Journal: Expert opinion on emerging drugs
Introduction: Leishmaniasis is a parasitic disease transmitted by phlebotomine sandflies. Between 700,000 and 1.2 million cases of cutaneous leishmaniasis and between 200,000 and 400,000 cases of visceral leishmaniasis (VL), which is fatal if left untreated, occur annually worldwide. Liposomal amphotericin B (LAMB), alone or in combination with other drugs, has been extensively studied as VL treatment, but data on routine field use are limited, and several challenges to patients' access to this life-saving drug remain. Areas covered: This article provides a review of clinical studies on LAMB for VL and other forms of leishmaniasis. The current development of generic versions of LAMB and related challenges are also discussed. Expert opinion: LAMB proved to be highly efficacious and safe in over 8000 VL patients treated by MÉdecins Sans Frontières in South Asia, and its use was feasible even at primary healthcare level. Despite requiring higher doses, LAMB is the drug of choice to treat vulnerable groups (e.g., pregnant or HIV positive) and relapsing VL patients in East Africa. LAMB should be included in national VL guidelines and registered in all VL endemic countries. Its cost should be further reduced and regulatory pathways to prove bioequivalence for generic LAMB products should be implemented.
After sixty years of continuous use, primaquine remains the only therapy licensed for arresting transmission and relapse of malaria. The US Army developed primaquine for soldiers in a wartime crisis setting. Dosing strategies suited to that narrow population were adopted without modification or validation for the broader population of humans exposed to risk of malaria. The poor suitability of these strategies in populations exhibiting greater vulnerability to hemolytic toxicity among glucose-6-phosphate dehydrogenase deficient patients has not been addressed. Primaquine requires chemotherapeutic reinvention delivering less threatening doses by leveraging unexplored co-drug synergies.
Introduction: Myelofibrosis (MF), a Philadelphia chromosome-negative myeloproliferative neoplasm, is a life-threatening heterogeneous disorder characterized by dysregulation of the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) signaling network. The clinical hallmarks of MF are progressive splenomegaly, anemia and debilitating symptoms attributable to ineffective hematopoiesis and excessive production of proinflammatory cytokines. Areas covered: This review describes the pathogenesis, clinical features and current treatment of MF, clinical data for ruxolitinib, a potent oral JAK1/JAK2 inhibitor and the only therapy approved for the treatment of MF, and agents in development for the treatment of MF. Information was derived from relevant MF articles identified in the published literature and abstracts of recent congresses. Expert opinion: Ruxolitinib reduces spleen size and alleviates MF-related symptoms, thereby improving quality of life. Ruxolitinib may increase the risk of anemia and thrombocytopenia and does not appear to reverse bone marrow fibrosis. Studies are exploring ruxolitinib dosing strategies for patients with low platelet counts and combination therapies. Several other JAK inhibitors and other agents (i.e., immunomodulators, antifibrotic agents, anti-anemia agents, mammalian target of rapamycin [mTOR] inhibitors, epigenetic modifiers, pegylated interferon-α2a) to treat various aspects of MF (i.e., to improve blood counts or forestall marrow fibrosis) are in early clinical development.
Introduction: Chronic kidney disease (CKD) is a worldwide health problem. Despite remarkable headway in slowing the progression of kidney diseases, the incidence of end-stage renal disease (ESRD) is increasing in all countries with a severe impact on patients and society. The high incidence of diabetes and hypertension, along with the aging population, may partially explain this growth. Currently, the mainstay of pharmacological treatment for CKD, aiming to slow progression to ESRD are ACE inhibitors and angiotensin II receptor blockers for their hemodynamic/antihypertensive and anti-inflammatory/antifibrotic action. However, novel drugs would be highly desirable to effectively slow the progressive renal function loss. Areas covered: Through the search engines, PubMed and ClinicalTrial.gov, the scientific literature was reviewed in search of emerging drugs in Phase II or III trials, which appear to be the most promising for CKD treatment. Expert opinion: The great expectations for new drugs for the management of CKD over the last decade have unfortunately not been met. Encouraging results from preliminary studies with specific agents need to be tempered with caution, given the absence of consistent and adequate data. To date, several agents that showed great promise in animal studies have been less effective in humans.
Dravet syndrome (DS) is an early-onset genetic developmental epileptic encephalopathy characterized by multiple seizure types which are refractory to antiseizure medication. There is an unmet need for effective and tolerable drugs to control different seizure types in DS types, with the aim of improving quality of life and preventing neurological impairment. Areas covered: Narrative review of efficacy and tolerability of fenfluramine, cannabidiol (CBD), verapamil and modulators of serotonin signaling pathways (lorcaserin or trazodone) in the treatment of DS. Expert Opinion/Commentary: A recent large randomized controlled-trial has shown that CBD is effective in the treatment of DS; preliminary data from the placebo-controlled trial on fenfluramine are also promising. Further studies are definitely required to evaluate the role of verapamil and modulators of serotonin signaling in DS. At present, drugs used to treat seizures in DS treat the symptoms of epilepsy rather than its cause(s). Future research should focus on elucidating the natural history of DS and whether appropriate treatment can have a beneficial impact on its disease course. A multidisciplinary, individualized approach to care of DS patients is required.
Introduction: Rosacea is a common, chronic and relapsing inflammatory skin disease of the centrofacial area. Despite advancing knowledge on its pathogenesis, diagnosis, and treatment, some major unknowns still remain, including systematic evidence-based guidelines useful both for clinical assessment and therapeutic management. Topical treatment is regarded as a first-line option for mild to moderate rosacea and includes traditional and new FDA-approved prescription drugs, as well as off-label alternative topical agents. Areas covered: Since improved awareness of rosacea pathogenetic mechanisms has led to the development of new potential therapeutic agents, a search was performed on the ClinicalTrial.gov registry. The results identified several investigational topical drugs able to target one or more of the pathogenetic factors of rosacea. Expert opinion: The main unmet needs in the topical treatment of rosacea remain the management of vasomotor flushes and telangiectasias, as well as of troublesome symptoms such as burning and/or stinging. No single agent effective on all rosacea phenotypes is available so far, and preventive treatments capable of halting disease progression have not been identified yet. Finally, data on long-term efficacy and tolerability are still incomplete, especially for drugs more recently introduced in the market.
Basal cell carcinoma (BCC) is the most frequent skin malignancy, with incidence increasing worldwide. Most BCC can be cured with local treatments (surgery or topical therapies), but advanced or recurrent forms require specific therapies. Significant developments targeting the sonic hedgehog signalization pathway have been made in the past years, paving the way for new therapies.
Introduction: Chronic myelomonocytic leukemia (CMML) is a clonal hematologic disorder with heterogenous prognosis, but with no curative therapies with exception of allogeneic transplant. Therapeutic options for patients with CMML are limited, and although hypomethylating agents such as azacitidine and decitabine are the standard of care, only 40% of patients achieve and response and most responses are transient. Over the last 5 years significant advances have been made in the understanding of the clonal landscape of CMML, some of the mechanisms associated to resistance to HMA and other key biological processes involved in disease pathogenesis. Areas covered: The current article reviews the most relevant emerging therapies currently undergoing clinical trials for the treatment of previously untreated or relapsed CMML. Expert opinion: The presence of recurrent somatic mutations in CMML represent therapeutic opportunities to utilize specific small molecule inhibitors such as IDH, FLT3, MEK/ERK, PLK1 or splicing inhibitors and modulators. In addition, other novel agents such as immune therapies, BCL2 or MCL1 inhibitors and other monoclonal antibodies could lead to therapeutic advances. Identifying specific patient populations likely to benefit from some of these interventions, and development of optimal combinations will remain the challenge when determining their role in therapy.
Introduction: The introduction of immunotherapy to the treatment landscape of head and neck cancer (HNC) led to the approval of two immune checkpoint inhibitors (ICIs), nivolumab and pembrolizumab, for the treatment of recurrent and/or metastatic (R/M) head and neck squamous cell carcinoma (HNSCC). The benefits of ICIs in HNSCC have been demonstrated through multiple studies to improve overall survival (OS) with decreased side effects when compared to the standard of care (SOC) treatment regimens in place for decades. There has been a subsequent influx in the development of novel immunotherapy agents for the treatment of HNSCC. Areas covered: Data for anti-programmed cell death protein 1 (PD-1)/programmed death ligand 1 (PD-L1) and anti-cytotoxic T-lymphocyte associated protein 4 (CTLA-4) antibodies in treatment of R/M HNSCC will be reviewed. Emerging immune checkpoint inhibitors as well as combined therapies in HNSCC will be discussed. The role of predictive biomarkers, HPV-status, PD-L1 expression, and challenges related to treating patients with ICIs will be summarized. Expert opinion: A shift towards ICIs as SOC for the treatment of R/M HNSCC will continue as emerging immune checkpoints and combination therapies are evaluated. Response rates are variable in this patient population underlying the importance of identifying predictive biomarkers to aid in patient selection for ICI treatment.
Introduction Acute myeloid leukemia (AML) is a clinically heterogeneous hematologic malignancy with poor long term outcomes. Cytotoxic chemotherapy remains the backbone of therapy especially among younger patients; however the effective incorporation of targeted therapies continues to be an area of active research in an effort to improve response durations and survival. Cell cycle inhibitors (CCI) are a novel class of agents which may be of particular interest for development in patients with AML. Areas covered We will review the concept of CCIs along with available pre-clinical and clinical data in the treatment of AML both in North America and abroad. Specific drug targets reviewed include cyclin D kinase, Aurora kinase, CHK1, and WEE1. Expert opinion Utilization of CCIs in patients with AML is an emerging approach that has shown promise in pre-clinical models. It has been challenging to translate this concept into clinical success thus far, due to marginal single-agent activity and significant toxicity profiles, however clinical evaluation is ongoing. Addition of these agents to cytotoxic chemotherapy and other targeted therapies provides a potential combinatorial path forward for this novel class of therapies. Developing optimal combinations while balancing toxicity are among the top clinical challenges that must be overcome before we can anticipate adoption of these agents into the armamentarium of AML therapy.