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A R T I C L E I N F O A B S T R A C T
they met the following criteria: age P18 years; WHO perfor- The acute MTD was defined as the dose level that induced
mance status 62; estimated life expectancy P12 weeks; no DLT in 20% of patients. DLTs for determining the acute
previous chemotherapy for at least 4 weeks; no radiotherapy MTD were defined as grade 4 granulocytopenia for 7 or more
for at least 6 weeks; no significant stomach or small intestine days, febrile neutropenia, platelets <25.0 109/L or <50.0 109/
disease that might influence the absorption of the drug; and L and complicated by bleeding and/or non-haematologic
adequate haematopoietic (haemoglobin P6.2 mmol/L, abso- toxicity Pgrade 3. Nausea and vomiting subsequently respond-
lute peripheral granulocyte count P1.5 109/L, WBC ing to anti-emetic therapy were excluded from being an acute
P3.0 109/L and platelet count P100 109/L), hepatic (biliru- DLT. For the chronic MTD any haematologic toxicity Pgrade
bin 61.5 times the upper normal limit, and serum aspartate 3 and/or any toxicity resulting in omission of more than 10%
aminotransferase and alanine aminotransferase 62.5 times of the intended dose and/or nausea/vomiting requiring the
the upper normal limit) and renal (serum creatinine concen- administration of 5HT3 antagonist were also considered as
tration 61.5 times the upper normal limit) functions. Patients a DLT. The dose recommended for further investigation was
with symptomatic brain or leptomeningeal metastases were defined as the dose that could be administered for 8 weeks
excluded. All patients gave written informed consent before with a 90% dose-intensity in 80% of the patients without
study entry. The study was approved by the Institutions Med- causing any toxicity >grade 2.
ical Ethic Committees. If a patient encountered DLT, the treatment of halofugi-
none was interrupted until resolution of toxicity to 6grade
2.2. Treatment and dose escalation 1, with a maximum of 1 week. If after re-introduction of the
drug the toxicity re-occurred, halofuginone was decreased
Halofuginone was supplied by Collgard Biopharmaceuticals with one dose level at re-treatment. In case toxicity persisted
Ltd. (Tel-Aviv, Israel) as round tablets of about 200 mg com- after 1 week of treatment interruption but resolved during the
prising 0.5, 2.5 or 5.0 mg of active drug and aerosil, crospovi- second week, halofuginone was decreased with one dose level
done, lactose, talc, avicel and Mg stearate. The tablets were at re-treatment. If toxicity had not resolved to 6grade 1 after 2
stored at 28 C. Tablets were taken once a day during break- weeks of interruption, patients would go off study. Toxicities
fast or twice daily during breakfast and dinner. The daily dose were evaluated according to the National Cancer Institute
of halofuginone was provided in separate boxes, with each Common Toxicity Criteria, version 2.0.
daily dosing clearly identifiable by the patient. Patients were
instructed to record their daily amount of tablets taken, the 2.3. Treatment assessment
time of administration, and the timing in relation to breakfast
or dinner. Compliance with the scheduled treatment was as- Before treatment a complete medical history was recorded
sessed at the end of each cycle, by counting the used and re- and a physical examination performed. A complete CBC
turned capsules of halofuginone in relation to the record kept including white blood cell differential, and serum biochemis-
by the patient for the given cycle. A cycle was defined as a per- try, which involved sodium, potassium, calcium, urea, creati-
iod of 2 weeks. With the exception of the first cycle, during nine, total protein, albumin, total bilirubin, alkaline
which patients were hospitalised for pharmacokinetic sam- phosphatase, aspartate aminotransferase, alanine amino-
pling for 3 days, patients were treated on an outpatients basis. transferase, lactate dehydrogenase, and creatine phosphoki-
The starting dose of halofuginone was 1 mg/day, 1/3 of the nase, were performed, as were urinalysis, pregnancy test,
no observed adverse effect level and 1/10 of the maximum relevant tumour markers, electrocardiogram and a chest X-
tolerated dose (MTD) in rat. The total dose prescribed was ray. Weekly evaluations included history, physical examina-
rounded to the nearest 0.5 mg. During the first cycle halofugi- tion, toxicity assessment according to the CTC criteria, CBC
none was administered on day 1 followed by 2 days with no and serum chemistries. Tumour evaluation was performed
medication administration in order to describe the full kinetic every 8 weeks according to the Response Evaluation Criteria
profile of the drug. Daily treatment was resumed on day 4. Ini- in Solid Tumours (RECIST).17 Patients were taken off protocol
tially, only one patient per dose level had to be treated. In case at the onset of disease progression.
a patient at a given dose level experienced grade 3 haemato-
logical toxicity and/or non-haematological toxicity Pgrade 2 2.4. Sample collection and drug analysis
during the first cycle, the dose level had to be expanded to
three patients. Dose escalations were based on the prior dose For pharmacokinetic analysis, ten blood samples (5 mL
level toxicity and pharmacological data allowing a dose esca- each) were obtained from an indwelling intravenous canula
lation up to 100% (which was determined by the worst signif- and collected in vials containing lithium heparin as anticoag-
icant toxicity). Once Pgrade 2 non-haematological toxicity or ulant. The samples were taken immediately before dosing on
Pgrade 3 haematological toxicity was observed in one pa- day 1 and 1, 2, 4, 8, 24, 48 and 72 h after administration of the
tient, further dose escalation would follow a modified Fibo- drug. On day 15 and 29 samples were taken prior to dosing to
nacci scheme. As soon as a DLT was observed the CRM measure the accumulation of halofuginone.
model provided dose recommendations. Because of the All samples were cooled on ice and centrifuged immedi-
mechanism of action of the drug a chronic dosing regimen ately after sampling at 1500g for 1015 min at 4 C and the plas-
would be preferred for further development of the drug, ma was stored at 20 C or lower in polypropylene tubes in the
therefore it was decided to determine two MTDs. First an dark until analysis. A total of four urine samples were also
acute MTD during the first 2 weeks of treatment, and sec- collected over a 48-h period; 06 , 612 , 1224 and 2448 h
ond, a chronic MTD over the first 8 weeks of treatment. post-dosing on day 1 of the first cycle only. Of the total amount
EUROPEAN JOURNAL OF CANCER 4 2 ( 2 0 0 6 ) 1 7 6 8 1 7 7 4 1771
Sex
2.5. Pharmacokinetic data analysis
Female 9
Male 15
The terminal disposition half-life [T1/2(z)] of halofuginone was
Performance status
calculated as ln 2/k, where k is the terminal elimination rate
WHO 0 11
constant (expressed in h1). The peak plasma concentrations
WHO 1 12
(Cmax) and the time to peak plasma concentration (Tmax) were WHO 2 1
determined graphically from the experimental values. The
Tumour type
area under the plasma concentrationtime curve (AUC) of
Melanoma 6
halofuginone were estimated using the experimental values Renal 4
(trapezoidal rule) with extrapolation to infinity (AUC01) using NSCLC 4
the terminal elimination rate constant, defined as the slope of Sarcoma 3
final 34 data points of the log-linear concentrationtime plot. Miscellaneous 7
The total body clearance (CL) was calculated as the ratio be- Previous treatment
tween the administered dose and the AUC01. The extent of Chemotherapy 22
accumulation (R0) was calculated as the ratio between the Radiation 12
plasma concentration 24 h after dosing on day 15 and day 1.
The fraction of the administered dose (Fe) excreted in the
urine and the cumulative amount of halofuginone excreted Table 2 Dose levels studied
in the urine (Ae) was determined. PK data analysis was carried
Dose (mg/day) Number of Number of cycles/
out using a non-compartmental analysis approach with the
patients range per patient
aid of WinNonlin Version 3.0 (Pharsight, 1999).
1 1 4
2 6 19/14
2.6. Statistical analysis
3.5 3 16/212
1 3 13/45
All pharmacokinetic data are presented as mean values and 0.5 5 33/415
coefficient of variability. The effect of drug dose on clearance, 0.5 bid 7 21/05
volume of distribution and terminal disposition half-life was
analysed using a KruskalWallis multiple comparison test.
The level of significance was set at P = 0.05. DLT was observed at 1 mg/day. Since grade 2 nausea was ob-
served at 2 mg/day the cohort was expanded to three pa-
3. Results tients. All three patients experienced grade 2 nausea/
vomiting. Therefore another three patients were entered at
Between August 2001 and February 2004 25 patients, whose the same dose with the introduction of prophylactic anti-
main characteristics are listed in Table 1, were enrolled onto emetics. No DLTs were encountered at the 2 mg/day dose
the study at two centres. All patients were eligible apart from level. However at 3.5 mg/day two patients experienced DLT
one who had undergone a partial esophagectomy and gas- despite prophylactic anti-emetics. One patient had grade 3
trectomy prior to study entry and did not fulfill the entry cri- nausea, accompanied by grade 2 vomiting, grade 2 dehydra-
teria. The last patient entered did not receive treatment. The tion and grade 3 fatigue. The other patient experienced fati-
majority of the patients were either asymptomatic or had gue grade 3, hyponatremia grade 4 and nausea grade 2. It
only mild symptoms at study entry. Patients were pre-treated was concluded that the acute MTD was exceeded and the
with median three prior chemotherapy regimens (range 15). first phase of the study completed. In order to define the
The total number of assessable cycles was 106. The median chronic MTD the dose was de-escalated. Since according to
number of cycles per patient was 4 (range 015). Dose levels the definition of chronic DLT also the requirement of 5HT3
studied were 1, 2, 3.5, 0.5 mg/day and 0.5 mg twice daily antagonists to control nausea and vomiting was considered
administered orally on a continuous basis, with cycles de- a DLT, and at the 2 mg dose level 5 out of 6 patients had used
fined as a treatment period of 14 days (Table 2). 5HT3 antagonists, the 1 mg dose level was expanded. One pa-
tient erroneously only used 0.5 mg/day and had to be re-
3.1. Tolerability placed. Of the three evaluable patients, one patient
experienced a DLT requiring the use of 5HT3 antagonists to
According to protocol in the first part of the study the acute control nausea and vomiting. According to the protocol the
MTD was defined during the first 2 weeks of treatment. No next lower dose level of 0.5 mg/day was subsequently
1772 EUROPEAN JOURNAL OF CANCER 4 2 ( 2 0 0 6 ) 1 7 6 8 1 7 7 4
explored. Five patients were treated at this dose level and static rectal cancer died suddenly during cycle 5 due to mas-
none experienced a DLT. Based on these data it was decided sive hepatic bleeding of liver metastases. The last patient
to study the 0.5 mg twice daily dose level. Two out of six pa- with a metastatic melanoma experienced intestinal bleeding
tients at this dose level had nausea/vomiting grade 2 requir- requiring multiple transfusions during cycles 24. No changes
ing the use of 5HT3 antagonists, defining the recommended in thrombocyte counts, nor clotting parameters, were re-
dose of halofuginone for further studies at 0.5 mg once daily. corded in any of the patients. This number of bleeding com-
Based on these findings the seventh patient, who had already plications is reason for sincere concern. Although it might
given his informed consent, was withdrawn from the study be a coincidence in a patient population known to be prone
and did not start treatment. to developing bleedings at metastatic sites, the total number
Overall halofuginone predominantly caused gastro-intes- encountered could point to a possible relationship with the
tinal toxicity consisting of nausea and vomiting chronologi- administration of the study drug. Further drug administration
cally related to the administration of the drug (Tables 3 and therefore requires relevant measurements to monitor this
4). Most patients experienced nausea and vomiting within possible side-effect.
30 min to 1 h after ingestion of the drug. Only at the lowest
dose level did no patients require 5HT3 antagonist to control 3.2. Antitumour activity
nausea and vomiting. However, even at this dose level of
0.5 mg/day three out of five patients used domperidon or met- No objective responses were observed. Six patients experi-
oclopramide as anti-emetics. enced stabilisation of their disease (sarcoma, melanoma,
Fatigue was the second most common side-effect. How- non-small cell and small cell lung, rectal and renal cancer)
ever, this might partially be related to the disease. for a median duration of 11 weeks (range 830 weeks).
No haematological toxicity was observed.
Seven patients experienced bleeding complications during 3.3. Pharmacokinetics
treatment with halofuginone, divided over all dose levels. At
the 2 mg/day dose level one patient, with extensively meta- Full kinetic data were obtained from 24 patients following the
static melanoma, developed a bleeding in an, until then, un- administration of halofuginone.
known brain metastasis during cycle 3. A second patient at The plasma concentrationtime profiles of halofuginone
this dose level experienced a gastric bleeding with gastros- were similar for all patients studied, as shown in Fig. 2. The
copy showing a benign ulcer during cycle 4. One patient with absorption of halofuginone after oral drug administration
a carcinoma of unknown primary treated at 1 mg/day dose le- was associated with maximum peak drug levels at 3.4 4.8 h.
vel had epistaxis. At the 0.5 mg/day dose level a patient with Inspection of the scatterplots of dose versus AUC01 (Fig. 3A)
metastatic renal cancer died due to a bleeding in an unknown and Cmax (Fig. 3B) for halofuginone revealed an increase in both
brain metastasis. A second patient at this dose level showed parameters with the dose level administered.
an enlargement of an old haematoma during the first treat- The long half-life resulted in accumulation of halofugi-
ment cycle. At the 0.5 mg twice daily dose level two patients none, such that exposure was two- to three-fold higher by
also had a bleeding complication; one patient with a meta- day 15 of dosing.
1 4 1 3 2 3 1*
2 6 1 4 2 3 2 3
3.5 3 1 1 1 1 2 2
0.5 5 1 1 2 1
0.5 2 7 2 1 1 3 2*
Abbreviations. No. pts, number of patients; Plt, platelets; DLT, dose limiting toxicity; *, DLT for chronic administration.
Table 4 Worse toxicity per patient for all cycles according to NCI-CTC version 2.0
Dose (mg/day) No. pts/cycles WBC ANC Plt Nausea Vomiting Fatigue
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 1 2 3 4 1 2 3 4
1 4/17 1 2 2 3 1 4
2 6/19 2 4 2 3 2 3
3.5 3/16 1 1 2 1 1 2
0.5 5/33 1 1 2 1 3 1
0.5 2 7/21 4 1 2 2 3
HALOFUGINONE - Mean and SD plasma profiles dose levels suggesting a linear pharmacokinetic behaviour.
6.0 The mean pharmacokinetic parameters determined using a
non-compartmental analysis are listed in Table 5. Only 4
5.0 0.5 mg 12% of the administered dose of halofuginone was excreted
Conc. (ng/mL)
1 mg
4.0 unchanged in the urine mainly in the first 24 h after drug
2 mg
administration.
3.0 3.5 mg
2.0 4. Discussion
Table 5 Summary of the pharmacokinetics of halofuginone during the first treatment course
Dose level (mg/day) n AUC0t (ng h/mL) AUC01 (ng h/mL) Cmax (ng/mL) Tmax (h) T1/2 (h) R0
Abbreviations. n, number of patients; CV, coefficient of variation; AUC, area under the concentrationtime curve; Cmax, peak plasma level; Tmax,
time to maximal concentration; T1/2, terminal elimination half-life; R0, ratio of accumulation.
of the drug. Yet, it turned out that it was not feasible to esca- 6. Pines M, Nagler A. Halofuginone: a novel antifibrotic therapy.
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fects. The observed interpatient variability in AUC for 7. Elkin M, Miao H-Q, Nagler A, et al. Halofuginone: a potent
inhibitor of critical steps in angiogenesis progression. FASEB J
halofuginone was large with a coefficient of variability of
2000;14:247785.
74%. This is, however, in the range observed for other oral 8. McGaha TL, Phelps RG, Spiera H, Bona C. Halofuginone, an
anti-tumour agents. The AUC reached at the recommended inhibitor of type-I collagen synthesis and skin sclerosis,
dose of 0.5 mg/day is within the range in which anti-tumour blocks transforming-growth-factor-b-mediated Smad3
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induced intimal hyperplasia by halofuginone. Arterioscler
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Conflict of interest statement 12. Abramovitch R, Itzik A, Harel H, Nagler A, Vlodavsky I, Siegal
T. Halofuginone inhibits angiogenesis and growth in
None declared. implanted metastatic rat brain tumor model an MRI study.
Neoplasia 2004;6:4809.
13. Nagler A, Ohana M, Shibolet O, et al. Suppression of
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