Verbesserung der oralen antineoplastischen Therapie mit Hilfe von pharmakometrischen Ansätzen und therapeutischem drug monitoring

Oral antineoplastic drugs are an important component in the treatment of solid tumour diseases, haematological and immunological malignancies. Oral drug administration is associated with positive features (e.g., non-invasive drug administration, outpatient care with a high level of independence for the patient and reduced costs for the health care system). The systemic exposure after oral intake however is prone to high IIV as it strongly depends on gastrointestinal absorption processes, which are per se characterized by high inter-and intraindividual variability. Disease and patient-specific characteristics (e.g., disease state, concomitant diseases, concomitant medication, patient demographics) may additionally contribute to variability in plasma concentrations between individual patients. In addition, many oral antineoplastic drugs show complex PK, which has not yet been fully investigated and elucidated for all substances. All this may increase the risk of suboptimal plasma exposure (either subtherapeutic or toxic), which may ultimately jeopardise the success of therapy, either through a loss of efficacy or through increased, intolerable adverse drug reactions. TDM can be used to detect suboptimal plasma levels and prevent permanent under- or overexposure. It is essential in the treatment of ACC with mitotane, a substance with unfavourable PK and high IIV. In the current work a HPLC-UV method for the TDM of mitotane using VAMS was developed. A low sample volume (20 µl) of capillary blood was used in the developed method, which facilitates dense sampling e.g., at treatment initiation. However, no reference ranges for measurements from capillary blood are established so far and a simple conversion from capillary concentrations to plasma concentrations was not possible. To date the therapeutic range is established only for plasma concentrations and observed capillary concentrations could not be reliable interpretated.The multi-kinase inhibitor cabozantinib is also used for the treatment of ACC. However, not all PK properties, like the characteristic second peak in the cabozantinib concentration-time profile have been fully understood so far. To gain a mechanistic understanding of the compound, a PBPK model was developed and various theories for modelling the second peak were explored, revealing that EHC of the compound is most plausible. Cabozantinib is mainly metabolized via CYP3A4 and susceptible to DDI with e.g., CYP3A4 inducers. The DDI between cabozantinib and rifampin was investigated with the developed PBPK model and revealed a reduced cabozantinib exposure (AUC) by 77%. Hence, the combination of cabozantinib with strong CYP inducers should be avoided. If this is not possible, co administration should be monitored using TDM. The model was also used to simulate cabozantinib plasma concentrations at different stages of liver injury. This showed a 64% and 50% increase in total exposure for mild and moderate liver injury, respectively.Ruxolitinib is used, among others, for patients with acute and chronic GvHD. These patients often also receive posaconazole for invasive fungal prophylaxis leading to CYP3A4 mediated DDI between both substances. Different dosing recommendations from the FDA and EMA on the use of ruxolitinib in combination with posaconazole complicate clinical use. To simulate the effect of this relevant DDI, two separate PBPK models for ruxolitinib and posaconazole were developed and combined. Predicted ruxolitinib exposure was compared to observed plasma concentrations obtained in GvHD patients. The model simulations showed that the observed ruxolitinib concentrations in these patients were generally higher than the simulated concentrations in healthy individuals, with standard dosing present in both scenarios. According to the developed model, EMA recommended RUX dose reduction seems to be plausible as due to the complexity of the disease and intake of extensive co-medication, RUX plasma concentration can be higher than expected.Orale antineoplastische Arzneimittel (OADs) sind ein wichtiger Bestandteil der Behandlung von soliden Tumorerkrankungen, hämatologischen und immunologischen Malignomen. Die orale Verabreichung von Arzneimitteln geht mit positiven Eigenschaften einher (z. B. nicht-invasive Anwendung, ambulante Versorgung mit einem hohen Maß an Unabhängigkeit für den Patienten und geringere Kosten für das Gesundheitssystem). Die systemische Exposition nach oraler Einnahme unterliegt jedoch einer hohen interindividuellen Variabilität, da sie stark von gastrointestinalen Absorptionsprozessen abhängt, die per se durch eine hohe inter- und intraindividuelle Variabilität gekennzeichnet sind. Krankheits- und patientenspezifische Merkmale (z. B. Krankheitszustand, Begleiterkrankungen, Begleitmedikation, Demographie der Patienten) können zusätzlich zu einer Variabilität in den Plasmakonzentrationen zwischen einzelnen Patienten beitragen. Darüber hinaus weisen viele OADs eine komplexe Pharmakokinetik (PK) auf, die noch nicht für alle Substanzen hinreichend untersucht und aufgeklärt wurde. All dies kann das Risiko einer suboptimalen Plasmaexposition (entweder subtherapeutisch oder toxisch) erhöhen, was letztendlich den Therapieerfolg gefährden kann, entweder durch einen Wirkungsverlust oder durch vermehrt auftretende, nicht tolerierbare unerwünschte Arzneimittelwirkungen. Therapeutisches Drug Monitoring (TDM) kann eingesetzt werden, um suboptimale Plasmaspiegel zu erkennen und eine dauerhafte Unter- oder Überexposition zu verhindern. TDM ist in der Behandlung des Nebennierenrindenkarzinoms (ACC) mit Mitotane, einer Substanz, die sich durch ungünstige PK-Eigenschaften und einer hohen IIV auszeichnet, unerlässlich. In der vorliegenden Arbeit wurde eine HPLC-UV Methode für das TDM von Mitotane aus Trockenblut unter Verwendung volumetrisch absorptiver Mikroprobenahme (VAMS) entwickelt. Bei der entwickelten Methode wurde ein geringes Probenvolumen (20 µl) aus Kapillarblut verwendet, was eine häufigere Probenahme, z. B. zu Beginn der Behandlung, erleichtert. Allerdings gibt es bisher keine Referenzbereiche für Messungen aus Kapillarblut, und eine einfache Umrechnung von Kapillarkonzentrationen in Plasmakonzentrationen erwies sich als schwierig. Bislang ist der therapeutische Bereich nur für Plasmakonzentrationen festgelegt, und beobachtete Kapillarkonzentrationen konnten nicht zuverlässig interpretiert werden. Der Multi-Kinase-Inhibitor Cabozantinib wird ebenfalls für die Behandlung des ACC eingesetzt. Allerdings sind noch nicht alle PK-Eigenschaften, wie der charakteristische zweite Peak im Konzentrations-Zeit-Profil von Cabozantinib, vollständig untersucht. Um ein mechanistisches Verständnis des Wirkstoffs zu erlangen, wurde ein physiologie basiertes pharmakokinetisches (PBPK) Model entwickelt und verschiedene Theorien zur Modellierung des zweiten Peaks untersucht, wobei sich herausstellte, dass eine enterohepatische Rezirkulation der Substanz am plausibelsten ist. Cabozantinib wird hauptsächlich über CYP3A4 metabolisiert und ist daher anfällig für Wechselwirkungen mit z. B. CYP3A4-Induktoren. Die DDI zwischen Cabozantinib und Rifampin wurde mit dem entwickelten PBPK-Modell untersucht und ergab eine um 77 % verringerte Cabozantinib-Exposition (AUC). Daher sollte die Kombination von Cabozantinib mit starken CYP-Induktoren vermieden werden. Wenn dies nicht möglich ist, sollte die gemeinsame Verabreichung mittels TDM überwacht werden. Das Modell wurde außerdem verwendet, um die Cabozantinib Plasmakonzentrationen bei unterschiedlicher Schwere einer Leberschädigung zu simulieren. Hier zeigte sich eine um 64 % bzw. 50 % erhöhte Gesamtexposition bei leichter beziehungsweise mittlerer Leberschädigung. Ruxolitinib wird unter anderem bei Patienten mit akuter (aGvHD) und chronischer (cGvHD) Graft-versus-Host-Erkrankung eingesetzt. Diese Patienten erhalten häufig auch Posaconazol zur Prophylaxe invasiver Pilzerkrankungen, was zu einer CYP3A4-vermittelten DDI zwischen beiden Substanzen führen kann. Unterschiedliche Dosierungsempfehlungen der FDA und der EMA für die Verwendung von Ruxolitinib in Kombination mit Posaconazol erschweren die klinische Anwendung. Um die Auswirkung dieser relevanten DDI zu simulieren, wurden zunächst zwei separate PBPK-Modelle für Ruxolitinib und Posaconazol entwickelt, welche anschließend miteinander kombiniert wurden. Die vorhergesagte Ruxolitinib Exposition wurde mit beobachteten Plasmakonzentrationen von GvHD-Patienten verglichen. Die Modellsimulationen zeigten, dass die beobachteten Ruxolitinib Konzentrationen bei diesen Patienten im Allgemeinen höher waren als die simulierten Konzentrationen bei gesunden Personen, wobei in beiden Szenarien eine Standarddosierung vorlag. Dem Modell zufolge schient die von der EMA empfohlene Reduzierung der RUX-Dosis um 50 % daher plausibler bzw. ausreichend zu sein

Physiologically based pharmacokinetic modelling of Cabozantinib to simulate enterohepatic recirculation, drug−drug interaction with Rifampin and liver impairment

Cabozantinib (CAB) is a receptor tyrosine kinase inhibitor approved for the treatment of several cancer types. Enterohepatic recirculation (EHC) of the substance is assumed but has not been further investigated yet. CAB is mainly metabolized via CYP3A4 and is susceptible for drug–drug interactions (DDI). The goal of this work was to develop a physiologically based pharmacokinetic (PBPK) model to investigate EHC, to simulate DDI with Rifampin and to simulate subjects with hepatic impairment. The model was established using PK-Sim® and six human clinical studies. The inclusion of an EHC process into the model led to the most accurate description of the pharmacokinetic behavior of CAB. The model was able to predict plasma concentrations with low bias and good precision. Ninety-seven percent of all simulated plasma concentrations fell within 2-fold of the corresponding concentration observed. Maximum plasma concentration (C$_{max}$) and area under the curve (AUC) were predicted correctly (predicted/observed ratio of 0.9–1.2 for AUC and 0.8–1.1 for C$_{max}$). DDI with Rifampin led to a reduction in predicted AUC by 77%. Several physiological parameters were adapted to simulate hepatic impairment correctly. This is the first CAB model used to simulate DDI with Rifampin and hepatic impairment including EHC, which can serve as a starting point for further simulations with regard to special populations

Moor muss nass, aber wie? – Ergebnisbericht der Sektionstagung in Lübbenau

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Phenobarbital induces alterations in the proteome of hepatocytes and mesenchymal cells of rat livers.

Preceding studies on the mode of action of non-genotoxic hepatocarcinogens (NGCs) have concentrated on alterations induced in hepatocytes (HCs). A potential role of non-parenchymal liver cells (NPCs) in NGC-driven hepatocarcinogenesis has been largely neglected so far. The aim of this study is to characterize NGC-induced alterations in the proteome profiles of HCs as well as NPCs. We chose the prototypic NGC phenobarbital (PB) which was applied to male rats for a period of 14 days. The livers of PB-treated rats were perfused by collagenase and the cell suspensions obtained were subjected to density gradient centrifugation to separate HCs from NPCs. In addition, HCs and NPC isolated from untreated animals were treated with PB in vitro. Proteome profiling was done by CHIP-HPLC and ion trap mass spectrometry. Proteome analyses of the in vivo experiments showed many of the PB effects previously described in HCs by other methods, e.g. induction of phase I and phase II drug metabolising enzymes. In NPCs proteins related to inflammation and immune regulation such as PAI-1 and S100-A10, ADP-ribosyl cyclase 1 and to cell migration such as kinesin-1 heavy chain, myosin regulatory light chain RLC-A and dihydropyrimidinase-related protein 1 were found to be induced, indicating major PB effects on these cells. Remarkably, in vitro treatment of HCs and NPCs with PB hardly reproduced the proteome alterations observed in vivo, indicating differences of NGC induced responses of cells at culture conditions compared to the intact organism. To conclude, the present study clearly demonstrated that PB induces proteome alterations not only in HCs but also in NPCs. Thus, any profound molecular understanding on the mode of action of NGCs has to consider effects on cells of the hepatic mesenchyme

Neurotoxicity of lidocaine involves specific activation of the p38 mitogen-activated protein kinase, but not extracellular signal-regulated or c-jun N-terminal kinases, and is mediated by arachidonic acid metabolites

Pharmacologic inhibition of the p38 mitogen-activated protein kinase (MAPK) leads to a reduction in lidocaine neurotoxicity in vitro and in vivo. The current study investigated in vitro the hypotheses that lidocaine neurotoxicity is specific for dorsal root ganglion cells of different size or phenotype, involves time-dependent and specific activation of the p38 MAPK, that p38 MAPK inhibitors are only effective if applied with local anesthetic, and that p38 MAPK activation triggers activation of lipoxygenase pathways. The authors used primary sensory neuron cultures and pheochromocytoma cell line cultures to detect time-dependent activation of the p38 MAPK or related pathways such as extracellular signal-regulated kinases and c-jun N-terminal kinases. Cells were divided by size or by immunoreactivity for calcitonin gene-related peptide or isolectin B4, indicative of nociceptive phenotype. The authors also investigated whether arachidonic acid pathways represent a downstream effector of the p38 MAPK in local anesthetic-induced neurotoxicity. All types of dorsal root ganglion cells were subject to neurotoxic effects of lidocaine, which were mediated by specific activation of the p38 MAPK but not extracellular signal-regulated kinases or c-jun N-terminal kinases. Neuroprotective efficacy of p38 MAPK inhibitors declined significantly when administered more than 1 h after lidocaine exposure. Activation of p38 MAPK preceded activation of arachidonic acid pathways. Neurotoxicity of lidocaine, specific activation of p38 MAPK, and neuroprotective effects of a p38 MAPK inhibitor were further confirmed in pheochromocytoma cell line cultures. Specific and time-dependent activation of the p38 MAPK is involved in lidocaine-induced neurotoxicity, most likely followed by activation of lipoxygenase pathway

In vitro, inhibition of mitogen-activated protein kinase pathways protects against bupivacaine- and ropivacaine-induced neurotoxicity

Animal models show us that specific activation of the p38 mitogen-activated protein kinase (MAPK) may be a pivotal step in lidocaine neurotoxicity, but this has not been investigated in the case of two very widely used local anesthetics, bupivacaine and ropivacaine. We investigated the hypotheses that these drugs (A) are less neurotoxic than the prototype local anesthetic, lidocaine (B) are selectively toxic for subcategories of dorsal root ganglion neurons and (C) induce activation of either p38 MAPK or related enzymes, such as the c-jun terminal N-kinase (JNK) and extracellular signal-regulated kinase (ERK). We incubated primary sensory neuron cultures with doses of lidocaine, bupivacaine, and ropivacaine equipotent at blocking sodium currents. Next, we sought to determine potential selectivity of bupivacaine and ropivacaine toxicity on neuron categories defined by immunohistochemical staining, or size. Subsequently, the involvement of p38 MAPK, JNK, and ERK was tested using enzyme-linked immunosorbent assays. Finally, the relevance of MAPK pathways in bupivacaine- and ropivacaine-induced neurotoxicity was determined by selectively inhibiting activity of p38 MAPK, JNK, and ERK. We found that the neurotoxic potency of bupivacaine and ropivacaine is dose-dependent and similar in vitro, but is not selective for any of the investigated subgroups of neurons. Neurotoxicity of bupivacaine and ropivacaine was mediated, at least in part, by MAPKs. Specifically, we demonstrated the relevance of both p38 MAPK and JNK pathways for the neurotoxicity of bupivacaine and characterized the involvement of the p38 MAPK pathway in the neurotoxicity of ropivacaine. Given equipotent doses, the neurotoxic potential of lidocaine does not appear to be significantly different from that of bupivacaine and ropivacaine in vitro. Moreover, bupivacaine and ropivacaine do not exert their neurotoxicity differently on specific subsets of dorsal root ganglion neurons. Their neurotoxic effects are brought about through the activation of specific MAPKs; the specific pharmacologic inhibition of these kinases attenuates toxicity in vitr

Diagnostic Use of PCR for Detection of Pneumocystis carinii in Oral Wash Samples

There is a need to develop noninvasive methods for the diagnosis of Pneumocystis carinii pneumonia in patients unable to undergo bronchoscopy or induction sputum. Oral wash specimens are easily obtained, and P. ca- rinii nucleic acid can be amplified and demonstrated by PCR. In routine clinical use, easy sample processing and single-round PCR are needed to ensure rapid analysis and to reduce the risk of contamination. We developed a single-round Touchdown PCR (TD-PCR) protocol with the ability to detect PCR inhibition in the specimen. The TD-PCR was evaluated in a routine diagnostic laboratory and was compared to a previously described PCR protocol (mitochondrial RNA) run in a research laboratory. Both PCR methods amplified a sequence of the mitochondrial rRNA gene of P. carinii. Paired bronchoalveolar lavage (BAL) and oral wash specimens from 76 consecutive human immunodeficiency virus type 1-infected persons undergoing a diagnostic bronchoscopy were included. The TD-PCR procedure was quicker than the mitochondrial PCR procedure (<24 versus 48 h) and, compared to microscopy, had sensitivity, specificity, and positive and negative predictive values of 89, 94, 93, and 91%, respectively, for oral wash specimens and 100, 91, 90, and 100%, respectively, for BAL specimens. Our results suggest that oral wash specimens are a potential noninvasive method to obtain a diagnostic specimen during P. carinii pneumonia infection and that it can be applied in a routine diagnostic laboratory

A Physiologically-Based Pharmacokinetic Model of Ruxolitinib and Posaconazole to Predict CYP3A4-Mediated Drug&ndash;Drug Interaction Frequently Observed in Graft versus Host Disease Patients

Ruxolitinib (RUX) is approved for the treatment of steroid-refractory acute and chronic graft versus host disease (GvHD). It is predominantly metabolized via cytochrome P450 (CYP) 3A4. As patients with GvHD have an increased risk of invasive fungal infections, RUX is frequently combined with posaconazole (POS), a strong CYP3A4 inhibitor. Knowledge of RUX exposure under concomitant POS treatment is scarce and recommendations on dose modifications are inconsistent. A physiologically based pharmacokinetic (PBPK) model was developed to investigate the drug&ndash;drug interaction (DDI) between POS and RUX. The predicted RUX exposure was compared to observed concentrations in patients with GvHD in the clinical routine. PBPK models for RUX and POS were independently set up using PK-Sim&reg; Version 11. Plasma concentration-time profiles were described successfully and all predicted area under the curve (AUC) values were within 2-fold of the observed values. The increase in RUX exposure was predicted with a DDI ratio of 1.21 (Cmax) and 1.59 (AUC). Standard dosing in patients with GvHD led to higher RUX exposure than expected, suggesting further dose reduction if combined with POS. The developed model can serve as a starting point for further simulations of the implemented DDI and can be extended to further perpetrators of CYP-mediated PK-DDIs or disease-specific physiological changes

Distribution of distinct proteins, when comparing controls with PB-treatment from the <i>in</i><i>vitro</i> and <i>in</i><i>vivo</i> sample pools, respectively.

<p>This figure demonstrates the distribution of distinct proteins found in HCs and NPCs during the pooled A) <i>in </i><i>vitro</i> and B) <i>in </i><i>vivo</i> experiments, while including only proteins found with at least 2 peptides. The up- and down-regulation of proteins were neglected in this qualitative comparison.</p

Proteome alterations induced by <i>in</i><i>vitro</i> treatment of primary cells.

<div><p>Part A) shows schematic representations of a cell and her three sub-compartments, namely the supernatant, the cytoplasm and the nucleus. The intensity of red represents the degree of amount of the selected protein found in the respective compartment in contrast to the other experiments. The higher intensity of red corresponds to a higher occurrence. This allows an easy comparison of the expression levels of a protein in different experimental setups.</p> <p>NPCs induce the secretion of IL-1beta and TNF-alpha upon inflammatory stimulation with LPS. <i>In </i><i>vitro</i> treatment with PB induced coronin-7 and ADP-ribosyl cyclase 1, which both are also induced by <i>in </i><i>vivo</i> treatment. The expression of Hsp90, a stress response related protein, was increased upon LPS and PB treatment. Prostaglandin, a protein involved in promotion of proliferation in normal and preneoplastic cells, was induced upon LPS and in vivo PB treatment. HCs respond hardly to the <i>in </i><i>vitro</i> treatment with PB. Treatment with IL-6 specifically induced the acute phase protein T-kininogen-2. UDP-glucuronosyltransferase 2B37 and the chaperone peptidyl-prolyl cis-trans isomerase D were induced by both <i>in </i><i>vitro</i> stimulation experiments as well as by the <i>in </i><i>vivo</i> treatment with PB. Carbamoyl-phosphate synthase is part of the urea cycle and has to be found in all four categories.</p> <p>Proteins in NPC: (1) <b>O35828</b> Coronin-7, (2) <b>P16599</b> Tumor necrosis factor, (3) <b>P34058</b> Heat shock protein HSP 90-beta, (4) <b>Q63264</b> Interleukin-1 beta, (5) <b>Q63921</b> Prostaglandin G/H synthase 1, (6) <b>Q64244</b> ADP-ribosyl cyclase 1.</p> <p>Proteins in HC: (1) <b>P07756</b> Carbamoyl-phosphate synthase [ammonia], (2) <b>P08932</b> T-kininogen 2, (3) <b>P19488</b> UDP-glucuronosyltransferase 2B37, (4) <b>Q6DGG0</b> Peptidyl-prolyl cis-trans isomerase D.</p> <p>Part B) demonstrates the distribution of distinct proteins within the three fractions, supernatant, cytoplasm and nuclear protein fractions, underneath the respective treatment of the cells, which gives an overview of the responsiveness of the cells.</p> <p>Abbr.: SN –proteome of the supernatant, Cyt – proteome of the cytoplasm, NE – proteome of the nuclear extract.</p></div