ES2359465T3 - OPTIMIZATION OF THE POSITIVE PHILADELPHIA LEUKEMIA TREATMENT WITH THE IMATINIB INHIBITOR OF THE TIROSINA QUINASA ABL. - Google Patents

Abstract

Use of Imatinib or a pharmaceutically acceptable salt thereof for the manufacture of a medicament, for the treatment of a Ph + leukemia, wherein (a) a fixed, predetermined daily amount between 200 and 800 mg of Imatinib mono-mesylate salt is You must administer orally to a human patient suffering from Ph + leukemia, (b) at least one blood sample from that patient, which is collected in the first 3 months of treatment, (c) the minimum plasma level (Cmin ) of Imatinib should be determined, and (d) the dose of Imatinib or a pharmaceutically acceptable salt thereof, should be adjusted in a manner that a Cmin between 1000 and 3000 ng / mL of Imatinib is achieved, when the patient does not reach a Cmin between 1000 and 3000 ng / mL of Imatinib, after administration of the fixed, predetermined amount of Imatinib mono-mesylate salt.

Description

The present invention relates to the use of imatinib mono-mesylate salt, to treat positive leukemia for Philadelphia (Ph + leukemia) in a population of human patients. In a particular aspect, the present invention relates to the use of imatinib mono-mesylate salt, to treat chronic myeloid leukemia (CML) 5 in a population of human patients.

In CML a reciprocally balanced chromosomal translocation in hematopoietic stem cells (HSCs) produces the hybrid BCR-ABL gene. The latter encodes the oncogenic fusion protein Bcr-Abl. Considering that ABL encodes a tightly regulated tyrosine kinase protein, which plays a fundamental role in the regulation of cell proliferation, adhesion and apoptosis, the BCR-ABL fusion gene encodes constitutively activated kinase 10, which transforms HSCs to produce a phenotype that it shows deregulated clonal proliferation, reduced adhesion capacity with bone marrow stroma and a reduced apoptotic response to mutagenic stimuli, which allow it to progressively accumulate more malignant transformations. The resulting granulocytes do not develop in mature lymphocytes and are released into the circulation, which leads to a deficiency in mature cells and increased susceptibility to infection. It has been described that, competitive Bcr-Abl ATP inhibitors prevent kinase from the activation of mitogenic and anti-apoptotic pathways (for example P-3 and STAT5 kinase), which lead to the death of the cells of the BCR-ABL phenotype and thus providing an effective therapy against CML.

In May 2001, the N- {5- [4- (4-methyl-piperazino-methyl) -benzoylamido] -2-methylphenyl} -4- (3-pyridyl) -2-pyrimidine-amine mesylate salt ( Imatinib mesylate, STI571, Glivec®) was approved by the FDA for the treatment of CML in 20 patients who have not been able to benefit from IFN-alpha therapy. Already in June 2000, the first patients with CML were included in the International Randomized Interferon Study and STI571 (IRIS). This ambitious 3-phase test was unique in both size and scope. The IRIS researchers recruited more than 1000 patients in 16 countries to conduct a comparative study between Glivec and interferon-alpha (SG O'Brien, F. Guilhot, RA Larson, et al, N. Engl. J. Med. 2003 , 348: 994-1004). Imatinib at a dose of 400 mg daily has been shown to be more effective than IFN + Ara-C in newly diagnosed patients with chronic CML (CML-CP). Recently, IRIS five-year follow-up data indicated an estimated cumulative rate of complete cytogenic response (CRC) of 87% among patients who received imatinib as first-line treatment and an overall survival of 89% (Druker BJ, Guilhot F, O'Brien SG, et al on behalf of the IRIS Investigators Five-Year Follow-up of Imatinib Therapy for Newly Diagnosed Myeloid Leukemia in Chronic-Phase Shows Sustained 30 Responses and High Overall Survival New Eng J Med 2006; 355: 2408-17). It should be noted that no patient of those who achieved CRC and the main molecular response (MMR) within 18 months of the start of therapy has progressed to an accelerated or blastic phase in 60 months.

However, the variable responses to imatinib mesylate in the treatment of chronic CML are not sufficiently known. Previous studies focused on the cellular mechanisms of resistance to Imatinib. Considering that pharmacokinetic monitoring is widely used in different medical specialties, such as neurology, cardiology, and psychiatry, this has rarely been applied in clinical cancer practice. Pharmacokinetic studies in patients with CML who are treated with imatinib mesylate, showed that the minimum plasma concentrations of Imatinib correlate with the dose of imatinib mesylate, while body weight or body surface area are of less importance. Peng et al., Determined the minimum Imatinib concentration in plasma and adjusted the Imatinib regimen according to the plasma concentration parameters (Peng B., Hayes M., Resta, D. et al, J. Clin. Oncol 2004, 22, 935-942). Mahon et al. (Blood. 106 (11, Part 1). Nov. 16 2005. 565A) measured the concentration of Imatinib in blood in support of the treatment regimen.

The present invention solves the problem of minimizing or avoiding tolerance issues, lack of efficacy and risk of relapse in human patients with CML who are treated with a Bcr-Abl tyrosine kinase inhibitor. 45 Based on the analysis of a study conducted at the University of Bordeaux and the IRIS study data that correlate the pharmacokinetic data with the cytogenic and molecular response in patients recently diagnosed with chronic phase CML (CML-CP), currently Surprisingly, he found that the CML treatment, using a Bcr-Abl tyrosine kinase inhibitor, can be optimized by adjusting the dose of the Bcr-Abl tyrosine kinase inhibitor applied to an individual patient, so that a specific minimum plasma level 50 (Cmin), is achieved in each individual patient. An individual adjustment for each patient is needed in view of the patient's high interval of Cmin values, under the administration of the same dose of the Bcr-Abl tyrosine kinase inhibitor to each patient as observed in the IRIS study. The present invention provides, for the first time, an individualized treatment program for individual patients with CML based on a lower Cmin threshold, which has been shown to correlate with a higher probability of survival.

CML belongs to the Ph + leukemia group. The results obtained with the population of CML patients described in this document can be transferred directly to the entire Ph + leukemia group. The reason for this is that the characterization feature of Ph + leukemia is the existence of the Philadelphia chromosome that causes the Bcr-Abl fusion protein. This last protein is the goal of all Bcr-Abl inhibitors.

The abbreviation "Ph + ALL" as used herein indicates acute acute lymphoblastic leukemia for the Philadelphia chromosome.

The term "principal molecular response (MMR)" as used herein means a reduction of 3 logarithms in BCR-ABL transcripts, quantified from peripheral blood using the real-time quantitative reverse polymerase transcriptase chain reaction, preferably after 12 months of therapy, for example imatinib mesylate therapy of 12 months. 10

The term "complete cytogenic response (CRC)" as used herein means 0% positive metaphases for the Philadelphia chromosome between at least 20 or 25 metaphase cells in the bone marrow aspirate (Colombat M, Fort MP, Chollet C , et al. Molecular remission in chronic myeloid leukemia patients with sustained complete cytogenetic remission after imatinib mesylate treatment. Haematologica 2006; 91: 162-8.).

The term "use" as used in this document also relates to the prevention of the diseases mentioned in this document, i.e. Prophylactic administration of a pharmaceutical composition comprising a Bcr-Abl tyrosine kinase inhibitor according to the invention to healthy patients to prevent the development of the diseases mentioned herein.

The terms "dose adjustment" and "the dose of ... was adjusted" as used herein preferably indicates that the dose refers to its increase or decrease. In a broader sense of the invention, the terms "dose adjustment" and "dose adjusted ..." encompass a situation where the dose remains unchanged.

The term "Bcr-Abl tyrosine kinase inhibitor" according to the invention as used herein refers to the imatinib monomesylate salt which shows inhibition of c-Abl or Bcr-Abl, from cell lysates. transfected with an IC50 value below 0.1 µM in in vitro kinase assays performed on immunoprecipitates in an assay as described by BJ Druker et al in Nat. Med. 1996, 2, 561-566. ng / mL. The upper limit of the plasma level corresponds to the closest level below the blood level that causes dose-limiting toxicity (DLT) in an individual patient. Typically, the upper range observed is approximately 3500 ng / mL, sometimes around 3000 ng / mL.

The present invention relates to a method of treating a Ph + leukemia, especially CML or Ph + ALL, in a human patient comprising the steps of

(a) administration of a predetermined fixed amount of imatinib, in a daily oral dose of 200 mg or 800 mg of Imatinib monomesylate salt, with the human patient suffering from Ph + leukemia,

(b) collection of at least one blood sample from said patient, for example in the first 3 months of treatment,

(c) determination of Imaminib Cmin, and 35

(d) dose adjustment of imatinib or a pharmaceutically acceptable salt thereof in such a way that a Cmin of between 1000 and about 3000 ng / mL of Imatinib is achieved in said patient, when the patient does not reach a Cmin between 1000 and 3000 ng / ml, after administration of the predetermined fixed amount

The dose of the pharmaceutically acceptable salt of Imatinib was preferably adjusted in a way that a Cmin between about 1000 and about 3000 ng / mL of Imatinib is achieved in said patient, more preferably a Cmin of about 1000 ng / mL.

Imatinib is metabolized through the cytochrome P450 system, CYP3A4 is the main isoenzyme responsible for imatinib metabolism, although CYP1A2, CYP2D6, CYP2C9, and CYP2C19 also contribute to a lesser extent. A major metabolite, N- {5- [4- (piperazino-methyl) -benzoylamido] -2-methylphenyl} -4- (3-pyridyl) -2-pyrimidinaamine (CGP74588), is observed in blood that has a biological activity similar to Imatinib and represents approximately 20% of the level of the original plasma drug in patients. Due to the intrinsic variability of CYP enzyme activity (Wilkinson GR, J Pharmacokinet Biopharm. 1996; 24: 475-90.) High inter-patient variability has been reported in imatinib exposure in patients with CML (Peng BM Hayes M, Resta D, et al. J Clin Oncol. 2004; 22: 935-42). It has been shown that drugs that inhibit or induce CYP3A4 isozyme influence the pharmacokinetics of imatinib (Bolton AE, Peng B, Hubert M, et al. Cancer Chemother Pharmacol. 50 2004; 53: 102-106; Dutreix C, Peng B, Mehring G, et al. Cancer Chemother Pharmacol. 2004; 54: 290-294; Smith PF,

Bullock JM, Booker BM, et al. Pharmacother 2004; 24 (11): 1508-1514; Frye RF, Fitzgerald SM, Lagattuta TF, Hruska MW, Egorin MJ. Clin Pharmacol Thr. 2004; 76: 323-329).

Throughout the present invention, the Imatinib mono-mesylate salt is used in step (a), for example in a daily oral dose of between 200 and 800 mg, preferably in a daily dose of 400 mg.

The methods described in this document are particularly beneficial for patients with CML who have an Intermediate score on the Sokal scale (ISS). The methods to determine the ISS are known by someone of skill in the trade.

Another important aspect of the present invention is the use of Imatinib Mesylate, for the manufacture of a medicament for the treatment of a Ph + leukemia, wherein the dose of the pharmaceutically acceptable salt was adjusted in a way that a Cmin of at least 1000 ng / mL of Imatinib, is preserved in said patient. 10

Brief discussion of the Figures

Fig. 1: Analysis of the ROC curve. The analysis of the receiver operating characteristic curve (ROC) was carried out in order to evaluate a potential discrimination of the minimum concentrations of Imatinib in plasma for MMR, and to identify a plasma threshold of optimal sensitivity and specificity . The area under the ROC curve (AUC) was 0.775, with better sensitivity (76.5 percent) and specificity (70.6 percent) at a plasma threshold of 1002 ng per milliliter. This threshold of 1002 ng per milliliter was significantly associated with the presence of MMR (adjusted odds ratio, 7.83; 95 percent confidence interval, 2.58 to 23.76; P <0.001).

Fig. 2: Box-plot chart. MMR means the main molecular response (3 log reduction in transcription levels of BCR-ABL). The graph shows the dispersion around the median of patients with MMR (34 patients, median = 1350.2 ng per milliliter) and those without (34 patients, median = 885.5 ng per milliliter). The line at 20 through each box is the median. The lower edge is the first quartile and the lower edge is the third quartile. Error bars represent the minimum and maximum values. The bottom line shows the target concentration of 493.6 ng per milliliter (1 micromol per liter), necessary to give rise to the positive cell death of BCRABL in vitro. The upper line shows the efficient threshold of 1002 ng per milliliter in plasma for the minimum concentrations of Imatinib in the CML treatment. 25

Fig. 3 shows the variability of the Imatinib Cmin level observed in the IRIS study, in all patients who obtained the same daily dose of 400 mg of imatinib mesylate.

Fig. 4 shows the distribution of imatinib through levels at 400 mg daily on Day 29 (n = 351).

Fig. 5 shows the minimum Imatinib level by body weight (BW) or body surface area (BSA).

Fig. 6 shows CCR or MMR by minimum imatinib level (Day 29). 30

Fig. 7 shows the corresponding minimum plasma levels for the achievement of CRC and non-CRC in CML-CP patients. The bottom and top walls of each box represent the 75th and 25th percentiles. The whiskers (error bars) above and below the box indicate the 90th and 10th percentiles, and the dots represent the 95th and 5th percentiles.

Fig. 8 represents the event-free survival (SAI), grouped on the basis of quartiles of the PK level of Imatinib. Group Q1 is described by the bottom line, group Q2-Q3 corresponds to the line in the middle and group 35 Q4 is represented by the highest line.

For the purposes of the present invention, Imatinib is applied in the form of its mono-mesylate salt. Imatinib mono-mesylate can also be prepared according to the processes disclosed in US 6,894,051. They are also composed of the corresponding polymorphs, for example crystal modifications, which are revealed therein.

In step (a) of the use described above, a daily dose of between 200 and 800 mg, for example 400 mg, of the salt of Imatinib monomesylate is administered orally. Imatinib mono-mesylate can be administered in dosage forms as described in US 5,521,184, US 6,894,051, US 2005-0267125 or WO2006 / 121941.

The collection of a blood sample from patients with CML needed in stage (b) of the uses described in this document can be achieved by standard procedures that are manifested in the trade. An appropriate procedure for the determination of the minimum Cmin plasma level of Imatinib and N- {5- [4- (piperazino-methyl) -45 benzoylamido] -2-methylphenyl} -4- (3-pyridyl) -2-pyrimidine -amina as described by R. Bakhtiar R et al. in J Chromatogr B Analyt Technol Biomed Life Sci. 2002 Mar 5; 768 (2): 325-40.

Examples

The following examples are illustrative, to suggest a method of practice of the present invention. The amounts of ingredients, represented by the percentage by weight of the pharmaceutical composition, used in each example are set forth below.

EXAMPLE 1 - Study Design, Statistical Analysis and Results of the Bordeaux Study 5

PATIENTS

The patients included in the study were in chronic or accelerated phase of CML. They were followed in the Department of Hematology and Blood Diseases of the Centro de Bordeaux Hospital (CHU de Bordeaux) and in the Bergonié Institut, Regional Cancer Center. All patients were treated orally with a standard dose of imatinib mesylate (i.e. 400 mg or 600 mg once daily for patients with chronic phase or accelerated phase-10 CML, respectively) for at least 12 months. In the study population, blood sample collections were carried out between June 2004 and March 2006, in order to test the association between the minimum concentrations of Imatinib in plasma and the response to treatment. Exclusion criteria were the start of imatinib mesylate therapy, at least one year before a blast crisis, before or during imatinib mesylate therapy, blood collection is performed outside the time limits at concentration, poor compliance with treatment, identification of mutation (s) of the gene in the kinase domain of Bcr-Abl.

QUANTIFICATION OF THE THERAPY RESPONSE

The cytogenic response to imatinib Mesylate therapy was evaluated using a conventional cytogenetic analysis of bone marrow metaphases. Patients with cytogenetic response were defined as having 20 CRC, i.e. 0 percent of positive Philadelphia chromosome metaphases among at least 25 metaphase cells in the bone marrow aspirate (Colombat M, Fort MP, Chollet C, et al. Haematologica 2006; 91: 162-8.). The real-time quantitative reverse polymerase transcriptase chain reaction assay was used to assess the levels of BCR-ABL transcription and quantify the molecular response (Colombat M, Fort MP, Chollet C, et al. See above). In summary, peripheral anticoagulated-EDTA blood was collected to perform RNA extraction followed by the real-time quantitative reverse polymerase chain transcriptase chain reaction. Total RNA was extracted from peripheral blood cells of patients using standard methods. The quantification of the BCR-ABL transcripts was carried out according to the recently proposed recommendations for harmonization of results (Hughes TP, Deininger M, Hochhaus A, et al. Blood 2006; 108: 28-37.). Therefore, the results were expressed using the ABL gene as the control gene and were expressed as the percentage of BCR-ABL / ABL. A standardized baseline was calculated by measuring the ratio of BCR-ABL / ABL in 40 chronic phase patients with CML of the blood collected before any treatment. For each sample, this baseline was used to evaluate and calculate the reduction of BCR-ABL transcription. An MMR was defined as a reduction in BCR-ABL transcription levels of at least 3 log after 12 months of imatinib mesylate therapy (Hughes TP, Kaeda J, Branford S, et al. International Randomized Study of Interferon versus 35 STI571 (IRIS) Study Group. N Engl J Med 2003; 349: 1423-32.).

QUANTIFICATION OF IMATINIB CONCENTRATIONS IN PLASMA

Blood samples for plasma quantification of Imatinib were collected at steady state between 21 and 27 hours after the last administration of the drug. Minimum concentrations of Imatinib in plasma were determined using high performance liquid chromatography coupled to mass spectrometry in 40 tandem with electrospray ionization (Titier K, Picard S, Ducint D, et al. Ther Drug Monit 2005; 27: 634-40 . [Erratum, Ther Drug Monit 2005; 27: 810.]). Pure reference samples of Imatinib Mesylate and its internal standard (Imatinib-D8) were kindly donated by Novartis (Rueil-Malmaison, France). The sample preparation consisted of a liquid-liquid extraction, it is made from 200 microliters of plasma. Then, 5 microliters of extract were injected into the chromatographic system. The high-resolution liquid chromatography unit consisted of an Alliance® 2690 separation module (Waters, Milford, MA, USA) run by Masslynx® software. Imatinib and Imatinib-D8 were separated on a reverse phase column (X-Terra® RP18, [100x2.1 mm, 5 micrometers], Waters) with a gradient of acetonitrile-formate regulatory solution. The total run time of the analysis was 6 minutes at a flow rate of 0.3 milliliters per minute. Imatinib quantification was carried out using tandem mass spectrometry (QuattroMicro®, Watters, Milford MA, USA) 50 with an electrospray ionization interface in positive ion mode. The cone voltage was set at 40 volts for Imatinib and its internal standard, and the collision energy was set at 30 volts of electrons for the two compounds. Imatinib and Imatinib-D8 were detected in multiple reaction monitoring transitions. To quantify the Imatinib, the peak area corresponding to the reaction m / z 494.2 → 394.1 (Imatinib) was measured in relation to the reaction area m / z 502.2 → 394.1 (internal standard). Imatinib identification was confirmed by a second transition of specific multiple reaction monitoring: m / z 494.2 → 217.2.

STATISTIC ANALYSIS

Regarding quantitative variables, the comparisons of the means between two groups were made using Student's t-test or the Wilcoxon test of ranges when appropriate. In the presence of more than two groups, an analysis of variance or a Kruskal-Wallis test was used. Regarding qualitative variables, proportions comparisons were made using an 2 test or Fisher exact test when appropriate. In 5 steady state, the variability in the minimum concentrations of Imatinib in plasma was expressed by the following parameters: mean of the minimum concentrations in plasma, standard deviation (SD), coefficient of variation, median, first and third quartiles, maximum and minimum minimum plasma concentrations measured.

For CCR and MMR successively, the group of patients with response and the group of patients who did not respond were compared with respect to their mean minimum plasma concentrations of Imatinib. A possible association between MMR and the following variables was investigated: quantitative characteristics such as age and the Sokal scale score; and qualitative characteristics such as sex, Sokal risk group, phase-accelerated CML at the start of imatinib mesylate therapy, administration of interferon before treatment with imatinib mesylate, daily dose level of imatinib mesylate. Any relationship between the levels of BCR-ABL transcription and the time interval from the start date of imatinib Mesylate treatment to the date of molecular analysis was evaluated.

The analysis of the ROC curve was carried out with a multivariate logistic regression model, adjusted for age and sex, in order to evaluate a potential discrimination of the minimum concentrations of Imatinib in plasma for MMR, and to identify a threshold in plasma of the sensitivity and optimum specificity. The results were expressed as adjusted odds ratio; 95 percent of the confidence interval; P value of the 20 Wald test.

Two-sided P values were reported for statistical tests (P <0.05 indicated significance). All analyzes were done using SAS Software (version 9.1, Cary, NC, USA).

PATIENTS INCLUDED IN THE RESEARCH

Ninety-five patients with CML were considered for participation in the study. One patient was excluded because he was in a blast crisis. Twenty-four patients were excluded due to inadequate blood collection i.e. it is carried out outside the time limits for the determination of the minimum imatinib concentration. One patient was excluded due to the recognized poor compliance with imatinib therapy: this patient did not respond hematologically and had plasma imatinib levels below 10 ng per milliliter. One patient was excluded because the G250E mutation was identified in the Bcr-Abl kinase domain. 30 Finally, 68 patients with CML were included for the investigation. Fifty patients and 18 patients were treated respectively with 400 mg and 600 mg of imatinib once daily.

VARIABILITY IN MINIMUM CONCENTRATIONS OF IMATINIB IN PLASMA BETWEEN PATIENTS

Variations in the minimum concentrations of Imatinib in plasma for each daily dose regimen of Imatinib Mesylate (400 mg and 600 mg) are shown in Table 1.1. These Imatinib concentrations were very 35 variables ranging from 181 to 2947 ng per milliliter, confirming the high variability previously described among the subjects in the minimum concentrations of Imatinib in plasma for a given daily dose (Peng B, Hayes M, Subtraction D, et al. J Clin Oncol 2004; 22: 935-42.)

Table 1.1 Variability in the minimum concentrations of Imatinib in plasma among patients (n = 68) *.

 Daily dose level

 Dispersion around the mean Medium Q 25Ť Q 75 ‡ Minimum Maximum

 Middle value

 SD § CV¦

 400 mg

 1058 557 52.6 997 722 1285 181 2947

 600 mg

 1444 710 49.2 1315 902 1629 603 2922

 * The parameters of variations in the minimum concentrations of Imatinib in plasma are expressed in ng per milliliter and are reported for each daily dose regimen of Imatinib Mesylate: 400 mg (50 patients) and 600 mg (18 patients). These data result from the analysis of the blood samples collected, at steady state (using high performance liquid chromatography coupled to tandem mass spectrometry with electrospray ionization), in the 68 patients with CML included in the study. Ť Q 25 is the first quartile. ‡ Q 75 is the third quartile. § SD is the standard deviation. ¦ CV is the coefficient of variation expressed as a percentage.

 40

CHARACTERISTICS OF THE PATIENT ACCORDING TO THE IMATINIB RESPONSES

Of the 68 patients with CML included for the investigation, 56 achieved a CRC after at least one year of treatment. The means (± SD) of the minimum concentrations of Imatinib in plasma were 1123.3 ± 616.6 ng per milliliter and 694.2 ± 556.0 ng per milliliter in patients with CRC (56 patients) and without CRC (12 patients), respectively (P = 0.02) . Regarding the molecular response, the main characteristics of the 68 patients 5 with CML, classified as those with or without MMR, are summarized in Table 1.2. The mean of the minimum concentrations of Imatinib in plasma were significantly higher in the MMR group (1452.1 ± 649.1 ng per milliliter) than in the group without (869.3 ± 427.5 ng per milliliter, P <0.001). No significant differences were found in the daily dose of imatinib mesylate between patients with or without MMR. In addition, MMR for Imatinib was not related to the following characteristics: clinical data (age, sex), phase-accelerated CML at the start of therapy 10 with imatinib mesylate, administration of interferon before treatment with imatinib mesylate . Additionally, the MMR to the treatment was not statistically associated with the time elapsed between the start of imatinib Mesylate therapy and the molecular analysis: the mean values (± SD) were 986.5 ± 427 days and 966.5 ± 560 days in groups with and without MMR, respectively (P = 0.87). Four groups of patients were compared according to the date of their molecular analysis (using a Kruskal-Wallis test): within 560 days of the start of treatment 15 with Imatinib mesylate (16 patients), between 560 and 900 days later of the start of treatment with Imatinib Mesylate (18 patients), between 900 and 1325 days after (17 patients), more than 1325 days after the start of treatment with Imatinib Mesylate (17 patients). The test showed that there was no significant difference in the levels of transcription of BCR-ABL between the four groups (P = 0.48). The molecular response rate was therefore not time dependent, in our investigation. twenty

Table 1.2 Patient characteristics according to molecular response to Imatinib therapy.

 features

 Without MMR * With MMR value PŤ

 No. ‡

 data § No. data

 Quantitative traits

 Minimum concentrations of imatinib in plasma¦

 34 869.3 ± 427.5 34 1452.1 ± 649.1 <0.001

 Age

 34 50.7 ± 13.6 34 51.7 ± 13.7 0.76

 Sokal scale score

 32 0.9 ± 0.4 33 1.0 ± 0.4 0.33

 Qualitative features

 Sex

             0.09

 Male gender

 24 70.6 17 50.0

 Female gender

 10 29.4 17 50.0

 Sokal risk group

             0.69

 <0.8

 15 44.1 14 41.2

 [0.8-1.2]

 12 35.3 11 32.4

 > 1.2

 5 14.7 8 23.5

 CML accelerated phase

             0.58

 no

 26 76.5 24 70.6

 yes

 8 23.5 10 29.4

 Interferon before imatinib

             0.62

 no

 15 44.1 13 38.2

 yes

 19 55.9 21 61.8

 Daily dose of imatinib

             1.00

 400 mg

 25 73.5 25 73.5

 600 mg

 9 26.5 9 26.5

 * MMR means principal molecular response (3 log reduction in transcription levels of BCR-ABL). The main characteristics of the 68 patients with CML are classified in those with or without MMR. P-value was evaluated using the Student's t-test for quantitative variables and the 2 test for qualitative variables. No. ‡ is the number of patients. Data § are the values of the mean (± standard deviation) of the quantitative characteristics. The data are proportions in percentage of the qualitative characteristics. Ť Minimum concentrations of Imatinib in plasma are expressed in ng per milliliter.

MINIMUM THRESHOLD IN IMATINIB PLASMA OF THE MAIN MOLECULAR RESPONSE

The analysis of the ROC curve effect concentration proved the potential discrimination of the minimum concentrations of Imatinib in plasma for MMR (Fig. 1). In the latter case, the area under the ROC curve was 0.775, with better sensitivity (76.5 percent) and specificity (70.6 percent) at a plasma threshold of 1002 ng of Imatinib per milliliter. This threshold of 1002 ng per milliliter was significantly associated with the presence of MMR (quotient of

adjusted odds, 7.83; 95 percent confidence interval, 2.58 to 23.76; P <0.001). Box-plots of the minimum concentrations of Imatinib in plasma showed the dispersion around the median (Fig. 2) for patients with MMR (34 patients, median = 1350.2 ng per milliliter) and those without (34 patients, median = 885.5 ng per milliliter). In the MMR group, 26 patients (76.5 percent) of the 34 patients had the minimum Imatinib concentrations in plasma that exceed the threshold of 1002 ng per milliliter and there were no patients who had 5 the minimum Imatinib concentrations in plasma per below 493.6 ng per milliliter (1 micromol per liter) which is the target concentration initially described, necessary to result in BCR-ABL-positive cell death in vitro. In the group without MMR, 24 patients (70.6 percent) of the 34 patients had the minimum plasma Imatinib concentrations below the threshold of 1002 ng per milliliter and there were 7 patients (20.6 percent) who had the minimum Imatinib concentrations in plasma below 493.6 ng per milliliter (1 micromol per liter). 10

EXAMPLE 2 - Analysis of IRIS Study data

In this study, the minimum plasma levels of Imatinib at steady state after the first month of treatment (Day 29) proved that they were a significant covariate prognosis for long-term clinical responses in patients with CML.

The variability of exposure to Imatinib has clinical implications. The achievement of a CRC is a valid substitute for clinical benefit in CML and an appropriate measure of initial antileukemic efficacy. The times for CRC and MMR within CCR patients were significantly different between patients with different Imatinib plasma exposures grouped into quartiles (p <0.025). Patients who achieved CRC for one year had steady-state concentrations of Imatinib after one month that were higher than those who did not achieve CRC. All Cmin values were statistically significantly higher in patients who achieved 20 CCR during the study (mean 1009 ng / mL vs 812 ng / mL). In this way, maintaining a minimum level of Imatinib at or above 1000 ng / mL may be important for CCR. This result is consistent with the threshold value of approximately 100 ng / mL found in Example 1.

In this analysis, we assume that patients maintained adherence to Imatinib therapy, both during the first and subsequent months. However, this is an unknown variable despite the records of 25 patients undergoing dosing during this test. While adherence to therapy is a critical factor for the accuracy and validity of the pharmacokinetic analysis, it was reasonable to assume that plasma imatinib and CGP74588 levels were steady state on Day 29 in this well-monitored clinical study. Patients recruited in this study were once again diagnosed with a life-threatening disease and in the early stages of treatment - a point when there was a great incentive to take daily doses of Imatinib, a relatively well tolerated drug. High levels of non-adherence to Imatinib in this study were unlikely for most patients. Out of the 553 patients recruited in the Imatinib treatment branch, almost 20% of the patients had a dose increase for a clinical reason at a daily dose of 600-800 mg, the average time for the dose increase was 22 months (Data not shown). Non-adherence to Imatinib has been documented in patients with CML and could have affected clinical responses and the correlation between clinical response and minimal PK exposure.

We found a correlation between MMR speeds and Imatinib exposure. The estimated MMR velocity was significantly lower in patients with low Imatinib levels; Only an estimated 25% of all patients with Imatinib levels <647 ng / mL achieved an MMR in 1 year, while 40% of patients with higher Imatinib levels achieved this response within 1 year. At 4 years, an estimated 40 53% of patients in Q1 have achieved an MMR despite low levels of Imatinib steady state (day 29) compared to 80% of patients in Q4 (and 72% of patients). patients within the inter-quartile range, IQ). An MMR is a prognosis of efficacy and long-term survival. Patients who lack MMR have increased disease progression rates. In this way, early dose adjustment for patients with low Imatinib levels at steady state can improve long-term efficacy. Four. Five

In addition to the CCR and MMR response rates, minimum PK level of imatinib seems to correlate somewhat with event-free survival (EFS), although no statistically significant difference was achieved. Event-free survival is a complicated event that can be confused with many different factors such as accessibility of other treatments, increase in intra-patient dose at the last moment of the treatment period, etc. However, patients with a low minimum level of Imatinib tend to have a poorer SAI than patients with higher levels of Imatinib. As expected, exposure to Imatinib was correlated with the rate of interruption. Patients in the lowest quartile had the highest interruption rate than in the inter and superior quartiles. Interestingly, one of the reasons for the interruption was related to the unsatisfactory therapeutic effect, which was consistent with the findings of the correlation analyzes between the clinical response (CCR or MMR) and the imatinib quartile concentrations. 55

Our report describes the minimum level of Imatinib in the steady state. Similar results were observed for the main active metabolite, CGP74588. However, considering the relatively small contribution of the metabolite for exposure to Imatinib (<20%), the measurement of the original drug in plasma represents the

Main active component for biological activity. If Imatinib metabolism is altered, for example by a CYP inducer or inhibitor, measurement of both Imatinib and metabolite may be necessary.

In conclusion, plasma exposure of Imatinib at steady state measured after the first month of treatment with a standard 400 mg dose correlated with long-term cytogenic and molecular responses. The demographic parameters of the patient including age, gender, and body size have a minimum impact on plasma exposure to Imatinib considering the large inter-patient variability of exposure. Maintaining minimum plasma levels at or above the concentration of the average population of approximately 1000 ng / mL may be important for CCR and MMR response, free survival, and satisfactory therapeutic efficacy in patients with chronic CML phase . Any of the factors that may affect Imatinib exposure, such as drug absorption, metabolism, and interactions between prescribed medications, which may affect the ability to achieve maximum therapeutic benefit. Information regarding Imatinib blood exposure during therapy has the potential to serve as a valuable tool and deserves prospective validation.

Methods

The patients included in this analysis were recruited on the IRIS test and randomized at the start of the Imatinib treatment at 400 mg / day. The study design and patient characteristics for all 553 patients randomized to Imatinib including age, gender, body weight, body surface area, as well as the results have been previously described (O'Brien SG , Guilhot F, Larson RA, et al. N Eng J Med. 2003; 348: 994-1004.).

The CRC velocities (defined as 0% of Ph + metaphase cells outside at least 20 examined) in the study population and the main molecular response (MMR, defined as reduction ≥ 3 log in the BCR-ABUBCR ratio of a standardized baseline) in subjects who achieved CRC before, were previously reported (O'Brien SG, Guilhot F, Larson RA, et al., see above).

This Example focuses on those 351 patients with available PK measurements. Event-free survival (SAI), a maximum of 5 years was evaluated and measured from enrollment in the clinical trial to any 25 of the following events: death from any cause, loss of an MMR, loss of a complete hematological response , or progression to an accelerated or blastic phase. Live patients were censored for survival at the last follow-up. RCCs were evaluated up to 5 years. The achievement of MMR was analyzed only up to 24 months after starting treatment due to the lack of data after this point. Patient disposition (with available PK information) and reasons for discontinuation after 5 years of treatment were 30 tabulated with respect to the crossing of the other treatment branch, adverse events, unsatisfactory therapeutic effect, and other reasons (including procedure abnormal, does not require another study of the drug (BMT), violation of the protocol, consented withdrawal of the subject, loss of follow-up, and death).

Pharmacokinetic Analysis of the Sample

Blood samples were collected before Imatinib dosing on Day 2 (i.e. 24 hours after the first dose) and again on Day 29 (minimum level at steady state). Imatinib and CGP74588 plasma concentrations were determined by liquid chromatography and tandem mass spectrometry (LC / MS / MS). The limit of quantification was 5 ng / ml for both Imatinib and CGP74588; The trial was fully validated (Bakhtiar R, Lohne J, Ramos L, Khemani L, Hayes M, Tse F; J Chromatog B Anal Technol Biomed Life Sci. 2002; 768: 325-40.) Accuracy and accuracy were 104% ± 6% at the lower quantification limit and 99% ± 40 5% at 108% ± 5% over the total concentration range of 4-10,000 ng / ml.

Data analysis

The minimum plasma concentrations (Cmin value) of Imatinib and its metabolite after the first dose and at steady state were analyzed and the correlation analysis was carried out retrospectively with clinical responses including CCR and MMR, as well as the patient's disposition. after 2 and 5 years of treatment. The correlation of the minimum PK levels with age, gender, body weight and body surface area was evaluated. The minimum plasma levels of both Imatinib and CGP74588 on Days 2 and 29 were grouped into four quartiles. The lower quartile (Q1) includes data in 25% of patients with the lowest concentration values observed, while quartiles Q2 and Q3 extend 25% below and above the average concentration, respectively. The upper quartile (Q4) includes 25% of patients with the highest concentration values. The center of 50% of the data, i.e. excluding Q1 and Q4, they were combined for all analyzes and jointly referred to as intermediate quartiles (IQ). These three groups (Q1, IQ and Q4), were used for stratification as appropriate. The cytogenic and molecular response rates were estimated using the Kaplan-Meier method, and the strata exploratively compared by the rank-log test. The correlation between the minimum levels and the demographic variables was evaluated by means of the correlation coefficient 55 of the Spearman range.

Results

Minimum plasma and demographic levels of imatinib and its metabolite

Pharmacokinetic data were obtained from a total of 351 patients (221 men and 130 women). The mean body weight was 85.9 ± 16.8 (SD) kg for men (median, 83.6, and range, 52.9 to 163.3) and 72.4 ± 18.1 kg for women (median, 68.9, and range, 40.0 to 133.0). The body surface area (BSA) was 2.0 ± 0.2 m2 for the 5 men (median, 2.0 and range, 1.53 to 2.8) and 1.8 ± 0.2 m2 for the women (median, 1.75 and range, 1.35 to 2.54). The average age of the population was 50 years (range, 18 to 70 years). Of the 351 patients who had evaluable samples in the PK sub-study, 238 remain in the study (67.8%), 10 intersected (2.8%), 113 (32.2%) left Imatinib in the study due to a therapeutic effect not satisfactory (n = 51.14.5%), adverse events (n = 15, 4.3%), death (n = 6, 1.7%), bone marrow transplant (n = 11, 3.1%), withdrawal of consent (n = 15, 10 4.3), or other reasons such as abnormal procedures, violation of the protocol, loss of follow-up, or administrative problems (n = 15, 4.3%).

After the first dose of the first 400 mg, the minimum concentrations of Imatinib and CGP74588 at 24-hours were 517.7 ± 369.6 ng / mL and 82.7 ± 47.4 ng / mL, respectively. On day 29, the minimum concentrations of Imatinib and CGP74588 were 979.0 ± 529.6 ng / mL and 241.9 ± 105.5 ng / mL, respectively; The ratio of the metabolite concentration to the original drug was 0.268 ± 0.085 (n = 351). Based on the minimum levels on days 2 and 29 on the same subject, the accumulation relationship with the steady state was estimated to be 2.21 ± 1.15 for Imatinib and 3.38 ± 1.54 for CGP74588. The distribution of Imatinib minimum concentrations at steady state is shown in Figure 4. There were 19 patients with minimum levels of Day 29> 2000 ng / ml included in the 4th quartile for analysis. twenty

The minimum plasma level of Imatinib was slightly higher in women than in men (1078 ± 514.5 ng / mL vs 921 ± 530.8 ng / mL, respectively, and differ by 17.2%), probably due to body weight differences (18.7%) between genders. The minimum plasma levels of the CGP74588 metabolite followed a similar pattern, while the original metabolite / drug ratio was the same in men and women. There was a weak correlation between the minimum levels of Imatinib at steady state and both body weight (r2 = 25 0.015) and BSA (r2 = 0.038) as shown in Figure 5. Assuming a simple linear relationship between body weight and the minimum level, an increase of 40 kg to 120 kg in weight results in an estimated decrease in the minimum level of approximately 280 ng / ml. There was also a weak correlation between the minimum levels (or original metabolite / drug ratio) and the age of the patients (R2 = 0.02). Once again making a simplifying assumption of linear relationship, the minimum Imatinib levels increased by 295 ng / ml as the age over 20 years to 70 years 30. However, due to the great variability in the minimum plasma level among individuals, these effects of age, gender, and BW or BSA in minimal exposure to Imatinib are not likely to be clinically significant.

Correlation of PK exposure with clinical responses

Table 2.1 lists the minimum levels in the steady state of Imatinib, CGP74588, and their relationship grouped in quartiles. The minimum exposures in Q2 and Q3 were combined as IQ to represent the central 50% of the population. Figure 6 (upper panel) shows that the CCR response rates at 5 years were significantly different between the different quartiles of the minimum Imatinib level (p = 0.0125). The difference was mainly attributed to a lower CRC rate in group Q1 (p = 0.005, Q1 vs. others). A similar trend was observed for MMR velocities at 2 years with respect to the minimum plasma levels of steady state exposure. Patients in Q1 had a lower MMR velocity than in other combined groups, although a statistically different difference between the three individual quartile groups was not achieved (p = 0.08). The minimum exposure to imatinib in patients who eventually achieved CRC was significantly higher than those who did not achieve CRC, 1009 ± 544 ng / mL vs 812 ± 409 ng / mL, respectively (p = 0.01 Figure 7). There was no significant difference in PK exposure between those patients with MMR response and 45 patients without MMR response. The statistical analysis of MMR speeds was carried out up to 24 months due to limited data later.

There seems to be a trend in event-free survival (SAI) with respect to minimum Imatinib levels, a relatively poorer SAI in the Q1 group than in the other quartiles. However, no statistically significant differences were achieved with the available data set (Figure 8). A similar trend of correlation was observed between patient disposition (or discontinuation) and minimum PK levels (Table 2.3). After 2 years of treatment, the number of patients in progress was low in the Q1 group, 75.9%, compared to 84.3% and 89.5% in the IQ and Q4 groups. After 5 years of treatment, the number of patients in progress was 58.6%, 72.5%, and 76.7%, for Q1, IQ, and Q4, respectively.

The main reason for the interruption seems to be related to the unsatisfactory therapeutic effect, 10.3%, 55 6.2%, and 4.7% in Q1, IQ, and Q4, respectively, after 2 years of treatment, and 18.4%, 14.6%, and 8.1%, respectively after 5 years of treatment. The speed of adverse events - or death-related abandonment was similar between the different quartile groups after both 2 and 4 years of treatment. Do not

there were patients in the Q4 group intersected with other treatment branches (Interferon branch) compared with 4.6% and 3.4% in the Q1 and IQ groups, respectively. The crossing occurred mostly in the first year or two years after the start of treatment.

The clinical response (CCR, MMR or survival) or patient disposition was also correlated with the minimum levels of the metabolite CGP74588, since the levels of the original drug and metabolite were highly correlated (0.76, Spearman correlation coefficient). The minimum plasma level after the first dose also showed a correlation with CCR and MMR responses, but appears to be less predictive than the minimum level at steady state.

Table 2.1 Minimum levels at steady state (Mean (± SD) [range]) of Imatinib and CGP74588 by quartiles 10

 Data of Day 29

 Complete N = 351 Quartile 1 N = 87 Quartiles 2 and 3 N = 178 Quartile 4 N = 86

 Imatinib (ng / mL)

 979 (± 529.6) [153, 3910] 490 (± 119.7) [153, 644] 889 (± 148.2) [647, 1170] 1661 (± 602.0) [1180, 3910]

 CGP74588 (ng / mL)

 242 (± 105.5) [50.2, 841] 153 (± 48.5) [50.2, 322] 236 (± 65.8) [105, 455] 343 (± 126.1) [160, 841]

 CGP74588 / Imatinib

 0.27 (± 0.085) [0.11, 0.84] 0.32 (± 0.106) [0.15, 0.84] 0.27 (± 0.068) [0.11, 0.51] 0.21 (± 0.052) [0.13, 0.36]

Table 2.2 Speeds of CCR and MMR (%) in the different quartiles of the minimum Imatinib level in the steady state

 Results

 Quartile 1 (n = 87) Quartiles 2 and 3 (n = 178) Quartile 4 (n = 86)

 RCC (% [95% CI]) 1 year 2 years 4 years

    59 [48, 70] * 73 [63, 83] 81 [71, 91] 71 [64, 78] 80 [73, 86] 87 [81, 93] 73 [63, 83] 84 [75, 92] 89 [82, 96]

 MMR (%) in patients with CRC 1 year 2 years 4 years

    43 [28, 59] 63 [49, 78] 65 [50, 80] 56 [47, 66] 78 [69, 86] 83 [75, 91] 55 [41, 68] 86 [76, 96] 90 [ 81, 100]

 Time for CCR (Month [95% CI])

 8.3 [2.7, 56.9] 5.7 [2.7, 50.4] 5.6 [2.8, 55.3]

 Time for MMR in patients with CRC (months)

 16.7 [2.8, 59.0] 11.5 [2.7, 59.0] 12.2 [2.8, 52.4]

Table 2.3 Patient disposition after 2 and 5 years of treatment grouped based on the minimum level of Imatinib at steady state

 Results

 Quartile 1 (n = 87) n (%) Quartiles 2 and 3 (n = 178) n (%) Quartile 4 (n = 86) n (%)

 Disposition after 2 years

 Number of patients in progress

 66 (75.9) 150 (84.3) 77 (89.5)

 Crossed with another treatment branch

 4 (4.6) 6 (3.4) 0 (0)

 Discontinued treatment 1. Unsatisfactory effect 2. Adverse event (s) 3. Death 4. Others *

 9 (10.3) 3 (3.4) 0 9 (10.3) 11 (6.2) 5 (2.8) 3 (1.7) 9 (5.1) 4 (4.7) 2 (2.3) 1 (1.2) 2 (2.3)

 Disposition after 5 years

 Number of patients in progress

 51 (58.6) 129 (72.5) 66 (76.7)

 Crossed with another treatment branch

 4 (4.6) 6 (3.4) 0 (0)

 Discontinued treatment 1. Unsatisfactory effect 2. Adverse event (s) 3. Death 4. Others *

    16 (18.4) 4 (4.6) 1 (1.1) 15 (17.2) 26 (14.6) 5 (2.8) 4 (2.2) 14 (7.9) 7 (8.1) 6 (7.0) 1 (1.2) 6 (7.0)

 * Others include: abnormal procedure, does not require further study of the drug (BMT), violation of the protocol, consented withdrawal of the subject, loss of follow-up, administrative problems.

REFERENCES CITED IN THE DESCRIPTION

This list of references cited by the applicant is only for the convenience of the reader. It is not part of the European patent document. Even though great care has been taken in collecting references, errors or omissions cannot be excluded and the EPO disclaims all responsibility in this regard.

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Claims (3)

1. Use of Imatinib or a pharmaceutically acceptable salt thereof for the manufacture of a medicament, for the treatment of a Ph + leukemia, where (a) a fixed, predetermined daily amount between 200 and 800 mg of Imatinib mono-mesylate salt should be administered orally to a human patient suffering from Ph +, 5 leukemia. (b) at least one blood sample from said patient, which is collected in the first 3 months of treatment, (c) the minimum plasma level (Cmin) of Imatinib should be determined, and (d) the dose of Imatinib or a pharmaceutically acceptable salt thereof, should be adjusted in a way that a Cmin between 1000 and 3000 ng / mL of Imatinib is achieved, when the patient does not reach a Cmin between 1000 and 3000 ng / mL Imatinib, after administration of the fixed, predetermined amount of the mono-mesylate salt of 10 Imatinib. 2. The use according to claim 1, wherein the Ph + leukemia, is a positive acute lymphoblastic leukemia for the Philadelphia chromosome (Ph + ALL) or a chronic myeloid leukemia (CML). 3. The use according to claim 1, wherein in step (a), a daily dose of 400 mg of Imatinib mono-mesylate salt is administered. fifteen