Drug interactions and oncological outcomes: a hidden adversary

Do proton pump inhibitors affect the effectiveness of cyclin-dependent kinase 4/6 inhibitors in advanced HR positive, HER2 negative breast cancer? A meta-analysis

Background

The CDK 4/6 inhibitors, including palbociclib and ribociclib, are the standard first-line treatment for hormone receptor-positive (HR+) and human epidermal growth factor receptor 2-negative (HER2-) metastatic breast cancer. Proton pump inhibitors are one of the most globally prescribed types of medications as part of the treatment for gastroesophageal reflux and heartburn complaints. Medication interactions have been demonstrated, leading to a decrease in the effectiveness of chemotherapy drugs such as capecitabine and pazopanib. However, their role and interaction with targeted therapies such as CDK inhibitors are still poorly understood.

Methods

We searched PubMed, Embase and Web of Science databases for studies that investigated the use of PPI with CDK 4/6 inhibitors versus CDK4/6 alone for advanced or metastatic breast cancer. We systematically searched for the currently available CDK inhibitors: palbociclib, ribociclib and abemaciclib. We computed hazard ratios (HRs), with 95% confidence intervals (CIs). We used DerSimonian and Laird random-effect models for all endpoints. Heterogeneity was assessed using I2 statistics. R, version 4.2.3, was used for statistical analyses.

Results

A total of 2,737 patients with advanced breast cancer in 9 studies were included, with six studies described the status menopausal as 217 (7.9%) pre-menopause and 1851 (67.6%) post-menopause, for endocrine sensitivity only five studies described1489 (54.4%) patients were endocrine-sensitive and 498 (182%) endocrine-resistent, 910 (33.2%) patients used PPIs. The overall Progression-Free Survival was in favor of the PPI non-users (HR 2.0901; 95% CI 1.410-2.9498; p < 0.001). As well as the subgroup taking palbociclib, revealing statistical relevance for the PPI non-users (HR 2.2539; 95% CI 1.3213-3.8446; p = 0.003) and ribociclib subgroup with a slight decrease in hazard ratio (HR 1.74 95% CI 1.02-2.97; p = 0.04; I2 = 40%). In the multivariate analysis, there was no statistical signifance with ECOG (HR 0.9081; 95% CI 0.4978-16566; p 0.753) and Age (HR 1.2772; 95% CI 0.8790-1.8559; p = 0.199). Either, the univariate analysis did not show statistical significance.

Conclusion

Women with HR+ and HER2-advanced metastatic breast undergoing treatment with targeted therapies, specifically CDK 4/6 inhibitors, should be monitored for the use of proton pump inhibitors. Therefore, the use of PPIs should be discussed, weighing the advantages and disadvantages for specific cases. It should be individualized based on the necessity in clinical practice for these cases.

Systematic Review Registration

identifier CRD42023484755.

Synthesis and Antiproliferative Potential of Thiazole and 4-Thiazolidinone Containing Motifs as Dual Inhibitors of EGFR and BRAFV600E

Thiazole and thiazolidinone recur in a wide range of biologically active compounds that reach different targets within the context of tumors and represent a promising starting point to access potential candidates for treating metastatic cancer. Therefore, searching for new lead compounds that show the highest anticancer potency with the fewest adverse effects is a major drug-discovery challenge. Because the thiazole ring is present in dasatinib, which is currently used in anticancer therapy, it is important to highlight the ring. In this study, cycloalkylidenehydrazinecarbothioamides (cyclopentyl, cyclohexyl, cyclooctyl, dihydronapthalenylidene, flurine-9-ylidene, and indolinonyl) reacted with 2-bromoacetophenone and diethylacetylenedicarboxylate to yield thiazole and 4-thiazolidinone derivatives. The structure of the products was confirmed by using infrared (IR) spectroscopy, nuclear magnetic resonance (NMR) spectroscopy, mass spectrometry, and single-crystal X-ray analyses. The antiproliferative activity of the newly synthesized compounds was evaluated. The most effective inhibitory compounds were further tested in vitro against both epidermal growth factor receptor (EGFR) and B-Raf proto-oncogene, serine/threonine kinase (BRAFV600E) targets. Additionally, molecular docking analysis examined how these molecules bind to the active sites of EGFR and BRAFV600E.

The use of therapeutic drug monitoring to highlight an over-looked drug-drug interaction leading to imatinib treatment failure

BACKGROUND

Chronic oral anticancer therapies, are increasingly prescribed and present new challenges including the enhanced risk of overlooked drug-drug interactions (DDIs). Lengthy treatments and patients' management by different professionals can lead to serious prescribing errors that therapeutic drug monitoring (TDM) can help identifying thus allowing a more effective and safer treatment of patients with polypharmacy.

OBJECTIVES

This report aims to exemplify how an intensified pharmacological approach could help in the clinical monitoring of patients on chronic treatments.

METHODS

A patient with gastrointestinal stromal tumor was referred to our clinical pharmacology service due to tumor progression while on imatinib therapy. The investigation was based on TDM, pharmacogenetics, DDI evaluation and Circulating tumor DNA (ctDNA) analysis. The patient underwent repeated blood samplings to measure imatinib and norimatinib plasma concentrations through a validated LC-MS/MS method. Polymorphisms affecting genes involved in imatinib metabolism and transport were investigated using SNPline PCR Genotyping System. Drug-drug interactions were evaluated though Lexicomp. ctDNA analysis was performed on MiSeq platform.

RESULTS

TDM analysis revealed that the patient was underexposed to imatinib (Cmin = 406 ng/mL; target Cmin = 1100 ng/mL). Subsequent DDI analysis highlighted a dangerous interaction with carbamazepine, via CYP3A4 and P-gp strong induction, omitted at the time of imatinib treatment start. No relevant pharmacogenetic variants were identified and appropriate compliance to treatment was ascertained. ctDNA monitoring was performed to assess potential tumor-related resistance to imatinib. Carbamazepine was cautiously switched to a non-interacting antiepileptic drug, restoting IMA plasma concentration (i.e. Cmin = 4298 ng/mL). The progression of the disease, which in turn led to the patient's death, was also witnessed by an increasing fraction of ctDNA in plasma.

CONCLUSION

The active pharmacological monitoring allowed the identification of a dangerous previously over-looked DDI leading to IMA under-exposure. The switch to a different antiepileptic treatment, reversed the effect of DDI, restoring therapeutic IMA plasmatic concentrations.

Frequencies of Combined Dysfunction of Cytochromes P450 2C9, 2C19, and 2D6 in an Italian Cohort: Suggestions for a More Appropriate Medication Prescribing Process

Improper drug prescription is a main cause of both drug-related harms (inefficacy and toxicity) and ineffective spending and waste of the healthcare system's resources. Nowadays, strategies to support an improved, informed prescription process may benefit from the adequate use of pharmacogenomic testing. Using next-generation sequencing, we analyzed the genomic profile for three major cytochromes P450 (CYP2C9, CYP2C19, CYP2D6) and studied the frequencies of dysfunctional isozymes (e.g., poor, intermediate, or rapid/ultra-rapid metabolizers) in a cohort of 298 Italian subjects. We found just 14.8% of subjects with a fully normal set of cytochromes, whereas 26.5% of subjects had combined cytochrome dysfunction (more than one isozyme involved). As improper drug prescription is more frequent, and more burdening, in polytreated patients, since drug-drug interactions also cause patient harm, we discuss the potential benefits of a more comprehensive PGX testing approach to support informed drug selection in such patients.

Nutritional status assessed by Patient-Generated Subjective Global Assessment is associated with toxicity to chemoradiotherapy in women with cervical cancer: a prospective study

BACKGROUND

Patient-generated subjective global assessment (PG-SGA), a validated tool for nutritional assessment, has been associated with worse clinical outcomes in patients with cancer. However, studies assessing its relationship in chemoradiotherapy outcomes are scarce. The study aimed to determine the prevalence of malnutrition according to PG-SGA and its association with the incidence of toxicity to chemoradiotherapy treatment in women with cervical cancer.

METHODS

In a single-centre prospective observational study, we enrolled 391 women with locally advanced cervical cancer. Patients were assessed on the day of their first chemotherapy infusion, when nutritional status was evaluated by the PG-SGA form and anthropometric measurements. Sociodemographic and clinical data were also collected. Toxicity to chemoradiotherapy was assessed weekly and toxicity-induced modification of treatment (TIMT) was defined as any serious adverse event that resulted in treatment delay, interruption, or dose reduction. Multivariate mixed-effects Poisson and Logistic regression models were performed to identify the factors contributing to the outcome number of adverse events ≥ grade 3 and TIMT, respectively.

RESULTS

Malnutrition was found in 47.6% of the population. Roughly 1/3 had TIMT and 54.2% experienced at least one symptom ≥grade 3. In the adjusted models, PG-SGA B and C, as well as the score ≥9 were independent predictors of the number of toxicity events ≥grade 3 and higher incidence of TIMT.

CONCLUSIONS

PG-SGA may represent an important assessment tool to predict toxicity outcomes in women with cervical cancer, besides being considered a simple, fast, and low-cost tool, which allows early nutritional care.

A Study of Self-Care Practice in Routine Radiotherapy Care: Identifying Differences Between Practitioners and Non-Practitioners in Sociodemographic, Clinical, Functional, and Quality-of-Life-Related Characteristics

Objectives:

The objective of this study was to describe self-care practice during radiotherapy for cancer and to identify potential differences between practitioners and non-practitioners of self-care regarding sociodemographic, clinical, functional, and quality-of-life-related characteristics.

Methods:

In this descriptive study, 439 patients (87% response rate) undergoing radiotherapy responded to a study questionnaire regarding self-care, sociodemographic, clinical (eg, experienced symptoms), functional, and quality-of-life-related characteristics.

Results:

Of the 439 patients, 189 (43%) practiced at least one self-care strategy, while 250 (57%) did not. In total, the patients described 332 self-care practices, resulting in 14 different categories of self-care strategies. The 5 most common indicators of practicing self-care were fatigue, general wellbeing, psychological symptoms, nausea, vomiting and improving physical condition. The 5 most common self-care strategies were physical activity, increased recovery, healthy eating, distraction, and skincare. Patients who were married, were older than 69, patients with less education than university education, patients undergoing a combination of internal and external radiotherapy, patients experiencing fewer than 8 symptoms, and better quality of life, practiced self-care to a lower extent than did other patients. Functional capacity did not differ between self-care practitioners and non-practitioners.

Conclusion and Implications for Practice:

Of the patients undergoing radiotherapy, slightly less than half practiced self-care during an ordinary week of radiotherapy. Because older and less-educated patients were less likely to practice self-care, cancer care practitioners should consider paying particular attention to helping such patients with their self-care practice.

Proton pump inhibitors may reduce the efficacy of ribociclib and palbociclib in metastatic breast cancer patients based on an observational study

INTRODUCTION

Approximately 20-33% of all cancer patients are treated with acid-reducing agents (ARAs), most commonly proton pump inhibitors (PPIs), to reduce gastroesophageal reflux disease symptoms. Palbociclib and ribociclib are weak bases so their solubility depends on different pH. The solubility of palbociclib dramatically decreases to < 0.5 mg/ml when pH is above 4,5 but ribociclibs' solubility decreases when pH increases above 6,5. In the current study, we aimed to investigate the effects of concurrent PPIs on palbociclib and ribociclib efficacy in terms of progression-free survival in metastatic breast cancer (mBC) patients.

PATIENTS AND METHODS

We enrolled hormone receptor-positive, HER2-negative mBC patients treated with endocrine treatment (letrozole or fulvestrant) combined palbociclib or ribociclib alone or with PPI accompanying our observational study. During palbociclib/ribociclib therapy, patients should be treated with "concurrent PPIs" defined as all or more than half of treatment with palbociclib/ribociclib, If no PPI was applied, it was defined as 'no concurrent PPI', those who used PPI but less than half were excluded from the study. All data was collected from real-life retrospectively.

RESULTS

Our study included 217 patients, 105 of whom received palbociclib and 112 received ribociclib treatment. In the study population CDK inhibitor treatment was added to fulvestrant 102 patients ( 47%), to letrozole 115 patients (53%). In the Palbociclib arm fulvestrant/letrozole ratio was 53.3/46.7%, in the ribociclib arm it was 41.07/58.93%. Of 105 patients who received palbociclib, 65 were on concomitant PPI therapy, 40 were not. Of the 112 patients who received ribociclib, 61 were on concomitant PPI therapy, 51 were not. In the palbociclib group, the PFS of the patients using PPIs was shorter than the PFS of the patients not using (13.04 months vs. unreachable, p < 0.001). It was determined that taking PPIs was an independent predictor of shortening PFS (p < 0.001) in the multivariate analysis, In the ribociclib group, the PFS of the patients using PPIs was shorter than the PFS of the patients not using (12.64 months vs. unreachable, p = 0.003). It was determined that taking PPIs was single statistically independent predictor of shortening PFS (p = 0.003, univariate analysis).

CONCLUSIONS

Our study demonstrated that concomitant usage of PPIs was associated with shorter PFS in mBC treated with both ribociclib and especially palbociclib. If it needs to be used, PPI selection should be made carefully and low-strength PPI or other ARAs (eg H2 antagonists, antacids) should be preferred.

Association of body composition with toxicity to first-line chemotherapy and three-year survival in women with ovarian adenocarcinoma

BACKGROUND

This study aimed to evaluate the association of body composition with toxicity to first-line chemotherapy and three-year survival in women with ovarian adenocarcinoma.

METHODS

We enrolled, in a retrospective cohort, 239 women treated with carboplatin and paclitaxel between 2008 and 2017. Pretreatment computed tomography scans were used to quantify skeletal muscle index (SMI), skeletal muscle radiodensity (SMD), and subcutaneous adipose tissue index (SATI). Chemotherapy doses, related toxicities, potential drug-drug interactions (DDI), and clinical variables were collected from medical records. Outcomes were the number of adverse events ≥ grade 3 toxicity, toxicity-induced modification of treatment (TIMT), and three-year survival.

RESULTS

Average age was 56.3 years and 35.1% had myopenia. Almost 33% had TIMT and 51.3% presented any grade 3 toxicity. Potential severe DDI occurred in 48.1% of the patients and 65.1% died three years after the first treatment. The SMD and SATI below the median were independent predictors for the number of adverse events ≥ grade 3 and TIMT. Also, SMD was the only body composition parameter able to predict reduced three-year survival. The SMI was not associated with any of the outcomes.

CONCLUSION

Fewer amounts of SATI and low SMD were associated with the occurrence of toxicity to chemotherapy, and the low SMD increased the risk of death in the three years after oncologic treatment.

Drug-drug interactions between palbociclib and proton pump inhibitors may significantly affect clinical outcome of metastatic breast cancer patients

Background

Proton-pump-inhibitors (PPIs) are frequently prescribed for the management of anticancer drug-related gastrointestinal symptoms. Palbociclib is a weak base with pH-dependent solubility and potential drug-drug interaction at the absorption level may affect clinical pharmacokinetics. The current study was aimed at investigating the effect of co-administration of PPIs and palbociclib on progression-free survival (PFS) in metastatic breast cancer (mBC) patients.

Patients and methods

Patients affected by estrogen receptor-positive, human epidermal growth factor receptor 2-negative mBC, who were candidates for first-line treatment with palbociclib, were enrolled in this retrospective observational study. Patients were defined as ‘no concomitant PPIs’ if no PPIs were administered during palbociclib treatment, and as ‘concomitant PPIs’ if the administration of PPIs covered the entire or not less than two-thirds of treatment with palbociclib. All clinical interventions were made according to clinical practice.

Results

A total of 112 patients were enrolled in the study; 56 belonged to the ‘no concomitant PPIs’ group and 56 to the ‘concomitant PPIs’ group. Seventy-one patients were endocrine-sensitive and received palbociclib and letrozole, and 43 were endocrine-resistant and were treated with palbociclib and fulvestrant. The most prescribed PPI was lansoprazole. Patients taking PPIs had a shorter PFS than those taking palbociclib and endocrine therapy alone (14.0 versus 37.9 months, P < 0.0001). Multivariate analysis confirmed concomitant PPIs as the only independent predictive factor for shorter PFS (P = 0.0002). PFS was significantly longer in estrogen-sensitive mBC with no concomitant PPIs compared with patients taking PPIs or estrogen-resistant patients, with and without PPIs (P < 0.0001). No correlation with adverse events was found when considering grade >2 hematological toxicities [Common Terminology Criteria for Adverse Events (CTCAE) scale].

Conclusions

The present study demonstrates that concomitant use of PPIs in mBC patients treated with palbociclib has a detrimental effect on PFS. Therefore, it is recommended to prescribe PPIs with caution in these patients, strictly adhering to the indications in the summary of product characteristics (RCP).

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PPIs are widely used in cancer patients to manage chemotherapy-related gastrointestinal adverse events.

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Palbociclib is a weak base with a pH-dependent solubility.

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Breast cancer patients treated with palbociclib and PPIs have significantly shorter PFS.

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Drug-drug interactions should be clearly evaluated in patients taking PPIs.