Optimizing Platelet GPVI Inhibition versus Haemostatic Impairment by the Btk Inhibitors Ibrutinib, Acalabrutinib, ONO/GS-4059, BGB-3111 and Evobrutinib

Abstract

Ibrutinib and acalabrutinib are approved for B cell malignancies and novel Bruton's tyrosine kinase (Btk) inhibitors undergo clinical testing also in B cell-driven autoimmune disorders. Btk in platelets mediates platelet activation via glycoprotein (GP) VI, which is crucial for atherosclerotic plaque-induced platelet thrombus formation. This can be selectively inhibited by Btk inhibitors. Since patients on second-generation Btk inhibitors apparently show less bleeding than patients on ibrutinib, we compared the effects of ibrutinib and four novel irreversible Btk inhibitors on GPVI-dependent platelet aggregation in blood and in vitro bleeding time. Low concentrations of collagen which induced the same low degree of GPVI-mediated platelet aggregation as atherosclerotic plaque material were applied. IC₅₀ values for collagen (0.2–0.5 µg/mL)-induced platelet aggregation after 15-minute pre-incubation were: ibrutinib 0.12 µM, BGB-3111 0.51 µM, acalabrutinib 1.21 µM, ONO/GS-4059 1.20 µM and evobrutinib 5.84 µM. Peak venous plasma concentrations of ibrutinib (0.5 µM), acalabrutinib (2 µM) and ONO/GS-4059 (2 µM) measured after anti-proliferative dosage inhibited collagen-induced platelet aggregation, but did not increase PFA-200 closure time on collagen/epinephrine. Closure times were moderately increased by 2- to 2.5-fold higher concentrations of these inhibitors, but not by BGB-3111 (1 µM) and evobrutinib (10 µM). Prolonging platelet drug exposure to 60 minutes lowered IC₅₀ values of any Btk inhibitor for GPVI-mediated aggregation by several fold, and 5- to 10-fold below anti-proliferative therapeutic drug plasma levels. In conclusion, low blood concentrations of ibrutinib and the novel Btk inhibitors suffice for GPVI selective platelet inhibition relevant for atherothrombosis but do not impair primary haemostasis.

Keywords

Btk inhibitor - platelet aggregation - bleeding - PFA - GPVI

• References

• 1 Honigberg LA, Smith AM, Sirisawad M. , et al. The Bruton tyrosine kinase inhibitor PCI-32765 blocks B-cell activation and is efficacious in models of autoimmune disease and B-cell malignancy. Proc Natl Acad Sci U S A 2010; 107 (29) 13075-13080
• 2 Byrd JC, Furman RR, Coutre SE. , et al. Targeting BTK with ibrutinib in relapsed chronic lymphocytic leukemia. N Engl J Med 2013; 369 (01) 32-42
• 3 Wang ML, Rule S, Martin P. , et al. Targeting BTK with ibrutinib in relapsed or refractory mantle-cell lymphoma. N Engl J Med 2013; 369 (06) 507-516
• 4 Byrd JC, Furman RR, Coutre SE. , et al. Three-year follow-up of treatment-naïve and previously treated patients with CLL and SLL receiving single-agent ibrutinib. Blood 2015; 125 (16) 2497-2506
• 5 Quek LS, Bolen J, Watson SP. A role for Bruton's tyrosine kinase (Btk) in platelet activation by collagen. Curr Biol 1998; 8 (20) 1137-1140
• 6 Oda A, Ikeda Y, Ochs HD. , et al. Rapid tyrosine phosphorylation and activation of Bruton's tyrosine/Tec kinases in platelets induced by collagen binding or CD32 cross-linking. Blood 2000; 95 (05) 1663-1670
• 7 Penz S, Reininger AJ, Brandl R. , et al. Human atheromatous plaques stimulate thrombus formation by activating platelet glycoprotein VI. FASEB J 2005; 19 (08) 898-909
• 8 Schulz C, Penz S, Hoffmann C. , et al. Platelet GPVI binds to collagenous structures in the core region of human atheromatous plaque and is critical for atheroprogression in vivo. Basic Res Cardiol 2008; 103 (04) 356-367
• 9 Reininger AJ, Bernlochner I, Penz SM. , et al. A 2-step mechanism of arterial thrombus formation induced by human atherosclerotic plaques. J Am Coll Cardiol 2010; 55 (11) 1147-1158
• 10 Jamasbi J, Megens RT, Bianchini M. , et al. Differential inhibition of human atherosclerotic plaque-induced platelet activation by dimeric GPVI-Fc and anti-GPVI antibodies: functional and imaging studies. J Am Coll Cardiol 2015; 65 (22) 2404-2415
• 11 Mojica Muñoz AK, Jamasbi J, Uhland K. , et al. Recombinant GPVI-Fc added to single or dual antiplatelet therapy in vitro prevents plaque-induced platelet thrombus formation. Thromb Haemost 2017; 117 (08) 1651-1659
• 12 Busygina K, Jamasbi J, Seiler T. , et al. Oral Bruton tyrosine kinase inhibitors selectively block atherosclerotic plaque-triggered thrombus formation in humans. Blood 2018; 131 (24) 2605-2616
• 13 Wang ML, Blum KA, Martin P. , et al. Long-term follow-up of MCL patients treated with single-agent ibrutinib: updated safety and efficacy results. Blood 2015; 126 (06) 739-745
• 14 Shillitoe B, Gennery A. X-Linked Agammaglobulinaemia: outcomes in the modern era. Clin Immunol 2017; 183: 54-62
• 15 Stewart DM, Lian L, Nelson DL. The clinical spectrum of Bruton's agammaglobulinemia. Curr Allergy Asthma Rep 2001; 1 (06) 558-565
• 16 Lipsky AH, Farooqui MZ, Tian X. , et al. Incidence and risk factors of bleeding-related adverse events in patients with chronic lymphocytic leukemia treated with ibrutinib. Haematologica 2015; 100 (12) 1571-1578
• 17 Byrd JC, Harrington B, O'Brien S. , et al. Acalabrutinib (ACP-196) in relapsed chronic lymphocytic leukemia. N Engl J Med 2016; 374 (04) 323-332
• 18 Bye AP, Unsworth AJ, Desborough MJ. , et al. Severe platelet dysfunction in NHL patients receiving ibrutinib is absent in patients receiving acalabrutinib. Blood Adv 2017; 1 (26) 2610-2623
• 19 Nicolson PLR, Hughes CE, Watson S. , et al. Inhibition of Btk by Btk-specific concentrations of ibrutinib and acalabrutinib delays but does not block platelet aggregation to GPVI. Haematologica 2018 Doi: 10.3324/haematol.2018.193391
• 20 Atkinson BT, Ellmeier W, Watson SP. Tec regulates platelet activation by GPVI in the absence of Btk. Blood 2003; 102 (10) 3592-3599
• 21 Bye AP, Unsworth AJ, Vaiyapuri S, Stainer AR, Fry MJ, Gibbins JM. Ibrutinib inhibits platelet integrin alphaiibbeta3 outside-in signaling and thrombus stability but not adhesion to collagen. Arterioscler Thromb Vasc Biol 2015; 35 (11) 2326-2335
• 22 Senis YA, Mazharian A, Mori J. Src family kinases: at the forefront of platelet activation. Blood 2014; 124 (13) 2013-2024
• 23 Calquence. Full prescribing information; 2017. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/210259s000lbl.pdf . Accessed January 8, 2019
• 24 Walter HS, Rule SA, Dyer MJ. , et al. A phase 1 clinical trial of the selective BTK inhibitor ONO/GS-4059 in relapsed and refractory mature B-cell malignancies. Blood 2016; 127 (04) 411-419
• 25 Wu J, Liu C, Tsui ST, Liu D. Second-generation inhibitors of Bruton tyrosine kinase. J Hematol Oncol 2016; 9 (01) 80
• 26 ClinicalTrials.gov. A study of efficacy and safety of M2951 in subjects with relapsing multiple sclerosis; 2018. Available at: https://clinicaltrials.gov/ct2/show/NCT02975349?term=evobrutinib&rank=6 . Accessed January 8, 2019
• 27 Tóth O, Calatzis A, Penz S, Losonczy H, Siess W. Multiple electrode aggregometry: a new device to measure platelet aggregation in whole blood. Thromb Haemost 2006; 96 (06) 781-788
• 28 Bampalis VG, Brantl SA, Siess W. Why and how to eliminate spontaneous platelet aggregation in blood measured by multiple electrode aggregometry. J Thromb Haemost 2012; 10 (08) 1710-1714
• 29 Kundu SK, Heilmann EJ, Sio R, Garcia C, Davidson RM, Ostgaard RA. Description of an in vitro platelet function analyzer--PFA-100. Semin Thromb Hemost 1995; 21 (Suppl. 02) 106-112
• 30 von Pape KW, Aland E, Bohner J. Platelet function analysis with PFA-100 in patients medicated with acetylsalicylic acid strongly depends on concentration of sodium citrate used for anticoagulation of blood sample. Thromb Res 2000; 98 (04) 295-299
• 31 Reny JL, De Moerloose P, Dauzat M, Fontana P. Use of the PFA-100 closure time to predict cardiovascular events in aspirin-treated cardiovascular patients: a systematic review and meta-analysis. J Thromb Haemost 2008; 6 (03) 444-450
• 32 Advani RH, Buggy JJ, Sharman JP. , et al. Bruton tyrosine kinase inhibitor ibrutinib (PCI-32765) has significant activity in patients with relapsed/refractory B-cell malignancies. J Clin Oncol 2013; 31 (01) 88-94
• 33 Barf T, Covey T, Izumi R. , et al. Acalabrutinib (ACP-196): a covalent Bruton tyrosine kinase inhibitor with a differentiated selectivity and in vivo potency profile. J Pharmacol Exp Ther 2017; 363 (02) 240-252
• 34 Liu J, Fitzgerald ME, Berndt MC, Jackson CW, Gartner TK. Bruton tyrosine kinase is essential for botrocetin/VWF-induced signaling and GPIb-dependent thrombus formation in vivo. Blood 2006; 108 (08) 2596-2603
• 35 Kazianka L, Drucker C, Skrabs C. , et al. Ristocetin-induced platelet aggregation for monitoring of bleeding tendency in CLL treated with ibrutinib. Leukemia 2017; 31 (05) 1117-1122
• 36 Shatzel JJ, Olson SR, Tao DL, McCarty OJT, Danilov AV, DeLoughery TG. Ibrutinib-associated bleeding: pathogenesis, management and risk reduction strategies. J Thromb Haemost 2017; 15 (05) 835-847
• 37 Walter HS, Jayne S, Rule SA. , et al. Long-term follow-up of patients with CLL treated with the selective Bruton's tyrosine kinase inhibitor ONO/GS-4059. Blood 2017; 129 (20) 2808-2810
• 38 Chen J, Kinoshita T, Gururaja T. , et al. The effect of Bruton's tyrosine kinase (BTK) inhibitors on collagen-induced platelet aggregation, BTK, and tyrosine kinase expressed in hepatocellular carcinoma (TEC). Eur J Haematol 2018 Doi: 10.1111/ejh.13148
• 39 Lorenz RL, Boehlig B, Uedelhoven WM, Weber PC. Superior antiplatelet action of alternate day pulsed dosing versus split dose administration of aspirin. Am J Cardiol 1989; 64 (18) 1185-1188
• 40 Ungerer M, Rosport K, Bültmann A. , et al. Novel antiplatelet drug Revacept (Dimeric Glycoprotein VI-Fc) specifically and efficiently inhibited collagen-induced platelet aggregation without affecting general hemostasis in humans. Circulation 2011; 123 (17) 1891-1899
• 41 ClinicalTrials.gov. Revacept in symptomatic carotid stenosis; 2012. Available at: https://clinicaltrials.gov/ct2/show/NCT01645306 . Accessed December 5, 2016
• 42 ClinicalTrials.gov. Intracoronary stenting and antithrombotic regimen: lesion platelet adhesion as selective target of endovenous Revacept (ISAR-PLASTER); 2017. Available at: https://clinicaltrials.gov/ct2/show/NCT03312855 . Accessed December 5, 2018
• 43 Alshehri OM, Hughes CE, Montague S. , et al. Fibrin activates GPVI in human and mouse platelets. Blood 2015; 126 (13) 1601-1608
• 44 Mammadova-Bach E, Ollivier V, Loyau S. , et al. Platelet glycoprotein VI binds to polymerized fibrin and promotes thrombin generation. Blood 2015; 126 (05) 683-691
• 45 Mangin PH, Onselaer MB, Receveur N. , et al. Immobilized fibrinogen activates human platelets through glycoprotein VI. Haematologica 2018; 103 (05) 898-907
• 46 Ebrahim M, Jamasbi J, Adler K. , et al. Dimeric glycoprotein VI binds to collagen but not to fibrin. Thromb Haemost 2018; 118 (02) 351-361
• 47 Ungerer M, Li Z, Baumgartner C. , et al. The GPVI-Fc fusion protein Revacept reduces thrombus formation and improves vascular dysfunction in atherosclerosis without any impact on bleeding times. PLoS One 2013; 8 (08) e71193
• 48 Jamasbi J, Megens RT, Bianchini M. , et al. Cross-linking GPVI-Fc by anti-Fc antibodies potentiates its inhibition of atherosclerotic plaque- and collagen-induced platelet activation. JACC Basic Transl Sci 2016; 1 (03) 131-142