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Al-Sawaf O. High-risk stays high-risk: Bruton tyrosine kinase inhibitors in B-cell malignancies. Haematologica 2024; 109:2035-2037. [PMID: 38450529 PMCID: PMC11215391 DOI: 10.3324/haematol.2024.285029] [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: 02/14/2024] [Accepted: 02/29/2024] [Indexed: 03/08/2024] Open
Abstract
Not available.
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Affiliation(s)
- Othman Al-Sawaf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Germany, Cancer Institute, University College London, UK and Francis Crick Institute, London, UK
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2
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Yin S, Zheng X, Zhang W, Zhao H, Zhang R, Li W, Chen F. Efficacy and safety of new-generation Bruton tyrosine kinase inhibitors in chronic lymphocytic leukemia/small lymphocytic lymphoma: a systematic review and meta-analysis. Ann Hematol 2024; 103:2231-2244. [PMID: 37843620 PMCID: PMC11224099 DOI: 10.1007/s00277-023-05486-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/27/2023] [Indexed: 10/17/2023]
Abstract
Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is a type of mature B lymphocyte clonal proliferative tumor with a specific immunophenotype. Bruton tyrosine kinase inhibitors (BTKi) have been approved for the treatment of CLL/SLL. However, the efficacy and safety of new-generation BTKi-based regimens have not been systematically studied. In this systematic review, we evaluated the efficacy and safety of new-generation BTKi-based regimens for the treatment of patients with CLL/SLL. A comprehensive search on PubMed, Embase, Cochrane Library, and ClinicalTrials.gov. up to January 31, 2023, was conducted by us. Studies reporting data on CLL/SLL patients treated with new-generation BTKi were included. We assessed the overall response rate (ORR), complete response (CR) rate, and 24-month OS/PFS rates for efficacy analysis. For safety analysis, we evaluated the incidence of grade ≥ 3 adverse events (AEs). The meta-analysis included twenty studies. The pooled ORR for new-generation BTKi was 92% (95% CI, 89-95%, I2 = 80.68%, P = 0.00), while the pooled CR rate was 10% (95% CI, 6-14%, I2 = 88.11%, P = 0.00). Research has found that the new-generation BTKi-based therapy had higher efficacy under the following treatment conditions: < 65 years old, treatment-naive (TN)-CLL, and BTKi combination therapy. The ORR/CR rates and 24-month OS/PFS rates of BTKi combination therapy were higher than that of BTKi monotherapy. Compared to acalabrutinib monotherapy, zanubrutinib monotherapy demonstrated higher ORR/CR rates and 24-month OS/PFS rates. Common grade ≥ 3 AEs included cytopenia and hypertension. The new-generation BTKi-based therapy has good tolerance and provides incremental benefits for CLL/SLL patients. Despite the superior efficacy of BTKi combination therapy compared to monotherapy, its AEs rates are relatively high. Compared to acalabrutinib, Zanubrutinib may be the preferred monotherapy for CLL. However, randomized-controlled studies are still needed.
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Affiliation(s)
- Shuo Yin
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Xiaohong Zheng
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Weichunbai Zhang
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Hanyun Zhao
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Rong Zhang
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Wenbin Li
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
| | - Feng Chen
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
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3
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Cheson BD, Sharman JP. Current Approaches and Novel New Agents in the Treatment of Chronic Lymphocytic Leukemia. JCO Oncol Pract 2024:OP2300770. [PMID: 38848511 DOI: 10.1200/op.23.00770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 04/04/2024] [Accepted: 04/16/2024] [Indexed: 06/09/2024] Open
Abstract
The treatment of CLL has evolved from traditional chemoimmunotherapy (CIT) to an increasing number of targeted and biologic approaches. Randomized trials have demonstrated superiority of covalent bruton tyrosine kinase inhibitors (cBTKis) over CIT, and second-generation compounds such as acalabrutinib and zanubrutinib appear to have a more favorable efficacy/safety profile than ibrutinib. The noncovalent BTKi, pirtobrutinib, has shown impressive activity after failure of the cBTKis and is quite tolerable. The Bcl-2 inhibitor venetoclax plus a CD20, generally obinutuzumab, provides a high level of efficacy as initial treatment or after failure on a cBTKi, with many patients achieving a state of undetectable minimal residual disease. Promising novel approaches include BTK degraders, bispecific antibodies, and chimeric antigen receptor T-cell (CAR-T)-cell therapy. What is clear is that CIT is archaic, and current and future targeted approaches will continue to improve the outcome for patients with chronic lymphocytic leukemia.
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Affiliation(s)
| | - Jeff P Sharman
- Willamette Valley Cancer Institute, Medical Director of Hematology Research: Sara Cannon, Eugene, OR
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Park D, Chan-Golston AM, Yan Y, Al-Manaseer F, Akhtari M. Meta-analysis of the efficacy and adverse effects of acalabrutinib in the management of relapsed/refractory chronic lymphocytic leukemia. J Chemother 2024:1-12. [PMID: 38803142 DOI: 10.1080/1120009x.2024.2357980] [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: 03/07/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024]
Abstract
The advent of Bruton tyrosine kinase inhibitor (BTKi) therapy with ibrutinib introduced a highly effective targeted therapy in the management of chronic lymphocytic leukemia (CLL). However, due to the adverse effect profile some patients cannot tolerate this novel therapy. Newer, more potent and targeted BTK inhibitors such as acalabrutinib have been developed. Acalabrutinib is an irreversible and second generation BTKi that covalently inhibits BTK with greater selectivity than ibrutinib. As novel BTKis are developed, a greater understanding of their efficacy and adverse effect rates can assist clinicians and patients in the shared clinical decision-making process. A search was conducted using the PICOS model and PRISMA guidelines. PubMeb, Embase, and Cochrane Library databases were searched using the keywords: Acalabrutinib, Acalabrutinib Monotherapy, Tyrosine Kinase Inhibitor, and Relapsed/Refractory (R/R) CLL. After initial literature review 12 studies were chosen for evaluation in this meta-analysis. Meta-analysis and follow up meta-regression models were completed. The results were as follows: ORR 82% (95% CI 74%-90%, I2 = 84.14%, p < 0.01), CR 4% (95% CI 2%-6%, I2 = 0.00%, p = 0.99), mortality rate 12% (95% CI 6%-19%, I2 = 87.23%, p < 0.01), mortality rate due to adverse effect 7% (95% CI 3%-10%, I2 = 67.67%, p = 0.01), mortality due to pneumonia 2% (95% CI 1%-3%, I2 = 0.00%, p = 0.43), mortality due to CLL progression 4% (95% CI 2%-6%, I2 = 61.03%, p = 0.04), neutropenia (≥ grade 3) 18% (95% CI 15%-20%, I2 = 0.00%, p = 0.70), thrombocytopenia (≥ grade 3) 7% (95% CI 4%-11%, I2 = 54%, p = 0.09), anemia (≥ grade 3) 9% (95% CI 6%-12%, I2 = 36.93%, p = 0.18), pneumonia (≥ grade 3) 10% (95% CI 6%-14%, I2 = 66.37%, p = 0.02) and atrial fibrillation 7% (95% CI 3%-11%, I2 = 80.13%, p = 0.00). The results demonstrate that acalabrutinib shows efficacy in the treatment of R/R CLL with tolerable adverse reaction rates.
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Affiliation(s)
- Daniel Park
- Department of Medicine, University of California San Francisco Medical Center-Fresno Campus, Fresno, California, USA
| | - Alec M Chan-Golston
- Department of Public Health, University of California, Merced, California, USA
| | - Yueqi Yan
- Health Sciences Research Institute, University of California, Merced, California, USA
| | - Farris Al-Manaseer
- Department of Internal Medicine, Loma Linda University School of Medicine, Loma Linda California, USA
| | - Mojtaba Akhtari
- Department of Medicine, Division of Hematology & Oncology, Loma Linda University School of Medicine, Loma Linda California, USA
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Fresa A, Innocenti I, Tomasso A, Stirparo L, Mosca A, Iadevaia F, Autore F, Ghia P, Laurenti L. Treatment Sequencing in Chronic Lymphocytic Leukemia in 2024: Where We Are and Where We Are Headed. Cancers (Basel) 2024; 16:2011. [PMID: 38893131 PMCID: PMC11171037 DOI: 10.3390/cancers16112011] [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: 04/16/2024] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
As treatments with BTK inhibitors and BCL2 inhibitors have replaced the use of chemoimmunotherapy in CLL in both first-line and relapsed patients, it becomes critical to rationalize their use and exploit the full potential of each drug. Despite their proven, robust, and manifest efficacy, BTKis and BCL2is fail to provide long-term disease control in some categories of patients, and to date this is an unmet clinical need that is critical to recognize and address. Ongoing clinical trials are evaluating new treatment algorithms and new molecules to progressively thin this population. In this review for each category of patients we explicate the different possible patterns of treatment sequencing based on currently available evidence, starting from the frontline to currently ongoing trials, in order to optimize therapies as much as possible.
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Affiliation(s)
- Alberto Fresa
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (A.F.); (I.I.); (F.A.)
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.T.); (L.S.); (A.M.); (F.I.)
| | - Idanna Innocenti
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (A.F.); (I.I.); (F.A.)
| | - Annamaria Tomasso
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.T.); (L.S.); (A.M.); (F.I.)
| | - Luca Stirparo
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.T.); (L.S.); (A.M.); (F.I.)
| | - Antonio Mosca
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.T.); (L.S.); (A.M.); (F.I.)
| | - Francesco Iadevaia
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.T.); (L.S.); (A.M.); (F.I.)
| | - Francesco Autore
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (A.F.); (I.I.); (F.A.)
| | - Paolo Ghia
- Division of Experimental Oncology, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Luca Laurenti
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (A.F.); (I.I.); (F.A.)
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.T.); (L.S.); (A.M.); (F.I.)
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6
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Galitzia A, Maccaferri M, Mauro FR, Murru R, Marasca R. Chronic Lymphocytic Leukemia: Management of Adverse Events in the Era of Targeted Agents. Cancers (Basel) 2024; 16:1996. [PMID: 38893115 PMCID: PMC11171383 DOI: 10.3390/cancers16111996] [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: 04/14/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
The treatment landscape for CLL has undergone a profound transformation with the advent of targeted agents (TAs) like Bruton's Tyrosine Kinase inhibitors (BTKis) and BCL-2 inhibitors (BCL-2is). These agents target crucial cellular pathways in CLL, offering superior efficacy over traditional chemo-immunotherapy, which has led to improved progression-free and overall survival rates. This advancement promises enhanced disease control and potentially normal life expectancy for many patients. However, the journey is not without challenges, as these TAs are associated with a range of adverse events (AEs) that can impact treatment efficacy and patient quality of life. This review focuses on detailing the various AEs related to TA management in CLL, evaluating their frequency and clinical impact. The aim is to present a comprehensive guide to the effective management of these AEs, ensuring optimal tolerability and efficacy of TAs. By reviewing the existing literature and consolidating findings, we provide insights into AE management, which is crucial for maximizing patient outcomes in CLL therapy.
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Affiliation(s)
- Andrea Galitzia
- Hematology and Stem Cell Transplantation Unit, Ospedale San Francesco, 08100 Nuoro, Italy;
| | - Monica Maccaferri
- Hematology Unit, Department of Oncology and Hematology, A.O.U of Modena, Policlinico, 41125 Modena, Italy; (M.M.); (R.M.)
| | - Francesca Romana Mauro
- Hematology, Department of Translational and Precision Medicine, Sapienza University, 00185 Rome, Italy;
| | - Roberta Murru
- Hematology and Stem Cell Transplantation Unit, Ospedale Oncologico A. Businco, ARNAS G. Brotzu, 09134 Cagliari, Italy
| | - Roberto Marasca
- Hematology Unit, Department of Oncology and Hematology, A.O.U of Modena, Policlinico, 41125 Modena, Italy; (M.M.); (R.M.)
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, 41121 Modena, Italy
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7
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Patton JT, Woyach JA. Targeting the B cell receptor signaling pathway in chronic lymphocytic leukemia. Semin Hematol 2024; 61:100-108. [PMID: 38749798 DOI: 10.1053/j.seminhematol.2024.04.002] [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: 11/14/2023] [Revised: 03/04/2024] [Accepted: 04/10/2024] [Indexed: 06/09/2024]
Abstract
Aberrant signal transduction through the B cell receptor (BCR) plays a critical role in the pathogenesis of chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). BCR-dependent signaling is necessary for the growth and survival of neoplastic cells, making inhibition of down-stream pathways a logical therapeutic strategy. Indeed, selective inhibitors against Bruton's tyrosine kinase (BTK) and phosphoinositide 3-kinase (PI3K) have been shown to induce high rates of response in CLL and other B cell lymphomas. In particular, the development of BTK inhibitors revolutionized the treatment approach to CLL, demonstrating long-term efficacy. While BTK inhibitors are widely used for multiple lines of treatment, PI3K inhibitors are much less commonly utilized, mainly due to toxicities. CLL remains an incurable disease and effective treatment options after relapse or development of TKI resistance are greatly needed. This review provides an overview of BCR signaling, a summary of the current therapeutic landscape, and a discussion of the ongoing trials targeting BCR-associated kinases.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Signal Transduction/drug effects
- Receptors, Antigen, B-Cell/metabolism
- Receptors, Antigen, B-Cell/antagonists & inhibitors
- Protein Kinase Inhibitors/therapeutic use
- Protein Kinase Inhibitors/pharmacology
- Agammaglobulinaemia Tyrosine Kinase/antagonists & inhibitors
- Agammaglobulinaemia Tyrosine Kinase/metabolism
- Molecular Targeted Therapy
- Antineoplastic Agents/therapeutic use
- Antineoplastic Agents/pharmacology
- Phosphoinositide-3 Kinase Inhibitors/therapeutic use
- Phosphoinositide-3 Kinase Inhibitors/pharmacology
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Affiliation(s)
- John T Patton
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Jennifer A Woyach
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH.
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Schmid VK, Hobeika E. B cell receptor signaling and associated pathways in the pathogenesis of chronic lymphocytic leukemia. Front Oncol 2024; 14:1339620. [PMID: 38469232 PMCID: PMC10926848 DOI: 10.3389/fonc.2024.1339620] [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: 11/16/2023] [Accepted: 02/06/2024] [Indexed: 03/13/2024] Open
Abstract
B cell antigen receptor (BCR) signaling is a key driver of growth and survival in both normal and malignant B cells. Several lines of evidence support an important pathogenic role of the BCR in chronic lymphocytic leukemia (CLL). The significant improvement of CLL patients' survival with the use of various BCR pathway targeting inhibitors, supports a crucial involvement of BCR signaling in the pathogenesis of CLL. Although the treatment landscape of CLL has significantly evolved in recent years, no agent has clearly demonstrated efficacy in patients with treatment-refractory CLL in the long run. To identify new drug targets and mechanisms of drug action in neoplastic B cells, a detailed understanding of the molecular mechanisms of leukemic transformation as well as CLL cell survival is required. In the last decades, studies of genetically modified CLL mouse models in line with CLL patient studies provided a variety of exciting data about BCR and BCR-associated kinases in their role in CLL pathogenesis as well as disease progression. BCR surface expression was identified as a particularly important factor regulating CLL cell survival. Also, BCR-associated kinases were shown to provide a crosstalk of the CLL cells with their tumor microenvironment, which highlights the significance of the cells' milieu in the assessment of disease progression and treatment. In this review, we summarize the major findings of recent CLL mouse as well as patient studies in regard to the BCR signalosome and discuss its relevance in the clinics.
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Affiliation(s)
| | - Elias Hobeika
- Institute of Immunology, Ulm University, Ulm, Germany
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9
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Bennett R, Seymour JF. Update on the management of relapsed/refractory chronic lymphocytic leukemia. Blood Cancer J 2024; 14:33. [PMID: 38378673 PMCID: PMC10879527 DOI: 10.1038/s41408-024-01001-1] [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: 12/19/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/22/2024] Open
Abstract
Chronic lymphocytic leukemia (CLL) predominantly affects older adults, characterized by a relapsing and remitting pattern with sequential treatments available for many patients. Identification of progressive/relapsed CLL should prompt close monitoring and early discussion about the next therapies when treatment indications are present. The intervening period represents an opportunity to optimize patient health, including establishing adequate vaccination and surveillance for second primary malignancies, and treating non-CLL-related comorbidities which may impact well-being and CLL therapy. We now see patients with relapsed/refractory (RR) CLL in the clinic who have been previously treated with chemoimmunotherapy (CIT) and/or one or more novel therapies. Continuous covalent inhibitors of Bruton's tyrosine kinase (cBTKi) and fixed-duration venetoclax (Ven)-anti-CD20 monoclonal antibody (mAb) are preferred over CIT given the survival advantages associated with these therapies, although have never been evaluated head-to-head. While both classes are effective for RR CLL, potential side effects and the logistics of administration differ. Few randomized data demonstrate the sequential use of cBTKi and fixed-duration Ven-anti-CD20 mAb; however, they may be used in either sequence. Newer non-covalent BTKi, active against BTK C481 resistance mutations emerging with continuous cBTKi exposure, and novel approaches such as BTK degraders, bispecific antibodies, and chimeric antigen receptor T-cell therapies demonstrate impressive efficacy. In this review of RR CLL we explore relevant investigations, consideration of broader CLL- and non-CLL-related health needs, and evidence for efficacy and safety of B-cell receptor inhibitors and Ven, including available data to support drug sequencing or switching. We describe novel approaches to RR CLL, including rechallenging with fixed-duration therapies, allogeneic stem cell transplant indications in the novel therapy era, and highlight early data supporting the use of T-cell directing therapies and novel drug targets.
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Affiliation(s)
- Rory Bennett
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia
| | - John F Seymour
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia.
- University of Melbourne, Grattan St, Parkville, Melbourne, VIC, 3010, Australia.
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10
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Sarosiek S, Castillo JJ. Waldenström Macroglobulinemia: Targeted Agents Taking Center Stage. Drugs 2024; 84:17-25. [PMID: 38055179 DOI: 10.1007/s40265-023-01974-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 12/07/2023]
Abstract
With the worldwide approval of the oral covalent Bruton tyrosine kinase (BTK) inhibitors ibrutinib and zanubrutinib for treating patients with Waldenström macroglobulinemia (WM), targeted agents have certainly taken center stage in the therapeutic landscape of WM. This review discusses the biological and clinical data supporting current and up-and-coming targeted agents in WM. Bruton tyrosine kinase inhibitors induce fast, deep, and durable responses in patients with WM, comparable to chemoimmunotherapy; however, there is a glaring absence of comparative studies between these regimens. The high response and progression-free survival rate and the ease of administration of BTK inhibitors must be balanced against their specific adverse-event profile with unique toxicity (e.g., bleeding and cardiac arrhythmia) and the indefinite duration of the therapy. Novel targeted agents of interest include BCL2 antagonists (e.g., venetoclax and sonrotoclax) and non-covalent BTK inhibitors (e.g., pirtobrutinib and nemtabrutinib), among others. The therapeutic landscape of patients with WM will benefit from the robust participation of patients in clinical trials.
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Affiliation(s)
- Shayna Sarosiek
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, 450 Brookline Ave, Mayer 221, Boston, MA, 02215, USA.
- Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | - Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, 450 Brookline Ave, Mayer 221, Boston, MA, 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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11
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Qiu TL, Miao Y, Li JY. [Advances in clinical research on novel BTK inhibitors for the treatment of chronic lymphocytic leukemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:963-968. [PMID: 38185530 PMCID: PMC10753254 DOI: 10.3760/cma.j.issn.0253-2727.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Indexed: 01/09/2024]
Affiliation(s)
- T L Qiu
- Department of Hematology, Key Laboratory of Nanjing Medical University, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing 210029, China
| | - Y Miao
- Department of Hematology, Key Laboratory of Nanjing Medical University, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing 210029, China
| | - J Y Li
- Department of Hematology, Key Laboratory of Nanjing Medical University, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing 210029, China
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12
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Song Y, Wu SJ, Shen Z, Zhao D, Chan TSY, Huang H, Qiu L, Li J, Tan TD, Zhu J, Song Y, Huang WH, Zhao W, Liu HSY, Xu W, Chen N, Ma J, Chang CS, Tse EWC. Chinese expert consensus on Bruton tyrosine kinase inhibitors in the treatment of B-cell malignancies. Exp Hematol Oncol 2023; 12:92. [PMID: 37845755 PMCID: PMC10578030 DOI: 10.1186/s40164-023-00448-5] [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: 07/19/2023] [Accepted: 09/15/2023] [Indexed: 10/18/2023] Open
Abstract
Targeted therapy with Bruton tyrosine kinase (BTK) inhibitors have revolutionized the treatment of patients with various B-cell malignancies. BTK inhibitors such as ibrutinib, zanubrutinib, orelabrutinib, and acalabrutinib have shown good clinical efficacy and better safety profiles than those of traditional chemotherapy and chemoimmunotherapy regimens. Multiple studies on new BTK inhibitors are ongoing, which may provide more therapeutic options for the treatment of B-cell malignancies. Considering the unmet need of evidence on BTK inhibitors in all clinical settings and to standardize the use of BTK inhibitors available in mainland China, Taiwan, Hong Kong, and Macau regions, this consensus has been formulated for the treatment of various B-cell malignancies based on the clinical practice and available evidences on the use of BTK inhibitors. The recommendations of this consensus will provide guidance to physicians and clinical researchers on the effective treatment of B-cell malignancies with BTK inhibitors.
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Affiliation(s)
- Yuqin Song
- Peking University Cancer Hospital and Institute, Beijing, China
| | - Shang-Ju Wu
- Hematology Division, Department of Internal Medicine, National Taiwan University Hospital, Taiwan, China
| | - Zhixiang Shen
- Shanghai Jiaotong University Affiliated Ruijin Hospital, Shanghai, China
| | - Donglu Zhao
- Harbin Hematology and Oncology Institute, Heilongjiang, 150007, China
| | | | | | - Lugui Qiu
- Institute of Hematology and Blood Diseases Hospital, Tianjing, China
| | - Jianyong Li
- Jiangsu Provincial People's Hospital, Jiangsu, China
| | - Tran-der Tan
- Department of Hematology and Medical Oncology, Koo Foundation Sun Yat-Sen Cancer Center, Taiwan, China
| | - Jun Zhu
- Peking University Cancer Hospital and Institute, Beijing, China
| | - Yongping Song
- The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Wei-Han Huang
- Department of Clinical Pathology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taiwan, China
| | - Weili Zhao
- Shanghai Jiaotong University Affiliated Ruijin Hospital, Shanghai, China
| | | | - Wei Xu
- Jiangsu Provincial People's Hospital, Jiangsu, China
| | - Naizhi Chen
- Macau Society of Hematology and Oncology, Macau, China
| | - Jun Ma
- Harbin Hematology and Oncology Institute, Heilongjiang, 150007, China.
| | - Cheng-Shyong Chang
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Bing Show Chwan Memorial Hospital, Taiwan, China.
- Department of Healthcare Administration, Central Taiwan University of Science and Technology, Taiwan, China.
| | - Eric Wai Choi Tse
- Department of Medicine, School of Clinical Medicine, University of Hong Kong, Hong Kong, China.
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13
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Abstract
PURPOSE OF REVIEW There have been significant advances in the treatment of relapsed/refractory chronic lymphocytic leukemia (CLL) over the past two decades. However, the intention of treatment remains control of the disease and delay of progression rather than a cure which remains largely elusive. Considering that CLL is mostly seen in older patients, there are multiple factors that play a role in the selection of CLL beyond the frontline treatment. Here, we review the concept of relapsed CLL, factors that predispose to relapse, and therapeutic options available to this patient population. We also review investigational therapies and provide a framework for selection of therapies in this setting. RECENT FINDINGS Targeted therapies with continuous BTK inhibitors (BTKi) or fixed duration venetoclax plus anti-CD20 monoclonal antibody therapy have established superiority over chemoimmunotherapy in relapsed CLL and have become the preferred standard of care treatment. The second-generation more selective BTK inhibitors (acalabrutinib and zanubrutinib) have shown improved safety profile compared to ibrutinib. However, resistance to the covalent BTK inhibitors may emerge and is commonly associated with mutations in BTK or other downstream enzymes. The novel non-covalent BTK inhibitors such as pirtobrutinib (Loxo-305) and nemtabrutinib (ARQ 531) are showing promising activities for relapsed CLL refractory to prior covalent BTKi. Other novel therapies such as chimeric antigen receptor (CAR) T cell therapy have also shown significant activities for relapsed and refractory CLL. Measurable residual disease (MRD) assessment has a growing importance in venetoclax-based limited-duration therapy and there is mounting evidence that MRD negativity improves outcomes. However, it remains to be seen if this will become an established clinically significant endpoint. Further, the optimal sequence of various treatment options remains to be determined. Patients with relapsed CLL now have more options for the treatment of the disease. The choice of therapy is best individualized especially in the absence of direct comparisons of targeted therapies, and the coming years will bring more data on the best sequence of use of the therapeutic agents.
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Affiliation(s)
- Oluwatobi Odetola
- Robert H. Lurie Comprehensive Cancer Center, Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 805, Chicago, IL, 60611, USA.
| | - Shuo Ma
- Robert H. Lurie Comprehensive Cancer Center, Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 805, Chicago, IL, 60611, USA
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14
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Simon F, Bohn JP. Next-Generation Sequencing-Optimal Sequencing of Therapies in Relapsed/Refractory Chronic Lymphocytic Leukemia (CLL). Curr Oncol Rep 2023; 25:1181-1189. [PMID: 37682487 PMCID: PMC10556156 DOI: 10.1007/s11912-023-01454-w] [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] [Accepted: 08/10/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW This research paper aims to provide an overview of evidence-based sequencing of therapies in relapsed/refractory chronic lymphocytic leukemia (CLL) in the era of targeted drugs. RECENT FINDINGS In the absence of data from randomized clinical trials comparing novel agents head-to-head, growing evidence suggests that patients with late relapse (> 2 years) after fixed-duration therapies benefit from identical retreatment, whereas a class switch is favorable in those with short-lived remissions or progressive disease on continuous drug intake. Treatment of patients previously exposed to both covalent inhibitors of BTK and BCL2 remains an unmet medical need. Novel drugs, in particular noncovalent BTKI, show promising efficacy in this difficult-to-treat subgroup in early clinical trials. The optimal sequencing of therapies in CLL requires consideration of individual patient factors and disease characteristics. Double-refractory disease continuous to pose a clinical challenge with a focus on participation in clinical trials whenever possible.
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Affiliation(s)
- Florian Simon
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German CLL Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Jan-Paul Bohn
- Department of Internal Medicine V, Hematology and Oncology, Comprehensive Cancer Center Innsbruck (CCCI), Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Innsbruck, Austria.
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15
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Quartermaine C, Ghazi SM, Yasin A, Awan FT, Fradley M, Wiczer T, Kalathoor S, Ferdousi M, Krishan S, Habib A, Shaaban A, Kola-Kehinde O, Kittai AS, Rogers KA, Grever M, Ruz P, Bhat S, Dickerson T, Byrd JC, Woyach J, Addison D. Cardiovascular Toxicities of BTK Inhibitors in Chronic Lymphocytic Leukemia: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2023; 5:570-590. [PMID: 37969643 PMCID: PMC10635896 DOI: 10.1016/j.jaccao.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 11/17/2023] Open
Abstract
Over the past decade, the treatment landscape of chronic lymphocytic leukemia (CLL) has dramatically changed, shifting from cytotoxic chemotherapy to targeted therapies. Bruton's tyrosine kinase (BTK) inhibitors have revolutionized the treatment of CLL and are increasingly applied in many other malignancies. However, ibrutinib, the first BTK inhibitor approved, is associated with serious toxicities, including atrial fibrillation in up to 38% of patients, ventricular arrhythmias, and other cardiovascular toxicities. Emerging data suggest several newer BTK inhibitors (eg, acalabrutinib, zanubrutinib) are still associated with cardiotoxic risks. This review examines the current state of evidence, including incidence rates, risk factors, mechanisms, and management strategies of cardiovascular toxicities with BTK inhibitors and other CLL therapies. We specifically focus on atrial fibrillation, ventricular arrhythmias/sudden death, hypertension, heart failure, bleeding, and stroke. We also touch on other emerging BTK therapies (eg, pirtobrutinib). Finally, we highlight key unanswered questions and future directions of research.
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Affiliation(s)
- Cooper Quartermaine
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Sanam M Ghazi
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Aneeq Yasin
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Farrukh T Awan
- Division of Hematology, UT-Southwestern Medical Center, Dallas, Texas, USA
| | - Michael Fradley
- Cardio-Oncology Program, Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tracy Wiczer
- Department of Pharmacy, James Cancer Hospital and Solove Research Institute, Columbus, Ohio, USA
| | - Sujay Kalathoor
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Mussammat Ferdousi
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Satyam Krishan
- Department of Medicine, University of Oklahoma Medical Center, Oklahoma City, Oklahoma, USA
| | - Alma Habib
- Division of Hematology, The Ohio State University, Columbus, Ohio, USA
| | - Adnan Shaaban
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Onaopepo Kola-Kehinde
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Adam S Kittai
- Division of Hematology, The Ohio State University, Columbus, Ohio, USA
| | - Kerry A Rogers
- Division of Hematology, The Ohio State University, Columbus, Ohio, USA
| | - Michael Grever
- Division of Hematology, The Ohio State University, Columbus, Ohio, USA
| | - Patrick Ruz
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Seema Bhat
- Division of Hematology, The Ohio State University, Columbus, Ohio, USA
| | - Tyler Dickerson
- Department of Pharmacy, James Cancer Hospital and Solove Research Institute, Columbus, Ohio, USA
| | - John C Byrd
- Department of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jennifer Woyach
- Division of Hematology, The Ohio State University, Columbus, Ohio, USA
| | - Daniel Addison
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
- Division of Cancer Prevention and Control, The Ohio State University, Columbus, Ohio, USA
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16
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Molica S, Tam C, Allsup D, Polliack A. Advancements in the Treatment of CLL: The Rise of Zanubrutinib as a Preferred Therapeutic Option. Cancers (Basel) 2023; 15:3737. [PMID: 37509398 PMCID: PMC10377923 DOI: 10.3390/cancers15143737] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/14/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023] Open
Abstract
Ibrutinib, the first-in-class Bruton's tyrosine kinase inhibitor (BTKi), is a commonly deployed therapeutic option for previously untreated and relapsed/refractory (R/R) patients with chronic lymphocytic leukemia (CLL). The use of ibrutinib is, however, partially limited by off-target side effects. Zanubrutinib (zanu) is a second-generation BTKi with enhanced target selectivity and occupancy of the kinase binding site. The SEQUOIA study showed that zanu significantly prolonged progression-free survival (PFS) when compared to bendamustine-rituximab (BR) in treatment-naive CLL patients. More recently, data from the phase III ALPINE trial, which directly compared zanu with ibrutinib, demonstrated that zanu's advantages include an improved safety profile as well as enhanced clinical efficacy. Based on the results of the SEQUOIA and ALPINE pivotal trials, the Food and Drug Administration (FDA) and European Medicines Agency (EMA) licensed zanu for the treatment of patients with CLL or small lymphocytic lymphoma (SLL) in January 2023. The updated (v2.2023) National Comprehensive Cancer Network (NCCN) guidelines and the most recent German CLL algorithm suggest that zanu may replace first-generation BTKis as a preferred therapeutic option for patients with CLL/SLL due to its increased selectivity for the kinase binding site, improved therapeutic efficacy, and favorable toxicity profile. Some drug class-related characteristics such as drug resistance, low complete remission (CR) rates, and indefinite treatment duration still remain with zanu, and the results from recently completed and ongoing fixed-duration clinical trials, combining zanu with an anti-BCL2 agent, are eagerly awaited with the possible promise of a reduced treatment duration and lower financial burden.
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Affiliation(s)
- Stefano Molica
- Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull University NHS Trust, Hull HU16 5JQ, UK
| | | | - David Allsup
- Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull University NHS Trust, Hull HU16 5JQ, UK
- Centre of Biomedicine, Hull York Medical School, University of Hull, Hull HU16 5JQ, UK
| | - Aaron Polliack
- Department of Hematology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel
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17
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Thompson PA, Tam CS. Pirtobrutinib: a new hope for patients with BTK inhibitor-refractory lymphoproliferative disorders. Blood 2023; 141:3137-3142. [PMID: 37156004 PMCID: PMC10646821 DOI: 10.1182/blood.2023020240] [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: 03/21/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/10/2023] Open
Abstract
Patients with lymphoproliferative disorders such as chronic lymphocytic leukemia and mantle cell lymphoma (MCL) who are resistant to covalent Bruton tyrosine kinase inhibitors (cBTKis), especially if also venetoclax refractory, have an unmet therapeutic need. Pirtobrutinib, a noncovalent BTKi, achieves high response rates in patients who are refractory to cBTKi, regardless of mechanism of cBTKi resistance. This led to recent accelerated US Food and Drug Administration approval in MCL. The toxicity profile in early studies suggests suitability for use in combination approaches. We summarize existing preclinical and clinical data for pirtobrutinib.
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Affiliation(s)
- Philip A. Thompson
- Clinical Haematology, Peter MacCallum Cancer Centre, Melbourne, Australia
- Clinical Haematology, Royal Melbourne Hospital, Parkville, Australia
- University of Melbourne, Parkville, Australia
| | - Constantine S. Tam
- The Alfred Hospital, Prahran, Australia
- Monash University, Clayton, Australia
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18
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Tohidi-Esfahani I, Trotman J. Dose of ibrutinib in Waldenström macroglobulinaemia: Less can be more. Br J Haematol 2023; 201:807-808. [PMID: 36715656 DOI: 10.1111/bjh.18664] [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: 01/11/2023] [Accepted: 01/11/2023] [Indexed: 01/31/2023]
Abstract
Ibrutinib changed the landscape of treatment in Waldenström macroglobulinaemia (WM) with excellent responses; however, there are high rates of dose reduction due to adverse events. The impact of this reduced dosing is unclear with regards to outcomes. Sarosiek and colleagues provide valuable data in a very large retrospective study demonstrating that dose reduction is effective in managing adverse events in the majority, with equivalent, if not better, outcomes than those without dose reductions.
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Affiliation(s)
- Ibrahim Tohidi-Esfahani
- Haematology Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Judith Trotman
- Haematology Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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19
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Seymour JF. Approach to relapsed CLL including Richter Transformation. Hematol Oncol 2023; 41 Suppl 1:136-143. [PMID: 37294971 DOI: 10.1002/hon.3146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 06/11/2023]
Affiliation(s)
- John F Seymour
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
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20
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[Expert consensus on the management of B-cell lymphoma-related cardiovascular diseases with Bruton tyrosine kinase inhibitors (2023)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:359-365. [PMID: 37550184 PMCID: PMC10440626 DOI: 10.3760/cma.j.issn.0253-2727.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Indexed: 08/09/2023]
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21
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Eyre TA, Riches JC. The Evolution of Therapies Targeting Bruton Tyrosine Kinase for the Treatment of Chronic Lymphocytic Leukaemia: Future Perspectives. Cancers (Basel) 2023; 15:cancers15092596. [PMID: 37174062 PMCID: PMC10177608 DOI: 10.3390/cancers15092596] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023] Open
Abstract
The development of inhibitors of Bruton tyrosine kinase (BTK) and B-cell lymphoma 2 (BCL2) has resulted in a paradigm shift in the treatment of chronic lymphocytic leukaemia (CLL) over the last decade. Observations regarding the importance of B-cell receptor signalling for the survival and proliferation of CLL cells led to the development of the first-in-class BTK inhibitor (BTKi), ibrutinib, for the treatment of CLL. Despite being better tolerated than chemoimmunotherapy, ibrutinib does have side effects, some of which are due to the off-target inhibition of kinases other than BTK. As a result, more specific inhibitors of BTK were developed, such as acalabrutinib and zanubrutinib, which have demonstrated equivalent/enhanced efficacy and improved tolerability in large randomized clinical trials. Despite the increased specificity for BTK, side effects and treatment resistance remain therapeutic challenges. As these drugs all bind covalently to BTK, an alternative approach was to develop noncovalent inhibitors of BTK, including pirtobrutinib and nemtabrutinib. The alternative mechanisms of BTK-binding of these agents has the potential to overcome resistance mutations, something that has been borne out in early clinical trial data. A further step in the clinical development of BTK inhibition has been the introduction of BTK degraders, which remove BTK by ubiquitination and proteasomal degradation, in marked contrast to BTK inhibition. This article will review the evolution of BTK inhibition for CLL and offer future perspectives on the sequencing of an increasing number of different agents, and how this may be impacted on by mutations in BTK itself and other kinases.
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Affiliation(s)
- Toby A Eyre
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Headington, Oxford OX3 7LE, UK
| | - John C Riches
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London EC1M 6BQ, UK
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22
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Mir SA, Madkhali Y, Firoz A, Al Othaim A, Alturaiki W, Almalki SG, Algarni A, Alsagaby SA. Inhibitory Potential of the Ocimum sanctum Phytochemicals on Bruton's Tyrosine Kinase, a Well-Known Drug Target for Treatment of Chronic Lymphocytic Leukemia: An In Silico Investigation. Molecules 2023; 28:molecules28083287. [PMID: 37110523 PMCID: PMC10144307 DOI: 10.3390/molecules28083287] [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: 03/07/2023] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 04/29/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is an incurable neoplasm of B-lymphocytes, which accounts for about one-third of all leukemias. Ocimum sanctum, an herbaceous perennial, is considered as one of the important sources of drugs for the treatment of various diseases, including cancers and autoimmune diseases. The present study was designed to screen various phytochemicals of O. sanctum for discovering their potential to inhibit Bruton's tyrosine kinase (BTK), a well-known drug target of CLL. Various phytochemicals of O. sanctum were screened for their potential to inhibit BTK using several in silico protocols. First, the molecular docking approach was used to calculate the docking scores of the selected phytochemicals. Then, the selected top-ranked phytochemicals were screened for their physicochemical characteristics using ADME analysis. Finally, the stability of the selected compounds in their corresponding docking complexes with BTK was analysed using molecular dynamics simulations. Primarily, our observations revealed that, out of the 46 phytochemicals of O. sanctum, six compounds possessed significantly better docking scores (ranging from -9.2 kcal/mol to -10 kcal/mol). Their docking scores were comparable to those of the control inhibitors, acalabrutinib (-10.3 kcal/mol), and ibrutinib (-11.3 kcal/mol). However, after ADME analysis of these top-ranked six compounds, only three compounds (Molludistin, Rosmarinic acid, and Vitexin) possessed drug likeliness characteristics. During the MD analysis, the three compounds Molludistin, Rosmarinic acid, and Vitexin were found to remain stable in the binding pocket in their corresponding docking complexes with BTK. Therefore, among the 46 phytochemicals of O. sanctum tested in this study, the three compounds, Molludistin, Rosmarinic acid, and Vitexin are the best inhibitors of BTK. However, these findings need to be confirmed by biological experiments in the laboratory.
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Affiliation(s)
- Shabir Ahmad Mir
- Department of Medical Laboratory Sciences, College of Applied Medical Science, Majmaah University, Al Majmaah 11952, Saudi Arabia
- Health and Basic Sciences Research Center, Majmaah University, Al Majmaah 11952, Saudi Arabia
| | - Yahya Madkhali
- Department of Medical Laboratory Sciences, College of Applied Medical Science, Majmaah University, Al Majmaah 11952, Saudi Arabia
| | - Ahmad Firoz
- Department of Biological Sciences, Faculty of Science, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Ayoub Al Othaim
- Department of Medical Laboratory Sciences, College of Applied Medical Science, Majmaah University, Al Majmaah 11952, Saudi Arabia
| | - Wael Alturaiki
- Department of Medical Laboratory Sciences, College of Applied Medical Science, Majmaah University, Al Majmaah 11952, Saudi Arabia
| | - Sami G Almalki
- Department of Medical Laboratory Sciences, College of Applied Medical Science, Majmaah University, Al Majmaah 11952, Saudi Arabia
| | - Abdulrahman Algarni
- Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, Northern Border University, Arar 91431, Saudi Arabia
| | - Suliman A Alsagaby
- Department of Medical Laboratory Sciences, College of Applied Medical Science, Majmaah University, Al Majmaah 11952, Saudi Arabia
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23
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Frustaci AM, Deodato M, Zamprogna G, Cairoli R, Montillo M, Tedeschi A. Next Generation BTK Inhibitors in CLL: Evolving Challenges and New Opportunities. Cancers (Basel) 2023; 15:cancers15051504. [PMID: 36900295 PMCID: PMC10000925 DOI: 10.3390/cancers15051504] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/05/2023] [Accepted: 02/24/2023] [Indexed: 03/08/2023] Open
Abstract
Ibrutinib revolutionized the CLL treatment approach and prognosis demonstrating its efficacy and safety even at extended follow-up. During the last few years, several next-generation inhibitors have been developed to overcome the occurrence of toxicity or resistance in patients on continuous treatment. In a head-to-head comparison of two phase III trials, both acalabrutinib and zanubrutinib demonstrated a lower incidence of adverse events in respect to ibrutinib. Nevertheless, resistance mutations remain a concern with continuous therapy and were demonstrated with both first- and next-generation covalent inhibitors. Reversible inhibitors showed efficacy independently of previous treatment and the presence of BTK mutations. Other strategies are currently under development in CLL, especially for high-risk patients, and include BTK inhibitor combinations with BCl2 inhibitors with or without anti-CD20 monoclonal antibodies. Finally, new mechanisms for BTK inhibition are under investigations in patients progressing with both covalent and non-covalent BTK and BCl2 inhibitors. Here we summarize and discuss results from main experiences on irreversible and reversable BTK inhibitors in CLL.
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24
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Dybowski S, Torke S, Weber MS. Targeting B Cells and Microglia in Multiple Sclerosis With Bruton Tyrosine Kinase Inhibitors: A Review. JAMA Neurol 2023; 80:404-414. [PMID: 36780171 DOI: 10.1001/jamaneurol.2022.5332] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Importance Currently, disease-modifying therapies for multiple sclerosis (MS) use 4 mechanisms of action: immune modulation, suppressing immune cell proliferation, inhibiting immune cell migration, or cellular depletion. Over the last decades, the repertoire substantially increased because of the conceptual progress that not only T cells but also B cells play an important pathogenic role in MS, fostered by the empirical success of B cell-depleting antibodies against the surface molecule CD20. Notwithstanding this advance, a continuous absence of B cells may harbor safety risks, such as a decline in the endogenous production of immunoglobulins. Accordingly, novel B cell-directed MS therapies are in development, such as inhibitors targeting Bruton tyrosine kinase (BTK). Observations BTK is centrally involved in the B cell receptor-mediated activation of B cells, one key requirement in the development of autoreactive B cells, but also in the activation of myeloid cells, such as macrophages and microglia. Various compounds in development differ in their binding mode, selectivity and specificity, relative inhibitory concentration, and potential to enter the central nervous system. The latter may be important in assessing whether BTK inhibition is a promising strategy to control inflammatory circuits within the brain, the key process that is assumed to drive MS progression. Accordingly, clinical trials using BTK inhibitors are currently conducted in patients with relapsing-remitting MS as well as progressive MS, so far generating encouraging data regarding efficacy and safety. Conclusions and Relevance While the novel approach of targeting BTK is highly promising, several questions remain unanswered, such as the long-term effects of using BTK inhibitors in the treatment of inflammatory CNS disease. Potential changes in circulating antibody levels should be evaluated and compared with B cell depletion. Also important is the potential of BTK inhibitors to enter the CNS, which depends on the given compound. Remaining questions involve where BTK inhibitors fit in the landscape of MS therapeutics. A comparative analysis of their distinct properties is necessary to identify which inhibitors may be used in relapsing vs progressive forms of MS as well as to clarify which agent may be most suitable for sequential use after anti-CD20 treatment.
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Affiliation(s)
- Sarah Dybowski
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
| | - Sebastian Torke
- Institute of Neuropathology, University Medical Center, Göttingen, Germany.,Experimental and Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Max-Delbrück-Center for Molecular Medicine, Berlin, Germany
| | - Martin S Weber
- Institute of Neuropathology, University Medical Center, Göttingen, Germany.,Department of Neurology, University Medical Center, Göttingen, Germany.,Fraunhofer Institute for Translational Medicine and Pharmacology, Göttingen, Germany
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25
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Castillo JJ, Buske C, Trotman J, Sarosiek S, Treon SP. Bruton tyrosine kinase inhibitors in the management of Waldenström macroglobulinemia. Am J Hematol 2023; 98:338-347. [PMID: 36415104 PMCID: PMC10107762 DOI: 10.1002/ajh.26788] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 11/08/2022] [Accepted: 11/14/2022] [Indexed: 11/24/2022]
Abstract
Bruton tyrosine kinase (BTK) inhibitors have taken a central role in the management of patients with Waldenström macroglobulinemia and are the only agents approved by the Food and Drug Administration (FDA) to treat these patients. Although associated with high rates of durable responses, unmet needs with BTK inhibitor therapy include indefinite duration therapy, high cost, scarcity of complete responses, and lower rates and shorter duration of response in patients with CXCR4 mutations. Herein, we review the data supporting the use of covalent BTK inhibitors, selected management issues, clinical trials with covalent BTK inhibitor combination regimens, and up-and-coming non-covalent BTK inhibitors.
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Affiliation(s)
- Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Christian Buske
- Comprehensive Cancer Center Ulm, Institute of Experimental Cancer Research, University Hospital Ulm, Ulm, Germany
| | - Judith Trotman
- Department of Haematology, Concord Repatriation General Hospital, Faculty of Medicine, University of Sydney, Concord, Australia
| | - Shayna Sarosiek
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Steven P Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
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26
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Kozaki R, Yasuhiro T, Kato H, Murai J, Hotta S, Ariza Y, Sakai S, Fujikawa R, Yoshida T. Investigation of the anti-tumor mechanism of tirabrutinib, a highly selective Bruton's tyrosine kinase inhibitor, by phosphoproteomics and transcriptomics. PLoS One 2023; 18:e0282166. [PMID: 36897912 PMCID: PMC10004634 DOI: 10.1371/journal.pone.0282166] [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: 06/07/2022] [Accepted: 02/09/2023] [Indexed: 03/11/2023] Open
Abstract
Tirabrutinib is a highly selective Bruton's tyrosine kinase (BTK) inhibitor used to treat hematological malignancies. We analyzed the anti-tumor mechanism of tirabrutinib using phosphoproteomic and transcriptomic methods. It is important to check the drug's selectivity against off-target proteins to understand the anti-tumor mechanism based on the on-target drug effect. Tirabrutinib's selectivity was evaluated by biochemical kinase profiling assays, peripheral blood mononuclear cell stimulation assays, and the BioMAP system. Next, in vitro and in vivo analyses of the anti-tumor mechanisms were conducted in activated B-cell-like diffuse large B-cell lymphoma (ABC-DLBCL) cells followed by phosphoproteomic and transcriptomic analyses. In vitro kinase assays showed that, compared with ibrutinib, tirabrutinib and other second-generation BTK inhibitors demonstrated a highly selective kinase profile. Data from in vitro cellular systems showed that tirabrutinib selectively affected B-cells. Tirabrutinib inhibited the cell growth of both TMD8 and U-2932 cells in correlation with the inhibition of BTK autophosphorylation. Phosphoproteomic analysis revealed the downregulation of ERK and AKT pathways in TMD8. In the TMD8 subcutaneous xenograft model, tirabrutinib showed a dose-dependent anti-tumor effect. Transcriptomic analysis indicated that IRF4 gene expression signatures had decreased in the tirabrutinib groups. In conclusion, tirabrutinib exerted an anti-tumor effect by regulating multiple BTK downstream signaling proteins, such as NF-κB, AKT, and ERK, in ABC-DLBCL.
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Affiliation(s)
- Ryohei Kozaki
- Discovery and Research, Ono Pharmaceutical Co., Ltd, Osaka, Japan
- * E-mail:
| | - Tomoko Yasuhiro
- Discovery and Research, Ono Pharmaceutical Co., Ltd, Osaka, Japan
| | - Hikaru Kato
- Discovery and Research, Ono Pharmaceutical Co., Ltd, Osaka, Japan
| | - Jun Murai
- Discovery and Research, Ono Pharmaceutical Co., Ltd, Osaka, Japan
| | - Shingo Hotta
- Discovery and Research, Ono Pharmaceutical Co., Ltd, Osaka, Japan
| | - Yuko Ariza
- Discovery and Research, Ono Pharmaceutical Co., Ltd, Osaka, Japan
| | - Shunsuke Sakai
- Discovery and Research, Ono Pharmaceutical Co., Ltd, Osaka, Japan
| | - Ryu Fujikawa
- Discovery and Research, Ono Pharmaceutical Co., Ltd, Osaka, Japan
| | - Takao Yoshida
- Discovery and Research, Ono Pharmaceutical Co., Ltd, Osaka, Japan
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Shadman M, Flinn IW, Levy MY, Porter RF, Burke JM, Zafar SF, Misleh J, Kingsley EC, Yimer HA, Freeman B, Rao SS, Chaudhry A, Tumula PK, Gandhi MD, Manda S, Chen DY, By K, Xu L, Liu Y, Crescenzo R, Idoine A, Zhang X, Cohen A, Huang J, Sharman JP. Zanubrutinib in patients with previously treated B-cell malignancies intolerant of previous Bruton tyrosine kinase inhibitors in the USA: a phase 2, open-label, single-arm study. Lancet Haematol 2023; 10:e35-e45. [PMID: 36400069 DOI: 10.1016/s2352-3026(22)00320-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/09/2022] [Accepted: 09/15/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND We hypothesised that zanubrutinib, a highly selective next-generation Bruton tyrosine kinase (BTK) inhibitor, would be a safe and active treatment for patients intolerant of ibrutinib, acalabrutinib, or both. We aimed to assess whether zanubrutinib would prolong treatment duration by minimising treatment-related toxicities and discontinuations in patients with previously treated B-cell malignancies. METHODS This ongoing, phase 2, multicentre, open-label, single-arm study was done in 20 centres in the USA. Patients aged 18 or older with previously treated B-cell malignancies (chronic lymphocytic leukaemia, small lymphocytic lymphoma, mantle cell lymphoma, Waldenström macroglobulinaemia, or marginal zone lymphoma) who became intolerant of ibrutinib, acalabrutinib, or both, were orally administered zanubrutinib 160 mg twice daily or 320 mg once daily per investigator. The primary endpoint was recurrence and change in severity of ibrutinib or acalabrutinib intolerance events based on investigator-assessed adverse events. Secondary endpoints were investigator-assessed overall response rate; duration of response; disease control rate; and progression-free survival. Analyses included all patients who received any dose of the study drug. This study is registered with ClinicalTrials.gov, NCT04116437. FINDINGS Between Oct 14, 2019, and Sept 8, 2021, 67 patients (36 [54%] men and 31 [46%] women) who were intolerant of ibrutinib (n=57; cohort 1) or of acalabrutinib or acalabrutinib and ibrutinib (n=10; cohort 2) were enrolled. 63 (94%) patients were White, one (2%) had multiple ethnicities, and three (5%) had unreported or unknown ethnicity. Most intolerance events (81 [70%] of 115 for ibrutinib; 15 [83%] of 18 for acalabrutinib) did not recur with zanubrutinib. Of the recurring events, seven (21%) of 34 ibrutinib intolerance events and two (67%) of three acalabrutinib intolerance events recurred at the same severity with zanubrutinib; 27 (79%) ibrutinib intolerance events and one (33%) acalabrutinib intolerance event recurred at a lower severity with zanubrutinib. No events recurred at higher severity. No grade 4 intolerance events recurred. 64 (96%) of 67 patients had one or more adverse events with zanubrutinib; the most common adverse events were contusion (in 15 [22%] of 67 patients), fatigue (14 [21%]), myalgia (ten [15%]), arthralgia (nine [13%]), and diarrhoea (nine [13%]). Atrial fibrillation occurred in three (4%) patients (all grade 2). Eight (12%) of 67 patients had serious adverse events (anaemia, atrial fibrillation, bronchitis, COVID-19, COVID-19 pneumonia, febrile neutropenia, salmonella gastroenteritis, transfusion reaction, trigeminal nerve disorder, and urinary tract infection). No treatment-related deaths occurred. The median follow-up time was 12·0 months (IQR 8·2-15·6). Among the 64 efficacy-evaluable patients, disease control rate was 93·8% (60; 95% CI 84·8-98·3) and overall response rate was 64·1% (41; 95% CI 51·1-75·7). The median duration of response was not reached; the 12-month event-free duration of response rate was 95·0% (95% CI 69·5-99·3). Similarly, median progression-free survival was not reached; 18-month progression-free survival was 83·8% (95% CI 62·6-93·6). INTERPRETATION Patients intolerant of previous BTK inhibitors have limited treatment options. These results suggest that zanubrutinib, a safe and viable treatment for patients with B-cell malignancies, might fill that unmet need for those who exhibit intolerance to ibrutinib or acalabrutinib. FUNDING BeiGene.
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Affiliation(s)
- Mazyar Shadman
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Division of Medical Oncology, University of Washington, Seattle, WA, USA.
| | - Ian W Flinn
- Sarah Cannon Research Institute/Tennessee Oncology, Nashville, TN, USA
| | - Moshe Y Levy
- Texas Oncology-Baylor Charles A Sammons Cancer Center, Dallas, TX, USA
| | | | - John M Burke
- Rocky Mountain Cancer Centers, US Oncology Research, Aurora, CO, USA
| | - Syed F Zafar
- Florida Cancer Specialists & Research Institute, Fort Myers, FL, USA
| | - Jamal Misleh
- Medical Oncology Hematology Consultants, Newark, DE, USA
| | | | - Habte A Yimer
- Texas Oncology-Tyler, US Oncology Research, Tyler, TX, USA
| | | | - Subramanya S Rao
- Affiliated Oncologists, Alpha Med Physicians Group, Tinley Park, IL, USA
| | | | | | | | - Sudhir Manda
- Arizona Oncology/US Oncology Research, Tucson, AZ, USA
| | | | | | | | - Ye Liu
- BeiGene USA, San Mateo, CA, USA; BeiGene Beijing, Beijing, China
| | | | | | | | | | | | - Jeff P Sharman
- Willamette Valley Cancer Institute and Research Center, US Oncology Research, Eugene, OR, USA
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Scarfò L. Novel therapies and combinations in CLL refractory to BTK inhibitors and venetoclax. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:316-322. [PMID: 36485153 PMCID: PMC9820511 DOI: 10.1182/hematology.2022000344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patients with chronic lymphocytic leukemia (CLL) refractory to covalent BTK and BCL2 inhibitors have a new unmet clinical need. Standard treatment options are able to obtain only limited and short-lasting disease control associated with reduced overall survival, and thus these patients have become ideal candidates for enrollment in clinical trials. Favorable results have been obtained with the use of noncovalent BTK inhibitors (roughly 70% overall response rate regardless of the actual resistance or intolerance to previous covalent BTK inhibitors) and anti-CD19 chimeric antigen receptor (CAR) T-cell therapy (with complete responses in up to 45% of cases and an undetectable measurable residual disease rate of 65% in the bone marrow). These 2 approaches should be considered valid options in this setting, although not yet approved. For young fit patients achieving remissions with salvage treatments, the option of allogeneic stem cell transplantation should be discussed as the outcome appears to be unaffected by number and type of previous targeted agents. Novel treatment strategies interfering with different mechanisms of CLL cell survival and proliferation are warranted, including small molecules with novel targets (eg, CDK9, MCL1, ERK inhibitors), CAR T cells targeting different antigens, CAR natural killer cells, or bispecific antibodies.
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Affiliation(s)
- Lydia Scarfò
- Università Vita-Salute San Raffaele, Milano, Italy
- IRCCS Ospedale San Raffaele, Milano, Italy
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Chronic lymphocytic leukemia treatment algorithm 2022. Blood Cancer J 2022; 12:161. [PMID: 36446777 PMCID: PMC9708674 DOI: 10.1038/s41408-022-00756-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 12/03/2022] Open
Abstract
The treatment landscape for patients with chronic lymphocytic leukemia (CLL) has changed considerably with the introduction of very effective oral targeted therapies (such as Bruton tyrosine kinase inhibitors and venetoclax) and next-generation anti-CD20 monoclonal antibodies (such as obinutuzumab). These agents lead to improved outcomes in patients with CLL, even among those with high-risk features, such as del17p13 or TP53 mutation and unmutated immunoglobulin heavy chain (IGHV) genes. Selecting the right treatment for the right patient requires consideration of disease characteristics and prior treatment sequence, as well as patient preferences and comorbidities. The CLL-International Prognostic Index (CLL-IPI) remains the best-validated tool in predicting the time to first therapy among previously untreated patients, which guides selection for early intervention efforts. This review summarizes our current approach to the management of CLL, right from the time of diagnosis through relapsed disease.
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30
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Wan Q, Li Q, Lai X, Xu T, Hu J, Peng H. Data mining and safety analysis of BTK inhibitors: A pharmacovigilance investigation based on the FAERS database. Front Pharmacol 2022; 13:995522. [PMID: 36438789 PMCID: PMC9691840 DOI: 10.3389/fphar.2022.995522] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 10/25/2022] [Indexed: 08/31/2023] Open
Abstract
Objective: The introduction of Bruton's tyrosine kinase (BTK) inhibitors was a milestone in the treatment of B-cell malignancies in recent years owing to its desired efficacy against chronic lymphocytic leukaemia and small cell lymphocytic lymphoma. However, safety issues have hindered its application in clinical practice. The current study aimed to explore the safety warning signals of BTK inhibitors in a real-world setting using the FDA Adverse Event Reporting System (FAERS) to provide reference for clinical rational drug use. Methods: Owing to the short marketing time of other drugs (zanbrutinib and orelabrutinib), we only analysed ibrutinib and acalabrutinib in this study. All data were obtained from the FAERS database from January 2004 to December 2021. Disproportionality analysis and Bayesian analysis were utilised to detect and assess the adverse event (AE) signals of BTK inhibitors. Results: In total, 43,429 reports of ibrutinib were extracted and 1527 AEs were identified, whereas 1742 reports of acalabrutinib were extracted and 220 AEs were identified by disproportionality analysis and Bayesian analysis. Among reports, males were more prone to develop AEs (58.2% for males vs. 35.6% for females treated with ibrutinib, and 55.9% vs. 31.9%, respectively, for acalabrutinib), and more than 30% of patients that suffered from AEs were over 65 years of age. Subsequently, we investigated the top 20 preferred terms (PTs) associated with the signal strength of ibrutinib and acalabrutinib, and our results identified 25 (13 vs. 12, respectively) novel risk signals. Among the top 20 PTs related to death reports, the terms infectious, pneumonia, pleural effusion, fall, asthenia, diarrhoea, and fatigue were all ranked high for these two BTK inhibitors. Further, cardiac disorders were also an important cause of death with ibrutinib. Conclusion: Patients treated with ibrutinib were more prone to develop AEs than those treated with acalabrutinib. Importantly, infection-related adverse reactions, such as pneumonia and pleural effusion, were the most common risk signals related to high mortality associated with both BTK inhibitors, especially in elderly patients. Moreover, cardiovascular-related adverse reactions, such as atrial fibrillation and cardiac failure, were fatal AEs associated with ibrutinib. Our results provide a rationale for physicians to choose suitable BTK inhibitors for different patients and provide appropriate monitoring to achieve safer therapy and longer survival.
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Affiliation(s)
- Qing Wan
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qiang Li
- Department of Chemotherapy, Jiangxi Cancer Hospital, Nanchang, China
| | - Xin Lai
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Tiantian Xu
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jinfang Hu
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hongwei Peng
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
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31
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Woyach JA. Management of relapsed/refractory Chronic Lymphocytic Leukemia. Am J Hematol 2022; 97 Suppl 2:S11-S18. [PMID: 36125037 PMCID: PMC9826056 DOI: 10.1002/ajh.26683] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/22/2022] [Accepted: 08/01/2022] [Indexed: 01/11/2023]
Abstract
The therapeutic landscape for chronic lymphocytic leukemia (CLL) has changed dramatically over the past decade as our understanding of the biology of CLL has advanced, allowing the development of oral therapies targeting key drivers of CLL. Currently, inhibitors of Bruton's Tyrosine Kinase and the BH3 mimetic venetoclax are standards of care for both frontline and relapsed/refractory CLL. Sequencing of available therapies, therefore, has become a major challenge of therapy. In this review, we will focus on the current landscape for the treatment of relapsed/refractory CLL. We will also discuss important considerations when sequencing these available treatments. The recent advances in this disease are significant steps forward, and raise new questions of how these available drugs should be given as well as how we can continue to improve the treatment of CLL.
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Affiliation(s)
- Jennifer A. Woyach
- Division of Hematology, Department of Internal MedicineThe Ohio State UniversityColumbusOhioUSA
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32
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Yin Y, Athanasiadis P, Karlsen L, Urban A, Xu H, Murali I, Fernandes SM, Arribas AJ, Hilli AK, Taskén K, Bertoni F, Mato AR, Normant E, Brown JR, Tjønnfjord GE, Aittokallio T, Skånland SS. Functional Testing to Characterize and Stratify PI3K Inhibitor Responses in Chronic Lymphocytic Leukemia. Clin Cancer Res 2022; 28:4444-4455. [PMID: 35998013 PMCID: PMC9588626 DOI: 10.1158/1078-0432.ccr-22-1221] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/17/2022] [Accepted: 08/19/2022] [Indexed: 01/21/2023]
Abstract
PURPOSE PI3K inhibitors (PI3Ki) are approved for relapsed chronic lymphocytic leukemia (CLL). Although patients may show an initial response to these therapies, development of treatment intolerance or resistance remain clinical challenges. To overcome these, prediction of individual treatment responses based on actionable biomarkers is needed. Here, we characterized the activity and cellular effects of 10 PI3Ki and investigated whether functional analyses can identify treatment vulnerabilities in PI3Ki-refractory/intolerant CLL and stratify responders to PI3Ki. EXPERIMENTAL DESIGN Peripheral blood mononuclear cell samples (n = 51 in total) from treatment-naïve and PI3Ki-treated patients with CLL were studied. Cells were profiled against 10 PI3Ki and the Bcl-2 antagonist venetoclax. Cell signaling and immune phenotypes were analyzed by flow cytometry. Cell viability was monitored by detection of cleaved caspase-3 and the CellTiter-Glo assay. RESULTS pan-PI3Kis were most effective at inhibiting PI3K signaling and cell viability, and showed activity in CLL cells from both treatment-naïve and idelalisib-refractory/intolerant patients. CLL cells from idelalisib-refractory/intolerant patients showed overall reduced protein phosphorylation levels. The pan-PI3Ki copanlisib, but not the p110δ inhibitor idelalisib, inhibited PI3K signaling in CD4+ and CD8+ T cells in addition to CD19+ B cells, but did not significantly affect T-cell numbers. Combination treatment with a PI3Ki and venetoclax resulted in synergistic induction of apoptosis. Analysis of drug sensitivities to 73 drug combinations and profiling of 31 proteins stratified responders to idelalisib and umbralisib, respectively. CONCLUSIONS Our findings suggest novel treatment vulnerabilities in idelalisib-refractory/intolerant CLL, and indicate that ex vivo functional profiling may stratify PI3Ki responders.
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Affiliation(s)
- Yanping Yin
- Department of Cancer Immunology, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
- K. G. Jebsen Centre for B Cell Malignancies, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - Paschalis Athanasiadis
- Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
- Oslo Centre for Biostatistics and Epidemiology (OCBE), Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Linda Karlsen
- Department of Cancer Immunology, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
- K. G. Jebsen Centre for B Cell Malignancies, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Aleksandra Urban
- Department of Cancer Immunology, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
- K. G. Jebsen Centre for B Cell Malignancies, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Haifeng Xu
- Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
- Oslo Centre for Biostatistics and Epidemiology (OCBE), Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ishwarya Murali
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Stacey M. Fernandes
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Alberto J. Arribas
- Institute of Oncology Research, Faculty of Biomedical Sciences, USI, 6500 Bellinzona, Switzerland
- SIB Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Abdul K. Hilli
- Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - Kjetil Taskén
- Department of Cancer Immunology, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
- K. G. Jebsen Centre for B Cell Malignancies, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Francesco Bertoni
- Institute of Oncology Research, Faculty of Biomedical Sciences, USI, 6500 Bellinzona, Switzerland
- Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, 6500 Bellinzona, Switzerland
| | | | | | - Jennifer R. Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Geir E. Tjønnfjord
- K. G. Jebsen Centre for B Cell Malignancies, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - Tero Aittokallio
- Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
- Oslo Centre for Biostatistics and Epidemiology (OCBE), Faculty of Medicine, University of Oslo, Oslo, Norway
- Institute for Molecular Medicine Finland (FIMM), HiLIFE, University of Helsinki, Helsinki, Finland
| | - Sigrid S. Skånland
- Department of Cancer Immunology, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
- K. G. Jebsen Centre for B Cell Malignancies, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Alu A, Lei H, Han X, Wei Y, Wei X. BTK inhibitors in the treatment of hematological malignancies and inflammatory diseases: mechanisms and clinical studies. J Hematol Oncol 2022; 15:138. [PMID: 36183125 PMCID: PMC9526392 DOI: 10.1186/s13045-022-01353-w] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/07/2022] [Indexed: 11/28/2022] Open
Abstract
Bruton's tyrosine kinase (BTK) is an essential component of multiple signaling pathways that regulate B cell and myeloid cell proliferation, survival, and functions, making it a promising therapeutic target for various B cell malignancies and inflammatory diseases. Five small molecule inhibitors have shown remarkable efficacy and have been approved to treat different types of hematological cancers, including ibrutinib, acalabrutinib, zanubrutinib, tirabrutinib, and orelabrutinib. The first-in-class agent, ibrutinib, has created a new era of chemotherapy-free treatment of B cell malignancies. Ibrutinib is so popular and became the fourth top-selling cancer drug worldwide in 2021. To reduce the off-target effects and overcome the acquired resistance of ibrutinib, significant efforts have been made in developing highly selective second- and third-generation BTK inhibitors and various combination approaches. Over the past few years, BTK inhibitors have also been repurposed for the treatment of inflammatory diseases. Promising data have been obtained from preclinical and early-phase clinical studies. In this review, we summarized current progress in applying BTK inhibitors in the treatment of hematological malignancies and inflammatory disorders, highlighting available results from clinical studies.
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Affiliation(s)
- Aqu Alu
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Hong Lei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xuejiao Han
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yuquan Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xiawei Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Dong R, Yan Y, Zeng X, Lin N, Tan B. Ibrutinib-Associated Cardiotoxicity: From the Pharmaceutical to the Clinical. Drug Des Devel Ther 2022; 16:3225-3239. [PMID: 36164415 PMCID: PMC9508996 DOI: 10.2147/dddt.s377697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/06/2022] [Indexed: 12/06/2022] Open
Abstract
Ibrutinib is the first-in-class Bruton tyrosine kinase (BTK) inhibitor that has revolutionized the treatment of B cell malignancies. Unfortunately, increased incidences of cardiotoxicity have limited its use. Despite over a decade of research, the biological mechanisms underlying ibrutinib cardiotoxicity remain unclear. In this review, we discuss the pharmacological properties of ibrutinib, the incidence and mechanisms of ibrutinib-induced cardiotoxicity, and practical management to prevent and treat this condition. We also synopsize and discuss the cardiovascular adverse effects related to other more selective BTK inhibitors, which may guide the selection of appropriate BTK inhibitors.
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Affiliation(s)
- Rong Dong
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People’s Republic of China
| | - Youyou Yan
- Translational Medicine Research Center, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 31006, People’s Republic of China
| | - Xiaokang Zeng
- Department of Critical Care Medicine, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 31006, People’s Republic of China
| | - Nengming Lin
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People’s Republic of China
- Translational Medicine Research Center, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 31006, People’s Republic of China
- Nengming Lin, Department of Clinical Pharmacy, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Room 903, No. 7 Building, Hangzhou, People’s Republic of China, Tel/Fax +86-571-56005600, Email
| | - Biqin Tan
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People’s Republic of China
- Correspondence: Biqin Tan, Department of Clinical Pharmacy, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Room 207, No. 5 Building, Hangzhou, People’s Republic of China, Tel +86-571-56007824, Fax +86-571-56005600, Email
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35
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Lovell AR, Jammal N, Bose P. Selecting the optimal BTK inhibitor therapy in CLL: rationale and practical considerations. Ther Adv Hematol 2022; 13:20406207221116577. [PMID: 35966045 PMCID: PMC9373150 DOI: 10.1177/20406207221116577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Bruton’s tyrosine kinase (BTK) inhibitors have dramatically changed the treatment
of newly diagnosed and relapsed/refractory chronic lymphocytic leukemia (CLL).
Ibrutinib, acalabrutinib, and zanubrutinib are Food and Drug Administration
(FDA)-approved BTK inhibitors that have all demonstrated progression-free
survival (PFS) benefit compared with chemoimmunotherapy. The efficacy of these
agents compared to one another is under study; however, current data suggest
they provide similar efficacy. Selectivity for BTK confers different adverse
effect profiles, and longer follow-up and real-world use have characterized side
effects over time. The choice of BTK inhibitor is largely patient-specific, and
this review aims to highlight the differences among the agents and guide the
choice of BTK inhibitor in clinical practice.
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Affiliation(s)
- Alexandra R Lovell
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nadya Jammal
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
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36
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Hatashima A, Karami M, Shadman M. Approved and emerging Bruton's tyrosine kinase inhibitors for the treatment of chronic lymphocytic leukemia. Expert Opin Pharmacother 2022; 23:1545-1557. [PMID: 35973973 DOI: 10.1080/14656566.2022.2113384] [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: 11/04/2022]
Abstract
INTRODUCTION The Bruton's tyrosine kinase (BTK) pathway has proven to be an effective and transformative therapeutic target in the treatment of chronic lymphocytic leukemia (CLL), fueling the growth of BTK inhibitors (BTKis) and landmark approval of first-generation BTKi, ibrutinib. However, ibrutinib's side effect profile left an unmet need for BTKis with improved tolerability thus spurring the subsequent development of second-generation acalabrutinib and zanubrutinib. The treatment landscape continues to evolve with studies using BTKi combination therapies, notably with venetoclax, with and without an anti-CD20 monoclonal antibody as well as third generation BTKis aimed to overcome BTKi resistance. AREAS COVERED This article details the current literature highlighting the efficacy, toxicities, and potential therapeutic combinations of approved and preclinical BTKis. EXPERT OPINION BTKis have signaled the start of a new treatment paradigm in CLL and improved clinical outcomes especially for patients with high-risk disease. However, drug resistance, low CR rates, and indefinite treatment necessitate the development of novel BTKis and fixed duration combination therapy. The results from recently completed and ongoing clinical trials are eagerly awaited with the potential promise of reduced treatment durations and financial burden while achieving durable remissions.
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Affiliation(s)
| | | | - Mazyar Shadman
- Fred Hutch Cancer Center, Seattle WA.,University of Washington, Seattle WA
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37
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Collins J, Stump SE, Heiling H, Muir M, Deal A, Proco D, Nguyen C, Cozad M, Mato A, Coombs CC, Muluneh B. Impact of adherence to ibrutinib on clinical outcomes in real-world patients with chronic lymphocytic leukemia. Leuk Lymphoma 2022; 63:1823-1830. [DOI: 10.1080/10428194.2022.2045597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- James Collins
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Sarah E. Stump
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Michele Muir
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
- GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Allison Deal
- UNC Lineberger Cancer Center, Chapel Hill, NC, USA
| | - Darrian Proco
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
- GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Catharine Nguyen
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Monica Cozad
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Anthony Mato
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Benyam Muluneh
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
- UNC Lineberger Cancer Center, Chapel Hill, NC, USA
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38
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Burke JM. SOHO State of the Art Updates and Next Questions | Management of Most Difficult Cases of Chronic Lymphocytic Leukemia: Relapse After Both BTK and BCL2 Inhibition and Richter Transformation. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:427-435. [PMID: 35577753 DOI: 10.1016/j.clml.2022.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/03/2022] [Accepted: 04/14/2022] [Indexed: 06/15/2023]
Abstract
The introduction of targeted therapies in chronic lymphocytic leukemia (CLL) has ushered in a new era in which patients achieve better control of their disease, survive longer, and experience fewer toxicities than before. Despite this progress, a subgroup of patients with CLL will develop resistance to both Bruton tyrosine kinase (BTK) and B-cell lymphoma 2 inhibitors. In addition, a subgroup of CLL cases will transform into aggressive lymphoma - called Richter transformation - either before or during targeted therapy. These two subgroups of patients have a poor prognosis, and available therapies lead to long-term remission in only a minority of patients. In this paper, two cases are presented that are reflective of these difficult scenarios. In the first case, a patient with CLL, complex karyotype, del 17p, and a mutation in TP53 experiences progression after ibrutinib, venetoclax, bendamustine, rituximab, and idelalisib. In the second case, a patient with CLL and del 17p develops a Richter transformation to diffuse large B-cell lymphoma after treatment with obinutuzumab, chlorambucil, ibrutinib, venetoclax, and idelalisib. The aggressive lymphoma is refractory to chemoimmunotherapy, and she expires. The literature pertaining to these two scenarios is reviewed, including the role of available targeted therapies, chemoimmunotherapy, and hematopoietic cell transplantation. Emerging novel therapies, including reversible BTK inhibitors and CAR T cell therapy, are discussed.
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Wierda WG, Brown J, Abramson JS, Awan F, Bilgrami SF, Bociek G, Brander D, Chanan-Khan AA, Coutre SE, Davis RS, Eradat H, Fletcher CD, Gaballa S, Ghobadi A, Hamid MS, Hernandez-Ilizaliturri F, Hill B, Kaesberg P, Kamdar M, Kaplan LD, Khan N, Kipps TJ, Ma S, Mato A, Mosse C, Schuster S, Siddiqi T, Stephens DM, Ujjani C, Wagner-Johnston N, Woyach JA, Ye JC, Dwyer MA, Sundar H. NCCN Guidelines® Insights: Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma, Version 3.2022. J Natl Compr Canc Netw 2022; 20:622-634. [PMID: 35714675 DOI: 10.6004/jnccn.2022.0031] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The treatment landscape of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) has significantly evolved in recent years. Targeted therapy with Bruton's tyrosine kinase (BTK) inhibitors and BCL-2 inhibitors has emerged as an effective chemotherapy-free option for patients with previously untreated or relapsed/refractory CLL/SLL. Undetectable minimal residual disease after the end of treatment is emerging as an important predictor of progression-free and overall survival for patients treated with fixed-duration BCL-2 inhibitor-based treatment. These NCCN Guidelines Insights discuss the updates to the NCCN Guidelines for CLL/SLL specific to the use of chemotherapy-free treatment options for patients with treatment-naïve and relapsed/refractory disease.
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Affiliation(s)
| | | | | | - Farrukh Awan
- UT Southwestern Simmons Comprehensive Cancer Center
| | | | | | | | | | | | | | | | | | | | - Armin Ghobadi
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Muhammad Saad Hamid
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | - Brian Hill
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | | | - Shuo Ma
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | | | | | - Chaitra Ujjani
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | - Jennifer A Woyach
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
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40
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Mato A. Optimizing Treatment of Patients With Relapsed or Refractory Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma. J Natl Compr Canc Netw 2022. [DOI: 10.6004/jnccn.2022.5008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Tremendous progress has been made in the treatment of relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) over the past few decades, starting with the development of glucocorticoids and alkylating agents, moving to combination chemotherapy, and then to chemoimmunotherapy. More recently, the advent of targeted agents has led to significant improvements in overall survival, progression-free survival, and quality of life. Most patients with R/R CLL and SLL are now treated with 1 of 5 approved targeted therapies rather than chemoimmunotherapy as standard of care. There are 2 main chemotherapy-free approaches in the R/R setting: Bruton’s tyrosine kinase inhibition and venetoclax-based therapy. Treatment after disease progression on first-line therapy depends on the initial choice of therapy, reason for discontinuation of prior lines of therapy, and available options.
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41
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Weis TM, Gutierrez J, Kabel CC, King AC, Daley RJ, Stump SE. Real-world management of targeted therapies in chronic lymphocytic leukemia. J Oncol Pharm Pract 2022; 28:1411-1433. [PMID: 35350909 DOI: 10.1177/10781552221090869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The advent of novel targeted therapies, including B-cell receptor (BCR) pathway and B-cell lymphoma 2 (BCL2) inhibitors, has substantially changed the treatment paradigm for chronic lymphocytic leukemia (CLL). Although targeted therapies have improved outcomes compared to traditional chemoimmunotherapy in the front-line and relapsed or refractory settings, they are associated with resistance mutations and suboptimal outcomes in certain high-risk patients. Additionally, targeted therapies are associated with drug interactions and unique adverse effect profiles which can be challenging for patients and clinicians to manage. Ongoing studies continue to address questions regarding optimal sequencing of therapies, the role of treatment combinations, and the efficacy of next-generation novel agents. This review provides a comprehensive overview regarding the clinical management of targeted therapies for CLL and applies current literature to clinical practice.
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Affiliation(s)
- Taylor M Weis
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Jillian Gutierrez
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Charlene C Kabel
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Amber C King
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Ryan J Daley
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Sarah E Stump
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
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42
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Walewska R, Parry-Jones N, Eyre TA, Follows G, Martinez-Calle N, McCarthy H, Parry H, Patten PEM, Riches JC, Hillmen P, Schuh AH. Guideline for the treatment of chronic lymphocytic leukaemia. Br J Haematol 2022; 197:544-557. [PMID: 35313007 DOI: 10.1111/bjh.18075] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/19/2022] [Accepted: 01/24/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Renata Walewska
- Department of Haematology, University Hospitals Dorset, Bournemouth, UK
| | - Nilima Parry-Jones
- Department of Haematology, Aneurin Bevan University Health Board, Wales, UK
| | - Toby A Eyre
- Department of Haematology, Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - Helen McCarthy
- Department of Haematology, University Hospitals Dorset, Bournemouth, UK
| | - Helen Parry
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Piers E M Patten
- Comprehensive Cancer Centre, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK.,Department of Haematology, King's College Hospital NHS Trust, London, UK
| | - John C Riches
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Peter Hillmen
- St. James's Institute of Oncology, Leeds, UK.,Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Anna H Schuh
- Department of Haematology, Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Department of Oncology, University of Oxford, John Radcliffe Hospital, Oxford, UK
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43
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Wolska-Washer A, Robak T. Acalabrutinib: a bruton tyrosine kinase inhibitor for the treatment of chronic lymphocytic leukemia. Expert Rev Hematol 2022; 15:183-194. [PMID: 35296194 DOI: 10.1080/17474086.2022.2054800] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : The first-in-class Bruton tyrosine kinase (BTK), ibrutinib, demonstrated remarkable activity in chronic lymphocytic leukemia (CLL). However, its toxicity profile renders it potentially inappropriate for use in patients with bleeding or cardiovascular disorders. In response to the high demand for a safer and efficient BTK inhibitor, with improved toxicity profile, acalabrutinib as a second-generation irreversible BTK inhibitor has been approved for the treatment of CLL. AREAS COVERED : This review examines the activity of acalabrutinib in treating treatment-naïve and relapsed refractory CLL and its toxicity profile when compared to ibrutinib and other drugs. It will examine the outcomes of the ELEVATE-TN, ASCEND and ELEVATE-RR studies in detail, with a particular focus on the safety and efficacy of acalabrutinib. The strengths and weaknesses of this drug will be highlighted and future directions for research will be identified. EXPERT OPINION : In patients with CLL, acalabrutinib demonstrates a superior safety profile than ibrutinib and similar activity. In the first direct comparison of acalabrutinib with ibrutinib in relapsed/refractory CLL, acalabrutinib was found to demonstrate non-inferior progression-free survival, with fewer cardiovascular adverse events.
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Affiliation(s)
- Anna Wolska-Washer
- Department of Experimental Hematology, Medical University of Lodz, Lodz, Poland.,Copernicus Memorial Hospital, Lodz, Poland
| | - Tadeusz Robak
- Copernicus Memorial Hospital, Lodz, Poland.,Department of Hematology, Medical University of Lodz, Lodz, Poland
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44
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Druggable Molecular Pathways in Chronic Lymphocytic Leukemia. Life (Basel) 2022; 12:life12020283. [PMID: 35207569 PMCID: PMC8875960 DOI: 10.3390/life12020283] [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] [Received: 12/24/2021] [Revised: 02/08/2022] [Accepted: 02/12/2022] [Indexed: 12/02/2022] Open
Abstract
Chronic lymphocytic leukemia (CLL), the most common type of leukemia in adults, is characterized by a high degree of clinical heterogeneity that is influenced by the disease’s molecular complexity. The genes most frequently affected in CLL cluster into specific biological pathways, including B-cell receptor (BCR) signaling, apoptosis, NF-κB, and NOTCH1 signaling. BCR signaling and the apoptosis pathway have been exploited to design targeted medicines for CLL therapy. Consistently, molecules that selectively inhibit specific BCR components, namely Bruton tyrosine kinase (BTK) and phosphoinositide 3-kinase (PI3K) as well as inhibitors of BCL2, have revolutionized the therapeutic management of CLL patients. Several BTK inhibitors and PI3K inhibitors with different modes of action are currently used or are in development in advanced stage clinical trials. Moreover, the restoration of apoptosis by the BCL2 inhibitor venetoclax offers meaningful clinical activity with a fixed-duration scheme. Inhibitors of the BCR and of BCL2 are able to overcome the chemorefractoriness associated with high-risk genetic features, including TP53 disruption. Other signaling cascades involved in CLL pathogenesis, in particular NOTCH signaling and NF-kB signaling, already provide biomarkers for a precision medicine approach to CLL and may represent potential druggable targets for the future. The aim of the present review is to discuss the druggable pathways of CLL and to provide the biological background of the high efficacy of targeted biological drugs in CLL.
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45
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Current Treatment of Chronic Lymphocytic Leukemia: The Diminishing Role of Chemoimmunotherapy. Drugs 2022; 82:133-143. [PMID: 34932207 PMCID: PMC9521791 DOI: 10.1007/s40265-021-01657-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 02/03/2023]
Abstract
In this review, we examine the literature supporting treatment decision making in the front-line and relapsed/refractory settings for patients with chronic lymphocytic leukemia (CLL). In the front-line setting, novel-agent-based approaches, including continuous Bruton tyrosine kinase (BTK) inhibitor-based therapy and time-limited venetoclax with obinutuzumab, have demonstrated survival benefit over chemoimmunotherapy. While novel-agent-based front-line approaches are appropriate for most patients, fludarabine, cyclophosphamide, and rituximab (FCR) remains a consideration for a selected population of young patients with immunoglobulin heavy chain variable region gene (IGHV)-mutated disease because of the possibility of a prolonged remission following FCR. As front-line novel-agent-based approaches have not been compared directly, decision making regarding which novel-agent-based approach to use in the front-line setting is often based on comorbidities and shared decision making. In the relapsed/refractory setting, BTK inhibitors, venetoclax-based therapy, and phosphoinositide 3-kinase (PI3K) inhibitors have demonstrated survival benefit when compared with chemoimmunotherapy regimens. Data to support various treatment sequences are limited, which highlights the need for prospective data to examine the optimal treatment sequence. Finally, we examine therapies with combinations of novel agents, and novel agents in development, including covalent and noncovalent BTK inhibitors, PI3K inhibitors, B-cell lymphoma 2 (BCL2) inhibitors, immunotherapies, and cellular therapies. With effective approved options and new agents in development, the role of chemoimmunotherapy in the management of CLL has diminished.
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46
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Kay NE, Hampel PJ, Van Dyke DL, Parikh SA. CLL update 2022: A continuing evolution in care. Blood Rev 2022; 54:100930. [DOI: 10.1016/j.blre.2022.100930] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 12/20/2022]
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47
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Shirley M. Bruton Tyrosine Kinase Inhibitors in B-Cell Malignancies: Their Use and Differential Features. Target Oncol 2022; 17:69-84. [PMID: 34905129 PMCID: PMC8783859 DOI: 10.1007/s11523-021-00857-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2021] [Indexed: 12/14/2022]
Abstract
Starting with the first-in-class agent ibrutinib, the development of Bruton tyrosine kinase (BTK) inhibitors has led to dramatic improvements in the management of B-cell malignancies. Subsequently, more-highly selective second-generation BTK inhibitors (including acalabrutinib, zanubrutinib, tirabrutinib and orelabrutinib) have been developed, primarily with an aim to reduce off-target toxicities. More recently, third-generation agents including the non-covalent BTK inhibitors pirtobrutinib and nemtabrutinib have entered later-stage clinical development. BTK inhibitors have shown strong activity in a range of B-cell malignancies, including chronic lymphocytic leukaemia/small lymphocytic lymphoma, mantle cell lymphoma, Waldenström's macroglobulinaemia and marginal zone lymphoma. The agents have acceptable tolerability, with adverse events generally being manageable with dosage modification. This review article summarises the evidence supporting the role of BTK inhibitors in the management of B-cell malignancies, including highlighting some differential features between agents.
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Affiliation(s)
- Matt Shirley
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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48
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Hallek M, Al‐Sawaf O. Chronic lymphocytic leukemia: 2022 update on diagnostic and therapeutic procedures. Am J Hematol 2021; 96:1679-1705. [PMID: 34625994 DOI: 10.1002/ajh.26367] [Citation(s) in RCA: 149] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/05/2021] [Indexed: 12/26/2022]
Abstract
DISEASE OVERVIEW Chronic lymphocytic leukemia (CLL) is one of the most frequent types of leukemia. It typically occurs in elderly patients and has a highly variable clinical course. Leukemic transformation is initiated by specific genomic alterations that interfere with the regulation of proliferation and of apoptosis in clonal B-cells. DIAGNOSIS The diagnosis is established by blood counts, blood smears, and immunophenotyping of circulating B-lymphocytes, which identify a clonal B-cell population carrying the CD5 antigen as well as typical B-cell markers. PROGNOSIS AND STAGING The clinical staging systems provide prognostic information by using the results of physical examination and blood counts. Various biological and genetic markers provide additional prognostic information. Deletions of the short arm of chromosome 17 (del[17p]) and/or mutations of the TP53 gene predict resistance to chemoimmunotherapy and a shorter time to progression with most targeted therapies. The CLL international prognostic index integrates genetic, biological, and clinical variables to identify distinct risk groups of patients with CLL. THERAPY Only patients with active or symptomatic disease or with advanced Binet or Rai stages require therapy. When treatment is indicated, several therapeutic options exist: a combination of the B-cell lymphoma 2 (BCL2) inhibitor venetoclax with obinutuzumab, monotherapy with inhibitors of Bruton tyrosine kinase (BTK) such as ibrutinib and acalabrutinib, or chemoimmunotherapy. At relapse, the initial treatment may be repeated, if the treatment-free interval exceeds 3 years. If the disease relapses earlier, therapy should be changed using an alternative regimen. Patients with a del(17p) or TP53 mutation are usually resistant to chemotherapy and should, therefore, be treated with targeted agents. FUTURE CHALLENGES Combinations of targeted agents are now being investigated to create efficient, potentially curative therapies of CLL with fixed duration. One of the most relevant questions currently addressed in clinical trials is the comparison of monotherapies with BTK inhibitors with fixed duration combination therapies. Moreover, the optimal sequencing of targeted therapies remains to be determined. Alternative therapies are needed for patients with BTK and BCL2 inhibitor double-refractory disease.
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Affiliation(s)
- Michael Hallek
- Department I of Internal Medicine, University of Cologne, Center for Integrated Oncology Aachen Bonn Köln Düsseldorf, Center of Excellence on “Cellular Stress Responses in Aging‐Associated Diseases” University of Cologne Köln Germany
| | - Othman Al‐Sawaf
- Department I of Internal Medicine, University of Cologne, Center for Integrated Oncology Aachen Bonn Köln Düsseldorf, Center of Excellence on “Cellular Stress Responses in Aging‐Associated Diseases” University of Cologne Köln Germany
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49
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Abdel-Qadir H, Sabrie N, Leong D, Pang A, Austin PC, Prica A, Nanthakumar K, Calvillo-Argüelles O, Lee DS, Thavendiranathan P. Cardiovascular Risk Associated With Ibrutinib Use in Chronic Lymphocytic Leukemia: A Population-Based Cohort Study. J Clin Oncol 2021; 39:3453-3462. [PMID: 34464154 DOI: 10.1200/jco.21.00693] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE Ibrutinib reduces mortality in chronic lymphocytic leukemia (CLL). It increases the risk of atrial fibrillation (AF) and bleeding and there are concerns about heart failure (HF) and central nervous system ischemic events. The magnitude of these risks remains poorly quantified. METHODS Using linked administrative databases, we conducted a population-based cohort study of Ontario patients who were treated for CLL diagnosed between 2007 and 2019. We matched ibrutinib-treated patients with controls treated with chemotherapy but unexposed to ibrutinib on prior AF, age ≥ 66 years, anticoagulant exposure, and propensity for receiving ibrutinib. Study outcomes were AF-related health care contact, hospital-diagnosed bleeding, new diagnoses of HF, and hospitalizations for stroke and acute myocardial infarction (AMI). The cumulative incidence function was used to estimate absolute risks. We used cause-specific regression to study the association of ibrutinib with bleeding rates, while adjusting for anticoagulation as a time-varying covariate. RESULTS We matched 778 pairs of ibrutinib-treated and unexposed patients with CLL (N = 1,556). The 3-year incidence of AF-related health care contact was 22.7% (95% CI, 19.0 to 26.6) in ibrutinib-treated patients and 11.7% (95% CI, 9.0 to 14.8) in controls. The 3-year risk of hospital-diagnosed bleeding was 8.8% (95% CI, 6.5 to 11.7) in ibrutinib-treated patients and 3.1% (95% CI, 1.9 to 4.6) in controls. Ibrutinib-treated patients were more likely to start anticoagulation after the index date. After adjusting for anticoagulation as a time-varying covariate, ibrutinib remained positively associated with bleeding (HR, 2.58; 95% CI, 1.76 to 3.78). The 3-year risk of HF was 7.7% (95% CI, 5.4 to 10.6%) in ibrutinib-treated patients and 3.6% (95% CI, 2.2 to 5.4) in controls. There was no significant difference in the risk of ischemic stroke or AMI. CONCLUSION Ibrutinib is associated with higher risk of AF, bleeding, and HF, but not AMI or stroke.
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Affiliation(s)
- Husam Abdel-Qadir
- Division of Cardiology and Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada.,Division of Cardiology, Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto
| | - Nasruddin Sabrie
- Division of Cardiology and Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - Darryl Leong
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrea Pang
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Peter C Austin
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Anca Prica
- Department of Medicine, University of Toronto.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Kumaraswamy Nanthakumar
- Division of Cardiology, Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto.,The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Oscar Calvillo-Argüelles
- Division of Cardiology, Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Douglas S Lee
- Division of Cardiology, Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto
| | - Paaladinesh Thavendiranathan
- Division of Cardiology, Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto
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50
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Integrated safety analysis of umbralisib, a dual PI3Kδ/CK1ε inhibitor, in relapsed/refractory lymphoid malignancies. Blood Adv 2021; 5:5332-5343. [PMID: 34547767 PMCID: PMC9153017 DOI: 10.1182/bloodadvances.2021005132] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/12/2021] [Indexed: 11/20/2022] Open
Abstract
Umbralisib is a unique PI3Kδ/casein kinase-1ε inhibitor with a tolerable safety profile in relapsed/refractory lymphoid malignancies. Low rates of immune-mediated toxicities were observed with umbralisib.
Phosphoinositide 3-kinase-δ (PI3Kδ) inhibitors are active in lymphoid malignancies, although associated toxicities can limit their use. Umbralisib is a dual inhibitor of PI3Kδ and casein kinase-1ε (CK1ε). This study analyzed integrated comprehensive toxicity data from 4 open-label, phase 1 and 2 studies that included 371 adult patients (median age, 67 years) with relapsed/refractory non-Hodgkin lymphoma (follicular lymphoma [n = 147]; marginal zone lymphoma [n = 82]; diffuse large B-cell lymphoma/mantle cell lymphoma [n = 74]; chronic lymphocytic leukemia [n = 43]; and other tumor types [n = 25]) who were treated with the recommended phase 2 dose of umbralisib 800 mg or higher once daily. At data cutoff, median duration of umbralisib treatment was 5.9 months (range, 0.1-75.1 months), and 107 patients (28.8%) received umbralisib for ≥12 months. Any-grade treatment-emergent adverse events (AEs) occurred in 366 (98.7%) of 371 patients, with the most frequent being diarrhea (52.3%), nausea (41.5%), and fatigue (31.8%). Grade 3 or higher treatment-emergent AEs occurred in 189 (50.9%) of 371 patients and included neutropenia (11.3%), diarrhea (7.3%), and increased aminotransferase levels (5.7%). Treatment-emergent serious AEs occurred in 95 (25.6%) of 371 patients. AEs of special interest were limited and included pneumonia (29 of 371 [7.8%]), noninfectious colitis (9 of 371 [2.4%]), and pneumonitis (4 of 371 [1.1%]). AEs led to discontinuation of umbralisib in 51 patients (13.7%). Four patients (1.1%) died of AEs, none of which was deemed related to umbralisib. No cumulative toxicities were reported. The favorable long-term tolerability profile and low rates of immune-mediated toxicities support the potential use of umbralisib for the benefit of a broad population of patients with lymphoid malignancies.
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