Sorafenib Dose Recommendation in Acute Myeloid Leukemia Based on Exposure-FLT3 Relationship

Sorafenib administered at the approved dose continuously is not tolerated long-term in patients with acute myeloid leukemia (AML). The purpose of this study was to optimize the dosing regimen by characterizing the sorafenib exposure-response relationship in patients with AML. A one-compartment model with a transit absorption compartment and enterohepatic recirculation described the exposure. The relationship between sorafenib exposure and target modulation of kinase targets (FMS-like tyrosine kinase 3 (FLT3)-ITD and extracellular signal-regulated kinase (ERK)) were described by an inhibitory maximum effect (E-max) model. Sorafenib could inhibit FLT3-ITD activity by 100% with an IC50 of 69.3ng/mL and ERK activity by 84% with an IC50 of 85.7ng/mL (both adjusted for metabolite potency). Different dosing regimens utilizing 200 or 400mg at varying frequencies were simulated based on the exposure-response relationship. Simulations demonstrate that a 200mg twice daily (b.i.d.) dosing regimen showed similar FLT3-ITD and ERK inhibitory activity compared with 400mg b.i.d. and is recommended in further clinical trials in patients with AML.