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Bleckman RF, Broekman KE, Roets E, Mohammadi M, Desar IME, Gelderblom H, Mathijssen RHJ, Steeghs N, de Graeff P, Reyners AKL. Individualized Dosing Patterns in the Treatment of Older Patients with Gastrointestinal Stromal Tumors: Results of a Registry-Based Observational National Cohort Study Including 871 Patients. Drugs Aging 2024; 41:165-176. [PMID: 38123766 DOI: 10.1007/s40266-023-01084-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND While the effectiveness of tyrosine kinase inhibitors (TKIs) seems similar in older patients with gastrointestinal stromal tumors (GIST) compared with younger patients, toxicities in older patients treated with TKIs more often lead to discontinuation of treatment. OBJECTIVE To better understand the age-related pharmacology and pharmacodynamic differences in patients with GIST treated with TKIs, the primary aim of this study was to evaluate TKI dosing patterns in older patients with GIST, while the secondary aims were to evaluate differences in imatinib trough plasma concentrations between age groups and to compare the overall survival (OS) in patients with and without dose reductions in all treatment lines in a palliative setting. METHODS Patients (18 years of age or older) with histologically proven GIST diagnosed between January 2009 and June 2021 and treated with one or more lines of TKIs were selected from the Dutch GIST Registry (DGR) database. Age groups were divided into younger patients (age <70 years) and older patients (age ≥70 years). All imatinib trough plasma concentrations of blood withdrawals taken from initiation of imatinib until a maximum of 1 year of treatment with imatinib were collected. Reasons for first adjustment of treatment were classified as adverse event, dose modification, progressive disease and other reasons. The next treatment steps after first adjustment of treatment were defined as dose escalation, dose reduction, dose interruption, or end of treatment. The association of dose reduction and OS was analyzed using the landmark approach. RESULTS Overall, 871 patients were included in this study, including 577 younger patients and 294 older patients. Older patients more often had an adverse event as the reason for first adjustment of treatment with both imatinib (45.6%; p < 0.001) and sunitinib (58.6%; p = 0.224) compared with younger patients (19.5% and 42.7%, respectively). Adjustment of imatinib and sunitinib after starting on a standard dose because of an adverse event most often resulted in dose reduction in both age groups. Median trough plasma concentrations of all samples taken within the first year after initiation of imatinib were higher in older patients (1228 ng/mL, interquartile range [IQR] 959-1687) compared with younger patients (1035 ng/mL [IQR 773-1377]; p < 0.001). No significant differences were seen between OS in patients with or without dose reduction in all treatment lines (imatinib: p = 0.270; sunitinib: p = 0.547; and regorafenib: p = 0.784). CONCLUSION Older patients showed higher imatinib trough plasma concentrations compared with younger patients and also had earlier and more often adverse events as the reason for first adjustment of treatment with imatinib followed by dose reduction. However, in a landmark analysis, patients with imatinib dose reductions had no poorer outcomes compared with patients not requiring a dose reduction.
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Affiliation(s)
- Roos F Bleckman
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
- Department of Medical Oncology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - K Esther Broekman
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Medical Oncology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Evelyne Roets
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | | | | | | | - Neeltje Steeghs
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Pauline de Graeff
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Medical Oncology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Anna K L Reyners
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Medical Oncology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
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Bellouard M, Donadieu J, Thiebot P, Giroux Leprieur E, Saiag P, Etting I, Dugues P, Abe E, Alvarez JC, Larabi IA. Validation of Liquid Chromatography Coupled with Tandem Mass Spectrometry for the Determination of 12 Tyrosine Kinase Inhibitors (TKIs) and Their Application to Therapeutic Drug Monitoring in Adult and Pediatric Populations. Pharmaceutics 2023; 16:5. [PMID: 38276485 PMCID: PMC10818921 DOI: 10.3390/pharmaceutics16010005] [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: 11/15/2023] [Revised: 12/12/2023] [Accepted: 12/15/2023] [Indexed: 01/27/2024] Open
Abstract
Tyrosine kinase inhibitors (TKIs) are used as targeted cancer therapies in adults and have an off-label pediatric application for the treatment of Langerhans cell histiocytosis. A multitarget LC-MS/MS method was developed and validated for the determination of alectinib, alectinib-M4, binimetinib, cobimetinib, crizotinib, dabrafenib, encorafenib, imatinib, lorlatinib, osimertinib, AZ5104, and trametinib. A total of 150 µL of internal standard methanolic solution was added to 50 µL of plasma sample to precipitate proteins. After centrifugation, 10 µL of the supernatant was injected into the chromatographic system. The chromatographic separation was conducted on a Kinetex C18 Polar column with a gradient of 2 mM ammonium formate in 0.1% formic acid and acetonitrile over 5 min. Limits of detection and quantification, linearity, accuracy, precision, selectivity, carryover, matrix effect, recovery, and stability were evaluated and satisfied EMA guidelines on bioanalytical methods. This method has been successfully applied to the therapeutic drug monitoring (TDM) of adults with melanoma and lung cancer, as well as children with histiocytosis, to improve the pharmacokinetic data for these drugs, with the aim of enhancing the therapeutic management and follow-up of patients. Blood concentrations of trametinib and binimetinib were different in the two groups, highlighting the age-related inter-individual variability of these molecules and the need for TDM.
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Affiliation(s)
- Marie Bellouard
- Toxicology Laboratory, Raymond Poincaré Hospital, AP-HP, 92380 Garches, France; (I.E.); (P.D.); (E.A.); (I.-A.L.); (J.-C.A.)
- Pediatric Hemato-Oncology Department, Trousseau Hospital, AP-HP, 75012 Paris, France;
| | - Jean Donadieu
- Pediatric Hemato-Oncology Department, Trousseau Hospital, AP-HP, 75012 Paris, France;
| | - Pauline Thiebot
- Toxicology Laboratory, Lariboisière Hospital, AP-HP, 75010 Paris, France;
| | | | - Philippe Saiag
- Dermatology Department, Ambroise Paré Hospital, AP-HP, 92100 Boulogne-Billancourt, France;
| | - Isabelle Etting
- Toxicology Laboratory, Raymond Poincaré Hospital, AP-HP, 92380 Garches, France; (I.E.); (P.D.); (E.A.); (I.-A.L.); (J.-C.A.)
| | - Pamela Dugues
- Toxicology Laboratory, Raymond Poincaré Hospital, AP-HP, 92380 Garches, France; (I.E.); (P.D.); (E.A.); (I.-A.L.); (J.-C.A.)
- Inserm U-1018, CESP, Team MOODS, Plateform MasSpecLab, Paris-Saclay/Versailles University, 78180 Montigny-le-Bretonneux, France
| | - Emuri Abe
- Toxicology Laboratory, Raymond Poincaré Hospital, AP-HP, 92380 Garches, France; (I.E.); (P.D.); (E.A.); (I.-A.L.); (J.-C.A.)
| | - Jean-Claude Alvarez
- Toxicology Laboratory, Raymond Poincaré Hospital, AP-HP, 92380 Garches, France; (I.E.); (P.D.); (E.A.); (I.-A.L.); (J.-C.A.)
- Inserm U-1018, CESP, Team MOODS, Plateform MasSpecLab, Paris-Saclay/Versailles University, 78180 Montigny-le-Bretonneux, France
| | - Islam-Amine Larabi
- Toxicology Laboratory, Raymond Poincaré Hospital, AP-HP, 92380 Garches, France; (I.E.); (P.D.); (E.A.); (I.-A.L.); (J.-C.A.)
- Inserm U-1018, CESP, Team MOODS, Plateform MasSpecLab, Paris-Saclay/Versailles University, 78180 Montigny-le-Bretonneux, France
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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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van Kampen E, van Bussel MTJ, Oude Munnink TH, Touw DJ, Broekman KE. Representation of older patients in the safety analysis of protein kinase inhibitor registration studies. J Geriatr Oncol 2023; 14:101636. [PMID: 37806290 DOI: 10.1016/j.jgo.2023.101636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 07/13/2023] [Accepted: 09/19/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Older patients (≥65 years old) make up the majority of the cancer population. Older patients seem to experience more adverse events (AEs) from protein kinase inhibitors (PKIs) in clinical practice. Yet they are underrepresented in clinical trials. We aimed to evaluate whether age-related safety differences were described at authorization of PKIs. Representation of older patients in registration studies was also evaluated. MATERIALS AND METHODS European Public Assessment Reports (EPARs) of PKIs authorized between 2010 and 2015 were evaluated for the description of age-related safety- and pharmacokinetic differences. The International Council for Harmonization of Technical Requirement for Pharmaceuticals for Human Use (ICH) E7 guideline was applied to EPARs to assess the representation of older patients. Study results were presented descriptively. RESULTS Eighteen PKIs with 19 EPARs were analyzed. Age-related safety differences were described in 14 out of 19 EPARs, and age-related pharmacokinetic differences in 1 out of 19 EPARs. More than 100 older patients were included in half of the studies. Older patients were not excluded solely by age, although other inclusion and exclusion criteria negatively influenced enrollment of older patients. None of the PKIs met all criteria from the ICH E7 guideline. DISCUSSION Age-related safety differences are described for most PKIs. Older patients were underrepresented in PKI registration studies. Adequate representation of older patients in clinical trials for PKIs is vital, since they make up most of the cancer population.
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Affiliation(s)
- Emma van Kampen
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands
| | - Mark T J van Bussel
- College ter Beoordeling van Geneesmiddelen, Dutch Medicines Evaluation Board (CBG-MEB), Graadt van Roggenweg 500, 3531 AH Utrecht, the Netherlands
| | - Thijs H Oude Munnink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands
| | - K Esther Broekman
- College ter Beoordeling van Geneesmiddelen, Dutch Medicines Evaluation Board (CBG-MEB), Graadt van Roggenweg 500, 3531 AH Utrecht, the Netherlands; Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands.
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Raynal M, Alvarez JC, Saiag P, Beauchet A, Funck-Brentano C, Funck-Brentano E. Monitoring of plasma concentrations of dabrafenib and trametinib in advanced BRAFV600 mut melanoma patients. Ann Dermatol Venereol 2021; 149:32-38. [PMID: 34183171 DOI: 10.1016/j.annder.2021.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/28/2021] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Dabrafenib (D) and trametinib (T) improved survival in patients with BRAFV600mut melanoma. High plasma concentration of D (PCD) is weakly associated with adverse events (AE). We investigated the relationship between PCD/T and tumour control or AE. METHODS We analysed PCD/T in patients treated with D+T for metastatic melanoma. We collected data of tumour response (RECIST 1.1) and AE (CTCAE 4.0) blinded to PCD/T results. RESULTS We analysed 71 D and 58T assays from 34 patients. High inter-individual variability of PCD (median: 65.0ng/mL; interquartile range (IQR) [4-945]) and of PCT (median: 8.6ng/mL; IQR [5-39]) was observed. We found a weak relationship between PCD and progression-free survival, taking follow-up time into account (hazard ratio 0.991; 95%CI, 0.981 to 1.000; P=0.06). However, no difference was observed between mean PCD/T of progressing patients (n=21; 125±183ng/mL and 9.3±3.6ng/mL, respectively) and responders (complete, partial or stable response) (n=13; 159±225ng/mL, P=0.58 and 10.6±24.4ng/mL, P=0.29, respectively). No significant relationship was found between PCD/T and most common AEs (fever, lymphopenia, CPK increase, and hepatic cytolysis), body mass index, or age. Mean CPT (n=16) was significantly higher for female subjects (n=18; 11.5±4.8ng/mL) than for male subjects (8.8ng/mL±2.9, P=0.01), but no difference was observed between sex and CPD (P=0.32). CONCLUSION Our study showed a weak relationship between PCD and progression-free survival, but no relationship between PCD/T and AE was found. Monitoring PCD and PCT alone is unlikely to be useful in assessing response to treatment.
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Affiliation(s)
- M Raynal
- Department of General and Oncologic Dermatology, Ambroise-Paré hospital, AP-HP, 9, avenue Charles de Gaulle, 92100 Boulogne-Billancourt, France; Research Unit EA4340 'Biomarkers and clinical trials in oncology and onco-hematology', Versailles-Saint-Quentin-en-Yvelines University, Paris - Saclay University, 9, avenue Charles de Gaulle, 92100 Boulogne-Billancourt, France
| | - J-C Alvarez
- Department of Pharmacology and Toxicology, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Inserm U-1173, Raymond Poincaré hospital, AP-HP, 104, boulevard Raymond Poincaré, 92380 Garches, France
| | - P Saiag
- Department of General and Oncologic Dermatology, Ambroise-Paré hospital, AP-HP, 9, avenue Charles de Gaulle, 92100 Boulogne-Billancourt, France; Research Unit EA4340 'Biomarkers and clinical trials in oncology and onco-hematology', Versailles-Saint-Quentin-en-Yvelines University, Paris - Saclay University, 9, avenue Charles de Gaulle, 92100 Boulogne-Billancourt, France
| | - A Beauchet
- Department of Bioinformatics, Ambroise Paré Hospital, AP-HP, 9 avenue Charles de Gaulle, 92100 Boulogne-Billancourt, France
| | - C Funck-Brentano
- Sorbonne Université, INSERM CIC Paris-Est (CIC-1901), AP-HP, Sorbonne Université, ICAN, Pitié-Salpêtrière Hospital, Department of Pharmacology, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - E Funck-Brentano
- Department of General and Oncologic Dermatology, Ambroise-Paré hospital, AP-HP, 9, avenue Charles de Gaulle, 92100 Boulogne-Billancourt, France; Research Unit EA4340 'Biomarkers and clinical trials in oncology and onco-hematology', Versailles-Saint-Quentin-en-Yvelines University, Paris - Saclay University, 9, avenue Charles de Gaulle, 92100 Boulogne-Billancourt, France.
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Dabrafenib and trametinib exposure-efficacy and tolerance in metastatic melanoma patients: a pharmacokinetic-pharmacodynamic real-life study. Cancer Chemother Pharmacol 2021; 88:427-437. [PMID: 34057572 DOI: 10.1007/s00280-021-04299-x] [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: 01/05/2021] [Accepted: 05/15/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Dabrafenib plus trametinib combination has greatly improved survival in BRAFV600mut metastatic melanoma patients. However, data regarding the influence of pharmacokinetic markers in real-life patients are lacking. In this study, we aimed to explore dabrafenib and trametinib pharmacokinetic impact on progression-free survival (PFS), duration of response (DOR) or all grades treatment-related adverse events (ARAE) occurrence in routine care patients. METHODS BRAFV600mut metastatic melanoma patients initiating standard doses of dabrafenib 150 mg BID plus trametinib 2 mg QD were included. Clinical data were collected via the French biobank MelBase, prospectively enrolling unresectable stage III or IV melanoma. Clinical response evaluation, ARAE reporting and dabrafenib and trametinib plasma quantification were performed. Association of individual Bayesian-estimated pharmacokinetic markers (AUC0-τ and Ctrough) and baseline clinical variables with DOR, PFS, clinical response, and ARAE was then assessed. RESULTS Fifty patients (comprising 4 AJCC stage IIIc and 46 stage IV) were included. Median PFS reached 11.4 months, and overall response rate 70%. Fifty percent of patients experienced ARAE (G3 n = 10, G4 n = 0). In univariate analysis, median dabrafenib Ctrough within intermediate range was associated with a significantly higher PFS (HR [95% CI] = 0.41 [0.18; 0.91], p = 0.029) and DOR (HR [95% CI] = 0.39 [0.16; 0.94], p = 0.024), and association with DOR remained significant in multivariate analysis (HR [95% CI] = 0.34 [0.12; 0.95], p = 0.040). Trametinib pharmacokinetic markers were significantly higher in patients experiencing ARAE compared to patients without ARAE. CONCLUSION In this study, exposure-efficacy and tolerance analysis highlighted the interest of therapeutic drug monitoring to optimize therapeutic management in BRAFV600mut metastatic melanoma patients based on trough concentrations of dabrafenib and trametinib.
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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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Mourey L, Le Louedec F, Ravaud A, Paludetto MN, Digue L, Gomez-Roca CA, Valentin T, Balardy L, Olivier P, Cabarrou B, Filleron T, Chatelut E. VOTRAGE study: Phase I dose-escalation study of pazopanib in unfit older patients. J Geriatr Oncol 2021; 12:759-764. [PMID: 33715996 DOI: 10.1016/j.jgo.2021.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/18/2020] [Accepted: 02/05/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pazopanib is a tyrosine kinase inhibitor given at the approved dose of 800 mg orally once daily (OD), but often requiring individual dose adjustment due to toxicity. Limited data is available to guide prescription in older patients especially the unfit according to geriatric assessment. PATIENTS AND METHODS VOTRAGE is a 3 + 3 dose-escalation, open-label phase I trial of continuous OD oral administration of pazopanib to evaluate safety, PK and PD data in unfit older patients with advanced solid tumors. The primary objective was to determine the maximum tolerated dose (MTD). PK data were compared with those obtained in younger adult patients in a population PK analysis. RESULTS Eighteen patients with a median age of 82.5 years (range 75-91) were included in three dosing cohorts (400, 600, and 800 mg daily). Three dose-limiting toxicities (DLT) were observed in five patients at 800 mg and one DLT at 600 mg in six evaluable patients. MTD was defined as level 2 dose (600 mg). Individual oral clearance was not correlated with age. A relationship was observed between the occurrence of DLT and pazopanib plasma exposure. Decreased oral bioavailability of pazopanib when given with proton-pump inhibitors was confirmed in this group of patients. CONCLUSION We recommend performing geriatric assessment in patients older than 75 and starting pazopanib at 600 mg per day in unfit older patients. Therapeutic drug monitoring appears very helpful in this population.
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Affiliation(s)
- Loïc Mourey
- Department of Medical Oncology, Institut Claudius Regaud, IUCT-Oncopole, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France.
| | - Félicien Le Louedec
- Laboratory of Phamacology, Institut Claudius Regaud, IUCT-Oncopole, and CRCT, Université de Toulouse, Inserm, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - Alain Ravaud
- Department of Medical Oncology, Saint André CHU Hospital, 1, rue Jean Burguet, 33000 Bordeaux, France
| | - Marie-Noëlle Paludetto
- Pharmacy Department, Institut Claudius Regaud, IUCT-Oncopole, Toulouse, France et Cancer Research Center of Toulouse (CRCT), INSERM UMR1037, University of Toulouse, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - Laurence Digue
- Department of Medical Oncology, Saint André CHU Hospital, 1, rue Jean Burguet, 33000 Bordeaux, France
| | - Carlos Alberto Gomez-Roca
- Department of Medical Oncology, Institut Claudius Regaud, IUCT-Oncopole, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - Thibaud Valentin
- Department of Medical Oncology, Institut Claudius Regaud, IUCT-Oncopole, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - Laurent Balardy
- Geriatric Department, Internal Medicine and Oncogeriatry Unit, Toulouse University Hospital Purpan, place du Docteur Joseph Baylac, 31300 Toulouse, France
| | - Pascale Olivier
- Department of Clinical and Medical Pharmacology and regional pharmacovigilance center, Toulouse University Hospital, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - Bastien Cabarrou
- Department of Biostatistics, Institut Claudius Regaud, IUCT-Oncopole, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - Thomas Filleron
- Department of Biostatistics, Institut Claudius Regaud, IUCT-Oncopole, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France
| | - Etienne Chatelut
- Laboratory of Phamacology, Institut Claudius Regaud, IUCT-Oncopole, and CRCT, Université de Toulouse, Inserm, 1, avenue Irène Joliot-Curie, 31059 Toulouse, France
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10
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Hohenegger M. Pharmacokinetic considerations in geriatric cancer patients. MEMO - MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2021; 14:11-14. [DOI: 10.1007/s12254-020-00668-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/11/2020] [Indexed: 08/30/2023]
Abstract
SummaryPharmacological anticancer therapy in elderly people has to account for pharmacokinetic aspects in view of age-related changes in organ function and disease-related alterations. Age-related changes in organ function might still be physiological and have to be discriminated from concomitant diseases and their pharmacotherapy. Although efficacy is retained with pharmacological anticancer therapies in elderly patients, plasma drug concentrations and the incidence of adverse reactions often increase. Thus, altered organ function in elderly will be reviewed with respect to clinically relevant outcomes. Furthermore, possible consequences of therapeutic drug monitoring will be discussed focusing on novel targeted therapies with small molecules. Examples of therapeutic drug monitoring during targeted therapies may represent an easy tool to overcome the individual pharmacokinetic situation of elderly cancer patients and may contribute to enhanced safety, when implemented in clinical routine.
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11
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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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12
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Wang Y, Zhang P, Han Y, Nelson RS, McLeod HL, Tao K, Yuan Y, Zhang M, Xiang H, Zhou H. Adherence to Adjuvant Imatinib Therapy in Patients with Gastrointestinal Stromal Tumor in Clinical Practice: A Cross-Sectional Study. Chemotherapy 2020; 64:197-204. [PMID: 31955170 DOI: 10.1159/000505177] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/03/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Adherence to imatinib therapy has been significantly associated with disease progression and direct medical costs in gastrointestinal stromal tumor (GIST) patients. However, adherence to oral anticancer drugs is frequently hindered by the influence of various factors. The aim of this study was to evaluate the prevalence of imatinib adherence and its influencing factors among GIST patients in the adjuvant setting. METHODS Adherence of GIST patients (receiving imatinib for ≥1 month) was assessed using the 8-item Morisky Medication Adherence Scale (MMAS), with a score <8 indicating nonadherence. Quality of life and social support were evaluated by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ C30) and Social Support Rating Scale (SSRS). Factors associated with nonadherence were identified by multivariate logistic regression analysis. Imatinib plasma concentrations were determined and compared between adherent and nonadherent groups. RESULTS A total of 158 GIST patients were enrolled, 92 (58.2%) patients were considered nonadherent. Intentional nonadherence, especially feeling hassled by treatment plan (34.2% of patients), was common. In the multivariate logistic regression analysis, gender (OR 2.68, 95% CI 1.33-5.41; p = 0.0058), place of residence (OR 3.20, 95% CI 1.39-7.35; p = 0.0061), and global health status (OR 1.02, 95% CI 1.00-1.04; p = 0.0378) were significantly associated with nonadherence. Moreover, imatinib plasma concentrations in nonadherent patients were significantly lower than that in the good adherence group (p = 0.0338). CONCLUSIONS Poor adherence to imatinib is a notable problem in Chinese GIST patients in the adjuvant therapy setting. The predominant indicators of nonadherence in this study were gender (female), living in a rural area, and harboring a low global health status score. These indicators may aid clinicians in determining where increased efforts in promoting adherence may be beneficial.
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Affiliation(s)
- Yirong Wang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Department of Clinical Pharmacy, College of Pharmacy, Chongqing Medical University, Chongqing, China
| | - Peng Zhang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yong Han
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ryan S Nelson
- DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, Florida, USA
| | - Howard L McLeod
- DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, Florida, USA
| | - Kaixiong Tao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yonghua Yuan
- Department of Clinical Pharmacy, College of Pharmacy, Chongqing Medical University, Chongqing, China
| | - Min Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Department of Clinical Pharmacy, College of Pharmacy, Chongqing Medical University, Chongqing, China
| | - Hongping Xiang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong Zhou
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,
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13
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Crombag MRBS, van Doremalen JGC, Janssen JM, Rosing H, Schellens JHM, Beijnen JH, Steeghs N, Huitema ADR. Therapeutic drug monitoring of small molecule kinase inhibitors in oncology in a real-world cohort study: does age matter? Br J Clin Pharmacol 2018; 84:2770-2778. [PMID: 30068020 DOI: 10.1111/bcp.13725] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/29/2018] [Accepted: 07/16/2018] [Indexed: 01/02/2023] Open
Abstract
AIM Pharmacokinetics of small molecule kinase inhibitors (KIs) used in cancer treatment may alter with increasing age, but results are conflicting. This study aims to compare exposure to KIs between older and younger patients (≥70 and <70 years) in clinical practice. METHODS KI plasma concentrations of routinely treated patients were measured using validated assays. Calculated trough concentrations were compared in both age groups. For KIs with a clinically meaningful target concentration (erlotinib, imatinib, pazopanib, sunitinib and vemurafenib), influence of older age on target attainment was assessed. RESULTS We analysed 616 samples from 454 patients (median age: 61; range 20-93 years), treated with dabrafenib (n = 105), erlotinib (n = 49), imatinib (n = 165), pazopanib (n = 63), sunitinib (n = 87), trametinib (n = 95) and vemurafenib (n = 52). Older age did not significantly influence exposure to erlotinib, imatinib, pazopanib, sunitinib, trametinib and vemurafenib. Elderly patients had significantly higher dabrafenib trough concentrations than younger patients (P = 0.02; 62 ng ml-1 (coefficient of variation [CV] 41%), vs. 53 ng ml-1 (CV 46%), respectively). For KIs with a predefined target concentration, 68% of older and 61% of younger patients reached target. CONCLUSIONS In this real-world study, exposure to most included KIs was comparable in older and younger patients, except for dabrafenib, which showed higher exposure in older patients. In the absence of an absolute target for this KI, clinical relevance remains unclear. For all other included KIs, our data suggest no clinically relevant influence of older age on KI exposure.
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Affiliation(s)
- Marie-Rose B S Crombag
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute and MC Slotervaart, Amsterdam, The Netherlands.,Division of Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jacobine G C van Doremalen
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute and MC Slotervaart, Amsterdam, The Netherlands.,Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht, The Netherlands
| | - Julie M Janssen
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute and MC Slotervaart, Amsterdam, The Netherlands.,Division of Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hilde Rosing
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute and MC Slotervaart, Amsterdam, The Netherlands
| | - Jan H M Schellens
- Division of Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht, The Netherlands.,Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute and MC Slotervaart, Amsterdam, The Netherlands.,Division of Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht, The Netherlands
| | - Neeltje Steeghs
- Division of Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute and MC Slotervaart, Amsterdam, The Netherlands.,Division of Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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