1
|
Isberner N, Kraus S, Grigoleit GU, Aghai F, Kurlbaum M, Zimmermann S, Klinker H, Scherf-Clavel O. Ruxolitinib exposure in patients with acute and chronic graft versus host disease in routine clinical practice-a prospective single-center trial. Cancer Chemother Pharmacol 2021; 88:973-983. [PMID: 34505930 PMCID: PMC8536600 DOI: 10.1007/s00280-021-04351-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/27/2021] [Indexed: 11/28/2022]
Abstract
Purpose Knowledge on Ruxolitinib exposure in patients with graft versus host disease (GvHD) is scarce. The purpose of this prospective study was to analyze Ruxolitinib concentrations of GvHD patients and to investigate effects of CYP3A4 and CYP2C9 inhibitors and other covariates as well as concentration-dependent effects. Methods 262 blood samples of 29 patients with acute or chronic GvHD who were administered Ruxolitinib during clinical routine were analyzed. A population pharmacokinetic model obtained from myelofibrosis patients was adapted to our population and was used to identify relevant pharmacokinetic properties and covariates on drug exposure. Relationships between Ruxolitinib exposure and adverse events were assessed. Results Median of individual mean trough serum concentrations was 39.9 ng/mL at 10 mg twice daily (IQR 27.1 ng/mL, range 5.6–99.8 ng/mL). Applying a population pharmacokinetic model revealed that concentrations in our cohort were significantly higher compared to myelofibrosis patients receiving the same daily dose (p < 0.001). Increased Ruxolitinib exposure was caused by a significant reduction in Ruxolitinib clearance by approximately 50%. Additional comedication with at least one strong CYP3A4 or CYP2C9 inhibitor led to a further reduction by 15% (p < 0.05). No other covariate affected pharmacokinetics significantly. Mean trough concentrations of patients requiring dose reduction related to adverse events were significantly elevated (p < 0.05). Conclusion Ruxolitinib exposure is increased in GvHD patients in comparison to myelofibrosis patients due to reduced clearance and comedication with CYP3A4 or CYP2C9 inhibitors. Elevated Ruxolitinib trough concentrations might be a surrogate for toxicity. Supplementary Information The online version contains supplementary material available at 10.1007/s00280-021-04351-w.
Collapse
Affiliation(s)
- Nora Isberner
- Department of Internal Medicine II, University Hospital Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany.
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
| | - Götz Ulrich Grigoleit
- Department of Internal Medicine II, University Hospital Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany.,Department of Hematology, Oncology and Immunology, Helios Hospital Duisburg, Duisburg, Germany
| | - Fatemeh Aghai
- Department of Internal Medicine II, University Hospital Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
| | - Max Kurlbaum
- Department of Internal Medicine I and Core Unit Clinical Mass Spectrometry, Division of Endocrinology and Diabetology, University Hospital Würzburg, Würzburg, Germany
| | - Sebastian Zimmermann
- Institute of Pharmacy and Food Chemistry, University of Würzburg, Würzburg, Germany
| | - Hartwig Klinker
- Department of Internal Medicine II, University Hospital Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
| | - Oliver Scherf-Clavel
- Institute of Pharmacy and Food Chemistry, University of Würzburg, Würzburg, Germany
| |
Collapse
|
2
|
Pourafshar N, Karimi A, Wen X, Sobel E, Pourafshar S, Agrawal N, Segal E, Mohandas R, Segal MS. The utility of trough mycophenolic acid levels for the management of lupus nephritis. Nephrol Dial Transplant 2019; 34:83-89. [PMID: 29548021 DOI: 10.1093/ndt/gfy026] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 01/11/2018] [Indexed: 01/27/2023] Open
Abstract
Background Monitoring of mycophenolic acid (MPA) levels may be useful for effective mycophenolate mofetil (MMF) dosing. However, whether commonly obtained trough levels are an acceptable method of surveillance remains debatable. We hypothesized that trough levels of MPA would be a poor predictor of area under the curve (AUC) for MPA. Methods A total of 51 patients with lupus nephritis who were on MMF 1500 mg twice a day and had a 4-h AUC done were included in this study. MPA levels were measured prior to (C0) and at 1 (C1), 2 (C2) and 4 (C4) h, followed by 1500 mg of MMF. The MPA AUC values were calculated using the linear trapezoidal rule. Regression analysis was used to examine the relationship between the MPA trough and AUC. Differences in the MPA trough and AUC between different clinical and demographic categories were compared using t-tests. Results When grouped by tertiles there was significant overlap in MPA, AUC 0-4 and MPA trough in all tertiles. Although there was a statistically significant correlation between MPA trough levels and AUC, this association was weak and accounted for only 30% of the variability in MPA trough levels. This relationship might be even more unreliable in men than women. The use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was associated with increased MPA trough levels and AUC at 0-4 h (AUC0-4). Conclusion Trough levels of MPA do not show a strong correlation with AUC. In clinical situations where MPA levels are essential to guide therapy, an AUC0-4 would be a better indicator of the adequacy of treatment.
Collapse
Affiliation(s)
- Negiin Pourafshar
- Division of Nephrology, Center for Immunity, Inflammation and Regenerative Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia.,Division of Nephrology, Hypertension and Renal Transplant, Department of Medicine, University of Florida, Gainesville, Florida
| | - Ashkan Karimi
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Xuerong Wen
- Division of Nephrology, Hypertension and Renal Transplant, Department of Medicine, University of Florida, Gainesville, Florida
| | - Eric Sobel
- Disvision of Rheumatology, Department of Medicine, University of Florida, Gainesville, Florida.,North Florida/South Georgia Veterans Health system, Gainesville, Florida
| | - Shirin Pourafshar
- Division of Nephrology, Center for Immunity, Inflammation and Regenerative Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Nikhil Agrawal
- Division of Nephrology, Hypertension and Renal Transplant, Department of Medicine, University of Florida, Gainesville, Florida
| | - Emma Segal
- Division of Nephrology, Hypertension and Renal Transplant, Department of Medicine, University of Florida, Gainesville, Florida
| | - Rajesh Mohandas
- Division of Nephrology, Hypertension and Renal Transplant, Department of Medicine, University of Florida, Gainesville, Florida.,North Florida/South Georgia Veterans Health system, Gainesville, Florida
| | - Mark S Segal
- Division of Nephrology, Hypertension and Renal Transplant, Department of Medicine, University of Florida, Gainesville, Florida.,North Florida/South Georgia Veterans Health system, Gainesville, Florida
| |
Collapse
|
3
|
McCune JS, Storer B, Thomas S, McKiernan J, Gupta R, Sandmaier BM. Inosine Monophosphate Dehydrogenase Pharmacogenetics in Hematopoietic Cell Transplantation Patients. Biol Blood Marrow Transplant 2018; 24:1802-1807. [PMID: 29656138 DOI: 10.1016/j.bbmt.2018.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 04/03/2018] [Indexed: 01/18/2023]
Abstract
We evaluated inosine monophosphate dehydrogenase (IMPDH) 1 and IMPDH2 pharmacogenetics in 247 recipient-donor pairs after nonmyeloablative hematopoietic cell transplant (HCT). Patients were conditioned with total body irradiation + fludarabine and received grafts from related or unrelated donors (10% HLA mismatch), with postgraft immunosuppression of mycophenolate mofetil (MMF) with a calcineurin inhibitor. Recipient and donor IMPDH genotypes (rs11706052, rs2278294, rs2278293) were not associated with day 28 T cell chimerism, acute graft-versus-host disease (GVHD), disease relapse, cytomegalovirus reactivation, nonrelapse mortality, or overall survival. Recipient IMPDH1 rs2278293 genotype was associated with a lower incidence of chronic GVHD (hazard ratio, .72; P = .008) in nonmyeloablative HCT recipients. Additional studies are needed to confirm these results with the goal of identifying predictive biomarkers to MMF that lower GVHD.
Collapse
Affiliation(s)
- Jeannine S McCune
- School of Pharmacy, University of Washington, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Population Sciences, City of Hope, Duarte, California; Department of Hematology and HCT, City of Hope, Duarte, California.
| | - Barry Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Sushma Thomas
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jožefa McKiernan
- Department of Population Sciences, City of Hope, Duarte, California
| | - Rohan Gupta
- Department of Hematology and HCT, City of Hope, Duarte, California
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| |
Collapse
|
4
|
Zhang D, Chow DSL. Clinical Pharmacokinetics of Mycophenolic Acid in Hematopoietic Stem Cell Transplantation Recipients. Eur J Drug Metab Pharmacokinet 2017; 42:183-189. [PMID: 27677732 DOI: 10.1007/s13318-016-0378-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mycophenolate mofetil (MMF), an ester prodrug of mycophenolic acid (MPA), is widely used as a maintenance immunosuppressive regimen in solid organ transplant patients. It is increasingly used for the prophylaxis and treatment of graft-versus-host disease (GVHD) in hematopoietic stem cell transplantation (HSCT) patients. MPA displays extensive binding to serum albumin and glucuronidation to the inactive MPA-7-O-glucuronide (MPAG). Here, we review and discuss the pertinent information regarding the clinical pharmacokinetics of MPA in HSCT patients. The pharmacokinetics of MPA are altered in HSCT patients with lower oral bioavailability, shorter half-life and higher clearance than those in healthy volunteers and renal transplant recipients. Moreover, clearance may be increased in young pediatric patients. The optimal MMF dosing and preferred targets are still under investigation in HSCT patients due to the substantial intra- and inter-individual pharmacokinetic variability of MPA and broad range of transplants (malignant vs. nonmalignant, related vs. unrelated donor, and human leukocyte antigen mismatch). The complex pharmacokinetics of MPA have partly hampered the efficient use of MMF, and pharmacokinetic studies in HSCT patients have been limited in size and mostly inconclusive. Future research should be multi-institutional and focus on developing clinical decisions with adequate statistical power to improve clinical care of HSCT recipients.
Collapse
Affiliation(s)
- Daping Zhang
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, 1441 Moursund Street, Houston, TX, 77030, USA.
| | - Diana S-L Chow
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, 1441 Moursund Street, Houston, TX, 77030, USA
| |
Collapse
|
7
|
Eapen M, Logan BR, Horowitz MM, Zhong X, Perales MA, Lee SJ, Rocha V, Soiffer RJ, Champlin RE. Bone marrow or peripheral blood for reduced-intensity conditioning unrelated donor transplantation. J Clin Oncol 2014; 33:364-9. [PMID: 25534391 DOI: 10.1200/jco.2014.57.2446] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There have been no randomized trials that have compared peripheral blood (PB) with bone marrow (BM) grafts in the setting of reduced-intensity conditioning (RIC) transplantations for hematologic malignancy. Because immune modulation plays a significant role in sustaining clinical remission after RIC, we hypothesize that higher graft-versus-host disease (GVHD) associated with PB transplantation may offer a survival advantage. PATIENTS AND METHODS The primary outcome evaluated was overall survival. Cox regression models were built to study outcomes after transplantation of PB (n = 887) relative to BM (n = 219) for patients with acute myeloid leukemia, myelodysplastic syndrome, or non-Hodgkin lymphoma, the three most common indications for unrelated RIC transplantation. Transplantations were performed in the United States between 2000 and 2008. Conditioning regimens consisted of an alkylating agent and fludarabine, and GVHD prophylaxis involved a calcineurin inhibitor (CNI) with either methotrexate (MTX) or mycophenolate mofetil (MMF). RESULTS After adjusting for age, performance score, donor-recipient HLA-match, disease, and disease status at transplantation (factors associated with overall survival), there were no significant differences in 5-year rates of survival after transplantation of PB compared with BM: 34% versus 38% with CNI-MTX and 27% versus 20% with CNI-MMF GVHD prophylaxis. CONCLUSION Survival after transplantation of PB and BM are comparable in the setting of nonirradiation RIC regimens for hematologic malignancy. The effect of GVHD prophylaxis on survival merits further evaluation.
Collapse
Affiliation(s)
- Mary Eapen
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX.
| | - Brent R Logan
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Mary M Horowitz
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Xiaobo Zhong
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Miguel-Angel Perales
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Stephanie J Lee
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Vanderson Rocha
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Robert J Soiffer
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Richard E Champlin
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| |
Collapse
|