091270008319330] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Iwamoto M, Kost JT, Misty GC, Wenning LA, Breidinger SA, Marbury TC, Stone JA, Gottesdiener KM, Bloomfield DM, Wagner JA. Raltegravir Thorough QT/QTc Study: A Single Supratherapeutic Dose of Raltegravir Does Not Prolong the QTcF Interval. J Clin Pharmacol 2013; 48:726-33. [DOI: 10.1177/0091270008318007] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Bonate PL. The effects of active metabolites on parameter estimation in linear mixed effect models of concentration–QT analyses. J Pharmacokinet Pharmacodyn 2013; 40:101-15. [DOI: 10.1007/s10928-012-9292-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 12/18/2012] [Indexed: 11/28/2022]
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Malik M, van Gelderen EM, Lee JH, Kowalski DL, Yen M, Goldwater R, Mujais SK, Schaddelee MP, de Koning P, Kaibara A, Moy SS, Keirns JJ. Proarrhythmic safety of repeat doses of mirabegron in healthy subjects: a randomized, double-blind, placebo-, and active-controlled thorough QT study. Clin Pharmacol Ther 2012; 92:696-706. [PMID: 23149929 DOI: 10.1038/clpt.2012.181] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Potential effects of the selective β(3)-adrenoceptor agonist mirabegron on cardiac repolarization were studied in healthy subjects. The four-arm, parallel, two-way crossover study was double-blind and placebo- and active (moxifloxacin)-controlled. After 2 baseline ECG days, subjects were randomized to one of eight treatment sequences (22 females and 22 males per sequence) of placebo crossed over with once-daily (10 days) 50, 100, or 200 mg mirabegron or a single 400-mg moxifloxacin dose on day 10. In each period, continuous ECGs were recorded at two baselines and on the last drug administration day. The lower one-sided 95% confidence interval for moxifloxacin effect on QTcI was >5 ms, demonstrating assay sensitivity. According to ICH E14 criteria, mirabegron did not cause QTcI prolongation at the 50-mg therapeutic and 100-mg supratherapeutic doses in either sex. Mirabegron prolonged QTcI interval at the 200-mg supratherapeutic dose (upper one-sided 95% CI >10 ms) in females, but not in males.
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Affiliation(s)
- M Malik
- St Paul's Cardiac Electrophysiology, London, UK
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Leone Roberti Maggiore U, Salvatore S, Alessandri F, Remorgida V, Origoni M, Candiani M, Venturini PL, Ferrero S. Pharmacokinetics and toxicity of antimuscarinic drugs for overactive bladder treatment in females. Expert Opin Drug Metab Toxicol 2012; 8:1387-408. [PMID: 22871042 DOI: 10.1517/17425255.2012.714365] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Antimuscarinics (AMs) are the mainstay of pharmacological treatment of overactive bladder (OAB), a symptom complex defined by the presence of urinary urgency, usually associated with frequency and nocturia, with or without urgency urinary incontinence. The AMs used to treat OAB differ in their pharmacological profiles, which may affect their potential for causing adverse effects (AEs). AREAS COVERED The present article aims to review the literature about pharmacokinetics (PK) of the different AMs used in the treatment of OAB. Furthermore, the AEs related to the use of these drugs and their incidence are presented. This systematic review is based on material searched and obtained via Medline, Pubmed and EMBASE up to March 2012 using the search terms "adverse events, pharmacokinetics, tolerability" in combination with "darifenacin, fesoterodine, imidafenacin, oxybutynin, propiverine, solifenacin, tolterodine, and trospium." EXPERT OPINION Antimuscarinics are the first-line pharmacological treatment for OAB. Despite the development of new molecules that improve their efficacy/safety profile, there are some drugs that are pharmacokinetically more appropriate to be prescribed in specific populations such as patients with neurological disease or the elderly. Moreover, research should be encouraged in evaluating antimuscarinics in conjunction with other drugs such as estrogens or beta-agonists. The identification of prognostic criteria for pharmacological therapy would be helpful.
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Affiliation(s)
- Umberto Leone Roberti Maggiore
- University of Genoa, San Martino Hospital and National Institute for Cancer Research, Department of Obstetrics and Gynaecology, Genoa, Italy
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Green CL, Kligfield P, George S, Gussak I, Vajdic B, Sager P, Krucoff MW. Detection of QT prolongation using a novel electrocardiographic analysis algorithm applying intelligent automation: prospective blinded evaluation using the Cardiac Safety Research Consortium electrocardiographic database. Am Heart J 2012; 163:365-71. [PMID: 22424006 DOI: 10.1016/j.ahj.2011.11.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 11/10/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Cardiac Safety Research Consortium (CSRC) provides both "learning" and blinded "testing" digital electrocardiographic (ECG) data sets from thorough QT (TQT) studies annotated for submission to the US Food and Drug Administration (FDA) to developers of ECG analysis technologies. This article reports the first results from a blinded testing data set that examines developer reanalysis of original sponsor-reported core laboratory data. METHODS A total of 11,925 anonymized ECGs including both moxifloxacin and placebo arms of a parallel-group TQT in 181 subjects were blindly analyzed using a novel ECG analysis algorithm applying intelligent automation. Developer-measured ECG intervals were submitted to CSRC for unblinding, temporal reconstruction of the TQT exposures, and statistical comparison to core laboratory findings previously submitted to FDA by the pharmaceutical sponsor. Primary comparisons included baseline-adjusted interval measurements, baseline- and placebo-adjusted moxifloxacin QTcF changes (ddQTcF), and associated variability measures. RESULTS Developer and sponsor-reported baseline-adjusted data were similar with average differences <1 ms for all intervals. Both developer- and sponsor-reported data demonstrated assay sensitivity with similar ddQTcF changes. Average within-subject SD for triplicate QTcF measurements was significantly lower for developer- than sponsor-reported data (5.4 and 7.2 ms, respectively; P < .001). CONCLUSION The virtually automated ECG algorithm used for this analysis produced similar yet less variable TQT results compared with the sponsor-reported study, without the use of a manual core laboratory. These findings indicate that CSRC ECG data sets can be useful for evaluating novel methods and algorithms for determining drug-induced QT/QTc prolongation. Although the results should not constitute endorsement of specific algorithms by either CSRC or FDA, the value of a public domain digital ECG warehouse to provide prospective, blinded comparisons of ECG technologies applied for QT/QTc measurement is illustrated.
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Glomb P, Ring A. Delayed Effects in the Exposure-Response Analysis of Clinical QTc Trials. J Biopharm Stat 2012; 22:387-400. [DOI: 10.1080/10543406.2010.539309] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Patricia Glomb
- a Clinical Biostatistics , Boehringer Ingelheim Pharma GmbH & Co. KG , Biberach , Germany
| | - Arne Ring
- a Clinical Biostatistics , Boehringer Ingelheim Pharma GmbH & Co. KG , Biberach , Germany
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Andersson KE, Campeau L, Olshansky B. Cardiac effects of muscarinic receptor antagonists used for voiding dysfunction. Br J Clin Pharmacol 2012; 72:186-96. [PMID: 21595741 DOI: 10.1111/j.1365-2125.2010.03813.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Antimuscarinic agents are the main drugs used to treat patients with the overactive bladder (OAB) syndrome, defined as urgency, with or without urgency incontinence, usually with increased daytime frequency and nocturia. Since the treatment is not curative and since OAB is a chronic disease, treatment may be life-long. Antimuscarinics are generally considered to be ‘safe’ drugs, but among the more serious concerns related to their use is the risk of cardiac adverse effects, particularly increases in heart rate (HR) and QT prolongation and induction of polymorphic ventricular tachycardia (torsade de pointes). An elevated resting HR has been linked to overall increased morbidity and mortality, particularly in patients with cardiovascular diseases. QT prolongation and its consequences are not related to blockade of muscarinic receptors, but rather linked to inhibition of the hERG potassium channel in the heart. However, experience with terodiline, an antimuscarinic drug causing torsade de pointes in patients, has placed the whole drug class under scrutiny. The potential of the different antimuscarinic agents to increase HR and/or prolong the QT time has not been extensively explored for all agents in clinical use. Differences between drugs cannot be excluded, but risk assessments based on available evidence are not possible.
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Affiliation(s)
- Karl-Erik Andersson
- Wake Forest Institute for Regenerative Medicine,Wake Forest University School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157, USA.
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Oefelein MG. Safety and Tolerability Profiles of Anticholinergic Agents Used for the Treatment of Overactive Bladder. Drug Saf 2011; 34:733-54. [DOI: 10.2165/11592790-000000000-00000] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Supplemental Studies for Cardiovascular Risk Assessment in Safety Pharmacology: A Critical Overview. Cardiovasc Toxicol 2011; 11:285-307. [DOI: 10.1007/s12012-011-9133-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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An overview of the clinical use of antimuscarinics in the treatment of overactive bladder. Adv Urol 2011; 2011:820816. [PMID: 21687579 PMCID: PMC3114080 DOI: 10.1155/2011/820816] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Accepted: 04/13/2011] [Indexed: 11/17/2022] Open
Abstract
Overactive bladder is a common and bothersome condition. Antimuscarinic agents, as a class, are the cornerstone of medical treatment of overactive bladder. They offer significant improvements in symptoms and patients' quality of life. Antimuscarinics are generally well tolerated with mild and predictable side effects. Available antimuscarinics have small, yet statistically significant, differences in their efficacy and tolerability profiles. In clinical practice, finding the agent that offers the optimum balance of efficacy and side effects for an individual patient remains the major challenge.
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Couderc JP, Garnett C, Li M, Handzel R, McNitt S, Xia X, Polonsky S, Zareba W. Highly automated QT measurement techniques in 7 thorough QT studies implemented under ICH E14 guidelines. Ann Noninvasive Electrocardiol 2011; 16:13-24. [PMID: 21251129 DOI: 10.1111/j.1542-474x.2010.00402.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Thorough QT (TQT) studies are designed to evaluate potential effect of a novel drug on the ventricular repolarization process of the heart using QTc prolongation as a surrogate marker for torsades de pointes. The current process to measure the QT intervals from the thousands of electrocardiograms is lengthy and expensive. In this study, we propose a validation of a highly automatic-QT interval measurement (HA-QT) method. We applied a HA-QT method to the data from 7 TQT studies. We investigated both the placebo and baseline-adjusted QTc interval prolongation induced by moxifloxacin (positive control drug) at the time of expected peak concentration. The comparative analysis evaluated the time course of moxifloxacin-induced QTc prolongation in one study as well. The absolute HA-QT data were longer than the FDA-approved QTc data. This trend was not different between ECGs from the moxifloxacin and placebo arms: 9.6 ± 24 ms on drug and 9.8 ± 25 ms on placebo. The difference between methods vanished when comparing the placebo-baseline-adjusted QTc prolongation (1.4 ± 2.8 ms, P = 0.4). The differences in precision between the HA-QT and the FDA-approved measurements were not statistically different from zero: 0.1 ± 0.1 ms (P = 0.7). Also, the time course of the moxifloxacin-induced QTc prolongation adjusted for placebo was not statistically different between measurements methods.
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Affiliation(s)
- Jean-Philippe Couderc
- Heart Research Follow-up Program, Cardiology Department, University of Rochester Medical Center, Rochester, NY 14642, USA.
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Athanasopoulos A, Cruz F. The medical treatment of overactive bladder, including current and future treatments. Expert Opin Pharmacother 2011; 12:1041-55. [PMID: 21299469 DOI: 10.1517/14656566.2011.554399] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Krishnaswami S, Kudlacz E, Wang R, Chan G. A supratherapeutic dose of the Janus kinase inhibitor tasocitinib (CP-690,550) does not prolong QTc interval in healthy participants. J Clin Pharmacol 2010; 51:1256-63. [PMID: 21148043 DOI: 10.1177/0091270010379809] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Tasocitinib (CP-690,550), a selective inhibitor of the Janus kinase (JAK) family, is being developed for the treatment of several autoimmune diseases and prevention of allograft rejection. The aim of this study was to characterize the effect of tasocitinib on QT interval. Sixty male and female healthy adults were enrolled in a single-dose, randomized, 3-period, crossover study of a supratherapeutic dose of tasocitinib (100 mg), placebo, and moxifloxacin 400 mg. Triplicate electrocardiograms were performed at predose baseline and serially over 24 hours postdose in each treatment period. The upper limits of the 2-sided 90% confidence intervals (CIs) for the difference in QTc interval, corrected using Fridericia correction (QTcF), between tasocitinib and placebo were less than 5 ms at all time points. Concentration-QTcF analysis showed that the predicted mean change (90% CI) in QTcF at the observed mean C(max) was -0.12 (-1.18, 0.94) ms. For moxifloxacin, mean (90% CI) estimates of the change in QTcF from placebo were 11.3 (9.4, 13.1) and 12.5 (10.7, 14.4) ms at 2 and 4 hours, respectively, thereby establishing study sensitivity. A single supratherapeutic dose of tasocitinib 100 mg was well tolerated and not associated with QTc prolongation.
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Omotosho T, Chen CCG. Update on tolterodine extended-release for treatment of overactive bladder. Open Access J Urol 2010; 2:185-91. [PMID: 24198627 PMCID: PMC3818890 DOI: 10.2147/oaju.s7232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Overactive bladder is a prevalent condition which negatively impacts quality of life and puts a significant economical burden on society. First-line therapy often includes pharmacotherapy with antimuscarinic medications, and numerous research studies have demonstrated that tolterodine extended-release (ER) is an efficacious and tolerable formulation of this class of medication. This review provides an update on the clinical use of tolterodine ER, detailing the current literature on its efficacy, tolerability, adverse effects, and comparability with other commonly prescribed medications for the treatment of overactive bladder.
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Affiliation(s)
- Tola Omotosho
- Women’s Center for Pelvic Health, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Chi Chiung Grace Chen
- Women’s Center for Pelvic Health, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Natekar M, Hingorani P, Gupta P, Karnad DR, Kothari S, de Vries M, Zumbrunnen T, Narula D. Effect of number of replicate electrocardiograms recorded at each time point in a thorough QT study on sample size and study cost. J Clin Pharmacol 2010; 51:908-14. [PMID: 20852005 DOI: 10.1177/0091270010376962] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In a "thorough QT/QTc" (TQT) study, several replicate electrocardiograms (ECGs) are recorded at each time point to reduce within-subject variability. This decreases the sample size but increases the cost of ECG analysis. To determine the most cost-effective number of ECG replicates, the authors retrospectively analyzed data from the placebo and moxifloxacin arms of a TQT study with crossover design. Six replicate ECGs were recorded at 7 time points on day -1 (baseline day), day 1, and day 3 in 124 normal healthy volunteers who were randomized to receive moxifloxacin or placebo on day 1 and the other treatment on day 3. QT interval was corrected for heart rate by the Fridericia (QTcF) and individual subject-specific (QTcI) formulas. Within-subject and between-subject standard deviations for QTcF obtained by repeated-measures analysis of covariance were 9.5 and 13.3 milliseconds with 1 replicate; 7.8 and 12.7 milliseconds with 2 replicates; 7.3 and 12.3 milliseconds with 3 replicates; 6.9 and 12.2 milliseconds with 4 replicates; 6.8 and 11.9 milliseconds with 5 replicates; and 6.6 and 11.8 milliseconds with 6 replicates. Within- and between-subject variance with QTcI also declined with increasing replicates. Sample size benefit based on these estimates was negligible beyond 4 replicates. The study cost was least with 3 or 4 replicates, depending on per-ECG and per-subject costs.
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Affiliation(s)
- Mili Natekar
- Quintiles Cardiac Safety Services, Research Section, 502A, Leela Business Park, M.V Road, Andheri East, Mumbai, India
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de Kam PJ, van Kuijk J, Prohn M, Thomsen T, Peeters P. Effects of Sugammadex Doses up to 32 mg/kg Alone or in Combination with Rocuronium or Vecuronium on QTc Prolongation. Clin Drug Investig 2010; 30:599-611. [DOI: 10.2165/11537210-000000000-00000] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Taubel J, Naseem A, Harada T, Wang D, Arezina R, Lorch U, Camm AJ. Levofloxacin can be used effectively as a positive control in thorough QT/QTc studies in healthy volunteers. Br J Clin Pharmacol 2010; 69:391-400. [PMID: 20406223 DOI: 10.1111/j.1365-2125.2009.03595.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIMS To characterize the effects of levofloxacin on QT interval in healthy subjects and the most appropriate oral positive control treatments for International Conference on Harmonization (ICH) E14 QT/QTc studies. METHODS Healthy subjects received a single dose of levofloxacin (1000 or 1500 mg), moxifloxacin (400 mg) or placebo in a four-period crossover design. Digital 12-lead ECGs were recorded in triplicate. Measurement of QT interval was performed automatically with subsequent manual onscreen over-reading using electronic callipers. Blood samples were taken for determination of levofloxacin and moxifloxacin concentrations. RESULTS Mean QTcI (QT interval corrected for heart rate using a correction factor that is applicable to each individual) was prolonged in subjects receiving moxifloxacin 400 mg compared with placebo. The largest time-matched difference in QTcI for moxifloxacin compared with placebo was observed to be 13.19 ms (95% confidence interval 11.21, 15.17) at 3.5 h post dose. Prolonged mean QTcI was also observed in subjects receiving levofloxacin 1000 mg and 1500 mg compared with placebo. The largest time-matched difference in QTcI compared with placebo was observed at 3.5 h post dose for both 1000 mg and 1500 mg of levofloxacin [mean (95%) 4.42 ms (2.44, 6.39) in 1000 mg and 7.44 ms (5.47, 9.42) in 1500 mg]. A small increase in heart rate was observed with levofloxacin during the course of the study. However, moxifloxacin showed a greater increase compared with levofloxacin. CONCLUSIONS Both levofloxacin and moxifloxacin can fulfil the criteria for a positive comparator. The ICH E14 guidelines recommend a threshold of around 5 ms for a positive QT/QTc study. The largest time-matched difference in QTc for levofloxacin suggests the potential for use in more rigorous QT/QTc studies. This study has demonstrated the utility of levofloxacin on the assay in measuring mean QTc changes around 5 ms.
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Affiliation(s)
- Jorg Taubel
- Richmond Pharmacology Ltd, St George's University of London, UK
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Komatsu R, Honda M, Holzgrefe HH, Kubo JI, Yamada Y, Isobe T, Kimura K, Itoh T, Tamaoki N, Tabo M. Sensitivity of common marmosets to detect drug-induced QT interval prolongation: Moxifloxacin case study. J Pharmacol Toxicol Methods 2010; 61:271-6. [DOI: 10.1016/j.vascn.2010.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Revised: 11/25/2009] [Accepted: 01/18/2010] [Indexed: 11/17/2022]
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Darpo B. The thorough QT/QTc study 4 years after the implementation of the ICH E14 guidance. Br J Pharmacol 2010; 159:49-57. [PMID: 19922536 PMCID: PMC2823351 DOI: 10.1111/j.1476-5381.2009.00487.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Revised: 08/11/2009] [Accepted: 08/20/2009] [Indexed: 01/08/2023] Open
Abstract
The ICH E14 guidance on how to clinically assess a new drug's liability to prolong the QT interval was adopted in May 2005. A centre-piece of the guidance was the establishment of one single trial, the 'thorough QT/QTc study', intended to confidently identify drugs that may cause QT prolongation. Initially perceived as a great challenge, this study has rapidly become a standard component of all clinical development programs for new molecular entities. The study is normally conducted in healthy volunteers, includes both a positive and a negative (placebo) control and is stringently powered to exclude an effect on the QTc interval exceeding 10 ms. The E14 guidance was intentionally not very prescriptive and allowed sponsors and service providers to explore new methodologies. This has allowed for a rapid development of new methods during the first years after the guidance's implementation, such as computer-assisted algorithms for QT measurements. Regulators have worked in close collaboration with pharmaceutical industry to set standards for the design and conduct of the 'thorough QT/QTc study', which therefore has evolved as a key component of cardiac safety assessment of new drugs. This paper summarizes the requirements on the 'thorough QT/QTc study' with emphasis on the standard that has evolved based on interactions between regulators and sponsors and the experience from a large number of completed studies.
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Affiliation(s)
- Borje Darpo
- Department of Clinical Science and Education, Section of Cardiology, Karolinska Institute, South Hospital, Stockholm, Sweden.
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Abstract
Overactive bladder (OAB) is a common problem. Affected individuals suffer decreased quality of life and productivity. The mainstay of pharmacological treatment of OAB is antimuscarinic agents. Tolterodine was the first antimuscarinic drug designed specifically for treating OAB. Compared with the immediate-release (IR) drug, once-daily tolterodine extended-release (ER) releases the drug in a steady but constant manner lowering peak and trough drug levels. This translates to more constant serum concentrations and theoretically better patient tolerability. The dry mouth rate for the ER formulation has been reported to be lower than for the IR formulation. Recent literature strongly supports the efficacy and safety of tolterodine ER in carefully selected older men with OAB symptoms. Tolterodine ER is well tolerated and withdrawal rates are similar to those in placebo. Fesoterodine is a new antimuscarinic that shares the same active metabolite as tolterodine and may provide less pharmacokinetic variability. We support tolterodine ER for treating for OAB. It has proven efficacy and tolerability.
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Affiliation(s)
- Doreen E Chung
- Weill Cornell Medical College, Department of Urology, 1300 York Avenue, Box 261, Suite F9 West, New York, NY 10065, USA.
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Bloomfield DM, Krishna R, Hreniuk D, Hickey L, Ghosh K, Bergman AJ, Miller J, Gutierrez MJ, Stoltz R, Gottesdiener KM, Herman GA, Wagner JA. A thorough QTc study to assess the effect of sitagliptin, a DPP4 inhibitor, on ventricular repolarization in healthy subjects. J Clin Pharmacol 2009; 49:937-46. [PMID: 19602719 DOI: 10.1177/0091270009337511] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
A randomized, double-blind, placebo-controlled, 4-period crossover study was performed with a single oral dose of sitagliptin (100 mg, 800 mg), moxifloxacin (400 mg), and placebo in order to provide a rigorous assessment of the effect of sitagliptin on ventricular repolarization based on the ICH E14 guidance. The clinical dose of sitagliptin 100 mg was not associated with an increase in QTc interval, corrected using the Fridericia correction (QTcf), at any time point. The supratherapeutic 800-mg dose of sitagliptin was generally well tolerated and was associated with minimal, clinically insignificant prolongation of the QTcf interval at concentrations approximately 11-fold higher than maximal concentrations following the 100-mg clinical dose. The PK/QTc model demonstrated a shallow relationship between the plasma concentration of sitagliptin and the placebo-subtracted QTcf change from baseline, with a 0.59-millisecond increase in QTc for every 1000-nM increment in sitagliptin plasma concentration. The sensitivity of the assay to detect modest increases in QTc interval was established with the active control moxifloxacin. In conclusion, at clinically relevant concentrations, sitagliptin is not associated with clinically meaningful QTcf prolongation.
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Salvi V, Karnad DR, Panicker GK, Kothari S. Update on the evaluation of a new drug for effects on cardiac repolarization in humans: issues in early drug development. Br J Pharmacol 2009; 159:34-48. [PMID: 19775279 DOI: 10.1111/j.1476-5381.2009.00427.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Following reports of death from cardiac arrhythmias with drugs like terfenadine and cisapride, the International Conference for Harmonization formulated a guidance (E14) document. This specifies that all new drugs must undergo a 'thorough QT/QTc' (TQT) study to detect drug-induced QT prolongation, a surrogate marker of ventricular tachycardia, especially torsades de pointes (TdPs). With better understanding of data from several completed TQT studies, regulatory requirements have undergone some changes since the E14 guidance was implemented in October 2005. This article reviews the implications of the E14 guidance and the changes in its interpretation including choice of baseline QT, demonstration of assay sensitivity, statistical analysis of the effect of new drug and positive control, and PK-PD modelling. Some issues like use of automated QT measurements remain unresolved. Pharmaceutical companies too are modifying Phase 1 studies to detect QTc liability early in order to save time and resources. After the E14 guidance, development of several drugs that prolong QTc by >5 ms is being abandoned by sponsors. However, all drugs that prolong the QT interval do not increase risk of TdP. Researchers in regulatory agencies, academia and industry are working to find better biomarkers of drug-induced TdP which could prevent many useful drugs from being prematurely abandoned. Drug-induced TdP is a rare occurrence. With fewer drugs that prolong QT interval reaching the licensing stage, knowing which of these drugs are torsadogenic is proving to be elusive. Thus, paradoxically, the effectiveness of the E14 guidance itself has made prospective validation of new biomarkers difficult.
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Affiliation(s)
- Vaibhav Salvi
- Quintiles ECG Services, Andheri (East), Mumbai, India.
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Chatterjee DJ, Khutoryansky N, Zdravkovic M, Sprenger CR, Litwin JS. Absence of QTc prolongation in a thorough QT study with subcutaneous liraglutide, a once-daily human GLP-1 analog for treatment of type 2 diabetes. J Clin Pharmacol 2009; 49:1353-62. [PMID: 19737980 DOI: 10.1177/0091270009339189] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this study was to establish effects of liraglutide on the QTc interval. In this randomized, placebo-controlled, double-blind crossover study, 51 healthy participants were administered placebo, 0.6, 1.2, and 1.8 mg liraglutide once daily for 7 days each. Electrocardiograms were recorded periodically over 24 hours at the end of placebo and highest dosing periods. Four different models for QT correction were used: QTci, as the primary endpoint, and QTciL, QTcF, and QTcB as secondary endpoints. The upper bound of the 1-sided 95% confidence interval for time-matched, baseline-corrected, placebo-subtracted QTc intervals was <10 ms for all 4 correction methods. Moxifloxacin (400 mg) increased QTc intervals by 10.6 to 12.3 ms at 2 hours. There was no concentration-exposure dependency on QTc interval changes by liraglutide and no QTc thresholds above 500 ms or QTc increases >60 ms. The authors conclude that liraglutide caused no clinically relevant increases in the QTc interval.
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Intra- and interreader variability in QT interval measurement by tangent and threshold methods in a central electrocardiogram laboratory. J Electrocardiol 2009; 42:348-52. [DOI: 10.1016/j.jelectrocard.2009.01.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Indexed: 11/23/2022]
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Comparison of QTinno, a fully automated electrocardiographic analysis program, to semiautomated electrocardiographic analysis methods in a drug safety study in healthy subjects. J Electrocardiol 2009; 42:358-66. [PMID: 19362316 DOI: 10.1016/j.jelectrocard.2009.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Indexed: 11/20/2022]
Abstract
BACKGROUND Improved automated methods for electrocardiographic (ECG) analysis are needed, particularly for drug development purposes. OBJECTIVES This study compared a novel fully automated method for ECG analysis (QTinno; NewCardio, Santa Clara, CA) to 2 semiautomated digital methods: global measurement from the earliest QRS onset to the latest T-wave offset on representative superimposed beats (global) and tangent measurement on 3 consecutive beats in one lead (tangent). METHODS All 3 methods were used to determine uncorrected and rate-corrected QT interval duration (QT and QTcF) and related metrics in 1422 digital 12-lead ECGs from a phase 1 drug study. Global and tangent annotations were manually adjusted by the same 3 cardiologists wherever necessary. No adjustments were made in QTinno determinations. RESULTS QTinno returned QTcF change from time-matched baseline (DeltaQTcF) that differed minimally from both global and tangent methods (mean pairwise difference: 0.1 millisecond between QTinno and global, 1.1 milliseconds between QTinno and tangent). The average absolute QT and QTcF intervals by QTinno were approximately 5 milliseconds longer than global and 25 milliseconds longer than by tangent. QTinno had lower intrinsic variability for DeltaQTcF than either global or tangent (between-subject SD: QTinno 4.0 milliseconds, global 5.6 milliseconds, tangent 6.4 milliseconds; within-subject SD: QTinno 4.8 milliseconds, global 7.4 milliseconds, tangent 10.6 milliseconds). All methods were robust in detecting the largest placebo-adjusted mean time-matched DeltaQTcF (15-25 milliseconds) induced by study drug. CONCLUSIONS The methods show good agreement for drug-induced QTc prolongation. Lower intrinsic variability of DeltaQTcF by QTinno could facilitate smaller sample sizes or increase study power in thorough QTc studies.
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