Post-Marketing Safety Study of Ramucirumab Plus FOLFIRI: Analysis of Age and Initial Dose of Irinotecan in Patients with Metastatic Colorectal Cancer.

BACKGROUND: There is limited real-world evidence regarding the safety of ramucirumab plus FOLFIRI in patients with metastatic colorectal cancer (mCRC). OBJECTIVE: We evaluated the safety of ramucirumab plus FOLFIRI in patients with mCRC by age and initial dose of irinotecan. PATIENTS AND METHODS: This single-arm, prospective, multicenter, non-interventional, observational study was conducted between December 2016 and April 2020. Patients were observed for 12 months. RESULTS: Of 366 enrolled Japanese patients, 362 were eligible for study inclusion. The frequency of grade ≥ 3 adverse events (AEs) by age (≥ 75 years vs < 75 years) was 56.1% versus 50.2%, indicating no substantial differences between age groups. Grade ≥ 3 notable AEs, including neutropenia, proteinuria, and hypertension, were also similar in both age groups, but the frequency of any grade venous thromboembolic events was higher in those aged ≥ 75 years than in those aged < 75 years (7.0% vs 1.3%). The frequency of grade ≥ 3 AEs was slightly lower in patients receiving > 150 mg/m2 of irinotecan than in those receiving ≤ 150 mg/m2 of irinotecan (42.1% vs 53.6%); however, the frequency of grade ≥ 3 diarrhea, but not any grade diarrhea, and liver failure/injury was higher in patients receiving > 150 mg/m2 of irinotecan than in those receiving ≤ 150 mg/m2 of irinotecan (4.6% vs 1.9% and 9.1% vs 2.3%, respectively). CONCLUSIONS: The safety profile of ramucirumab plus FOLFIRI in mCRC patients was similar in subgroups by age and initial irinotecan dose in real-world settings.

Colorectal cancer (CRC), also known as bowel cancer, is a common cancer and a leading cause of death. Chemotherapy is a treatment option for CRC. It consists of one or more powerful medications to destroy cancer cells with the aim of prolonging life and reducing symptoms. These medications can cause side effects such as nausea, vomiting, infections, and high blood pressure. Sometimes these side effects can be so severe that patients stop or reduce their treatment. The safety and efficacy of these anti-cancer drugs are established from clinical trials, but, in daily clinical practice, patient outcomes are affected by various factors, such as general health, age, prior treatments, and lifestyle. Ramucirumab plus FOLFIRI is considered a standard treatment for CRC in patients who have disease progression after first-line treatment. In this study, we collected data from patients with CRC who were given ramucirumab plus FOLFIRI under routine clinical practice in Japan. Data were collected for 12 months from the start of treatment and based on various patient demographics such as age less than or greater than 75 years and treatment with a lower or higher dose of the anti-cancer drug irinotecan. We found that ramucirumab plus FOLFIRI is manageable in patients with CRC regardless of these patient demographics and initial irinotecan dose. This article aims to inform patients and primary care providers regarding real-world treatment outcomes to assist with CRC treatment decision making.

A post-marketing safety study of ramucirumab with FOLFIRI in patients with metastatic colorectal cancer.

Background: Ramucirumab [human vascular endothelial growth factor (VEGF) receptor-2 monoclonal antibody] + levofolinate, fluorouracil, and irinotecan (FOLFIRI) was approved for the treatment of metastatic colorectal cancer (CRC) in Japan based on the results from the phase 3 RAISE trial (NCT01183780). However, safety information of ramucirumab + FOLFIRI in the real-world setting is limited. Therefore, the present study was conducted to evaluate the safety of ramucirumab + FOLFIRI under routine clinical practice in patients with metastatic CRC (mCRC) after first-line chemotherapy. Methods: A single-arm, prospective, multicenter, non-interventional, observational study was conducted between August 2016 and May 2020. Patients with mCRC treated with ramucirumab + FOLFIRI for the first time were included. Patients were observed for 12 months from the start of ramucirumab. Data were recorded using the electronic data capture system. Results: In total, 362 patients with a mean age of 64.1 years were evaluated for safety, of whom 355 patients were evaluated for effectiveness. A higher proportion of the patients were males (n=200; 55.2%), had metastases and recurrent sites (n=362, 100.0%), and had received prior anti-cancer treatment (n=355; 98.1%). Approximately 83.7% (n=303) and 25.4% (n=92) of patients had medication history of bevacizumab and anti-epidermal growth factor receptor (EGFR) antibodies, respectively. Overall, 84.3% (n=305) of patients experienced any grade adverse events (AEs). Neutrophil count decreased (n=138; 38.1%), hypertension (n=58; 16.0%), and diarrhea (n=57; 15.7%) were observed frequently. The clinically relevant grade ≥3 AEs of special interest (AESIs) with >2% incidence included neutropenia (n=101; 27.9%), hypertension (n=35; 9.7%), proteinuria (n=23; 6.4%), hepatic dysfunction (n=15; 4.1%), febrile neutropenia (n=10; 2.8%), and leukopenia (n=9; 2.5%). The presence of renal disease at baseline increased the risk of proteinuria [risk ratio: 2.1; 95% confidence interval (CI): 1.1-4.2]. Three deaths were reported due to AEs, of which 1 was study treatment related. The 12-month survival rate of the ramucirumab + FOLFIRI regimen was 59%, mortality mainly (90%) occurring due to progressive disease. Conclusions: Although the current observational study enrolled patients with various medication history, the regimen of ramucirumab + FOLFIRI was manageable under clinical practice. No new safety concerns beyond the findings observed in previous clinical trials were reported.

The clinical position of ramucirumab-containing regimens for advanced gastric cancer: a review of clinical trial data.

Despite the availability of multiple treatment options, the prognosis for advanced gastric cancer (AGC) remains poor and more effective treatment options are needed. Ramucirumab is an established and recommended second-line treatment for AGC. In recently completed and ongoing clinical trials, ramucirumab has been investigated in combination with new therapeutics and in new clinical settings to address the unmet treatment needs of AGC. In this review, the findings of recent clinical trials are discussed. The aims of this review are to present the current picture of ramucirumab-containing regimens in AGC and offer practical guidance on the clinical position and target populations of ramucirumab-containing regimens in light of emerging therapeutic developments.

Long-term safety and effectiveness of biosimilar insulin glargine in Japanese patients with diabetes mellitus in routine clinical practice: results of a post-marketing safety study.

Objective: To evaluate the long-term safety and effectiveness of biosimilar insulin glargine (GLY) in real-world clinical practice.Methods: This prospective, non-interventional, multicenter, observational, post-marketing safety study (PMSS) enrolled Japanese patients with type 1 or 2 diabetes mellitus (T1DM or T2DM) starting GLY therapy, and was required by Japanese Pharmaceutical Affairs Law mandating post-marketing safety surveillance to acquire safety and effectiveness data of biosimilar products. Data collected from the 12-month observation included patient characteristics, adverse events, and blood glucose control.Results: The study enrolled 141 patients with T1DM and 1104 patients with T2DM. Pre-study insulin was used by 94.1% of patients with T1DM and 75.0% with T2DM. 65.4% of patients with T1DM and 64.3% with T2DM switched from the reference product (GLY-switched), while 25.0% with T2DM were insulin-naive. Adverse events were reported by 5.7% and 8.5% in T1DM and T2DM, respectively. Similar incidences were reported in GLY-switched. Adverse events were reported by 10.7% in insulin-naive T2DM. Baseline mean hypoglycemic events/month were 1.8 and 0.1 in T1DM and T2DM, respectively: the mean change from baseline (CFB) was -1.2 (p = .066) and 0.0 (p = .915), respectively. Baseline mean HbA1c was 8.4% and 8.7% in T1DM and T2DM, respectively; the mean CFB was -0.5% (p < .001) and -0.9% (p < .001), respectively, and -1.5% (p < .001) in insulin-naive T2DM.Conclusions: This first long-term Japanese PMSS of GLY demonstrated adverse events, hypoglycemia, and glycemic control consistent with the known GLY profile for T1DM and T2DM patients, in routine clinical practice.

Population pharmacokinetic-pharmacodynamic target attainment analysis of imipenem plasma and urine data in neonates and children.

BACKGROUND: Population pharmacokinetic (PK)-pharmacodynamic target attainment analysis of imipenem was performed to elucidate the PK properties in neonates and children and to rationalize and optimize dosing regimens. METHODS: Population PK models were separately developed in neonates and children by simultaneously fitting plasma and urine data from 60 neonates and 39 children. The newly developed models were then used to estimate the probability of attaining the pharmacodynamic target (40% of the time above the minimum inhibitory concentration) against clinical isolates of common bacteria in pediatric patients. RESULTS: The data were best described by a 1-compartment model in neonates and a 2-compartment model in children, respectively. Renal clearance in children (0.187 L/h/kg) was double that of neonates (0.0783 L/h/kg), whereas the volume of distribution at steady-state was approximately 1.8-fold larger in neonates (0.466 L/kg) than in children (0.260 L/kg). Age was not a statistically significant covariate in the PK of both groups. Infusions (0.5 h) of 15 mg/kg every 8 h (45 mg/kg/day) and 25 mg/kg every 12 h (50 mg/kg/day) were shown to be sufficient against common bacterial isolates in both patient populations. However, 1.5-h infusions of 25 mg/kg every 8 h (75 mg/kg/day) in neonates and 25 mg/kg every 6 h (100 mg/kg/day) in children were required to be effective against Pseudomonas aeruginosa (minimum inhibitory concentration for 90% of the isolates=16 µg/mL). CONCLUSIONS: These results explain the changes in imipenem PK properties during the human growth process and provide guidance for tailoring dosing regimens in each pediatric age group.

Penetration of meropenem into human pancreatic juice.

This study examined the penetration of meropenem into pancreatic juice in patients who had undergone hepato-biliary-pancreatic surgery. The patients received a 0.5-h infusion of 500 mg meropenem. The observed maximum concentration (mean ± standard deviation, n = 5) was 39.1 ± 11.2 µg/ml at 0.5 h in plasma and 2.12 ± 0.73 µg/ml at 1.10 ± 0.14 h in pancreatic juice. The pancreatic juice/plasma ratio was 0.06 ± 0.02. The area under the drug concentration-time curve was 73.0 ± 37.5 µg•h/ml in plasma and 4.24 ± 2.77 µg•h/ml in pancreatic juice. The pancreatic juice/plasma ratio was 0.06 ± 0.01. The mean drug-exposure times above 0.125 µg/ml and 0.25 µg/ml (the minimum inhibitory concentrations (MIC) for common pathogens) in pancreatic juice were 99.4% and 87.3%, respectively, for 500 mg meropenem 3 times daily. This commonly used regimen for pancreatitis achieved the drug-exposure time target (40% of the time above the MIC) at the action site, despite the low penetrability of meropenem.

Optimisation of imipenem regimens in patients with impaired renal function by pharmacokinetic-pharmacodynamic target attainment analysis of plasma and urinary concentration data.

In this study, a pharmacokinetic-pharmacodynamic (PK-PD) target attainment analysis of imipenem (IPM) in patients with impaired renal function was conducted. IPM (500 mg) was administered via a 0.5-h or 1-h infusion to 27 patients with varying renal function. A population PK model was developed by simultaneously fitting plasma and urinary concentration data. A two-compartment model adequately described IPM pharmacokinetics, and creatinine clearance (CL(Cr)) was identified as the most significant covariate. A PK-PD simulation predicted the probabilities of attaining the target in plasma [40% of the time above the minimum inhibitory concentration (MIC)] and defined the PK-PD breakpoints (the highest MICs at which the probabilities were ≥90%). In a patient with a CL(Cr) of 90 mL/min, prolongation of infusion time (from 0.5 h to 1.5 h) increased the PK-PD breakpoint from 1 µg/mL to 2 µg/mL with a 500 mg dose every 8h (q8h) and from 2 µg/mL to 4 µg/mL with a 500 mg dose every 6h (q6h). Meanwhile, in a patient with a CL(Cr) of 20 mL/min, the PK-PD breakpoints for both 0.5-h and 1.5-h infusions were 1 µg/mL with a 250 mg dose every 12h (q12h), 2 µg/mL with a 250 mg dose q8h and a 500 mg dose q12h, and 4 µg/mL with a 250 mg dose q6h. These results indicate that a shorter dosing interval is beneficial in patients with impaired renal function as it results in greater PK-PD breakpoints and a reduction in excessive maximum plasma concentrations. These results help to optimise IPM regimens, particularly in patients with impaired renal function.

Phase I dose escalation and pharmacokinetic study of oral enzastaurin (LY317615) in advanced solid tumors.

Enzastaurin is an oral serine/threonine kinase inhibitor that targets the protein kinase C (PKC) and phosphoinositide 3-kinase/AKT pathways to induce apoptosis and suppress proliferation of various cancer cell lines. This phase I study evaluated the tolerability and pharmacokinetics of enzastaurin in Japanese patients with advanced solid tumors and determined the recommended dose for phase II. Eligible patients had advanced solid tumors and an Eastern Cooperative Oncology Group performance status of 0-2. Patients received enzastaurin orally once daily until disease progression (PD) or unacceptable toxicity occurred. Enzastaurin was started at 250 mg/day followed by stepwise dose increases based on the incidence of dose-limiting toxicities (DLT). Twenty-three patients (seven patients: 250 mg; six patients: 375 mg; six patients: 500 mg; four patients: 750 mg) were enrolled and received enzastaurin. The major tumor types were non-small-cell lung cancer (n = 5) and breast cancer (n = 3). No DLT was reported at doses of 500 mg or less. Because two DLT (grade 2 QTc prolongation lasting for a week) were observed at 750 mg enzastaurin, this was determined as the maximum tolerated dose. Multiple daily doses at 500 mg achieved the target plasma concentration to inhibit PKC activity (1400 nmol/L). Enzastaurin was well tolerated up to 500 mg in Japanese patients with advanced solid tumors. The recommended dose for phase II was determined to be 500 mg daily for a 28-day cycle on the basis of safety and plasma exposures.

[Detection of the preservative chlorphenesin in cosmetics by high-performance liquid chromatography].

A simple determination method for preservative chlorphenesin in cosmetics was developed. Cosmetic samples were dissolved in methanol. The sample solution was analyzed by high-performance liquid chromatography (HPLC) with ODS column, using water-methanol (55:45) or water-acetonitrile (3:1) adjusted to pH 2.5 with phosphoric acid as the mobile phase. Chlorphenesin was detected with ultraviolet light detection at 280 nm. A linear relation was obtained between the peak areas and the concentrations of chlorphenesin in the range of 1-500 microg/ml. The determination limit of chlorphenesin was 1-2 microg/ml. Recoveries of chlorphenesin spiked in lotion and milky lotion at the levels of 0.03% and 0.3% were 98.8-100.0%. This method was applied for cosmetics including 0.03% and 0.3% of chlorphenesin and their content corresponded with the determined values.

[Studies for analyzing restricted ingredients such as phenylbenzoimidazole sulfonic acid].

Phenylbenzoimidazol sulfonic acid (PBS) is a kind of sunscreens in cosmetics and is nominated as the restricted ingredients in cosmetics in Japanese Pharmaceutical Affairs Act. So the analytical method for PBS was investigated by HPLC. 1.0 g of the lotions with 1.0% PBS was exactly weighed, put into a 50-mL volumetric flask. Water was added to make exactly 50 mL and this mixture was used as the sample solution. On the other hand, 1.0 g of the creams with 1.0% PBS was exactly weighed, put into a beaker. After adding 1 mL of tetrahydrofuran and dissolving the cream, that mixture was transferred to a 50-mL volumetric flask. And then the beaker was rinsed with 1 mL of tetrahydrofuran and the rinsed solution was put together into the volumetric flask. After adding water to the volumetric flask to make exactly 50 mL, this mixture was used as the sample solution. If necessary, the mixture was filtrated with a membrane filter (0.45 microm). 5.0 mL of the sample solution was pipetted and put into a 200-mL volumetric flask. After adding water to make exactly 200 mL, 20 microL of this solution was analyzed by HPLC using the ODS column (CAPCELL PAK C18 column, 4.6 mm i.d. x 250 mm), the mixture of 40 mmol/L acetic buffer (pH 3.4) and acetonitrile (3:1) with 0.8 mmol/L dodecyltrimethyl ammonium bromide and the detection wavelength of 305 nm. The working curve from 0.5 to 20.0 microg/mL showed a linear line between the concentrations of PBS and the peak areas. There was no interference of peak of PBS from the lotion and cream.

Syntheses of potential metabolites of a potent kappa-opioid receptor agonist, TRK-820.

Chemical syntheses of three kinds of potential metabolites of TRK-820, a potent kappa-opioid receptor agonist, were described. One of the potential metabolites 2, 17-N-dealkylated TRK-820, was synthesized starting from noroxycodone through 8 steps in 21% total yield. Glucuronidation of intermediate 10 and compound 1, the free base of TRK-820, was carried out stereoselectively to give 3-O-beta-D-glucuronides 15 and 16 in good yields, respectively. Syntheses of potential conjugated metabolites 3 and 4 were accomplished through 10 steps and 2 steps in 11% and 43% total yields, respectively. Among the potential metabolites of TRK-820, compounds 2 and 4 were identified as metabolites in human hepatocytes. The results of pharmacological studies of compounds 2, 3, and 4 are described.

[Studies for analyzing restricted ingredients such as sodium benzoate].

Sodium benzoate is a kind of preservatives in cosmetics and is nominated as the restricted ingredients in cosmetics in Japanese Pharmaceutical Affairs Act. So the analytical method for sodium benzoate was investigated by HPLC. After adding 5 ml of tetrahydrofuran to 0.05 g of the lotions or creams with 0.1 or 1.0% sodium benzoate and dissolving them, that mixture was made up to 50 ml with methanol. If necessary, the mixture was filtrated with a membrane filter (0.45 microm). The testing solution of 20 micro1 was analyzed by HPLC using the ODS column (CAPCELL PAK C18 column, 4.6 x 250 mm), the mixture of 50 mmol/l phosphate buffer (pH5.5) and acetonitrile (7:3) and the detection wavelength of 227 nm. The working curve from 1.0 to 12.0 microg/ml showed a linear line between the concentrations of sodium benzoate and the peak area. There was no interference of peak of sodium benzoate from the lotion and cream.