@phdthesis{Gerner2023,
  author    = {Gerner, Bettina},
  title     = {Improvement of oral antineoplastic therapy by means of pharmacometric approaches \& therapeutic drug monitoring},
  doi       = {10.25972/OPUS-32196},
  url       = {http://nbn-resolving.de/urn:nbn:de:bvb:20-opus-321966},
  school      = {Universit{\"a}t W{\"u}rzburg},
  year      = {2023},
  abstract  = {Oral antineoplastic drugs are an important component in the treatment of solid tumour diseases, haematological and immunological malignancies. Oral drug administration is associated with positive features (e.g., non-invasive drug administration, outpatient care with a high level of independence for the patient and reduced costs for the health care system). The systemic exposure after oral intake however is prone to high IIV as it strongly depends on gastrointestinal absorption processes, which are per se characterized by high inter-and intraindividual variability. Disease and patient-specific characteristics (e.g., disease state, concomitant diseases, concomitant medication, patient demographics) may additionally contribute to variability in plasma concentrations between individual patients. In addition, many oral antineoplastic drugs show complex PK, which has not yet been fully investigated and elucidated for all substances. All this may increase the risk of suboptimal plasma exposure (either subtherapeutic or toxic), which may ultimately jeopardise the success of therapy, either through a loss of efficacy or through increased, intolerable adverse drug reactions. TDM can be used to detect suboptimal plasma levels and prevent permanent under- or overexposure. It is essential in the treatment of ACC with mitotane, a substance with unfavourable PK and high IIV. In the current work a HPLC-UV method for the TDM of mitotane using VAMS was developed. A low sample volume (20 µl) of capillary blood was used in the developed method, which facilitates dense sampling e.g., at treatment initiation. However, no reference ranges for measurements from capillary blood are established so far and a simple conversion from capillary concentrations to plasma concentrations was not possible. To date the therapeutic range is established only for plasma concentrations and observed capillary concentrations could not be reliable interpretated.The multi-kinase inhibitor cabozantinib is also used for the treatment of ACC. However, not all PK properties, like the characteristic second peak in the cabozantinib concentration-time profile have been fully understood so far. To gain a mechanistic understanding of the compound, a PBPK model was developed and various theories for modelling the second peak were explored, revealing that EHC of the compound is most plausible. Cabozantinib is mainly metabolized via CYP3A4 and susceptible to DDI with e.g., CYP3A4 inducers. The DDI between cabozantinib and rifampin was investigated with the developed PBPK model and revealed a reduced cabozantinib exposure (AUC) by 77\%. Hence, the combination of cabozantinib with strong CYP inducers should be avoided. If this is not possible, co administration should be monitored using TDM. The model was also used to simulate cabozantinib plasma concentrations at different stages of liver injury. This showed a 64\% and 50\% increase in total exposure for mild and moderate liver injury, respectively.Ruxolitinib is used, among others, for patients with acute and chronic GvHD. These patients often also receive posaconazole for invasive fungal prophylaxis leading to CYP3A4 mediated DDI between both substances. Different dosing recommendations from the FDA and EMA on the use of ruxolitinib in combination with posaconazole complicate clinical use. To simulate the effect of this relevant DDI, two separate PBPK models for ruxolitinib and posaconazole were developed and combined. Predicted ruxolitinib exposure was compared to observed plasma concentrations obtained in GvHD patients. The model simulations showed that the observed ruxolitinib concentrations in these patients were generally higher than the simulated concentrations in healthy individuals, with standard dosing present in both scenarios. According to the developed model, EMA recommended RUX dose reduction seems to be plausible as due to the complexity of the disease and intake of extensive co-medication, RUX plasma concentration can be higher than expected.},
  subject      = {Arzneimittel{\"u}berwachung},
  language  = {en}
}
@article{WernerSchmidMueggeetal.2015,
  author    = {Werner, R.A. and Schmid, J.S. and Muegge, D.O. and L{\"u}ckerath, K. and Higuchi, T. and H{\"a}nscheid, H. and Grelle, I. and Reiners, C. and Herrmann, K. and Buck, A.K. and Lapa, C.},
  title     = {Prognostic value of serum tumor markers in medullary thyroid cancer patients undergoing vandetanib treatment},
  series = {Medicine},
  volume    = {94},
  journal   = {Medicine},
  number    = {45},
  doi       = {10.1097/MD.0000000000002016},
  url       = {http://nbn-resolving.de/urn:nbn:de:bvb:20-opus-145154},
  pages     = {e2016},
  year      = {2015},
  abstract  = {Tyrosine kinase inhibitors (TKIs) such as vandetanib have shown clinical effectiveness in advanced medullary thyroid cancer (MTC). During TKI treatment, fluctuations in the tumor markers carcinoembryonic antigen (CEA) and calcitonin (CTN) are frequently observed. Their role for treatment monitoring and the decision-making process has not been fully elucidated yet. Twenty-one patients (male, 16, female, 5; mean age, 49±13 years) with progressive MTC receiving vandetanib (300mg orally per day) were considered. Tumor restaging was performed every 3 months including contrast-enhanced computed tomography (CT). Response was assessed according to recent criteria (Response Evaluation Criteria in Solid Tumors, RECIST 1.1). Additionally, CEA and CTN were measured at the day of CT imaging and alterations observed in tumor markers were compared to respective imaging findings (partial response, PR; stable disease, SD; progressive disease, PD). During long-term follow-up (510±350 days [range, 97-1140 days]), CTN and CEA levels initially dropped in 71.4\% and 61.9\% of the patients followed by fluctuations in serum marker levels. A rise in CTN ≥39.5\% between 2 subsequent measurements (defined by ROC analysis) had a sensitivity of 70.6\% and a specificity of 83.2\% in predicting PD with an accuracy of 82.0\% (area under the curve (AUC), 0.76). Oscillations in CEA levels were not predictive for PD. Whereas tumor marker fluctuations in MTC patients undergoing TKI treatment are a frequent phenomenon, a significant rise in CTN ≥40\% turns out to as an early indicator of tumor progression.},
  language  = {en}
}
@phdthesis{Robubi2007,
  author    = {Robubi, Armin},
  title     = {RAF Kinases: Pathway, Modulation and Modeling},
  url       = {http://nbn-resolving.de/urn:nbn:de:bvb:20-opus-26953},
  school      = {Universit{\"a}t W{\"u}rzburg},
  year      = {2007},
  abstract  = {The Ras/RAF/MEK/ERK cascade is a central cellular signal transduction pathway involved in cell proliferation, differentiation, and survival where RAF kinases are pivotal kinases implicated in cancer. The development of specific irreversible kinase inhibitors is a rewarding but difficult aim. CI-1033 was developed to irreversibly inhibit erbB receptor tyrosine kinases by reacting to the Cys113 residue (p38alpha MAP kinase numbering) of the kinase domain. In this study we tried a similar approach to target the RAF oncoproteins which posses a similar cysteine at position 108 in the hinge region between the small n-lobe and the large c-lobe of the kinase domain. A novel synthetic approach including a lyophilization step allowed us the synthesis of a diphenyl urea compound with an epoxide moiety (compound 1). Compound 1 possessed inhibitory activity in vitro. However our time kinetics experiments and mass spectroscopic studies clearly indicate that compound 1 does not react covalently with the cysteine residue in the hinge region. Moreover, in cell culture experiments, a strong activation of the RAF signaling pathway was observed, an effect which is known from several other RAF kinase inhibitors and is here reported for the first time for a diphenyl urea compound, to which the clinically used unspecific kinase inhibitor BAY 43-9006 (Sorafinib, Nexavar) belongs. Although activation was apparently independent on B- and C-RAF hetero-oligomerization in vitro, in vivo experiments support such a mechanism as the activation did not occur in starved knockout cells lacking either B-RAF or C-RAF. Furthermore, we developed a mathematical model of the Ras/RAF/MEK/ERK cascade demonstrating how stimuli induce different signal patterns and thereby different cellular responses, depending on cell type and the ratio between B-RAF and C-RAF. Based on biochemical data for activation and dephosphorylation, we set up differential equations for a dynamical model of the Ras/RAF/MEK/ERK cascade. We find a different signaling pattern and response result for B-RAF (strong activation, sustained signal) and C-RAF (steep activation, transient signal). We further support the significance of such differential modulatory signaling by showing different RAF isoform expression in various cell lines and experimental testing of the predicted kinase activities in B-RAF, C-RAF as well as mutated versions. Additionally the effect of the tumor suppressor DiRas3 (also known as Noey2 or ARHI) on RAF signaling was studied. I could show that DiRas3 down-regulates the mitogenic pathway by inhibition of MEK, a basis for a refined model of the Ras/RAF/MEK/ERK cascade.},
  subject      = {Systembiologie},
  language  = {en}
}