Inhibitory Brutonovy kinázy (BTKi) jsou první skupinou cílených léčiv, která výrazně zlepšila prognózu i kvalitu života nemocných s chronickou lymfocytární leukemií (CLL). Specifické nežádoucí účinky BTKi, zejména kardiovaskulární (KV) a krvácivé, však mohou limitovat jejich dlouhodobé užívání. Ibrutinib, BTKi první generace, byl pro nežádoucí účinky přerušen až u 26 % pacientů léčených v rámci klinických studií. I z těchto důvodů pokračují snahy o vývoj dalších generací BTKi, které by měly bezpečnější profil při zachovaném protinádorovém účinku. Patří mezi ně kovalentně se vázající BTKi akalabrutinib a zanubrutinib a reverzibilní, nekovalentní BTK inhibitory pirtobrutinib a nemtabrutinib. V České republice je v současnosti z veřejného zdravotního pojištění hrazen akalabrutinib. V rámci prevence KV komplikací je zásadní stanovení KV rizika u konkrétního pacienta; pro tyto potřeby lze využít jednoduché skórovací systémy typu Framinghamského skóre nebo tabulky SCORE. U nemocných s vysokým KV rizikem je doporučována léčba BTKi 2. generace nebo léky ze skupiny bcl-2 inhibitorů, případně inhibitorů fosfatidylinositol-3-kinázy. Pokud dojde k rozvoji fibrilace síní nebo srdečního selhání, je nezbytná spolupráce s kardiologem. Riziko závažného krvácení je, na rozdíl od KV komplikací, podobné u obou dostupných preparátů (2–9 % u ibrutinibu vs. 2–5 % u akalabrutinibu). V prevenci klinicky manifestního krvácení je zásadní přerušení léčby BTKi s dostatečným předstihem před každým invazivním výkonem a znovuzahájení terapie až ve chvíli, kdy je riziko krvácení již minimální. Důležitým faktorem pro snížení rizika rozvoje jakékoli komplikace je znalost stávající medikace pacienta a potenciálních lékových interakcí s BTKi. Tato práce shrnuje mechanizmus vniku kardiovaskulárních a krvácivých komplikací, jejich incidenci ve vybraných klinických studiích a doporučení pro prevenci a léčbu těchto nežádoucích účinků v běžné klinické praxi.
Bruton’s tyrosine kinase (BTK) inhibitors have altered the treatment landscape of chronic lymphocytic leukaemia (CLL). These highly eff ective drugs improve not only the prognosis but also the quality of life of CLL patients. Long-term BTK inhibitor treatment can be limited by specifi c adverse events (AEs) such as cardiovascular (CV) complications or bleeding. Ibrutinib, the fi rst-in-class BTK inhibitor, was discontinued in up to 26% of patients in clinical trials due to AEs. Therefore, there are continuing eff orts to develop BTK inhibitors with the same eff ectivity but better safety profi le, such as covalent BTKi acalabrutinib and zanubrutinib and non-covalent BTKi pirtobrutinib and nemtabrutinib. The pre-treatment workup for all patients should include CV risk level assessment using scoring systems, e. g., Framingham risk score or SCORE. In patients with high CV risk levels, next-generation BTK inhibitors or other targeted drugs (venetoclax or idelalisib) are generally preferred over ibrutinib. Patients who experience CV toxicity, particularly atrial fi brillation or heart failure, should be consulted with a cardiologist to defi ne the best treatment algorithm. In contrast to CV toxicity, the risk of major bleeding events is equal for both ibrutinib and acalabrutinib (2–9% vs. 2–5%) based on data from clinical trials. Regarding prevention of bleeding events, BTK inhibitor treatment should be appropriately held prior to any invasive procedure and cannot be restarted until the risk of bleeding is minimal. Good knowledge of the patient’s current medication and potential interactions is crucial in the prevention of any adverse event. This review describes the mechanisms of pathogenesis of cardiovascular complications and bleeding in BTK inhibitor-treated patients. It summarises their incidence in selected clinical trials and provides recommendations for managing these AEs in clinical practice.
- MeSH
- chronická lymfatická leukemie * farmakoterapie komplikace MeSH
- fibrilace síní chemicky indukované prevence a kontrola MeSH
- hypertenze chemicky indukované farmakoterapie prevence a kontrola MeSH
- krvácení * chemicky indukované farmakoterapie prevence a kontrola MeSH
- lidé MeSH
- nežádoucí účinky léčiv MeSH
- proteinkinasa BTK antagonisté a inhibitory škodlivé účinky terapeutické užití MeSH
- srdeční selhání chemicky indukované prevence a kontrola MeSH
- Check Tag
- lidé MeSH
- MeSH
- chronická lymfatická leukemie * farmakoterapie MeSH
- lidé MeSH
- proteinkinasa BTK MeSH
- pyrimidiny terapeutické užití MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- komentáře MeSH
- úvodníky MeSH
BACKGROUND: Rilzabrutinib, an oral, reversible covalent inhibitor of Bruton's tyrosine kinase, may increase platelet counts in patients with immune thrombocytopenia by means of dual mechanisms of action: decreased macrophage (Fcγ receptor)-mediated platelet destruction and reduced production of pathogenic autoantibodies. METHODS: In an international, adaptive, open-label, dose-finding, phase 1-2 clinical trial, we evaluated rilzabrutinib therapy in previously treated patients with immune thrombocytopenia. We used intrapatient dose escalation of oral rilzabrutinib over a period of 24 weeks; the lowest starting dose was 200 mg once daily, with higher starting doses of 400 mg once daily, 300 mg twice daily, and 400 mg twice daily. The primary end points were safety and platelet response (defined as at least two consecutive platelet counts of ≥50×103 per cubic millimeter and an increase from baseline of ≥20×103 per cubic millimeter without the use of rescue medication). RESULTS: Sixty patients were enrolled. At baseline, the median platelet count was 15×103 per cubic millimeter, the median duration of disease was 6.3 years, and patients had received a median of four different immune thrombocytopenia therapies previously. All the treatment-related adverse events were of grade 1 or 2 and transient. There were no treatment-related bleeding or thrombotic events of grade 2 or higher. At a median of 167.5 days (range, 4 to 293) of treatment, 24 of 60 patients (40%) overall and 18 of the 45 patients (40%) who had started rilzabrutinib treatment at the highest dose met the primary end point of platelet response. The median time to the first platelet count of at least 50×103 per cubic millimeter was 11.5 days. Among patients with a primary platelet response, the mean percentage of weeks with a platelet count of at least 50×103 per cubic millimeter was 65%. CONCLUSIONS: Rilzabrutinib was active and associated with only low-level toxic effects at all dose levels. The dose of 400 mg twice daily was identified as the dose for further testing. Overall, rilzabrutinib showed a rapid and durable clinical activity that improved with length of treatment. (Funded by Sanofi; ClinicalTrials.gov number, NCT03395210; EudraCT number, 2017-004012-19.).
- MeSH
- aplikace orální MeSH
- idiopatická trombocytopenická purpura * farmakoterapie MeSH
- inhibitory proteinkinas * aplikace a dávkování škodlivé účinky terapeutické užití MeSH
- lidé MeSH
- počet trombocytů MeSH
- proteinkinasa BTK antagonisté a inhibitory MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- klinické zkoušky, fáze I MeSH
- klinické zkoušky, fáze II MeSH
Bcr-Abl and Btk kinases are among the targets that have been considered for the treatment of leukemia. Therefore, several strategies have focused on the use of inhibitors as chemotherapeutic tools to treat these types of leukemia, such as imatinib (for Bcr-Abl) or ibrutinib (for Btk). However, the efficacy of these drugs has been reduced due to resistance mechanisms, which have motivated the development of new and more effective compounds. In this study, we designed, synthesized and evaluated 2,6,9-trisubstituted purine derivatives as novel Bcr-Abl and Btk inhibitors. We identified 5c and 5d as potent inhibitors of both kinases (IC50 values of 40 nM and 0.58/0.66 μM for Abl and Btk, respectively). From docking and QSAR analyses, we concluded that fluorination of the arylpiperazine system is detrimental to the activity against two kinases, and we also validated our hypothesis that the substitution on the 6-phenylamino ring is important for the inhibition of both kinases. In addition, our studies indicated that most compounds could suppress the proliferation of leukemia and lymphoma cells (HL60, MV4-11, CEM, K562 and Ramos cells) at low micromolar concentrations in vitro. Finally, we preliminarily demonstrated that 5c inhibited the downstream signaling of both kinases in the respective cell models. Therefore, 5c or 5d possessed potency to be further optimized as anti-leukemia drugs by simultaneously inhibiting the Bcr-Abl and Btk kinases.
- MeSH
- antitumorózní látky chemie farmakologie MeSH
- bcr-abl fúzové proteiny antagonisté a inhibitory MeSH
- buňky K562 MeSH
- kvantitativní vztahy mezi strukturou a aktivitou MeSH
- leukemie patologie prevence a kontrola MeSH
- lidé MeSH
- proteinkinasa BTK antagonisté a inhibitory MeSH
- puriny chemie farmakologie MeSH
- signální transdukce účinky léků MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
Better understanding of GBM signalling networks in-vivo would help develop more physiologically relevant ex vivo models to support therapeutic discovery. A "functional proteomics" screen was undertaken to measure the specific activity of a set of protein kinases in a two-step cell-free biochemical assay to define dominant kinase activities to identify potentially novel drug targets that may have been overlooked in studies interrogating GBM-derived cell lines. A dominant kinase activity derived from the tumour tissue, but not patient-derived GBM stem-like cell lines, was Bruton tyrosine kinase (BTK). We demonstrate that BTK is expressed in more than one cell type within GBM tissue; SOX2-positive cells, CD163-positive cells, CD68-positive cells, and an unidentified cell population which is SOX2-negative CD163-negative and/or CD68-negative. The data provide a strategy to better mimic GBM tissue ex vivo by reconstituting more physiologically heterogeneous cell co-culture models including BTK-positive/negative cancer and immune cells. These data also have implications for the design and/or interpretation of emerging clinical trials using BTK inhibitors because BTK expression within GBM tissue was linked to longer patient survival.
- MeSH
- glioblastom enzymologie mortalita patologie MeSH
- kokultivační techniky metody MeSH
- lidé MeSH
- míra přežití MeSH
- nádorové buněčné linie MeSH
- nádorové kmenové buňky enzymologie MeSH
- nádory mozku enzymologie mortalita patologie MeSH
- proteinkinasa BTK metabolismus MeSH
- proteom metabolismus MeSH
- proteomika metody MeSH
- signální transdukce * MeSH
- transkripční faktory SOXB1 metabolismus MeSH
- viabilita buněk MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
- Klíčová slova
- ibrutinib, Imbruvica,
- MeSH
- aplikace orální MeSH
- chronická lymfatická leukemie * farmakoterapie MeSH
- lidé MeSH
- lymfom z plášťových buněk * farmakoterapie MeSH
- pyrazoly terapeutické užití MeSH
- pyrimidiny terapeutické užití MeSH
- tyrosinkinasy * antagonisté a inhibitory MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- novinové články MeSH
AIM: Primary immunodeficiencies (PID) are becoming a recognized public health problem worldwide. The most important subgroup of these disorders are the antibody deficiencies. X-linked agammaglobulinaemia was the first described entity of this group and is characterised by early onset of recurrent bacterial infections, profound deficiency of all immunoglobulin isotypes and markedly reduced number of peripheral B-lymphocytes. CASE REPORT: We report the case of a 10-year old boy with X-linked agammaglobulinaemia caused by a previously non-described mutation in BTK gene with typical clinical presentation but delayed diagnosis. Following diagnosis, substitution therapy with intravenous immunoglobulins was started and the clinical status of the patient improved. CONCLUSION: We reported a case of X-linked agammaglobulinaemia with delayed diagnosis despite the typical anamnestic signs for primary humoral immunodeficiency. The disease was caused by a previously non-reported mutation in the BTK gene. Measurement of serum immunoglobulins should be performed in all children with recurrent, complicated respiratory infections as a screening test for humoral immunodeficiencies.
- MeSH
- agamaglobulinemie farmakoterapie genetika MeSH
- dítě MeSH
- genetické nemoci vázané na chromozom X farmakoterapie genetika MeSH
- intravenózní imunoglobuliny terapeutické užití MeSH
- lidé MeSH
- mutace * MeSH
- tyrosinkinasy genetika MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- mužské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- kazuistiky MeSH
- Klíčová slova
- zanubrutinib,
- MeSH
- chronická lymfatická leukemie * MeSH
- inhibitory tyrosinkinasy farmakologie terapeutické užití MeSH
- lidé MeSH
- piperidiny farmakologie terapeutické užití MeSH
- protokoly antitumorózní kombinované chemoterapie MeSH
- pyrazoly farmakologie terapeutické užití MeSH
- pyrimidiny farmakologie terapeutické užití MeSH
- randomizované kontrolované studie jako téma MeSH
- Check Tag
- lidé MeSH
X-linked agammaglobulinemia (XLA) is characterized by low levels of B-lymphocytes with early-onset, recurrent, microbial infections occasionally causing neurological symptoms. We observed an atypical clinical course of XLA, complicated since early childhood with neurological impairment, progressive sensorineural deafness, and dystonia in six boys of four unrelated families. The neurologic symptoms suggested the diagnosis of Mohr-Tranebjaerg syndrome, caused by mutations in the TIMM8A gene, previously known as DDP1, and located centromerically of BTK. Deafness dystonia peptide (DDP1) participates in neurological development and is a part of the mitochondrial protein import pathway. Mutation analysis of the BTK gene revealed gross deletions of different lengths in all patients, in one case extending approximately 196 kb, including the genes TIMM8A, TAF7L, and DRP2. The most prominent clinical findings of this contiguous deletion syndrome are the combination of immunodeficiency and sensorineural deafness, which were present in all affected boys. The severity of symptoms, however, did not correlate with the extent of the deletion.
- MeSH
- agamaglobulinemie genetika MeSH
- chromozomální delece MeSH
- diferenciální diagnóza MeSH
- dítě MeSH
- dospělí MeSH
- faktory asociované s proteinem vázajícím TATA box genetika MeSH
- genetické nemoci vázané na chromozom X genetika MeSH
- kohortové studie MeSH
- kojenec MeSH
- lidé MeSH
- lidské chromozomy X genetika MeSH
- mapování chromozomů MeSH
- membránové transportní proteiny genetika MeSH
- mezibuněčné signální peptidy a proteiny genetika MeSH
- mladiství MeSH
- proteiny nervové tkáně genetika MeSH
- RNA-polymerasa II MeSH
- transkripční faktor TFIID genetika MeSH
- tyrosinkinasy genetika MeSH
- Check Tag
- dítě MeSH
- dospělí MeSH
- kojenec MeSH
- lidé MeSH
- mladiství MeSH
- mužské pohlaví MeSH
- Publikační typ
- kazuistiky MeSH
- práce podpořená grantem MeSH
