Alectinib

Alectinib

Clinical data
Pronunciation	/əˈlɛktɪnɪb/ ə-LEK-ti-nib
Trade names	Alecensa
Other names	alectinib hydrochloride (JAN JP)
AHFS/Drugs.com	Monograph
MedlinePlus	a616007
License data	US DailyMed: Alectinib
Pregnancy category	AU: D[1]
Routes of administration	By mouth
ATC code	L01ED03 (WHO)
Legal status
Legal status	AU: S4 (Prescription only)[1][2][3] CA: ℞-only[4] UK: POM (Prescription only)[5] US: ℞-only[6] EU: Rx-only[7]
Pharmacokinetic data
Bioavailability	37% (under fed conditions)
Protein binding	>99%
Metabolism	Mainly CYP3A4
Metabolites	M4 (active)
Elimination half-life	33 hours (alectinib), 31 hours (M4)
Excretion	Feces (98%)[6]
Identifiers
IUPAC name 9-Ethyl-6,6-dimethyl-8-[4-(morpholin-4-yl)piperidin-1-yl]-11-oxo-6,11-dihydro-5H-benzo[b]carbazole-3-carbonitrile
CAS Number	1256580-46-7 as HCl: 1256589-74-8
PubChem CID	49806720
DrugBank	DB11363
ChemSpider	26326738
UNII	LIJ4CT1Z3Y as HCl: P9YY73LO6J
KEGG	D10542 as HCl: D10450
ChEBI	CHEBI:90936
CompTox Dashboard (EPA)	DTXSID50154840
ECHA InfoCard	100.256.083
Chemical and physical data
Formula	C30H34N4O2
Molar mass	482.628 g·mol^−1
3D model (JSmol)	Interactive image
SMILES CCc1cc2c(cc1N3CCC(CC3)N4CCOCC4)C(c5c(c6ccc(cc6[nH]5)C#N)C2=O)(C)C
InChI InChI=1S/C30H34N4O2/c1-4-20-16-23-24(17-26(20)34-9-7-21(8-10-34)33-11-13-36-14-12-33)30(2,3)29-27(28(23)35)22-6-5-19(18-31)15-25(22)32-29/h5-6,15-17,21,32H,4,7-14H2,1-3H3 COPY Key:KDGFLJKFZUIJMX-UHFFFAOYSA-N Key:GYABBVHSRIHYJR-UHFFFAOYSA-N

Alectinib (INN^[8]), sold under the brand name Alecensa, is an anticancer medication that is used to treat non-small-cell lung cancer (NSCLC).^[6][7] It blocks the activity of anaplastic lymphoma kinase (ALK).^[9][10] It is taken by mouth.^[6] It was developed by Chugai Pharmaceutical Co. Japan, which is part of the Hoffmann-La Roche group.

The most common side effects include constipation, muscle pain and edema (swelling) including of the ankles and feet, the face, the eyelids and the area around the eyes.^[7]

Alectinib was approved for medical use in Japan in 2014, the United States in 2015, Canada in 2016, Australia in 2017, the European Union in 2017, and the United Kingdom in 2021.^[6][7]

Medical uses

In the European Union, alectinib is indicated for the first-line treatment of adults with anaplastic lymphoma kinase (ALK)-positive advanced non-small cell lung cancer (NSCLC);^[7] and for the treatment of adults with ALK‑positive advanced NSCLC previously treated with crizotinib.^[7]

In the United States, it is indicated for the treatment of people with anaplastic lymphoma kinase (ALK)-positive metastatic non-small cell lung cancer (NSCLC) as detected by an FDA-approved test.^[6] In April 2024, the US Food and Drug Administration (FDA) expanded the indication of alectinib to include adjuvant treatment following tumor resection in people with anaplastic lymphoma kinase (ALK)-positive non-small cell lung cancer (NSCLC), as detected by an FDA-approved test.^[11]

Contraindications

There are no reported contraindications.^[6][12]

Side effects

Apart from unspecific gastrointestinal effects such as constipation (in 34% of patients) and nausea (22%), common adverse effects in studies included oedema (swelling; 34%), myalgia (muscle pain; 31%), anaemia (low red blood cell count), sight disorders, light sensitivity and rashes (all below 20%).^[13] Serious side effects occurred in 19% of patients; fatal ones in 2.8%.^[6]

Interactions

Alectinib has a low potential for interactions. While it is metabolised by the liver enzyme CYP3A4, and blockers of this enzyme accordingly increase its concentrations in the body, they also decrease concentrations of the active metabolite M4, resulting in only a small overall effect. Conversely, CYP3A4 inducers decrease alectinib concentrations and increase M4 concentrations. Interactions via other CYP enzymes and transporter proteins cannot be excluded but are unlikely to be of clinical significance.^[13][12]

Pharmacology

Mechanism of action

The substance potently and selectively blocks two receptor tyrosine kinase enzymes: anaplastic lymphoma kinase (ALK) and the RET proto-oncogene. The active metabolite M4 has similar activity against ALK. Inhibition of ALK subsequently blocks cell signalling pathways, including STAT3 and the PI3K/AKT/mTOR pathway, and induces death (apoptosis) of tumour cells.^[13][12]

Pharmacokinetics

Proposed metabolism of alectinib. Alectinib itself and the active metabolite M4 are the main compounds found in the circulation, while the others are minor metabolites.^[14]

When taken with a meal, the absolute bioavailability of the drug is 37%, and highest blood plasma concentrations are reached after four to six hours. Steady state conditions are reached within seven days. Plasma protein binding of alectinib and M4 is over 99%. The enzyme mainly responsible for alectinib metabolism is CYP3A4; other CYP enzymes and aldehyde dehydrogenases only play a small role. Alectinib and M4 account for 76% of the circulating substance, while the rest are minor metabolites.^[13][14]

Plasma half-life of alectinib is 32.5 hours, and that of M4 is 30.7 hours. 98% are excreted via the faeces, of which 84% are unchanged alectinib and 6% are M4. Less than 1% are found in the urine.^[13][14]

Chemistry

Alectinib has a pK_a of 7.05. It is used in form of the hydrochloride, which is a white to yellow-white lumpy powder.^[6]

History

The approvals were based mainly on two trials: In a Japanese Phase I–II trial, after approximately 2 years, 19.6% of patients had achieved a complete response, and the 2-year progression-free survival rate was 76%.^[10] In February 2016 the J-ALEX phase III study comparing alectinib with crizotinib was terminated early because an interim analysis showed that progression-free survival was longer with alectinib.^[15]

In November 2017, the FDA approved alectinib for the first-line treatment of people with ALK-positive metastatic non-small cell lung cancer.^[16] This based on the phase 3 ALEX trial comparing it with crizotinib.^[16]

Efficacy was demonstrated in a global, randomized, open-label trial (ALINA, NCT03456076) in participants with ALK-positive NSCLC who had complete tumor resection.^[11] Eligible participants were required to have resectable stage IB (tumors ≥ 4 cm) to IIIA NSCLC (by AJCC 7th edition) with ALK rearrangements identified by a locally performed FDA-approved ALK test or by a centrally performed VENTANA ALK (D5F3) CDx assay.^[11] A total of 257 participants were randomized (1:1) to receive alectinib 600 mg orally twice daily or platinum-based chemotherapy following tumor resection.^[11] The application was granted priority review and orphan drug designations.^[11]

In April 2024, the FDA approved alectinib as an adjuvant treatment for people with ALK-positive early-stage lung cancer.^[17] This was based on the Phase III ALINA study [NCT03456076].^[18]

On 25 April 2024, the Committee for Medicinal Products for Human Use (CHMP) adopted a positive opinion for the use of alectinib for adjuvant treatment of resected non‑small cell lung cancer (NSCLC).^[19] In June 2024, the EU approved alectinib as an adjuvant treatment for people in the EU with ALK-positive early-stage lung cancer.^[20] This was based on the Phase III ALINA study [NCT03456076].^[21]

Society and culture

Legal status

Alectinib was approved in Japan in July 2014,^[22] for the treatment of ALK fusion-gene positive, unresectable, advanced or recurrent non-small-cell lung cancer (NSCLC).^[10]

Alectinib was granted an accelerated approval by the US Food and Drug Administration (FDA) in December 2015, to treat people with advanced ALK-positive NSCLC whose disease worsened after, or who could not tolerate, treatment with crizotinib (Xalkori).^[9]

It received conditional approval by the European Medicines Agency in February 2017, for the same indication.^[23] The approval was upgraded from conditional to full approval in December 2017.^[24]

References

1. "Australian Product Information – Alecensa (alectinib)". Guildlink.gov.au. Archived from the original on 16 May 2023. Retrieved 16 May 2023.
2. "Prescription medicines: registration of new chemical entities in Australia, 2017". Therapeutic Goods Administration (TGA). 21 June 2022. Archived from the original on 10 April 2023. Retrieved 9 April 2023.
3. "Prescription medicines and biologicals: TGA annual summary 2017". Therapeutic Goods Administration (TGA). 21 June 2022. Archived from the original on 31 March 2024. Retrieved 31 March 2024.
4. "Health Canada New Drug Authorizations: 2016 Highlights". Health Canada. 14 March 2017. Archived from the original on 7 April 2024. Retrieved 7 April 2024.
5. "Alecensa 150 mg Hard Capsules Summary of Product Characteristics (SmPC)". (emc). 10 August 2023. Archived from the original on 21 August 2023. Retrieved 20 August 2023.
6. "Alecensa- alectinib hydrochloride capsule". DailyMed. 16 June 2022. Archived from the original on 9 November 2021. Retrieved 8 January 2023.
7. "Alecensa EPAR". European Medicines Agency (EMA). 29 March 2023. Archived from the original on 13 October 2021. Retrieved 20 August 2023. Text was copied from this source which is copyright European Medicines Agency. Reproduction is authorized provided the source is acknowledged.
8. World Health Organization (2013). "International nonproprietary names for pharmaceutical substances (INN): recommended INN: list 70". WHO Drug Information. 27 (3). hdl:10665/331167.
9. "New Oral Therapy To Treat ALK-Positive Lung Cancer. Dec 2015". Archived from the original on 16 February 2016. Retrieved 11 February 2016.
10. McKeage K (January 2015). "Alectinib: a review of its use in advanced ALK-rearranged non-small cell lung cancer". Drugs. 75 (1): 75–82. doi:10.1007/s40265-014-0329-y. PMID 25428710. S2CID 34062880.
11. "FDA approves alectinib as adjuvant treatment for ALK-positive non-small cell lung cancer". U.S. Food and Drug Administration (FDA). 18 April 2024. Archived from the original on 19 April 2024. Retrieved 20 April 2024. This article incorporates text from this source, which is in the public domain.
12. "Alecensa: EPAR – Product Information" (PDF). European Medicines Agency. 16 May 2017. Archived from the original (PDF) on 17 April 2018. Retrieved 27 May 2017.
13. Haberfeld, H, ed. (2017). Austria-Codex (in German). Vienna: Österreichischer Apothekerverlag. Alecensa 150 mg Hartkapseln.
14. "Alecensa: Assessment report" (PDF). European Medicines Agency. 15 December 2016. Archived from the original (PDF) on 20 September 2018. Retrieved 27 May 2017.
15. "Chugai's ALK Inhibitor "Alecensa" Trial Stopped Early for Benefit" (Press release). Roche. 10 February 2016. Archived from the original on 21 August 2023. Retrieved 20 August 2023 – via Business Wire.
16. "FDA approves Alecensa for ALK- positive metastatic non-small cell lung cancer". www.healio.com. Archived from the original on 8 May 2023. Retrieved 20 April 2024.
17. "FDA approves Roche's Alecensa as the first adjuvant treatment for people with ALK-positive early-stage lung cancer". www.roche.com. Archived from the original on 14 May 2024. Retrieved 14 May 2024.
18. Hoffmann-La Roche (2 April 2024). A Phase III, Open-Label, Randomized Study to Evaluate the Efficacy and Safety of Adjuvant Alectinib Versus Adjuvant Platinum-Based Chemotherapy in Patients With Completely Resected Stage IB (Tumors Equal to or Larger Than 4cm) to Stage IIIA Anaplastic Lymphoma Kinase Positive Non-Small Cell Lung Cancer (Report). clinicaltrials.gov. Archived from the original on 10 June 2024. Retrieved 14 May 2024.
19. "Alecensa - opinion on variation to marketing authorisation | European Medicines Agency". www.ema.europa.eu. Retrieved 14 May 2024.
20. Ltd, F. Hoffmann-La Roche (10 June 2024). "European Commission approves Roche's Alecensa as the first and only targeted adjuvant treatment for people with ALK-positive early-stage lung cancer". GlobeNewswire News Room. Archived from the original on 10 June 2024. Retrieved 10 June 2024.
21. Hoffmann-La Roche (2 April 2024). A Phase III, Open-Label, Randomized Study to Evaluate the Efficacy and Safety of Adjuvant Alectinib Versus Adjuvant Platinum-Based Chemotherapy in Patients With Completely Resected Stage IB (Tumors Equal to or Larger Than 4cm) to Stage IIIA Anaplastic Lymphoma Kinase Positive Non-Small Cell Lung Cancer (Report). clinicaltrials.gov. Archived from the original on 10 June 2024. Retrieved 14 May 2024.
22. "Japan becomes first country to approve Roche's alectinib for people with a specific form of advanced lung cancer" (Press release). 4 July 2014. Archived from the original on 15 February 2018. Retrieved 16 December 2015.
23. "Alecensa authorisation details". European Medicines Agency. 16 February 2017. Archived from the original on 20 June 2018. Retrieved 27 May 2017.
24. "CHMP post-authorisation summary of positive opinion for Alecensa" (PDF). Archived (PDF) from the original on 10 June 2024. Retrieved 10 June 2024.

External links

• Clinical trial number NCT01588028 for "A Study of Alectinib (CH5424802/RO5424802) in Participants With Anaplastic Lymphoma Kinase (ALK)-Rearranged Non-Small Cell Lung Cancer (NSCLC)" at ClinicalTrials.gov
• Clinical trial number NCT01801111 for "A Study of Alectinib (RO5424802) in Participants With Non-Small Cell Lung Cancer Who Have Anaplastic Lymphoma Kinase (ALK) Mutation and Failed Crizotinib Treatment" at ClinicalTrials.gov
• Clinical trial number NCT02075840 for "A Study Comparing Alectinib With Crizotinib in Treatment-Naive Anaplastic Lymphoma Kinase-Positive Advanced Non-Small Cell Lung Cancer Participants (ALEX)" at ClinicalTrials.gov