Perpetrator DDI Potential of Givinostat as Inhibitor and Inducer of CYP3A and P-gp Activity

Primary objective:

1. To assess the potential inhibitory and inducing effect of oral givinostat on the single dose pharmacokinetics (PK) of intravenous or oral midazolam.
2. To assess the potential inhibitory and inducing effect of oral givinostat on the single dose PK of oral dabigatran etexilate.

Secondary objective:

To assess the safety and tolerability of concomitant administration of givinostat plus midazolam and dabigatran etexilate.

This study was planned as a phase I, open-label, 3-part, fixed-sequence, nonrandomized study in healthy male and female subjects. The study evaluated the givinostat (ITF2357) potential drug-drug interaction (DDI) at level of CYP3A-mediated metabolism and P-glycoprotein (P-gp) transport with intravenous or oral midazolam and with oral dabigatran etexilate.

More precisely, the study aimed at assessing the potential (inhibitory or inducing) effect of givinostat on the PK of midazolam IV, on the PK of oral midazolam and on the PK of dabigatran etexilate.

The study lasted from Day 1 to Day 20. Subjects were confined from Day -1 to Day 20. On Days 6 and 17, single doses of 1 mg midazolam IV and 75 mg dabigatran etexilate, were administered 1 hour after the planned morning time of givinostat administration. On day 1, however, drugs were not administered 1h after gininostat.

On Days 7 and 18, a single oral dose of 2.5 mg midazolam oral solution was administered 1 hour after the planned morning time of givinostat administration.

On day 2, however, the drugs were not administered 1h after gininostat.

From Day 4 to Day 18, givinostat 50 mg as oral suspension was administered twice a day, in the morning and in the evening.

On Day 19, only the morning dose was administered.

The following assessments were performed:

* Blood collection for pharmacokinetic analysis on Days 1 to 4, 6 to 9 and 17 to 20.
* Vital signs measurements (BP, PR and RR) on Days 1, 2, and 4 to 19.
* 12-lead ECG on Days 3 to 19.
* Blood collection for laboratory tests (hematology, biochemistry and coagulation on Days 4 and 9 and hematology on Days 6, 12, 15 and 18). Subjects were discharged from BlueClinical Phase I in the morning of Day 20 if allowed by the investigator based on their medical condition. The following procedures were performed:
* Physical examination.
* Collection of body weight.
* Vital signs measurements (BP, PR, RR and body temperature).
* 12-lead ECG.
* Safety laboratory assessments (hematology, biochemistry, coagulation and urinalysis).
* Serum pregnancy test for all female subjects. Subjects returned to the site 10 to 14 days after the end of study to undergo additional assessments as required per protocol.

The total duration of Part 1 for each subject was up to approximately 8 weeks from Screening to Follow-up visit, divided as follows:

* Screening: up to 21 days
* Treatment Period: Days 1 to 20
* Safety follow-up visit: 12±2 days

Eligibility Criteria:
Inclusion criteria

A subject was considered eligible for the study if he/she fulfilled all the inclusion criteria:

1. Subject's written informed consent obtained prior to any study-related procedure.
2. Male or female subject, ≥18 and ≤55 years of age, at the time of signing the informed consent.
3. Body mass index (BMI) of 18.5 to 32.0 kg/m2 inclusive, and body weight ≥55 kg and ≤100 kg for females and body weight ≥60 kg and ≤110 kg for males.
4. Non-smoker or ex-smoker (i.e. someone who abstained from using tobaccoor nicotine-containing products for at least 3 months prior to Screening).
5. No clinically relevant diseases.
6. No major surgery within 4 weeks prior to dosing.
7. No clinically relevant abnormalities on physical examination.
8. No clinically relevant abnormalities on 12-lead ECG.
9. No clinically relevant abnormalities on clinical laboratory tests.
10. Negative test results for anti-Human Immunodeficiency virus 1 and 2 antibodies (anti-HIV-1Ab and anti-HIV-2Ab), Hepatitis B surface antigen (HBsAg) and anti-Hepatitis C virus antibodies (anti-HCVAb).
11. Female subjects are eligible if they are of non-childbearing potential or agree to use a non-hormonal highly effective contraceptive method from 28 days prior to Screening until at least 90 days after the last study drug administration. Nonchildbearing potential female is defined as:

    1. Menopausal, i.e. no menses for ≥ 12 months without an alternative medical cause other than menopause, and a high FSH level.
    2. Pre-menopausal female with documented hysterectomy, bilateral salpingectomy and/or bilateral oophorectomy.

    A non-hormonal effective contraceptive method is defined as:
    1. Intrauterine device.
    2. Bilateral tubal occlusion.
    3. Total abstinence of heterosexual intercourse, in accordance with the lifestyle of the subject.
    4. Vasectomized partner, who has received medical assessment of the surgical success, or clinically diagnosed infertile partner.
12. Male subjects who are sexually active with a female partner of childbearing potential (pregnant or non-pregnant) must use contraception (condom) from investigational product administration up to at least 90 days following the last study drug administration.
13. Male subjects must ensure that his non-pregnant female partner of childbearing potential agrees to consistently and correctly use for the same period a highly effective method of contraception (see Section 8.5.3).
14. Male subjects must be willing not to donate sperm until 90 days following the last study drug administration.
15. Willingness and capability to comply with the requirements of the study and ability to understand the study procedures and the risks involved.

Exclusion Criteria

A subject was excluded from the study if he/she fulfilled any of the exclusion criteria:

At Screening

1. Previous use of givinostat.
2. History of anaphylaxis reaction or clinically significant drug hypersensitivity reaction (e.g., angioedema, Stevens-Johnson syndrome, acute generalized exanthematous pustulosis, drug-induced hypersensitivity syndrome, druginduced neutropenia).
3. Known history of hypersensitivity and/or allergic reactions to givinostat, histone deacetylases (HDAC) inhibitors or to any excipient in the formulation.
4. History of sorbitol intolerance, sorbitol malabsorption or fructose intolerance.
5. Any medical condition (e.g. gastrointestinal, renal or hepatic, including peptic ulcer, inflammatory bowel disease or pancreatitis) or surgical condition (e.g. cholecystectomy, gastrectomy) that may affect drug pharmacokinetics (absorption, distribution, metabolism or excretion) or subject safety.
6. Systolic blood pressure lower than 90 or over 140 mmHg, diastolic blood pressure lower than 60 or over 90 mmHg, or pulse rate lower than 50 or over 100 bpm.
7. QTcF ˃450 msec.
8. Subjects with history of cardiac arrhythmias (documented), family history of sudden cardiac death or history of additional risk factors for torsades-depointes (e.g. heart failure, hypokalemia, long QT syndrome).
9. Having an estimated glomerular filtration (eGFR) \< 90 mL/min, based on creatinine clearance calculation by the Cockcroft-Gault formula and normalized to an average surface area of 1.73 m2.
10. Any of the following abnormal laboratory test values:

    1. Platelet count below the lower limit of the normal range (LLN)
    2. Total white blood cells count below the LLN
    3. Hemoglobin below the LLN
    4. Triglycerides above the upper limit of normal range (ULN)
    5. Potassium or magnesium below the LLN
11. Positive urine alcohol, drugs-of-abuse or cotinine screen tests.
12. Positive serum pregnancy test.
13. If woman, she is breast-feeding.
14. History of alcohol abuse within 1 year prior to screening or regular use of alcohol within 6 months prior to the screening visit (i.e. more than 14 units of alcohol per week for males or more than 7 units for females).
15. History of drug abuse within 1 year prior to screening or use of soft drugs (such as marijuana) within 3 months prior to the screening visit or hard drugs \[such as cocaine, phencyclidine (PCP), crack, opioid derivatives including heroin, and amphetamine derivatives\] within 1 year prior to screening.
16. Participation in any clinical trial within the previous 2 months.
17. Participation in more than 2 clinical trials within the previous 12 months.
18. Blood donation or significant blood loss (≥ 450 mL) due to any reason or had plasmapheresis within the previous 2 months.
19. Veins unsuitable for intravenous puncture on either arm.
20. Difficulty in swallowing capsules, tablets or suspensions.
21. Any reason which, in the opinion of the Investigator, would prevent the subject from participating in the study.

    Exclusion Criteria:

    At Admission to Treatment Period
22. Any clinically relevant abnormalities on clinical laboratory tests.
23. Positive urine alcohol, drugs-of-abuse or cotinine screen tests.
24. Positive urine pregnancy test.
25. Positive or inconclusive SARS-CoV-2 test prior to admission.
26. Use of prescription or non-prescription medicinal products within the previous 28 days or within 5-half-lives of the medicinal product, whichever is longer.
27. Any reason which, in the opinion of the Investigator, would prevent the subject from participating in the study.

    For Part 1 subjects:

    At Screening
28. Known history of hypersensitivity and/or allergic reactions to midazolam, other benzodiazepines, dabigatran etexilate or to any excipient of the formulations.
29. Clinically relevant history of impaired respiratory function, obstructive sleep apnea, myasthenia gravis, respiratory arrest and/or cardiac arrest.
30. History of glaucoma.
31. Presence of respiratory failure.
32. Presence of active clinically significant bleeding.
33. Lesion or condition considered to pose a significant risk factor for major bleeding including, but not limited to: current or recent gastrointestinal ulceration, malignant neoplasms, recent brain or spinal injury, recent brain, spinal or ophthalmic surgery, recent intracranial hemorrhage, known or suspected esophageal varices, arteriovenous malformations, vascular aneurysms or major intraspinal or intracerebral vascular abnormalities.
34. Presence of a medical condition requiring anticoagulant treatment.

    At Admission to Treatment Period
35. Treatment with anticoagulants within 28 days or 5 drug half-lives, whichever was longer, before admission.