1
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Hallin EI, Serkland TT, Bjånes TK, Skrede S. High-throughput, low-cost quantification of 11 therapeutic antibodies using caprylic acid precipitation and LC-MS/MS. Anal Chim Acta 2024; 1313:342789. [PMID: 38862206 DOI: 10.1016/j.aca.2024.342789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 05/25/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Therapeutic drug monitoring of treatment with therapeutic antibodies is hampered by the application of a wide range of different methods in the quantification of serum levels. LC-MS based methods could significantly improve comparability of results from different laboratories, but such methods are often considered complicated and costly. We developed a method for LC-MS/MS based quantification of 11 therapeutic antibodies concomitantly measured in a single run, with emphasis on simplicity in sample preparation and low cost. RESULTS After a single-step sample purification using caprylic acid precipitation to remove interfering proteins, the sample underwent proteolysis followed by LC-MS/MS analysis. Infliximab is used as internal standard for sample preparation while isotope-labeled signature peptides identified for each analyte are internal standards for the LC-MS/MS normalization. The method was validated according to recognized guidelines, and pipetting steps can be performed by automated liquid handling systems. The total precision of the method ranged between 2.7 and 7.3 % (5.1 % average) across the quantification range of 4-256 μg/ml for all 11 drugs, with an average accuracy of 96.3 %. Matrix effects were xamined in 55 individual patient samples instead of the recommended 6, and 147 individual patient samples were screened for interfering compounds. SIGNIFICANCE AND NOVELTY Our method for simultaneous quantification of 11 t-mAb in human serum allows an unprecedented integration of robustness, speed and reduced complexity, which could pave the way for uniform use in research projects and clinical settings alike. In addition, the first LC-MS protocol for signature peptide-based quantification of durvalumab is described. This high throughput method can be readily adapted to a drug panel of choice.
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Affiliation(s)
- Erik I Hallin
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Jonas Lies vei 87, N-5021, Bergen, Norway
| | - Trond Trætteberg Serkland
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Jonas Lies vei 87, N-5021, Bergen, Norway; Department of Clinical Science, Faculty of Medicine, University of Bergen, Jonas Lies vei 87, N-5021, Bergen, Norway
| | - Tormod K Bjånes
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Jonas Lies vei 87, N-5021, Bergen, Norway
| | - Silje Skrede
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Jonas Lies vei 87, N-5021, Bergen, Norway; Department of Clinical Science, Faculty of Medicine, University of Bergen, Jonas Lies vei 87, N-5021, Bergen, Norway.
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2
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Strohbehn GW, Stadler WM, Boonstra PS, Ratain MJ. Optimizing the doses of cancer drugs after usual dose finding. Clin Trials 2024; 21:340-349. [PMID: 38148731 DOI: 10.1177/17407745231213882] [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: 12/28/2023]
Abstract
Since the middle of the 20th century, oncology's dose-finding paradigm has been oriented toward identifying a drug's maximum tolerated dose, which is then carried forward into phase 2 and 3 trials and clinical practice. For most modern precision medicines, however, maximum tolerated dose is far greater than the minimum dose needed to achieve maximal benefit, leading to unnecessary side effects. Regulatory change may decrease maximum tolerated dose's predominance by enforcing dose optimization of new drugs. Dozens of already approved cancer drugs require re-evaluation, however, introducing a new methodologic and ethical challenge in cancer clinical trials. In this article, we assess the history and current landscape of cancer drug dose finding. We provide a set of strategic priorities for postapproval dose optimization trials of the future. We discuss ethical considerations for postapproval dose optimization trial design and review three major design strategies for these unique trials that would both adhere to ethical standards and benefit patients and funders. We close with a discussion of financial and reporting considerations in the realm of dose optimization. Taken together, we provide a comprehensive, bird's eye view of the postapproval dose optimization trial landscape and offer our thoughts on the next steps required of methodologies and regulatory and funding regimes.
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Affiliation(s)
- Garth W Strohbehn
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
- Division of Medical Oncology, Lieutenant Colonel Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Walter M Stadler
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Philip S Boonstra
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL, USA
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, USA
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3
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Dai L, Tan Q, Li L, Lou N, Zheng C, Yang J, Huang L, Wang S, Luo R, Fan G, Xie T, Yao J, Zhang Z, Tang L, Shi Y, Han X. High-Throughput Antigen Microarray Identifies Longitudinal Prognostic Autoantibody for Chemoimmunotherapy in Advanced Non-Small Cell Lung Cancer. Mol Cell Proteomics 2024; 23:100749. [PMID: 38513890 PMCID: PMC11070596 DOI: 10.1016/j.mcpro.2024.100749] [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: 08/11/2023] [Revised: 02/03/2024] [Accepted: 03/18/2024] [Indexed: 03/23/2024] Open
Abstract
Chemoimmunotherapy has evolved as a standard treatment for advanced non-small cell lung cancer (aNSCLC). However, inevitable drug resistance has limited its efficacy, highlighting the urgent need for biomarkers of chemoimmunotherapy. A three-phase strategy to discover, verify, and validate longitudinal predictive autoantibodies (AAbs) for aNSCLC before and after chemoimmunotherapy was employed. A total of 528 plasma samples from 267 aNSCLC patients before and after anti-PD1 immunotherapy were collected, plus 30 independent formalin-fixed paraffin-embedded samples. Candidate AAbs were firstly selected using a HuProt high-density microarray containing 21,000 proteins in the discovery phase, followed by validation using an aNSCLC-focused microarray. Longitudinal predictive AAbs were chosen for ELISA based on responders versus non-responders comparison and progression-free survival (PFS) survival analysis. Prognostic markers were also validated using immunohistochemistry and publicly available immunotherapy datasets. We identified and validated a panel of two AAbs (MAX and DHX29) as pre-treatment biomarkers and another panel of two AAbs (MAX and TAPBP) as on-treatment predictive markers in aNSCLC patients undergoing chemoimmunotherapy. All three AAbs exhibited a positive correlation with early responses and PFS (p < 0.05). The kinetics of MAX AAb showed an increasing trend in responders (p < 0.05) and a tendency to initially increase and then decrease in non-responders (p < 0.05). Importantly, MAX protein and mRNA levels effectively discriminated PFS (p < 0.05) in aNSCLC patients treated with immunotherapy. Our results present a longitudinal analysis of changes in prognostic AAbs in aNSCLC patients undergoing chemoimmunotherapy.
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Affiliation(s)
- Liyuan Dai
- Department of Clinical Laboratory, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Qiaoyun Tan
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Lin Li
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ning Lou
- Department of Clinical Laboratory, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Cuiling Zheng
- Department of Clinical Laboratory, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Jianliang Yang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Liling Huang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Shasha Wang
- Department of Clinical Laboratory, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Rongrong Luo
- Department of Clinical Laboratory, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Guangyu Fan
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Tongji Xie
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Jiarui Yao
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Zhishang Zhang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Le Tang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Yuankai Shi
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China.
| | - Xiaohong Han
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, State Key Laboratory of Complex Severe and Rare Diseases, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, Beijing Key Laboratory of Clinical PK & PD Investigation for Innovative Drugs, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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Marolleau S, Mogenet A, Boeri C, Hamimed M, Ciccolini J, Greillier L. Killing a fly with a sledgehammer: Atezolizumab exposure in real-world lung cancer patients. CPT Pharmacometrics Syst Pharmacol 2023; 12:1795-1803. [PMID: 38011601 PMCID: PMC10681534 DOI: 10.1002/psp4.13063] [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: 08/25/2023] [Revised: 09/25/2023] [Accepted: 10/02/2023] [Indexed: 11/29/2023] Open
Abstract
Atezolizumab is an anti-PDL1 approved for treating lung cancer. A threshold of 6 μg/mL in plasma has been associated with target engagement. The extent to which patients could be overexposed with the standard 1200 mg q3w dosing remains unknown. Here, we monitored atezolizumab peak and trough levels in 27 real-world patients with lung cancer as part of routine therapeutic drug monitoring. Individual pharmacokinetic (PK) parameters were calculated using a population approach and optimal dosing-intervals were simulated with respect to the target trough levels. No patient had plasma levels below 6 μg/mL. The results showed that the mean trough level after the first treatment was 78.3 ± 17 μg/mL, that is, 13 times above the target concentration. The overall response rate was 55.5%. Low-grade immune-related adverse events was observed in 37% of patients. No relationship was found between exposure metrics of atezolizumab (i.e., minimum plasma concentration, maximum plasma concentration, and area under the curve) and pharmacodynamic end points (i.e., efficacy and toxicity). Further simulations suggest that the dosing interval could be extended from 21 days to 49 up to 136 days (mean: 85.7 days, i.e., q12w), while ensuring plasma levels still above the 6 μg/mL target threshold. This observational, real-world study suggests that the standard 1200 mg q3w fixed-dose regimen of atezolizumab results in significant overexposure in all the patients. This was not associated with increased side effects. As plasma levels largely exceed pharmacologically active concentrations, interindividual variability in PK parameters did not impact efficacy. Our data suggest that dosing intervals could be markedly extended with respect to the target threshold associated with efficacy.
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Affiliation(s)
- Sophie Marolleau
- COMPO, Inserm U1068 Centre de Recherche en Cancérologie de Marseille & Inria Sophia AntipolisMarseilleFrance
| | - Alice Mogenet
- Oncologie multidisciplinaire et innovations thérapeutiquesNord University Hospital of MarseilleMarseilleFrance
| | - Clara Boeri
- COMPO, Inserm U1068 Centre de Recherche en Cancérologie de Marseille & Inria Sophia AntipolisMarseilleFrance
| | - Mourad Hamimed
- COMPO, Inserm U1068 Centre de Recherche en Cancérologie de Marseille & Inria Sophia AntipolisMarseilleFrance
| | - Joseph Ciccolini
- COMPO, Inserm U1068 Centre de Recherche en Cancérologie de Marseille & Inria Sophia AntipolisMarseilleFrance
| | - Laurent Greillier
- COMPO, Inserm U1068 Centre de Recherche en Cancérologie de Marseille & Inria Sophia AntipolisMarseilleFrance
- Oncologie multidisciplinaire et innovations thérapeutiquesNord University Hospital of MarseilleMarseilleFrance
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5
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Ratain MJ, Strohbehn GW. Combining atezolizumab 1200 mg with bevacizumab 15 mg/kg: based on science or just revenues? Eur J Cancer 2023; 194:113349. [PMID: 37806256 DOI: 10.1016/j.ejca.2023.113349] [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: 08/23/2023] [Revised: 09/12/2023] [Accepted: 09/14/2023] [Indexed: 10/10/2023]
Abstract
Dose optimisation is increasingly important in oncology, as exemplified by the US Food and Drug Administration's Project Optimus initiative, which is aligned with similar initiatives in other countries. In parallel, multiple stakeholders have raised concerns about anticancer drug prices, affordability, and access. This is of particular concern to government payers as well as patients and physicians in low- and middle-income countries. As anticancer drugs have historically been approved at the maximally tolerated dose, it is now highly relevant to question whether lower doses are equally effective and can be delivered at lower doses, resulting in less toxicity for patients, and lower costs for patients and payers. We illustrate this opportunity by discussing the combination of atezolizumab and bevacizumab, approved in multiple countries for both non-small cell lung cancer and hepatocellular cancer. Our conclusion is that the cost of this regimen can be reduced by more than 80%, an opportunity that should be considered by patients, prescribers, payers, and policymakers.
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Affiliation(s)
- Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, Illinois, USA.
| | - Garth W Strohbehn
- Veterans Affairs Center for Clinical Management Research and Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
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6
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Wesevich A, Goldstein DA, Paydary K, Peer CJ, Figg WD, Ratain MJ. Interventional pharmacoeconomics for immune checkpoint inhibitors through alternative dosing strategies. Br J Cancer 2023; 129:1389-1396. [PMID: 37542109 PMCID: PMC10628132 DOI: 10.1038/s41416-023-02367-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 05/05/2023] [Accepted: 07/12/2023] [Indexed: 08/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are approved for the treatment of a variety of cancer types. The doses of these drugs, though approved by the Food and Drug Administration (FDA), have never been optimised, likely leading to significantly higher doses than required for optimal efficacy. Dose optimisation would hypothetically decrease the risk, severity, and duration of immune-related adverse events, as well as provide an opportunity to reduce costs through interventional pharmacoeconomic strategies such as off-label dose reductions or less frequent dosing. We summarise existing evidence for ICI dose optimisation to advocate for the role of interventional pharmacoeconomics.
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Affiliation(s)
- Austin Wesevich
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Daniel A Goldstein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Clalit Health Service, Tel Aviv, Israel
- Optimal Cancer Care Alliance, Chicago, IL, USA
| | - Koosha Paydary
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Cody J Peer
- Clinical Pharmacology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - William D Figg
- Clinical Pharmacology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA.
- Optimal Cancer Care Alliance, Chicago, IL, USA.
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Bryant AK, Chopra Z, Edwards DM, Whalley AS, Bazzell BG, Moeller JA, Kelley MJ, Fendrick AM, Kerr EA, Ramnath N, Green MD, Hofer TP, Strohbehn GW. Adopting Weight-Based Dosing With Pharmacy-Level Stewardship Strategies Could Reduce Cancer Drug Spending By Millions. Health Aff (Millwood) 2023; 42:946-955. [PMID: 37406228 PMCID: PMC10985582 DOI: 10.1377/hlthaff.2023.00102] [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] [Indexed: 07/07/2023]
Abstract
Immune checkpoint inhibitors, a class of drugs used in approximately forty unique cancer indications, are a sizable component of the economic burden of cancer care in the US. Instead of personalized weight-based dosing, immune checkpoint inhibitors are most commonly administered at "one-size-fits-all" flat doses that are higher than necessary for the vast majority of patients. We hypothesized that personalized weight-based dosing along with common stewardship efforts at the pharmacy level, such as dose rounding and vial sharing, would lead to reductions in immune checkpoint inhibitor use and lower spending. Using data from the Veterans Health Administration (VHA) and Medicare drug prices, we estimated reductions in immune checkpoint inhibitor use and spending that would be associated with pharmacy-level stewardship strategies, in a case-control simulation study of individual patient-level immune checkpoint inhibitor administration events. We identified baseline annual VHA spending for these drugs of approximately $537 million. Combining weight-based dosing, dose rounding, and pharmacy-level vial sharing would generate expected annual VHA health system savings of $74 million (13.7 percent). We conclude that adoption of pharmacologically justified immune checkpoint inhibitor stewardship measures would generate sizable reductions in spending for these drugs. Combining these operational innovations with value-based drug price negotiation enabled by recent policy changes may improve the long-term financial viability of cancer care in the US.
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Affiliation(s)
- Alex K Bryant
- Alex K. Bryant, University of Michigan, Ann Arbor, Michigan
| | | | | | - Adam S Whalley
- Adam S. Whalley, Veterans Affairs (VA) Maine Health Care, Augusta, Maine
| | - Brian G Bazzell
- Brian G. Bazzell, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | | | - Michael J Kelley
- Michael J. Kelley, Duke University and VA National Oncology Program Office, Durham, North Carolina
| | | | - Eve A Kerr
- Eve A. Kerr, University of Michigan and VA Ann Arbor Healthcare System
| | | | | | - Timothy P Hofer
- Timothy P. Hofer, University of Michigan and VA Ann Arbor Healthcare System
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Peer CJ, Schmidt KT, Arisa O, Richardson WJ, Paydary K, Goldstein DA, Gulley JL, Figg WD, Ratain MJ. In Silico Re-Optimization of Atezolizumab Dosing Using Population Pharmacokinetic Simulation and Exposure-Response Simulation. J Clin Pharmacol 2023; 63:672-680. [PMID: 36624662 PMCID: PMC10175103 DOI: 10.1002/jcph.2203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023]
Abstract
Atezolizumab, a humanized monoclonal antibody against programmed cell death ligand 1 (PD-L1), was initially approved in 2016, around the same time that the sponsor published the minimum serum concentration to maintain the saturation of receptor occupancy (6 μg/mL). The initially approved dose regimen of 1200 mg every 3 weeks (q3w) was subsequently modified to 840 mg q2w or 1680 mg q4w through pharmacokinetic simulations. Yet, each standard regimen yields steady-state trough concentrations (CMIN,SS ) far exceeding (≈ 40-fold) the stated target concentration. Additionally, the steady-state area under the plasma drug concentration-time curve (AUCSS ) at 1200 mg q3w was significantly (P = .027) correlated with the probability of adverse events of special interest (AESIs) in patients with non-small cell lung cancer (NSCLC) and, coupled with excess exposure, this provides incentive to explore alternative dose regimens to lower the exposure burden while maintaining an effective CMIN,SS . In this study, we first identified 840 mg q6w as an extended-interval regimen that could robustly maintain a serum concentration of 6 μg/mL (≥99% of virtual patients simulated, n = 1000), then applied this regimen to an approach that administers 2 "loading doses" of standard-interval regimens for a future clinical trial aiming to personalize dose regimens. Each standard dose was simulated for 2 loading doses, then 840 mg q6w thereafter; all yielded cycle-7 CMIN,SS values of >6 μg/mL in >99% of virtual patients. Further, the AUCSS from 840 mg q6w resulted in a flattening (P = .63) of the exposure-response relationship with adverse events of special interest (AESIs). We next aim to verify this in a clinical trial seeking to validate extended-interval dosing in a personalized approach using therapeutic drug monitoring.
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Affiliation(s)
- Cody J. Peer
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, MD, USA
| | - Keith T. Schmidt
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, MD, USA
| | - Oluwatobi Arisa
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, MD, USA
| | | | - Koosha Paydary
- Department of Medicine, Section of Hematology/Oncology, and Committee on Clinical Pharmacology & Pharmacogenomics, The University of Chicago, Chicago, IL, USA
| | - Daniel A. Goldstein
- Faculty of Medicine, Tel Aviv University, Israel
- Davidoff Cancer Center, Rabin Medical Center, Israel
- Clalit Health Services, Tela Aviv, Israel
| | - James L. Gulley
- Genitourinary Malignancies Branch, National Cancer Institute, Bethesda, MD, USA
| | - William D. Figg
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, MD, USA
| | - Mark J. Ratain
- Department of Medicine, Section of Hematology/Oncology, and Committee on Clinical Pharmacology & Pharmacogenomics, The University of Chicago, Chicago, IL, USA
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9
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Gravis G, Marino P, Olive D, Penault-LLorca F, Delord JP, Simon C, Lamrani-Ghaouti A, Sabatier R, Ciccolini J, Boher JM. A non-inferiority randomized phase III trial of standard immunotherapy by checkpoint inhibitors vs. reduced dose intensity in responding patients with metastatic cancer: the MOIO protocol study. BMC Cancer 2023; 23:393. [PMID: 37131154 PMCID: PMC10155443 DOI: 10.1186/s12885-023-10881-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/24/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Immunotherapy (IO) has become a standard of care for treating various types of metastatic cancers and has significantly improved clinical outcome. With the exception of metastatic melanoma in complete response for which treatment can be stopped at 6 months, these treatments are currently administered until either disease progression for some IO, 2 years for others, or unacceptable toxicity. However, a growing number of studies are reporting maintenance of response despite discontinuation of therapy. There is currently no evidence of a dose effect of IO in pharmacokinetic studies. Maintaining efficacy despite a reduction in treatment intensity by decreasing the frequency of administration in patients with highly selected metastatic cancer, is the hypothesis evaluated in the MOIO study. METHOD/DESIGN This non-inferiority, randomized phase III study aims to compare the standard regimen to a 3 monthly regimen of variousIO drugs in adult patients with metastatic cancer in partial (PR) or complete response (CR) after 6 months of standard IO dosing (except melanoma in CR). This is a French national study conducted in 36 centers. The main objective is to demonstrate that the efficacy of a three-monthly administration is not unacceptably less efficacious than a standard administration. Secondary objectives are cost-effectiveness, quality of life (QOL), anxiety, fear of relapse, response rate, overall survival and toxicity. After 6 months of standard IO, patients with partial or complete response will be randomized 1:1 between standard IO or a reduced intensity dose of IO, administered every 3 months. The randomization will be stratified on therapy line,, tumor type, IO type and response status. The primary endpoint is the hazard ratio of progression-free survival. With a planned study duration of 6 years, including 36 months enrolment time, 646 patients are planned to demonstrate with a statistical level of evidence of 5% that the reduced IO regimen is non-inferior to the standard IO regimen, with a relative non-inferiority margin set at 1.3. DISCUSSION Should the hypothesis of non-inferiority with an IO reduced dose intensity be validated, alternate scheduling could preserve efficacy while being cost-effective and allowing a reduction of the toxicity, with an increase in patient's QOL. TRIAL REGISTRATION NCT05078047.
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Affiliation(s)
- Gwenaelle Gravis
- Department of Medical Oncology, Institut Paoli-Calmettes, Aix-Marseille University, CRCM,, Marseille, France.
| | - Patricia Marino
- Institut Paoli-Calmettes SESSTIM UMR 1252, INSERM, IRD, Aix Marseille University, Marseille, France
| | - Daniel Olive
- Institut Paoli Calmettes, Aix Marseille Université, CRCM, Inserm U1068, Marseille, France
| | - Frederique Penault-LLorca
- Centre Jean Perrin, Université Clermont Auvergne, INSERM, U1240 Imagerie Moléculaire Et Stratégies Théranostiques, Clermont Ferrand, France
| | | | | | | | - Renaud Sabatier
- Institut Paoli Calmettes, Aix Marseille Université, CRCM, Inserm U1068, Marseille, France
| | | | - Jean-Marie Boher
- Department of Biostatistics and Methodology, Institut Paoli Calmettes, and Aix-Marseille University, Unité Mixte de Recherche S1252, Institut de Recherche Pour Le Développement, 13009, Marseille, France
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10
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Likic R, Dear JW, Lewis LD. Spotlight commentary: Navigating between financial risks and improved treatment outcomes with immune checkpoint inhibitors in cancer patients: The need for biomarker identification and dose optimization. Br J Clin Pharmacol 2022; 88:5060-5063. [PMID: 36206769 DOI: 10.1111/bcp.15548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/19/2022] [Accepted: 09/23/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Robert Likic
- University of Zagreb Medical School, Zagreb, Croatia.,Department of Internal Medicine, Division of Clinical Pharmacology and Therapeutics, Clinical Hospital Centre Zagreb, Zagreb, Croatia
| | - James W Dear
- Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Lionel D Lewis
- Section of Clinical Pharmacology, Dept. of Medicine, The Geisel School of Medicine & Dartmouth-Hitchcock Medical Centre, Lebanon, New Hampshire, USA
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11
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Jiang M, Hu Y, Lin G, Chen C. Dosing Regimens of Immune Checkpoint Inhibitors: Attempts at Lower Dose, Less Frequency, Shorter Course. Front Oncol 2022; 12:906251. [PMID: 35795044 PMCID: PMC9251517 DOI: 10.3389/fonc.2022.906251] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/24/2022] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are a revolutionary breakthrough in the field of cancer by modulating patient's own immune system to exert anti-tumor effects. The clinical application of ICIs is still in its infancy, and their dosing regimens need to be continuously adjusted. Pharmacokinetic/pharmacodynamic studies showed a significant plateau in the exposure-response curve, with high receptor occupancy and plasma concentrations achieved at low dose levels. Coupled with concerns about drug toxicity and heavy economic costs, there has been an ongoing quest to reevaluate the current ICI dosing regimens while preserving maximum clinical efficacy. Many clinical data showed remarkable anticancer effects with ICIs at the doses far below the approved regimens, indicating the possibility of dose reduction. Our review attempts to summarize the clinical evidence for ICIs regimens with lower-dose, less-frequency, shorter-course, and provide clues for further ICIs regimen optimization.
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Affiliation(s)
| | | | | | - Chao Chen
- Department of Radiotherapy, The First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou, China
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12
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Homšek A, Radosavljević D, Miletić N, Spasić J, Jovanović M, Miljković B, Stanojković T, Vučićević K. Review of the Clinical Pharmacokinetics, Efficacy and Safety of Pembrolizumab. Curr Drug Metab 2022; 23:460-472. [PMID: 35692130 DOI: 10.2174/1389200223666220609125013] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/13/2022] [Accepted: 03/11/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Treatment of various types of cancer has been improved significantly with the discovery of biologic drugs that act as immune checkpoint inhibitors (ICIs). Pembrolizumab is a humanized monoclonal anti-PD-1 antibody currently approved for the treatment of a wide range of tumors, with more indications still being investigated in ongoing clinical trials. OBJECTIVE The aim of this paper is to present all currently available data regarding pembrolizumab pharmacokinetic and pharmacodynamic characteristics. Also, the possibility of using predicative biomarkers to monitor patients during cancer treatment is discussed. METHODS Database research was carried out (PubMed, ScienceDirect). Information was gathered from original articles, the European Medicines Agency datasheets and results from clinical trials. RESULTS This review summarizes present-day knowledge about the pharmacokinetics, different modeling approaches and dosage regimens, efficacy and safety of pembrolizumab and therapeutic monitoring of disease progression. CONCLUSION This review points out consistent pharmacokinetic characteristics of pembrolizumab in various cancer patients, the lack of pharmacokinetic-pharmacodynamic/outcome relationships, the need of adequate biomarkers predicting treatment success. Hence, there is a clear necessity for more data and experience in order to optimize pembrolizumab treatment for each individual patient.
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Affiliation(s)
- Ana Homšek
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade - Faculty of Pharmacy, Vojvode Stepe 450, Belgrade, Serbia
| | - Davorin Radosavljević
- Clinic for Medical Oncology, Institute for Oncology and Radiology of Serbia, Pasterova 14, Belgrade, Serbia
| | - Nebojša Miletić
- Clinic for Medical Oncology, Institute for Oncology and Radiology of Serbia, Pasterova 14, Belgrade, Serbia
| | - Jelena Spasić
- Clinic for Medical Oncology, Institute for Oncology and Radiology of Serbia, Pasterova 14, Belgrade, Serbia
| | - Marija Jovanović
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade - Faculty of Pharmacy, Vojvode Stepe 450, Belgrade, Serbia
| | - Branislava Miljković
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade - Faculty of Pharmacy, Vojvode Stepe 450, Belgrade, Serbia
| | - Tatjana Stanojković
- Department of Experimental Oncology, Institute for Oncology and Radiology of Serbia, Pasterova 14, Belgrade, Serbia
| | - Katarina Vučićević
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade - Faculty of Pharmacy, Vojvode Stepe 450, Belgrade, Serbia
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13
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Araujo DV, Uchoa B, Soto-Castillo JJ, Furlan LL, Oliva M. When Less May Be Enough: Dose Selection Strategies for Immune Checkpoint Inhibitors Focusing on AntiPD-(L)1 Agents. Target Oncol 2022; 17:253-270. [PMID: 35687223 DOI: 10.1007/s11523-022-00890-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2022] [Indexed: 10/18/2022]
Abstract
Early clinical trials investigating antiPD(L)-1 agents rarely reached a maximum tolerated dose (MTD), and efficacy signals were observed even at the lowest dose levels. Most extended treatment intervals investigated indicated that these drugs do not follow a direct dose-toxicity or dose-efficacy relationship. Within this context and considering the high cost of antiPD(L)-1 agents, there is a significant debate on whether lower doses or the administration of such agents at an extended interval should be prospectively evaluated in already-approved agents, or at least be considered in novel combination trials involving antiPD(L)-1 drugs. Herein, we review the dosing, overall response rates, and incidence of treatment-related adverse events of antiPD(L)-1 agents in early dose-escalation trials and discuss the appropriateness of recommended Phase 2 dose selection as well as the final regulatory approved doses of such agents. Efficacy and safety data from randomized dose-range Phase 2 trials and real-world data (RWD) on the usage of lower doses and/or non-standard extended treatment intervals are also examined. As the accumulating evidence suggests lower doses or extended dosing intervals of antiPD(L)-1 may achieve a similar clinical benefit in comparison to the currently approved doses, we address the clinical and financial toxicity implications of using potentially higher doses than necessary. Last, we discuss ways to resolve the current dosing conundrum of antiPD-(L)1 agents such as performing near-equivalence studies and propose a framework for future development of immunotherapeutics to find the lowest efficacious dose instead of MTD.
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Affiliation(s)
- Daniel V Araujo
- Department of Medical Oncology, Hospital de Base/HB Onco, FUNFARME/FAMERP, Av. Brigadeiro Faria Lima 5544, São José do Rio Preto, SP, Brazil.
| | - Bruno Uchoa
- Department of Medical Oncology, Hospital de Base/HB Onco, FUNFARME/FAMERP, Av. Brigadeiro Faria Lima 5544, São José do Rio Preto, SP, Brazil
| | - Juan José Soto-Castillo
- Department of Medical Oncology, Institut Català d'Oncologia (ICO), L'Hospitalet de Llobregat, Av. Gran Via de L'Hospitalet 199-203, 08908, Barcelona, Spain
| | - Larissa L Furlan
- Department of Medical Oncology, Hospital de Base/HB Onco, FUNFARME/FAMERP, Av. Brigadeiro Faria Lima 5544, São José do Rio Preto, SP, Brazil
| | - Marc Oliva
- Department of Medical Oncology, Institut Català d'Oncologia (ICO), L'Hospitalet de Llobregat, Av. Gran Via de L'Hospitalet 199-203, 08908, Barcelona, Spain. .,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
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14
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Peer CJ, Heiss BL, Goldstein DA, Goodell JC, Figg WD, Ratain MJ. Pharmacokinetic Simulation Analysis of Less Frequent Nivolumab and Pembrolizumab Dosing: Pharmacoeconomic Rationale for Dose Deescalation. J Clin Pharmacol 2022; 62:532-540. [PMID: 34648187 PMCID: PMC9749861 DOI: 10.1002/jcph.1984] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 10/09/2021] [Indexed: 12/16/2022]
Abstract
Nivolumab and pembrolizumab, anti-programmed cell death protein 1 monoclonal antibodies, have revolutionized oncology but are expensive. Using an interventional pharmacoeconomic approach, these drugs can be administered less often to reduce costs and increase patient convenience while maintaining efficacy. Both drugs are good candidates for less frequent dosing because of long half-lives and no evidence of a relationship of dose to efficacy. Established population pharmacokinetic models for both nivolumab and pembrolizumab were used to simulate profiles for multiple dosing regimens on 1000 randomly generated virtual patients. Simulations were initially performed on standard dose regimens to validate these in silico predictions. Next, simulations of nivolumab 0.3 mg/kg every 3 weeks revealed that >95% of patients maintained ≥1.5 μg/mL at steady state, which was inferred as the minimum effective concentration (MEC) for both drugs. Various alternative dosing regimens were simulated for both drugs to determine which regimen(s) can maintain this MEC in >95% of patients. Extended dosing regimens of nivolumab 240 mg every 4 weeks and 480 mg every 8 weeks along with pembrolizumab 200 mg every 6 weeks were simulated, showing that >95% of patients maintained MEC or greater. These simulations demonstrate the potential to reduce drug exposure by at least 50%, thus substantially reducing patient visits (as well as costs), while maintaining equivalent efficacy. These models provide the scientific justification for an ongoing prospective randomized clinical trial comparing standard interval fixed dosing with extended interval fixed dosing, and ultimately an efficacy-driven comparative trial.
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Affiliation(s)
- Cody J. Peer
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, Maryland, USA
| | - Brian L. Heiss
- Department of Medicine, Section of Hematology/Oncology, and Committee on Clinical Pharmacology & Pharmacogenomics, The University of Chicago, Chicago, Illinois, USA
| | - Daniel A. Goldstein
- Davidoff Cancer Center, Rabin Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jennifer C. Goodell
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, Maryland, USA
| | - William D. Figg
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, Maryland, USA
| | - Mark J. Ratain
- Department of Medicine, Section of Hematology/Oncology, and Committee on Clinical Pharmacology & Pharmacogenomics, The University of Chicago, Chicago, Illinois, USA
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15
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Maritaz C, Broutin S, Chaput N, Marabelle A, Paci A. Immune checkpoint-targeted antibodies: a room for dose and schedule optimization? J Hematol Oncol 2022; 15:6. [PMID: 35033167 PMCID: PMC8760805 DOI: 10.1186/s13045-021-01182-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/26/2021] [Indexed: 12/13/2022] Open
Abstract
Anti-CTLA-4 and anti-PD-1/PD-L1 immune checkpoint inhibitors are therapeutic monoclonal antibodies that do not target cancer cells but are designed to reactivate or promote antitumor immunity. Dosing and scheduling of these biologics were established according to conventional drug development models, even though the determination of a maximum tolerated dose in the clinic could only be defined for anti-CTLA-4. Given the pharmacology of these monoclonal antibodies, their high interpatient pharmacokinetic variability, the actual clinical benefit as monotherapy that is observed only in a specific subset of patients, and the substantial cost of these treatments, a number of questions arise regarding the selected dose and the dosing interval. This review aims to outline the development of these immunotherapies and considers optimization options that could be used in clinical practice.
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Affiliation(s)
- Christophe Maritaz
- Pharmacology Department, U1030 INSERM, University Paris-Saclay, Gustave Roussy Cancer Campus, Villejuif, France
| | - Sophie Broutin
- Pharmacology Department, U1030 INSERM, University Paris-Saclay, Gustave Roussy Cancer Campus, Villejuif, France
| | - Nathalie Chaput
- Laboratory for Immunomonitoring in Oncology (LIO), Faculty of Pharmacy, University Paris-Saclay, Gustave Roussy Cancer Campus, Villejuif, France
| | - Aurélien Marabelle
- Drug Development Unit (DITEP), LRTI U1015 INSERM, Gustave Roussy, Villejuif, France
| | - Angelo Paci
- Pharmacology Department, U1030 INSERM, University Paris-Saclay, Gustave Roussy Cancer Campus, Villejuif, France. .,Pharmacokinetic Unit, Faculty of Pharmacy, University Paris-Saclay, Chatenay-Malabry, France.
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16
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Strohbehn GW, Kacew AJ, Goldstein DA, Feldman RC, Ratain MJ. Combination therapy patents: a new front in evergreening. Nat Biotechnol 2021; 39:1504-1510. [PMID: 34880460 DOI: 10.1038/s41587-021-01137-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Garth W Strohbehn
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA.,Optimal Cancer Care Alliance, Ann Arbor, MI, USA.,Veterans Affairs Center for Clinical Management and Research, Ann Arbor, MI, USA
| | - Alec J Kacew
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Daniel A Goldstein
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA.,Tel Aviv University, Tel Aviv, Israel.,Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel.,Department of Health Policy and Management, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Robin C Feldman
- Center for Innovation, University of California Hastings College of the Law, San Francisco, CA, USA.
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA. .,Optimal Cancer Care Alliance, Ann Arbor, MI, USA.
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17
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Cross-Validation of a Multiplex LC-MS/MS Method for Assaying mAbs Plasma Levels in Patients with Cancer: A GPCO-UNICANCER Study. Pharmaceuticals (Basel) 2021; 14:ph14080796. [PMID: 34451893 PMCID: PMC8401780 DOI: 10.3390/ph14080796] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/28/2021] [Accepted: 08/02/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Different liquid chromatography tandem mass spectrometry (LC-MS/MS) methods have been published for quantification of monoclonal antibodies (mAbs) in plasma but thus far none allowed the simultaneous quantification of several mAbs, including immune checkpoint inhibitors. We developed and validated an original multiplex LC-MS/MS method using a ready-to-use kit to simultaneously assay 7 mAbs (i.e., bevacizumab, cetuximab, ipilimumab, nivolumab, pembrolizumab, rituximab and trastuzumab) in plasma. This method was next cross-validated with respective reference methods (ELISA or LC-MS/MS). METHODS The mAbXmise kit was used for mAb extraction and full-length stable-isotope-labeled antibodies as internal standards. The LC-MS/MS method was fully validated following current EMA guidelines. Each cross validation between reference methods and ours included 16-28 plasma samples from cancer patients. RESULTS The method was linear from 2 to 100 µg/mL for all mAbs. Inter- and intra-assay precision was <14.6% and accuracy was 90.1-111.1%. The mean absolute bias of measured concentrations between multiplex and reference methods was 10.6% (range 3.0-19.9%). CONCLUSIONS We developed and cross-validated a simple, accurate and precise method that allows the assay of up to 7 mAbs. Furthermore, the present method is the first to offer a simultaneous quantification of three immune checkpoint inhibitors likely to be associated in patients.
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18
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Evaluating the efficacy and safety of immune checkpoint inhibitors by detecting the exposure-response: An inductive review. Int Immunopharmacol 2021; 97:107703. [PMID: 33933843 DOI: 10.1016/j.intimp.2021.107703] [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: 03/15/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 11/23/2022]
Abstract
Immune checkpoint inhibitors (ICIs) have been demonstrated an effective treatment in multiple tumor type, which restore the immune response to against cancer cell. Currently, approved ICIs include anti-cytotoxic T-lymphocyte antigen-4 (CTLA-4); anti-programmed cell death 1 (PD-1) and anti-programmed cell death ligand 1 (PD-L1) monoclonal antibodies (mAbs). In most these drugs, unique pharmacokinetic (PK) and pharmacodynamics (PD) have shown significant influence on clinical outcomes, which occurred by target-mediated drug concentration and time-varying drug clearance. An exposure-response (E-R) relationship has been used to describe the safety and efficacy of ICIs, and shown a plateaued E-R and time dependent changes in exposure. Using an enzyme linked immunosorbent assay (ELISA) or LC-MS/MS method to measure the peak concentration, trough concentration or area under the curve (AUC) of ICIs to assess the drug exposure. There are lots of covariates that have an influence on exposure, such as sex, clearance, body weight and tumor burden. In this review, we pooled data from studies of concentration or other pharmacokinetics parameter of mAbs to assess E-R in efficacy and safety.
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19
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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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20
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Sureda M, Calvo E, Mata JJ, Escudero-Ortiz V, Martinez-Navarro E, Catalán A, Rebollo J. Dosage of anti-PD-1 monoclonal antibodies: a cardinal open question. Clin Transl Oncol 2021; 23:1511-1519. [PMID: 33583005 DOI: 10.1007/s12094-021-02563-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/28/2021] [Indexed: 12/11/2022]
Abstract
Discovery and clinical development of monoclonal antibodies with the ability to interfere in the regulation of the immune response have significantly changed the landscape of oncology in recent years. Among the active agents licensed by the regulatory agencies, nivolumab and pembrolizumab are paradigmatic as the most relevant ones according to the magnitude of available data derived from the extensive preclinical and clinical experience. Although in both cases the respective data sheets indicate well-defined dosage regimens, a review of the literature permits to verify the existence of many issues still unresolved about dosing the two agents, so it must be considered an open question of potentially important consequences, in which to work to improve the effectiveness and efficiency of use.
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Affiliation(s)
- M Sureda
- Plataforma de Oncología, Hospital Quironsalud Torrevieja, C/Partida de la Loma s/n, 03184, Torrevieja, Alicante, Spain.
| | - E Calvo
- START Madrid-Centro Integral Oncológico Clara Campal, Hospital Universitario HM Sanchinarro, Madrid, Spain
| | - J J Mata
- Plataforma de Oncología, Hospital Quironsalud Torrevieja, C/Partida de la Loma s/n, 03184, Torrevieja, Alicante, Spain
| | - V Escudero-Ortiz
- Plataforma de Oncología, Hospital Quironsalud Torrevieja, C/Partida de la Loma s/n, 03184, Torrevieja, Alicante, Spain
| | - E Martinez-Navarro
- Plataforma de Oncología, Hospital Quironsalud Torrevieja, C/Partida de la Loma s/n, 03184, Torrevieja, Alicante, Spain
| | - A Catalán
- Plataforma de Oncología, Hospital Quironsalud Torrevieja, C/Partida de la Loma s/n, 03184, Torrevieja, Alicante, Spain
| | - J Rebollo
- Plataforma de Oncología, Hospital Quironsalud Torrevieja, C/Partida de la Loma s/n, 03184, Torrevieja, Alicante, Spain
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21
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Direct analysis in real time-mass spectrometry for rapid quantification of five anti-arrhythmic drugs in human serum: application to therapeutic drug monitoring. Sci Rep 2020; 10:15550. [PMID: 32968164 PMCID: PMC7511339 DOI: 10.1038/s41598-020-72490-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/28/2020] [Indexed: 02/06/2023] Open
Abstract
Therapeutic drug monitoring (TDM) is necessary for the optimal administration of anti-arrhythmic drugs in the treatment of heart arrhythmia. The present study aimed to develop and validate a direct analysis in real time tandem mass spectrometry (DART–MS/MS) method for the rapid and simultaneous determination of five anti-arrhythmic drugs (metoprolol, diltiazem, amiodarone, propafenone, and verapamil) and one metabolite (5-hydroxy(OH)-propafenone) in human serum. After the addition of isotope-labeled internal standards and protein precipitation with acetonitrile, anti-arrhythmic drugs were ionized by DART in positive mode followed by multiple reaction monitoring (MRM) detection. The use of DART–MS/MS avoided the need for chromatographic separation and allowed rapid and ultrahigh throughput analysis of anti-arrhythmic drugs in a total run time of 30 s per sample. The DART–MS/MS method yielded satisfactory linearity (R2 ≥ 0.9906), accuracy (86.1–109.9%), and precision (≤ 14.3%) with minimal effect of biological matrixes. The method was successfully applied to analyzing 30 clinical TDM samples. The relative error (RE) of the concentrations obtained by DART–MS/MS and liquid chromatography-tandem mass spectrometry (LC–MS/MS) was within ± 13%. This work highlights the potential usefulness of DART for the rapid quantitative analysis of anti-arrhythmic drugs in human serum and gives rapid feedback in the clinical TDM practices.
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22
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Peer CJ, Goldstein DA, Goodell JC, Nguyen R, Figg WD, Ratain MJ. Opportunities for using in silico-based extended dosing regimens for monoclonal antibody immune checkpoint inhibitors. Br J Clin Pharmacol 2020; 86:1769-1777. [PMID: 32424951 PMCID: PMC7444775 DOI: 10.1111/bcp.14369] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 03/10/2020] [Accepted: 04/26/2020] [Indexed: 12/21/2022] Open
Abstract
Therapeutic drug monitoring (TDM) involves frequent measurements of drug concentrations to ensure levels remain within a therapeutic window, and it is especially useful for drugs with narrow therapeutic indices or extensive interindividual pharmacokinetic variability. This technique has never been applied to immuno-oncology drugs, but, given recent examinations of clinical data (both exposure and response) on a number of these drugs, further investigations into TDM may be justified to reduce costs as well as potentially reducing the severity and/or duration of immune-related adverse events. Specifically, all but one of the approved PD-1 and PD-L1 inhibitors (pembrolizumab, nivolumab, cemiplimab-rwlc, atezolizumab, avelumab, durvalumab) have been shown to exhibit a plateaued exposure-response (E-R) curve at doses evaluated extensively to date, as well as time-dependent changes in drug exposure. Furthermore, responders have a greater decrease in drug clearance over time and would, therefore, have supratherapeutic serum concentrations. With frequent trough measurements, it is possible to use pharmacokinetic modelling and simulation to estimate drug clearance via Bayesian methods. Based on patient-specific estimates for clearance, optimal alternative dosing strategies can be simulated to lower drug and cost burden yet maintain therapeutic levels, especially as the clearance of the drug decreases over time. This review will comprehensively discuss each of the FDA approved PD-1, PD-L1/2 and CTLA-4 inhibitors regarding their indications and current recommended dosing, with evidence supporting the investigation of these types of TDM strategies.
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Affiliation(s)
- Cody J. Peer
- Clinical Pharmacology ProgramNational Cancer InstituteBethesdaMDUSA
| | | | | | - Ryan Nguyen
- Clinical Pharmacology ProgramNational Cancer InstituteBethesdaMDUSA
| | - William D. Figg
- Clinical Pharmacology ProgramNational Cancer InstituteBethesdaMDUSA
| | - Mark J. Ratain
- Department of Medicine, Center for Personalized Therapeutics, and Comprehensive Cancer CenterThe University of ChicagoChicagoILUSA
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23
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Chou CH, Hsu LF. Model-based simulation to support the extended dosing regimens of atezolizumab. Eur J Clin Pharmacol 2020; 77:87-93. [PMID: 32808071 DOI: 10.1007/s00228-020-02980-3] [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: 04/15/2020] [Accepted: 08/11/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE The currently recommended dosages of atezolizumab for patients with non-small cell lung cancer (NSCLC) and urothelial carcinoma (UC) is 840 mg every 2 weeks, 1200 mg every 3 weeks (q3w), and 1680 mg every 4 weeks (q4w). However, it has been argued that these dosages may not be optimal. This study aimed to explore the feasibility of extended dosing regimens by population pharmacokinetics (PK) simulations and exposure-response (E-R) relationships. METHODS All simulations were conducted based on the established population PK and E-R model for safety (i.e., adverse events of special interest, AESI) and efficacy (i.e., objective response rate, ORR) for patients with NSCLC or UC. The PK, AESI, and ORR profiles of the following dosing regimens were simulated: (i) 840 mg q4w, (ii) 1200 mg every 6 weeks (q6w), and (iii) 1680 mg q8w. These regimens were compared with those of the 1200 mg q3w standard regimen. RESULTS The simulation revealed that the ranking of efficacy for different extended dosing regimens were 1680 mg q8w ≅ 1200 mg q3w ≅ 1200 mg q6w > 840 mg q4w based on the predicted probability of ORR in patients with NSCLC and UC, and this ranking order was similar to that of the safety outcome of the AESI. The minimum serum concentration at steady-state (Cmin,ss) values for all dosing regimens was all higher than the target effective concentration of 6 μg/mL. CONCLUSION The findings from this simulation suggest that extended dosing regimens are unlikely to significantly impair clinical outcomes and may provide more therapeutic benefits to patients in terms of safety.
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Affiliation(s)
- Chen-Hsi Chou
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,School of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Li-Feng Hsu
- Center of Consultation, Center for Drug Evaluation (CDE), 3F, No.465, Sec.6, Zhongxiao E. Rd., Taipei, 11557, Taiwan. .,Faculty of Pharmacy, National Yang-Ming University, Taipei, Taiwan.
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24
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Martin JH, Lewis LD. Taking the brake off the immune system: Hypotheses, trials, tribulations, and the evolving discipline of clinical immunopharmacology. Br J Clin Pharmacol 2020; 86:1674-1677. [PMID: 32770557 DOI: 10.1111/bcp.14481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/08/2020] [Accepted: 06/16/2020] [Indexed: 12/22/2022] Open
Affiliation(s)
- Jennifer H Martin
- Centre for Drug Repurposing and Medicines Research, Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Lionel D Lewis
- Section of Clinical Pharmacology, Department of Medicine, The Geisel School of Medicine at Dartmouth and The Norris Cotton Cancer Center, Lebanon, New Hampshire, USA
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