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US20180235935A1 - Treatment of Cancer with Enzalutamide and a CYP3A4 Inhibitor - Google Patents

Treatment of Cancer with Enzalutamide and a CYP3A4 Inhibitor Download PDF

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US20180235935A1
US20180235935A1 US15/751,542 US201615751542A US2018235935A1 US 20180235935 A1 US20180235935 A1 US 20180235935A1 US 201615751542 A US201615751542 A US 201615751542A US 2018235935 A1 US2018235935 A1 US 2018235935A1
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enzalutamide
rifampin
max
auc
mean
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Jacqueline GIBBONS
Joyce MORDENTI
Michiel DE VRIES
Walter KRAUWINKEL
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Astellas Pharma Inc
Medivation Prostate Therapeutics LLC
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/41—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with two or more ring hetero atoms, at least one of which being nitrogen, e.g. tetrazole
    • A61K31/4164—1,3-Diazoles
    • A61K31/4166—1,3-Diazoles having oxo groups directly attached to the heterocyclic ring, e.g. phenytoin
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
    • A61K31/438—The ring being spiro-condensed with carbocyclic or heterocyclic ring systems
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
    • A61K31/496—Non-condensed piperazines containing further heterocyclic rings, e.g. rifampin, thiothixene or sparfloxacin
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
    • A61K31/505—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim
    • A61K31/513—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim having oxo groups directly attached to the heterocyclic ring, e.g. cytosine
    • A61K31/515—Barbituric acids; Derivatives thereof, e.g. sodium pentobarbital
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
    • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P35/00—Antineoplastic agents
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K2300/00—Mixtures or combinations of active ingredients, wherein at least one active ingredient is fully defined in groups A61K31/00 - A61K41/00
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/55—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having seven-membered rings, e.g. azelastine, pentylenetetrazole

Definitions

  • This disclosure relates generally to cancer treatment.
  • FIG. 1 shows the effects of rifampin (as well as other drugs and intrinsic/extrinsic factors) on the pharmacokinetic parameters C max and AUC 0-inf for enzalutamide and its major active metabolite N-desmethyl enzalutamide.
  • FIGS. 2A-B Graphs showing mean plasma enzalutamide concentrations after a single dose of 160 mg enzalutamide alone or in the presence of multiple doses of 600 mg rifampin once daily.
  • the vertical line at 336 h signifies the end of rifampin treatment.
  • FIG. 2A linear.
  • FIG. 2B semi-log scale plot.
  • FIGS. 3A-B Graphs showing mean plasma M1 concentrations after a single dose of 160 mg enzalutamide alone or in the presence of multiple doses of 600 mg rifampin once daily.
  • the vertical line at 336 h signifies the end of rifampin treatment.
  • FIG. 3A linear.
  • FIG. 3B semi-log scale plot.
  • FIGS. 4A-B Graphs showing mean plasma M2 concentrations after a single dose of 160 mg enzalutamide alone or in the presence of multiple doses of 600 mg rifampin once daily.
  • the vertical line at 336 h signifies the end of rifampin treatment.
  • FIG. 4A linear.
  • FIG. 4B semi-log scale plot.
  • FIGS. 5A-B Graphs showing mean plasma sum of enzalutamide plus M2 concentrations after a single dose of 160 mg enzalutamide alone or in the presence of multiple doses of 600 mg rifampin once daily.
  • the vertical line at 336 h signifies the end of rifampin treatment.
  • FIG. 5A linear.
  • FIG. 5B semi-log scale plot.
  • FIG. 6 Graph showing mean plasma concentration-time curve of rifampin on day 8 after multiple doses of 600 mg rifampin once daily.
  • FIG. 7 Graph showing mean and individual C 2h plasma concentrations of rifampin during multiple doses of 600 mg rifampin once daily for 21 days.
  • Enzalutamide 4- ⁇ 3-[4-cyano-3-(trifluoromethyl)phenyl]-5,5-dimethyl-4-oxo-2-sulfanylideneimidazolidin-1-yl ⁇ -2-fluoro-N-methylbenzamide (e.g., XTANDI®), is an androgen receptor inhibitor and can be used to treat cancers such as prostate cancers, breast cancers, and ovarian cancers.
  • Enzalutamide is also a strong CYP3A4 inducer in humans; at steady state, enzalutamide reduces the plasma exposure to the CYP3A4 substrate midazolam.
  • enzalutamide with a strong CYP3A4 inducer (e.g., carbamazepine, phenobarbital, phenytoin, rifabutin, rifampin, rifapentine) are nevertheless desirable or cannot be avoided.
  • a strong CYP3A4 inducer e.g., carbamazepine, phenobarbital, phenytoin, rifabutin, rifampin, rifapentine
  • a strong CYP3A4 inducer was administered alone or after multiple oral doses of rifampin (strong CYP3A4 and moderate CYP2C8 inducer).
  • the daily dose of enzalutamide may be increased from, e.g., 160 mg/day to 200-300 mg/day (e.g., 200, 205, 210, 215, 220, 225, 230, 235, 240, 245, 250, 255, 260, 265, 270, 275, 280, 285, 290, 295, 300 mg/day).
  • a strong CYP3A4 inducer e.g., carbamazepine, phenobarbital, phenytoin, rifabutin, rifampin, rifapentine
  • the daily dose of enzalutamide may be increased from, e.g., 160 mg/day to 200-300 mg/day (e.g., 200, 205, 210, 215, 220, 225, 230, 235, 240, 245, 250, 255, 260, 265, 270, 275, 280, 285, 290, 295, 300 mg/day).
  • Co-administration of enzalutamide and a strong CYP3A4 inhibitor means administration in any manner in which the pharmacological effects of enzalutamide and the strong CYP3A4 inhibitor overlap in the patient at the same time. Co-administration does not require that both agents be administered in a single pharmaceutical composition, in the same dosage form, by the same route of administration, or for the same length of time.
  • Enzalutamide is typically formulated for oral administration.
  • Formulations of enzalutamide are disclosed, e.g., in the prescribing information for XTANDI®, and in US 2014/0378517, US 2014/0179749, and US 2014/0100256.
  • Patients who can be treated with the disclosed co-administration regimes include patients with prostate cancer (including metastatic prostate cancer, castration-resistant prostate cancer, hormone-sensitive prostate cancer, metastatic castration-resistant prostate cancer, metastatic hormone-sensitive prostate cancer), breast cancer (including triple-negative breast cancer), and ovarian cancer.
  • Prostate cancer patients who can be treated using the disclosed co-administration regimes include patients with metastatic castration-resistant prostate cancer (CRPC) who had previously received chemotherapy (e.g., docetaxel) as well as patients with CRPC who are chemotherapy-na ⁇ ve.
  • CRPC metastatic castration-resistant prostate cancer
  • FIG. 2 Mean enzalutamide plasma concentrations versus time profiles (linear and semi-logarithmic) are presented in FIG. 2 . Summary statistics of enzalutamide pharmacokinetic parameters are shown in Table 1. In Table 2., the statistical assessments of the effect of rifampin on enzalutamide after a single dose of enzalutamide are presented.
  • enzalutamide AUC 0-336hr and AUC inf were 63% (geometric mean ratio [GMR]:36.79; 90% CI: 33.36-40.57) and 66% (GMR: 33.76 (90% CI: 30.31-37.60) lower, respectively, compared to enzalutamide alone.
  • C max was not significantly changed (GMR: 93.03; 90% CI: 83.67-103.45), and similar mean tam values were observed (i.e., 1.039 hours versus 1.078 hours), with the comparable ranges of individual values.
  • AUC inf and C max were low and was not influenced by the presence of rifampin, with values ranging between 13.2% and 1.9.4%.
  • M1 AUC 0-336hr and AUC inf were 15% (GMR: 84,94; 90% CI: 69.07-104.46) and 32% (GMR: 67.53; 90% CI: 44.56-102.33) lower, respectively compared to enzalutamide alone.
  • the 90% CI of the GMRs for both parameters were wide. It should be noted that AUC inf could only be accurately determined for 4 subjects in the enzalutamide treatment arm (treatment arm 1) and 6 subjects in the enzalutamide+rifampin treatment arm (treatment arm 2). For AUC inf values for which the percentage extrapolated (% AUC) were higher than 20%, the AUC inf was excluded from the statistical analysis. Mean M1 t 1/2 was somewhat shorter in the presence of rifampin (194.5 hours) compared to enzalutamide alone (223.9 hours).
  • M1 MPRs molecular weight corrected and based on AUC inf , were higher in the presence of rifampin compared to enzalutamide alone, with mean values of 0.4897 (range: 0.210 to 0.809) and 0.2165 (range: 0.152 to 0.314), respectively.
  • M2 AUC 0-336h was 15% higher (GMR: 114.8; 90% CI: 103.49-127.34), while AUC inf was 15% lower (GMR: 84.74 (90% CI: 77.13-93.11) compared to enzalutamide alone. % AUC was low and ranged between 1.25% and 5.79%. Mean M2 t 1/2 was somewhat shorter in the presence of rifampin (154.7 hours) compared to enzalutamide alone (190.4 h). M2 C max was 34% higher (GMR: 133.7; 90% CI: 118.63-150.76), and median t max was reached earlier (i.e., 71.86 hours versus 167.7 hours).
  • M2 MPR molecular weight corrected and based on AUC inf , was higher in the presence of rifampin compared to enzalutamide alone, with mean values of 3.443 (range: 2.71 to 4.33) and 1.385 (range: 1.04 to 2.08), respectively.
  • C max was comparable between treatments (CMR.: 94.32; 90% CI: 85.05-104.60), and similar mean t max values were observed (i.e., 1.039 hours versus 1.078 hours) with the same ranges of individual values.
  • AUC inf and C max was low and was not influenced by presence of rifampin, with values ranging between 9.7% and 16.4%.
  • FIG. 6 Mean rifampin plasma concentrations versus time profile during 1 dosing interval on day 8 is presented in FIG. 6 .
  • FIG. 7 individual and mean rifampin C2h plasma concentrations that were obtained during the entire dosing period of 21 days are presented. Summary statistics of rifampin pharmacokinetic parameters are shown in Table 9.
  • Enzalutamide AUC inf was 66% lower (GMR 33,76; 90% CI: 30.31-37.60) compared to enzalutamide alone, while C max was comparable (GMR: 93.03; 90% CI: 83.67-103.45).
  • Mean t max values were similar (i.e., 1.039 hours versus 1.078 hours with comparable ranges of individual values.
  • M1 AUC 0-336hr and AUC inf were 15% (GMR: 84.94; 90% CI: 69.07-104.46) and 32% (GMR: 67.53; 90% CI: 44.56-102.33) lower, respectively, while appeared to he similar (GMR: 96.56; 90% CI: 77.68-120.02) however, median M1 t max was reached earlier (i.e., 58.21 hours versus 109.6 hours).
  • M2 AUC inf was 15% lower (GMR: 84.74; 90% CI: 77.13-93.10, while M2 C max was 34% higher (GMR: 133.7; 90% CI: 118.63-150.76). Median M2 t max was reached earlier (i.e., 71.86 hours versus 167.7 hours).
  • Rifampin C 2h concentrations indicated that steady-state rifampin exposure was achieved prior to and maintained after administration of enzalutamide on day 8.
  • the urinary 6 ⁇ -hydroxycortisollcortisol ratio increased from a baseline mean value of 6.9 ⁇ 4.2 on day 1 to 24.2 ⁇ 22.1 on day 8 (the day of enzalutamide administration), From day 8 to day 22 (the end of rifampin administration), mean ratios were variable and ranged between 19.12. and 29.38, returning to baseline(i.e., 6.4 ⁇ 3.2) by day 36.

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Abstract

This disclosure provides a dosage regimen for co-administration of enzalutamide and a strong CYP3A4 inducer in the treatment of cancer.

Description

  • This application claims priority to and incorporates by reference U.S. provisional application Ser. No. 62/204,281, filed on Aug. 12, 2015, and U.S. provisional application Ser. No. 62/204,954 filed on Aug. 13, 2015.
  • Each reference cited in this disclosure is incorporated herein in its entirety.
    • TECHNICAL FIELD
  • This disclosure relates generally to cancer treatment.
    • BRIEF DESCRIPTION OF THE DRAWINGS
  • FIG. 1 shows the effects of rifampin (as well as other drugs and intrinsic/extrinsic factors) on the pharmacokinetic parameters Cmax and AUC0-inf for enzalutamide and its major active metabolite N-desmethyl enzalutamide.
  • FIGS. 2A-B. Graphs showing mean plasma enzalutamide concentrations after a single dose of 160 mg enzalutamide alone or in the presence of multiple doses of 600 mg rifampin once daily. The vertical line at 336 h signifies the end of rifampin treatment. FIG. 2A, linear. FIG. 2B, semi-log scale plot.
  • FIGS. 3A-B, Graphs showing mean plasma M1 concentrations after a single dose of 160 mg enzalutamide alone or in the presence of multiple doses of 600 mg rifampin once daily. The vertical line at 336 h signifies the end of rifampin treatment. FIG. 3A, linear. FIG. 3B, semi-log scale plot.
  • FIGS. 4A-B. Graphs showing mean plasma M2 concentrations after a single dose of 160 mg enzalutamide alone or in the presence of multiple doses of 600 mg rifampin once daily. The vertical line at 336 h signifies the end of rifampin treatment. FIG. 4A, linear. FIG. 4B, semi-log scale plot.
  • FIGS. 5A-B. Graphs showing mean plasma sum of enzalutamide plus M2 concentrations after a single dose of 160 mg enzalutamide alone or in the presence of multiple doses of 600 mg rifampin once daily. The vertical line at 336 h signifies the end of rifampin treatment. FIG. 5A, linear. FIG. 5B, semi-log scale plot.
  • FIG. 6. Graph showing mean plasma concentration-time curve of rifampin on day 8 after multiple doses of 600 mg rifampin once daily.
  • FIG. 7. Graph showing mean and individual C2h plasma concentrations of rifampin during multiple doses of 600 mg rifampin once daily for 21 days.
    •  DETAILED DESCRIPTION
  • Enzalutamide, 4-{3-[4-cyano-3-(trifluoromethyl)phenyl]-5,5-dimethyl-4-oxo-2-sulfanylideneimidazolidin-1-yl}-2-fluoro-N-methylbenzamide (e.g., XTANDI®), is an androgen receptor inhibitor and can be used to treat cancers such as prostate cancers, breast cancers, and ovarian cancers. Enzalutamide is also a strong CYP3A4 inducer in humans; at steady state, enzalutamide reduces the plasma exposure to the CYP3A4 substrate midazolam. There are, however, situations in which co-administration of enzalutamide with a strong CYP3A4 inducer (e.g., carbamazepine, phenobarbital, phenytoin, rifabutin, rifampin, rifapentine) are nevertheless desirable or cannot be avoided. In a drug-drug interaction trial in healthy volunteers, a single 160 mg oral dose of XTANDI® was administered alone or after multiple oral doses of rifampin (strong CYP3A4 and moderate CYP2C8 inducer). Rifampin decreased the AUC0-inf of enzalutamide and its major active metabolite N-destnethyl enzalutamide by 37% with no effect on Cmax. The results are summarized in FIG. 1. Thus, in which co-administration of enzalutamide with a strong CYP3A4 inducer (e.g., carbamazepine, phenobarbital, phenytoin, rifabutin, rifampin, rifapentine) are desirable or cannot be avoided, the daily dose of enzalutamide may be increased from, e.g., 160 mg/day to 200-300 mg/day (e.g., 200, 205, 210, 215, 220, 225, 230, 235, 240, 245, 250, 255, 260, 265, 270, 275, 280, 285, 290, 295, 300 mg/day).
  • “Co-administration ” of enzalutamide and a strong CYP3A4 inhibitor means administration in any manner in which the pharmacological effects of enzalutamide and the strong CYP3A4 inhibitor overlap in the patient at the same time. Co-administration does not require that both agents be administered in a single pharmaceutical composition, in the same dosage form, by the same route of administration, or for the same length of time.
  • Enzalutamide is typically formulated for oral administration. Formulations of enzalutamide are disclosed, e.g., in the prescribing information for XTANDI®, and in US 2014/0378517, US 2014/0179749, and US 2014/0100256.
  • Patients who can be treated with the disclosed co-administration regimes include patients with prostate cancer (including metastatic prostate cancer, castration-resistant prostate cancer, hormone-sensitive prostate cancer, metastatic castration-resistant prostate cancer, metastatic hormone-sensitive prostate cancer), breast cancer (including triple-negative breast cancer), and ovarian cancer. Prostate cancer patients who can be treated using the disclosed co-administration regimes include patients with metastatic castration-resistant prostate cancer (CRPC) who had previously received chemotherapy (e.g., docetaxel) as well as patients with CRPC who are chemotherapy-naïve.
  • The following example illustrates but does not limit the scope of the appended claims.
    • EXAMPLE 1 Pharmacokinetics
  • Data handling. The actual sampling time of enzalutamide and its metabolites for 6 subjects (7 samples in total), and the actual sampling time of the 2-hour rifampin sample of subject 10002 on Day 21 deviated more than 10% (of the scheduled time point. Therefore, the concentrations from these samples were excluded from the summary statistics, but were included in the calculation of the pharmacokinetic parameters.
    • Enzalutamide and its Metabolites M1 (Inactive) and M2 (Active)
  • Mean enzalutamide plasma concentrations versus time profiles (linear and semi-logarithmic) are presented in FIG. 2. Summary statistics of enzalutamide pharmacokinetic parameters are shown in Table 1. In Table 2., the statistical assessments of the effect of rifampin on enzalutamide after a single dose of enzalutamide are presented.
  • As indicated in the semi-logarithmic concentrations versus time profiles, elimination of enzalutamide was faster in the presence of rifampin compared to after administration of enzalutamide alone. For all subjects in the rifampin treatment arm, the last quantifiable enzalutamide concentration was measured prior to the end of the rifampin dosing period (up to 13 days after enzalutamide dosing). Therefore, it was deemed appropriate to calculate AUCinf, t1/2, CL/F and Vz/F using non-compartmental methods. % AUC was low and individual values ranged between 0.658% and 4.56%.
  • In the presence of rifampin, enzalutamide AUC0-336hr and AUCinf were 63% (geometric mean ratio [GMR]:36.79; 90% CI: 33.36-40.57) and 66% (GMR: 33.76 (90% CI: 30.31-37.60) lower, respectively, compared to enzalutamide alone. Cmax was not significantly changed (GMR: 93.03; 90% CI: 83.67-103.45), and similar mean tam values were observed (i.e., 1.039 hours versus 1.078 hours), with the comparable ranges of individual values.
  • Mean t1/2 was shorter when enzalutamide was given in the in the presence of rifampin (30.70 h) compared to enzalutamide alone (90.10 hours). Mean apparent clearance was higher in the presence of rifampin (1.856 L/h) compared to enzalutamide alone (0.6330 L/h), while the apparent volume of distribution (Vz/F) did not change.
  • Between subject variation in enzalutamide AUC0-336hr, AUCinf and Cmax was low and was not influenced by the presence of rifampin, with values ranging between 13.2% and 1.9.4%.
  • TABLE 1
    Summary Statistics of Plasma Enzalutamide Pharmacokinetic Parameters
    After Single Dose Administration of 160 mg Enzalutamide Alone or
    in the Presence of Multiple Doses of 600 mg Rifampin Once Daily
    Parameter n Mean SD (CV %) Min Median Max
    Enzalutamide
    AUC0-336 h (μg · h/mL) 14 239.2 41.06 (17.2) 179 233.0 320
    AUC0-t (μg · h/mL) 14 257.7 50.35 (19.5) 187 253.7 336
    AUCinf (μg · h/mL) 14 262.0 50.91 (19.4) 191 259.0 341
    Cmax (μg/mL) 14 4.931 0.8196 (16.6) 3.10 5.140 5.94
    tmax (h) 14 1.078 0.4804 (NA) 0.500 0.9100 2.00
    t1/2 (h) 14 90.10 27.25 (30.2) 35.5 85.69 142
    CL/F (L/h) 14 0.6330 0.1259 (19.9) 0.470 0.6184 0.840
    Vz/F (L) 14 79.82 21.68 (27.2) 41.1 78.11 123
    Enzalutamide + Rifampin (Test)
    AUC0-336 h (μg · h/mL) 14 87.50 11.55 (13.2) 71.8 84.80 109
    AUC0-t (μg · h/mL) 14 85.41 10.99 (12.9) 69.3 82.67 105
    AUCinf (μg · h/mL) 14 87.58 11.68 (13.3) 72.0 84.75 110
    Cmax (μg/mL) 14 4.567 0.6435 (14.1) 3.20 4.560 5.70
    tmax (h) 14 1.039 0.3497 (NA) 0.500 1.000 2.00
    t1/2 (h) 14 30.70 6.162 (20.1) 17.7 31.80 39.4
    CL/F (L/h) 14 1.856 0.2350 (12.7) 1.46 1.888 2.22
    Vz/F (L) 14 81.59 17.45 (21.4) 52.0 80.49 119
    CV %: coefficient of variation expressed as percentage;
    Max: maximum;
    Min: minimum;
    NA: not applicable
  • TABLE 2
    Statistical Assessment of the Effect of Multiple Doses of Rifampin on Exposure Parameters
    of Plasma Enzalutamide After Single Dose Administration of 160 mg Enzalutamide
    Geometric LS Means
    Enzalutamide Enzalutamide + Ratio (%)
    Parameter (Units) (Reference) Rifampin (Test) (Test/Reference) 90% CI (%)
    n 14 14
    AUC0-336 h (μg · h/mL) 236.0 86.82 36.79 33.36-40.57
    AUCinf (μg · h/mL) 257.4 86.89 33.76 30.31-37.60
    Cmax (μg/mL) 4.862 4.523 93.03  83.67-103.45
    LS: Least squares
  • Enzalulamide Metabolite M1
  • Mean M1 plasma concentrations versus time profiles (linear and semi-logarithmic) are presented in FIG. 3. Summary statistics of M1 pharmacokinetic parameters are shown in Table 3. In Table 4, the statistical results of the effect of rifatnpin on M1 after a single dose of enzalutamide are presented.
  • Based on the mean concentration-time profiles, the maximum MI plasma concentrations were comparable between treatments; however, the maximum plasma concentration was reached somewhat earlier in the presence of rifampin. Elimination of M1 was faster in the presence of rifampin, though the elimination of M1 did not change after discontinuation of rifampin at t=336 hours.
  • In the presence of rifampin, M1 AUC0-336hr and AUCinf were 15% (GMR: 84,94; 90% CI: 69.07-104.46) and 32% (GMR: 67.53; 90% CI: 44.56-102.33) lower, respectively compared to enzalutamide alone. The 90% CI of the GMRs for both parameters were wide. It should be noted that AUCinf could only be accurately determined for 4 subjects in the enzalutamide treatment arm (treatment arm 1) and 6 subjects in the enzalutamide+rifampin treatment arm (treatment arm 2). For AUCinf values for which the percentage extrapolated (% AUC) were higher than 20%, the AUCinf was excluded from the statistical analysis. Mean M1 t1/2 was somewhat shorter in the presence of rifampin (194.5 hours) compared to enzalutamide alone (223.9 hours).
  • Cmax appeared to be similar (GMR:96.56; 90% CI: 77.68-120.02); however, median tmax was reached earlier in the presence of rifampin (58.21 hours) compared to after administration of enzalutamide alone (109.6 hours), with smaller ranges of individual values in the presence of rifampin.
  • M1 MPRs, molecular weight corrected and based on AUCinf, were higher in the presence of rifampin compared to enzalutamide alone, with mean values of 0.4897 (range: 0.210 to 0.809) and 0.2165 (range: 0.152 to 0.314), respectively.
  • Between subject variation in M1 AUC0-336hr, AUCinf and Cmax was moderate and was not influenced by the presence of rifampin, with values ranging between 27.5% and 47.3%.
  • TABLE 3
    Summary Statistics of Plasma M1 Pharmacokinetic Parameters After
    Single Dose Administration of 160 mg Enzalutamide Alone or in
    the Presence of Multiple Doses of 600 mg Rifampin Once Daily
    Parameter n Mean SD (CV %) Min Median Max
    Enzalutamide
    AUC0-336 h (μg · h/mL) 14 32.49 8.930 (27.5) 20.3 31.38 54.5
    AUC0-t (μg · h/mL) 14 47.87 16.73 (35.0) 25.9 46.66 92.4
    AUCinf (μg · h/mL) 8 62.14 19.84 (31.9) 38.2 57.39 102
    Cmax (μg/mL) 14 0.1414 0.04662 (33.0) 0.0761 0.1350 0.238
    tmax (h) 14 109.6 74.5 (NA) 36.0 119.1 263
    t1/2 (h) 12 223.9 62.85 (28.1) 86.2 236.6 303
    MPR (MWC) 12 0.2233 0.05737 (25.7) 0.157 0.2194 0.323
    Enzalutamide + Rifampin (Test)
    AUC0-336 h (μg · h/mL) 14 28.35 9.840 (34.7) 13.0 27.54 47.8
    AUC0-t (μg · h/mL) 14 34.33 13.76 (40.1) 13.0 34.59 64.5
    AUCinf (μg · h/mL) 4 44.09 20.87 (47.3) 22.3 42.40 69.3
    Cmax (μg/mL) 14 0.1374 0.04751 (34.6) 0.0724 0.1370 0.230
    tmax (h) 14 58.21 32.19 (NA) 12.0 47.92 120
    t1/2 (h) 10 194.5 53.56 (27.5) 131 183.2 274
    MPR (MWC) 10 0.4894 0.2085 (42.6) 0.217 0.4757 0.844
    CV %: coefficient of variation expressed as percentage;
    Max: maximum;
    Min: minimum;
    MPR (MWC): metabolite versus parent ratio (molecular weight corrected);
    NA: not applicable
  • TABLE 4
    Statistical Assessment of the Effect of Multiple Doses of Rifampin on Exposure
    Parameters of Plasma M1 After Single Dose Administration of 160 mg Enzalutamide
    Enzalutamide Enzalutamide +
    (Reference) Rifampin (Test)
    Geometric Geometric Ratio (%)
    Parameter (Units) n LS Mean n LS Mean (Test/Reference) 90% CI (%)
    AUC0-336 h (μg · h/mL) 14 31.43 14 26.70 84.94 69.07-104.46
    AUCinf (μg · h/mL) 8 59.62 4 40.26 67.53 44.56-102.33
    Cmax (μg/mL) 14 0.1346 14 0.1300 96.56 77.68-120.02
    LS: Least Squares
  • Enzalutamide Metabolite M2
  • Mean M2. plasma concentrations versus time profiles (linear and semi-logarithmic) are presented in FIG. 4. Summary statistics of M2 pharmacokinetic parameters are shown in Table 5. In Table 6, the statistical results of the effect of rifampin on M2 after a single dose of enzalutamide are presented.
  • Based on the mean concentration-time profiles, maximum M2 plasma concentrations were higher and were reached earlier in the presence of rifampin compared to enzalutamide alone. Elimination of M2 was slightly faster in the presence of rifampin. The elimination of M2 did not change after discontinuation of rifampin at t=336 hours.
  • In the presence of rifampin, M2 AUC0-336h, was 15% higher (GMR: 114.8; 90% CI: 103.49-127.34), while AUCinf was 15% lower (GMR: 84.74 (90% CI: 77.13-93.11) compared to enzalutamide alone. % AUC was low and ranged between 1.25% and 5.79%. Mean M2 t1/2 was somewhat shorter in the presence of rifampin (154.7 hours) compared to enzalutamide alone (190.4 h). M2 Cmax was 34% higher (GMR: 133.7; 90% CI: 118.63-150.76), and median tmax was reached earlier (i.e., 71.86 hours versus 167.7 hours).
  • M2 MPR, molecular weight corrected and based on AUCinf, was higher in the presence of rifampin compared to enzalutamide alone, with mean values of 3.443 (range: 2.71 to 4.33) and 1.385 (range: 1.04 to 2.08), respectively.
  • Between subject variation in M2 AUC0-336hr, AUCinf and Cmax was low and was not influenced by the presence of rifampin, with values ranging between 11.0% and 20.8%.
  • TABLE 5
    Summary Statistics of Plasma M2 Pharmacokinetic Parameters After
    Single Dose Administration of 160 mg Enzalutamide Alone or in
    the Presence of Multiple Doses of 600 mg Rifampin Once Daily
    Parameter n Mean SD (CV %) Min Median Max
    Enzalutamide
    AUC0-336 h (μg · h/mL) 14 197.6 41.15 (20.8) 146 184.1 286
    AUC0-t (μg · h/mL) 14 344.3 58.19 (16.9) 249 338.3 440
    AUCinf (μg · h/mL) 14 354.0 59.18 (16.7) 255 351.0 451
    Cmax (μg/mL) 14 0.7546 0.1778 (23.6) 0.542 0.7145 1.18
    tmax (h) 14 161.3 37.00 (NA) 120 167.7 265
    t1/2 (h) 14 190.4 31.07 (16.3) 142 182.3 253
    MPR (MWC) 14 1.431 0.3156 (22.1) 1.07 1.373 2.15
    Enzalutamide + Rifampin (Test)
    AUC0-336 h (μg · h/mL) 14 224.0 24.72 (11.0) 173 221.9 263
    AUC0-t (μg · h/mL) 14 292.1 33.51 (11.5) 221 293.5 338
    AUCinf (μg · h/mL) 14 297.9 33.52 (11.3) 226 299.4 343
    Cmax (μg/mL) 14 0.9949 0.1413 (14.2) 0.743 1.010 1.29
    tmax (h) 14 66.75 19.23 (NA) 47.9 71.86 120
    t1/2 (h) 14 154.7 18.58 (12.0) 125 152.5 190
    MPR (MWC) 14 3.558 0.5368 (15.1) 2.81 3.372 4.47
    CV %: coefficient of variation expressed as percentage;
    Max: maximum;
    Min: minimum;
    MPR (MWC): metabolite versus parent ratio (molecular weight corrected);
    NA: not applicable
  • TABLE 6
    Statistical Assessment of the Effect of Multiple Doses of Rifampin on Exposure
    Parameters of Plasma M2 After Single Dose Administration of 160 mg Enzalutamide
    Geometric LS Means
    Enzalutamide Enzalutamide + Ratio (%)
    Parameter (Units) (Reference) Rifampin (Test) (Test/Reference) 90% CI (%)
    n 14 14
    AUC0-336 h (μg · h/mL) 194.0 222.7 114.8 103.49-127.34
    AUCinf (μg · h/mL) 349.3 296.0 84.74 77.13-93.11
    Cmax (μg/mL) 0.7370 0.9856 133.7 118.63-150.76
    LS: Least Squares
  • Sum of Enzalutamide Plus M2
  • Mean sum of enzalutamide plus M2 plasma concentrations versus time profiles (linear and semi-logarithmic) are presented in FIG. 5. Summary statistics of the sum of enzalutamide plus M2 pharmacokinetic parameters are shown in Table 7. In Table 8, the statistical results of the effect of rifampin on the sum of enzalutamide plus M2 after a single dose of enzalutamide are presented.
  • Based on the mean concentration-time profiles, mean sum of enzalutamide plus M2 plasma concentrations were comparable between treatments up to roughly 48 hours after administration. Thereafter, plasma concentrations of the sum of enzalutamide plus M2 declined slightly faster in the presence of rifampin. After discontinuation of rifampin at t=336 hours, no change in decline was observed.
  • In the presence of rifampin, sum of enzalutamide plus M2 AUC0-336hr and AUCinf were 28% (GMR: 71.56; 90% CI: 66.39-77.13) and 37% (GMR 63.26; 90% CI: 58.17-68.79) lower, respectively, compared to enzalutamide alone. Mean tv, was somewhat shorter in the presence of rifampin (149.4 hours) compared to enzalutamide alone (178.6 hours)
  • Cmax was comparable between treatments (CMR.: 94.32; 90% CI: 85.05-104.60), and similar mean tmax values were observed (i.e., 1.039 hours versus 1.078 hours) with the same ranges of individual values. Between subject variation in sum of enzalutamide plus M2 AUC0-336hr, AUCinf and Cmax was low and was not influenced by presence of rifampin, with values ranging between 9.7% and 16.4%.
  • TABLE 7
    Summary Statistics of Plasma Sum of Enzalutamide plus M2 Pharmacokinetic
    Parameters After Single Dose Administration of 160 mg Enzalutamide Alone
    or in the Presence of Multiple Doses of 600 mg Rifampin Once Daily
    Parameter n Mean SD (CV %) Min Median Max
    Enzalutamide
    AUC0-336 h (μg · h/mL) 14 436.9 59.33 (13.6) 359 421.1 574
    AUC0-t (μg · h/mL) 14 603.5 90.32 (15.0) 466 604.9 774
    AUCinf (μg · h/mL) 14 612.5 92.00 (15.0) 472 614.5 779
    Cmax (μg/mL) 14 4.980 0.8153 (16.4) 3.36 5.192 5.97
    tmax (h) 14 1.078 0.4804 (NA) 0.500 0.9100 2.00
    t1/2 (h) 14 178.6 29.04 (16.3) 128 168.3 221
    Enzalutamide + Rifampin (Test)
    AUC0-336 h (μg · h/mL) 14 311.5 30.34 (9.7) 256 311.9 371
    AUC0-t (μg · h/mL) 14 379.6 38.40 (10.1) 304 384.9 445
    AUCinf (μg · h/mL) 14 385.2 38.38 (10.0) 309 390.8 450
    Cmax (μg/mL) 14 4.674 0.6340 (13.6) 3.33 4.665 5.80
    tmax (h) 14 1.039 0.3497 (NA) 0.500 1.000 2.00
    t1/2 (h) 14 149.4 17.79 (11.9) 119 148.5 179
    CV %: coefficient of variation expressed as percentage;
    Max: maximum;
    Min: minimum;
    NA: not applicable
  • TABLE 8
    Statistical Assessment of the Effect of Multiple Doses of Rifampin
    on Exposure Parameters of Plasma Sum of Enzalutamide plus M2
    After Single Dose Administration of 160 mg Enzalutamide
    Geometric LS Means
    Enzalutamide Enzalutamide + Ratio (%)
    Parameter (Units) (Reference) Rifampin (Test) (Test/Reference) 90% CI (%)
    n 14 14
    AUC0-336 h (μg · h/mL) 433.3 310.1 71.56 66.39-77.13
    AUCinf (μg · h/mL) 606.0 383.3 63.26 58.17-68.79
    Cmax (μg/mL) 4.911 4.633 94.32  85.05-104.60
    LS: Least Squares
  • Rifampin
  • Mean rifampin plasma concentrations versus time profile during 1 dosing interval on day 8 is presented in FIG. 6. In FIG. 7, individual and mean rifampin C2h plasma concentrations that were obtained during the entire dosing period of 21 days are presented. Summary statistics of rifampin pharmacokinetic parameters are shown in Table 9.
  • Mean plasma rifampin concentrations on day 8 were in line with reported concentrations (Martin et al, 2011; Polk et al, 2001) indicating that relevant concentrations for CYP3A4 and CYP2C8 induction were likely reached by day 8. Median tmax was reached 2 hours post-dose. C2h concentrations were generally consistent throughout the 21-day dosing period indicating that steady-state rifampin exposure was achieved prior to and maintained after administration of enzalutamide.
  • Intersubject variation in rifampin C2h was low with values ranging between 12.0% and 22.6%
  • TABLE 9
    Summary Statistics of Rifampin Pharmacokinetic Parameters
    After Multiple Doses of 600 mg Rifampin Once Daily
    Day 8
    Parameter n Mean SD (CV %) Min-Max Median
    Cmin (μg/mL) 14 0  NA (NA) 0-0 NA
    C2 h (μg/mL) 14 6.759 0.9330 (13.8)  5.24-8.27 6.625
    Cmax (μg/mL) 14 7.163 1.222 (17.1) 5.24-8.89 7.035
    tmax (h) 14 1.720 0.4700 (NA)  1.00-2.00 2.000
    AUCtau 14 35.59 4.450 (12.5) 28.3-46.4 35.25
    CV %: coefficient of variation expressed as percentage;
    Max: maximum;
    Min: minimum;
    NA: not applicable
  • Conclusion
  • After administration of a 160 mg single enzalutamide dose in the presence of multiple doses of 600 mg rifampin once daily:
  • Enzalutamide AUCinf was 66% lower (GMR 33,76; 90% CI: 30.31-37.60) compared to enzalutamide alone, while Cmax was comparable (GMR: 93.03; 90% CI: 83.67-103.45).
  • Mean tmax values were similar (i.e., 1.039 hours versus 1.078 hours with comparable ranges of individual values.
  • M1 AUC0-336hr and AUCinf were 15% (GMR: 84.94; 90% CI: 69.07-104.46) and 32% (GMR: 67.53; 90% CI: 44.56-102.33) lower, respectively, while appeared to he similar (GMR: 96.56; 90% CI: 77.68-120.02) however, median M1 tmax was reached earlier (i.e., 58.21 hours versus 109.6 hours).
  • M2 AUCinf was 15% lower (GMR: 84.74; 90% CI: 77.13-93.10, while M2 Cmax was 34% higher (GMR: 133.7; 90% CI: 118.63-150.76). Median M2 tmax was reached earlier (i.e., 71.86 hours versus 167.7 hours).
  • Sum of enzalutamide plus M2 AUCinf was 37% lower (GMR 63.26; 90% CI: 58.17-68.79), while was similar (GMR: 94.32; 90% CI: 85.05-104.60). Mean tmax values were similar 1.039 hours versus 1.078 hours), with comparable ranges of individual values.
  • Rifampin C2h concentrations indicated that steady-state rifampin exposure was achieved prior to and maintained after administration of enzalutamide on day 8.
    • EXAMPLE 2 Pharmacodynamics
  • Datahandling. For subject 10037 and subject 10046 in the enzalutamide treatment arm (treatment arm 1), the actual time of urine sampling on day 1 was not within 180 minutes inclusive of enzalutamide dosing and/or pre-dose of rifampin. In addition, for many subjects, urine samples taken post enzalutamide dose were not taken within 180 minutes of the ‘virtual’ enzalutamide dosing time (i.e., day 1 enzalutamide dosing time [enzalutamide treatment arm {treatment arm 1}] and day 8 enzalutamide dosing time [enzalutamide+rifampin treatment arm {treatment arm 2}]) and/or pre-dose of rifampin. The 6β-hydroxycortisol and cortisol concentrations of these urine samples and obtained 6β-hydroxycortisol/cortisol ratios were excluded from summary statistics.
    • 6β-Hydroxycortisol/Cortisol Ratio for Treatment Arm 1
  • In treatment arm 1 (enzalutamide alone), the urinary 6β-hydroxycortisol/cortisol ratio increased from a baseline mean value of 6.8±5.1 on day Ito a maximum value of 8.3±3.6 on day 15, returning to baseline (i.e., 6.2±1.9) on day 22.
    • 6β-Hydroxycortisol/Cortisol Ratio for Treatment Arm 2
  • In treatment arm 2 (enzalutamide in combination with rifampin), the urinary 6β-hydroxycortisollcortisol ratio increased from a baseline mean value of 6.9±4.2 on day 1 to 24.2±22.1 on day 8 (the day of enzalutamide administration), From day 8 to day 22 (the end of rifampin administration), mean ratios were variable and ranged between 19.12. and 29.38, returning to baseline(i.e., 6.4±3.2) by day 36.
  • TABLE 10
    Summary Statistics of Urine 6β-hydroxycortisol/Cortisol
    Ratio After a Single Dose of 160 mg Enzalutamide Alone or in
    the Presence of Multiple Doses of 600 mg Rifampin Once Daily
    Enzalutamide
    Day n Mean SD CV % Min Max Median
    1 11 6.844 5.060 73.9 1.74 17.3 5.256
    4 11 5.760 1.840 32.0 2.51 8.11 6.390
    8 9 7.855 3.232 41.1 3.83 14.5 8.094
    15 11 8.347 3.637 43.6 4.28 14.8 6.872
    22 9 6.204 1.892 30.5 3.71 9.31 5.647
    29 8 6.519 2.785 42.7 3.15 11.5 6.590
    36 8 8.212 5.261 64.1 2.00 19.6 7.153
    43 8 6.576 3.062 46.6 3.13 13.1 6.294
    50 7 5.119 2.094 40.9 2.15 7.59 4.802
    Enzalutamide + Rifampin
    n Mean SD CV % Min Max Median
    1 14 6.855 4.238 61.8 2.73 17.7 5.730
    4 14 19.25 14.43 75.0 6.94 65.8 14.44
    8 14 24.23 22.12 91.3 9.16 92.2 15.98
    11 14 23.04 13.19 57.3 11.2 56.2 16.82
    15 14 19.12 8.586 44.9 8.28 41.7 17.95
    22 14 29.38 16.64 56.6 7.26 56.4 23.42
    29 12 13.01 11.77 90.5 4.98 47.8 9.727
    36 11 6.356 3.164 49.8 4.14 15.0 5.410
    43 10 6.216 2.581 41.5 2.58 9.86 6.486
    50 10 7.067 2.724 38.5 3.31 10.9 6.894
    57 12 6.974 2.235 32.0 2.84 10.0 7.018
    CV %: coefficient of variation expressed as percentage;
    Max: maximum;
    Min: minimum
  • Conclusion
  • The pharmacodynamic assessment confirmed that rifampin had produced an inductive effect on CYP3A4 by the time that enzalutamide was administered on day 8; whereas, a single dose of enzalutamide alone produced a minimal inductive effect on CYP3A4.

Claims (6)

1. A method of treating cancer, comprising co-administration to a patient in need thereof a therapeutically effective dose of enzalutamide and a CYP3A4 inducer, wherein the therapeutically effective dose of enzalutamide is 200-300 mg per day.
2. The method of claim 1, wherein the cancer is selected from the group consisting of prostate cancer, breast cancer, and ovarian cancer.
3. The method of claim 1, wherein the therapeutically effective dose of enzalutamide is 240 mg per day.
4. A method of treating metastatic castration-resistant prostate cancer, comprising co-administration to a patient in need thereof (i) 240 mg/day of enzalutamide and (ii) a CYP3A4 inducer.
5. The method of claim 1, wherein the CYP3A4 inducer is selected from the group consisting of carbamazepine, phenobarbital, phenytoin, rifabutin, rifampin, and rifapentine.
6. The method of claim 4, wherein the CYP3A4 inducer is selected from the group consisting of carbamazepine, phenobarbital, phenytoin, rifabutin, rifampin, and rifapentine.
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