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Axitinib for the management of metastatic renal cell carcinoma.

Escudier B, Gore M - Drugs R D (2011)

Bottom Line: In addition, proton pump inhibitors reduce the rate of axitinib absorption.Increased axitinib exposure is associated with higher efficacy indicated by decreased tumor perfusion and volume.In the three studies, the most common adverse events reported were fatigue, hypertension, hand-foot syndrome (HFS), and gastrointestinal toxicity, which were generally manageable with standard medical intervention.

View Article: PubMed Central - PubMed

Affiliation: Institut Gustave Roussy, Villejuif, France. Bernard.Escudier@igr.fr

ABSTRACT
In recent years, targeted agents have changed the treatment landscape for patients with advanced renal cell carcinoma (RCC), greatly improving treatment outcomes. Several targeted agents are now licensed for the treatment of metastatic RCC (mRCC), and a number of new agents are under investigation. Axitinib, a small molecule indazole derivative is an oral, potent multitargeted tyrosine kinase receptor inhibitor, which selectively inhibits vascular endothelial growth factor receptors (VEGFR)-1, -2, and -3 at subnanomolar concentrations, in vitro. In various nonclinical models, axitinib has demonstrated in vivo target modulation and antiangiogenesis. In pharmacokinetic studies, axitinib administered orally with food at the proposed regimen of 5 mg twice daily continuous daily dosing, is rapidly absorbed, reaching peak concentrations within 2-6 hours. Axitinib is metabolized primarily in the liver via the cytochrome P450 (CYP) system with less than 1% of the administered drug passing unchanged in the urine. The pharmacokinetics of axitinib do not appear to be altered by coadministered chemotherapies, and antacids do not have a clinically significant effect. However, coadministration with CYP3A4 and 1A2 inducers is contraindicated. In addition, proton pump inhibitors reduce the rate of axitinib absorption. Increased axitinib exposure is associated with higher efficacy indicated by decreased tumor perfusion and volume. In three phase II clinical trials in patients with advanced RCC previously treated with cytokines, chemotherapy or targeted agents, axitinib has demonstrated antitumor activity with a favorable non-cumulative toxicity profile. In one study of Western patients with cytokine-refractory mRCC, an objective response rate (ORR) of 44.2% (95% CI 30.5, 58.7) was achieved. The median time to progression was 15.7 months (95% CI 8.4, 23.4) and the median overall survival (OS) was 29.9 months (95% CI 20.3, not estimable). In the second study of patients with sorafenib-refractory mRCC, ORR was 22.6% (95% CI 12.9, 35.0). The median progression-free survival (PFS) was 7.4 months (95% CI 6.7, 11.0) and a median OS of 13.6 months (95% CI 8.4, 18.8) was achieved. Results from the third study in Japanese patients with cytokine-refractory mRCC reported an ORR of 55% and median PFS of 12.9 months (95% CI 9.8, 15.6). In the three studies, the most common adverse events reported were fatigue, hypertension, hand-foot syndrome (HFS), and gastrointestinal toxicity, which were generally manageable with standard medical intervention. Of note, the incidence of HFS and proteinuria in the Japanese study was higher than that reported in the Western study in cytokine-refractory mRCC patients. An observed association between diastolic blood pressure ≥90 mmHg and increased efficacy suggests potential use as a prognostic biomarker. However, this requires further investigation. Two randomized phase III clinical trials are ongoing to determine the efficacy of axitinib in patients with mRCC in the first- and second-line setting. These results will help to determine the place of axitinib in the mRCC treatment algorithm.

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Tumor responses from phase II trials of axitinib in patients with metastatic renal cell carcinoma (mRCC). Each bar represents one patient. Maximum percentage reduction in tumor size of target lesions by Response Evaluation Criteria In Solid Tumors (RECIST).[-100% = complete response; -30% = partial response; n = 48]. Reproduced from (a) Rini et al.[57] and (b) Rixe et al.,[56] with permissionbid = twice daily; CR = complete response; PR = partial response.
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Fig4: Tumor responses from phase II trials of axitinib in patients with metastatic renal cell carcinoma (mRCC). Each bar represents one patient. Maximum percentage reduction in tumor size of target lesions by Response Evaluation Criteria In Solid Tumors (RECIST).[-100% = complete response; -30% = partial response; n = 48]. Reproduced from (a) Rini et al.[57] and (b) Rixe et al.,[56] with permissionbid = twice daily; CR = complete response; PR = partial response.

Mentions: In the first study, conducted in 52 patients with cytokine-refractory mRCC, patients received axitinib (administered as 5 mg twice daily) in the fasted state in 28-day treatment cycles until disease progression or unacceptable toxicity.[56,58] Results from this study demonstrated an ORR of 44.2% (23 patients; 95% CI 30.5, 58.7), as indicated by two complete responses (4%) and 21 partial responses (PR; 40%) based on the Response Evaluation Criteria In Solid Tumors (RECIST).[59] Additionally, 22 patients (42%) showed stable disease (SD) lasting for longer than 8 weeks, including 13 (25%) patients with SD for at least 24 weeks. The median duration of response was 23.0 months. The median time to progression was 15.7 months (95% CI 8.4, 23.4), and the median OS was 29.9 months (95% CI 20.3, not estimable). Maximum percentage decrease in target lesion size, based on RECIST is shown in figure 4a.


Axitinib for the management of metastatic renal cell carcinoma.

Escudier B, Gore M - Drugs R D (2011)

Tumor responses from phase II trials of axitinib in patients with metastatic renal cell carcinoma (mRCC). Each bar represents one patient. Maximum percentage reduction in tumor size of target lesions by Response Evaluation Criteria In Solid Tumors (RECIST).[-100% = complete response; -30% = partial response; n = 48]. Reproduced from (a) Rini et al.[57] and (b) Rixe et al.,[56] with permissionbid = twice daily; CR = complete response; PR = partial response.
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Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3585900&req=5

Fig4: Tumor responses from phase II trials of axitinib in patients with metastatic renal cell carcinoma (mRCC). Each bar represents one patient. Maximum percentage reduction in tumor size of target lesions by Response Evaluation Criteria In Solid Tumors (RECIST).[-100% = complete response; -30% = partial response; n = 48]. Reproduced from (a) Rini et al.[57] and (b) Rixe et al.,[56] with permissionbid = twice daily; CR = complete response; PR = partial response.
Mentions: In the first study, conducted in 52 patients with cytokine-refractory mRCC, patients received axitinib (administered as 5 mg twice daily) in the fasted state in 28-day treatment cycles until disease progression or unacceptable toxicity.[56,58] Results from this study demonstrated an ORR of 44.2% (23 patients; 95% CI 30.5, 58.7), as indicated by two complete responses (4%) and 21 partial responses (PR; 40%) based on the Response Evaluation Criteria In Solid Tumors (RECIST).[59] Additionally, 22 patients (42%) showed stable disease (SD) lasting for longer than 8 weeks, including 13 (25%) patients with SD for at least 24 weeks. The median duration of response was 23.0 months. The median time to progression was 15.7 months (95% CI 8.4, 23.4), and the median OS was 29.9 months (95% CI 20.3, not estimable). Maximum percentage decrease in target lesion size, based on RECIST is shown in figure 4a.

Bottom Line: In addition, proton pump inhibitors reduce the rate of axitinib absorption.Increased axitinib exposure is associated with higher efficacy indicated by decreased tumor perfusion and volume.In the three studies, the most common adverse events reported were fatigue, hypertension, hand-foot syndrome (HFS), and gastrointestinal toxicity, which were generally manageable with standard medical intervention.

View Article: PubMed Central - PubMed

Affiliation: Institut Gustave Roussy, Villejuif, France. Bernard.Escudier@igr.fr

ABSTRACT
In recent years, targeted agents have changed the treatment landscape for patients with advanced renal cell carcinoma (RCC), greatly improving treatment outcomes. Several targeted agents are now licensed for the treatment of metastatic RCC (mRCC), and a number of new agents are under investigation. Axitinib, a small molecule indazole derivative is an oral, potent multitargeted tyrosine kinase receptor inhibitor, which selectively inhibits vascular endothelial growth factor receptors (VEGFR)-1, -2, and -3 at subnanomolar concentrations, in vitro. In various nonclinical models, axitinib has demonstrated in vivo target modulation and antiangiogenesis. In pharmacokinetic studies, axitinib administered orally with food at the proposed regimen of 5 mg twice daily continuous daily dosing, is rapidly absorbed, reaching peak concentrations within 2-6 hours. Axitinib is metabolized primarily in the liver via the cytochrome P450 (CYP) system with less than 1% of the administered drug passing unchanged in the urine. The pharmacokinetics of axitinib do not appear to be altered by coadministered chemotherapies, and antacids do not have a clinically significant effect. However, coadministration with CYP3A4 and 1A2 inducers is contraindicated. In addition, proton pump inhibitors reduce the rate of axitinib absorption. Increased axitinib exposure is associated with higher efficacy indicated by decreased tumor perfusion and volume. In three phase II clinical trials in patients with advanced RCC previously treated with cytokines, chemotherapy or targeted agents, axitinib has demonstrated antitumor activity with a favorable non-cumulative toxicity profile. In one study of Western patients with cytokine-refractory mRCC, an objective response rate (ORR) of 44.2% (95% CI 30.5, 58.7) was achieved. The median time to progression was 15.7 months (95% CI 8.4, 23.4) and the median overall survival (OS) was 29.9 months (95% CI 20.3, not estimable). In the second study of patients with sorafenib-refractory mRCC, ORR was 22.6% (95% CI 12.9, 35.0). The median progression-free survival (PFS) was 7.4 months (95% CI 6.7, 11.0) and a median OS of 13.6 months (95% CI 8.4, 18.8) was achieved. Results from the third study in Japanese patients with cytokine-refractory mRCC reported an ORR of 55% and median PFS of 12.9 months (95% CI 9.8, 15.6). In the three studies, the most common adverse events reported were fatigue, hypertension, hand-foot syndrome (HFS), and gastrointestinal toxicity, which were generally manageable with standard medical intervention. Of note, the incidence of HFS and proteinuria in the Japanese study was higher than that reported in the Western study in cytokine-refractory mRCC patients. An observed association between diastolic blood pressure ≥90 mmHg and increased efficacy suggests potential use as a prognostic biomarker. However, this requires further investigation. Two randomized phase III clinical trials are ongoing to determine the efficacy of axitinib in patients with mRCC in the first- and second-line setting. These results will help to determine the place of axitinib in the mRCC treatment algorithm.

Show MeSH
Related in: MedlinePlus