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Arriola E, de Castro J, García-Campelo R, Bernárdez B, Bernabé R, Bruna J, Dómine M, Isla D, Juan-Vidal Ó, López-Fernández T, Nadal E, Rodríguez-Abreu D, Vares M, Asensio Ú, García LF, Felip E. Expert Consensus on the Management of Adverse Events of Lorlatinib in the Treatment of ALK+ Advanced Non-small Cell Lung Cancer. Clin Drug Investig 2024; 44:553-576. [PMID: 39085682 PMCID: PMC11338981 DOI: 10.1007/s40261-024-01379-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2024] [Indexed: 08/02/2024]
Abstract
The use of anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs), such as lorlatinib, for the treatment of patients with ALK gene rearrangement (or ALK-positive) non-small cell lung cancer (NSCLC) has been shown to improve the overall survival and quality of life of these patients. However, lorlatinib is not exempt from potential adverse events. Adequate monitoring and management of these adverse events are critical for increasing patient adherence to lorlatinib, thereby maximizing the benefits of treatment and minimizing the risks associated with treatment discontinuation. Considering that the adverse events of lorlatinib can affect different organs and systems, the participation of a multidisciplinary team, including cardiologists, neurologists, internal medicine specialists, and oncology pharmacists, is needed. This article presents specific and pragmatic strategies for identifying and treating the most relevant adverse events associated with lorlatinib in patients with advanced ALK-positive NSCLC based on the clinical experience of a multidisciplinary panel of experts.
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Affiliation(s)
- Edurne Arriola
- Medical Oncology Department, Hospital del Mar, Center for Biomedical Network Research on Cancer (CIBERONC), Barcelona, Spain.
| | - Javier de Castro
- Medical Oncology Department, La Paz University Hospital, Hospital La Paz Health Research Institute (IdiPAZ), Center for Biomedical Network Research on Cancer (CIBERONC), Madrid, Spain
| | - Rosario García-Campelo
- Medical Oncology Department, A Coruña University Hospital, Biomedical Research Institute of A Coruña (INIBIC), A Coruña, Spain
| | - Beatriz Bernárdez
- Oncological Pharmacy Unit, Santiago de Compostela University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela, A Coruña, Spain
| | - Reyes Bernabé
- Medical Oncology Department, Virgen del Rocío University Hospital, Biomedicine Institute of Sevilla (IBIS), University of Sevilla, Sevilla, Spain
| | - Jordi Bruna
- Neuro-Oncology Unit, Bellvitge University Hospital, Catalan Institute of Oncology, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Manuel Dómine
- Medical Oncology Department, Fundación Jiménez Díaz University Hospital, Fundación Jiménez Díaz Health Research Institute (IIS-FJD), Autonomous University of Madrid, Madrid, Spain
| | - Dolores Isla
- Medical Oncology Department, University Hospital Lozano Blesa, Health Research Institute of Aragon (IIS Aragón), Zaragoza, Spain
| | - Óscar Juan-Vidal
- Medical Oncology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Teresa López-Fernández
- Cardiology Department, La Paz University Hospital, Hospital La Paz Health Research Institute (IdiPAZ), Madrid, Spain
| | - Ernest Nadal
- Medical Oncology Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Delvys Rodríguez-Abreu
- Insular-Maternity and Pediatric University Hospital Complex of Gran Canaria, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - María Vares
- Internal Medicine Department, A Coruña University Hospital, A Coruña, Spain
| | | | | | - Enriqueta Felip
- Medical Oncology Department, Vall d'Hebron University Hospital and Vall d'Hebron Institute of Oncology, Barcelona, Spain
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Latham BD, Geffert RM, Jackson KD. Kinase Inhibitors FDA Approved 2018-2023: Drug Targets, Metabolic Pathways, and Drug-Induced Toxicities. Drug Metab Dispos 2024; 52:479-492. [PMID: 38286637 PMCID: PMC11114602 DOI: 10.1124/dmd.123.001430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/11/2024] [Accepted: 01/24/2024] [Indexed: 01/31/2024] Open
Abstract
Small molecule kinase inhibitors are one of the fastest growing classes of drugs, which are approved by the US Food and Drug Administration (FDA) for cancer and noncancer indications. As of September 2023, there were over 70 FDA-approved small molecule kinase inhibitors on the market, 42 of which were approved in the past five years (2018-2023). This minireview discusses recent advances in our understanding of the pharmacology, metabolism, and toxicity profiles of recently approved kinase inhibitors with a central focus on tyrosine kinase inhibitors (TKIs). In this minireview we discuss the most common therapeutic indications and molecular target(s) of kinase inhibitors FDA approved 2018-2023. We also describe unique aspects of the metabolism, bioactivation, and drug-drug interaction (DDI) potential of kinase inhibitors; discuss drug toxicity concerns related to kinase inhibitors, such as drug-induced liver injury; and highlight clinical outcomes and challenges relevant to TKI therapy. Case examples are provided for common TKI targets, metabolism pathways, DDI potential, and risks for serious adverse drug reactions. The minireview concludes with a discussion of perspectives on future research to optimize TKI therapy to maximize efficacy and minimize drug toxicity. SIGNIFICANCE STATEMENT: This minireview highlights important aspects of the clinical pharmacology and toxicology of small molecule kinase inhibitors FDA approved 2018-2023. We describe key advances in the therapeutic indications and molecular targets of TKIs. The major metabolism pathways and toxicity profiles of recently approved TKIs are discussed. Clinically relevant case examples are provided that demonstrate the risk for hepatotoxic drug interactions involving TKIs and coadministered drugs.
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Affiliation(s)
- Bethany D Latham
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Raeanne M Geffert
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Klarissa D Jackson
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Verdura S, Encinar JA, Fernández-Arroyo S, Joven J, Cuyàs E, Bosch-Barrera J, Menendez JA. Silibinin Suppresses the Hyperlipidemic Effects of the ALK-Tyrosine Kinase Inhibitor Lorlatinib in Hepatic Cells. Int J Mol Sci 2022; 23:9986. [PMID: 36077379 PMCID: PMC9456400 DOI: 10.3390/ijms23179986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/27/2022] [Accepted: 08/30/2022] [Indexed: 11/25/2022] Open
Abstract
The third-generation anaplastic lymphoma tyrosine kinase inhibitor (ALK-TKI) lorlatinib has a unique side effect profile that includes hypercholesteremia and hypertriglyceridemia in >80% of lung cancer patients. Here, we tested the hypothesis that lorlatinib might directly promote the accumulation of cholesterol and/or triglycerides in human hepatic cells. We investigated the capacity of the hepatoprotectant silibinin to modify the lipid-modifying activity of lorlatinib. To predict clinically relevant drug−drug interactions if silibinin were used to clinically manage lorlatinib-induced hyperlipidemic effects in hepatic cells, we also explored the capacity of silibinin to interact with and block CYP3A4 activity using in silico computational descriptions and in vitro biochemical assays. A semi-targeted ultrahigh pressure liquid chromatography accurate mass quadrupole time-of-flight mass spectrometry with electrospray ionization (UHPLC-ESI-QTOF-MS/MS)-based lipidomic approach revealed that short-term treatment of hepatic cells with lorlatinib promotes the accumulation of numerous molecular species of cholesteryl esters and triglycerides. Silibinin treatment significantly protected the steady-state lipidome of hepatocytes against the hyperlipidemic actions of lorlatinib. Lipid staining confirmed the ability of lorlatinib to promote neutral lipid overload in hepatocytes upon long-term exposure, which was prevented by co-treatment with silibinin. Computational analyses and cell-free biochemical assays predicted a weak to moderate inhibitory activity of clinically relevant concentrations of silibinin against CYP3A4 when compared with recommended (rosuvastatin) and non-recommended (simvastatin) statins for lorlatinib-associated dyslipidemia. The elevated plasma cholesterol and triglyceride levels in lorlatinib-treated lung cancer patients might involve primary alterations in the hepatic accumulation of lipid intermediates. Silibinin could be clinically explored to reduce the undesirable hyperlipidemic activity of lorlatinib in lung cancer patients.
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Affiliation(s)
- Sara Verdura
- Metabolism and Cancer Group, Program Against Cancer Therapeutic Resistance (ProCURE), Catalan Institute of Oncology, 17007 Girona, Spain
- Girona Biomedical Research Institute (IDIBGI), Salt, 17190 Girona, Spain
| | - José Antonio Encinar
- Institute of Research, Development and Innovation in Biotechnology of Elche (IDiBE) and Molecular and Cell Biology Institute (IBMC), Miguel Hernández University (UMH), 03207 Elche, Spain
| | - Salvador Fernández-Arroyo
- Department of Medicine and Surgery, Universitat Rovira i Virgili, 43204 Reus, Spain
- Unitat de Recerca Biomèdica (URB-CRB), Hospital Universitari de Sant Joan, Institut d’Investigació Sanitaria Pere Virgili, Universitat Rovira i Virgili, 43204 Reus, Spain
| | - Jorge Joven
- Department of Medicine and Surgery, Universitat Rovira i Virgili, 43204 Reus, Spain
- Unitat de Recerca Biomèdica (URB-CRB), Hospital Universitari de Sant Joan, Institut d’Investigació Sanitaria Pere Virgili, Universitat Rovira i Virgili, 43204 Reus, Spain
| | - Elisabet Cuyàs
- Metabolism and Cancer Group, Program Against Cancer Therapeutic Resistance (ProCURE), Catalan Institute of Oncology, 17007 Girona, Spain
- Girona Biomedical Research Institute (IDIBGI), Salt, 17190 Girona, Spain
| | - Joaquim Bosch-Barrera
- Girona Biomedical Research Institute (IDIBGI), Salt, 17190 Girona, Spain
- Medical Oncology, Catalan Institute of Oncology, 17007 Girona, Spain
- Department of Medical Sciences, Medical School, University of Girona, 17071 Girona, Spain
| | - Javier A. Menendez
- Metabolism and Cancer Group, Program Against Cancer Therapeutic Resistance (ProCURE), Catalan Institute of Oncology, 17007 Girona, Spain
- Girona Biomedical Research Institute (IDIBGI), Salt, 17190 Girona, Spain
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Baba K, Goto Y. Lorlatinib as a treatment for ALK-positive lung cancer. Future Oncol 2022; 18:2745-2766. [PMID: 35787143 DOI: 10.2217/fon-2022-0184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Lorlatinib, a third-generation ALK tyrosine kinase inhibitor, has been approved as a treatment for ALK-positive lung cancer. This review provides information regarding the pharmacology and clinical features of lorlatinib, including its efficacy and associated adverse events. Pivotal clinical trials are discussed along with the current status of lorlatinib as a treatment for ALK-positive lung cancer and future therapeutic challenges.
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Affiliation(s)
- Keisuke Baba
- Department of Thoracic Oncology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Yasushi Goto
- Department of Thoracic Oncology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
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