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Lewis R, Niazi-Ali S, McIvor A, Kanj SS, Maertens J, Bassetti M, Levine D, Groll AH, Denning DW. Triazole antifungal drug interactions-practical considerations for excellent prescribing. J Antimicrob Chemother 2024; 79:1203-1217. [PMID: 38629250 DOI: 10.1093/jac/dkae103] [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: 06/04/2024] Open
Abstract
Systemic antifungal therapy is critical for reducing the mortality from many invasive and chronic fungal infections. Triazole antifungals are the most frequently prescribed antifungals but require attention to dosing and drug interactions. Nearly 600 severe drug-drug interactions and over 1100 moderate interactions requiring dose modifications are described or anticipated with systemic antifungal agents (see https://www.aspergillus.org.uk/antifungal-drug-interactions/). In this article, we address the common and less common, but serious, drug interactions observed in clinical practice with triazole antifungals, including a group of drugs that cannot be prescribed with all or most triazole antifungals (ivabradine, ranolazine, eplerenone, fentanyl, apomorphine, quetiapine, bedaquiline, rifampicin, rifabutin, sirolimus, phenytoin and carbamazepine). We highlight interactions with drugs used in children and new agents introduced for the treatment of haematological malignancies or graft versus host disease (midostaurin, ibrutinib, ruxolitinib and venetoclax). We also summarize the multiple interactions between oral and inhaled corticosteroids and triazole antifungals, and the strategies needed to optimize the therapeutic benefits of triazole antifungal therapy while minimizing potential harm to patients.
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Affiliation(s)
- Russell Lewis
- Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Saarah Niazi-Ali
- Antifungal Database Consultancy Pharmacist, Fungal Infection Trust, PO Box 482, Macclesfield, Cheshire SK10 9AR, UK
| | - Andrew McIvor
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Souha S Kanj
- Division of Infectious Diseases, Department of Internal Medicine and Center for Infectious Diseases Research, American University of Beirut Medical Center, Beirut, Lebanon
| | - Johan Maertens
- Department of Microbiology, Immunology, and Transplantation, Department of Haematology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Matteo Bassetti
- Department of Health Sciences, Infectious Diseases Clinic, University of Genoa and Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Deborah Levine
- Lung Transplant Program, Division of Pulmonary Critical Care and Allergy, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital, Albert-Schweitzer-Campus 1, Building A1, Münster, 48149, Germany
| | - David W Denning
- Manchester Fungal Infection Group, The University of Manchester and Manchester Academic Health Science Centre, Manchester, UK
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Zhao Y, Zhang X, Ding X, Wang Y, Li Z, Zhao R, Cheng HE, Sun Y. Efficacy and safety of FLT3 inhibitors in monotherapy of hematological and solid malignancies: a systemic analysis of clinical trials. Front Pharmacol 2024; 15:1294668. [PMID: 38828446 PMCID: PMC11140126 DOI: 10.3389/fphar.2024.1294668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 04/29/2024] [Indexed: 06/05/2024] Open
Abstract
Introduction: FLT3 mutations are closely associated with the occurrence of hematological and solid malignancies, especially with acute myeloid leukemia. Currently, several FLT3 inhibitors are in clinical trials, and some have been applied in clinic. However, the safety, efficacy and pharmacodynamics of these FLT3 inhibitors have not been systemically analyzed before. Methods: We searched and reviewed clinical trial reports on the monotherapy of 13 FLT3 inhibitors, including sorafenib, lestaurtinib, midostaurin, gilteritinib, quizartinib, sunitinib, crenolanib, tandutinib, cabozantinib, pexidartinib, pacritinib, famitinib, and TAK-659 in patients with hematological and solid malignancies before May 31, 2023. Results: Our results showed the most common adverse events (AEs) were gastrointestinal adverse reactions, including diarrhea, hand-foot syndrome and nausea, while the most common hematological AEs were febrile neutropenia, anemia, and thrombocytopenia. Based on the published data, the mean overall survival (OS) and the mean progression-free survival (PFS) were 9.639 and 5.905 months, respectively. The incidence of overall response rate (ORR), complete remission (CR), partial response (PR), and stable disease (SD) for all these FLT3 inhibitors was 29.0%, 8.7%, 16.0%, and 42.3%, respectively. The ORRs of FLT3 inhibitors in hematologic malignancies and solid tumors were 40.8% and 18.8%, respectively, indicating FLT3 inhibitors were more effective for hematologic malignancies than for solid tumors. In addition, time to maximum plasma concentration (Tmax) in these FLT3 inhibitors ranged from 0.7-12.0 hours, but the elimination half-life (T1/2) range was highly variable, from 6.8 to 151.8 h. Discussion: FLT3 inhibitors monotherapy has shown significant anti-tumor effect in clinic, and the effectiveness may be further improved through combination medication.
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Affiliation(s)
| | | | | | | | | | | | - Hai-En Cheng
- School of Medical Laboratory, Shandong Second Medical University, Weifang, China
| | - Yanli Sun
- School of Medical Laboratory, Shandong Second Medical University, Weifang, China
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3
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Sechaud R, Gu H, Rahmanzadeh G, Taylor A, Chiparus O, Sharma GK, Breitschaft A, Menssen HD. Midostaurin drug interaction profile: a comprehensive assessment of CYP3A, CYP2B6, and CYP2C8 drug substrates, and oral contraceptives in healthy participants. Cancer Chemother Pharmacol 2024; 93:439-453. [PMID: 38270613 DOI: 10.1007/s00280-023-04635-3] [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: 10/20/2023] [Accepted: 12/21/2023] [Indexed: 01/26/2024]
Abstract
PURPOSE Midostaurin, approved for treating FLT-3-mutated acute myeloid leukemia and advanced systemic mastocytosis, is metabolized by cytochrome P450 (CYP) 3A4 to two major metabolites, and may inhibit and/or induce CYP3A, CYP2B6, and CYP2C8. Two studies investigated the impact of midostaurin on CYP substrate drugs and oral contraceptives in healthy participants. METHODS Using sentinel dosing for participants' safety, the effects of midostaurin at steady state following 25-day (Study 1) or 24-day (Study 2) dosing with 50 mg twice daily were evaluated on CYP substrates, midazolam (CYP3A4), bupropion (CYP2B6), and pioglitazone (CYP2C8) in Study 1; and monophasic oral contraceptives (containing ethinylestradiol [EES] and levonorgestrel [LVG]) in Study 2. RESULTS In Study 1, midostaurin resulted in a 10% increase in midazolam peak plasma concentrations (Cmax), and 3-4% decrease in total exposures (AUC). Bupropion showed a 55% decrease in Cmax and 48-49% decrease in AUCs. Pioglitazone showed a 10% decrease in Cmax and 6% decrease in AUC. In Study 2, midostaurin resulted in a 26% increase in Cmax and 7-10% increase in AUC of EES; and a 19% increase in Cmax and 29-42% increase in AUC of LVG. Midostaurin 50 mg twice daily for 28 days ensured that steady-state concentrations of midostaurin and the active metabolites were achieved by the time of CYP substrate drugs or oral contraceptive dosing. No safety concerns were reported. CONCLUSION Midostaurin neither inhibits nor induces CYP3A4 and CYP2C8, and weakly induces CYP2B6. Midostaurin at steady state has no clinically relevant PK interaction on hormonal contraceptives. All treatments were well tolerated.
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Affiliation(s)
| | - Helen Gu
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Amanda Taylor
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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Wiesen MHJ, Stemler J, Fietz C, Joisten C, Cornely OA, Verougstraete N, Streichert T, Müller C. Quantification of midostaurin in plasma and serum by stable isotope dilution liquid chromatography-tandem mass spectrometry: Application to a cohort of patients with acute myeloid leukemia. Eur J Haematol 2024. [PMID: 38297484 DOI: 10.1111/ejh.14178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 02/02/2024]
Abstract
OBJECTIVES Midostaurin is an oral multitargeted tyrosine kinase inhibitor for the treatment of acute myeloid leukemia (AML). Therapeutic drug monitoring of midostaurin may support its safe use when suspecting toxicity or combined with strong CYP3A4 inhibitors. METHODS A stable isotope dilution liquid chromatography-tandem mass spectrometry method was developed and validated for the determination and quantification of midostaurin in human plasma and serum. Midostaurin serum concentrations were analyzed in 12 patients with FMS-like tyrosine kinase 3 (FLT3)-mutated AML during induction chemotherapy with cytarabine, daunorubicin, and midostaurin. Posaconazole was used as prophylaxis of invasive fungal infections. RESULTS Linear quantification of midostaurin was demonstrated across a concentration range of 0.01-8.00 mg/L. Inter- and intraday imprecisions of the proposed method were well within ±10%. Venous blood samples were taken in nine and three patients in the first and second cycle of induction chemotherapy. Median (range) midostaurin serum concentration was 7.9 mg/L (1.5-26.1 mg/L) as determined in 37 independent serum specimens. CONCLUSION In a real-life cohort of AML patients, interindividual variability in midostaurin serum concentrations was high, highlighting issues concerning optimal drug dosing in AML patients. A personalized dosage approach may maximize the safety of midostaurin. Prospective studies and standardization of analytical methods to support such an approach are needed.
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Affiliation(s)
- Martin H J Wiesen
- Therapeutic Drug Monitoring, Pharmacology at the Laboratory Diagnostics Centre, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Clinical Chemistry, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jannik Stemler
- Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Cornelia Fietz
- Therapeutic Drug Monitoring, Pharmacology at the Laboratory Diagnostics Centre, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Carolin Joisten
- Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Oliver A Cornely
- Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | - Nick Verougstraete
- Laboratory of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Thomas Streichert
- Therapeutic Drug Monitoring, Pharmacology at the Laboratory Diagnostics Centre, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Clinical Chemistry, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Carsten Müller
- Therapeutic Drug Monitoring, Pharmacology at the Laboratory Diagnostics Centre, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Xu Y, Baylink DJ, Chen CS, Tan L, Xiao J, Park B, Valladares I, Reeves ME, Cao H. Transient TKI-resistant CD44+pBAD+ blasts undergo intrinsic homeostatic adaptation to promote the survival of acute myeloid leukemia in vitro. Front Oncol 2023; 13:1286863. [PMID: 38023123 PMCID: PMC10664142 DOI: 10.3389/fonc.2023.1286863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023] Open
Abstract
Acute myeloid leukemia (AML) patients have frequent mutations in FMS-like receptor tyrosine kinase 3 (FLT3-mut AML), who respond poorly to salvage chemotherapies and targeted therapies such as tyrosine kinase inhibitors (TKIs). Disease relapse is a common reason of treatment failures in FLT3-mut AML patients, but its intracellular refractory mechanism remains to be discovered. In this study, we designed serial in vitro time-course studies to investigate the biomarkers of TKI-resistant blasts and their survival mechanism. First, we found that a group of transient TKI-resistant blasts were CD44+Phosphorylated-BAD (pBAD)+ and that they could initiate the regrowth of blast clusters in vitro. Notably, TKI-treatments upregulated the compensation pathways to promote PIM2/3-mediated phosphorylation of BAD to initiate the blast survival. Next, we discovered a novel process of intracellular adaptive responses in these transient TKI-resistant blasts, including upregulated JAK/STAT signaling pathways for PIM2/3 expressions and activated SOCS1/SOCS3/PIAS2 inhibitory pathways to down-regulate redundant signal transduction and kinase phosphorylation to regain intracellular homeostasis. Finally, we found that the combination of TKIs with TYK2/STAT4 pathways-driven inhibitors could effectively treat FLT3-mut AML in vitro. In summary, our findings reveal that TKI-treatment can activate a JAK/STAT-PIM2/3 axis-mediated signaling pathways to promote the survival of CD44+pBAD+blasts in vitro. Disrupting these TKIs-activated redundant pathways and blast homeostasis could be a novel therapeutic strategy to treat FLT3-mut AML and prevent disease relapse in vivo.
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Affiliation(s)
- Yi Xu
- Division of Hematology and Oncology, Loma Linda University Medical Center and Loma Linda University Cancer Center, Loma Linda University Health, Loma Linda, CA, United States
- Division of Regenerative Medicine, Department of Medicine, Loma Linda University, Loma Linda, CA, United States
- Department of Medicine, Loma Linda University School of Medicine, Loma Linda University Health, Loma Linda, CA, United States
| | - David J. Baylink
- Division of Regenerative Medicine, Department of Medicine, Loma Linda University, Loma Linda, CA, United States
- Department of Medicine, Loma Linda University School of Medicine, Loma Linda University Health, Loma Linda, CA, United States
| | - Chien-Shing Chen
- Division of Hematology and Oncology, Loma Linda University Medical Center and Loma Linda University Cancer Center, Loma Linda University Health, Loma Linda, CA, United States
- Department of Medicine, Loma Linda University School of Medicine, Loma Linda University Health, Loma Linda, CA, United States
| | - Laren Tan
- Department of Medicine, Loma Linda University School of Medicine, Loma Linda University Health, Loma Linda, CA, United States
- Department of Pulmonary, Critical Care, Hyperbaric and Sleep Medicine, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Jeffrey Xiao
- Division of Regenerative Medicine, Department of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Brandon Park
- Division of Regenerative Medicine, Department of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Ismael Valladares
- Division of Regenerative Medicine, Department of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Mark E. Reeves
- Division of Hematology and Oncology, Loma Linda University Medical Center and Loma Linda University Cancer Center, Loma Linda University Health, Loma Linda, CA, United States
- Department of Medicine, Loma Linda University School of Medicine, Loma Linda University Health, Loma Linda, CA, United States
| | - Huynh Cao
- Division of Hematology and Oncology, Loma Linda University Medical Center and Loma Linda University Cancer Center, Loma Linda University Health, Loma Linda, CA, United States
- Department of Medicine, Loma Linda University School of Medicine, Loma Linda University Health, Loma Linda, CA, United States
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Menna P, Marchesi F, Cattaneo C, Candoni A, Delia M, Nadali G, Vatteroni A, Pasciolla C, Perrone S, Verga L, Armiento D, Del Principe MI, Fracchiolla NS, Salvatorelli E, Lupisella S, Terrenato I, Busca A, Minotti G, Pagano L. Posaconazole and midostaurin in patients with FLT3-mutated acute myeloid leukemia: Pharmacokinetic interactions and clinical facts in a real life study. Clin Transl Sci 2023; 16:1876-1885. [PMID: 37515369 PMCID: PMC10582652 DOI: 10.1111/cts.13595] [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: 06/09/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023] Open
Abstract
Midostaurin is used in combination with chemotherapy to treat patients with newly diagnosed FLT3-mutated acute myeloid leukemia. Chemotherapy-induced neutropenia exposes these patients to a significant risk of invasive fungal infections (IFIs). International guidelines recommend primary antifungal prophylaxis with posaconazole (PCZ) but nested analysis of a phase III trial showed that strong PCZ inhibition of CYP3A4 diminished midostaurin metabolism and increased midostaurin plasma levels; however, midostaurin-related adverse events (AEs) were only moderately exacerbated. We conducted a prospective multicenter real-life study to evaluate (i) how often concerns around PCZ-midostaurin interactions made the hematologist prescribe antifungals other than PCZ, (ii) how remarkably PCZ increased midostaurin plasma levels, and (iii) how significantly PCZ-midostaurin interactions influenced hematologic and safety outcomes of induction therapy. Although the hematologists were blinded to pharmacokinetic findings, as many as 16 of 35 evaluable patients were prescribed antifungal prophylaxis with micafungin, weak CYP3A4 inhibitor, in place of PCZ (p < 0.001 for deviation from guidelines). In the 19 patients managed as per guidelines, PCZ-midostaurin interactions were more remarkable than previously characterized, such that at the end of induction therapy midostaurin minimum plasma concentration (Cmin ) was greater than three times higher than reported; moreover, midostaurin Cmin , maximum plasma concentration, and area under the curve were more than or equal to four times higher with PCZ than micafungin. Hematologic outcomes (complete remission and duration of severe neutropenia) and safety outcomes (midostaurin-related any grade or grade ≥3 AEs) were nonetheless similar for patients exposed to PCZ or micafungin, as was the number of breakthrough IFIs. In waiting for randomized phase III trials of new prophylaxis regimens, these findings show that PCZ should remain the antifungal of choice for the midostaurin-treated patient.
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Affiliation(s)
- Pierantonio Menna
- University Campus Bio‐Medico andFondazione Policlinico Universitario Campus Bio‐MedicoRomeItaly
| | - Francesco Marchesi
- Hematology and Stem Cell Transplant UnitIRCCS Regina Elena National Cancer InstituteRomeItaly
| | - Chiara Cattaneo
- Azienda Socio Sanitaria Territoriale and Spedali CiviliBresciaItaly
| | - Anna Candoni
- Azienda Sanitaria Universitaria IntegrataUniversity HospitalUdineItaly
| | - Mario Delia
- Hematology Section, Department of Emergency and Organ TransplantUniveristy of BariBariItaly
| | - Gianpaolo Nadali
- U.O.C. Ematologia, Azienda Ospedaliera Universitaria Integrata di Verona, Ospedale Borgo Roma, Verona, ItalyAzienda Ospedaliera Universitaria IntegrataVeronaItaly
| | - Alessandra Vatteroni
- U.O.C. Ematologia, Azienda Ospedaliera Universitaria Integrata di Verona, Ospedale Borgo Roma, Verona, ItalyAzienda Ospedaliera Universitaria IntegrataVeronaItaly
| | | | | | | | - Daniele Armiento
- University Campus Bio‐Medico andFondazione Policlinico Universitario Campus Bio‐MedicoRomeItaly
| | | | | | | | | | - Irene Terrenato
- Hematology and Stem Cell Transplant UnitIRCCS Regina Elena National Cancer InstituteRomeItaly
| | - Alessandro Busca
- Department of Hematology and Stem Cell Transplant UnitAzienda Ospedaliera Universitaria Citta' della Salute e della ScienzaTorinoItaly
| | - Giorgio Minotti
- University Campus Bio‐Medico andFondazione Policlinico Universitario Campus Bio‐MedicoRomeItaly
| | - Livio Pagano
- Fondazione Policlinico Universitario Agostino Gemelli IRCCSRomeItaly
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Haefliger D, Marzolini C, Lamoth F, Pabst T, Buclin T, Livio F. Clinically relevant bidirectional drug-drug interaction between midostaurin and voriconazole. Br J Clin Pharmacol 2023; 89:2304-2308. [PMID: 37050863 DOI: 10.1111/bcp.15743] [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: 01/16/2023] [Revised: 03/20/2023] [Accepted: 03/25/2023] [Indexed: 04/14/2023] Open
Abstract
Midostaurin is often prescribed with azole antifungals in patients with leukaemia, either for aspergillosis prophylaxis or treatment. Midostaurin is extensively metabolized by cytochrome (CYP) 3A4. In addition, it inhibits and induces various CYPs at therapeutic concentrations. Thus, midostaurin is associated with a high potential for drug-drug interactions (DDIs), both as a substrate (victim) and as a perpetrator. However, data on midostaurin as a perpetrator of DDIs are scarce, as most pharmacokinetic studies have focused on midostaurin as a victim drug. We report a clinically relevant bidirectional DDI between midostaurin and voriconazole during induction treatment. A 49-year-old woman with acute myeloid leukaemia developed invasive pulmonary aspergillosis after induction chemotherapy. She was treated with voriconazole at standard dosage. Six days after starting midostaurin, she developed visual hallucinations with a concurrent sharp increase in voriconazole blood concentration (Ctrough 10.3 mg L-1 , target Ctrough 1-5 mg L-1 ). Neurotoxicity was considered to be related to voriconazole overexposure. The concentration of midostaurin was concomitantly six-fold above the average expected level, but without safety issues. Midostaurin was stopped and the dosage of voriconazole was adjusted with therapeutic drug monitoring. The evolution was favourable, with quick resolution and no recurrence of visual hallucinations. To our knowledge, this is the first case suggesting that midostaurin and voriconazole reciprocally inhibit each other's metabolism, leading to increased exposure of both. This case highlights the knowledge gap regarding drug-drug interactions between midostaurin and azole antifungals. Close clinical and therapeutic drug monitoring is advised in such cases.
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Affiliation(s)
- David Haefliger
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Frederic Lamoth
- Service of Infectious Diseases, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, Inselspital, University Hospital, Bern, Switzerland
| | - Thierry Buclin
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Francoise Livio
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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8
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Solana-Altabella A, Megías-Vericat JE, Ballesta-López O, Martínez-Cuadrón D, Montesinos P. Drug-drug interactions associated with FLT3 inhibitors for acute myeloblastic leukemia: current landscape. Expert Rev Clin Pharmacol 2023; 16:133-148. [PMID: 36708283 DOI: 10.1080/17512433.2023.2174523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION FLT3 inhibitors (FLT3i) are drugs in which there is limited experience and not yet enough information on the mechanisms of absorption, transport, and elimination; but especially on the potential drug-drug interactions (DDIs). There are therefore risks in the management of FLT3i DDIs (i.e. sorafenib, ponatinib, crenolanib, midostaurin, quizartinib, and gilteritinib) and ignoring them can compromise therapeutic success in acute myeloid leukemia (AML) treatment, in complex patients and secondary pathologies. AREAS COVERED This review summarizes the DDIs of FLT3i with P-glycoprotein (P-gp), breast cancer resistance protein (BCRP), organic anion transporting (OAT), organic cationic transporting (OCT), cytochrome P450 (CYP) subunits, and other minor metabolic/transport pathways. EMBASE, PubMed, the Cochrane Central Register and the Web of Science were searched. The last literature search was performed on the 14 February 2022. EXPERT OPINION FLT3i will be combined with other therapeutic agents (supportive care, doublet, or triplet therapy) and in different clinical settings, which means a greater chance of controlling and even eradicating the disease effectively, but also an increased risk to patients due to potential DDIs. Healthcare professionals should be aware of the potential interactions that may occur and be vigilant in monitoring those patients who are receiving any potentially interacting drug.
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Affiliation(s)
- Antonio Solana-Altabella
- Servicio de Farmacia Área del Medicamento, Hospital Universitari i Politècnic La Fe Av. Valencia, Spain.,Grupo de Investigación en Hematología y Hemoterapia, Instituto de Investigación Sanitaria La Fe (IISLAFE), Valencia, Spain
| | | | - Octavio Ballesta-López
- Servicio de Farmacia Área del Medicamento, Hospital Universitari i Politècnic La Fe Av. Valencia, Spain.,Grupo de Investigación en Hematología y Hemoterapia, Instituto de Investigación Sanitaria La Fe (IISLAFE), Valencia, Spain
| | - David Martínez-Cuadrón
- Grupo de Investigación en Hematología y Hemoterapia, Instituto de Investigación Sanitaria La Fe (IISLAFE), Valencia, Spain.,Servicio de Hematología y Hemoterapia Hospital Universitari i Politècnic La Fe. Valencia Spain
| | - Pau Montesinos
- Grupo de Investigación en Hematología y Hemoterapia, Instituto de Investigación Sanitaria La Fe (IISLAFE), Valencia, Spain.,Servicio de Hematología y Hemoterapia Hospital Universitari i Politècnic La Fe. Valencia Spain
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Rietscher K, Jahnke HG, Rübsam M, Lin EW, Has C, Omary MB, Niessen CM, Magin TM. Kinase Inhibition by PKC412 Prevents Epithelial Sheet Damage in Autosomal Dominant Epidermolysis Bullosa Simplex through Keratin and Cell Contact Stabilization. J Invest Dermatol 2022; 142:3282-3293. [PMID: 35691363 DOI: 10.1016/j.jid.2022.05.1088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/24/2022] [Accepted: 05/22/2022] [Indexed: 01/05/2023]
Abstract
Epidermolysis bullosa simplex (EBS) is a severe and potentially life-threatening disorder for which no adequate therapy exists. Most cases are caused by dominant sequence variations in keratin genes K5 or K14, leading to the formation of cytoplasmic keratin aggregates, profound keratinocyte fragility, and cytolysis. We hypothesized that pharmacological reduction of keratin aggregates, which compromise keratinocyte integrity, represents a viable strategy for the treatment of EBS. In this study, we show that the multikinase inhibitor PKC412, which is currently in clinical use for acute myeloid leukemia and advanced systemic mastocytosis, reduced keratin aggregation by 40% in patient-derived K14.R125C EBS-associated keratinocytes. Using a combination of epithelial shear stress assay and real-time impedance spectroscopy, we show that PKC412 restored intercellular adhesion. Molecularly, global phosphoproteomic analysis together with immunoblots using phosphoepitope-specific antibodies revealed that PKC412 treatment altered phosphorylated sites on keratins and desmoplakin. Thus, our data provide a proof of concept to repurpose existing drugs for the targeted treatment of EBS and showcase how one broad-range kinase inhibitor reduced keratin filament aggregation in patient-derived EBS keratinocytes and the fragility of EBS cell monolayers. Our study paves the way for a clinical trial using PKC412 for systemic or local application in patients with EBS.
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Affiliation(s)
- Katrin Rietscher
- Institute of Biology, Division of Cell and Developmental Biology, Leipzig University, Leipzig, Germany.
| | - Heinz-Georg Jahnke
- Division of Molecular Biological-Biochemical Processing Technology, Center for Biotechnology and Biomedicine, Leipzig University, Leipzig, Germany
| | - Matthias Rübsam
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany; Department Cell Biology of the Skin, Center for Molecular Medicine Cologne, University of Cologne, Cologne, Germany
| | - Eric W Lin
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Cristina Has
- Department of Dermatology, Medical Center, University of Freiburg, Freiburg, Germany
| | - M Bishr Omary
- Center for Advanced Biotechnology and Medicine, Rutgers University, Piscataway, New Jersey, USA; Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - Carien M Niessen
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany; Department Cell Biology of the Skin, Center for Molecular Medicine Cologne, University of Cologne, Cologne, Germany
| | - Thomas M Magin
- Institute of Biology, Division of Cell and Developmental Biology, Leipzig University, Leipzig, Germany
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10
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Spetz JKE, Florido MHC, Fraser CS, Qin X, Choiniere J, Yu SJ, Singh R, Friesen M, Rubin LL, Salem JE, Moslehi JJ, Sarosiek KA. Heightened apoptotic priming of vascular cells across tissues and life span predisposes them to cancer therapy-induced toxicities. SCIENCE ADVANCES 2022; 8:eabn6579. [PMID: 36351019 PMCID: PMC9645721 DOI: 10.1126/sciadv.abn6579] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 09/22/2022] [Indexed: 06/16/2023]
Abstract
Although major organ toxicities frequently arise in patients treated with cytotoxic or targeted cancer therapies, the mechanisms that drive them are poorly understood. Here, we report that vascular endothelial cells (ECs) are more highly primed for apoptosis than parenchymal cells across many adult tissues. Consequently, ECs readily undergo apoptosis in response to many commonly used anticancer agents including cytotoxic and targeted drugs and are more sensitive to ionizing radiation and BH3 mimetics than parenchymal cells in vivo. Further, using differentiated isogenic human induced pluripotent stem cell models of ECs and vascular smooth muscle cells (VSMCs), we find that these vascular cells exhibit distinct drug toxicity patterns, which are linked to divergent therapy-induced vascular toxicities in patients. Collectively, our results demonstrate that vascular cells are highly sensitive to apoptosis-inducing stress across life span and may represent a "weakest link" vulnerability in multiple tissues for development of toxicities.
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Affiliation(s)
- Johan K. E. Spetz
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, MA, USA
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mary H. C. Florido
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, MA, USA
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, MA, USA
- Harvard Stem Cell Institute, Harvard University, Cambridge, MA, USA
| | - Cameron S. Fraser
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, MA, USA
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Xingping Qin
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, MA, USA
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jonathan Choiniere
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, MA, USA
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Stacey J. Yu
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, MA, USA
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Rumani Singh
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, MA, USA
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Max Friesen
- Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, MA, USA
- Harvard Stem Cell Institute, Harvard University, Cambridge, MA, USA
| | - Lee L. Rubin
- Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, MA, USA
- Harvard Stem Cell Institute, Harvard University, Cambridge, MA, USA
| | - Joe-Elie Salem
- Clinical Investigation Center Paris-Est, CIC-1901, INSERM, UNICO-GRECO Cardio-Oncology Program, Department of Pharmacology, Pitié-Salpêtrière University Hospital, Sorbonne Université, Paris, France
- Cardio-Oncology Program, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Javid J. Moslehi
- Section of Cardio-Oncology and Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Kristopher A. Sarosiek
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, MA, USA
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Cancer Center, Boston, MA, USA
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11
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Skolnick J, Zhou H. Implications of the Essential Role of Small Molecule Ligand Binding Pockets in Protein-Protein Interactions. J Phys Chem B 2022; 126:6853-6867. [PMID: 36044742 PMCID: PMC9484464 DOI: 10.1021/acs.jpcb.2c04525] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/18/2022] [Indexed: 11/28/2022]
Abstract
Protein-protein interactions (PPIs) and protein-metabolite interactions play a key role in many biochemical processes, yet they are often viewed as being independent. However, the fact that small molecule drugs have been successful in inhibiting PPIs suggests a deeper relationship between protein pockets that bind small molecules and PPIs. We demonstrate that 2/3 of PPI interfaces, including antibody-epitope interfaces, contain at least one significant small molecule ligand binding pocket. In a representative library of 50 distinct protein-protein interactions involving hundreds of mutations, >75% of hot spot residues overlap with small molecule ligand binding pockets. Hence, ligand binding pockets play an essential role in PPIs. In representative cases, evolutionary unrelated monomers that are involved in different multimeric interactions yet share the same pocket are predicted to bind the same metabolites/drugs; these results are confirmed by examples in the PDB. Thus, the binding of a metabolite can shift the equilibrium between monomers and multimers. This implicit coupling of PPI equilibria, termed "metabolic entanglement", was successfully employed to suggest novel functional relationships among protein multimers that do not directly interact. Thus, the current work provides an approach to unify metabolomics and protein interactomics.
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Affiliation(s)
- Jeffrey Skolnick
- Center for the Study of Systems
Biology, School of Biological Sciences, Georgia Institute of Technology, 950 Atlantic Drive, NW, Atlanta, Georgia 30332, United States
| | - Hongyi Zhou
- Center for the Study of Systems
Biology, School of Biological Sciences, Georgia Institute of Technology, 950 Atlantic Drive, NW, Atlanta, Georgia 30332, United States
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12
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Reddy MP, Konduru N, Gundla R, Kowtharapu LP. Regulatory Perspective Development and Validation of Novel RP-HPLC Method of Midostaurin Drug Substance using Analytical Quality by Design approach; Identified Major Degradation Compounds Mass by Using LC-MS technique. Biomed Chromatogr 2022; 36:e5486. [PMID: 36001450 DOI: 10.1002/bmc.5486] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/01/2022] [Accepted: 08/22/2022] [Indexed: 11/10/2022]
Abstract
Midostaurin (MTN) was designated as an orphan medicinal product, and it is an emerging drug for treating acute myeloid leukemia and advanced systematic mastocytosis, respectively. The proposed method was developed and validated to evaluate related impurities of MTN. Those impurities were separated by using YMC Trait C18 ExRS, (150 mm × 4.6 mm), 3 μm column. The mobile phase A consists of a 10 mM concentration of phosphate buffer adjusted to pH 3.0 with diluted orthophosphoric acid and mobile phase B contains 90 % acetonitrile with 10 % water. The optimized chromatographic conditions such as flow rate 0.5 mL min-1 , injection volume 10 μL, UV detection at 290 nm, and a linear gradient program set upto 65 minutes. It was developed through an analytical QbD approach. A systematic flow chart explained the evaluation, control, and life cycle management method. As part of the method evaluation, a risk assessment was conducted. It has been validated as per current ICH guidelines. The recovery study and linearity ranges were established from LOQ to 150 % optimal concentrations. The validation results were found between 95.5 to 102.5 % for recovery and r2 0.9998 to 0.9999 for linearity of all identified impurities. The method precision results were achieved below 10% of RSD. Performed forced degradation studies in chemical and physical stress conditions. The compound was sensitive to chemical stress conditions. During the study, the analyte was degraded, converted into identified degradation impurities, and found its molecular mass by the LC-MS technique.
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Affiliation(s)
- Madhu Prakash Reddy
- Department of Chemistry, School of Science, GITAM (Deemed to be University) Hyderabad, Rudraram, Sangareddy, Telangana, INDIA
| | - Naresh Konduru
- Analytical Research and Development, Zhuhai Resproly Pharmaceutical Technology Co., Ltd., Zhuhai city, Guangdong province, CHINA
| | - Rambabu Gundla
- Department of Chemistry, School of Science, GITAM (Deemed to be University) Hyderabad, Rudraram, Sangareddy, Telangana, INDIA
| | - Leela Prasad Kowtharapu
- Analytical Development, WUXI STA (Wuxi app Tec Company) Pharmaceutical Co., Ltd., Wuxi, China
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13
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Sechaud R, Sinclair K, Grosch K, Ouatas T, Pathak D. Evaluation of drug-drug interactions between midostaurin and strong CYP3A4 inhibitors in patients with FLT-3-mutated acute myeloid leukemia (AML). Cancer Chemother Pharmacol 2022; 90:19-27. [PMID: 35751657 DOI: 10.1007/s00280-022-04448-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 06/04/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE Midostaurin, approved for the treatment of newly diagnosed, FLT3-mutated acute myeloid leukemia (AML), is metabolized by cytochrome P450 3A4 (CYP3A4). Midostaurin with concomitant strong CYP3A4 inhibitors use (e.g., antifungal azoles) may result in drug-drug interactions. This post hoc analysis of RATIFY phase 3 study data evaluated effects of strong CYP3A4 inhibitor use on the exposure and safety of midostaurin. METHODS Trough concentrations were used to assess midostaurin and metabolite exposure in the presence and absence of strong CYP3A4 inhibitors. Adverse event (AE) frequency was assessed in patients who received concomitant strong CYP3A4 inhibitors vs those who did not. Time to first clinically notable AE (CNAE) was also assessed in patients with high midostaurin plasma exposure vs those of matched placebo controls. RESULTS Use of concomitant strong CYP3A4 inhibitors was most frequent during the induction phase (60.8%). A 1.44-fold increase in midostaurin plasma exposure was observed in patients with concomitant strong CYP3A4 inhibitor use vs those without. Midostaurin-treated patients who received concomitant strong CYP3A4 inhibitors experienced grade 3/4 infection-related AEs more frequently vs those who did not. Patients with high levels of midostaurin exposure had a shorter median time to first grade 3/4 CNAE vs placebo controls (36 vs 41 days, respectively; P = .012). CONCLUSION Although concomitantly administered strong CYP3A4 inhibitors increased midostaurin exposure 1.44-fold, no clinically relevant differences in safety were noted. Midostaurin dose adjustment is not necessary with concomitant strong CYP3A4 inhibitors in patients with FLT3-mutated AML; however, caution is advised, and patients should be closely monitored.
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Affiliation(s)
| | | | - Kai Grosch
- Novartis Pharma AG, CH-4002, Basel, Switzerland
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14
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Cattaneo C, Marchesi F, Terrenato I, Bonuomo V, Fracchiolla NS, Delia M, Criscuolo M, Candoni A, Prezioso L, Facchinelli D, Pasciolla C, Del Principe MI, Dargenio M, Buquicchio C, Mitra ME, Farina F, Borlenghi E, Nadali G, Gagliardi VP, Fianchi L, Sciumè M, Menna P, Busca A, Rossi G, Pagano L. High Incidence of Invasive Fungal Diseases in Patients with FLT3-Mutated AML Treated with Midostaurin: Results of a Multicenter Observational SEIFEM Study. J Fungi (Basel) 2022; 8:jof8060583. [PMID: 35736066 PMCID: PMC9224885 DOI: 10.3390/jof8060583] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 05/22/2022] [Accepted: 05/27/2022] [Indexed: 12/04/2022] Open
Abstract
The potential drug-drug interactions of midostaurin may impact the choice of antifungal (AF) prophylaxis in FLT3-positive acute myeloid leukemia (AML) patients. To evaluate the incidence of invasive fungal diseases (IFD) during the treatment of FLT3-mutated AML patients and to correlate it to the different AF prophylaxis strategies, we planned a multicenter observational study involving 15 SEIFEM centers. One hundred fourteen patients treated with chemotherapy + midostaurin as induction/reinduction, consolidation or both were enrolled. During induction, the incidence of probable/proven and possible IFD was 10.5% and 9.7%, respectively; no statistically significant difference was observed according to the different AF strategy adopted. The median duration of neutropenia was similar in patients with or without IFD. Proven/probable and possible IFD incidence was 2.4% and 1.8%, respectively, during consolidation. Age was the only risk factor for IFD (OR, 95% CI, 1.10 [1.03–1.19]) and complete remission achievement after first induction the only one for survival (OR, 95% CI, 5.12 [1.93–13.60]). The rate of midostaurin discontinuation was similar across different AF strategies. The IFD attributable mortality during induction was 8.3%. In conclusion, the 20.2% overall incidence of IFD occurring in FLT3-mutated AML during induction with chemotherapy + midostaurin, regardless of AF strategy type, was noteworthy, and merits further study, particularly in elderly patients.
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Affiliation(s)
- Chiara Cattaneo
- Hematology, Azienda Socio Sanitaria Territoriale-Spedali Civili, 25123 Brescia, Italy; (E.B.); (G.R.)
- Correspondence: ; Tel.: +39-0303996573; Fax: +39-0303700852
| | - Francesco Marchesi
- Hematology and Stem Cell Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico Regina Elena National Cancer Institute, 00144 Roma, Italy;
| | - Irene Terrenato
- Unità Operativa Semplice Dipartimentale, Clinical Trial Center e Biostatistica e Bioinformatica, Istituto di Ricovero e Cura a Carattere Scientifico Regina Elena National Cancer Institute, 00144 Roma, Italy;
| | - Valentina Bonuomo
- Hematology Unit, Azienda Ospedaliera Universitaria Integrata, 37126 Verona, Italy; (V.B.); (G.N.)
| | - Nicola Stefano Fracchiolla
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (N.S.F.); (M.S.)
| | - Mario Delia
- Hematology and Stem Cell Transplantation Unit, Azienda Ospedaliero Universitaria Consorziale Policlinico, 70124 Bari, Italy; (M.D.); (V.P.G.)
| | - Marianna Criscuolo
- Institute of Hematology, Università Cattolica del Sacro Cuore, 20123 Roma, Italy; (M.C.); (L.F.); (L.P.)
| | - Anna Candoni
- Division of Hematology and Stem Cell Transplantation, University Hospital of Udine, 33100 Udine, Italy;
| | - Lucia Prezioso
- Hematology and Stem Cell Transplant Unit, Ospedale Maggiore, 20122 Parma, Italy;
| | | | - Crescenza Pasciolla
- Haematology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy;
| | | | - Michelina Dargenio
- Unità Operativa di Ematologia e Trapianto di Cellule Staminali Emopoietiche Vito Fazzi, 73100 Lecce, Italy;
| | - Caterina Buquicchio
- Haematology and Bone Marrow Transplant Unit, Ospedale Monsignor R. Dimiccoli, 70051 Barletta, Italy;
| | - Maria Enza Mitra
- Hematology, Policlinico Universitario “Paolo Giaccone”, 90127 Palermo, Italy;
| | - Francesca Farina
- Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale San Raffaele, University Vita-Salute San Raffaele, 20132 Milan, Italy;
| | - Erika Borlenghi
- Hematology, Azienda Socio Sanitaria Territoriale-Spedali Civili, 25123 Brescia, Italy; (E.B.); (G.R.)
| | - Gianpaolo Nadali
- Hematology Unit, Azienda Ospedaliera Universitaria Integrata, 37126 Verona, Italy; (V.B.); (G.N.)
| | - Vito Pier Gagliardi
- Hematology and Stem Cell Transplantation Unit, Azienda Ospedaliero Universitaria Consorziale Policlinico, 70124 Bari, Italy; (M.D.); (V.P.G.)
| | - Luana Fianchi
- Institute of Hematology, Università Cattolica del Sacro Cuore, 20123 Roma, Italy; (M.C.); (L.F.); (L.P.)
| | - Mariarita Sciumè
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (N.S.F.); (M.S.)
| | - Pierantonio Menna
- Department of Sciences and Technologies for Humans and the Environment, University Campus Bio-Medico of Rome, Italy, University Hospital Foundation Campus Bio-Medico of Rome, 00128 Roma, Italy;
| | - Alessandro Busca
- Stem Cell Transplant Center, Azienda Ospedaliero-Universitaria Città della Salute e Della Scienza, 10126 Torino, Italy;
| | - Giuseppe Rossi
- Hematology, Azienda Socio Sanitaria Territoriale-Spedali Civili, 25123 Brescia, Italy; (E.B.); (G.R.)
| | - Livio Pagano
- Institute of Hematology, Università Cattolica del Sacro Cuore, 20123 Roma, Italy; (M.C.); (L.F.); (L.P.)
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15
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Arnán Sangerman M, Fernández Moreno A, García Quintana A, García-Vidal C, Olave Rubio MT, Del Mar Tormo Díaz M, Vendranas M, Rodriguez Macias G. Practical tips for managing FLT3 mutated acute myeloid leukemia with midostaurin. Expert Rev Hematol 2022; 15:203-214. [PMID: 35332831 DOI: 10.1080/17474086.2022.2054801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION FLT3 inhibitors have been recently introduced as novel treatment targets in patients with FLT3-mutated acute myeloid leukemia (AML). Midostaurin is an oral multikinase inhibitor that targets multiple receptor tyrosine kinases including FLT3 and has been approved for the treatment of AML with FLT3 mutations in patients candidates for intensive chemotherapy. This article presents an updated overall overview of the use of midostaurin in clinical practice. AREAS COVERED Tests and examinations to be performed before the use of midostaurin, antifungal and antimicrobial treatment, as well as antifungal and antimicrobial prophylaxis are discussed. Practical tips for the treatment of QTc interval prolongation and heart failure are also presented. EXPERT OPINION Midostaurin is the first agent showing significant survival benefit when combined with chemotherapy in FLT3-mutated AML patients. Optimal use of midostaurin should be a priority, being essential to know the interactions with other drugs like strong CYP3A4 inhibitors or inducers, which are particularly used in the concomitant treatment of AML patients and may increase toxicity or decrease therapeutic benefit. The active role of hematologists and nursing teams is crucial to ensure patient adherence to midostaurin treatment and to minimize adverse effects by administrating the optimal dose for each situation.
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Affiliation(s)
- Montserrat Arnán Sangerman
- Hematology Department, Institut Català d'Oncologia-Hospital Duran i Reynals, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Antonio García Quintana
- Cardiology Unit, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | | | | | - María Del Mar Tormo Díaz
- Hematology Department, Hospital Clínico Universitario de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
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16
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Lakka NS, Kuppan C, Ravinathan P. Impurity profiling and stability-indicating method development and validation for the estimation of assay and degradation impurities of midostaurin in softgel capsules using HPLC and LC-MS. Biomed Chromatogr 2021; 35:e5222. [PMID: 34331472 DOI: 10.1002/bmc.5222] [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: 05/04/2021] [Revised: 07/08/2021] [Accepted: 07/23/2021] [Indexed: 11/09/2022]
Abstract
Midostaurin (MDS) is used for the treatment of acute myeloid leukemia, myelodysplastic syndrome, and advanced systemic mastocytosis. MDS softgel capsule samples were subjected to stress testing per International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use guidelines for impurity profiling study. MDS underwent extensive degradation under stress testing (acid, alkaline, oxidative, photolytic, thermolytic, and hydrolysis conditions) and formed four degradation products (DPs). MDS and its DPs were separated well from one another with good resolution using reserved-phase HPLC using an Inertsil ODS-3V column (250 × 4.6 mm, 5 μm) and a mobile phase of ammonium formate (40 mM) and acetonitrile. The stability-indicating characteristic of the newly developed method was proven for the estimation of MDS assay, and its organic impurities were free from interference. The validated method exhibited excellent linearity, accuracy, precision, specificity, detection limit, and quantitation limit within 25 min run time. Stress testing, robustness, and solution stability were performed to ensure the continuous performance of the developed method. The peak fractions of DPs formed under stress testing were isolated and characterized using LC-MS, 1 H and 13 C NMR, IR, and UV-Vis. The structure of the major DPs was predicted as DP1 based on the spectral data. The proposed method is effectively used for MDS in bulk drug and finished formulations in the pharmaceutical industry.
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Affiliation(s)
- Narasimha Swamy Lakka
- Division of Chemistry, Department of Science and Humanities, VIGNAN'S Foundation for Science, Technology and Research (VFSTR), Vadlamudi, Guntur, India
| | - Chandrasekar Kuppan
- Division of Chemistry, Department of Science and Humanities, VIGNAN'S Foundation for Science, Technology and Research (VFSTR), Vadlamudi, Guntur, India
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17
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Marconi G, Giannini MB, Bagnato G, Simonetti G, Cerchione C, Mosquera Orgueira A, Musuraca G, Martinelli G. The safety profile of FLT3 inhibitors in the treatment of newly diagnosed or relapsed/refractory acute myeloid leukemia. Expert Opin Drug Saf 2021; 20:791-799. [PMID: 33853481 DOI: 10.1080/14740338.2021.1913120] [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] [Indexed: 12/19/2022]
Abstract
INTRODUCTION FLT3 inhibitors are important drugs in the therapy of FLT3 positive acute myeloid leukemia (AML). Midostaurin was registered in combination with chemotherapy to treat newly diagnosed AML. Gilteritinib and quizartinib demonstrate effectiveness in a randomized trial in relapsed/refractory AML. Several promising FLT3 inhibitors are being evaluated in clinical research. AREAS COVERED This review will report the safety of FLT3 inhibitors that are registered for acute myeloid leukemia induction and rescue therapy. EXPERT OPINION In the near future, it is possible that all the FLT3 positive non M3-AML patients will receive a FLT3 inhibitor. Therapy adherence and strategies to mitigate adverse events must be pursued. The treatment with FLT3 inhibitors may be optimized in terms of toxicities with a rational evaluation of antifungal prophylaxis and concomitant therapy, cardiology monitoring, and keeping in mind rare adverse events. Future studies on unfit patients, special populations, and maintenance settings are warranted, together with post-market studies and real-life experiences. Whenever new FLT3 inhibitors will come to the clinic, we could face a scenario in which profound knowledge of effectiveness, toxicities, and off-target effects will be relevant to choose the best drug for each patient.
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Affiliation(s)
- Giovanni Marconi
- Istituto Romagnolo per Lo Studio Dei Tumori "Dino Amadori" - IRST, Meldola (FC), Italy
| | | | - Gianmarco Bagnato
- Istituto Romagnolo per Lo Studio Dei Tumori "Dino Amadori" - IRST, Meldola (FC), Italy
| | - Giorgia Simonetti
- Istituto Romagnolo per Lo Studio Dei Tumori "Dino Amadori" - IRST, Meldola (FC), Italy
| | - Claudio Cerchione
- Istituto Romagnolo per Lo Studio Dei Tumori "Dino Amadori" - IRST, Meldola (FC), Italy
| | - Adrián Mosquera Orgueira
- Health Research Institute of Santiago De Compostela (IDIS), Santiago De Compostela, Spain.,Division of Hematology, Complexo Hospitalario Universitario De Santiago De Compostela (CHUS - SERGAS), Santiago De Compostela, Spain.,University of Santiago De Compostela, Santiago De Compostela, Spain
| | - Gerardo Musuraca
- Istituto Romagnolo per Lo Studio Dei Tumori "Dino Amadori" - IRST, Meldola (FC), Italy
| | - Giovanni Martinelli
- Istituto Romagnolo per Lo Studio Dei Tumori "Dino Amadori" - IRST, Meldola (FC), Italy
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18
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Menna P, Salvatorelli E, Del Principe MI, Perrone S, Pagano L, Marchesi F, Minotti G. Choosing Antifungals for the Midostaurin-Treated Patient: Does CYP3A4 Outweigh Recommendations? A Brief Insight from Real Life. Chemotherapy 2021; 66:47-52. [PMID: 33677444 DOI: 10.1159/000513989] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 12/22/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Patients treated with midostaurin and chemotherapy are at risk of invasive fungal disease. Prophylactic posaconazole is recommended for these patients, but posaconazole strongly inhibits the CYP3A4 isozyme that metabolizes midostaurin. Posaconazole therefore introduces a risk of patient's overexposure to midostaurin. METHODS Blood samples were obtained from 4 patients treated with midostaurin for newly diagnosed FLT3-mutAML. Patients had received a concomitant treatment with posaconazole, isavuconazole, or micafungin, respectively. All blood samples were drawn before daily dose administration of midostaurin. RESULTS Posaconazole caused a ≥8-fold increase of midostaurin plasma levels at through, which was accompanied by a decreased plasma exposure to O-demethylated or hydroxylated midostaurin metabolites. We also show that hematologists react to risk perception by replacing posaco-nazole with antifungals like micafungin or isavuconazole, which lack a strong inhibition of CYP3A4 and fail to modify midostaurin pharmacokinetics but are not formally recommended in these settings. DISCUSSION In real-life scenarios, concerns about CYP3A4 inhibition may outweigh compliance with recommendations. Large studies are needed to survey the risk:benefit of hematologist's decision to replace posaconazole with other antifungals.
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Affiliation(s)
- Pierantonio Menna
- Clinical Pharmacology Unit, Campus Bio-Medico University Hospital, Rome, Italy,
| | - Emanuela Salvatorelli
- Department of Medicine and Center for Integrated Research, Drug Sciences, University Campus Bio-Medico, Rome, Italy
| | | | - Salvatore Perrone
- Hematology, Polo Universitario Pontino, S.M. Goretti Hospital, Latina, Italy
| | - Livio Pagano
- Institute of Hematology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Catholic University School of Medicine, Rome, Italy
| | - Francesco Marchesi
- Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giorgio Minotti
- Clinical Pharmacology Unit, Campus Bio-Medico University Hospital, Rome, Italy.,Department of Medicine and Center for Integrated Research, Drug Sciences, University Campus Bio-Medico, Rome, Italy
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19
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Raghuvanshi R, Bharate SB. Recent Developments in the Use of Kinase Inhibitors for Management of Viral Infections. J Med Chem 2021; 65:893-921. [PMID: 33539089 DOI: 10.1021/acs.jmedchem.0c01467] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Kinases are a group of therapeutic targets involved in the progression of numerous diseases, including cancer, rheumatoid arthritis, Alzheimer's disease, and viral infections. The majority of approved antiviral agents are inhibitors of virus-specific targets that are encoded by individual viruses. These inhibitors are narrow-spectrum agents that can cause resistance development. Viruses are dependent on host cellular proteins, including kinases, for progression of their life-cycle. Thus, targeting kinases is an important therapeutic approach to discovering broad-spectrum antiviral agents. As there are a large number of FDA approved kinase inhibitors for various indications, their repurposing for viral infections is an attractive and time-sparing strategy. Many kinase inhibitors, including baricitinib, ruxolitinib, imatinib, tofacitinib, pacritinib, zanubrutinib, and ibrutinib, are under clinical investigation for COVID-19. Herein, we discuss FDA approved kinase inhibitors, along with a repertoire of clinical/preclinical stage kinase inhibitors that possess antiviral activity or are useful in the management of viral infections.
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Affiliation(s)
- Rinky Raghuvanshi
- Medicinal Chemistry Division,CSIR-Indian Institute of Integrative Medicine, Canal Road, Jammu 180001, India.,Academy of Scientific & Innovative Research, Ghaziabad 201002, India
| | - Sandip B Bharate
- Medicinal Chemistry Division,CSIR-Indian Institute of Integrative Medicine, Canal Road, Jammu 180001, India.,Academy of Scientific & Innovative Research, Ghaziabad 201002, India
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20
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Shanu-Wilson J, Evans L, Wrigley S, Steele J, Atherton J, Boer J. Biotransformation: Impact and Application of Metabolism in Drug Discovery. ACS Med Chem Lett 2020; 11:2087-2107. [PMID: 33214818 DOI: 10.1021/acsmedchemlett.0c00202] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/13/2020] [Indexed: 02/07/2023] Open
Abstract
Biotransformation has a huge impact on the efficacy and safety of drugs. Ultimately the effects of metabolism can be the lynchpin in the discovery and development cycle of a new drug. This article discusses the impact and application of biotransformation of drugs by mammalian systems, microorganisms, and recombinant enzymes, covering active and reactive metabolites, the impact of the gut microbiome on metabolism, and how insights gained from biotransformation studies can influence drug design from the combined perspectives of a CRO specializing in a range of biotransformation techniques and pharma biotransformation scientists. We include a commentary on how biology-driven approaches can complement medicinal chemistry strategies in drug optimization and the in vitro and surrogate systems available to explore and exploit biotransformation.
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Affiliation(s)
- Julia Shanu-Wilson
- Hypha Discovery Ltd., 154B Brook Drive, Milton Park, Abingdon, Oxfordshire OX14 4SD, U.K
| | - Liam Evans
- Hypha Discovery Ltd., 154B Brook Drive, Milton Park, Abingdon, Oxfordshire OX14 4SD, U.K
| | - Stephen Wrigley
- Hypha Discovery Ltd., 154B Brook Drive, Milton Park, Abingdon, Oxfordshire OX14 4SD, U.K
| | - Jonathan Steele
- Hypha Discovery Ltd., 154B Brook Drive, Milton Park, Abingdon, Oxfordshire OX14 4SD, U.K
| | - James Atherton
- Incyte Corporation, 1801 Augustine Cut-off, Wilmington, Delaware 19803, United States
| | - Jason Boer
- Incyte Corporation, 1801 Augustine Cut-off, Wilmington, Delaware 19803, United States
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21
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Cairoli R, Ferrara F, Girmenia C, Luppi M, Pea F, Specchia G, Venditti A. Management of patients with acute myeloid leukemia undergoing therapy with midostaurin: a focus on antifungal prophylaxis. Hematol Oncol 2020. [DOI: 10.1002/hon.2788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Roberto Cairoli
- Department of Hematology Niguarda Cancer Center ASST Grande Ospedale Metropolitano Niguarda Milan Italy
| | | | - Corrado Girmenia
- Department of Hematology, Oncology and Dermatology Azienda Policlinico Umberto I Sapienza University Rome Italy
| | - Mario Luppi
- Department of Medical and Surgical Sciences Section of Hematology Azienda Ospedaliero‐Universitaria Policlinico University of Modena and Reggio Emilia Modena Italy
| | - Federico Pea
- Department of Medicine University of Udine Udine Italy
- Institute of Clinical Pharmacology Santa Maria della Misericordia University Hospital of Udine ASUIUD Udine Italy
| | - Giorgina Specchia
- Department of Emergency and Organ Transplantation Hematology Section University of Bari Bari Italy
| | - Adriano Venditti
- Department of Biomedicine and Prevention Fondazione Policlinico Tor Vergata University of Rome “Tor Vergata” Rome Italy
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22
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Weisberg E, Parent A, Yang PL, Sattler M, Liu Q, Liu Q, Wang J, Meng C, Buhrlage SJ, Gray N, Griffin JD. Repurposing of Kinase Inhibitors for Treatment of COVID-19. Pharm Res 2020; 37:167. [PMID: 32778962 PMCID: PMC7417114 DOI: 10.1007/s11095-020-02851-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/03/2020] [Indexed: 12/15/2022]
Abstract
The outbreak of COVID-19, the pandemic disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spurred an intense search for treatments by the scientific community. In the absence of a vaccine, the goal is to target the viral life cycle and alleviate the lung-damaging symptoms of infection, which can be life-threatening. There are numerous protein kinases associated with these processes that can be inhibited by FDA-approved drugs, the repurposing of which presents an alluring option as they have been thoroughly vetted for safety and are more readily available for treatment of patients and testing in clinical trials. Here, we characterize more than 30 approved kinase inhibitors in terms of their antiviral potential, due to their measured potency against key kinases required for viral entry, metabolism, or reproduction. We also highlight inhibitors with potential to reverse pulmonary insufficiency because of their anti-inflammatory activity, cytokine suppression, or antifibrotic activity. Certain agents are projected to be dual-purpose drugs in terms of antiviral activity and alleviation of disease symptoms, however drug combination is also an option for inhibitors with optimal pharmacokinetic properties that allow safe and efficacious co-administration with other drugs, such as antiviral agents, IL-6 blocking agents, or other kinase inhibitors.
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Affiliation(s)
- Ellen Weisberg
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA. .,Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | - Alexander Parent
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Priscilla L Yang
- Department of Cancer Cell Biology, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA, USA
| | - Martin Sattler
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Qingsong Liu
- High Magnetic Field Laboratory, Chinese Academy of Sciences, Hefei, Anhui, China
| | - Qingwang Liu
- High Magnetic Field Laboratory, Chinese Academy of Sciences, Hefei, Anhui, China
| | - Jinhua Wang
- Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, MA, USA
| | - Chengcheng Meng
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sara J Buhrlage
- Department of Cancer Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, 02215, USA
| | - Nathanael Gray
- Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, MA, USA
| | - James D Griffin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
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23
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Megías-Vericat JE, Solana-Altabella A, Ballesta-López O, Martínez-Cuadrón D, Montesinos P. Drug-drug interactions of newly approved small molecule inhibitors for acute myeloid leukemia. Ann Hematol 2020; 99:1989-2007. [PMID: 32683457 DOI: 10.1007/s00277-020-04186-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/13/2020] [Indexed: 01/13/2023]
Abstract
Several small molecule inhibitors (SMIs) have been recently approved for AML patients. These targeted therapies could be more tolerable than classical antineoplastics, but potential drug-drug interactions (DDI) are relatively frequent. Underestimation or lack of appropriate awareness and management of DDIs with SMIs can jeopardize therapeutic success in AML patients, which often require multiple concomitant medications in the context of prior comorbidities or for the prevention and treatment of infectious and other complications. In this systematic review, we analyze DDIs of glasdegib, venetoclax, midostaurin, quizartinib, gilteritinib, enasidenib, and ivosidenib. CYP3A4 is the main enzyme responsible for SMIs metabolism, and strong CYP3A4 inhibitors, such azoles, could increase drug exposure and toxicity; therefore dose adjustments (venetoclax, quizartinib, and ivosidenib) or alternative therapies or close monitoring (glasdegib, midostaurin, and gilteritinib) are recommended. Besides, coadministration of strong CYP3A4 inducers with SMIs should be avoided due to potential decrease of efficacy. Regarding tolerability, QTc prolongation is frequently observed for most of approved SMIs, and drugs with a potential to prolong the QTc interval and CYP3A4 inhibitors should be avoided and replaced by alternative treatments. In this study, we critically assess the DDIs of SMIs, and we summarize best management options for these new drugs and concomitant medications.
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Affiliation(s)
- Juan Eduardo Megías-Vericat
- Servicio de Farmacia, Área del Medicamento, Hospital Universitari i Politècnic La Fe. Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Antonio Solana-Altabella
- Servicio de Farmacia, Área del Medicamento, Hospital Universitari i Politècnic La Fe. Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Octavio Ballesta-López
- Servicio de Farmacia, Área del Medicamento, Hospital Universitari i Politècnic La Fe. Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - David Martínez-Cuadrón
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe. Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Pau Montesinos
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe. Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain. .,CIBERONC, Instituto Carlos III, Madrid, Spain.
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24
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A Systematic Review of Recently Reported Marine Derived Natural Product Kinase Inhibitors. Mar Drugs 2019; 17:md17090493. [PMID: 31450856 PMCID: PMC6780990 DOI: 10.3390/md17090493] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/16/2019] [Accepted: 08/18/2019] [Indexed: 12/13/2022] Open
Abstract
Protein kinases are validated drug targets for a number of therapeutic areas, as kinase deregulation is known to play an essential role in many disease states. Many investigated protein kinase inhibitors are natural product small molecules or their derivatives. Many marine-derived natural products from various marine sources, such as bacteria and cyanobacteria, fungi, animals, algae, soft corals, sponges, etc. have been found to have potent kinase inhibitory activity, or desirable pharmacophores for further development. This review covers the new compounds reported from the beginning of 2014 through the middle of 2019 as having been isolated from marine organisms and having potential therapeutic applications due to kinase inhibitory and associated bioactivities. Moreover, some existing clinical drugs based on marine-derived natural product scaffolds are also discussed.
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25
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Sly N, Gaspar K. Midostaurin for the management of FLT3-mutated acute myeloid leukemia and advanced systemic mastocytosis. Am J Health Syst Pharm 2019; 76:268-274. [PMID: 30753289 DOI: 10.1093/ajhp/zxy050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose This article reviews the pharmacology, efficacy, safety, cost, and future directions of midostaurin for the treatment of acute myeloid leukemia (AML), aggressive systemic mastocytosis, systemic mastocytosis with associated hematological neoplasm, and mast cell leukemia, collectively known as advanced systemic mastocytosis (SM). Summary Midostaurin was approved by the U.S. Food and Drug Administration for the treatment of FMS-like tyrosine kinase-3 (FLT3)- mutated AML. FLT3 is a tyrosine kinase which plays a key role in proliferation of early hematopoietic progenitor cells. In addition to having activity against FLT3, midostaurin inhibits several other tyrosine kinases which led to its approval for the treatment of advanced SM. Conclusion Midostaurin offers a novel strategy to treat both FLT3-mutated AML and advanced SM. With a comparable adverse effect profile to other agents and substantial antiproliferative activity, midostaurin offers a therapeutic option for patients who have historically been difficult to treat.
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Affiliation(s)
- Nichole Sly
- Department of Pharmaceutical Care, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Katie Gaspar
- Department of Pharmaceutical Care, University of Iowa Hospitals & Clinics, Iowa City, IA.,University of Iowa College of Pharmacy, Iowa City, IA
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26
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Midostaurin: its odyssey from discovery to approval for treating acute myeloid leukemia and advanced systemic mastocytosis. Blood Adv 2019; 2:444-453. [PMID: 29487059 DOI: 10.1182/bloodadvances.2017011080] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 12/21/2017] [Indexed: 02/04/2023] Open
Abstract
Midostaurin was a prototype kinase inhibitor, originally developed as a protein kinase C inhibitor and subsequently as an angiogenesis inhibitor, based on its inhibition of vascular endothelial growth factor receptor. Despite promising preclinical data, early clinical trials in multiple diseases showed only modest efficacy. In 1996, the relatively frequent occurrence of fms-like tyrosine kinase 3 (FLT3) activating mutations in acute myeloid leukemia (AML) was first recognized. Several years later, midostaurin was discovered to be a potent inhibitor of the FLT3 tyrosine kinase and to have activity against mutant forms of KIT proto-oncogene receptor tyrosine kinase, which drive advanced systemic mastocytosis (SM). Through a series of collaborations between industry and academia, midostaurin in combination with standard chemotherapy was evaluated in the Cancer and Leukemia Group B 10603/RATIFY study, a large, phase 3, randomized, placebo-controlled trial in patients with newly diagnosed FLT3-mutated AML. This was the first study to show significant improvements in overall survival and event-free survival with the addition of a targeted therapy to standard chemotherapy in this population. Around the same time, durable responses were also observed in other trials of midostaurin in patients with advanced SM. Collectively, these clinical data led to the approval of midostaurin by the US Food and Drug Administration and the European Medicines Agency for both newly diagnosed FLT3-mutated AML and advanced SM.
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27
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Isbell J, Yuan D, Torrao L, Gatlik E, Hoffmann L, Wipfli P. Plasma Protein Binding of Highly Bound Drugs Determined With Equilibrium Gel Filtration of Nonradiolabeled Compounds and LC-MS/MS Detection. J Pharm Sci 2018; 108:1053-1060. [PMID: 30336155 DOI: 10.1016/j.xphs.2018.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 10/05/2018] [Indexed: 10/28/2022]
Abstract
Accurate determination of the free fraction of a drug in plasma can be challenging when it falls below 1% and even more so when below 0.1%. Equilibrium dialysis with diluted plasma has been used to determine unbound fraction below 1%, but some analytes are not amenable to this method. One robust alternative for accurately measuring very highly bound compounds is equilibrium gel filtration; however, radiolabeled compounds have been used with this technique to quantify the low analyte concentrations. This report examined results obtained using radiolabeled compounds with liquid scintillation detection and those obtained using their nonradiolabeled analogs with liquid chromatography-tandem mass spectrometry detection. The 2 methods provided comparable results over the range of 0.005%-4% free, with a slope of 1.0 and a R2 = 0.93. These results demonstrate that equilibrium gel filtration with liquid chromatography-tandem mass spectrometry detection can be used earlier in the drug discovery process to determine the unbound fraction of highly bound drugs and may help obviate the need for radiolabeled compound.
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Affiliation(s)
- John Isbell
- Discovery Chemistry, Genomics Institute of the Novartis Research Foundation, Metabolism and Pharmacokinetics, San Diego, California 92121.
| | - Ding Yuan
- Discovery Chemistry, Genomics Institute of the Novartis Research Foundation, Metabolism and Pharmacokinetics, San Diego, California 92121
| | - Leonel Torrao
- Novartis Institutes for BioMedical Research Basel, PK Sciences, Basel, Switzerland
| | - Ewa Gatlik
- Novartis Institutes for BioMedical Research Basel, PK Sciences, Basel, Switzerland
| | - Laurent Hoffmann
- Novartis Institutes for BioMedical Research Basel, PK Sciences, Basel, Switzerland
| | - Peter Wipfli
- Novartis Institutes for BioMedical Research Basel, PK Sciences, Basel, Switzerland
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28
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Tollkuci E, Seddon A, Geswein L, Mulseh M. Midostaurin administration in two hemodialysis patients. J Oncol Pharm Pract 2018; 25:1285-1288. [PMID: 30253726 DOI: 10.1177/1078155218801067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Midostaurin is a multitargeted tyrosine kinase inhibitor approved by the Food and Drug Administration for FMS-related tyrosine kinase 3-positive acute myeloid leukemia in combination with standard daunorubicin and cytarabine induction and high-dose cytarabine consolidation. The pharmacokinetics of midostaurin in the setting of severe renal impairment (creatinine clearance [CrCl] 15-29 mL/min utilizing Cockcroft-Gault method) and end-stage renal disease are unknown. Midostaurin is primarily metabolized by the liver through the CYP3A4 enzyme with fecal excretion accounting for 95% of the dose (4% recovered as unchanged drug). Only 5% of the parent drug is found in the urine. This is the first case report documenting the administration of midostaurin in two patients with end-stage renal disease on HD. Given the limited excretion of both active and inactive metabolites of midostaurin in the urine, one does not expect an increase in toxicity related to impaired drug excretion. Although this report describes the likely successful utilization of midostaurin, caution should be exercised when administering in patient populations with end organ disease. Medical history, concomitant comorbidities, and goals of therapy should be taken into account.
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Affiliation(s)
- Eris Tollkuci
- 1 College of Pharmacy, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA.,2 Division of Pharmacy, Rush University Medical Center, Chicago, IL, USA
| | - Amanda Seddon
- 2 Division of Pharmacy, Rush University Medical Center, Chicago, IL, USA.,3 College of Pharmacy, Midwestern University, Downers Grove, IL, USA
| | - Laura Geswein
- 2 Division of Pharmacy, Rush University Medical Center, Chicago, IL, USA
| | - Musa Mulseh
- 3 College of Pharmacy, Midwestern University, Downers Grove, IL, USA
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29
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Manley PW, Caravatti G, Furet P, Roesel J, Tran P, Wagner T, Wartmann M. Comparison of the Kinase Profile of Midostaurin (Rydapt) with That of Its Predominant Metabolites and the Potential Relevance of Some Newly Identified Targets to Leukemia Therapy. Biochemistry 2018; 57:5576-5590. [PMID: 30148617 DOI: 10.1021/acs.biochem.8b00727] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The multitargeted protein kinase inhibitor midostaurin is approved for the treatment of both newly diagnosed FLT3-mutated acute myeloid leukemia (AML) and KIT-driven advanced systemic mastocytosis. AML is a heterogeneous malignancy, and investigational drugs targeting FLT3 have shown disparate effects in patients with FLT3-mutated AML, probably as a result of their inhibiting different targets and pathways at the administered doses. However, the efficacy and side effects of drugs do not just reflect the biochemical and pharmacodynamic properties of the parent compound but are often comprised of complex cooperative effects between the properties of the parent and active metabolites. Following chronic dosing, two midostaurin metabolites attain steady-state plasma trough levels greater than that of the parent drug. In this study, we characterized these metabolites and determined their profiles as kinase inhibitors using radiometric transphosphorylation assays. Like midostaurin, the metabolites potently inhibit mutant forms of FLT3 and KIT and several additional kinases that either are directly involved in the deregulated signaling pathways or have been implicated as playing a role in AML via stromal support, such as IGF1R, LYN, PDPK1, RET, SYK, TRKA, and VEGFR2. Consequently, a complex interplay between the kinase activities of midostaurin and its metabolites is likely to contribute to the efficacy of midostaurin in AML and helps to engender the distinctive effects of the drug compared to those of other FLT3 inhibitors in this malignancy.
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Affiliation(s)
- Paul W Manley
- Global Discovery Chemistry, Novartis Institutes for Biomedical Research , Novartis International AG , CH-4002 Basel , Switzerland
| | - Giorgio Caravatti
- Global Discovery Chemistry, Novartis Institutes for Biomedical Research , Novartis International AG , CH-4002 Basel , Switzerland
| | - Pascal Furet
- Global Discovery Chemistry, Novartis Institutes for Biomedical Research , Novartis International AG , CH-4002 Basel , Switzerland
| | - Johannes Roesel
- Oncology Disease Area, Novartis Institutes for Biomedical Research , Novartis International AG , CH-4002 Basel , Switzerland
| | - Phi Tran
- Department of Drug Metabolism and Pharmacokinetics , Novartis Institutes for Biomedical Research , East Hanover , New Jersey 07936 , United States
| | - Trixie Wagner
- Global Discovery Chemistry, Novartis Institutes for Biomedical Research , Novartis International AG , CH-4002 Basel , Switzerland
| | - Markus Wartmann
- Oncology Disease Area, Novartis Institutes for Biomedical Research , Novartis International AG , CH-4002 Basel , Switzerland
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30
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Review of Chromatographic Bioanalytical Assays for the Quantitative Determination of Marine-Derived Drugs for Cancer Treatment. Mar Drugs 2018; 16:md16070246. [PMID: 30041477 PMCID: PMC6071085 DOI: 10.3390/md16070246] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 06/15/2018] [Accepted: 07/18/2018] [Indexed: 12/20/2022] Open
Abstract
The discovery of marine-derived compounds for the treatment of cancer has seen a vast increase over the last few decades. Bioanalytical assays are pivotal for the quantification of drug levels in various matrices to construct pharmacokinetic profiles and to link drug concentrations to clinical outcomes. This review outlines the different analytical methods that have been described for marine-derived drugs in cancer treatment hitherto. It focuses on the major parts of the bioanalytical technology, including sample type, sample pre-treatment, separation, detection, and quantification.
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31
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Javarappa KK, Tsallos D, Heckman CA. A Multiplexed Screening Assay to Evaluate Chemotherapy-Induced Myelosuppression Using Healthy Peripheral Blood and Bone Marrow. SLAS DISCOVERY 2018; 23:687-696. [DOI: 10.1177/2472555218777968] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Myelosuppression is a major side effect of chemotherapy in cancer patients and can result in infections, bleeding complications, and increased risk of morbidity and mortality, as well as limit the drug dose and frequency of administration. Chemotherapy-induced myelosuppression is caused by the disruption of normal hematopoiesis. Thus, prior understanding of the adverse effects of chemotherapies on hematopoietic cells is essential to minimize the side effects of cancer treatment. Traditional methods such as colony-forming assays for studying chemotherapy-induced myelosuppression are time-consuming and labor intensive. High-throughput flow cytometry technologies and methods to detect rare hematopoietic cell populations are critical in advancing our understanding of how different blood cell types in complex biological samples respond to chemotherapeutic drugs. In the present study, hematopoietic progenitor cells were induced to differentiate into megakaryocytes and myeloid lineage cells. The expanded cells were then used in a multiplexed assay to monitor the dose-response effects of multiple chemotherapies on different stages of megakaryocyte differentiation and myeloid cell populations in a 96-well plate format. The assay offers an alternative method to evaluate the myelosuppressive potential of novel chemotherapeutic drugs compared to traditional lower throughput and labor-intensive assays.
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Affiliation(s)
- Komal K. Javarappa
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Dimitrios Tsallos
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Caroline A. Heckman
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
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Schlenk RF, Kayser S. Midostaurin: A Multiple Tyrosine Kinases Inhibitor in Acute Myeloid Leukemia and Systemic Mastocytosis. Recent Results Cancer Res 2018; 212:199-214. [PMID: 30069632 DOI: 10.1007/978-3-319-91439-8_10] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Midostaurin (PKC412, Rydapt®) is an oral multiple tyrosine kinase inhibitor. Main targets are the kinase domain receptor, vascular endothelial-, platelet derived-, and fibroblast growth factor receptor, stem cell factor receptor c-KIT, as well as mutated and wild-type FLT3 kinases. Midostaurin was approved by the Food and Drug Administration (FDA) and the European Medical Agency (EMA) for acute myeloid leukemia with activating FLT3 mutations in combination with intensive induction and consolidation therapy as well as aggressive systemic mastocytosis (ASM), systemic mastocytosis with associated hematological neoplasm (SM-AHN) or mast cell leukemia (MCL). Several clinical trials are active or are planned to further investigate the role of midostaurin in myeloid malignancies and mastocytosis.
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Affiliation(s)
- Richard F Schlenk
- NCT-Trial Center, German Cancer Research Center, Heidelberg, Germany.
| | - Sabine Kayser
- Department of Internal Medicine V, University Hospital of Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ), University of Heidelberg, Heidelberg, Germany
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Gu H, Dutreix C, Rebello S, Ouatas T, Wang L, Chun DY, Einolf HJ, He H. Simultaneous Physiologically Based Pharmacokinetic (PBPK) Modeling of Parent and Active Metabolites to Investigate Complex CYP3A4 Drug-Drug Interaction Potential: A Case Example of Midostaurin. Drug Metab Dispos 2017; 46:109-121. [DOI: 10.1124/dmd.117.078006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 11/03/2017] [Indexed: 12/19/2022] Open
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Kayser S, Levis MJ, Schlenk RF. Midostaurin treatment in FLT3-mutated acute myeloid leukemia and systemic mastocytosis. Expert Rev Clin Pharmacol 2017; 10:1177-1189. [PMID: 28960095 DOI: 10.1080/17512433.2017.1387051] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION A number of tyrosine kinase inhibitors (TKIs) have been developed that inhibit the constitutively activated kinase activity caused by activating tyrosine kinase mutations, such as FLT3 or KIT, thus interrupting signaling pathways. Currently, midostaurin is the only approved TKI as monotherapy for aggressive systemic mastocytosis (SM), SM with associated hematological neoplasm, or mast cell leukemia displaying a KIT mutation as well as in combination with standard intensive chemotherapy for adult patients with newly diagnosed FLT3-mutated acute myeloid leukemia (AML). Areas covered: We provide a concise review of the pharmacology, tolerability and clinical efficacy of midostaurin and emerging new treatment options for ASM and FLT3-mutated AML. Expert commentary: Currently, midostaurin is the only approved TKI in aggressive SM, SM with associated hematological neoplasm, or mast cell leukemia inducing responses including complete remissions. With regard to AML, midostaurin is the first drug to receive regulatory approval in this indication in the molecularly defined subgroup of AML with FLT3 mutations. By introduction of this new standard in AML with FLT3 mutations, the bare has been raised for future approvals of next generation FLT3 inhibitors which will be based increasingly on head to head comparisons with midostaurin.
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Affiliation(s)
- Sabine Kayser
- a Department of Internal Medicine V , University Hospital of Heidelberg , Heidelberg , Germany.,b Clinical Cooperation Unit Molecular Hematology/Oncology , German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg , Heidelberg , Germany
| | - Mark J Levis
- c Sidney Kimmel Comprehensive Cancer Center , Johns Hopkins University , Baltimore , MD , USA
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