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Faiz AS, Guo S, Sridharan A, Lin Y, Philipp CS. Risk factors and mortality associated with venous thromboembolism in the elderly US population with chronic lymphocytic leukemia. Leuk Res 2024; 146:107585. [PMID: 39255637 DOI: 10.1016/j.leukres.2024.107585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 08/26/2024] [Accepted: 09/03/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND Venous thromboembolism (VTE) causes morbidity and mortality in cancer patients. The association of VTE with known risk factors in chronic lymphocytic leukemia (CLL) is not known. OBJECTIVE To examine risk factors and mortality associated with VTE in White, Black, and Asian CLL patients. METHODS The United States SEER-Medicare database (2000-2015) was used for CLL patients ≥ 65 years. Logistic regression was used to examine VTE risk factors and Cox proportional regression was used to evaluate the effect of VTE on mortality in White, Black, and Asian CLL patients. RESULTS Among 34,075 CLL patients, VTE was diagnosed in 11.6 % of 31,395 White, 14.6 % of 2062 Black and 6.3 % of 618 Asian patients. Risk of having VTE was, ORa = 1.2 (95 % CI, 1.0-1.4) for Black patients and ORa = 0.5 (95 % CI, 0.4-0.7) for Asian patients compared to White patients. Anemia and heart failure were associated with VTE in all three racial cohorts and were the only risk factors in Asian patients. Other risk factors in White patients were the same as in the overall population, including hypertension, obesity, COPD, kidney disease, diabetes, hyperlipidemia, myocardial infarction, and chemotherapy. In Black patients, other risk factors were hypertension, and chemotherapy. Mortality was slightly higher with VTE in the overall population and in White patients. CONCLUSION There was difference in VTE risk factors in White, Black, and Asian patients. VTE was marginally associated with mortality in CLL patients. Our findings may help to identify patients at higher risk of VTE in racially diverse CLL populations.
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Affiliation(s)
- Ambarina S Faiz
- Division of Hematology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Shuang Guo
- Division of Hematology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Ashwin Sridharan
- Division of Hematology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Yong Lin
- Department of Biostatistics, Rutgers School of Public Health, Piscataway, NJ, USA; Division of Biometrics, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Claire S Philipp
- Division of Hematology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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2
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Nunes RAB, Avezum Á, de Oliveira Marques M, Baiocchi OCCG, Bachour P. Three-year cardiovascular and non-cardiovascular adverse events in patients with chronic lymphocytic leukemia or small cell lymphocytic lymphoma treated with Bruton tyrosine kinase inhibitors acalabrutinib or ibrutinib: a real-world analysis. Ann Hematol 2024:10.1007/s00277-024-05921-7. [PMID: 39153144 DOI: 10.1007/s00277-024-05921-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 07/28/2024] [Indexed: 08/19/2024]
Abstract
Bruton tyrosine kinase (BTK) inhibitors play an important role in targeted treatment of B-cell lymphoproliferative disorders. However, adverse events may limit the proper course of treatment in many patients. The purpose of this study is to compare the risk of cardiovascular and non-cardiovascular adverse events in patients with chronic lymphocytic leukemia (CLL) or small cell lymphocytic lymphoma (SLL) treated with the first-generation BTK inhibitor ibrutinib versus second-generation acalabrutinib, using real-world data from a collaborative multinational network. We used data from the network (TriNetX), which encompasses more than 100 healthcare organizations worldwide. We queried the database for patients aged ≥ 18 years with chronic lymphocytic leukemia or small-cell lymphomas treated with ibrutinib or acalabrutinib in the past ten years before the analysis. We used propensity score matching to balance the cohorts. The 3-year cumulative incidences and hazard ratios for the following outcomes were calculated: atrial flutter or fibrillation, other arrhythmias, heart failure, ischemic stroke or peripheral embolism, acute coronary syndrome, bleeding, and sepsis. We compared 2,107 patients in each group. Atrial fibrillation or flutter occurred in 150 (7.1%) patients with acalabrutinib and 310 (14.7%) patients with ibrutinib during the 3-year follow-up (hazard ratio, 0.68, 95% CI 0.55-0.84). New-onset hypertension occurred in 342 (16.3%) patients in the acalabrutinib group and 584 (27.7%) patients in the ibrutinib group (hazard ratio 0.81, 95% CI 0.66-0.98). Sepsis was diagnosed in 136 (6.5%) patients in the acalabrutinib group versus 239 (11.3%) patients in the ibrutinib group (hazard ratio 0.77, 95 CI 0.60-0.98). The two groups had no significant differences concerning the other adverse events. In a large retrospective cohort using real-world data from electronic medical registers, patients with CLL or SLL treated with acalabrutinib had a better cardiovascular and non-cardiovascular safety profile than those treated with ibrutinib, with lower risks of atrial flutter or fibrillation, new-onset arterial hypertension, and sepsis.
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Affiliation(s)
- Rafael Amorim Belo Nunes
- Department of Cardiology, Hospital Alemão Oswaldo Cruz, Rua Treze de Maio 1815, 1º subsolo Bloco B, Bela Vista, São Paulo, SP, 01323-020, Brazil.
| | - Álvaro Avezum
- Department of Cardiology, Hospital Alemão Oswaldo Cruz, Rua Treze de Maio 1815, 1º subsolo Bloco B, Bela Vista, São Paulo, SP, 01323-020, Brazil
| | | | | | - Philip Bachour
- Department of Hematology and Bone Marrow Transplant, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
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3
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Li X, Shang N, Yan Q, Yue X, Liu Y, Zheng X. Investigating bleeding adverse events associated with BTK inhibitors in the food and drug administration adverse event reporting system (FAERS). Expert Opin Drug Saf 2024:1-10. [PMID: 38568245 DOI: 10.1080/14740338.2024.2339448] [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: 02/14/2024] [Accepted: 03/28/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND This study analyzed the bleeding adverse events (AEs) resulting from the treatment of B-cell lymphoma with Bruton tyrosine kinase (BTK) inhibitors, according to reports in the US Food and Drug Administration's Adverse Event Reporting System (FAERS). METHODS Bleeding AEs associated with BTK inhibitors (including ibrutinib, zanubrutinib, and acalabrutinib) from the first quarter of 2013 to the third quarter of 2023 were extracted. Reporting odds ratio (ROR) and proportional reporting ratio (PRR) were reported. Preferred Terms (PTs) of Medical Dictionary for Regulatory Activities (MedDRA) terms were mapped to System Organ Class terms (SOC) terms and analyzed bleeding AEs associated with three BTK inhibitors. RESULTS A total of 463 cases of bleeding AEs were included. Contusion, subcutaneous hemorrhage, hematuria, and cerebral hemorrhage were included in PTs. Blood urine was present and subdural hematoma were also reported. The incidence of bleeding AEs was higher with ibrutinib (Case number = 10,696) than with zanubrutinib (Case number = 213) and acalabrutinib (Case number = 314). CONCLUSION Our findings indicate that bleeding AEs linked to BTK inhibitors in various conditions underscore the need for cautious clinical decision-making, particularly in nervous system disorders, injuries, poisoning, surgical complications, vascular disorders, and others.
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Affiliation(s)
- Xianlin Li
- Department of Pharmacy, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Nan Shang
- Department of Pharmacy, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Qianci Yan
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xiunan Yue
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yang Liu
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xiaojun Zheng
- Department of Pharmacy, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
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4
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Gomaa A, Skelly R. Pituitary macroadenoma apoplexy as a rare complication of Bruton tyrosine kinase inhibitor in chronic lymphoid leukaemia. Chin Neurosurg J 2023; 9:30. [PMID: 37875968 PMCID: PMC10594721 DOI: 10.1186/s41016-023-00345-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/10/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Pituitary apoplexy is a neurosurgical emergency and is a known yet rare complication of pituitary macroadenoma. Patients typically present with visual field defects, headache and altered sensorium. There are multiple risk factors for this complication and a thorough drug history is essential to exclude iatrogenic causes of disease. We present an extremely rare case of newly diagnosed pituitary insufficiency unveiled by ibrutinib therapy (a Bruton tyrosine kinase inhibitor). Furthermore, after initial withdrawal of ibrutinib because of the erroneous diagnosis of Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH), its re-administration led to the development of classical pituitary apoplexy 4 months after treatment was restarted. CASE PRESENTATION A male patient in his 60s with a background of chronic lymphocytic leukaemia (CLL) on ibrutinib and venetoclax presents with acute confusion and deranged electrolytes. He is found to be hyponatraemic and is diagnosed with Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) and treated with fluid restriction. He represents again 3 weeks later with hyponatraemia and further investigations reveal pituitary insufficiency and macroadenoma. He was restarted on ibrutinib and venetoclax at the time of discharge. Four months later, he presents with sudden retro-orbital headache associated with vomiting. Clinical findings include cranial nerve III, IV and XI palsy. Humphrey's visual field examination revealed a left visual field index (VFI) of only 1% while the right was 64% with temporal hemianopia. Both pupils were mid-dilated and poorly reactive to light. MRI pituitary with contrast showed features of pituitary apoplexy and optic nerve compression. He was urgently referred to the neurosurgical team and underwent an emergency trans-sphenoidal hypophysectomy with circumferential excision of the macroadenoma. Post-operative recovery was uneventful with marked improvement in vision bilaterally. The patient was restarted on ibrutinib and venetoclax 2 weeks post-operatively. Approximately 1 year post-treatment, he remains in radiological, clinical and biochemical remission from CLL and all medications have been withdrawn. CONCLUSIONS This is a unique and rare case of pituitary macroadenoma apoplexy following the commencement of ibrutinib for CLL. Central nervous system haemorrhage is a rare side effect of ibrutinib due to its platelet dysfunction effects. A thorough assessment is required to assess the risks and benefits of using ibrutinib in patients with pituitary macroadenoma to avoid serious complications.
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Affiliation(s)
- Aysha Gomaa
- East Sussex Healthcare NHS Trust, Eastbourne, UK.
- East Suffolk and North Essex NHS Foundation Trust, Colcchester, UK.
| | - Robert Skelly
- East Suffolk and North Essex NHS Foundation Trust, Colcchester, UK
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5
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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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6
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Johnson G, Baviriseaty N, Massanet N, Kooper J. Serositis causing pericardial and pleural effusions after eight years of maintenance ibrutinib for Waldenstrom's macroglobulinemia. J Oncol Pharm Pract 2023:10781552231171925. [PMID: 37097903 DOI: 10.1177/10781552231171925] [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: 04/26/2023]
Abstract
INTRODUCTION Ibrutinib is a tyrosine kinase inhibitor approved for multiple B-cell malignancies, including Waldenstrom's macroglobulinemia in 2014. Although the drug portends favorable outcomes, it also bears a profile of side effects. Current literature describes only two cases of nonhemorrhagic pericardial effusion associated with ibrutinib use, and here we present the third. This case recounts an episode of serositis causing pericardial and pleural effusions and diffuse edema after eight years of maintenance ibrutinib for Waldenstrom's macroglobulinemia (WM). CASE REPORT A 90-year-old male with WM and atrial fibrillation presented to the emergency department for a week of progressive periorbital and upper and lower extremity edema, dyspnea, and gross hematuria, despite increasing at-home diuretic dose. The patient was on 140 mg ibrutinib twice daily. Labs showed stable creatinine, serum IgMs of 97, and negative serum and urine protein electrophoresis. Imaging revealed bilateral pleural effusions and pericardial effusion with impending tamponade. All other workup was unrevealing, diuretics were ceased, pericardial effusion was monitored with serial echocardiograms, and ibrutinib was exchanged for low-dose prednisone. MANAGEMENT AND OUTCOME After five days, the effusions and edema dissipated, hematuria resolved, and patient was discharged. Resumption of lower dose ibrutinib one month later led to a subsequent return of edema, which again subsided with cessation. Reevaluation of maintenance therapy continues outpatient. CONCLUSION Patients on ibrutinib presenting with dyspnea and edema should be monitored for pericardial effusion; the drug should be held in exchange for anti-inflammatory therapy, and future management should involve cautious, low-dose resumption, or exchange for alternative therapy.
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Affiliation(s)
- Grace Johnson
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | | | - Nicholas Massanet
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Jeffrey Kooper
- James A Haley Veteran's Affairs Hospital, Tampa, FL, USA
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7
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Gent DG, Rivera-Caravaca JM, Dobson R, Wright DJ, Lip GYH. Ibrutinib use and adverse cardiovascular outcomes: A United States federated electronic medical records analysis. Eur J Intern Med 2023; 108:117-119. [PMID: 36163123 DOI: 10.1016/j.ejim.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/12/2022] [Accepted: 09/18/2022] [Indexed: 02/07/2023]
Affiliation(s)
- David G Gent
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
| | - José M Rivera-Caravaca
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Rebecca Dobson
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - David J Wright
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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8
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Dhopeshwarkar N, Yang W, Hennessy S, Rhodes JM, Cuker A, Leonard CE. Rate of major bleeding with ibrutinib versus bendamustine-rituximab in chronic lymphocytic leukemia: A population-based cohort study. Am J Hematol 2022; 97:E332-E335. [PMID: 35713560 PMCID: PMC10368070 DOI: 10.1002/ajh.26632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/03/2022] [Accepted: 06/13/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Neil Dhopeshwarkar
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, PerelmanSchool of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wei Yang
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, PerelmanSchool of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, PerelmanSchool of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joanna M. Rhodes
- Division of Hematology/Medical Oncology, Department of Medicine, Northwell Health, New Hyde Park, New York, USA
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charles E. Leonard
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, PerelmanSchool of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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9
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Madnick DL, Fradley MG. Atrial Fibrillation and Cancer Patients: Mechanisms and Management. Curr Cardiol Rep 2022; 24:1517-1527. [PMID: 35976601 DOI: 10.1007/s11886-022-01769-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Cancer-related mortality has significantly declined over the past several decades as a result of improved screening, diagnostics, and therapeutics. Although cancer patients and survivors are living longer, there is increased risk of both short-term and long-term cardiovascular complications, including arrhythmia. In this review, we highlight the current evidence detailing the connections between atrial fibrillation and cancer, provide insight into the mechanisms driving this relationship, and share practical considerations for the management of atrial fibrillation in cancer patients and cancer survivors. RECENT FINDINGS Atrial fibrillation is an increasingly recognized condition among cancer patients, with epidemiological data showing increased incidence and worse outcomes in patients with cancer. Studies also describe a bidirectional relationship between cancer and atrial fibrillation, attributable in part to shared risk factors but also potentially due to shared biology. Cancer treatment-associated arrhythmia is an active area of investigation, with ongoing research to identify the mechanisms and pathophysiology behind this phenomenon. Furthermore, management of atrial fibrillation in patients with cancer presents unique challenges, particularly in management of anti-coagulation. Cancer patients have increased risk of developing atrial fibrillation due to the shared risk factors and biology of the two conditions. Moreover, various cancer therapeutics are known to be arrhythmogenic; however, mechanisms remain unclear. Further research is needed to better understand the pathophysiology of atrial fibrillation in cancer patient in order to establish prevention and treatment strategies specific to this population.
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Affiliation(s)
- David L Madnick
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael G Fradley
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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10
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Jiang D, Song Z, Hu Y, Dong F, Zhao R. Risk of bleeding associated with BTK inhibitor monotherapy: a systematic review and meta-analysis of randomized controlled trials. Expert Rev Clin Pharmacol 2022; 15:987-996. [PMID: 35892246 DOI: 10.1080/17512433.2022.2106968] [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: 11/04/2022]
Abstract
BACKGROUND The risk of bleeding associated with Bruton's tyrosine kinase inhibitor (BTKi) monotherapy remains to be understood. This systematic review aims to evaluate BTKi monotherapy related bleeding risk. RESEARCH DESIGN AND METHODS PubMed, Embase, and CENTRAL were searched up to December 5, 2021. We included randomized controlled trials (RCTs) comparing BTKi monotherapy with control drugs or placebo, or comparing different BTKi monotherapies. The risk ratios (RR) with 95% confidence intervals (95% CI) were calculated. RESULTS 10 studies with 3139 patients were included. Ibrutinib (vs. control drugs or placebo) significantly increased the risk of overall bleeding and major bleeding (RR=2.22, 95% CI 1.80-2.75, P<0.00001; RR=1.80, 95% CI 1.02-3.18, P=0.04, respectively). Acalabrutinib (vs. control drugs) had a significantly increased overall bleeding risk (RR=3.45, 95% CI 2.39-4.99, p<0.00001). A significant difference was found in overall bleeding between ibrutinib and acalabrutinib (RR=1.35, 95% CI 1.11-1.64, P=0.002). Compared to zanubrutinib, ibrutinib tended to increase the risk of major bleeding (RR=1.55, 95% CI 0.57-4.18, P=0.39). CONCLUSIONS Ibrutinib and acalabrutinib (vs. control drugs or placebo) have a higher risk of bleeding and overall bleeding, respectively. Limited evidence suggests that ibrutinib (vs. acalabrutinib) significantly increases overall bleeding risk, but the differences are not observed in other comparisons.
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Affiliation(s)
- Dan Jiang
- Department of Pharmacy, Peking University Third Hospital, Beijing 100191, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing 100191, China.,Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing 100191, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Zaiwei Song
- Department of Pharmacy, Peking University Third Hospital, Beijing 100191, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing 100191, China.,Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing 100191, China
| | - Yang Hu
- Department of Pharmacy, Peking University Third Hospital, Beijing 100191, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing 100191, China.,Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing 100191, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Fei Dong
- Department of Hematology, Peking University Third Hospital, Beijing 100191, China
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, Beijing 100191, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing 100191, China.,Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing 100191, China
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11
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Nocco S, Andriano TM, Bose A, Chilov M, Godwin K, Dranitsaris G, Wu S, Lacouture ME, Roeker LE, Mato AR, Markova A. Ibrutinib-associated dermatologic toxicities: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2022; 174:103696. [PMID: 35523374 DOI: 10.1016/j.critrevonc.2022.103696] [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: 03/03/2022] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 11/17/2022] Open
Abstract
The scope of dermatologic adverse events to ibrutinib has not been systematically described. We sought to determine the incidence and severity of ibrutinib-associated dermatologic toxicities and provide management recommendations. We conducted a systematic literature search of clinical trials and cohorts investigating ibrutinib monotherapy for cancer or chronic graft-versus-host disease through June 2020. Thirty-two studies with 2258 patients were included. The incidence of all-grade toxicities included cutaneous bleeds (24.8%; 95%CI, 18.6-31.0%), mucocutaneous infections (4.9%; 95%CI, 2.9-7.0%), rash (10.8%; 95%CI. 6.1-15.5%), mucositis (6%; 95%CI, 3.6-8.5%), edema (15.9%; 95%CI, 11.1-20.6%), pruritus (4.0%; 95%CI, 0.0-7.9%), xerosis (9.2%; 95%CI, 5.5-13.0%), nail changes (17.8%; 95%CI, 4.1-31.5%), and hair changes (7.9%; 95%CI, 0.0-21.3%). The incidence of high-grade toxicities included mucocutaneous infection (1.3%; 95%CI, 0.5-2.2%), rash (0.1%; 95%CI, 0.0-0.2%), mucositis (0.1%; 95%CI, 0.0-0.3%), and edema (0.1%; 95%CI, 0.0-0.2%). It is imperative that clinicians familiarize themselves with ibrutinib-associated dermatologic toxicities to learn how to manage them, prevent discontinuation, and improve patient outcomes.
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Affiliation(s)
- Sarah Nocco
- Weill Cornell Medical College, New York, NY, USA; Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Arpita Bose
- Weill Cornell Medical College, New York, NY, USA
| | - Marina Chilov
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kendra Godwin
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Shenhong Wu
- Division of Medical Oncology, Department of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA; Division of Hematology and Oncology, Department of Medicine, Northport VA Medical Center, Northport, NY, USA
| | - Mario E Lacouture
- Weill Cornell Medical College, New York, NY, USA; Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lindsay E Roeker
- Weill Cornell Medical College, New York, NY, USA; Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anthony R Mato
- Weill Cornell Medical College, New York, NY, USA; Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alina Markova
- Weill Cornell Medical College, New York, NY, USA; Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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12
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Comparative Clinical Value of Pharmacologic Therapies for B-Cell Chronic Lymphocytic Leukemia: An Umbrella Analysis. J Clin Med 2022; 11:jcm11071868. [PMID: 35407474 PMCID: PMC8999707 DOI: 10.3390/jcm11071868] [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: 01/30/2022] [Revised: 03/21/2022] [Accepted: 03/23/2022] [Indexed: 12/04/2022] Open
Abstract
Several new drugs are progressively improving the life span of patients with B-cell chronic lymphocytic leukemia (CLL). However, the rapidly evolving standard of care precludes robust assessments of the incremental clinical value of further innovative drugs. Therefore, we systematically reviewed comparative evidence on newly authorized CLL drugs, as reported by standard and network meta-analyses (MA) published since 2016. Overall, 17 MAs addressed the relative survival or safety of naïve and/or refractory/relapsed (R/R) CLL patients. In R/R patients, therapies including BTK- and BCL2-inhibitors reported progression free survival (PFS) hazard ratios ranging from 0.08 to 0.24 (versus chemotherapy) and a significant advantage in overall survival (OS). In naïve patients, the PFS hazard ratios associated with four recent chemo-free therapies (obinutuzumab- and/or acalabrutinib-based) ranged from 0.11 to 0.61 versus current standard treatments (STs), without a significant OS advantage. Ten MAs addressed the risk of cardiovascular, bleeding, and infective events associated with BTK inhibitors, with some reporting a different relative safety in naïve and R/R patients. In conclusion, last-generation therapies for CLL consistently increase PFS, but not OS, and minimally decrease safety, as compared with STs. Based on available evidence, the patient-customized adoption of new therapies, rather than universal recommendations, seems desirable in CLL patients.
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13
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Lynes J, Rubino S, Rogers A, Gaballa S, Liu HD, Arrington JA, Peguero E, Liu JKC. Spontaneous Spinal Subdural Hematoma Secondary to Hemophilia A and Zanubrutinib. J Neurol Surg Rep 2022; 83:e19-e22. [PMID: 35273899 DOI: 10.1055/s-0042-1744128] [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: 11/17/2021] [Accepted: 01/11/2022] [Indexed: 10/18/2022] Open
Abstract
Spontaneous spinal subdural hematomas (SSH) are rare occurrences that can occur most commonly secondary to vascular malformations or coagulopathies. Only a small fraction of spontaneous SSHs are caused by acquired coagulation disorders such as leukemia, hemophilia, and thrombocytopenia. This case report describes a patient with a history of Guillain-Barré syndrome (GBS), hemophilia A, and mantle cell lymphoma, on zanubrutinib therapy, a Bruton tyrosine kinase inhibitor associated with a risk of spontaneous hemorrhage. This patient developed a spontaneous spinal subdural hematoma, most likely due to the zanubrutinib therapy and exacerbated due to hemophilia. Treatment was delayed due to the patient's history of GBS that confounded the clinical diagnosis. This case is the first report of a spontaneous SSH in a patient on zanubrutinib, highlighting the need for a high index of suspicion for CNS hemorrhage in patients on Bruton's tyrosine kinase (BTK) inhibitor therapy.
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Affiliation(s)
- John Lynes
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States
| | - Sebastian Rubino
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States
| | - Andrea Rogers
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States
| | - Sameh Gaballa
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States
| | - Hien D Liu
- Department of Bone Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States
| | - John A Arrington
- Department of Radiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States
| | - Edwin Peguero
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States
| | - James K C Liu
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States.,Department of Oncologic Sciences, University of South Florida Morsani College of Medicine,. Tampa, Florida, United States
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14
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Lynes J, Rubino S, Rogers A, Gaballa S, Liu H, Arrington J, Peguero E, Liu JKC. Spontaneous Spinal Subdural Hematoma Secondary to Hemophilia A and Zanubrutinib. J Neurol Surg Rep 2022. [PMID: 35273899 PMCID: PMC8920709 DOI: 10.1055/a-1759-9841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Spontaneous spinal subdural hematomas (SSH) are rare occurrences that can occur most commonly secondary to vascular malformations or coagulopathies. Only a small fraction of spontaneous SSHs are caused by acquired coagulation disorders such as leukemia, hemophilia, and thrombocytopenia. This case report describes a patient with a history of Guillain–Barré syndrome (GBS), hemophilia A, and mantle cell lymphoma, on zanubrutinib therapy, a Bruton tyrosine kinase inhibitor associated with a risk of spontaneous hemorrhage. This patient developed a spontaneous spinal subdural hematoma, most likely due to the zanubrutinib therapy and exacerbated due to hemophilia. Treatment was delayed due to the patient's history of GBS that confounded the clinical diagnosis. This case is the first report of a spontaneous SSH in a patient on zanubrutinib, highlighting the need for a high index of suspicion for CNS hemorrhage in patients on Bruton's tyrosine kinase (BTK) inhibitor therapy.
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Affiliation(s)
- John Lynes
- Neuro-Oncology, H Lee Moffitt Cancer Center and Research Center Inc, TAMPA, United States
| | - Sebastian Rubino
- Neuro-Oncology, H Lee Moffitt Cancer Center and Research Center Inc, TAMPA, United States
| | - Andrea Rogers
- Neuro-Oncology, H Lee Moffitt Cancer Center and Research Center Inc, TAMPA, United States
| | - Sameh Gaballa
- Neuro-Oncology, H Lee Moffitt Cancer Center and Research Center Inc, TAMPA, United States
| | - Hien Liu
- Neuro-Oncology, H Lee Moffitt Cancer Center and Research Center Inc, TAMPA, United States
| | - John Arrington
- Neuro-Oncology, H Lee Moffitt Cancer Center and Research Center Inc, TAMPA, United States
| | - Edwin Peguero
- Neuro-Oncology, H Lee Moffitt Cancer Center and Research Center Inc, TAMPA, United States
| | - James K. C. Liu
- Neuro-Oncology, H Lee Moffitt Cancer Center and Research Center Inc, TAMPA, United States
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15
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Is BTKi or BCL2i preferable as first novel therapy in patients with CLL? The case for BCL2i. Blood Adv 2021; 6:1365-1370. [PMID: 34965297 PMCID: PMC8864649 DOI: 10.1182/bloodadvances.2019001205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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