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van der Kleij MBA, Guchelaar NAD, Meertens M, Westerdijk K, Giraud EL, Bleckman RF, Groenland SL, van Eerden RAG, Imholz ALT, Vulink AJE, Otten HM, Fiebrich-Westra HB, Lubberman FJE, Desar IME, Moes DJAR, Touw DJ, Koolen SLW, Gelderblom H, Reyners AKL, van Erp NP, Mathijssen RHJ, Huitema ADR, Steeghs N. Reasons for non-feasibility of therapeutic drug monitoring of oral targeted therapies in oncology - an analysis of the closed cohorts of a multicentre prospective study. Br J Cancer 2024; 131:843-851. [PMID: 38971952 PMCID: PMC11369282 DOI: 10.1038/s41416-024-02789-2] [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: 04/15/2024] [Revised: 06/25/2024] [Accepted: 07/01/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) - performing dose adjustments based on measured drug levels and established pharmacokinetic (PK) targets - could optimise treatment with drugs that show large interpatient variability in exposure. We evaluated the feasibility of TDM for multiple oral targeted therapies. Here we report on drugs for which routine TDM is not feasible. METHODS We evaluated drug cohorts from the Dutch Pharmacology Oncology Group - TDM study. Based on PK levels taken at pre-specified time points, PK-guided interventions were performed. Feasibility of TDM was evaluated, and based on the success and practicability of TDM, cohorts could be closed. RESULTS For 10 out of 24 cohorts TDM was not feasible and inclusion was closed. A high incidence of adverse events resulted in closing the cabozantinib, dabrafenib/trametinib, everolimus, regorafenib and vismodegib cohort. The enzalutamide and erlotinib cohorts were closed because almost all PK levels were above target. Other, non-pharmacological reasons led to closing the palbociclib, olaparib and tamoxifen cohort. CONCLUSIONS Although TDM could help personalising treatment for many drugs, the above-mentioned reasons can influence its feasibility, usefulness and clinical applicability. Therefore, routine TDM is not advised for cabozantinib, dabrafenib/trametinib, enzalutamide, erlotinib, everolimus, regorafenib and vismodegib. Nonetheless, TDM remains valuable for individual clinical decisions.
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Affiliation(s)
- Maud B A van der Kleij
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Niels A D Guchelaar
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Marinda Meertens
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Kim Westerdijk
- Department of Medical Oncology, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Eline L Giraud
- Department of Pharmacy and Clinical Pharmacology, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Roos F Bleckman
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Stefanie L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Ruben A G van Eerden
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Alex L T Imholz
- Department of Medical Oncology, Deventer Hospital, Deventer, The Netherlands
| | - Annelie J E Vulink
- Department of Medical Oncology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Hans-Martin Otten
- Department of Medical Oncology, Meander Medical Centre, Amersfoort, The Netherlands
| | | | | | - Ingrid M E Desar
- Department of Medical Oncology, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Dirk-Jan A R Moes
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
- Department of Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - An K L Reyners
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Nielka P van Erp
- Department of Pharmacy and Clinical Pharmacology, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, Utrecht University Medical Centre, Utrecht, The Netherlands
- Department of Pharmacology, Princess Máxima Centre for Paediatric Oncology, Utrecht, The Netherlands
| | - Neeltje Steeghs
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Medical Oncology, Utrecht University Medical Centre, Utrecht University, Utrecht, The Netherlands
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Centanni M, Zaher O, Elhad D, Karlsson MO, Friberg LE. Physiologically-based pharmacokinetic models versus allometric scaling for prediction of tyrosine-kinase inhibitor exposure from adults to children. Cancer Chemother Pharmacol 2024; 94:297-310. [PMID: 38782791 PMCID: PMC11390758 DOI: 10.1007/s00280-024-04678-0] [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: 12/05/2023] [Accepted: 05/06/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE Model-based methods can predict pediatric exposure and support initial dose selection. The aim of this study was to evaluate the performance of allometric scaling of population pharmacokinetic (popPK) versus physiologically based pharmacokinetic (PBPK) models in predicting the exposure of tyrosine kinase inhibitors (TKIs) for pediatric patients (≥ 2 years), based on adult data. The drugs imatinib, sunitinib and pazopanib were selected as case studies due to their complex PK profiles including high inter-patient variability, active metabolites, time-varying clearances and non-linear absorption. METHODS Pediatric concentration measurements and adult popPK models were derived from the literature. Adult PBPK models were generated in PK-Sim® using available physicochemical properties, calibrated to adult data when needed. PBPK and popPK models for the pediatric populations were translated from the models for adults and were used to simulate concentration-time profiles that were compared to the observed values. RESULTS Ten pediatric datasets were collected from the literature. While both types of models captured the concentration-time profiles of imatinib, its active metabolite, sunitinib and pazopanib, the PBPK models underestimated sunitinib metabolite concentrations. In contrast, allometrically scaled popPK simulations accurately predicted all concentration-time profiles. Trough concentration (Ctrough) predictions from the popPK model fell within a 2-fold range for all compounds, while 3 out of 5 PBPK predictions exceeded this range for the imatinib and sunitinib metabolite concentrations. CONCLUSION Based on the identified case studies it appears that allometric scaling of popPK models is better suited to predict exposure of TKIs in pediatric patients ≥ 2 years. This advantage may be attributed to the stable enzyme expression patterns from 2 years old onwards, which can be easily related to adult levels through allometric scaling. In some instances, both methods performed comparably. Understanding where discrepancies between the model methods arise, can further inform model development and ultimately support pediatric dose selection.
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Affiliation(s)
- Maddalena Centanni
- Department of Pharmacy, Uppsala University, Box 580, Uppsala, 751 23, Sweden
| | - Omar Zaher
- Department of Pharmacy, Uppsala University, Box 580, Uppsala, 751 23, Sweden
| | - David Elhad
- Department of Pharmacy, Uppsala University, Box 580, Uppsala, 751 23, Sweden
| | - Mats O Karlsson
- Department of Pharmacy, Uppsala University, Box 580, Uppsala, 751 23, Sweden
| | - Lena E Friberg
- Department of Pharmacy, Uppsala University, Box 580, Uppsala, 751 23, Sweden.
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Zettler ME. Dose Optimization of Targeted Therapies for Oncologic Indications. Cancers (Basel) 2024; 16:2180. [PMID: 38927886 PMCID: PMC11202153 DOI: 10.3390/cancers16122180] [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: 04/30/2024] [Revised: 05/22/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
Therapeutic advances in oncology in the 21st century have contributed to significant declines in cancer mortality. Notably, targeted therapies comprised the largest proportion of oncology drugs approved by the United States (US) Food and Drug Administration (FDA) over the past 25 years and have become the standard of care for the treatment of many cancers. However, despite the metamorphosis of the therapeutic landscape, some aspects of cancer drug development have remained essentially unchanged. In particular, the dose-finding methodology originally developed for cytotoxic chemotherapy drugs continues to be implemented, even though this approach no longer represents the most appropriate strategy for modern cancer therapies. In recognition of the need to reconsider assumptions, adapt the dose selection process for newer drugs, and design alternative strategies, the FDA has undertaken several initiatives in recent years to address these concerns. These actions include the launch of Project Optimus in 2021 and the issuance of draft guidance for industry on dose optimization of oncology drugs in 2023. Amid this evolving regulatory environment, the present manuscript reviews case studies for six different targeted cancer therapies, highlighting how dose-finding challenges have been managed to date by oncologists, sponsors, and regulators.
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Giraud EL, Westerdijk K, van der Kleij MBA, Guchelaar NAD, Meertens M, Bleckman RF, Rieborn A, Mohammadi M, Roets E, Mathijssen RHJ, Huitema ADR, Koolen SLW, Gelderblom H, Moes DJAR, Reyners AKL, Touw DJ, Keizer-Heldens P, Oosten AW, van der Graaf WTA, Steeghs N, van Erp NP, Desar IME. Sunitinib for the treatment of metastatic gastrointestinal stromal tumors: the effect of TDM-guided dose optimization on clinical outcomes. ESMO Open 2024; 9:103477. [PMID: 38833964 PMCID: PMC11179075 DOI: 10.1016/j.esmoop.2024.103477] [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: 02/01/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Sunitinib is an oral anticancer drug approved for the treatment of among others gastrointestinal stromal tumor (GIST). Previous analyses demonstrated an exposure-response relationship at the standard dose, and minimum target levels of drug exposure have been defined above which better treatment outcomes are observed. Therapeutic drug monitoring (TDM) could be used as a tool to optimize the individual dose, aiming at sunitinib trough concentrations ≥37.5 ng/ml for continuous dosing. Nonetheless, data on the added value of TDM-guided dosing on clinical endpoints are currently lacking. Therefore, we evaluate the effect of TDM in patients with advanced and metastatic GIST treated with sunitinib in terms of efficacy and toxicity. PATIENTS AND METHODS A TDM-guided cohort was compared to a non-TDM-guided cohort in terms of median progression-free survival (mPFS) and overall survival (mOS). Also, mPFS between patients with and without dose-limiting toxicities (DLTs) was compared. Patients in the prospective cohort were included in two studies on TDM-guided dosing (the DPOG-TDM study and TUNE study). The retrospective cohort consisted of patients from the Dutch GIST Registry who did not receive TDM-guided dosing. RESULTS In total, 51 and 106 patients were included in the TDM-guided cohort and non-TDM-guided cohort, respectively. No statistical difference in mPFS was observed between these two cohorts (39.4 versus 46.9 weeks, respectively; P = 0.52). Patients who experienced sunitinib-induced DLTs had longer mPFS compared to those who did not (51.9 versus 28.9 weeks, respectively; P = 0.002). CONCLUSIONS Our results do not support the routine use of TDM-guided dose optimization of sunitinib in patients with advanced/metastatic GIST to improve survival.
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Affiliation(s)
- E L Giraud
- Department of Pharmacy, Radboud University Medical Center, Radboud University Medical Center, Nijmegen, The Netherlands. https://twitter.com/ElineGirau45556
| | - K Westerdijk
- Department of Medical Oncology, Radboud University Medical Center, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M B A van der Kleij
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - N A D Guchelaar
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - M Meertens
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - R F Bleckman
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A Rieborn
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - M Mohammadi
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Roets
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - R H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - A D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - S L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands; Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - H Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - D J A R Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - A K L Reyners
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - D J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - P Keizer-Heldens
- Department of Medical Oncology, Rijnstate Hospital, Arnhem, The Netherlands
| | - A W Oosten
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - W T A van der Graaf
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - N Steeghs
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - N P van Erp
- Department of Pharmacy, Radboud University Medical Center, Radboud University Medical Center, Nijmegen, The Netherlands
| | - I M E Desar
- Department of Medical Oncology, Radboud University Medical Center, Radboud University Medical Center, Nijmegen, The Netherlands.
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Liu M, Guo T, Ma Z, Du L, Hou J, Tian Y, Meng M, Chen X. Correlation Between N-Demethyl Imatinib Trough Concentration and Serious Adverse Reactions in Patients with Gastrointestinal Stromal Tumors: A Retrospective Cohort Study. Ther Drug Monit 2024; 46:344-350. [PMID: 38176855 DOI: 10.1097/ftd.0000000000001160] [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: 01/29/2023] [Accepted: 06/04/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Imatinib is the first-line treatment for gastrointestinal stromal tumors; however, the clinical prognosis and adverse reactions of patients vary owing to individualized discrepancies in plasma exposure. METHODS To determine the safe interval for steady-state plasma trough concentrations (C min ) of imatinib and its active metabolite, N-demethyl imatinib (NDI), 328 plasma samples from 273 patients treated with imatinib were retrospectively analyzed. Imatinib C min and NDI C min were tested, and adverse reactions were recorded. The association between imatinib C min , NDI C min , and serious adverse reactions was evaluated. RESULTS The C min range of imatinib was 209.5-4950.0 ng/mL, with the mean value and SD of 1491.8 ± 731.4 ng/mL. The C min range of NDI was 80.0-2390.0 ng/mL with the mean value and SD of 610.8 ± 281.5 ng/mL. NDI C min was positively correlated with imatinib C min , whereas the ratio of NDI C min to imatinib C min (NDI C min /imatinib C min ) was negatively correlated with imatinib C min . Univariate logistic regression analysis demonstrated that the treatment objective, daily dose, imatinib C min , NDI C min , and imatinib C min + NDI C min were significantly associated with serious adverse reactions. Multivariate logistic regression analysis showed that NDI C min was an independent risk factor for serious adverse reactions, with a threshold of 665 ng/mL. CONCLUSIONS NDI C min was an independent risk factor for serious adverse reactions, with a threshold of 665 ng/mL. Monitoring NDI C min was beneficial for the rational application of imatinib and individualized treatment of patients with gastrointestinal stromal tumors.
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Affiliation(s)
- Mingfeng Liu
- Department of Pharmacy, the Fourth Hospital of Hebei Medical University, Hebei Key Laboratory of Clinical Pharmacy, Shijiazhuang City, Hebei Province, China; and
| | - Teng Guo
- Department of Pharmacy, the Fourth Hospital of Hebei Medical University, Hebei Key Laboratory of Clinical Pharmacy, Shijiazhuang City, Hebei Province, China; and
| | - Zhixue Ma
- Third Department of Surgery, the Fourth Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province, China
| | - Liying Du
- Department of Pharmacy, the Fourth Hospital of Hebei Medical University, Hebei Key Laboratory of Clinical Pharmacy, Shijiazhuang City, Hebei Province, China; and
| | - Juan Hou
- Department of Pharmacy, the Fourth Hospital of Hebei Medical University, Hebei Key Laboratory of Clinical Pharmacy, Shijiazhuang City, Hebei Province, China; and
| | - Yuan Tian
- Third Department of Surgery, the Fourth Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province, China
| | - Meng Meng
- Department of Pharmacy, the Fourth Hospital of Hebei Medical University, Hebei Key Laboratory of Clinical Pharmacy, Shijiazhuang City, Hebei Province, China; and
| | - Xinran Chen
- Department of Pharmacy, the Fourth Hospital of Hebei Medical University, Hebei Key Laboratory of Clinical Pharmacy, Shijiazhuang City, Hebei Province, China; and
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Turjap M, Pelcová M, Gregorová J, Šmak P, Martin H, Štingl J, Peš O, Juřica J. Therapeutic Drug Monitoring of Pazopanib in Renal Cell Carcinoma and Soft Tissue Sarcoma: A Systematic Review. Ther Drug Monit 2024; 46:321-331. [PMID: 38723115 DOI: 10.1097/ftd.0000000000001206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 01/28/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Pazopanib, an anti-angiogenic multitarget tyrosine kinase inhibitor, has been approved for the treatment of metastatic renal cell carcinoma and soft tissue sarcoma. However, its recommended dose does not always produce consistent outcomes, with some patients experiencing adverse effects or toxicity. This variability is due to differences in the systemic exposure to pazopanib. This review aimed to establish whether sufficient evidence exists for the routine or selective therapeutic drug monitoring of pazopanib in adult patients with approved indications. METHODS A systematic search of the PubMed and Web of Science databases using search terms related to pazopanib and therapeutic drug monitoring yielded 186 and 275 articles, respectively. Ten articles associated with treatment outcomes or toxicity due to drug exposure were selected for review. RESULTS The included studies were evaluated to determine the significance of the relationship between drug exposure/Ctrough and treatment outcomes and between drug exposure and toxicity. A relationship between exposure and treatment outcomes was observed in 5 studies, whereas the trend was nonsignificant in 4 studies. A relationship between exposure and toxicity was observed in 6 studies, whereas 2 studies did not find a significant relationship; significance was not reported in 3 studies. CONCLUSIONS Sufficient evidence supports the therapeutic drug monitoring of pazopanib in adult patients to improve its efficacy and/or safety in the approved indications.
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Affiliation(s)
- Miroslav Turjap
- Department of Clinical Pharmacy, University Hospital Ostrava, Ostrava, Czech Republic
| | - Marta Pelcová
- Department of Biochemistry, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Jana Gregorová
- Department of Biochemistry, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Pavel Šmak
- Department of Biochemistry, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Hiroko Martin
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jan Štingl
- Department of Biochemistry, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ondřej Peš
- Department of Biochemistry, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jan Juřica
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Masaryk Memorial Cancer Institute, Brno, Czech Republic; and
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Masaryk University, Brno, Czech Republic
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Giraud EL, Te Brake LMH, van den Hombergh ECA, Desar IME, Kweekel DM, van Erp NP. Results of the first international quality control programme for oral targeted oncolytics. Br J Clin Pharmacol 2024; 90:336-343. [PMID: 37776845 DOI: 10.1111/bcp.15918] [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: 06/22/2023] [Revised: 09/20/2023] [Accepted: 09/22/2023] [Indexed: 10/02/2023] Open
Abstract
AIMS With the rising number of oral targeted oncolytics and growing awareness of the benefits of therapeutic drug monitoring (TDM) within the field of oncology, it is expected that the requests for quantifying concentrations of these drugs will increase. It is important to (cross-)validate available assays and ensure its quality, as results may lead to altered dosing recommendations. Therefore, we aimed to evaluate the performance of laboratories measuring concentrations of targeted oral oncolytics in a one-time international quality control (QC) programme. METHODS Participating laboratories received a set of plasma samples containing low, medium and high concentrations of imatinib, sunitinib, desethylsunitinib, pazopanib, cabozantinib, olaparib, enzalutamide, desmethylenzalutamide and abiraterone, with the request to report their results back within five weeks after shipment. Accuracy was defined acceptable if measurements where within 85%-115% from the weighed-in reference concentrations. Besides descriptive statistics, an exploratory ANOVA was performed. RESULTS Seventeen laboratories from six countries reported 243 results. Overall, 80.7% of all measurements were within the predefined range of acceptable accuracy. Laboratories performed best in quantifying imatinib and poorest in quantifying desethylsunitinib (median absolute inaccuracy respectively 4.0% (interquartile range (IQR) 1.8%-6.5%) and 15.5% (IQR 8.8%-34.9%)). The poorest performance of desethylsunitinib might be caused by using the stable-isotope-labelled sunitinib instead of desethylsunitinib as an internal standard, or due to the light-induced cis(Z)/trans(E) isomerization of (desethyl)sunitinib. Overall, drug substance and performing laboratory seemed to influence the absolute inaccuracy (F = 16.4; p < 0.001 and F = 35.5; p < 0.001, respectively). CONCLUSION Considering this is the first evaluation of an international QC programme for oral targeted oncolytics, an impressive high percentage of measurements were within the predefined range of accuracy. Cross-validation of assays that are used for dose optimization of oncolytics will secure the performance and will protect patients from incorrect advices.
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Affiliation(s)
- Eline L Giraud
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lindsey M H Te Brake
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Erik C A van den Hombergh
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ingrid M E Desar
- Department of Medical Oncology, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Dina M Kweekel
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, The Netherlands
- Drug Analysis and Toxicology division (KKGT) of the Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Utrecht, The Netherlands
| | - Nielka P van Erp
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
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Huang X, Liu Y, Chen J, Zheng H, Ding Y, He Z. Therapeutic Drug Monitoring of Imatinib and N-Desmethyl Imatinib in Chronic Myeloid Leukemia Patients Using LC-MS/MS in a Cohort Study. J Clin Pharmacol 2023; 63:1438-1447. [PMID: 37563838 DOI: 10.1002/jcph.2329] [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: 06/16/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
Imatinib is an oral tyrosine kinase inhibitor (TKI) and first-line therapy for patients with chronic myeloid leukemia (CML). There is a positive correlation between serum imatinib concentrations and treatment response. However, the specific relationship between the blood concentration of imatinib and its influencing factors remains unclear. This study collected basic information from 102 patients using imatinib as first-line treatment for CML. Further, we analyzed the individual differences in imatinib concentration and explored its influencing factors. Through intra-day and inter-day precision studies, we found that the precision for the imatinib assay methodology was within ±13% and that the recovery rate was above 85%. There is notable individual variation in the blood concentration of imatinib; the recommended treatment concentration is 860-1500 ng/mL, with only 41.40% of patients achieving this concentration. Also, there was a negative correlation between age and imatinib trough concentration (Ctrough ), as is observed between age and N-desmethyl imatinib. Moreover, compared with the adolescent group, the serum imatinib Ctrough for groups aged 17-47 and 48-68 years was significantly reduced. Further analysis shows that imatinib Ctrough values reaching therapeutic concentrations (59%) increased dramatically for patients with CML aged 17-47 years. Moreover, groups dosed with 400 mg/day resulted in therapeutic imatinib concentrations for 68% of patients with CML, which was the best performance. The established method was validated, with acceptable accuracy, precision, linearity, and stability, as required, and then successfully applied to the therapeutic drug monitoring of imatinib. Age, dose, and metabolites can influence the imatinib concentration and its therapeutic effect in patients with CML.
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Affiliation(s)
- Xiaoxing Huang
- Department of Blood Transfusion, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yiwei Liu
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jie Chen
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Heng Zheng
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yufeng Ding
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zheng He
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Westerdijk K, Steeghs N, Tacke CSJ, van der Graaf WTA, van Erp NP, van Oortmerssen G, Hermens RPMG, Desar IME. Therapeutic drug monitoring to personalize dosing of imatinib, sunitinib, and pazopanib: A mixed methods study on barriers and facilitators. Cancer Med 2023; 12:21041-21056. [PMID: 37902257 PMCID: PMC10709747 DOI: 10.1002/cam4.6663] [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: 03/28/2023] [Revised: 08/20/2023] [Accepted: 10/03/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND Personalized dosing based on measurement of individual drug levels and adjusting the dose accordingly can improve efficacy and decrease unnecessary toxicity of oncological treatment. For imatinib, sunitinib, and pazopanib, this therapeutic drug monitoring (TDM)-guided dosing is, however, not routinely used, despite accumulating evidence favoring individualized dosing. Therefore, we aimed to identify and quantify (potential) barriers and facilitators in TDM-guided dosing for imatinib, sunitinib, and pazopanib. METHODS We performed a mixed methods study among all stakeholders involved: patients, healthcare professionals (HCPs), pharmaceutical companies, and health insurance companies. During the first qualitative part of this study, we performed semi-structured individual interviews and one focus group interview to identify all (potential) barriers and facilitators, and during the second quantitative part of this study, we used a web-based survey to quantify these findings. The interviews addressed the six domains of the implementation of change model of Grol and Wensing: (1) the innovation itself; (2) the HCP; (3) the patient; (4) social context; (5) organizational context; and (6) finances, law, and governance. RESULTS In the qualitative study, we interviewed 20 patients, 18 HCPs and 10 representatives of pharmaceutical and health insurance companies and identified 72 barriers and 90 facilitators. In the quantitative study, the survey was responded by 66 HCPs and 58 patients. Important barriers were on the domain of the HCP, such as a lack of experience with TDM (36.4%), on the domain of the patient, such as lack of awareness of TDM (39.7%), and the processing time for measurement and interpretation of the TDM result (40.9%) (organizational domain). Important facilitators were education of HCPs (95.5%), education of patients (87.9%) and facilitating an overview of when and where TDM measurements are being performed (86.4%). CONCLUSION We identified and quantified important barriers and facilitators for the implementation of TDM-guided dosing for imatinib, sunitinib, and pazopanib. Based on our results, the implementation strategy should mainly focus on educating both HCPs and patients and on the organizational aspect of TDM.
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Affiliation(s)
- Kim Westerdijk
- Department of Medical OncologyResearch Institute for Medical Innovation, Radboud University Medical CenterNijmegenThe Netherlands
| | - Neeltje Steeghs
- Department of Medical OncologyNetherlands Cancer Institute, Antoni van LeeuwenhoekAmsterdamThe Netherlands
| | - Casper S. J. Tacke
- Department of Medical OncologyResearch Institute for Medical Innovation, Radboud University Medical CenterNijmegenThe Netherlands
| | - Winette T. A. van der Graaf
- Department of Medical OncologyNetherlands Cancer Institute, Antoni van LeeuwenhoekAmsterdamThe Netherlands
- Department of Medical OncologyErasmus MC Cancer Institute, Erasmus Medical Center RotterdamRotterdamThe Netherlands
| | - Nielka P. van Erp
- Department of PharmacyResearch Institute for Medical Innovation, Radboud University Medical CenterNijmegenThe Netherlands
| | | | | | - Ingrid M. E. Desar
- Department of Medical OncologyResearch Institute for Medical Innovation, Radboud University Medical CenterNijmegenThe Netherlands
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10
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van der Kleij MBA, Guchelaar NAD, Mathijssen RHJ, Versluis J, Huitema ADR, Koolen SLW, Steeghs N. Therapeutic Drug Monitoring of Kinase Inhibitors in Oncology. Clin Pharmacokinet 2023; 62:1333-1364. [PMID: 37584840 PMCID: PMC10519871 DOI: 10.1007/s40262-023-01293-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/17/2023]
Abstract
Although kinase inhibitors (KI) frequently portray large interpatient variability, a 'one size fits all' regimen is still often used. In the meantime, relationships between exposure-response and exposure-toxicity have been established for several KIs, so this regimen could lead to unnecessary toxicity and suboptimal efficacy. Dose adjustments based on measured systemic pharmacokinetic levels-i.e., therapeutic drug monitoring (TDM)-could therefore improve treatment efficacy and reduce the incidence of toxicities. Therefore, the aim of this comprehensive review is to give an overview of the available evidence for TDM for the 77 FDA/EMA kinase inhibitors currently approved (as of July 1st, 2023) used in hematology and oncology. We elaborate on exposure-response and exposure-toxicity relationships for these kinase inhibitors and provide practical recommendations for TDM and discuss corresponding pharmacokinetic targets when possible.
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Affiliation(s)
- Maud B A van der Kleij
- Division of Medical Oncology, Department of Clinical Pharmacology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Niels A D Guchelaar
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jurjen Versluis
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
- Department of Pharmacy, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Neeltje Steeghs
- Division of Medical Oncology, Department of Clinical Pharmacology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
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11
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Del Rosario García B, Morales Barrios JA, Jurado JC, Díaz RR, Viña Romero MM, Padrón IM, Nazco Casariego GJ, Nicolás FG. Imatinib plasma levels in patients with gastrointestinal stromal tumour under routine clinical practice conditions. J Oncol Pharm Pract 2023; 29:1613-1618. [PMID: 36482704 DOI: 10.1177/10781552221143788] [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] [Indexed: 10/28/2023]
Abstract
OBJECTIVES Imatinib is the first therapeutic option for the treatment of unresectable or metastatic gastrointestinal stromal tumours. Previous studies have shown an improvement in patient survival rates following the use of imatinib. Nevertheless, adequate plasma concentrations of imatinib are necessary to achieve such improvement in survival and limit the toxicity of the drug. This study aims to analyse the influence of imatinib plasma concentrations on efficacy and safety in the treatment of gastrointestinal stromal tumour. MATERIALS AND METHODS This descriptive, multicentre study analysed plasma levels of imatinib in patients diagnosed with gastrointestinal stromal tumour in the period 2019-2020. An optimal therapeutic range of 750-1500 ng/mL was established for the patient stratification based on their minimum plasma concentrations measured at the steady state. RESULTS This study included 11 patients with metastatic disease in total, among whom only 54.5% (n = 6) had a minimum plasma concentrations measured at the steady state value within the therapeutic range. A median progression-free survival of 7.0 months was recorded for those patients with minimum plasma concentrations measured at the steady state < 750 ng/mL, while that median progression-free survival value remained unachieved for the group with minimum plasma concentrations measured at the steady state > 750 ng/mL (p = 0.005). The toxicity rate was 25% and 14.3% for patients with minimum plasma concentrations measured at the steady state > 1500 ng/mL and minimum plasma concentrations measured at the steady state ≤1500 ng/mL, respectively (p = 0.66). CONCLUSIONS The present study aims to describe the correlation between the toxicity and effectiveness of imatinib as a function of minimum plasma concentrations measured at the steady state under routine clinical practice conditions. The results described here show the usefulness of imatinib plasma concentrations monitoring as part of the standard daily routine in our hospitals.
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Affiliation(s)
- Betel Del Rosario García
- Servicio de Farmacia, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Tenerife, España
| | - José Alberto Morales Barrios
- Servicio de Farmacia, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Tenerife, España
| | - Josefina Cruz Jurado
- Servicio de Oncología Médica, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Tenerife, España
| | - Ruth Ramos Díaz
- Fundación Canaria Instituto de Investigación Sanitaria de Canarias (FIISC), San Cristóbal de La Laguna, Tenerife, España
| | - María Micaela Viña Romero
- Servicio de Farmacia, Complejo Hospitalario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, España
| | - Ivette Mourani Padrón
- Fundación Canaria Instituto de Investigación Sanitaria de Canarias (FIISC), San Cristóbal de La Laguna, Tenerife, España
| | - Gloria Julia Nazco Casariego
- Servicio de Farmacia, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Tenerife, España
| | - Fernando Gutiérrez Nicolás
- Servicio de Farmacia, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Tenerife, España
- Unidad de Investigación del Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Tenerife, España
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12
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Chen F, Chen W, Wang Z, Peng Y, Wang B, Pan B, Guo W. Development and clinical application of a liquid chromatography-tandem mass spectrometry-based assay to quantify eight tyrosine kinase inhibitors in human plasma. J Mass Spectrom Adv Clin Lab 2023; 29:2-8. [PMID: 37234251 PMCID: PMC10205537 DOI: 10.1016/j.jmsacl.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 04/13/2023] [Accepted: 05/01/2023] [Indexed: 05/27/2023] Open
Abstract
Introduction Tyrosine kinase inhibitors (TKIs) are widely used in tumor treatment. The detection of these medicines by liquid chromatography-tandem mass spectrometry (LC-MS/MS) can avoid the interference of structurally similar compounds. Objectives This study aimed to develop and validate a new LC-MS/MS assay for the quantification of eight tyrosine kinase inhibitors in human plasma and to preliminarily evaluate the clinical utility of the therapeutic drug monitoring method. Methods Plasma samples were prepared by simple protein precipitation and separated using an ultra-high-performance reversed phase column. Detection was achieved using a triple quadrupole mass spectrometer in the positive ionization mode. The assay was validated against standard guidelines. We reviewed and analyzed the results of 268 plasma samples obtained from patients administered imatinib and other TKIs collected from January 2020 to November 2021 at Zhongshan Hospital. The analytes were separated and quantified within 3.5 min. Results The newly developed method demonstrated linearity for the detected drug concentration in the range of 20 to 2000 ng/ml for gefitinib (r2 = 0.991) and crizotinib (r2 = 0.992), 50 to 5000 ng/ml for nilotinib (r2 = 0.991) and imatinib (r2 = 0.995), 1500-150,000 ng/ml for vemurafenib (r2 = 0.998), 1000-100,000 ng/ml for pazopanib (r2 = 0.993), 0.5-100 ng/ml for axitinib (r2 = 0.992) and 5-500 ng/ml for sunitinib (r2 = 0.991) and N-desethyl sunitinib (r2 = 0.998). The lower limit of quantification (LLOQ) was 20 ng/ml for gefitinib and crizotinib, 50 ng/ml for nilotinib and imatinib, 1500 ng/ml for vemurafenib, 1000 ng/ml for pazopanib, 0.5, and 5 ng/ml for sunitinib and N-desethyl sunitinib, respectively. Specificity, precision, accuracy, and stability were tested, and met the requirements of the guidelines. At the same dose, there was no significant difference in plasma drug concentration between the original imatinib medicine and the generic medicine after patent expiration. Conclusion We developed a sensitive and reliable method for the quantification of eight TKIs.
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13
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van Leuven J, Evans S, Kichenadasse G, Steeghs N, Bonevski B, Mikus G, van Dyk M. Framework for Implementing Individualised Dosing of Anti-Cancer Drugs in Routine Care: Overcoming the Logistical Challenges. Cancers (Basel) 2023; 15:3293. [PMID: 37444404 DOI: 10.3390/cancers15133293] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/26/2022] [Accepted: 12/26/2022] [Indexed: 07/15/2023] Open
Abstract
Precision medicine in oncology involves identifying the 'right drug', at the 'right dose', for the right person. Currently, many orally administered anti-cancer drugs, particularly kinase inhibitors (KIs), are prescribed at a standard fixed dose. Identifying the right dose remains one of the biggest challenges to optimal patient care. Recently the Precision Dosing Group established the Accurate Dosing of Anti-cancer Patient-centred Therapies (ADAPT) Program to address individualised dosing; thus, use existing anti-cancer drugs more safely and efficiently. In this paper, we outline our framework, based on the Medical Research Council (MRC) framework, with a simple 6-step process and strategies which have led to the successful implementation of the ADAPT program in South Australia. Implementation strategies in our 6-step process involve: (1) Evaluate the evidence and identify the cancer drugs: Literature review, shadowing other experts, establishing academic partnerships, adaptability/flexibility; (2) Establishment of analytical equipment for drug assays for clinical purposes: assessment for readiness, accreditation, feasibility, obtaining formal commitments, quality assurance to all stakeholders; (3) Clinical preparation and education: educational material, conducted educational meetings, involve opinion leaders, use of mass media, promote network weaving, conduct ongoing training; (4) Blood collection, sample preparation and analyses: goods received procedures, critical control points (transport time); (5) Interpret and release results with recommendations: facilitate the relay of clinical data to providers; (6) Clinical application: providing ongoing consultation, identify early adopters, identify, and prepare champions. These strategies were selected from the 73 implementation strategies outlined in the Expert Recommendations for Implementing Change (ERIC) study. The ADAPT program currently provides routine plasma concentrations for patients on several orally administered drugs in South Australia and is currently in its evaluation phase soon to be published. Our newly established framework could provide great potential and opportunities to advance individualised dosing of oral anti-cancer drugs in routine clinical care.
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Affiliation(s)
- Jason van Leuven
- College of Medicine and Public Health, Flinders University, Adelaide 5042, Australia
- Medical Oncology, Flinders Medical Centre, Adelaide 5042, Australia
| | - Simon Evans
- Implementation Science Unit, Department for Health and Wellbeing, Adelaide 5042, Australia
| | - Ganessan Kichenadasse
- College of Medicine and Public Health, Flinders University, Adelaide 5042, Australia
- Medical Oncology, Flinders Medical Centre, Adelaide 5042, Australia
| | - Neeltje Steeghs
- Antoni van Leeuwenhoek Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
- Department of Medical Oncology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Billie Bonevski
- College of Medicine and Public Health, Flinders University, Adelaide 5042, Australia
| | - Gerd Mikus
- College of Medicine and Public Health, Flinders University, Adelaide 5042, Australia
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Madelé van Dyk
- College of Medicine and Public Health, Flinders University, Adelaide 5042, Australia
- Medical Oncology, Flinders Medical Centre, Adelaide 5042, Australia
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14
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Giraud EL, de Jong LAW, van den Hombergh E, Kaal SEJ, van Erp NP, Desar IME. Measuring Tumour Imatinib Concentrations in Gastrointestinal Stromal Tumours: Relevant or Redundant? Cancers (Basel) 2023; 15:cancers15112875. [PMID: 37296838 DOI: 10.3390/cancers15112875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/17/2023] [Accepted: 05/20/2023] [Indexed: 06/12/2023] Open
Abstract
Imatinib plasma trough concentrations are associated with efficacy for patients treated for advanced or metastatic KIT-positive gastrointestinal stromal tumours (GISTs). This relationship has not been studied for patients treated in the neoadjuvant setting, let alone its correlation with tumour drug concentrations. In this exploratory study we aimed to determine the correlation between plasma and tumour imatinib concentrations in the neoadjuvant setting, investigate tumour imatinib distribution patterns within GISTs, and analyse its correlation with pathological response. Imatinib concentrations were measured in both plasma and in three regions of the resected primary tumour: the core, middle part, and periphery. Twenty-four tumour samples derived from the primary tumours of eight patients were included in the analyses. Imatinib tumour concentrations were higher compared to plasma concentrations. No correlation was observed between plasma and tumour concentrations. Interpatient variability in tumour concentrations was high compared to interindividual variability in plasma concentrations. Although imatinib accumulates in tumour tissue, no distribution pattern of imatinib in tumour tissue could be identified. There was no correlation between imatinib concentrations in tumour tissue and pathological treatment response.
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Affiliation(s)
- Eline L Giraud
- Radboud University Medical Centre, Department of Pharmacy, 6500 HB Nijmegen, The Netherlands
| | - Loek A W de Jong
- Radboud University Medical Centre, Department of Pharmacy, 6500 HB Nijmegen, The Netherlands
| | - Erik van den Hombergh
- Radboud University Medical Centre, Department of Pharmacy, 6500 HB Nijmegen, The Netherlands
| | - Suzanne E J Kaal
- Radboud University Medical Centre, Department of Medical Oncology, 6500 HB Nijmegen, The Netherlands
| | - Nielka P van Erp
- Radboud University Medical Centre, Department of Pharmacy, 6500 HB Nijmegen, The Netherlands
| | - Ingrid M E Desar
- Radboud University Medical Centre, Department of Medical Oncology, 6500 HB Nijmegen, The Netherlands
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15
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Cheng F, Li Q, Cui Z, Hong M, Li W, Zhang Y. Dose optimization strategy of the tyrosine kinase inhibitors imatinib, dasatinib, and nilotinib for chronic myeloid leukemia: From clinical trials to real-life settings. Front Oncol 2023; 13:1146108. [PMID: 37091188 PMCID: PMC10113500 DOI: 10.3389/fonc.2023.1146108] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/23/2023] [Indexed: 04/08/2023] Open
Abstract
With the advent of tyrosine kinase inhibitors (TKIs), the treatment prospects of chronic myeloid leukemia (CML) have changed markedly. This innovation can lengthen the long-term survival of patients suffering from CML. However, long-term exposure to TKIs is accompanied by various adverse events (AEs). The latter affect the quality of life and compliance of patients with CML, and may lead to serious disease progression (and even death). Recently, increasing numbers of patients with CML have begun to pursue a dose optimization strategy. Dose optimization may be considered at all stages of the entire treatment, which includes dose reduction and discontinuation of TKIs therapy. In general, reduction of the TKI dose is considered to be an important measure to reduce AEs and improve quality of life on the premise of maintaining molecular responses. Furthermore, discontinuation of TKIs therapy has been demonstrated to be feasible and safe for about half of patients with a stable optimal response and a longer duration of TKI treatment. This review focuses mainly on the latest research of dose optimization of imatinib, dasatinib, and nilotinib in CML clinical trials and real-life settings. We consider dose reduction in newly diagnosed patients, or in optimal response, or for improving AEs, either as a prelude to treatment-free remission (TFR) or as maintenance therapy in those patients unable to discontinue TKIs therapy. In addition, we also focus on discontinuation of TKIs therapy and second attempts to achieve TFR.
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Affiliation(s)
- Fang Cheng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiang Li
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Zheng Cui
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Mei Hong
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weiming Li
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
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16
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Dalle Fratte C, Gagno S, Roncato R, Polesel J, Zanchetta M, Buzzo M, Posocco B, De Mattia E, Borsatti R, Puglisi F, Foltran L, Guardascione M, Buonadonna A, Cecchin E, Toffoli G. CYP2D6 and CYP2C8 pharmacogenetics and pharmacological interactions to predict imatinib plasmatic exposure in GIST patients. Br J Clin Pharmacol 2023; 89:1089-1098. [PMID: 36178950 DOI: 10.1111/bcp.15551] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/14/2022] [Accepted: 09/22/2022] [Indexed: 11/30/2022] Open
Abstract
AIMS Patients on treatment with oral fixed dose imatinib are frequently under- or overexposed to the drug. We investigated the association between the gene activity score (GAS) of imatinib-metabolizing cytochromes (CYP3A4, CYP3A5, CYP2D6, CYP2C9, CYP2C19, CYP2C8) and imatinib and nor-imatinib exposure. We also investigated the impact of concurrent drug-drug-interactions (DDIs) on the association between GAS and imatinib exposure. METHODS Serial plasma samples were collected from 33 GIST patients treated with imatinib 400 mg daily within a prospective clinical trial. Imatinib and nor-imatinib Ctrough were quantified by liquid chromatography with tandem mass spectrometry (LC-MS/MS). Genetic polymorphisms with a functional impact on imatinib-metabolizing cytochromes were identified and a GAS was calculated for each gene. A DDI-adjusted GAS was also generated. RESULTS Imatinib and nor-imatinib Ctrough were measured in 161 plasma samples. CYP2D6 GAS and metabolizer status based on genotype were associated with imatinib and (imatinib + nor-imatinib) Ctrough . CYP2D6 poor and intermediate metabolizers were predicted to have a lower nor-imatinib/imatinib metabolic ratio than normal metabolizers (0.197 and 0.193 vs. 0.247, P = .0205), whereas CYP2C8*3 carriers had a higher ratio than CYP2C8*1/*1 patients (0.263 vs. 0.201, P = .0220). CYP2C9 metabolizer status was inversely related to the metabolic ratio with an effect probably driven by the linkage disequilibrium between CYP2C9*2 and CYP2C8*3. The CYP2D6 DDI-adjusted GAS was still predictive of imatinib exposure. CONCLUSIONS These findings highlight that CYP2D6 plays a major role in imatinib pharmacokinetics, but other players (i.e., CYP2C8) may influence imatinib exposure. These findings could drive the selection of patients more susceptible to imatinib under- or overexposure who could be candidates for personalized treatment and intensified monitoring strategies.
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Affiliation(s)
- Chiara Dalle Fratte
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Sara Gagno
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Rossana Roncato
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Jerry Polesel
- Unit of Cancer Epidemiology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Martina Zanchetta
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Mauro Buzzo
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Bianca Posocco
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Elena De Mattia
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Rachele Borsatti
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Fabio Puglisi
- Department of Medical Oncology, Unit of Medical Oncology and Cancer Prevention, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy.,Department of Medicine, University of Udine, Udine, Italy
| | - Luisa Foltran
- Department of Medical Oncology, Unit of Medical Oncology and Cancer Prevention, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Michela Guardascione
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy.,Department of Medical Oncology, Unit of Medical Oncology and Cancer Prevention, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Angela Buonadonna
- Department of Medical Oncology, Unit of Medical Oncology and Cancer Prevention, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Erika Cecchin
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Giuseppe Toffoli
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
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17
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The Application of Virtual Therapeutic Drug Monitoring to Assess the Pharmacokinetics of Imatinib in a Chinese Cancer Population Group. J Pharm Sci 2023; 112:599-609. [PMID: 36202248 DOI: 10.1016/j.xphs.2022.09.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/28/2022] [Accepted: 09/28/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Imatinib is used in gastrointestinal stromal tumours (GIST) and chronic myeloid leukaemia (CML). Oncology patients demonstrate altered physiology compared to healthy adults, e.g. reduced haematocrit, increased α-1 acid glycoprotein, decreased albumin and reduced glomerular filtration rate (GFR), which may influence imatinib pharmacokinetics. Given that Chinese cancer patients often report raised imatinib plasma concentrations and wider inter-individual variability reported in trough concentration when compared to Caucasian cancer patients, therapeutic drug monitoring (TDM) has been advocated. METHOD This study utilised a previously validated a Chinese cancer population and assessed the impact of imatinib virtual-TDM in Chinese and Caucasian cancer populations across a dosing range from 200-800 mg daily. RESULTS Staged dose titration to 800 mg daily, resulted in recapitulation to within the target therapeutic range for 50 % (Chinese) and 42.1% (Caucasian) subjects possessing plasma concentration < 550 ng/mL when dosed at 400 mg daily. For subjects with plasma concentrations >1500 ng/mL when dosed at 400 mg daily, a dose reduction to 200 mg once daily was able to recover 67 % (Chinese) and 87.4 % (Caucasian) patients to the target therapeutic range. CONCLUSION Virtual TDM highlights the benefit of pharmacokinetic modelling to optimising treatments in challenging oncology population groups.
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18
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Krützmann ME, Martini RR, de Souza Guterres F, Kohlrausch R, Wagner SC, Mattevi VS, Torriani MS, Fogliatto LM, Linden R, Antunes MV. Volumetric dried blood microsampling for monitoring imatinib mesylate therapy: Method development and clinical application in patients with chronic myeloid leukemia. J Pharm Biomed Anal 2023; 222:115108. [DOI: 10.1016/j.jpba.2022.115108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/29/2022] [Accepted: 10/11/2022] [Indexed: 11/05/2022]
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Jiang X, Fu Q, Jing Y, Kong Y, Liu H, Peng H, Rexiti K, Wei X. Personalized Dose of Adjuvant Imatinib in Patients with Gastrointestinal Stromal Tumors: Results from a Population Pharmacokinetic Analysis. Drug Des Devel Ther 2023; 17:809-820. [PMID: 36942304 PMCID: PMC10024496 DOI: 10.2147/dddt.s400986] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 03/06/2023] [Indexed: 03/15/2023] Open
Abstract
Purpose Imatinib is the first-line treatment for patients with gastrointestinal stromal tumors (GIST) after surgery. However, its pharmacokinetic profile varies remarkably between individuals and has not been well characterized in postoperative Chinese patients with GIST. Therefore, this study aimed to develop a population pharmacokinetic (PPK) model and recommend appropriate doses for different patients to achieve the target trough concentration in such a population. Patients and Methods A total of 110 surgically treated GIST patients were enrolled, of which 85 were applied to conduct a PPK analysis with a nonlinear mixed-effect model and 25 for external validation of the model. Demographic and biomedical covariates, as well as six single nucleotide polymorphisms were tested to explore the sources of variation in pharmacokinetic parameters of imatinib. Monte Carlo simulations were performed to establish the initial dosing regimens. Results A one-compartment model was established in postoperative GIST patients. The red blood cell count (RBC) and ABCG2 rs2231142 were observed to have a significant effect on the clearance of imatinib. The typical values estimated by the final model were 9.72 L/h for clearance (CL/F) and 229 L for volume of distribution (V/F). Different from the fixed dose regimen of 400 mg each day, patients carrying rs2231142 heterozygous type and with a lower level of RBC (2.9 × 1012/L), 300 mg imatinib daily is enough to achieve the target trough concentration. When RBC rises to 4.9 × 1012/L, 500 mg daily is recommended. For patients with rs2231142 GG genotype, 500 mg a day is required at RBCs of 3.9 × 1012/L and 4.9 × 1012/L. Conclusion RBC and rs2231142 contribute to the pharmacokinetic variation of imatinib and personalized dose recommendations based on patient characteristics may be necessary.
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Affiliation(s)
- Xuehui Jiang
- School of Pharmacy, Nanchang University, Nanchang, People’s Republic of China
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Qun Fu
- Jiangxi Provincial Drug Inspector Center, Jiangxi Provincial Drug Administration, Nanchang, People’s Republic of China
| | - Yan Jing
- Department of Pharmacy, Linyi Central Hospital, Linyi, People’s Republic of China
| | - Ying Kong
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Hong Liu
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Hongwei Peng
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Kaisaner Rexiti
- School of Pharmacy, Nanchang University, Nanchang, People’s Republic of China
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Xiaohua Wei
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
- Correspondence: Xiaohua Wei, Department of Pharmacy, The First Affiliated Hospital of Nanchang University, No. 17 Yong Wai Zheng Street, Nanchang, 330006, People’s Republic of China, Tel +86 13803523639, Email
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Chen L, Jiang H, Rao JJ, Wang LS, Yan W, Ye J, Lou J. Association between anlotinib trough plasma concentration and treatment outcomes in advanced non-small-cell lung cancer. Front Oncol 2023; 13:1146362. [PMID: 36937430 PMCID: PMC10020721 DOI: 10.3389/fonc.2023.1146362] [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: 01/17/2023] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
Background Efficacy and toxicities of anlotinib (ANL) show large inter-patient variation, which may partly be explained by differences in ANL exposure. Exposure-response/toxicities relationship have not been investigated for ANL. Therefore, the aim of the present study was to explore the association between the trough plasma concentration (Ctrough) of ANL and treatment outcomes in Chinese patients with advanced non-small cell lung cancer (NSCLC). Methods Patients with advanced NSCLC who started third-line or further ANL alone therapy between January 2021 and October 2022. This study examined the ANL Ctrough and clinical response evaluation at day 43 after initiation of ANL treatment. We evaluated the association between the ANL Ctrough and clinical efficacy and toxicities. Additionally, this study defined patients with complete response (CR), partial response (PR) and stable disease (SD) as responder. The receiver-operating characteristic (ROC) curve combined with Youden index was identify the potential threshold value of ANL Ctrough for the responder. Results 52 patients were evaluated for analyses. The median ANL Ctrough was 11.45ng/ml (range, 3.69-26.36 ng/ml). The ANL Ctrough values in the PR group (n=6, 15.51 ng/ml (range, 8.19-17.37 ng/ml)) was significantly higher than in the PD group (n=8, 7.44 ng/ml (range, 5.41-14.69 ng/ml), p=0.001). The area under the ROC curve (AUCROC) was 0.76 (95% confidence interval (CI), 0.58-0.93; p=0.022) and threshold value of ANL Ctrough predicting responder was 10.29 ng/ml (sensitivity 65.9% and specificity 87.5%, the best Youden index was 0.53). The disease control rate (DCR) was 84.6%, and DCR was significantly higher in the high-exposure group (≥10.29ng/ml) than low-exposure group (<10.29ng/ml) (96.67% vs 68.18%, p=0.005). Although there was no significant difference in ANL Ctrough between grade ≥ 3 and grade ≤2 toxicities, the incidence of any grade hand-foot syndrome (70.0% vs 36.36%, p=0.016) and thyroid-stimulating hormone elevation (53.33% vs 22.73%, p =0.026) was significantly higher in the high-exposure group compared with the low-exposure group. Conclusions Considering these results, we propose that maintaining ANL Ctrough ≥ 10.29ng/ml was important for achieving the response in advanced NSCLC patients treated with ANL.
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Affiliation(s)
- Ling Chen
- Department of Pharmacy, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hong Jiang
- Department of Cardiothoracic Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jun-jie Rao
- Department of Clinical Laboratory, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Liu-sheng Wang
- Department of Respiratory, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Yan
- Department of Pharmacy, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jian Ye
- Department of Respiratory, Zhejiang Hospital, Hangzhou, China
| | - Jiang Lou
- Department of Pharmacy, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Jiang Lou,
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21
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Groenland SL, van Eerden RAG, Westerdijk K, Meertens M, Koolen SLW, Moes DJAR, de Vries N, Rosing H, Otten H, Vulink AJE, Desar IME, Imholz ALT, Gelderblom H, van Erp NP, Beijnen JH, Mathijssen RHJ, Huitema ADR, Steeghs N. Therapeutic drug monitoring-based precision dosing of oral targeted therapies in oncology: a prospective multicenter study. Ann Oncol 2022; 33:1071-1082. [PMID: 35777707 DOI: 10.1016/j.annonc.2022.06.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/08/2022] [Accepted: 06/20/2022] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Oral targeted therapies show a high pharmacokinetic (PK) interpatient variability. Even though exposure has been positively correlated with efficacy for many of these drugs, these are still dosed using a one-size-fits-all approach. Consequently, individuals have a high probability to be either underexposed or overexposed, potentially leading to suboptimal outcomes. Therapeutic drug monitoring, which is personalized dosing based on measured systemic drug concentrations, could address these problems. PATIENTS AND METHODS Patients were enrolled in this prospective multicenter study (www.trialregister.nl; NL6695) if they started treatment with one of the 24 participating oral targeted therapies. Primary outcome was to halve the proportion of underexposed patients, compared with historical data. PK sampling was carried out after 4, 8 and 12 weeks, and every 12 weeks thereafter. In case of Cmin below the predefined target and manageable toxicity, a pharmacokinetically guided intervention was proposed (i.e. checking compliance and drug-drug interactions, concomitant intake with food, splitting intake moments or dose increments). RESULTS In total, 600 patients were included of whom 426 patients are assessable for the primary outcome and 552 patients had ≥1 PK sample(s) available and were therefore assessable for the overall analyses. Pharmacokinetically guided dosing reduced the proportion of underexposed patients at the third PK measurement by 39.0% (95% confidence interval 28.0% to 49.0%) compared with historical data. At the third PK measurement, 110 out of 426 patients (25.8%) had a low exposure. In total, 294 patients (53.3%) had ≥1 PK sample(s) below the preset target at a certain time point during treatment. In 166 of these patients (56.5%), pharmacokinetically guided interventions were carried out, which were successful in 113 out of 152 assessable patients (74.3%). CONCLUSIONS Pharmacokinetically guided dose optimization of oral targeted therapies was feasible in clinical practice and reduced the proportion of underexposed patients considerably.
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Affiliation(s)
- S L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - R A G van Eerden
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - K Westerdijk
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M Meertens
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - S L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands; Department of Pharmacy, Erasmus Medical Center, Rotterdam, The Netherlands
| | - D J A R Moes
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - N de Vries
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - H Rosing
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - H Otten
- Department of Medical Oncology, Meander Medical Center, Amersfoort, The Netherlands
| | - A J E Vulink
- Department of Medical Oncology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - I M E Desar
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A L T Imholz
- Department of Medical Oncology, Deventer Hospital, Deventer, The Netherlands
| | - H Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - N P van Erp
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - R H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - A D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - N Steeghs
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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22
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van Linde ME, Labots M, Brahm CG, Hovinga KE, De Witt Hamer PC, Honeywell RJ, de Goeij-de Haas R, Henneman AA, Knol JC, Peters GJ, Dekker H, Piersma SR, Pham TV, Vandertop WP, Jiménez CR, Verheul HM. Tumor Drug Concentration and Phosphoproteomic Profiles After Two Weeks of Treatment With Sunitinib in Patients with Newly Diagnosed Glioblastoma. Clin Cancer Res 2022; 28:1595-1602. [PMID: 35165100 PMCID: PMC9365363 DOI: 10.1158/1078-0432.ccr-21-1933] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/14/2021] [Accepted: 02/09/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Tyrosine kinase inhibitors (TKI) have poor efficacy in patients with glioblastoma (GBM). Here, we studied whether this is predominantly due to restricted blood-brain barrier penetration or more to biological characteristics of GBM. PATIENTS AND METHODS Tumor drug concentrations of the TKI sunitinib after 2 weeks of preoperative treatment was determined in 5 patients with GBM and compared with its in vitro inhibitory concentration (IC50) in GBM cell lines. In addition, phosphotyrosine (pTyr)-directed mass spectrometry (MS)-based proteomics was performed to evaluate sunitinib-treated versus control GBM tumors. RESULTS The median tumor sunitinib concentration of 1.9 μmol/L (range 1.0-3.4) was 10-fold higher than in concurrent plasma, but three times lower than sunitinib IC50s in GBM cell lines (median 5.4 μmol/L, 3.0-8.5; P = 0.01). pTyr-phosphoproteomic profiles of tumor samples from 4 sunitinib-treated versus 7 control patients revealed 108 significantly up- and 23 downregulated (P < 0.05) phosphopeptides for sunitinib treatment, resulting in an EGFR-centered signaling network. Outlier analysis of kinase activities as a potential strategy to identify drug targets in individual tumors identified nine kinases, including MAPK10 and INSR/IGF1R. CONCLUSIONS Achieved tumor sunitinib concentrations in patients with GBM are higher than in plasma, but lower than reported for other tumor types and insufficient to significantly inhibit tumor cell growth in vitro. Therefore, alternative TKI dosing to increase intratumoral sunitinib concentrations might improve clinical benefit for patients with GBM. In parallel, a complex profile of kinase activity in GBM was found, supporting the potential of (phospho)proteomic analysis for the identification of targets for (combination) treatment.
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Affiliation(s)
- Myra E. van Linde
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Mariette Labots
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Cyrillo G. Brahm
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Koos E. Hovinga
- Department of Neurosurgery, Cancer Center Amsterdam, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Philip C. De Witt Hamer
- Department of Neurosurgery, Cancer Center Amsterdam, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Richard J. Honeywell
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Pharmacy, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Richard de Goeij-de Haas
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Alex A. Henneman
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jaco C. Knol
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Godefridus J. Peters
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Biochemistry, Medical University of Gdansk, Gdansk, Poland
| | - Henk Dekker
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Sander R. Piersma
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Thang V. Pham
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - William P. Vandertop
- Department of Neurosurgery, Cancer Center Amsterdam, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Connie R. Jiménez
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Henk M.W. Verheul
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Medical Oncology, Radboud UMC, Nijmegen, the Netherlands
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23
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Ferrer F, Chauvin J, Deville JL, Ciccolini J. Adaptive dosing of sunitinib in a metastatic renal cell carcinoma patient: when in silico modeling helps to go quicker to the point. Cancer Chemother Pharmacol 2022; 89:565-569. [PMID: 35147741 DOI: 10.1007/s00280-021-04383-2] [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: 10/11/2021] [Accepted: 12/07/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Adaptive dosing strategy with oral targeted therapies in oncology is mostly based upon clinical signs. Using pharmacokinetics (PK) models to customize dosing could help saving time, i.e., by predicting clinical outcome through early monitoring of drug levels. CASE REPORT We present the case of a metastatic renal cell carcinoma patient treated with standard Sunitinib dosing (i.e., 50 mg QD). Clinical signs suggested lack of efficacy. Therapeutic Drug Monitoring (TDM) confirmed that exposure was below the expected target exposure. PK modeling suggested that dosing could be increased safely to 75 mg QD. Sunitinib dosing was instead changed empirically to 62.5 mg only, increasing drug exposure to the lower part of the therapeutic window. Resolution of bone pains plus Stable Disease were observed. Even though further modeling suggested to increase Sunitinib dosing to 75 mg again, the intermediate dosing was maintained for the subsequent cycles to preserve the safety. Unfortunately, severe pains plus degradation of the general state were reported and imaging showed Progressive Disease. The patient was finally switched to alternative therapy, without being treated at the 75 mg level of Suntitinib. CONCLUSIONS AND DISCUSSION This case suggests that model-based adaptive dosing could have allowed to reach quicker the best dosing with Sunitinib, thus possibly ensuring a better management of this patient. Model-informed dosing should be used instead of empirical search for the most appropriate dosing to ensure a good benefit/risk ratio with Sunitinib, especially in the context of such aggressive disease.
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Affiliation(s)
- Florent Ferrer
- COMPO Unit, Centre de Recherche en Cancérologie de Marseille, Inserm U1068 Inria Centre de Recherches Sophia Méditerranée, Aix Marseille Université, 13385, Marseille, France.,SMARTc, Centre de Recherche en Cancérologie de Marseille, Inserm U1068 Aix Marseille Université, 13385, Marseille, France.,Laboratoire de Pharmacocinétique Clinique Et de Toxicologie, La Timone University Hospital of Marseille, 13385, Marseille, France
| | | | - Jean-Laurent Deville
- Medical Oncology, La Timone University Hospital of Marseille, 13385, Marseille, France
| | - Joseph Ciccolini
- COMPO Unit, Centre de Recherche en Cancérologie de Marseille, Inserm U1068 Inria Centre de Recherches Sophia Méditerranée, Aix Marseille Université, 13385, Marseille, France. .,SMARTc, Centre de Recherche en Cancérologie de Marseille, Inserm U1068 Aix Marseille Université, 13385, Marseille, France. .,Laboratoire de Pharmacocinétique Clinique Et de Toxicologie, La Timone University Hospital of Marseille, 13385, Marseille, France.
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24
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Studentova H, Volakova J, Spisarova M, Zemankova A, Aiglova K, Szotkowski T, Melichar B. Severe tyrosine-kinase inhibitor induced liver injury in metastatic renal cell carcinoma patients: two case reports assessed for causality using the updated RUCAM and review of the literature. BMC Gastroenterol 2022; 22:49. [PMID: 35123392 PMCID: PMC8818210 DOI: 10.1186/s12876-022-02121-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 01/25/2022] [Indexed: 11/24/2022] Open
Abstract
Background Sunitinib and pazopanib are both oral small molecule multityrosine kinase inhibitors (MTKI) used in the treatment of renal cell carcinoma (RCC). Hepatotoxicity or “liver injury” is the most important adverse effect of pazopanib administration, but little is known about the underlying mechanism. Liver injury may also occur in patients treated with sunitinib, but severe toxicity is extremely rare. Herein we report two new cases of severe liver injury induced by MTKI. Both cases are unique and exceptional. We assessed both cases for drug-induced liver injury (DILI) using the updated score Roussel Uclaf causality assessment method (RUCAM). The literature on potential pathogenic mechanisms and precautionary measures is reviewed.
Case presentation A case of a metastatic RCC (mRCC) patient treated with pazopanib who had manifestation of severe liver injury is presented. These manifestations consisted of grade 4 alanine aminotransferase (ALT) increase and grade 4 hyperbilirubinemia. Alternate causes of acute or chronic liver disease were excluded. The patient gradually recovered from the liver injury and refused any further therapy for mRCC. The patient was diagnosed with acute myeloid leukemia (AML) two years later and eventually succumbed to the disease. The second case describes a mRCC patient treated with sunitinib for 3,5 years and fatal liver failure after 2 weeks of clarithromycin co-medication for acute bronchitis. Conclusions Liver injury has been commonly observed in TKI-treated patients with unpredictable course. Management requires regular routine liver enzyme-monitoring and the collaboration of medical oncologist and hepatologist. There is an unmet medical need for a risk stratification and definition of predictive biomarkers to identify potential genetic polymorphisms or other factors associated with TKI-induced liver injury. Any potential unrecommended concomitant therapy has to be avoided.
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Barnett S, Holden V, Campbell-Hewson Q, Veal GJ. Perspectives and Expertise in Establishing a Therapeutic Drug Monitoring Programme for Challenging Childhood Cancer Patient Populations. Front Oncol 2022; 11:815040. [PMID: 35071019 PMCID: PMC8770741 DOI: 10.3389/fonc.2021.815040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
The utility of Therapeutic Drug Monitoring (TDM) in the setting of childhood cancer is a largely underused tool, despite the common use of cytotoxic chemotherapeutics. While it is encouraging that modern advances in chemotherapy have transformed outcomes for children diagnosed with cancer, this has come at the cost of an elevated risk of life-changing long-term morbidity and late effects. This concern can limit the intensity at which these drugs are used. Widely used chemotherapeutics exhibit marked inter-patient variability in drug exposures following standard dosing, with fine margins between exposures resulting in toxicity and those resulting in potentially suboptimal efficacy, thereby fulfilling criteria widely accepted as fundamental for TDM approaches. Over the past decade in the UK, the paediatric oncology community has increasingly embraced the potential benefits of utilising TDM for particularly challenging patient groups, including infants, anephric patients and those receiving high dose chemotherapy. This has been driven by a desire from paediatric oncologists to have access to clinical pharmacology information to support dosing decisions being made. This provides the potential to modify doses between treatment cycles based on a comprehensive set of clinical information, with individual patient drug exposures being used alongside clinical response and tolerability data to inform dosing for subsequent cycles. The current article provides an overview of recent experiences of conducting TDM in a childhood cancer setting, from the perspectives of the clinicians, scientists and pharmacists implementing TDM-based dosing recommendations. The ongoing programme of work has facilitated investigations into the validity of current approaches to dosing for some of the most challenging childhood cancer patient groups, with TDM approaches now being expanded from well-established cytotoxic drugs through to newer targeted treatments.
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Affiliation(s)
- Shelby Barnett
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | | | - Gareth J Veal
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, United Kingdom
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Physiologically based pharmacokinetic model predictions of natural product-drug interactions between goldenseal, berberine, imatinib and bosutinib. Eur J Clin Pharmacol 2022; 78:597-611. [DOI: 10.1007/s00228-021-03266-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 12/13/2021] [Indexed: 11/03/2022]
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27
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Groenland SL, Verheijen RB, Joerger M, Mathijssen RHJ, Sparreboom A, Beijnen JH, Beumer JH, Steeghs N, Huitema ADR. Precision Dosing of Targeted Therapies Is Ready for Prime Time. Clin Cancer Res 2021; 27:6644-6652. [PMID: 34548319 PMCID: PMC8934568 DOI: 10.1158/1078-0432.ccr-20-4555] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/19/2021] [Accepted: 09/13/2021] [Indexed: 12/16/2022]
Abstract
Fixed dosing of oral targeted therapies is inadequate in the era of precision medicine. Personalized dosing, based on pharmacokinetic (PK) exposure, known as therapeutic drug monitoring (TDM), is rational and supported by increasing evidence. The purpose of this perspective is to discuss whether randomized studies are needed to confirm the clinical value of precision dosing in oncology. PK-based dose adjustments are routinely made for many drugs and are recommended by health authorities, for example, for patients with renal impairment or for drug-drug interaction management strategies. Personalized dosing simply extrapolates this paradigm from selected patient populations to each individual patient with suboptimal exposure, irrespective of the underlying cause. If it has been demonstrated that exposure is related to a relevant clinical outcome, such as efficacy or toxicity, and that exposure can be optimized by PK-guided dosing, it could be logically assumed that PK-guided dosing would result in better treatment outcomes without the need for randomized confirmatory trials. We propose a path forward to demonstrate the clinical relevance of individualized dosing of molecularly-targeted anticancer drugs.
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Affiliation(s)
- Stefanie L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Remy B Verheijen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Markus Joerger
- Department of Medical Oncology and Hematology, Cantonal Hospital, St. Gallen, Switzerland
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Alex Sparreboom
- Division of Pharmaceutics and Pharmacology, College of Pharmacy and Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Jan H Beumer
- Cancer Therapeutics Program, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Neeltje Steeghs
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.
- Department of Clinical Pharmacy, Utrecht University Medical Center, Utrecht, the Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
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Developing a Nationwide Infrastructure for Therapeutic Drug Monitoring of Targeted Oral Anticancer Drugs: The ON-TARGET Study Protocol. Cancers (Basel) 2021; 13:cancers13246281. [PMID: 34944899 PMCID: PMC8699239 DOI: 10.3390/cancers13246281] [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: 11/10/2021] [Revised: 12/10/2021] [Accepted: 12/12/2021] [Indexed: 12/28/2022] Open
Abstract
Simple Summary Relationships between drug concentrations in blood and efficacy and/or toxicity have been reported for up to 80% of oral anticancer drugs (OADs). Most OADs exhibit highly variable drug concentrations at the approved dose. This may result in a significant proportion of patients with suboptimal drug concentrations. Therapeutic Drug Monitoring (TDM), which is dose optimization based on measured drug concentrations, can be used to personalize drug dosing with the overall goal to improve the benefit-risk ratio of anticancer drug treatment. The ON-TARGET study aims to investigate the feasibility of TDM in patients receiving either axitinib or cabozantinib for the treatment of renal-cell carcinoma with the main objective to improve severe tyrosine kinase inhibitor associated toxicity. Additionally, the feasibility of volumetric absorptive microsampling (VAMS), a novel minimally invasive and easy to handle blood sampling technique, for TDM sample collection is investigated. Abstract Exposure-efficacy and/or exposure-toxicity relationships have been identified for up to 80% of oral anticancer drugs (OADs). Usually, OADs are administered at fixed doses despite their high interindividual pharmacokinetic variability resulting in large differences in drug exposure. Consequently, a substantial proportion of patients receive a suboptimal dose. Therapeutic Drug Monitoring (TDM), i.e., dosing based on measured drug concentrations, may be used to improve treatment outcomes. The prospective, multicenter, non-interventional ON-TARGET study (DRKS00025325) aims to investigate the potential of routine TDM to reduce adverse drug reactions in renal cell carcinoma patients receiving axitinib or cabozantinib. Furthermore, the feasibility of using volumetric absorptive microsampling (VAMS), a minimally invasive and easy to handle blood sampling technique, for sample collection is examined. During routine visits, blood samples are collected and sent to bioanalytical laboratories. Venous and VAMS blood samples are collected in the first study phase to facilitate home-based capillary blood sampling in the second study phase. Within one week, the drug plasma concentrations are measured, interpreted, and reported back to the physician. Patients report their drug intake and toxicity using PRO-CTCAE-based questionnaires in dedicated diaries. Ultimately, the ON-TARGET study aims to develop a nationwide infrastructure for TDM for oral anticancer drugs.
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Corral Alaejos Á, Zarzuelo Castañeda A, Jiménez Cabrera S, Sánchez-Guijo F, Otero MJ, Pérez-Blanco JS. External evaluation of population pharmacokinetic models of imatinib in adults diagnosed with chronic myeloid leukaemia. Br J Clin Pharmacol 2021; 88:1913-1924. [PMID: 34705297 DOI: 10.1111/bcp.15122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/29/2021] [Accepted: 10/21/2021] [Indexed: 12/30/2022] Open
Abstract
AIMS Imatinib is considered the standard first-line treatment in newly diagnosed patients with chronic-phase myeloid leukaemia (CML). Several imatinib population pharmacokinetic (popPK) models have been developed. However, their predictive performance has not been well established when extrapolated to different populations. Therefore, this study aimed to perform an external evaluation of available imatinib popPK models developed mainly in adult patients, and to evaluate the improvement in individual model-based predictions through Bayesian forecasting computed by each model at different treatment occasions. METHODS A literature review was conducted through PubMed and Scopus to identify popPK models. Therapeutic drug monitoring data collected in adult CML patients treated with imatinib was used for external evaluation, including prediction- and simulated-based diagnostics together with Bayesian forecasting analysis. RESULTS Fourteen imatinib popPK studies were included for model-performance evaluation. A total of 99 imatinib samples were collected from 48 adult CML patients undergoing imatinib treatment with a minimum of one plasma concentration measured at steady-state between January 2016 and December 2020. The model proposed by Petain et al showed the best performance concerning prediction-based diagnostics in the studied population. Bayesian forecasting demonstrated a significant improvement in predictive performance at the second visit. Inter-occasion variability contributed to reducing bias and improving individual model-based predictions. CONCLUSIONS Imatinib popPK studies developed in Caucasian subjects including α1-acid glycoprotein showed the best model performance in terms of overall bias and precision. Moreover, two imatinib samples from different visits appear sufficient to reach an adequate model-based individual prediction performance trough Bayesian forecasting.
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Affiliation(s)
| | | | | | - Fermín Sánchez-Guijo
- Institute for Biomedical Research of Salamanca, Salamanca, Spain.,Haematology Department, University Hospital of Salamanca, Salamanca, Spain.,Department of Medicine, University of Salamanca, Salamanca, Spain
| | - María José Otero
- Pharmacy Service, University Hospital of Salamanca, Salamanca, Spain.,Institute for Biomedical Research of Salamanca, Salamanca, Spain
| | - Jonás Samuel Pérez-Blanco
- Department of Pharmaceutical Sciences, Pharmacy Faculty, University of Salamanca, Salamanca, Spain.,Institute for Biomedical Research of Salamanca, Salamanca, Spain
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Clarke WA, Chatelut E, Fotoohi AK, Larson RA, Martin JH, Mathijssen RHJ, Salamone SJ. Therapeutic drug monitoring in oncology: International Association of Therapeutic Drug Monitoring and Clinical Toxicology consensus guidelines for imatinib therapy. Eur J Cancer 2021; 157:428-440. [PMID: 34597977 DOI: 10.1016/j.ejca.2021.08.033] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/17/2021] [Accepted: 08/19/2021] [Indexed: 12/30/2022]
Abstract
Although therapeutic drug monitoring (TDM) is an important tool in guiding drug dosing for other areas of medicine including infectious diseases, cardiology, psychiatry and transplant medicine, it has not gained wide acceptance in oncology. For imatinib and other tyrosine kinase inhibitors, a flat dosing approach is utilised for management of oral chemotherapy. There are many published studies examining the correlation of blood concentrations with clinical effects of imatinib. The International Association of Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT) determined that there was a need to examine the published literature regarding utility of TDM in imatinib therapy and to develop consensus guidelines for TDM based on the available data. This article summarises the scientific evidence regarding TDM of imatinib, as well as the consensus guidelines developed by the IATDMCT.
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Affiliation(s)
- William A Clarke
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Etienne Chatelut
- Université de Toulouse, Inserm, Institut Claudius-Regaud, Toulouse, France
| | - Alan K Fotoohi
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institute, Karolinska University Hospital, Huddinge, Stockholm, 141 86, Sweden
| | - Richard A Larson
- Department of Medicine and Comprehensive Cancer Center, University of Chicago, Chicago, IL, USA
| | - Jennifer H Martin
- Centre for Drug Repurposing and Medicines Research, University of Newcastle. Level 3, Hunter Medical Research Institute, New Lambton Heights, 2305, New South Wales, Australia. https://twitter.com/jenhelenmar
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
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Adiwidjaja J, Gross AS, Boddy AV, McLachlan AJ. Physiologically-based pharmacokinetic model predictions of inter-ethnic differences in imatinib pharmacokinetics and dosing regimens. Br J Clin Pharmacol 2021; 88:1735-1750. [PMID: 34535920 DOI: 10.1111/bcp.15084] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 07/28/2021] [Accepted: 09/04/2021] [Indexed: 01/06/2023] Open
Abstract
AIMS This study implements a physiologically-based pharmacokinetic (PBPK) modelling approach to investigate inter-ethnic differences in imatinib pharmacokinetics and dosing regimens. METHODS A PBPK model of imatinib was built in the Simcyp Simulator (version 17) integrating in vitro drug metabolism and clinical pharmacokinetic data. The model accounts for ethnic differences in body size and abundance of drug-metabolising enzymes and proteins involved in imatinib disposition. Utility of this model for prediction of imatinib pharmacokinetics was evaluated across different dosing regimens and ethnic groups. The impact of ethnicity on imatinib dosing was then assessed based on the established range of trough concentrations (Css,min ). RESULTS The PBPK model of imatinib demonstrated excellent predictive performance in describing pharmacokinetics and the attained Css,min in patients from different ethnic groups, shown by prediction differences that were within 1.25-fold of the clinically-reported values in published studies. PBPK simulation suggested a similar dose of imatinib (400-600 mg/d) to achieve the desirable range of Css,min (1000-3200 ng/mL) in populations of European, Japanese and Chinese ancestry. The simulation indicated that patients of African ancestry may benefit from a higher initial dose (600-800 mg/d) to achieve imatinib target concentrations, due to a higher apparent clearance (CL/F) of imatinib compared to other ethnic groups; however, the clinical data to support this are currently limited. CONCLUSION PBPK simulations highlighted a potential ethnic difference in the recommended initial dose of imatinib between populations of European and African ancestry, but not populations of Chinese and Japanese ancestry.
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Affiliation(s)
- Jeffry Adiwidjaja
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Faculty of Pharmacy, Gadjah Mada University, Yogyakarta, Special Region of Yogyakarta, Indonesia
| | - Annette S Gross
- Clinical Pharmacology Modelling & Simulation, GlaxoSmithKline R&D, Sydney, NSW, Australia
| | - Alan V Boddy
- UniSA Cancer Research Institute and UniSA Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Noda S, Iida H, Fujimoto T, Wakasugi Y, Yabuta N, Sudou M, Hira D, Tani M, Andoh A, Morita SY, Terada T. Exploratory analysis of target concentration of lenvatinib in the treatment of hepatocellular carcinoma. Cancer Chemother Pharmacol 2021; 88:281-288. [PMID: 33928425 DOI: 10.1007/s00280-021-04286-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/19/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE We aimed to evaluate exposure-toxicity/efficacy relationship of lenvatinib by determining its target trough concentration for patients with hepatocellular carcinoma (HCC). METHODS In this retrospective, observational study, 28 HCC patients who had been treated with lenvatinib were enrolled between August 2018 and April 2020. We evaluated the association between the trough lenvatinib concentration and occurrence of grade ≥ 3 toxicities. Additionally, we estimated the association of the trough lenvatinib concentration with responder status (disease control; complete response, partial response, or stable disease), and progression-free survival (PFS). RESULTS The mean trough lenvatinib concentration was significantly higher in the group with grade ≥ 3 toxicity (n = 15) than in the group with grade ≤ 2 toxicity (n = 13). Based on the receiver operating characteristic curve, the threshold values of the trough lenvatinib concentrations for predicting grade ≥ 3 toxicities and responder status were 71.4 ng/mL [area under the curve (AUC) 0.86, 95% confidence interval (CI) 0.71-1.00; p < 0.05] and 36.8 ng/mL (AUC 0.95, 95% CI 0.85-1.00; p < 0.05), respectively. Lenvatinib concentrations of 36.8-71.4 ng/mL resulted in longer PFS than concentrations < 36.8 ng/mL and ≥ 71.4 ng /mL [median 13.3 months (36.8-71.4 ng/mL) vs. 3.5 months (< 36.8 ng/mL) and 7.8 months (≥ 71.4 ng /mL), respectively]. CONCLUSIONS Considering these results, we propose that the target trough concentration of lenvatinib could be 36.8-71.4 ng/mL for maintaining disease control status and reducing grade ≥ 3 toxicity in the treatment of HCC.
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Affiliation(s)
- Satoshi Noda
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu City, Shiga, 520-2192, Japan.
| | - Hiroya Iida
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Takehide Fujimoto
- Department of Gastroenterology, Shiga University of Medical Science, Otsu, Japan
| | - Yoshinori Wakasugi
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu City, Shiga, 520-2192, Japan
| | - Naoki Yabuta
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu City, Shiga, 520-2192, Japan
| | - Masatomo Sudou
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu City, Shiga, 520-2192, Japan
| | - Daiki Hira
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu City, Shiga, 520-2192, Japan.,College of Pharmaceutical Sciences, Ritsumeikan University, Kusatsu, Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Akira Andoh
- Department of Gastroenterology, Shiga University of Medical Science, Otsu, Japan
| | - Shin-Ya Morita
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu City, Shiga, 520-2192, Japan
| | - Tomohiro Terada
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu City, Shiga, 520-2192, Japan
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Therapeutic Drug Monitoring of Targeted Anticancer Protein Kinase Inhibitors in Routine Clinical Use: A Critical Review. Ther Drug Monit 2021; 42:33-44. [PMID: 31479043 DOI: 10.1097/ftd.0000000000000699] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Therapeutic response to oral targeted anticancer protein kinase inhibitors (PKIs) varies widely between patients, with insufficient efficacy of some of them and unacceptable adverse reactions of others. There are several possible causes for this heterogeneity, such as pharmacokinetic (PK) variability affecting blood concentrations, fluctuating medication adherence, and constitutional or acquired drug resistance of cancer cells. The appropriate management of oncology patients with PKI treatments thus requires concerted efforts to optimize the utilization of these drug agents, which have probably not yet revealed their full potential. METHODS An extensive literature review was performed on MEDLINE on the PK, pharmacodynamics, and therapeutic drug monitoring (TDM) of PKIs (up to April 2019). RESULTS This review provides the criteria for determining PKIs suitable candidates for TDM (eg, availability of analytical methods, observational PK studies, PK-pharmacodynamics relationship analysis, and randomized controlled studies). It reviews the major characteristics and limitations of PKIs, the expected benefits of TDM for cancer patients receiving them, and the prerequisites for the appropriate utilization of TDM. Finally, it discusses various important practical aspects and pitfalls of TDM for supporting better implementation in the field of cancer treatment. CONCLUSIONS Adaptation of PKIs dosage regimens at the individual patient level, through a rational TDM approach, could prevent oncology patients from being exposed to ineffective or unnecessarily toxic drug concentrations in the era of personalized medicine.
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Demlová R, Turjap M, Peš O, Kostolanská K, Juřica J. Therapeutic Drug Monitoring of Sunitinib in Gastrointestinal Stromal Tumors and Metastatic Renal Cell Carcinoma in Adults-A Review. Ther Drug Monit 2021; 42:20-32. [PMID: 31259881 DOI: 10.1097/ftd.0000000000000663] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Sunitinib is an inhibitor of multiple receptor tyrosine kinases and is a standard-of-care treatment for advanced and metastatic renal cell carcinoma and a second-line treatment in locally advanced inoperable and metastatic gastrointestinal stromal tumors. A fixed dose of the drug, however, does not produce a uniform therapeutic outcome in all patients, and many face adverse effects and/or toxicity. One of the possible causes of the interindividual variability in the efficacy and toxicity response is the highly variable systemic exposure to sunitinib and its active metabolite. This review aims to summarize all available clinical evidence of the treatment of adult patients using sunitinib in approved indications, addressing the necessity to introduce proper and robust therapeutic drug monitoring (TDM) of sunitinib and its major metabolite, N-desethylsunitinib. METHODS The authors performed a systematic search of the available scientific literature using the PubMed online database. The search terms were "sunitinib" AND "therapeutic drug monitoring" OR "TDM" OR "plasma levels" OR "concentration" OR "exposure." The search yielded 520 journal articles. In total, 447 publications were excluded because they lacked sufficient relevance to the reviewed topic. The remaining 73 articles were, together with currently valid guidelines, thoroughly reviewed. RESULTS There is sufficient evidence confirming the concentration-efficacy and concentration-toxicity relationship in the indications of gastrointestinal stromal tumors and metastatic renal clear-cell carcinoma. For optimal therapeutic response, total (sunitinib + N-desethylsunitinib) trough levels of 50-100 ng/mL serve as a reasonable target therapeutic range. To avoid toxicity, the total trough levels should not exceed 100 ng/mL. CONCLUSIONS According to the current evidence presented in this review, a TDM-guided dose modification of sunitinib in selected groups of patients could provide a better treatment outcome while simultaneously preventing sunitinib toxicity.
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Affiliation(s)
- Regina Demlová
- Department of Pharmacology, Medical Faculty, Masaryk University, Brno
| | - Miroslav Turjap
- Department of Clinical Pharmacy, University Hospital Ostrava, Ostrava
| | - Ondřej Peš
- Department of Biochemistry, Medical Faculty, Masaryk University
| | | | - Jan Juřica
- Department of Pharmacology, Medical Faculty, Masaryk University, Masaryk Memorial Cancer Institute; and.,Department of Human Pharmacology and Toxicology, University of Veterinary and Pharmaceutical Sciences, Brno, Czech Republic
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Mueller-Schoell A, Groenland SL, Scherf-Clavel O, van Dyk M, Huisinga W, Michelet R, Jaehde U, Steeghs N, Huitema ADR, Kloft C. Therapeutic drug monitoring of oral targeted antineoplastic drugs. Eur J Clin Pharmacol 2021; 77:441-464. [PMID: 33165648 PMCID: PMC7935845 DOI: 10.1007/s00228-020-03014-8] [Citation(s) in RCA: 112] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/01/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE This review provides an overview of the current challenges in oral targeted antineoplastic drug (OAD) dosing and outlines the unexploited value of therapeutic drug monitoring (TDM). Factors influencing the pharmacokinetic exposure in OAD therapy are depicted together with an overview of different TDM approaches. Finally, current evidence for TDM for all approved OADs is reviewed. METHODS A comprehensive literature search (covering literature published until April 2020), including primary and secondary scientific literature on pharmacokinetics and dose individualisation strategies for OADs, together with US FDA Clinical Pharmacology and Biopharmaceutics Reviews and the Committee for Medicinal Products for Human Use European Public Assessment Reports was conducted. RESULTS OADs are highly potent drugs, which have substantially changed treatment options for cancer patients. Nevertheless, high pharmacokinetic variability and low treatment adherence are risk factors for treatment failure. TDM is a powerful tool to individualise drug dosing, ensure drug concentrations within the therapeutic window and increase treatment success rates. After reviewing the literature for 71 approved OADs, we show that exposure-response and/or exposure-toxicity relationships have been established for the majority. Moreover, TDM has been proven to be feasible for individualised dosing of abiraterone, everolimus, imatinib, pazopanib, sunitinib and tamoxifen in prospective studies. There is a lack of experience in how to best implement TDM as part of clinical routine in OAD cancer therapy. CONCLUSION Sub-therapeutic concentrations and severe adverse events are current challenges in OAD treatment, which can both be addressed by the application of TDM-guided dosing, ensuring concentrations within the therapeutic window.
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Affiliation(s)
- Anna Mueller-Schoell
- Dept. of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
- Graduate Research Training Program, PharMetrX, Berlin/Potsdam, Germany
| | - Stefanie L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Oliver Scherf-Clavel
- Institute of Pharmacy and Food Chemistry, Julius-Maximilians-Universität Würzburg, Würzburg, Germany
| | - Madelé van Dyk
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Robin Michelet
- Dept. of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Ulrich Jaehde
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany
| | - Neeltje Steeghs
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Charlotte Kloft
- Dept. of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany.
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Groenland SL, Ratain MJ, Chen LS, Gandhi V. The Right Dose: From Phase I to Clinical Practice. Am Soc Clin Oncol Educ Book 2021; 41:92-106. [PMID: 34010057 DOI: 10.1200/edbk_319567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To realize the full potential of promising new anticancer drugs, it is of paramount importance to administer them at the right dose. The aim of this educational article is to provide several opportunities to optimize anticancer drug dosing, focusing on oral targeted therapies. First, therapeutic drug monitoring can optimize exposure in individual patients, if the optimal concentration is known. This approach is of particular interest in regard to oral kinase inhibitors with high interindividual pharmacokinetic variability. If exposure is related to response, then therapeutic drug monitoring is potentially feasible, although the clinical utility of this approach has not yet been established. Other approaches to reduce variability include administration of more frequent, smaller doses and administration under optimal prandial conditions. However, for many drugs, the labeled dose has not been demonstrated to be the optimal dose; for such agents, the vast majority of patients may be receiving excessive doses, which results in excessive toxicity. Furthermore, administration of lower off-label doses may reduce both medical and financial toxicity. These strategies should be applied from registration studies to clinical practice, with the goal of better optimizing anticancer treatment.
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Affiliation(s)
- Stefanie L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, the Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL
| | - Lisa S Chen
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Varsha Gandhi
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX.,Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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Krens SD, Lubberman FJE, van Egmond M, Jansman FGA, Burger DM, Hamberg P, Vervenne WL, Gelderblom H, van der Graaf WTA, Desar IME, van Herpen CML, van Erp NP. The impact of a 1-hour time interval between pazopanib and subsequent intake of gastric acid suppressants on pazopanib exposure. Int J Cancer 2021; 148:2799-2806. [PMID: 33428771 PMCID: PMC8048885 DOI: 10.1002/ijc.33469] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/16/2020] [Accepted: 12/17/2020] [Indexed: 01/01/2023]
Abstract
Co‐treatment with gastric acid suppressants (GAS) in patients taking anticancer drugs that exhibit pH‐dependant absorption may lead to decreased drug exposure and may hamper drug efficacy. In our study, we investigated whether a 1‐hour time interval between subsequent intake of pazopanib and GAS could mitigate this negative effect on drug exposure. We performed an observational study in which we collected the first steady‐state pazopanib trough concentration (Cmin) levels from patients treated with pazopanib 800 mg once daily (OD) taken fasted or pazopanib 600 mg OD taken with food. All patients were advised to take GAS 1 hour after pazopanib. Patients were grouped based on the use of GAS and the geometric (GM) Cmin levels were compared between groups for each dose regimen. Additionally, the percentage of patients with exposure below the target threshold of 20.5 mg/L and the effect of the type of PPI was explored. The GM Cmin levels were lower in GAS users vs non‐GAS users for both the 800 and 600 mg cohorts (23.7 mg/L [95% confidence interval [CI]: 21.1‐26.7] vs 28.2 mg/L [95% CI: 25.9‐30.5], P = .015 and 26.0 mg/L [95% CI: 22.4‐30.3] vs 33.5 mg/L [95% CI: 30.3‐37.1], P = .006). Subtherapeutic exposure was more prevalent in GAS users vs non‐GAS users (33.3% vs 19.5% and 29.6% vs 14%). Sub‐analysis showed lower GM pazopanib Cmin in patients who received omeprazole, while minimal difference was observed in those receiving pantoprazole compared to non‐users. Our research showed that a 1‐hour time interval between intake of pazopanib and GAS did not mitigate the negative effect of GAS on pazopanib exposure and may hamper pazopanib efficacy.
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Affiliation(s)
- Stefanie D. Krens
- Department of PharmacyRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenThe Netherlands
| | | | - Marthe van Egmond
- Department of Clinical PharmacyRadboud University Medical CenterNijmegenThe Netherlands
| | - Frank G. A. Jansman
- Department of PharmacyDeventer HospitalDeventerThe Netherlands
- PharmacoTherapy, ‐Epidemiology & ‐EconomicsUniversity of Groningen, Groningen Research Institute of PharmacyGroningenThe Netherlands
| | - David M. Burger
- Department of PharmacyRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenThe Netherlands
| | - Paul Hamberg
- Department of Medical OncologyFranciscus Gasthuis & VlietlandRotterdamThe Netherlands
| | | | - Hans Gelderblom
- Department of Medical OncologyLeiden University Medical CenterLeidenThe Netherlands
| | - Winette T. A. van der Graaf
- Department of Medical OncologyRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenThe Netherlands
| | - Ingrid M. E. Desar
- Department of Medical OncologyRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenThe Netherlands
| | - Carla M. L. van Herpen
- Department of Medical OncologyRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenThe Netherlands
| | - Nielka P. van Erp
- Department of Clinical PharmacyRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenThe Netherlands
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Xu H, Liu Q. Individualized Management of Blood Concentration in Patients with Gastrointestinal Stromal Tumors. Onco Targets Ther 2021; 13:13345-13355. [PMID: 33456310 PMCID: PMC7804055 DOI: 10.2147/ott.s279998] [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: 09/02/2020] [Accepted: 11/18/2020] [Indexed: 01/29/2023] Open
Abstract
Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor, and surgical resection is the first choice for the treatment of the disease, but since the advent of tyrosine kinase inhibitors (TKIs) such as imatinib (IM), the prognosis of the disease has undergone revolutionary changes. According to the current version of the guidelines, most GIST patients receive a fixed dose without taking into account their own individual differences, resulting in a wide difference in blood concentration, adverse reactions and prognosis. With more studies on the relationship between blood drug concentrations and prognosis, the concept of individualized therapy has been paid more attention by researchers. Therapeutic drug monitoring (TDM) has also been made available for the research field of GIST targeted therapy. How to reduce the incidence of drug resistance and adverse reactions in patients with GISTs has become the focus of the current research. This article reviews the common monitoring methods and timing of TKIs blood concentration, the reasonable range of blood drug concentration, the toxic or adverse effects caused by high blood drug concentration, some possible factors affecting blood drug concentration and recent research progress, in order to discuss and summarize the treatment strategy of individual blood drug concentration, improve the prognosis of patients and reduce the adverse effects as much as possible.
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Affiliation(s)
- Hao Xu
- Department of Gastrointestinal Surgery, The First Hospital of China Medical University, Shenyang, People's Republic of China
| | - Qi Liu
- Trauma Center, The First Hospital of China Medical University, Shenyang, People's Republic of China
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Fukudo M, Tamaki G, Azumi M, Shibata H, Tandai S. Pharmacokinetically guided dosing has the potential to improve real-world outcomes of pazopanib. Br J Clin Pharmacol 2020; 87:2132-2139. [PMID: 33010046 DOI: 10.1111/bcp.14580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/16/2020] [Accepted: 09/27/2020] [Indexed: 01/04/2023] Open
Abstract
It remains unclear whether therapeutic drug monitoring (TDM) of pazopanib improves treatment outcomes in routine clinical practice. We did a prospective cohort study to evaluate the benefits of TDM for pazopanib therapy in real-world practice. Among 25 patients with pharmacokinetically guided dosing, only 5 (20%, 95% confidence interval 6.8-40.7%) discontinued treatment because of adverse events. However, 5 (41.7%, 95% confidence interval 15.2-72.3%) of historical controls including 12 patients not receiving such a strategy experienced adverse events leading to early termination. PK-guided dosing significantly increased median time-to-treatment discontinuation (252 vs 74 days, P = .012) with reduced toxicity and improved overall survival (not reached vs 313 days, P = .002) relative to conventional dosing in the control group. In conclusion, PK-guided dose adaptation through the use of TDM has the potential to improve treatment outcomes of pazopanib in routine clinical practice, warranting larger, randomized studies.
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Affiliation(s)
- Masahide Fukudo
- Department of Hospital Pharmacy and Pharmacology, Asahikawa Medical University, Asahikawa, Japan.,Department of Pharmacy, Sapporo Medical University Hospital, Sapporo, Japan
| | - Gaku Tamaki
- Department of Renal and Urologic Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Makoto Azumi
- Department of Renal and Urologic Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Hiroaki Shibata
- Department of Orthopedic Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Susumu Tandai
- Department of Orthopedic Surgery, Asahikawa Medical University, Asahikawa, Japan
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40
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Aghai F, Zimmermann S, Kurlbaum M, Jung P, Pelzer T, Klinker H, Isberner N, Scherf-Clavel O. Development and validation of a sensitive liquid chromatography tandem mass spectrometry assay for the simultaneous determination of ten kinase inhibitors in human serum and plasma. Anal Bioanal Chem 2020; 413:599-612. [PMID: 33155133 PMCID: PMC7644392 DOI: 10.1007/s00216-020-03031-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/02/2020] [Accepted: 10/27/2020] [Indexed: 11/29/2022]
Abstract
A liquid chromatography tandem mass spectrometry method for the analysis of ten kinase inhibitors (afatinib, axitinib, bosutinib, cabozantinib, dabrafenib, lenvatinib, nilotinib, osimertinib, ruxolitinib, and trametinib) in human serum and plasma for the application in daily clinical routine has been developed and validated according to the US Food and Drug Administration and European Medicines Agency validation guidelines for bioanalytical methods. After protein precipitation of plasma samples with acetonitrile, chromatographic separation was performed at ambient temperature using a Waters XBridge® Phenyl 3.5 μm (2.1 × 50 mm) column. The mobile phases consisted of water-methanol (9:1, v/v) with 10 mM ammonium bicarbonate as phase A and methanol-water (9:1, v/v) with 10 mM ammonium bicarbonate as phase B. Gradient elution was applied at a flow rate of 400 μL/min. Analytes were detected and quantified using multiple reaction monitoring in electrospray ionization positive mode. Stable isotopically labeled compounds of each kinase inhibitor were used as internal standards. The acquisition time was 7.0 min per run. All analytes and internal standards eluted within 3.0 min. The calibration curves were linear over the range of 2–500 ng/mL for afatinib, axitinib, bosutinib, lenvatinib, ruxolitinib, and trametinib, and 6–1500 ng/mL for cabozantinib, dabrafenib, nilotinib, and osimertinib (coefficients of correlation ≥ 0.99). Validation assays for accuracy and precision, matrix effect, recovery, carryover, and stability were appropriate according to regulatory agencies. The rapid and sensitive assay ensures high throughput and was successfully applied to monitor concentrations of kinase inhibitors in patients. Graphical abstract ![]()
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Affiliation(s)
- Fatemeh Aghai
- Department of Internal Medicine II, University of Würzburg Medical Center, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Sebastian Zimmermann
- Institute of Pharmacy and Food Chemistry, University of Würzburg, Am Hubland, 97074, Würzburg, Germany
| | - Max Kurlbaum
- Department of Internal Medicine I, University of Würzburg Medical Center, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.,Core Unit Clinical Mass Spectrometry, University of Würzburg Medical Center, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Pius Jung
- Department of Internal Medicine I, Division of Pneumonology, University of Würzburg Medical Center, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Theo Pelzer
- Department of Internal Medicine I, Division of Pneumonology, University of Würzburg Medical Center, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Hartwig Klinker
- Department of Internal Medicine II, University of Würzburg Medical Center, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Nora Isberner
- Department of Internal Medicine II, University of Würzburg Medical Center, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Oliver Scherf-Clavel
- Institute of Pharmacy and Food Chemistry, University of Würzburg, Am Hubland, 97074, Würzburg, Germany.
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Ferrer F, Fanciullino R, Milano G, Ciccolini J. Towards Rational Cancer Therapeutics: Optimizing Dosing, Delivery, Scheduling, and Combinations. Clin Pharmacol Ther 2020; 108:458-470. [PMID: 32557660 DOI: 10.1002/cpt.1954] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/30/2020] [Indexed: 12/16/2022]
Abstract
The current trend to personalize anticancer therapies mostly relies on selecting the best drug or combination of drugs to achieve optimal efficacy in patients. In addition to the comprehensive genetic and molecular knowledge of each tumor before choosing the drugs to be given, there is probably much room left for improvement by further personalizing the very modes by which the drugs are given, once they have been carefully selected. In particular, shifting from standard dosing to tailored dosing should help in maintaining drug exposure levels in the right therapeutic window, thus ensuring that the efficacy/toxicity balance is optimal. This paper covers the current knowledge regarding pharmacokinetic/pharmacodynamic relationships of anticancer agents, from decades-old cytotoxics to the latest immune checkpoint inhibitors, the most frequent sources for long-neglected interpatient variability impacting on drug exposure levels, and what could be done to achieve real personalized medicine in oncology such as implementing therapeutic drug monitoring with adaptive dosing strategies or using model-driven modalities for personalized dosing and scheduling.
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Affiliation(s)
- Florent Ferrer
- SMARTc Unit, CRCM Inserm U1068, Aix Marseille Univ and APHM, Marseille, France
| | | | - Gérard Milano
- Onco-Pharmacology Unit, Centre Antoine Lacassagne, Nice, France
| | - Joseph Ciccolini
- SMARTc Unit, CRCM Inserm U1068, Aix Marseille Univ and APHM, Marseille, France
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IJzerman NS, Groenland SL, Koenen AM, Kerst M, van der Graaf WTA, Rosing H, Beijnen JH, Huitema ADR, Steeghs N. Therapeutic drug monitoring of imatinib in patients with gastrointestinal stromal tumours - Results from daily clinical practice. Eur J Cancer 2020; 136:140-148. [PMID: 32688207 DOI: 10.1016/j.ejca.2020.05.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/13/2020] [Accepted: 05/19/2020] [Indexed: 11/20/2022]
Abstract
AIM Higher imatinib exposure is correlated with longer time to progression, while the variability in exposure is high. This provides a strong rationale for therapeutic drug monitoring, which has therefore been implemented in routine clinical practice in our institute. The aim of this study is to evaluate whether pharmacokinetically (PK)-guided dose increases are feasible in daily clinical practice and result in an improved exposure (Cmin≥1100 ng/mL) and longer progression-free survival (PFS). METHODS This retrospective study included all patients with a gastrointestinal stromal tumour (GIST) in the Netherlands Cancer Institute who started imatinib treatment at a dose of 400 mg and of whom PK plasma samples were available. Of these patients, minimum plasma concentrations (Cmin) of imatinib, frequency and successfulness of PK-guided dose increases and PFS in the palliative treatment setting were analysed. RESULTS In total, 169 consecutive patients were included, of whom 1402 PK samples were collected. In 126 patients (75%), Cmin was below the efficacy threshold of 1100 ng/mL. In 78 of these patients (62%), a PK-guided dose increase was performed, which was successful in 49 patients (63%). PFS was similar in patients with and without imatinib dose increase. However, due to the small number of patients with progressive disease, no definite conclusions on the effect on PFS could yet be drawn. CONCLUSION This is the largest cohort evaluating PK-guided dose increases of imatinib in patients with GIST in routine clinical practice and demonstrating its feasibility. PK-guided dose increases should be applied to optimise exposure in the significant subset of patients with a low Cmin.
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Affiliation(s)
- Nikki S IJzerman
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands; Erasmus MC - Cancer Institute, Department of Medical Oncology, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - Stefanie L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Anne Miek Koenen
- Division of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Martijn Kerst
- Division of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Winette T A van der Graaf
- Division of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Hilde Rosing
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands; Department of Pharmaceutical Sciences, Utrecht University, Heidelberglaan 8, 3584 CS, Utrecht, the Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands; Department of Clinical Pharmacy, University Medical Center, Utrecht University, Heidelberglaan 8, 3584 CS, Utrecht, the Netherlands
| | - Neeltje Steeghs
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
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Lyashchenko AK, Cremers S. On precision dosing of oral small molecule drugs in oncology. Br J Clin Pharmacol 2020; 87:263-270. [PMID: 32621551 DOI: 10.1111/bcp.14454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/06/2020] [Accepted: 06/17/2020] [Indexed: 12/17/2022] Open
Abstract
Personalization of oral small molecule anticancer drug doses based on individual patient blood drug levels, also known as therapeutic drug monitoring (TDM), has the potential to significantly improve the effectiveness of treatment by maximizing drug efficacy and minimize toxicity. However, this option has not yet been widely embraced by the oncology community. Some reasons for this include increased logistical complexity of dose individualization, the lack of clinical laboratories that measure small molecule drug concentrations in support of patient care, and the lack of reimbursement of costs. However, the main obstacle may be the lack of studies clearly demonstrating that monitoring of oral small molecule anticancer drug levels actually improves clinical outcomes. Without unequivocal evidence in support of TDM-guided dose individualization, especially demonstration of improved survival with TDM in randomized controlled trials, wide acceptance of this approach by oncologists and reimbursement by insurance companies is unlikely, and patients may continue to suffer as a result of receiving incorrect drug doses. This article reviews the current status of TDM of oral small molecule drugs in oncology and intends to provide strategic insights into the design of studies for evaluating the utility of TDM in this clinical context.
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Affiliation(s)
- Alex K Lyashchenko
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Serge Cremers
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Westerdijk K, Krens SD, van der Graaf WTA, Mulder SF, van Herpen CML, Smilde T, van Erp NP, Desar IME. The relationship between sunitinib exposure and both efficacy and toxicity in real-world patients with renal cell carcinoma and gastrointestinal stromal tumour. Br J Clin Pharmacol 2020; 87:326-335. [PMID: 32358810 PMCID: PMC9328649 DOI: 10.1111/bcp.14332] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 04/03/2020] [Accepted: 04/16/2020] [Indexed: 02/06/2023] Open
Abstract
Aim Sunitinib is an oral tyrosine kinase inhibitor approved for the treatment of renal cell carcinoma (RCC) and gastrointestinal stromal tumor (GIST). Because of the large interpatient pharmacokinetic variability and established exposure‐response and exposure‐toxicity relationships in clinical trial patients, therapeutic drug monitoring (TDM) seems promising for optimizing sunitinib exposure. We aimed to investigate the relationship between sunitinib exposure and treatment outcome in a real‐world patient cohort. Methods We performed a retrospective observational cohort study in 53 patients with metastatic RCC and 18 patients with metastatic GIST treated with sunitinib and receiving TDM‐guided dosing. Time on treatment – as a surrogate for progression‐free survival – in patients who achieved adequate sunitinib exposure was compared with patients who did not. Additionaly, the median sunitinib exposure was compared in patients with or without sunitinib‐induced toxicity leading to dose reduction. Results The median time on treatment in patients with RCC who achieved adequate sunitinib exposure (n = 39) was 32 weeks, compared to 15 weeks in patients who did not achieve adequate sunitinib exposure (n = 12) (P = 0.244). In 29 patients (41%) with toxicity leading to dose reduction, sunitinib sum plasma trough concentration (Ctrough) until dose reduction was significantly higher compared to patients without toxicity leading to dose reduction (median 60 ng/mL vs 44 ng/mL; P < 0.001) and reduced to comparable levels after dose reduction (44 ng/mL; P = 0.488). Conclusion In our real‐world patient cohort, patients with sunitinib‐induced toxicity requiring dose reduction had significantly higher sunitinib exposure compared to patients without toxicity. The threshold for toxicity, however, was lower compared to that previously described in clinical trials.
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Affiliation(s)
- Kim Westerdijk
- Department of Medical Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Stefanie D Krens
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Winette T A van der Graaf
- Department of Medical Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Sasja F Mulder
- Department of Medical Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Carla M L van Herpen
- Department of Medical Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Tineke Smilde
- Department of Medical Oncology, Jeroen Bosch Hospital, 's Hertogenbosch, Netherlands
| | - Nielka P van Erp
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ingrid M E Desar
- Department of Medical Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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45
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Toh YL, Pang YY, Shwe M, Kanesvaran R, Toh CK, Chan A, Ho HK. HPLC-MS/MS coupled with equilibrium dialysis method for quantification of free drug concentration of pazopanib in plasma. Heliyon 2020; 6:e03813. [PMID: 32373731 PMCID: PMC7191207 DOI: 10.1016/j.heliyon.2020.e03813] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/10/2020] [Accepted: 04/16/2020] [Indexed: 12/12/2022] Open
Abstract
Background The selective occurrence of hepatotoxicity observed with use of pazopanib may be attributed to its high level of plasma protein binding and low hepatic extraction ratio. The primary objective was to investigate changes in free drug concentration amongst patients with varying albumin concentrations. Methods A HPLC-MS/MS method using C18 column (4.6 × 150 mm, 5 μm) with ESI source in positive mode had been developed and validated for the quantitative determination of free pazaopanib concentration in human plasma. Prior to sample preparation, patient samples were subjected to 6-hour equilibrium dialysis with molecular weight cut-off set at 8000 Da. Results The calibration curves were linear over the range of 5–1000 ng/mL, with a lower limit of quantification of 5 ng/mL. The intra-day and inter-day precisions and accuracies were all within ± 15 %, at 3 different quality controls. Higher median fraction unbound of pazopanib were observed in patients (n = 17) with lower than normal albumin concentrations. Conclusion With the developed assay, monitoring of plasma free concentrations may be evaluated as an indicator of pazopanib exposure in patients.
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Affiliation(s)
- Yi Long Toh
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
| | - Yi Yun Pang
- Division of Chemistry and Biological Chemistry, Nanyang Technological University, Singapore
| | - Maung Shwe
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore.,Oncology Pharmacy, National Cancer Centre Singapore, Singapore
| | | | - Chee Keong Toh
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - Alexandre Chan
- Oncology Pharmacy, National Cancer Centre Singapore, Singapore.,Department of Clinical Pharmacy Practice, University of California, Irvine, USA
| | - Han Kiat Ho
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
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Therapeutic Drug Monitoring of Oral Anticancer Drugs: The Dutch Pharmacology Oncology Group-Therapeutic Drug Monitoring Protocol for a Prospective Study. Ther Drug Monit 2020; 41:561-567. [PMID: 31568233 DOI: 10.1097/ftd.0000000000000654] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Oral anticancer drugs show a high interpatient variability in pharmacokinetics (PK), leading to large differences in drug exposure. For many of these drugs, exposure has been linked to efficacy and toxicity. Despite this knowledge, these drugs are still administered in a one-size-fits-all approach. Consequently, individual patients have a high probability to be either underdosed, which can lead to decreased antitumor efficacy, or overdosed, which could potentially result in increased toxicity. Therapeutic drug monitoring (TDM), personalized dosing based on measured drug levels, could be used to circumvent underdosing and overdosing and thereby optimize treatment outcomes. METHODS In this prospective clinical study (www.trialregister.nl; NL6695), the feasibility, tolerability, and efficacy of TDM of oral anticancer drugs will be evaluated. In total, at least 600 patients will be included for (at least) 23 different compounds. Patients starting regular treatment with one of these compounds at the approved standard dose can be included. PK sampling will be performed at 4, 8, and 12 weeks after the start of treatment and every 12 weeks thereafter. Drug concentrations will be measured, and trough concentrations (Cmin) will be calculated. In cases where Cmin falls below the predefined target and acceptable toxicity, a PK-guided intervention will be recommended. This could include emphasizing compliance, adapting concomitant medication (due to drug-drug interactions), instructing to take the drug concomitant with food, splitting intake moments, or recommending a dose increase. DISCUSSION Despite a strong rationale for the use of TDM for oral anticancer drugs, this is currently not yet widely adopted in routine patient care. This prospective study will be a valuable contribution to demonstrate the additional value of dose optimization on treatment outcome for these drugs.
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47
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Cost-Neutral Optimization of Pazopanib Exposure by Splitting Intake Moments: A Prospective Pharmacokinetic Study in Cancer Patients. Clin Pharmacokinet 2020; 59:941-948. [PMID: 32020530 DOI: 10.1007/s40262-020-00863-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Pazopanib is an oral tyrosine kinase inhibitor used in the treatment of renal cell carcinoma and soft-tissue sarcoma. At the approved dose of 800 mg once daily (QD), 16-20% of patients are being underdosed and at risk of decreased efficacy. This study aimed to show whether splitting intake moments, as a cost-neutral alternative to a dose increase, leads to an increased exposure. METHODS We performed a cross-over trial comparing the pharmacokinetics of pazopanib 800 mg QD with pazopanib 400 mg twice daily. Pharmacokinetic sampling was performed at steady-state for both dosing schedules. RESULTS Nine evaluable patients were included. At the 800 mg QD dosing schedule, median minimum plasma concentration (Cmin), area under the concentration-time curve from 0 to 24 h (AUC0-24h), and maximum plasma concentration (Cmax) were 23.2 mg/L (interquartile range 18.5-27.6), 773 mg h/L (557-1009), and 40.6 mg/L (36.4-56.4) compared with 41.6 mg/L (30.5-55.8, p = 0.004), 942 mg h/L (885-1419, p = 0.027), and 50.2 mg/L (46.8-72.5, p = 0.074) at 400 mg twice daily. One patient experienced a grade 3 event (i.e., diarrhea). CONCLUSIONS This study demonstrates that splitting intake moments of pazopanib leads to a 79% increase in Cmin, with acceptable tolerability. Therefore, this new dosing schedule offers a cost-neutral opportunity to optimize treatment in patients with low exposure. CLINICAL TRIAL REGISTRATION NL6137 ( http://www.trialregister.nl ).
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Adiwidjaja J, Boddy AV, McLachlan AJ. Implementation of a Physiologically Based Pharmacokinetic Modeling Approach to Guide Optimal Dosing Regimens for Imatinib and Potential Drug Interactions in Paediatrics. Front Pharmacol 2020; 10:1672. [PMID: 32082165 PMCID: PMC7002565 DOI: 10.3389/fphar.2019.01672] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 12/23/2019] [Indexed: 12/18/2022] Open
Abstract
Long-term use of imatinib is effective and well-tolerated in children with chronic myeloid leukaemia (CML) yet defining an optimal dosing regimen for imatinib in younger patients is a challenge. The potential interactions between imatinib and coadministered drugs in this "special" population also remains largely unexplored. This study implements a physiologically based pharmacokinetic (PBPK) modeling approach to investigate optimal dosing regimens and potential drug interactions with imatinib in the paediatric population. A PBPK model for imatinib was developed in the Simcyp Simulator (version 17) utilizing in silico, in vitro drug metabolism, and in vivo pharmacokinetic data and verified using an independent set of published clinical pharmacokinetic data. The model was then extrapolated to children and adolescents (aged 2-18 years) by incorporating developmental changes in organ size and maturation of drug-metabolising enzymes and plasma protein responsible for imatinib disposition. The PBPK model described imatinib pharmacokinetics in adult and paediatric populations and predicted drug interaction with carbamazepine, a cytochrome P450 (CYP)3A4 and 2C8 inducer, with a good accuracy (evaluated by visual inspections of the simulation results and predicted pharmacokinetic parameters that were within 1.25-fold of the clinically observed values). The PBPK simulation suggests that the optimal dosing regimen range for imatinib is 230-340 mg/m2/d in paediatrics, which is supported by the recommended initial dose for treatment of childhood CML. The simulations also highlighted that children and adults being treated with imatinib have similar vulnerability to CYP modulations. A PBPK model for imatinib was successfully developed with an excellent performance in predicting imatinib pharmacokinetics across age groups. This PBPK model is beneficial to guide optimal dosing regimens for imatinib and predict drug interactions with CYP modulators in the paediatric population.
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Affiliation(s)
- Jeffry Adiwidjaja
- Sydney Pharmacy School, The University of Sydney, Sydney, NSW, Australia
| | - Alan V. Boddy
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, SA, Australia
- University of South Australia Cancer Research Institute, University of South Australia, Adelaide, SA, Australia
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Westerdijk K, Desar IME, Steeghs N, van der Graaf WTA, van Erp NP. Imatinib, sunitinib and pazopanib: From flat-fixed dosing towards a pharmacokinetically guided personalized dose. Br J Clin Pharmacol 2020; 86:258-273. [PMID: 31782166 PMCID: PMC7015742 DOI: 10.1111/bcp.14185] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/21/2019] [Accepted: 11/07/2019] [Indexed: 12/13/2022] Open
Abstract
Tyrosine kinase inhibitors (TKIs) are anti‐cancer drugs that target tyrosine kinases, enzymes that are involved in multiple cellular processes. Currently, multiple oral TKIs have been introduced in the treatment of solid tumours, all administered in a fixed dose, although large interpatient pharmacokinetic (PK) variability is described. For imatinib, sunitinib and pazopanib exposure‐treatment outcome (efficacy and toxicity) relationships have been established and therapeutic windows have been defined, therefore dose optimization based on the measured blood concentration, called therapeutic drug monitoring (TDM), can be valuable in increasing efficacy and reducing the toxicity of these drugs. In this review, an overview of the current knowledge on TDM guided individualized dosing of imatinib, sunitinib and pazopanib for the treatment of solid tumours is presented. We summarize preclinical and clinical data that have defined thresholds for efficacy and toxicity. Furthermore, PK models and factors that influence the PK of these drugs which partly explain the interpatient PK variability are summarized. Finally, pharmacological interventions that have been performed to optimize plasma concentrations are described. Based on current literature, we advise which methods should be used to optimize exposure to imatinib, sunitinib and pazopanib.
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Affiliation(s)
- Kim Westerdijk
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ingrid M E Desar
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Neeltje Steeghs
- Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek hospital, Amsterdam, the Netherlands
| | - Winette T A van der Graaf
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek hospital, Amsterdam, the Netherlands
| | - Nielka P van Erp
- Department of Clinical Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
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Den Hollander D, Van der Graaf WTA, Desar IME, Le Cesne A. Predictive factors for toxicity and survival of second-line sunitinib in advanced gastrointestinal stromal tumours (GIST). Acta Oncol 2019; 58:1648-1654. [PMID: 31345082 DOI: 10.1080/0284186x.2019.1637017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Introduction: Sunitinib is a standard second-line treatment in advanced gastrointestinal stromal tumours (GIST). We aimed to search for predictive factors for grade 3 and 4 toxicity, progression-free survival (PFS) and overall survival (OS) in a GIST reference center patient population, outside clinical trials.Methods: A retrospective analysis was performed of patients treated in two European Comprehensive Cancer Centers between January 2005 and December 2015. Demographic and clinical features, tumour characteristics and biological parameters were investigated. Logistic regression models were used to find factors associated with grade 3 and 4 toxicity. To identify predictive factors for PFS and OS, variables that were statistically significant in univariate analysis were used in the multivariate Cox proportional hazards model.Results: Ninety-one patients were included in this analysis. Age >60 years (HR 5.0, p = .006) and body weight ≤70 kg (HR 4.7, p = .009) were predictive factors for grade 3 and 4 toxicity. When divided into two categories, non-haematological grade 3 and 4 toxicity was predicted by age >60 years (HR 3.8, p = .012) and body weight ≤70 kg (HR 3.3, p = .025) whereas haematological toxicity had no significantly associated predictive factors. The median PFS and OS with sunitinib were 8.8 months and 27.5 months, respectively. The use of imatinib less than six months compared to 6-12 months (HR 0.2, p = .013) and to >12 months (HR 0.3, p = .016) and liver and/or peritoneal metastases (HR 0.1, p < .001, HR 0.2, p = .003 and HR 0.2, p = .004) compared to locally advanced disease only were predictive for longer PFS. High neutrophil (HR 3.1, p = 0.04) and platelet count (HR 2.4, p = .046) predicted a shorter OS. Flexible sunitinib dosing was associated with superior OS (p = .021).Conclusion: In advanced GIST patients treated with sunitinib, older and low-weight patients are at risk for grade 3 and 4 toxicity. Clinical (prior imatinib use and metastases), biological (neutrophil and platelet count) and treatment characteristics independently predict PFS and OS.
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Affiliation(s)
- D. Den Hollander
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - W. T. A. Van der Graaf
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - I. M. E. Desar
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - A. Le Cesne
- Department of Medical Oncology, Gustave Roussy, Villejuif, France
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