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Glaspy J, Bondarenko I, Krasnozhon D, Rutty D, Chen J, Fu Y, Wang S, Hou Q, Li S. Efbemalenograstim alfa not inferior to pegfilgrastim in providing neutrophil support in women with breast cancer undergoing myelotoxic chemotherapy: results of a phase 2 randomized, multicenter, open-label trial. Support Care Cancer 2024; 32:91. [PMID: 38194162 PMCID: PMC10776461 DOI: 10.1007/s00520-023-08260-x] [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: 07/27/2023] [Accepted: 12/15/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE Evaluate the safety and efficacy of efbemalenograstim alfa for neutrophil support in breast cancer patients undergoing myelosuppressive chemotherapy in a phase 2, dose-finding, open-label study (NCT01648322, ClinicalTrials.gov, 2012-07-19). METHODS 232 patients received up to 4 cycles of chemotherapy, 141 patients with docetaxel + cyclophosphamide (TC) and 91 patients with docetaxel + doxorubicin + cyclophosphamide (TAC). Patients were randomized to efbemalenograstim alfa (80, 240, or 320 µg/kg [TC]; 240 or 320 µg/kg [TAC]) or pegfilgrastim (6 mg) on Day 2 of each cycle. RESULTS Efbemalenograstim alfa was non-inferior to pegfilgrastim in duration of moderate and severe neutropenia (absolute neutrophil count [ANC] < 1.0 × 109/L) in TAC Cycle 1 (mean [SD] of 2.1 [1.58] and 2.1 [1.46] days for 240 µg/kg and 320 µg/kg efbemalenograstim alfa, respectively, and 1.8 [1.28] days for pegfilgrastim), with a difference (95% CI) of 0.3 (-0.4, 1.1) days. ANC nadir occurred between Days 7-8 of TAC Cycle 1, with mean [SD] of 0.68 [1.064], 0.86 [1.407] and 0.78[1.283] × 109/L for 240 µg/kg, 320 µg/kg efbemalenograstim alfa and pegfilgrastim, respectively. Time to ANC recovery post nadir (defined as an ANC > 2.0 × 109/L after the expected ANC nadir) was 2.0-2.4 and 1.9 days for TAC patients treated with efbemalenograstim alfa and pegfilgrastim, respectively. No significant difference was found between any dose of efbemalenograstim alfa and pegfilgrastim in TAC Cycle 1 for incidence of moderate to severe neutropenia (76%-77% of patients) or incidence of severe neutropenia (ANC < 0.5 × 109/L; 63%-72%). Efbemalenograstim alfa exhibited similar safety profile to pegfilgrastim. Febrile neutropenia occurred in 4 (1.8%) patients, 2 patients each for 320 µg/kg efbemalenograstim alfa and pegfilgrastim, with no event considered related to study drug. CONCLUSION Efbemalenograstim alfa was comparable to pegfilgrastim in efficacy and safety. CLINICALTRIALS GOV IDENTIFIER NCT01648322.
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Affiliation(s)
- John Glaspy
- UCLA School of Medicine, 100 UCLA Medical Plaza, Suite 550, Los Angeles, CA, 90095-6956, USA.
| | | | - Dmitrii Krasnozhon
- GBUZ LOOD Surgery Department, Leningrad Regional Oncology Center, Saint Petersburg, Russia
| | - Dean Rutty
- Everest Clinical Research, Markham, Ontario, Canada
| | - Jianmin Chen
- Evive Biotechnology (Shanghai) Ltd, Shanghai, China
| | - Yanyan Fu
- Evive Biotechnology (Shanghai) Ltd, Shanghai, China
| | - Shufang Wang
- Evive Biotechnology (Shanghai) Ltd, Shanghai, China
| | - Qingsong Hou
- Evive Biotechnology (Shanghai) Ltd, Shanghai, China
| | - Simon Li
- Evive Biotechnology (Shanghai) Ltd, Shanghai, China
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Vuong HL, Lan CT, Le HTT. The development and technologies of RNA therapeutics. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2024; 203:13-39. [PMID: 38359995 DOI: 10.1016/bs.pmbts.2023.12.017] [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: 02/17/2024]
Abstract
Since it was discovered for over 20 years ago, the potentiality of siRNAs in gene silencing in vitro and in vivo models has been recognized. Several studies in the new generation, molecular mechanisms, target attachment, and purification of RNA have supported the development of RNA therapeutics for a variety of applications. RNA therapeutics are growing rapidly with various platforms contributing to the standard of personalized medicine and rare disease treatment. Therefore, understanding the development and technologies of RNA therapeutics becomes a crucial point for new drug generation. Here, the primary purpose of this review is to provide a general view of six therapeutic categories that make up RNA-based therapeutic approaches, including RNA-target therapeutics, protein-targeted therapeutics, cellular reprogramming and tissues engineering, RNA-based protein replacement therapeutics, RNA-based genome editing, and RNA-based immunotherapies based on non-coding RNAs and coding RNA. Furthermore, we present an overview of the RNA strategies regarding viral approaches and nonviral approaches in designing a new generation of RNA technologies. The advantages and challenges of using RNA therapeutics are also discussed along with various approaches for RNA delivery. Therefore, this review is designed to provide updated reference evidence of RNA therapeutics in the battle against rare or difficult-to-treat diseases for researchers in this field.
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Affiliation(s)
- Huong Lan Vuong
- Pharmacy Department, National Hospital for Tropical Diseases, Hanoi, Vietnam
| | - Chu Thanh Lan
- Department of Regenerative Medicine, Institute of Tissue Regeneration, College of Medicine, Soonchunghyang University, South Korea
| | - Hien Thi Thu Le
- Intestinal Signaling and Epigenetics, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
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Glaspy J, Bondarenko I, Burdaeva O, Chen J, Rutty D, Li R, Wang S, Hou Q, Li S. Efbemalenograstim alfa, an Fc fusion protein, long-acting granulocyte-colony stimulating factor for reducing the risk of febrile neutropenia following chemotherapy: results of a phase III trial. Support Care Cancer 2023; 32:34. [PMID: 38103088 PMCID: PMC10725375 DOI: 10.1007/s00520-023-08176-6] [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: 07/21/2023] [Accepted: 11/08/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE Evaluate the safety and efficacy of efbemalenograstim alfa for reducing the risk of febrile neutropenia in breast cancer patients undergoing myelosuppressive chemotherapy. METHODS A phase III, randomized, double-blind, placebo-controlled study was conducted. A total of 122 subjects received up to 4 cycles of TA chemotherapy (75 mg/m2 docetaxel + 60 mg/m2 doxorubicin). Patients were randomized in a 2:1 ratio to subcutaneously inject a single 20 mg of efbemalenograstim alfa or placebo on day 2 of cycle 1, and all subjects received efbemalenograstim alfa on day 2 of cycles 2, 3, and 4. Duration of severe (grade 4) neutropenia (DSN), depth of neutrophil nadir, incidence of febrile neutropenia (FN), time to neutrophil recovery, and safety information were recorded. RESULTS For the primary endpoint, the mean DSN in cycle 1 was 1.3 days and 3.9 days for efbemalenograstim alfa and placebo respectively (95% CI, 2.3, 3.4). As the lower bound of the 95% CI was > 0, superiority of efbemalenograstim alfa over placebo can be declared. In addition, the incidence of FN in Cycle 1 was lower in efbemalenograstim alfa group than in placebo group (4.8% vs. 25.6%; p = 0.0016). Patients in the efbemalenograstim alfa group required less intravenous antibiotics (3.6% vs. 17.9%; p = 0.0119). Most adverse events were consistent with those expected for breast cancer patient receiving TA chemotherapy. CONCLUSION Efbemalenograstim alfa is effective and safe for significantly decreasing the duration of severe neutropenia and the incidence of febrile neutropenia in breast cancer patients who are receiving TA chemotherapy. TRIAL REGISTRATION NCT02872103, August 19, 2016.
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Affiliation(s)
- John Glaspy
- UCLA School of Medicine, UCLA Medical Plaza, 100Suite 550, Los Angeles, CA, 90095-6956, USA.
| | - Igor Bondarenko
- Oncology and Medical Radiology Dept, Dnepropetrovsk Medical Academy, Dnepropetrovsk, Ukraine
| | - Olga Burdaeva
- Arkhangelsk Regional Clinical Hospital, Arkhangelsk, Russia
| | - Jianmin Chen
- Evive Biotechnology (Shanghai) Ltd, Shanghai, China
| | - Dean Rutty
- Everest Clinical Research, Markham, ON, Canada
| | - Renshu Li
- Evive Biotechnology (Shanghai) Ltd, Shanghai, China
| | - Shufang Wang
- Evive Biotechnology (Shanghai) Ltd, Shanghai, China
| | - Qingsong Hou
- Evive Biotechnology (Shanghai) Ltd, Shanghai, China
| | - Simon Li
- Evive Biotechnology (Shanghai) Ltd, Shanghai, China
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Lee A, Kang T, Kang SH, Park WC, Lim W, Chang MC, Kim HY, Song JY, Lee J, Byun KD, Kim HA, Son GS, Kim JY, Oh SJ, Chung MS, Choi YJ, Shin HJ, Baek JM, Yoo Y, Um E, Choi JH, Kwak BS, Park MH, Lee SH, Kim CS, Lee I, Kim JR, Lee HS, Lim CW. An observational, prospective, open label, multicenter study to evaluate the safety and effectiveness of pegfilgrastim as secondary prophylaxis to decrease the incidence of febrile neutropenia in Korean female patients with breast cancer. Breast 2023; 72:103585. [PMID: 37802015 PMCID: PMC10568407 DOI: 10.1016/j.breast.2023.103585] [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: 08/02/2023] [Revised: 09/25/2023] [Accepted: 09/25/2023] [Indexed: 10/08/2023] Open
Abstract
PURPOSE Pegfilgrastim is a widely used long-acting granulocyte colony-stimulating factor (G-CSF) that prevents febrile neutropenia (FN) in patients with breast cancer receiving chemotherapy. This study aimed to evaluate the incidence of chemotherapy-related FN events and other adverse events (AEs) during chemotherapy in Korean patients with breast cancer treated with pegfilgrastim as secondary prophylactic support. MATERIALS AND METHODS This was a multicenter, open-label, prospective, observational study. A total of 1255 patients were enrolled from 43 institutions. The incidence of FN was evaluated as the primary endpoint. The secondary endpoints included (1) incidence of bone pain, (2) proportion of patients with a relative dose intensity (RDI) of ≥85%, and (3) proportion of patients with AE. RESULTS Pegfilgrastim administration reduced FN by 11.8-1.6%. The highest incidence of bone pain was observed at the time point of the 1st day after the administration and mild bone pain was the most common of all bone pain severity. The mean RDI was 98.5 ± 7.3%, and the proportion of the patients with and RDI≥85% was 96.9% (1169/1233). AEs were reported in 52.6% of the patients, and serious drug reactions occurred in only 0.7%. CONCLUSION The use of pegfilgrastim as secondary prophylaxis was effective and safe for preventing FN in patients with breast cancer who were treated with chemotherapy.
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Affiliation(s)
- Anbok Lee
- Department of Surgery, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gyeonggi-do, Republic of Korea
| | - Taewoo Kang
- Busan Cancer Center and Biomedical Research Institute, Pusan National University Hospital, and Department of Surgery, Pusan National University, School of Medicine, Busan, Republic of Korea
| | - Su Hwan Kang
- Department of Surgery, Yeungnam University Hospital, Daegu, Republic of Korea
| | - Woo-Chan Park
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Woosung Lim
- Department of Surgery, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Myung-Chul Chang
- Department of Surgery, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Hyun Yul Kim
- Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Jeong-Yoon Song
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Jihyoun Lee
- Department of Surgery, Soonchunhyang University Hospital, Seoul, Republic of Korea
| | - Kyung Do Byun
- Department of Surgery, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Hyun-Ah Kim
- Department of Surgery, Korea Cancer Center Hospital, Korea Institute of Radiological & Medical Sciences, Seoul, Republic of Korea
| | - Gil Soo Son
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ju-Yeon Kim
- Department of Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
| | - Se Jeong Oh
- Department of Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Sung Chung
- Department of Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Young Jin Choi
- Department of Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Hyuk-Jai Shin
- Department of Surgery, Myongji Hospital, Hanyang University, Goyang, Republic of Korea
| | - Jong Min Baek
- Department of Surgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Youngbum Yoo
- Department of Surgery, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Eunhae Um
- Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
| | - Jin Hyuk Choi
- Department of Breast Surgery, Kosin University Gospel Hospital, Busan, Republic of Korea
| | - Beom Seok Kwak
- Department of Surgery, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - Min Ho Park
- Department of Surgery, Chonnam National University Medical School and Chonnam National University Hwasun Hospital, Hwasun 58128, Republic of Korea
| | - Suok Hyun Lee
- Department of Surgery, Cheil Hospital, Seoul, Republic of Korea
| | - Cheol Seung Kim
- Department of Surgery, Presbyterian Medical Center, Jeonju, Republic of Korea
| | - Ilkyun Lee
- Department of Surgery, Catholic Kwandong University International St. Mary's Hospital, Incheon, Republic of Korea
| | - Je-Ryong Kim
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Han Shin Lee
- Department of Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
| | - Cheol Wan Lim
- Department of Surgery, Soonchunhyang University Bucheon Hospital, 170 Jomaru-ro, Wonmi-gu, Bucheon, 14584, Republic of Korea.
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Marsh MC, Owen SC. Therapeutic Fusion Proteins. AAPS J 2023; 26:3. [PMID: 38036919 DOI: 10.1208/s12248-023-00873-8] [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: 08/17/2023] [Accepted: 11/08/2023] [Indexed: 12/02/2023] Open
Abstract
Therapeutic fusion proteins are a class of hybrid constructs that combine distinct biomolecules into a single platform with the additive effects of the components. The ability to fuse two unrelated proteins provides a means to localize mechanisms to better treat a range of diseases. Fusion proteins can be designed to impart diverse functions, including increasing half-life, providing targeting, and enabling sustained signaling. Of these, half-life extenders, which are fused to a therapeutic protein to increase exposure, are the most established group of fusion proteins, with many clinical successes. Rapid advances in antibody and antibody-derivative technology have enabled the fusion of targeting domains with therapeutic proteins. An emerging group of therapeutic fusion proteins has two separate active functions. Although most research for therapeutic fusion proteins focuses on cancer, prior successes provide a foundation for studies into other diseases as well. The exponential emergence of biopharmaceuticals gives precedence for increased research into therapeutic fusion proteins for a multitude of diseases.
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Affiliation(s)
- Morgan C Marsh
- Department of Molecular Pharmaceutics, University of Utah, 30 South 2000 East, Room 301, Salt Lake City, Utah, 84112, USA
| | - Shawn C Owen
- Department of Molecular Pharmaceutics, University of Utah, 30 South 2000 East, Room 301, Salt Lake City, Utah, 84112, USA.
- Department of Medicinal Chemistry, University of Utah, Salt Lake City, Utah, 84112, USA.
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, 84112, USA.
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Yuan S, Shen DD, Jia R, Sun JS, Song J, Liu HM. New drug approvals for 2022: Synthesis and clinical applications. Med Res Rev 2023; 43:2352-2391. [PMID: 37211904 DOI: 10.1002/med.21976] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/13/2023] [Accepted: 05/08/2023] [Indexed: 05/23/2023]
Abstract
The U.S. Food and Drug Administration has approved a total of 37 new drugs in 2022, which are composed of 20 chemical entities and 17 biologics. In particular, 20 chemical entities, including 17 small molecule drugs, 1 radiotherapy, and 2 diagnostic agents, provide privileged scaffolds, breakthrough clinical benefits, and a new mechanism of action for the discovery of more potent clinical candidates. The structure-based drug development with clear targets and fragment-based drug development with privileged scaffolds have always been the important modules in the field of drug discovery, which could easily bypass the patent protection and bring about improved biological activity. Therefore, we summarized the relevant valuable information about clinical application, mechanism of action, and chemical synthesis of 17 newly approved small molecule drugs in 2022. We hope this timely and comprehensive review could bring about creative and elegant inspiration on the synthetic methodologies and mechanism of action for the discovery of new drugs with novel chemical scaffolds and extended clinical indications.
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Affiliation(s)
- Shuo Yuan
- Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, China
- School of Pharmaceutical Sciences & Key Laboratory of Advanced Drug Preparation Technologies, Zhengzhou University, Zhengzhou, China
- Department of Pharmacology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Dan-Dan Shen
- Department of Obstetrics and Gynecology, Zhengzhou Key Laboratory of Endometrial Disease Prevention and Treatment Zhengzhou China, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Rui Jia
- Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, China
| | - Ju-Shan Sun
- Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, China
| | - Jian Song
- School of Pharmaceutical Sciences & Key Laboratory of Advanced Drug Preparation Technologies, Zhengzhou University, Zhengzhou, China
- Department of Pharmacology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Hong-Min Liu
- School of Pharmaceutical Sciences & Key Laboratory of Advanced Drug Preparation Technologies, Zhengzhou University, Zhengzhou, China
- Department of Pharmacology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, China
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Takano T, Ito M, Kadoya T, Osako T, Aruga T, Masuda N, Miyaki T, Niikura N, Shimizu D, Yokoyama Y, Watanabe M, Tomomitsu M, Aogi K. Efficacy and safety of pegfilgrastim biosimilar MD-110 in patients with breast cancer receiving chemotherapy: Single-arm phase III. Cancer Med 2023; 12:20242-20250. [PMID: 37824431 PMCID: PMC10652341 DOI: 10.1002/cam4.6519] [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: 04/04/2023] [Revised: 06/13/2023] [Accepted: 06/21/2023] [Indexed: 10/14/2023] Open
Abstract
INTRODUCTION Pegfilgrastim is indicated to decrease the incidence of chemotherapy-induced febrile neutropenia. It is the first granulocyte-colony stimulating factor approved for prophylactic use regardless of carcinoma type and is marketed in Japan as G-LASTA (Kyowa Kirin Co., Ltd., Tokyo, Japan). MD-110 is a biosimilar of pegfilgrastim. This phase III, multicenter, open-label, single-arm study investigated the efficacy and safety of MD-110 in early-stage breast cancer patients receiving neoadjuvant or adjuvant myelosuppressive chemotherapy. METHODS A total of 101 patients received the study drug. Each patient received docetaxel 75 mg/m2 and cyclophosphamide 600 mg/m2 (TC) for four cycles on day 1 of each cycle. MD-110 (3.6 mg) was administered subcutaneously on day 2 of each cycle. The primary efficacy endpoint was the duration of severe neutropenia during cycle 1 (days with absolute neutrophil count < 500/mm3 ). The safety endpoints were adverse events and the presence of antidrug antibodies. RESULTS The mean (SD) duration of severe neutropenia for MD-110 was 0.2 (0.4) days. The upper limit of the two-sided 95% confidence interval for the mean duration of severe neutropenia was 0.2 days, below the predefined threshold of 3.0 days. The incidence of febrile neutropenia, the secondary efficacy endpoint, was 6.9% (7/101). Adverse events, occurring in more than 50% of patients, were alopecia, constipation, and malaise, which are common side effects of TC chemotherapy. Antidrug antibodies were negative in all patients. CONCLUSION MD-110 was effective against chemotherapy-induced neutropenia. No additional safety concern, compared with the originator, was observed in patients with breast cancer receiving TC chemotherapy.(JapicCTI-205230).
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Affiliation(s)
- Toshimi Takano
- Breast Medical Oncology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Mitsuya Ito
- Department of Breast Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Takayuki Kadoya
- Department of Breast Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Tomofumi Osako
- Breast Center, Kumamoto Shinto General Hospital, Kumamoto, Japan
| | - Tomoyuki Aruga
- Department of Breast Surgery, Tokyo Metropolitan Center and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Norikazu Masuda
- Department of Surgery, Breast Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Toshiko Miyaki
- Department of Breast Surgery, Chiba Cancer Center, Chiba, Japan
| | - Naoki Niikura
- Department of Breast Oncology, Tokai University Hospital, Isehara, Japan
| | - Daisuke Shimizu
- Breast Center, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | | | | | | | - Kenjiro Aogi
- Department of Breast Surgery, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
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Kayki-Mutlu G, Aksoyalp ZS, Wojnowski L, Michel MC. A year in pharmacology: new drugs approved by the US Food and Drug Administration in 2022. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2023; 396:1619-1632. [PMID: 36951997 PMCID: PMC10034907 DOI: 10.1007/s00210-023-02465-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 03/13/2023] [Indexed: 03/24/2023]
Abstract
While new drug approvals by the U.S. Food and Drug Administration (FDA) had remained stable or even increased in the first 2 years of the COVID-19 pandemic, the 37 newly approved drugs in 2022 are considerably less than the 53 and 50 new drugs approved in 2020 and 2021, respectively, and less than the rolling 10-year average of 43. As in previous years of this annual review, we assign these new drugs to one of three levels of innovation: first drug against a condition ("first-in-indication"), first drug using a novel molecular mechanism ("first-in-class"), and "next-in-class," i.e., a drug using an already exploited molecular mechanism. We identify two "first-in-indication" (ganaxolon and teplizumab), 20 (54%) "first-in-class," and 17 (46%) "next-in-class" drugs. By treatment area, rare diseases and cancer drugs were once again the most prevalent (partly overlapping) therapeutic areas. Other continuing trends were the use of accelerated regulatory approval pathways and the reliance on biopharmaceuticals (biologics).
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Affiliation(s)
- Gizem Kayki-Mutlu
- Department of Pharmacology, Faculty of Pharmacy, Ankara University, Ankara, Turkey
| | - Zinnet Sevval Aksoyalp
- Department of Pharmacology, Faculty of Pharmacy, Izmir Katip Celebi University, Izmir, Turkey
| | - Leszek Wojnowski
- Department of Pharmacology, University Medical Center, Universitätsmedizin Mainz, Johannes Gutenberg University, Langenbeckstr. 1, 55118 Mainz, Germany
| | - Martin C. Michel
- Department of Pharmacology, University Medical Center, Universitätsmedizin Mainz, Johannes Gutenberg University, Langenbeckstr. 1, 55118 Mainz, Germany
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You Z, Zhang H, Huang Y, Zhao L, Tu H, Zhang Y, Lin X, Liang W. Assessing the Optimal Regimen: A Systematic Review and Network Meta-Analysis of the Efficacy and Safety of Long-Acting Granulocyte Colony-Stimulating Factors in Patients with Breast Cancer. Cancers (Basel) 2023; 15:3675. [PMID: 37509336 PMCID: PMC10378237 DOI: 10.3390/cancers15143675] [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: 04/25/2023] [Revised: 06/21/2023] [Accepted: 07/16/2023] [Indexed: 07/30/2023] Open
Abstract
Patients with breast cancer undergoing chemotherapy are susceptible to prolonged and severe neutropenia. Multiple biosimilars of long-acting granulocyte colony-stimulating factors (LA-G-CSFs) have been newly developed to prevent this disease. Nonetheless, which LA-G-CSF regimen has the optimal balance of efficacy and safety remains controversial. Moreover, there is a lack of evidence supporting clinical decisions on LA-G-CSF dose escalation in poor conditions. PubMed, Embase, Cochrane Library, Web of Science, and several Chinese databases were searched (December 2022) to collect randomized controlled trials (RCTs) about LA-G-CSFs preventing chemotherapy-induced neutropenia in breast cancer patients. No restrictions were imposed on language. A Bayesian network meta-analysis was performed. We assessed the incidence of severe neutropenia (SN) and febrile neutropenia (FN), the duration of SN (DSN), and the absolute neutrophil account recovery time (ANCrt) for efficacy, while the incidence of severe adverse events (SAE) was assessed for safety. The study was registered in PROSPERO (CRD42022361606). A total of 33 RCTs were included. Our network meta-analysis demonstrated that lipegfilgrastim 6 mg and eflapegrastim 13.2 mg outperformed other LA-G-CSFs with high efficacy rates and few safety concerns (SUCRA of lipegfilgrastim 6 mg: ANC rt 95.2%, FN 97.4%; eflapegrastim 13.2 mg: FN 87%, SN 89.3%). Additionally, 3.6 mg, 4.5 mg, 6 mg, and 13.2 mg dosages all performed significantly better than 1.8 mg in reducing the duration of SN (3.6 mg: DSN, SMD -0.68 [-1.13, -0.22; moderate]; 4.5 mg: -0.87 [-1.57, -0.17; low]; 6 mg: -0.89 [-1.49, -0.29; moderate]; 13.2 mg: -1.02 [1.63, -0.41; high]). Increasing the dosage from the guideline-recommended 6 mg to 13.2 mg can reduce both the duration and incidence of SN (SMD -0.13 [-0.24 to -0.03], RR 0.65 [0.43 to 0.96], respectively), with no significant difference in SAE. For patients with breast cancer, lipegfilgrastim 6 mg and eflapegrastim 13.2 mg might be the most effective regimen among LA-G-CSFs. Higher doses of LA-G-CSF may enhance efficacy without causing additional SAEs.
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Affiliation(s)
- Zhixuan You
- Department of Clinical Medicine, Nanshan School, Guangzhou Medical University, Guangzhou 510182, China
| | - Haotian Zhang
- Department of Clinical Medicine, Nanshan School, Guangzhou Medical University, Guangzhou 510182, China
| | - Yining Huang
- Department of Clinical Medicine, Nanshan School, Guangzhou Medical University, Guangzhou 510182, China
| | - Lei Zhao
- Department of Clinical Medicine, Nanshan School, Guangzhou Medical University, Guangzhou 510182, China
| | - Hengjia Tu
- Department of Clinical Medicine, Nanshan School, Guangzhou Medical University, Guangzhou 510182, China
| | - Yuzhuo Zhang
- Department of Clinical Medicine, Nanshan School, Guangzhou Medical University, Guangzhou 510182, China
| | - Xinqing Lin
- Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Wenhua Liang
- Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
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10
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Crawford J, Oswalt C. The impact of new and emerging agents on outcomes for febrile neutropenia: addressing clinical gaps. Curr Opin Oncol 2023; 35:241-247. [PMID: 37222193 DOI: 10.1097/cco.0000000000000952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
PURPOSE OF REVIEW While chemotherapy treatment options for patients with solid and hematologic malignancies have dramatically improved over recent years, chemotherapy-induced neutropenia (CIN) and febrile neutropenia (FN) remain major barriers to delivering treatment at full doses and optimal timing. Despite concurrent advances in granulocyte colony-stimulating factor (G-CSF) administration, multiple barriers to the administration of and disparities in the access to these agents remain. The introduction of new, emerging agents, including biosimilars and novel therapies show promise in improving outcomes for CIN. RECENT FINDINGS The introduction of biosimilar filgrastim products has improved access to G-CSF administration by driving marketplace competition and has reduced costs for both patients and healthcare systems without sacrificing efficacy. Emerging therapies to address similar issues include long-acting G-CSF products, efbemalenograstim alfa and eflapegrastin-xnst, as well as agents with novel mechanisms of action, plinabulin and trilaciclib. These agents have shown efficacy and cost-saving benefits in certain populations and disease groups. SUMMARY Multiple emerging agents show promise in decreasing the burden of CIN. Use of these therapies will reduce access disparities and will improve outcomes for patients with cancer receiving cytotoxic chemotherapy. Many ongoing trials are underway to evaluate the roles of these agents for more widespread use.
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Affiliation(s)
- Jeffrey Crawford
- George Barth Geller Professor for Research in Cancer, Department of Medicine, Lead PI of NCTN LAPS Grant, Duke Cancer Institute
| | - Cameron Oswalt
- Hematology & Oncology, Department of Medicine, Duke University Health System, Durham, North Carolina, USA
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11
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Theyab A, Alsharif KF, Alzahrani KJ, Oyouni AAA, Hawsawi YM, Algahtani M, Alghamdi S, Alshammary AF. New insight into strategies used to develop long-acting G-CSF biologics for neutropenia therapy. Front Oncol 2023; 12:1026377. [PMID: 36686781 PMCID: PMC9850083 DOI: 10.3389/fonc.2022.1026377] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/08/2022] [Indexed: 01/07/2023] Open
Abstract
Over the last 20 years, granulocyte colony-stimulating factors (G-CSFs) have become the major therapeutic option for the treatment of patients with neutropenia. Most of the current G-CSFs require daily injections, which are inconvenient and expensive for patients. Increased understanding of G-CSFs' structure, expression, and mechanism of clearance has been very instrumental in the development of new generations of long-acting G-CSFs with improved efficacy. Several approaches to reducing G-CSF clearance via conjugation techniques have been investigated. PEGylation, glycosylation, polysialylation, or conjugation with immunoglobulins or albumins have successfully increased G-CSFs' half-lives. Pegfilgrastim (Neulasta) has been successfully approved and marketed for the treatment of patients with neutropenia. The rapidly expanding market for G-CSFs has increased demand for G-CSF biosimilars. Therefore, the importance of this review is to highlight the principle, elimination's route, half-life, clearance, safety, benefits, and limitations of different strategies and techniques used to increase the half-life of biotherapeutic G-CSFs. Understanding these strategies will allow for a new treatment with more competitive manufacturing and lower unit costs compared with that of Neulasta.
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Affiliation(s)
- Abdulrahman Theyab
- Department of Laboratory and Blood Bank, Security Forces Hospital, Makkah, Saudi Arabia,College of Medicine, Al-Faisal University, Riyadh, Saudi Arabia,*Correspondence: Abdulrahman Theyab, ; Khalaf F. Alsharif,
| | - Khalaf F. Alsharif
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia,*Correspondence: Abdulrahman Theyab, ; Khalaf F. Alsharif,
| | - Khalid J. Alzahrani
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia
| | | | - Yousef MohammedRabaa Hawsawi
- College of Medicine, Al-Faisal University, Riyadh, Saudi Arabia,Research Center, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Mohammad Algahtani
- Department of Laboratory and Blood Bank, Security Forces Hospital, Makkah, Saudi Arabia
| | - Saad Alghamdi
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Amal F. Alshammary
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
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12
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Blayney DW, Schwartzberg L. Chemotherapy-Induced Neutropenia and Emerging Agents for Prevention and Treatment: A Review. Cancer Treat Rev 2022; 109:102427. [DOI: 10.1016/j.ctrv.2022.102427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/09/2022] [Accepted: 06/12/2022] [Indexed: 11/02/2022]
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13
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Jeon Y, Lee N, Baek S, Choi J, Jhee S, Lee H. A Randomized, Double-Blind, Placebo- and Active-Controlled, Escalating Single-Dose Study to Evaluate the Safety, Tolerability, Pharmacokinetic, and Pharmacodynamic Profiles of Subcutaneous Eflapegrastim in Healthy Japanese and Caucasian Subjects. Drugs R D 2022; 22:71-87. [PMID: 34993933 PMCID: PMC8885935 DOI: 10.1007/s40268-021-00379-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 11/05/2022] Open
Abstract
Background Eflapegrastim (Rolontis®) is a novel long‐acting pegylated recombinant human granulocyte colony-stimulating factor (G-CSF). Eflapegrastim has been developed to reduce the duration and incidence of chemotherapy-induced neutropenia in cancer patients using patient-friendly, less-frequent administration. Objective This phase I study aimed to evaluate the safety, tolerability, pharmacokinetic (PK), pharmacodynamic (PD), and immunogenicity of eflapegrastim following a single subcutaneous administration to healthy Japanese and Caucasian subjects. Methods A randomized, double-blind, placebo- and active-controlled, dose-escalation study was conducted in healthy Japanese and Caucasian subjects. Eligible subjects randomly received a single subcutaneous administration of eflapegrastim (1.1, 3.3, 10, 45, 135, and 270 μg/kg), pegfilgrastim 6 mg, or placebo in a ratio of 6:2:2 (Cohorts 1–2, Caucasian subjects only) or 12:2:2 (Cohorts 3–6, Japanese and Caucasian subjects). Safety and tolerability were assessed throughout the study. Serial blood samples were collected predose and up to day 22 postdose for PK and PD analyses. PK assessments were performed in the 45, 135, and 270 µg/kg dose groups. Antidrug antibodies to eflapegrastim were determined at baseline up to day 42 after the first dose for immunogenicity. Results A total of 84 subjects (42 males and 42 females) were enrolled, and 78 (31 Japanese and 47 Caucasian subjects) completed the study as planned. Japanese and Caucasian subjects showed similar PK and PD profiles. In the 45, 135, and 270 µg/kg dose groups, the maximum serum concentration (Cmax) of eflapegrastim exhibited a dose-proportional increase, whereas its exposure increased greater than dose proportional in both ethnic groups. The mean area under the effect-time curve (AUEClast) and maximum serum concentration of both absolute neutrophil count (ANCmax) and CD34+ cell count (CD34+max) increased in a dose-dependent manner. There were no significant adverse events attributable to eflapegrastim or pegfilgrastim in both Japanese and Caucasian subjects. No neutralizing antibodies against G‐CSF were detected. Conclusions Eflapegrastim was safe and well tolerated at doses up to 270 μg/kg in healthy Japanese and Caucasian subjects. In both ethnic groups, eflapegrastim showed dose-dependent PK and the exposure to eflapegrastim was positively correlated with ANC and CD34+ cell count. The comparable PK and PD profiles of eflapegrastim in Japanese and Caucasian subjects may indicate the same dosage regimen is acceptable. Clinical Trial Registration ClinicalTrials.gov: NCT01037543 (23 December 2009).
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Affiliation(s)
- Yoomin Jeon
- Department of Applied Biomedical Engineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, 08826, South Korea.,Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, 08826, South Korea.,Center for Convergence Approaches in Drug Development, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, 08826, South Korea
| | - Nora Lee
- Hanmi Pharmaceutical Co., Ltd., Seoul, 05545, South Korea
| | - Seungjae Baek
- Hanmi Pharmaceutical Co., Ltd., Seoul, 05545, South Korea
| | - JaeDuk Choi
- Hanmi Pharmaceutical Co., Ltd., Seoul, 05545, South Korea
| | | | - Howard Lee
- Department of Applied Biomedical Engineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, 08826, South Korea. .,Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, 08826, South Korea. .,Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, 03080, South Korea. .,Center for Convergence Approaches in Drug Development, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, 08826, South Korea. .,Advanced Institute of Convergence Technology, Gyeonggi-do, 16229, South Korea.
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Shayne M, Harvey RD, Lyman GH. Prophylaxis and treatment strategies for optimizing chemotherapy relative dose intensity. Expert Rev Anticancer Ther 2021; 21:1145-1159. [PMID: 34114525 DOI: 10.1080/14737140.2021.1941891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION A decrease in relative-dose intensity (RDI) of chemotherapy has been shown to be associated with poor patient outcomes in solid tumors and non-Hodgkin's lymphoma. The actual delivered chemotherapy dose received by patients can be influenced by dose reductions and treatment delays, often due to toxicities, most commonly chemotherapy-induced neutropenia (CIN). AREAS COVERED We review seminal evidence and more recent studies that have shown an association between higher RDI and improved patient survival. A smaller number of studies has shown no association between RDI and outcomes. These differences may be due to study limitations, including low power, differences in patient and disease characteristics, or the chemotherapeutic regimen. We describe guidelines recommendations to prevent and treat CIN with granulocyte-colony stimulating factor (G-CSF) and describe novel approaches to prevent neutropenia that are being developed that may provide greater value and be associated with fewer adverse events than standard G-CSF options. EXPERT OPINION Maintaining RDI is important to ensure optimal patient outcomes. This can be achieved through the proper administration of G-CSF prophylaxis and treatment. Newer agents in development to treat and/or prevent CIN are entering regulatory review and may potentially change the treatment landscape for CIN in the future.
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Affiliation(s)
| | - R Donald Harvey
- Winship Cancer Institute and Emory University School of Medicine, Department of Hematology and Medical Oncology, Atlanta, GA, USA
| | - Gary H Lyman
- Fred Hutchinson Cancer Research Center, The University of Washington, Seattle, WA, USA
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Barrett JA, Greene D, Lakshmikanthan S, Kolli P, Chawla S, Lebel F. Justification for a Fixed Dose of Eflapegrastim, a Long-Acting G-CSF, in Patients Receiving Docetaxel-Cyclophosphamide Chemotherapy. J Clin Pharmacol 2020; 61:204-210. [PMID: 32827162 DOI: 10.1002/jcph.1723] [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: 05/15/2020] [Accepted: 08/01/2020] [Indexed: 11/09/2022]
Abstract
Eflapegrastim (Rolontis) is a long-acting granulocyte colony-stimulating factor (G-CSF) produced by conjugating a human G-CSF analogue and a human immunoglobulin G4 Fc fragment, linked via a polyethylene glycol linker. Weight-based doses of 45 to 270 μg/kg eflapegrastim (12.3-73.6 μg/kg as G-CSF) were evaluated in a phase 2 study in patients. Based on these results, a fixed dose of 13.2 mg eflapegrastim (3.6 mg G-CSF) was compared with pegfilgrastim (6 mg G-CSF) in 2 phase 3 studies and in a pharmacokinetic single-arm multicenter study. Absolute neutrophil count (ANC) data from these 3 studies were evaluated in patients with early-stage breast cancer who were treated with docetaxel and cyclophosphamide (n = 669). Serum concentrations of eflapegrastim were determined by enzyme-linked immunosorbent assay. Eflapegrastim systemic exposures were higher in cycle 1 than in cycle 3, likely attributable to the higher ANC in cycle 3, increasing neutrophil-mediated clearance. Eflapegrastim elicited a greater effect on ANC than pegfilgrastim in patients at ∼60% of the G-CSF dose. Body weight had no clinically significant effect on response, justifying administration of a fixed dose of eflapegrastim. The results from 2 phase 3 studies demonstrate that eflapegrastim at a fixed dose of 13.2 mg (3.6 mg G-CSF) administered once per chemotherapy cycle is effective in prophylactic treatment of chemotherapy-induced neutropenia.
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Affiliation(s)
| | | | | | - Prasad Kolli
- Spectrum Pharmaceuticals, Inc., Irvine, California, USA
| | - Shanta Chawla
- Spectrum Pharmaceuticals, Inc., Irvine, California, USA
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Cobb PW, Moon YW, Mezei K, Láng I, Bhat G, Chawla S, Hasal SJ, Schwartzberg LS. A comparison of eflapegrastim to pegfilgrastim in the management of chemotherapy-induced neutropenia in patients with early-stage breast cancer undergoing cytotoxic chemotherapy (RECOVER): A Phase 3 study. Cancer Med 2020; 9:6234-6243. [PMID: 32687266 PMCID: PMC7476820 DOI: 10.1002/cam4.3227] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/15/2020] [Accepted: 05/26/2020] [Indexed: 11/23/2022] Open
Abstract
Eflapegrastim (Rolontis®) is a novel, long‐acting hematopoietic growth factor consisting of a recombinant human granulocyte‐colony stimulating factor (rhG‐CSF) analog conjugated to a human IgG4 Fc fragment via a short polyethylene glycol linker. We report results from a second pivotal, randomized, open‐label, Phase 3 study comparing the efficacy and safety of eflapegrastim to pegfilgrastim for reducing the risk of chemotherapy‐induced neutropenia. Patients with Stage I to IIIA early‐stage breast cancer (ESBC) were randomized 1:1 to fixed‐dose eflapegrastim 13.2 mg (3.6 mg G‐CSF) or pegfilgrastim (6 mg G‐CSF) administered one day after standard docetaxel/cyclophosphamide (TC) therapy for four cycles. The primary objective was to demonstrate noninferiority (NI) of eflapegrastim compared to pegfilgrastim in mean duration of severe neutropenia (DSN; Grade 4) in Cycle 1. A total of 237 eligible patients were randomized 1:1 to receive either eflapegrastim (n = 118) or pegfilgrastim (n = 119). Cycle 1 severe neutropenia was observed in 20.3% (n = 24) of patients receiving eflapegrastim and 23.5% (n = 28) receiving pegfilgrastim. The DSN of eflapegrastim in Cycle 1 was noninferior to pegfilgrastim with a mean difference of −0.074 days (NI P‐value < .0001). Noninferiority was maintained throughout the four treatment cycles (P < .0001 in all cycles). Other efficacy endpoints results were comparable between treatment arms, and adverse events, irrespective of causality and grade, were comparable between treatment arms. The results demonstrate noninferior efficacy and comparable safety for eflapegrastim, at a lower G‐CSF dose, vs pegfilgrastim. The potential for the increased potency of eflapegrastim to deliver improved clinical benefit warrants further clinical study.
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Affiliation(s)
- Patrick Wayne Cobb
- St. Vincent's Frontier Cancer Center, Frontier Cancer Center, Billings, MT, USA
| | | | - Klára Mezei
- Szabolcs-Szatmár - Bereg County Hospital, Nyíregyháza, Hungary
| | - István Láng
- National Institute of Oncology, Budapest, Hungary
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