Ignite Creation Date:
2024-05-06 @ 1:39 AM
Last Modification Date:
2024-10-26 @ 11:07 AM
Study NCT ID:
NCT01860456
Status:
RECRUITING
Last Update Posted:
2023-10-10
First Post:
2013-05-15
Brief Title:
TyrosIne Kinase Inhibitors in Chronic Myeloid Leukemia Efficacy and Tolerability The TIKlet Study
Sponsor:
University of Pisa
Organization:
University of Pisa
Study Overview
Official Title:
Tyrosine Kinase Inhibitors of BCRABL Pharmacokinetic and Pharmacogenetic Study in Patients Affected by Chronic Myeloid Leukemia Evaluation of Efficacy and Tolerability
Status:
RECRUITING
Status Verified Date:
2023-10
Last Known Status:
None
Delayed Posting:
No
If Stopped, Why?:
Not Stopped
Has Expanded Access:
False
If Expanded Access, NCT#:
N/A
Has Expanded Access, NCT# Status:
N/A
Acronym:
TIKlet
Brief Summary:
Rationale
The pharmacokinetics of imatinib and nilotinib two BCRAbl tyrosine-kinase inhibitors TKI is variable among patients suffering from chronic myeloid leukemia CML Transmembrane transporters may play a pivotal role in interindividual variability in TKI disposition Furthermore minimum plasma concentrations Cmin higher than 1 mgL could be associated with a higher likelihood of molecular and cytogenetic responses
The TIKlet study is aimed at evaluating correlations among the pharmacogenetics pharmacokinetics and treatment efficacytolerability of imatinib and nilotinib in CML patients
1 PATIENTS AND METHODS
11 Patients
Patients affected by CML will be enrolled after the informed consent will be signed according to the following inclusion criteria
patients of both sexes
age between 18 and 80 years
treated with imatinib or nilotinib
included in follow-up activities at the participating Hematology Divisions
able to give informed consent
with a proved compliance with the scheduled treatment
The administration of other drugs will be allowed being known the dose and duration of treatment as well as smoking and herbal products
Alterations in organ functions or physicochemical exams body mass index 28 do not represent exclusion criteria
12 Enrollment and follow-up visits
During enrollment visit
patients will be informed about the study their signed informed consent form will be collected and an individual alphanumeric code will be assigned
Patients data will be recorded within the individual case report form CRF and a blood sample will be obtained
At follow-up visits a blood sample will be collected for therapeutic drug monitoring TDM and patients CRF will be updated
13 Blood samples
After centrifugation the resulting plasma will be collected for TDM During the enrollment visit an aliquot of whole blood will be collected for molecular analyses
14 Laboratory analyses
TDM will be performed by high-performance liquid chromatography systems then results will be evaluated by a population pharmacokinetic analysis Single nucleotide polymorphisms will be investigated in the following genes ABCB1 ABCG2 hOCT1 OCTN1 OATP1A2
Finally response to drugs in terms of Major Molecular Response MMR and Complete Cytogenetic Response CCyR and tolerability will be evaluated Any possible correlation among drug disposition pharmacogenetics and treatment effects will be analyzed
The pharmacokinetics of imatinib and nilotinib two BCRAbl tyrosine-kinase inhibitors TKI is variable among patients suffering from chronic myeloid leukemia CML Transmembrane transporters may play a pivotal role in interindividual variability in TKI disposition Furthermore minimum plasma concentrations Cmin higher than 1 mgL could be associated with a higher likelihood of molecular and cytogenetic responses
The TIKlet study is aimed at evaluating correlations among the pharmacogenetics pharmacokinetics and treatment efficacytolerability of imatinib and nilotinib in CML patients
1 PATIENTS AND METHODS
11 Patients
Patients affected by CML will be enrolled after the informed consent will be signed according to the following inclusion criteria
patients of both sexes
age between 18 and 80 years
treated with imatinib or nilotinib
included in follow-up activities at the participating Hematology Divisions
able to give informed consent
with a proved compliance with the scheduled treatment
The administration of other drugs will be allowed being known the dose and duration of treatment as well as smoking and herbal products
Alterations in organ functions or physicochemical exams body mass index 28 do not represent exclusion criteria
12 Enrollment and follow-up visits
During enrollment visit
patients will be informed about the study their signed informed consent form will be collected and an individual alphanumeric code will be assigned
Patients data will be recorded within the individual case report form CRF and a blood sample will be obtained
At follow-up visits a blood sample will be collected for therapeutic drug monitoring TDM and patients CRF will be updated
13 Blood samples
After centrifugation the resulting plasma will be collected for TDM During the enrollment visit an aliquot of whole blood will be collected for molecular analyses
14 Laboratory analyses
TDM will be performed by high-performance liquid chromatography systems then results will be evaluated by a population pharmacokinetic analysis Single nucleotide polymorphisms will be investigated in the following genes ABCB1 ABCG2 hOCT1 OCTN1 OATP1A2
Finally response to drugs in terms of Major Molecular Response MMR and Complete Cytogenetic Response CCyR and tolerability will be evaluated Any possible correlation among drug disposition pharmacogenetics and treatment effects will be analyzed
Detailed Description:
1 Patients
11 Patients
CML patients will be included according to the following inclusion criteria a patients of both sexes b age between 18 and 80 years c treated with imatinib or nilotinib d included in the follow-up in the Divisions Units of Hematology involved in the project e able to give informed consent to trial participation f with a proved compliance with the scheduled treatment
Patients will be excluded from participation to the study if a age 18 or 80 years or b unable to provide informed consent The inability to attend the follow-up visits will not be considered an exclusion criterion from the study In this case collected data will be used in pharmacokinetic and statistical analyses on the basis of an intention-to-treat criterion
The following conditions should be noted
1 the concomitant administration of other drugs will be allowed provided it will be known the active ingredient the dose and the period of administration
2 smoking and herbal products will be allowed but they should be reported on patients case report form
3 alterations in liver and kidney functions body mass index higher than 28 or any other alteration in physicochemical exams do not represent exclusion criteria
12 Sample size
For the purposes of this study it has been estimated that it will need to recruit at least 206 subjects per drug total 412 patients taking into account
1 the minor allele frequency of the most studied polymorphism evaluated in this research protocol ie 03 T allele of the ABCB1 c3435CT polymorphism
2 the 11 ratio allele C carriers and patients homozygous for the T allele of the ABCB1 c3435CT polymorphism
3 covariate effects on drug pharmacokinetics will be considered significant when the mean difference in pharmacokinetic parameters will be at least 20
4 the power of the study will be 80
5 the alpha error will be set at 005
13 Enrollment
Patient enrollment in the various participating centers will be competitive up to the achievement of 206 individuals per drug
At the first visit the TIKlet study will be presented to patients who will satisfy the inclusion exclusion criteria The following activities will take place
patients will be informed about the characteristics objectives and procedures of the study
Consent to study participation will be confirmed by signing the informed consent form
Personal alphanumeric code assignment for patients identification and privacy
Updating of the enrollment list
Collection of main data of the patient age sex age at diagnosis clinical chemistry test results as reported in the patients record and any combination therapies with their doses and duration within the individual case report form CRF
A blood withdrawal approximately 4 mL will be performed from a peripheral vein of the forearm The time at which blood will be withdrawn will be registered within patients CRF together with the time elapsed from the last administration of imatinib or nilotinib For sample handling see section 21 Blood sample handling
The updated list of enrolled patients and individual case report forms will be sent to the Division of Hematology Dept of Clinical and Experimental Medicine University of Pisa
14 Follow-up visits
According to clinical routine at each participating center the following activities should be performed during each follow-up visit
Collection of patients data clinical chemistry test results cytogenetic analysis and molecular biology results BCRAbl transcript levels any concomitant therapy any adverse drug reaction
A blood sample approximately 4 mL will be collected from a peripheral vein of the forearm The time at which blood will be withdrawn will be registered within patients CRF together with the time elapsed from the intake of last imatinib or nilotinib dose For sample handling see section 21 Blood sample handling
2 Laboratory analyses
Laboratory analyses will be conducted at the Division of Pharmacology Department of Clinical and Experimental Medicine University of Pisa measurement of drug plasma concentrations pharmacogenetic analyses and at the Department of Pharmacology University of Bologna pharmacogenetic analyses
21 Blood sample handling
Each tube containing the patients whole blood plasma or DNA see below and used for the execution of therapeutic monitoring or pharmacogenetic analyses will be identified by a the patients code and b the date of execution of blood withdrawal
All blood samples will be collected in lithium-heparin Vacutainer tubes then they will be stored at 4 C until centrifugation The sample will be centrifuged and the resulting plasma 15 mL will be collected and stored in a tube for therapeutic drug monitoring Only during the enrollment visit an aliquot of whole blood 05 mL will be collected in a sterile eppendorf for molecular analyses Both samples will be stored at -20 C for a maximum of 2 weeks then they will be sent to the Dept of Clinical and Experimental Medicine University of Pisa
For sample storage see section 27 Biological sample storage
22 Measurement of plasma concentration of drugs
The measurement of plasma concentrations of imatinib and its active metabolite and nilotinib will be conducted by a high-performance liquid chromatography HPLC method using commercially available kits Chromsystems GmbH Munich Germany on Waters Breeze and Alliance instruments Waters USA
Briefly solid-phase extraction columns will be balanced with Equilibration buffers 1 and 2 then the internal standard and plasma 05 mL will be added The column will be centrifuged and subsequently washed with Wash buffer and water for HPLC The eluate will be collected by centrifugation diluted with water for HPLC and injected 0025 mL into the HPLC system for the execution of the analysis The peak area of the analytes of interest imatinib and its active metabolite nilotinib and internal standard will be recorded and the actual concentration of drug in plasma will be obtained by comparison with standard calibration curves for each day of analysis
The HPLC analyses will be carried out on a weekly basis The reports of the analysis will be sent to the Divisions Units of Hematology and registered into both the patients medical record and study CRFs
23 Pharmacokinetic analyses
Plasma concentrations of imatinibactive metabolite and nilotinib will be analyzed trough a population pharmacokinetic analysis according to a nonlinear mixed-effects modeling approach using the NONMEM software version 72 The Xpose and PsN packages will be used to check database for model diagnostic and covariate testing Former models for imatinibmetabolite and nilotinib will be 1- and 2-compartment models with first-order elimination and parameterized in terms of apparent drug clearance CLF volume of distribution VF and absorption constant ka while the residual error will be modeled as additive proportional or mixed additive and proportional error The availability of records goodness-of-fit plots and the precision of parameter estimates together with a generalized additive modeling procedure GAM implemented in the Xpose package will be adopted for model development and to explore correlations among the covariates In particular age weight body mass index liver ALT AST and renal function creatinine plasma concentration albumin and α1-acid glycoprotein plasma concentrations and results of pharmacogenetic analyses will be considered as possible covariates A stepwise covariate model building will be performed with forward inclusion and backward exclusion In particular a decrease in the objective function value OFV greater than 384 points ie p005 and 663 points ie p001 will be the criteria used in the forward inclusion and backward exclusion steps respectively The goodness of the final model will be checked by bootstrap analysis using the PsN and Xpose packages and calculating η-shrinkage The area under the plasma concentration-time curve from time zero up to infinity AUC and terminal elimination half-life t12 will be calculated from the individual empirical Bayes estimates EBE from the final population pharmacokinetic model as follows
AUCTotal daily doseCLF t12ln2kel where kel is imatinib elimination constant
24 Pharmacogenetic analyses
The aliquot of frozen whole blood will be employed for the extraction of genomic DNA with a suitable kit Qiagen Milan Italy following manufacturers instructions and the nucleic acid will be stored at -80 C until the time of analysis in sterile tube bearing the identification code of the patient
Single nucleotide polymorphisms SNPs of the following genes will be assayed ABCB1 ABCG2 hOCT1 OCTN1 OATP1A2 SNPs will be evaluated by specific kits from Applied Biosystems Life Sciences Milan Italy on an ABI Prism 7900HT Sequence Detection System Life Sciences Each analysis will be performed in triplicate Genotypes will be automatically identified through the software SDS Life Sciences Frequency of alleles and genotypes according to the Hardy-Weinberg law haplotype and linkage disequilibrium analysis will be performed using Arlequin software package
25 Treatment effectiveness and tolerability
The response to the therapy with imatinib will be evaluated in agreement with criteria recently published and adopted In particular results from chemical biochemical and molecular analyses will be performed every 2 weeks during the first 3 months of treatment then cytogenetic metaphase chromosomal banding assay and molecular analyses quantification of BCR-ABL transcription levels in plasma by real-time-PCR were performed every 6 and 3 months respectively until the attainment of a complete response The time to complete cytogenetic response CCyR and to major molecular response MMR will be defined as the length of time elapsed from diagnosis and response attainment for every patient
Furthermore treatment-associated adverse reactions ie nausea and vomiting periorbital oedema cramps and myalgia neutropenia skin and liver toxicities will be identified and scored according to the Common Toxicity Criteria-NCI grading system version 3
26 Statistical analysis
The results will be analyzed in aggregate form Parameter of dispersion standard deviation range central indexes mean median and distribution ie Kolmogorov-Smirnov test will be calculated The most appropriate statistical tests ANOVA Fisher test etc will be applied to investigate any possible difference between groups and the level of significance will be set at p 005 The identification of cut-off values for parameters predictive of efficacy tolerability plasma concentrations polymorphisms will be pursued trough ad hoc analyses receiver operating characteristics analysis evaluation of positive and negative predictive values
27 Biological sample storage
All biological samples whole blood 05 mL plasma 15 mL and genomic DNA will be stored at the Division of Pharmacology Department of Clinical and Experimental Medicine University of Pisa Aliquots of DNA samples for pharmacogenetic analyses will be stored at the Department of Pharmacology University of Bologna
Each sample will be identified by the individual alphanumeric code assigned to every patient According to protocol patients may require the destruction of their own biological samples
28 Authorship
The criteria declared by the ICMJE International Committee of Medical Journal Editors will be adopted for authorship definition
11 Patients
CML patients will be included according to the following inclusion criteria a patients of both sexes b age between 18 and 80 years c treated with imatinib or nilotinib d included in the follow-up in the Divisions Units of Hematology involved in the project e able to give informed consent to trial participation f with a proved compliance with the scheduled treatment
Patients will be excluded from participation to the study if a age 18 or 80 years or b unable to provide informed consent The inability to attend the follow-up visits will not be considered an exclusion criterion from the study In this case collected data will be used in pharmacokinetic and statistical analyses on the basis of an intention-to-treat criterion
The following conditions should be noted
1 the concomitant administration of other drugs will be allowed provided it will be known the active ingredient the dose and the period of administration
2 smoking and herbal products will be allowed but they should be reported on patients case report form
3 alterations in liver and kidney functions body mass index higher than 28 or any other alteration in physicochemical exams do not represent exclusion criteria
12 Sample size
For the purposes of this study it has been estimated that it will need to recruit at least 206 subjects per drug total 412 patients taking into account
1 the minor allele frequency of the most studied polymorphism evaluated in this research protocol ie 03 T allele of the ABCB1 c3435CT polymorphism
2 the 11 ratio allele C carriers and patients homozygous for the T allele of the ABCB1 c3435CT polymorphism
3 covariate effects on drug pharmacokinetics will be considered significant when the mean difference in pharmacokinetic parameters will be at least 20
4 the power of the study will be 80
5 the alpha error will be set at 005
13 Enrollment
Patient enrollment in the various participating centers will be competitive up to the achievement of 206 individuals per drug
At the first visit the TIKlet study will be presented to patients who will satisfy the inclusion exclusion criteria The following activities will take place
patients will be informed about the characteristics objectives and procedures of the study
Consent to study participation will be confirmed by signing the informed consent form
Personal alphanumeric code assignment for patients identification and privacy
Updating of the enrollment list
Collection of main data of the patient age sex age at diagnosis clinical chemistry test results as reported in the patients record and any combination therapies with their doses and duration within the individual case report form CRF
A blood withdrawal approximately 4 mL will be performed from a peripheral vein of the forearm The time at which blood will be withdrawn will be registered within patients CRF together with the time elapsed from the last administration of imatinib or nilotinib For sample handling see section 21 Blood sample handling
The updated list of enrolled patients and individual case report forms will be sent to the Division of Hematology Dept of Clinical and Experimental Medicine University of Pisa
14 Follow-up visits
According to clinical routine at each participating center the following activities should be performed during each follow-up visit
Collection of patients data clinical chemistry test results cytogenetic analysis and molecular biology results BCRAbl transcript levels any concomitant therapy any adverse drug reaction
A blood sample approximately 4 mL will be collected from a peripheral vein of the forearm The time at which blood will be withdrawn will be registered within patients CRF together with the time elapsed from the intake of last imatinib or nilotinib dose For sample handling see section 21 Blood sample handling
2 Laboratory analyses
Laboratory analyses will be conducted at the Division of Pharmacology Department of Clinical and Experimental Medicine University of Pisa measurement of drug plasma concentrations pharmacogenetic analyses and at the Department of Pharmacology University of Bologna pharmacogenetic analyses
21 Blood sample handling
Each tube containing the patients whole blood plasma or DNA see below and used for the execution of therapeutic monitoring or pharmacogenetic analyses will be identified by a the patients code and b the date of execution of blood withdrawal
All blood samples will be collected in lithium-heparin Vacutainer tubes then they will be stored at 4 C until centrifugation The sample will be centrifuged and the resulting plasma 15 mL will be collected and stored in a tube for therapeutic drug monitoring Only during the enrollment visit an aliquot of whole blood 05 mL will be collected in a sterile eppendorf for molecular analyses Both samples will be stored at -20 C for a maximum of 2 weeks then they will be sent to the Dept of Clinical and Experimental Medicine University of Pisa
For sample storage see section 27 Biological sample storage
22 Measurement of plasma concentration of drugs
The measurement of plasma concentrations of imatinib and its active metabolite and nilotinib will be conducted by a high-performance liquid chromatography HPLC method using commercially available kits Chromsystems GmbH Munich Germany on Waters Breeze and Alliance instruments Waters USA
Briefly solid-phase extraction columns will be balanced with Equilibration buffers 1 and 2 then the internal standard and plasma 05 mL will be added The column will be centrifuged and subsequently washed with Wash buffer and water for HPLC The eluate will be collected by centrifugation diluted with water for HPLC and injected 0025 mL into the HPLC system for the execution of the analysis The peak area of the analytes of interest imatinib and its active metabolite nilotinib and internal standard will be recorded and the actual concentration of drug in plasma will be obtained by comparison with standard calibration curves for each day of analysis
The HPLC analyses will be carried out on a weekly basis The reports of the analysis will be sent to the Divisions Units of Hematology and registered into both the patients medical record and study CRFs
23 Pharmacokinetic analyses
Plasma concentrations of imatinibactive metabolite and nilotinib will be analyzed trough a population pharmacokinetic analysis according to a nonlinear mixed-effects modeling approach using the NONMEM software version 72 The Xpose and PsN packages will be used to check database for model diagnostic and covariate testing Former models for imatinibmetabolite and nilotinib will be 1- and 2-compartment models with first-order elimination and parameterized in terms of apparent drug clearance CLF volume of distribution VF and absorption constant ka while the residual error will be modeled as additive proportional or mixed additive and proportional error The availability of records goodness-of-fit plots and the precision of parameter estimates together with a generalized additive modeling procedure GAM implemented in the Xpose package will be adopted for model development and to explore correlations among the covariates In particular age weight body mass index liver ALT AST and renal function creatinine plasma concentration albumin and α1-acid glycoprotein plasma concentrations and results of pharmacogenetic analyses will be considered as possible covariates A stepwise covariate model building will be performed with forward inclusion and backward exclusion In particular a decrease in the objective function value OFV greater than 384 points ie p005 and 663 points ie p001 will be the criteria used in the forward inclusion and backward exclusion steps respectively The goodness of the final model will be checked by bootstrap analysis using the PsN and Xpose packages and calculating η-shrinkage The area under the plasma concentration-time curve from time zero up to infinity AUC and terminal elimination half-life t12 will be calculated from the individual empirical Bayes estimates EBE from the final population pharmacokinetic model as follows
AUCTotal daily doseCLF t12ln2kel where kel is imatinib elimination constant
24 Pharmacogenetic analyses
The aliquot of frozen whole blood will be employed for the extraction of genomic DNA with a suitable kit Qiagen Milan Italy following manufacturers instructions and the nucleic acid will be stored at -80 C until the time of analysis in sterile tube bearing the identification code of the patient
Single nucleotide polymorphisms SNPs of the following genes will be assayed ABCB1 ABCG2 hOCT1 OCTN1 OATP1A2 SNPs will be evaluated by specific kits from Applied Biosystems Life Sciences Milan Italy on an ABI Prism 7900HT Sequence Detection System Life Sciences Each analysis will be performed in triplicate Genotypes will be automatically identified through the software SDS Life Sciences Frequency of alleles and genotypes according to the Hardy-Weinberg law haplotype and linkage disequilibrium analysis will be performed using Arlequin software package
25 Treatment effectiveness and tolerability
The response to the therapy with imatinib will be evaluated in agreement with criteria recently published and adopted In particular results from chemical biochemical and molecular analyses will be performed every 2 weeks during the first 3 months of treatment then cytogenetic metaphase chromosomal banding assay and molecular analyses quantification of BCR-ABL transcription levels in plasma by real-time-PCR were performed every 6 and 3 months respectively until the attainment of a complete response The time to complete cytogenetic response CCyR and to major molecular response MMR will be defined as the length of time elapsed from diagnosis and response attainment for every patient
Furthermore treatment-associated adverse reactions ie nausea and vomiting periorbital oedema cramps and myalgia neutropenia skin and liver toxicities will be identified and scored according to the Common Toxicity Criteria-NCI grading system version 3
26 Statistical analysis
The results will be analyzed in aggregate form Parameter of dispersion standard deviation range central indexes mean median and distribution ie Kolmogorov-Smirnov test will be calculated The most appropriate statistical tests ANOVA Fisher test etc will be applied to investigate any possible difference between groups and the level of significance will be set at p 005 The identification of cut-off values for parameters predictive of efficacy tolerability plasma concentrations polymorphisms will be pursued trough ad hoc analyses receiver operating characteristics analysis evaluation of positive and negative predictive values
27 Biological sample storage
All biological samples whole blood 05 mL plasma 15 mL and genomic DNA will be stored at the Division of Pharmacology Department of Clinical and Experimental Medicine University of Pisa Aliquots of DNA samples for pharmacogenetic analyses will be stored at the Department of Pharmacology University of Bologna
Each sample will be identified by the individual alphanumeric code assigned to every patient According to protocol patients may require the destruction of their own biological samples
28 Authorship
The criteria declared by the ICMJE International Committee of Medical Journal Editors will be adopted for authorship definition
Study Oversight
Has Oversight DMC:
None
Is a FDA Regulated Drug?:
None
Is a FDA Regulated Device?:
None
Is an Unapproved Device?:
None
Is a PPSD?:
None
Is a US Export?:
None
Is an FDA AA801 Violation?:
None