new drugs in haematology
TRANSCRIPT
EBMT Meeting, France, March 2007
NEW DRUGS
in TRANSPLANTATION
C. PAILLET, Pharmacist, Pharm D.C. RENZULLO, Pharmacist, Pharm D.
Edouard Herriot Hospital, Lyon, FRANCE
EBMT Meeting, France, March 2007
DEVELOPMENT of NEW DRUGS (1)
RATIONALEMore efficacyNew target
EVALUATIONScientific performanceCost efficiencyToxicity patterns
EBMT Meeting, France, March 2007
CYTOTOXICCYTOTOXICNON NON
CYTOTOXICCYTOTOXIC
DEVELOPMENT of NEW DRUGS (2)
IMMUNO-
MODULATORY
AGENT
IMMUNO-SUPPRESSIVE
AGENT
GROWTH FACTOR
ANTIFUNGAL AGENT
EBMT Meeting, France, March 2007
CYTOTOXIC DRUG RECONSTITUTION IN E. HERRIOT HOSPITAL (1)
A Centralized Pharmacy Unit for Cytotoxic drugs Reconstitution
A set up within the Haematology Department
The manpower figures for 15 000 cytotoxic / year
An unit managed by the Pharmacy Department2 pharmacists1 pharmacist student4 pharmacy technicians
EBMT Meeting, France, March 2007
CYTOTOXIC DRUG RECONSTITUTION IN E. HERRIOT HOSPITAL (2)
EBMT Meeting, France, March 2007
CYTOTOXIC DRUG RECONSTITUTION IN E. HERRIOT HOSPITAL (3)
EBMT Meeting, France, March 2007
CYTOTOXIC DRUGS (1)
Conditioning regimens prior to allogeneic stem celltransplantation (SCT)
Treosulfan BusulfanMyeloablative and immunosuppressive effects
Alkylating agents (inhibiting DNA replication )
Tolerance of the conditioning and compliance
EBMT Meeting, France, March 2007
Injectable drugs (2)CYTOTOXIC DRUGS (2)
Treosulfan
12 g/m²/day over 3 consecutive days (D-6 to D-4)
Single-use vial containing 1000 mg or 5000 mg
Lyophilized powder reconstituted with 20 or 100 ml ofhot sterile water for injection
Difficult to dissolute
CYTOTOXIC
EBMT Meeting, France, March 2007
Injectable drugs (3)
TreosulfanAdministered pure or diluted (D5W or NS) I.V as a 2 hours infusion
Stable up 4 days at room temperature
SAFETYo Haematotoxicity (thrombocytopenia)o Fatigueo Skin (mild alopecia, skin pigmentation, urticaria…)o Respiratory (allergic alveolitis, pneumonia and pulmonary fibrosis)o Gastrointestinal (nausea +/- vomiting)
CYTOTOXIC DRUGS (3)
EBMT Meeting, France, March 2007
Injectable drugs (4)CYTOTOXIC DRUGS (4)
Busulfan (BUSILVEX®)New galenic formulation of the existing oral busulfan
0.8 mg/kg every 6 hours for 4 consecutive days(D-4 to D-1)
Single-use ampul containing 60mg (10ml)
Ready to use
CYTOTOXIC
EBMT Meeting, France, March 2007
Injectable drugs (5)
Busulfan (BUSILVEX®)Diluted in 100ml NS
Administered IV as a 2 hours infusion
Stable up to 12 hours under refrigeration
Cost : o 290 euros / ampul 7.000 euros / dayo 28.000 euros / transplantationo much higher than the oral form(Esperou, EBMT 2005 ; Groves, Proc. British Oncology Pharmacy Association 2005)
CYTOTOXIC DRUGS (5)
EBMT Meeting, France, March 2007
Injectable drugs (6)CYTOTOXIC DRUGS (6)
Busulfan (BUSILVEX®)Premedication before infusion : anticonvulsant and antiemetic
SAFETYo Haematotoxicity (pancytopenia)o Gastrointestinal (nausea, vomiting, stomatis, diarrhoea) o Skin (alopecia, skin pigmentation, urticaria…)o Significant reduction of VOD (20% to 5%)o Respiratory (tussis, dyspnea)o Fever
EBMT Meeting, France, March 2007
Chronic lymphoblastic leukaemia
Alemtuzumab (MABCAMPATH®)
Facilitate engraftment and prevent GvHD
Monoclonal antibody
Premedication : antihistamine, antipyretic
CYTOTOXIC
CYTOTOXIC DRUGS (7)
EBMT Meeting, France, March 2007
CYTOTOXIC DRUGS (8)
Alemtuzumab (MABCAMPATH®)30mg / day, 3 times / weekon alternate days for up to 12 weeks
Escalating dose : 3mg D1, 10mg D2, 30mg D3
Vial containing a 30mg/ml solution
Cost : 445 euros per vialPatient 1.7m² :
1.335 euros / week16.020 euros / treatment
EBMT Meeting, France, March 2007
CYTOTOXIC DRUGS (9)
Alemtuzumab (MABCAMPATH®)Subcutaneous administration or IV (diluent : D5W or NS)
Stable for 8 hours at room temperature in the dark
SAFETYo Haematotoxicityo Gastrointestinal (nausea, vomiting)o Cardiovascular disorders (hyper or hypo tension)o Skin (prurit, rash…)o Hypersensitivityo Fevero Respiratory (bronchospasm, dyspnea, pneumonia…)
EBMT Meeting, France, March 2007
CYTOTOXIC DRUGS (10)
Refractory myelomaBortezomib (VELCADE ®)
Prolongate the median time to progression of disease
Proteasoma inhibitor induces apoptosis
CYTOTOXIC
EBMT Meeting, France, March 2007
CYTOTOXIC DRUGS (11)
Bortezomib (VELCADE ®)
1.3 mg/m² day 1, day 4, day 8 and day 11
Vial containing 3.5mg
Reconstituted with 3.5ml of NS
Cost : 1.170 euros per vialPatient 1.7m² : 4.700 euros/cycle (3.500 euros/cycle if centralized)
EBMT Meeting, France, March 2007
CYTOTOXIC DRUGS (12)
Bortezomib (VELCADE ®)
Direct IV administration
SAFETYo Haematotoxicityo Peripheral neuropathyo Gastrointestinal (diarrhoea, constipation)o Cardiovascular disorders (hypotension)
San Miguel, Oncologist 2006
EBMT Meeting, France, March 2007
IMMUNOMODULATORY AGENT (1)
Treatment of multiple myeloma
Lenalidomide (REVLIMID®)
Inhibited the secretion of cytokines from peripheralblood mononuclear cells
Anti-angiogenic properties (thalidomide analogue)
Mutagenic risk
EBMT Meeting, France, March 2007
IMMUNOMODULATORY AGENT (2)
Lenalidomide (REVLIMID®)25 mg/d, 21 days / month
+ dexamethasone 40mg/day
Capsules for oral administration 5,10, 15, 25 mg
Cost : 310 euros / capsules of 25mgPatient : 6.500 euros / month
EBMT Meeting, France, March 2007
IMMUNOMODULATORY AGENT (3)
Lenalidomide (REVLIMID®)
Patient should not break, chew or open the capsule
SAFETYo Haematotoxicityo Gastrointestinal toxicity (constipation, diarrhoea)o Teratogenico Deep vein thrombosiso Pulmonary embolism
EBMT Meeting, France, March 2007
IMMUNOSUPPRESSIVE AGENTS (1)
2 phases of acute Graft versus Host Disease (aGvHD)
Afferent phaseEfferent phase
TreatmentSteroidsCiclosporineAnti-Thymocyte Globulin (THYMOGLOBULINE ®)Inolimomab (LEUKOTAC®)
EBMT Meeting, France, March 2007
IMMUNOSUPPRESSIVE AGENTS (2)
Rejection prevention and treatment
Anti-thymocyte globulin (THYMOGLOBULIN®)
Suppress immune responses
Polyclonal rabbit antiserum specific for human T cells
EBMT Meeting, France, March 2007
IMMUNOSUPPRESSIVE AGENTS (3)
Anti-thymocyte globulin (THYMOGLOBULINE®)
2.5 mg/kg/d (D-4 to D-2 or D-1)
Single-use vial containing 25 mg
Lyophilized powder reconstituted with 5 ml ofsterile water for injection
Cost : 155 euros / vialPatient 70 kg : 3.255 euros / 3 days
NON
CYTOTOXIC
EBMT Meeting, France, March 2007
IMMUNOSUPPRESSIVE AGENTS (4)
Anti-thymocyte globulin (THYMOGLOBULINE®)
Diluted in 50ml per one vial (NS or D5W)Premedication : corticosteroïdes, antihistamine, adapt thethe flow rate of infusion
SAFETYo Haematotoxicityo Peripheral oedema, chills, fever, pain, headache, hypotension,
tachycardia, asthenia
SURVEILLANCE +++
EBMT Meeting, France, March 2007
Treatment of acute graft versus host disease
Inolimomab (LEUKOTAC®)Specific binding to the IL2 receptorexpressed on activated T cells
Mouse monoclonal IgG1 anti human IL2 receptor
IMMUNOSUPPRESSIVE AGENTS (5)
NON
CYTOTOXIC
EBMT Meeting, France, March 2007
IMMUNOSUPPRESSIVE AGENTS (6)
Inolimomab (LEUKOTAC®)
0.2 to 0.4 mg/kg/d over 8 consecutive days
Single-use ampul containing 5mg/5ml
Ready to use
Cost : 270 euros / ampulPatient 70 kg : 23.000 euros
(1 week of induction, 2 weeks of maintenance)
EBMT Meeting, France, March 2007
IMMUNOSUPPRESSIVE AGENTS (7)
Inolimomab (LEUKOTAC®)
IV infusion over 20-30 minutes
Diluted in NS
Used immediately
SAFETYo Well toleratedo No infusion related adverse events recordedo Other events are attributable to immunosuppressive therapy
EBMT Meeting, France, March 2007
GROWTH FACTOR (1)
Severe oral mucositis
Palifermin (KEPIVANCE®)
Binding the KGF receptor : proliferation, differentiation and migration of epithelial cells
Human keratinocyte growth factor
EBMT Meeting, France, March 2007
GROWTH FACTOR (2)
Palifermin (KEPIVANCE®)60 µg/kilo/d for a total of 6 doses
Single-use vial containing 6.25 mg
Lyophilized powder (reconstituted with 1.2 ml of sterilewater for injection)
Do not shake or vigourously agitate the vial
Cost : 810 euros per vialPatient 70kg : 5.000 euros / treatment
NON
CYTOTOXIC
EBMT Meeting, France, March 2007
GROWTH FACTOR (3)
Palifermin (KEPIVANCE ®)IV Bolus Injection
Protect from light
SAFETYo Skin toxicity (rash, erythema, oedema, pruritus)
o Oral toxicity (disesthesia, tong discoloration, tong thickening, alteration taste)
o Pain arthralgias
EBMT Meeting, France, March 2007
ANTIFUNGAL AGENT (1)
Treatment and prophylaxis of invasive fungalinfections : aspergillosis, fusariosis, zygomycosis, candidiasis andcoccidioidomycosis in patients intolerant of or refractory to other antifungal therapies
Posaconazole (NOXAFIL®)
Triazole antifungal agent
EBMT Meeting, France, March 2007
ANTIFUNGAL AGENT (2)
Posaconazole (NOXAFIL®)
800 mg/d in 2 or 4 divided doses
Should be taken after meals to ensure maximal absorption
Cost : 660 euros / vialPatient : 4.000 euros / month
EBMT Meeting, France, March 2007
ANTIFUNGAL AGENT (3)
Posaconazole (NOXAFIL®)PRECAUTIONS
o Hypersensitivity
o Co-administration with tacrolimus or cyclosporin (dosage adjustments may be required)
SAFETYo Gastrointestinal (nausea, vomiting, diarrhoea, abdominal pain)o Headacheo Fatigue o Fever
EBMT Meeting, France, March 2007
CONCLUSION
An increasing number of molecularly targetedagents are :
already in the pipelineundergoing late experimental testingin early clinical trials
At least some of them will reach clinicalpractice during the coming 5 years