An Evaluation of Biometric Monitoring Technologies for Vital Signs in the Era of COVID‐19

The novel coronavirus disease 2019 (COVID‐19) global pandemic has shifted how many patients receive outpatient care. Telehealth and remote monitoring have become more prevalent, and measurements taken in a patient’s home using biometric monitoring technologies (BioMeTs) offer convenient opportunities to collect vital sign data. Healthcare providers may lack prior experience using BioMeTs in remote patient care, and, therefore, may be unfamiliar with the many versions of BioMeTs, novel data collection protocols, and context of the values collected. To make informed patient care decisions based on the biometric data collected remotely, it is important to understand the engineering solutions embedded in the products, data collection protocols, form factors (physical size and shape), data quality considerations, and availability of validation information. This article provides an overview of BioMeTs available for collecting vital signs (temperature, heart rate, blood pressure, oxygen saturation, and respiratory rate) and discusses the strengths and limitations of continuous monitoring. We provide considerations for remote data collection and sources of validation information to guide BioMeT use in the era of COVID‐19 and beyond.

In an effort to mitigate the spread of the novel coronavirus disease 2019 (COVID‐19), the disease caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), healthcare providers are increasingly using telehealth for remote patient visits. At the beginning of the pandemic, amidst fears of being infected and having to visit overcrowded hospitals, individuals were rapidly purchasing technologies, such as pulse oximeters, to use at home to monitor for early signs of infection. ¹ Entering early summer, the Centers for Disease Control and Prevention (CDC) reported an increase in cases in several regions of the United States; without a vaccine, experts are concerned for a second wave of the virus. ² , ³ , ⁴ , ⁵ As the healthcare system faces an unprecedented need for remote monitoring due to the COVID‐19 pandemic, Biometric Monitoring Technologies (BioMeTs) offer solutions for collecting disease‐related measurements from patients at home. ⁶ , ⁷ , ⁸ BioMeTs are internet‐connected digital medicine products, such as smart thermometers or heart rate monitors with Bluetooth connectivity, that process data captured by mobile sensors using algorithms to generate measures of behavioral and/or physiological function. ⁹ These connected technologies are used in a variety of contexts, including but not limited to healthcare delivery, ¹⁰ clinical trials, ¹¹ and public health. ¹² , ¹³ BioMeTs offer convenient opportunities to collect frequent and objective data and disease‐related measurements, which facilitates assessing trends ¹² and detecting changes in vital signs not traceable by conventional spot check data collection protocols. ¹⁴ In response to the COVID‐19 pandemic, BioMeTs can be used for many clinical needs, such as aiding preliminary patient physical assessments, assisting with triage of patients with COVID‐19 symptoms, and monitoring patients post‐hospital discharge for risks of readmission. ⁸ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ For clinical teams implementing remote monitoring for the first time or for those already familiar with these technologies and exploring new options, there is an overwhelming variety of BioMeTs available as the market has seen an exponential growth over the past 2 decades. ¹¹ Navigating engineering solutions, form factors (physical size and shape), corresponding data collection protocols, and knowing how to interpret generated values can be challenging, especially if a healthcare provider is unfamiliar with how a BioMeT compares with conventional clinical instruments. Healthcare providers may question the accuracy of measurements taken by patients at home without supervision and it may be unclear how a BioMeT collects and processes data. Understanding data quality and potential biases in data collection is key to drawing appropriate inferences, especially because some of the data may be used for clinical decision making.In this paper, we will discuss the following: (i) sources of information one can use to identify high‐quality BioMeTs, (ii) products and engineering solutions for remote vital sign monitoring, including temperature, heart rate, blood pressure (BP), oxygen saturation, and respiratory rate, and (iii) considerations for choosing a product, including form factors, usability and data collection protocols, and interfering factors that can produce altered readings. Although certain vital sign abnormalities have been associated with COVID‐19 and will be highlighted in this review, we believe the foundations of evaluating these BioMeTs can be applied broadly whenever remote vital sign monitoring is needed. Although overviews of wearable sensor applications for COVID‐19 have been published, ⁸ , ¹⁹ this paper provides a critical review of technologies and is intended as an aid to navigate the plethora of remote monitoring sensors.     

Safety and Pharmacokinetics of the Oral TYK2 Inhibitor PF‐06826647: A Phase I,Randomized, Double‐Blind,Placebo‐Controlled,Dose‐Escalation Study

Selective inhibition of tyrosine kinase 2 (TYK2) may offer therapeutic promise in inflammatory conditions, with its role in downstream pro‐inflammatory cytokine signaling. In this first‐in‐human study, we evaluated the safety, tolerability, and pharmacokinetics (PK) of a novel TYK2 inhibitor, PF‐06826647, in healthy participants. This phase I, randomized, double‐blind, placebo‐controlled, parallel‐group study included two treatment periods (single ascending dose (SAD) and multiple ascending dose (MAD)) in healthy participants and a cohort of healthy Japanese participants receiving 400 mg q.d. or placebo in the MAD period ({"type":"clinical-trial","attrs":{"text":"NCT03210961","term_id":"NCT03210961"}}NCT03210961). Participants were randomly assigned to PF‐06826647 or placebo (3:1). Participants received a single oral study drug dose of 3, 10, 30, 100, 200, 400, or 1,600 mg (SAD period), then 30, 100, 400, or 1,200 mg q.d. or 200 mg b.i.d. for 10 days (MAD period). Safety (adverse events (AEs), vital signs, and clinical laboratory parameters), tolerability, and PK were assessed. Overall, 69 participants were randomized to treatment, including six Japanese participants. No deaths, serious AEs, severe AEs, or AEs leading to dose reduction or temporary/permanent discontinuation were observed. All AEs were mild in severity. No clinically relevant laboratory abnormalities or changes in vital signs were detected. PF‐06826647 was rapidly absorbed with a median time to maximum plasma concentration of 2 hours in a fasted state, with modest accumulation (< 1.5‐fold) after multiple dosing and low urinary recovery. PF‐06826647 was well‐tolerated, with an acceptable safety profile for doses up to 1,200 mg q.d. for 10 days, supporting further testing in patients.

Study Highlights

• WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC?

☑ Tyrosine kinase 2 (TYK2) inhibitors offer therapeutic promise for the many patients with inflammatory conditions in which IL‐12/23 signaling is implicated, and who have an inadequate response to existing systemic treatment options.

• WHAT QUESTION DID THIS STUDY ADDRESS?

☑ PF‐06826647 is an oral TYK2 inhibitor with potency against TYK2‐dependent signaling. We aimed to assess the safety, tolerability, and pharmacokinetics of PF‐06826647 in healthy participants.

• WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE?

☑ PF‐06826647 was well‐tolerated, with an acceptable safety profile at a single dose of up to 1,600 mg, or multiple doses up to 1,200 mg daily.

• HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE?

☑ PF‐06826647 may offer a future oral treatment option for patients with inflammatory and autoimmune conditions in which IL‐12/23 signaling is implicated.

Tyrosine kinase 2 (TYK2), a member of the Janus kinase (JAK) family, is essential for IL‐12/T‐helper cell 1 and IL‐23/T‐helper cell 17 signaling ¹ , ² and IFN type I/II receptor functioning, ² , ³ and both preclinical and clinical studies have implicated these pathways in the pathogenesis of autoimmune disorders, including psoriasis, inflammatory bowel disease, and systemic lupus erythematosous. ¹ , ² , ³ , ⁴ , ⁵ , ⁶ , ⁷ , ⁸ , ⁹ In large, human, genome‐wide association studies, single nucleotide polymorphisms of the TYK2 gene have been shown to confer protection against psoriasis, ankylosing spondylitis, Crohn’s disease, multiple sclerosis, and ulcerative colitis. ⁵ Blocking signaling from the pro‐inflammatory cytokines, as well as their downstream pathways, with the TYK2 JH2 domain inhibitor BMS‐986165, ¹⁰ the TYK2/JAK1 inhibitor brepocitinib, ¹¹ or with the monoclonal antibodies ustekinumab (anti‐IL‐12 and IL‐23), ¹² , ¹³ , ¹⁴ risankizumab (anti‐IL‐23), ¹⁴ , ¹⁵ secukinumab (anti‐IL‐17A), ¹⁶ mirikizumab (anti‐IL‐23), ¹⁷ or guselkumab (anti‐IL‐23), ¹⁸ , ¹⁹ has shown efficacy in the treatment of various autoimmune conditions.PF‐06826647 is an oral TYK2 inhibitor with potency against TYK2‐dependent signaling (IFNα/IL‐12/IL‐23), but may have dose‐dependent inhibitory activity against other, TYK2‐independent pathways (IFNγ/erythropoeitin). PF‐06826647 is a compound with a low pKa (< 1.7), low solubility across physiological pH (~ 0.3 μg/mL at pH 6.5), and high cellular permeability (~ 17 × 10^‐6 cm/s). However, based on preclinical exposure data in rats, using a spray‐dried dispersion formulation, it was expected to be moderately‐to‐well absorbed at the predicted clinically effective dose range in the clinic. In addition, preclinical studies demonstrated limited drug clearance via renal and biliary excretion in rats, and the major human clearance pathway for PF‐06826647 was identified to be cytochrome P450 (CYP)‐mediated (via CYP1A2, CYP2D6, and CYP3A) metabolism. ²⁰ PF‐06826647 has shown minimal inhibition of transporter proteins (i.e., MATE1, MRP1, MRP2, MRP3, sodium/Na+ taurocholate co‐transporting polypeptide, OATP1B1, OATP1B3, and OCT2), with the exception of MATE2 inhibition. ²⁰ In a phase I, first‐in‐human study ({"type":"clinical-trial","attrs":{"text":"NCT03210961","term_id":"NCT03210961"}}NCT03210961), we evaluated the safety, tolerability, and pharmacokinetics (PK) of PF‐06826647 in healthy participants. In this report, we present safety, tolerability, and PK data for escalating single and multiple doses of PF‐06826647. We also present the impact of food on PK parameters, and a comparison of PK parameters in plasma and urine between Western participants and a Japanese cohort during the multiple ascending dose (MAD) period at an expected clinically relevant dose of 400 mg q.d. Doses for the single ascending dose (SAD) and MAD study periods were initially selected based on data from in vitro pharmacologic/toxicologic studies. ²⁰ During the dose escalation, the available safety data (adverse events (AEs), vital signs, electrocardiogram (ECG), clinical laboratory, hematology, and urinalysis) from the ongoing cohort were reviewed and the appropriate dose for the next cohort was selected to provide the projected average exposure (based on available PK data from all doses) being ~ ≤ 3‐fold of the exposure and less or equal to the PK stopping limit.     

Early M‐Protein Dynamics Predicts Progression‐Free Survival in Patients With Relapsed/Refractory Multiple Myeloma

This study aimed to predict long‐term progression‐free survival (PFS) using early M‐protein dynamic measurements in patients with relapsed/refractory multiple myeloma (MM). The PFS was modeled based on dynamic M‐protein data from two phase III studies, POLLUX and CASTOR, which included 569 and 498 patients with relapsed/refractory MM, respectively. Both studies compared active controls (lenalidomide and dexamethasone, and bortezomib and dexamethasone, respectively) alone vs. in combination with daratumumab. Three M‐protein dynamic features from the longitudinal M‐protein data were evaluated up to different time cutoffs (1, 2, 3, and 6 months). The abilities of early M‐protein dynamic measurements to predict the PFS were evaluated using Cox proportional hazards survival models. Both univariate and multivariable analyses suggest that maximum reduction of M‐protein (i.e., depth of response) was the most predictive of PFS. Despite the statistical significance, the baseline covariates provided very limited predictive value regarding the treatment effect of daratumumab. However, M‐protein dynamic features obtained within the first 2 months reasonably predicted PFS and the associated treatment effect of daratumumab. Specifically, the areas under the time‐varying receiver operating characteristic curves for the model with the first 2 months of M‐protein dynamic data were ~ 0.8 and 0.85 for POLLUX and CASTOR, respectively. Early M‐protein data within the first 2 months can provide a prospective and reasonable prediction of future long‐term clinical benefit for patients with MM.

Study Highlights

• WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC?

☑ M‐protein is a biomarker for tumor burden and its levels in the serum and urine have been used to assess treatment responses for patients with multiple myeloma (MM).

• WHAT QUESTION DID THIS STUDY ADDRESS?

☑ Whether early M‐protein data in the first several months can provide a prospective prediction for long‐term benefit and treatment effect.

• WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE?

☑ By using clinical data collected from two pivotal phase III trials of daratumumab in relapsed or refractory MM, we demonstrated that M‐protein dynamic data collected during the first 2 months of therapy can provide a prospective and reasonable prediction for not only long‐term progression‐free survival (PFS) but also the treatment effects of daratumumab on PFS compared with other active controls.

• HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE?

☑ Early M‐protein dynamic data within the first 2 months of therapy may enable the designers of clinical trials to predict the probability of treatment success, and thus facilitate decision making in developing new drugs for MM.

Daratumumab is a human immunoglobulin G (IgGκ) monoclonal antibody that targets CD38 and kills malignant plasma cells via direct antitumor and immunomodulatory mechanisms of action. ¹ , ² , ³ , ⁴ , ⁵ , ⁶ , ⁷ Daratumumab induces antitumor activity through several CD38 immune‐mediated actions, including complement‐dependent cytotoxicity, antibody‐dependent cellular cytotoxicity, antibody‐dependent cellular phagocytosis, apoptosis, and modulation of CD38 enzymatic activity. ¹ , ² , ³ , ⁴ , ⁵ Daratumumab also induces an immunomodulatory effect by minimizing the immune‐suppressive functions of CD38⁺ myeloid‐derived suppressor cells, regulatory T cells, and regulatory B cells, and increasing T‐cell clonality. ⁶ In the phase III clinical studies POLLUX (MMY3003) and CASTOR (MMY3004), daratumumab in combination with standards of care regimens lenalidomide and dexamethasone (Rd), and bortezomib and dexamethasone (Vd), respectively, reduced the risk of disease progression or death by ≥ 50%, doubled the rates of complete response or better, and more than tripled the rates of minimal residual disease negativity based on next‐generation sequencing at the 10^–5 sensitivity threshold vs. standard of care alone in patients with relapsed/refractory multiple myeloma (MM). ⁸ , ⁹ , ¹⁰ , ¹¹ These findings led to the approval of daratumumab (16 mg/kg) in combination with Rd, and Vd in patients with relapsed and refractory MM in many countries worldwide. Daratumumab has also been approved as monotherapy in many countries and in combination with pomalidomide and dexamethasone in the United States.In MM, tumor plasma cell produces a large amount of monoclonal IgG or IgG free light chain (FLC), known as M‐protein. M‐protein is a biomarker for tumor burden and its levels in the serum and urine have been used to assess treatment responses for patients with MM. ¹² Dispenzieri et al. ¹³ demonstrated the utility of FLC after 2 months of therapy to predict the overall response. Furthermore, several other studies have shown retrospective association between FLC/M‐protein reduction and the long‐term benefit, such as progression‐free survival (PFS) or overall survival, ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ which is critical for predicting antitumor activities for new agents and personalizing therapy for patients with myeloma.To date, the retrospective studies of the association between M‐protein dynamics and PFS or overall survival have been mainly based on complete M‐protein dynamic data collected up to the time of disease progression. ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ Therefore, the prospective ability of M‐protein, particularly early measurements within 2–3 months of therapy, to predict long‐term survivals remains unknown. Moreover, because most of existing association studies were performed based on nonrandomized, single‐arm phase II studies, ¹³ , ¹⁴ , ¹⁵ , ¹⁷ , ¹⁹ translation of the significant association between M‐protein and survival in these studies to treatment effects compared with control arms in the randomized phase III studies is still challenging. Furthermore, existing association studies have mainly focused on reduction in the M‐protein level at a static single time point (e.g., end of 8 weeks) without considering dynamic information or features of M‐protein (e.g., variation in M‐protein levels over time, and rate of M‐protein changes). ¹³ , ¹⁴ , ¹⁸ Here, we investigated the usefulness of early M‐protein dynamic data collected during the first several months after treatment initiation as a predictor of PFS and the effects of treatment on PFS. This analysis is based on the clinical data of two, large‐scale phase III studies, POLLUX and CASTOR for daratumumab. We evaluated different features of M‐protein dynamics in addition to M‐protein reduction and compared the predictive performance of M‐protein dynamic data within different periods after treatment. With this analysis, we hypothesized that an early interim analysis based on M‐protein dynamics within a couple of months after treatment could prospectively predict the future long‐term treatment effect on PFS. Such predictions would contribute greatly to predictions of the probability of success of future clinical trials, decision making in drug development, and the prevision of individualized guidance for treatment and patient care.     

Evaluating Potential Disease‐Mediated Protein‐Drug Interactions in Patients With Moderate‐to‐Severe Plaque Psoriasis Receiving Subcutaneous Guselkumab

This open‐label, multicenter, phase I therapeutic protein‐drug interaction study was designed to evaluate the potential effect of guselkumab, a fully human anti‐interleukin‐23 immunoglobulin G1 lambda monoclonal antibody, on the pharmacokinetics of a cocktail of representative cytochrome P450 (CYP) probe substrates (midazolam (CYP3A4), S‐warfarin (CYP2C9), omeprazole (CYP2C19), dextromethorphan (CYP2D6), and caffeine (CYP1A2)). Fourteen participants with psoriasis received a single subcutaneous dose of guselkumab 200 mg on day 8 and an oral probe cocktail on days 1, 15, and 36. Blood samples were collected for measuring plasma concentrations of these probe substrates on days 1, 15, and 36. No consistent trends in observed maximum plasma concentration and area under the curve from time 0 to infinity values of each probe CYP‐substrate before (day 1) and after guselkumab treatment (days 15 and 36) could be identified in each individual patient, suggesting that the use of guselkumab in patients with psoriasis is unlikely to influence the systemic exposure of drugs metabolized by CYP isozymes (CYP3A4, CYP2C9, CYP2C19, CYP2D6, and CYP1A2). The probe cocktail was generally well‐tolerated when administered in combination with guselkumab in patients with psoriasis.Clinicaltrials.gov Identifiers: {"type":"clinical-trial","attrs":{"text":"NCT02397382","term_id":"NCT02397382"}}NCT02397382.

Study Highlights

• WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC?

☑ Therapeutic proteins (TPs) that modulate cytokine concentrations and activity can indirectly influence expression of cytochrome P450 (CYP) isoenzymes and may alter CYP‐mediated metabolism of concomitantly administrated small molecule drugs. An in vitro study ¹ and two phase I studies ² , ³ were previously conducted to assess if interleukin (IL)‐23 modulates the expression or activity of multiple CYP isoenzymes (including CYP1A2, 2C9, 2C19, 2D6, and 3A4). These results suggest that potential TP‐drug interactions between guselkumab and drugs metabolized by CYP450 could be low.

• WHAT QUESTION DID THIS STUDY ADDRESS?

☑ This phase I study evaluated whether treatment with guselkumab, which selectively binds and inhibits IL‐23, affects CYP450 isoenzyme activity in patients with moderate‐to‐severe psoriasis.

• WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE?

☑ Subcutaneous administration of guselkumab to patients with psoriasis has no effect on the pharmacokinetics (PK) of the evaluated CYP substrates.

• HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE?

☑ These results suggest that guselkumab can be used for the treatment of psoriasis without significant PK interactions with drugs metabolized by CYP3A4, CYP2C9, CYP2C19, CYP2D6, or CYP1A2.

Psoriasis is a chronic inflammatory disease affecting 1–3% of the world’s population. ⁴ Traditional systemic therapies for psoriasis have not fully met patients’ needs. ⁵ Highly effective antibody‐based or fusion protein‐based biologics targeting key inflammatory mediators have been developed for psoriasis treatment. ⁶ Based on their mechanisms of action, biological psoriasis therapies can be classified as: (i) T‐cell modulating agents, (ii) tumor necrosis factor (TNF)‐α antagonists, (iii) interleukin (IL)‐12/23 and/or IL‐23 inhibitors, and (iv) IL‐17 inhibitors. ⁴ , ⁷ Guselkumab (Tremfya, Janssen Research & Development, Spring House, PA) is a fully human immunoglobulin G1 lambda (IgG1λ) monoclonal antibody (mAb) that selectively binds and inhibits IL‐23, a critical driver of pathogenic T cells in chronic plaque psoriasis. Clinical trials have demonstrated that guselkumab had favorable efficacy and safety profiles for the treatment of moderate‐to‐severe plaque psoriasis. ⁸ , ⁹ , ¹⁰ As a fully human IgG1λ mAb, guselkumab is expected to be metabolized in the same manner as any other endogenous IgG antibody (degraded into small peptides and amino acids via catabolic pathways) and subject to similar routes for elimination. ¹¹ Therefore, the likelihood of direct therapeutic protein (TP)‐drug interaction occurring during co‐administration of guselkumab and other concomitant small molecule medications is assumed to be low. In line with this, clinically relevant information has been published about potential TP‐drug interactions, ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ and supports that mAbs do not elicit a direct effect on the metabolic/clearance pathways of small molecular therapeutics. However, the immunomodulatory properties of mAbs may indirectly alter the clearance of certain small molecules through noncatabolic hepatic metabolism pathways. ¹⁴ , ¹⁵ An in vitro study ¹ using cryopreserved human hepatocytes to assess whether IL‐12 and/or IL‐23 modulate the expression or activity of multiple cytochrome P450 (CYP) enzymes (i.e., CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6, and CYP3A4) suggested that TP‐drug interactions between guselkumab and CYP450 substrates are unlikely. However, in vitro studies may have limitations in predicting clinical interactions between TPs and small molecule drugs. ¹⁷ To confirm these findings, we conducted a phase I study in patients with moderate‐to‐severe plaque psoriasis to determine if blocking IL‐23 with guselkumab for treatment of psoriasis would clinically alter the metabolism of probe substrates metabolized by CYP isozymes (CYP3A4, CYP2C9, CYP2C19, CYP2D6, or CYP1A2).     

Pharmacoenhancement of Low Crizotinib Plasma Concentrations in Patients with Anaplastic Lymphoma Kinase‐Positive Non‐Small Cell Lung Cancer using the CYP3A Inhibitor Cobicistat

The inhibitor of anaplastic lymphoma kinase (ALK) crizotinib significantly increases survival in patients with ALK‐positive non‐small cell lung cancer (NSCLC). When evaluating crizotinib pharmacokinetics (PKs) in patients taking the standard flat oral dose of 250 mg b.i.d., interindividual PK variability is substantial and patient survival is lower in the quartile with the lowest steady‐state trough plasma concentrations (C_min,ss), suggesting that concentrations should be monitored and doses individualized. We investigated whether the CYP3A inhibitor cobicistat increases C_min,ss of the CYP3A substrate crizotinib in patients with low exposure. Patients with ALK‐positive NSCLC of our outpatient clinic treated with crizotinib were enrolled in a phase I trial (EudraCT 2016‐002187‐14, DRKS00012360) if crizotinib C_min,ss was below 310 ng/mL and treated with cobicistat for 14 days. Crizotinib plasma concentration profiles were established before and after a 14‐day co‐administration of cobicistat to construct the area under the plasma concentration‐time curve in the dosing interval from zero to 12 hours (AUC_0–12). Patients were also monitored for adverse events by physical examination, laboratory tests, and 12‐lead echocardiogram. Enrolment was prematurely stopped because of the approval of alectinib, a next‐generation ALK‐inhibitor with superior efficacy. In the only patient enrolled, cobicistat increased C_min,ss from 158 ng/mL (before cobicistat) to 308 ng/mL (day 8) and 417 ng/mL (day 14 on cobicistat), concurrently the AUC_0–12 increased by 78% from 2,210 ng/mL*h to 3,925 ng/mL*h. Neither safety signals nor serious adverse events occurred. Pharmacoenhancement with cobicistat as an alternative for dose individualisation for patients with NSCLC with low crizotinib exposure appears to be safe and is cost‐effective and feasible.

Study Highlights

• WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC?

☑ Crizotinib is an oral inhibitor of anaplastic lymphoma kinase, prolonging progression‐free survival and overall survival in patients with non‐small cell lung cancer. There is considerable variability in exposure and the lowest exposure quartile is associated with worse outcome.

• WHAT QUESTION DID THIS STUDY ADDRESS?

☑ Does inhibition of CYP3A, the enzyme metabolizing crizotinib, significantly increase crizotinib exposure and is it safe?

• WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE?

☑ Experience from a single case suggests that cobicistat can substantially and cost‐effectively boost crizotinib exposure in patients with low plasma concentrations.

• HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE?

☑ These data expand the concept of pharmacoenhancement into the indication of oncology. Inhibition of CYP3A‐mediated drug metabolism can increase plasma crizotinib concentration and hence possibly improve outcome.

Non‐small cell lung cancer (NSCLC) is the predominant type of lung cancer and a leading cause of death worldwide. Anaplastic lymphoma kinase (ALK) is a druggable driver mutation of NSCLC. ¹ Targeting ALK with the small molecule inhibitor crizotinib demonstrated significant clinical benefit improving progression‐free survival, overall response rate (ORR), lung cancer symptoms, and global quality of life. ² , ³ Oral crizotinib exhibits substantial variability in steady‐state plasma trough concentrations (C_min,ss), associated with a concentration‐dependent variability in ORR ⁴ ; the ORR was only 24–47% in the quartile with the lowest C_min,ss (< 310 ng/mL) as opposed to 60–75% in the quartile with the highest C_min,ss. ⁴ The benefit in ORR translates into longer progression‐free survival of patients with higher exposure. The model suggested a higher hazard in the lowest quartile vs. the combined upper three quartiles with a hazard ratio of 3.2 (90% confidence interval: 1.62–6.36). ⁴ The high rate of isolated intracranial disease progression under crizotinib has been linked to reduced local central nervous concentrations due to poor penetration. ⁵ , ⁶ Based on preclinical and clinical considerations, a lower effective plasma concentration limit of 235 ng/mL for C_min,ss has been proposed. ⁷ Interestingly, no exposure‐response relationship was observed for adverse events related to respiratory or liver function, albeit a dose reduction strategy is recommended in the drug label. ⁸ In patients experiencing disease progression, an ALK mutation explaining crizotinib resistance is found in only 30%. ⁹ Subtherapeutic exposure is a possible explanation for some of the remaining cases, suggesting that fixed standard doses might not meet the needs of these patients and exposure should be monitored early in therapy. Crizotinib is the primary active circulating moiety. ⁸ , ¹⁰ Its lactam metabolite (PF‐06260182), which consists of two diastereoisomers, is formed by CYP3A‐dependent oxidation but does not contribute significanty to pharmacological activity despite ALK‐inhibiting activity (4–8%). ⁸ , ¹⁰ Crizotinib exposure critically depends on the highly variable CYP3A activity: ⁸ , ¹⁰ , ¹¹ Co‐administration of CYP3A‐inducing rifampin decreases the area under the concentration‐time curve (AUC) by 72% and, conversely, the strong CYP3A inhibitor ketoconazole increases crizotinib AUC by 220%. ⁸ , ¹² Therefore, we screened patients with ALK‐positive metastasized NSCLC for subtherapeutic drug levels. Patients within the lowest quartile of exposure (i.e., C_min,ss < 310 ng/mL) were eligible to participate in a pharmacokinetic (PK) drug trial and were to receive the CYP3A inhibitor cobicistat to determine whether pharmacoenhancement will boost crizotinib exposure in the range of patients previously reported to have a better outcome.     

The Potential of Low Molecular Weight Heparin to Mitigate Cytokine Storm in Severe COVID‐19 Patients: A Retrospective Cohort Study

On March 11, 2020, the World Health Organization declared its assessment of coronavirus disease 2019 (COVID‐19) as a global pandemic. However, specific anti‐severe acute respiratory syndrome‐coronavirus 2 (SARS‐CoV‐2) drugs are still under development, and patients are managed by multiple complementary treatments. We performed a retrospective analysis to compare and evaluate the effect of low molecular weight heparin (LMWH) treatment on disease progression. For this purpose, the clinical records and laboratory indicators were extracted from electronic medical records of 42 patients with COVID‐19 (21 of whom were treated with LMWH, and 21 without LMWH) hospitalized (Union Hospital of Huazhong University of Science and Technology) from February 1 to March 15, 2020. Changes in the percentage of lymphocytes before and after LMWH treatment were significantly different from those in the control group (P = 0.011). Likewise, changes in the levels of D‐dimer and fibrinogen degradation products in the LMWH group before and after treatment were significantly different from those in the control group (P = 0.035). Remarkably, IL‐6 levels were significantly reduced after LMWH treatment (P = 0.006), indicating that, besides other beneficial properties, LMWH may exert an anti‐inflammatory effect and attenuate in part the “cytokine storm” induced by the virus. Our results support the use of LMWH as a potential therapeutic drug for the treatment of COVID‐19, paving the way for a subsequent well‐controlled clinical study.

Study Highlights

• WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC?

☑ Our results strongly suggest low molecular weight heparin (LMWH) as an effective strategy in a therapeutic or combination therapy against coronavirus disease 2019 (COVID‐19).

• WHAT QUESTION DID THIS STUDY ADDRESS?

☑ LMWH exerts an anti‐inflammatory effect by means of reducing IL‐6 and increasing lymphocyte%. We, therefore, favor the use of LMWH as a potential therapeutic drug for the treatment of COVID‐19.

• WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE?

☑ A new therapeutic approach for COVID‐19 was proposed based on the non‐anticoagulant properties of LMWH.

• HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE?

☑ In view of the COVID‐19 pandemic, our study will be of pronounced interest to a broad spectrum of clinicians and scientists of several disciplines focusing on translational and basic aspects related to COVID‐19 and virology in general.

On March 11, 2020, the World Health Organization (WHO) declared its assessment of coronavirus disease 2019 (COVID‐19) as a global pandemic. Severe acute respiratory syndrome‐coronavirus 2 (SARS‐CoV‐2) is characterized by a long incubation period, high infectivity, and multiple routes of transmission. ¹ , ² However, no effective medicines are currently available, so patients are treated symptomatically. A better understanding of the mechanisms of pathological changes will help to screen potential drugs out of the currently available medications.Several clinical studies revealed that cytokine storms are important mechanisms underlying disease exacerbation and death of patients with COVID‐19. ³ , ⁴ , ⁵ Particularly, IL‐6 levels in severely ill patients were significantly higher than in mild cases. ⁶ IL‐6 is one of the core cytokines, ⁷ contributing to many of the key symptoms of cytokine storm, such as vascular leakage, activation of the complement, and coagulation cascades, inducing disseminated intravascular coagulation. ⁸ , ⁹ Reducing the levels of IL‐6 and decreasing its activity may prevent or even reverse the cytokine storm syndrome, ¹⁰ thereby improving the condition of patients with COVID‐19.Substantial studies have reported that low molecular weight heparin (LMWH) has various non‐anticoagulant properties that play an anti‐inflammatory role by reducing the release of IL‐6. ¹¹ , ¹² , ¹³ However, the anti‐inflammatory effects of LMWH in COVID‐19 are currently unknown. By analyzing the effect of LMWH in patients with COVID‐19, our retrospective cohort study demonstrates, for the first time, the significant beneficial effect of LMWH in controlling cytokine storm and delaying disease progression (Figure 1 ).Open in a separate windowFigure 1Possible mechanism of anti‐inflammatory effects of low molecular weight heparin (LMWH) in patients with coronavirus disease 2019 (COVID‐19). Under conventional antiviral treatment regimens, LMWH improves hypercoagulability, inhibits IL‐6 release, and attenuates IL‐6 biological activity. It has potential antiviral effects and helps delay or block inflammatory cytokine storms. LMWH can increases the lymphocyte% in the patients. The multiple effects of LMWH encourages its application for the treatment of patients with COVID‐19. HSPG, heparin sulfate proteoglycan; SARS‐CoV‐2, severe acute respiratory syndrome‐coronavirus 2.     

Dose‐Dependent Acute Effects of Everolimus Administration on Immunological,Neuroendocrine and Psychological Parameters in Healthy Men

The rapamycin analogue everolimus (EVR) is a potent inhibitor of the mammalian target of rapamycin (mTOR) and clinically used to prevent allograft rejections as well as tumor growth. The pharmacokinetic and immunosuppressive efficacy of EVR have been extensively reported in patient populations and in vitro studies. However, dose‐dependent ex vivo effects upon acute EVR administration in healthy volunteers are rare. Moreover, immunosuppressive drugs are associated with neuroendocrine changes and psychological disturbances. It is largely unknown so far whether and to what extend EVR affects neuroendocrine functions, mood, and anxiety in healthy individuals. Thus, in the present study, we analyzed the effects of three different clinically applied EVR doses (1.5, 2.25, and 3 mg) orally administered 4 times in a 12‐hour cycle to healthy male volunteers on immunological, neuroendocrine, and psychological parameters. We observed that oral intake of medium (2.25 mg) and high doses (3 mg) of EVR efficiently suppressed T cell proliferation as well as IL‐10 cytokine production in ex vivo mitogen‐stimulated peripheral blood mononuclear cell. Further, acute low (1.5 mg) and medium (2.25 mg) EVR administration increased state anxiety levels accompanied by significantly elevated noradrenaline (NA) concentrations. In contrast, high‐dose EVR significantly reduced plasma and saliva cortisol as well as NA levels and perceived state anxiety. Hence, these data confirm the acute immunosuppressive effects of the mTOR inhibitor EVR and provide evidence for EVR‐induced alterations in neuroendocrine parameters and behavior under physiological conditions in healthy volunteers.

Study Highlights

• WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC?

☑ Everolimus (EVR) is a potent inhibitor of mTOR and clinically used to prevent organ rejection and to fight tumor growth. EVR is associated with neurobehavioral and psychological changes in patient studies. However, the effects of EVR under normal physiological conditions are unknown.

• WHAT QUESTION DID THIS STUDY ADDRESS?

☑ What is the impact of clinically employed doses of EVR on immunological, psychological and neuroendocrine parameters in healthy male individuals?

• WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE?

☑ Our data demonstrate that oral intake of medium and high doses of EVR suppressed T cell proliferation as well as IL‐10 cytokine production in ex vivo mitogen‐stimulated PBMCs. Acute low and medium EVR administration increased state anxiety and noradrenaline concentrations. In contrast, high dose EVR reduced cortisol levels but did not affect state anxiety levels.

• HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE?

☑ These findings demonstrate a dose dependent impact of EVR on state anxiety and neuroendocrine functions under normal physiological conditons in healthy individuals providing important information for monitoring drug efficacy and unwanted drug side effect for future clinical studies employing immunopharmacotherapy with EVR.

Everolimus (EVR) is a macrolide rapamycin analogue initially developed as an immunosuppressive drug with improved pharmacokinetic properties, including increased solubility, bioavailability, and reduced half‐life in comparison to other rapalogues. ¹ , ² EVR efficiently inhibits the mammalian target of rapamycin (mTOR), a serine/threonine protein kinase and substrate of the PI3K/Akt signaling pathway, crucial for the regulation of cellular homeostasis, including cell growth, proliferation, protein synthesis, cellular stress, and survival. ³ Further, mTOR has been shown to play an essential role in innate and adaptive immune responses either by regulating T cell and B cell proliferation and differentiation as well as inflammatory cytokine and antibody production. ² , ⁴ So far, EVR is the only clinically used mTOR inhibitor approved by the US Food and Drug Administration (FDA) for the oral administration and treatment of malignancies, including breast carcinoma, gastrointestinal tract‐derived neuroendocrine tumors, renal cell carcinoma, and to prevent allograft rejection after heart, kidney, and liver transplantations. ¹ , ² , ⁵ Pharmacokinetic studies with transplant recipients obtaining EVR either with 0.75 mg/dose or 1.5 mg/dose twice a day combined with cyclosporin revealed maximal blood concentration of 11.1 ± 4.6 µg/L and 20.3 ± 8.0 µg/L, respectively, after 1 to 2 hours. ⁶ , ⁷ The elimination half‐life amounts for 18–32 hours and steady‐state is achieved between 4 and 7 days. ⁶ , ⁷ However, in patient studies, EVR intake is frequently accompanied with other immunosuppressive drugs like cyclosporin affecting the pharmacokinetic profile of EVR. ² Pharmacokinetics derived from healthy probands receiving a single 2 mg and 4 mg EVR dose revealed maximal EVR blood concentrations of 17.9 ± 5.9 µg/L and 44.2 ± 13.3 µ/L, respectively, reached after 0.5 to 1 hour with an elimination half‐life of 32 hours ⁸ , ⁹ and that single doses up to 5 mg are well‐tolerated. ¹⁰ Experimental and clinical studies in animal models and patients showed the potent immunosuppressive efficacy of the rapamycin analogue EVR in vitro mediated by blocking lymphocyte proliferation and in vivo by preventing rejections of transplanted organs. ¹¹ , ¹² , ¹³ , ¹⁴ Further, impaired renal function exerted by other medication regimens solely using calcineurin inhibitors in patients improved after acute and chronic treatment with EVR. ¹⁵ , ¹⁶ However, in patient studies, it is difficult to discriminate whether the examined effects solely were induced by EVR because the patients usually obtain a combination therapy consisting of more than one immunosuppressive drug. ¹¹ , ¹⁷ , ¹⁸ Accumulating clinical evidence document that patients receiving immunosuppressive medication, including calcineurin inhibitors like tacrolimus or cyclosporin A, frequently develop affective and cognitive dysfunctions, such as depression or anxiety, and exhibit neurotoxic side effects, including tremor and peripheral neuropathy potentially manifesting in psychoses and seizures. ¹⁹ , ²⁰ , ²¹ , ²² Although a growing body of studies in experimental animal models and clinical trials documented neurobehavioral effects exerted by mTOR inhibitors, the observed findings are controversial. EVR treatment improves neuropsychological deficits and autism in patients with tuberous sclerosis complex ²³ and has beneficial effects on memory and psychiatric symptoms in heart transplant recipients. ¹⁹ However mTOR inhibition also has been linked to depressive and anxiety‐like behavior in rodents and the induction of euphoria followed by melancholy, mimicking biopolar disorder in patients with breast cancer. ²⁴ , ²⁵ , ²⁶ , ²⁷ These observations indicate that mTOR inhibition is associated with neurobehavioral and psychiatric symptoms but the impact of comorbidities on the action of EVR is inconclusive since the findings have been acquired from patient studies. Hence, so far, no data exist documenting whether and to what extent clinically used doses of the mTOR inhibitor EVR affect cellular immunosuppressive responses, central functions on behavioral, neuroendocrine and psychological levels, and, thus, may contribute to central side effects, including anxiety in healthy individuals. Against this background, the present study determined systemic blood levels of EVR after an acute, four‐time oral administration of three different, pharmacological relevant doses of the drug along with its effects on T cell specific cytokine production and proliferation as well as behavioral and neuroendocrine parameters in healthy men.     

hIL‐7‐hyFc,A Long‐Acting IL‐7, Increased Absolute Lymphocyte Count in Healthy Subjects

A low lymphocyte count puts immune‐compromised patients at risk of mortality. hIL‐7‐hyFc is a homodimeric interleukin‐7 (IL‐7), a potent T‐cell amplifier, fused to the hybridizing IgD/IgG4 immunoglobulin domain. We performed a randomized, double‐blind, placebo‐controlled, dose‐escalation, phase I study to assess the pharmacokinetic, pharmacodynamic, safety, tolerability, and immunogenicity profiles of hIL‐7‐hyFc administered s.c. and i.m. to healthy volunteers. Thirty subjects randomly received hIL‐7‐hyFc or its matching placebo in an 8:2 ratio at 20, 60 μg/kg s.c., or 60 μg/kg i.m. The hIL‐7‐hyFc was slowly absorbed and its terminal half‐life was 63.26 hours after i.m. administration. The hIL‐7‐hyFc increased absolute lymphocyte count, mostly in T‐cells, which peaked 3 weeks after administration and then lasted for several additional weeks. The hIL‐7‐hyFc was well‐tolerated after a single s.c. and i.m. administration. Injection site reaction was the most common treatment‐emergent adverse event, which resolved spontaneously without treatment. The hIL‐7‐hyFc can be developed into a beneficial treatment option for patients with compromised T‐cell immunity. This trial was registered at www.clinicaltrials.gov as #{"type":"clinical-trial","attrs":{"text":"NCT02860715","term_id":"NCT02860715"}}NCT02860715.

Study Highlights

• WHAT IS THE CURRENT KNOWLEDGE ON THIS TOPIC?

☑ Exogenously administered interleukin (IL)‐7 has shown to increase T cells in various immune‐deficient patients. However, exogenously administered IL‐7, particularly nonglycosylated IL‐7, are known to have a relatively short half‐life.

• WHAT QUESTION DID THIS STUDY ADDRESS?

☑ We performed this study to assess the pharmacokinetics, pharmacodynamics, safety, and tolerability profiles of hIL‐7‐hyFc, a novel long‐acting IL‐7, in humans.

• WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE?

☑ Our results clearly showed that hIL‐7‐hyFc stays longer in the body, is well‐tolerated, and increases T cells in a dose‐dependent manner.

• HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE?

☑ Our results provide evidence that a single dose of hIL‐7‐hyFc can be further developed into a beneficial treatment option for a variety of patients with a low T‐cell count or compromised T‐cell immunity. Several phase II studies in immune‐compromised patients or patients with a low T‐cell count are currently ongoing (ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT03478995","term_id":"NCT03478995"}}NCT03478995, {"type":"clinical-trial","attrs":{"text":"NCT03619239","term_id":"NCT03619239"}}NCT03619239, {"type":"clinical-trial","attrs":{"text":"NCT03733587","term_id":"NCT03733587"}}NCT03733587, and {"type":"clinical-trial","attrs":{"text":"NCT03752723","term_id":"NCT03752723"}}NCT03752723). Decrease in lymphocyte counts caused by anticancer therapy is associated with frequent relapse, severe toxicity, and mortality. ¹ , ² , ³ Likewise, increased neutrophil‐to‐lymphocyte ratio was a poor prognostic predictor in patients with cancer. ⁴ Furthermore, patients with a low lymphocyte count were significantly less benefited from immune checkpoint inhibitors. ⁵ Additionally, low lymphocyte count increased the risk for serious opportunistic infections in patients with AIDS, primary immunodeficiency, and idiopathic CD4 lymphopenia or patients receiving chronic immunosuppressive therapy. ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ Interleukin‐7 (IL‐7) plays a critical role in the development, proliferation, maintenance, and reinvigoration of T‐cells. ¹² The effects of IL‐7 are mediated via a heterodimeric receptor consisting of the IL‐7 receptor α‐chain (IL‐7Rα) and the common cytokine receptor γ‐chain. IL‐7Rα, expressed on naïve T‐cells, is downregulated upon activation of IL‐7‐mediated signaling and re‐expressed in memory T‐cells. ¹³ , ¹⁴ Exogenously administered IL‐7 to humans and mice proliferated T‐cells in the peripheral blood, increased tumor infiltrating lymphocytes, enhanced the survival of T‐cells, and generated memory T‐cells. ¹⁵ , ¹⁶ , ¹⁷ Furthermore, exogenously administered IL‐7 was well‐tolerated and increased the number of T‐cells in a dose‐dependent manner in patients with viral infections (e.g., HIV and hepatitis B and C), cancer, and rare disease, such as progressive multifocal leukoencephalopathy and idiopathic CD4 lymphopenia. ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² However, exogenously administered IL‐7 had a relatively short half‐life in humans, particularly for non‐glycosylated IL‐7, which ranged only 6.46–9.80 hours, ¹⁵ similar to other cytokines. ²³ , ²⁴ Therefore, a novel long‐standing formulation of IL‐7 has been an unmet medical need.The hIL‐7‐hyFc is a homodimeric IL‐7 fused to the hybridizing IgD/IgG4 immunoglobulin domain (hyFc). The hyFc region in hIL‐7‐hyFc is composed of the hinge and N‐terminal portion of the heavy chain constant region 2 (hinge‐CH2) of human IgD, which is fused to the C‐terminal region of CH2 and the entire CH3 region of human IgG4. The hyFc region helps IL‐7 stay longer in the body through neonatal Fc receptor‐mediated recycling. ²⁵ A single s.c. administration of hIL‐7‐hyFc at 0.1, 0.3, or 1.0 mg/kg in rats increased the peripheral lymphocyte count by ~ 1.5‐fold. Additionally, the terminal half‐life of hIL‐7‐hyFc after a single s.c. administration in rats ranged from 19–25 hours.Based on the preclinical findings that support the notion that hIL‐7‐hyFc can be developed as a beneficial therapeutic option for patients with low lymphocyte count, we performed a phase I study to assess the pharmacokinetic (PK), pharmacodynamic (PD), safety, tolerability, and immunogenicity profiles of hIL‐7‐hyFc in humans.     

Therapeutic Opportunities for Intestinal Angioectasia‐ Targeting PPARγ and Oxidative Stress

Recurrent and acute bleeding from intestinal tract angioectasia (AEC) presents a major challenge for clinical intervention. Current treatments are empiric, with frequent poor clinical outcomes. Improvements in understanding the pathophysiology of these lesions will help guide treatment. Using data from the US Food and Drug Administration (FDA)’s Adverse Event Reporting System (FAERS), we analyzed 12 million patient reports to identify drugs inversely correlated with gastrointestinal bleeding and potentially limiting AEC severity. FAERS analysis revealed that drugs used in patients with diabetes and those targeting PPARγ‐related mechanisms were associated with decreased AEC phenotypes (P < 0.0001). Electronic health records (EHRs) at University of Cincinnati Hospital were analyzed to validate FAERS analysis. EHR data showed a 5.6% decrease in risk of AEC and associated phenotypes in patients on PPARγ agonists. Murine knockout models of AEC phenotypes were used to construct a gene‐regulatory network of candidate drug targets and pathways, which revealed that wound healing, vasculature development and regulation of oxidative stress were impacted in AEC pathophysiology. Human colonic tissue was examined for expression differences across key pathway proteins, PPARγ, HIF1α, VEGF, and TGFβ1. In vitro analysis of human AEC tissues showed lower expression of PPARγ and TGFβ1 compared with controls (0.55 ± 0.07 and 0.49 ± 0.05). National Center for Biotechnology Information (NCBI) Gene Expression Omnibus (GEO) RNA‐Seq data was analyzed to substantiate human tissue findings. This integrative discovery approach showing altered expression of key genes involved in oxidative stress and injury repair mechanisms presents novel insight into AEC etiology, which will improve targeted mechanistic studies and more optimal medical therapy for AEC.

Study Highlights

• WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC?

☑ The clinical detection of angioectasia (AEC) has increased using push‐enteroscopy, capsule enterography, colonoscopy, and esophagogastroduodenoscopy. Management is difficult. Currently, endoscopic ablation is an option for lesions within endoscopic reach, whereas angiogenesis inhibitors and octreotide are pharmacological agents additionally used in the treatment of AEC often with limited clinical benefit. The precise pathophysiology of AEC is unknown; however, AECs are known to result from an imbalance between the pro‐angiogenic and anti‐angiogenic factors.

• WHAT QUESTION DID THIS STUDY ADDRESS?

☑ How do intestinal AEC develop and how can we design targeted therapeutic discovery for AEC.

• WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE?

☑ Insight into the development of intestinal AEC and a targeted approach for novel therapeutic strategies.

• HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE?

☑ The results of this study demonstrate the complexity of AEC development and novel therapeutic directions that could impact patient care and treatment.

Angioectasia (AEC) lesions are common vascular abnormalities characterized by ectatic, dilated, and proliferated blood vessels, and are a significant source of obscure gastrointestinal (GI) bleeding. These aberrant blood vessels are typically < 10 mm in diameter, thin walled with little or no smooth muscle, malformed, and uncommunicative, ¹ , ² and symptomatically present with overt and occult GI hemorrhage, ¹ melena, hematochezia, and resulting anemia. ¹ , ³ The clinical procedure of endoscopy has shown the presence of AEC in the upper GI tract, ¹ small bowel, ¹ , ³ descending colon, ¹ , ⁴ and linked their existence to upper and lower GI hemorrhage. ¹ , ⁵ AECs are also significantly correlated with occurrence of synchronous lesions ⁶ , ⁷ , ⁸ and aging. ¹ , ⁹ The clinical detection of AEC has increased using push‐enteroscopy, capsule enterography, colonoscopy, and esophagogastroduodenoscopy, and management of these lesions is difficult with options for treatment being suboptimal. ¹ , ¹⁰ , ¹¹ Currently, endoscopic ablation is an option for lesions within endoscopic reach, whereas angiogenesis inhibitors, such as thalidomide, lenalidomide (thalidomide derivative), and octreotide, are pharmacological agents additionally used in the treatment of AEC often with limited clinical benefit. ¹¹ , ¹² The precise pathophysiology of AEC is unknown; however, AECs are known to result from an imbalance between the pro‐angiogenic and anti‐angiogenic factors and expression of growth factors, including VEGF in AECs, is suggestive of angiogenesis playing a role in their development. ¹ Angiogenesis promotes formation of new functional microvascular networks in human tissues in response to hypoxia or ischemia. ¹ AEC formation appears to be linked to patients with von Willebrand factor in Heyde’s syndrome and left ventricular assist device, whereas mutations in several genes in the TGFβ pathway are common in patients with hereditary hemorrhagic telangiectasia. ¹³ The VEGF‐dependent proliferation and migration represents an important angiogenesis‐hemostasis relationship that may have therapeutic implications in the management of AEC. ¹ , ¹⁴ , ¹⁵ , ¹⁶ Understanding the role of key mediators in AEC development will be important in identifying novel therapeutic strategies that will overcome this unmet clinical need.In this report, we describe a novel integrative systems biology‐based approach and clinical validation study that evaluates the pathophysiology of these lesions. We sought to identify if reduction in severity or decrease in rate of AEC and AEC‐correlated events occurred with use of specific drugs, hence using the medication’s own mechanism of action to ascertain a “first‐cut” of the inflammatory processes at work in vivo. To understand how therapeutic agents may impact AEC‐associated disease pathology, we used in silico drug discovery and gene regulatory networks analysis to identify key pathways/proteins involved in the pathophysiology of AEC and test candidate therapeutics for their protective mechanisms.     

Predicting Resolvin D1 Pharmacokinetics in Humans with Physiologically‐Based Pharmacokinetic Modeling

Sjögren’s syndrome (SS) is an autoimmune disease with no effective treatment options. Resolvin D1 (RvD1) belongs to a class of lipid‐based specialized pro‐resolving mediators that showed efficacy in preclinical models of SS. We developed a physiologically‐based pharmacokinetic (PBPK) model of RvD1 in mice and optimized the model using plasma and salivary gland pharmacokinetic (PK) studies performed in NOD/ShiLtJ mice with SS‐like features. The predictive performance of the PBPK model was also evaluated with two external datasets from the literature reporting RvD1 PKs. The PBPK model adequately captured the observed concentrations of RvD1 administered at different doses and in different species. The PKs of RvD1 in virtual humans were predicted using the verified PBPK model at various doses (0.01–10 mg/kg). The first‐in‐human predictions of RvD1 will be useful for the clinical trial design and translation of RvD1 as an effective treatment strategy for SS.

Study Highlights

• WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC?

☑ Sjögren’s syndrome (SS) is a complex inflammatory disorder with no clinically approved treatment options. Resolvin D1 (RvD1), a specialized pro‐resolving mediator with potent anti‐inflammatory effects, has shown promise in preclinical studies to restore the salivary gland function and promote tissue repair.

• WHAT QUESTION DID THIS STUDY ADDRESS?

☑ We leveraged physiologically‐based pharmacokinetic (PBPK) modeling to predict the RvD1 pharmacokinetics (PKs) in humans by extrapolation from PK data obtained from in vivo experiments in a mouse model of SS.

• WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE?

☑ The PBPK model provides an appropriate dose and estimates of clearance and other PK parameters for RvD1 in humans. These PK parameters and dose will inform the initial dosing of RvD1 for first‐in‐human clinical studies.

• HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE?

☑ This study significantly advances the potential for clinical translation of RvD1 into clinical trials for the treatment of SS.

Sjögren’s syndrome (SS) is a chronic inflammatory autoimmune disease characterized by the diminished secretory function of the exocrine glands. ¹ It affects ~ 1% of the general population and up to 3% of people above the age of 50 years. ² Women account for > 90% of diagnosed cases. ² Diagnostic hallmarks for SS include xerostomia or dry mouth, impaired tear production, lymphocytic infiltration into salivary glands, and presence of anti‐Ro and anti‐La autoantibodies in plasma. ¹ SS reduces salivary gland function and leads to oral diseases, such as gingivitis and caries, and candidiasis. ³ The advanced complications of reduced salivary gland function include recurrent infection of the parotid gland ⁴ and lymphomas. ⁵ Together, these issues impose significant physical, psychological, and economic burdens on patients with SS. ⁶ Furthermore, the cause of SS is still unknown, and current therapeutic interventions are ineffective and limited to the use of saliva substitutes and medications that provide only temporary relief. ⁷ Therefore, the development of alternative treatments to restore salivary gland function are an urgent and unmet medical need.Viral and bacterial infections, in conjunction with the activation of susceptibility genes, stimulates chronic salivary gland inflammation. ⁸ A state of chronic inflammation causes tissue damage followed by cytokine and chemokine release. ⁸ When resolution mechanisms are working correctly, neutrophils and M2 macrophages can clear the site of injury or infection. ⁹ However, in SS, these resolution mechanisms are impaired, ¹⁰ and the dead cells involved in the process cannot be removed from the injury/infection site leading to the production of autoantigens and elevations in proinflammatory cytokine levels. ¹¹ The increased production of autoantigens and proinflammatory cytokines stimulate peripheral lymphocytes to bind to and infiltrate across the vascular endothelium into the salivary gland. ¹² Lymphocyte infiltration exacerbates the pathologic proinflammatory state, tissue damage, and hastens salivary gland dysfunction. ¹³ The cascade of events leading to inflammation resolution is an actively regulated process mediated in part by a family of endogenous lipid‐based specialized pro‐resolving mediators, which include resolvins, maresins, lipoxins, and protectins. ¹⁴ The administration of pro‐resolving lipid mediators have demonstrated efficacy in treating diseases having a pathologic proinflammatory basis, such as osteoarthritis, by terminating proinflammatory signaling, thereby enhancing tissue regeneration. ¹⁵ These pro‐resolving lipid mediators have been detected in animal models of infection and chronic inflammation. ¹⁶ Specific to SS, exogenous resolvin administration has the potential to reduce inflammation and restore salivary gland function. ¹⁷ Naturally occurring resolvin subtypes include the D series (derived from docosahexaenoic acid), the E series (derived from eicosapentaenoic acid), and six analogs of the D series, which are produced in response to aspirin. ¹⁸ Previously, we identified resolvin D1 (RvD1) as a therapeutic candidate for the treatment of SS. ¹⁹ RvD1 reduced inflammation and restored salivary gland tissue integrity in animal models of SS. ¹⁹ , ²⁰ , ²¹ In addition, the progression of SS‐like features in NOD/ShiLtJ mice can be halted using an aspirin‐triggered form of RvD1. In this circumstance, mice treated systemically, prior to disease onset, displayed downregulation of proinflammatory cytokines, upregulation of anti‐inflammatory mediators, and intact saliva production. ²² , ²³ Based on the preclinical safety and efficacy data of RvD1, we are preparing for phase I studies in humans. Therefore, the purpose of this study was to perform first‐in‐human predictions of RvD1 pharmacokinetics (PKs) in plasma and saliva using a verified whole‐body physiologically‐based pharmacokinetic (PBPK) model. The mouse PBPK model of RvD1 was developed using the physical, chemical, and biological properties of RvD1 and was optimized with plasma and salivary gland PK data obtained in SS‐like mice. The mouse PBPK model was then extrapolated to humans to generate appropriate first‐in‐human dose predictions.     

Effect of Combination Therapy of Hydroxychloroquine and Azithromycin on Mortality in Patients With COVID‐19

Conflicting evidence regarding the use of hydroxychloroquine (HCQ) and azithromycin for the treatment of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection do exist. We performed a retrospective single‐center cohort study including 377 consecutive patients admitted for pneumonia related to coronavirus disease 2019 (COVID‐19). Of these, 297 were in combination treatment, 17 were on HCQ alone, and 63 did not receive either of these 2 drugs because of contraindications. The primary end point was in‐hospital death. Mean age was 71.8 ± 13.4 years and 34.2% were women. We recorded 146 deaths: 35 in no treatment, 7 in HCQ treatment group, and 102 in HCQ + azithromycin treatment group (log rank test for Kaplan–Meier curve P < 0.001). At multivariable Cox proportional hazard regression analysis, age (hazard ratio (HR) 1.057, 95% confidence interval (CI) 1.035–1.079, P < 0.001), mechanical ventilation/continuous positive airway pressure (HR 2.726, 95% CI 1.823–4.074, P < 0.001), and C reactive protein above the median (HR 2.191, 95% CI 1.479–3.246, P < 0.001) were directly associated with death, whereas use of HCQ + azithromycin (vs. no treatment; HR 0.265, 95% CI 0.171–0.412, P < 0.001) was inversely associated. In this study, we found a reduced in‐hospital mortality in patients treated with a combination of HCQ and azithromycin after adjustment for comorbidities. A large randomized trial is necessary to confirm these findings.

The severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection is spreading worldwide since December 2019 and still no proven effective therapy has been found. First therapy proposed to treat coronavirus disease 2019 (COVID‐19) has been the association of lopinavir‐ritonavir, a protease inhibitor approved for HIV infection. However, Cao et al. observed no benefit comparing lopinavir‐ritonavir treatment of hospitalized patients with severe COVID‐19, ¹ and this treatment is currently not recommended. Currently, only remdesivir has been approved for COVID‐19 treatment, as it reduced recovery time by 4 days in 1,063 patients randomized to either remdesivir 200 mg loading dose followed by 100 mg daily or placebo for up to 10 days ² with a similar rate of adverse events between the 2 groups. ³ However, no effect on in‐hospital mortality was found.Chloroquine and its derivative hydroxychloroquine (HCQ), based on few preclinical studies, have also been proposed as therapies for COVID‐19. A Chinese randomized trial in patients with mild disease showed a significantly shorter recovery time in the group treated with HCQ vs. the standard of care along with a radiological improvement. ⁴ Differently, a retrospective study performed in the United States Veterans Health Administration medical centers found an increased mortality associated with the treatment with HCQ. ⁵ Moreover, an observational study has shown no significant association between HCQ use and risk of intubation or death. ⁶ Furthermore, a recent randomized controlled trial has found no differences between patients treated with HCQ plus the standard of care vs. the standard of care alone in terms of virus elimination. ⁷ On the basis of a very small nonrandomized study, azithromycin has been proposed as possible treatment in association with HCQ. ⁸ Azithromycin, is an antibiotic belonging to the class of macrolides, with some proven efficacy in acute respiratory distress syndrome. ⁹ , ¹⁰ It is known to have immunomodulatory properties through the polarization of macrophages toward the reparative state ¹¹ and the reduction in the production of pro‐inflammatory cytokines, such as IL‐8, IL‐6, TNF alpha, ¹² and iNOS expression. ¹³ Recently, two large retrospective studies evaluating in‐hospital mortality associated with the use of the combination of HCQ and azithromycin (or another macrolide, such as clarithromycin), have shown no benefits. ¹⁴ Despite the lack of a proven clinical efficacy and some concerns regarding the possible QT prolongations caused by the association of HCQ and azithromycin, ¹⁵ given the low price and the wide availability, the association of these two drugs has become the most used treatment in patients with moderate‐severe COVID‐19.Because of the urgent need to find answers to the many questions posed by the fight to SARS‐CoV2 infection and some negative evidences regarding the use of HCQ, we here propose a retrospective observational study to assess the efficacy of the combination of HCQ plus azithromycin for hospitalized patients with medium‐severe COVID‐19.     

Human Induced Pluripotent Stem Cell Derived Sensory Neurons are Sensitive to the Neurotoxic Effects of Paclitaxel

Chemotherapy‐induced peripheral neuropathy (CIPN) is a dose‐limiting adverse event associated with treatment with paclitaxel and other chemotherapeutic agents. The prevention and treatment of CIPN are limited by a lack of understanding of the molecular mechanisms underlying this toxicity. In the current study, a human induced pluripotent stem cell–derived sensory neuron (iPSC‐SN) model was developed for the study of chemotherapy‐induced neurotoxicity. The iPSC‐SNs express proteins characteristic of nociceptor, mechanoreceptor, and proprioceptor sensory neurons and show Ca²⁺ influx in response to capsaicin, α,β‐meATP, and glutamate. The iPSC‐SNs are relatively resistant to the cytotoxic effects of paclitaxel, with half‐maximal inhibitory concentration (IC₅₀) values of 38.1 µM (95% confidence interval (CI) 22.9–70.9 µM) for 48‐hour exposure and 9.3 µM (95% CI 5.7–16.5 µM) for 72‐hour treatment. Paclitaxel causes dose‐dependent and time‐dependent changes in neurite network complexity detected by βIII‐tubulin staining and high content imaging. The IC₅₀ for paclitaxel reduction of neurite area was 1.4 µM (95% CI 0.3–16.9 µM) for 48‐hour exposure and 0.6 µM (95% CI 0.09–9.9 µM) for 72‐hour exposure. Decreased mitochondrial membrane potential, slower movement of mitochondria down the neurites, and changes in glutamate‐induced neuronal excitability were also observed with paclitaxel exposure. The iPSC‐SNs were also sensitive to docetaxel, vincristine, and bortezomib. Collectively, these data support the use of iPSC‐SNs for detailed mechanistic investigations of genes and pathways implicated in chemotherapy‐induced neurotoxicity and the identification of novel therapeutic approaches for its prevention and treatment.

Study Highlights

• WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC?

☑ Sensory peripheral neuropathy is a common and dose‐limiting adverse event during chemotherapy. The lack of a molecular understanding of this toxicity limits options for its prevention and treatment.

• WHAT QUESTION DID THIS STUDY ADDRESS?

☑ The current study tested whether sensory neurons differentiated from human induced pluripotent stem cells (iPSC‐SNs) can be used to investigate chemotherapy‐induced neurotoxicity, using paclitaxel as a model neurotoxic chemotherapeutic.

• WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE?

☑ The iPSC‐SNs are a robust and reproducible model of paclitaxel‐induced neurotoxicity. Treatment of iPSC‐SNs with paclitaxel affects neurite networks, neuron excitability, and mitochondrial function.

• HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE?

☑ This novel stem cell model of chemotherapy‐induced neurotoxicity will be valuable for identifying genes and pathways critical for this toxicity and could be a useful platform for testing therapeutic approaches for treatment.

Chemotherapy‐induced peripheral neuropathy (CIPN) is a dose‐limiting toxicity associated with a number of drugs used for the treatment of solid tumors and hematological cancers. ¹ , ² , ³ Drugs with diverse mechanisms of action, including microtubule disruptors, proteasome inhibitors, and DNA‐crosslinking agents, all cause significant peripheral neuropathy. CIPN typically presents as burning, tingling, or numbness in the hands and feet that occurs in a glove and stocking distribution. ² , ⁴ In addition to negatively affecting a patient’s quality of life, dose reductions, treatment delays, and discontinuation can impact the therapeutic effectiveness of these drugs. ² Despite years of research, there are no effective therapies to prevent and/or treat CIPN, highlighting the need to define the molecular basis of this toxicity to support the development of novel strategies for treatment.Most mechanistic studies of CIPN have used behavioral testing in rodent models or cell‐based studies using primary rodent dorsal root ganglion (DRG) neurons. Common mechanisms associated with the development of CIPN include axon degeneration, altered Ca²⁺ homeostasis, mitochondrial dysfunction, changes in neuronal excitability, and neuroinflammation, although the relative contribution of these mechanisms varies for individual drugs. ⁵ , ⁶ , ⁷ For example, the microtubule stabilizing effects of paclitaxel inhibit anterograde and retrograde transport of synaptic vesicles down the microtubules, resulting in axon degeneration and membrane remodeling. This phenomenon is thought to be a major contributor to paclitaxel‐induced peripheral neuropathy. ⁸ In contrast, the ability of DNA alkylators, like cisplatin and oxaliplatin, to form adducts with mitochondrial DNA and increase reactive oxygen species contributes significantly to their peripheral neuropathy. ⁵ Although these studies in preclinical models and primary cultures of rodent DRG neurons have enhanced our knowledge of potential mechanisms for CIPN, attempts to translate these findings into humans have been largely unsuccessful. ³ In recent years, human induced pluripotent stem cell (iPSC)‐derived neurons have been used for the study of CIPN. Commercially available iPSC‐derived neurons (e.g., iCell neurons and Peri.4U neurons) have been evaluated as a model of neurotoxicity, ⁹ used to screen for neurotoxic compounds, ¹⁰ , ¹¹ , ¹² , ¹³ and utilized for functional validation of genes identified in human genomewide association studies of CIPN. ⁹ , ¹⁴ , ¹⁵ , ¹⁶ The use of human iPSC‐derived neurons affords an advantage over rodent DRG neurons in their human origin and the potential to differentiate into specific peripheral sensory neuron populations. The iCell neurons are a mixture of postmitotic GABAergic and glutamatergic cortical neurons that are more characteristic of relatively immature forebrain neurons than the sensory neurons found in the DRG. ¹⁷ , ¹⁸ Peri.4U neurons are more peripheral‐like, expressing βIII‐tubulin, peripherin, MAP2, and vGLUT2, but have been minimally characterized with respect to functional properties. ¹⁰ , ¹⁹ Additionally, neurons derived from human fibroblasts, blood, and embryonic stem cells that express more canonical nociceptive markers, like ISL1, BRN3A, P2RX3, the NTRK receptors, and NF200, ²⁰ , ²¹ , ²² , ²³ have also been used to study chemotherapy toxicity. Although these human derived cells resemble the DRG sensory neurons that are targeted by chemotherapeutics, there is significant interindividual variation across donor samples that limits their routine use for mechanistic studies and confounds the evaluation of functional consequences of genetic variation associated with human CIPN. ²⁴ Despite advances made in recent years in the development of human cell‐based models for the study of CIPN, there remains a need for a robust, widely available, and reproducible model for detailed mechanistic studies of this dose‐limiting toxicity. The goal of the studies described below was to develop an iPSC‐derived sensory neuron (iPSC‐SN) model for the study of chemotherapy‐induced neurotoxicity. Paclitaxel was used as a model neurotoxic chemotherapeutic to evaluate morphological, mitochondrial, and functional changes associated with exposure of iPSC‐SNs to neurotoxic compounds.     

Good Manufacturing Practice‐Grade of Megakaryocytes Produced by a Novel Ex Vivo Culturing Platform

Ex vivo (EV)‐derived megakaryocytes (MKs) have shown great promise as a substitute for platelets in transfusion medicine to alleviate a severe shortage of donor‐platelets. Challenges remain that include poor efficiency, a limited scale of production, and undefined short‐term storage conditions of EV‐derived MKs. This study aims to develop a high‐efficiency system for large‐scale production of Good Manufacturing Practice (GMP)‐grade MKs and determine the short‐term storage condition for the MKs. A roller‐bottle culture system was introduced to produce GMP‐grade MKs from small‐molecule/cytokine cocktail expanded hematopoietic stem cells. Various buffer systems and temperatures for the short‐term storage of MKs were assessed by cell viability, biomarker expression, and DNA ploidy levels. MKs stored for 24 hours were transplanted into sublethally irradiated nonobese diabetic/severe combined immunodeficient (NOD/SCID) mice to confirm their platelet‐releasing and tissue‐homing ability in vivo. A yield of ~ 2.5 × 10⁴ CD41a⁺/CD42b⁺ MKs with purity of ~ 80% was achieved from one original cord blood CD34⁺ cell. Compared with the static culture, the roller‐bottle culture system significantly enhanced megakaryopoiesis, as shown by the cell size, DNA ploidy, and megakaryopoiesis‐related gene expression. The optimal storage condition for the MKs was defined as normal saline with 10% human serum albumin at 22℃. Stored MKs were capable of rapidly producing functional platelets and largely distributing in the lungs of NOD/SCID mice. The novel development of efficient production and storage system for GMP‐grade MKs represents a significant step toward application of these MKs in the clinic.

Study Highlights

• WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC?

☑ Ex vivo (EV)‐derived megakaryocytes (MKs) potentially function as a substitute for donor‐platelets in clinical transfusion, but the poor yield and purity, insufficient production scale, and undefined short‐term storage conditions of the MKs limit their application.

• WHAT QUESTION DID THIS STUDY ADDRESS?

☑ This study aimed to develop a system for production of high‐yield and high‐purity MKs, and determine the optimal short‐term storage condition.

• WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE?

☑ This study developed a roller‐bottle culture system that can produce high‐yield and high‐purity MKs from small‐molecule/cytokine cocktail pre‐expanded hematopoietic stem cells. In addition, the optimal storage condition for the MKs was defined as normal saline with 10% human serum albumin at 22℃.

• HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE?

☑ To reduce the dependence on donor‐platelets, the development of efficient production and storage system for EV‐derived MKs represents a significant step toward application of these MKs in the clinic.

Platelet transfusion is the most important treatment option to increase the number of circulating platelets, thus alleviating uncontrolled bleeding in patients with hematological diseases or after radiotherapy, chemotherapy, or hematopoietic stem cell transplantation. ¹ , ² As the population is aging coupled with an increased number of patients with cancer, the demand for platelets in the clinic has risen drastically, leading to a severe shortage of platelet resources around the world. ³ , ⁴ Besides, there are some distinct disadvantages in donor‐derived platelets including the short‐life span, potential refractoriness to repeated transfusions, and a risk of potential viral or bacterial contaminations. Thus, it is imperative that alternative strategies need to be developed for obtaining donor‐independent platelets for clinical uses. ⁵ , ⁶ Ex vivo (EV) production of megakaryocytes (MKs) and platelets has been successfully achieved from various stem origins, including hematopoietic stem cells (HSCs), embryonic stem cells, and induced pluripotent stem cells, which raises a possibility of applying donor‐independent platelets in the clinic. ⁷ , ⁸ , ⁹ , ¹⁰ However, challenges remain regarding EV‐produced platelets, which include a low yield of production and lack of full functional capacity. Only 5–35 platelets are released from one MK on average in vitro, which is far less than the platelet output of MKs from adult bone marrow (BM) where a mature MK is capable of producing > 2,000 platelets. Besides, > 50% of EV‐produced platelets are CD41^‐ with a weak agonist response and compromised thrombin‐incorporated functions in vivo. In contrast, MKs can function not only as precursors of platelets but also as a direct substitute for platelet transfusion. ¹¹ , ¹² The research by Wang et al. demonstrated that platelets shed in vivo by EV‐derived MKs are very similar to donor‐derived platelets in terms of size distribution, circulating half‐life, and functionality in the mouse model. ¹³ Moreover, EV‐derived MKs have been successfully transfused into the human, thus demonstrating their safety. ¹¹ , ¹⁴ Despite the promise of EV‐produced MKs as a substitute for donor‐platelets in the clinic there are several challenges: first, HSCs usually need to expand before their differentiating into MKs. This expansion process is frequently done along with the nondirective differentiation, leading to a relatively low yield and purity of terminally differentiated MKs. ¹⁵ , ¹⁶ , ¹⁷ Second, to date, most production processes are carried out in a limited scale using culture dishes or flasks. Thus, it is necessary to develop a novel culture system that is suitable for a large‐scale production of MKs. Finally, EV‐produced MKs need to be preserved and stored, even for a short period of time, without a loss of functions before their usage in the clinic.We previously reported an optimal small‐molecule/cytokine cocktail (SMC) for HSC expansion via inhibition of differentiation. ¹⁸ After a 7‐day culture, HSCs achieved an ~ 28‐fold expansion with a purity of CD34⁺ cells > 85%. In this study, we reported the production of MKs from SMC‐expanded HSCs with a high yield and purity on a large scale based on Good Manufacturing Practice (GMP) standards. We also developed an optimal short‐term storage condition for EV‐produced MKs and verified their platelet‐releasing ability and tissue distribution in a mouse model.     

Clinical Evaluation of an Investigational 5 mL Wearable Injector in Healthy Human Subjects

An investigational wearable injector (WI), the BD Libertas Wearable Injector (BD Libertas is a trademark of Becton, Dickinson and Company), was evaluated in an early feasibility clinical study for functional performance, tissue effects, subject tolerability, and acceptability of 5 mL, non‐Newtonian ~ 8 cP subcutaneous placebo injections in 52 healthy adult subjects of 2 age groups (18–64 years and ≥ 65 years). Randomized WI subcutaneous injections (n = 208, 4/subject) were delivered to the right and left abdomen and thigh of each subject, 50% (1 thigh and 1 abdomen) with a defined movement sequence during injection. Injector functional performance was documented. Deposition was qualified and quantified with ultrasound. Tissue effects and tolerability (pain) were monitored through 24 hours with corresponding acceptability questionnaires administered through 72 hours. WI (n = 205) automatically inserted the needle, delivered 5 mL ± 5% in 5.42 minutes (SD 0.74) and retracted. Depots were entirely (93.2%) or predominantly (5.4%) localized within the target subcutaneous tissue. Slight to moderate wheals (63.9%) and erythema (75.1%) were observed with ≥ 50% resolution within 30–60 minutes. Subject pain (100 mm Visual Analog Scale) peaked mid‐injection (mean 9.1 mm, SD 13.4) and rapidly resolved within 30 minutes (mean 0.4 mm, SD 2.6). Subjects’ peak pain (≥ 90.2%), injection site appearance (≥ 92.2%) and injector wear, size, and removal (≥ 92.1%) were acceptable (Likert responses) with 100% likely to use the injector if prescribed. Injection site preference was divided between none (46%), abdomen (25%), or thigh (26.9%). The investigational WI successfully delivered 5 mL viscous subcutaneous injections. Tissue effects and pain were transient, well‐tolerated and acceptable. Neither injection site, movement or subject age affected injector functional performance or subject pain and acceptability.

Study Highlights

• WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC?

☑ Transitioning chronic disease therapies from intravenous infusion to large volume subcutaneous injection requires reliable and accurate delivery devices that may enable intuitive self or care‐giver administration. Limited options are commercially available.

• WHAT QUESTION DID THIS STUDY ADDRESS?

☑ An investigational wearable injector’s functionality and tolerability for 5 mL, ~ 8 cP subcutaneous placebo injections to the thigh and abdomen with and without movement in healthy adults of 2 age groups (18–64 years and ≥ 65 years) is described. Depot location, corresponding local tissue effects, and acceptability are documented.

• WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE?

☑ The investigational injector performed as designed, consistently delivering 5 mL ± 5% to the target subcutaneous tissue in ~ 5.5 minutes with transient, well‐tolerated tissue effects and pain. Neither injection site, movement or subject age affected injector functional performance or subject pain and acceptability.

• HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE?

☑ The investigational injector demonstrated equivalent functional performance with broad acceptability across subject genders, body mass index categories, and age range with and without movement. Results indicate promising potential of device design and delivery boundaries.

Chronic disease biological therapies are transitioning from traditional intravenous to subcutaneous administration. Adapting intravenous therapies to subcutaneous administration creates delivery challenges, such as larger than traditional volumes and viscosities. ¹ , ² , ³ , ⁴ , ⁵ , ⁶ Intuitive and reliable subcutaneous injection system design will help navigate the complexity of these new delivery challenges while ensuring patient ease of wear and use. Effective subcutaneous injection system design requires a strong understanding of the biomechanical and physiological impact to subcutaneous tissue of delivery at increased volumes and viscosities with corresponding subject tolerability and acceptability. ¹ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ Subcutaneous administration conveys many benefits, such as reduced cost and treatment time and increased patient autonomy, convenience, and tolerance/acceptance. ³ , ²¹ Multiple comparative studies report that both patients and health care providers (HCPs) prefer subcutaneous to intravenous administration, citing improved clinical management, efficiency, and convenience with decreased pain and adverse systemic effects. ¹² , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ Historically, literature has identified multiple thresholds for the subcutaneous bolus limit between 1.5 and 3 mL due to subject pain and tissue feasibility. ¹ , ² , ³ , ⁷ , ¹⁵ , ²⁶ Observation that injection volumes > 2 mL may create site wheals (surface tissue displacement) or induration (hardening of the soft tissue) likely contributed to the anticipated low tolerability of these injections despite the absence of relevant clinical evidence linking wheal formation or induration to pain. ² Multiple studies using pump‐driven injection systems as surrogates for functional subcutaneous injection devices document the feasibility and tolerability of 3 to 20 mL single subcutaneous bolus injections in human clinical subjects. ¹ , ¹⁰ , ¹² , ²⁷ , ²⁸ Subcutaneous administration is both feasible and convenient with the introduction of combination products, such as wearable or on‐body injectors, autoinjectors, and prefilled syringes that use fixed dosing to reduce dosing errors and enable patient choice in injection provider, device type, and setting. ² , ¹² Wearable injectors (WIs) complement and may exceed the volume and viscosity capacities currently available in prefilled syringes or autoinjectors; however, there are currently limited commercial on‐body or WI options available. ³ , ¹⁰ , ²⁹ The current study is a first‐in‐human clinical assessment of an investigational WI for functional performance and corresponding tissue effects, depot location, subject tolerability, and acceptability for 5 mL, ~ 8 cP injections of a viscous non‐Newtonian placebo, hyaluronic acid (HA) diluted in saline. The study included 52 healthy adult subjects of both genders and 2 age groups (18–64 years and ≥ 65 years). Each subject received four injections (2 abdominal and 2 thigh) with and without movement for each location. WI functional performance (injection duration, delivered volume, adherence, and status indicator) was documented from application through removal. Depot location was qualified and quantified via ultrasound. Site tissue effects (wheal and erythema) and subject pain tolerance (100 mm Visual Analog Scale, VAS) were monitored through 24 hours with corresponding acceptability documented via questionnaires through 72 hours postinjection.     

Fasting Status and Circadian Variation Must be Considered When Performing AUC‐based Therapeutic Drug Monitoring of Tacrolimus in Renal Transplant Recipients

Therapeutic drug monitoring (TDM) is mandatory for the immunosuppressive drug tacrolimus (Tac). For clinical applicability, TDM is performed using morning trough concentrations. With recent developments making tacrolimus concentration determination possible in capillary microsamples and Bayesian estimator predicted area under the concentration curve (AUC), AUC‐guided TDM may now be clinically applicable. Tac circadian variation has, however, been reported, with lower systemic exposure following the evening dose. The aim of the present study was to investigate tacrolimus pharmacokinetic (PK) after morning and evening administrations of twice‐daily tacrolimus in a real‐life setting without restrictions regarding food and concomitant drug timing. Two 12 hour tacrolimus investigations were performed; after the morning dose and the following evening dose, respectively, in 31 renal transplant recipients early after transplantation both in a fasting‐state and under real‐life nonfasting conditions (14 patients repeated the investigation). We observed circadian variation under fasting‐conditions: 45% higher peak‐concentration and 20% higher AUC following the morning dose. In the real‐life nonfasting setting, the PK‐profiles were flat but comparable after the morning and evening doses, showing slower absorption rate and lower AUC compared with the fasting‐state. Limited sampling strategies using concentrations at 0, 1, and 3 hours predicted AUC after fasting morning administration, and samples obtained at 1, 3, and 6 hours predicted AUC for the other conditions (evening and real‐life nonfasting). In conclusion, circadian variation of tacrolimus is present when performed in patients who are in the fasting‐state, whereas flatter PK‐profiles and no circadian variation was present in a real‐life, nonfasting setting.

Study Highlights

• WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC?

☑ Circadian variation of tacrolimus (Tac) is controversial. Most Tac population pharmacokinetic (PK) models are based on fasting‐day data.

• WHAT QUESTION DID THIS STUDY ADDRESS?

☑ It investigated circadian variation in Tac PK and the effect on Tac PK‐profiles when administered in a real‐life setting with regard to food and concomitant drug timing.

• WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE?

☑ In a real‐life nonfasting setting, the PK‐profiles were flat without circadian variation. The study supports circadian variation of Tac under fasting conditions. Data on the real‐world behavior of the patients are needed for a population PK model to predict area under the concentration curve (AUC) during both conditions.

• HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE?

☑ Proposed Tac AUC‐target levels need to be redefined due to circadian variation and flat real‐life nonfasting PK‐profiles. The association between high peak concentrations and side effects of Tac may be overestimated given the flat real‐life nonfasting PK‐profiles. The effect of real‐life dosing of Tac may very well be present for other drugs and should be investigated for drugs where TDM is indicated.

Following organ transplantation, there is a need for life‐long immunosuppressive therapy. For the last 10–15 years, the calcineurin inhibitor tacrolimus (Tac) has been the cornerstone in most transplant centers. ¹ The narrow therapeutic index and large pharmacokinetic (PK) interindividual and intra‐individual variability makes therapeutic drug monitoring (TDM) of Tac mandatory, ² and is normally performed using morning trough concentrations.When Tac was introduced in transplant protocols, importance of avoiding acute rejections led to TDM targeting high Tac trough concentrations. High concentrations induce nephrotoxicity and development of other side effects, like hypertension, post‐transplant diabetes mellitus, neurotoxicity, and cancer. ³ , ⁴ In combination with mycophenolate mofetil (MMF) and modern induction therapy, the recommended Tac trough concentration target has gradually been reduced. ⁵ , ⁶ There is still room for improving long‐term outcomes following renal transplantation, ⁷ , ⁸ and improved tailoring of the Tac dosing may be an important contributor. ⁹ The area under the concentration vs. time curve (AUC), reflecting total systemic Tac exposure, should theoretically be a more relevant measure for both efficacy and side effects compared with trough concentrations. ¹⁰ A recent consensus report also recommended AUC thresholds and advocates the need for prospective AUC‐dosed studies. ¹⁰ By utilizing limited sampling strategies (LSS), preferably by capillary microsampling, in combination with population PK model‐derived Bayesian estimators have made AUC‐targeted dosing of Tac applicable in clinical practice. ¹¹ , ¹² However, data used to develop most Tac population PK models are based on data from clinical trials. ¹³ , ¹⁴ Such data are generally obtained in selected patients under highly controlled conditions (i.e., fasting, without concomitant drugs at time of Tac dose administration); hence, these results may not reflect a real‐life situation of individual transplant recipients. In addition, the majority of AUC data are obtained during the day (i.e., following the morning dose of Tac). Because Tac has shown circadian variation, with higher drug exposure after the morning dose, ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ using models that assume a similar PK‐profile following the morning dose and evening dose will introduce biased Tac exposure 0–24‐hour AUC (AUC_0–24) predictions. In addition, Tac PK is also affected by food consumption. ¹⁹ If there is a correlation between systemic Tac exposure and long‐term outcomes, models reflecting the real‐life scenario over the entire dosing interval may prove advantageous.The primary aim of this study was to investigate Tac PK after the morning and evening administration of twice‐daily Tac in a real‐life setting with regard to food and concomitant drug timing. Second, we aimed to determine the predictive performance of Tac AUC predictions using LSS and Bayesian estimators from a nonparametric population PK model.     

YH12852, a Potent and Selective Receptor Agonist of 5‐hydroxytryptamine,Increased Gastrointestinal Motility in Healthy Volunteers and Patients With Functional Constipation

Gastrointestinal (GI) motility disorders are common, decreases quality of life, and imposes a substantial economic burden. YH12852 is a novel agonist of 5‐hydroxytryptamine for the treatment of GI motility disorders. This phase I/IIa study assessed the tolerability, pharmacodynamic (PD) and pharmacokinetic (PK) profiles of YH12852. In the multiple dose (MD) cohort, healthy subjects and patients with functional constipation were randomized and received orally YH12852 at 0.3, 0.5, 1, 2, or 3 mg or prucalopride 2 mg or their matching placebo, once daily for 14 days after breakfast. In the multiple low‐dose cohort (MLD), healthy subjects randomly received once‐daily oral doses of YH12852 at 0.05 or 0.1 mg for 14 days after breakfast. Questionnaires, gastric emptying breath test for PDs, and plasma samples for PKs were collected. In the MD cohort, a total of 56 subjects (29 healthy volunteers and 27 patients with functional constipation) were randomized, of whom 48 completed the study. In the MLD cohort, a total of 16 healthy subjects were randomized, and 15 subjects completed the study. YH12852 increased the average weekly frequency of spontaneous bowel movements and loosened the stool. In addition, YH12852 increased quality of life satisfaction, and decreased severity of constipation symptom and GI symptoms. YH12852 was safe and well‐tolerated up to 3 mg and showed nearly dose proportional PKs. In conclusion, YH12852 was safe and enhanced GI motility. YH12852 can be developed as an effective treatment option for GI motility disorders, including functional constipation. Further studies are warranted to confirm this possibility.

Study Highlights

• WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC?

☑ Five‐hydroxytryptamine (5‐HT) promotes gastrointestinal (GI) motility in the small and large intestines through the 5‐HT receptor such as 5‐HT₄ receptor. The 5‐HT receptor is considered an attractive drug target to treat patients with constipation. YH12852 is a novel and highly selective agonist of the 5‐HT₄ receptor.

• WHAT QUESTION DID THIS STUDY ADDRESS?

☑ This phase I/IIa study evaluated the tolerability, pharmacodynamic and pharmacokinetic profiles of YH12852 after multiple oral administration in healthy volunteers and patients with functional constipation.

• WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE?

☑ YH12852 was safe and well‐tolerated. Multiple oral administration of YH12852 enhanced GI motility. Oral YH12852 was absorbed fast, and its exposure increased in a dose‐proportional manner over 0.05–3 mg.

• HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE?

☑ YH12852 appeared to have a more potent prokinetic effect than other 5‐HT₄ receptor agonists, such as velusetrag, tegaserod, cisaprid, and prucalopride. YH12852 can be developed as an effective treatment for functional constipation.

Chronic constipation, irritable bowel syndrome, and functional dyspepsia are collectively referred to as gastrointestinal (GI) motility disorders. GI motility disorders are a common and debilitating disease that profoundly decreases quality of life and imposes a substantial economic burden. ¹ Traditional medications, including bulk forming laxatives, osmotic laxatives, and stool softeners, have been used to treat GI motility disorders. Although laxatives are effective, some patients could experience adverse drug reactions. ² Constipation is one of the most common GI motility disorders in Western countries. ³ The prevalence of constipation is higher in adults > 50 years of age than in younger adults of 18–35 years, and severe constipation is common in elderly women. ⁴ , ⁵ Current treatment strategies for constipation primarily aim to restore the normal neurogenic regulation of gut function. Five‐hydroxytryptamine (5‐HT) or serotonin, an important signaling molecule in the brain‐gut axis, plays an important role in promoting GI motility, such as peristalsis, in the small and large intestines. ⁶ , ⁷ , ⁸ Although endogenous 5‐HT is not essentially required for peristalsis or colonic migrating motor complexes, exogenous 5‐HT agonists potently increase GI motility. ⁹ , ¹⁰ , ¹¹ Five‐HT signaling is mediated through the 5‐HT receptor, of which 5‐HT₁, 5‐HT₂, 5‐HT₃, 5‐HT₄, and 5‐HT₇ subtypes are known to affect GI motility. ¹² , ¹³ Particularly, the 5‐HT₄ receptor subtype has been intensively studied in association with GI motility because it is distributed along the gut and plays a role in mediating peristalsis and mucosal secretion. Thus, the 5‐HT₄ receptor is an attractive drug target to treat constipation. ¹⁴ To support this notion, 5‐HT₄ receptor agonists, such as cisapride, tegaserod, and prucalopride, have been demonstrated to stimulate both whole gut transit and colonic transit, and were approved to treat patients with gastro‐esophageal reflux disease, dyspepsia, or constipation. ¹⁵ , ¹⁶ , ¹⁷ However, several 5‐HT₄ receptor agonists were withdrawn from the market due to cardiovascular concerns. For example, cisapride was withdrawn from the global market in 2000 after multiple reports of life‐threatening arrhythmias associated with prolonged corrected QT syndrome. ¹⁸ Likewise, tegaserod was withdrawn in 2007, although its relation with cardiovascular events remains inconclusive. ¹⁹ The limited selectivity of cisapride and tegaserod for the 5‐HT₄ receptor could have contributed to the cardiovascular adverse effects commonly seen in patients treated with them. ⁵ YH12852 is a novel, highly selective agonist of the 5‐HT₄ receptor. YH12852 has 84 times higher binding affinity for the 5‐HT₄ receptor than tegaserod. In the preclinical studies, YH12852 significantly improved motility in both upper and lower GI tracts, reduced visceral hypersensitivity, and showed an excellent safety profile. ²⁰ YH12852 was also approximately three times more potent than prucalopride for contractile activity in the distal colon of guinea pigs (mean half maximal effective concentration: 4.2 vs. 13 nM). ²⁰ , ²¹ Furthermore, all electrocardiogram (ECG) outputs were qualitatively and quantitatively normal in cynomolgus monkeys, which received a single oral dose of YH12852 up to at 60 mg/kg/day. YH12852 exhibited high selectivity for the human 5‐HT₄ receptors, whereas YH12852 had no significant affinity for other 5‐HT (5‐HT_1A, 5‐HT_1B, 5‐HT_2A, 5‐HT_2B, or 5‐HT₃) and non 5‐HT receptors or channels. Consistent with the very low affinity of YH12852 with the hERG channel, it had no meaningful effect on blood pressure, heart rate, or ECG, as measured in male cynomolgus monkeys using a telemetry system after single oral administration of YH12852 up to 60 mg/kg. Furthermore, no significant QT prolongation was observed in a previous human study (ClinicalTrials.gov Identifier: {"type":"clinical-trial","attrs":{"text":"NCT01870674","term_id":"NCT01870674"}}NCT01870674). These findings suggest that the clinical use of YH12852 would be associated with a low cardiac safety risk.The objective of this study was to evaluate the tolerability, pharmacodynamic (PD) and pharmacokinetic (PK) profiles of YH12852 after multiple oral administration in humans. To this end, we performed a phase I/IIa study in healthy volunteers and patients with functional constipation after multiple oral administrations of YH12852.