onivyde is pushed to 3rdL in sequencing......in real life...
MM-398 (Onivyde) is irinotecan, approximately 80,000 molecules, encapsulated in a nanoparticle, liposome drug delivery system. In preclinical studies, this formulation improves pharmacokinetics and tumor biodistribution of both irinotecan and its active metabolite, SN-38, compared with free irinotecan. This leads to increased efficacy as observed in an orthotopic PC mouse model with less exposure to non-target organs and associated toxicities. MM398 was studied in a randomized phase III trial (NAPOLI-1) in 417 gemcitabine-refractory metastatic cancer patients (
11). This 2nd line trial randomized patients to either MM-398 alone, MM-398 + 5-FU/LV, or the control arm of 5-FU/LV, with OS as the primary endpoint. Patients on the MM-398 + 5-FU/LV arms achieved a median OS benefit of 6.1
vs. 4.2 months for the 5-FU/LV control arm (HR 0.68, P=0.014). There was no statistical benefit for the single agent MM-398 arm compared to control. MM-398 is approved by the FDA for treatment of patients with advanced PC who was previously treated with gemcitabine-based chemotherapy.
With MM-398 now available, sequencing of treatments for PC can be considered. If patients receive a gemcitabine-based regimen in the first-line setting, it is practical to use MM-398 as 2nd line treatment. This is especially true for patients receiving nab-P or oxaliplatin in whom neuropathy and thrombocytopenia are common adverse events leading to treatment discontinuation. The MM398/5-FU/LV regimen is not associated with these specific side effects. If patients receive upfront FOLFIRINOX, a gemcitabine-based combination such as gemcitabine/nab-P can be considered but this places MM-398 to a later line of treatment and fewer patients would be eligible for treatment with the agent. Whichever approach is favored, the need to strategize which regimen to use in the first-line to facilitate treatment in the second line is a new and welcomed consideration in the treatment of advanced PC.