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Navitoclax, a targeted high-affinity inhibitor of BCL-2, in lymphoid malignancies: a phase 1 dose-escalation study of safety, pharmacokinetics, pharmacodynamics, and antitumour activity
Open accessAbstract
Background Proteins of the BCL-2 family regulate clonal selection and survival of lymphocytes, and are frequently overexpressed in lymphomas. Navitoclax is a targeted high-affinity small molecule that inhibits the anti-apoptotic activity of BCL-2 and BCL-XL. We aimed to assess the safety and antitumour activity of navitoclax in patients with lymphoid tumours, and establish the drug's pharmacokinetic and pharmacodynamic profiles.Methods In this phase 1 dose-escalation study, patients (aged ≥18 years) with relapsed or refractory lymphoid malignancies were enrolled and treated at seven sites in the USA between November, 2006, and November, 2009. A modified Fibonacci 3+3 design was used to assign patients to receive oral navitoclax once daily by one of two dosing schedules: intermittently for the first 14 days of a 21-day cycle (14/21) at doses of 10, 20, 40, 80, 110, 160, 225, 315, or 440 mg/day; or continuously for 21 days of a 21-day cycle (21/21) at doses of 200, 275, 325, or 425 mg/day. Study endpoints were safety, maximum tolerated dose, pharmacokinetic profile, pharmacodynamic effects on platelets and T cells, and antitumour activity. This trial is registered with ClinicalTrials.gov, number NCT00406809.Findings 55 patients were enrolled (median age 59 years, IQR 51-67), 38 to receive the 14/21 dosing schedule, and 17 to receive the 21/21 dosing schedule. Common toxic effects included grade 1 or 2 anaemia (41 patients), infection (39), diarrhoea (31), nausea (29), and fatigue (21); and grade 3 or 4 thrombocytopenia (29), lymphocytopenia (18), and neutropenia (18). On the intermittent 14/21 schedule, dose-limiting toxic effects were hospital admissions for bronchitis (one) and pleural effusion (one), grade 3 increase in aminotransferases (one), grade 4 thrombocytopenia (one), and grade 3 cardiac arrhythmia (one). To reduce platelet nadir associated with intermittent 14/21 dosing, we assessed a 150 mg/day lead-in dose followed by a continuous 21/21 dosing schedule. On the 21/21 dosing schedule, two patients did not complete the first cycle and were excluded from assessment of dose-limiting toxic effects; dose-limiting toxic effects were grade 4 thrombocytopenia (one), grade 3 increase in aminotransferases (one), and grade 3 gastrointestinal bleeding (one). Navitoclax showed a pharmacodynamic effect on circulating platelets and T cells. Clinical responses occurred across the range of doses and in several tumour types. Ten of 46 patients with assessable disease had a partial response, and these responders had median progression-free survival of 455 days (IQR 40-218).Interpretation Navitoclax has a novel mechanism of peripheral thrombocytopenia and T-cell lymphopenia, attributable to high-affinity inhibition of BCL-XL and BCL-2, respectively. On the basis of these findings, a 150 mg 7-day lead-in dose followed by a 325 mg dose administered on a continuous 21/21 dosing schedule was selected for phase 2 study.Funding Abbott Laboratories, Genentech, and National Cancer Institute, National Institutes of Health.
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“Drugs with single or limited targets, such as Nutlin3a (an MDM2 inhibitor) or navitoclax (a BCL-2 inhibitor), can have off-target apoptotic effects on multiple non-Snc types, such as neutrophils and platelets in the case of navitoclax (75), making them panolytic.”
From Senolytic Drugs: Reducing Senescent Cell Viability to Extend Health Span (2021) · cites this paper as [75]
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“N can cause thrombocytopenia and neutropenia, even after brief exposures57,88–91”
From Cellular senescence and senolytics: the path to the clinic (2022) · cites this paper as [89]
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“these agents exhibited notable drawbacks, such as dose-dependent thrombocytopenia, variable therapeutic efficacy, and the emergence of resistance mechanisms.”
From Emerging strategies in senotherapeutics: from broad-spectrum senolysis to precision reprogramming (2026) · cites this paper as [33]
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“Trials assessing navitoclax as an anticancer agent report neutropenia and thrombocytopenia (Wilson et al. 2010).”
From Senescence and the SASP: many therapeutic avenues (2020) · cites this paper as Wilson et al. 2010
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“However, chronic administration of at least some senolytics in humans can be associated with toxic side effects (Kaefer et al., 2014; Wilson et al., 2010) which may be due to off-target killing of non-senescent cells.”
From Cytoplasmic DNA: sources, sensing, and role in aging and disease (2021) · cites this paper as Wilson et al., 2010
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“In oncology trials, 44–50% of patients experienced grade 3 or 4 thrombocytopenia33,34.”
From Emerging strategies in senotherapeutics: from broad-spectrum senolysis to precision reprogramming (2026) · cites this paper as [33]
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Ku, Y., Chan, V. S., Christesen, A. C., Grieme, T., Mulhern, M. M., Pu, Y., & Wendt, M. D. (2019) · The Journal of Organic Chemistry · doi:10.1021/acs.joc.8b02750 · Cited by 50
Senolytic Targeting of Bcl-2 Anti-Apoptotic Family Increases Cell Death in Irradiated Sarcoma Cells
Lafontaine, J., Cardin, G. B., Malaquin, N., Boisvert, J.-S., Rodier, F., & Wong, P. (2021) · Cancers · doi:10.3390/cancers13030386 · Cited by 54
Casson, L. K., Howell, L. A., Mathews, L., Ferrer, M., Southall, N. T., Guha, R., Keller, J. M., Thomas, C. J., Siskind, L. J., & Beverly, L. J. (2013) · PLoS ONE · doi:10.1371/journal.pone.0054525 · Cited by 49
Management of indolent lymphoma: Where are we now and where are we going
Lunning, M. A., & Vose, J. M. (2012) · Blood Reviews · doi:10.1016/j.blre.2012.09.004 · Cited by 49
Lanning, M. E., Yu, W., Yap, J. L., Chauhan, J., Chen, L., Whiting, E., Pidugu, L. S. M., Atkinson, T., Bailey, H., Li, W., et al. (2016) · European Journal of Medicinal Chemistry · doi:10.1016/j.ejmech.2016.02.006 · Cited by 50
“The specific and generic FragMap types that were used include: (1) aromatic, AROM (benzene carbons); (2) aliphatic, ALIP (propane carbons); (3) dual role hydrogen bonding atom, MEOO (methanol oxygens); (4) FORN, (formamide nitrogen); (5) FORO, (formamide oxygen); (6) IMIN, (imidazole acceptor nitrogen); (7) IMIH, (imi…”
MethodToward Targeting Antiapoptotic MCL-1 for Cancer Therapy
Kelly, G. L., & Strasser, A. (2019) · Annual Review of Cancer Biology · doi:10.1146/annurev-cancerbio-030419-033510 · Cited by 50
“…of genes encoding proapoptotic BCL-2 family members has also been observed in diverse cancers, including loss of BIM in mantle cell B lymphoma (Tagawa et al. 2005) and renal cell carcinoma (Zantl et al. 2007) or loss of BAX in DNA mismatch repair–defective colon cancer (Rampino et al. 1997).”
BackgroundBertino, E. M., Gentzler, R. D., Clifford, S. E., Kolesar, J., Muzikansky, A., Haura, E. B., Piotrowska, Z., Camidge, D. R., Stinchcombe, T. E., Hann, C. L., et al. (2020) · Clinical Cancer Research · doi:10.1158/1078-0432.ccr-20-4084 · Cited by 48
“At doses above 150 mg, a navitoclax lead-in dose of 150 mg daily for 7 days was included prior to escalation to permit stabilization of platelet levels, which are known to drop during this lead-in period (11, 12).”
BackgroundMethodGanesh, A. N., Heusser, C., Garad, S., & Sánchez-Félix, M. V. (2020) · Medicine in Drug Discovery · doi:10.1016/j.medidd.2020.100079 · Cited by 49
Cristofanon, S., & Fulda, S. (2012) · Cell Death and Disease · doi:10.1038/cddis.2012.163 · Cited by 48
Targeting Bcl-2/Bcl-XL Induces Antitumor Activity in Uveal Melanoma Patient-Derived Xenografts
Némati, F., de Montrion, C., Lang, G., Kraus‐Berthier, L., Carita, G., Sastre‐Garau, X., Berniard, A., Vallerand, D., Geneste, O., de Plater, L., et al. (2014) · PLoS ONE · doi:10.1371/journal.pone.0080836 · Cited by 49
“As relatively few clinical studies using these new compounds have been reported [26,27], no randomized clinical data are already available.”
BackgroundTargeting Cell Survival Proteins for Cancer Cell Death
Pandey, M. K., Prasad, S., Tyagi, A. K., Deb, L., Huang, J. M., Karelia, D. N., Amin, S., & Aggarwal, B. B. (2016) · Pharmaceuticals · doi:10.3390/ph9010011 · Cited by 50
Torres‐Collado, A. X., & Jazirehi, A. R. (2018) · Cancers · doi:10.3390/cancers10060200 · Cited by 48
“Numerous additional clinical trials have resulted in partial or complete remissions in CLL, B cell ALL, and NHL receiving autologous CD19-redirected CAR T cells.”
BackgroundInfluentialThe Role of Inhibition of Apoptosis in Acute Leukemias and Myelodysplastic Syndrome
McBride, A., Houtmann, S., Wilde, L. R., Vigil, C. E., Eischen, C. M., Kasner, M. T., & Palmisiano, N. D. (2019) · Frontiers in Oncology · doi:10.3389/fonc.2019.00192 · Cited by 49
Physiological restraint of Bak by Bcl-x L is essential for cell survivalPreprint
Lee, E. F., Grabow, S., Chappaz, S., Dewson, G., Hockings, C., Kluck, R. M., Debrincat, M. A., Gray, D. H. D., Witkowski, M. T., Evangelista, M., et al. (2016) · Genes & Development · doi:10.1101/gad.279414.116 · Cited by 48
Resistance to venetoclax and hypomethylating agents in acute myeloid leukemia
Saliba, A. N., John, A. J., & Kaufmann, S. H. (2020) · Cancer Drug Resistance · doi:10.20517/cdr.2020.95 · Cited by 47
“However, navitoclax also displayed dose-limiting thrombocytopenia([123,124]) that was traced to involvement of BCLXL in platelet survival ([125]).”
BackgroundRichardson, M., & Richardson, D. R. (2023) · Molecular Pharmacology · doi:10.1124/molpharm.123.000803 · Cited by 48
Rajan, S. S., Choi, M., Baek, K., & Yoon, H. S. (2015) · Proteins Structure Function and Bioinformatics · doi:10.1002/prot.24816 · Cited by 50
Targeting the mitochondrial apoptotic pathway: a preferred approach in hematologic malignancies?
Brinkmann, K., & Kashkar, H. (2014) · Cell Death and Disease · doi:10.1038/cddis.2014.61 · Cited by 47
“However, owing to the crucial role of Bcl-xl in platelet homeostasis(34) the therapeutic use of ABT-263 was associated with transient thrombocytopenia in preclinical trials.(142) Based on the results obtained by ABT-737 and ABT-263, Abbott Laboratories has recently developed a high-affinity Bcl-2-selective BH3 mimetic…”
BackgroundSenescent Mesenchymal Stem Cells: Disease Mechanism and Treatment Strategy
Liu, Y., & Chen, Q. (2020) · Current Molecular Biology Reports · doi:10.1007/s40610-020-00141-0 · Cited by 41
Valentini, E., D’Aguanno, S., Martile, M. D., Montesano, C., Ferraresi, V., Patsilinakos, A., Sabatino, M., Antonini, L., Chiacchiarini, M., Valente, S., et al. (2022) · Theranostics · doi:10.7150/thno.64233 · Cited by 46
Can Drug Repurposing Accelerate Precision Oncology?
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Mukherjee, N., Schwan, J. V., Fujita, M., Norris, D. A., & Shellman, Y. G. (2015) · Journal of Investigative Dermatology · doi:10.1038/jid.2015.145 · Cited by 46
“Currently ABT-263 (navitoclax) and ABT-199 are in clinical trials, with encouraging preliminary results (Gandhi et al., 2011; Roberts et al., 2012; Wilson et al., 2010).”
BackgroundRadiosensitization by a novel Bcl-2 and Bcl-XL inhibitor S44563 in small-cell lung cancer
Loriot, Y., Mordant, P., Dugué, D., Geneste, O., Gombos, A., Opolon, P., Guégan, J., Perfettini, J., Pierré, A., Kraus‐Berthier, L., et al. (2014) · Cell Death and Disease · doi:10.1038/cddis.2014.365 · Cited by 46
Double-hit lymphomas: current paradigms and novel treatment approaches
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Self-citationChemical Strategies for the Detection and Elimination of Senescent Cells
García-Fleitas, J., García‐Fernández, A., Martí‐Centelles, V., Sancenón, F., Bernardos, A., & Martínez‐Máñez, R. (2024) · Accounts of Chemical Research · doi:10.1021/acs.accounts.3c00794 · Cited by 46
Venetoclax: Targeting BCL2 in Hematological Cancers
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Treatment strategies for aggressive lymphomas: what works?
Wilson, W. H. (2013) · Hematology · doi:10.1182/asheducation-2013.1.584 · Cited by 44
Self-citationSrinivas, N. R. (2016) · Drugs in R&D · doi:10.1007/s40268-016-0133-0 · Cited by 44
“Navitoclax represents a novel first-in-class small-molecule drug that has a high inhibitory affinity to the Bcl-2 family of receptors [20].”
BackgroundOverview of BCL-2 Family Proteins and Therapeutic Potentials
Huska, J. D., Lamb, H. M., & Hardwick, J. M. (2018) · Methods in molecular biology · doi:10.1007/978-1-4939-8861-7_1 · Cited by 44
Venetoclax in acute myeloid leukemia – current and future directions
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Venetoclax Resistance in Acute Myeloid Leukemia
Garciaz, S., Collette, Y., & Vey, N. (2024) · Cancers · doi:10.3390/cancers16061091 · Cited by 45
“…of the treatment Although ABT-263 (navitoclax) showed promising results in phase I studies, the dose limiting toxicity of the treatment was thrombocytopenia, as BCL-XL is essential for mature platelet survival [15]. was thrombocytopenia as BCL-XL is essential for mature platelet survival [15].”
BackgroundNew molecular targets in mantle cell lymphoma
Parekh, S. S., Weniger, M. A., & Wiestner, A. U. (2011) · Seminars in Cancer Biology · doi:10.1016/j.semcancer.2011.09.008 · Cited by 43
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Targeting Cellular Senescence for Age-Related Diseases: Path to Clinical Translation
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Mitchell, W. B., Pinheiro, M. D. O., Boulad, N., Kaplan, D. R., Edison, M. N., Psaila, B., Karpoff, M. N., White, M. J., Josefsson, E. C., Kile, B. T., et al. (2014) · American Journal of Hematology · doi:10.1002/ajh.23832 · Cited by 42
“Pharmacological inhibition of Bcl-xL with the BH3 mimetic drugs such as ABT-737 [9] or ABT-263 (Navitoclax) [10] triggers platelet death [6,11–14] and thrombocytopenia in mice [6,15], dogs [14], and humans [16,17].”
BackgroundDunleavy, K. M., Roschewski, M. J., & Wilson, W. H. (2014) · Clinical Cancer Research · doi:10.1158/1078-0432.ccr-14-0497 · Cited by 42
“Several specific inhibitors of BCL2, such as navitoclax and ABT-199, are in development (86).”
BackgroundSelf-citation
Metadata
- Authors
- Wilson, W. H., O'Connor, O. A., Czuczman, M. S., LaCasce, A. S., Gerecitano, J. F., Leonard, J. P., Tulpule, A., Dunleavy, K., Xiong, H., Chiu, Y.-L., Cui, Y., Busman, T., Elmore, S. W., Rosenberg, S. H., Krivoshik, A. P., Enschede, S. H., & Humerickhouse, R. A.
- Affiliations
- National Institutes of Health (US)
- Roswell Park Comprehensive Cancer Center (US)
- Dana-Farber Cancer Institute (US)
- Memorial Sloan Kettering Cancer Center (US)
- Cornell University (US)
- University of Southern California (US)
- Abbott (United States) (US)
- Corresponding author
- Wilson, Wyndham H
- ORCID
- Venue
- The Lancet Oncology
- Publisher
- Elsevier BV
- Published
- 2010-12
- Volume
- 11
- Issue
- 12
- Pages
- 1149-1159
- ISSN
- 1470-2045 (ISSN-L)
- PMC
- PMC3025495
- OpenAlex
- W2150680216
- Cited by
- 876
- References
- 47
- Citations by year
- 2026: 44 · 2025: 58 · 2024: 66 · 2023: 49 · 2022: 66 · 2021: 69 · 2020: 70 · 2019: 43 · 2018: 42 · 2017: 53 · 2016: 52 · 2015: 63 · 2014: 60 · 2013: 55 · 2012: 50
- FWCI
- 18.10
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- The Lancet Oncology (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Abbott Fund
- Abbott Laboratories
- National Institutes of Health
- National Cancer Institute (ZIABC010716)
- Topics
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Cell death mechanisms and regulation
- Health Sciences › Medicine › Pathology and Forensic Medicine › Lymphoma Diagnosis and Treatment
- Health Sciences › Medicine › Hematology › Chronic Lymphocytic Leukemia Research
- Keywords
- navitoclax, BCL-2 inhibitor, Bcl-xL, lymphoid malignancies, relapsed/refractory lymphoma, dose-limiting toxicity, thrombocytopenia, neutropenia, anemia, pharmacokinetics, pharmacodynamics, T cell proliferation, platelet function, antitumour activity, intermittent dosing
- MeSH terms
- Aged, Aniline Compounds, Antineoplastic Agents, Blood Platelets, Dosage Forms, Humans, Lymphoma, Middle Aged, Sulfonamides, T-Lymphocytes, Survival Analysis, Drug Delivery Systems, Proto-Oncogene Proteins c-bcl-2, Maximum Tolerated Dose
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