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Tracksdorf T, Smith DM, Pearse S, Cicali EJ, Aquilante CL, Scott SA, Ho TT, Patel JN, Hicks JK, Hertz DL. Strategies for DPYD testing prior to fluoropyrimidine chemotherapy in the US. Support Care Cancer 2024; 32:497. [PMID: 38980476 DOI: 10.1007/s00520-024-08674-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 06/20/2024] [Indexed: 07/10/2024]
Abstract
PURPOSE Patients with dihydropyrimidine dehydrogenase (DPD) deficiency are at high risk for severe and fatal toxicity from fluoropyrimidine (FP) chemotherapy. Pre-treatment DPYD testing is standard of care in many countries, but not the United States (US). This survey assessed pre-treatment DPYD testing approaches in the US to identify best practices for broader adoption. METHODS From August to October 2023, a 22-item QualtricsXM survey was sent to institutions and clinicians known to conduct pre-treatment DPYD testing and broadly distributed through relevant organizations and social networks. Responses were analyzed using descriptive analysis. RESULTS Responses from 24 unique US sites that have implemented pre-treatment DPYD testing or have a detailed implementation plan in place were analyzed. Only 33% of sites ordered DPYD testing for all FP-treated patients; at the remaining sites, patients were tested depending on disease characteristics or clinician preference. Almost 50% of sites depend on individual clinicians to remember to order testing without the assistance of electronic alerts or workflow reminders. DPYD testing was most often conducted by commercial laboratories that tested for at least the four or five DPYD variants considered clinically actionable. Approximately 90% of sites reported receiving results within 10 days of ordering. CONCLUSION Implementing DPYD testing into routine clinical practice is feasible and requires a coordinated effort among the healthcare team. These results will be used to develop best practices for the clinical adoption of DPYD testing to prevent severe and fatal toxicity in cancer patients receiving FP chemotherapy.
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Affiliation(s)
- Tabea Tracksdorf
- Deparment of Clinical Pharmacy, University of Michigan College of Pharmacy, 428 Church St, Room 2560C, Ann Arbor, MI, 48109-1065, USA
| | - D Max Smith
- Department of Oncology, Georgetown University Medical Center, Washington, DC, USA
- MedStar Health, Columbia, MD, USA
| | - Skyler Pearse
- Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Emily J Cicali
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, USA
| | - Christina L Aquilante
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
- Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Stuart A Scott
- Department of Pathology, Stanford University, Stanford, CA, USA
- Clinical Genomics Laboratory, Stanford Medicine, Palo Alto, CA, USA
| | - Teresa T Ho
- Department of Pathology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jai N Patel
- Department of Cancer Pharmacology and Pharmacogenomics, Atrium Health Levine Cancer Institute, Charlotte, NC, USA
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - J Kevin Hicks
- Department of Pathology, Moffitt Cancer Center, Tampa, FL, USA
| | - Daniel L Hertz
- Deparment of Clinical Pharmacy, University of Michigan College of Pharmacy, 428 Church St, Room 2560C, Ann Arbor, MI, 48109-1065, USA.
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De Metz C, Hennart B, Aymes E, Cren P, Martignène N, Penel N, Barthoulot M, Carnot A. Complete DPYD genotyping combined with dihydropyrimidine dehydrogenase phenotyping to prevent fluoropyrimidine toxicity: A retrospective study. Cancer Med 2024; 13:e7066. [PMID: 38523525 PMCID: PMC10961597 DOI: 10.1002/cam4.7066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 01/19/2024] [Accepted: 02/18/2024] [Indexed: 03/26/2024] Open
Abstract
INTRODUCTION In April 2019, French authorities mandated dihydropyrimidine dehydrogenase (DPD) screening, specifically testing uracilemia, to mitigate the risk of toxicity associated with fluoropyrimidine-based chemotherapy. However, this subject is still of debate as there is no consensus on a standardized DPD deficiency screening test. We conducted a real-life retrospective study with the aim of assessing the impact of DPD screening on the occurrence of severe toxicity and exploring the potential benefits of complete genotyping using next-generation sequencing. METHODS All adult patients consecutively treated with 5-fluorouracil (5-FU) or its oral prodrug at six cancer centers between March 2018 and February 2019 were considered for inclusion. Dihydropyrimidine dehydrogenase deficiency screening included gene encoding DPD (DPYD) genotyping using complete genome sequencing and DPD phenotyping (uracilemia or dihydrouracilemia/uracilemia ratio) or both tests. Associations between each DPD screening method and (i) severe (grade ≥3) early toxicity and (ii) fluoropyrimidine dose reduction in the second chemotherapy cycle were evaluated using multivariable logistic regression analysis. Furthermore, we assessed the concordance between DPD genotype and phenotype using Cohen's kappa. RESULTS A total of 551 patients were included. Most patients were tested for DPD deficiency (86%) including DPYD genotyping only (6%), DPD phenotyping only (8%), or both (72%). Complete DPD deficiency was not detected in the study population. Severe early toxicity events were observed in 73 patients (13%), with two patients (0.30%) presenting grade 5 toxicity. Despite the numerically higher toxicity rate in untested patients, the occurrence of severe toxicity was not significantly associated with the DPD screening method (p = 0.69). Concordance between the DPD genotype and phenotype was weak (Cohen's kappa of 0.14). CONCLUSION Due to insufficient numbers, our study was not able to demonstrate any added value of DPYD genotyping using complete genome sequencing to prevent 5-FU toxicity. The optimal strategy for DPD screening before fluoropyrimidine-based chemotherapy requires further clinical evaluation.
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Affiliation(s)
- Côme De Metz
- Department of Medical OncologyCentre Oscar LambretLilleFrance
| | - Benjamin Hennart
- Toxicology Unit, Biology and Pathology CentreLille University Medical CentreLilleFrance
| | - Estelle Aymes
- Department of BiostatisticsCentre Oscar LambretLilleFrance
| | - Pierre‐Yves Cren
- Department of Medical OncologyCentre Oscar LambretLilleFrance
- Department of BiostatisticsCentre Oscar LambretLilleFrance
| | | | - Nicolas Penel
- Department of Medical OncologyCentre Oscar LambretLilleFrance
- Univ. Lille, CHU Lille, ULR 2694 ‐ Metrics: Evaluation des technologies de santé et des pratiques médicalesLilleFrance
| | | | - Aurélien Carnot
- Department of Medical OncologyCentre Oscar LambretLilleFrance
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Le Teuff G, Cozic N, Boyer JC, Boige V, Diasio RB, Taieb J, Meulendijks D, Palles C, Schwab M, Deenen M, Largiadèr CR, Marinaki A, Jennings BA, Wettergren Y, Di Paolo A, Gross E, Budai B, Ackland SP, van Kuilenburg ABP, McLeod HL, Milano G, Thomas F, Loriot MA, Kerr D, Schellens JHM, Laurent-Puig P, Shi Q, Pignon JP, Etienne-Grimaldi MC. Dihydropyrimidine dehydrogenase gene variants for predicting grade 4-5 fluoropyrimidine-induced toxicity: FUSAFE individual patient data meta-analysis. Br J Cancer 2024; 130:808-818. [PMID: 38225422 PMCID: PMC10912560 DOI: 10.1038/s41416-023-02517-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/30/2023] [Accepted: 11/23/2023] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Dihydropyrimidine dehydrogenase (DPD) deficiency is the main known cause of life-threatening fluoropyrimidine (FP)-induced toxicities. We conducted a meta-analysis on individual patient data to assess the contribution of deleterious DPYD variants *2A/D949V/*13/HapB3 (recommended by EMA) and clinical factors, for predicting G4-5 toxicity. METHODS Study eligibility criteria included recruitment of Caucasian patients without DPD-based FP-dose adjustment. Main endpoint was 12-week haematological or digestive G4-5 toxicity. The value of DPYD variants *2A/p.D949V/*13 merged, HapB3, and MIR27A rs895819 was evaluated using multivariable logistic models (AUC). RESULTS Among 25 eligible studies, complete clinical variables and primary endpoint were available in 15 studies (8733 patients). Twelve-week G4-5 toxicity prevalence was 7.3% (641 events). The clinical model included age, sex, body mass index, schedule of FP-administration, concomitant anticancer drugs. Adding *2A/p.D949V/*13 variants (at least one allele, prevalence 2.2%, OR 9.5 [95%CI 6.7-13.5]) significantly improved the model (p < 0.0001). The addition of HapB3 (prevalence 4.0%, 98.6% heterozygous), in spite of significant association with toxicity (OR 1.8 [95%CI 1.2-2.7]), did not improve the model. MIR27A rs895819 was not associated with toxicity, irrespective of DPYD variants. CONCLUSIONS FUSAFE meta-analysis highlights the major relevance of DPYD *2A/p.D949V/*13 combined with clinical variables to identify patients at risk of very severe FP-related toxicity.
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Affiliation(s)
- Gwénaël Le Teuff
- Service de Biostatistique et d'Epidémiologie, Gustave Roussy, Oncostat U1018 INSERM, labeled Ligue Contre le Cancer, Université Paris-Saclay, Villejuif, France.
| | - Nathalie Cozic
- Service de Biostatistique et d'Epidémiologie, Gustave Roussy, Oncostat U1018 INSERM, labeled Ligue Contre le Cancer, Université Paris-Saclay, Villejuif, France
| | | | - Valérie Boige
- Department of cancer medicine, Gustave-Roussy Cancer Campus, Paris-Saclay and Paris-Sud Universities, Villejuif, France
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Equipe Labellisée Ligue Nationale Contre le Cancer, CNRS SNC, 5096, Paris, France
| | - Robert B Diasio
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Cancer Center, Rochester, MN, USA
| | - Julien Taieb
- Université Paris-Cité, SIRIC CARPEM, Department of Gastroenterology and Digestive Oncology, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - Didier Meulendijks
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Claire Palles
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany
- Departments of Clinical Pharmacology, and of Biochemistry and Pharmacy, University of Tuebingen, Tuebingen, Germany
- Cluster of Excellence IFIT (EXC 2180) "Image-Guided and Functionally Instructed Tumor Therapies", University of Tübingen, 72074, Tübingen, Germany
| | - Maarten Deenen
- Department of Clinical Pharmacy, Catharina Hospital, Eindhoven, the Netherlands
| | - Carlo R Largiadèr
- Department of Clinical Chemistry, Bern University Hospital, University of Bern, Inselspital, Bern, Switzerland
| | | | | | | | - Antonello Di Paolo
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Eva Gross
- LMU Munich, University Hospital, Campus Grosshadern, Munich, Germany
| | - Barna Budai
- National Institute of Oncology, Budapest, Hungary
| | - Stephen P Ackland
- College of Heath, Medicine and Wellbeing, University of Newcastle, Newcastle, NSW, Australia
| | - André B P van Kuilenburg
- Amsterdam UMC, location University of Amsterdam, Laboratory Genetic Metabolic Diseases, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Imaging and biomarkers, Amsterdam, The Netherlands
| | - Howard L McLeod
- Intermountain Precision Genomics, Intermountain Healthcare, St George, UT, USA
| | - Gérard Milano
- Oncopharmacology Laboratory, Centre Antoine Lacassagne, Nice, France
| | - Fabienne Thomas
- Institut Claudius Regaud, IUCT-Oncopôle and CRCT, University of Toulouse, Inserm, Toulouse, France
| | - Marie-Anne Loriot
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Equipe Labellisée Ligue Nationale Contre le Cancer, CNRS SNC, 5096, Paris, France
- Hôpital Européen Georges Pompidou, Hôpitaux Universitaires Paris Ouest, Paris, France
| | - David Kerr
- Nuffield Division of Clinical and Laboratory Sciences and University of Oxford, Oxford, UK
| | - Jan H M Schellens
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Pierre Laurent-Puig
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Equipe Labellisée Ligue Nationale Contre le Cancer, CNRS SNC, 5096, Paris, France
- Hôpital Européen Georges Pompidou, Hôpitaux Universitaires Paris Ouest, Paris, France
| | - Qian Shi
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Jean-Pierre Pignon
- Service de Biostatistique et d'Epidémiologie, Gustave Roussy, Oncostat U1018 INSERM, labeled Ligue Contre le Cancer, Université Paris-Saclay, Villejuif, France
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4
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Knikman JE, Lopez-Yurda M, Meulendijks D, Deenen MJ, Schellens JHM, Beijnen J, Cats A, Guchelaar HJ. A Nomogram to Predict Severe Toxicity in DPYD Wild-Type Patients Treated With Capecitabine-Based Anticancer Regimens. Clin Pharmacol Ther 2024; 115:269-277. [PMID: 37957132 DOI: 10.1002/cpt.3100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023]
Abstract
DPYD-guided dosing has improved the safety of fluoropyrimidine-based chemotherapy in recent years. However, severe toxicity remains in ~ 23% of patients not carrying DPYD variant alleles treated with capecitabine. Therefore, we developed a predictive model based on patient-related and treatment-related factors aimed at estimating the risk of developing severe capecitabine-related toxicity. The nomogram was developed using data from two large clinical trials (NCT00838370 and NCT02324452). Patients with cancer carrying a DPYD variant allele (DPYD*2A, c.1236G>A, c.2846A>T, and c.1679T>G) were excluded. Univariable and multivariable logistic regression using predetermined predictors based on previous findings, including age, sex, body surface area, type of treatment regimen, and creatinine levels were used to develop the nomogram. The developed model was internally validated using bootstrap resampling and cross-validation. This model was not externally or clinically validated. A total of 2,147 DPYD wild-type patients with cancer treated with capecitabine-based chemotherapy regimens were included of which complete data of 1,745 patients were available and used for the development of the nomogram. Univariable and multivariable logistic regression showed that age, sex, and type of treatment regimen were strong predictors of severe capecitabine-related toxicity in DPYD wild-type patients. Internal validation demonstrated a concordance index of 0.68 which indicates a good discriminative ability for prediction of severe capecitabine-related toxicity. The developed nomogram includes readily available parameters and may be a helpful tool for clinicians to assess the risk of developing severe capecitabine-related toxicity in patients without known risk DPYD variant alleles treated with capecitabine-based anticancer regimens.
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Affiliation(s)
- Jonathan E Knikman
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marta Lopez-Yurda
- Biometrics Department, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Didier Meulendijks
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Division of Medical Oncology, Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Late Development Oncology, AstraZeneca, Cambridge, UK
| | - Maarten J Deenen
- Department of Clinical Pharmacy, Catharina Hospital, Eindhoven, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jan H M Schellens
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Jos Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Annemieke Cats
- Division of Medical Oncology, Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, The Netherlands
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Larrue R, Fellah S, Hennart B, Sabaouni N, Boukrout N, Van der Hauwaert C, Delage C, Cheok M, Perrais M, Cauffiez C, Allorge D, Pottier N. Integrating rare genetic variants into DPYD pharmacogenetic testing may help preventing fluoropyrimidine-induced toxicity. THE PHARMACOGENOMICS JOURNAL 2024; 24:1. [PMID: 38216550 PMCID: PMC10786722 DOI: 10.1038/s41397-023-00322-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/23/2023] [Accepted: 12/05/2023] [Indexed: 01/14/2024]
Abstract
Variability in genes involved in drug pharmacokinetics or drug response can be responsible for suboptimal treatment efficacy or predispose to adverse drug reactions. In addition to common genetic variations, large-scale sequencing studies have uncovered multiple rare genetic variants predicted to cause functional alterations in genes encoding proteins implicated in drug metabolism, transport and response. To understand the functional importance of rare genetic variants in DPYD, a pharmacogene whose alterations can cause severe toxicity in patients exposed to fluoropyrimidine-based regimens, massively parallel sequencing of the exonic regions and flanking splice junctions of the DPYD gene was performed in a series of nearly 3000 patients categorized according to pre-emptive DPD enzyme activity using the dihydrouracil/uracil ([UH2]/[U]) plasma ratio as a surrogate marker of DPD activity. Our results underscore the importance of integrating next-generation sequencing-based pharmacogenomic interpretation into clinical decision making to minimize fluoropyrimidine-based chemotherapy toxicity without altering treatment efficacy.
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Affiliation(s)
- Romain Larrue
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France.
- Service de Toxicologie et Génopathies, CHU Lille, F-59000, Lille, France.
| | - Sandy Fellah
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Benjamin Hennart
- Service de Toxicologie et Génopathies, CHU Lille, F-59000, Lille, France
| | - Naoual Sabaouni
- Service de Toxicologie et Génopathies, CHU Lille, F-59000, Lille, France
| | - Nihad Boukrout
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Cynthia Van der Hauwaert
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Clément Delage
- Service de Toxicologie et Génopathies, CHU Lille, F-59000, Lille, France
| | - Meyling Cheok
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Michaël Perrais
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Christelle Cauffiez
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Delphine Allorge
- Service de Toxicologie et Génopathies, CHU Lille, F-59000, Lille, France
| | - Nicolas Pottier
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
- Service de Toxicologie et Génopathies, CHU Lille, F-59000, Lille, France
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6
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Glewis S, Lingaratnam S, Krishnasamy M, H Martin J, Tie J, Alexander M, Michael M. Pharmacogenetics testing (DPYD and UGT1A1) for fluoropyrimidine and irinotecan in routine clinical care: Perspectives of medical oncologists and oncology pharmacists. J Oncol Pharm Pract 2024; 30:30-37. [PMID: 37021580 DOI: 10.1177/10781552231167554] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
BACKGROUND Despite robust evidence and international guidelines, to support routine pharmacogenetic (PGx) testing, integration in practice has been limited. This study explored clinicians' views and experiences of pre-treatment DPYD and UGT1A1 gene testing and barriers to and enablers of routine clinical implementation. METHODS A study-specific 17-question survey was emailed (01 February-12 April 2022) to clinicians from the Medical Oncology Group of Australia (MOGA), the Clinical Oncology Society of Australia (COSA) and International Society of Oncology Pharmacy Practitioners (ISOPP). Data were analysed and reported using descriptive statistics. RESULTS Responses were collected from 156 clinicians (78% medical oncologists, 22% pharmacists). Median response rate of 8% (ranged from 6% to 24%) across all organisations. Only 21% routinely test for DPYD and 1% for UGT1A1. For patients undergoing curative/palliative intent treatments, clinicians reported intent to implement genotype-guided dosing by reducing FP dose for DPYD intermediate metabolisers (79%/94%), avoiding FP for DPYD poor metabolisers (68%/90%), and reducing irinotecan dose for UGT1A1 poor metabolisers (84%, palliative setting only). Barriers to implementation included: lack of financial reimbursements (82%) and perceived lengthy test turnaround time (76%). Most Clinicians identified a dedicated program coordinator, i.e., PGx pharmacist (74%) and availability of resources for education/training (74%) as enablers to implementation. CONCLUSION PGx testing is not routinely practised despite robust evidence for its impact on clinical decision making in curative and palliative settings. Research data, education and implementation studies may overcome clinicians' hesitancy to follow guidelines, especially for curative intent treatments, and may overcome other identified barriers to routine clinical implementation.
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Affiliation(s)
- Sarah Glewis
- Department of Pharmacy, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | | | - Mei Krishnasamy
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Academic Nursing Unit, Peter MacCallum Cancer Centre, Melbourne, Australia
- VCCC Alliance, Parkville, Australia
| | - Jennifer H Martin
- School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
| | - Jeanne Tie
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
- Personalised Oncology Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Marliese Alexander
- Department of Pharmacy, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Michael Michael
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
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7
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Knikman JE, Wilting TA, Lopez-Yurda M, Henricks LM, Lunenburg CATC, de Man FM, Meulendijks D, Nieboer P, Droogendijk HJ, Creemers GJ, Mandigers CMPW, Imholz ALT, Mathijssen RHJ, Portielje JEA, Valkenburg-van Iersel L, Vulink A, van der Poel MHW, Baars A, Swen JJ, Gelderblom H, Schellens JHM, Beijnen JH, Guchelaar HJ, Cats A. Survival of Patients With Cancer With DPYD Variant Alleles and Dose-Individualized Fluoropyrimidine Therapy-A Matched-Pair Analysis. J Clin Oncol 2023; 41:5411-5421. [PMID: 37639651 DOI: 10.1200/jco.22.02780] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 04/24/2023] [Accepted: 07/11/2023] [Indexed: 08/31/2023] Open
Abstract
PURPOSE DPYD-guided fluoropyrimidine dosing improves patient safety in carriers of DPYD variant alleles. However, the impact on treatment outcome in these patients is largely unknown. Therefore, progression-free survival (PFS) and overall survival (OS) were compared between DPYD variant carriers treated with a reduced dose and DPYD wild-type controls receiving a full fluoropyrimidine dose in a retrospective matched-pair survival analysis. METHODS Data from a prospective multicenter study (ClinicalTrials.gov identifier: NCT02324452) in which DPYD variant carriers received a 25% (c.1236G>A and c.2846A>T) or 50% (DPYD*2A and c.1679T>G) reduced dose and data from DPYD variant carriers treated with a similarly reduced dose of fluoropyrimidines identified during routine clinical care were obtained. Each DPYD variant carrier was matched to three DPYD wild-type controls treated with a standard dose. Survival analyses were performed using Kaplan-Meier estimates and Cox regression. RESULTS In total, 156 DPYD variant carriers and 775 DPYD wild-type controls were available for analysis. Sixty-one c.1236G>A, 25 DPYD*2A, 13 c.2846A>T, and-when pooled-93 DPYD variant carriers could each be matched to three unique DPYD wild-type controls. For pooled DPYD variant carriers, PFS (hazard ratio [HR], 1.23; 95% CI, 1.00 to 1.51; P = .053) and OS (HR, 0.95; 95% CI, 0.75 to 1.51; P = .698) were not negatively affected by DPYD-guided dose individualization. In the subgroup analyses, a shorter PFS (HR, 1.43; 95% CI, 1.10 to 1.86; P = .007) was found in c.1236G>A variant carriers, whereas no differences were found for DPYD*2A and c.2846A>T carriers. CONCLUSION In this exploratory analysis, DPYD-guided fluoropyrimidine dosing does not negatively affect PFS and OS in pooled DPYD variant carriers. Close monitoring with early dose modifications based on toxicity is recommended, especially for c.1236G>A carriers receiving a reduced starting dose.
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Affiliation(s)
- Jonathan E Knikman
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Tycho A Wilting
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Marta Lopez-Yurda
- Biometrics Department, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Linda M Henricks
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Carin A T C Lunenburg
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Femke M de Man
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Didier Meulendijks
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
- Late Development Oncology, AstraZeneca, Cambridge, UK
| | - Peter Nieboer
- Department of Internal Medicine, Wilhelmina Hospital Assen, Assen, the Netherlands
| | - Helga J Droogendijk
- Department of Internal Medicine, Bravis Hospital, Roosendaal, the Netherlands
| | - Geert-Jan Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | | | | | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Johanneke E A Portielje
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Medical Oncology, Haga Hospital, The Hague, the Netherlands
| | | | - Annelie Vulink
- Department of Medical Oncology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | | | - Arnold Baars
- Department of Internal Medicine, Hospital Gelderse Vallei, Ede, the Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jan H M Schellens
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Annemieke Cats
- Department of Gastrointestinal Oncology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
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8
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Hertz DL, Smith DM, Scott SA, Patel JN, Hicks JK. Response to the FDA Decision Regarding DPYD Testing Prior to Fluoropyrimidine Chemotherapy. Clin Pharmacol Ther 2023; 114:768-779. [PMID: 37350752 DOI: 10.1002/cpt.2978] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/31/2023] [Indexed: 06/24/2023]
Abstract
Fluoropyrimidine (FP) chemotherapy is associated with severe, life-threatening toxicities, particularly among patients who carry deleterious germline variants in the DPYD gene. Pretreatment DPYD testing is standard of care throughout most of Europe; however, it has not been recommended in clinical practice guidelines in the United States. Due to increased risk of severe toxicity, a Citizen's Petition asked the US Food and Drug Administration (FDA) to update language in FP drug labels to recommend DPYD testing as part of a boxed warning and recommend FP dose reduction in patients carrying deleterious germline variants. In response, the FDA updated the capecitabine package insert to inform patients about the toxicity risk and test availability and consider DPYD testing. However, the FDA did not include a testing recommendation or requirement, or a boxed warning. Additionally, the FDA did not recommend FP dose adjustment in DPYD variant carriers. This review provides a critical assessment of the DPYD-FP pharmacogenetic association using the FDA's previously published Pharmacogenetic Pyramid, demonstrating that the evidence is compelling for recommending DPYD testing prior to FP treatment. Additionally, the FDA's stated concerns about recommending DPYD testing and DPYD-guided FP dose adjustment are addressed and discussed in the context of the FDA's other genetic testing and dose adjustment recommendations. We call on the FDA to follow our European counterparts in recommending DPYD testing and genotype-based dose adjustment to ensure patients with cancer receive safe and effective FP chemotherapy.
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Affiliation(s)
- Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - D Max Smith
- Department of Oncology, Georgetown University Medical Center, Washington, DC, USA
- MedStar Health, Columbia, Maryland, USA
| | - Stuart A Scott
- Department of Pathology, Stanford University, Stanford, California, USA
- Clinical Genomics Laboratory, Stanford Medicine, Palo Alto, California, USA
| | - Jai N Patel
- Department of Cancer Pharmacology and Pharmacogenomics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - J Kevin Hicks
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, Florida, USA
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9
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Wu A, Anderson H, Hughesman C, Young S, Lohrisch C, Ross CJD, Carleton BC. Implementation of pharmacogenetic testing in oncology: DPYD-guided dosing to prevent fluoropyrimidine toxicity in British Columbia. Front Pharmacol 2023; 14:1257745. [PMID: 37745065 PMCID: PMC10515725 DOI: 10.3389/fphar.2023.1257745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
Background: Fluoropyrimidine toxicity is often due to variations in the gene (DPYD) encoding dihydropyrimidine dehydrogenase (DPD). DPYD genotyping can be used to adjust doses to reduce the likelihood of fluoropyrimidine toxicity while maintaining therapeutically effective drug levels. Methods: A multiplex QPCR assay was locally developed to allow genotyping for six DPYD variants. The test was offered prospectively for all patients starting on fluoropyrimidines at the BC Cancer Centre in Vancouver and then across B.C., Canada as well as retrospectively for patients suspected to have had an adverse reaction to therapy. Dose adjustments were made for variant carriers. The incidence of toxicity in the first three cycles was compared between DPYD variant allele carriers and non-variant carriers. Subsequent to an initial implementation phase, this test was made available province-wide. Results: In 9 months, 186 patients were tested and 14 were found to be heterozygous variant carriers. Fluoropyrimidine-related toxicity was higher in DPYD variant carriers. Of 127 non-variant carriers who have completed chemotherapy, 18 (14%) experienced severe (grade ≥3, Common Terminology Criteria for Adverse Events version 5.0). Of note, 22% (3 patients) of the variant carriers experienced severe toxicity even after DPYD-guided dose reductions. For one of these carriers who experienced severe thrombocytopenia within the first week, DPYD testing likely prevented lethal toxicity. In DPYD variant carriers who tolerate reduced doses, a later 25% increase led to chemotherapy discontinuation. As a result, a recommendation was made to clinicians based on available literature and expert opinion specifying that variant carriers who tolerated two cycles without toxicity can have a dose escalation of only 10%. Conclusion: DPYD-guided dose reductions were a feasible and acceptable method of preventing severe toxicity in DPYD variant carriers. Even with dose reductions, there were variant carriers who still experienced severe fluoropyrimidine toxicity, highlighting the importance of adhering to guideline-recommended dose reductions. Following the completion of the pilot phase of this study, DPYD genotyping was made available province-wide in British Columbia.
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Affiliation(s)
- Angela Wu
- Department of Experimental Medicine, University of British Columbia, Vancouver, BC, Canada
- BC Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - Helen Anderson
- Medical Oncology, BC Cancer, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Curtis Hughesman
- Cancer Genetics and Genomics Laboratory, BC Cancer, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Sean Young
- Cancer Genetics and Genomics Laboratory, BC Cancer, Provincial Health Services Authority, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Caroline Lohrisch
- Medical Oncology, BC Cancer, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Colin J. D. Ross
- BC Children’s Hospital Research Institute, Vancouver, BC, Canada
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Bruce C. Carleton
- BC Children’s Hospital Research Institute, Vancouver, BC, Canada
- Division of Translational Therapeutics, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
- Therapeutic Evaluation Unit, Provincial Health Services Authority, Vancouver, BC, Canada
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10
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Winther-Larsen A, Madsen AT, Nissen PH, Hoffmann-Lücke E, Greibe E. Short-term biological variation of plasma uracil in a Caucasian healthy population. Clin Chem Lab Med 2023; 61:1490-1496. [PMID: 36856054 DOI: 10.1515/cclm-2022-1167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/22/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVES Plasma uracil is a new biomarker to assess the activity of dihydropyrimidine dehydrogenase before cancer treatment with fluoropyrimidine drugs. Knowledge on the biological variation of plasma uracil is important to assess the applicability of plasma uracil as a biomarker of drug tolerance and efficacy. METHODS A total of 33 apparently healthy individuals were submitted to sequential blood draws for three days. On the second day, blood draws were performed every third hour for 12 h. Plasma uracil was quantified by LC-MS/MS. The within-subject (CVI) and between-subject (CVG) biological variation estimates were calculated using linear mixed-effects models. RESULTS The overall median value of plasma uracil was 10.6 ng/mL (range 5.6-23.1 ng/mL). The CVI and CVG were 13.5 and 22.1%, respectively. Plasma uracil remained stable during the day, and there was no day-to-day variation observed. No differences in biological variation components were found between sex and no correlation to age was found. Four samples were calculated to be required to estimate the homeostatic set-point ±15% with 95% confidence. CONCLUSIONS Plasma uracil is subject to tight homeostatic regulation without semidiurnal and day-to-day variation, however between-subject variation exists. This emphasizes plasma uracil as a well-suited biomarker for evaluation of dihydropyrimidine dehydrogenase activity, but four samples are required to establish the homeostatic set-point in a patient.
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Affiliation(s)
- Anne Winther-Larsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Anne Tranberg Madsen
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, USA
| | - Peter H Nissen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Elke Hoffmann-Lücke
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Eva Greibe
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
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11
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Bignucolo A, De Mattia E, Roncato R, Peruzzi E, Scarabel L, D’Andrea M, Sartor F, Toffoli G, Cecchin E. Ten-year experience with pharmacogenetic testing for DPYD in a national cancer center in Italy: Lessons learned on the path to implementation. Front Pharmacol 2023; 14:1199462. [PMID: 37256229 PMCID: PMC10225682 DOI: 10.3389/fphar.2023.1199462] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/05/2023] [Indexed: 06/01/2023] Open
Abstract
Background: Awareness about the importance of implementing DPYD pharmacogenetics in clinical practice to prevent severe side effects related to the use of fluoropyrimidines has been raised over the years. Since 2012 at the National Cancer Institute, CRO-Aviano (Italy), a diagnostic DPYD genotyping service was set up. Purpose: This study aims to describe the evolution of DPYD diagnostic activity at our center over the last 10 years as a case example of a successful introduction of pharmacogenetic testing in clinical practice. Methods: Data related to the diagnostic activity of in-and out-patients referred to our service between January 2012 and December 2022 were retrieved from the hospital database. Results: DPYD diagnostic activity at our center has greatly evolved over the years, shifting gradually from a post-toxicity to a pre-treatment approach. Development of pharmacogenetic guidelines by national and international consortia, genotyping, and IT technology evolution have impacted DPYD testing uptake in the clinics. Our participation in a large prospective implementation study (Ubiquitous Pharmacogenomics) increased health practitioners' and patients' awareness of pharmacogenetic matters and provided additional standardized infrastructures for genotyping and reporting. Nationwide test reimbursement together with recommendations by regulatory agencies in Europe and Italy in 2020 definitely changed the clinical practice guidelines of fluoropyrimidines prescription. A dramatic increase in the number of pre-treatment DPYD genotyping and in the coverage of new fluoropyrimidine prescriptions was noticed by the last year of observation (2022). Conclusion: The long path to a successful DPYD testing implementation in the clinical practice of a National Cancer Center in Italy demonstrated that the development of pharmacogenetic guidelines and genotyping infrastructure standardization as well as capillary training and education activity for all the potential stakeholders are fundamental. However, only national health politics of test reimbursement and clear recommendations by drug regulatory agencies will definitely move the field forward.
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12
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Narjoz C, Nadour Z, Zaanan A, Taieb J, Loriot MA, Pallet N. Screening for dihydropyrimidine dehydrogenase deficiency by measuring uracilemia in chronic kidney disease patients is associated with a high rate of false positives. Clin Chim Acta 2023; 543:117326. [PMID: 37011867 DOI: 10.1016/j.cca.2023.117326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Pretherapeutic screening for dihydropyrimidine dehydrogenase (DPD) deficiency based on the measurement of plasma uracil ([U]) is recommended prior to the administration of fluoropyrimidine-based chemotherapy. Cancer patients frequently have impaired kidney function, but the extent to which kidney function decline impacts [U] levels has not been comprehensively investigated. METHODS We assessed the relationship between DPD phenotypes and estimated glomerular filtration rate (eGFR) in 1751 patients who benefited on the same day from a screening for DPD deficiency by measuring [U] and [UH2]:[U], and an evaluation of eGFR. The impact of a kidney function decline on [U] levels and [UH2]:[U] ratio was evaluated. RESULTS We observed that [U] was negatively correlated with eGFR, indicating that [U] levels increase as eGFR declines. For each ml/min of eGFR decrease, [U] value increased in average by 0.035 ng/ml. Using the KDIGO classification of chronic kidney disease (CKD), we observed that [U] values >16 ng/ml (DPD deficiency) were measured in 3.6 % and 4.4 % of stage 1 and 2 CKD (normal-high eGFR, >60 ml/min/1.73m2) patients, but in 6.7 % of stage 3A CKD patients (45 to 59 ml/min/1.73m2), 25% of stage 3B CKD patients (30 to 44 ml/min/1.73m2), 22.7% of stage 4 CKD patients (15 to 29 ml/min/1.73m2 and 26.7% of stage 5 CKD patients (<15 ml/min/1.73m2). [UH2]:[U] ratios were not impacted by kidney function. CONCLUSION DPD phenotyping based on the measurement of plasma [U] in patients with decreased eGFR is associated with an exceedingly high rate of false positives when kidney function decline reaches 45 ml/minute/1.73m2 of eGFR or lower. In this population, an alternative strategy that remain to be evaluated would be to measure the [UH2]:[U] ratio in addition to [U].
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Affiliation(s)
- Céline Narjoz
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Zahia Nadour
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Aziz Zaanan
- Department of Gastroenterology and Digestive Oncology, Hôpital Européen Georges Pompidou, Paris University, France
| | - Julien Taieb
- Department of Gastroenterology and Digestive Oncology, Hôpital Européen Georges Pompidou, Paris University, France
| | - Marie-Anne Loriot
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Nicolas Pallet
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France.
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13
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de With M, Sadlon A, Cecchin E, Haufroid V, Thomas F, Joerger M, van Schaik RHN, Mathijssen RHJ, Largiadèr CR. Implementation of dihydropyrimidine dehydrogenase deficiency testing in Europe. ESMO Open 2023; 8:101197. [PMID: 36989883 PMCID: PMC10163157 DOI: 10.1016/j.esmoop.2023.101197] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/16/2023] [Accepted: 02/18/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND The main cause for fluoropyrimidine-related toxicity is deficiency of the metabolizing enzyme dihydropyrimidine dehydrogenase (DPD). In 2020, the European Medicines Agency (EMA) recommended two methods for pre-treatment DPD deficiency testing in clinical practice: phenotyping using endogenous uracil concentration or genotyping for DPYD risk variant alleles. This study assessed the DPD testing implementation status in Europe before (2019) and after (2021) the release of the EMA recommendations. METHODS The survey was conducted from 16 March 2022 to 31 July 2022. An electronic form with seven closed and three open questions was e-mailed to 251 professionals with DPD testing expertise of 34 European countries. A descriptive analysis was conducted. RESULTS We received 79 responses (31%) from 23 countries. Following publication of the EMA recommendations, 87% and 75% of the countries reported an increase in the amount of genotype and phenotype testing, respectively. Implementation of novel local guidelines was reported by 21 responders (27%). Countries reporting reimbursement of both tests increased in 2021, and only four (18%) countries reported no coverage for any testing type. In 2019, major implementation drivers were 'retrospective assessment of fluoropyrimidine-related toxicity' (39%), and in 2021, testing was driven by 'publication of guidelines' (40%). Although the major hurdles remained the same after EMA recommendations-'lack of reimbursement' (26%; 2019 versus 15%; 2021) and 'lack of recognizing the clinical relevance by medical oncologists' (25%; 2019 versus 8%; 2021)-the percentage of specialists citing these decreased. Following EMA recommendations, 25% of responders reported no hurdles at all in the adoption of the new testing practice in the clinics. CONCLUSIONS The EMA recommendations have supported the implementation of DPD deficiency testing in Europe. Key factors for successful implementation were test reimbursement and clear clinical guidelines. Further efforts to improve the oncologists' awareness of the clinical relevance of DPD testing in clinical practice are needed.
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Affiliation(s)
- M de With
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - A Sadlon
- Department of Clinical Chemistry, Inselspital, Bern University Hospital & University of Bern, INO F, Bern, Switzerland
| | - E Cecchin
- Department Experimental and Clinical Pharmacology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - V Haufroid
- Louvain Center for Toxicology and Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium; Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - F Thomas
- Institut Claudius Regaud, IUCT-Oncopole and CRCT, University of Toulouse, Inserm, Toulouse, France
| | - M Joerger
- Department of Internal Medicine, Klinik für Medizinische Onkologie & Hämatologie, Kantonsspital, St.Gallen, Switzerland
| | - R H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - R H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - C R Largiadèr
- Department of Clinical Chemistry, Inselspital, Bern University Hospital & University of Bern, INO F, Bern, Switzerland.
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14
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de With M, Knikman J, Schellens JHM, Gelderblom H, Cats A, Guchelaar HJ, Mathijssen RHJ, Swen JJ, Meulendijks D. Response to "Plasma Uracil as a DPD Phenotyping Test: Pre-analytical Handling Matters". Clin Pharmacol Ther 2023; 113:473-475. [PMID: 36352517 DOI: 10.1002/cpt.2775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/23/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Mirjam de With
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands.,Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jonathan Knikman
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan H M Schellens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Annemieke Cats
- Division of Medical Oncology, Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands.,Leiden Network for Personalised Therapeutics (LNPT), Leiden, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands.,Leiden Network for Personalised Therapeutics (LNPT), Leiden, The Netherlands
| | - Didier Meulendijks
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Division of Medical Oncology, Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Late Development Oncology, AstraZeneca, Cambridge, UK
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15
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Etienne-Grimaldi MC, Pallet N, Boige V, Ciccolini J, Chouchana L, Barin-Le Guellec C, Zaanan A, Narjoz C, Taieb J, Thomas F, Loriot MA. Current diagnostic and clinical issues of screening for dihydropyrimidine dehydrogenase deficiency. Eur J Cancer 2023; 181:3-17. [PMID: 36621118 DOI: 10.1016/j.ejca.2022.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
Fluoropyrimidine drugs (FP) are the backbone of many chemotherapy protocols for treating solid tumours. The rate-limiting step of fluoropyrimidine catabolism is dihydropyrimidine dehydrogenase (DPD), and deficiency in DPD activity can result in severe and even fatal toxicity. In this review, we survey the evidence-based pharmacogenetics and therapeutic recommendations regarding DPYD (the gene encoding DPD) genotyping and DPD phenotyping to prevent toxicity and optimize dosing adaptation before FP administration. The French experience of mandatory DPD-deficiency screening prior to initiating FP is discussed.
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Affiliation(s)
| | - Nicolas Pallet
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Valérie Boige
- Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France; Department of Cancer Medicine, Institut Gustave Roussy, Villejuif, France
| | - Joseph Ciccolini
- SMARTc, CRCM INSERM U1068, Université Aix-Marseille, Marseille, France; Laboratory of Pharmacokinetics and Toxicology, Hôpital Universitaire La Timone, F-13385 Marseille, France; COMPO, CRCM INSERM U1068-Inria, Université Aix-Marseille, Marseille, France
| | - Laurent Chouchana
- Regional Center of Pharmacovigilance, Department of Pharmacology, Hôpital Cochin, Assistance Publique-Hopitaux de Paris, Université de Paris, Paris, France; French Pharmacovigilance Network, France
| | - Chantal Barin-Le Guellec
- Laboratory of Biochemistry and Molecular Biology, Centre Hospitalo-uinversitaire de Tours, Tours, France; INSERM U1248, IPPRITT, University of Limoges, Limoges, France
| | - Aziz Zaanan
- Department of Gastroenterology and Digestive Oncology, Hôpital Européen Georges Pompidou, Paris University; Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Céline Narjoz
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Julien Taieb
- SIRIC CARPEM, Université de Paris; Fédération Francophone de Cancérologie Digestive (FFCD), Assistance Publique-Hôpitaux de Paris, Department of Gastroenterology and Digestive Oncology, Hôpital Européen Georges Pompidou, Paris, France
| | - Fabienne Thomas
- Laboratory of Pharmacology, Institut Claudius Regaud, IUCT-Oncopole and CRCT, INSERM UMR1037, Université Paul Sabatier, Toulouse, France
| | - Marie-Anne Loriot
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France.
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16
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Thomas F, Launay M, Guitton J, Loriot MA, Boyer JC, Haufroid V, Etienne-Grimaldi MC, Royer B. Plasma Uracil as a DPD Phenotyping Test: Pre-Analytical Handling Matters! Clin Pharmacol Ther 2023; 113:471-472. [PMID: 36412238 DOI: 10.1002/cpt.2772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/30/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Fabienne Thomas
- Centre de Recherches en Cancérologie, Inserm, CNRS, Université Toulouse III-Paul Sabatier and IUCT-Oncopole, Toulouse, France
| | - Manon Launay
- Plateau de Biologie, CHU Saint Etienne, Saint Etienne, France
| | - Jérôme Guitton
- Laboratoire de Pharmacologie Toxicologie, CHU de Lyon, Lyon, France
| | - Marie-Anne Loriot
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France.,INSERM UMRS1138, Centre de Recherche des Cordeliers, Université de Paris, Paris, France
| | | | - Vincent Haufroid
- Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc and Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | | | - Bernard Royer
- Laboratoire de Pharmacologie Clinique et Toxicologie, CHU Besançon, Besançon, France.,INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, University of Bourgogne Franche-Comté, Besançon, France
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17
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Knikman JE, Rosing H, Guchelaar HJ, Cats A, Beijnen JH. Assay performance and stability of uracil and dihydrouracil in clinical practice. Cancer Chemother Pharmacol 2023; 91:257-266. [PMID: 36905444 DOI: 10.1007/s00280-023-04518-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/25/2023] [Indexed: 03/12/2023]
Abstract
PURPOSE Measurement of endogenous uracil (U) is increasingly being used as a dose-individualization method in the treatment of cancer patients with fluoropyrimidines. However, instability at room temperature (RT) and improper sample handling may cause falsely increased U levels. Therefore we aimed to study the stability of U and dihydrouracil (DHU) to ensure proper handling conditions. METHODS Stability of U and DHU in whole blood, serum, and plasma at RT (up to 24 h) and long-term stability (≥ 7 days) at - 20 °C were studied in samples from 6 healthy individuals. U and DHU levels of patients were compared using standard serum tubes (SSTs) and rapid serum tubes (RSTs). The performance of our validated UPLC-MS/MS assay was assessed over a period of 7 months. RESULTS U and DHU levels significantly increased at RT in whole blood and serum after blood sampling with increases of 12.7 and 47.6% after 2 h, respectively. A significant difference (p = 0.0036) in U and DHU levels in serum was found between SSTs and RSTs. U and DHU were stable at - 20 °C at least 2 months in serum and 3 weeks in plasma. Assay performance assessment fulfilled the acceptance criteria for system suitability, calibration standards, and quality controls. CONCLUSION A maximum of 1 h at RT between sampling and processing is recommended to ensure reliable U and DHU results. Assay performance tests showed that our UPLC-MS/MS method was robust and reliable. Additionally, we provided a guideline for proper sample handling, processing and reliable quantification of U and DHU.
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Affiliation(s)
- Jonathan E Knikman
- Division of Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Hilde Rosing
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Annemieke Cats
- Department of Gastroenterology and Hepatology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jos H Beijnen
- Division of Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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18
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Maillard M, Launay M, Royer B, Guitton J, Gautier-Veyret E, Broutin S, Tron C, Le Louedec F, Ciccolini J, Richard D, Alarcan H, Haufroid V, Tafzi N, Schmitt A, Etienne-Grimaldi MC, Narjoz C, Thomas F. Quantitative impact of pre-analytical process on plasma uracil when testing for dihydropyrimidine dehydrogenase deficiency. Br J Clin Pharmacol 2023; 89:762-772. [PMID: 36104927 PMCID: PMC10092089 DOI: 10.1111/bcp.15536] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/29/2022] [Accepted: 08/15/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS Determining dihydropyrimidine dehydrogenase (DPD) activity by measuring patient's uracil (U) plasma concentration is mandatory before fluoropyrimidine (FP) administration in France. In this study, we aimed to refine the pre-analytical recommendations for determining U and dihydrouracil (UH2 ) concentrations, as they are essential in reliable DPD-deficiency testing. METHODS U and UH2 concentrations were collected from 14 hospital laboratories. Stability in whole blood and plasma after centrifugation, the type of anticoagulant and long-term plasma storage were evaluated. The variation induced by time and temperature was calculated and compared to an acceptability range of ±20%. Inter-occasion variability (IOV) of U and UH2 was assessed in 573 patients double sampled for DPD-deficiency testing. RESULTS Storage of blood samples before centrifugation at room temperature (RT) should not exceed 1 h, whereas cold (+4°C) storage maintains the stability of uracil after 5 hours. For patients correctly double sampled, IOV of U reached 22.4% for U (SD = 17.9%, range = 0-99%). Notably, 17% of them were assigned with a different phenotype (normal or DPD-deficient) based on the analysis of their two samples. For those having at least one non-compliant sample, this percentage increased up to 33.8%. The moment of blood collection did not affect the DPD phenotyping result. CONCLUSION Caution should be taken when interpreting U concentrations if the time before centrifugation exceeds 1 hour at RT, since it rises significantly afterwards. Not respecting the pre-analytical conditions for DPD phenotyping increases the risk of DPD status misclassification.
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Affiliation(s)
- Maud Maillard
- Laboratoire de Pharmacologie, Institut Claudius Regaud, IUCT-Oncopole et Centre de Recherches en Cancérologie de Toulouse, Inserm UMR1037, Université Paul Sabatier, Toulouse, France
| | - Manon Launay
- Laboratoire de Pharmacologie et Toxicologie, CHU de Saint-Etienne, Saint-Etienne, France
| | - Bernard Royer
- Laboratoire de Pharmacologie Clinique et Toxicologie, CHU Besançon and Univ. Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France
| | - Jérôme Guitton
- Laboratoire de Pharmacologie Toxicologie, CHU de Lyon, Lyon, France
| | - Elodie Gautier-Veyret
- Laboratoire de Pharmacologie, Pharmacogénétique et Toxicologie, CHU Grenoble-Alpes et Université Grenoble-Alpes, laboratoire HP2, INSERM U1300, Grenoble, France
| | - Sophie Broutin
- Département de Biologie et Pathologie Médicale, Service de Pharmacologie, Gustave Roussy, Villejuif, France
| | - Camille Tron
- Laboratoire de pharmacologie CHU de Rennes, Université de Rennes, CHU de Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail), UMR_S 1085, Rennes, France
| | - Félicien Le Louedec
- Laboratoire de Pharmacologie, Institut Claudius Regaud, IUCT-Oncopole et Centre de Recherches en Cancérologie de Toulouse, Inserm UMR1037, Université Paul Sabatier, Toulouse, France
| | - Joseph Ciccolini
- SMARTc Unit, CRCM Inserm U1068 et Laboratoire de Pharmacocinétique, CHU La Timone, Marseille, France
| | - Damien Richard
- Laboratoire de Pharmacologie et Toxicologie, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Hugo Alarcan
- Service de Biochimie et Biologie Moléculaire, CHRU de Tours, Tours, France
| | - Vincent Haufroid
- Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Clinical and Experimental Research Institute (IREC), Université catholique de Louvain, Brussels, Belgium.,Clinical Chemistry Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Naïma Tafzi
- INSERM, Université de Limoge, Service de Pharmacologie et Toxicologie, CHU de Limogess, U1248 IPPRITT, Limoges, France
| | - Antonin Schmitt
- Service Pharmacie, Centre Georges-François Leclerc et INSERM U1231, Université de Bourgogne, Dijon, France
| | | | - Céline Narjoz
- Assistance Publique des Hôpitaux de Paris, Hôpital européen Georges-Pompidou, Service de biochimie, Paris, France
| | - Fabienne Thomas
- Laboratoire de Pharmacologie, Institut Claudius Regaud, IUCT-Oncopole et Centre de Recherches en Cancérologie de Toulouse, Inserm UMR1037, Université Paul Sabatier, Toulouse, France
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19
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Paulsen NH, Pfeiffer P, Ewertz M, Fruekilde PBN, Feddersen S, Holm HS, Bergmann TK, Qvortrup C, Damkier P. Implementation and clinical benefit of DPYD genotyping in a Danish cancer population. ESMO Open 2023; 8:100782. [PMID: 36791638 PMCID: PMC10024141 DOI: 10.1016/j.esmoop.2023.100782] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/21/2022] [Accepted: 12/24/2022] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND In 2020, the European Medicines Agency recommended testing patients for dihydropyrimidine dehydrogenase (DPD) deficiency before systemic treatment with fluoropyrimidines (FP). DPD activity testing identifies patients at elevated risk of severe FP-related toxicity (FP-TOX). The two most used methods for DPD testing are DPYD genotyping and DPD phenotyping (plasma uracil concentration). The primary objective of this study was to compare the overall frequency of overall grade ≥3 FP-TOX before and after the implementation of DPYD genotyping. PATIENTS AND METHODS Two hundred thirty Danish, primarily gastrointestinal cancer patients, were DPYD-genotyped before their first dose of FP, and blood was sampled for post hoc assessment of P-uracil. The initial dose was reduced for variant carriers. Grade ≥3 FP-TOX was registered after the first three treatment cycles of FP. The frequency of toxicity was compared to a historical cohort of 492 patients with post hoc determined DPYD genotype from a biobank. RESULTS The frequency of overall grade ≥3 FP-TOX was 27% in the DPYD genotype-guided group compared to 24% in the historical cohort. In DPYD variant carriers, DPYD genotyping reduced the frequency of FP-related hospitalization from 19% to 0%. In the control group, 4.8% of DPYD variant carriers died due to FP-TOX compared to 0% in the group receiving DPYD genotype-guided dosing of FP. In the intervention group, wild-type patients with uracil ≥16 ng/ml had a higher frequency of FP-TOX than wild-type patients with uracil <16 ng/ml (55% versus 28%). CONCLUSIONS We found no population-level benefit of DPYD genotyping when comparing the risk of grade ≥3 FP-TOX before and after clinical implementation. We observed no deaths or FP-related hospitalizations in patients whose FP treatment was guided by a variant DPYD genotype. The use of DPD phenotyping may add valuable information in DPYD wild-type patients.
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Affiliation(s)
- N H Paulsen
- Department of Clinical Pharmacology, Odense University Hospital, Odense, Denmark; Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark.
| | - P Pfeiffer
- Department of Oncology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - M Ewertz
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - P B N Fruekilde
- Department of Clinical Biochemistry, Odense University Hospital, Odense, Denmark
| | - S Feddersen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Department of Clinical Biochemistry, Odense University Hospital, Odense, Denmark
| | - H S Holm
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - T K Bergmann
- Department of Clinical Pharmacology, Odense University Hospital, Odense, Denmark; Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | - C Qvortrup
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - P Damkier
- Department of Clinical Pharmacology, Odense University Hospital, Odense, Denmark; Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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20
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Callon S, Brugel M, Botsen D, Royer B, Slimano F, Feliu C, Gozalo C, Konecki C, Devie B, Carlier C, Daire V, Laurés N, Perrier M, Djerada Z, Bouché O. Renal impairment and abnormal liver function tests in pre-therapeutic phenotype-based DPD deficiency screening using uracilemia: a comprehensive population-based study in 1138 patients. Ther Adv Med Oncol 2023; 15:17588359221148536. [PMID: 36643657 PMCID: PMC9837271 DOI: 10.1177/17588359221148536] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 12/13/2022] [Indexed: 01/13/2023] Open
Abstract
Background Dihydropyrimidine dehydrogenase (DPD) deficiency screening is a pre-therapeutic standard to prevent severe fluoropyrimidine-related toxicity. Although several screening methods exist, the accuracy of their results remains debatable. In France, the uracilemia measurement is considered the standard in DPD deficiency screening. The objective of this study was to describe the hyperuracilemia (⩾16 ng/mL) rate and investigate the influence of hepatic and renal impairment in uracilemia measurements since the guidelines were implemented. Patients and methods Using a cohort of 1138 patients screened between 18 October 2018 and 18 October 2021, basic demographic characteristics, date of blood sampling, and potential biological confounders including liver function tests [aspartate aminotransaminase (AST), alanine aminotransaminase (ALT), gamma-glutamyl transferase (γGT), alkaline phosphatase (ALP), and bilirubin] and estimated glomerular filtration rate (eGFR) were collected. The second same-patient uracilemia analysis was also performed. Temporal change was graphically represented while potential confounders were stratified to show linearity when suspected. Results Hyperuracilemia was diagnosed in 12.7% (n = 150) samples with 6.7%, 5.4%, 0.5%, and 0.08% between 16 and 20 ng/mL, 20 and 50 ng/mL, 50 and 150 ng/mL, and >150 ng/mL, respectively. The median uracilemia concentration was 9.4 ng/mL (range: 1.2 and 172.3 ng/mL) and the monthly hyperuracilemia rate decreased steadily from >30% to around 9%. Older age, normalized AST, γGT, ALP results, bilirubin levels, and decreased eGFR were linearly associated with higher plasma uracil concentrations (all p < 0.001). In the adjusted multivariate linear model, AST, eGFR, and ALP remained associated with uracilemia (p < 0.05). When measured twice in 39 patients, the median uracilemia rate of change was -2.5%, which subsequently changed the diagnosis in nine patients (23.1%). Conclusions Better respect of pre-analytical conditions may explain the steady decrease in monthly hyperuracilemia rates over the 3 years. Elevated AST, ALP levels, and reduced eGFR could induce a false increase in uracilemia and second uracilemia measurements modified the first DPD deficiency diagnosis in almost 25% of the patients.
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Affiliation(s)
| | | | - Damien Botsen
- Department of Medical Oncology, Godinot Cancer Institute, Reims, France,Department of Digestive Oncology and Gastroenterology, University of Reims Champagne-Ardenne (URCA), CHU Reims, Reims, France
| | - Bernard Royer
- Clinical Pharmacology and Toxicology Laboratory, CHU Besançon, Besançon, France
| | | | - Catherine Feliu
- Pharmacology and Toxicology Department, CHU Reims, Reims, France
| | - Claire Gozalo
- Pharmacology and Toxicology Department, CHU Reims, Reims, France
| | - Céline Konecki
- Pharmacology and Toxicology Department, CHU Reims, Reims, France
| | - Bruno Devie
- Clairmarais Bioxa Medical Biology Laboratory, Reims, France
| | - Claire Carlier
- Department of Medical Oncology, Godinot Cancer Institute, Reims, France,Department of Digestive Oncology and Gastroenterology, University of Reims Champagne-Ardenne (URCA), CHU Reims, Reims, France
| | - Viktor Daire
- Department of Digestive Oncology and Gastroenterology, University of Reims Champagne-Ardenne (URCA), CHU Reims, Reims, France
| | - Nicolas Laurés
- Department of Digestive Oncology and Gastroenterology, University of Reims Champagne-Ardenne (URCA), CHU Reims, Reims, France
| | - Marine Perrier
- Department of Digestive Oncology and Gastroenterology, University of Reims Champagne-Ardenne (URCA), CHU Reims, Reims, France
| | - Zoubir Djerada
- Pharmacology and Toxicology Department, CHU Reims, Reims, France
| | - Olivier Bouché
- Department of Digestive Oncology and Gastroenterology, University of Reims Champagne-Ardenne (URCA), CHU Reims, Reims, France
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21
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Tybirk L, Hoffmann-Lücke E, Greibe E. Instability of uracil in whole blood might affect cancer treatment with fluoropyrimidines. Clin Chim Acta 2023; 538:87-90. [PMID: 36347332 DOI: 10.1016/j.cca.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/23/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND AIMS Measurement of plasma uracil is used before cancer treatment with fluoropyrimidines to determine if patients tolerate a full dose. Incorrect preanalytical handling may cause falsely elevated concentration and result in suboptimal cancer treatment. We aimed to examine the stability of uracil in whole blood stored at room temperature (RT) and the effect of centrifugation temperature. MATERIALS AND METHODS EDTA tubes (6x4 mL) were collected from 25 healthy volunteers. Five samples were stored 0, 1.5, 2, 3, and 4 h at RT and centrifuged at 4 °C. The sixth sample was centrifuged at RT after 1.5 h. Uracil was measured using an in-house LC-MS/MS method. RESULTS Storage of whole blood at RT followed by centrifugation at 4 °C caused a rapid increase in uracil concentration. Already after 1.5 h, the mean change (20.5 % (95 % CI: 11.9-29.2 %)) exceeded the maximum permissible difference. Centrifugation at RT instead of 4 °C after 1.5 h resulted in a smaller increase (7.0 % (95 % CI: 0.7-13.4 %)), although not statistically significant (p = 0.0527). CONCLUSION Uracil was unstable in samples processed according to current recommendations. Our data indicates better stability when centrifugation is performed at RT compared with 4 °C but further research into this is necessary.
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Affiliation(s)
- Lea Tybirk
- Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark.
| | - Elke Hoffmann-Lücke
- Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark; Department of Clinical Medicine, Health, Aarhus University, Palle Juul-Jensens Blvd. 82, 8200 Aarhus N, Denmark
| | - Eva Greibe
- Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark; Department of Clinical Medicine, Health, Aarhus University, Palle Juul-Jensens Blvd. 82, 8200 Aarhus N, Denmark
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22
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Medwid S, Wigle TJ, Kim RB. Fluoropyrimidine-associated toxicity and DPYD variants c.85T>C, c.496A>G, and c.1236G>A: impact of haplotype. Cancer Chemother Pharmacol 2023; 91:97-102. [PMID: 36357798 DOI: 10.1007/s00280-022-04491-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/04/2022] [Indexed: 11/12/2022]
Abstract
Dihydropyrimidine dehydrogenase (DPYD) is the rate-limiting step in fluoropyrimidines metabolism. Currently, genotype-guided fluoropyrimidine dosing is recommended for four DPYD single nucleotide variants (SNVs). However, the clinical impact of additional DPYD SNVs on fluoropyrimidine-related toxicity remains controversial. We assessed common DPYD SNVs c.85T>C, and c.496A>G which are often in linkage disequilibrium with c.1236G>A, a variant currently recommended for DPYD genotyping, in a retrospective cohort of cancer patients who had received fluoropyrimidines (N = 1371). When assessing individual SNVs, during the total chemotherapy treatment period, a significant increased risk of severe grade ≥ 3 toxicity was seen in carriers of c.496A>G (OR = 1.38, 95% CI 1.01-1.88, p = 0.0405) after adjusting for age, sex and treatment drug (capecitabine or 5-Fluorouracil). No association with fluoropyrimidine-related toxicity was seen in patients given standard dosing among those carrying one allele of DPYD c.1236G>A (OR = 1.19, 95% CI 0.59-2.27, p = 0.6147) or c.85T>C (OR = 1.04, 95% CI 0.80-1.62, p = 0.7536). Haplotype analysis confirmed a high linkage disequilibrium of these three variants. Toxicity was not significantly increased in haplotypes containing only one of c.85T>C or c.496A>G or c.1236G>A alleles. However, the haplotype containing both c.85T>C and c.496A>G alleles, which had a predicted frequency of 7.1%, was associated with an increased risk of fluoropyrimidine toxicity (OR = 1.57, 95% CI 1.15-2.13, p = 0.0041). This study suggests DPYD haplotype structure may help explain previous conflicting studies concerning the impact of these variants. Our findings suggest patients with both DPYD c.85T>C and c.496A>G variants have a significant increased risk for toxicity and may potentially benefit from genotype-guided fluoropyrimidine dosing.
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Affiliation(s)
- Samantha Medwid
- London Health Sciences Centre, London, ON, Canada.,Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Theodore J Wigle
- London Health Sciences Centre, London, ON, Canada.,Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Richard B Kim
- London Health Sciences Centre, London, ON, Canada. .,Department of Medicine, University of Western Ontario, London, ON, Canada. .,Lawson Health Research Institute, London, ON, Canada.
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23
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Paulsen NH, Qvortrup C, Vojdeman FJ, Plomgaard P, Andersen SE, Ramlov A, Bertelsen B, Rossing M, Nielsen CG, Hoffmann-Lücke E, Greibe E, Spangsberg Holm H, Nielsen HH, Lolas IBY, Madsen JS, Bergmann ML, Mørk M, Fruekilde PBN, Bøttger P, Petersen PC, Nissen PH, Feddersen S, Bergmann TK, Pfeiffer P, Damkier P. Dihydropyrimidine dehydrogenase (DPD) genotype and phenotype among Danish cancer patients: prevalence and correlation between DPYD-genotype variants and P-uracil concentrations. Acta Oncol 2022; 61:1400-1405. [PMID: 36256873 DOI: 10.1080/0284186x.2022.2132117] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Niels Herluf Paulsen
- Department of Clinical Pharmacology, Odense University Hospital, Odense, Denmark.,Clinical Pharmacology, Pharmacy and Environmental Medicine Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Camilla Qvortrup
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Fie Juhl Vojdeman
- Department of Clinical Biochemistry, Holbaek Hospital, Holbaek, Denmark
| | - Peter Plomgaard
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Anne Ramlov
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Birgitte Bertelsen
- Center for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Maria Rossing
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Center for Genomic Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Claus Gyrup Nielsen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
| | - Elke Hoffmann-Lücke
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus N, Denmark.,Institute for Clinical Medicine, Aarhus University of Health, Aarhus, Denmark
| | - Eva Greibe
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus N, Denmark.,Institute for Clinical Medicine, Aarhus University of Health, Aarhus, Denmark
| | | | - Heidi Hvid Nielsen
- Department of Clinical Biochemistry, Zealand University Hospital, Køge, Denmark
| | | | - Jonna Skov Madsen
- Department of Biochemistry and Immunology, Lillebaelt Hospital - University Hospital of Southern Denmark, Vejle, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Marianne Lerbaek Bergmann
- Department of Biochemistry and Immunology, Lillebaelt Hospital - University Hospital of Southern Denmark, Vejle, Denmark
| | - Morten Mørk
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark.,Department of Molecular Diagnostics, Aalborg University Hospital, Aalborg, Denmark
| | | | - Pernille Bøttger
- Department of Biochemistry and Immunology, Lillebaelt Hospital - University Hospital of Southern Denmark, Vejle, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | - Peter Henrik Nissen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus N, Denmark.,Denmark and Institute for Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Søren Feddersen
- Department of Clinical Biochemistry, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Troels K Bergmann
- Department of Clinical Pharmacology, Odense University Hospital, Odense, Denmark.,Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Per Damkier
- Department of Clinical Pharmacology, Odense University Hospital, Odense, Denmark.,Clinical Pharmacology, Pharmacy and Environmental Medicine Department of Public Health, University of Southern Denmark, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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24
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Paulsen NH, Vojdeman F, Andersen SE, Bergmann TK, Ewertz M, Plomgaard P, Hansen MR, Esbech PS, Pfeiffer P, Qvortrup C, Damkier P. DPYD genotyping and dihydropyrimidine dehydrogenase (DPD) phenotyping in clinical oncology. A clinically focused minireview. Basic Clin Pharmacol Toxicol 2022; 131:325-346. [PMID: 35997509 PMCID: PMC9826411 DOI: 10.1111/bcpt.13782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND In clinical oncology, systemic 5-fluorouracil (5-FU) and its oral pro-drugs are used to treat a broad group of solid tumours. Patients with dihydropyrimidine dehydrogenase (DPD) enzyme deficiency are at elevated risk of toxicity if treated with standard doses of 5-FU. DPYD genotyping and measurements of plasma uracil concentration (DPD phenotyping) can be applied as tests for DPD deficiency. In April 2020, the European Medicines Agency recommended pre-treatment DPD testing to reduce the risk of 5-FU-related toxicity. OBJECTIVES The objective of this study is to present the current evidence for DPD testing in routine oncological practice. METHODS Two systematic literature searches were performed following the PRISMA guidelines. We identified studies examining the possible benefit of DPYD genotyping or DPD phenotyping on the toxicity risk. FINDINGS Nine and 12 studies met the criteria for using DPYD genotyping and DPD phenotyping, respectively. CONCLUSIONS The evidence supporting either DPYD genotyping or DPD phenotyping as pre-treatment tests to reduce 5-FU toxicity is poor. Further evidence is still needed to fully understand and guide clinicians to dose by DPD activity.
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Affiliation(s)
- Niels Herluf Paulsen
- Department of Clinical PharmacologyOdense University HospitalOdenseDenmark,Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark
| | - Fie Vojdeman
- Department of Clinical BiochemistryHolbaek HospitalHolbaekDenmark
| | | | - Troels K. Bergmann
- Department of Clinical PharmacologyOdense University HospitalOdenseDenmark,Department of Regional Health ResearchUniversity of Southern DenmarkEsbjergDenmark
| | - Marianne Ewertz
- Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Peter Plomgaard
- Department of Clinical Biochemistry, Rigshospitalet, Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Morten Rix Hansen
- Department of Clinical PharmacologyOdense University HospitalOdenseDenmark,Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark,Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark,Novo NordiskSøborgDenmark
| | - Peter Skov Esbech
- Department of Clinical PharmacologyOdense University HospitalOdenseDenmark
| | - Per Pfeiffer
- Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark,Department of OncologyOdense University HospitalOdenseDenmark
| | - Camilla Qvortrup
- Department of Oncology, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
| | - Per Damkier
- Department of Clinical PharmacologyOdense University HospitalOdenseDenmark,Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark,Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
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25
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Laures N, Konecki C, Brugel M, Giffard AL, Abdelli N, Botsen D, Carlier C, Gozalo C, Feliu C, Slimano F, Djerada Z, Bouché O. Impact of Guidelines Regarding Dihydropyrimidine Dehydrogenase (DPD) Deficiency Screening Using Uracil-Based Phenotyping on the Reduction of Severe Side Effect of 5-Fluorouracil-Based Chemotherapy: A Propension Score Analysis. Pharmaceutics 2022; 14:pharmaceutics14102119. [PMID: 36297556 PMCID: PMC9610761 DOI: 10.3390/pharmaceutics14102119] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/07/2022] Open
Abstract
Dihydropyrimidine dehydrogenase (DPD) deficiency is associated with severe fluoropyrimidines-induced toxicity. As of September 2018, French recommendations call for screening for DPD deficiency by plasma uracil quantification prior to all fluoropyrimidine-based chemotherapy. A dose reduction of fluoropyrimidine is recommended when uracil concentration is equal to or greater than 16 ng/mL. This matched retrospective study assessed the impact of DPD screening on the reduction of severe side effects and on the management of DPD-deficient patients. Using a propensity score, we balanced the factors influencing 5-Fluorouracil (5-FU) toxicity. Then, the severity scores (G3 and G4 severity as well as their frequency) of patients who did not benefit from DPD screening were compared with those of patients who benefited from DPD screening for each treatment cycle (from 1 to 4). Among 349 screened patients, 198 treated patients were included. Among them, 31 (15.7%) had DPD deficiency (median uracilemia 19.8 ng/mL (range: 16.1−172.3)). The median toxicity severity score was higher in the unscreened group for each treatment cycle (0 vs. 1, p < 0.001 at each cycle from 1 to 4) as well as the cumulative score during all courses of treatment (p = 0.028). DPD-deficient patients received a significantly lower dose of 5-FU (p < 0.001). This study suggests that pretherapeutic plasmatic uracil assessment, along with 5-FU dosage adjustment, may be beneficial in reducing 5-FU toxicity in real-life patients.
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Affiliation(s)
- Nicolas Laures
- Department of Gastroenterology and Digestive Oncology, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
| | - Céline Konecki
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA3801, 51097 Reims, France
- Department of Pharmacology and Toxicology, CHU Reims, 51100 Reims, France
| | - Mathias Brugel
- Department of Gastroenterology and Digestive Oncology, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
- Department of Hepato-Gastroenterology and Digestive Oncology, Centre Hospitalier Auban-Moët, 51200 Epernay, France
| | - Anne-Lise Giffard
- Department of Gastroenterology and Digestive Oncology, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
| | - Naceur Abdelli
- Department of Hepato-Gastroenterology and Digestive Oncology, Centre Hospitalier de Chalons en Champagne, 51000 Chalons en Champagne, France
| | - Damien Botsen
- Department of Gastroenterology and Digestive Oncology, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
| | - Claire Carlier
- Department of Gastroenterology and Digestive Oncology, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
| | - Claire Gozalo
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA3801, 51097 Reims, France
- Department of Pharmacology and Toxicology, CHU Reims, 51100 Reims, France
| | - Catherine Feliu
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA3801, 51097 Reims, France
- Department of Pharmacology and Toxicology, CHU Reims, 51100 Reims, France
| | - Florian Slimano
- Department of Pharmacy, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
| | - Zoubir Djerada
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA3801, 51097 Reims, France
- Department of Pharmacology and Toxicology, CHU Reims, 51100 Reims, France
- Correspondence:
| | - Olivier Bouché
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA3801, 51097 Reims, France
- Department of Pharmacology and Toxicology, CHU Reims, 51100 Reims, France
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26
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De Mattia E, Silvestri M, Polesel J, Ecca F, Mezzalira S, Scarabel L, Zhou Y, Roncato R, Lauschke VM, Calza S, Spina M, Puglisi F, Toffoli G, Cecchin E. Rare genetic variant burden in DPYD predicts severe fluoropyrimidine-related toxicity risk. Biomed Pharmacother 2022; 154:113644. [PMID: 36063648 PMCID: PMC9463069 DOI: 10.1016/j.biopha.2022.113644] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/23/2022] [Accepted: 08/31/2022] [Indexed: 11/30/2022] Open
Abstract
Preemptive targeted pharmacogenetic testing of candidate variations in DPYD is currently being used to limit toxicity associated with fluoropyrimidines. The use of innovative next generation sequencing (NGS) approaches could unveil additional rare (minor allele frequency <1%) genetic risk variants. However, their predictive value and management in clinical practice are still controversial, at least partly due to the challenges associated with functional analyses of rare variants. The aim of this study was to define the predictive power of rare DPYD variants burden on the risk of severe fluoropyrimidine-related toxicity. The DPYD coding sequence and untranslated regions were analyzed by NGS in 120 patients developing grade 3–5 (NCI-CTC vs3.0) fluoropyrimidine-related toxicity and 104 matched controls (no-toxicity). The functional impact of rare variants was assessed using two different in silico predictive tools (i.e., Predict2SNP and ADME Prediction Framework) and structural modeling. Plasma concentrations of uracil (U) and dihydrouracil (UH2) were quantified in carriers of the novel variants. Here, we demonstrate that the burden of rare variants was significantly higher in patients with toxicity compared to controls (p = 0.007, Mann-Whitney test). Carriers of at least one rare missense DPYD variant had a 16-fold increased risk in the first cycle and an 11-fold increased risk during the entire course of chemotherapy of developing a severe adverse event compared to controls (p = 0.013 and p = 0.0250, respectively by multinomial regression model). Quantification of plasmatic U/UH2 metabolites and in silico visualization of the encoded protein were consistent with the predicted functional effect for the novel variations. Analysis and consideration of rare variants by DPYD-sequencing could improve prevention of severe toxicity of fluoropyrimidines and improve patients’ quality of life. DPYD genotype-guided dosing reduces fluoropyrimidine (FP) toxicity risk. Rare DPYD variants associate with severe FP toxicities. Carriers of rare DPYD variants have 11-fold increased risk of toxicity. DPYD sequencing and in silico functional prediction could prevent FP toxicity events.
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Affiliation(s)
- Elena De Mattia
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, via Franco Gallini n. 2, 33081 Aviano PN, Italy.
| | - Marco Silvestri
- Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Department of Applied Research and Technological Development, Via Giacomo Venezian 1, 20133 Milano, Italy.
| | - Jerry Polesel
- Unit of Cancer Epidemiology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, via Franco Gallini n. 2, 33081 Aviano PN, Italy.
| | - Fabrizio Ecca
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, via Franco Gallini n. 2, 33081 Aviano PN, Italy.
| | - Silvia Mezzalira
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, via Franco Gallini n. 2, 33081 Aviano PN, Italy.
| | - Lucia Scarabel
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, via Franco Gallini n. 2, 33081 Aviano PN, Italy.
| | - Yitian Zhou
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden.
| | - Rossana Roncato
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, via Franco Gallini n. 2, 33081 Aviano PN, Italy.
| | - Volker M Lauschke
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden; Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Auerbachstraße 112, 70376 Stuttgart, Germany; University of Tuebingen, Geschwister-Scholl-Platz, 72074 Tuebingen, Germany.
| | - Stefano Calza
- University of Brescia, Department of Molecular and Translational Medicine, Viale Europa 11, 25123 Brescia, Italy.
| | - Michele Spina
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCSS, via Franco Gallini n. 2, 33081 Aviano PN, Italy.
| | - Fabio Puglisi
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCSS, via Franco Gallini n. 2, 33081 Aviano PN, Italy; Department of Medicine, University of Udine, Via delle Scienze, 206, 33100 Udine UD, Italy.
| | - Giuseppe Toffoli
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, via Franco Gallini n. 2, 33081 Aviano PN, Italy.
| | - Erika Cecchin
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, via Franco Gallini n. 2, 33081 Aviano PN, Italy.
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27
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van den Wildenberg SA, Streng AS, van den Broek R, Broeren MA, Deenen MJ, van Dongen JL, Hanrath MA, Lapré C, Brunsveld L, Scharnhorst V, van de Kerkhof D. Quantification of uracil, dihydrouracil, thymine and dihydrothymine for reliable dihydropyrimidine dehydrogenase (DPD) phenotyping critically depend on blood and plasma storage conditions. J Pharm Biomed Anal 2022; 221:115027. [DOI: 10.1016/j.jpba.2022.115027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/12/2022] [Accepted: 08/30/2022] [Indexed: 12/01/2022]
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28
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Carriat L, Quaranta S, Solas C, Rony M, Ciccolini J. Renal impairment and DPD testing: watch out for false-positive results! Br J Clin Pharmacol 2022; 88:4928-4932. [PMID: 35939355 DOI: 10.1111/bcp.15482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/21/2022] [Accepted: 07/29/2022] [Indexed: 11/30/2022] Open
Abstract
Measuring uracil (U) levels in plasma is a convenient surrogate to establish DPD status in patients scheduled with 5-fluorouracil (5-FU) or capecitabine. To what extent renal impairment could impact on U levels and thus be a confounding factor is a rising concern. Here, we report the case of a cancer patient with severe renal impairment scheduled for 5-FU-based regimen. Determination of his DPD status was complicated because of his condition and the influence of intermittent hemodialysis when monitoring U levels. The patient was initially identified as markedly DPD-deficient upon U measurement (i.e., U = 40 ng/ml), but further monitoring between and immediately after dialysis showed mild deficiency only (i.e., U = 34 and U = 19 ng/ml, respectively). Despite this discrepancy, starting dose of 5-FU was cut by 50% upon treatment initiation. Tolerance was good and 5-FU dosing was next shifted to 25% reduction, then further shifted to normal dosing at the 5th course, with still no sign for drug-related toxicities. Further DPYD genotyping showed none of the 4 allelic variants usually associated with loss of DPD activity. Of note, the excellent tolerance upon standard dosing strongly suggests that this patient was actually not DPD-deficient, despite U values always above normal concentrations. This case report highlights how critical is the information regarding the renal function of patients with cancer when phenotyping DPD using U plasma as a surrogate, and that U accumulation in patients with such condition is likely to yield false-positive results.
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Affiliation(s)
- Laure Carriat
- Laboratoire de Pharmacocinétique et Toxicologie, CHU Timone, APHM, Marseille, France.,SMARTc unit, Centre de Recherche en Cancérologie de Marseille, Inserm, Marseille, France
| | - Sylvie Quaranta
- Laboratoire de Pharmacocinétique et Toxicologie, CHU Timone, APHM, Marseille, France
| | - Caroline Solas
- Laboratoire de Pharmacocinétique et Toxicologie, CHU Timone, APHM, Marseille, France
| | - Maelle Rony
- Oncologie Digestive, CHU Timone, APHM, Marseille, France
| | - Joseph Ciccolini
- Laboratoire de Pharmacocinétique et Toxicologie, CHU Timone, APHM, Marseille, France.,SMARTc unit, Centre de Recherche en Cancérologie de Marseille, Inserm, Marseille, France
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29
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Testing for Dihydropyrimidine Dehydrogenase Deficiency to Individualize 5-Fluorouracil Therapy. Cancers (Basel) 2022; 14:cancers14133207. [PMID: 35804978 PMCID: PMC9264755 DOI: 10.3390/cancers14133207] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 12/24/2022] Open
Abstract
Simple Summary 5-Fluorouracil (5-FU) is a chemotherapy drug that is commonly used to treat multiple cancers. Many people who are treated with 5-FU experience severe toxicity to the drug, and in severe cases, patients can die. This review discusses current methods for identifying people who are at high risk for severe side effects to 5-FU therapy. Abstract Severe adverse events (toxicity) related to the use of the commonly used chemotherapeutic drug 5-fluorouracil (5-FU) affect one in three patients and are the primary reason cited for premature discontinuation of therapy. Deficiency of the 5-FU catabolic enzyme dihydropyrimidine dehydrogenase (DPD, encoded by DPYD) has been recognized for the past 3 decades as a pharmacogenetic syndrome associated with high risk of 5-FU toxicity. An appreciable fraction of patients with DPD deficiency that receive 5-FU-based chemotherapy die as a result of toxicity. In this manuscript, we review recent progress in identifying actionable markers of DPD deficiency and the current status of integrating those markers into the clinical decision-making process. The limitations of currently available tests, as well as the regulatory status of pre-therapeutic DPYD testing, are also discussed.
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