Ibrutinib (Imbruvica)

General information

Class/mechanism: Irreversible inhibitor of Bruton's tyrosine kinase (BTK), which is an enzyme that participates in the B-cell receptor (BCR) signal cascade and cytokine receptor pathways. BCR signaling is believed to promote cell proliferation, adhesion, and survival in B-cell malignancies. Inhibition of BTK interferes with the processes above, as well as B-cell chemotaxis and trafficking.^[1]^[2]^[3] ^[4]
Route: PO
Extravasation: n/a

For conciseness and simplicity, HemOnc.org currently will focus on treatment regimens and not list information such as: renal/hepatic dose adjustments, metabolism (including CYP450), excretion, monitoring parameters (although this will be considered for checklists), or manufacturer. Instead, for the most current information, please refer to your preferred pharmacopeias such as Micromedex, Lexicomp, UpToDate (courtesy of Lexicomp), or the prescribing information.^[1]

Resistance mechanisms

Woyach JA, Furman RR, Liu TM, Ozer HG, Zapatka M, Ruppert AS, Xue L, Li DH, Steggerda SM, Versele M, Dave SS, Zhang J, Yilmaz AS, Jaglowski SM, Blum KA, Lozanski A, Lozanski G, James DF, Barrientos JC, Lichter P, Stilgenbauer S, Buggy JJ, Chang BY, Johnson AJ, Byrd JC. Resistance mechanisms for the Bruton's tyrosine kinase inhibitor ibrutinib. N Engl J Med. 2014 Jun 12;370(24):2286-94. Epub 2014 May 28. link to original article PubMed

Significant side effects

Cardiovascular

Review: Leong DP, Caron F, Hillis C, Duan A, Healey JS, Fraser G, Siegal D. The risk of atrial fibrillation with ibrutinib use: a systematic review and meta-analysis. Blood. 2016 Jul 7;128(1):138-40. Epub 2016 May 31. link to original article PubMed
Dickerson T, Wiczer T, Waller A, Philippon J, Porter K, Haddad D, Guha A, Rogers KA, Bhat S, Byrd JC, Woyach JA, Awan F, Addison D. Hypertension and incident cardiovascular events following ibrutinib initiation. Blood. 2019 Nov 28;134(22):1919-1928. link to original article PubMed

Hematologic

Review: Caron F, Leong DP, Hillis C, Fraser G, Siegal D. Current understanding of bleeding with ibrutinib use: a systematic review and meta-analysis. Blood Adv. 2017 May 9;1(12):772-778. eCollection 2017 May 9. Review. link to original article link to PMC article PubMed

Infectious

Review: Tillman BF, Pauff JM, Satyanarayana G, Talbott M, Warner JL. Systematic review of infectious events with the Bruton tyrosine kinase inhibitor ibrutinib in the treatment of hematologic malignancies. Eur J Haematol. 2018 Apr;100(4):325-334. Epub 2018 Feb 6. link to original article PubMed
Ghez D, Calleja A, Protin C, Baron M, Ledoux MP, Damaj G, Dupont M, Dreyfus B, Ferrant E, Herbaux C, Laribi K, Le Calloch R, Malphettes M, Paul F, Souchet L, Truchan-Graczyk M, Delavigne K, Dartigeas C, Ysebaert L; on behalf on the French Innovative Leukemia Organization (FILO) CLL group. Early-onset invasive aspergillosis and other fungal infections in patients treated with ibrutinib. Blood. 2018 Apr 26;131(17):1955-1959. Epub 2018 Feb 1. link to original article PubMed

Diseases for which it is established (work in progress)

Diseases for which it is used

Patient drug information

History of changes in FDA indication

Chronic graft versus host disease (cGVHD)

2017-08-02: FDA indication expanded for the treatment of adult patients with chronic graft versus host disease (cGVHD) after failure of one or more lines of systemic therapy. (Based on PCYC-1129-CA)
2022-08-24: Approved for pediatric patients at least 1 year of age with chronic graft versus host disease (cGVHD) after failure of 1 or more lines of systemic therapy. (Based on iMAGINE)

Chronic lymphocytic leukemia

2014-02-12: Granted accelerated approval for the treatment of patients with chronic lymphocytic leukemia (CLL) who have received at least one prior therapy. (Based on PCYC-1102 relapsed, RESONATE, HELIOS)
- 2014-07-28: Converted to regular approval and approval expanded to include patients with chronic lymphocytic leukemia (CLL) who carry a deletion in chromosome 17 (17p deletion). (Based on RESONATE and iLLUMINATE)
2016-03-04: Approval expanded for the treatment of patients with chronic lymphocytic leukemia (CLL). (Based on RESONATE-2 and HELIOS)
2020-04-21: Approval expanded to include its combination with rituximab for the initial treatment of adult patients with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL). (Based on ECOG E1912)

Mantle cell lymphoma - WITHDRAWN

2013-11-13: Accelerated approval for the treatment of patients with mantle cell lymphoma (MCL) who have received at least one prior therapy. (Based on PCYC-1104-CA)
- 2023-05-18: Accelerated approval for the treatment of patients with mantle cell lymphoma (MCL) who have received at least one prior therapy withdrawn.

Marginal zone lymphoma - WITHDRAWN

2017-01-18: Accelerated approval for treatment of patients with marginal zone lymphoma (MZL) who require systemic therapy and have received at least one prior anti-CD20-based therapy. (Based on PCYC-1121-CA)
- 2023-05-18: Accelerated approval for treatment of patients with marginal zone lymphoma (MZL) who require systemic therapy and have received at least one prior anti-CD20-based therapy withdrawn.

Waldenström macroglobulinemia

2015-01-29: FDA approval expanded for the treatment of patients with Waldenström’s macroglobulinemia (WM). (Based on DFCI 12-015 and iNNOVATE)

History of changes in EMA indication

2014-10-21: Initial authorization

History of changes in Health Canada indication

2015-07-28: Initial notice of compliance with conditions
2017-09-12: Conditions were met

History of changes in PMDA indication

2016-03-26: Initial approval for the treatment of relapsed or refractory chronic lymphocytic leukemia/small lymphocytic lymphoma.
2016-12-02: New additional indication and a new dosage for the treatment of relapsed or refractory mantle cell lymphoma.
2018-07-02: New additional indication for the treatment of chronic lymphocytic leukemia (including small lymphocytic lymphoma).
2021-09-27: new indication and a new dosage for the treatment of chronic graft-versus-host disease after hematopoietic stem cell transplantation (for use when steroid drugs are not sufficiently effective).

Also known as

Code names: CRA-032765, PCI-32765
Brand names: Ibrunib, Ibrutix, Imbruvica, Lucibru

References

[insert-1] 1.0 ^1.1 ^1.2 Ibrutinib (Imbruvica) package insert

[2] Ibrutinib (Imbruvica) package insert (locally hosted backup)

[3] Imbruvica manufacturer's website

[4] Pharmacyclics BTK inhibitor website

[5] Ibrutinib (Imbruvica) patient drug information (Chemocare)

[6] Ibrutinib (Imbruvica) patient drug information (UpToDate)

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