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Gangat N, Tefferi A. Targeting anemia in myeloid neoplasms. Am J Hematol 2024; 99:1663-1666. [PMID: 38837732 DOI: 10.1002/ajh.27408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 05/25/2024] [Indexed: 06/07/2024]
Abstract
Anemia-directed therapeutic approaches targeting the TGF-β-SMAD and HIF-PH pathways.
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Affiliation(s)
- Naseema Gangat
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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2
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Hunter AM, Bose P. Advances with janus kinase inhibitors for the treatment of myeloproliferative neoplasms: an update of the literature. Expert Opin Pharmacother 2024:1-14. [PMID: 39067001 DOI: 10.1080/14656566.2024.2385729] [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: 06/12/2024] [Revised: 07/16/2024] [Accepted: 07/24/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION The hallmark discovery of hyperactivation of the janus kinase (JAK)-signal transducer and activator of transcription (STAT) pathway was a sentinel moment in the history of myeloproliferative neoplasms (MPNs). This finding paved the way for the development of JAK inhibitors, which now represent the foundation of myelofibrosis therapy. With four JAK inhibitors now approved for myelofibrosis, awareness of their clinical efficacy and safety data and recognition of their unique pharmacologic attributes are of critical importance. Additionally, ruxolitinib represents an integral part of the therapeutic arsenal for polycythemia vera. AREAS COVERED This review provides a broad overview of the published literature supporting JAK inhibitor therapy for MPNs. Primarily focusing on myelofibrosis, each of the four available JAK inhibitors is reviewed in detail, including pharmacology, efficacy, and safety data. Failure of JAK inhibitors and future directions in JAK inhibitor therapy are also discussed. EXPERT OPINION JAK inhibitors revolutionized the treatment of MPNs and have dramatically improved patient outcomes. However, data informing selection between currently available JAK inhibitors is limited. These agents are not curative and eventually fail most patients with myelofibrosis. Combining JAK inhibitors with novel targeted agents appears to be the most promising path to further improve outcomes.
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Affiliation(s)
- Anthony M Hunter
- Department of Hematology and Medical oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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3
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Masarova L, Verstovsek S, Liu T, Rao S, Sajeev G, Fillbrunn M, Simpson R, Li W, Yang J, Lorier YL, Gorsh B, Signorovitch J. Transfusion-related cost offsets and time burden in patients with myelofibrosis on momelotinib vs. danazol from MOMENTUM. Future Oncol 2024:1-12. [PMID: 39072442 DOI: 10.1080/14796694.2024.2368450] [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: 04/04/2024] [Accepted: 06/12/2024] [Indexed: 07/30/2024] Open
Abstract
Aim: To estimate projected US-based cost and time burden for patients with myelofibrosis and anemia treated with momelotinib compared with danazol. Methods: Cost and time burden were calculated based on the transfusion status of patients in the MOMENTUM trial and estimates extracted from previous studies. Results: Reductions in transfusion associated with momelotinib are projected to result in cost and time savings compared with danazol in transfusion-dependent and transfusion-independent/requiring patients with myelofibrosis, respectively: annual medical costs ($53,143 and $46,455 per person), outpatient transfusion costs ($42,021 and $8,370 per person) and annual time savings (173 and 35 h per person). Conclusion: Fewer transfusions with momelotinib are projected to result in cost and time savings in patients with myelofibrosis and anemia compared with danazol.
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Affiliation(s)
- Lucia Masarova
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer, Houston, TX 77030, USA
| | - Srdan Verstovsek
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer, Houston, TX 77030, USA
| | - Tom Liu
- GSK plc, Philadelphia, PA 19104, USA
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Jilg S, Schwaab J, Sockel K, Crodel CC, Brueckl V, Stegelmann F, Jentzsch M, Sasca D, Moyses M, Fuhrmann S, Gundel D, Caduc M, Teichmann LL, Heidel F, Al-Ali HK, Petrides PE. MoReLife - real-life data support the potential of momelotinib as a safe and effective treatment option for cytopenic myelofibrosis patients. Ann Hematol 2024:10.1007/s00277-024-05908-4. [PMID: 39073589 DOI: 10.1007/s00277-024-05908-4] [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: 05/20/2024] [Accepted: 07/19/2024] [Indexed: 07/30/2024]
Abstract
Recurrent problems of patients with myelofibrosis (MF) are cytopenias, debiliating disease-related symptoms and splenomegaly. Whereas the latter are usually addressed by the JAK1/2 inhibitors ruxolitinib and fedratinib, cytopenias often remain critical. Momelotinib, a JAK1/2 inhibitor recently approved for the treatment of anemic MF patients, was shown to improve anemia via a direct inhibition of activin A receptor type I. In this German-wide, multicenter, retrospective analysis the safety and efficacy profile of momelotinib was evaluated in a real world setting within a cohort of 60 MF patients independent of pre-treatment. The median duration of treatment was 12 weeks. As a new, but manageable safety finding, creatinine increase (CTC°1-2) was detected in 10/60 patients (17%). Interestingly, not only hemoglobin levels increased in 84% of patients, but also platelet values (67%). In the cohort of transfusion-dependent individuals (n = 38), transfusion requirement improved in 15 patients (39%) with 8 reaching transfusion independency (21%). Transfusion independency was achieved within a median of 4 weeks (range 2-12). Spleen size decreased in 13/53 individuals (25%) with a median response time of 6 weeks. Thereof, 11 patients had been pre-treated with JAK inhibitor(s) (85%). Clinical improvement was detected in 24/51 symptomatic individuals (47%) with a median response time of 4 weeks. 5 patients stopped treatment due to side effects (8%), 6 patients due to a worsening of clinical symptoms (10%). Taken together, the MoReLife analysis identifies momelotinib as potent and safe therapeutic option also for heavily pre-treated cytopenic MF patients under real world conditions.
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Affiliation(s)
- Stefanie Jilg
- Onkologie Erding, Bajuwarenstr.3, Erding, Germany.
- Department of Medicine III, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
| | - Juliana Schwaab
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Katja Sockel
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany
| | - Carl C Crodel
- Abteilung Hämatologie und Internistische Onkologie, Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena, Germany
| | - Valeska Brueckl
- Department of Hematology and Oncology, University Hospital Erlangen, Friedrich- Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Frank Stegelmann
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Madlen Jentzsch
- Medizinische Klinik I - Hämatologie, Hämostaseologie und Infektiologie, Zelltherapie, Leipzig, Germany
| | - Daniel Sasca
- Department of Hematology, Oncology and Pneumology, University Medical Center Mainz, Mainz, Germany
| | - Margarete Moyses
- Department of Internal Medicine II, Medical University Hospital, Tübingen, Germany
| | | | - Daniel Gundel
- Hämatologisch-Onkologische Praxis Würzburg, Würzburg, Germany
| | - Madlen Caduc
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Lino L Teichmann
- Department of Medicine III, University Hospital Bonn, Bonn, Germany
| | - Florian Heidel
- Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School (MHH), Hannover, Germany
| | - Haifa K Al-Ali
- Krukenberg Cancer Center, University Hospital of Halle, Halle, Germany
| | - Petro E Petrides
- Hematology Oncology Center Munich, Munich, Germany
- Ludwig Maximilians University Munich, Munich, Germany
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Cuenca-Zamora EJ, Guijarro-Carrillo PJ, López-Poveda MJ, Morales ML, Lozano ML, Gonzalez-Conejero R, Martínez C, Teruel-Montoya R, Ferrer-Marín F. miR-146a -/- mice model reveals that NF-κB inhibition reverts inflammation-driven myelofibrosis-like phenotype. Am J Hematol 2024; 99:1326-1337. [PMID: 38646919 DOI: 10.1002/ajh.27322] [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: 08/18/2023] [Revised: 03/13/2024] [Accepted: 03/18/2024] [Indexed: 04/23/2024]
Abstract
Emerging evidence shows the crucial role of inflammation (particularly NF-κB pathway) in the development and progression of myelofibrosis (MF), becoming a promising therapeutic target. Furthermore, tailoring treatment with currently available JAK inhibitors (such as ruxolitinib or fedratinib) does not modify the natural history of the disease and has important limitations, including cytopenias. Since recent studies have highlighted the role of miR-146a, a negative regulator of the NF-κB pathway, in the pathogenesis of MF; here we used miR-146a-/- (KO) mice, a MF-like model lacking driver mutations, to investigate whether pharmacological inhibition of JAK/STAT and/or NF-κB pathways may reverse the myelofibrotic phenotype of these mice. Specifically, we tested the JAK1/2 inhibitor, ruxolitinib; the NF-κB inhibitor via IKKα/β, BMS-345541; both inhibitors in combination; or a dual inhibitor of both pathways (JAK2/IRAK1), pacritinib. Although all treatments decreased spleen size and partially recovered its architecture, only NF-κB inhibition, either using BMS-345541 (alone or in combination) or pacritinib, resulted in a reduction of extramedullary hematopoiesis, bone marrow (BM) fibrosis and osteosclerosis, along with an attenuation of the exacerbated inflammatory state (via IL-1β and TNFα). However, although dual inhibitor improved anemia and reversed thrombocytopenia, the combined therapy worsened anemia by inducing BM hypoplasia. Both therapeutic options reduced NF-κB and JAK/STAT signaling in a context of JAK2V617F-driven clonal hematopoiesis. Additionally, combined treatment reduced both COL1A1 and IL-6 production in an in vitro model mimicking JAK2-driven fibrosis. In conclusion, NF-κB inhibition reduces, in vitro and in vivo, disease burden and BM fibrosis, which could provide benefits in myelofibrosis patients.
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Affiliation(s)
- Ernesto José Cuenca-Zamora
- Hematology Department, Hospital Universitario Morales-Meseguer, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
- CIBERER-ISCIII CB15/00055 (U765), Murcia, Spain
- Universidad de Murcia, Murcia, Spain
| | - Pedro J Guijarro-Carrillo
- Hematology Department, Hospital Universitario Morales-Meseguer, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | | | - María Luz Morales
- Hematology Department, Hospital Universitario Morales-Meseguer, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | - María Luisa Lozano
- Hematology Department, Hospital Universitario Morales-Meseguer, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
- CIBERER-ISCIII CB15/00055 (U765), Murcia, Spain
- Universidad de Murcia, Murcia, Spain
| | - Rocío Gonzalez-Conejero
- Hematology Department, Hospital Universitario Morales-Meseguer, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
- Universidad de Murcia, Murcia, Spain
| | - Constantino Martínez
- Hematology Department, Hospital Universitario Morales-Meseguer, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | - Raúl Teruel-Montoya
- Hematology Department, Hospital Universitario Morales-Meseguer, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
- CIBERER-ISCIII CB15/00055 (U765), Murcia, Spain
- Universidad de Murcia, Murcia, Spain
| | - Francisca Ferrer-Marín
- Hematology Department, Hospital Universitario Morales-Meseguer, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
- CIBERER-ISCIII CB15/00055 (U765), Murcia, Spain
- Universidad de Murcia, Murcia, Spain
- Universidad Católica San Antonio (UCAM), Murcia, Spain
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Gupta V, Oh S, Devos T, Dubruille V, Catalano J, Somervaille TCP, Platzbecker U, Giraldo P, Kosugi H, Sacha T, Mayer J, Illes A, Ellis C, Wang Z, Gonzalez Carreras FJ, Strouse B, Mesa R. Momelotinib vs. ruxolitinib in myelofibrosis patient subgroups by baseline hemoglobin levels in the SIMPLIFY-1 trial. Leuk Lymphoma 2024; 65:965-977. [PMID: 38501751 DOI: 10.1080/10428194.2024.2328800] [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: 01/31/2024] [Accepted: 03/03/2024] [Indexed: 03/20/2024]
Abstract
A key hallmark of myelofibrosis is anemia, which ranges from mild to severe based on hemoglobin levels. To more clearly define outcomes with the Janus kinase (JAK) 1/JAK2/activin A receptor type 1 inhibitor momelotinib by anemia severity, we performed a descriptive post hoc exploratory analysis of the double-blind, randomized, phase 3 SIMPLIFY-1 study (NCT01969838; N = 432, JAK inhibitor naive, momelotinib vs. ruxolitinib); subgroups were defined by baseline hemoglobin: <10 (moderate/severe), ≥10 to <12 (mild), or ≥12 g/dL (nonanemic). Spleen and symptom results were generally consistent with those previously reported for the intent-to-treat population. In anemic subgroups, momelotinib was associated with higher rates of transfusion independence and reduced/stable transfusion intensity vs. ruxolitinib. No new or unexpected safety signals were identified. Overall, momelotinib provides spleen, symptom, and anemia benefits to JAK inhibitor-naive patients with myelofibrosis regardless of baseline hemoglobin level, and greater anemia-related benefits vs. ruxolitinib in patients with hemoglobin <12 g/dL.
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Affiliation(s)
- Vikas Gupta
- Princess Margaret Cancer Centre, Toronto, Canada
| | - Stephen Oh
- Washington University School of Medicine, St. Louis, MO, USA
| | - Timothy Devos
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology and Immunology, Laboratory of Molecular Immunology (Rega Institute), KU Leuven, Leuven, Belgium
| | | | - John Catalano
- Monash University & Frankston Hospital, Frankston, Australia
| | - Tim C P Somervaille
- The Christie NHS Foundation Trust & Cancer Research UK Manchester Institute, Manchester, UK
| | - Uwe Platzbecker
- Clinic of Hematology, Cellular Therapy, and Hemostaseology, University of Leipzig, Leipzig, Germany
| | - Pilar Giraldo
- Department of Hematology, Hospital Quironsalud, Zaragoza, Spain
| | - Hiroshi Kosugi
- Department of Hematology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Tomasz Sacha
- Jagiellonian University Hospital, Kraków, Poland
| | - Jiri Mayer
- University Hospital Brno, Brno, Czech Republic
| | - Arpad Illes
- Department of Internal Medicine, Division of Haematology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | | | | | | | | | - Ruben Mesa
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Yang Y, Lin Y, Han Z, Wang B, Zheng W, Wei L. Ferroptosis: a novel mechanism of cell death in ophthalmic conditions. Front Immunol 2024; 15:1440309. [PMID: 38994366 PMCID: PMC11236620 DOI: 10.3389/fimmu.2024.1440309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 06/14/2024] [Indexed: 07/13/2024] Open
Abstract
Ferroptosis, a new type of programmed cell death proposed in recent years, is characterized mainly by reactive oxygen species and iron-mediated lipid peroxidation and differs from programmed cell death, such as apoptosis, necrosis, and autophagy. Ferroptosis is associated with a variety of physiological and pathophysiological processes. Recent studies have shown that ferroptosis can aggravate or reduce the occurrence and development of diseases by targeting metabolic pathways and signaling pathways in tumors, ischemic organ damage, and other degenerative diseases related to lipid peroxidation. Increasing evidence suggests that ferroptosis is closely linked to the onset and progression of various ophthalmic conditions, including corneal injury, glaucoma, age-related macular degeneration, diabetic retinopathy, retinal detachment, and retinoblastoma. Our review of the current research on ferroptosis in ophthalmic diseases reveals significant advancements in our understanding of the pathogenesis, aetiology, and treatment of these conditions.
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Affiliation(s)
- Yaqi Yang
- College of Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Yumeng Lin
- Naniing Tongren Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zhongyu Han
- College of Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin, China
- Naniing Tongren Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Bo Wang
- Ophthalmology Department, Affiliated Hospital of Changchun University of Traditional Chinese Medicine, Changchun, Jilin, China
| | - Wei Zheng
- Ophthalmology Department, Affiliated Hospital of Changchun University of Traditional Chinese Medicine, Changchun, Jilin, China
| | - Lijuan Wei
- Ophthalmology Department, Affiliated Hospital of Changchun University of Traditional Chinese Medicine, Changchun, Jilin, China
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Wang L, Fang L, Shi H, Liu Y, Long C, Guo S, Yang X, Hu Q, Liu Z, Yang C, Chen M, Han B. Treatment of myelofibrosis with refractory anemia with luspatercept: a multicenter Chinese study. Ann Hematol 2024:10.1007/s00277-024-05847-0. [PMID: 38907072 DOI: 10.1007/s00277-024-05847-0] [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: 04/22/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024]
Abstract
Myelofibrosis is a rare and often fatal hematological neoplasm, and the treatment of myelofibrosis-associated anemia remains suboptimal, with no improved therapies. Luspatercept was shown to display some efficacy in a phase 2 clinical trial for Myelofibrosis with anemia, yet relevant research are limited. Threrfore, data from patients diagnosed with refractory anemic primary or post-essential thrombocythemia/polycythemia vera myelofibrosis, who were treated with luspatercept for at least 9 weeks, were retrospectively collected. Eighteen patients with myelofibrosis treated with luspatercept were enrolled. Median age was 68 years (range, 44-80 years), and 27.8% were males. Ten (55.6%) were transfusion-dependent. Ten (55.6%) were Dynamic International Prognostic Scoring System intermediate-1, and eight (44.4%) were intermediate-2. The median follow-up was 7 (4-16) months. Erythroid response occurred in eight patients (44.4%) at week 12, four patients (30.8%) at week 24, and nine (50%) at the end of follow-up. Patients who were transfusion-dependent and not transfusion-dependent had similar HI-E responses, at different time points (P > 0.05). Patients had a significantly higher hemoglobin level at 12 weeks, 24 weeks, and at the end of follow-up, than at baseline (P = 0.001, P = 0.021, and P = 0.005, respectively). Treatment-related adverse events occurred in five (16.7%) patients, with no serious adverse events. Two (11.1%) patients relapsed at weeks 15 and 31. One patient progressed to acute myeloid leukemia. No patients had died by the end of follow-up. Luspatercept induced a good response in patients with anemic myelofibrosis, with a low relapse rate and good tolerance.
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Affiliation(s)
- Leyu Wang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academe of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Liwei Fang
- State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Hongxia Shi
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yinghui Liu
- Department of Hematology, Yantai Yuhuangding Hospital, Yantai, China
| | - Chan Long
- Department of Hematology, Huizhou First People's Hospital, Huzhou, China
| | - Shuxia Guo
- Department of Hematology, People's hospital of Zhengzhou, Zhengzhou, China
| | - Xiuli Yang
- Department of Hematology, Harbin Institute of Hematology and Oncology, Harbin, China
| | - Qinglin Hu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academe of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Ziwei Liu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academe of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Chen Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academe of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academe of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academe of Medical Science and Peking Union Medical College, Beijing, 100730, China.
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Rippel N, Kremyanskaya M. Recent advances in JAK2 inhibition for the treatment of myelofibrosis. Expert Opin Pharmacother 2024; 25:1175-1186. [PMID: 38919983 DOI: 10.1080/14656566.2024.2372453] [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: 05/15/2024] [Accepted: 06/21/2024] [Indexed: 06/27/2024]
Abstract
INTRODUCTION Myelofibrosis (MF) is a BCR-ABL-negative myeloproliferative neoplasm characterized by splenomegaly, constitutional symptoms, cytopenias, a potential for leukemic transformation, and increased mortality. Patients who are ineligible for stem cell transplant rely on pharmacologic therapies of noncurative intent, whose cornerstone consists of JAK inhibitors (JAKi). While current JAKi are efficacious in controlling symptoms and splenic volume, none meaningfully reduce clonal burden nor halt disease progression, and patients oftentimes develop JAKi intolerant, relapsed, or refractory MF. As such, there remains an urgent necessity for second-line options and novel therapies with disease-modifying properties. AREAS COVERED In this review, we delineate the mechanistic rationale, along with the latest safety and efficacy data, of investigational JAKi-based MF treatment strategies, with a focus on JAKi monotherapies and combinations of novel agents with approved JAKi. Our literature search consisted of extensive review of PubMed and clinicaltrials.gov. EXPERT OPINION A myriad of promising MF-directed therapies are in late-phase studies. Following their approval, treatment selection should be tailored to patient-specific treatment goals and disease characteristics, with an emphasis on combination therapies of JAKi with novel agents of differing mechanistic targets that possess anti-clonal properties, in attempt to alter disease course and concurrently limit dose-dependent JAKi toxicities.
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Affiliation(s)
- Noa Rippel
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marina Kremyanskaya
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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10
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Papapetropoulos A, Topouzis S, Alexander SPH, Cortese-Krott M, Kendall DA, Martemyanov KA, Mauro C, Nagercoil N, Panettieri RA, Patel HH, Schulz R, Stefanska B, Stephens GJ, Teixeira MM, Vergnolle N, Wang X, Ferdinandy P. Novel drugs approved by the EMA, the FDA, and the MHRA in 2023: A year in review. Br J Pharmacol 2024; 181:1553-1575. [PMID: 38519837 DOI: 10.1111/bph.16337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 03/25/2024] Open
Abstract
In 2023, seventy novel drugs received market authorization for the first time in either Europe (by the EMA and the MHRA) or in the United States (by the FDA). Confirming a steady recent trend, more than half of these drugs target rare diseases or intractable forms of cancer. Thirty drugs are categorized as "first-in-class" (FIC), illustrating the quality of research and innovation that drives new chemical entity discovery and development. We succinctly describe the mechanism of action of most of these FIC drugs and discuss the therapeutic areas covered, as well as the chemical category to which these drugs belong. The 2023 novel drug list also demonstrates an unabated emphasis on polypeptides (recombinant proteins and antibodies), Advanced Therapy Medicinal Products (gene and cell therapies) and RNA therapeutics, including the first-ever approval of a CRISPR-Cas9-based gene-editing cell therapy.
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Affiliation(s)
- Andreas Papapetropoulos
- Laboratory of Pharmacology, Department of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
- Clinical, Experimental Surgery and Translational Research Center, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Stavros Topouzis
- Laboratory of Molecular Pharmacology Department of Pharmacy, University of Patras, Patras, Greece
| | | | - Miriam Cortese-Krott
- Myocardial Infarction Research Laboratory, Department of Cardiology, Pneumology, Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
- CARID, Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany
| | | | | | - Claudio Mauro
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | | | - Hemal H Patel
- VA San Diego Healthcare System and University of California/San Diego, San Diego, CA, USA
| | | | | | | | | | - Nathalie Vergnolle
- IRSD, Université de Toulouse, INSERM, INRAE, ENVT, UPS, Toulouse, France
| | - Xin Wang
- University of Manchester, Manchester, UK
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
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11
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Gangat N, Tefferi A. New drugs in myelofibrosis: Critical assessment of additional value to monotherapy with JAK inhibitors. Am J Hematol 2024; 99:978-981. [PMID: 38332640 DOI: 10.1002/ajh.27248] [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: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/10/2024]
Abstract
Ruxolitinib in combination with navitoclax or pelabresib in myelofibrosis: activity in JAKi-naïve patients.
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Affiliation(s)
- Naseema Gangat
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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Bozzini C, Busti F, Marchi G, Vianello A, Cerchione C, Martinelli G, Girelli D. Anemia in patients receiving anticancer treatments: focus on novel therapeutic approaches. Front Oncol 2024; 14:1380358. [PMID: 38628673 PMCID: PMC11018927 DOI: 10.3389/fonc.2024.1380358] [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: 02/01/2024] [Accepted: 03/19/2024] [Indexed: 04/19/2024] Open
Abstract
Anemia is common in cancer patients and impacts on quality of life and prognosis. It is typically multifactorial, often involving different pathophysiological mechanisms, making treatment a difficult task. In patients undergoing active anticancer treatments like chemotherapy, decreased red blood cell (RBC) production due to myelosuppression generally predominates, but absolute or functional iron deficiency frequently coexists. Current treatments for chemotherapy-related anemia include blood transfusions, erythropoiesis-stimulating agents, and iron supplementation. Each option has limitations, and there is an urgent need for novel approaches. After decades of relative immobilism, several promising anti-anemic drugs are now entering the clinical scenario. Emerging novel classes of anti-anemic drugs recently introduced or in development for other types of anemia include activin receptor ligand traps, hypoxia-inducible factor-prolyl hydroxylase inhibitors, and hepcidin antagonists. Here, we discuss their possible role in the treatment of anemia observed in patients receiving anticancer therapies.
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Affiliation(s)
- Claudia Bozzini
- Department of Medicine, Section of Internal Medicine, University of Verona, Verona, Italy
- EuroBloodNet Referral Center, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Fabiana Busti
- Department of Medicine, Section of Internal Medicine, University of Verona, Verona, Italy
- EuroBloodNet Referral Center, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Giacomo Marchi
- Department of Medicine, Section of Internal Medicine, University of Verona, Verona, Italy
- EuroBloodNet Referral Center, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Alice Vianello
- Department of Medicine, Section of Internal Medicine, University of Verona, Verona, Italy
- EuroBloodNet Referral Center, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Claudio Cerchione
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Giovanni Martinelli
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Domenico Girelli
- Department of Medicine, Section of Internal Medicine, University of Verona, Verona, Italy
- EuroBloodNet Referral Center, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
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13
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Ho YL, Gorycki P, Ferron‐Brady G, Martin P, Vlasakakis G. Clinical assessment of momelotinib drug-drug interactions via CYP3A metabolism and transporters. Clin Transl Sci 2024; 17:e13799. [PMID: 38634429 PMCID: PMC11024956 DOI: 10.1111/cts.13799] [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: 01/26/2024] [Revised: 03/05/2024] [Accepted: 03/18/2024] [Indexed: 04/19/2024] Open
Abstract
Momelotinib-approved for treatment of myelofibrosis in adults with anemia-and its major active metabolite, M21, were assessed as drug-drug interaction (DDI) victims with a strong cytochrome P450 (CYP) 3A4 inhibitor (multiple-dose ritonavir), an organic anion transporting polypeptide (OATP) 1B1/1B3 inhibitor (single-dose rifampin), and a strong CYP3A4 inducer (multiple-dose rifampin). Momelotinib DDI perpetrator potential (multiple-dose) was evaluated with CYP3A4 and breast cancer resistance protein (BCRP) substrates (midazolam and rosuvastatin, respectively). DDI was assessed from changes in maximum plasma concentration (Cmax), area under the concentration-time curve (AUC), time to reach Cmax, and half-life. The increase in momelotinib (23% Cmax, 14% AUC) or M21 (30% Cmax, 24% AUC) exposure with ritonavir coadministration was not clinically relevant. A moderate increase in momelotinib (40% Cmax, 57% AUC) and minimal change in M21 was observed with single-dose rifampin. A moderate decrease in momelotinib (29% Cmax, 46% AUC) and increase in M21 (31% Cmax, 15% AUC) were observed with multiple-dose rifampin compared with single-dose rifampin. Due to potentially counteracting effects of OATP1B1/1B3 inhibition and CYP3A4 induction, multiple-dose rifampin did not significantly change momelotinib pharmacokinetics compared with momelotinib alone (Cmax no change, 15% AUC decrease). Momelotinib did not alter the pharmacokinetics of midazolam (8% Cmax, 16% AUC decreases) or 1'-hydroxymidazolam (14% Cmax, 16% AUC decreases) but increased rosuvastatin Cmax by 220% and AUC by 170%. Safety findings were mild in this short-term study in healthy volunteers. This analysis suggests that momelotinib interactions with OATP1B1/1B3 inhibitors and BCRP substrates may warrant monitoring for adverse reactions or dose adjustments.
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14
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Klencke BJ, Donahue R, Gorsh B, Ellis C, Kawashima J, Strouse B. Anemia-related response end points in myelofibrosis clinical trials: current trends and need for renewed consensus. Future Oncol 2024; 20:703-715. [PMID: 38318719 DOI: 10.2217/fon-2023-0964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
JAK inhibitors are the current standard of care in myelofibrosis, but many do not address and may worsen anemia; thus, anemia-related responses have traditionally been overlooked as efficacy end points in pivotal clinical trials, leading to a lack of consistency and analytic detail in their reporting. Here we apply our experiences in the phase III trials of momelotinib, a JAK1/JAK2/ACVR1 inhibitor and the first therapy indicated by the US FDA for myelofibrosis patients with anemia, to highlight how application of different criteria impacts the anemia-related benefits reported for any potential treatment in myelofibrosis. We advocate for a convention of a new expert consensus panel to bring consistency and transparency to the definition of anemia-related response in myelofibrosis.
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Affiliation(s)
| | - Rafe Donahue
- Sierra Oncology, a GSK company, San Mateo, CA 94404, USA
| | | | | | - Jun Kawashima
- Sierra Oncology, a GSK company, San Mateo, CA 94404, USA
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15
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Bruzzese A, Martino EA, Labanca C, Mendicino F, Lucia E, Olivito V, Zimbo A, Fragliasso V, Neri A, Morabito F, Vigna E, Gentile M. Momelotinib in myelofibrosis. Expert Opin Pharmacother 2024; 25:521-528. [PMID: 38623844 DOI: 10.1080/14656566.2024.2343780] [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: 03/08/2024] [Accepted: 04/12/2024] [Indexed: 04/17/2024]
Abstract
INTRODUCTION Myelofibrosis (MF) is a hematologic disease characterized by bone marrow fibrosis, cytopenias, splenomegaly, and constitutional symptoms. Recent years have seen the emergence of novel therapeutic agents, notably ruxolitinib and fedratinib, which target the Janus kinases (JAK) pathway. However, their myelosuppressive effect coupled with the persistence, and even worsening anemia remains a significant challenge, leading usually to treatment discontinuation. AREAS COVERED This review focuses on Momelotinib (MMB), a unique JAK inhibitor that has shown promise in MF treatment, particularly in improving anemia. MMB inhibits type 1 kinase activin A receptor or activin receptor-like kinase-2 (ACVR1/ALK2), with consequent rebalancing of the SMAD pathways and reduced transcription of hepcidin. Moreover, it seems that MMB could reduce the serum levels of several inflammatory cytokines responsible for anemia. Clinical trials have demonstrated MMB's efficacy in reducing spleen size, alleviating symptoms, and improving anemia, with a favorable safety profile compared to other JAK inhibitors, both in treatment-naïve and in pre-treated patients. EXPERT OPINION Due to its mechanism of action, MMB represents a valuable therapeutic option in MF, addressing the clinical challenge of anemia and potentially improving outcomes for patients with hematologic malignancies. Ongoing research explores MMB's potential in acute myeloid leukemia and combination therapies.
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Affiliation(s)
| | | | | | | | - Eugenio Lucia
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | | | - Annamaria Zimbo
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- UOC Laboratorio Analisi Cliniche, Biomolecolari e Genetica, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | - Valentina Fragliasso
- Laboratorio di Ricerca Traslazionale Azienda USL-IRCSS Reggio Emilia, Emilia-Romagna, Italy
| | - Antonino Neri
- Scientific Directorate IRCCS of Reggio Emilia, Reggio Emilia, EmiliaRomagna, Italy
| | | | - Ernesto Vigna
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, Rende, Italy
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Tefferi A, Pardanani A, Begna KH, Al-Kali A, Hogan WJ, Litzow MR, Ketterling RP, Reichard KK, Gangat N. Calr type 1/like mutation in myelofibrosis is the most prominent predictor of momelotinib drug survival and longevity without transplant. Blood Cancer J 2024; 14:51. [PMID: 38503764 PMCID: PMC10951334 DOI: 10.1038/s41408-024-01028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 02/20/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024] Open
Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
| | | | | | - Aref Al-Kali
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - Mark R Litzow
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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Labib M, Wang Z, Kim Y, Lin S, Abdrabou A, Yousefi H, Lo PY, Angers S, Sargent EH, Kelley SO. Identification of druggable regulators of cell secretion via a kinome-wide screen and high-throughput immunomagnetic cell sorting. Nat Biomed Eng 2024; 8:263-277. [PMID: 38012306 DOI: 10.1038/s41551-023-01135-w] [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: 03/18/2022] [Accepted: 10/16/2023] [Indexed: 11/29/2023]
Abstract
The identification of genetic regulators of cell secretions is challenging because it requires the sorting of a large number of cells according to their secretion patterns. Here we report the development and applicability of a high-throughput microfluidic method for the analysis of the secretion levels of large populations of immune cells. The method is linked with a kinome-wide loss-of-function CRISPR screen, immunomagnetically sorting the cells according to their secretion levels, and the sequencing of their genomes to identify key genetic modifiers of cell secretion. We used the method, which we validated against flow cytometry for cytokines secreted from primary mouse CD4+ (cluster of differentiation 4-positive) T cells, to discover a subgroup of highly co-expressed kinase-coding genes that regulate interferon-gamma secretion by these cells. We validated the function of the kinases identified using RNA interference, CRISPR knockouts and kinase inhibitors and confirmed the druggability of selected kinases via the administration of a kinase inhibitor in an animal model of colitis. The technique may facilitate the discovery of regulatory mechanisms for immune-cell activation and of therapeutic targets for autoimmune diseases.
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Affiliation(s)
- Mahmoud Labib
- Peninsula Medical School, Faculty of Health, University of Plymouth, Plymouth, UK
- Department of Chemistry, Northwestern University, Evanston, IL, USA
- Department of Pharmaceutical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Zongjie Wang
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, USA
| | - Yunhye Kim
- Department of Pharmaceutical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Sichun Lin
- Department of Pharmaceutical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Abdalla Abdrabou
- Robert H. Laurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Hanie Yousefi
- Department of Chemistry, Northwestern University, Evanston, IL, USA
| | - Pei-Ying Lo
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, USA
| | - Stéphane Angers
- Department of Pharmaceutical Sciences, University of Toronto, Toronto, Ontario, Canada
- Department of Biochemistry, University of Toronto, Toronto, Ontario, Canada
- Donnelly Centre for Cellular and Biomolecular Research, Toronto, Ontario, Canada
| | - Edward H Sargent
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, USA
- Department of Electrical & Computer Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Shana O Kelley
- Department of Chemistry, Northwestern University, Evanston, IL, USA.
- Department of Pharmaceutical Sciences, University of Toronto, Toronto, Ontario, Canada.
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, USA.
- Robert H. Laurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA.
- Department of Biochemistry, University of Toronto, Toronto, Ontario, Canada.
- Donnelly Centre for Cellular and Biomolecular Research, Toronto, Ontario, Canada.
- Institute for Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada.
- Chan Zuckerberg Biohub Chicago, Chicago, IL, USA.
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Roskoski R. Properties of FDA-approved small molecule protein kinase inhibitors: A 2024 update. Pharmacol Res 2024; 200:107059. [PMID: 38216005 DOI: 10.1016/j.phrs.2024.107059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 01/14/2024]
Abstract
Owing to the dysregulation of protein kinase activity in many diseases including cancer, this enzyme family has become one of the most important drug targets in the 21st century. There are 80 FDA-approved therapeutic agents that target about two dozen different protein kinases and seven of these drugs were approved in 2023. Of the approved drugs, thirteen target protein-serine/threonine protein kinases, four are directed against dual specificity protein kinases (MEK1/2), twenty block nonreceptor protein-tyrosine kinases, and 43 inhibit receptor protein-tyrosine kinases. The data indicate that 69 of these drugs are prescribed for the treatment of neoplasms. Six drugs (abrocitinib, baricitinib, deucravacitinib, ritlecitinib, tofacitinib, upadacitinib) are used for the treatment of inflammatory diseases (atopic dermatitis, rheumatoid arthritis, psoriasis, alopecia areata, and ulcerative colitis). Of the 80 approved drugs, nearly two dozen are used in the treatment of multiple diseases. The following seven drugs received FDA approval in 2023: capivasertib (HER2-positive breast cancer), fruquintinib (metastatic colorectal cancer), momelotinib (myelofibrosis), pirtobrutinib (mantle cell lymphoma, chronic lymphocytic leukemia, small lymphocytic lymphoma), quizartinib (Flt3-mutant acute myelogenous leukemia), repotrectinib (ROS1-positive lung cancer), and ritlecitinib (alopecia areata). All of the FDA-approved drugs are orally effective with the exception of netarsudil, temsirolimus, and trilaciclib. This review summarizes the physicochemical properties of all 80 FDA-approved small molecule protein kinase inhibitors including the molecular weight, number of hydrogen bond donors/acceptors, polar surface area, potency, solubility, lipophilic efficiency, and ligand efficiency.
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Affiliation(s)
- Robert Roskoski
- Blue Ridge Institute for Medical Research, 221 Haywood Knolls Drive, Hendersonville, NC 28791, United States.
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Oh ST, Verstovsek S, Gupta V, Platzbecker U, Devos T, Kiladjian J, McLornan DP, Perkins A, Fox ML, McMullin MF, Mead AJ, Egyed M, Mayer J, Sacha T, Kawashima J, Huang M, Strouse B, Mesa R. Changes in bone marrow fibrosis during momelotinib or ruxolitinib therapy do not correlate with efficacy outcomes in patients with myelofibrosis. EJHAEM 2024; 5:105-116. [PMID: 38406514 PMCID: PMC10887367 DOI: 10.1002/jha2.854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 02/27/2024]
Abstract
Bone marrow fibrosis (BMF) is a pathological feature of myelofibrosis, with higher grades associated with poor prognosis. Limited data exist on the association between outcomes and BMF changes. We present BMF data from Janus kinase (JAK) inhibitor-naive patients from SIMPLIFY-1 (NCT01969838), a double-blind, randomized, phase 3 study of momelotinib vs ruxolitinib. Baseline and week 24 bone marrow biopsies were graded from 0 to 3 as per World Health Organization criteria. Other assessments included Total Symptom Score, spleen volume, transfusion independence status, and hemoglobin levels. Paired samples were available from 144 and 160 patients randomized to momelotinib and ruxolitinib. With momelotinib and ruxolitinib, transfusion independence was achieved by 87% and 44% of patients with BMF improvement of ≥1 grade and 76% and 56% of those with stable/worsening BMF; there was no association between BMF changes and transfusion independence for either arm (momelotinib, p = .350; ruxolitinib, p = .096). Regardless of BMF changes, hemoglobin levels also generally increased on momelotinib but decreased on ruxolitinib. In addition, no associations between BMF changes and spleen (momelotinib, p = .126; ruxolitinib, p = .407)/symptom (momelotinib, p = .617; ruxolitinib, p = .833) outcomes were noted, and no improvement in overall survival was observed with ≥1-grade BMF improvement (momelotinib, p = .395; ruxolitinib, p = .407). These data suggest that the anemia benefit of momelotinib is not linked to BMF changes, and question the use of BMF assessment as a surrogate marker for clinical benefit with JAK inhibitors.
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Affiliation(s)
- Stephen T. Oh
- Division of HematologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Srdan Verstovsek
- Department of LeukemiaThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Vikas Gupta
- Department of Medicine, Princess Margaret Cancer CentreUniversity of TorontoTorontoCanada
| | - Uwe Platzbecker
- Clinic of Hematology, Cellular Therapy, and HemostaseologyUniversity of Leipzig Medical CenterLeipzigGermany
| | - Timothy Devos
- Microbiology, and Immunology, Laboratory of Molecular Immunology (Rega Institute)Department of Hematology, University Hospitals Leuven and Department of Microbiology and Immunology, Laboratory of Molecular Immunology (Rega Institute), KU LeuvenLeuvenBelgium
| | - Jean‐Jacques Kiladjian
- Université Paris Cité, AP‐HP, Hôpital Saint‐Louis, Centre d’Investigations CliniquesParisFrance
| | - Donal P. McLornan
- Department of HaematologyGuy's and St Thomas’ NHS Foundation Trust and University College HospitalLondonUK
| | - Andrew Perkins
- Australian Centre for Blood DiseasesMonash UniversityMelbourneAustralia
| | - Maria Laura Fox
- Department of HaematologyVall d'Hebron University HospitalBarcelonaSpain
| | | | - Adam J. Mead
- MRC Molecular Haematology UnitMRC Weatherall Institute of Molecular MedicineNIHR Biomedical Research CentreUniversity of OxfordOxfordUK
| | - Miklos Egyed
- Department of HematologySomogy County Kaposi Mór General HospitalKaposvárHungary
| | - Jiri Mayer
- Department of Internal Medicine, Hematology and OncologyMasaryk University and University Hospital BrnoBrnoCzech Republic
| | - Tomasz Sacha
- Department of HematologyJagiellonian University HospitalKrakówPoland
| | - Jun Kawashima
- Sierra Oncology, a GSK companySan MateoCaliforniaUSA
| | - Mei Huang
- Sierra Oncology, a GSK companySan MateoCaliforniaUSA
| | - Bryan Strouse
- Sierra Oncology, a GSK companySan MateoCaliforniaUSA
| | - Ruben Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer CenterWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
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20
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Tefferi A, Pardanani A, Gangat N. Momelotinib expands the therapeutic armamentarium for myelofibrosis: Impact on hierarchy of treatment choices. Am J Hematol 2024; 99:300-308. [PMID: 38164985 DOI: 10.1002/ajh.27163] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/05/2023] [Indexed: 01/03/2024]
Abstract
The primary objective of treatment in myelofibrosis (MF) is prolongation of life, which is currently accomplished only by allogeneic hematopoietic stem cell transplantation (AHSCT). Determination of optimal timing for AHSCT is facilitated by molecular risk stratification. Non-transplant treatment options in MF are palliative in scope and include Janus kinase 2 (JAK2) inhibitors (JAKi): momelotinib (FDA approved on September 15, 2023), ruxolitinib (November 16, 2011), fedratinib (August 16, 2019), and pacritinib (February 28, 2022); all four JAKi are effective in reducing spleen size and alleviating symptoms, considered a drug class effect and attributed to their canonical JAK-STAT inhibitory mechanism of action. In addition, momelotinib exhibits erythropoietic effect, attributed to alleviation of ineffective erythropoiesis through inhibition of activin A receptor type-I (ACVR1). In transplant-ineligible or deferred patients, the order of treatment preference is based on specific symptoms and individual assessment of risk tolerance. Because of drug-induced immunosuppression and other toxicities attributed to JAKi, we prefer non-JAKi drugs as initial treatment for MF-associated anemia that is not accompanied by treatment-requiring splenomegaly or constitutional symptoms. Otherwise, it is reasonable to consider momelotinib as the first-line JAKi treatment of choice, in order to target the triad of quality-of-life offenders in MF: anemia, splenomegaly, and constitutional symptoms/cachexia. For second-line therapy, we favor ruxolitinib, over fedratinib, based on toxicity profile. Pacritinib and fedratinib provide alternative options in the presence of severe thrombocytopenia or ruxolitinib-resistance/intolerance, respectively. Splenectomy remains a viable option for drug-resistant symptomatic splenomegaly and cytopenia.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Animesh Pardanani
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Naseema Gangat
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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21
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Gupta V. Evidence creation for myelofibrosis: Challenges and opportunities. Br J Haematol 2024; 204:19-21. [PMID: 38083995 DOI: 10.1111/bjh.19257] [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: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 01/11/2024]
Abstract
Evidence-based guidelines for rare diseases, such as myelofibrosis (MF), continue to prove challenging to develop, and decision-making for MF is complex. The British Society for Haematology (BSH) has created a pragmatic symptom-guided risk-adapted framework on all aspects of management of MF and shared best practices on the use of JAK inhibitors, transplantation and other conventional therapies in the management of myelofibrosis. Commentary on: McLornan et al. The management of myelofibrosis: A British Society for Haematology Guideline. Br J Haematol 2024;204:136-150.
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Affiliation(s)
- Vikas Gupta
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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22
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Arslan Davulcu E, Oğuz MB, Kılıç E, Eşkazan AE. Treatment of anemia in myelofibrosis: focusing on novel therapeutic options. Expert Opin Investig Drugs 2024; 33:27-37. [PMID: 38073183 DOI: 10.1080/13543784.2023.2294324] [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: 07/08/2023] [Accepted: 12/09/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Myelofibrosis is a clonal myeloproliferative neoplasm associated with the proliferation of hematopoietic stem cells, increased bone marrow fibrosis, extramedullary hematopoiesis, hepatosplenomegaly, abnormal cytokine production, and constitutional symptoms. These and many other factors contribute to the development of anemia in myelofibrosis patients. AREAS COVERED This review summarizes novel and promising treatments for anemia in myelofibrosis including transforming growth factor-β inhibitors luspatercept and KER-050, JAK inhibitors momelotinib, pacritinib, and jaktinib, BET inhibitors pelabresib and ABBV-744, antifibrotic PRM-151, BCL2/BCL-XL inhibitor navitoclax, and telomerase inhibitor imetelstat. EXPERT OPINION Standard approaches to treat myelofibrosis-related anemia have limited efficacy and are associated with toxicity. New drugs have shown positive results in myelofibrosis-associated anemia when used alone or in combination.
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Affiliation(s)
- Eren Arslan Davulcu
- Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Hematology Clinic, University of Health Sciences, Istanbul, Turkey
| | - Merve Beyza Oğuz
- Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Emre Kılıç
- Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Ahmet Emre Eşkazan
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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23
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Duminuco A, Chifotides HT, Giallongo S, Giallongo C, Tibullo D, Palumbo GA. ACVR1: A Novel Therapeutic Target to Treat Anemia in Myelofibrosis. Cancers (Basel) 2023; 16:154. [PMID: 38201581 PMCID: PMC10778144 DOI: 10.3390/cancers16010154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024] Open
Abstract
Activin receptor type I (ACVR1) is a transmembrane kinase receptor belonging to bone morphogenic protein receptors (BMPs). ACVR1 plays an important role in hematopoiesis and anemia via the BMP6/ACVR1/SMAD pathway, which regulates expression of hepcidin, the master regulator of iron homeostasis. Elevated hepcidin levels are inversely associated with plasma iron levels, and chronic hepcidin expression leads to iron-restricted anemia. Anemia is one of the hallmarks of myelofibrosis (MF), a bone marrow (BM) malignancy characterized by BM scarring resulting in impaired hematopoiesis, splenomegaly, and systemic symptoms. Anemia and red blood cell transfusions negatively impact MF prognosis. Among the approved JAK inhibitors (ruxolitinib, fedratinib, momelotinib, and pacritinib) for MF, momelotinib and pacritinib are preferably used in cytopenic patients; both agents are potent ACVR1 inhibitors that suppress hepcidin expression via the BMP6/ACVR1/SMAD pathway and restore iron homeostasis/erythropoiesis. In September 2023, momelotinib was approved as a treatment for patients with MF and anemia. Zilurgisertib (ACVR1 inhibitor) and DISC-0974 (anti-hemojuvelin monoclonal antibody) are evaluated in early phase clinical trials in patients with MF and anemia. Luspatercept (ACVR2B ligand trap) is assessed in transfusion-dependent MF patients in a registrational phase 3 trial. Approved ACVR1 inhibitors and novel agents in development are poised to improve the outcomes of anemic MF patients.
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Affiliation(s)
- Andrea Duminuco
- Hematology Unit with BMT, A.O.U. Policlinico “G.Rodolico-San Marco”, 95123 Catania, Italy;
| | - Helen T. Chifotides
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1400 Holcombe Blvd., Houston, TX 77030, USA;
| | - Sebastiano Giallongo
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy; (S.G.); (C.G.)
| | - Cesarina Giallongo
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy; (S.G.); (C.G.)
| | - Daniele Tibullo
- Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy;
| | - Giuseppe A. Palumbo
- Hematology Unit with BMT, A.O.U. Policlinico “G.Rodolico-San Marco”, 95123 Catania, Italy;
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy; (S.G.); (C.G.)
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24
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Abstract
Momelotinib (OJJAARA) is an oral Janus kinase 1 and 2 (JAK1/JAK2) and activin A receptor, type I (ACVR1) inhibitor that has been developed for the treatment of myelofibrosis (MF). In September 2023, momelotinib was approved in the USA for the treatment of intermediate or high-risk MF, including primary MF or secondary MF [post-polycythemia vera (PV) and post-essential thrombocythemia (ET)], in adults with anemia. This article summarizes the milestones in the development of momelotinib leading to this first approval for MF.
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Affiliation(s)
- Susan J Keam
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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25
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Gill H, Leung GMK, Ooi MGM, Teo WZY, Wong CL, Choi CW, Wong GC, Lao Z, Rojnuckarin P, Castillo MRID, Xiao Z, Hou HA, Kuo MC, Shih LY, Gan GG, Lin CC, Chng WJ, Kwong YL. Management of classical Philadelphia chromosome-negative myeloproliferative neoplasms in Asia: consensus of the Asian Myeloid Working Group. Clin Exp Med 2023; 23:4199-4217. [PMID: 37747591 DOI: 10.1007/s10238-023-01189-9] [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: 03/18/2023] [Accepted: 09/04/2023] [Indexed: 09/26/2023]
Abstract
Myeloproliferative neoplasms (MPN) are a heterogeneous group of clonal hematopoietic stem cell disorders characterized clinically by the proliferation of one or more hematopoietic lineage(s). The classical Philadelphia-chromosome (Ph)-negative MPNs include polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF). The Asian Myeloid Working Group (AMWG) comprises representatives from fifteen Asian centers experienced in the management of MPN. This consensus from the AMWG aims to review the current evidence in the risk stratification and treatment of Ph-negative MPN, to identify management gaps for future improvement, and to offer pragmatic approaches for treatment commensurate with different levels of resources, drug availabilities and reimbursement policies in its constituent regions. The management of MPN should be patient-specific and based on accurate diagnostic and prognostic tools. In patients with PV, ET and early/prefibrotic PMF, symptoms and risk stratification will guide the need for early cytoreduction. In younger patients requiring cytoreduction and in those experiencing resistance or intolerance to hydroxyurea, recombinant interferon-α preparations (pegylated interferon-α 2A or ropeginterferon-α 2b) should be considered. In myelofibrosis, continuous risk assessment and symptom burden assessment are essential in guiding treatment selection. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) in MF should always be based on accurate risk stratification for disease-risk and post-HSCT outcome. Management of classical Ph-negative MPN entails accurate diagnosis, cytogenetic and molecular evaluation, risk stratification, and treatment strategies that are outcome-oriented (curative, disease modification, improvement of quality-of-life).
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Affiliation(s)
- Harinder Gill
- Department of Medicine, LKS Faculty of Medicine, School of Clinical Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, China.
- Department of Medicine, Professorial Block, Queen Mary Hospital, Pokfulam Road, Pok Fu Lam, Hong Kong, China.
| | - Garret M K Leung
- Department of Medicine, LKS Faculty of Medicine, School of Clinical Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, China
| | - Melissa G M Ooi
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University, Singapore, Singapore
| | - Winnie Z Y Teo
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Fast and Chronic Program, Alexandra Hospital, Singapore, Singapore
| | - Chieh-Lee Wong
- Department of Medicine, Sunway Medical Centre, Shah Alam, Selangor, Malaysia
| | - Chul Won Choi
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Gee-Chuan Wong
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Zhentang Lao
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Ponlapat Rojnuckarin
- King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | | | - Zhijian Xiao
- Blood Disease Hospital and Institute of Hematology, Chinese Academy of Medical Sciences Peking Union Medical College, Tianjin, China
| | - Hsin-An Hou
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Chung Kuo
- Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Lee-Yung Shih
- Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Gin-Gin Gan
- University of Malaya, Kuala Lumpur, Malaysia
| | - Chien-Chin Lin
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wee-Joo Chng
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University, Singapore, Singapore
| | - Yok-Lam Kwong
- Department of Medicine, LKS Faculty of Medicine, School of Clinical Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, China
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26
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Riege D, Herschel S, Fenkl T, Schade D. Small-Molecule Probes as Pharmacological Tools for the Bone Morphogenetic Protein Signaling Pathway. ACS Pharmacol Transl Sci 2023; 6:1574-1599. [PMID: 37974621 PMCID: PMC10644459 DOI: 10.1021/acsptsci.3c00170] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/21/2023] [Accepted: 09/28/2023] [Indexed: 11/19/2023]
Abstract
The bone morphogenetic protein (BMP) pathway is highly conserved and plays central roles in health and disease. The quality and quantity of its signaling outputs are regulated at multiple levels, offering pharmacological options for targeted modulation. Both target-centric and phenotypic drug discovery (PDD) approaches were applied to identify small-molecule BMP inhibitors and stimulators. In this Review, we accumulated and systematically classified the different reported chemotypes based on their targets as well as modes-of-action, and herein we illustrate the discovery history of selected candidates. A comprehensive summary of available biochemical, cellular, and in vivo activities is provided for the most relevant BMP modulators, along with recommendations on their preferred use as chemical probes to study BMP-related (patho)physiological processes. There are a number of high-quality probes used as BMP inhibitors that potently and selectively interrogate the kinase activities of distinct type I (16 chemotypes available) and type II receptors (3 chemotypes available). In contrast, only a few high-quality BMP stimulator modalities have been introduced to the field due to a lack of profound target knowledge. FK506-derived macrolides such as calcineurin-sparing FKBP12 inhibitors currently represent the best-characterized chemical tools for direct activation of BMP-SMAD signaling at the receptor level. However, several PDD campaigns succeeded in expanding the druggable space of BMP stimulators. Albeit the majority of them do not entirely fulfill the strict chemical probe criteria, many chemotypes exhibit unique and unrecognized mechanisms as pathway potentiators or synergizers, serving as valuable pharmacological tools for BMP perturbation.
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Affiliation(s)
- Daniel Riege
- Department
of Pharmaceutical & Medicinal Chemistry, Christian-Albrechts-University of Kiel, Gutenbergstrasse 76, 24118 Kiel, Germany
| | - Sven Herschel
- Department
of Pharmaceutical & Medicinal Chemistry, Christian-Albrechts-University of Kiel, Gutenbergstrasse 76, 24118 Kiel, Germany
| | - Teresa Fenkl
- Department
of Pharmaceutical & Medicinal Chemistry, Christian-Albrechts-University of Kiel, Gutenbergstrasse 76, 24118 Kiel, Germany
| | - Dennis Schade
- Department
of Pharmaceutical & Medicinal Chemistry, Christian-Albrechts-University of Kiel, Gutenbergstrasse 76, 24118 Kiel, Germany
- Partner
Site Kiel, DZHK, German Center for Cardiovascular
Research, 24105 Kiel, Germany
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27
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Passeron T, King B, Seneschal J, Steinhoff M, Jabbari A, Ohyama M, Tobin DJ, Randhawa S, Winkler A, Telliez JB, Martin D, Lejeune A. Inhibition of T-cell activity in alopecia areata: recent developments and new directions. Front Immunol 2023; 14:1243556. [PMID: 38022501 PMCID: PMC10657858 DOI: 10.3389/fimmu.2023.1243556] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/05/2023] [Indexed: 12/01/2023] Open
Abstract
Alopecia areata (AA) is an autoimmune disease that has a complex underlying immunopathogenesis characterized by nonscarring hair loss ranging from small bald patches to complete loss of scalp, face, and/or body hair. Although the etiopathogenesis of AA has not yet been fully characterized, immune privilege collapse at the hair follicle (HF) followed by T-cell receptor recognition of exposed HF autoantigens by autoreactive cytotoxic CD8+ T cells is now understood to play a central role. Few treatment options are available, with the Janus kinase (JAK) 1/2 inhibitor baricitinib (2022) and the selective JAK3/tyrosine kinase expressed in hepatocellular carcinoma (TEC) inhibitor ritlecitinib (2023) being the only US Food and Drug Administration-approved systemic medications thus far for severe AA. Several other treatments are used off-label with limited efficacy and/or suboptimal safety and tolerability. With an increased understanding of the T-cell-mediated autoimmune and inflammatory pathogenesis of AA, additional therapeutic pathways beyond JAK inhibition are currently under investigation for the development of AA therapies. This narrative review presents a detailed overview about the role of T cells and T-cell-signaling pathways in the pathogenesis of AA, with a focus on those pathways targeted by drugs in clinical development for the treatment of AA. A detailed summary of new drugs targeting these pathways with expert commentary on future directions for AA drug development and the importance of targeting multiple T-cell-signaling pathways is also provided in this review.
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Affiliation(s)
- Thierry Passeron
- University Côte d’Azur, Centre Hospitalier Universitaire Nice, Department of Dermatology, Nice, France
- University Côte d’Azur, INSERM, U1065, C3M, Nice, France
| | - Brett King
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, United States
| | - Julien Seneschal
- Department of Dermatology and Paediatric Dermatology, National Reference Centre for Rare Skin Diseases, Saint-André Hospital, University of Bordeaux, Bordeaux, France
- Bordeaux University, Centre national de la recherche scientifique (CNRS), ImmunoConcept, UMR5164, Bordeaux, France
| | - Martin Steinhoff
- Department of Dermatology and Venereology, Hamad Medical Corporation, Doha, Qatar
- Translational Research Institute, Academic Health System, Hamad Medical Corporation, Doha, Qatar
- Dermatology Institute, Academic Health System, Hamad Medical Corporation, Doha, Qatar
- Department of Dermatology and Venereology, Weill Cornell Medicine-Qatar, Doha, Qatar
- College of Medicine, Qatar University, Doha, Qatar
- Department of Dermatology, Weill Cornell Medicine, New York, NY, United States
- College of Health and Life Sciences, Hamad Bin Khalifa University-Qatar, Doha, Qatar
| | - Ali Jabbari
- Department of Dermatology, University of Iowa, Iowa City, IA, United States
- Iowa City VA Medical Center, Iowa City, IA, United States
| | - Manabu Ohyama
- Department of Dermatology, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Desmond J. Tobin
- Charles Institute of Dermatology, UCD School of Medicine, University College Dublin, Dublin, Ireland
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28
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Tefferi A, Pardanani A, Gangat N. Momelotinib (JAK1/JAK2/ACVR1 inhibitor): mechanism of action, clinical trial reports, and therapeutic prospects beyond myelofibrosis. Haematologica 2023; 108:2919-2932. [PMID: 36861402 PMCID: PMC10620561 DOI: 10.3324/haematol.2022.282612] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/20/2023] [Indexed: 03/03/2023] Open
Abstract
Janus kinase (JAK) 2 inhibitors are now part of the therapeutic armamentarium for primary and secondary myelofibrosis (MF). Patients with MF endure shortened survival and poor quality of life. Allogeneic stem cell transplantation (ASCT) is currently the only treatment modality in MF with the potential to cure the disease or prolong survival. By contrast, current drug therapy in MF targets quality of life and does not modify the natural history of the disease. The discovery of JAK2 and other JAK-STAT activating mutations (i.e., CALR and MPL) in myeloproliferative neoplasms, including MF, has facilitated the development of several JAK inhibitors that are not necessarily specific to the oncogenic mutations themselves but have proven effective in countering JAK-STAT signaling, resulting in suppression of inflammatory cytokines and myeloproliferation. This non-specific activity resulted in clinically favorable effects on constitutional symptoms and splenomegaly and, consequently, approval by the Food and Drug Administration (FDA) of three small molecule JAK inhibitors: ruxolitinib, fedratinib, and pacritinib. A fourth JAK inhibitor, momelotinib, is poised for FDA approval soon and has been shown to provide additional benefit in alleviating transfusion-dependent anemia in MF. The salutary effect of momelotinib on anemia has been attributed to inhibition of activin A receptor, type 1 (ACVR1) and recent information suggests a similar effect from pacritinib. ACRV1 mediates SMAD2/3 signaling which contributes to upregulation of hepcidin production and iron-restricted erythropoiesis. Targeting ACRV1 raises therapeutic prospects in other myeloid neoplasms associated with ineffective erythropoiesis, such as myelodysplastic syndromes with ring sideroblasts or SF3B1 mutation, especially those with co-expression of a JAK2 mutation and thrombocytosis.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - Animesh Pardanani
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Naseema Gangat
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
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29
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Kiladjian JJ, Vannucchi AM, Gerds AT, Gupta V, Verstovsek S, Egyed M, Platzbecker U, Mayer J, Grosicki S, Illés Á, Woźny T, Oh ST, McLornan D, Kirgner I, Yoon SS, Harrison CN, Klencke B, Huang M, Kawashima J, Mesa R. Momelotinib in Myelofibrosis Patients With Thrombocytopenia: Post Hoc Analysis From Three Randomized Phase 3 Trials. Hemasphere 2023; 7:e963. [PMID: 37908862 PMCID: PMC10615557 DOI: 10.1097/hs9.0000000000000963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/25/2023] [Indexed: 11/02/2023] Open
Abstract
The oral activin A receptor type I, Janus kinase 1 (JAK1), and JAK2 inhibitor momelotinib demonstrated symptom, spleen, and anemia benefits in intermediate- and high-risk myelofibrosis (MF). Post hoc analyses herein evaluated the efficacy and safety of momelotinib in patients with MF and thrombocytopenia (platelet counts <100 × 109/L) from randomized phase 3 studies: MOMENTUM (momelotinib versus danazol; JAK inhibitor experienced); SIMPLIFY-1 (momelotinib versus ruxolitinib; JAK inhibitor naïve); and SIMPLIFY-2 (momelotinib versus best available therapy; JAK inhibitor experienced); these studies were not statistically powered to assess differences in thrombocytopenic subgroups, and these analyses are descriptive. The treatment effect of momelotinib versus ruxolitinib on week 24 response rates (spleen volume reduction ≥35%/Total Symptom Score reduction ≥50%/transfusion independence) was numerically comparable or better in thrombocytopenic patients versus the overall JAK inhibitor naive population; rates were preserved with momelotinib in thrombocytopenic patients but attenuated with ruxolitinib (momelotinib: 27%/28%/67% overall versus 39%/35%/61% in thrombocytopenic group; ruxolitinib: 29%/42%/49% overall versus 0%/22%/39% in thrombocytopenic group, respectively). In contrast to ruxolitinib, momelotinib maintained high dose intensity throughout the treatment. In the JAK inhibitor experienced population, thrombocytopenic patients had the following: (1) numerically higher symptom and transfusion independence response rates with momelotinib than in control arms; and (2) preserved spleen, symptom, and transfusion independence response rates with momelotinib relative to the overall study populations. The safety profile of momelotinib in thrombocytopenic patients was also consistent with the overall study population. In summary, momelotinib represents a safe and effective treatment option for patients with MF and moderate-to-severe thrombocytopenia.
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Affiliation(s)
- Jean-Jacques Kiladjian
- Université de Paris, AP-HP, Hôpital Saint-Louis, Centre d’Investigations Cliniques, INSERM, Paris, France
| | - Alessandro M. Vannucchi
- Department of Experimental and Clinical Medicine, Center of Research and Innovation of Myeloproliferative Neoplasms (CRIMM), University of Florence, Careggi University Hospital, Florence, Italy
| | - Aaron T. Gerds
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Vikas Gupta
- Princess Margaret Cancer Center, University of Toronto, ON, Canada
| | - Srdan Verstovsek
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Uwe Platzbecker
- Clinic of Hematology, Cellular Therapy, and Hemostaseology, University of Leipzig, Germany
| | - Jiří Mayer
- Department of Internal Medicine, Haematology and Oncology, University Hospital Brno, Czech Republic
- University Hospital Brno and Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention, Faculty of Health Sciences in Bytom, Silesian Medical University, Katowice, Poland
| | - Árpád Illés
- Department of Hematology, Faculty of Medicine, University of Debrecen, Hungary
| | - Tomasz Woźny
- Department of Hematology, Szpital MSWiA w Poznaniu, Poznan, Poland
| | - Stephen T. Oh
- Department of Medicine and Department of Pathology and Immunology, Division of Hematology, Washington University School of Medicine, St. Louis, MO, USA
| | - Donal McLornan
- Guy’s and St Thomas’ NHS Foundation Trust and University College London Hospitals, London, United Kingdom
| | - Ilya Kirgner
- The Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
- Hematology Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Center for Medical Innovation, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | | | | | - Mei Huang
- Sierra Oncology, a GSK company, San Mateo, CA, USA
| | | | - Ruben Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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30
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Mesa RA, Harrison C, Palmer JM, Gupta V, McLornan DP, McMullin MF, Kiladjian JJ, Foltz L, Platzbecker U, Fox ML, Mead AJ, Ross DM, Oh ST, Perkins AC, Leahy MF, Kawashima J, Ro S, Donahue R, Gorsh B, Deheshi S, Verstovsek S. Patient-reported Outcomes and Quality of Life in Anemic and Symptomatic Patients With Myelofibrosis: Results From the MOMENTUM Study. Hemasphere 2023; 7:e966. [PMID: 37901848 PMCID: PMC10599984 DOI: 10.1097/hs9.0000000000000966] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/04/2023] [Indexed: 10/31/2023] Open
Abstract
Myelofibrosis (MF) is a chronic myeloproliferative neoplasm that typically manifests with debilitating symptoms that progressively worsen, negatively impacting patients' quality of life. Fatigue is a multifactorial and burdensome MF-related symptom due to its severity, persistence, and prevalence, with anemia a contributing factor and major unmet need. Clinical trials of the Janus kinase (JAK)1/JAK2/activin A receptor type 1 inhibitor momelotinib have shown consistent anemia benefits, in addition to improvements in MF-related symptoms. The phase 3 MOMENTUM trial in symptomatic and anemic patients met its primary end point, with a greater proportion having a Myelofibrosis Symptom Assessment Form (MFSAF) Total Symptom Score (TSS) reduction ≥50% at week 24 with momelotinib versus danazol. To support the positive primary end point result, we conducted longitudinal, responder, and time-to-event analyses of patient-reported outcomes from MOMENTUM, as measured by the MFSAF, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), and Patient-Reported Outcomes Measurement Information System (PROMIS) assessments. These analyses demonstrated rapid and durable response benefits with momelotinib, with achievement of first TSS response by day 29 and continued improvement over time. Improvements favored momelotinib versus danazol for each MFSAF individual item, and greater improvements were observed for disease- and cancer-related fatigue and physical functioning at week 24, with significant results for multiple items/domains across the 3 assessments. These findings are consistent in demonstrating that momelotinib provides substantial symptom benefit.
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Affiliation(s)
- Ruben A Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
- Atrium Health, Charlotte, NC, USA
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Claire Harrison
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Vikas Gupta
- Princess Margaret Cancer Centre, University of Toronto, ON, Canada
| | - Donal P McLornan
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- University College Hospital, London, United Kingdom
| | | | - Jean-Jacques Kiladjian
- Université de Paris, AP-HP, Hôpital Saint-Louis, Centre d'Investigations Cliniques, Paris, France
| | - Lynda Foltz
- University of British Columbia, Vancouver, BC, Canada
| | | | - Maria Laura Fox
- Servei d'Hematologia, Vall d'Hebron Hospital Universitari, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Adam J Mead
- Oxford University Hospitals NHS Foundation Trust, United Kingdom
| | - David M Ross
- Flinders Medical Centre and SA Pathology, Adelaide, SA, Australia
| | - Stephen T Oh
- Washington University School of Medicine, St Louis, MO, USA
| | - Andrew Charles Perkins
- The Alfred Hospital and Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Michael F Leahy
- Royal Perth Hospital, PathWest Laboratory Medicine; University of Western Australia, Perth, WA, Australia
| | - Jun Kawashima
- Sierra Oncology, Inc., a GSK company, San Mateo, CA, USA
| | - Sunhee Ro
- Sierra Oncology, Inc., a GSK company, San Mateo, CA, USA
| | - Rafe Donahue
- Sierra Oncology, Inc., a GSK company, San Mateo, CA, USA
| | | | | | - Srdan Verstovsek
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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31
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Oh ST, Mesa RA, Harrison CN, Bose P, Gerds AT, Gupta V, Scott BL, Kiladjian JJ, Lucchesi A, Kong T, Buckley SA, Tyavanagimatt S, Harder BG, Roman-Torres K, Smith J, Craig AR, Mascarenhas J, Verstovsek S. Pacritinib is a potent ACVR1 inhibitor with significant anemia benefit in patients with myelofibrosis. Blood Adv 2023; 7:5835-5842. [PMID: 37552106 PMCID: PMC10561048 DOI: 10.1182/bloodadvances.2023010151] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/28/2023] [Accepted: 07/29/2023] [Indexed: 08/09/2023] Open
Abstract
In patients with cytopenic myelofibrosis, treatment with the JAK2/IRAK1 inhibitor pacritinib was associated with anemia benefit in the phase 3 PERSIST-2 study. The impact of pacritinib on transfusion independence (TI) has not been previously described, nor has the mechanism by which pacritinib improves anemia been elucidated. Because it has been previously postulated that inhibition of activin A receptor, type 1 (ACVR1)/activin receptor-like kinase-2 improves anemia in patients with myelofibrosis via suppression of hepcidin production, we assessed the relative inhibitory potency of pacritinib compared with other JAK2 inhibitors against ACVR1. Pacritinib inhibited ACVR1 with greater potency (half-maximal inhibitory concentration [IC50] = 16.7 nM; Cmax:IC50 = 12.7) than momelotinib (IC50 = 52.5 nM; Cmax:IC50 = 3.2), fedratinib (IC50 = 273 nM; Cmax:IC50 = 1.0), or ruxolitinib (IC50 > 1000; Cmax:IC50 < 0.01). Pacritinib's inhibitory activity against ACVR1 was corroborated via inhibition of downstream SMAD signaling in conjunction with marked suppression of hepcidin production. Among patients on PERSIST-2 who were not transfusion independent at baseline based on Gale criteria, a significantly greater proportion achieved TI on pacritinib compared with those treated on best available therapy (37% vs 7%, P = .001), and significantly more had a ≥50% reduction in transfusion burden (49% vs 9%, P < .0001). These data indicate that the anemia benefit of the JAK2/IRAK1 inhibitor pacritinib may be a function of potent ACVR1 inhibition.
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Affiliation(s)
- Stephen T. Oh
- Washington University School of Medicine, St. Louis, MO
| | - Ruben A. Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | | | - Prithviraj Bose
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Aaron T. Gerds
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Vikas Gupta
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | | | - Alessandro Lucchesi
- Hematology Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori “Dino Amadori,” Meldola, Italy
| | - Tim Kong
- Washington University School of Medicine, St. Louis, MO
| | | | | | | | | | | | | | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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32
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Tefferi A. Jaktinib and momelotinib for the treatment of myelofibrosis-Birds of a feather? Am J Hematol 2023; 98:1517-1519. [PMID: 37471656 DOI: 10.1002/ajh.27036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/09/2023] [Indexed: 07/22/2023]
Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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33
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Vainchenker W, Yahmi N, Havelange V, Marty C, Plo I, Constantinescu SN. Recent advances in therapies for primary myelofibrosis. Fac Rev 2023; 12:23. [PMID: 37771602 PMCID: PMC10523375 DOI: 10.12703/r/12-23] [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] [Indexed: 09/30/2023] Open
Abstract
Primary myelofibrosis (PMF), polycythemia vera (PV) and essential thrombocythemia (ET) form the classical BCR-ABL1-negative myeloproliferative neoplasms (MPNs) that are driven by a constitutive activation of JAK2 signaling. PMF as well as secondary MF (post-ET and post-PV MF) are the most aggressive MPNs. Presently, there is no curative treatment, except allogenic hematopoietic stem cell transplantation. JAK inhibitors, essentially ruxolitinib, are the therapy of reference for intermediate and high-risk MF. However, presently the current JAK inhibitors behave mainly as anti-inflammatory drugs, improving general symptoms and spleen size without major impact on disease progression. A better understanding of the genetics of MF, the biology of its leukemic stem cells (LSCs), the mechanisms of fibrosis and of cytopenia and the role of inflammatory cytokines has led to new approaches with the development of numerous therapeutic agents that target epigenetic regulation, telomerase, apoptosis, cell cycle, cytokines and signaling. Furthermore, the use of a new less toxic form of interferon-α has been revived, as it is presently one of the only molecules that targets the mutated clone. These new approaches have different aims: (a) to provide alternative therapy to JAK inhibition; (b) to correct cytopenia; and (c) to inhibit fibrosis development. However, the main important goal is to find new disease modifier treatments, which will profoundly modify the progression of the disease without major toxicity. Presently the most promising approaches consist of the inhibition of telomerase and the combination of JAK2 inhibitors (ruxolitinib) with either a BCL2/BCL-xL or BET inhibitor. Yet, the most straightforward future approaches can be considered to be the development of and/or selective inhibition of JAK2V617F and the targeting MPL and calreticulin mutants by immunotherapy. It can be expected that the therapy of MF will be significantly improved in the coming years.
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Affiliation(s)
- William Vainchenker
- INSERM, UMR1287, Gustave Roussy, Villejuif, France
- Université Paris-Saclay, UMR1287, Gustave Roussy, Villejuif, France
- Gustave Roussy, UMR1287, Villejuif, France
| | - Nasrine Yahmi
- INSERM, UMR1287, Gustave Roussy, Villejuif, France
- Université Paris-Saclay, UMR1287, Gustave Roussy, Villejuif, France
- Gustave Roussy, UMR1287, Villejuif, France
| | - Violaine Havelange
- de Duve Institute, Université catholique de Louvain, Brussels, Belgium
- Cliniques universitaires Saint Luc, Department of Hematology, Université Catholique de Louvain, Brussels, Belgium
| | - Caroline Marty
- INSERM, UMR1287, Gustave Roussy, Villejuif, France
- Université Paris-Saclay, UMR1287, Gustave Roussy, Villejuif, France
- Gustave Roussy, UMR1287, Villejuif, France
| | - Isabelle Plo
- INSERM, UMR1287, Gustave Roussy, Villejuif, France
- Université Paris-Saclay, UMR1287, Gustave Roussy, Villejuif, France
- Gustave Roussy, UMR1287, Villejuif, France
| | - Stefan N Constantinescu
- de Duve Institute, Université catholique de Louvain, Brussels, Belgium
- Ludwig Institute for Cancer Research, Brussels, Belgium
- WEL Research Institute, WELBIO Department, Wavre, Belgium
- Ludwig Institute for Cancer Research, Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
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Hung CN, Chen M, DeArmond DT, Chiu CHL, Limboy CA, Tan X, Kusi M, Chou CW, Lin LL, Zhang Z, Wang CM, Chen CL, Mitsuya K, Osmulski PA, Gaczynska ME, Kirma NB, Vadlamudi RK, Gibbons DL, Warner S, Brenner AJ, Mahadevan D, Michalek JE, Huang THM, Taverna JA. AXL-initiated paracrine activation of pSTAT3 enhances mesenchymal and vasculogenic supportive features of tumor-associated macrophages. Cell Rep 2023; 42:113067. [PMID: 37659081 PMCID: PMC10577802 DOI: 10.1016/j.celrep.2023.113067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 07/14/2023] [Accepted: 08/18/2023] [Indexed: 09/04/2023] Open
Abstract
Tumor-associated macrophages (TAMs) are integral to the development of complex tumor microenvironments (TMEs) and can execute disparate cellular programs in response to extracellular cues. However, upstream signaling processes underpinning this phenotypic plasticity remain to be elucidated. Here, we report that concordant AXL-STAT3 signaling in TAMs is triggered by lung cancer cells or cancer-associated fibroblasts in the cytokine milieu. This paracrine action drives TAM differentiation toward a tumor-promoting "M2-like" phenotype with upregulation of CD163 and putative mesenchymal markers, contributing to TAM heterogeneity and diverse cellular functions. One of the upregulated markers, CD44, mediated by AXL-IL-11-pSTAT3 signaling cascade, enhances macrophage ability to interact with endothelial cells and facilitate formation of primitive vascular networks. We also found that AXL-STAT3 inhibition can impede the recruitment of TAMs in a xenograft mouse model, thereby suppressing tumor growth. These findings suggest the potential application of AXL-STAT3-related markers to quantitatively assess metastatic potential and inform therapeutic strategies in lung cancer.
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Affiliation(s)
- Chia-Nung Hung
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Meizhen Chen
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Daniel T DeArmond
- Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Cheryl H-L Chiu
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Catherine A Limboy
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Xi Tan
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Meena Kusi
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Chih-Wei Chou
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Li-Ling Lin
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Zhao Zhang
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Chiou-Miin Wang
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Chun-Liang Chen
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA; Office of Nursing Research & Scholarship, School of Nursing, University of Texas Health Science Center, San Antonio, TX, USA
| | - Kohzoh Mitsuya
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Pawel A Osmulski
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Maria E Gaczynska
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Nameer B Kirma
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Ratna K Vadlamudi
- Mays Cancer Center, University of Texas Health Science Center, San Antonio, TX, USA; Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX, USA
| | - Don L Gibbons
- Department of Thoracic, Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Andrew J Brenner
- Mays Cancer Center, University of Texas Health Science Center, San Antonio, TX, USA; Division of Hematology and Oncology, Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Daruka Mahadevan
- Mays Cancer Center, University of Texas Health Science Center, San Antonio, TX, USA; Division of Hematology and Oncology, Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Joel E Michalek
- Department of Population Health Sciences, University of Texas Health Science Center, San Antonio, TX, USA
| | - Tim H-M Huang
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA; Mays Cancer Center, University of Texas Health Science Center, San Antonio, TX, USA.
| | - Josephine A Taverna
- Department of Molecular Medicine, University of Texas Health Science Center, San Antonio, TX, USA; Mays Cancer Center, University of Texas Health Science Center, San Antonio, TX, USA; Division of Hematology and Oncology, Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA.
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Nair PC, Piehler J, Tvorogov D, Ross DM, Lopez AF, Gotlib J, Thomas D. Next-Generation JAK2 Inhibitors for the Treatment of Myeloproliferative Neoplasms: Lessons from Structure-Based Drug Discovery Approaches. Blood Cancer Discov 2023; 4:352-364. [PMID: 37498362 PMCID: PMC10472187 DOI: 10.1158/2643-3230.bcd-22-0189] [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: 12/04/2022] [Revised: 04/20/2023] [Accepted: 06/07/2023] [Indexed: 07/28/2023] Open
Abstract
Selective inhibitors of Janus kinase (JAK) 2 have been in demand since the discovery of the JAK2 V617F mutation present in patients with myeloproliferative neoplasms (MPN); however, the structural basis of V617F oncogenicity has only recently been elucidated. New structural studies reveal a role for other JAK2 domains, beyond the kinase domain, that contribute to pathogenic signaling. Here we evaluate the structure-based approaches that led to recently-approved type I JAK2 inhibitors (fedratinib and pacritinib), as well as type II (BBT594 and CHZ868) and pseudokinase inhibitors under development (JNJ7706621). With full-length JAK homodimeric structures now available, superior selective and mutation-specific JAK2 inhibitors are foreseeable. SIGNIFICANCE The JAK inhibitors currently used for the treatment of MPNs are effective for symptom management but not for disease eradication, primarily because they are not strongly selective for the mutant clone. The rise of computational and structure-based drug discovery approaches together with the knowledge of full-length JAK dimer complexes provides a unique opportunity to develop better targeted therapies for a range of conditions driven by pathologic JAK2 signaling.
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Affiliation(s)
- Pramod C. Nair
- Cancer Program, South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide, Adelaide, Australia
- Discipline of Medicine, Adelaide Medical School, The University of Adelaide, Adelaide, Australia
- Discipline of Clinical Pharmacology, Flinders Health and Medical Research Institute (FHMRI) Cancer Program, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Jacob Piehler
- Department of Biology and Center of Cellular Nanoanalytics, University of Osnabrück, Osnabrück, Germany
| | - Denis Tvorogov
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, Australia
| | - David M. Ross
- Cancer Program, South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide, Adelaide, Australia
- Discipline of Medicine, Adelaide Medical School, The University of Adelaide, Adelaide, Australia
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, Australia
- Department of Hematology and Bone Marrow Transplantation, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Angel F. Lopez
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, Australia
| | - Jason Gotlib
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Daniel Thomas
- Cancer Program, South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide, Adelaide, Australia
- Discipline of Medicine, Adelaide Medical School, The University of Adelaide, Adelaide, Australia
- Department of Hematology and Bone Marrow Transplantation, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Kirito K. Recent progress of JAK inhibitors for hematological disorders. Immunol Med 2023; 46:131-142. [PMID: 36305377 DOI: 10.1080/25785826.2022.2139317] [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: 07/23/2022] [Accepted: 10/19/2022] [Indexed: 10/31/2022] Open
Abstract
JAK inhibitors are important therapeutic options for hematological disorders, especially myeloproliferative neoplasms. Ruxolitinib, the first JAK inhibitor approved for clinical use, improves splenomegaly and ameliorates constitutional symptoms in both myelofibrosis and polycythemia vera patients. Ruxolitinib is also useful for controlling hematocrit levels in polycythemia vera patients who were inadequately controlled by conventional therapies. Furthermore, pretransplantation use of ruxolitinib may improve the outcome of allo-hematopoietic stem cell transplantation in myelofibrosis. In contrast to these clinical merits, evidence of the disease-modifying action of ruxolitinib, i.e., reduction of malignant clones or improvement of bone marrow pathological findings, is limited, and many myelofibrosis patients discontinued ruxolitinib due to adverse events or disease progression. To overcome these limitations of ruxolitinib, several new types of JAK inhibitors have been developed. Among them, fedratinib was proven to provide clinical merits even in patients who were resistant or intolerant to ruxolitinib. Pacritinib and momelotinib have shown merits for myelofibrosis patients with thrombocytopenia or anemia, respectively. In addition to treatment for myeloproliferative neoplasms, recent studies have demonstrated that JAK inhibitors are novel and attractive therapeutic options for corticosteroid-refractory acute as well as chronic graft versus host disease.
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Affiliation(s)
- Keita Kirito
- Department of Hematology and Oncology, University of Yamanashi, Yamanashi, Japan
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37
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Gerds AT, Verstovsek S, Vannucchi AM, Al-Ali HK, Lavie D, Kuykendall AT, Grosicki S, Iurlo A, Goh YT, Lazaroiu MC, Egyed M, Fox ML, McLornan D, Perkins A, Yoon SS, Gupta V, Kiladjian JJ, Granacher N, Lee SE, Ocroteala L, Passamonti F, Harrison CN, Oh S, Klencke BJ, Yu J, Donahue R, Kawashima J, Mesa R. Momelotinib versus danazol in symptomatic patients with anaemia and myelofibrosis previously treated with a JAK inhibitor (MOMENTUM): an updated analysis of an international, double-blind, randomised phase 3 study. Lancet Haematol 2023; 10:e735-e746. [PMID: 37517413 DOI: 10.1016/s2352-3026(23)00174-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/06/2023] [Accepted: 06/08/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND The MOMENTUM study met all key endpoints at week 24, demonstrating symptom, spleen, and anaemia benefits with momelotinib versus danazol in patients with myelofibrosis. In this updated analysis, we report duration of week 24 responses and new responses with momelotinib through week 48. METHODS MOMENTUM is an international, double-blind, randomised, phase 3 study done at 107 sites across 21 countries. Patients were 18 years or older with primary, post-polycythaemia vera, or post-essential thrombocythaemia myelofibrosis, previously treated with an approved Janus kinase (JAK) inhibitor for 90 days or more (≥28 days with haematological complications), and had an Eastern Cooperative Oncology Group performance status of 2 or less. Patients were randomly assigned (2:1) to either the momelotinib group (200 mg orally once per day) or danazol group (300 mg orally twice per day) through week 24 via non-deterministic biased coin minimisation and an interactive response system. Stratification factors were Total Symptom Score (TSS; <22 vs ≥22), spleen size (<12 cm vs ≥12 cm), transfusion burden (0 units vs 1-4 units vs ≥5 units), and study site. After week 24, all patients initially randomly assigned to either group who remained on the study received open-label momelotinib. The primary endpoint, which has already been reported, was Myelofibrosis Symptom Assessment Form TSS response rate at week 24. Predefined secondary endpoints were duration of week 24 TSS and transfusion independence responses, safety, and survival, which are summarised post hoc at the week 48 data cutoff (May 17, 2022). TSS, transfusion independence, and splenic responses at week 48 were defined post hoc and assessed in all evaluable patients who entered the open-label period and provided sufficient data. The timing of this updated analysis was defined post hoc after all patients had the opportunity to complete their week 48 assessments, as most patients entered an extended access study (NCT03441113) after week 48. This study is registered with ClinicalTrials.gov, number NCT04173494, and is now complete. FINDINGS Between April 24, 2020, and Dec 3, 2021, a total of 195 patients were randomised (130 [67%] in the momelotinib group and 65 [33%] in the danazol group). 93 (72%) of 130 patients in the momelotinib group and 41 (63%) of 65 in the danazol group entered the momelotinib open-label extension period. Median follow-up was 48·4 weeks (IQR 40·6-55·7). Among TSS-evaluable patients at week 48, 30 (45%) of 67 patients in the momelotinib group who continued treatment and 15 (50%) of 30 in the danazol group who crossed over were responders. TSS responders at any time during the open-label period by week 48 were 46 (61%) of 75 evaluable patients in the momelotinib group who continued and 19 (59%) of 32 in the danazol group who crossed over, including most week 24 responders plus new responders after week 24. No new safety signals emerged with long-term follow-up. The most common non-haematological treatment-emergent adverse events in momelotinib-treated patients over the entire study period as of the data cutoff were diarrhoea (45 [26%] of 171) and asthenia (28 [16%]); the most common grades 3-4 treatment-emergent adverse events were thrombocytopenia (33 [19%]) and anaemia (19 [11%]). Serious treatment-emergent adverse events were reported in 79 (46%) of 171 patients, and fatal treatment-emergent adverse events were reported in 30 (18%); two fatal treatment-emergent adverse events were considered possibly related to momelotinib (rotaviral enteritis and Staphylococcus pneumonia). INTERPRETATION Momelotinib was associated with durable symptom, spleen, and anaemia benefits, late responses after week 24, and favourable safety through week 48. These results highlight the potential benefits of treatment with momelotinib in patients with myelofibrosis, particularly those with anaemia. FUNDING Sierra Oncology, a GSK company.
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Affiliation(s)
- Aaron T Gerds
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA.
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alessandro M Vannucchi
- Department of Hematology, University of Florence, Florence, Italy; Center of Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy
| | | | - David Lavie
- Department of Hematology and Bone Marrow Transplantation, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention, Medical University of Silesia, Katowice, Poland
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Yeow Tee Goh
- Department of Haematology, Singapore General Hospital, Singapore
| | - Mihaela C Lazaroiu
- Department of Hematology, Policlinica de Diagnostic Rapid Brasov, Brasov, Romania
| | - Miklos Egyed
- Department of Hematology, Somogy County Mór Kaposi General Hospital, Kaposvár, Hungary
| | - Maria Laura Fox
- Department of Haematology, Vall d'Hebron Hospital Universitari, Experimental Hematology, Vall d'Hebron Institute of Oncology, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Donal McLornan
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Andrew Perkins
- Department of Haematology, Alfred Hospital, Monash University, Melbourne, VIC, Australia
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Vikas Gupta
- Department of Medicine, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jean-Jacques Kiladjian
- Université de Paris, AP-HP, Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM, CIC1427, Paris, France
| | - Nikki Granacher
- Department of Hematology, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
| | - Sung-Eun Lee
- Department of Hematology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | | | | | - Claire N Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Stephen Oh
- Division of Hematology, Washington University School of Medicine, St Louis, MO, USA
| | | | | | | | | | - Ruben Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Verstovsek S, Mesa R, Gupta V, Lavie D, Dubruille V, Cambier N, Platzbecker U, Hus M, Xicoy B, Oh ST, Kiladjian JJ, Vannucchi AM, Gerds A, Egyed M, Mayer J, Sacha T, Kawashima J, Morris M, Huang M, Harrison C. Momelotinib long-term safety and survival in myelofibrosis: integrated analysis of phase 3 randomized controlled trials. Blood Adv 2023; 7:3582-3591. [PMID: 37042865 PMCID: PMC10368854 DOI: 10.1182/bloodadvances.2022009311] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 02/08/2023] [Accepted: 03/06/2023] [Indexed: 04/13/2023] Open
Abstract
Momelotinib is the first inhibitor of Janus kinase 1 (JAK1) and JAK2 shown to also inhibit activin A receptor type 1 (ACVR1), a key regulator of iron homeostasis, and has demonstrated improvements in splenomegaly, constitutional symptoms, and anemia in myelofibrosis (MF). This long-term analysis pooled data from 3 randomized phase 3 studies of momelotinib (MOMENTUM, SIMPLIFY-1, and SIMPLIFY-2), representing MF disease from early (JAK inhibitor-naive) to late (JAK inhibitor-experienced) stages. Patients in the control arms (danazol in MOMENTUM, ruxolitinib in SIMPLIFY-1, and best available therapy in SIMPLIFY-2) could cross over to receive momelotinib at the end of the 24-week randomized period, and all patients could continue momelotinib treatment after the completion of these studies via an extended access protocol (XAP). Across these studies, 725 patients with MF received momelotinib; 12% remained on therapy for ≥5 years, with a median treatment exposure of 11.3 months (range, 0.1-90.4 months). The most common nonhematologic treatment-emergent adverse event (AE) occurring in ≥20% of patients was diarrhea (any grade, 27% and grade ≥3, 3%). Any-grade thrombocytopenia, anemia, and neutropenia occurred in 25%, 23%, and 7% of patients, respectively. The most common reason for momelotinib discontinuation was thrombocytopenia (4% discontinuation rate). The incidence of AEs of clinical importance (eg, infections, malignant transformation, peripheral neuropathy, and hemorrhage) did not increase over time. This analysis of one of the largest randomized trial databases for a JAK inhibitor to date in MF demonstrated a consistent safety profile of momelotinib without long-term or cumulative toxicity. These trials were registered at www.clinicaltrials.gov as: MOMENTUM (#NCT04173494), SIMPLIFY-1 (#NCT01969838), SIMPLIFY-2 (#NCT02101268), and XAP (#NCT03441113).
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Affiliation(s)
| | - Ruben Mesa
- UT Health San Antonio Cancer Center, San Antonio, TX
| | - Vikas Gupta
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - David Lavie
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Viviane Dubruille
- Centre Hospitalier Universitaire de Nantes (CHU de Nantes), Nantes, France
| | - Nathalie Cambier
- Service d’hématologie, Centre hospitalier régional universitaire de Lille (CHRU Lille), Lille, France
| | - Uwe Platzbecker
- Clinic of Hematology, Cellular Therapy, and Hemostaseology, University of Leipzig, Leipzig, Germany
| | - Marek Hus
- Uniwersytet Medyczny w Lublinie, Lublin, Poland
| | - Blanca Xicoy
- Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Stephen T. Oh
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Jean-Jacques Kiladjian
- Université de Paris, Assistance Publique–Hôpitaux de Paris (AP-HP), Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM, Paris, France
| | - Alessandro M. Vannucchi
- Center of Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Department of Experimental and Clinical Medicine, University of Florence, Careggi University Hospital, Florence, Italy
| | | | | | - Jiří Mayer
- Department of Internal Medicine, Haematology and Oncology, University Hospital Brno, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomasz Sacha
- Uniwersytet Jagielloński Collegium Medicum, Krakow, Poland
| | | | | | | | - Claire Harrison
- Guy's and St Thomas' National Health Services (NHS) Foundation Trust, London, United Kingdom
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Ipek Y, Kilic B, Gunay UB, Eskazan AE. Novel Janus-kinase (JAK) Inhibitors in Myelofibrosis. Expert Opin Investig Drugs 2023; 32:931-940. [PMID: 37811861 DOI: 10.1080/13543784.2023.2269078] [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: 07/22/2023] [Accepted: 10/06/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION JAK inhibitors (JAKis), used in the treatment of myelofibrosis, have entered standard treatment, providing significant improvements in spleen size and symptom burden. Although splenomegaly provides a reduction and some improvement in cytopenia, there is still a way to go. Novel JAKis are being investigated to overcome barriers to treatment access, such as therapeutic challenges, intolerance, and unresponsiveness. AREAS COVERED This review includes the current status of JAKi treatment for myelofibrosis, mainly focusing on investigational JAKis; jaktinib, lestaurtinib, itacitinib, gandotinib, BMS-911543, ilginatinib, TQ05105, and flonoltinib maleate. MEDLINE and clinicaltrials.gov were screened to identify all completed or active studies on this topic. The outcomes of the preclinical studies and clinical trials are presented and discussed for each drug. EXPERT OPINION In patients with myelofibrosis, momelotinib was effective in treating anemia, whereas jaktinib was effective in both anemia and Total Symptom Score (TSS). More phase 3 studies are needed to provide more precise evidence. The increasing variety of JAKis will allow for more personalized treatment options for myelofibrosis in the future. The potential impact on disease progression, molecular responses, and the duration of this response will become important parameters for future evaluations of these drugs.
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Affiliation(s)
- Yildiz Ipek
- Division of Hematology, Department of Internal Medicine, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey
| | - Berkay Kilic
- Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Ulgar Boran Gunay
- Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Ahmet Emre Eskazan
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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Kong T, Yu L, Laranjeira ABA, Fisher DA, He F, Cox MJ, Oh ST. Comprehensive profiling of clinical JAK inhibitors in myeloproliferative neoplasms. Am J Hematol 2023; 98:1029-1042. [PMID: 37203407 PMCID: PMC10525038 DOI: 10.1002/ajh.26935] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/03/2023] [Indexed: 05/20/2023]
Abstract
Small molecule inhibitors targeting JAK2 provide symptomatic benefits for myeloproliferative neoplasm (MPN) patients and are among first-line therapeutic agents. However, despite all having potent capacity to suppress JAK-STAT signaling, they demonstrate distinct clinical profiles suggesting contributory effects in targeting other ancillary pathways. Here, we performed comprehensive profiling on four JAK2 inhibitors either FDA-approved (ruxolitinib, fedratinib, and pacritinib) or undergoing phase 3 studies (momelotinib) to better outline mechanistic and therapeutic efficacy. Across JAK2-mutant in vitro models, all four inhibitors demonstrated similar anti-proliferative phenotypes, whereas pacritinib yielded greatest potency on suppressing colony formation in primary samples, while momelotinib exhibited unique erythroid colony formation sparing. All inhibitors reduced leukemic engraftment, disease burden, and extended survival across patient-derived xenograft (PDX) models, with strongest effects elicited by pacritinib. Through RNA-sequencing and gene set enrichment analyses, differential suppressive degrees of JAK-STAT and inflammatory response signatures were revealed, which we validated with signaling and cytokine suspension mass cytometry across primary samples. Lastly, we assessed the capacity of JAK2 inhibitors to modulate iron regulation, uncovering potent suppression of hepcidin and SMAD signaling by pacritinib. These comparative findings provide insight into the differential and beneficial effects of ancillary targeting beyond JAK2 and may help guide the use of specific inhibitors in personalized therapy.
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Affiliation(s)
- Tim Kong
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - LaYow Yu
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Angelo B. A. Laranjeira
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel A.C. Fisher
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Fan He
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Maggie J. Cox
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Stephen T. Oh
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Immunomonitoring Laboratory, Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
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Bose P, Kuykendall AT, Miller C, Kurtin S, Farina K, Harting DM, Mascarenhas JO, Mesa RA. Moving Beyond Ruxolitinib Failure in Myelofibrosis: Evolving Strategies for Second Line Therapy. Expert Opin Pharmacother 2023; 24:1091-1100. [PMID: 37163478 DOI: 10.1080/14656566.2023.2213435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Ruxolitinib has been the cornerstone of pharmacologic therapy for myelofibrosis for over a decade. However, the last several years have witnessed the regulatory approval of other Janus kinase (JAK) inhibitors for myelofibrosis, i.e. fedratinib, pacritinib, and US approval of momelotinib is widely anticipated in 2023. Due to the multifaceted clinical presentation of myelofibrosis, a watertight definition of ruxolitinib failure has remained elusive, as "progression" on ruxolitinib can take many forms and management is highly nuanced. Yet, the availability of other JAK inhibitors and potential future availability of non-JAK inhibitor agents for myelofibrosis make a consensus on management of ruxolitinib failure critically important. This consensus paper summarizes a discussion between multiple academic and community physician experts, a pharmacist and an advanced practice provider around the issues to be considered for the optimal care of patients with myelofibrosis whose disease is refractory to or does not respond adequately to ruxolitinib, or who exhibit intolerance to ruxolitinib. The panel identified several areas of consensus, as well as some areas where more data to inform evidence-based practice are needed. In some situations, maintaining ruxolitinib while adding another agent, e.g. to address anemia, is appropriate, whereas in others, switching to a different drug has merit.
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Affiliation(s)
- Prithviraj Bose
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Sandra Kurtin
- University of Arizona Cancer Center, Tucson, Arizona
| | - Kyle Farina
- The Mount Sinai Hospital, Department of Pharmacy, New York, New York
| | | | | | - Ruben A Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston Salem and Charlotte, North Carolina
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Tefferi A, Vannucchi AM. JAK2 inhibitor treatment of anemia in myelofibrosis. Am J Hematol 2023. [PMID: 37084128 DOI: 10.1002/ajh.26934] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 04/10/2023] [Indexed: 04/22/2023]
Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alessandro M Vannucchi
- CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, University of Florence, AOU Careggi, Florence, Italy
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Pemmaraju N, Bose P, Rampal R, Gerds AT, Fleischman A, Verstovsek S. Ten years after ruxolitinib approval for myelofibrosis: a review of clinical efficacy. Leuk Lymphoma 2023:1-19. [PMID: 37081809 DOI: 10.1080/10428194.2023.2196593] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Myelofibrosis (MF) is a chronic myeloproliferative neoplasm characterized by splenomegaly, abnormal cytokine expression, cytopenias, and progressive bone marrow fibrosis. The disease often manifests with burdensome symptoms and is associated with reduced survival. Ruxolitinib, an oral Janus kinase (JAK) 1 and JAK2 inhibitor, was the first agent approved for MF. As a first-in-class targeted treatment, ruxolitinib approval transformed the MF treatment approach and remains standard of care. In addition, targeted inhibition of JAK1/JAK2 signaling, a key molecular pathway underlying MF pathogenesis, and the large volume of literature evaluating ruxolitinib, have led to a better understanding of the disease and improved management in general. Here we review ruxolitinib efficacy in patients with MF in the 10 years following approval, including demonstration of clinical benefit in the phase 3 COMFORT-I/II trials, real-world evidence, translational studies, and expanded access data. Lastly, future directions for MF treatment are discussed, including ruxolitinib-based combination therapies.
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Affiliation(s)
- Naveen Pemmaraju
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prithviraj Bose
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Raajit Rampal
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Aaron T Gerds
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Angela Fleischman
- Division of Hematology/Oncology, Medicine, University of California, Irvine, CA, USA
| | - Srdan Verstovsek
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Chifotides HT, Masarova L, Verstovsek S. SOHO State of the Art Updates and Next Questions: Novel Therapeutic Strategies in Development for Myelofibrosis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:219-231. [PMID: 36797153 PMCID: PMC10378306 DOI: 10.1016/j.clml.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/19/2022] [Accepted: 12/22/2022] [Indexed: 01/07/2023]
Abstract
Development of myelofibrosis (MF) therapeutics has reached fruition as the transformative impact of JAK2 inhibitors in the MPN landscape is complemented/expanded by a profusion of novel monotherapies and rational combinations in the frontline and second line settings. Agents in advanced clinical development span various mechanisms of action (eg, epigenetic or apoptotic regulation), may address urgent unmet clinical needs (cytopenias), increase the depth/duration of spleen and symptom responses elicited by ruxolitinib, improve other aspects of the disease besides splenomegaly/constitutional symptoms (eg, resistance to ruxolitinib, bone marrow fibrosis or disease course), provide personalized strategies, and extend overall survival (OS). Ruxolitinib had a dramatic impact on the quality of life and OS of MF patients. Recently, pacritinib received regulatory approval for severely thrombocytopenic MF patients. Momelotinib is advantageously poised among JAK inhibitors given its differentiated mode of action (suppression of hepcidin expression). Momelotinib demonstrated significant improvements in anemia measures, spleen responses, and MF-associated symptoms in MF patients with anemia; and will likely receive regulatory approval in 2023. An array of other novel agents combined with ruxolitinib, such as pelabresib, navitoclax, parsaclisib, or as monotherapies (navtemadlin) are evaluated in pivotal phase 3 trials. Imetelstat (telomerase inhibitor) is currently evaluated in the second line setting; OS was set as the primary endpoint, marking an unprecedented goal in MF trials, wherein SVR35 and TSS50 at 24 weeks have been typical endpoints heretofore. Transfusion independence may be considered another clinically meaningful endpoint in MF trials given its correlation with OS. Overall, therapeutics are at the cusp of an exponential expansion and advancements that will likely lead to the golden era in treatment of MF.
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Affiliation(s)
- Helen T Chifotides
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lucia Masarova
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX.
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45
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Ginzburg YZ. Hepcidin and its multiple partners: Complex regulation of iron metabolism in health and disease. VITAMINS AND HORMONES 2023; 123:249-284. [PMID: 37717987 DOI: 10.1016/bs.vh.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
The peptide hormone hepcidin is central to the regulation of iron metabolism, influencing the movement of iron into the circulation and determining total body iron stores. Its effect on a cellular level involves binding ferroportin, the main iron export protein, preventing iron egress and leading to iron sequestration within ferroportin-expressing cells. Hepcidin expression is enhanced by iron loading and inflammation and suppressed by erythropoietic stimulation. Aberrantly increased hepcidin leads to systemic iron deficiency and/or iron restricted erythropoiesis as occurs in anemia of chronic inflammation. Furthermore, insufficiently elevated hepcidin occurs in multiple diseases associated with iron overload such as hereditary hemochromatosis and iron loading anemias. Abnormal iron metabolism as a consequence of hepcidin dysregulation is an underlying factor resulting in pathophysiology of multiple diseases and several agents aimed at manipulating this pathway have been designed, with some already in clinical trials. In this chapter, we assess the complex regulation of hepcidin, delineate the many binding partners involved in its regulation, and present an update on the development of hepcidin agonists and antagonists in various clinical scenarios.
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Affiliation(s)
- Yelena Z Ginzburg
- Tisch Cancer Institute, Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United Sates.
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46
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Tremblay D, Mascarenhas J. Pharmacotherapeutic advances for splenomegaly in myelofibrosis. Expert Opin Pharmacother 2023; 24:577-585. [PMID: 36922391 DOI: 10.1080/14656566.2023.2192350] [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: 03/18/2023]
Abstract
INTRODUCTION Myelofibrosis is a hematologic malignancy with a variety of clinical manifestations including splenomegaly, which is present in approximately 80% of newly diagnosed patients. JAK inhibitors are the mainstay of pharmacologic treatment for splenomegaly in myelofibrosis, although spleen size reduction is not universal, and the duration of benefit is only moderately durable. AREAS COVERED We first discuss the pathobiology of splenomegaly in myelofibrosis before detailing approved and novel pharmacotherapies that can reduce spleen size while also highlighting non-pharmacologic approaches. In this review, efficacy of these treatments is measured solely by spleen volume reduction, acknowledging that other outcome measures such as symptom improvement and survival are also critical. EXPERT OPINION Currently, ruxolitinib can be administered to the majority of frontline patients although those with severe thrombocytopenia should receive pacritinib to address spleen burden. Momelotinib may be particularly well suited for patients with significant anemia and novel combination treatments in clinical development may improve the depth and duration of spleen responses. After frontline treatment failure, fedratinib, or pacritinib are commercial options for patients with persistent symptomatic splenomegaly. Novel agents given alone or in combination with a JAK inhibitor are being explored in trials, which may ameliorate splenomegaly and ultimately improve disease progression.
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Affiliation(s)
- Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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47
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Stein BL. JAK inhibition in myelofibrosis: how to sequence treatment in this new era of multiple options. Leuk Lymphoma 2023; 64:292-299. [PMID: 36301740 DOI: 10.1080/10428194.2022.2136970] [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: 11/05/2022]
Abstract
The management of myelofibrosis has improved following approval of the JAK1/JAK2 inhibitor, ruxolitinib. This agent laid the foundation for JAK inhibitor therapy, yet limitations have included myelosuppression and other adverse events (skin cancer, weight gain, and infection), as well as loss of response. Recently, two additional JAK inhibitors were approved for use in myelofibrosis. Fedratinib can be used front-line and has demonstrated impressive responses as a salvage option after ruxolitinib loss of response. Previously, patients with severe thrombocytopenia had limited treatment options; approval of pacritinib offers an option to address splenomegaly and/or symptoms in these patients. A significant unmet need has been the treatment of anemia; momelotinib (not approved at the time of writing) has demonstrated spleen, symptom, and anemia responses. The possibility of having four approved options for myelofibrosis may be soon realized. This speaks to progress in the past decade, though achieving clinical and molecular remissions remain paramount.
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Affiliation(s)
- Brady L Stein
- Division of Hematology/Oncology and Department of Medicine, Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
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48
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Gangat N, Begna KH, Al-Kali A, Hogan W, Litzow M, Pardanani A, Tefferi A. Predictors of anemia response to momelotinib therapy in myelofibrosis and impact on survival. Am J Hematol 2023; 98:282-289. [PMID: 36349465 DOI: 10.1002/ajh.26778] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/05/2022] [Indexed: 11/10/2022]
Abstract
We retrospectively reviewed 72 anemic patients with myelofibrosis (MF; median age 68 years), who were JAK2 inhibitor-naïve at the time of study entry to a phase-1/2 momelotinib clinical trial. Driver mutation profile included JAK2 69%, CALR 17%, MPL 8%, and triple-negative 6%; other mutations included ASXL1 39% and SRSF2 17%. Momelotinib was administered at a median dose of 300 mg daily. Anemia response was assessed by formal criteria and documented in 44% of all patients with hemoglobin levels below the sex-adjusted reference range (n = 72), 48% of those with hemoglobin <10 g/dl (n = 54), and 46% of those who were transfusion-dependent at the time of study entry (n = 28). Anemia response was more likely with post-essential thrombocythemia MF (83% vs 37%; p = .001), lower serum ferritin (p = .003), and shorter time from diagnosis to momelotinib therapy (p = .001); the first two variables were also predictive in transfusion-dependent patients. Post-momelotinib median survival was 3.2 years; in univariate analysis, survival was superior in anemia responders (median 3.8 vs. 2.8 years; p = .14) and in the presence of type 1/like CALR mutation and inferior in the presence of age > 65 years, ASXL1/SRSF2 mutation, unfavorable karyotype, DIPSS-plus high risk, red cell transfusion need and higher serum ferritin. Multivariable analysis confirmed the favorable impact of anemia response on survival (p = .02; HR 0.5, 3/5/10-year survival; 69%/38%/25%). This survival advantage was also noted in transfusion-dependent patients (3.7 vs. 1.9 years; p = .01; HR 0.3) and appeared to be restricted to patients with an unfavorable genetic profile. The current study suggests a short-term survival benefit associated with anemia response in momelotinib-treated patients with MF.
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Affiliation(s)
- Naseema Gangat
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kebede H Begna
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Aref Al-Kali
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - William Hogan
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark Litzow
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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49
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Abstract
OPINION STATEMENT Currently approved therapies for myelofibrosis (MF) consist of JAK inhibitors, which produce meaningful improvements in spleen size and symptom burden but do not significantly impact leukemic progression. In addition, many patients develop resistance or intolerance to existing therapies and are left without meaningful therapeutic options. There has been recent rapid development of agents in MF that may be able to fill these unmet needs. Importantly, most treatments currently in clinical development have targets outside the JAK-STAT pathway, including BET, BCL-2/BCL-xL, PI3k, HDM2, PIM-1, SINE, telomerase, LSD1, and CD123. These therapies are being tested in combination with JAK inhibitors in the front-line setting and in patients with a suboptimal response, as well as a single agent after JAK inhibitor failure. This next generation of agents is likely to produce a paradigm shift in MF treatment with a focus on combination treatment targeting multiple areas of MF pathophysiology.
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Affiliation(s)
- Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruben Mesa
- UT Health San Antonio Cancer Center, San Antonio, TX, USA.
- Mays Cancer Center at UT Health San Antonio MD Anderson, San Antonio, TX, USA.
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50
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Verstovsek S, Gerds AT, Vannucchi AM, Al-Ali HK, Lavie D, Kuykendall AT, Grosicki S, Iurlo A, Goh YT, Lazaroiu MC, Egyed M, Fox ML, McLornan D, Perkins A, Yoon SS, Gupta V, Kiladjian JJ, Granacher N, Lee SE, Ocroteala L, Passamonti F, Harrison CN, Klencke BJ, Ro S, Donahue R, Kawashima J, Mesa R. Momelotinib versus danazol in symptomatic patients with anaemia and myelofibrosis (MOMENTUM): results from an international, double-blind, randomised, controlled, phase 3 study. Lancet 2023; 401:269-280. [PMID: 36709073 DOI: 10.1016/s0140-6736(22)02036-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/30/2022] [Accepted: 10/13/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Janus kinase (JAK) inhibitors approved for myelofibrosis provide spleen and symptom improvements but do not meaningfully improve anaemia. Momelotinib, a first-in-class inhibitor of activin A receptor type 1 as well as JAK1 and JAK2, has shown symptom, spleen, and anaemia benefits in myelofibrosis. We aimed to confirm the differentiated clinical benefits of momelotinib versus the active comparator danazol in JAK-inhibitor-exposed, symptomatic patients with anaemia and intermediate-risk or high-risk myelofibrosis. METHODS MOMENTUM is an international, double-blind, randomised, controlled, phase 3 study that enrolled patients at 107 sites across 21 countries worldwide. Eligible patients were 18 years or older with a confirmed diagnosis of primary myelofibrosis or post-polycythaemia vera or post-essential thrombocythaemia myelofibrosis. Patients were randomly assigned (2:1) to receive momelotinib (200 mg orally once per day) plus danazol placebo (ie, the momelotinib group) or danazol (300 mg orally twice per day) plus momelotinib placebo (ie, the danazol group), stratified by total symptom score (TSS; <22 vs ≥22), spleen size (<12 cm vs ≥12 cm), red blood cell or whole blood units transfused in the 8 weeks before randomisation (0 units vs 1-4 units vs ≥5 units), and study site. The primary endpoint was the Myelofibrosis Symptom Assessment Form (MFSAF) TSS response rate at week 24 (defined as ≥50% reduction in mean MFSAF TSS over the 28 days immediately before the end of week 24 compared with baseline). MOMENTUM is registered with ClinicalTrials.gov, number NCT04173494, and is active but not recruiting. FINDINGS 195 patients were randomly assigned to either the momelotinib group (130 [67%]) or danazol group (65 [33%]) and received study treatment in the 24-week randomised treatment period between April 24, 2020, and Dec 3, 2021. A significantly greater proportion of patients in the momelotinib group reported a 50% or more reduction in TSS than in the danazol group (32 [25%] of 130 vs six [9%] of 65; proportion difference 16% [95% CI 6-26], p=0·0095). The most frequent grade 3 or higher treatment-emergent adverse events with momelotinib and danazol were haematological abnormalities by laboratory values: anaemia (79 [61%] of 130 vs 49 [75%] of 65) and thrombocytopenia (36 [28%] vs 17 [26%]). The most frequent non-haematological grade 3 or higher treatment-emergent adverse events with momelotinib and danazol were acute kidney injury (four [3%] of 130 vs six [9%] of 65) and pneumonia (three [2%] vs six [9%]). INTERPRETATION Treatment with momelotinib, compared with danazol, resulted in clinically significant improvements in myelofibrosis-associated symptoms, anaemia measures, and spleen response, with favourable safety. These findings support the future use of momelotinib as an effective treatment in patients with myelofibrosis, especially in those with anaemia. FUNDING Sierra Oncology.
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Affiliation(s)
- Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Aaron T Gerds
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Alessandro M Vannucchi
- Department of Hematology, University of Florence, Florence, Italy; Center of Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy
| | | | - David Lavie
- Department of Hematology and Bone Marrow Transplantation, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention, Medical University of Silesia, Katowice, Poland
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Yeow Tee Goh
- Department of Haematology, Singapore General Hospital, Singapore
| | - Mihaela C Lazaroiu
- Department of Hematology, Policlinica de Diagnostic Rapid Brasov, Brasov, Romania
| | - Miklos Egyed
- Department of Hematology, Somogy County Mór Kaposi General Hospital, Kaposvár, Hungary
| | - Maria Laura Fox
- Vall d'Hebron Institute of Oncology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Donal McLornan
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Andrew Perkins
- Department of Haematology, Alfred Hospital, Monash University, Melbourne, Australia
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Vikas Gupta
- Department of Medicine, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jean-Jacques Kiladjian
- Université de Paris, AP-HP, Hoôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM, CIC1427, Paris, France
| | - Nikki Granacher
- Department of Hematology, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
| | - Sung-Eun Lee
- Department of Laboratory Medicine, Seoul St Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | | | | | - Claire N Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | | | | | | | - Ruben Mesa
- Mays Cancer Center, UT Health San Antonio MD Anderson, San Antonio, TX, USA
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