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Rodríguez-Mauriz R, González-Laguna M, Perayre-Badia M, Lozano-Andreu T, Miquel-Zurita ME, Cañizares-Paz S, Santulario-Verdú L, Millan-Coll M, Fontanals S, Clopés-Estela A. Pharmaceutical care in the screening process of phase I oncohaematological clinical trials. Eur J Hosp Pharm 2024:ejhpharm-2024-004168. [PMID: 39137972 DOI: 10.1136/ejhpharm-2024-004168] [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: 03/11/2024] [Accepted: 07/29/2024] [Indexed: 08/15/2024] Open
Abstract
OBJECTIVE To determine the pharmaceutical interventions in patients eligible for phase I cancer clinical trials, focusing specifically on exclusion criteria related to medication or relevant interactions. METHOD Descriptive, observational study conducted at a comprehensive cancer centre. Patients undergoing screening for phase I clinical trials (March 2019-December 2022) were included. The pharmacist reviewed concomitant medication and provided a recommendation. RESULTS The concomitant medication of 512 patients eligible to participate in 84 phase I clinical trials was analysed. In 230 (44.9%) patients, the clinical trial treatment included oral medication. The median number of concomitant medications was 5 (IQR 3-8) per patient.A total of 280 pharmaceutical interventions were performed in 140 (27.3%) patients: 240 (85.7%) were due to interactions in 124 (24.2%) patients, and 40 (14.3%) were due to exclusion criteria in 34 (6.6%) patients. Interactions and exclusion criteria were detected in 18 (3.5%) patients. The main groups of drugs involved were 68 (24.3%) antacids and antiulcer drugs, 28 (10.0%) antidepressants and 26 (9.3%) opioids. Acceptance analysis of the recommendation was applicable in 215 cases; in 208 (96.7%), the pharmaceutical intervention was accepted.Differences were identified for exclusion criteria (7 vs 27) and interactions (37 vs 87) between parenteral and oral clinical trial medication (p<0.001). CONCLUSION The pharmacist's review of concomitant medication during the screening period in phase I clinical trials enables the detection of prohibited medication or relevant interactions, potentially avoiding screening failures and increasing the efficacy and safety of treatments.
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Affiliation(s)
- Rosa Rodríguez-Mauriz
- Pharmacy Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Monica González-Laguna
- Pharmacy Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Maria Perayre-Badia
- Pharmacy Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Toni Lozano-Andreu
- Pharmacy Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Salomé Cañizares-Paz
- Pharmacy Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Lorena Santulario-Verdú
- Pharmacy Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Marina Millan-Coll
- Pharmacy Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sandra Fontanals
- Pharmacy Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
- Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
| | - Ana Clopés-Estela
- Pharmacy Department, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
- Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
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Malifarge L, Deppenweiler M, Italiano A, Lortal B. Impact of Medication Reconciliation in Oncology Early Phase Studies: A Drug-Drug Interaction Retrospective Study. JCO Oncol Pract 2024; 20:386-392. [PMID: 37944082 DOI: 10.1200/op.22.00281] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/20/2023] [Accepted: 08/29/2023] [Indexed: 11/12/2023] Open
Abstract
PURPOSE This study aims to investigate the impact of medication reconciliation (MR) conducted by pharmacists before patient enrollment and the initiation of investigational treatments. By implementing MR, the primary objective is to evaluate the extent to which the inclusion of patients with prohibited or not recommended concomitant medications in clinical trials can be significantly reduced. MATERIALS AND METHODS The study included all patients who participated in clinical trials and underwent MR between September 1, 2015, and September 1, 2020. To identify prohibited or monitored drugs, protocols and investigator's brochures provided by the sponsor were meticulously reviewed and taken into consideration. RESULTS MR was performed for 501 patients, uncovering 35% of the medications they were currently taking. Through the pharmaceutical analysis, a total of 346 drug-drug interactions (DDIs) were identified, of which 188 required monitoring and 158 were strictly prohibited. More than half of the prohibited medications were herbal drugs. A significant portion of these prohibited drugs were discontinued, with only 6% being replaced by suitable alternatives. The implementation of MR played a crucial role in the identification of 51% of the prohibited or monitored drugs that were initially overlooked by oncologists. CONCLUSION MR is a highly effective measure aimed at reducing the risk of DDIs with investigational drugs, thereby minimizing protocol deviations and enhancing patient care. Sponsors of clinical trials value its implementation and recognize the substantial benefits it brings to the entire trial process. Consequently, many sponsors willingly provide funding to investigational sites that adopt MR as part of their standard practice, acknowledging its critical role in ensuring patient safety and maintaining data integrity throughout the course of clinical research studies.
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Affiliation(s)
- Laura Malifarge
- Department of Pharmacy, Bergonié Institute, Bordeaux, France
| | | | - Antoine Italiano
- Early Phase Trials Unit, Bergonié Institute, Bordeaux, France
- University of Bordeaux, Bordeaux, France
| | - Barbara Lortal
- Department of Pharmacy, Bergonié Institute, Bordeaux, France
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Dai X, Karol MD, Hitron M, Hard ML, Goulet MT, McLaughlin CF, Brantley SJ. Napabucasin Drug-Drug Interaction Potential, Safety, Tolerability, and Pharmacokinetics Following Oral Dosing in Healthy Adult Volunteers. Clin Pharmacol Drug Dev 2021; 10:824-839. [PMID: 34107166 PMCID: PMC8453567 DOI: 10.1002/cpdd.961] [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: 06/15/2020] [Accepted: 04/10/2021] [Indexed: 12/05/2022]
Abstract
Napabucasin is an orally administered reactive oxygen species generator that is bioactivated by the intracellular antioxidant nicotinamide adenine dinucleotide phosphate:quinone oxidoreductase 1. Napabucasin induces cell death in cancer cells, including cancer stem cells. This phase 1 study (NCT03411122) evaluated napabucasin drug‐drug interaction potential for 7 cytochrome P450 (CYP) enzymes and the breast cancer resistance protein transporter/organic anion transporter 3. Healthy volunteers who tolerated napabucasin during period 1 received probe drugs during period 2, and in period 3 received napabucasin (240 mg twice daily; days 1‐11) plus a phenotyping cocktail containing omeprazole (CYP2C19), caffeine (CYP1A2), flurbiprofen (CYP2C9), bupropion (CYP2B6), dextromethorphan (CYP2D6), midazolam (CYP3A) (all oral; day 6), intravenous midazolam (day 7), repaglinide (CYP2C8; day 8), and rosuvastatin (breast cancer resistance protein/organic anion transporter 3; day 9). Drug‐drug interaction potential was evaluated in 17 of 30 enrolled volunteers. Napabucasin coadministration increased the area under the plasma concentration–time curve from time 0 extrapolated to infinity (geometric mean ratio [90% confidence interval]) of caffeine (124% [109.0%‐141.4%]), intravenous midazolam (118% [94.4%‐147.3%]), repaglinide (127% [104.7%‐153.3%]), and rosuvastatin (213% [42.5%‐1068.3%]) and decreased the area under the plasma concentration–time curve from time 0 extrapolated to infinity of dextromethorphan (71% [47.1%‐108.3%]), bupropion (79% [64.6%‐97.0%]), and hydroxybupropion (45% [15.7%‐129.6%]). No serious adverse events/deaths were reported. Generally, napabucasin is not expected to induce/inhibit drug clearance to a clinically meaningful degree.
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Affiliation(s)
- Xiaoshu Dai
- Clinical Pharmacology and Drug Metabolism, Sumitomo Dainippon Pharma Oncology, Inc., Cambridge, Massachusetts, USA
| | - Michael D Karol
- Clinical Pharmacology and Drug Metabolism, Sumitomo Dainippon Pharma Oncology, Inc., Cambridge, Massachusetts, USA
| | - Matthew Hitron
- Clinical Development, Sumitomo Dainippon Pharma Oncology, Inc., Cambridge, Massachusetts, USA
| | - Marjie L Hard
- Clinical Pharmacology, Nuventra, Inc., Durham, North Carolina, USA.,Current address: Praxis Precision Medicines, Cambridge, Massachusetts, USA
| | - Matthew T Goulet
- Clinical Pharmacology, Nuventra, Inc., Durham, North Carolina, USA.,Current address: Program Management Department, KSQ Therapeutics, Cambridge, Massachusetts, USA
| | | | - Scott J Brantley
- Clinical NCA & PK/PD, Nuventra, Inc., Durham, North Carolina, USA
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Roydhouse JK, Menapace LA, Xia H, Song P, Berman T, Agarwal R, Suzman DL, Wright K, Beaver JA, Kluetz PG. Concomitant botanical medicine use among patients participating in commercial prostate cancer trials. Complement Ther Med 2020; 54:102549. [PMID: 33183667 DOI: 10.1016/j.ctim.2020.102549] [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: 03/11/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Patients with cancer frequently use botanical medications. The concomitant use of such medications by patients on commercial trials has not been well-described, despite the importance of these trials for evaluating the safety and efficacy of new agents. We sought to describe the use of botanical medications taken by patients with prostate cancer enrolled on global commercial trials. DESIGN Retrospective study. SETTING Regulatory repository of commercial clinical trial data. INTERVENTIONS Anti-cancer therapy. MAIN OUTCOME MEASURES Botanical and medication use data were pooled across six international commercial randomized trials for metastatic prostate cancer with detailed information on medication and indications. Botanical products were considered to have potential for drug interaction if they led to a change in drug exposure in human trials. Potential for interaction was ascertained by PubMed review. Descriptive statistics were used for analysis. RESULTS Of 7318 enrolled patients, 700 (10 %) reported botanical use at any time and 653 (9%) reported use of botanical products while on trial. Nearly half of botanical product types were not classified by plant (43 %). The highest proportion of botanical use was among patients in Asian countries (32 %), followed by patients in North America (13 %). Eighty-six different types of botanical products were used; of these, nineteen had a patient-reported anti-cancer indication. CONCLUSIONS Botanical medicine use among patients with prostate cancer in commercial trials is moderate, although it varies by region. Practitioners should be aware of the use of botanical interventions in a clinical trial context.
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Affiliation(s)
- J K Roydhouse
- ORISE Fellow, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, Food and Drug Administration (US FDA), Silver Spring, MD, USA; Menzies Institute for Medical Research, University of Tasmania, Hobart TAS, Australia.
| | - L A Menapace
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, US FDA, Silver Spring, MD, USA; National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - H Xia
- Division of Clinical Pharmacology, Center for Drug Evaluation and Research, US FDA, Silver Spring, MD, USA
| | - P Song
- Division of Clinical Pharmacology, Center for Drug Evaluation and Research, US FDA, Silver Spring, MD, USA
| | - T Berman
- Office of Oncologic Diseases, Center for Drug Evaluation and Research, US FDA, Silver Spring, MD, USA
| | - R Agarwal
- New Drug Products Branch II, Center for Drug Evaluation and Research, US FDA, Silver Spring, MD, USA
| | - D L Suzman
- Office of Oncologic Diseases, Center for Drug Evaluation and Research, US FDA, Silver Spring, MD, USA
| | - K Wright
- Office of Prescription Drug Promotion, Center for Drug Evaluation and Research, US FDA, Silver Spring, MD, USA
| | - J A Beaver
- Office of Oncologic Diseases, Center for Drug Evaluation and Research, US FDA, Silver Spring, MD, USA
| | - P G Kluetz
- Oncology Center of Excellence, US FDA, Silver Spring, MD, USA
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5
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Lockery JE, Rigby J, Collyer TA, Stewart AC, Woods RL, McNeil JJ, Reid CM, Ernst ME. Optimising medication data collection in a large-scale clinical trial. PLoS One 2019; 14:e0226868. [PMID: 31881040 DOI: 10.1371/journal.pone.0226868] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 12/08/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Pharmaceuticals play an important role in clinical care. However, in community-based research, medication data are commonly collected as unstructured free-text, which is prohibitively expensive to code for large-scale studies. The ASPirin in Reducing Events in the Elderly (ASPREE) study developed a two-pronged framework to collect structured medication data for 19,114 individuals. ASPREE provides an opportunity to determine whether medication data can be cost-effectively collected and coded, en masse from the community using this framework. METHODS The ASPREE framework of type-to-search box with automated coding and linked free text entry was compared to traditional method of free-text only collection and post hoc coding. Reported medications were classified according to their method of collection and analysed by Anatomical Therapeutic Chemical (ATC) group. Relative cost of collecting medications was determined by calculating the time required for database set up and medication coding. RESULTS Overall, 122,910 participant structured medication reports were entered using the type-to-search box and 5,983 were entered as free-text. Free-text data contributed 211 unique medications not present in the type-to-search box. Spelling errors and unnecessary provision of additional information were among the top reasons why medications were reported as free-text. The cost per medication using the ASPREE method was approximately USD $0.03 compared with USD $0.20 per medication for the traditional method. CONCLUSION Implementation of this two-pronged framework is a cost-effective alternative to free-text only data collection in community-based research. Higher initial set-up costs of this combined method are justified by long term cost effectiveness and the scientific potential for analysis and discovery gained through collection of detailed, structured medication data.
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Affiliation(s)
- Jessica E Lockery
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jason Rigby
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Taya A Collyer
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ashley C Stewart
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Robyn L Woods
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - John J McNeil
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher M Reid
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Michael E Ernst
- Department of Pharmacy Practice and Science, College of Pharmacy and Department of Family Medicine, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, United States of America
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Babiker HM, Davis L, Larson K, Placencia C, Swensen C, Tenneti P, Lim M, Cañamar R, Curtis J, Castillo E, Mancuso J, Rensvold D, Martinez S, Macias L, Recio-Boiles A, Chandana SR, Mahadevan D. A Multidisciplinary Evaluation of Barriers to Enrolling Cancer Patients into Early Phase Clinical Trials: Challenges and Patient-centric Recommendations. Expert Opin Investig Drugs 2019; 28:675-686. [PMID: 31327293 DOI: 10.1080/13543784.2019.1646726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Early phase clinical trials are the first clinical research step to bringing new cancer therapeutics to patients. At this stage, a new drug's safety, dosing, and scheduling profiles are established as the main endpoints. However, excellent responses due to biomarker-guided and immune checkpoint trials in early phase have resulted in direct approvals of new anti-cancer drugs. Despite doubling of the success rate of new drug approvals, many barriers exist to expeditiously bring active new drugs to the clinic. Areas covered: This review covers roles of members of the early phase program and the challenges they face in enrolling advanced cancer patients to trials. Practical solutions are provided from the perspective of the investigators, regulatory, investigational pharmacy, research nurses, clinical research coordinators, budgets, contracts, and data management. Expert opinion: We are witnessing a burgeoning era in drug development with rapid approval of efficacious drugs. This is achieved by a strong collaboration between investigators, academic institutions, pharmaceutical sponsors, scientists, Food and Drug Administration (FDA), and community practices. Herein, we discuss some of the challenges faced by early phase clinical trials programs and discuss methods of improvement.
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Affiliation(s)
- Hani M Babiker
- a Department of Medicine, Division of Hematology-Oncology, University of Arizona Cancer Center, Early Phase Clinical Trials Program , Tucson , AZ , USA
| | - Lisa Davis
- a Department of Medicine, Division of Hematology-Oncology, University of Arizona Cancer Center, Early Phase Clinical Trials Program , Tucson , AZ , USA
| | - Kristian Larson
- a Department of Medicine, Division of Hematology-Oncology, University of Arizona Cancer Center, Early Phase Clinical Trials Program , Tucson , AZ , USA
| | - Crystal Placencia
- a Department of Medicine, Division of Hematology-Oncology, University of Arizona Cancer Center, Early Phase Clinical Trials Program , Tucson , AZ , USA
| | - Connor Swensen
- a Department of Medicine, Division of Hematology-Oncology, University of Arizona Cancer Center, Early Phase Clinical Trials Program , Tucson , AZ , USA
| | - Pavan Tenneti
- b Department of Medicine, Banner University Medical Center Phoenix , Phoenix , AZ , USA
| | - Melissa Lim
- a Department of Medicine, Division of Hematology-Oncology, University of Arizona Cancer Center, Early Phase Clinical Trials Program , Tucson , AZ , USA
| | - Ruth Cañamar
- a Department of Medicine, Division of Hematology-Oncology, University of Arizona Cancer Center, Early Phase Clinical Trials Program , Tucson , AZ , USA
| | - Jacqueline Curtis
- a Department of Medicine, Division of Hematology-Oncology, University of Arizona Cancer Center, Early Phase Clinical Trials Program , Tucson , AZ , USA
| | - Erica Castillo
- a Department of Medicine, Division of Hematology-Oncology, University of Arizona Cancer Center, Early Phase Clinical Trials Program , Tucson , AZ , USA
| | - James Mancuso
- c Department of Immunology, University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Diane Rensvold
- a Department of Medicine, Division of Hematology-Oncology, University of Arizona Cancer Center, Early Phase Clinical Trials Program , Tucson , AZ , USA
| | - Sarah Martinez
- a Department of Medicine, Division of Hematology-Oncology, University of Arizona Cancer Center, Early Phase Clinical Trials Program , Tucson , AZ , USA
| | - Lora Macias
- a Department of Medicine, Division of Hematology-Oncology, University of Arizona Cancer Center, Early Phase Clinical Trials Program , Tucson , AZ , USA
| | - Alejandro Recio-Boiles
- a Department of Medicine, Division of Hematology-Oncology, University of Arizona Cancer Center, Early Phase Clinical Trials Program , Tucson , AZ , USA
| | - Sreenivasa R Chandana
- d Department of Gastrointestinal Medical Oncology, Cancer and Hematology Centers of Western Michigan, Phase I Program, START Midwest , Grand Rapids , MI , USA
| | - Daruka Mahadevan
- a Department of Medicine, Division of Hematology-Oncology, University of Arizona Cancer Center, Early Phase Clinical Trials Program , Tucson , AZ , USA
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Buechel M, McGinnis A, Vesely SK, Wade KS, Moore KN, Gunderson CC. Consideration of older patients for enrollment in phase 1 clinical trials: Exploring treatment related toxicities and outcomes. Gynecol Oncol 2018; 149:28-32. [DOI: 10.1016/j.ygyno.2017.11.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 11/17/2017] [Accepted: 11/17/2017] [Indexed: 11/29/2022]
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Liu S, Nikanjam M, Kurzrock R. Dosing de novo combinations of two targeted drugs: Towards a customized precision medicine approach to advanced cancers. Oncotarget 2017; 7:11310-20. [PMID: 26824502 PMCID: PMC4905475 DOI: 10.18632/oncotarget.7023] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 01/15/2016] [Indexed: 02/07/2023] Open
Abstract
Metastatic cancers harbor complex genomic alterations. Thus, monotherapies are often suboptimal. Individualized combinations are needed in order to attenuate resistance. To help inform selection of safe starting doses for novel, two-agent, targeted drug combinations, we identified clinical trials in adult oncology patients who received targeted drug doublets (PubMed, January 1, 2010 through December 31, 2013). The dose percentage was calculated for each drug: (safe dose in combination divided by single agent full dose) X 100. Additive dose percentage represented the sum of the dose percentage for each drug. A total of 144 studies (N = 8568 patients; 95 combinations) were analyzed. In 51% of trials, each of the two drugs could be administered at 100% of their full dose. The lowest safe additive dose percentage was 60% if targets and/or class of drugs overlapped, or in the presence of mTor inhibitors, which sometimes compromised the combination dose. If neither class nor target overlapped and if mTor inhibitors were absent, the lowest safe additive dose percentage was 143%. The current observations contribute to the knowledge base that informs safe starting doses for new combinations of targeted drugs in the context of clinical trials or practice, hence facilitating customized combination therapies.
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Affiliation(s)
- Sariah Liu
- Department of Hematology-Oncology, Kaiser Permanente San Diego Medical Center, San Diego, CA, USA
| | - Mina Nikanjam
- Division of Hematology-Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, UC San Diego Moores Cancer Center, San Diego, CA, USA
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Nikanjam M, Patel H, Kurzrock R. Dosing immunotherapy combinations: Analysis of 3,526 patients for toxicity and response patterns. Oncoimmunology 2017; 6:e1338997. [PMID: 28920006 DOI: 10.1080/2162402x.2017.1338997] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/31/2017] [Accepted: 06/01/2017] [Indexed: 01/08/2023] Open
Abstract
Immunotherapy combinations are used to improve outcomes in metastatic cancer, but evidence-based knowledge of appropriate starting doses for novel combinations is lacking. Phase I-III adult combination clinical trials (≥ 1 drug was immunotherapy; anti-PD-1, PD-L1, or CTLA-4) were reviewed (PubMed Jan 1, 2010 to Sep 1, 2016; ASCO 2014-2016, ASH/ESMO 2014-2015 abstracts). The safe dose for each drug used in each combination was divided by the single-agent recommended dose to calculate dose percentage. Additive dose percentage was the sum of each dose percentage. Overall, 84 studies (N = 3,526 patients, 59 combinations) were analyzed. In 50% of studies, all drugs could be administered at full dose; 63%, in the presence of anti-PD-1/PD-L1 and 36% with anti-CTLA-4. The lowest safe starting dose for a doublet combination including a second immunotherapy was 50% of each drug; 60%, for a targeted agent. Most doublet/triplets combining anti-PD-1/PD-L1 with cytotoxics were tolerable at full doses. Response rates (median [interquartile range]) were higher for 3-drug than 2-drug combinations (53% [33-63%] (N = 23 studies) vs. 23% [14-39%]) (N = 60 studies) (p < 0.0001) with similar rates seen for targeted, cytotoxic, biologic, or additional immunotherapy combinations (p = 0.35). In conclusion, anti-PD-1/PD-L1 checkpoint inhibitors can be safely given with a variety of other immunotherapy and targeted agents, albeit at about half dose. Doublet and triplet combinations with cytotoxics could mostly be given at full doses. Anti-CTLA-4 agents compromised dosing more than anti-PD-1/PD-L1 agents. Response rates were significantly higher for 3- versus 2-drug combinations.
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Affiliation(s)
- Mina Nikanjam
- Division of Hematology-Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Harsh Patel
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, UC San Diego Moores Cancer Center, San Diego, CA, USA
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10
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Nikanjam M, Liu S, Yang J, Kurzrock R. Dosing Three-Drug Combinations That Include Targeted Anti-Cancer Agents: Analysis of 37,763 Patients. Oncologist 2017; 22:576-584. [PMID: 28424323 PMCID: PMC5423521 DOI: 10.1634/theoncologist.2016-0357] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 01/10/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Combining targeted and cytotoxic agents has the potential to improve efficacy and attenuate resistance for metastatic cancer. Information regarding safe starting doses for clinical trials of novel three-drug combinations is lacking. MATERIALS AND METHODS Published phase I-III adult oncology clinical trials of three-drug combinations involving a targeted agent were identified by PubMed search (January 1, 2010 to December 31, 2013). A dose percentage was calculated to compare the dose used in combination to the single agent recommended dose: (U.S. Food and Drug Administration-approved/recommended phase II dose/maximum tolerated dose). The additive dose percentage was the sum of the dose percentages for each drug in the combination. RESULTS A total of 37,763 subjects and 243 drug combinations were included. Only 28% of studies could give each of the three agents at 100%. For combinations involving two targeted agents and a cytotoxic agent, the lowest starting additive dose percentage was 133%, which increased to 250% if two antibodies were included. For combinations of one targeted agent and two cytotoxic agents, the lowest additive safe dose percentage was 137%. When both cytotoxic agents were held at 100%, as occurred in 56% of studies (which generally used cytotoxic doublets with known combination safety dosing), the lowest safe dose percentage was 225% (providing that a histone deacetylase inhibitor was not the targeted agent). CONCLUSION These findings serve as a safe starting point for dosing novel three-drug combinations involving a targeted agent in clinical trials and practice. The Oncologist 2017;22:576-584 IMPLICATIONS FOR PRACTICE: Targeted and cytotoxic drug combinations can improve efficacy and overcome resistance. More knowledge of safe starting doses would facilitate use of combinations in clinical trials and practice. Analysis of 37,763 subjects (243 combinations) showed three drugs could be safely administered, but less than 30% of combinations could include all three drugs at full dose. Dose reductions to 45% of the dose of each single agent may be required. Combinations involving two antibodies required fewer dose reductions, and the use of established cytotoxic doublets made initial dose assignment easier.
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Affiliation(s)
- Mina Nikanjam
- Division of Hematology-Oncology, University of California Los Angeles, Los Angeles, California, USA
| | - Sariah Liu
- Department of Hematology-Oncology, Kaiser Permanente San Diego Medical Center, San Diego, California, USA
| | - Jincheng Yang
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, California, USA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, UC San Diego Moores Cancer Center, San Diego, California, USA
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Nikanjam M, Liu S, Kurzrock R. Dosing targeted and cytotoxic two-drug combinations: Lessons learned from analysis of 24,326 patients reported 2010 through 2013. Int J Cancer 2016; 139:2135-41. [PMID: 27389805 PMCID: PMC5096042 DOI: 10.1002/ijc.30262] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 06/26/2016] [Accepted: 06/30/2016] [Indexed: 02/05/2023]
Abstract
Combining agents has the potential to attenuate resistance in metastatic cancer. However, knowledge of appropriate starting doses for novel drug combinations in clinical trials and practice is lacking. Analysis of 372 published studies was used to ascertain safe starting doses for doublets involving a cytotoxic and targeted agent. Phase I–III adult oncology clinical trial publications (January 1, 2010 to December 31, 2013) were identified (PubMed). The dose of drug used in each combination was compared to the single agent recommended dose [FDA‐approved/recommended phase 2 dose (RP2D)/maximum tolerated dose (MTD)]. Dose percentages were calculated as: (safe dose of drug in combination/dose of drug as single agent at FDA/RP2D/MTD) × 100. Additive dose percentages were the sum of the dose percentage for each drug. A total of 24,326 patients (248 drug combinations) were analyzed. In 38% of studies, both drugs could be administered at 100% of their FDA‐approved/RP2D/MTD dose. The lowest safe additive dose percentage was 41% with poly‐ADP ribose polymerase (PARP) or histone deacetylase inhibitors as the targeted agents; 82%, in the absence of these agents; and 97%, with an antibody in the combination. If one drug was administered at 100% of the single agent dose, the lowest safe dose percentage for the second drug was 17% (cytotoxic at 100%) or 36% (targeted at 100%) of the FDA‐approved/RP2D/MTD dose. The current findings can help inform safe starting doses for novel two‐drug combinations (cytotoxic and targeted agents) in the context of clinical trials and practice. What's new? Cytotoxic and targeted cancer drugs act through distinct mechanisms, and when used in combination they can potentially augment therapeutic effectiveness while minimally impacting toxicity. However, whereas algorithms for safe starting doses for new single‐agent therapies are well established, there are few guidelines for combination therapies. Here, analyses of data from published Phase I–III clinical trials shows that about 38% of patients tolerated combinations in which both drugs were administered at full starting doses. In the majority of patients, significant dose reductions were required to guard against toxicity. Intrapatient dose escalation is possible, however, potentially allowing for increased efficacy.
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Affiliation(s)
- Mina Nikanjam
- Division of Hematology-Oncology, University of California Los Angeles, Los Angeles, CA
| | - Sariah Liu
- Department of Hematology-Oncology, Kaiser Permanente San Diego Medical Center, San Diego, CA
| | - Razelle Kurzrock
- Division of Hematology and Oncology, Center for Personalized Cancer Therapy, UC San Diego Moores Cancer Center, San Diego, CA
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12
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Lam LH, Capparelli EV, Kurzrock R. Association of concurrent acid-suppression therapy with survival outcomes and adverse event incidence in oncology patients receiving erlotinib. Cancer Chemother Pharmacol 2016; 78:427-32. [PMID: 27372908 DOI: 10.1007/s00280-016-3087-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 06/09/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE Acid-suppression therapy is known to decrease the systemic exposure of erlotinib. The erlotinib prescribing information recommends staggering dosing with a histamine-2 receptor antagonist (H2RA) and avoiding concurrent use of a proton pump inhibitor (PPI). This retrospective analysis evaluated the frequency of concurrent acid-suppression therapy in oncology patients receiving erlotinib and its association with outcomes. METHODS All patients prescribed erlotinib within UC San Diego Health System between February 26, 2011, and February 28, 2014, were assessed for eligibility, survival outcomes and adverse events. RESULTS Of the 76 patients in the analysis, 24 were prescribed both a PPI and an H2RA with erlotinib therapy (31.6 %). The two patient groups, with (n = 24) and without PPI/H2RA (n = 52), were similar in clinical characteristics and erlotinib dose. One patient received an H2RA therapy alone and was excluded from the analysis; no one received PPI therapy alone. Patients receiving erlotinib alone had a longer median progression-free survival (PFS) compared to patients with concurrent PPI/H2RA therapy (11.0 months vs. 5.3 months; P = 0.029). Overall survival (OS) and incidence of rash and/or diarrhea did not correlate with use of acid-suppression therapy. CONCLUSION Nearly one-third of patients received acid-suppression therapy. Patients treated with erlotinib and PPI/H2RA therapy had shorter PFS, but similar OS and adverse event profile compared to those who did not receive acid-suppression.
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Affiliation(s)
- Lisa H Lam
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, 9500 Gilman Drive, MC 0657, San Diego, La Jolla, CA, 92093-0657, USA
| | - Edmund V Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, 9500 Gilman Drive, MC 0657, San Diego, La Jolla, CA, 92093-0657, USA.
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, Moores Cancer Center, UC San Diego Health System, La Jolla, CA, USA
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13
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Ranchon F, Vial T, Rioufol C, Hénin E, Falandry C, Freyer G, Trillet-Lenoir V, Le Tourneau C, You B. Concomitant drugs with low risks of drug-drug interactions for use in oncology clinical trials. Crit Rev Oncol Hematol 2015; 94:189-200. [PMID: 25638703 DOI: 10.1016/j.critrevonc.2014.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 12/10/2014] [Accepted: 12/23/2014] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Drug-drug interactions (DDIs) may occur with investigational drugs and affect patient safety, trial outcomes, and drug development. A list of preferred drugs with minimal risks of DDIs for treatment of symptoms or comorbidities frequently encountered by cancer patients would be helpful. METHODS We reviewed the literature to assess DDIs reported for the main drugs available for treatment of symptoms/comorbidities frequently encountered by cancer patients. Reviews and relevant original articles cited were retrieved and analyzed, and the following data were collected and double-checked: pharmacological properties; effects, if any, of drugs on CYP enzymes, membrane transporters, and QT interval; and involvement in significant DDIs. RESULTS A list of preferred drugs with minimal risks of DDIs was compiled. CONCLUSION Acknowledging for heterogeneity in data sources, prevention of unexpected DDIs during clinical trials may be improved by using this list of preferred drugs for the management of study patient's symptoms.
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Affiliation(s)
- Florence Ranchon
- Unité de Pharmacie Clinique Oncologique, Groupement Hospitalier Sud, Hospices Civils de Lyon, Lyon, France; EMR UCBL/HCL 3738, Faculté de médecine Lyon-Sud, Université Claude Bernard Lyon 1, Lyon, France
| | - Thierry Vial
- Centre régional de Pharmacovigilance, Lyon, France
| | - Catherine Rioufol
- Unité de Pharmacie Clinique Oncologique, Groupement Hospitalier Sud, Hospices Civils de Lyon, Lyon, France; EMR UCBL/HCL 3738, Faculté de médecine Lyon-Sud, Université Claude Bernard Lyon 1, Lyon, France
| | - Emilie Hénin
- EMR UCBL/HCL 3738, Faculté de médecine Lyon-Sud, Université Claude Bernard Lyon 1, Lyon, France
| | - Claire Falandry
- EMR UCBL/HCL 3738, Faculté de médecine Lyon-Sud, Université Claude Bernard Lyon 1, Lyon, France; Oncologie Médicale, Centre d'Investigation des Thérapeutiques en Oncologie et Hématologie de Lyon (CITOHL), Groupement Hospitalier Sud, Institut de Cancérologie des Hospices, Civils de Lyon (IC-HCL), Lyon, France
| | - Gilles Freyer
- EMR UCBL/HCL 3738, Faculté de médecine Lyon-Sud, Université Claude Bernard Lyon 1, Lyon, France; Oncologie Médicale, Centre d'Investigation des Thérapeutiques en Oncologie et Hématologie de Lyon (CITOHL), Groupement Hospitalier Sud, Institut de Cancérologie des Hospices, Civils de Lyon (IC-HCL), Lyon, France
| | - Véronique Trillet-Lenoir
- EMR UCBL/HCL 3738, Faculté de médecine Lyon-Sud, Université Claude Bernard Lyon 1, Lyon, France; Oncologie Médicale, Centre d'Investigation des Thérapeutiques en Oncologie et Hématologie de Lyon (CITOHL), Groupement Hospitalier Sud, Institut de Cancérologie des Hospices, Civils de Lyon (IC-HCL), Lyon, France
| | - Christophe Le Tourneau
- Département d'Oncologie Médicale, Unité d'Investigation Clinique, INSERM U900, Institut Curie, Paris, France
| | - Benoit You
- EMR UCBL/HCL 3738, Faculté de médecine Lyon-Sud, Université Claude Bernard Lyon 1, Lyon, France; Oncologie Médicale, Centre d'Investigation des Thérapeutiques en Oncologie et Hématologie de Lyon (CITOHL), Groupement Hospitalier Sud, Institut de Cancérologie des Hospices, Civils de Lyon (IC-HCL), Lyon, France.
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14
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Wheler J, Lee JJ, Kurzrock R. Unique molecular landscapes in cancer: implications for individualized, curated drug combinations. Cancer Res 2014; 74:7181-4. [PMID: 25326492 DOI: 10.1158/0008-5472.can-14-2329] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
With increasingly sophisticated technologies in molecular biology and "omic" platforms to analyze patients' tumors, more molecular diversity and complexity in cancer are being observed. Recently, we noted unique genomic profiles in a group of patients with metastatic breast cancer based on an analysis with next-generation sequencing. Among 57 consecutive patients, no two had the same molecular portfolio. Applied genomics therefore appears to represent a disruptive innovation in that it unveils a heterogeneity to metastatic cancer that may be ill-suited to canonical clinical trials and practice paradigms. Upon recognizing that patients have unique tumor landscapes, it is possible that there may be a "mismatch" between our traditional clinical trials system that selects patients based on common characteristics to evaluate a drug (drug-centric approach) and optimal treatment based on curated, individualized drug combinations for each patient (patient-centric approach).
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Affiliation(s)
- Jennifer Wheler
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - J Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Razelle Kurzrock
- Division of Hematology and Oncology, Center for Personalized Cancer Therapy, University of California San Diego Moores Cancer Center, San Diego, California
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