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Panobinostat

Panobinostat is an oral histone deacetylase (HDAC) inhibitor that was approved by the U.S. Food and Drug Administration (FDA) in February 2015 under the accelerated approval pathway for the treatment of multiple myeloma in patients who have received at least two prior standard therapies, including bortezomib and an immunomodulatory agent, in combination with bortezomib and dexamethasone.^[1] However, the FDA approval was withdrawn in 2022 at the request of the sponsor due to incomplete confirmatory trials.^[2] It remains authorised in the European Union as of 2025.^[3] Marketed under the brand name Farydak by Novartis at the time of initial approval, it was the first HDAC inhibitor approved for this indication.^[4] The drug's mechanism of action involves non-selective inhibition of HDAC enzymes, which leads to hyperacetylation of histones and non-histone proteins, resulting in chromatin relaxation, re-expression of tumor suppressor genes, cell cycle arrest, and induction of apoptosis in cancer cells.^[1] This approval was based on demonstrated improvement in progression-free survival (PFS) in a phase III clinical trial (PANORAMA 1), where the median PFS was 10.6 months with panobinostat plus bortezomib and dexamethasone compared to 5.8 months with placebo plus bortezomib and dexamethasone (hazard ratio 0.52).^[1]^[5] While primarily indicated for relapsed or refractory multiple myeloma, panobinostat has been investigated in clinical trials for other hematologic malignancies and solid tumors due to its epigenetic modulating effects that may enhance the efficacy of combination therapies.^[6] Common administration involved 20 mg capsules taken every other day for specified doses in 21-day cycles, with monitoring required for severe adverse effects including thrombocytopenia, diarrhea, fatigue, and cardiac toxicities.^[1] As of 2025, following its withdrawal from the US market, panobinostat continues to be available in regions like the EU, with ongoing research exploring broader applications in oncology.^[3]^[6]

Medical uses

Approved indications

Panobinostat is approved for the treatment of adult patients with relapsed and/or refractory multiple myeloma who have received at least two prior regimens, including bortezomib and an immunomodulatory agent. It is indicated in combination with bortezomib and dexamethasone.^[7] The European Medicines Agency (EMA) granted marketing authorization for this indication on August 28, 2015, and the authorization remains active as of 2025. In the United States, the Food and Drug Administration (FDA) provided accelerated approval on February 23, 2015, based on progression-free survival data, but the approval was voluntarily withdrawn by the sponsor effective March 2022, with the product discontinued in the US market.^[3]^[1]^[2] The recommended dosing regimen consists of oral capsules administered at 20 mg once daily on days 1, 3, 5, 8, 10, and 12 of a 21-day cycle. Treatment is given for an initial 8 cycles, and may be continued for up to 8 additional cycles (totaling 48 weeks) if the patient derives clinical benefit, with dose reductions to 15 mg or 10 mg possible based on tolerability. This regimen is administered alongside bortezomib (1.3 mg/m² subcutaneously on days 1, 4, 8, and 11) and dexamethasone (20 mg orally on days 1, 2, 4, 5, 8, 9, 11, and 12).^[7] Approval was supported by efficacy data from the phase 3 PANORAMA-1 trial, a randomized, double-blind, placebo-controlled study in 768 patients with relapsed or refractory multiple myeloma. In the subgroup of patients who had received at least two prior regimens including bortezomib and an immunomodulatory agent (n=147), the panobinostat combination extended median progression-free survival to 12.5 months compared with 4.7 months for placebo plus bortezomib and dexamethasone (hazard ratio 0.47; 95% CI 0.31-0.72; p=0.0004). Overall response rates were 59% and 39%, respectively, in this subgroup. An earlier analysis reported median progression-free survival of 11.99 months versus 8.08 months overall, but the confirmatory subgroup data aligned with the approved patient population.^[7]^[8] As a histone deacetylase inhibitor, panobinostat enhances the antitumor effects of bortezomib and dexamethasone in this combination regimen.^[7]

Investigational uses

Panobinostat has been investigated for its potential in treating cutaneous T-cell lymphoma (CTCL), particularly in refractory cases, through a phase II trial that demonstrated clinical activity with an overall response rate of approximately 16% in patients previously exposed or naïve to bexarotene, though this did not advance to regulatory approval.^[9] In Hodgkin's lymphoma, a phase III randomized, double-blind, placebo-controlled trial evaluated panobinostat as maintenance therapy following autologous stem cell transplantation in patients at high risk of relapse. The trial was discontinued early due to slow recruitment after enrolling only 41 patients, with no efficacy data available, but showed acceptable tolerability.^[10]^[11] Similarly, a phase II study in myelodysplastic syndromes (MDS) explored panobinostat in low- or intermediate-1 risk patients, reporting limited hematologic improvements in a small subset (8%), which highlighted its role in epigenetic modulation without leading to approved indications.^[12] Combination regimens incorporating panobinostat have been assessed in phase II trials for non-Hodgkin lymphoma, such as with rituximab in relapsed diffuse large B-cell lymphoma, yielding response rates of 11% with no added benefit from rituximab observed in this small study.^[13] In breast cancer, panobinostat monotherapy has been evaluated in a phase II trial (NCT00777049) in HER2-negative metastatic disease, underscoring its investigational utility in hormone receptor-positive subtypes, though specific results are not publicly available.^[14] For prostate cancer, a phase II trial of intravenous panobinostat in castration-resistant cases post-chemotherapy reported limited activity, with 24-week progression-free survival of 11% and some disease stabilization, though progression-free survival remained limited and no major PSA responses were seen.^[15] Beyond oncology, panobinostat's HDAC inhibitory properties have prompted exploration in non-malignant conditions, such as a phase I trial (NCT01245179) in sickle cell disease aiming to induce fetal hemoglobin production for improved red blood cell function, with the study completed but detailed results not publicly available.^[16]

Safety and tolerability

Contraindications

Panobinostat is contraindicated in patients with known hypersensitivity to panobinostat or any of the excipients.^[7] Breastfeeding is contraindicated with panobinostat use, as the drug or its metabolites may be excreted in human milk, potentially causing serious adverse effects in nursing infants due to its cytotoxic properties. Women should discontinue breastfeeding prior to initiating treatment or choose to discontinue the drug, taking into account the importance of the drug to the mother.^[7]^[1] Panobinostat should be avoided in patients with severe hepatic impairment (Child-Pugh class C), owing to significantly increased systemic exposure and heightened risk of toxicity, as no safety or efficacy data exist for this population. Dose reductions are recommended for mild or moderate hepatic impairment.^[1]^[7] Panobinostat can cause fetal harm when administered to pregnant women and should be avoided during pregnancy unless the potential benefit justifies the potential risk to the fetus, as evidenced by teratogenic effects observed in animal studies, including embryofetal toxicity in rats and rabbits at doses similar to human exposure levels. In the United States, the FDA described panobinostat as carrying a high risk of fetal harm based on its mechanism of action and animal data (prior to approval withdrawal in 2022), recommending avoidance unless the potential benefit justifies the risk, with effective contraception advised for women of childbearing potential during treatment and for at least one month thereafter.^[1]^[17] Treatment should not be initiated in patients with active severe infections or uncontrolled comorbidities that could be exacerbated by panobinostat-induced immunosuppression, such as unresolved bacterial, viral, or fungal infections, until these conditions are adequately managed. Cardiac risks, including QT interval prolongation, represent a broader precaution but are not an absolute contraindication unless associated with severe underlying heart disease.^[1]^[7]

Adverse effects

Although Farydak's approval was withdrawn in the United States in 2022 due to failure to confirm clinical benefit in confirmatory trials, it remains authorized in the European Union as of 2025, with the following safety profile derived from clinical trials such as PANORAMA-1.^[2]^[3] Panobinostat treatment is associated with a high incidence of adverse effects, with 97% of patients in the PANORAMA-1 trial experiencing all-grade adverse events compared to 91% in the placebo group.^[1] Common adverse effects, occurring in more than 10% of patients, include gastrointestinal disturbances and hematologic toxicities. Diarrhea affects 68% of patients, with severe (grade 3/4) cases in 25%; fatigue occurs in 60% (grade 3/4 in 25%); nausea in 36% (grade 3/4 in 6%); peripheral edema in 29%; and anemia in approximately 62% (grade 3/4 in 18%).^[1] Thrombocytopenia is particularly frequent as a laboratory abnormality, seen in 97% of patients (grade 3/4 in 67%).^[1]^[18] Serious adverse effects include cardiac events, which carry a boxed warning due to risks of QT interval prolongation, arrhythmias (12% incidence, grade 3/4 in 3%), and potentially fatal outcomes; baseline and periodic ECG monitoring with electrolyte assessment is required.^[1] Infections occur in 31% of patients with severe cases, often linked to myelosuppression from hematologic toxicities like neutropenia (75% incidence, grade 3/4 in 34%) and lymphopenia (82%, grade 3/4 in 53%).^[1] Electrolyte imbalances are common, including hypokalemia (52%, grade 3/4 in 18%), hypomagnesemia (not directly quantified but monitored with others like hypophosphatemia at 63%, grade 3/4 in 20%), and hyponatremia (49%, grade 3/4 in 13%), necessitating regular electrolyte checks.^[1] Management strategies emphasize proactive monitoring and dose adjustments. Antidiarrheal prophylaxis, such as loperamide, should be initiated at the onset of diarrhea, with treatment interruption or dose reduction for grade 3/4 severity; severe diarrhea led to discontinuation in 8% of patients.^[1] ECG monitoring is recommended every 2 weeks for the first 8 weeks, then periodically, with immediate evaluation for arrhythmias.^[1] Dose interruptions are advised for grade 3/4 toxicities, including thrombocytopenia (managed with platelet transfusions if needed) and infections; in PANORAMA-1, adverse events prompted discontinuation in 36% of panobinostat-treated patients versus 20% in placebo.^[1]^[18] Hydration and electrolyte correction are essential to mitigate imbalances.^[1]

Pharmacology

Mechanism of action

Panobinostat is a non-selective histone deacetylase (HDAC) inhibitor that targets enzymes from classes I, II, and IV, resulting in hyperacetylation of histones and non-histone proteins.^[19] By blocking the removal of acetyl groups from lysine residues on these proteins, panobinostat disrupts normal epigenetic regulation and protein function at nanomolar concentrations.^[1] It exhibits potent activity against specific isoforms, including HDAC1, HDAC2, HDAC3, HDAC6, and HDAC10, with IC₅₀ values below 13.2 nM across class I, II, and IV HDACs.^[19] The hyperacetylation induced by panobinostat relaxes chromatin structure, promoting the transcription of genes that were previously silenced and thereby altering overall gene expression patterns in cancer cells.^[1] This leads to downstream cellular effects, including cell cycle arrest, promotion of differentiation, and induction of apoptosis, with greater cytotoxicity observed in transformed cells compared to normal cells.^[1] These mechanisms contribute to its antineoplastic activity by restoring normal gene regulation and triggering programmed cell death pathways.^[20] In combination with bortezomib, a proteasome inhibitor, panobinostat demonstrates synergistic effects in multiple myeloma cells by enhancing proteasomal inhibition through upregulation of the unfolded protein response and increased endoplasmic reticulum stress.^[21] This combination amplifies the accumulation of misfolded proteins, further promoting apoptosis and overcoming resistance mechanisms in relapsed disease.^[22]

Pharmacokinetics

Panobinostat is administered orally and exhibits low absolute bioavailability of approximately 21%, with peak plasma concentrations (C_max) achieved within 2 hours post-dose. The pharmacokinetics are linear over the dose range of 10–60 mg, with proportional increases in both C_max and area under the curve (AUC). Administration with a high-fat meal results in a modest reduction in C_max by about 44% and AUC by 16%, along with a delay in T_max to approximately 4.5 hours; however, due to the minimal impact on overall exposure, panobinostat may be taken without regard to food.^[1]^[7] Following absorption, panobinostat is highly bound to plasma proteins (approximately 90%), primarily albumin, and demonstrates extensive tissue distribution with an apparent volume of distribution at steady state of around 1000 L. It is a substrate for the P-glycoprotein (P-gp) efflux transporter, which may influence its distribution across biological barriers.^[1]^[7]^[23] Panobinostat undergoes extensive hepatic metabolism, producing at least 77 identified metabolites through pathways including oxidation, reduction, hydrolysis, and glucuronidation. The cytochrome P450 (CYP) system contributes to its metabolism, with CYP3A accounting for approximately 40% of hepatic elimination, and minor roles played by CYP2D6 and CYP2C19; non-CYP mechanisms, such as flavin-containing monooxygenases and amidases, also participate. None of the metabolites exhibit significant pharmacological activity against histone deacetylases at relevant concentrations.^[1]^[24]^[23] Elimination of panobinostat occurs primarily through fecal (44–77%) and urinary (29–51%) routes as metabolites, with less than 5% of the unchanged parent drug recovered in excreta (<2.5% in urine and <3.5% in feces). The terminal elimination half-life ranges from 30 to 37 hours, and oral clearance is approximately 160 L/h, leading to up to twofold accumulation upon repeated dosing. Renal clearance is low (2.4–5.5 L/h), indicating minimal direct renal elimination.^[1]^[7]^[20] In special populations, hepatic impairment significantly affects panobinostat clearance. Exposure (AUC) increases by 43% in mild hepatic impairment and by 105% in moderate impairment, corresponding to approximately 30% and 50% reductions in clearance, respectively; dose reductions are recommended in these cases. Use in severe hepatic impairment is not advised due to insufficient data. No clinically significant differences in pharmacokinetics are observed based on age, sex, race, body weight, or mild to moderate renal impairment.^[1]^[7]^[20]

Clinical development

Approval history

Panobinostat was developed by Novartis as an oral histone deacetylase inhibitor for oncology indications.^[25] Initial Phase I clinical trials evaluating its safety and tolerability in patients with advanced solid tumors commenced in 2006.^[26] The U.S. Food and Drug Administration (FDA) granted accelerated approval for panobinostat (branded as Farydak) on February 23, 2015, for use in combination with bortezomib and dexamethasone in patients with multiple myeloma who had received at least two prior standard therapies, including bortezomib and an immunomodulatory agent; this approval was based on improved progression-free survival demonstrated in the PANORAMA-1 trial. The European Medicines Agency (EMA) followed with marketing authorization on August 28, 2015, under the same brand name and indications.^[7] Regulatory approval was also obtained in Japan by the Pharmaceuticals and Medical Devices Agency (PMDA) in July 2015 for similar use in relapsed or refractory multiple myeloma.^[27] In the United States, approval was withdrawn effective March 24, 2022, following a voluntary request by Secura Bio, Inc., the marketing authorization holder at the time; this action was prompted by the failure of the confirmatory PANORAMA-2 trial to demonstrate an overall survival benefit and the inability to complete required post-approval studies.^[2] As of November 2025, panobinostat remains available in Europe as Farydak, in Japan, and in various other regions outside the U.S., with its EMA orphan medicinal product designation having concluded in September 2025 after the 10-year market exclusivity period, though the core approval persists.^[3] The primary U.S. composition-of-matter patent for panobinostat, U.S. Patent No. 7,919,505, is set to expire in 2026.

Key clinical trials

The development of panobinostat involved several early-phase studies to establish its safety profile. In a phase I dose-escalation trial involving patients with advanced solid tumors and non-Hodgkin lymphoma, oral panobinostat was administered thrice weekly, with the maximum tolerated dose determined to be 20 mg, based on dose-limiting toxicities such as thrombocytopenia and fatigue.^[28] These findings supported further investigation in hematologic malignancies. Phase II trials explored panobinostat's efficacy in cutaneous T-cell lymphoma (CTCL). In a multicenter study of 139 patients with relapsed or refractory CTCL, single-agent oral panobinostat at 20 mg thrice weekly yielded an overall response rate of 17%, with responses observed in both bexarotene-exposed and bexarotene-naïve subgroups, and a median duration of response of 5.6 months.^[9] Similarly, in relapsed or refractory Hodgkin lymphoma, a phase II trial of 129 patients post-autologous stem-cell transplantation treated with panobinostat 40 mg orally thrice weekly demonstrated an objective response rate of 27%, including 4% complete responses, with a median progression-free survival of 6.1 months.^[29] The pivotal phase III PANORAMA-1 trial evaluated panobinostat in combination with bortezomib and dexamethasone versus placebo plus bortezomib and dexamethasone in 768 patients with relapsed or relapsed and refractory multiple myeloma who had received at least one prior therapy. This double-blind study met its primary endpoint in the full population, showing a significant improvement in median progression-free survival of 12.0 months versus 8.1 months (hazard ratio 0.63, 95% CI 0.52–0.76; p<0.0001).^[18] The FDA accelerated approval was based on a prespecified subgroup of patients who had received prior bortezomib and an immunomodulatory agent, with median PFS of 10.6 months versus 5.8 months (hazard ratio 0.52). However, the final overall survival analysis, with a median follow-up of 48.5 months, revealed no significant benefit, with median overall survival of 40.3 months versus 35.8 months (hazard ratio 0.87, 95% CI 0.69–1.10; p=0.25).^[30] The phase II PANORAMA-2 trial assessed panobinostat plus bortezomib and dexamethasone in 55 patients with bortezomib-refractory multiple myeloma. This open-label study reported an overall response rate of 34%, including 5% complete responses, demonstrating the ability to recapture responses in heavily pretreated patients, though progression-free survival was shorter at a median of approximately 5 months.^[31] Despite these results contributing to initial regulatory considerations, subsequent analyses and the absence of confirmatory overall survival benefits from phase III studies, including mature data from PANORAMA-1, led to the voluntary withdrawal of panobinostat's approval for multiple myeloma in the United States in 2022.^[2]

Research and potential applications

Preclinical studies

Preclinical studies of panobinostat, a pan-histone deacetylase inhibitor, have demonstrated its antiproliferative effects in various cancer cell lines, particularly in multiple myeloma. In vitro experiments using multiple myeloma cell lines such as KMS-12PE, KMS-18, LP-1, NCI-H929, KMS-11, RPMI-8226, and OPM-2 showed potent cytotoxic activity with IC50 values below 10 nM.^[32] Furthermore, panobinostat exhibited synergy with bortezomib in multiple myeloma cells by enhancing endoplasmic reticulum stress, leading to increased apoptosis through upregulation of pro-apoptotic proteins like CHOP and Noxa.^[33] In animal models, panobinostat induced tumor regression in xenograft studies of solid tumors. For pancreatic cancer, oral administration in a mouse xenograft model resulted in tumor growth inhibition comparable to gemcitabine, with significant reductions in tumor volume at doses of 10-15 mg/kg.^[34] In triple-negative breast cancer xenografts, panobinostat treatment at 10 mg/kg three times per week led to substantial tumor shrinkage and reduced metastatic potential by modulating E-cadherin expression and inhibiting migration pathways.^[35] Beyond oncology, panobinostat showed promise in non-cancer models. In spinal muscular atrophy cellular models derived from patient fibroblasts, panobinostat (LBH589) induced up to a 10-fold increase in SMN2 protein levels by promoting inclusion of exon 7 in SMN2 transcripts, without cytotoxicity at effective concentrations.^[36] Similarly, in preclinical models of sickle cell disease, including human erythroid cells and Townes mouse models, panobinostat upregulated fetal hemoglobin expression, achieving up to 20-30% gamma-globin levels and ameliorating sickling pathology.^[37] Regarding toxicity, preclinical safety studies identified potential adverse effects. In telemetered Beagle dogs dosed orally at 1.5 mg/kg three times per week, panobinostat caused QTc interval prolongation of up to 25 msec, observed via electrocardiography without accompanying clinical signs.^[38] In rodents, repeat-dose toxicity studies in rats at 30-300 mg/kg/day revealed gastrointestinal effects, including mucosal hemorrhage and erosion in the stomach and intestines, along with inflammation in the cecum at higher doses.^[38]

Ongoing investigations

As of 2025, panobinostat is being evaluated in active clinical trials, with a shift toward solid tumors and non-oncologic applications following its 2022 FDA withdrawal for multiple myeloma due to unmet post-marketing commitments.^[2] The withdrawal has limited access in the United States, prompting focus on international cohorts in Europe and Asia.^[2] Completed studies in hematologic malignancies include a phase II trial of panobinostat with rituximab in relapsed or refractory diffuse large B-cell lymphoma (DLBCL), which demonstrated a 28% response rate.^[39] A phase II study of panobinostat with everolimus in relapsed or refractory DLBCL reported a 25% overall response rate but with significant toxicity and non-durable responses.^[40] Similarly, a completed phase II monotherapy trial in non-Hodgkin lymphoma, including AIDS-related cases, showed an overall response rate of 21% and median progression-free survival of 3 months, assessing tolerability in immunocompromised patients.^[41] A completed phase I study of panobinostat with letrozole in metastatic breast cancer (primarily ER-positive, with limited triple-negative breast cancer enrollment) determined the maximum tolerated dose but did not advance to phase II evaluations.^[42] For solid tumors, a phase II trial (NCT05009992) combining panobinostat with ONC201 in diffuse midline gliomas, including diffuse intrinsic pontine glioma (DIPG), is actively recruiting.^[43] Recent preclinical data as of 2025 highlight panobinostat's potential in hepatocellular carcinoma (HCC), where nanodelivery induced cell cycle arrest and apoptosis, and in non-small cell lung cancer (NSCLC), potentiating adagrasib-induced death via mitochondrial dysfunction.^[44]^[6] Additionally, drug prioritization studies identify panobinostat for MYC-driven cancers, and a phase I trial (NCT04897880) is evaluating it in pediatric patients with solid tumors, including osteosarcoma and atypical teratoid/rhabdoid tumors.^[45]^[46] Research in glioblastoma is exploring its use in recurrent cases.^[47] In non-malignant applications, a phase I trial (NCT01245179) for sickle cell disease remains recruiting to assess safety and fetal hemoglobin induction.^[16] Studies are also investigating its senolytic properties for age-related diseases, where panobinostat selectively clears senescent cells by downregulating anti-apoptotic proteins like BCL-XL, with preclinical models demonstrating reduced frailty and improved tissue function in aged organisms.^[48] These investigations emphasize optimizing dosing and combinations to mitigate toxicity while exploring panobinostat's therapeutic utility beyond its former indication.

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