The finding that the Bortenat samples analyzed did not comply with the US- and European-approved regulatory assay limits and contained higher than labeled amounts of active drug has potential clinical consequences. If this bortezomib-containing product were administered in accordance with the approved single-agent dose and schedule for VELCADE in patients with multiple myeloma (1.3 mg/m
2 on days 1, 4, 8, and 11 every 3 weeks), the potencies of 116.5% and 117.9% determined for the Bortenat 2-mg and 3.5-mg vials would result in the equivalent administration of 1.51 and 1.53 mg/m
2 bortezomib, respectively, at each dosing. There are several indications in the medical literature (
5–
8) as well as in publicly available regulatory review documents from the US FDA (
9) and European Medicines Agency (
10) that administering bortezomib at doses greater than 1.3 mg/m
2 on the standard biweekly schedule increases the incidence of toxicities known to be associated with bortezomib use.
This increase in toxicity with higher bortezomib dose has been demonstrated in several clinical trials. An early dose-finding phase I study of bortezomib using the standard biweekly schedule initially recommended administering bortezomib at 1.56 mg/m
2 (
5). This was later revised to 1.3 mg/m
2 (
10,
11) due to dose-limiting toxicities that included diarrhea and painful sensory neuropathy (
5,
9,
10). Across a variety of phase I studies, the dose–toxicity relationship was confirmed, with the proportion of patients that stopped receiving treatment due to toxicity being higher with increased dose (10% at doses of 0.7–1.3 mg/m
2 and 30% at doses greater than 1.3 mg/m
2) (
10). After these findings were reported, the development of bortezomib for the treatment of multiple myeloma continued using the standard twice-weekly schedule with the 1.3 mg/m
2 dose (
12–
14). Similarly, in two separate phase II studies investigating bortezomib using the twice-weekly schedule in patients with advanced renal cell carcinoma and in recurrent ovarian cancer, the initial dose of 1.5 mg/m
2 had to be decreased to 1.3 mg/m
2 during the course of the study as the majority of patients treated at the 1.5 mg/m
2 dose required dose reductions or premature treatment discontinuations due to toxicity (
6,
8). Recently, a case series of three patients with newly diagnosed multiple myeloma and renal impairment reported the development of severe neuropathy in two of these three patients after treatment with Bortenat, at a reduced dose in the first cycle and at a dose of 1.3 mg/m
2 in subsequent cycles (
15).
Additional differences between the two products were identified. Bortenat 2-mg vials contained isovaleraldehyde, a compound used in fragrances or as a flavoring agent; the origin of this compound is unknown. Bortenat also contained higher levels of polysiloxane compounds. The toxicologic and clinical impact of these differences is unknown. It is also interesting to note that the NMR and MS analyses indicated the presence of a higher proportion of free boronic acid in the aqueous Bortenat solution. The ratio of free acid to boronic ester was higher in the Bortenat 2-mg (0.27:1) and 3.5-mg (0.13:1) vials than in the VELCADE 3.5-mg vials (0.10:1). Ratio data were included in regulatory applications for VELCADE and the ratio of boronic acid to boronic ester is used to characterize the innovator product. These ratio data also indicate that the Bortenat bortezomib product is not equivalent to the innovator product. The clinical impact of these differences is unknown.