|Drug class||Proteasome inhibitor|
|Main uses||Multiple myeloma (MM)|
|Side effects||Low red blood cells, tiredness, nausea, diarrhea, low platelets, fever, shortness of breath, cough, low white blood cells|
|Metabolism||Extensive; CYP plays a minor role|
|Chemical and physical data|
|Molar mass||719.924 g·mol−1|
|3D model (JSmol)|
Carfilzomib, sold under the brand name Kyprolis, is a medication used to treat multiple myeloma (MM). It is used in those who have not improved with other treatment. It is given by injection into a vein.
Common side effects include low red blood cells, tiredness, nausea, diarrhea, low platelets, fever, shortness of breath, cough, and low white blood cells. Other side effects may include heart problems, liver problems, lung problems, kidney problems, bleeding, infection, and high blood pressure. Use in pregnancy may harm the baby. It is a proteasome inhibitor.
Carfilzomib was approved for medical use in the United States in 2012 and Europe in 2015. In the United Kingdom it costs the NHS about £1,050 for 60 mg as of 2021. In the United States this amount costs about 2,700 USD.
It is used in MS when at least two prior therapies, including treatment with bortezomib and an immunomodulatory therapy (such as lenalidomide) and have demonstrated disease progression on or within 60 days of completion of the last therapy. Initial approval was based on response rate.
Carfilzomib covalently  irreversibly binds to and inhibits the chymotrypsin-like activity of the 20S proteasome, an enzyme that degrades unwanted cellular proteins. Carfilzomib displays minimal interactions with non-proteasomal targets, thereby improving safety profiles over bortezomib. Inhibition of proteasome-mediated proteolysis results in a build-up of polyubiquitinated proteins, which may cause cell cycle arrest, apoptosis, and inhibition of tumor growth.
Carfilzomib is derived from epoxomicin, a natural product that was shown by the laboratory of Craig Crews at Yale University to inhibit the proteasome. The Crews laboratory subsequently invented a more specific derivative of epoxomicin named YU101, which was licensed to Proteolix, Inc. Scientists at Proteolix invented a new, distinct compound that had potential use as a drug in humans, known as carfilzomib. Proteolix advanced carfilzomib to multiple Phase I and II clinical trials, including a pivotal phase 2 clinical trial designed to seek accelerated approval. Clinical trials for carfilzomib continue under Onyx Pharmaceuticals, which acquired Proteolix in 2009.
In January 2011, the FDA granted carfilzomib fast-track status, allowing Onyx to initiate a rolling submission of its new drug application for carfilzomib. In December 2011, the FDA granted Onyx standard review designation, for its new drug application submission based on the 003-A1 study, an open-label, single-arm phase IIb trial. The trial evaluated 266 heavily-pretreated patients with relapsed and refractory multiple myeloma who had received at least two prior therapies, including bortezomib and either thalidomide or lenalidomide.
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It costs approximately $10,000 per 28-day cycle.
The abbreviation "CFZ" is common for referring to carfilzomib, but abbreviating drug names is not best practice in medicine.
A single-arm, Phase II trial (003-A1) of carfilzomib in patients with relapsed and refractory multiple myeloma showed that single-agent carfilzomib demonstrated a clinical benefit rate of 36% in the 266 patients evaluated and had an overall response rate of 22.9% and median duration of response of 7.8 months. The FDA approval of carfilzomib was based on results of the 003-A1 trial.
In a Phase II trial (004), carfilzomib had a 53% overall response rate among patients with relapsed and/or refractory multiple myeloma who had not previously received bortezomib. This study also included a bortezomib-treated cohort. Results were reported separately. This study also found prolonged carfilzomib treatment was tolerable, with approximately 22% of patients continuing treatment beyond one year. The 004 trial was a smaller study originally designed to investigate the impact of carfilzomib treatment in relationship to bortezomib treatment in less heavily pretreated (1–3 prior regimens) patients.
A Phase II trial (005), which assessed the safety, pharmacokinetics, pharmacodynamics and efficacy of carfilzomib, in patients with multiple myeloma and varying degrees of renal impairment, where nearly 50% of patients were refractory to both bortezomib and lenalidomide, demonstrated that pharmacokinetics and safety were not influenced by the degree of baseline renal impairment. Carfilzomib was tolerable and demonstrated efficacy.
In another Phase II trial (006) of patients with relapsed and/or refractory multiple myeloma, carfilzomib in combination with lenalidomide and dexamethasone demonstrated an overall response rate of 69%.
In Phase II trials of carfilzomib, the most common grade 3 or higher treatment-emergent adverse events were hematologic toxicity  with thrombocytopenia, anemia, lymphopenia, neutropenia, pneumonia, fatigue and hyponatremia.
In a frontline Phase I/II study, the combination of carfilzomib, lenalidomide, and low-dose dexamethasone was highly active and well tolerated, permitting the use of full doses for an extended time in newly diagnosed multiple myeloma patients, with limited need for dose modification. Responses were rapid and improved over time, reaching 100% very good partial response.
Furthermore, gastrointestinal disturbances, including diarrhea and nausea are non hematologic group of side effects commonly reported with proteasome inhibitors. Additionally, cardiovascular toxicity may be an outcome of carfilzomib treatment due to the effects on proteasomes in the myocardium. Thus, patient evaluation and risk assessment prior to initiation of therapy with carfilzomib is crucial.
A phase III confirmatory clinical trial, known as the ASPIRE trial, compared carfilzomib, lenalidomide, and dexamethasone (KRd) versus lenalidomide and dexamethasone (Rd) in patients with relapsed multiple myeloma and found improved progression-free survival and overall survival. Treatment discontinuation because of adverse effects occurred less frequently in the KRd arm, and events included thrombocytopenia, hypertension, and heart failure.
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