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Kashiv P, Malde S, Dubey S, Gupta S, Pawar T, Sejpal KN, Gurjar P, Pasari A, Balwani M, Bhawane A, Tolani P, Bawankule CP. A Case of Erythropoietin (EPO)-Induced Pure Red Cell Aplasia and Its Treatment Efficacy With Desidustat. Cureus 2024; 16:e62022. [PMID: 38989377 PMCID: PMC11235398 DOI: 10.7759/cureus.62022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 06/09/2024] [Indexed: 07/12/2024] Open
Abstract
Pure red cell aplasia (PRCA), a rare hematological disorder marked by severe anemia and reticulocytopenia, results from the near absence of developing erythroid precursors in the otherwise normal bone marrow. This case report focuses on a 48-year-old female with chronic kidney disease (CKD) who received erythropoietin injections for CKD-related secondary anemia. Despite an initial positive response, a sudden drop in hemoglobin levels prompted investigations, revealing endogenous erythropoietin (EPO)-induced PRCA due to anti-EPO antibodies. In response, desidustat, an oral hypoxia-inducible factor-prolyl hydroxylase inhibitor, was successfully introduced as an alternative treatment. This led to a substantial and sustained improvement in hemoglobin levels, emphasizing the crucial role of swift diagnosis and intervention in EPO-induced PRCA cases. Administration method and storage conditions are noteworthy factors influencing recombinant human erythropoietin (rHuEPO) immunogenicity. The case underscores desidustat's emergence as a less immunogenic and effective alternative for anemia, marking a significant advancement, particularly in the context of this pioneering case in India showcasing its efficacy.
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Affiliation(s)
- Pranjal Kashiv
- Nephrology, Jawaharlal Nehru Medical College, Wardha, IND
| | - Sunny Malde
- Nephrology, Jawaharlal Nehru Medical College, Wardha, IND
| | - Shubham Dubey
- Nephrology, Jawaharlal Nehru Medical College, Wardha, IND
| | - Sushrut Gupta
- Nephrology, Jawaharlal Nehru Medical College, Wardha, IND
| | - Twinkle Pawar
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Kapil N Sejpal
- Nephrology, Jawaharlal Nehru Medical College, Wardha, IND
| | - Prasad Gurjar
- Nephrology, Jawaharlal Nehru Medical College, Wardha, IND
| | - Amit Pasari
- Nephrology, Saraswati Kidney Care Center, Nagpur, IND
- Nephrology, Jawaharlal Nehru Medical College, Wardha, IND
| | - Manish Balwani
- Nephrology, Saraswati Kidney Care Center, Nagpur, IND
- Nephrology, Jawaharlal Nehru Medical College, Wardha, IND
| | - Amol Bhawane
- Nephrology, All India Institute of Medical Sciences, Nagpur, Nagpur, IND
| | - Priyanka Tolani
- Internal Medicine, Jawaharlal Nehru Medical College, Wardha, IND
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Yang L, Niu H, Zhang T, Cao Q, Liu M, Liu Y, Yan L, Qi W, Wang T, Liu C, Li L, Xing L, Wang H, Shao Z, Fu R. A nomogram model for predicting the efficacy of cyclosporine in patients with pure red cell aplasia. Ann Hematol 2024; 103:1877-1885. [PMID: 38308019 DOI: 10.1007/s00277-024-05636-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/19/2024] [Indexed: 02/04/2024]
Abstract
Pure red cell aplasia (PRCA) is a rare bone marrow disorder characterized by a severe reduction or absence of erythroid precursor cells, without affecting granulocytes and megakaryocytes. Immunosuppressive therapies, particularly cyclosporine, have demonstrated efficacy as a primary treatment. This study aims to develop a predictive model for assessing the efficacy of cyclosporine in acquired PRCA (aPRCA). This retrospective study encompasses newly treated aPRCA patients at the General Hospital of Tianjin Medical University. Diagnosis criteria include severe anemia, and absolute reticulocyte count below 10 × 109/L, with normal white blood cell and platelet counts, and a severe reduction in bone marrow erythroblasts. Cyclosporine therapy was administered, with dose adjustments based on blood concentration. Response to cyclosporine was evaluated according to established criteria. Statistical analysis involved logistic multi-factor regression, generating a predictive model. The study included 112 aPRCA patients with a median age of 63.5 years. Patients presented with severe anemia (median Hb, 56 g/L) and reduced reticulocyte levels. Eighty-six patients had no bone marrow nucleated erythroblasts. Primary PRCA accounted for 62 cases (55.4%), and secondary PRCA accounted for 50 cases (44.6%). Univariate analysis revealed that ferritin, platelet to lymphocyte ratio (PLR), and CD4/CD8 ratio influenced treatment response. Multivariate analysis further supported the predictive value of these factors. A prediction model was constructed using ferritin, PLR, and CD4/CD8 ratio, demonstrating high sensitivity and specificity. The ferritin, PLR, and CD4/CD8-based nomogram showed good predictive ability for aPRCA response to cyclosporine. This model has potential clinical value for individualized diagnosis and treatment of aPRCA patients.
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Affiliation(s)
- Liyan Yang
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Haiyue Niu
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Tian Zhang
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Qiuying Cao
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Mengyuan Liu
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Yumei Liu
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Li Yan
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Weiwei Qi
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Ting Wang
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Chunyan Liu
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Lijuan Li
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Limin Xing
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Huaquan Wang
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China.
| | - Zonghong Shao
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China.
| | - Rong Fu
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China.
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Martin MU, Frevert J, Tay CM. Complexing Protein-Free Botulinum Neurotoxin A Formulations: Implications of Excipients for Immunogenicity. Toxins (Basel) 2024; 16:101. [PMID: 38393178 PMCID: PMC10892905 DOI: 10.3390/toxins16020101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
The formation of neutralizing antibodies is a growing concern in the use of botulinum neurotoxin A (BoNT/A) as it may result in secondary treatment failure. Differences in the immunogenicity of BoNT/A formulations have been attributed to the presence of pharmacologically unnecessary bacterial components. Reportedly, the rate of antibody-mediated secondary non-response is lowest in complexing protein-free (CF) IncobotulinumtoxinA (INCO). Here, the published data and literature on the composition and properties of the three commercially available CF-BoNT/A formulations, namely, INCO, Coretox® (CORE), and DaxibotulinumtoxinA (DAXI), are reviewed to elucidate the implications for their potential immunogenicity. While all three BoNT/A formulations are free of complexing proteins and contain the core BoNT/A molecule as the active pharmaceutical ingredient, they differ in their production protocols and excipients, which may affect their immunogenicity. INCO contains only two immunologically inconspicuous excipients, namely, human serum albumin and sucrose, and has demonstrated low immunogenicity in daily practice and clinical studies for more than ten years. DAXI contains four excipients, namely, L-histidine, trehalosedihydrate, polysorbate 20, and the highly charged RTP004 peptide, of which the latter two may increase the immunogenicity of BoNT/A by introducing neo-epitopes. In early clinical studies with DAXI, antibodies against BoNT/A and RTP004 were found at low frequencies; however, the follow-up period was critically short, with a maximum of three injections. CORE contains four excipients: L-methionine, sucrose, NaCl, and polysorbate 20. Presently, no data are available on the immunogenicity of CORE in human beings. It remains to be seen whether all three CF BoNT/A formulations demonstrate the same low immunogenicity in patients over a long period of time.
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Suttichet TB, Chamnanphon M, Pongpanich M, Chokyakorn S, Kupatawintu P, Srichomthong C, Chetruengchai W, Chuntakaruk H, Rungrotmongkol T, Chariyavilaskul P, Shotelersuk V, Praditpornsilpa K. HLA-B*46:01:01:01 and HLA-DRB1*09:01:02:01 are associated with anti-rHuEPO-induced pure red cell aplasia. Sci Rep 2023; 13:22759. [PMID: 38123661 PMCID: PMC10733298 DOI: 10.1038/s41598-023-50211-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 12/16/2023] [Indexed: 12/23/2023] Open
Abstract
Treatment of anemia in patients with chronic kidney disease (CKD) with recombinant human erythropoietin (rHuEPO) can be disrupted by a severe complication, anti-rHuEPO-induced pure red cell aplasia (PRCA). Specific HLA genotypes may have played a role in the high incidence of PRCA in Thai patients (1.7/1,000 patient years vs. 0.03/10,000 patient years in Caucasians). We conducted a case-control study in 157 CKD patients with anti-rHuEPO-induced PRCA and 56 controls. The HLA typing was determined by sequencing using a highly accurate multiplex single-molecule, real-time, long-read sequencing platform. Four analytical models were deployed: Model 1 (additive: accounts for the number of alleles), Model 2 (dominant: accounts for only the presence or absence of alleles), Model 3 (adjusted additive with rHuEPO types) and Model 4 (adjusted dominant with rHuEPO types). HLA-B*46:01:01:01 and DRB1*09:01:02:01 were found to be independent risk markers for anti-rHuEPO-induced PRCA in all models [OR (95%CI), p-values for B*46:01:01:01: 4.58 (1.55-13.51), 0.006; 4.63 (1.56-13.75), 0.006; 5.72 (1.67-19.67), 0.006; and 5.81 (1.68-20.09), 0.005; for DRB1*09:01:02:01: 3.99 (1.28-12.49), 0.017, 4.50 (1.32-15.40), 0.016, 3.42 (1.09-10.74), 0.035, and 3.75 (1.08-13.07), 0.038, in Models 1-4, respectively. HLA-B*46:01:01:01 and DRB1*09:01:02:01 are susceptible alleles for anti-rHuEPO-induced PRCA. These findings support the role of HLA genotyping in helping to monitor patients receiving rHuEPO treatment.
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Affiliation(s)
- Thitima Benjachat Suttichet
- Center of Excellence in Clinical Pharmacokinetics and Pharmacogenomics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Monpat Chamnanphon
- Center of Excellence in Clinical Pharmacokinetics and Pharmacogenomics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Monnat Pongpanich
- Department of Mathematics and Computer Science, Faculty of Science, Chulalongkorn University, Bangkok, Thailand
- Faculty of Science, Omics Sciences and Bioinformatics Center, Chulalongkorn University, Bangkok, Thailand
| | - Sarun Chokyakorn
- Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Chalurmpon Srichomthong
- Department of Pediatrics, Faculty of Medicine, Center of Excellence for Medical Genomics, Chulalongkorn University, Bangkok, Thailand
- Excellence Center for Genomics and Precision Medicine, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Wanna Chetruengchai
- Department of Pediatrics, Faculty of Medicine, Center of Excellence for Medical Genomics, Chulalongkorn University, Bangkok, Thailand
- Excellence Center for Genomics and Precision Medicine, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Hathaichanok Chuntakaruk
- Program in Bioinformatics and Computational Biology, Graduate School, Chulalongkorn University, Bangkok, Thailand
- Department of Biochemistry, Faculty of Science, Center of Excellence in Structural and Computational Biology, Chulalongkorn University, Bangkok, Thailand
| | - Thanyada Rungrotmongkol
- Program in Bioinformatics and Computational Biology, Graduate School, Chulalongkorn University, Bangkok, Thailand
- Department of Biochemistry, Faculty of Science, Center of Excellence in Structural and Computational Biology, Chulalongkorn University, Bangkok, Thailand
| | - Pajaree Chariyavilaskul
- Center of Excellence in Clinical Pharmacokinetics and Pharmacogenomics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
- Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Vorasuk Shotelersuk
- Department of Pediatrics, Faculty of Medicine, Center of Excellence for Medical Genomics, Chulalongkorn University, Bangkok, Thailand
- Excellence Center for Genomics and Precision Medicine, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Nag K, Sarker EH, Kumar S, Chakraborty S, Khan MR, Chowdhury MR, Roy R, Roy R, Biswas BK, Bappi EH, Mohiuddin M, Sultana N. Satisfying QTPP of Erythropoietin Biosimilar by QbD through DoE-Derived Downstream Process Engineering. Pharmaceutics 2023; 15:2087. [PMID: 37631301 PMCID: PMC10460001 DOI: 10.3390/pharmaceutics15082087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/04/2023] [Accepted: 06/22/2023] [Indexed: 08/27/2023] Open
Abstract
Well-characterized and scalable downstream processes for the purification of biologics are extremely demanding for delivering quality therapeutics to patients at a reasonable price. Erythropoietin (EPO) is a blockbuster biologic with diverse clinical applications, but its application is limited to financially well-off societies due to its high price. The high price of EPO is associated with the technical difficulties related to the purification challenge to obtain qualified products with a cost-effective defined process. Though there are reports for the purification of EPO there is no report of a well-characterized downstream process with critical process parameters (CPPs) that can deliver EPO consistently satisfying the quality target product profile (QTPP), which is a critical regulatory requirement. To advance the field, we applied the quality by design (QbD) principle and design of experiment (DoE) protocol to establish an effective process, which is scalable up to 100× batch size satisfying QTPP. We have successfully transformed the process from static mode to dynamic mode and validated it. Insignificant variation (p > 0.05) within and between 1×, 10×, and 100× batches showed that the process is reproducible and seamlessly scalable. The biochemical analysis along with the biofunctionality data ensures that the products from different scale batches were indifferent and comparable to a reference product. Our study thereby established a robust and scalable downstream process of EPO biosimilar satisfying QTPP. The technological scheme presented here can speed up the production of not only EPO but also many other life-saving biologics and make them available to the mass population at a reduced cost.
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Affiliation(s)
- Kakon Nag
- Globe Biotech Limited, 3/Ka (New), Tejgaon I/A, Dhaka 1208, Bangladesh
| | | | | | | | | | | | | | | | | | | | | | - Naznin Sultana
- Globe Biotech Limited, 3/Ka (New), Tejgaon I/A, Dhaka 1208, Bangladesh
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Ismail S, Abu Esba L, Khan M, Al-Abdulkarim H, Modimagh H, Yousef C. An Institutional Guide for Formulary Decisions of Biosimilars. Hosp Pharm 2023; 58:38-48. [PMID: 36644755 PMCID: PMC9837324 DOI: 10.1177/00185787221138007] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Biologics have changed the landscape for the management of many debilitating chronic diseases but account for a significant expenditure of medications globally. Fortunately, advances in technology paved the way for the introduction of biosimilars, which are highly similar to the originator biologics. In the quest to reduce the budget impact of biologics, organizations have begun to adopt biosimilars. Institutions evaluating biosimilars for inclusion in the hospital formulary must make informed formulary decisions by conducting a thorough review of key elements for evaluation of biosimilars and address the multidimensional aspects during the selection process of different biosimilar products. Therefore, we aim to present an institutional guide of these elements to inform formulary decisions. These key elements include biosimilar evaluation for formulary addition; regulatory approval; substitution, interchangeability, and switching; extrapolation; product characteristics, manufacturing, and supply chain issues; pharmacoeconomic evaluations; traceability, nomenclature, and coding; education; and pharmacovigilance.
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Affiliation(s)
- Sherin Ismail
- Pharmaceutical Care Department, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
- University of North Carolina, Chapel Hill, NC, USA
| | - Laila Abu Esba
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
- College of pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mansoor Khan
- Pharmaceutical Care Department, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
| | - Hana Al-Abdulkarim
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
- Doctoral School of Applied Informatics and Applied Mathematics, Óbuda University, Budapest, Hungary
- Drug Policy and Economic Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Hind Modimagh
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
- College of pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Consuela Yousef
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, Ministry of National Guard Affairs, Dammam, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Al Ahsa, Saudi Arabia
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Gascón P, Goldsmith D, Aapro M, Dellanna F, Esmael A, Zabransky M. Epoetin alfa biosimilar (HX575): A review of 15 years' post-approval clinical experience. Crit Rev Oncol Hematol 2023; 181:103894. [PMID: 36481307 DOI: 10.1016/j.critrevonc.2022.103894] [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: 08/12/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Biosimilars offer the potential to expand patient access and reduce healthcare costs. Therefore, it is of importance that clinicians and patients are reassured about their efficacy and safety in practice. In 2007, Binocrit® (HX575; Sandoz GmbH, Kundl, Austria) was the first epoetin alfa biosimilar approved for use in chemotherapy induced anaemia (CIA), chronic renal failure (CRF), and more recently myelodysplastic (MDS) anaemia. Since its approval, there has been a plethora of data demonstrating the well-tolerated safety profile of HX575. This review will outline the safety results collected from key studies that have added to the extensive HX575 (Binocrit® unless otherwise stated) clinical experience. With a focus on all approved indications, we will review the safety data collected across a range of study types, to further consolidate the reassurance for the use of HX575 in these indications.
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Affiliation(s)
- Pere Gascón
- Division of Medical Oncology, IDIBAPS, Hospital Clinic, Casanova 143, 08036 Barcelona, Spain
| | - David Goldsmith
- Division of Nephrology, Guy's and St Thomas' Hospitals, London, UK
| | - Matti Aapro
- Cancer Center, Clinique de Genolier, P.O. Box CASE POSTALE 100, 3 route du Muids, 1272 Genolier, Switzerland
| | - Frank Dellanna
- MVZ Davita Rhein-Ruhr, Dialysis Centre, Karlstrasse 17-19, D-40210 Düsseldorf, Germany
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Okahashi N, Kubo M, Hoshino E, Uchihara M, Amano I, Tanaka H. Successful Treatment of Antibody-mediated Pure Red Cell Aplasia Induced by Continuous Erythropoietin Receptor Activator with Prednisolone. Intern Med 2022; 61:2209-2213. [PMID: 34980800 PMCID: PMC9381349 DOI: 10.2169/internalmedicine.8823-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pure red cell aplasia (PRCA) associated with erythropoiesis-stimulating agents (ESAs), which were first reported in 1998, usually occurs with subcutaneous administration of epoetin alfa (Eprex®). Improvements in ESA storage, handling, and administration methods have reduced the PRCA incidence. Continuous erythropoietin receptor activator (CERA) is a third-generation ESA that is rarely reported to induce PRCA. We herein report a case of CERA-induced PRCA presenting with positive anti-erythropoietin (EPO) and anti-CERA antibodies, which was successfully treated with prednisolone. Clinicians should be aware of the possibility of antibody-mediated PRCA induced by an ESA in CKD patients with anemia with reticulocytopenia and low serum EPO levels.
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Affiliation(s)
- Nozomi Okahashi
- Department of Internal Medicine, Saiseikai Chuwa Hospital, Japan
| | - Masayuki Kubo
- Department of Hematology, Nara Medical University, Japan
| | - Ei Hoshino
- Department of Internal Medicine, Saiseikai Chuwa Hospital, Japan
| | | | - Itsuto Amano
- Department of Hematology, Nara Medical University, Japan
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9
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Incidence of acquired pure red cell aplasia: a nationwide epidemiologic analysis with 2 registry databases in Japan. Blood Adv 2022; 6:6282-6290. [PMID: 35522950 PMCID: PMC9806328 DOI: 10.1182/bloodadvances.2021006486] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 04/20/2022] [Accepted: 04/23/2022] [Indexed: 01/07/2023] Open
Abstract
Acquired pure red cell aplasia (PRCA) is a rare syndrome characterized by anemia with reticulocytopenia and a marked reduction in erythroid precursors. Given its rarity, the true incidence is largely unknown, and epidemiological data representing the general population, with a description of the full spectrum of etiologies, are scarce. An epidemiological study on PRCA in Japan conducted 30 years ago estimated the annual incidence as 0.3 per million. To update the data and investigate the incidence and demographics of PRCA, we conducted a nationwide epidemiological study using the Japanese Society of Hematology (JSH) Hematologic Disease Registry, a hematologic disease registration database managed by the JSH and the Diagnosis Procedure Combination (DPC) study data available at a website of the Ministry of Health, Labor, and Welfare (MHLW) of Japan. A total of 1055 patients with newly diagnosed acquired PRCA were identified between 2012 and 2019, and the average annual incidence was calculated at 1.06 (95% confidence interval [CI], 0.83-1.28) per million. The median age was 73 (range, 18-99) years. The female-to-male ratio was 1.5:1, and the female predominance was most prominent in the child-bearing age group. Sixty-nine percent of acquired PRCA was idiopathic. The incidence of PRCA was approximately 20% of that of aplastic anemia (AA) during the same period. Approximately 0.98 patients per million per year (95% CI, 0.89-1.07) required hospitalization for the treatment of PRCA. These results are expected to contribute to the discussion of resource allocation for PRCA in the aging population in many countries, including Japan.
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Shrestha R, Shrestha S, Sapkota B, Thapa S, Ansari M, Khatiwada AP, Roien R, Ozaki A. Generic Medicine and Generic Prescribing in Nepal: An Implication for Policymakers. J Multidiscip Healthc 2022; 15:365-373. [PMID: 35237042 PMCID: PMC8884710 DOI: 10.2147/jmdh.s348282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 01/06/2022] [Indexed: 12/13/2022] Open
Abstract
Generic medicines are being promoted in many countries for their added benefits over branded drugs, such as reduced price, therapeutic equivalence, and convenience to the patients. However, generic prescribing is still not up to the optimum level in Nepal to assure access to cost-effective, quality medicines to the public and to reduce the overall economic burden and practice-related errors of medications. This review aimed to discuss the current scenario of generic medicine, generic prescribing, hurdles on the one hand, and potentials ways in promoting generic medicine usage and generic prescribing in Nepal on the other. Extensive literature on generic medicine usage and generic prescribing practice in Nepal was reviewed. This review found some of the major challenges to be addressed for the proper implementation of generic medicine prescribing, and utilization. These challenges include lack of facilities and competency to assure therapeutic equivalence of different brand-name medicines, lack of understanding about generic medicines among health care providers (HCPs) and the public, and lack of stringent regulation towards promoting generic medicines. Rational pharmaceutical promotion and awareness about generic medication to the medical students are also inevitable towards promoting the practice of generic medicines. The practice of generic medicine and generic prescribing is not possible without the assurance of therapeutically equivalent generic alternatives. The study recommended the prompt effort of the regulatory authority to enforce the generic prescribing and generic substitution policy through strengthening policies, procedures and laboratory testing to assure citizens’ right to access to cost-effective, and affordable quality medicine, as the Nepal’s National Health and Drug Policy mandated.
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Affiliation(s)
- Rajeev Shrestha
- Department of Pharmacy, District Hospital Lamjung, Lamjung, Nepal
| | - Sunil Shrestha
- Department of Pharmaceutical and Health Service Research, Nepal Health Research and Innovation Foundation, Lalitpur, Province Bagmati, Nepal
- Department of Nursing, Nobel College, Sinamangal, Kathmandu, Nepal
| | - Binaya Sapkota
- Department of Pharmaceutical Sciences, Nobel College, Affiliated to Pokhara University, Kathmandu, Province Bagmati, Nepal
| | | | - Mukhtar Ansari
- Department of Clinical Pharmacy, College of Pharmacy, University of Hail, Hail, Saudi Arabia
| | - Asmita Priyadarshini Khatiwada
- Department of Pharmaceutical and Health Service Research, Nepal Health Research and Innovation Foundation, Lalitpur, Province Bagmati, Nepal
| | - Rohullah Roien
- Medical Research Centre, Kateb University, Kabul, Afghanistan
- Correspondence: Rajeev Shrestha; Rohullah Roien Email ;
| | - Akihiko Ozaki
- Department of Breast Surgery, Jyoban Hospital of Tokiwa Foundation, Iwaki, Fukushima, Japan
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11
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Bennett CL, Hoque S. Investigating Severe Adverse Reactions: Examples of the ANTICIPATE Methodology at Work. Cancer Treat Res 2022; 184:129-140. [PMID: 36449193 DOI: 10.1007/978-3-031-04402-1_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Severe adverse drug reactions (sADRs) are important causes of morbidity and mortality. The Southern Network on Adverse Drug Reactions (SONAR), a National Cancer Institute-funded pharmacovigilance program, has outlined a novel 9-stop methodology, termed ANTICIPATE, that has evaluated this methodology, among persons with chronic kidney disease (CKD).
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Affiliation(s)
- Charles L Bennett
- SONAR (Southern Network on Adverse Reactions) Program, University of South Carolina College of Pharmacy, Columbia, SC, 29208, USA
| | - Shamia Hoque
- SONAR (Southern Network on Adverse Reactions) Program, University of South Carolina College of Pharmacy, Columbia, SC, 29208, USA.
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12
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Chen ZS, Yang C, Chen M, Han B. [Evaluation of the efficacy and safety of recombined human erythropoietin combined with cyclosporin A in the treatment of patients with pure red cell aplasia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:952-955. [PMID: 35045658 PMCID: PMC8763588 DOI: 10.3760/cma.j.issn.0253-2727.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Z S Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - C Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - M Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - B Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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13
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Sardella M, Belcher G, Lungu C, Ignoni T, Camisa M, Stenver DI, Porcelli P, D'Antuono M, Castiglione NG, Adams A, Furlan G, Grisoni I, Hall S, Boga L, Mancini V, Ciuca M, Chonzi D, Edwards B, Mangoni AA, Tuccori M, Prokofyeva E, De Gregorio F, Bertazzoli Grabinski Broglio M, van Leeuwen B, Kruger P, Rausch C, Le Louet H. Monitoring the manufacturing and quality of medicines: a fundamental task of pharmacovigilance. Ther Adv Drug Saf 2021; 12:20420986211038436. [PMID: 34394910 PMCID: PMC8361554 DOI: 10.1177/20420986211038436] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/23/2021] [Indexed: 11/18/2022] Open
Abstract
The collection and assessment of individual case safety reports (ICSRs) is
important to detect unknown adverse drug reactions particularly in the first
decade after approval of new chemical entities. However, regulations require
that these activities are routinely undertaken for all medicinal products,
including older medicines such as generic medicinal products with a
well-established safety profile. For the latter, the risk management plans no
longer contain important risks, considered important safety concerns, on the
basis that routine pharmacovigilance activity would not allow their further
characterisation. Society assumes that unexpected adverse reactions causally
related to pharmacological activity are very unlikely to be detected for such
well-established medicines, but important risks can still occur. For these
products, a change in the safety profile which is brand or source specific and
usually local in nature, associated with failures with the adequate control of
quality of manufacturing or distribution are important safety issues. These may
be the consequence of manufacturing and pharmacovigilance quality systems that
are not fully integrated over the product life cycle (e.g. inadequate control of
quality defects affecting one or multiple batches; inadequate impact assessment
of change/variation of manufacturing, quality control testing, storage and
distribution processes; inadequate control over the distribution channels
including the introduction of counterfeit or falsified products into the supply
chain). Drug safety hazards caused by the above-mentioned issues have been
identified with different products and formulations, from small molecules to
complex molecules such as biological products extracted from animal sources,
biosimilars and advanced therapy medicinal products. The various phases of the
drug manufacturing and distribution of pharmaceutical products require inputs
from pharmacovigilance to assess any effects of quality-related issues and to
identify proportionate risk minimisation measures that often have design
implications for a medicine which requires a close link between proactive
vigilance and good manufacturing practice. To illustrate our argument for closer
organisational integration, some examples of drug safety hazards originating
from quality, manufacturing and distribution issues are discussed.
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Affiliation(s)
- Marco Sardella
- Chief Pharmacovigilance Officer, EU&UK QPPV, Adienne Srl. S.U., Via Galileo Galilei, 19, Caponago 20867 Italy
| | | | - Calin Lungu
- Drug Development Consulting Services Sa, Luxemburg City, Luxemburg
| | | | | | | | | | | | | | - Anna Adams
- Medicines and Healthcare Products Regulatory Agency (MHRA), London, UK
| | | | | | | | - Laura Boga
- Dompè farmaceutici S.p.A., Milano, Italy
| | | | | | | | | | - Arduino A Mangoni
- Department of Clinical Pharmacology, School of Medicine, Flinders University, Adelaide, SA, Australia
| | | | - Elena Prokofyeva
- Division Research & Development, DG PRE Authorisation, Federal Agency for Medicines and Health Products (FAMHP), Sciensano, Brussels, Belgium
| | | | | | | | - Paola Kruger
- European Patient's Academy on Therapeutic Innovation (EUPATI), Rome, Italy
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14
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Wu R, Peng Y. Roxadustat on anti-erythropoietin antibody-related pure red cell aplasia in the patient with end-stage renal disease. Semin Dial 2021; 34:319-322. [PMID: 34128578 DOI: 10.1111/sdi.12991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Indexed: 02/05/2023]
Abstract
Anti-erythropoietin antibody-related pure red cell aplasia (anti-EPO PRCA) is a severe complication in patients who receive erythropoiesis-stimulating agents for nephrogenic anemia. The standard therapy is withdrawl of EPO and immunosuppression. Here, we present successful treatment of anti-EPO PRCA with roxadustat, a hypoxia-inducible factor prolyl hydroxylase inhibitor. A 39-year-old woman with end-stage renal disease received recombinant human erythropoietin (rhEPO) subcutaneously. Unfortunately, she developed anti-EPO PRCA and her hemoglobin dropped continuously, whereas she rejected immunosuppressive therapy. The patient failed to achieve spontaneous hematologic recovery with cessation of rhEPO alone, and she became transfusion dependent. Thus, she accepted our advice to try roxadustat for nephrogenic anemia. Surprisingly, after starting roxadustat treatment, her reticulocyte and hemoglobin improved gradually. Four months later, the bone marrow aspiration smear demonstrated a return to normal in erythroid cells. Besides, her anti-erythropoietin antibody converted to negative. All in all, this case reveals the potential effect of roxadustat on anti-EPO PRCA.
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Affiliation(s)
- Rui Wu
- Department of Nephrology, The First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Yanqiang Peng
- Department of Nephrology, The First Affiliated Hospital of Shantou University Medical College, Shantou, China
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15
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Zhang Y, Bian SZ, Yang K, Wang Y, Tang S, Wang W, Wang D, Nie L, Zhao J. Baseline Soluble Anti-erythropoietin Antibody Level Is an Independent Associated Factor for Follow-Up Erythropoietin Demand in Maintenance Dialysis Patients With End-Stage Renal Disease: A Prospective Cohort Study. Front Med (Lausanne) 2020; 7:109. [PMID: 32318578 PMCID: PMC7154121 DOI: 10.3389/fmed.2020.00109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 03/10/2020] [Indexed: 01/07/2023] Open
Abstract
Aims: The aim of this study was to identify the predictive role of baseline anti-erythropoietin (anti-EPO) antibody levels in follow-up EPO demand in maintenance dialysis patients with end-stage renal disease (ESRD). Methods: Baseline routine blood parameters, clinical data, dialysis-related parameters, EPO, anti-EPO antibody, and anti-EPO-receptor antibody were also measured. Differences in the abovementioned variables were compared among four intervals of the EPO demand index (EDI). Further univariate and adjusted logistic regression analyses were performed to identify the independent predictors for higher EPO demand. Results: The predialysis potassium ion concentration was significantly higher in the fourth quartile (Q4) population than in the other three populations (p < 0.05). Furthermore, the anti-EPO antibody level showed significant differences among the four intervals (p = 0.006). The baseline anti-EPO antibody level was correlated with the follow-up EDI (r 2 = 0.0377, p = 0.030). Furthermore, the follow-up EDI was significantly higher in the anti-EPO antibody-positive group (p = 0.02). Age (OR = 1.071, p = 0.005), ferritin (OR = 1.001, p = 0.038), potassium ion concentration before dialysis (OR = 2.781, p = 0.012), dialysis duration (OR = 1.025, p = 0.030), and anti-EPO antibody level (OR = 7.694, p = 0.004) were potential predictors for higher EPO demand. After adjustment, age (OR = 1.072, p = 0.026), potassium ion concentration before dialysis (OR = 3.425, p = 0.013), and EPO level (OR = 5.27, p = 0.007) were independent predictors for higher EDI demand. Conclusion: The baseline anti-EPO antibody level combined with an older age and a higher predialysis potassium ion concentration are independent predictors for a higher follow-up EPO demand in maintenance dialysis patients with ESRD.
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Affiliation(s)
- Ying Zhang
- Department of Nephrology, Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Medical University), Chongqing, China
| | - Shi-Zhu Bian
- Department of Cardiology, Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Kun Yang
- Department of Nephrology, Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Medical University), Chongqing, China
| | - Yiqing Wang
- Department of Nephrology, Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Medical University), Chongqing, China
| | - Sha Tang
- Department of Nephrology, Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Medical University), Chongqing, China
| | - Weili Wang
- Department of Nephrology, Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Medical University), Chongqing, China
| | - Daihong Wang
- Department of Nephrology, Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Medical University), Chongqing, China
| | - Ling Nie
- Department of Nephrology, Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Medical University), Chongqing, China
| | - Jinghong Zhao
- Department of Nephrology, Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Medical University), Chongqing, China
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16
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Analysis of regulatory guidance on antidrug antibody testing for therapeutic protein products. Bioanalysis 2020; 11:2283-2296. [PMID: 31845602 DOI: 10.4155/bio-2019-0241] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Therapeutic proteins have the potential to induce unwanted immune responses. The potential impact of immunogenicity on pharmacokinetics, pharmacodynamics, safety and efficacy are well established. Here, we analyze key aspects of current US FDA and EMA guidelines on the development and validation of antidrug antibody assays. Although FDA and EMA guidance documents are in harmony on most points, EMA allows greater leeway for scientific judgement, while FDA recommends specific approaches that may not be appropriate in some situations. Many white papers suggest approaches different from the guidance documents, however, these can conflict with each other and are themselves only scientifically valid in certain situations. Here, we indicate when alternatives to guidance may be needed and what those approaches might be.
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17
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Sia CSM, Jen WY, Poon MLM. Acquired Antibody-Mediated Pure Red Cell Aplasia Following Treatment With Darbepoetin. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2020. [DOI: 10.47102/annals-acadmedsg.2019192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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18
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Jing X, Jin K. A gold mine for drug discovery: Strategies to develop cyclic peptides into therapies. Med Res Rev 2019; 40:753-810. [PMID: 31599007 DOI: 10.1002/med.21639] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/05/2019] [Accepted: 09/26/2019] [Indexed: 12/19/2022]
Abstract
As a versatile therapeutic modality, peptides attract much attention because of their great binding affinity, low toxicity, and the capability of targeting traditionally "undruggable" protein surfaces. However, the deficiency of cell permeability and metabolic stability always limits the success of in vitro bioactive peptides as drug candidates. Peptide macrocyclization is one of the most established strategies to overcome these limitations. Over the past decades, more than 40 cyclic peptide drugs have been clinically approved, the vast majority of which are derived from natural products. The de novo discovered cyclic peptides on the basis of rational design and in vitro evolution, have also enabled the binding with targets for which nature provides no solutions. The current review summarizes different classes of cyclic peptides with diverse biological activities, and presents an overview of various approaches to develop cyclic peptide-based drug candidates, drawing upon series of examples to illustrate each strategy.
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Affiliation(s)
- Xiaoshu Jing
- Shandong University-Helmholtz Institute of Biotechnology, State Key Laboratory of Microbial Technology, Shandong University, Qingdao, China
| | - Kang Jin
- Department of Medicinal Chemistry, School of Pharmacy, Shandong University, Jinan, Shandong, China
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19
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Investigating Serious Adverse Drug Reactions in Patients Receiving Erythropoiesis-Stimulating Agents: A Root Cause Analysis Using the "ANTICIPATE" Framework. Am J Ther 2019; 25:e670-e674. [PMID: 30169374 DOI: 10.1097/mjt.0000000000000768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Unexpected serious adverse drug reactions (sADRs) affecting patients with chronic kidney disease (CKD) who received erythropoiesis-stimulating agents were identified by study co-authors. These included pure red cell aplasia (PRCA) after administration of the Eprex formulation of epoetin or the epoetin biosimilar HX575 and fatal anaphylaxis associated with peginesatide, an erythropoietin receptor agonist. We developed and applied a structured framework to describe these sADRs, including root cause analyses and eradication efforts. METHODS A 10-step framework termed "ANTICIPATE," focusing on signal identification, incidence, causality, and eradication guided our evaluations. RESULTS Initial cases were identified by a hematologist (Eprex), clinical study monitors (HX575), and 4 nurses (peginesatide). The number of persons with individual ADRs was 13 PRCA cases for epoetin, 2 antibody-mediated PRCA cases for HX575, and 5 fatal anaphylaxis cases for peginesatide. Initial incidence estimates per 1000 treated persons were 0.27 for Eprex-associated PRCA, 11 for HX575-associated PRCA, and 0.38 for peginesatide fatalities. Likely causes were subcutaneous administration of epoetin formulated with polysorbate 80 (Eprex), tungsten leaching from pins included in product syringes (HX575), and inclusion of a phenol stabilizer (peginesatide). Eradication strategies included restricting Eprex administration to the intravenous route, excluding tungsten from HX575 syringes, and for peginesatide, proposed eradication was to return to single-dose vials without preservatives. CONCLUSION Although the number of cases of each sADR was small, eradication was successful for 2 sADRs, and a proposed eradication was developed for a third sADR. The structured framework used to describe the above 3 sADRs in patients with CKD can also be used in other clinical settings.
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20
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Felix T, Jordan JB, Akers C, Patel B, Drago D. Current state of biologic pharmacovigilance in the European Union: improvements are needed. Expert Opin Drug Saf 2019; 18:231-240. [DOI: 10.1080/14740338.2019.1577818] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Thomas Felix
- Global Regulatory and R&D Policy, Amgen Inc., Washington, DC, USA
| | - John B. Jordan
- Global Regulatory and R&D Policy, Amgen Inc., Thousand Oaks, CA, USA
| | | | - Bina Patel
- Global Patient Safety, Amgen Ltd., Cambridge, UK
| | - Daniela Drago
- Regulatory Affairs, School of Medicine and Health Science, The George Washington University, Washington, DC, USA
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21
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Aapro M, Gascón P, Patel K, Rodgers GM, Fung S, Arantes LH, Wish J. Erythropoiesis-Stimulating Agents in the Management of Anemia in Chronic Kidney Disease or Cancer: A Historical Perspective. Front Pharmacol 2019; 9:1498. [PMID: 30687083 PMCID: PMC6333861 DOI: 10.3389/fphar.2018.01498] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 12/07/2018] [Indexed: 11/23/2022] Open
Abstract
Anemia is common in patients with cancer or with chronic kidney disease (CKD). Although the introduction of erythropoiesis-stimulating agents (ESAs) has transformed the management of anemia, their use has been complicated by a number of factors including frequent guideline updates, safety concerns and, in the United States, a Risk Evaluation and Mitigation Strategy (REMS) program, which aimed to ensure that the benefits of ESAs outweigh the risks. Many previous concerns around ESA use in cancer and CKD have been addressed by the reassuring results of post-approval studies, and biosimilar ESAs have been used in Europe for many years, with safety and efficacy profiles similar to originator products. This review describes the evolution of the use of ESAs from approval to the present day, discussing results from clinical studies of ESAs in cancer and CKD, and the influence of these findings on product labeling and guideline updates. We also discuss the impact of the introduction of ESA biosimilars in Europe, bringing cost savings and increased access to patients.
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Affiliation(s)
- Matti Aapro
- Genolier Cancer Centre, Clinique de Genolier, Genolier, Switzerland
| | - Pere Gascón
- Division of Medical Oncology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Kashyap Patel
- Carolina Blood and Cancer Care, Rock Hill, SC, United States
| | - George M. Rodgers
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Selwyn Fung
- Supportive Care Biosimilars, Pfizer Inc., New York, NY, United States
| | - Luiz H. Arantes
- Supportive Care Biosimilars, Pfizer Inc., New York, NY, United States
| | - Jay Wish
- Division of Nephrology, Indiana University Health, Indianapolis, IN, United States
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23
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HIF stabilizers in the management of renal anemia: from bench to bedside to pediatrics. Pediatr Nephrol 2019; 34:365-378. [PMID: 29569190 PMCID: PMC6349802 DOI: 10.1007/s00467-017-3849-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 10/28/2017] [Accepted: 10/31/2017] [Indexed: 02/06/2023]
Abstract
Anemia is a common complication of chronic kidney disease (CKD) in adult and pediatric patients. It has traditionally been treated with erythropoietin therapy and iron supplementation, with great success. With the discovery of the major transcription factor hypoxia inducible factor (HIF) for the erythropoietin gene in 1992, molecules were created that inhibit the HIF prolyl-hydroxylase enzyme. This new class of drug-called HIF stabilizers, or HIF prolyl-hydroxylase inhibitors-prevents the proteasomal degradation of HIF-α, thereby inducing upregulation of the erythropoietin gene. This new strategy for treating CKD anemia is already in phase III clinical trials in adults, and the potential advantages of this therapy are that it is orally active (thereby avoiding injections), and patients are exposed to lower circulating levels of erythropoietin. The long-term safety of this strategy, however, requires elucidation in these trials, particularly since there are many other hypoxia-sensitive genes, notably, angiogenic factors such as vascular endothelial growth factors (VEGF), as well as glycolytic enzymes. As with all new therapies, it is only once a positive benefit: risk profile has been ascertained in adults that the treatment will translate across into pediatrics. Specific issues in the pediatric CKD population are discussed in this review.
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24
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Feng S, Chang S, Yan L, Dong H, Xu X, Wang C, Liang Y, Liu K. Design, synthesis, and activity evaluation of novel erythropoietin mimetic peptides. Bioorg Med Chem Lett 2018; 28:3038-3041. [PMID: 30097369 DOI: 10.1016/j.bmcl.2018.08.004] [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: 04/03/2018] [Revised: 07/27/2018] [Accepted: 08/01/2018] [Indexed: 11/19/2022]
Abstract
The approval of the erythropoietin (EPO) mimetic peptide drug peginesatide in 2012 was a breakthrough for the treatment of secondary anemia. However, due to severe allergic reactions, peginesatide was recalled a year later. In this study, 12 novel peptides were designed and synthesized by substituting specific amino acids of the monomeric peptide in peginesatide, with the aim of obtaining new EPO mimetic peptides with higher activities and lower side effects than the parent compound. Their cell proliferation activities were evaluated, and the structure-activity relationships were analyzed. Five compounds had equal cell proliferation activity to the control peptide. Among them, one compound showed a higher in vivo activity than the control peptide, with no obvious side effects.
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Affiliation(s)
- Siliang Feng
- Beijing Institute of Pharmacology and Toxicology, State Key Laboratory of Toxicology and Medical Countermeasures, Beijing 100850, China
| | - Shaohua Chang
- Beijing Prowincan Pharmaceutical Technology Co. Ltd., Beijing 102600, China
| | - Lingdi Yan
- Beijing Institute of Pharmacology and Toxicology, State Key Laboratory of Toxicology and Medical Countermeasures, Beijing 100850, China
| | - Huajin Dong
- Beijing Institute of Pharmacology and Toxicology, State Key Laboratory of Toxicology and Medical Countermeasures, Beijing 100850, China
| | - Xiaoyu Xu
- Beijing Prowincan Pharmaceutical Technology Co. Ltd., Beijing 102600, China
| | - Chenhong Wang
- Beijing Institute of Pharmacology and Toxicology, State Key Laboratory of Toxicology and Medical Countermeasures, Beijing 100850, China
| | - Yuanjun Liang
- Beijing Prowincan Pharmaceutical Technology Co. Ltd., Beijing 102600, China.
| | - Keliang Liu
- Beijing Institute of Pharmacology and Toxicology, State Key Laboratory of Toxicology and Medical Countermeasures, Beijing 100850, China.
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25
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Goldsmith D, Dellanna F, Schiestl M, Krendyukov A, Combe C. Epoetin Biosimilars in the Treatment of Renal Anemia: What Have We Learned from a Decade of European Experience? Clin Drug Investig 2018; 38:481-490. [PMID: 29500617 PMCID: PMC5951862 DOI: 10.1007/s40261-018-0637-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Biosimilars are biological medicines that are approved via stringently defined regulatory pathways on the basis that comparable safety, efficacy, and quality have been demonstrated to their reference medicine. The advantage of biosimilar drugs is that they may be less expensive than the reference medicine, allowing for greater patient access and cost savings in already stretched healthcare budgets. Biosimilar epoetins have been available in Europe for a decade. Complementing in vitro and preclinical characterization, and pharmacokinetic/pharmacodynamic studies, clinical trials provided the additional data needed to reassure European authorities that biosimilar epoetins were sufficiently similar to the reference epoetin to warrant approval. Post-approval, real-world studies have provided further evidence that biosimilar epoetins are an effective and well-tolerated option for the treatment of renal anemia, with ongoing pharmacovigilance and observational studies monitoring for any unexpected long-term signals that have not been identified in clinical development studies. As the evidence and experience with these products increase, many of the initial concerns are being alleviated. Nephrologists can be increasingly confident that European Medicines Agency-approved biosimilars offer high-quality, affordable, effective alternatives to existing reference medicines used to treat renal anemia, and may help yield cost savings and improve patient access.
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Affiliation(s)
- David Goldsmith
- Division of Nephrology, Guy's and St. Thomas' Hospitals, London, UK
| | | | - Martin Schiestl
- Sandoz Biopharmaceuticals, Sandoz International GmbH, Kundl, Austria
| | - Andriy Krendyukov
- Hematology/Nephrology, Sandoz Biopharmaceuticals, Hexal AG, Industriestr. 25, 83607, Holzkirchen, Germany.
| | - Christian Combe
- Service de Néphrologie Transplantation Dialyse Aphérèse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.,Université de Bordeaux, INSERM 1026, Bordeaux, France
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26
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Lacreta G, Bucharles SGE, Sevignani G, Riella MC, Nascimento MMD. Pure red cell aplasia and anti-erythropoietin antibodies in patients on hemodialysis: a report of two cases and a literature review. ACTA ACUST UNITED AC 2018; 41:145-151. [PMID: 30160771 PMCID: PMC6534017 DOI: 10.1590/2175-8239-jbn-2018-0054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 06/18/2018] [Indexed: 11/25/2022]
Abstract
Introduction: Anemia is a frequent multifactorial complication of CKD seen in patients on dialysis derived mainly from impaired erythropoietin (EPO) production. A less common cause of anemia in individuals with CKD is pure red cell aplasia (PRCA) secondary to the production of anti-EPO antibodies. Objective: This paper aimed two describe two cases of PRCA secondary to the production of anti-EPO antibodies including choice of treatment, patient progression, and a literature review. Materials: This study included the cases of two patients with CKD on hemodialysis with severe anemia in need of specific investigation and management. Results: Patient 1 with CKD secondary to hypertension treated with EPO for 7 months showed persistent decreases in hemoglobin (Hb) levels despite the subcutaneous administration of increasing doses of EPO; the patient required recurring blood transfusions. Workup and imaging tests were negative for the main causes of anemia in individuals with CKD on dialysis. Patient 2 with CKD secondary to adult polycystic kidney disease had been taking EPO for 2 years. The patient developed severe abrupt anemia the month he was started on HD, and required recurring transfusions to treat the symptoms of anemia. Workup and imaging findings were inconclusive. Specific laboratory tests confirmed the patients had anti-EPO antibodies. After six months of immunosuppressant therapy (corticosteroids + cyclosporine) the patients were stable with Hb > 9.0 g/dl. Conclusion: PRCA is a rare condition among patients on dialysis treated with rhEPO and should be considered as a possible cause of refractory anemia. Treating patients with PRCA may be challenging, since the specific management and diagnostic procedures needed in this condition are not always readily available.
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Affiliation(s)
- Gabriela Lacreta
- Universidade Federal do Paraná, Hospital de Clínicas, Serviço de Nefrologia, Curitiba, PR, Brasil.,Fundação Pró Renal, Curitiba, PR, Brasil
| | - Sérgio Gardano Elias Bucharles
- Universidade Federal do Paraná, Hospital de Clínicas, Serviço de Nefrologia, Curitiba, PR, Brasil.,Fundação Pró Renal, Curitiba, PR, Brasil.,Clínica Evangélico de Hemodiálise, Curitiba, PR, Brasil
| | - Gabriela Sevignani
- Universidade Federal do Paraná, Hospital de Clínicas, Curitiba, PR, Brasil
| | | | - Marcelo Mazza do Nascimento
- Universidade Federal do Paraná, Hospital de Clínicas, Serviço de Nefrologia, Curitiba, PR, Brasil.,Clínica Evangélico de Hemodiálise, Curitiba, PR, Brasil
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Anti-Drug Antibodies: Emerging Approaches to Predict, Reduce or Reverse Biotherapeutic Immunogenicity. Antibodies (Basel) 2018; 7:antib7020019. [PMID: 31544871 PMCID: PMC6698869 DOI: 10.3390/antib7020019] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 05/25/2018] [Accepted: 05/29/2018] [Indexed: 12/13/2022] Open
Abstract
The development of anti-drug antibodies (ADAs) following administration of biotherapeutics to patients is a vexing problem that is attracting increasing attention from pharmaceutical and biotechnology companies. This serious clinical problem is also spawning creative research into novel approaches to predict, avoid, and in some cases even reverse such deleterious immune responses. CD4+ T cells are essential players in the development of most ADAs, while memory B-cell and long-lived plasma cells amplify and maintain these responses. This review summarizes methods to predict and experimentally identify T-cell and B-cell epitopes in therapeutic proteins, with a particular focus on blood coagulation factor VIII (FVIII), whose immunogenicity is clinically significant and is the subject of intensive current research. Methods to phenotype ADA responses in humans are described, including T-cell stimulation assays, and both established and novel approaches to determine the titers, epitopes and isotypes of the ADAs themselves. Although rational protein engineering can reduce the immunogenicity of many biotherapeutics, complementary, novel approaches to induce specific tolerance, especially during initial exposures, are expected to play significant roles in future efforts to reduce or reverse these unwanted immune responses.
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Lamanna WC, Holzmann J, Cohen HP, Guo X, Schweigler M, Stangler T, Seidl A, Schiestl M. Maintaining consistent quality and clinical performance of biopharmaceuticals. Expert Opin Biol Ther 2018; 18:369-379. [DOI: 10.1080/14712598.2018.1421169] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
| | - Johann Holzmann
- Technical Development Biosimilars, Biologics Technical Development and Manufacturing, Novartis, Sandoz GmbH, Kundl, Austria
| | | | - Xinghua Guo
- Technical Development Biosimilars, Biologics Technical Development and Manufacturing, Novartis, Sandoz GmbH, Kundl, Austria
| | - Monika Schweigler
- Technical Development Biosimilars, Biologics Technical Development and Manufacturing, Novartis, Sandoz GmbH, Kundl, Austria
| | - Thomas Stangler
- Technical Development Biosimilars, Biologics Technical Development and Manufacturing, Novartis, Sandoz GmbH, Kundl, Austria
| | - Andreas Seidl
- Technical Development Biosimilars, Biologics Technical Development and Manufacturing, Novartis, Hexal AG, Oberhaching, Germany
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Affiliation(s)
| | - Matti Aapro
- Multidisciplinary Oncology Institute, Clinique de Genolier, Genolier, Switzerland
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30
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Ogoshi Y, Matsui T, Mitani I, Yokota M, Terashita M, Motoda D, Ueyama K, Hotta T, Ito T, Hase Y, Fukui K, Deai K, Yoshiuchi H, Ito S, Abe H. Discovery of JTZ-951: A HIF Prolyl Hydroxylase Inhibitor for the Treatment of Renal Anemia. ACS Med Chem Lett 2017; 8:1320-1325. [PMID: 29259755 DOI: 10.1021/acsmedchemlett.7b00404] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 11/20/2017] [Indexed: 12/12/2022] Open
Abstract
Inhibition of hypoxia inducible factor prolyl hydroxylase (PHD) represents a promising strategy for the discovery of a next generation treatment for renal anemia. We identified several 5,6-fused ring systems as novel scaffolds of the PHD inhibitor on the basis of pharmacophore analysis. In particular, triazolopyridine derivatives showed potent PHD2 inhibitory activities. Examination of the predominance of the triazolopyridines in potency by electrostatic calculations suggested favorable π-π stacking interactions with Tyr310. Lead optimization to improve the efficacy of erythropoietin release in cells and in vivo by improving cell permeability led to the discovery of JTZ-951 (compound 14), with a 5-phenethyl substituent on the triazolopyridine group, which increased hemoglobin levels with daily oral dosing in rats. Compound 14 was rapidly absorbed after oral administration and disappeared shortly thereafter, which could be advantageous in terms of safety. Compound 14 was selected as a clinical candidate.
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Affiliation(s)
- Yosuke Ogoshi
- Chemical Research Laboratories, ‡Biological Pharmacological Research Laboratories, §Drug Metabolism & Pharmacokinetics Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., 1-1, Murasaki-cho, Takatsuki, Osaka 569-1125, Japan
| | - Takuya Matsui
- Chemical Research Laboratories, ‡Biological Pharmacological Research Laboratories, §Drug Metabolism & Pharmacokinetics Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., 1-1, Murasaki-cho, Takatsuki, Osaka 569-1125, Japan
| | - Ikuo Mitani
- Chemical Research Laboratories, ‡Biological Pharmacological Research Laboratories, §Drug Metabolism & Pharmacokinetics Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., 1-1, Murasaki-cho, Takatsuki, Osaka 569-1125, Japan
| | - Masahiro Yokota
- Chemical Research Laboratories, ‡Biological Pharmacological Research Laboratories, §Drug Metabolism & Pharmacokinetics Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., 1-1, Murasaki-cho, Takatsuki, Osaka 569-1125, Japan
| | - Masakazu Terashita
- Chemical Research Laboratories, ‡Biological Pharmacological Research Laboratories, §Drug Metabolism & Pharmacokinetics Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., 1-1, Murasaki-cho, Takatsuki, Osaka 569-1125, Japan
| | - Dai Motoda
- Chemical Research Laboratories, ‡Biological Pharmacological Research Laboratories, §Drug Metabolism & Pharmacokinetics Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., 1-1, Murasaki-cho, Takatsuki, Osaka 569-1125, Japan
| | - Kazuhito Ueyama
- Chemical Research Laboratories, ‡Biological Pharmacological Research Laboratories, §Drug Metabolism & Pharmacokinetics Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., 1-1, Murasaki-cho, Takatsuki, Osaka 569-1125, Japan
| | - Takahiro Hotta
- Chemical Research Laboratories, ‡Biological Pharmacological Research Laboratories, §Drug Metabolism & Pharmacokinetics Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., 1-1, Murasaki-cho, Takatsuki, Osaka 569-1125, Japan
| | - Takashi Ito
- Chemical Research Laboratories, ‡Biological Pharmacological Research Laboratories, §Drug Metabolism & Pharmacokinetics Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., 1-1, Murasaki-cho, Takatsuki, Osaka 569-1125, Japan
| | - Yasunori Hase
- Chemical Research Laboratories, ‡Biological Pharmacological Research Laboratories, §Drug Metabolism & Pharmacokinetics Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., 1-1, Murasaki-cho, Takatsuki, Osaka 569-1125, Japan
| | - Kenji Fukui
- Chemical Research Laboratories, ‡Biological Pharmacological Research Laboratories, §Drug Metabolism & Pharmacokinetics Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., 1-1, Murasaki-cho, Takatsuki, Osaka 569-1125, Japan
| | - Katsuya Deai
- Chemical Research Laboratories, ‡Biological Pharmacological Research Laboratories, §Drug Metabolism & Pharmacokinetics Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., 1-1, Murasaki-cho, Takatsuki, Osaka 569-1125, Japan
| | - Hiromi Yoshiuchi
- Chemical Research Laboratories, ‡Biological Pharmacological Research Laboratories, §Drug Metabolism & Pharmacokinetics Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., 1-1, Murasaki-cho, Takatsuki, Osaka 569-1125, Japan
| | - Soichiro Ito
- Chemical Research Laboratories, ‡Biological Pharmacological Research Laboratories, §Drug Metabolism & Pharmacokinetics Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., 1-1, Murasaki-cho, Takatsuki, Osaka 569-1125, Japan
| | - Hiroyuki Abe
- Chemical Research Laboratories, ‡Biological Pharmacological Research Laboratories, §Drug Metabolism & Pharmacokinetics Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., 1-1, Murasaki-cho, Takatsuki, Osaka 569-1125, Japan
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Yoon S, Rhee SJ, Heo SJ, Oh TY, Yoon SH, Cho JY, Lee S, Yu KS. Comparable pharmacokinetics and pharmacodynamics of two epoetin alfa formulations Eporon ® and Eprex ® following a single subcutaneous administration in healthy male volunteers. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:3127-3135. [PMID: 29138535 PMCID: PMC5667778 DOI: 10.2147/dddt.s142673] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose This study aimed to assess and compare the pharmacokinetic (PK) and pharmacodynamic (PD) properties following a single subcutaneous injection of epoetin alfa (Eporon®) with those of the comparator (Eprex®) in healthy male subjects. Subjects and methods A randomized, double-blind, two-sequence, crossover study was conducted. Subjects were randomly assigned to receive a single dose, that is, 4,000 IU, of the test or comparator epoetin alfa. After 4 weeks, all subjects received the alternative formulation. The primary PK parameters, maximum observed concentration (Cmax) and area under the curve extrapolated to infinity (AUCinf), were calculated with the serum erythropoietin (EPO) concentrations from blood samples collected for 144 h after dosing. The reticulocyte, hematocrit, hemoglobin and red blood cell counts were measured up to 312 h as PD markers. The primary PD parameters, maximum observed effect (Emax) and area under the effect curve (AUEC), were obtained from the baseline-corrected reticulocyte count. The serum EPO concentration and the reticulocyte count were used to assess the concentration–response relationship. The tolerability and immunogenicity profiles were assessed together. Results Forty-two subjects completed the study. The mean EPO concentration–time profiles were comparable between the two formulations. The geometric mean ratios (90% CI) of the Cmax and AUCinf were 0.908 (0.843–0.978) and 1.049 (0.999–1.101), respectively, both of which were within the regulatory range of 0.80–1.25. Additionally, the PD and tolerability profiles were similar between the two formulations. The time-matched serum EPO concentration and PD markers presented a counterclockwise hysteresis, suggesting a time delay between the measured concentration and the response. Both formulations were well tolerated, and production of anti-drug antibodies was not observed. Conclusion The two epoetin alfa formulations had similar PK, PD and tolerability profiles. Furthermore, both formulations had a similar time-matched serum EPO concentration and erythropoietic response profile. Thus, the two formulations are expected to be used interchangeably in clinical settings.
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Affiliation(s)
- Sumin Yoon
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul
| | - Su-Jin Rhee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul
| | | | | | - Seo Hyun Yoon
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul
| | - Joo-Youn Cho
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul
| | - SeungHwan Lee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul.,Clinical Trials Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul.,Clinical Trials Center, Seoul National University Hospital, Seoul, Republic of Korea
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32
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Casadevall N, Dobronravov V, Eckardt KU, Ertürk S, Martynyuk L, Schmitt S, Schaffar G, Rudy A, Krendyukov A, Ode M. Evaluation of the safety and immunogenicity of subcutaneous HX575 epoetin alfa in the treatment of anemia associated with chronic kidney disease in predialysis and dialysis patients
. Clin Nephrol 2017; 88:190-197. [PMID: 28766493 PMCID: PMC5607454 DOI: 10.5414/cn109159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 09/07/2017] [Indexed: 01/22/2023] Open
Abstract
AIM To assess the safety and immunogenicity of subcutaneous (SC) HX575 (epoetin-α) in dialysis- and nondialysis-dependent adult patients with chronic kidney disease (CKD). METHODS Open-label, single-arm, multicenter study in patients (n = 416) from Germany, Italy, Poland, Romania, Russia, Turkey, and Ukraine. RESULTS Mean (standard deviation (SD)) age was 52.3 (15.8) years, all patients were Caucasian, and similar proportions were male/female. 250 patients (60.1%) were erythropoiesis-stimulating agent (ESA)-naïve, and 166 (39.9%) were receiving ESA maintenance therapy at study start; mean (SD) on-study treatment duration with HX575 was 43.4 (15.8) weeks and 45.3 (13.7) weeks, respectively. Binding antierythropoietin (EPO) antibodies were detected by radioimmunoprecipitation (RIP) assay in 7 patients (1.7%; incidence 0.019); 5 of these were ESA-naïve at study entry. No patient developed neutralizing antibodies as determined in a cell-based epoetin neutralizing assay. Of the 7 patients with a positive binding anti-EPO RIP assay, 4 tested negative at later time points while continuing HX575 treatment. Three patients had low titers of anti-EPO antibodies at the last study assessment. There were no clinical signs of immunogenicity or hypersensitivity. CONCLUSIONS SC HX575 was effective for correcting and maintaining correction of anemia, and the mean weekly dose remained stable over time.
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Affiliation(s)
- Nicole Casadevall
- Service d’Immunologie et Hématologie Biologiques, Hopital Saint Antoine, Paris, France
| | - Vladimir Dobronravov
- Research Institute of Nephrology, 1st St Petersburg Pavlov State Medical University, St. Petersburg, Russia
| | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, University of Erlangen-Nürnberg, Germany
| | - Sehsuvar Ertürk
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Liliya Martynyuk
- Subdepartment of Internal Medicine, Higher Educational Institution, I. Ya. Horbachevsky Ternopil State Medical University, Ternopil, Ukraine, and
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33
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Mesgarpour B, Heidinger BH, Roth D, Schmitz S, Walsh CD, Herkner H. Harms of off-label erythropoiesis-stimulating agents for critically ill people. Cochrane Database Syst Rev 2017; 8:CD010969. [PMID: 28841235 PMCID: PMC6373621 DOI: 10.1002/14651858.cd010969.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Anaemia is a common problem experienced by critically-ill people. Treatment with erythropoiesis-stimulating agents (ESAs) has been used as a pharmacologic strategy when the blunted response of endogenous erythropoietin has been reported in critically-ill people. The use of ESAs becomes more important where adverse clinical outcomes of transfusing blood products is a limitation. However, this indication for ESAs is not licensed by regulatory authorities and is called off-label use. Recent studies concern the harm of ESAs in a critical care setting. OBJECTIVES To focus on harms in assessing the effects of erythropoiesis-stimulating agents (ESAs), alone or in combination, compared with placebo, no treatment or a different active treatment regimen when administered off-label to critically-ill people. SEARCH METHODS We conducted a systematic search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO via OvidSP, CINAHL, all evidence-based medicine (EBM) reviews including IPA and SCI-Expanded, Conference Proceedings Citation Index- Science, BIOSIS Previews and TOXLINE up to February 2017. We also searched trials registries, checked reference lists of relevant studies and tracked their citations by using SciVerse Scopus. SELECTION CRITERIA We considered randomized controlled trials (RCTs) and controlled observational studies, which compared scheduled systemic administration of ESAs versus other effective interventions, placebo or no treatment in critically-ill people. DATA COLLECTION AND ANALYSIS Two review authors independently screened and evaluated the eligibility of retrieved records, extracted data and assessed the risks of bias and quality of the included studies. We resolved differences in opinion by consensus or by involving a third review author. We assessed the evidence using GRADE and created a 'Summary of findings' table. We used fixed-effect or random-effects models, depending on the heterogeneity between studies. We fitted three-level hierarchical Bayesian models to calculate overall treatment effect estimates. MAIN RESULTS Of the 27,865 records identified, 39 clinical trials and 14 observational studies, including a total of 945,240 participants, were eligible for inclusion. Five studies are awaiting classification. Overall, we found 114 adverse events in 33 studies (30 RCTs and three observational studies), and mortality was reported in 41 studies (32 RCTs and nine observational studies). Most studies were at low to moderate risk of bias for harms outcomes. However, overall harm assessment and reporting were of moderate to low quality in the RCTs, and of low quality in the observational studies. We downgraded the GRADE quality of evidence for venous thromboembolism and mortality to very low and low, respectively, because of risk of bias, high inconsistency, imprecision and limitations of study design.It is unclear whether there is an increase in the risk of any adverse events (Bayesian risk ratio (RR) 1.05, 95% confidence interval (CI) 0.93 to 1.21; 3099 participants; 9 studies; low-quality evidence) or venous thromboembolism (Bayesian RR 1.04, 95% CI 0.70 to 1.41; 18,917 participants; 18 studies; very low-quality evidence).There was a decreased risk of mortality with off-label use of ESAs in critically-ill people (Bayesian RR 0.76, 95% CI 0.61 to 0.92; 930,470 participants; 34 studies; low-quality evidence). AUTHORS' CONCLUSIONS Low quality of evidence suggests that off-label use of ESAs may reduce mortality in a critical care setting. There was a lack of high-quality evidence about the harm of ESAs in critically-ill people. The information for biosimilar ESAs is less conclusive. Most studies neither evaluated ESAs' harm as a primary outcome nor predefined adverse events. Any further studies of ESA should address the quality of evaluating, recording and reporting of adverse events.
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Affiliation(s)
| | | | - Dominik Roth
- Medical University of ViennaDepartment of Emergency MedicineAllgemeines Krankenhaus, Währinger Gürtel
18‐20,ViennaAustria1090
| | - Susanne Schmitz
- Luxembourg Institute of HealthDepartment of Population Health1A‐B, rue Thomas EdisonStrassenLuxembourg1445
| | - Cathal D Walsh
- Department of Mathematics and StatisticsHealth Research Institute (HRI) and MACSIUniversity of LimerickIreland
| | - Harald Herkner
- Medical University of ViennaDepartment of Emergency MedicineAllgemeines Krankenhaus, Währinger Gürtel
18‐20,ViennaAustria1090
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Abstract
Pure red cell aplasia (PRCA) is a syndrome defined by a normocytic normochromic anemia with severe reticulocytopenia and marked reduction or absence of erythroid precursors from the bone marrow. Diamond-Blackfan anemia is a congenital form of PRCA. Acquired PRCA may be either a primary disorder or secondary to some other disorder or agent. Primary acquired PRCA is an autoimmune disorder that is frequently antibody-mediated. Myelodysplastic syndromes may also present with the morphologic appearance of PRCA. Secondary acquired PRCA may be associated with collagen vascular/autoimmune disorders such as systemic lupus erythematosus; lymphoproliferative disorders such as chronic lymphocytic leukemia or large granular lymphocyte leukemia; infections, particularly B19 parvovirus; thymoma and other solid tumors; or a variety of other disorders, drugs, or toxic agents. The therapeutic approach to PRCA typically involves immunosuppression, but specific pathogenic subtypes are associated with specific therapeutic approaches. Cyclosporine A, with or without concurrent corticosteroids, appears to be the single most effective immunosuppressive agent.
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O'Donnell C, Michael N, Bloch N, Erickson M, Garg S. Strategies to Minimize Blood Loss and Transfusion in Pediatric Spine Surgery. JBJS Rev 2017; 5:e1. [PMID: 28471775 DOI: 10.2106/jbjs.rvw.16.00064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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36
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Fiocchi EH, Cowgill LD, Brown DC, Markovich JE, Tucker S, Labato MA, Callan MB. The Use of Darbepoetin to Stimulate Erythropoiesis in the Treatment of Anemia of Chronic Kidney Disease in Dogs. J Vet Intern Med 2017; 31:476-485. [PMID: 28256075 PMCID: PMC5354051 DOI: 10.1111/jvim.14681] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 01/16/2017] [Accepted: 01/30/2017] [Indexed: 11/30/2022] Open
Abstract
Background Darbepoetin alfa (darbepoetin) is an erythropoiesis‐stimulating agent used for the treatment of anemia secondary to chronic kidney disease (CKD) in dogs, but reports describing response are lacking. Hypothesis/Objectives To evaluate the effectiveness of darbepoetin in dogs with anemia secondary to CKD, dosing protocols, and adverse events. Animals Thirty‐three client‐owned dogs with naturally occurring CKD, including 26 with comorbidities. Methods Multi‐institutional retrospective study. Results The median starting dosage and highest dosage of darbepoetin administered were 0.5 and 0.8 μg/kg SC once weekly, respectively. Response to treatment was defined as achieving a packed cell volume (PCV) ≥30% or an increase in PCV ≥10%. Twenty‐eight of 33 dogs (85%) achieved a PCV ≥30% and 22 of 33 (67%) dogs achieved an increase in PCV ≥10%. Median time to achieve a PCV ≥30% was 29 days. A higher starting dosage was associated with achieving an increase in PCV ≥10% (P = .01). No dog sustained a response at a dosing interval >q21d. Potential adverse events included increased blood pressure requiring treatment (n = 12), seizures (n = 5), vomiting (n = 3), diarrhea (n = 3), and possible pure red cell aplasia (PRCA) (n = 2). Conclusions and Clinical Importance Darbepoetin, when combined with treatment of comorbidities, is an effective treatment for anemia secondary to CKD in dogs. A dosing interval >q21d was ineffective at maintaining a response to treatment. PRCA was a possible adverse event in 2 of 33 dogs (6%).
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Affiliation(s)
- E H Fiocchi
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
| | - L D Cowgill
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - D C Brown
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
| | - J E Markovich
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA
| | - S Tucker
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA
| | - M A Labato
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA
| | - M B Callan
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
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37
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Abstract
Pure red cell aplasia (PRCA) is a syndrome defined by a normocytic normochromic anemia with severe reticulocytopenia and marked reduction or absence of erythroid precursors from the bone marrow. Diamond-Blackfan anemia is a congenital form of PRCA. Acquired PRCA may be either a primary disorder or secondary to some other disorder or agent. Primary acquired PRCA is an autoimmune disorder that is frequently antibody-mediated. Myelodysplastic syndromes may also present with the morphologic appearance of PRCA. Secondary acquired PRCA may be associated with collagen vascular/autoimmune disorders such as systemic lupus erythematosus; lymphoproliferative disorders such as chronic lymphocytic leukemia or large granular lymphocyte leukemia; infections, particularly B19 parvovirus; thymoma and other solid tumors; or a variety of other disorders, drugs, or toxic agents. The therapeutic approach to PRCA typically involves immunosuppression, but specific pathogenic subtypes are associated with specific therapeutic approaches. Cyclosporine A, with or without concurrent corticosteroids, appears to be the single most effective immunosuppressive agent.
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MESH Headings
- Adrenal Cortex Hormones/therapeutic use
- Anemia, Diamond-Blackfan/drug therapy
- Anemia, Diamond-Blackfan/immunology
- Anemia, Diamond-Blackfan/pathology
- Autoimmune Diseases/drug therapy
- Autoimmune Diseases/immunology
- Autoimmune Diseases/pathology
- Cyclosporine/therapeutic use
- Humans
- Immunosuppressive Agents/therapeutic use
- Leukemia, Large Granular Lymphocytic/drug therapy
- Leukemia, Large Granular Lymphocytic/immunology
- Leukemia, Large Granular Lymphocytic/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Myelodysplastic Syndromes/drug therapy
- Myelodysplastic Syndromes/etiology
- Myelodysplastic Syndromes/immunology
- Myelodysplastic Syndromes/pathology
- Parvoviridae Infections/drug therapy
- Parvoviridae Infections/immunology
- Parvoviridae Infections/pathology
- Parvovirus B19, Human/immunology
- Thymoma/drug therapy
- Thymoma/immunology
- Thymoma/pathology
- Vasculitis/drug therapy
- Vasculitis/immunology
- Vasculitis/pathology
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Affiliation(s)
- Robert T Means
- Office of the Dean, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN
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Groenendaal-van de Meent D, Adel MD, Noukens J, Rijnders S, Krebs-Brown A, Mateva L, Alexiev A, Schaddelee M. Effect of Moderate Hepatic Impairment on the Pharmacokinetics and Pharmacodynamics of Roxadustat, an Oral Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitor. Clin Drug Investig 2016; 36:743-751. [PMID: 27352308 PMCID: PMC4987405 DOI: 10.1007/s40261-016-0422-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Roxadustat is a hypoxia-inducible factor prolyl hydroxylase inhibitor in phase III development for the treatment of anaemia associated with chronic kidney disease. This study evaluated the effects of moderate hepatic impairment on roxadustat pharmacokinetics, pharmacodynamics and tolerability. METHODS This was an open-label study in which eight subjects with moderate hepatic impairment (liver cirrhosis Child-Pugh score 7-9) and eight subjects with normal hepatic function (matched for body mass index, age and sex) received a single oral 100 mg roxadustat dose under fasted conditions. Blood samples were collected until 144 h post-dose in subjects with moderate hepatic impairment and until 96 h post-dose in subjects with normal hepatic function. RESULTS In subjects with moderate hepatic impairment, area under the concentration-time curve (AUC) from the time of drug administration to infinity (AUC∞) and observed maximum concentration (C max) were 23 % higher [geometric least-squares mean ratio (GMR) 123 %; 90 % CI 86.1-175] and 16 % lower (GMR 83.6 %; 90 % CI 67.5-104), respectively, than in subjects with normal hepatic function. Mean terminal half-life (t ½) appeared to be longer (17.7 vs. 12.8 h) in subjects with moderate hepatic impairment, however intersubject variability on apparent total systemic clearance after single oral dosing (CL/F), apparent volume of distribution at equilibrium after oral administration (V z/F) and t ½ was approximately twofold higher. Erythropoietin (EPO) baseline-corrected AUC from administration to the last measurable EPO concentration (AUCE,last) and maximum effect (E max) were 31 % (GMR 68.95 %; 90 % CI 29.29-162.29) and 48 % (GMR 52.29 %; 90 % CI 28.95-94.46) lower, respectively, than in subjects with normal hepatic function. The single oral roxadustat dose was generally well tolerated. CONCLUSIONS This study demonstrated the effect of moderate hepatic impairment on the pharmacokinetics and pharmacodynamics of roxadustat relative to subjects with normal hepatic function. These differences are not expected to be of clinical significance.
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Affiliation(s)
| | | | | | | | | | - Lyudmila Mateva
- Gastroenterology Clinic, University Hospital St Ivan Rilski, Medical University-Sofia, COMAC Medical Ltd, Sofia, Bulgaria
| | - Assen Alexiev
- Gastroenterology Clinic, University Hospital St Ivan Rilski, Medical University-Sofia, COMAC Medical Ltd, Sofia, Bulgaria
| | - Marloes Schaddelee
- Astellas Pharma Europe B.V., Leiden, The Netherlands.
- Business Development, Transaction Execution Group, Astellas Pharma Inc., Sylviusweg 62, PO Box 344, 2300 AH, Leiden, The Netherlands.
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Hermanson T, Bennett CL, Macdougall IC. Peginesatide for the treatment of anemia due to chronic kidney disease - an unfulfilled promise. Expert Opin Drug Saf 2016; 15:1421-6. [PMID: 27551882 DOI: 10.1080/14740338.2016.1218467] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The introduction of recombinant human erythropoietin revolutionized the management of anemia in patients with chronic kidney disease (CKD). In order to circumvent costly recombinant DNA technology, synthetic chemistry techniques were used to manufacture peginesatide, a synthetic peptide that bore no resemblance to previous erythropoiesis-stimulating agents (ESAs), and yet was capable of stimulating erythropoiesis. Compared with other ESAs, peginesatide was deemed to have advantages related to immunogenicity, administration schedule, and cost. Marketing approval was restricted to CKD patients on dialysis because cardiovascular events were more common with peginesatide than with darbepoetin in non-dialysis CKD patients. Unfortunately, unexplained serious adverse drug reactions (sADR) led to quick withdrawal of peginesatide from the market. AREAS COVERED This review describes the efficacy and safety of peginesatide in pre-approval clinical trials, sADRs after marketing approval, and lessons learned during its short life-span. EXPERT OPINION The case of peginesatide illustrates the difficulties in detecting rare sADRs in trials with limited patient populations and the need for improved pharmacovigilance after marketing approval. However, the need for simpler drug production methods as a result of non-dependence on recombinant DNA techniques and mammalian cell lines remains. Lessons learned during the scientific development of peginesatide can be used in developing other drugs.
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Affiliation(s)
- Terhi Hermanson
- a Comprehensive Cancer Center , Helsinki University Central Hospital , Helsinki , Finland
| | - Charles L Bennett
- a Comprehensive Cancer Center , Helsinki University Central Hospital , Helsinki , Finland.,b SmartState Center for Medication Safety and Efficacy, South Carolina College of Pharmacy , University of South Carolina , Columbia , SC , United States.,c Medical University of South Carolina , Hollings Cancer Center , Charleston , SC , United States
| | - Iain C Macdougall
- d Department of Renal Medicine , King's College Hospital , London , UK
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40
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Hermanson T, Bennett CL, Macdougall IC. Peginesatide for the treatment of anemia due to chronic kidney disease – an unfulfilled promise. Expert Opin Drug Saf 2016. [DOI: 10.1080/14740338.2016.1218467 pmid: 27551882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Affiliation(s)
- Terhi Hermanson
- Comprehensive Cancer Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Charles L. Bennett
- Comprehensive Cancer Center, Helsinki University Central Hospital, Helsinki, Finland
- SmartState Center for Medication Safety and Efficacy, South Carolina College of Pharmacy, University of South Carolina, Columbia, SC, United States
- Medical University of South Carolina, Hollings Cancer Center, Charleston, SC, United States
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Tan CW, Tan-Koi WC, Ng J, Chan CM, Hwang WYK. A cluster of Epoetin-associated pure red cell aplasia: clinical features and the possible association of HLA-DRB1*12:02. Pharmacogenomics 2016; 17:1235-1243. [PMID: 27348021 DOI: 10.2217/pgs-2016-0018] [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] [Indexed: 01/19/2023] Open
Abstract
Antibody-mediated pure red cell aplasia is a rare but serious complication in chronic kidney disease patients receiving recombinant human erythropoietin (r-HuEpo). Between April 2012 and May 2013, eight such cases were reported in our institution. Their clinical features were reviewed and their HLA alleles were compared with those of healthy controls. All patients were exposed to epoetin alfa (Eprex®) with polysorbate-80 as stabilizer via subcutaneous route with a mean age of 61.9 years and mean exposure of 11.2 months of r-HuEpo before loss of efficacy. 87.5% of the cases were male and Chinese and received immunosuppression as treatment for pure red cell aplasia. All three of the successfully treated patients are alive compared with only 40% of the transfusion-dependent patients. DRB1*12:02 was more frequently expressed among the cases than healthy controls suggesting a plausible molecular link.
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Affiliation(s)
- Chuen Wen Tan
- Department of Haematology, Singapore General Hospital, Singapore
| | - Wei-Chuen Tan-Koi
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Jennifer Ng
- Department of Paediatrics, Georgetown University, Washington, DC 20007, USA
| | - Choong Meng Chan
- Department of Renal Medicine, Singapore General Hospital, Singapore
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Del Vecchio L, Locatelli F. An overview on safety issues related to erythropoiesis-stimulating agents for the treatment of anaemia in patients with chronic kidney disease. Expert Opin Drug Saf 2016; 15:1021-30. [PMID: 27149639 DOI: 10.1080/14740338.2016.1182494] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Erythropoiesis stimulating agents (ESA) are effective drugs, which have been used for decades in patients with chronic kidney disease (CKD) with few side effects. More recently, concern has been raised around their safety, from higher cardiovascular and thrombosis risk to cancer progression and increased mortality. AREAS COVERED We made a literature search on PubMed looking for adverse effects of ESA in CKD patients. The topics covered are cardiovascular adverse events, thrombosis, increased mortality, hypertension, cancer progression, diabetic retinopathy, pure red cell aplasia and anaphylactic reactions. EXPERT OPINION Concerns around ESA therapy have questioned treatment indications in high-risk CKD patients (those with cancer, diabetes and cardiovascular comorbidities). A more cautious approach has then prevailed. In our opinion, intermediate Hb values (Hb 10-12 g/dl) should be aimed with ESA therapy, being more cautious in high-risk patients. As a consequence, IV iron is administered more frequently. However, excessive iron use may cause iron overload and in rare cases severe anaphylactic reactions. There are expectations of new erythropoietic agents, such as those manipulating the hypoxia-inducible transcription factors (HIF) system. Differing from ESAs, they stimulate the production of endogenous EPO, avoiding over-physiological plasmatic levels.
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Affiliation(s)
- Lucia Del Vecchio
- a Department of Nephrology and Dialysis , A. Manzoni Hospital , Lecco , Italy
| | - Francesco Locatelli
- a Department of Nephrology and Dialysis , A. Manzoni Hospital , Lecco , Italy
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Panichi V, Ricchiuti G, Scatena A, Del Vecchio L, Locatelli F. Pure red cell aplasia induced by epoetin zeta. Clin Kidney J 2016; 9:599-602. [PMID: 27478604 PMCID: PMC4957714 DOI: 10.1093/ckj/sfw030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/04/2016] [Indexed: 01/08/2023] Open
Abstract
Pure red cell aplasia (PRCA) may develop in patients with chronic kidney disease receiving erythropoiesis-stimulating agents (ESA). We report on a 72-year-old patient who developed hypo-proliferative anaemia unresponsive to ESA following the administration of epoetin zeta subcutaneously for 7 months. On the basis of severe isolated hypoplasia of the erythroid line in the bone marrow and high-titre neutralizing anti-erythropoietin antibodies (Ab), a diagnosis of Ab-mediated PRCA was made. Epoetin zeta was discontinued and the patient was given steroids. This was associated with anaemia recovery. To our knowledge this is the first PRCA case related to epoetin zeta.
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Affiliation(s)
- Vincenzo Panichi
- Department of Nephrology and Dialysis , Versilia Hospital , Lido di Camaiore (LU) , Italy
| | - Guido Ricchiuti
- Department of Nephrology and Dialysis , Versilia Hospital , Lido di Camaiore (LU) , Italy
| | - Alessia Scatena
- Department of Nephrology and Dialysis , Versilia Hospital , Lido di Camaiore (LU) , Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis , A. Manzoni Hospital , Lecco , Italy
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Jefferis R. Posttranslational Modifications and the Immunogenicity of Biotherapeutics. J Immunol Res 2016; 2016:5358272. [PMID: 27191002 PMCID: PMC4848426 DOI: 10.1155/2016/5358272] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 03/20/2016] [Indexed: 12/23/2022] Open
Abstract
Whilst the amino acid sequence of a protein is determined by its gene sequence, the final structure and function are determined by posttranslational modifications (PTMs), including quality control (QC) in the endoplasmic reticulum (ER) and during passage through the Golgi apparatus. These processes are species and cell specific and challenge the biopharmaceutical industry when developing a production platform for the generation of recombinant biologic therapeutics. Proteins and glycoproteins are also subject to chemical modifications (CMs) both in vivo and in vitro. The individual is naturally tolerant to molecular forms of self-molecules but nonself variants can provoke an immune response with the generation of anti-drug antibodies (ADA); aggregated forms can exhibit enhanced immunogenicity and QC procedures are developed to avoid or remove them. Monoclonal antibody therapeutics (mAbs) are a special case because their purpose is to bind the target, with the formation of immune complexes (ICs), a particular form of aggregate. Such ICs may be removed by phagocytic cells that have antigen presenting capacity. These considerations may frustrate the possibility of ameliorating the immunogenicity of mAbs by rigorous exclusion of aggregates from drug product. Alternate strategies for inducing immunosuppression or tolerance are discussed.
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Affiliation(s)
- Roy Jefferis
- Institute of Immunology & Immunotherapy, College of Medical & Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
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Vermeer NS, Ebbers HC, Straus SMJM, Leufkens HGM, Egberts TCG, De Bruin ML. The effect of exposure misclassification in spontaneous ADR reports on the time to detection of product-specific risks for biologicals: a simulation study. Pharmacoepidemiol Drug Saf 2015; 25:297-306. [PMID: 26676881 DOI: 10.1002/pds.3929] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 10/06/2015] [Accepted: 11/11/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVE The availability of accurate product-specific exposure information is essential in the pharmacovigilance of biologicals, because differences in the safety profile may emerge between products containing the same active substance. In spontaneous adverse drug reaction (ADR) reports, drug exposure may, however, be misclassified, that is, attributed to the incorrect product. The aim of this study was to explore the effect of exposure misclassification on the time to detection of product-specific risks in spontaneous reporting systems. METHODS We used data simulations to explore the effect of exposure misclassification. We simulated an active substance-specific subset of a spontaneous reporting system and used the proportional reporting ratio for signal detection. The effect of exposure misclassification was evaluated in three test cases representing product-specific ADRs that may occur for biologicals and studied in relative terms by varying the model parameters (market share and relative risk). RESULTS We found that exposure misclassification results in the largest delay in identification of risks that have a weak association (relative risk < 2 or 3) with the product of interest and in situations where the product associated with the unique risk has a large (>50%) market share. The absolute public health impact of exposure misclassification, in terms of cases/time to detection, varied considerably across the test cases. CONCLUSION Exposure misclassification in ADR reports may result in a delayed detection of product-specific risks, particularly in the detection of weak drug-event associations. Our findings can help inform the future implementation and refinement of product-specific and batch-specific signal detection procedures.
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Affiliation(s)
- Niels S Vermeer
- Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands.,Medicines Evaluation Board, Utrecht, The Netherlands
| | - Hans C Ebbers
- Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Sabine M J M Straus
- Medicines Evaluation Board, Utrecht, The Netherlands.,Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Hubert G M Leufkens
- Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands.,Medicines Evaluation Board, Utrecht, The Netherlands
| | - Toine C G Egberts
- Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marie L De Bruin
- Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands.,Medicines Evaluation Board, Utrecht, The Netherlands
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Maxwell PH, Eckardt KU. HIF prolyl hydroxylase inhibitors for the treatment of renal anaemia and beyond. Nat Rev Nephrol 2015; 12:157-68. [DOI: 10.1038/nrneph.2015.193] [Citation(s) in RCA: 177] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Covic A, Abraham I. State-of-the-art biosimilar erythropoietins in the management of renal anemia: lessons learned from Europe and implications for US nephrologists. Int Urol Nephrol 2015. [DOI: 10.1007/s11255-015-1042-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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