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Celio L, Cortinovis D, Cogoni AA, Cavanna L, Martelli O, Carnio S, Collovà E, Bertolini F, Petrelli F, Cassano A, Chiari R, Zanelli F, Pisconti S, Vittimberga I, Letizia A, Misino A, Gernone A, Bonizzoni E, Pilotto S, De Placido S, Bria E. Dexamethasone-Sparing Regimens with Oral Netupitant and Palonosetron for the Prevention of Emesis Caused by High-Dose Cisplatin: A Randomized Noninferiority Study. Oncologist 2021; 26:e1854-e1861. [PMID: 34101934 PMCID: PMC8488764 DOI: 10.1002/onco.13851] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/25/2021] [Indexed: 11/19/2022] Open
Abstract
Background To reduce the overall exposure to dexamethasone (DEX) in patients receiving cisplatin‐based chemotherapy, we evaluated the noninferiority of DEX on day 1, with or without low‐dose DEX on days 2 and 3, combined with an oral fixed‐dose combination of netupitant and palonosetron (NEPA), compared with the guideline‐consistent use of 4‐day DEX. Patients and Methods In this open‐label, multicenter study, chemotherapy‐naïve patients undergoing high‐dose cisplatin (≥70 mg/m2), were given NEPA and DEX (12 mg) on day 1 and randomized (1:1:1 ratio) to receive either (a) no further DEX (DEX1), (b) oral DEX (4 mg daily) on days 2–3 (DEX3), or (c) DEX (4 mg twice daily) on days 2–4 (DEX4). The primary efficacy endpoint was complete response (CR: no emesis and no rescue medication) during the 5‐day overall phase. The noninferiority margin was set at −15% difference (DEX1 or DEX3 minus DEX4). Secondary efficacy endpoints included complete protection (CP: CR and none or mild nausea). Results Two‐hundred twenty‐eight patients, 76 in each arm, were assessable. Noninferiority was met for both DEX‐sparing regimens and the reference arm, with overall phase CR rates of 76.3% in each of the DEX1 and DEX3 arms and 75.0% in the DEX4 arm (95% confidence interval, −12.3% to 15% for each comparison). During the overall phase, CP rates were similar between groups. Conclusion A simplified regimen of NEPA plus single‐dose DEX offers comparable chemotherapy‐induced nausea and vomiting prevention throughout 5 days post‐chemotherapy with the advantage of sparing patients additional doses of DEX in the high–emetic‐risk setting of cisplatin‐based chemotherapy. Implications for Practice Dexamethasone (DEX) has traditionally played an integral role in the management of chemotherapy‐induced emesis. Although generally considered safe, even short‐term DEX use is associated with various side effects, and some evidence suggests that concurrent steroids may reduce the efficacy of immunotherapies. This study demonstrates comparable antiemetic control during the 5 days post‐chemotherapy with a simplified regimen of netupitant/palonosetron plus single‐dose DEX versus the standard 4‐day DEX reference treatment in high‐dose cisplatin. This represents a clinically relevant achievement as it not only simplifies antiemetic prophylaxis but also offers an opportunity to appropriately use in patients where caution with corticosteroid use is advised. This study was designed to test whether two different dexamethasone‐sparing regimens, when administered with NEPA, might provide the opportunity to reduce the total corticosteroid dose while maintaining the same degree of chemotherapy‐induced nausea and vomiting control in patients undergoing cisplatin‐based chemotherapy.
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Affiliation(s)
- Luigi Celio
- Oncology Unit, Azienda Socio Sanitaria Territoriale del Garda, Desenzano del Garda Hospital, Brescia, Italy
| | - Diego Cortinovis
- Medical Oncology Department, Azienda Socio Sanitaria Territoriale Monza San Gerardo Hospital, Monza, Italy
| | - Alessio Aligi Cogoni
- Medical Oncology Department, Azienda Ospedaliero-Universitaria di Sassari, Sassari, Italy
| | - Luigi Cavanna
- Oncology Department, Azienda Ospedaliera di Piacenza, Piacenza, Italy
| | - Olga Martelli
- Medical Oncology, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Simona Carnio
- Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Elena Collovà
- Cancer Centre Department, Oncology Unit, Azienda Socio Sanitaria Territoriale Ovest Milanese, Legnano Hospital, Legnano, Milan, Italy
| | - Federica Bertolini
- Department of Oncology and Hematology, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Fausto Petrelli
- Medical Oncology Unit, Azienda Socio Sanitaria Territoriale Bergamo Ovest, Treviglio, Bergamo, Italy
| | - Alessandra Cassano
- Medical Oncology, Università Cattolica del Sacro Cuore, Rome, Italy.,Comprehensive Cancer Center, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Rita Chiari
- Oncology Unit, AULSS6 Euganea, Padova, Italy
| | - Francesca Zanelli
- Medical Oncology Unit, Istituto di Ricovero e Cura a Carattere Scientifico Santa Maria Nuova, Reggio Emilia, Italy
| | - Salvatore Pisconti
- Medical Oncology Department, San Giuseppe Moscati Hospital, Statte, Taranto, Italy
| | - Isabella Vittimberga
- Department of Oncology, Azienda Socio Sanitaria Territoriale Lecco, Lecco, Italy
| | - Antonietta Letizia
- Department of Pneumology and Oncology, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Ospedale Monaldi, Naples, Italy
| | - Andrea Misino
- Medical Oncology, Clinical Cancer Center "Giovanni Paolo II," Istituto di Ricovero e Cura a Carattere Scientifico, Bari, Italy
| | - Angela Gernone
- Medical Oncology Unit, University of Bari, Policlinico di Bari, Bari, Italy
| | - Erminio Bonizzoni
- Department of Clinical Science and Community. Section of Medical Statistics, Biometry and Epidemiology "G.A. Maccacaro," Faculty of Medicine and Surgery, University of Milan, Milan, Italy
| | - Sara Pilotto
- Section of Oncology, Department of Medicine, University and Hospital Trust of Verona, Verona, Italy
| | - Sabino De Placido
- Clinical Medicine and Surgery Department, University of Naples "Federico II," Naples, Italy
| | - Emilio Bria
- Medical Oncology, Università Cattolica del Sacro Cuore, Rome, Italy.,Comprehensive Cancer Center, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
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Fabi A, Malaguti P. An update on palonosetron hydrochloride for the treatment of radio/chemotherapy-induced nausea and vomiting. Expert Opin Pharmacother 2013; 14:629-41. [PMID: 23414148 DOI: 10.1517/14656566.2013.771166] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Nausea and vomiting are well recognized in different clinical situations, suggesting that no single mechanism is likely to be responsible for their production. Chemotherapy-induced nausea and vomiting (CINV) can have a negative impact on quality of life and this may lead to a refusal of curative therapy or to a decline in palliative benefits offered by cytotoxic treatment. Palonosetron is a new agent in the class of 5-HT3 receptor antagonists (5-HT3RAs), and differs from the other agents by its higher receptor-binding affinity and longer half-life. These pharmacological properties have resulted in improved antiemetic activity in clinical trials, particularly in the treatment of delayed CINV following moderate emetogenic chemotherapy (MEC). AREA COVERED A systematic review of the medical literature was completed to inform this update. MEDLINE, the Cochrane Collaboration Library and meeting materials from ASCO and MASCC were all searched. EXPERT OPINION Palonosetron was the only serotonin receptor antagonist approved for prevention of delayed CINV caused by MEC and its use was incorporated in guideline recommendations. To date, several treatment settings such as multiple day chemotherapy require further studies to improve emesis related to therapy.
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Affiliation(s)
- Alessandra Fabi
- Regina Elena National Cancer Institute, Division of Medical Oncology, Via Elio Chianesi, 53 00144, Rome, Italy.
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Celio L, Bonizzoni E, Bajetta E, Sebastiani S, Perrone T, Aapro MS. Palonosetron plus single-dose dexamethasone for the prevention of nausea and vomiting in women receiving anthracycline/cyclophosphamide-containing chemotherapy: meta-analysis of individual patient data examining the effect of age on outcome in two phase III trials. Support Care Cancer 2012; 21:565-73. [PMID: 22869054 PMCID: PMC3538015 DOI: 10.1007/s00520-012-1558-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 07/23/2012] [Indexed: 11/29/2022]
Abstract
Purpose Data from two randomized trials, evaluating a single-day regimen of palonosetron plus dexamethasone against emesis due to moderately emetogenic chemotherapy, were assessed for the impact of age on outcome in a pooled sample of women receiving anthracycline and/or cyclophosphamide (AC)-containing chemotherapy. Methods Chemo-naïve breast cancer patients randomized to receive palonosetron (0.25 mg) plus dexamethasone (8 mg IV) on day 1 of chemotherapy (n = 200), or the same regimen followed by oral dexamethasone (8 mg) on days 2 and 3 (n = 205), were included in the analysis. The primary endpoint was complete response (CR: no vomiting and no rescue anti-emetics) in the 5-day study period. The effect of the 1-day regimen and age (<50 and ≥50 years) was investigated by a meta-analysis of individual patient data. Results Younger patients comprised 43 % and 49 % of the 1-day and 3-day regimen groups, respectively; 94 % of the pooled sample received the AC combination. There were no between-treatment differences in CR rate according to age during all observation periods. In the 1-day regimen group, 55.2 % of younger patients achieved overall CR compared with 54 % of older patients. In the 3-day regimen group, 51.5 % of younger patients achieved overall CR compared with 58.7 % of older patients. In the adjusted analysis, younger age was not associated with overall CR to treatment (risk difference, −3.1 %; 95 % CI, −13.0 to 6.7 %; P = 0.533). Conclusions These results provide evidence that, irrespective of age, the dexamethasone-sparing regimen is not associated with a significant loss in overall anti-emetic protection in women undergoing AC-containing chemotherapy.
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Affiliation(s)
- Luigi Celio
- Medical Oncology Unit 1, Fondazione IRCCS Istituto Nazionale Tumori, Via Venezian 1, 20133, Milan, Italy.
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Celio L, Agustoni F, Testa I, Dotti K, de Braud F. Palonosetron: An Evidence-Based Choice in Prevention of Nausea and Vomiting Induced by Moderately Emetogenic Chemotherapy. TUMORI JOURNAL 2012; 98:279-86. [DOI: 10.1177/030089161209800301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and background In 2003, the second-generation, 5-HT3 receptor antagonist (5-HT3 RA) palonosetron was approved by the FDA for the prevention of nausea and vomiting associated with highly and moderately emetogenic chemotherapy. We reviewed the current knowledge on the role of palonosetron against acute and delayed emesis in patients with solid tumors undergoing single-day moderately emetogenic chemotherapy regimens. Methods A literature review in PubMed was performed to update currently available preclinical and clinical evidence on palonosetron, prioritizing randomized clinical trials. Results The distinct pharmacology of palonosetron provides a rationale behind the improved efficacy observed with the drug in prevention of delayed symptoms. This may be explained by allosteric binding properties and by palonosetron-triggered receptor internalization, which result in prolonged inhibition of the 5-HT3 receptor function. Very recent pharmacology experiments have also suggested that palonosetron would be able to differentially inhibit 5-HT3/neurokinin 1 (NK-1) receptor signaling cross-talk. In two recent meta-analyses, palonosetron was shown to be more effective than other available 5-HT3 RAs in preventing acute and delayed nausea and vomiting for both HEC and MEC. Recent findings also suggest that a single-day regimen of palonosetron plus dexamethasone (both drugs administered intravenously) may provide a reasonable therapeutic alternative to reduce the total dexamethasone dose administered in patients undergoing moderately emetogenic chemotherapy. Conclusions On the basis of accumulating data, the evidence-based international guidelines devised from the major organizations have been recently updated to recommend the use of palonosetron plus 3-day dexamethasone for the optimal prevention of nausea and vomiting due to moderately emetogenic chemotherapy. There is still a need to investigate the efficacy of palonosetron in combination with an NK-1 receptor antagonist and dexamethasone in well-designed randomized trials.
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Affiliation(s)
- Luigi Celio
- Medical Oncology Unit 1, Fondazione IRCCS Istituto
Nazionale Tumori, Milan, Italy
| | - Francesco Agustoni
- Medical Oncology Unit 1, Fondazione IRCCS Istituto
Nazionale Tumori, Milan, Italy
| | - Isabella Testa
- Medical Oncology Unit 1, Fondazione IRCCS Istituto
Nazionale Tumori, Milan, Italy
| | - Katia Dotti
- Medical Oncology Unit 1, Fondazione IRCCS Istituto
Nazionale Tumori, Milan, Italy
| | - Filippo de Braud
- Medical Oncology Unit 1, Fondazione IRCCS Istituto
Nazionale Tumori, Milan, Italy
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Antiemetic efficacy of single-dose palonosetron and dexamethasone in patients receiving multiple cycles of multiple day-based chemotherapy. Support Care Cancer 2012; 20:3241-6. [PMID: 22534864 PMCID: PMC3480578 DOI: 10.1007/s00520-012-1469-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 04/09/2012] [Indexed: 12/02/2022]
Abstract
Introduction The goal of pharmacological prophylaxis of chemotherapy-induced nausea and vomiting (CINV) should be the elimination of both nausea and vomiting symptoms during all planned chemotherapy cycles. The aim of this study was to assess the efficacy of a single dose of palonosetron and dexamethasone to prevent CINV and to guarantee an adequate food intake (FI) in patients receiving several cycles of multiple day-based chemotherapy (MD-CT). Methods Patients with advanced cancer but without a compromised nutritional status (bone mass index ≥ 18.5) were treated with 0.25 mg palonosetron plus 20 mg dexamethasone before MD-CT. The MD-CT regimen was either epirubicin plus ifosfamide or paclitaxel plus cisplatin and ifosfamide. Nausea, vomiting, and FI were monitored in a 7-day diary. Complete response (CR: no vomiting and no rescue therapy) was the primary endpoint, while complete control (CC: CR and no more than mild nausea) and the evaluation of FI were secondary endpoints. The endpoints were evaluated during the overall timescale (0–168 h) of the chemotherapy regimen. Results Fifty patients were enrolled, 80% of whom achieved CR and 78% achieved CC. During the six chemotherapy cycles, CR and CC ranged from 76% to 88% and from 62% to 88%, respectively. Moreover, patients with CR had a significantly (p < 0.0001) higher weekly food intake compared with patients not achieving CR. Conclusions This trial was the first to assess the efficacy of palonosetron and dexamethasone for the prevention of both nausea and vomiting in patients receiving multiple cycles of MD-CT. In this trial, the ability of patients to intake an adequate amount of food each week was correlated with nausea, thus providing clinicians with an objective parameter for the measurement of the effects of nausea. A single dose of palonosetron and dexamethasone was able to prevent CINV in most patients receiving 3 days of chemotherapy during all planned chemotherapy cycles.
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Celio L, Denaro A, Agustoni F, Bajetta E. Palonosetron plus 1-day dexamethasone for the prevention of nausea and vomiting due to moderately emetogenic chemotherapy: effect of established risk factors on treatment outcome in a phase III trial. ACTA ACUST UNITED AC 2011; 10:65-71. [PMID: 22005217 DOI: 10.1016/j.suponc.2011.06.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Revised: 06/02/2011] [Accepted: 06/16/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND The non-inferiority of palonosetron plus 1-day versus 3-day dexamethasone in preventing chemotherapy-induced nausea and vomiting (CINV) due to moderately emetogenic chemotherapy (MEC) has been previously demonstrated. OBJECTIVE The objectives of this prespecified post hoc analysis were to demonstrate the non-inferiority hypothesis in an adjusted model for known risk factors (age, gender, alcohol consumption, and type of MEC [anthracycline plus cyclophosphamide (AC)-based versus other MEC]) for CINV and to explore the impact on antiemetic outcome of these risk factors. METHODS Chemonaive patients (n = 324) with solid tumors were randomized to receive palonosetron 0.25 mg IV plus dexamethasone 8 mg IV on day 1 of chemotherapy or the same regimen followed by oral dexamethasone 8 mg on days 2 and 3. The primary end point was complete response (CR, no emesis and no rescue antiemetics) during the 5-day study period. A modified intention-to-treat approach was used for multivariable analysis. RESULTS Non-inferiority of the 1-day regimen was confirmed even after adjusting for risk factors (risk difference -4.4%, 95% CI -14.1% to 5.4%; P = .381). Only age less than 50 years (P = .044) independently predicted a poor outcome of antiemetic treatment. However, most of the younger patients were women (1-day regimen 81.8%, 3-day regimen 88.4%) who underwent AC-based chemotherapy (1-day regimen 61.1%, 3-day regimen 71.0%). There were no significant between-treatment differences in the CR rate according to risk factors. CONCLUSION This analysis confirmed that the 1-day regimen provides a valid treatment option for prevention of CINV in delayed, non-AC-based MEC.
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Affiliation(s)
- Luigi Celio
- Department of Medical Oncology, Istituto Nazionale Tumori, Milan, Italy.
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Smith DA, Morgan P, Vogel WM, Walker DK. The use of C(av) rather than AUC in safety assessment. Regul Toxicol Pharmacol 2010; 57:70-3. [PMID: 20074607 DOI: 10.1016/j.yrtph.2010.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 12/22/2009] [Accepted: 01/05/2010] [Indexed: 11/27/2022]
Abstract
Toxicokinetic data have traditionally been presented as maximum observed plasma concentrations (C(max)) and area under the concentration time curve (AUC) values. These values have been used to compare exposures across studies and species to provide valuable interpretation of drug safety data. Increasingly, questions are asked of toxicology studies to more accurately describe the concentration effect relationships in terms of compound affinity for target and off-target receptors. C(max) values can immediately be referenced to known pharmacological activities, particularly when the extent of plasma protein binding is taken into account. This provides a measure of the more pharmacologically relevant free drug exposure. AUC values on the other hand contain the component of time, which means that direct comparison to pharmacological activity values are not immediately possible. Conversion of AUC to average plasma concentration (C(av)) provides a simple and convenient means to allow such a comparison without losing any information imparted by AUC values. In this paper, the benefit and advantage of applying C(av) values is illustrated using examples taken from the literature.
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Affiliation(s)
- D A Smith
- Pharmacokinetics, Dynamics and Metabolism, Pfizer Global Research and Development, Sandwich CT13 9NJ, UK.
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