ORIGINAL ARTICLE
`
`Effect of CYP3A perpetrators on ibrutinib exposure in
`healthy participants
`Jan de Jong1,, Donna Skee2, Joe Murphy2, Juthamas Sukbuntherng3, Peter Hellemans4, Johan Smit4,
`Ronald de Vries4, Juhui James Jiao2, Jan Snoeys4 & Erik Mannaert4
`1Janssen Research & Development, San Diego, California
`2Janssen Research & Development, Raritan, New Jersey
`3Pharmacyclics Inc., Sunnyvale, California
`4Janssen Research & Development, Beerse, Belgium
`
`Keywords
`Bioavailability, CYP3A perpetrators, grapefruit
`juice, ibrutinib, ketoconazole, rifampin
`
`Correspondence
`Jan de Jong, 3210 Merryfield Row, San
`Diego, CA 92121. Tel: 1 (858) 320-3480;
`E-mail: jdejong1@its.jnj.com
`
`Funding Information
`This study was supported by funding from
`Janssen Research & Development, LLC.
`
`Received: 15 May 2015; Accepted: 24 May
`2015
`
`Pharma Res Per, 3(4), 2015, e00156,
`doi: 10.1002/prp2.156
`
`doi: 10.1002/prp2.156
`
`Previous Presentation: American Society for
`Clinical Pharmacology and Therapeutics
`(ASCPT), March 18–24, 2014.
`
`Abstract
`
`Ibrutinib (PCI-32765), a potent covalent inhibitor of Bruton’s tyrosine kinase,
`has shown efficacy against a variety of B-cell malignancies. Given the prominent
`role of CYP3A in ibrutinib metabolism, effect of coadministration of CYP3A
`perpetrators with ibrutinib was evaluated in healthy adults. Ibrutinib (120 mg
`[Study 1, fasted], 560 mg [studies 2 (fasted), and 3 (nonfasted)]) was given
`alone and with ketoconazole [Study 1; 400 mg q.d.], rifampin [Study 2;
`600 mg q.d.], and grapefruit juice [GFJ, Study 3]. Lower doses of ibrutinib
`were used together with CYP3A inhibitors [Study 1: 40 mg; Study 3: 140 mg],
`as safety precaution. Under fasted condition, ketoconazole increased ibrutinib
`dose-normalized (DN) exposure [DN-AUClast: 24-fold; DN-Cmax: 29-fold],
`rifampin decreased ibrutinib exposure [Cmax: 13-fold; AUClast: 10-fold]. Under
`nonfasted condition, GFJ caused a moderate increase [DN-Cmax: 3.5-fold; DN-
`AUC: 2.2-fold], most likely through inhibition of intestinal CYP3A. Half-life
`was not affected by CYP perpetrators indicating the interaction was mainly on
`first-pass extraction. All treatments were well-tolerated.
`
`Abbreviations
`AE, adverse events; BCR, B-cell antigen receptor; BTK, Bruton’s tyrosine kinase;
`DDI, drug–drug interaction; GFJ, grapefruit juice; LC-MS/MS, liquid chromatogra-
`phy-tandem mass spectroscopy; PBPK, physiologically based pharmacokinetic.
`
`Introduction
`
`B-cell antigen receptor (BCR) signaling is implicated as a
`pivotal pathway in tumorigenesis in majority of B-cell
`malignancies. Antigen stimulation of normal B cells trig-
`gers dimerization of BCR initiating a downstream signal-
`ing kinase cascade, which in turn regulates multiple
`cellular processes, including proliferation, differentiation,
`apoptosis, and survival (Fuentes-Panana et al. 2004; Ad-
`vani et al. 2013). Bruton’s tyrosine kinase (BTK), a criti-
`cal terminal kinase enzyme in the BCR signaling pathway,
`is a promising target
`for therapeutic intervention in
`
`human malignancies. This downstream signal transduc-
`tion protein plays a key role in the activation of pathways
`necessary for B-cell trafficking, chemotaxis, and adhesion,
`and has also been implicated in initiation, survival, and
`progression of mature B-cell
`lymphoproliferative disor-
`ders (Kuppers 2005).
`â
`, PCI–32765), an orally active,
`Ibrutinib (Imbruvica
`BTK-targeting inhibitor, has been recently approved for
`the treatment of patients with chronic lymphocytic leuke-
`mia and mantle cell lymphoma who have received at least
`one prior therapy; Ibrutinib being the first covalent inhib-
`itor of BTK to be advanced into human clinical trials. It
`
`ª 2015 Janssen Research and Development, LLC. Pharmacology Research & Perspectives published by John Wiley & Sons Ltd,
`British Pharmacological Society and American Society for Pharmacology and Experimental Therapeutics.
`This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License,
`which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and
`no modifications or adaptations are made.
`
`2015 | Vol. 3 | Iss. 4 | e00156
`Page 1
`
`SANDOZ INC.
`
`IPR2023-00478
`
`Ex. 1036, p. 1 of 11
`
`

`

`CYP3A Perpetrators and Ibrutinib Exposure
`
`Jan de Jong et al.
`
`forms a stable covalent bond with cysteine-481 on the
`active site of BTK and irreversibly inhibits BTK phos-
`phorylation on Tyr223, impairing BCR signaling, and dis-
`rupting the proliferation and survival of malignant B-cells
`Ibrutinib is
`(IC50: 0.39 nM) (Honigberg et al. 2010).
`almost
`exclusively metabolized by cytochrome P450
`(CYP) CYP3A. Absolute oral bioavailability (F) is low,
`ranging from 3.9% in the fasted state to 8.4% following a
`standard breakfast without grapefruit
`juice (GFJ) and
`15.9% with GFJ (de Vries et al. 2015). A major metabo-
`lite of ibrutinib, PCI-45227, is a dihydrodiol metabolite
`that displays reversible binding with an inhibitory activity
`toward BTK approximately 15 times lower than that of
`ibrutinib (Parmar et al. 2014).
`Ibrutinib has a mean peak plasma concentration
`observed at 1–2 h after administration. The mean termi-
`nal half-life is 4–13 h, with minimum drug accumulation
`after repeated dosing (<twofold) (Advani et al. 2013; Byrd
`et al. 2013; ImbruvicaTM., 2014). Population pharmacoki-
`netic (PK) analysis indicated that ibrutinib clearance is
`independent of age (Marostica et al. 2015).
`Multiple medications are administered in conjunction
`with ibrutinib for concurrent diseases including those for
`opportunistic infections. Given the prominent role of
`CYP3A in ibrutinib metabolism, drug–drug interactions
`(DDIs) that affect ibrutinib exposure and its metabolites,
`may occur when coadministered with potent CYP3A
`inhibitors or inducers. It is thus essential to understand
`the PK profile of ibrutinib when interacting with the CYP
`enzyme system, which can affect drug metabolism and
`clearance as well as, alter their safety and efficacy profile
`and/or of their active metabolites.
`This paper discusses results from three phase 1 studies
`which were undertaken to obtain a comprehensive under-
`standing of DDI between ibrutinib and CYP3A perpetra-
`tors ketoconazole (strong inhibitor) (Study 1), rifampin
`(strong inducer) (Study 2),and single-strength GFJ (classi-
`fied as a moderate inhibitor,
`specific for
`intestinal
`CYP3A) (Study 3) and their effect on ibrutinib exposure.
`Because it became clear during clinical development that
`food by itself significantly increases the relative bioavail-
`ability, Study 3 was performed in nonfasted condition. In
`this way, the CYP3A DDI could be assessed under more
`relevant conditions, and data from both fasted and non-
`fasted condition could be used in building a robust
`physiologically based pharmacokinetic (PBPK) model.
`
`Materials and methods
`
`Study population
`
`aged 18–55 years
`(nonsmokers)
`Healthy participants
`(inclusive) with body mass index 18–30 kg/m2 and body
`
`weight ≥50 kg were enrolled in all three studies. Study 1
`enrolled only men, whereas studies 2 and 3 enrolled both
`men and women.
`Participants with evidence of any clinically significant
`medical illness that could interfere with interpretation of
`study results or other abnormalities in physical examina-
`tion, clinical
`laboratory parameters, vital signs, or ECG
`abnormalities etc. detected at screening, were excluded
`from all three studies. Women were required to be post-
`menopausal or surgically sterile. In all three studies, par-
`ticipants were to refrain from taking any over-the-counter
`or prescribed medications except acetaminophen (<3 g
`per day).
`Protocols for each study were approved by an Indepen-
`dent Ethics Committee or Institutional Review Board at
`each study site and the studies were conducted in accor-
`dance with the ethical principles originating in the Decla-
`ration of Helsinki and in accordance with the ICH Good
`Clinical Practice guidelines, applicable regulatory require-
`ments, and in compliance with the protocol. All partici-
`pants provided written informed consent to participate in
`the studies.
`
`Study design and treatment
`
`Studies 1 and 2 were sequential design dedicated DDI
`studies of
`ibrutinib with ketoconazole and rifampin,
`respectively, versus Study 3, which was a two-way cross-
`over DDI study with GFJ, combined with a formal abso-
`lute bioavailability study following single oral dose
`administration of ibrutinib in comparison with a single
`intravenous (i.v.) administration. All three studies were
`single center, and open-label.
`Study 1 (clinicaltrials.gov identifier: NCT01626651)
`consisted of
`three phases: screening period (21 days),
`open-label treatment period (10 days), and follow-up per-
`(10  2 days).
`iod
`Participants
`received
`ibrutinib
`(120 mg, oral) on day 1 followed by blood sampling for
`PK analysis upto 72 h. Ketoconazole (Tara Pharmaceuti-
`cals), 400 mg oral, was given once-daily (q.d.) from days
`4 to 9 (except on day 7); on day 7 they received ibrutinib
`(40 mg, oral) in combination with ketoconazole (400 mg,
`oral) 1 h before ibrutinib dosing.
`Study 2 (clinicaltrials.gov identifier: NCT01763021)
`consisted of screening period (21 days), open-label treat-
`ment
`period
`(14 days)
`and
`follow-up
`period
`(10  2 days). Participants received ibrutinib, 560 mg,
`oral, q.d. on day 1. Rifampin (VersaPharm) 600 mg
`oral, q.d. was given from days 4 to 13 (after the last ibr-
`utinib sample collection for PK [over 72 h]). On day
`11, a second single oral dose of ibrutinib 560 mg was
`administered,
`followed by the blood sample collection
`over 72 h.
`
`2015 | Vol. 3 | Iss. 4 | e00156
`Page 2
`
`ª 2015 Janssen Research and Development, LLC. Pharmacology Research & Perspectives published by John Wiley & Sons Ltd,
`British Pharmacological Society and American Society for Pharmacology and Experimental Therapeutics.
`
`SANDOZ INC.
`
`IPR2023-00478
`
`Ex. 1036, p. 2 of 11
`
`

`

`Jan de Jong et al.
`
`CYP3A Perpetrators and Ibrutinib Exposure
`
`ibrutinib was administered after
`In studies 1 and 2,
`overnight fast; food was withheld for 4 h after ibrutinib
`administration on dosing days.
`Study 3 (clinicaltrials.gov identifier: NCT01866033) con-
`sisted of screening period (21 days), open-label treatment
`period (treatment A, B and C) (19 days), and follow-up
`period (10  2 days). All participants received ibrutinib
`(560 mg) in treatment A and then randomized to either
`treatment B (ibrutinib [560 mg] administered 30 min after
`240 mL of glucose in water) or treatment C (240 mL of
`GFJ [Albert Heijn pink] the evening before and 30 min
`before ibrutinib [140 mg]). In treatments B and C, partici-
`pants had standard breakfast 30 min after ibrutinib dosing,
`as opposed to treatment A which was given in fasted condi-
`tion. A single i.v. dose of 100 lg 13C6 PCI–32765 was
`administered 2 h after each ibrutinib oral dose.
`In all three studies, participants took ibrutinib with
`240 mL of water and lunch and subsequent standard
`meals were provided 4 h after oral ibrutinib dosing. Par-
`ticipants
`remained seated throughout morning (from
`30 min before dosing until after lunch),
`in order to
`minimize inter and intrasubject intestinal blood flow dif-
`ferences.
`
`Pharmacokinetic evaluations
`
`Sample collection
`
`Blood samples for all studies were collected by direct
`venipuncture or through an indwelling peripheral venous
`heparin lock catheter into heparin collection tubes. Sam-
`ples were centrifuged at approximately 4°C (15 min at
`1300 g); plasma was stored at ≤70°C.
`Blood samples for PK analysis were collected predose
`and 0.5, 1, 1.5, 2, 3, 4, 6, 8, 12, 16, 24, 48, and 72 h post-
`dose on days 1 and 7 (Study 1 and 3) and days 1 and 11
`(Study 2) for quantification of ibrutinib and PCI-45227.
`Additional blood samples were collected 2 h after ketoco-
`nazole dosing on day 7 (1 h after ibrutinib dosing) (Study
`1) and 2 h after rifampin dosing on day 11 (Study 2) for
`ketoconazole and rifampin measurement, respectively. In
`Study 2, samples were collected and analyzed for determi-
`nation of 4-b-hydroxycholesterol concentration on day -1,
`12 h after ibrutinib administration on day 11 and 14.
`
`Quantification range was 0.100–25.0 ng/mL for ibrutinib
`and PCI-45227 (Study 1 and 2) and 0.5–100 ng/mL (Study
`3) (de Vries et al. 2015). Quantification range for 13C6 PCI-
`32765 was 2–1000 pg/mL (de Vries et al. 2015).
`
`Pharmacokinetic analysis
`
`PK analyses were performed by noncompartmental meth-
`â
`software Version 5.2.1
`ods using validated WinNonlin
`(Certara USA, Inc. Princeton, NJ) and Phoenix WinNonlin
`6.3. Key PK parameters included maximum observed
`plasma concentration (Cmax), time to reach maximum
`observed plasma concentration (tmax), elimination half-life
`associated with terminal slope (kz) of the semilogarithmic
`drug concentration-time curve (t1/2k), area under the
`plasma concentration-time curve (AUC) from time 0 to
`24 h (AUC24), AUC from time 0 to time of the last quanti-
`fiable concentration (AUClast), AUC from time 0 to infin-
`ity (AUC∞) and metabolite/parent ratios. In Study 1,
`apparent total clearance of drug after extravascular admin-
`istration (CL/F), and apparent volume of distribution
`based on the terminal phase (Vdz) were also estimated.
`Additionally, in Study 3, absolute bioavailability (F) and
`total clearance of drug after i.v. administration (CL) were
`also estimated.
`
`Safety evaluations
`
`treatment-
`included assessments of
`Safety evaluations
`related adverse events (AE), vital signs, 12-lead electrocar-
`diograms, clinical laboratory tests, and physical examina-
`tions. The AE severity was graded according to the
`National Cancer Institute - Common Terminology Crite-
`ria for Adverse Events (NCI-CTCAE) grading system ver-
`sion 4.03.
`
`Analysis sets
`
`Participants who had estimations of PK parameters of
`ibrutinib for both periods (ibrutinib administered alone
`and in combination with CYP3A perpetrators) were
`included in PK analysis set
`for statistical comparison.
`Participants who received at least one dose of study medi-
`cation were included in safety analysis set.
`
`Analytical methods
`Plasma concentrations of ibrutinib, its metabolite, PCI–
`45227, ketoconazole, rifampin, and 13C6 ibrutinib, were
`determined using validated analytical liquid chromatogra-
`phy-tandem mass
`spectroscopy (LC-MS/MS) methods.
`Bioanalyses were conducted at Department of Bioanalysis,
`Janssen R&D and at Frontage Laboratories, Inc., Exton, PA.
`
`Sample size determination
`
`For all three studies, sample size determinations were
`based on statistical estimation. A sample size is consid-
`ered adequate if the point estimates of GMR for PK
`parameters of primary interest (Cmax, AUCs) fall within
`the no-effect boundaries of clinical equivalence (90% CI)
`to the compound.
`
`ª 2015 Janssen Research and Development, LLC. Pharmacology Research & Perspectives published by John Wiley & Sons Ltd,
`British Pharmacological Society and American Society for Pharmacology and Experimental Therapeutics.
`
`2015 | Vol. 3 | Iss. 4 | e00156
`Page 3
`
`SANDOZ INC.
`
`IPR2023-00478
`
`Ex. 1036, p. 3 of 11
`
`

`

`CYP3A Perpetrators and Ibrutinib Exposure
`
`Jan de Jong et al.
`
`Statistical analyses
`
`All individual and mean plasma concentrations and esti-
`mated PK parameters were presented by graphic and
`descriptive statistics methods for each treatment. Linear
`mixed-effect models were applied to evaluate potential
`DDI effect. Log-transformation was performed on PK
`parameters (Cmax, AUCs) prior to the analysis, and 90%
`confidence intervals for GMR (with/without coadminis-
`tration of interacting drugs) were constructed on original
`scale.
`
`Results
`
`Subject disposition and demographics
`All enrolled participants (Study 1: n = 18; Study 3: n = 8)
`completed studies 1 and 3. In Study 2, 17/18 enrolled
`participants completed the study. One participant was
`excluded from the PK-evaluable population due to a pro-
`tocol deviation (use of prohibited concomitant pain med-
`ication). Demographics and baseline characteristics of the
`participants in three studies were consistent with the
`inclusion and exclusion criteria (Table 1). All participants
`received scheduled doses of the study drugs.
`
`Pharmacokinetic results
`
`Study 1: effect of ketoconazole on pharmacokinetics of
`ibrutinib and its metabolite
`
`Following coadministration of ibrutinib with ketoconazole
`under fasted condition, mean DN_Cmax (dose normalized
`to 120 mg) of ibrutinib increased from 11.8 to 325 ng/mL
`and mean DN_AUClast increased from 71.4 to 1599 ng h/
`
`mL (Fig. 1A). Although dose proportionality was not for-
`mally tested for ibrutinib, no deviations from linearity
`were observed neither in the Phase I escalating dose study
`nor population PK study (imbruvicaTM 2014; Marostica
`et al. 2015), thus justifying the dose-normalization of ibr-
`utinib exposure in this study. Intersubject variability in
`ibrutinib+ketoconazole treated participants for both Cmax
`and AUClast were >50% following ibrutinib administra-
`tion alone and approximately 40% when coadministered
`with ketoconazole. The Vd/F and CL/F were both lower
`following ibrutinib + ketoconazole compared with ibruti-
`nib alone (Vd/F: 885 L vs. 19049 L; CL/F: 92.0 L/h vs.
`2014 L/h, whereas there was no change in mean tmax
`(2.00 h vs. 1.75 h) and t1/2 (6.32 h vs. 8.20 h) (Table S1).
`On the other hand, dose-normalized PCI-45227 expo-
`sure was lower following coadministration with ketoconaz-
`ole
`compared with ibrutinib
`administration alone
`(Fig. 1B). The DN_Cmax was 2.6 times lower (11.1 ng/mL
`
`Table 1. Demographics and baseline characteristics (safety analysis
`set).
`
`Sex, n
`Women
`Men
`Race, n (%)
`White
`Black or African American
`Other/multiple
`Ethnicity, n (%)
`Not Hispanic or Latino
`Hispanic or Latino
`Age (years)
`Mean (SD)
`Baseline weight (kg)
`Mean (SD)
`Baseline BMI (kg/m2)
`Mean (SD)
`
`Study 11
`(n = 18)
`
`Study 22
`(n = 18)
`
`Study 33
`(n = 8)
`
`–
`
`18
`
`4 (22)
`11 (61)
`2 (11)
`
`16 (89)
`2 (11)
`
`8
`10
`
`5 (28)
`11 (61)
`2 (11)
`
`16 (89)
`2 (11)
`
`5
`3
`
`8 (100)
`
`8 (100)
`0
`
`–
`–
`
`33.7 (8.8)
`
`41.1 (11.6)
`
`46.4 (8.1)
`
`78.0 (7.4)
`
`77.6 (8.7)
`
`70.0 (13.2)
`
`26.1 (2.3)
`
`26.4 (2.5)
`
`23.5 (2.7)
`
`BMI, body mass index; GFJ, grapefruit juice; SD, standard deviation.
`1Study 1: ibrutinib + ketoconazole.
`2Study 2: ibrutinib + rifampin.
`3Study 3: Ibrutinib + grapefruit juice.
`
`vs. 29.1 ng/mL) and DN_AUClast was 1.2 times lower
`(256 ng h/mL vs. 304 ng h/mL) following ibrutinib + ke-
`toconazole treatment compared with ibrutinib alone. In-
`tersubject variability for both Cmax and AUClast was
`approximately 40% following ibrutinib administration
`alone and approximately 20% following ibrutinib + ke-
`toconazole. Tmax and t1/2 were both slightly longer follow-
`ing ibrutinib + ketoconazole (Tmax: 4.00 h vs. 2.00 h; t1/2
`18.00 h vs. 11.41 h). Following coadministration with ke-
`toconazole, ibrutinib mean DN_Cmax increased approxi-
`mately 29-fold (geometric mean [GM]: 285.49 vs. 10.0 ng/
`mL), and mean DN_AUClast increased approximately 24-
`fold (GM: 1463.43 vs. 61.16 ng h/mL) (Table 2). Mean
`metabolite to parent ratios decreased from 2.64 to 0.05 for
`Cmax and from 5.03 to 0.19 for AUC24 following ibruti-
`nib+ketoconazole coadministration.
`Plasma concentrations for ketoconazole at 1 h after
`drug intake on day 7 ranged from 231 to 15,800 ng/mL.
`Two participants had very low ketoconazole concentra-
`tions (352 ng/mL and 231 ng/mL); the interaction was
`still within the observed range.
`
`Study 2: effect of rifampin on the pharmacokinetics of
`ibrutinib and its metabolite
`
`Following coadministration with rifampin under fasted
`ibrutinib mean Cmax and AUClast decreased
`condition,
`(Cmax: 42.1 ng/mL to 3.38 ng/mL; AUClast: 335 ng h/mL
`
`2015 | Vol. 3 | Iss. 4 | e00156
`Page 4
`
`ª 2015 Janssen Research and Development, LLC. Pharmacology Research & Perspectives published by John Wiley & Sons Ltd,
`British Pharmacological Society and American Society for Pharmacology and Experimental Therapeutics.
`
`SANDOZ INC.
`
`IPR2023-00478
`
`Ex. 1036, p. 4 of 11
`
`

`

`Jan de Jong et al.
`
`CYP3A Perpetrators and Ibrutinib Exposure
`
`(A)
`
`(B)
`
`Figure 1. Dose-normalized mean (SD) logarithmic-linear plasma concentration-time profiles following oral administration of ibrutinib (120 mg)
`alone (day 1) and in combination with ketoconazole (40 mg Ibrutinib+400 mg Ketoconazole) (day 7) to healthy men. (A) Ibrutinib; (B) PCI-45227.
`374 ng h/mL (Fig. 2B). Intersubject variability for both
`to 38.0 ng h/mL) compared with ibrutinib administration
`Cmax and AUClast was greater than 30% following ibruti-
`alone (Fig. 2A). Intersubject variability for both Cmax and
`AUClast was greater than 60% following ibrutinib admin-
`nib administration alone and greater than 20% following
`ibrutinib + rifampin. Similar to the parent, median tmax
`istration alone and greater than 70% following ibruti-
`of the metabolite was delayed following ibrutinib + rifam-
`nib+rifampin. Median tmax was delayed from 1.76 to
`3.00 h. Terminal t1/2 was similar; due to multiple data
`pin coadministration compared with ibrutinib treatment
`alone (from 2.02 to 3.00 h). Terminal t1/2 trended shorter
`points below the quantification limit in the elimination
`for the combination treatment. The GMR for Cmax and
`phase, it could only be calculated for 5 of 17 participants.
`AUClast was 7.94% and 10.44% (or a 13- and 10-fold
`Following coadministration with rifampin, PCI-45227
`decrease), respectively, for ibrutinib + rifampin compared
`mean Cmax decreased from 70.0 ng/mL to 49.9 ng/mL
`and mean AUClast decreased from 946 ng h/mL to
`with ibrutinib alone (Table 2). Metabolite to parent ratio
`
`ª 2015 Janssen Research and Development, LLC. Pharmacology Research & Perspectives published by John Wiley & Sons Ltd,
`British Pharmacological Society and American Society for Pharmacology and Experimental Therapeutics.
`
`2015 | Vol. 3 | Iss. 4 | e00156
`Page 5
`
`SANDOZ INC.
`
`IPR2023-00478
`
`Ex. 1036, p. 5 of 11
`
`

`

`CYP3A Perpetrators and Ibrutinib Exposure
`
`Jan de Jong et al.
`
`Table 2. Geometric mean ratio and the 90% CI of the combination treatment (studies 1, 2, and 3) over ibrutinib.
`
`Parameter
`
`Ibrutinib + Ketoconazole4
`Cmax (ng/mL)1,2
`AUC24 (ng h/mL)1,2
`AUClast (ng h/mL)1,2
`AUC∞ (ng h/mL)1,2
`
`Ibrutinib + Rifampin5
`Cmax (ng/mL)2
`AUC24h (ng h/mL)2
`
`AUClast (ng.h/mL)2
`AUC∞ (ng h/mL)2
`
`Ibrutinib + Grapefruit Juice6
`Cmax (ng/mL)2,3
`AUC24 (ng h/mL)2,3
`AUClast (ng h/mL)2,3
`AUC∞ (ng h/mL)2,3
`
`Test treatment/reference
`treatment7
`
`Ibrutinib + Ketoconazole
`Ibrutinib
`Ibrutinib + Ketoconazole
`Ibrutinib
`Ibrutinib + Ketoconazole
`Ibrutinib
`Ibrutinib + Ketoconazole
`Ibrutinib
`
`Ibrutinib + Rifampin
`Ibrutinib
`Ibrutinib + Rifampin
`Ibrutinib
`Ibrutinib + Rifampin
`Ibrutinib
`Ibrutinib + Rifampin
`Ibrutinib
`
`Ibrutinib + GFJ
`Ibrutinib
`Ibrutinib + GFJ
`Ibrutinib
`Ibrutinib + GFJ
`Ibrutinib
`Ibrutinib + GFJ
`Ibrutinib
`
`N
`
`18
`18
`18
`18
`18
`18
`12
`12
`
`17
`17
`17
`17
`17
`17
`4
`4
`
`8
`8
`7
`7
`8
`8
`7
`7
`
`Geometric
`mean
`
`Ratio: (%)8
`
`90% CI (%)8
`
`Intrasubject
`CV (%)
`
`286
`10
`1390
`56
`1463
`61
`1860
`71
`
`3
`32
`23
`214
`28
`267
`46
`300
`
`437
`121
`1337
`529
`1236
`588
`1378
`643
`
`2854.5
`
`2480.1
`
`2392.8
`
`2620.2
`
`7.9
`
`10.9
`
`10.4
`
`15.2
`
`360.4
`
`252.9
`
`210.2
`
`214.5
`
`2397–3400
`
`2002–3073
`
`1901–3012
`
`1996–3440
`
`6–12
`
`8–15
`
`7–15
`
`5–46
`
`269–483
`
`219–293
`
`182–243
`
`184–250
`
`31
`
`38
`
`41
`
`39
`
`69
`
`61
`
`62
`
`74
`
`31
`
`13
`
`15
`
`14
`
`CV, coefficient of variation; GFJ, grapefruit juice.
`1Parameter values were natural log (ln) transformed and dose normalized to 120 mg ibrutinib before analysis.
`2A mixed-effect model with treatment as a fixed effect and participant as a random effect was used. Parameter values were natural log (ln) trans-
`formed before analysis.
`3The oral ibrutinib with grapefruit juice treatment group was dose normalized to 560 mg.
`4Ibrutinib: 40 mg and ketoconazole: 400 mg.
`5Ibrutinib: 560 mg and rifampin: 600 mg.
`6Ibrutinib: 560 mg and GFJ: 240 mL.
`7Test Treatment: ibrutinib + ketoconazole/ibrutinib + rifampin/ibrutinib + grapefruit juice, Reference Treatment: ibrutinib.
`8Ratio of parameter means (expressed as a percent) and 90% CIs were transformed back to the linear scale.
`
`for Cmax increased from 2.09 to 20.80, and the ratio for
`AUClast increased from 3.10 to 15.50.
`Plasma concentrations for rifampin on day 11, 2 h after
`drug intake ranged from 289 ng/mL to 18400 ng/mL
`(mean  SD = 9247  4957 ng/mL). Low concentration
`of 289 ng/mL did not adversely affect
`induction, as
`decrease
`in ibrutinib exposure on day 11 in this
`participant was comparable with that observed in other
`participants. Compared with predose
`values
`(39.9
`[15.50]) ng/mL), 4-b-hydroxycholesterol
`concentrations
`increased following multiple once-daily oral administra-
`tions of
`rifampin, providing evidence that
`sufficient
`induction of CYP3A had occurred when 560 mg ibrutinib
`(day 11) was administered after 1 week of
`rifampin
`600 mg q.d., and that induction was maintained until the
`
`72-h PK sample was collected on day 14 (day 11: 97.3
`[29.4] ng/mL and day 14: 119 [39.6] ng/mL).
`
`Study 3: effect of GFJ on ibrutinib exposure
`
`Pretreatment with GFJ increased ibrutinib concentrations
`in plasma. DN_Cmax of ibrutinib increased by 3.5-fold,
`whereas DN_AUC increased by 2.2-fold in presence of
`single-strength GFJ compared with oral administration of
`560 mg ibrutinib without GFJ under nonfasted condition
`(Fig. 2C). On the other hand, the AUCs of ibrutinib fol-
`lowing i.v. administration under nonfasted conditions
`with and without GFJ were the same. Mean Cmax was
`slightly higher with GFJ, but intrasubject variability was
`very high (84%) (Fig. 3).
`
`2015 | Vol. 3 | Iss. 4 | e00156
`Page 6
`
`ª 2015 Janssen Research and Development, LLC. Pharmacology Research & Perspectives published by John Wiley & Sons Ltd,
`British Pharmacological Society and American Society for Pharmacology and Experimental Therapeutics.
`
`SANDOZ INC.
`
`IPR2023-00478
`
`Ex. 1036, p. 6 of 11
`
`

`

`Jan de Jong et al.
`
`(A)
`
`CYP3A Perpetrators and Ibrutinib Exposure
`
`(B)
`
`(C)
`
`(D)
`
`Figure 2. Mean (SD)
`logarithmic-linear plasma concentration-time profiles of ibrutinib (560 mg) and metabolite PCI-45227 in absence and
`presence of CYP perpetrators: Rifampin (600 mg) (A and B: fasted condition) Grapefruit Juice (C and D: nonfasted condition).
`
`without GFJ were comparable. Cmax metabolite-to-parent
`ratio decreased from 1.03 to 0.32 with the addition of GFJ.
`When ibrutinib was orally administered with GFJ,
`apparent clearance, CL/F and half-life both decreased by
`half; CL after i.v. administration, however, was unchanged
`with or without GFJ. The CL following i.v. administration
`under nonfasted condition was higher than that under
`fasted condition.
`The magnitude of observed DDI was higher with
`higher baseline clearance. The higher the baseline CL/F,
`the larger the effect of ketoconazole. This trend was not
`observed clearly for the weaker (and intestine-specific)
`inhibitor GFJ, or for the inducer rifampin (Fig. 4).
`
`Safety
`
`Figure 3. Mean (SD) AUClast and Cmax of ibrutinib following oral
`administration
`of
`ibrutinib
`alone
`and
`in
`combination with
`ketoconazole, rifampin, or grapefruit juice; data dose normalized to
`560 mg.
`
`There was no effect of GFJ on tmax of PCI-45227
`(Fig. 2D). Dose-normalized PCI-45227 concentrations and
`AUCs following oral administration of ibrutinib with or
`
`Treatments were generally well-tolerated in all three stud-
`ies. In Study 1, only one (6%) participant reported ≥1 AE
`(musculoskeletal discomfort) after ibrutinib administra-
`tion alone, and six participants (33%) reported ≥1 AE
`
`ª 2015 Janssen Research and Development, LLC. Pharmacology Research & Perspectives published by John Wiley & Sons Ltd,
`British Pharmacological Society and American Society for Pharmacology and Experimental Therapeutics.
`
`2015 | Vol. 3 | Iss. 4 | e00156
`Page 7
`
`SANDOZ INC.
`
`IPR2023-00478
`
`Ex. 1036, p. 7 of 11
`
`

`

`CYP3A Perpetrators and Ibrutinib Exposure
`
`Jan de Jong et al.
`
`Most common AEs following treatment with ibrutinib
`alone were musculoskeletal discomfort (n = 2, 11%) and
`following ibrutinib+rifampin included toothache (n = 2,
`11%) and headache (n = 3, 17%). All AE were of grade 1
`intensity except for two participants who experienced grade
`2 AEs (headache and morbilliform skin rash) following
`rifampin treatment. In Study 3, the most common AEs
`reported by >1 subject included abdominal pain, diarrhea,
`and dizziness. All events were grade 1 in severity except for
`grade 2 abdominal pain in one participant. There were no
`serious AEs, AEs leading to discontinuation or AEs that
`did not resolve at end of the study, reported in the three
`studies. There were no relevant changes in vital signs or
`12-lead ECG,
`laboratory safety or changes in physical
`examination findings in any of the studies.
`
`Discussion
`
`Ibrutinib is extensively metabolized by CYP3A and has
`low bioavailability due to extensive first-pass metabolism.
`Low bioavailability results
`in more variable PK and
`potential variability in desired therapeutic response as
`well as undesirable adverse effects. Studies reported here
`were therefore designed to understand the DDI potential
`between ibrutinib and CYP3A perpetrators (ketoconazole,
`rifampin and GFJ) and their probable effects on ibrutinib
`bioavailability in healthy participants.
`In line with in vitro data that showed 96% of micro-
`somal clearance could be attributed to CYP3A4 (Scheers
`et al. 2015), CYP3A perpetrators had a major effect on
`ibrutinib exposure, without affecting the terminal half-life.
`There was an increase in ibrutinib concentration follow-
`ing coadministration with ketoconazole; intersubject vari-
`ability was lower compared to ibrutinib alone, which can
`be explained by close to complete bioavailability in this
`situation. Though ketoconazole concentration was within
`the observed range, a low value observed in two partici-
`pants may be due to the over-expression of CYP3A in
`these two participants. These values correlated with ibr-
`utinib Cmax and AUC that were approximately 80% and
`70% lower, respectively, than the mean values, both with
`and without ketoconazole coadministration. Thus,
`the
`interaction did not differ significantly from the mean
`value,
`suggesting that
`complete
`inhibition was
`still
`obtained. In fasted condition, F was found to be 3.9%
`(90% CI = 3.06–5.02) in Study 3 (de Vries et al. 2015),
`implying that a 24-fold increase in ibrutinib AUC∞ with
`ketoconazole (Study 1 and hence a different cohort of
`participants) would result in F of approximately 73–121%
`(24 9 3.06 to 5.02%). In line with ketoconazole study
`observations, intersubject variability of ibrutinib exposure
`increased following rifampin coadministration, due to sig-
`nificantly decreased bioavailability.
`
`Figure 4. Fold-change in AUC versus baseline apparent clearance
`following oral administration of
`ibrutinib with ketoconazole or
`rifampin (both under fasted conditions) or with grapefruit juice (with
`standard meal).
`
`Table 3. Summary of treatment-emergent adverse events (AE) seen
`in more than 10% of participants in any study (safety analysis set).
`
`Study 11
`n = 18
`n (%)
`
`Study 22
`n = 18
`n (%)
`
`Study 33
`n = 8
`n (%)
`
`6 (33)
`
`7 (39)
`
`3 (38)
`
`–
`–
`–
`–
`–
`–
`–
`–
`–
`–
`–
`
`4 (22)
`–
`
`–
`–
`–
`–
`–
`–
`
`2 (11)
`2 (11)
`–
`–
`–
`
`3 (17)
`–
`
`3 (38)
`3 (38)
`1 (13)
`1 (13)
`1 (13)
`1 (13)
`
`1 (13)
`1 (13)
`2 (25)
`1 (13)
`1 (13)
`
`Number of participants
`with treatment-emergent AE
`Diarrhea
`Abdominal pain
`Dyspepsia
`Flatulence
`Vomiting
`Nausea
`Toothache
`Musculoskeletal discomfort
`Back injury
`Epicondylitis
`Dizziness
`Headache
`Hyperventilation
`
`1Study 1: ibrutinib + ketoconazole.
`2Study 2: ibrutinib + rifampin.
`3Study 3: ibrutinib + grapefruit juice.
`
`following coadministration with ketoconazole. In Study 1,
`the most common AEs (>10%) following ibrutinib+ke-
`toconazole coadministration were headache (n = 4, 22%),
`venipuncture-related hematoma and pain (n = 1, 6%),
`(n = 2,
`abdominal discomfort
`and dyspepsia
`11%)
`(Table 3). All AEs were mild in severity (grade 1), limited
`in duration, and, resolved without medical intervention.
`In Study 2, 5 participants (28%) reported ≥1AE after
`ibrutinib administration alone,
`compared with 22%
`(n = 4) following combination therapy with rifampin.
`
`2015 | Vol. 3 | Iss. 4 | e00156
`Page 8
`
`ª 2015 Janssen Research and Development, LLC. Pharmacology Research & Perspectives published by John Wiley & Sons Ltd,
`British Pharmacological Society and American Society for Pharmacology and Experimental Therapeutics.
`
`SANDOZ INC.
`
`IPR2023-00478
`
`Ex. 1036, p. 8 of 11
`
`

`

`Jan de Jong et al.
`
`CYP3A Perpetrators and Ibrutinib Exposure
`
`There was a concomitant decrease in metabolite PCI-
`45227 concentration following coadministration of ibruti-
`nib with both ketoconazole and rifampin. Decrease in
`exposure of PCI-45227 observed with rifampin may be
`attributed to further metabolism of PCI-45227 involving
`CYP3A or induction of P-gp, of which PCI-45227 is a
`substrate. Reductions in Cmax and AUC in Study 2 corre-
`lated with an increase in 4-b-hydroxycholesterol, an
`endogenous biomarker of CYP3A activity (Bjorkhem-
`Bergman et al. 2013; Marde Arrhen et al. 2013;