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Jiang Z, Sun W, Du R, Yang R. A review of dose escalation for FDA-approved products treating solid tumors and hematological malignancies in first-in-human trials. Clin Transl Oncol 2024:10.1007/s12094-024-03451-2. [PMID: 38558284 DOI: 10.1007/s12094-024-03451-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024]
Abstract
First-in-human (FIH) dose-escalation trials on oncology should prioritize safety and emphasize efficacy. We reviewed the FIH trials of 67 anti-tumor products approved by the Food and Drug Administration between 2018 and 2023 and found that the "3 + 3" design remains the predominant dose-escalation method (66.2%). The number of patients receiving sub-therapeutic doses is positively correlated with the maximum tolerated dose (MTD) or maximum dose (MD) to starting dose ratio (P = 0.056) and the number of dose levels in trials (P < 0.001). In addition, the proportion of products with a high ratio in antibody drugs is higher than that in small molecules (P < 0.001). The MTD or MD exceeded the label dose by three or more doses in 22.03% of the products. In conclusion, optimizing the starting dose selection method, refining the way of determining doses, and finding alternative indicators to replace toxicity as the endpoints will increase the effectiveness and broaden the beneficiary scope.
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Affiliation(s)
- Zehui Jiang
- Gobroad Healthcare Group, 20 Lize Road, Beijing, 100073, China
| | - Wenxuan Sun
- Gobroad Healthcare Group, 20 Lize Road, Beijing, 100073, China
| | - Rui Du
- Gobroad Healthcare Group, 20 Lize Road, Beijing, 100073, China
| | - Rui Yang
- Gobroad Healthcare Group, 20 Lize Road, Beijing, 100073, China.
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2
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Solovyeva O, Dimairo M, Weir CJ, Hee SW, Espinasse A, Ursino M, Patel D, Kightley A, Hughes S, Jaki T, Mander A, Evans TRJ, Lee S, Hopewell S, Rantell KR, Chan AW, Bedding A, Stephens R, Richards D, Roberts L, Kirkpatrick J, de Bono J, Yap C. Development of consensus-driven SPIRIT and CONSORT extensions for early phase dose-finding trials: the DEFINE study. BMC Med 2023; 21:246. [PMID: 37408015 PMCID: PMC10324137 DOI: 10.1186/s12916-023-02937-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/12/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Early phase dose-finding (EPDF) trials are crucial for the development of a new intervention and influence whether it should be investigated in further trials. Guidance exists for clinical trial protocols and completed trial reports in the SPIRIT and CONSORT guidelines, respectively. However, both guidelines and their extensions do not adequately address the characteristics of EPDF trials. Building on the SPIRIT and CONSORT checklists, the DEFINE study aims to develop international consensus-driven guidelines for EPDF trial protocols (SPIRIT-DEFINE) and reports (CONSORT-DEFINE). METHODS The initial generation of candidate items was informed by reviewing published EPDF trial reports. The early draft items were refined further through a review of the published and grey literature, analysis of real-world examples, citation and reference searches, and expert recommendations, followed by a two-round modified Delphi process. Patient and public involvement and engagement (PPIE) was pursued concurrently with the quantitative and thematic analysis of Delphi participants' feedback. RESULTS The Delphi survey included 79 new or modified SPIRIT-DEFINE (n = 36) and CONSORT-DEFINE (n = 43) extension candidate items. In Round One, 206 interdisciplinary stakeholders from 24 countries voted and 151 stakeholders voted in Round Two. Following Round One feedback, one item for CONSORT-DEFINE was added in Round Two. Of the 80 items, 60 met the threshold for inclusion (≥ 70% of respondents voted critical: 26 SPIRIT-DEFINE, 34 CONSORT-DEFINE), with the remaining 20 items to be further discussed at the consensus meeting. The parallel PPIE work resulted in the development of an EPDF lay summary toolkit consisting of a template with guidance notes and an exemplar. CONCLUSIONS By detailing the development journey of the DEFINE study and the decisions undertaken, we envision that this will enhance understanding and help researchers in the development of future guidelines. The SPIRIT-DEFINE and CONSORT-DEFINE guidelines will allow investigators to effectively address essential items that should be present in EPDF trial protocols and reports, thereby promoting transparency, comprehensiveness, and reproducibility. TRIAL REGISTRATION SPIRIT-DEFINE and CONSORT-DEFINE are registered with the EQUATOR Network ( https://www.equator-network.org/ ).
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Affiliation(s)
| | - Munyaradzi Dimairo
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Siew Wan Hee
- University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
- University of Warwick, Coventry, UK
| | | | - Moreno Ursino
- Inserm, Centre de Recherche Des Cordeliers, Sorbonne UniversitéUniversité Paris Cité, 75006, Paris, France
- HeKA, Inria Paris, 75015, Paris, France
- Unit of Clinical Epidemiology, AP-HP, CHU Robert Debré, CIC-EC 1426, Paris, France
- RECaP/F-CRIN, Inserm, 5400, Nancy, France
| | | | - Andrew Kightley
- Patient and Public Involvement and Engagement (PPIE) Lead, Lichfield, UK
| | | | - Thomas Jaki
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- University of Regensburg, Regensburg, Germany
| | | | | | - Shing Lee
- Columbia University, Mailman School of Public Health, New York, USA
| | - Sally Hopewell
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | | | - An-Wen Chan
- Department of Medicine, Women's College Research Institute, University of Toronto, Toronto, Canada
| | | | | | | | | | | | - Johann de Bono
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
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3
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Pawaskar D, Chen X, Glassman F, May F, Roberts A, Biondo M, McKenzie A, Nolte MW, Jusko WJ, Tortorici M. Pharmacokinetic/pharmacodynamic modeling for dose selection for the first-in-human trial of the activated Factor XII inhibitor garadacimab (CSL312). Clin Transl Sci 2021; 15:709-720. [PMID: 34811931 PMCID: PMC8932701 DOI: 10.1111/cts.13192] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/17/2021] [Accepted: 10/11/2021] [Indexed: 12/19/2022] Open
Abstract
Factor XII (FXII) is a serine protease involved in multiple cascades, including the kallikrein–kinin system. It may play a role in diseases in which the downstream cascades are dysregulated, such as hereditary angioedema. Garadacimab (CSL312) is a first‐in‐class, fully human, monoclonal antibody targeting activated FXII (FXIIa). We describe how translational pharmacokinetic (PK) and pharmacodynamic (PD) modeling enabled dose selection for the phase I, first‐in‐human trial of garadacimab. The PK/PD data used for modeling were derived from preclinical PK/PD and safety studies. Garadacimab plasma concentrations rose with increasing dose, and clear dose‐related PD effects were observed (e.g., a mechanism‐based prolongation of activated partial thromboplastin time). The PK/PD profile from cynomolgus monkeys was used to generate minimal physiologically‐based pharmacokinetic (mPBPK) models with target‐mediated drug disposition (TMDD) for data prediction in cynomolgus monkeys. These models were later adapted for prediction of human data to establish dose selection. Based on the final mPBPK model with TMDD and assuming a weight of 70 kg for an adult human, a minimal inhibition (<10%) of FXIIa with a starting dose of 0.1 mg/kg garadacimab and a near maximal inhibition (>95%) at 10 mg/kg garadacimab were predicted. The phase I study is complete, and data on exposure profiles and inhibition of FXIIa‐mediated kallikrein activity observed in the trial support and validate these simulations. This emphasizes the utility and relevance of translational modeling and simulation in drug development.
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Affiliation(s)
| | - Xi Chen
- Genentech, San Francisco, California, USA
| | | | - Frauke May
- CSL Behring Innovation GmbH, Marburg, Germany
| | | | | | | | | | - William J Jusko
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
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4
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Alsultan A, Alghamdi WA, Alghamdi J, Alharbi AF, Aljutayli A, Albassam A, Almazroo O, Alqahtani S. Clinical pharmacology applications in clinical drug development and clinical care: A focus on Saudi Arabia. Saudi Pharm J 2020; 28:1217-1227. [PMID: 33132716 PMCID: PMC7584801 DOI: 10.1016/j.jsps.2020.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 08/14/2020] [Indexed: 01/10/2023] Open
Abstract
Drug development, from preclinical to clinical studies, is a lengthy and complex process. There is an increased interest in the Kingdom of Saudi Arabia (KSA) to promote innovation, research and local content including clinical trials (Phase I-IV). Currently, there are over 650 registered clinical trials in Saudi Arabia, and this number is expected to increase. An important part of drug development and clinical trials is to assure the safe and effective use of drugs. Clinical pharmacology plays a vital role in informed decision making during the drug development stage as it focuses on the effects of drugs in humans. Disciplines such as pharmacokinetics, pharmacodynamics and pharmacogenomics are components of clinical pharmacology. It is a growing discipline with a range of applications in all phases of drug development, including selecting optimal doses for Phase I, II and III studies, evaluating bioequivalence and biosimilar studies and designing clinical studies. Incorporating clinical pharmacology in research as well as in the requirements of regulatory agencies will improve the drug development process and accelerate the pipeline. Clinical pharmacology is also applied in direct patient care with the goal of personalizing treatment. Tools such as therapeutic drug monitoring, pharmacogenomics and model informed precision dosing are used to optimize dosing for patients at an individual level. In KSA, the science of clinical pharmacology is underutilized and we believe it is important to raise awareness and educate the scientific community and healthcare professionals in terms of its applications and potential. In this review paper, we provide an overview on the use and applications of clinical pharmacology in both drug development and clinical care.
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Affiliation(s)
- Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.,Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Wael A Alghamdi
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | - Jahad Alghamdi
- The Saudi Biobank, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abeer F Alharbi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh 11426, Saudi Arabia
| | | | - Ahmed Albassam
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | | | - Saeed Alqahtani
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.,Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia
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5
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Lemoine M. Animal extrapolation in preclinical studies: An analysis of the tragic case of TGN1412. STUDIES IN HISTORY AND PHILOSOPHY OF BIOLOGICAL AND BIOMEDICAL SCIENCES 2017; 61:35-45. [PMID: 28039775 DOI: 10.1016/j.shpsc.2016.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 12/19/2016] [Accepted: 12/22/2016] [Indexed: 06/06/2023]
Abstract
According to the received view, the transportation view, animal extrapolation consists in inductive prediction of the outcome of a mechanism in a target, based on an analogical mechanism in a model. Through an analysis of the failure of preclinical studies of TGN1412, an innovative drug, to predict the tragic consequences of its first-in-man trial in 2006, the received view is challenged by a proposed view of animal extrapolation, the chimera view. According to this view, animal extrapolation is based on a hypothesis about how human organisms work, supported by the amalgamation of results drawn from various experimental organisms, and only predicting the 'predictive grid', that is, a global framework of the effects to be expected.
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Affiliation(s)
- Maël Lemoine
- INSERM U930, France; Université de Tours - Faculté de Médecine - Département de SHS, 10 Bd Tonnellé 37032 Tours Cedex, France.
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Eddleston M, Cohen AF, Webb DJ. Implications of the BIA-102474-101 study for review of first-into-human clinical trials. Br J Clin Pharmacol 2016; 81:582-6. [PMID: 26996741 DOI: 10.1111/bcp.12920] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 02/22/2016] [Indexed: 01/04/2023] Open
Abstract
Over the past 10 years, thousands of first-into-human (FIH) clinical trials have been performed in Europe, with few severe adverse events (SAEs). Each has received detailed prior safety review at both the local clinical research facility and at national drug regulatory authority level. The recent fatal SAE in the BIA-102474-101 clinical trial shows the limitations of this process. Although criticized for not sequentially dosing subjects both within and between cohorts - as recommended by the European Medicines Agency for high-risk compounds after the TeGenero clinical trial disaster in 2006 - BIA-102474-101 was not considered to be high risk. Indeed, compounds with similar mechanisms of action had previously been taken through phase I and II trials without incident, and higher doses had been safely given for longer durations to nonhuman primates. If the available data are comprehensive and accurate, and further investigation does not reveal unreported warning signs, this study has serious implications for ongoing and future review of FIH clinical trials. All preclinical study documents and clinical data collected during the BIA-102474-101 trial should be made available urgently so that lessons can be learnt. In the meantime, reviewers and clinical researchers should always ask for information on drug and target interactions and full reports of preclinical toxicity studies, and plan sequential dosing with longer delays between patients and cohorts, particularly if late SAEs might be anticipated. The use of individual patient pharmacokinetic and dynamic data should guide sequential dosing. A process for systematic risk assessment, like that currently used in the Netherlands, should be applied routinely to all trials with novel compounds.
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Affiliation(s)
- Michael Eddleston
- Pharmacology, Toxicology, & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,National Poisons Information Service - Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Adam F Cohen
- Centre for Human Drug Research, Leiden, the Netherlands
| | - David J Webb
- Pharmacology, Toxicology, & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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Suh HY, Peck CC, Yu KS, Lee H. Determination of the starting dose in the first-in-human clinical trials with monoclonal antibodies: a systematic review of papers published between 1990 and 2013. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:4005-4016. [PMID: 27994442 PMCID: PMC5153257 DOI: 10.2147/dddt.s121520] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
A systematic review was performed to evaluate how the maximum recommended starting dose (MRSD) was determined in first-in-human (FIH) studies with monoclonal antibodies (mAbs). Factors associated with the choice of each MRSD determination method were also identified. PubMed was searched for FIH studies with mAbs published in English between January 1, 1990 and December 31, 2013, and the following information was extracted: MRSD determination method, publication year, therapeutic area, antibody type, safety factor, safety assessment results after the first dose, and number of dose escalation steps. Seventy-nine FIH studies with mAbs were identified, 49 of which clearly reported the MRSD determination method. The no observed adverse effects level (NOAEL)-based approach was the most frequently used method, whereas the model-based approach was the least commonly used method (34.7% vs 16.3%). The minimal anticipated biological effect level (MABEL)- or minimum effective dose (MED)-based approach was used more frequently in 2011–2013 than in 1990–2007 (31.6% vs 6.3%, P=0.036), reflecting a slow, but steady acceptance of the European Medicines Agency’s guidance on mitigating risks for FIH clinical trials (2007). The median safety factor was much lower for the MABEL- or MED-based approach than for the other MRSD determination methods (10 vs 32.2–53). The number of dose escalation steps was not significantly different among the different MRSD determination methods. The MABEL-based approach appears to be safer and as efficient as the other MRSD determination methods for achieving the objectives of FIH studies with mAbs faster.
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Affiliation(s)
- Hoon Young Suh
- Department of Clinical Pharmacology and Therapeutics, College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Carl C Peck
- Department of Bioengineering and Therapeutic Sciences, School of Pharmacy, University of California, San Francisco, CA, USA
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics, College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Howard Lee
- Department of Clinical Pharmacology and Therapeutics, College of Medicine, Seoul National University Hospital, Seoul, Korea; Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
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8
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Affiliation(s)
- Sergio Bonini
- From the European Medicines Agency, London (S.B., G.R.); and the Second University of Naples, Naples (S.B.), and Istituto di Farmacologia Traslazionale del Consiglio Nazionale delle Ricerche (S.B.) and the University of Rome Tor Vergata (G.R.), Rome - all in Italy
| | - Guido Rasi
- From the European Medicines Agency, London (S.B., G.R.); and the Second University of Naples, Naples (S.B.), and Istituto di Farmacologia Traslazionale del Consiglio Nazionale delle Ricerche (S.B.) and the University of Rome Tor Vergata (G.R.), Rome - all in Italy
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9
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Baumann A, Fischmann S, Blaich G, Friedrich M. Leverage nonclinical development of bispecifics by translational science. DRUG DISCOVERY TODAY. TECHNOLOGIES 2016; 21-22:95-102. [PMID: 27978993 DOI: 10.1016/j.ddtec.2016.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/09/2016] [Accepted: 08/11/2016] [Indexed: 06/06/2023]
Abstract
Bispecific antibody constructs (Bispecifics, bsAbs) may have greater functionality compared to established monoclonal antibodies because they bind to 2 different targets or, potentially, to 2 epitopes on the same target (dual targeting). This may result in enhanced binding avidity with preferential binding to cells that express both targets or binding to targets on different cells. However, development of these next-generation biologics, including new formats, creates unique challenges due to their increased complexity. Here we review aspects of bsAbs preclinical development programs that may increase the success rates of bsAbs in clinical development.
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Affiliation(s)
| | | | - Guenter Blaich
- AbbVie Germany GmbH & Co. KG, Knollstrasse, 67061 Ludwigshafen, Germany
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Brussee JM, Calvier EAM, Krekels EHJ, Välitalo PAJ, Tibboel D, Allegaert K, Knibbe CAJ. Children in clinical trials: towards evidence-based pediatric pharmacotherapy using pharmacokinetic-pharmacodynamic modeling. Expert Rev Clin Pharmacol 2016; 9:1235-44. [PMID: 27269200 DOI: 10.1080/17512433.2016.1198256] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION In pediatric pharmacotherapy, many drugs are still used off-label, and their efficacy and safety is not well characterized. Different efficacy and safety profiles in children of varying ages may be anticipated, due to developmental changes occurring across pediatric life. AREAS COVERED Beside pharmacokinetic (PK) studies, pharmacodynamic (PD) studies are urgently needed. Validated PKPD models can be used to derive optimal dosing regimens for children of different ages, which can be evaluated in a prospective study before implementation in clinical practice. Strategies should be developed to ensure that formularies update their drug dosing guidelines regularly according to the most recent advances in research, allowing for clinicians to integrate these guidelines in daily practice. Expert commentary: We anticipate a trend towards a systems-level approach in pediatric modeling to optimally use the information gained in pediatric trials. For this approach, properly designed clinical PKPD studies will remain the backbone of pediatric research.
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Affiliation(s)
- Janneke M Brussee
- a Division of Pharmacology, Leiden Academic Centre for Drug Research , Leiden University , Leiden , The Netherlands
| | - Elisa A M Calvier
- a Division of Pharmacology, Leiden Academic Centre for Drug Research , Leiden University , Leiden , The Netherlands
| | - Elke H J Krekels
- a Division of Pharmacology, Leiden Academic Centre for Drug Research , Leiden University , Leiden , The Netherlands
| | - Pyry A J Välitalo
- a Division of Pharmacology, Leiden Academic Centre for Drug Research , Leiden University , Leiden , The Netherlands
| | - Dick Tibboel
- b Intensive Care and Department of Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Karel Allegaert
- b Intensive Care and Department of Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,c Department of Development and Regeneration , KU Leuven , Leuven , Belgium
| | - Catherijne A J Knibbe
- a Division of Pharmacology, Leiden Academic Centre for Drug Research , Leiden University , Leiden , The Netherlands.,d Department of Clinical Pharmacy , St. Antonius Hospital , Nieuwegein , The Netherlands
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van Meer PJ, Graham ML, Schuurman HJ. The safety, efficacy and regulatory triangle in drug development: Impact for animal models and the use of animals. Eur J Pharmacol 2015; 759:3-13. [DOI: 10.1016/j.ejphar.2015.02.055] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 01/15/2015] [Accepted: 02/09/2015] [Indexed: 11/26/2022]
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12
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Hansen AR, Cook N, Ricci MS, Razak A, Le Tourneau C, McKeever K, Roskos L, Dixit R, Siu LL, Hinrichs MJ. Choice of Starting Dose for Biopharmaceuticals in First-in-Human Phase I Cancer Clinical Trials. Oncologist 2015; 20:653-9. [PMID: 25964306 DOI: 10.1634/theoncologist.2015-0008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/03/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND First-in-human (FIH) trials of low-molecular-weight anticancer agents conventionally derive a safe start dose (SD) from one-tenth the severely toxic dose in 10% of rodents or one-sixth the highest nonseverely toxic dose (HNSTD) in nonrodent species. No consensus has been reached on whether this paradigm can be safely applied to biotechnology-derived products (BDPs). MATERIALS AND METHODS A comprehensive search was conducted to identify all BDPs (excluding immune checkpoint inhibitors and antibody drug conjugates) with sufficient nonclinical and clinical data to assess the safety of hypothetical use of one-sixth HNSTD in an advanced cancer FIH trial. RESULTS The search identified 23 BDPs, of which 21 were monoclonal antibodies. The median ratio of the maximum tolerated or maximum administered dose (MTD or MAD) to the actual FIH SD was 36 (range, 8-500). Only 2 BDPs reached the MTD. Hypothetical use of one-sixth HNSTD (allometrically scaled to humans) would not have exceeded the MTD or MAD for all 23 BDPs and would have reduced the median ratio of the MTD or MAD to a SD to 6.1 (range, 3.5-55.3). Pharmacodynamic (PD) markers were included in some animal toxicology studies and were useful to confirm the hypothetical SD of one-sixth HNSTD. CONCLUSION One-sixth HNSTD would not have resulted in unacceptable toxicities in the data available. Supporting its use could reduce the number of dose escalations needed to reach the recommended dose. A low incidence of toxicities in animals and humans underscores the need to identify the pharmacokinetic and PD parameters to guide SD selection of BDPs for FIH cancer trials. IMPLICATIONS FOR PRACTICE Start dose (SD) for biotechnology-derived products (BDPs) can be safely derived from one-sixth the highest nonseverely toxic dose in nonrodent species and may reduce the number of dose escalations needed to reach the recommended dose in first-in-human studies while limiting unnecessary exposure to high drug levels in humans. The use of this type of SD could improve the design of phase I studies of BDPs by making them more efficient. The role of preclinical pharmacodynamic markers was useful in confirming the hypothetical SD, and attempts should be explored in future animal studies to identify such parameters.
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Affiliation(s)
- Aaron R Hansen
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Natalie Cook
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - M Stacey Ricci
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Albiruni Razak
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Christophe Le Tourneau
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Kathleen McKeever
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Lorin Roskos
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Rakesh Dixit
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Lillian L Siu
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Mary Jane Hinrichs
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
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Ethics in clinical trials. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Blandizzi C, Viscomi GC, Scarpignato C. Impact of crystal polymorphism on the systemic bioavailability of rifaximin, an antibiotic acting locally in the gastrointestinal tract, in healthy volunteers. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 9:1-11. [PMID: 25565769 PMCID: PMC4274041 DOI: 10.2147/dddt.s72572] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Rifaximin is an antibiotic, acting locally in the gastrointestinal tract, which may exist in different crystal as well as amorphous forms. The current marketed rifaximin formulation contains polymorph alpha, the systemic bioavailability of which is very limited. This study compared the pharmacokinetics of this formulation with those of the amorphous form. Methods Amorphous rifaximin was specifically prepared for the study and formulated as the marketed product. Two doses (200 mg and 400 mg) of both formulations were given to two groups of 12 healthy volunteers of either sex according to a single-blind, randomized, two-treatment, single-dose, two-period, cross-over design. Plasma and urine samples were collected at preset times (for 24 hours or 48 hours, respectively) after dosing, and assayed for rifaximin concentrations by high-performance liquid chromatography-mass spectrometry. Results For both dose levels, peak plasma concentration, area under the concentration-time curve, and cumulative urinary excretion were significantly higher after administration of amorphous rifaximin than rifaximin-α. Ninety percent confidence intervals for peak plasma concentration, area under the concentration-time curve, and urinary excretion ratios were largely outside the upper limit of the accepted (0.80–1.25) range, indicating higher systemic bioavailability of the amorphous rifaximin. The few adverse events recorded were not serious and not related to the study medications. Conclusion Rifaximin-α, a crystal polymorph, does differ from the amorphous form, the latter being systemically more bioavailable. In this regard, care must be taken when using – as a medicinal product – a formulation containing even small amounts of amorphous form, which may alter the peculiar pharmacologic properties of this poorly absorbed antibiotic.
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Affiliation(s)
- Corrado Blandizzi
- Division of Pharmacology and Chemotherapy, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Carmelo Scarpignato
- Clinical Pharmacology and Digestive Pathophysiology Unit, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
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15
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Moore NA, Sargent BJ, Guzzo PR, Surman MD. From preclinical to clinical development: The example of a novel treatment for obesity. Neurobiol Dis 2014; 61:47-54. [DOI: 10.1016/j.nbd.2013.07.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 07/12/2013] [Accepted: 07/17/2013] [Indexed: 11/27/2022] Open
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Foster JR, Lund G, Sapelnikova S, Tyrrell DL, Kneteman NM. Chimeric rodents with humanized liver: bridging the preclinical/clinical trial gap in ADME/toxicity studies. Xenobiotica 2013; 44:109-22. [DOI: 10.3109/00498254.2013.867553] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Sathish JG, Sethu S, Bielsky MC, de Haan L, French NS, Govindappa K, Green J, Griffiths CEM, Holgate S, Jones D, Kimber I, Moggs J, Naisbitt DJ, Pirmohamed M, Reichmann G, Sims J, Subramanyam M, Todd MD, Van Der Laan JW, Weaver RJ, Park BK. Challenges and approaches for the development of safer immunomodulatory biologics. Nat Rev Drug Discov 2013; 12:306-24. [PMID: 23535934 PMCID: PMC7097261 DOI: 10.1038/nrd3974] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Immunomodulatory biologics are a class of biotechnology-derived therapeutic products that are designed to engage immune-relevant targets and are indicated in the treatment and management of a range of diseases, including immune-mediated inflammatory diseases and malignancies. Despite their high specificity and therapeutic advantages, immmunomodulatory biologics have been associated with adverse reactions such as serious infections, malignancies and cytokine release syndrome, which arise owing to the on-target or exaggerated pharmacological effects of these drugs. Immunogenicity resulting in the generation of antidrug antibodies is another unwanted effect that leads to loss of efficacy and — rarely — hypersensitivity reactions. For some adverse reactions, mitigating and preventive strategies are in place, such as stratifying patients on the basis of responsiveness to therapy and the risk of developing adverse reactions. These strategies depend on the availability of robust biomarkers for therapeutic efficacy and the risk of adverse reactions: for example, seropositivity for John Cunningham virus is a risk factor for progressive multifocal leukoencephalopathy. The development of effective biomarkers will greatly aid these strategies. The development and design of safer immunomodulatory biologics is reliant on a detailed understanding of the nature of the disease, target biology, the interaction of the target with the immunomodulatory biologic and the inherent properties of the biologic that elicit unwanted effects. The availability of in vitro and in vivo models that can be used to predict adverse reactions associated with immunomodulatory biologics is central to the development of safer immunomodulatory biologics. Some progress has been made in developing in vitro and in silico tests for predicting cytokine release syndrome and immunogenicity, but there is still a lack of models for effectively predicting infections and malignancies. Two pathways can be followed in designing and developing safer immunomodulatory biologics. The first pathway involves generating a biologic that engages an alternative target or mechanism to produce the desired pharmacodynamic effect without the associated adverse reaction, and is followed when the adverse reaction cannot be dissociated from the target biology. The second pathway involves redesigning the biologic to 'engineer out' components within the biologic structure that trigger adverse effects or to alter the nature of the target–biologic interactions.
Owing to their specificity, immunomodulatory biologics generally have better safety profiles than small-molecule drugs. However, adverse effects such as an increased risk of infections or cytokine release syndrome are of concern. Here, Park and colleagues discuss the current strategies used to predict and mitigate these adverse effects and consider how they can be used to inform the development of safer immunomodulatory biologics. Immunomodulatory biologics, which render their therapeutic effects by modulating or harnessing immune responses, have proven their therapeutic utility in several complex conditions including cancer and autoimmune diseases. However, unwanted adverse reactions — including serious infections, malignancy, cytokine release syndrome, anaphylaxis and hypersensitivity as well as immunogenicity — pose a challenge to the development of new (and safer) immunomodulatory biologics. In this article, we assess the safety issues associated with immunomodulatory biologics and discuss the current approaches for predicting and mitigating adverse reactions associated with their use. We also outline how these approaches can inform the development of safer immunomodulatory biologics.
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Affiliation(s)
- Jean G Sathish
- MRC Centre for Drug Safety Science and Institute of Translational Medicine, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool L69 3GE, UK
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Mackenzie CR, Paget SA. Ethics in clinical trials. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00026-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Muller PY, Milton M, Lloyd P, Sims J, Brennan FR. The minimum anticipated biological effect level (MABEL) for selection of first human dose in clinical trials with monoclonal antibodies. Curr Opin Biotechnol 2009; 20:722-9. [PMID: 19896825 DOI: 10.1016/j.copbio.2009.10.013] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Accepted: 10/20/2009] [Indexed: 11/26/2022]
Abstract
Dose selection for first-in-human (FIH) clinical trials with monoclonal antibodies (mAbs) is based on specifically designed preclinical pharmacology and toxicology studies, mechanistic ex vivo/in vitro investigations with human and animal cells and pharmacokinetic/pharmacodynamic (PK/PD) modeling approaches and requires a thorough understanding of the biology of the target and the relative binding and pharmacological activity of the mAb in animals and humans. These investigations provide the essential information required for the selection of a safe starting dose and escalation for FIH trials based on toxicology and pharmacology data and the minimal anticipated biological effect level (MABEL) by integrating all available in vivo and in vitro data. In this review, strategies for estimation of the MABEL for mAbs specific for both membrane and soluble targets are presented and the scientific and regulatory challenges highlighted.
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Affiliation(s)
- Patrick Y Muller
- Novartis Institutes for BioMedical Research, Basel, Switzerland.
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Stebbings R, Poole S, Thorpe R. Safety of biologics, lessons learnt from TGN1412. Curr Opin Biotechnol 2009; 20:673-7. [PMID: 19892543 DOI: 10.1016/j.copbio.2009.10.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Accepted: 10/05/2009] [Indexed: 12/14/2022]
Abstract
In 2006, a first-in-man phase-I clinical trial of an immunomodulatory mAb, TGN1412, ended in disaster when six healthy recipients suffered a life-threatening systemic inflammatory response, termed a 'Cytokine Storm'. A subsequent investigation concluded that these serious adverse events, not predicted by pre-clinical safety testing, were unforeseen biological effects in man. However, the adverse events had been exacerbated by administration of a near-maximum immuno-stimulatory dose to volunteers, because the calculation of a safe starting dose in man had been based upon results from pre-clinical safety testing in a non-responsive species. In hindsight, many lessons have been learnt from this experience and these have prompted a revision of the European guidelines for first-in-man phase-I clinical trials of biologics. Perhaps the most important lesson is that greater caution needs to be exercised when evaluating new biologics.
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Affiliation(s)
- Richard Stebbings
- Biotherapeutics Group, National Institute for Biological Standards and Control, Potters Bar, Hertfordshire EN6 3QG, UK.
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Ochoa R, Rousseaux C. The role of the toxicologic pathologist in risk management. Toxicol Pathol 2009; 37:705-7. [PMID: 19773592 DOI: 10.1177/0192623309344434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Affiliation(s)
- James D. Green
- Preclinical and Clinical Sciences, Biogen Idec, Inc., Cambridge, MA, USA
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Horvath CJ, Milton MN. The TeGenero incident and the Duff Report conclusions: a series of unfortunate events or an avoidable event? Toxicol Pathol 2009; 37:372-83. [PMID: 19244218 DOI: 10.1177/0192623309332986] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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