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van der Heijden LT, Steeghs N, Beijnen JH, Huitema ADR, Dorlo TPC. The use of microtracers in food-effect trials: An alternative study design for toxic drugs with long half-lives exemplified by the case for alectinib. Clin Transl Sci 2023; 16:2557-2564. [PMID: 37828717 PMCID: PMC10719472 DOI: 10.1111/cts.13647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/04/2023] [Accepted: 09/08/2023] [Indexed: 10/14/2023] Open
Abstract
The traditional design of food-effect studies has a high patient burden for toxic drugs with long half-lives (e.g., anticancer agents). Microtracers could be used to assess food-effect in patients without influencing their ongoing treatment. The feasibility of a microtracer food-effect study during steady-state of the therapeutic drug was investigated in an in silico simulation study with alectinib as an example for a relative toxic drug with a long half-life. Microtracer pharmacokinetics were simulated based on a previously published population pharmacokinetic model and used for estimation of a model with and a model without food as a covariate on oral bioavailability of alectinib (assuming a 40% food-effect). Power was defined as the fraction of clinical trials where a significant (p < 0.01) food-effect was identified. The proposed study design of 10 patients on steady-state treatment, 10 blood samples collected within 24 h after administration and an assumed food-effect of 40% had a power of 99.9%. The mean estimated food-effect was 39.8% (80% confidence interval: 31.0%-48.6%). The feasibility of microtracer food-effect studies was demonstrated. The design of the microtracer food-effect study allowed estimation of the food-effect with minimal influence on therapeutic treatment and reducing patient burden compared to the traditional study design for toxic drugs with long half-lives.
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Affiliation(s)
- L. T. van der Heijden
- Department of Pharmacy & PharmacologyAntoni van Leeuwenhoek/The Netherlands Cancer InstituteAmsterdamThe Netherlands
- Division of PharmacologyAntoni van Leeuwenhoek/The Netherlands Cancer InstituteAmsterdamThe Netherlands
| | - N. Steeghs
- Division of Medical Oncology, Department of Clinical PharmacologyAntoni van Leeuwenhoek Hospital/The Netherlands Cancer InstituteAmsterdamThe Netherlands
| | - J. H. Beijnen
- Department of Pharmacy & PharmacologyAntoni van Leeuwenhoek/The Netherlands Cancer InstituteAmsterdamThe Netherlands
- Division of PharmacologyAntoni van Leeuwenhoek/The Netherlands Cancer InstituteAmsterdamThe Netherlands
- Division of Pharmaco‐epidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Faculty of ScienceUtrecht UniversityUtrechtThe Netherlands
| | - A. D. R. Huitema
- Department of Pharmacy & PharmacologyAntoni van Leeuwenhoek/The Netherlands Cancer InstituteAmsterdamThe Netherlands
- Division of PharmacologyAntoni van Leeuwenhoek/The Netherlands Cancer InstituteAmsterdamThe Netherlands
- Department of Clinical Pharmacy, University Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
- Department of PharmacologyPrincess Maxima CenterUtrechtThe Netherlands
| | - T. P. C. Dorlo
- Department of Pharmacy & PharmacologyAntoni van Leeuwenhoek/The Netherlands Cancer InstituteAmsterdamThe Netherlands
- Division of PharmacologyAntoni van Leeuwenhoek/The Netherlands Cancer InstituteAmsterdamThe Netherlands
- Department of PharmacyUppsala UniversityUppsalaSweden
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Araujo D, Greystoke A, Bates S, Bayle A, Calvo E, Castelo-Branco L, de Bono J, Drilon A, Garralda E, Ivy P, Kholmanskikh O, Melero I, Pentheroudakis G, Petrie J, Plummer R, Ponce S, Postel-Vinay S, Siu L, Spreafico A, Stathis A, Steeghs N, Yap C, Yap TA, Ratain M, Seymour L. Oncology phase I trial design and conduct: time for a change - MDICT Guidelines 2022. Ann Oncol 2023; 34:48-60. [PMID: 36182023 DOI: 10.1016/j.annonc.2022.09.158] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/18/2022] [Indexed: 02/03/2023] Open
Abstract
In 2021, the Food and Drug Administration Oncology Center of Excellence announced Project Optimus focusing on dose optimization for oncology drugs. The Methodology for the Development of Innovative Cancer Therapies (MDICT) Taskforce met to review and discuss the optimization of dosage for oncology trials and to develop a practical guide for oncology phase I trials. Defining a single recommended phase II dose based on toxicity may define doses that are neither the most effective nor the best tolerated. MDICT recommendations address the need for robust non-clinical data which are needed to inform trial design, as well as an expert team including statisticians and pharmacologists. The protocol must be flexible and adaptive, with clear definition of all endpoints. Health authorities should be consulted early and regularly. Strategies such as randomization, intrapatient dose escalation, and real-world eligibility criteria are encouraged whereas serial tumor sampling is discouraged in the absence of a strong rationale and appropriately validated assay. Endpoints should include consideration of all longitudinal toxicity. The phase I dose escalation trial should define the recommended dose range for later testing in randomized phase II trials, rather than a single recommended phase II dose, and consider scenarios where different populations may require different dosages. The adoption of these recommendations will improve dosage selection in early clinical trials of new anticancer treatments and ultimately, outcomes for patients.
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Affiliation(s)
- D Araujo
- Hospital de Base, Sao Jose do Rio Preto, Brazil
| | - A Greystoke
- Northern Centre for Cancer Care, Newcastle, UK
| | - S Bates
- Division of Hematology and Oncology, Department of Medicine, Columbia University, New York, USA
| | - A Bayle
- Institut Gustave Roussy, Paris, France
| | - E Calvo
- START Madrid-CIOCC, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - L Castelo-Branco
- European Society for Medical Oncology (ESMO), Lugano, Switzerland
| | - J de Bono
- Institute of Cancer Research, University of London, London; The Royal Marsden Hospital, London, UK
| | - A Drilon
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, USA
| | - E Garralda
- Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - P Ivy
- National Cancer Institute, USA Cancer Therapy Evaluation Program Investigational Drug Branch (NCI/CTEP/IDB), Bethesda, USA
| | - O Kholmanskikh
- European Medicines Agency, Amsterdam, Netherlands; Federal Agency for Medicines and Health Products, Brussels, Belgium
| | - I Melero
- CUN and CIMA, University of Navarra, Pamplona, Spain
| | - G Pentheroudakis
- European Society for Medical Oncology (ESMO), Lugano, Switzerland
| | - J Petrie
- Canadian Cancer Trials Group, Queen's University, Kingston
| | - R Plummer
- Northern Centre for Cancer Care, Newcastle, UK
| | - S Ponce
- Institut Gustave Roussy, Paris, France
| | | | - L Siu
- Princess Margaret Cancer Centre, Toronto, Canada
| | - A Spreafico
- Princess Margaret Cancer Centre, Toronto, Canada
| | - A Stathis
- Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
| | - N Steeghs
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - C Yap
- Institute of Cancer Research, University of London, London
| | - T A Yap
- Department of Investigational Cancer Therapeutics, University of Texas, MD Anderson Cancer Center, Houston
| | - M Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, USA
| | - L Seymour
- Canadian Cancer Trials Group, Queen's University, Kingston.
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Hukkanen RR, Moriyama T, Patrick DJ, Werner J. Toxicologic Pathology Forum: Opinion on Approaches for Reporting Toxic and Adverse Dose Levels in Nonclinical Toxicology Studies Supporting the Development of Anticancer Pharmaceuticals. Toxicol Pathol 2023; 51:81-86. [PMID: 36695335 DOI: 10.1177/01926233221146937] [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: 01/26/2023]
Abstract
The advancement of an investigational new drug in humans is a significant developmental milestone. In first-in-human (FIH)-enabling toxicology studies, the highest dose without a test article-related adverse effect (no-observed-adverse-effect-level [NOAEL]) serves as the basis for deriving a safe FIH starting dose. For anticancer pharmaceuticals, the FIH dose may be calculated using the highest non-severely toxic dose (HNSTD) in nonrodent models or the dose severely toxic to 10% (STD10) in rodents. Given the practice of reporting the NOAEL, but the lack of regulatory requirements to do so for anticancer pharmaceuticals, we conducted an informal survey of 20 companies to answer the question "How is our industry reporting toxic/adverse dose levels in FIH-enabling toxicology studies for anticancer indications?" The data indicated 4 reporting approaches, each providing a path to regulatory acceptance. Within the integrated toxicology study report, 45% of respondents report the HNSTD/STD10, 25% report the NOAEL, 20% report both the HNSTD/STD10 and NOAEL, and 10% do not define either, reserving definitions for regulatory submissions. One reporting approach may be preferred over another for reasons including consistency across indications, repurposing pharmaceuticals, regulatory feedback, or simplicity. The reporting approach should be defined in advance of study initiation, and the pathologist should provide context to support the chosen approach.
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Effects of food and race on the pharmacokinetics of lazertinib in healthy subjects and patients with EGFR mutation-positive advanced non-small cell lung cancer. Lung Cancer 2023; 175:112-120. [PMID: 36495784 DOI: 10.1016/j.lungcan.2022.11.021] [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: 08/24/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES Lazertinib is a potent, irreversible, brain-penetrant, mutant-selective, and wild type-sparing third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor indicated for advanced non-small cell lung cancer (NSCLC). The study aimed to evaluate the effects of food and race on the pharmacokinetics (PK) of lazertinib from a healthy volunteer trial and PK data from NSCLC patients with EGFR mutation. MATERIALS AND METHODS An open-label, single-dose, two-period, single-sequence crossover study was conducted in healthy subjects with two race groups (non-Asian and Asian). Subjects orally received a single dose of lazertinib 240 mg in fasted and fed state (high-fat meal) in each period separated by a 21-day washout. An open-label, multicenter, phase 1/2 study was conducted in Asian and non-Asian patients with NSCLC. Patients were given oral lazertinib 20-320 mg once daily in fasted state continuously in 21-day cycles. PK parameters were evaluated using non-compartmental analysis. RESULTS A total of 24 healthy subjects (12 non-Asians and 12 Asians) and 52 NSCLC patients (22 non-Asians and 30 Asians) were evaluated. The change in the overall systemic exposure of lazertinib at fed state was less than 15%. Non-Asians showed 58-76% of the systemic exposure than Asians in healthy subjects. In contrast, there were no significant differences in systemic exposure by race both after single and multiple doses among NSCLC patients. CONCLUSION Lazertinib can be taken with or without food considering the comparable systemic exposures related to food. Although effect of race was not consistent across studies, there was no evidence for dose adjustment based on race.
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Radanovic I, Klarenbeek N, Rissmann R, Groeneveld GJ, van Brummelen EMJ, Moerland M, Bosch JJ. Integration of healthy volunteers in early phase clinical trials with immuno-oncological compounds. Front Oncol 2022; 12:954806. [PMID: 36106110 PMCID: PMC9465458 DOI: 10.3389/fonc.2022.954806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/09/2022] [Indexed: 11/24/2022] Open
Abstract
Aim Traditionally, early phase clinical trials in oncology have been performed in patients based on safety risk-benefit assessment. Therapeutic transition to immuno-oncology may open new opportunities for studies in healthy volunteers, which are conducted faster and are less susceptible to confounders. Aim of this study was to investigate to what extent this approach is utilized and whether pharmacodynamic endpoints are evaluated in these early phase trials. We conducted a comprehensive review of clinical trials with healthy volunteers using immunotherapies potentially relevant for oncology. Methods Literature searches according to PRISMA guidelines and after registration in PROSPERO were conducted in PubMed, Embase, Web of Science and Cochrane databases with the cut-off date 20 October 2020, using search terms of relevant targets in immuno-oncology. Articles describing clinical trials with immunotherapeutics in healthy volunteers with a mechanism relevant for oncology were included. “Immunotherapeutic” was defined as compounds exhibiting effects through immunological targets. Data including study design and endpoints were extracted, with specific attention to pharmacodynamic endpoints and safety. Results In total, we found 38 relevant immunotherapeutic compounds tested in HVs, with 86% of studies investigating safety, 82% investigating the pharmacokinetics (PK) and 57% including at least one pharmacodynamic (PD) endpoint. Most of the observed adverse events (AEs) were Grade 1 and 2, consisting mostly of gastrointestinal, cutaneous and flu-like symptoms. Severe AEs were leukopenia, asthenia, syncope, headache, flu-like reaction and liver enzymes increase. PD endpoints investigated comprised of cytokines, immune and inflammatory biomarkers, cell counts, phenotyping circulating immune cells and ex vivo challenge assays. Discussion Healthy volunteer studies with immuno-oncology compounds have been performed, although not to a large extent. The integration of healthy volunteers in well-designed proof-of-mechanism oriented drug development programs has advantages and could be pursued more in the future, since integrative clinical trial protocols may facilitate early dose selection and prevent cancer patients to be exposed to non-therapeutic dosing regimens. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=210861, identifier CRD42020210861
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Affiliation(s)
- Igor Radanovic
- Centre for Human Drug Research, Leiden, Netherlands
- Leiden University Medical Center, Leiden, Netherlands
| | | | - Robert Rissmann
- Centre for Human Drug Research, Leiden, Netherlands
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research, Leiden University, Leiden, Netherlands
| | - Geert Jan Groeneveld
- Centre for Human Drug Research, Leiden, Netherlands
- Leiden University Medical Center, Leiden, Netherlands
| | | | - Matthijs Moerland
- Centre for Human Drug Research, Leiden, Netherlands
- Leiden University Medical Center, Leiden, Netherlands
| | - Jacobus J. Bosch
- Centre for Human Drug Research, Leiden, Netherlands
- Leiden University Medical Center, Leiden, Netherlands
- *Correspondence: Jacobus J. Bosch,
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