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Spallone G, Sollena P, Ventura A, Fargnoli MC, Gutierrez C, Piccerillo A, Tambone S, Bianchi L, Peris K. Efficacy and safety of Vismodegib treatment in patients with advanced basal cell carcinoma and multiple comorbidities. Dermatol Ther 2019; 32:e13108. [DOI: 10.1111/dth.13108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 09/19/2019] [Accepted: 10/04/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Giulia Spallone
- Department of Dermatology“Tor Vergata” University of Rome Rome Italy
| | - Pietro Sollena
- Institute of DermatologyCatholic University‐Fondazione Policlinico Universitario A. Gemelli, IRCCS Rome Italy
| | | | - Maria C. Fargnoli
- Department of Applied Clinical and Biotechnological SciencesUniversity of L'Aquila L'Aquila Italy
| | - Carlota Gutierrez
- Department of Applied Clinical and Biotechnological SciencesUniversity of L'Aquila L'Aquila Italy
| | - Alfredo Piccerillo
- Institute of DermatologyCatholic University‐Fondazione Policlinico Universitario A. Gemelli, IRCCS Rome Italy
| | - Sara Tambone
- Department of Applied Clinical and Biotechnological SciencesUniversity of L'Aquila L'Aquila Italy
| | - Luca Bianchi
- Department of Dermatology“Tor Vergata” University of Rome Rome Italy
| | - Ketty Peris
- Institute of DermatologyCatholic University‐Fondazione Policlinico Universitario A. Gemelli, IRCCS Rome Italy
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Carpenter RL, Ray H. Safety and Tolerability of Sonic Hedgehog Pathway Inhibitors in Cancer. Drug Saf 2019; 42:263-279. [PMID: 30649745 DOI: 10.1007/s40264-018-0777-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The hedgehog pathway, for which sonic hedgehog (Shh) is the most prominent ligand, is highly conserved and is tightly associated with embryonic development in a number of species. This pathway is also tightly associated with the development of several types of cancer, including basal cell carcinoma (BCC) and acute promyelocytic leukemia, among many others. Inactivating mutations in Patched-1 (PTCH1), leading to ligand-independent pathway activation, are frequent in several cancer types, but most prominent in BCC. This has led to the development of several compounds targeting this pathway as a cancer therapeutic. These compounds target the inducers of this pathway in Smoothened (SMO) and the GLI transcription factors, although targeting SMO has had the most success. Despite the many attempts at targeting this pathway, only three US FDA-approved drugs for cancers affect the Shh pathway. Two of these compounds, vismodegib and sonidegib, target SMO to suppress signaling from either PTCH1 or SMO mutations that lead to upregulation of the pathway. The other approved compound is arsenic trioxide, which can suppress this pathway at the level of the GLI proteins, although current evidence suggests it also has other targets. This review focuses on the safety and tolerability of these clinically approved drugs targeting the Shh pathway, along with a discussion on other Shh pathway inhibitors being developed.
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Affiliation(s)
- Richard L Carpenter
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, 1001 E. 3rd St, Bloomington, IN, 47405, USA. .,Medical Sciences, Indiana University School of Medicine, 1001 E. 3rd St, Bloomington, IN, 47405, USA. .,Simon Cancer Center, Indiana University School of Medicine, 535 Barnhill Dr., Indianapolis, IN, 46202, USA.
| | - Haimanti Ray
- Medical Sciences, Indiana University School of Medicine, 1001 E. 3rd St, Bloomington, IN, 47405, USA
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Abstract
Vismodegib (GDC-0449, Erivedge®) is a small molecule antagonist of the hedgehog (Hh) pathway that binds to smoothened (SMO) and leads to inhibition of an aberrant activation of the Hh pathway. Dysregulated Hh signaling results in uncontrolled proliferation in basal cell carcinoma (BCC) and has also been found present in medulloblastoma, and many other cancers such as those of gastrointestinal tract, brain, lung, breast, and prostate. In January 2012, vismodegib became the first agent to target the Hh pathway to receive approval by the United States Food and Drug Administration (FDA) and in July 2013 approval by the European Medicines Agency (EMA) followed for the treatment of adult patients with symptomatic metastatic BCC, or locally advanced BCC inappropriate for surgery or radiotherapy. The role of vismodegib in other malignancies than BCC has still to be investigated.
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Affiliation(s)
- Frank Meiss
- Department of Dermatology and Venereology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hauptstr. 7, 79104, Freiburg, Germany.
| | - Hana Andrlová
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Robert Zeiser
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
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Malhi V, Colburn D, Williams SJ, Hop CECA, Dresser MJ, Chandra P, Graham RA. A clinical drug-drug interaction study to evaluate the effect of a proton-pump inhibitor, a combined P-glycoprotein/cytochrome 450 enzyme (CYP)3A4 inhibitor, and a CYP2C9 inhibitor on the pharmacokinetics of vismodegib. Cancer Chemother Pharmacol 2016; 78:41-9. [PMID: 27154174 PMCID: PMC4921109 DOI: 10.1007/s00280-016-3020-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 03/24/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE The Hedgehog pathway inhibitor vismodegib exhibits pH-dependent solubility, and in vitro studies have shown that vismodegib is a substrate of P-glycoprotein (P-gp) and is metabolized by cytochrome P450 (CYP) 2C9 and 3A4. The objective of this four-arm parallel study in healthy subjects was to evaluate the effect of the proton-pump inhibitor rabeprazole, the P-gp/CYP3A4 inhibitor itraconazole, and the CYP2C9 and 3A4 inhibitor fluconazole on vismodegib steady-state pharmacokinetics. METHODS Cohorts included a control arm (n = 22), in which vismodegib 150 mg was administered once daily (QD) for 7 days, and 3 arms in which vismodegib was co-administered QD for 7 days with rabeprazole 20 mg (including a 4-day lead-in; n = 24); itraconazole 200 mg (n = 22); or fluconazole 400 mg (n = 22). RESULTS Area under the vismodegib concentration-time curve from zero to 24 h (AUC0-24h) at steady state was lower with concomitant rabeprazole administration relative to vismodegib alone [geometric mean ratio (GMR), 86.2 (associated 90 % confidence interval [CI], 76.1, 97.7)]. There was no effect of itraconazole on steady-state exposure of vismodegib [GMR, 96.4 (90 % CI 84.9, 109.6)]. Co-administration with fluconazole increased vismodegib steady-state AUC0-24h [GMR, 130.9 (90 % CI 115.2, 148.7)]. Co-administration of rabeprazole, itraconazole, and fluconazole had similar effects on the exposure of unbound vismodegib and total vismodegib. CONCLUSION The results of this study suggest that vismodegib can be administered with acid-reducing agents and P-gp and CYP inhibitors without the risk of a clinically meaningful pharmacokinetic drug-drug interaction. CLINICALTRIALS. GOV IDENTIFIER NCT01772290.
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Affiliation(s)
- Vikram Malhi
- Genentech, Inc., 1 DNA Way, South San Francisco, CA, 94080, USA.
| | - Dawn Colburn
- Genentech, Inc., 1 DNA Way, South San Francisco, CA, 94080, USA
| | | | | | - Mark J Dresser
- Genentech, Inc., 1 DNA Way, South San Francisco, CA, 94080, USA
- Denali Therapeutics, South San Francisco, CA, USA
| | - Priya Chandra
- Genentech, Inc., 1 DNA Way, South San Francisco, CA, 94080, USA
| | - Richard A Graham
- Genentech, Inc., 1 DNA Way, South San Francisco, CA, 94080, USA
- Theravance Biopharma, South San Francisco, CA, USA
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Tylutki Z, Polak S, Wiśniowska B. Top-down, Bottom-up and Middle-out Strategies for Drug Cardiac Safety Assessment via Modeling and Simulations. CURRENT PHARMACOLOGY REPORTS 2016; 2:171-177. [PMID: 27429898 PMCID: PMC4929154 DOI: 10.1007/s40495-016-0060-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiac safety is an issue causing early terminations at various stages of drug development. Efforts are put into the elimination of false negatives as well as false positives resulting from the current testing paradigm. In silico approaches offer mathematical system and data description from the ion current, through cardiomyocytes level, up to incorporation of inter-individual variability at the population level. The article aims to review three main modelling and simulation approaches, i.e. "top-down" which refers to models built on the observed data, "bottom-up", which stands for a mechanistic description of human physiology, and "middle-out" which combines both strategies. Modelling and simulation is a well-established tool in the assessment of drug proarrhythmic potency with an impact on research and development as well as on regulatory decisions, and it is certainly here to stay. What is more, the shift to systems biology and physiology-based models makes the cardiac effect more predictable.
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Affiliation(s)
- Zofia Tylutki
- Unit of Pharmacoepidemiology and Pharmacoeconomics, Department of Social Pharmacy, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Str., 30-688 Cracow, Poland
| | - Sebastian Polak
- Unit of Pharmacoepidemiology and Pharmacoeconomics, Department of Social Pharmacy, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Str., 30-688 Cracow, Poland
- Simcyp Ltd. (part of Certara), Blades Enterprise Centre, S2 4SU Sheffield, UK
| | - Barbara Wiśniowska
- Unit of Pharmacoepidemiology and Pharmacoeconomics, Department of Social Pharmacy, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Str., 30-688 Cracow, Poland
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Abstract
With the adoption of the ICH E14 guidance, the thorough QT/QTc (TQT) study has become the focus of clinical assessment of an NCE's effects on ECG parameters. The TQT study is used as a guide to the liability of a drug to cause proarrhythmias on the basis of delayed cardiac repolarization. Around 300 TQT studies have been performed since 2005 and through interactions between sponsors and regulators, especially FDA's Interdisciplinary Review Team (IRT) for QT studies. These studies can today be performed more effectively and with great confidence in the generated data. This chapter will discuss technical features and the design and analysis of TQT studies, how assay sensitivity is demonstrated, and examples from recently conducted studies. ECG assessment for drugs that cannot be safely given to healthy volunteers is also addressed, and examples from studies in cancer patients and in healthy volunteers with tyrosine kinase inhibitors are discussed. The TQT study is resource intensive and designed to solely evaluate whether an NCE prolongs the QTc interval. If data with similar confidence can be generated from other studies that are routinely performed as part of the clinical development, this would represent a more optimal use of human resources. Methods and approaches to increase the confidence in ECG data derived from "early QT assessment" in single-ascending/multiple-ascending dose studies are therefore discussed, and a path toward replacing the TQT study using these approaches will be outlined.
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Affiliation(s)
- Borje Darpo
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd's Hospital, Stockholm, Sweden,
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Darpo B, Zhou M, Matthews J, Zhi H, Young MA, Perry C, Reinhardt RR. Albiglutide Does Not Prolong QTc Interval in Healthy Subjects: A Thorough ECG Study. Diabetes Ther 2014; 5:141-53. [PMID: 24510375 PMCID: PMC4065291 DOI: 10.1007/s13300-014-0055-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Albiglutide, a selective once-weekly glucagon-like peptide-1 receptor agonist, is being developed for the treatment of type 2 diabetes mellitus. Albiglutide's effect on cardiac repolarization (QTc interval) was assessed in a randomized, double-blind, placebo-controlled, parallel-group study in healthy subjects with a nested crossover comparison for moxifloxacin. METHODS Subjects were randomized to albiglutide (n = 85) or placebo (n = 89) and received injections of 30 mg albiglutide or placebo on Days 1 and 8 and 50 mg albiglutide or placebo on Days 15, 22, 29, and 36. In the placebo group, moxifloxacin was administered on Day -1 in half the subjects and on Day 40 in the other half. Blood samples for albiglutide plasma concentration were drawn on Days 4 and 39 and serial ECGs were extracted from continuous recordings on Days -2 (baseline), -1, 4, 39, and 40. RESULTS Demographics were generally similar between albiglutide and placebo subjects: mean age was 29 years and BMI 25 kg/m(2). Mean change-from-baseline QTcI (∆QTcI, which was corrected for individual heart rate) on Day 4 after a single dose of albiglutide 30 mg and on Day 39 after repeat dosing with albiglutide 50 mg once weekly was similar to the placebo response. The placebo-corrected ΔQTcI (ΔΔQTcI) on both albiglutide doses was small with the largest ΔΔQTcI of 1.1 ms (upper bound of 90% CI 3.8 ms) on Day 4 and -0.6 ms (upper bound of CI 1.8 ms) on Day 39. Moxifloxacin caused the largest mean effect on ΔΔQTcI of 10.9 ms and the lower bound of the CI was above 5 ms at all preselected timepoints, thereby demonstrating assay sensitivity. Albiglutide was well tolerated and there were no clinically relevant differences in safety data between albiglutide and placebo. CONCLUSION Albiglutide at doses up to 50 mg in healthy subjects did not prolong the QTc interval.
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Affiliation(s)
- Borje Darpo
- Department of Clinical Sciences, Karolinska Institute, Division of Cardiovascular Medicine, Danderyd's Hospital, Stockholm, Sweden,
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Abstract
Vismodegib (GDC-0449, Erivedge®) is a novel small molecule antagonist of the hedgehog (Hh) pathway that binds to smoothened (SMO) and leads to inhibition of an aberrant activation of the Hh pathway. Dysregulated Hh signaling results in uncontrolled proliferation in basal cell carcinoma (BCC) and has also been found present in medulloblastoma, and many other cancers such as those of gastrointestinal tract, brain, lung, breast, and prostate. In January 2012, vismodegib became the first agent to target the Hh pathway to receive approval by the United States Food and Drug Administration (FDA) and in July 2013 approval by the European Medicines Agency (EMA) followed for the treatment of adult patients with symptomatic metastatic BCC, or locally advanced BCC inappropriate for surgery or radiotherapy. At the moment, many trials are ongoing to further investigate the role of vismodegib in other malignancies than BCC.
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Affiliation(s)
- F Meiss
- Department of Dermatology and Venereology, Freiburg University Medical Center, Albert-Ludwigs-University, Hauptstr. 7, 79104, Freiburg, Germany,
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Proctor AE, Thompson LA, O'Bryant CL. Vismodegib: an inhibitor of the Hedgehog signaling pathway in the treatment of basal cell carcinoma. Ann Pharmacother 2013; 48:99-106. [PMID: 24259609 DOI: 10.1177/1060028013506696] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To review vismodegib, the first Food and Drug Administration (FDA)-approved Hedgehog (Hh) signaling pathway inhibitor, in the treatment of advanced basal cell carcinoma (BCC). DATA SOURCES MEDLINE and PubMed were searched using the terms vismodegib, GDC-0449, RG3616, and basal cell carcinoma for relevant clinical trials through September 2013. The FDA Web site, the National Clinical Trials registry, and abstracts from the American Society of Clinical Oncology (ASCO) were also evaluated to identify unpublished data and future clinical trials. STUDY SELECTION/DATA EXTRACTION All identified clinical and preclinical studies published in the English language were assessed, including selected references from the bibliographies of articles. DATA SYNTHESIS Activation of the Hh signaling pathway is well documented in BCC. Vismodegib is a small-molecule inhibitor of Hh signaling that acts by antagonizing the protein Smoothened (SMO), thereby preventing downstream transcriptional activation of genes involved in cell proliferation and survival. Vismodegib was approved by the FDA in January 2012 for the treatment of recurrent, locally advanced BCC (laBCC), or metastatic BCC (mBCC) for which surgery or radiation cannot be utilized. A pivotal phase 2 trial evaluating 104 patients demonstrated that treatment with vismodegib, 150 mg orally once daily, resulted in a 30% and 43% objective response rate in patients with mBCC and laBCC, respectively. The most common adverse effects from vismodegib were mild to moderate and included muscle spasms, dysgeusia, decreased weight, fatigue, alopecia, and diarrhea. However, clinical studies noted a high incidence of discontinuation of therapy by patients for reasons other than disease progression. CONCLUSIONS The approval of vismodegib represents the only targeted, prospectively studied treatment option for patients with advanced BCC. Further research assessing the utility of vismodegib in the treatment of other malignancies and the development of resistance patterns will more clearly define the role of Hedgehog inhibition in the broader scheme of oncological disorders.
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Affiliation(s)
- Amber E Proctor
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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