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Briki M, Murisier A, Guidi M, Seydoux C, Buclin T, Marzolini C, Girardin FR, Thoma Y, Carrara S, Choong E, Decosterd LA. Liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) methods for the therapeutic drug monitoring of cytotoxic anticancer drugs: An update. J Chromatogr B Analyt Technol Biomed Life Sci 2024; 1236:124039. [PMID: 38490042 DOI: 10.1016/j.jchromb.2024.124039] [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: 11/16/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 03/17/2024]
Abstract
In the era of precision medicine, there is increasing evidence that conventional cytotoxic agents may be suitable candidates for therapeutic drug monitoring (TDM)- guided drug dosage adjustments and patient's tailored personalization of non-selective chemotherapies. To that end, many liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) assays have been developed for the quantification of conventional cytotoxic anticancer chemotherapies, that have been comprehensively and critically reviewed. The use of stable isotopically labelled internal standards (IS) of cytotoxic drugs was strikingly uncommon, accounting for only 48 % of the methods found, although their use could possible to suitably circumvent patients' samples matrix effects variability. Furthermore, this approach would increase the reliability of cytotoxic drug quantification in highly multi-mediated cancer patients with complex fluctuating pathophysiological and clinical conditions. LC-MS/MS assays can accommodate multiplexed analyses of cytotoxic drugs with optimal selectivity and specificity as well as short analytical times and, when using stable-isotopically labelled IS for quantification, provide concentrations measurements with a high degree of certainty. However, there are still organisational, pharmacological, and medical constraints to tackle before TDM of cytotoxic drugs can be more largely adopted in the clinics for contributing to our ever-lasting quest to improve cancer treatment outcomes.
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Affiliation(s)
- M Briki
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; Bio/CMOS Interfaces Laboratory, École Polytechnique Fédérale de Lausanne-EPFL, 2002 Neuchâtel, Switzerland
| | - A Murisier
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - M Guidi
- Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, 1206 Geneva, Switzerland; Centre for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - C Seydoux
- Internal Medicine Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - T Buclin
- Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - C Marzolini
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - F R Girardin
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Y Thoma
- School of Engineering and Management Vaud, HES-SO University of Applied Sciences and Arts Western Switzerland, 1401 Yverdon-les-Bains, Switzerland
| | - S Carrara
- Bio/CMOS Interfaces Laboratory, École Polytechnique Fédérale de Lausanne-EPFL, 2002 Neuchâtel, Switzerland
| | - E Choong
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - L A Decosterd
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland.
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Janssen Bonás M, Sundaresan J, Keijsers RGM, Struys EA, Peters BJM, Kahlmann V, Wijsenbeek MS, de Rotte MCFJ, Grutters JC, Veltkamp M. Methotrexate Polyglutamate Concentrations as a Possible Predictive Marker for Effectiveness of Methotrexate Therapy in Patients with Sarcoidosis: A Pilot Study. Lung 2023; 201:617-624. [PMID: 37973683 DOI: 10.1007/s00408-023-00656-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/05/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Methotrexate (MTX), a folate antagonist, is often used as second-line treatment in patients with sarcoidosis. Effectiveness of MTX has large inter-patient variability and at present therapeutic drug monitoring (TDM) of MTX is not possible. Upon administration, MTX is actively transported into cells and metabolized to its active forms by adding glutamate residues forming MTXPG(n=1-5) resulting in enhanced cellular retention. In this study we address the question whether different MTXPG(n) concentrations in red blood cells (RBC) of patients with sarcoidosis after 3 months of MTX therapy correlate with response to treatment. METHODS We retrospectively included patients with sarcoidosis that had started on MTX therapy and from whom blood samples and FDG-PET/CT were available 3 and 6-12 months after MTX initiation, respectively. FDG-uptake was measured by SUVmax in the heart, lungs and thoracic lymph nodes. Changes in SUVmax was used to determine anti-inflammatory response after 6-12 months of MTX therapy. MTXPG(n) concentrations were measured from whole blood RBC using an LC-MS/MS method. Pearson correlation coefficients were calculated to evaluate the relationship between changes in the SUVmax and MTXPG(n) concentrations. RESULTS We included 42 sarcoidosis patients treated with MTX (15 mg/week); 31 with cardiac sarcoidosis and 11 with pulmonary sarcoidosis. In MTXPG3 and MTXPG4 a significant negative relation between the absolute changes in SUVmax and MTXPG(n) was found r = - 0.312 (n = 42, p = 0.047) for MTXPG3 and r = - 0.336 (n = 42, p = 0.031 for MTXPG4). The other MTXPG(n) did not correlate to changes in SUVmax. CONCLUSION These results suggest a relation between MTXPG(n) concentrations and the anti-inflammatory effect in patients with sarcoidosis. Further prospective validation is warranted, but if measuring MTXPG concentrations could predict treatment effect of MTX this would be a step in the direction of personalized medicine.
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Affiliation(s)
- Montse Janssen Bonás
- Department of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Janani Sundaresan
- Department of Clinical Chemistry, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ruth G M Keijsers
- Department of Nuclear Medicine, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Eduard A Struys
- Department of Clinical Chemistry, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Bas J M Peters
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Vivienne Kahlmann
- Center of Excellence for ILD and Sarcoidosis, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marlies S Wijsenbeek
- Center of Excellence for ILD and Sarcoidosis, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maurits C F J de Rotte
- Department of Clinical Chemistry, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jan C Grutters
- Department of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, The Netherlands
- Division of Heart & Lungs, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Marcel Veltkamp
- Department of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, The Netherlands.
- Division of Heart & Lungs, Utrecht University Medical Center, Utrecht, The Netherlands.
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3
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Hebing RCF, Bartelink IH, Gosselt HR, Heil SG, de Rotte MCFJ, de Jong PHP, Nurmohamed MT, de Jonge R, Mathôt RAA. Methotrexate Polyglutamates Exposure - Response Modeling in a Large Cohort of Rheumatoid Arthritis Patients Starting Methotrexate. Clin Pharmacol Ther 2023; 114:893-903. [PMID: 37313979 DOI: 10.1002/cpt.2974] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/30/2023] [Indexed: 06/15/2023]
Abstract
Methotrexate polyglutamates (MTX-PG) concentrations in red blood cells (RBCs) have been suggested as a biomarker of response in patients with rheumatoid arthritis (RA) receiving low-dose MTX therapy. We investigated the association and interpatient variability between RBC-MTX-PG3-5 -exposure and response in patients with RA starting MTX. Data of three prospective cohorts were available. The relationship between exposure and Disease Activity Score in 28 joints (DAS28) was analyzed using a population pharmacokinetic-pharmacodynamic model. Relevant covariates were tested using full covariate modeling and backward elimination. From 395 patients, 3,401 MTX-PG concentrations and 1,337 DAS28 measurements were available between 0 and 300 days after MTX treatment onset. The developed model adequately described the time course of MTX-PG3-5 and DAS28. The median MTX-PG3-5 level at month 1 was 30.9 nmol/L (interquartile range (IQR): 23.6-43.7; n = 41) and at month 3: 69.3 nmol/L (IQR: 17.9-41.2; n = 351). Clearance of MTX-PG3-5 from RBCs was 28% lower (95% confidence interval (CI): 23.6-32.8%) in a woman and 10% lower (95% CI: 7.7-12.4%) in a 65-year-old compared with a 35-year-old patient. MTX-PG3-5 concentrations associated with DAS28: half-maximal effective concentration (EC50 ) was 9.14 nmol/L (95% CI: 4.2 nmol/L-14.1 nmol/L). EF at 80% (EC80 ) above 47 nmol/L was regarded as the optimal response. Independent of the MTX-PG 3-5 - response association, co-administration of disease-modifying antirheumatic drugs and corticosteroids improved response (additive effect on maximum effect (Emax )), whereas smoking, high body mass index and low albumin decreased Emax . In patients with RA starting MTX, RBC-MTX-PG3-5 was associated with clinical response. A dose increase is suggested when MTX-PG3-5 at month 1 is below 9.15 nmol/L, continued with the same dose when the concentration is above 47 nmol/L, and consider other treatment options above 78 nmol/L from 3 months onwards.
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Affiliation(s)
- Renske C F Hebing
- Amsterdam Rheumatology and Immunology Center, Amsterdam UMC Location Reade, Amsterdam, The Netherlands
| | - Imke H Bartelink
- Department of Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Helen R Gosselt
- Department of Clinical Chemistry, Amsterdam University Medical Center - Location VUmc, Amsterdam, The Netherlands
| | - Sandra G Heil
- Department of Clinical Chemistry, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mauritis C F J de Rotte
- Department of Clinical Chemistry, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Pascal H P de Jong
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Mike T Nurmohamed
- Amsterdam Rheumatology and Immunology Center, Amsterdam UMC Location Reade, Amsterdam, The Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry, Amsterdam University Medical Center - Location VUmc, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, Amsterdam, The Netherlands
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4
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Perez-Garcia LF, Röder E, Krijthe BP, Kranenburg-van Koppen LJ, van Adrichem R, Zirkzee E, Griffioen PH, Peeters K, Lin M, Struys EA, Jansen G, van Doorn MB, de Jonge R, Dohle GR, Dolhain RJ. Is methotrexate safe for men with an immune-mediated inflammatory disease and an active desire to become a father? Results of a prospective cohort study (iFAME-MTX). Ann Rheum Dis 2023; 82:1068-1075. [PMID: 37263756 PMCID: PMC10359513 DOI: 10.1136/ard-2023-224032] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/12/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Current scientific evidence guiding the decision whether men with an active desire to become a father should be treated with methotrexate (MTX) remains controversial. We aimed to prospectively evaluate the testicular toxicity profile of MTX focusing on several markers of male fertility, including semen parameters and sperm DNA fragmentation index (sDFI). As a secondary outcome, we aimed to evaluate whether MTX-polyglutamates can be detected in spermatozoa and seminal plasma and to evaluate the enzymatic activity in spermatozoa of folylpolyglutamate synthetase (FPGS). METHODS In a prospective cohort study, men ≥18 years who started therapy with MTX were invited to participate (MTX-starters). Participants were instructed to produce two semen samples (a pre-exposure and a post-exposure sample after 13 weeks). Healthy men ≥18 years were invited to participate as controls. Conventional semen analyses, male reproductive endocrine axis and sDFI were compared between groups. FPGS enzymatic activity and MTX-PG1-5 concentrations were determined by mass spectrometry analytical methods. RESULTS In total, 20 MTX-starters and 25 controls were included. The pre-exposure and postexposure semen parameters of MTX-starters were not statistically significant different. Compared with healthy controls, the conventional semen parameters and the sDFI of MTX-starters were not statistically significant different. These data were corroborated by the marginal accumulation of MTX-PGs in spermatozoa, consistent with the very low FPGS enzymatic activity associated with the expression of an alternative FPGS splice-variant. DISCUSSION Treatment with MTX is not associated with testicular toxicity, consistent with the very low concentration of intracellular MTX-PG. Therefore, therapy with MTX can be safely started or continued in men and with a wish to become a father.
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Affiliation(s)
| | - Esther Röder
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Bouwe P Krijthe
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, Netherlands
- Department of Rheumatology, Sint Franciscus Vlietland Group, Rotterdam, Netherlands
| | - Laura Jc Kranenburg-van Koppen
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, Netherlands
- Department of Rheumatology, IJsselland Hospital, Capelle aan den IJssel, Netherlands
| | | | - Els Zirkzee
- Department of Rheumatology, Maasstad Ziekenhuis, Rotterdam, Netherlands
| | - Pieter H Griffioen
- Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, Netherlands
| | - Kris Peeters
- Centre for Reproductive Medicine, University of Antwerp, Antwerpen, Belgium
| | - Marry Lin
- Department of Laboratory Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Eduard A Struys
- Department of Laboratory Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Gerrit Jansen
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Center, location VUmc, Amsterdam, Netherlands
| | | | - Robert de Jonge
- Department of Laboratory Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Gert R Dohle
- Department of Urology, Erasmus Medical Center, Rotterdam, Netherlands
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5
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Hebing RC, Lin M, Bulatovic Calasan M, Muller IB, Mahmoud S, Heil S, Struys EA, van den Bemt BJ, Twisk JW, Lems W, Nurmohamed MT, Jansen G, de Jonge R. Pharmacokinetics of oral and subcutaneous methotrexate in red and white blood cells in patients with early rheumatoid arthritis: the methotrexate monitoring trial. Ann Rheum Dis 2023; 82:460-467. [PMID: 36543526 DOI: 10.1136/ard-2022-223398] [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: 09/25/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate the pharmacokinetics of methotrexate polyglutamate (MTX-PG) accumulation in red blood cells (RBCs) and peripheral blood mononuclear cells (PBMCs) in patients with early rheumatoid arthritis (RA) after oral and subcutaneous MTX treatment. METHODS In a clinical prospective cohort study (Methotrexate Monitoring study), newly diagnosed patients with RA were randomised for oral or subcutaneous MTX. At 1, 2, 3 and 6 months after therapy initiation, blood was collected and RBCs and PBMCs were isolated. MTX-PG1-6 concentrations were determined by mass spectrometry methods using stable isotopes of MTX-PG1-6 as internal standards. RESULTS 43 patients (mean age: 58.5 years, 77% female) were included. PBMCs and RBCs revealed disparate pharmacokinetic profiles in both absolute MTX-PG accumulation levels and distribution profiles. Intracellular MTX-PG accumulation in PBMCs was significantly (p<0.001) 10-fold to 20-fold higher than RBCs at all time points, regardless of the administration route. MTX-PG distribution in PBMCs was composed of mostly MTX-PG1 (PG1>PG2>PG3). Remarkably, the distribution profile in PBMCs remained constant over 6 months. RBCs accumulated mainly MTX-PG1 and lower levels of MTX-PG2-5 at t=1 month. After 3 months, MTX-PG3 was the main PG-moiety in RBCs, a profile retained after 6 months of MTX therapy. Subcutaneous MTX administration results in higher RBC drug levels than after oral administration, especially shortly after treatment initiation. CONCLUSIONS This is the first study reporting disparate MTX-PG accumulation profiles in RBCs versus PBMCs in newly diagnosed patients with RA during 6 months oral or subcutaneous MTX administration. This analysis can contribute to improved MTX therapeutic drug monitoring for patients with RA. TRIAL REGISTRATION NUMBER NTR 7149.
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Affiliation(s)
- Renske Cf Hebing
- Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
- Rheumatology, Amsterdam UMC VUMC Site, Amsterdam, The Netherlands
| | - Marry Lin
- Clinical Chemistry, Amsterdam UMC VUMC Site, Amsterdam, The Netherlands
| | - Maja Bulatovic Calasan
- Clinical Chemistry, Amsterdam UMC VUMC Site, Amsterdam, The Netherlands
- Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Ittai B Muller
- Clinical Chemistry, Amsterdam UMC VUMC Site, Amsterdam, The Netherlands
| | - Sohaila Mahmoud
- Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Sandra Heil
- Clinical Chemistry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Eduard A Struys
- Clinical Chemistry, Amsterdam UMC VUMC Site, Amsterdam, The Netherlands
| | | | - Jos Wr Twisk
- Methodology and Applied Biostatistics, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Willem Lems
- Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
- Rheumatology, Amsterdam UMC VUMC Site, Amsterdam, The Netherlands
| | - Michael T Nurmohamed
- Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
- Rheumatology, Amsterdam UMC VUMC Site, Amsterdam, The Netherlands
| | - Gerrit Jansen
- Rheumatology, Amsterdam UMC VUMC Site, Amsterdam, The Netherlands
| | - Robert de Jonge
- Clinical Chemistry, Amsterdam UMC VUMC Site, Amsterdam, The Netherlands
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6
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van de Meeberg MM, Seinen ML, Fidder HH, Lin M, Oldenburg B, de Boer NK, Bouma G, de Jonge R, Bulatović Ćalasan M. Subcutaneous administration, higher age and lower renal function are associated with erythrocyte methotrexate accumulation in Crohn's disease: a cross-sectional study. BMC Gastroenterol 2022; 22:365. [PMID: 35907797 PMCID: PMC9338675 DOI: 10.1186/s12876-022-02439-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 07/20/2022] [Indexed: 11/25/2022] Open
Abstract
Background Methotrexate is an immunomodulatory drug for patients with Crohn’s disease. Erythrocyte MTX-polyglutamates (MTX-PG1-5) may be used for therapeutic drug monitoring (TDM) as MTX-PG is thought to mediate MTX’s efficacy. Information on determinants of the concentration of MTX-PG in patients with Crohn’s disease is lacking. We aim to identify clinical and biochemical determinants of the erythrocyte MTX-PG1-5 and MTX-PGtotal concentration in patients with Crohn’s disease. Methods Adults with Crohn’s disease on methotrexate treatment who visited the outpatient clinic of Amsterdam UMC were included. Erythrocyte MTX-PGs were measured by tandem mass spectrometry. Results Nineteen patients were included, with a median duration of MTX use of 77 months (range 7–202). Twelve patients received MTX monotherapy, whereas 7 patients were on concomitant TNF-α inhibitors. The mean dose of MTX was 15.5 mg (SD ± 2.8) and 12 (63%) patients used subcutaneous MTX. MTX-PG1-5 were successfully measured in 18 patients, showing substantial variability in concentrations of MTX-PGtotal and individual species. The median MTX-PGtotal was 117.1 nmol/L (range 46.4–258.7) with preferential accumulation of MTX-PG3 (43.1 nmol/L, range 15.3–96.1). Patients on subcutaneous compared to oral MTX had higher median MTX-PG(4,5) levels (55 versus 9 nmol/L, p = 0.01). Higher age (β = 0.71) and lower estimated glomerular filtration rate (β = − 0.52) were associated with a significantly higher MTX-PGtotal concentration (R2 = 0.60, p = 0.001). Conclusion MTX-PG concentrations display a considerable inter-individual variability. Higher MTX-PG accumulation is associated with subcutaneous administration, higher age, and lower renal function in Crohn’s disease patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02439-y.
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Affiliation(s)
- M M van de Meeberg
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands. .,Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Research Institute, Amsterdam, The Netherlands.
| | - M L Seinen
- Department of Gastroenterology, OLVG, Amsterdam, The Netherlands
| | - H H Fidder
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - M Lin
- Department of Clinical Chemistry, Amsterdam UMC, Amsterdam, The Netherlands
| | - B Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - N K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Research Institute, Amsterdam, The Netherlands
| | - G Bouma
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Research Institute, Amsterdam, The Netherlands
| | - R de Jonge
- Department of Clinical Chemistry, Amsterdam UMC, Amsterdam, The Netherlands
| | - M Bulatović Ćalasan
- Department of Clinical Chemistry, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands
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7
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Daraghmeh DN, Moghaddami M, Bobrovskaya L, Proudman SM, Wiese MD. Quantitation of methotrexate polyglutamates in human whole blood, erythrocytes and leukocytes collected via venepuncture and volumetric absorptive micro-sampling: a green LC-MS/MS-based method. Anal Bioanal Chem 2022; 414:6029-6046. [PMID: 35796782 PMCID: PMC9314280 DOI: 10.1007/s00216-022-04186-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/29/2022] [Accepted: 06/17/2022] [Indexed: 11/01/2022]
Abstract
Low-dose methotrexate (MTX) plays a key role in treatment of rheumatoid arthritis. However, not all patients respond satisfactorily, and no therapeutic drug monitoring has been implemented in clinical practice, despite the fact that MTX therapy has now been available for decades. Analysis of individual intracellular MTX metabolites among rheumatoid arthritis (RA) patients is hampered by the low intracellular concentrations of MTX-PGs which require a highly sensitive method to quantify. Here, we present a rapid and highly sensitive LC (HILIC) MS/MS method with LLOQ 0.1 nM, 0.8 nmol/L for each metabolite of MTX-PG1-5 and MTX-PG6-7 respectively. Over a linear range of 0.1-100 nM, 0.8-100 nmol/L for each metabolite of MTX-PG1-5 and MTX-PG6-7, respectively, the inter- and intra- accuracy and precision were within 15% of the nominal value for all MTX metabolites. The presented assay was used to assess and compare MTX metabolite concentrations extracted from four different matrices: red blood cells, plasma, peripheral blood mononuclear cells, and whole blood that have been collected either using traditional venepuncture or volumetric absorptive micro-sampling (VAMS) sampling techniques. The presented method not only improves analyte coverage and sensitivity as compared to other published methods; it also improves the greenness.
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Affiliation(s)
- Dala N Daraghmeh
- Centre for Pharmaceutical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, GPO Box 2471, North Terrace, Adelaide, SA, 5000, Australia.
| | - Mahin Moghaddami
- Centre for Pharmaceutical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, GPO Box 2471, North Terrace, Adelaide, SA, 5000, Australia
| | - Larisa Bobrovskaya
- Centre for Pharmaceutical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, GPO Box 2471, North Terrace, Adelaide, SA, 5000, Australia
| | - Susanna M Proudman
- Royal Adelaide Hospital and The University of Adelaide, Adelaide Medical School, Adelaide, SA, Australia
| | - Michael D Wiese
- Centre for Pharmaceutical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, GPO Box 2471, North Terrace, Adelaide, SA, 5000, Australia
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8
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Grosen A, Bellaguarda E, Nersting J, Hvas CL, Liljeqvist-Soltic I, Stein A, Christensen LA, Ruderman EM, Brown CR, Schmiegelow K, Zhang JX, Kelsen J, Hanauer SB. Low-dose Methotrexate Therapy Does Not Affect Semen Parameters and Sperm DNA. Inflamm Bowel Dis 2022; 28:1012-1018. [PMID: 34463329 DOI: 10.1093/ibd/izab205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Methotrexate is widely used in inflammatory diseases during the patients' reproductive years. The effect on male fertility and sperm DNA integrity is largely unknown. We evaluated sperm DNA integrity and basic semen parameters according to the World Health Organization (WHO) in male patients with inflammatory diseases treated with methotrexate. METHODS Semen samples from 14 patients on low-dose maintenance methotrexate were compared with samples from 40 healthy volunteers. Further, 5 patients delivered samples on and off methotrexate therapy for paired comparison. Sperm DNA fragmentation index (DFI), concentration, motility, and morphology were evaluated. Blood sex hormones and methotrexate levels were measured in blood and semen. RESULTS DNA fragmentation index in methotrexate-treated patients was comparable with that in healthy volunteers (DFI, 11.5 vs 15.0; P = .06), and DFI did not change significantly on and off methotrexate in the paired samples (DFI, 12.0 vs 14.0; P = 0.35). Sperm concentration, motility, and morphology did not differ between men treated with methotrexate and healthy volunteers. Sperm progressive motility increased off therapy compared with on therapy (65.0% vs 45.0%, P = .04), but all fluctuations in progressive motility were within the WHO reference interval. All methotrexate polyglutamates1-5 were detected in blood, but only methotrexate polyglutamate1 in semen. Serum testosterone was unaffected by methotrexate therapy. CONCLUSIONS Patients treated with low-dose methotrexate have a sperm quality comparable with that of healthy volunteers, and methotrexate treatment does not increase sperm DNA fragmentation. This study does not support cryopreservation of semen before treatment initiation nor a 3-month methotrexate-free interval prior to conception.
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Affiliation(s)
- Anne Grosen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Emanuelle Bellaguarda
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jacob Nersting
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Christian Lodberg Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Adam Stein
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Lisbet Ambrosius Christensen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Eric M Ruderman
- Division of Rheumatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Calvin R Brown
- Division of Rheumatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - John X Zhang
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jens Kelsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Stephen B Hanauer
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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9
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Rajšić I, Lazarević S, Đanić M, Al-Salami H, Mooranian A, Vukmirović S, Mikov M, Goločorbin-Kon S. Plasma Distribution of Methotrexate and Its Polyglutamates in Pediatric Acute Lymphoblastic Leukemia: Preliminary Insights. Eur J Drug Metab Pharmacokinet 2021; 47:127-134. [PMID: 34637107 DOI: 10.1007/s13318-021-00726-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE High-dose methotrexate (HD-MTX) is the mainstream therapy of current acute lymphoblastic leukemia (ALL) regimens, but frequent intra- and interindividual differences in the clinical response to HD-MTX lead to chemotherapeutic interruption or discontinuation. The exact mechanism of transport across the cell membrane and the disposition of active methotrexate metabolites-methotrexate polyglutamates (MTXPGs)-are not well described in the literature. The aim of this study was to gain more insight into the plasma distribution of methotrexate and MTXPGs in pediatric patients with ALL and to clarify the obscure pathways of MTXPGs. METHODS We prospectively measured the concentrations of MTXPG1-7 in plasma samples from three male pediatric patients treated with HD-MTX and leucovorin rescue according to the IC-BFM 2009 protocol using liquid chromatography-mass spectrometry (LC-MS). Blood samples were obtained at 24, 36, 42, and 48 h after the start of HD-MTX treatment. RESULTS Noticeable plasma concentrations of MTXPGs with a 2.2-fold interpatient variability were detected. The highest interindividual variability in total plasma MTXPG concentration was observed at 36 h, and ranged from 13.78 to 30.82 μmol/L. Among all patients, the predominant polyglutamate types in relation to the total plasma MTXPG concentration at each time point were MTXPG3 (16.71-30.02%) and MTXPG5 (26.23-38.60%), while MTXPG7 was the least abundant MTXPG (3.22-5.02%). CONCLUSION The presence of MTXPGs in plasma of patients with ALL could be related to the action of ABC efflux transporters on blood cells and hepatocytes resulting from the administration of high doses of methotrexate. This study may not draw definitive conclusions, but it does reduce uncertainty about the dynamics of methotrexate and its active metabolites, which may be of vital importance for achieving a clinical response.
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Affiliation(s)
- Ivana Rajšić
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000, Novi Sad, Serbia
| | - Slavica Lazarević
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000, Novi Sad, Serbia.
| | - Maja Đanić
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000, Novi Sad, Serbia
| | - Hani Al-Salami
- Biotechnology and Drug Development Research Laboratory, Curtin Medical School, Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia.,Ear Science Institute Australia, Queen Elizabeth II Medical Centre, Hearing Therapeutics, Nedlands, Perth, WA, 6102, Australia
| | - Armin Mooranian
- Biotechnology and Drug Development Research Laboratory, Curtin Medical School, Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia.,Ear Science Institute Australia, Queen Elizabeth II Medical Centre, Hearing Therapeutics, Nedlands, Perth, WA, 6102, Australia
| | - Saša Vukmirović
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000, Novi Sad, Serbia
| | - Momir Mikov
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000, Novi Sad, Serbia
| | - Svetlana Goločorbin-Kon
- Department of Pharmacy, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000, Novi Sad, Serbia
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10
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Xu C, Selhub J, Jacques P, Paynter NP, MacFadyen JG, Glynn RJ, Ridker PM, Solomon DH. Adverse effects related to methotrexate polyglutamate levels: adjudicated results from the cardiovascular inflammation reduction trial. Rheumatology (Oxford) 2021; 60:2963-2968. [PMID: 34144603 DOI: 10.1093/rheumatology/keaa650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/14/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Methotrexate is widely used at low dosages (LD-MTX) for non-oncologic indications and is associated with a variety of adverse effects (AEs). We sought to determine whether concentrations of the active metabolite, MTX polyglutamates (MTX-PGs) 1-5, correlate with AEs. METHOD We examined data from the LD-MTX arm of the randomized double-blind Cardiovascular Inflammation Reduction Trial (CIRT). All AEs were blindly adjudicated and monitoring laboratories were tested centrally. The MTX-PGs 1-5 were assessed in one reference laboratory using liquid chromatography-tandem mass spectrometry. Based on prior literature, MTX-PGs 3-5 were chosen as the exposure of interest and quartiles of MTX-PGs 3-5 were assessed for their relationship with all AEs and each pre-specified category of AE using adjusted Cox proportional hazards regression. RESULTS Of the 2391 subjects randomized to LD-MTX, MTX-PG levels were available for 1319 subjects (median dosage 16.1 mg/week) from the 8 month visit. We followed these subjects for a median of 2.2 years [interquartile range (IQR) 1.5-2.9]. Higher MTX-PG3-5 levels were related to an increased risk of anaemia [compared with quartile 1 (Q1); hazard ratio (HR) for Q4 1.27 (95% CI 0.98, 1.65), P for trend = 0.05] and a decreased risk of thrombocytopenia [HR for Q4 0.52 (95% CI 0.32, 0.84), P for trend = 0.05]. MTX-PG3-5 levels >134 nmol/l were associated with an increased risk of liver abnormalities [HR 1.36 (95% CI 1.08, 1.72)]. CONCLUSIONS Higher MTX- PG3-5 levels were modestly associated with LD-MTX AEs, including anaemia and liver function abnormalities, but a reduced risk of thrombocytopenia and haemorrhage. CLINICAL TRIAL REGISTRATION NCT01594333.
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Affiliation(s)
- Chang Xu
- Division of Rheumatology, Inflammation, Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Jacob Selhub
- USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA, USA
| | - Paul Jacques
- USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA, USA
| | - Nina P Paynter
- Division of Preventive Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jean G MacFadyen
- Division of Preventive Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Robert J Glynn
- Division of Preventive Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Paul M Ridker
- Division of Preventive Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel H Solomon
- Division of Rheumatology, Inflammation, Immunity, Brigham and Women's Hospital, Boston, MA, USA
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11
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Maintenance therapy and risk of osteonecrosis in children and young adults with acute lymphoblastic leukemia: a NOPHO ALL2008 sub-study. Cancer Chemother Pharmacol 2021; 88:911-917. [PMID: 34145469 DOI: 10.1007/s00280-021-04316-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/07/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Osteonecrosis is a burdensome treatment-related toxicity that is mostly diagnosed during or soon after 6-mercaptopurine (6MP)/methotrexate (MTX) maintenance therapy for acute lymphoblastic leukemia (ALL), possibly indicating a pathogenic role of these drugs. METHODS We prospectively registered symptomatic osteonecrosis during treatment of 1234 patients aged 1.0-45.9 years treated according to the Nordic Society of Hematology and Oncology (NOPHO) ALL2008 protocol. MTX/6MP metabolites were measured as part of the NOPHO ALL2008 maintenance therapy study. RESULTS After a median follow-up of 5.6 years [interquartile range (IQR) 3.6-7.5], 68 patients had been diagnosed with symptomatic osteonecrosis. The cumulative incidence was 2.7% [95% confidence interval (CI) 1.6-3.8%] for patients aged < 10 years, 14.9% (95% CI 9.7-20.2%) for patients aged 10.0-17.9 years, and 14.4% (95% CI 8.0-20.8%) for patients aged ≥ 18 years. The median time from diagnosis of ALL to diagnosis of osteonecrosis in these age groups was 1.0 year (IQR 0.7-2.0), 2.0 years (IQR 1.1-2.4), and 2.2 years (IQR 1.8-2.8), respectively (p = 0.001). With 17,854 blood samples available for MTX and 6MP metabolite analysis, neither erythrocyte levels of 6-thioguanine (TG) nucleotides (p > 0.99), methylated 6MP metabolites (p = 0.37), MTX polyglutamates (p = 0.98) nor DNA-TG (p = 0.53) were significantly associated with the hazard of osteonecrosis in Cox models stratified by the three age groups and adjusted for sex. CONCLUSION Maintenance therapy intensity determined by 6MP and MTX metabolites was not associated with the risk of developing osteonecrosis in the NOPHO ALL2008 cohort.
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12
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Zhang Y, Sun L, Zhao L, Wang X, Zhao Z, Mei S. Methotrexate Polyglutamates Analysis by Chromatography Methods in Biological Matrices: A Review. ANAL SCI 2021; 37:1655-1664. [PMID: 34024867 DOI: 10.2116/analsci.21r001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Methotrexate (MTX) is used as an immunosuppressant and antineoplastic drug in clinical practice. MTX is a parent drug and converts to MTX polyglutamates (MTXPGs) to exhibit its biological activity. Clinical studies found that MTXPG levels were associated with MTX response and toxicities, especially at low doses. Due to huge variance of MTX response and toxicities between individuals, therapeutic drug monitoring is necessary for its use in individualized therapy. Various chromatography methods coupled with ultraviolet-visible detector, fluorescence detector and mass spectrometry have been reported for MTXPG analysis in various biological matrices. The aim of this paper is to review the chromatographic based methods for the measurement of total and/or individual MTXPGs. We searched Embase, Science Direct and PubMed databases using "methotrexate polyglutamate" and "chromatography" as search terms, and found 745 articles. Of those, 14 articles were extracted for this study. The key steps for method development (sample pretreatment, parameter optimization of liquid chromatography and mass spectrometry, selection of internal standard) and validation (lower limit of quantitation, accuracy, precision, recovery, matrix effect and stability) were analyzed and summarized, which might be helpful for researchers to develop their own methods.
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Affiliation(s)
- Yiming Zhang
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University.,Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University
| | - Liyu Sun
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University.,Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University
| | - Libo Zhao
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University.,Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Xiaoling Wang
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University.,Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Zhigang Zhao
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University.,Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University
| | - Shenghui Mei
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University.,Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University
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13
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Choi R, Chun MR, Park J, Won H, Kim S, Lee JW, Ju HY, Cho HW, Hyun JK, Koo HH, Yi ES, Lee SY. Methotrexate polyglutamate quantification for clinical application in patients with pediatric acute lymphoblastic leukemia in association with genetic polymorphisms. J Pharm Biomed Anal 2021; 201:114124. [PMID: 34000579 DOI: 10.1016/j.jpba.2021.114124] [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: 02/02/2021] [Revised: 04/22/2021] [Accepted: 05/03/2021] [Indexed: 11/16/2022]
Abstract
We developed and validated a quantification method for methotrexate (MTX) polyglutamates (MTX-PGs, MTX-PG1 to MTX-PG5) by liquid chromatography-tandem mass spectrometry using stable isotope-labeled internal standards and applied to 196 clinical samples collected from pediatric acute lymphoblastic leukemia patients treated with MTX. MTX-PGs levels and their proportions (%) in sum of all MTX-PGs (MTXSum) were evaluated in relation to TPMT, NUDT15, and MTHFR genotypes. For the developed method, linearity ranges 1-500 nmol/L, bias for accuracy 0.3-13.5 %, coefficient of variation for within- and between-run imprecision of 3.2-9.5% and 1.5-12.0%, respectively. Recoveries achieved were 74.2-105.8 %. There was no significant carryover. The median level of the MTXSum for 196 clinical samples was 129.4 nmol/L (interquartile range 28.1-241.2). MTX dose and MTX-PGs were associated (P < 0.05) and among five MTX-PGs, MTX-PG3 was the predominant form (median 41.7 %). The MTX-PG3 level was significantly higher in patients with TPMT *1/*3C than in patients with wild type and MTX-PG3% was significantly higher and MTX-PG5% was significantly lower in NUDT15 intermediate metabolizers than normal or indeterminate phenotypes (P < 0.05). This validated MTX-PGs quantification method can facilitate a better understanding of MTX metabolism and therapeutic drug monitoring for MTX treatment.
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Affiliation(s)
- Rihwa Choi
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Laboratory Medicine, Green Cross Laboratories, Yongin, Gyeonggi, Republic of Korea
| | - Mi Ryung Chun
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jisook Park
- Samsung Biomedical Research Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hojeong Won
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Seonwoo Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Ji Won Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Hee Young Ju
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hee Won Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ju Kyung Hyun
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hong Hoe Koo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun Sang Yi
- Department of Pediatrics, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Soo-Youn Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Clinical Pharmacology and Therapeutics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Health Science and Technology, Samsung Advanced Institute of Health Science and Technology, Sungkyunkwan University, Seoul, Republic of Korea.
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14
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Kim DH, Yoo YS, Yoo HJ, Choi YJ, Kim SA, Sheen DH, Lee SK, Lim MK, Cho K. Analysis of hair and plasma samples for methotrexate (MTX) and metabolite using high-performance liquid chromatography triple quadrupole mass spectrometry (LC-MS/MS) detection. JOURNAL OF MASS SPECTROMETRY : JMS 2021; 56:e4648. [PMID: 32954603 DOI: 10.1002/jms.4648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/12/2020] [Accepted: 08/17/2020] [Indexed: 06/11/2023]
Abstract
Methotrexate (MTX), a folate antagonist, is the anchor drug used to treat several diseases. Therapeutic effects are attributed to intracellular levels of various methotrexate conjugates that are present in the cell as polyglutamates (MTX-Glu). The present study was conducted to develop a new liquid chromatography-electrospray ionization-tandem mass spectrometry (LC-ESI-MS/MS)-based assay to separately quantitate the MTX-Glu in hair cells, red blood cells, and serum using internal standards. Sample preparation consisted of extraction with an organic solution followed by solid-phase extraction. The presented methodology was applied for the analysis of methotrexate and its polyglutamates in hair cells, red blood cells, and serum obtained from clinical patients. The developed LC-ESI-MS/MS method for the quantitative measurement of MTX-Glu was both sensitive and precise within the clinically relevant range. This method is possibly be superior with respect to sensitivity, selectivity, and speed than all previously described approaches and can be easily applied in routine clinical tests owing to the combination of a simple pretreatment process with robust LC-MS/MS.
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Affiliation(s)
- Duck Hyun Kim
- Center of Research Equipment, Korea Basic Science Institute, 162, Yeonggudanji-ro, Ochang-eup, Cheongwon-gu, Cheongju-si, 28119, Republic of Korea
| | - Yeong Suk Yoo
- Product Analysis Team, Boryung Phamaceutical, 107, Neungan-ro, Danwon-gu, Ansan-si, Gyeonggi-do, Republic of Korea
| | - Hee Jin Yoo
- Center of Research Equipment, Korea Basic Science Institute, 162, Yeonggudanji-ro, Ochang-eup, Cheongwon-gu, Cheongju-si, 28119, Republic of Korea
| | - Yoon Ji Choi
- Center of Research Equipment, Korea Basic Science Institute, 162, Yeonggudanji-ro, Ochang-eup, Cheongwon-gu, Cheongju-si, 28119, Republic of Korea
| | - Soon Ae Kim
- Department of Pharmacology, Eulji University School of Medicine, Daejeon, Republic of Korea
| | - Dong-Hyuk Sheen
- Department of Medicine Division of Rheumatology, Eulji University School of Medicine, Daejeon, Republic of Korea
| | - Sang Kwang Lee
- Eulji Medi-Bio Research Insititute, Eulji University, Daejeon, Republic of Korea
| | - Mi Kyoung Lim
- Department of Medicine Division of Rheumatology, Eulji University School of Medicine, Daejeon, Republic of Korea
| | - Kun Cho
- Center of Research Equipment, Korea Basic Science Institute, 162, Yeonggudanji-ro, Ochang-eup, Cheongwon-gu, Cheongju-si, 28119, Republic of Korea
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15
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Epigenome wide association study of response to methotrexate in early rheumatoid arthritis patients. PLoS One 2021; 16:e0247709. [PMID: 33690661 PMCID: PMC7946177 DOI: 10.1371/journal.pone.0247709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 02/11/2021] [Indexed: 11/21/2022] Open
Abstract
Aim To identify differentially methylated positions (DMPs) and regions (DMRs) that predict response to Methotrexate (MTX) in early rheumatoid arthritis (RA) patients. Materials and methods DNA from baseline peripheral blood mononuclear cells was extracted from 72 RA patients. DNA methylation, quantified using the Infinium MethylationEPIC, was assessed in relation to response to MTX (combination) therapy over the first 3 months. Results Baseline DMPs associated with response were identified; including hits previously described in RA. Additionally, 1309 DMR regions were observed. However, none of these findings were genome-wide significant. Likewise, no specific pathways were related to response, nor could we replicate associations with previously identified DMPs. Conclusion No baseline genome-wide significant differences were identified as biomarker for MTX (combination) therapy response; hence meta-analyses are required.
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16
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Wu J, Zhang S, Li J, Zhong X, Feng G, Hu L, He F, Cen H, Chen Y, He Y, Zeng H, Chen X, Mo X. Simultaneous determination of erythrocyte methotrexate polyglutamates by a novel and simple HPLC-MS/MS method with stable isotope-labeled internal standards. J Sep Sci 2021; 44:1852-1865. [PMID: 33646615 DOI: 10.1002/jssc.202001081] [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: 10/17/2020] [Revised: 02/21/2021] [Accepted: 02/23/2021] [Indexed: 11/09/2022]
Abstract
Low-dose methotrexate is the first-line therapy for juvenile idiopathic arthritis. In vivo, methotrexate is converted into a series of methotrexate polyglutamates whose intracellular levels contribute significantly to its efficacy and toxicity. In this study, a novel high-performance liquid chromatography-tandem mass spectrometry method was developed and validated to simultaneously determine erythrocyte methotrexate polyglutamates using stable isotope-labeled internal standards. Erythrocyte samples were precipitated by perchloric acid and then determined on an XBridge BEH C18 column with an XP vanguard precolumn in 12 min. The mobile phase consisted of 10 nM ammonium acetate (pH 10) and methanol under gradient elution. The detection was carried out in multiple reaction monitoring mode via an electrospray ionization source in positive ionization mode. The calibration curve for each metabolite was linear from 2.0 to 500.0 nmol/L (r2 > 0.99). The intraday and interday accuracies were between 93.0 and 107.0%, and the corresponding precisions were between 0.8 and 5.2%. The relative recovery ranged from 82.7 to 105.1%, and the relative matrix effect varied from 96.5 to 104.4%. The erythrocyte metabolites were stable for 30 days at -80°C. This simple and accurate method is applicable to routine monitoring of the concentration of erythrocyte methotrexate polyglutamates in patients to achieve individualized treatment.
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Affiliation(s)
- Jingjing Wu
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P. R. China
| | - Song Zhang
- Pediatric Allergy Immunology & Rheumatology Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, P. R. China
| | - Jiali Li
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, P. R. China
| | - Xiaoli Zhong
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, P. R. China
| | - Guiping Feng
- Pediatric Allergy Immunology & Rheumatology Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, P. R. China
| | - Liangqing Hu
- Pediatric Allergy Immunology & Rheumatology Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, P. R. China
| | - Fan He
- Department of Pharmacy, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, P. R. China
| | - Hanjing Cen
- Department of Pharmacy, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, P. R. China
| | - Yilu Chen
- Department of Pharmacy, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, P. R. China
| | - Yanling He
- Department of Pharmacy, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, P. R. China
| | - Huasong Zeng
- Pediatric Allergy Immunology & Rheumatology Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, P. R. China
| | - Xiao Chen
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, P. R. China
| | - Xiaolan Mo
- Department of Pharmacy, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, P. R. China.,Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, Sun Yat-sen University, Guangzhou, P. R. China
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17
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Oosterom N, Fiocco M, Kloos RQH, van der Sluis IM, Pieters R, van Zelst BD, Smith DEC, van den Heuvel-Eibrink MM, de Jonge R, Heil SG. The evaluation of red blood cell folate and methotrexate levels during protocol M in childhood acute lymphoblastic leukemia. BMC Cancer 2020; 20:940. [PMID: 32998716 PMCID: PMC7526241 DOI: 10.1186/s12885-020-07422-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND After High-Dose Methotrexate (HD-MTX), folinic acid rescue therapy (Leucovorin) is administered to reduce side effects in pediatric acute lymphoblastic leukemia (ALL) patients. Leucovorin and MTX are structural analogues, possibly competing for cellular transport and intracellular metabolism. We hypothesize that Leucovorin accumulates during consecutive courses, which might result in a lower MTX uptake. METHODS We prospectively measured red blood cell (RBC) folate and MTX levels during four HD-MTX and Leucovorin courses in 43 patients treated according the DCOG ALL-11 protocol with 2-weekly HD-MTX (5 g/m2/dose) and Leucovorin (15 mg/m2/dose) using LC-MS/MS. We estimated a linear mixed model to assess the relationship between these variables over time. RESULTS Both RBC MTX-PG and folate levels increased significantly during protocol M. MTX-PG2-5 levels increased most substantially after the first two HD-MTX courses (until median 113.0 nmol/L, IQR 76.8-165.2) after which levels plateaued during the 3d and 4th course (until median 141.3 nmol/L, IQR 100.2-190.2). In parallel, folate levels increased most substantially after the first two HD-MTX courses (until median 401.6 nmol/L, IQR 163.3-594.2) after which levels plateaued during the 3d and 4th course (until median 411.5 nmol/L, IQR 240.3-665.6). The ratio folate/MTX-PG decreased significantly over time, which was mostly due to the relatively higher increase (delta) of MTX-PG. CONCLUSION These results suggest that the increase in RBC folate levels does not seem to have a large effect on RBC MTX levels. Future studies, assessing competition of Leucovorin and MTX on other cellular mechanisms which might negatively affect treatment efficacy, are necessary.
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Affiliation(s)
- N Oosterom
- Princess Máxima Center for Pediatric Oncology, Postbus 113, 3720 AC Bilthoven, Utrecht, The Netherlands. .,Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - M Fiocco
- Princess Máxima Center for Pediatric Oncology, Postbus 113, 3720 AC Bilthoven, Utrecht, The Netherlands.,Mathematical Institute, Leiden University, Leiden, The Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Center, Medical Statistics, Leiden, The Netherlands
| | - R Q H Kloos
- Department of Pediatric Oncology/Hematology, Erasmus Medical Center-Sophia's Children's Hospital, Rotterdam, The Netherlands
| | - I M van der Sluis
- Princess Máxima Center for Pediatric Oncology, Postbus 113, 3720 AC Bilthoven, Utrecht, The Netherlands
| | - R Pieters
- Princess Máxima Center for Pediatric Oncology, Postbus 113, 3720 AC Bilthoven, Utrecht, The Netherlands
| | - B D van Zelst
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - D E C Smith
- Department of Clinical Chemistry, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - R de Jonge
- Department of Clinical Chemistry, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - S G Heil
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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18
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Nagaoka S, Katayama K, Kasama T, Sato M, Ohno S, Amasaki Y, Kataoka H, Furusaki A, Kon Y, Okamoto M, Sasano M, Sagawa A. Weekly split-dose regimen for oral methotrexate reduced polyglutamation in red blood cells in patients with rheumatoid arthritis compared with single-dose regimen: Results from a multicentered randomized control trial. Int J Rheum Dis 2020; 23:1328-1336. [PMID: 32896992 DOI: 10.1111/1756-185x.13931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/25/2020] [Accepted: 07/13/2020] [Indexed: 11/28/2022]
Abstract
AIMS We compared the incidence of adverse events between single and divided-dose regimens of methotrexate (MTX) by using a multicenter randomized controlled trial. METHODS Eighty-nine patients with insufficient control on MTX 8 mg/wk were randomly assigned into single-dose (39 patients) or triple dose (39 patients) groups. The MTX dose for all patients was gradually increased to 16 mg/wk. The primary endpoint was the occurrence of liver dysfunction during the observation period (20 weeks). RESULTS There were no differences in baseline data and MTX dose at Week 20 between groups. There was no significant difference in the incidence of liver dysfunction between groups (single dose, 3 [7.7%] patients vs. triple dose, 5 [13.2%] patients; P = .455). The incidence of adverse event increased in triple dose (single dose, 12 [30.8%] patients vs. triple dose, 20 [51.3%]), but the difference was not significant (P = .066). There was no significant difference in disease activity between groups, although MTX-triglutamate (PG3), MTX-PG4, and MTX-PG5 were significantly higher in the single dose group. CONCLUSIONS Weekly split dosing reduced the polyglutamation of MTX. There was no significant difference in efficacy and safety between the 2 groups.
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Affiliation(s)
- Shouhei Nagaoka
- Yokohama Minami Kyosai Hospital, Yokohama city, Kanagawa, Japan
| | - Kou Katayama
- Katayama Orthopedic Rheumatology Clinic, Asahikawa city, Hokkaido, Japan
| | | | - Masao Sato
- Ohashi Tani Orthopedics, Gifu city, Gifu, Japan
| | - Shigeru Ohno
- Yokohama City University Medical Center, Yokohama city, Kanagawa, Japan
| | | | | | - Akira Furusaki
- KKR Sapporo Medical Center, Sapporo, Japan.,Sagawa Akira Rheumatology Clinic, Sapporo city, Hokkaido, Japan
| | - Yujiro Kon
- Katayama Orthopedic Rheumatology Clinic, Asahikawa city, Hokkaido, Japan.,Sapporo Rheumatology and immunology clinic, Sapporo city, Hokkaido, Japan
| | | | | | - Akira Sagawa
- Sagawa Akira Rheumatology Clinic, Sapporo city, Hokkaido, Japan
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19
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Driehuis E, Oosterom N, Heil SG, Muller IB, Lin M, Kolders S, Jansen G, de Jonge R, Pieters R, Clevers H, van den Heuvel-Eibrink MM. Patient-derived oral mucosa organoids as an in vitro model for methotrexate induced toxicity in pediatric acute lymphoblastic leukemia. PLoS One 2020; 15:e0231588. [PMID: 32421698 PMCID: PMC7233536 DOI: 10.1371/journal.pone.0231588] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 03/27/2020] [Indexed: 12/22/2022] Open
Abstract
We have recently established a protocol to grow wildtype human oral mucosa organoids. These three-dimensional structures can be maintained in culture long-term, do not require immortalization, and recapitulate the multilayered composition of the epithelial lining of the oral mucosa. Here, we validate the use of this model to study the effect of Leucovorin (LV) on Methotrexate (MTX)-induced toxicity. MTX is a chemotherapeutic agent used in the treatment of pediatric acute lymphoblastic leukemia. Although effective, the use of MTX often results in severe side-effects, including oral mucositis, which is characterized by epithelial cell death. Here, we show that organoids are sensitive to MTX, and that the addition of LV reduces MTX toxicity, in both a concentration- and timing-dependent manner. Additionally, we show that a 24 hour ‘pretreatment’ with LV reduces MTX-induced cell death, suggesting that such a pretreatment could decrease mucositis in patients. Taken together, we provide the first in vitro model to study the effect of MTX on wildtype oral mucosa cells. Our findings underscore the relevance of the clinically applied LV regimen and highlight the potential of this model to further optimize modifications in dosing and timing of Leucovorin on oral mucosa cells.
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Affiliation(s)
- E. Driehuis
- Oncode Institute, Hubrecht Institute, Royal Netherlands Academy of Arts and Sciences (KNAW) and University Medical Center Utrecht, Utrecht, The Netherlands
| | - N. Oosterom
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - S. G. Heil
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - I. B. Muller
- Department of Clinical Chemistry, Amsterdam UMC, Amsterdam, The Netherlands
| | - M. Lin
- Department of Clinical Chemistry, Amsterdam UMC, Amsterdam, The Netherlands
| | - S. Kolders
- Oncode Institute, Hubrecht Institute, Royal Netherlands Academy of Arts and Sciences (KNAW) and University Medical Center Utrecht, Utrecht, The Netherlands
| | - G. Jansen
- Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, Amsterdam UMC, Amsterdam, The Netherlands
| | - R. de Jonge
- Department of Clinical Chemistry, Amsterdam UMC, Amsterdam, The Netherlands
| | - R. Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - H. Clevers
- Oncode Institute, Hubrecht Institute, Royal Netherlands Academy of Arts and Sciences (KNAW) and University Medical Center Utrecht, Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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20
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Rostang A, Desjardins I, Espana B, Panzuti P, Berny P, Prouillac C, Pin D. Pharmacokinetics of low-dose methotrexate in horses. J Vet Pharmacol Ther 2020; 43:461-469. [PMID: 32216109 DOI: 10.1111/jvp.12857] [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: 11/13/2019] [Revised: 02/10/2020] [Accepted: 02/28/2020] [Indexed: 11/30/2022]
Abstract
This study aimed to investigate both the pharmacokinetic behavior and tolerance of methotrexate (MTX) in horses to design a specific dosing regimen as a new immunomodulatory drug for long-term treatment. To determine the primary plasma pharmacokinetic variables after single intravenous, subcutaneous or oral administration, six horses were administered 0.3 mg/kg MTX in a crossover design study. After a 10-week washout, MTX was administered subcutaneously to three of the six previously treated horses at a dose of 0.3 mg/kg once per week for 3 months. In both studies, MTX and metabolite concentrations were measured using LC-MS/MS. The absolute bioavailability of MTX was 73% following subcutaneous administration but less than 1% following oral administration. The plasma clearance was 1.54 ml min-1 kg-1 (extraction ratio = 2%). After 24 hr, plasma concentrations were below the LOQ. No adverse effects were noted except for a moderate reversible elevation in liver enzymes (GLDH). With regards to the main metabolites of MTX, very low concentrations of 7-hydroxy-MTX were found, whereas polyglutamated forms (mainly short chains) were found in red blood cells. A subcutaneous dose of 0.2 mg kg-1 week-1 may be safe and relevant in horses, although this has yet to be clinically confirmed.
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Affiliation(s)
- Antoine Rostang
- Université de Lyon, VetAgro Sup, UPSP ICE 'Interactions Cellules Environnement', Marcy l'Etoile, France
| | - Isabelle Desjardins
- Université de Lyon, VetAgro Sup, UPSP ICE 'Interactions Cellules Environnement', Marcy l'Etoile, France
| | - Bernadette Espana
- Université de Lyon, VetAgro Sup, UPSP ICE 'Interactions Cellules Environnement', Marcy l'Etoile, France
| | - Pauline Panzuti
- Université de Lyon, VetAgro Sup, UPSP ICE 'Interactions Cellules Environnement', Marcy l'Etoile, France
| | - Philippe Berny
- Université de Lyon, VetAgro Sup, UPSP ICE 'Interactions Cellules Environnement', Marcy l'Etoile, France
| | - Caroline Prouillac
- Université de Lyon, VetAgro Sup, UPSP ICE 'Interactions Cellules Environnement', Marcy l'Etoile, France
| | - Didier Pin
- Université de Lyon, VetAgro Sup, UPSP ICE 'Interactions Cellules Environnement', Marcy l'Etoile, France
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21
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Kyvsgaard N, Thastum M, Mikkelsen TS, Christensen AE, Herlin T. Coping strategies and anxiety in association with methotrexate-induced nausea in juvenile idiopathic arthritis. Rheumatol Int 2020; 40:591-598. [PMID: 31996982 DOI: 10.1007/s00296-020-04520-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/18/2020] [Indexed: 10/25/2022]
Abstract
The aim of this study is to investigate whether methotrexate-induced nausea is associated with anxiety or the use of coping strategies in children with juvenile idiopathic arthritis (JIA) treated with methotrexate (MTX). This is an observational study of children diagnosed with JIA (ILAR criteria), treated with MTX and aged 9 years or above. MTX-induced nausea was determined by the children's completion of a nausea diary and the parents' completion of the Methotrexate Intolerance Severity Score (MISS). Anxiety was assessed by the Beck Youth Inventories-Anxiety Inventory (BYI-A) and coping strategies were evaluated by an adapted Nausea Coping Questionnaire. Enrolled were 121 children (82 girls: 39 boys) with a median age (IQR) of 13.3 (11.3-15.1) years. The median MTX-dose (IQR) was 9.7 (9.0-10.9) mg/m2/week. The median treatment duration (IQR) was 340 (142-766) days. The MISS was completed for 120 children; 77 children completed the nausea diary for at least 7 days. MTX-induced nausea was present in 61% (73/120) of the children according to the MISS and in 73% (56/77) of the children according to the nausea diary. MTX-induced nausea was associated with a more frequent use of the coping strategy internalizing/catastrophizing (MISS, p = 0.012; diary, p < 0.0001) and higher BYI-A raw scores (diary, p = 0.016). MTX-induced nausea was associated with anxiety and the use of coping strategies in children with JIA. These psychological factors may be part of the mechanism behind the inter-individual variation in the level of nausea to MTX treatment.
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Affiliation(s)
- Nini Kyvsgaard
- Pediatric and Adolescent Medicine, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Mikael Thastum
- Department of Psychology and Behavioral Sciences, Aarhus BSS, Aarhus University, Aarhus, Denmark
| | - Torben Stamm Mikkelsen
- Pediatric and Adolescent Medicine, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Anne Estmann Christensen
- Department of Pediatric Rheumatology, H.C. Andersen's Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Troels Herlin
- Pediatric and Adolescent Medicine, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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22
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Karami F, Ranjbar S, Ghasemi Y, Negahdaripour M. Analytical methodologies for determination of methotrexate and its metabolites in pharmaceutical, biological and environmental samples. J Pharm Anal 2019; 9:373-391. [PMID: 31890337 PMCID: PMC6931080 DOI: 10.1016/j.jpha.2019.06.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 05/05/2019] [Accepted: 06/19/2019] [Indexed: 02/08/2023] Open
Abstract
Methotrexate (MTX) is a folate antagonist drug used for several diseases, such as cancers, various malignancies, rheumatoid arthritis (RA) and inflammatory bowel disease. Due to its structural features, including the presence of two carboxylic acid groups and its low native fluorescence, there are some challenges to develop analytical methods for its determination. MTX is metabolized to 7-hydroxymethotrexate (7-OH-MTX), 2,4-diamino-N10-methylpteroic acid (DAMPA), and the active MTX polyglutamates (MTXPGs) in the liver, intestine, and red blood cells (RBCs), respectively. Additionally, the drug has a narrow therapeutic range; hence, its therapeutic drug monitoring (TDM) is necessary to regulate the pharmacokinetics of the drug and to decrease the risk of toxicity. Due to environmental toxicity of MTX; its sensitive, fast and low cost determination in workplace environments is of great interest. A large number of methodologies including high performance liquid chromatography equipped with UV-visible, fluorescence, or electrochemical detection, liquid chromatography-mass spectroscopy, capillary electrophoresis, UV-visible spectrophotometry, and electrochemical methods have been developed for the quantitation of MTX and its metabolites in pharmaceutical, biological, and environmental samples. This paper will attempt to review several published methodologies and the instrumental conditions, which have been applied to measure MTX and its metabolites within the last decade.
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Affiliation(s)
- Forough Karami
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Central Research Laboratory, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
- Chemistry Department, Yasouj University, Yasouj, Iran
| | - Sara Ranjbar
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Younes Ghasemi
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Manica Negahdaripour
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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23
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Oosterom N, de Jonge R, Smith DEC, Pieters R, Tissing WJE, Fiocco M, van Zelst BD, van den Heuvel-Eibrink MM, Heil SG. Changes in intracellular folate metabolism during high-dose methotrexate and Leucovorin rescue therapy in children with acute lymphoblastic leukemia. PLoS One 2019; 14:e0221591. [PMID: 31527879 PMCID: PMC6748431 DOI: 10.1371/journal.pone.0221591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/09/2019] [Indexed: 01/19/2023] Open
Abstract
Background Methotrexate (MTX) is an important anti-folate agent in pediatric acute lymphoblastic leukemia (ALL) treatment. Folinic acid rescue therapy (Leucovorin) is administered after MTX to reduce toxicity. Previous studies hypothesized that Leucovorin could ‘rescue’ both normal healthy cells and leukemic blasts from cell death. We assessed whether Leucovorin is able to restore red blood cell folate levels after MTX. Methods We prospectively determined erythrocyte folate levels (5-methyltetrahydrofolate (THF) and non-methyl THF) and serum folate levels in 67 children with ALL before start (T0) and after stop (T1) of HD-MTX and Leucovorin courses. Results Erythrocyte folate levels increased between T0 and T1 (mean ± SD: 416.7 ± 145.5 nmol/L and 641.2 ± 196.3 nmol/L respectively, p<0.001). This was due to an increase in 5-methyl THF levels (mean increase: 217.7 ± 209.5 nmol/L, p<0.001), whereas non-methyl THF levels did not change (median increase: 0.6 nmol/L [-9.9–11.1], p = 0.676). Serum folate levels increased between T0 and T1 (median increase: 29.2 nmol/L [32.9–74.0], p<0.001). Results were not significantly affected by age, sex, ALL immunophenotype and MTHFR c.677C>T genotype. Conclusion Intracellular folate levels accumulate after HD-MTX and Leucovorin therapy in children with ALL, suggesting that Leucovorin restores the intracellular folate pool. Future studies are necessary to assess concomitant lower uptake of MTX.
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Affiliation(s)
- Natanja Oosterom
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Erasmus MC, University Medical Center Rotterdam, Department of Clinical Chemistry, Rotterdam, The Netherlands
| | - Robert de Jonge
- VU Medical Center, Department of Clinical Chemistry, Amsterdam, The Netherlands.,Academic Medical Center, Department of Clinical Chemistry, Amsterdam, The Netherlands
| | - Desiree E C Smith
- VU Medical Center, Department of Clinical Chemistry, Amsterdam, The Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Wim J E Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pediatric Oncology, University of Groningen, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Marta Fiocco
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Mathematical Institute, Leiden University, Leiden, The Netherlands.,Leiden University Medical Center, Department of Biomedical Data Sciences, Leiden, The Netherlands
| | - Bertrand D van Zelst
- Erasmus MC, University Medical Center Rotterdam, Department of Clinical Chemistry, Rotterdam, The Netherlands
| | | | - Sandra G Heil
- Erasmus MC, University Medical Center Rotterdam, Department of Clinical Chemistry, Rotterdam, The Netherlands
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24
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Kloos RQH, Pieters R, van den Bos C, van Eijkelenburg NKA, de Jonge R, van der Sluis IM. The effect of asparaginase therapy on methotrexate toxicity and efficacy in children with acute lymphoblastic leukemia. Leuk Lymphoma 2019; 60:3002-3010. [PMID: 31120351 DOI: 10.1080/10428194.2019.1613537] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Asparaginase and methotrexate (MTX), both essential for pediatric acute lymphoblastic leukemia therapy, are often used concomitantly. Depending on the sequence, in vitro, asparaginase inhibits MTX-polyglutamate (MTXPG) formation, and side effects overlap. MTX toxicity and efficacy, reflected by intracellular erythrocyte MTXPG's, were compared between children treated with and without asparaginase during high dose MTX (HD-MTX) courses of the DCOG ALL-11 protocol (NL50250.078.14). Seventy-three patients, of whom 23 received asparaginase during the HD-MTX courses, were included. Grade 3-4 leukopenia and neutropenia occurred more often (59% and 86% vs. 30% and 62%). The number of infections, grade 3-4 hepatotoxicity, nephrotoxicity, and neurotoxicity did not differ. Patients with asparaginase had lower MTXPG levels, although to a lesser extent than in vitro studies. Although patients with asparaginase during HD-MTX courses showed more myelosuppression, this had no (serious) clinical consequences. Regarding the MTX efficacy, the schedule-related antagonism seen in in vitro seems less important in vivo.
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Affiliation(s)
- Robin Q H Kloos
- Department of Pediatric Oncology and Hematology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Cor van den Bos
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Academic Medical Center, Amsterdam, The Netherlands
| | | | - Robert de Jonge
- Department of Clinical Chemistry, Amsterdam UMC, Amsterdam, The Netherlands
| | - Inge M van der Sluis
- Department of Pediatric Oncology and Hematology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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25
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Nersting J, Nielsen SN, Grell K, Paerregaard M, Abrahamsson J, Lund B, Jonsson OG, Pruunsild K, Vaitkeviciene G, Kanerva J, Schmiegelow K. Methotrexate polyglutamate levels and co-distributions in childhood acute lymphoblastic leukemia maintenance therapy. Cancer Chemother Pharmacol 2018; 83:53-60. [PMID: 30324220 DOI: 10.1007/s00280-018-3704-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/10/2018] [Indexed: 01/14/2023]
Abstract
PURPOSE Methotrexate polyglutamates (MTXpg) facilitate incorporation of thioguanine nucleotides into DNA (DNA-TG, the primary cytotoxic thiopurine metabolite and outcome determinant in MTX/6-mercaptopurine treatment of childhood ALL). We hypothesized that mapping erythrocyte levels of MTXpg with 1-6 glutamates and their associations with DNA-TG formation would facilitate future guidelines for maintenance therapy dosing. METHODS AND RESULTS Summed MTX with 1-6 glutamates resolved by LCMS [median (interquartile): 5.47 (3.58-7.69) nmol/mmol hemoglobin] was in agreement with total MTX by radio ligand assay. In 16,389 blood samples from 1426 ALL maintenance therapy patients, MTXpg3 21.0 (15.2-27.4)% was the predominant metabolite, and MTXpg1 (the maternal drug) constituted 38.6 (27.2-50.2)% of MTXpg1-6. All subsets correlated; the strongest associations were between metabolites with similar polyglutamate lengths. Correlations of MTXpg1 with MTXpg2 and MTXpg3,4,5,6 were rs = 0.68 and rs = 0.25-0.42, respectively. Intercorrelations of MTXpg3,4,5,6 were all rs ≥ 0.51. MTXpg4 accounted for 29.8 (24.7-33.3)% of MTXpg3-6, yet explained 96% of the summed MTXpg3-6 variation. MTXpg1-4, MTXpg1-6, MTXpg2-6 and MTXpg3 were all associated with DNA-TG levels (p < 0.00001), but collinearity precluded identification of the most informative subset. CONCLUSIONS Measuring erythrocyte MTXpg4 simplifies and can replace longer chain MTXpg monitoring. Resolving individual MTXpg identifies samples that are unsuitable for dose guidance due to high levels of MTXpg1 remaining in the plasma fraction because of recent MTX intake. All tested MTXpg subsets correlated with DNA-TG and may be used for ALL maintenance therapy dose adjustments, but the most informative subset remains to be identified.
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Affiliation(s)
- Jacob Nersting
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Stine Nygaard Nielsen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Kathrine Grell
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Maria Paerregaard
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jonas Abrahamsson
- Department of Pediatrics, Institution for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Bendik Lund
- Department of Pediatrics, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | | | | | | | - Jukka Kanerva
- Children's Hospital, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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26
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Wang M, Huang J, Fan H, He D, Zhao S, Shu Y, Li H, Liu L, Lu S, Xiao C, Liu Y. Treatment of Rheumatoid Arthritis Using Combination of Methotrexate and Tripterygium Glycosides Tablets-A Quantitative Plasma Pharmacochemical and Pseudotargeted Metabolomic Approach. Front Pharmacol 2018; 9:1051. [PMID: 30356765 PMCID: PMC6189563 DOI: 10.3389/fphar.2018.01051] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 08/31/2018] [Indexed: 11/29/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by chronic destructive synovitis and is associated with progressive disability, systemic difficulties, premature death, and socioeconomic costs. Early intervention with disease-modifying antirheumatic drugs (DMARDs) like methotrexate (MTX) and its combination regimen would provide obvious benefits to patients, healthcare systems and society. MTX and tripterygium glycosides tablets (TGTS) are most frequently prescribed medicines for RA, and the combination of them occurs frequently in anti-RA prescriptions. While the underlying combination mechanisms and the affected variation of drug blood level remain unclear. According to the American College of Rheumatology criteria for improvement, clinical evaluation following three treatment groups (i.e., MTX and TGTS mono- and combined groups) were carried out at baseline and at the end of 12 weeks in a randomized controlled clinical trial. To monitor the affected variation of drug blood level and perturbation of metabolites caused by MTX plus TGTS combined to treat active RA, the collected plasma samples were analyzed using RRLC-QqQ-MS and UHPLC-QE Orbitrap HRMS instruments. As a result, 39 metabolites including 7 MTX-related metabolites, 13 TGTS-related migratory ingredients and 19 characteristic endogenous metabolites, were quantitatively determined in plasma samples of RA patients after oral administration. The potential mechanism of MTX and TGTS combination were preliminarily elucidated on the aspect of clinical biochemical test indicators integrated with quantitative plasma pharmacochemistry and the pseudotargeted metabolomics.
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Affiliation(s)
- Menglei Wang
- Department of Chinese Medicine Chemistry, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Jing Huang
- Institute of Clinical Medicine, China-Japan Friendship Hospital, Beijing, China.,Jianguomen Community Health Service Center of Dongcheng District, Beijing, China
| | - Huizhen Fan
- Department of Gastroenterology, People's Hospital of Yichun, Jiangxi Yichun, China
| | - Dan He
- Department of Chinese Medicine Chemistry, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Siyu Zhao
- Department of Chinese Medicine Chemistry, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Yisong Shu
- Department of Chinese Medicine Chemistry, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Hui Li
- Department of Chinese Medicine Chemistry, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Linlin Liu
- Department of Chinese Medicine Chemistry, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Shuang Lu
- Institute of Clinical Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Cheng Xiao
- Institute of Clinical Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Yuanyan Liu
- Department of Chinese Medicine Chemistry, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
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27
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Muller IB, Hebing RF, Jansen G, Nurmohamed MT, Lems WF, Peters GJ, de Jonge R. Personalized medicine in rheumatoid arthritis: methotrexate polyglutamylation revisited. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2018. [DOI: 10.1080/23808993.2018.1517025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Ittai B. Muller
- Department of Clinical Chemistry, VU University Medical Center, Amsterdam, The Netherlands
| | - Renske F. Hebing
- Reade Research, Amsterdam Rheumatology and immunology Center, Amsterdam, The Netherlands
| | - Gerrit Jansen
- Amsterdam Rheumatology and immunology Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Mike T. Nurmohamed
- Reade Research, Amsterdam Rheumatology and immunology Center, Amsterdam, The Netherlands
- Amsterdam Rheumatology and immunology Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Willem F. Lems
- Amsterdam Rheumatology and immunology Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Godefridus J. Peters
- Department of Medical Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry, VU University Medical Center, Amsterdam, The Netherlands
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28
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Silva MF, Ribeiro C, Gonçalves VMF, Tiritan ME, Lima Á. Liquid chromatographic methods for the therapeutic drug monitoring of methotrexate as clinical decision support for personalized medicine: A brief review. Biomed Chromatogr 2018; 32:e4159. [PMID: 29226354 DOI: 10.1002/bmc.4159] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 11/22/2017] [Accepted: 11/29/2017] [Indexed: 01/24/2023]
Abstract
Methotrexate (MTX) is an antifolate drug used for several diseases. Depending on the disease, MTX can be administered at low dose (LDMTX) in some autoimmune diseases, like rheumatoid arthritis, or at high dose (HDMTX) in some cancers, such as acute lymphoblastic leukemia. After absorption, MTX is metabolized in the liver to 7-hydroxymethotrexate and in the intestine to 2,4-diamino-N10-methylpteroic acid (DAMPA). Moreover, inside red blood cells, MTX is converted to active metabolites, MTX polyglutamates (MTXPGs), contributing to its pharmacodynamics. Owing to its narrow therapeutic range, and inter- and intra-patient variability, either noneffectiveness and/or toxicity may occur. Because of the existence of a relationship between drug therapeutic outcome and its systemic concentration, therapeutic drug monitoring (TDM) may ensure the effectiveness and safety of MTX use. In order to monitor the optimization of patient clinical response profile, several analytical methods have been described for TDM in biological samples. These include liquid chromatography (LC) coupled with ultraviolet detection, fluorescence detection or mass spectrometry, each one presenting advantages and drawbacks. This paper reviews the most commonly used techniques for sample preparation and critically discusses the current LC methods applied for the TDM of MTX in biological samples, at LDMTX and HDMTX.
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Affiliation(s)
- Mónica Francisco Silva
- CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Rua Central de Gandra, Gandra, PRD, Portugal.,Faculdade de Medicina da Universidade de Coimbra, R. Larga, Coimbra, Portugal
| | - Cláudia Ribeiro
- CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Rua Central de Gandra, Gandra, PRD, Portugal.,Centro Interdisciplinar de Investigação Marinha e Ambiental, Universidade do Porto, Rua dos Bragas, Porto, Portugal
| | - Virgínia M F Gonçalves
- CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Rua Central de Gandra, Gandra, PRD, Portugal
| | - Maria Elizabeth Tiritan
- CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Rua Central de Gandra, Gandra, PRD, Portugal.,Centro Interdisciplinar de Investigação Marinha e Ambiental, Universidade do Porto, Rua dos Bragas, Porto, Portugal.,Laboratório de Química Orgânica e Farmacêutica, Departamento de Ciências Químicas, Faculdade de Farmácia, Universidade do Porto, Rua de Jorge Viterbo Ferreira, Porto, Portugal
| | - Áurea Lima
- CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Rua Central de Gandra, Gandra, PRD, Portugal.,Grupo de Oncologia Molecular e Patologia Viral, Centro de Investigação, Instituto Português de Oncologia do Porto, Rua Dr. António Bernardino de Almeida, Porto, Portugal.,Hospital de Santo António, Centro Hospitalar do Porto, E.P.E. Largo do Prof. Abel Salazar, Porto, Portugal
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29
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Ullah F, Iqbal Z, Raza A, Khan I, Ullah Khan F, Hassan M. Simultaneous determination of methotrexate and metoclopramide in physiological fluids using RP-HPLC with ultra-violet detection; application in evaluation of polymeric nanoparticles. J LIQ CHROMATOGR R T 2017. [DOI: 10.1080/10826076.2017.1399417] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Farhad Ullah
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| | - Zafar Iqbal
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| | - Abida Raza
- National Institute of Lasers and Optronics, Nilore, Isalamabad, Pakistan
| | - Ismail Khan
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| | - Fahim Ullah Khan
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| | - Muhammad Hassan
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
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30
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Toksvang LN, De Pietri S, Nielsen SN, Nersting J, Albertsen BK, Wehner PS, Rosthøj S, Lähteenmäki PM, Nilsson D, Nystad TA, Grell K, Frandsen TL, Schmiegelow K. Hepatic sinusoidal obstruction syndrome during maintenance therapy of childhood acute lymphoblastic leukemia is associated with continuous asparaginase therapy and mercaptopurine metabolites. Pediatr Blood Cancer 2017; 64. [PMID: 28423235 DOI: 10.1002/pbc.26519] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/19/2017] [Accepted: 02/10/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatic sinusoidal obstruction syndrome (SOS) during treatment of childhood acute lymphoblastic leukemia (ALL) has mainly been associated with 6-thioguanine. The occurrence of several SOS cases after the introduction of extended pegylated asparaginase (PEG-asparaginase) therapy in the Nordic Society of Paediatric Haematology and Oncology (NOPHO) ALL2008 protocol led us to hypothesize that PEG-asparaginase, combined with other drugs, may trigger SOS during 6-thioguanine-free maintenance therapy. PROCEDURE In children with ALL treated in Denmark according to the NOPHO ALL2008 protocol, we investigated the risk of SOS during methotrexate (MTX)/6-mercaptopurine (6MP) maintenance therapy that included PEG-asparaginase until week 33 (randomized to two- vs. six-week intervals), as well as alternating high-dose MTX or vincristine/dexamethasone pulses every four weeks. RESULTS Among 130 children receiving PEG-asparaginase biweekly, 29 developed SOS (≥2 criteria: hyperbilirubinemia, hepatomegaly, ascites, weight gain ≥2.5%, unexplained thrombocytopenia <75 × 109 l-1 ) at a median of 30 days (interquartile range [IQR]: 17-66) into maintenance (cumulative incidence: 27%). SOS cases fulfilling one, two, or three Ponte di Legno criteria were classified as possible (n = 2), probable (n = 8), or verified (n = 19) SOS, respectively. Twenty-six cases (90%) occurred during PEG-asparaginase treatment, including 21 (81%) within 14 days from the last chemotherapy pulse compared with the subsequent 14 days (P = 0.0025). Cytotoxic 6MP metabolites were significantly higher on PEG-asparaginase compared to after its discontinuation. Time-dependent Cox regression analysis showed increased SOS hazard ratio (HR) for erythrocyte levels of methylated 6MP metabolites (HR: 1.09 per 1,000 nmol/mmol hemoglobin increase, 95% confidence interval: 1.05-1.14). Six-week PEG-asparaginase intervals significantly reduced SOS-specific hazards (P < 0.01). CONCLUSIONS PEG-asparaginase increases cytotoxic 6MP metabolite levels and risk of SOS, potentially interacting with other chemotherapy pulses.
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Affiliation(s)
- Linea Natalie Toksvang
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Silvia De Pietri
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Stine N Nielsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jacob Nersting
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Peder S Wehner
- Department of Pediatric Hematology and Oncology, H. C. Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Steen Rosthøj
- Department of Pediatrics, Aalborg University Hospital, Aalborg, Denmark
| | - Päivi M Lähteenmäki
- Department of Pediatric and Adolescent Medicine, Turku University Hospital, Turku, Finland
| | - Daniel Nilsson
- Department of Pediatrics, Astrid Lindgrens Hospital, Stockholm, Sweden
| | - Tove A Nystad
- Department of Pediatrics, University Hospital North Norway, Tromsø, Norway
| | - Kathrine Grell
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Thomas L Frandsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, The Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
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31
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Sparks JA, Barbhaiya M, Karlson EW, Ritter SY, Raychaudhuri S, Corrigan CC, Lu F, Selhub J, Chasman DI, Paynter NP, Ridker PM, Solomon DH. Investigating methotrexate toxicity within a randomized double-blinded, placebo-controlled trial: Rationale and design of the Cardiovascular Inflammation Reduction Trial-Adverse Events (CIRT-AE) Study. Semin Arthritis Rheum 2017; 47:133-142. [PMID: 28284844 PMCID: PMC5765986 DOI: 10.1016/j.semarthrit.2017.02.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/01/2017] [Accepted: 02/04/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND The role of low dose methotrexate (LDM) in potential serious toxicities remains unclear despite its common use. Prior observational studies investigating LDM toxicity compared LDM to other active drugs. Prior placebo-controlled clinical trials of LDM in inflammatory conditions were not large enough to investigate toxicity. The Cardiovascular Inflammation Reduction Trial (CIRT) is an ongoing NIH-funded, randomized, double-blind, placebo-controlled trial of LDM in the secondary prevention of cardiovascular disease. We describe here the rationale and design of the CIRT-Adverse Events (CIRT-AE) ancillary study which aims to investigate adverse events within CIRT. DESIGN CIRT will randomize up to 7000 participants with cardiovascular disease and no systemic rheumatic disease to either LDM (target dose: 15-20mg/week) or placebo for an average follow-up period of 3-5 years; subjects in both treatment arms receive folic acid 1mg daily for 6 days each week. The primary endpoints of CIRT include recurrent cardio vascular events, incident diabetes, and all-cause mortality, and the ancillary CIRT-AE study has been designed to adjudicate other clinically important adverse events including hepatic, gastrointestinal, respiratory, hematologic, infectious, mucocutaneous, oncologic, renal, neurologic, and musculoskeletal outcomes. Methotrexate polyglutamate levels and genome-wide single nucleotide polymorphisms will be examined for association with adverse events. SUMMARY CIRT-AE will comprehensively evaluate potential LDM toxicities among subjects with cardiovascular disease within the context of a large, ongoing, double-blind, placebo-controlled trial. This information may lead to a personalized approach to monitoring LDM in clinical practice.
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Affiliation(s)
- Jeffrey A Sparks
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Medha Barbhaiya
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Elizabeth W Karlson
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Susan Y Ritter
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Soumya Raychaudhuri
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA; Program in Medical and Population Genetics, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA
| | - Cassandra C Corrigan
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA
| | - Fengxin Lu
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA
| | - Jacob Selhub
- Jean Mayer USDA, Human Nutrition Center on Aging, Tufts University, Boston, MA
| | - Daniel I Chasman
- Harvard Medical School, Boston, MA; Department of Medicine, Center for Cardiovascular Disease Prevention, Brigham and Women׳s Hospital, Boston, MA
| | - Nina P Paynter
- Harvard Medical School, Boston, MA; Department of Medicine, Center for Cardiovascular Disease Prevention, Brigham and Women׳s Hospital, Boston, MA
| | - Paul M Ridker
- Harvard Medical School, Boston, MA; Department of Medicine, Center for Cardiovascular Disease Prevention, Brigham and Women׳s Hospital, Boston, MA
| | - Daniel H Solomon
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA
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32
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Caetano-Pinto P, Jamalpoor A, Ham J, Goumenou A, Mommersteeg M, Pijnenburg D, Ruijtenbeek R, Sanchez-Romero N, van Zelst B, Heil SG, Jansen J, Wilmer MJ, van Herpen CML, Masereeuw R. Cetuximab Prevents Methotrexate-Induced Cytotoxicity in Vitro through Epidermal Growth Factor Dependent Regulation of Renal Drug Transporters. Mol Pharm 2017; 14:2147-2157. [PMID: 28493713 PMCID: PMC5462489 DOI: 10.1021/acs.molpharmaceut.7b00308] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
![]()
The combination of methotrexate with
epidermal growth factor receptor
(EGFR) recombinant antibody, cetuximab, is currently being investigated
in treatment of head and neck carcinoma. As methotrexate is cleared
by renal excretion, we studied the effect of cetuximab on renal methotrexate
handling. We used human conditionally immortalized proximal tubule
epithelial cells overexpressing either organic anion transporter 1
or 3 (ciPTEC-OAT1/ciPTEC-OAT3) to examine OAT1 and OAT3, and the efflux
pumps breast cancer resistance protein (BCRP), multidrug resistance
protein 4 (MRP4), and P-glycoprotein (P-gp) in methotrexate handling
upon EGF or cetuximab treatment. Protein kinase microarrays and knowledge-based
pathway analysis were used to predict EGFR-mediated transporter regulation.
Cytotoxic effects of methotrexate were evaluated using the dimethylthiazol
bromide (MTT) viability assay. Methotrexate inhibited OAT-mediated
fluorescein uptake and decreased efflux of Hoechst33342 and glutathione-methylfluorescein
(GS-MF), which suggested involvement of OAT1/3, BCRP, and MRP4 in
transepithelial transport, respectively. Cetuximab reversed the EGF-increased
expression of OAT1 and BCRP as well as their membrane expressions
and transport activities, while MRP4 and P-gp were increased. Pathway
analysis predicted cetuximab-induced modulation of PKC and PI3K pathways
downstream EGFR/ERBB2/PLCg. Pharmacological inhibition of ERK decreased
expression of OAT1 and BCRP, while P-gp and MRP4 were increased. AKT
inhibition reduced all transporters. Exposure to methotrexate for
24 h led to a decreased viability, an effect that was reversed by
cetuximab. In conclusion, cetuximab downregulates OAT1 and BCRP while
upregulating P-gp and MRP4 through an EGFR-mediated regulation of
PI3K-AKT and MAPKK-ERK pathways. Consequently, cetuximab attenuates
methotrexate-induced cytotoxicity, which opens possibilities for further
research into nephroprotective comedication therapies.
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Affiliation(s)
- Pedro Caetano-Pinto
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University , 3584 CG Utrecht, The Netherlands
| | - Amer Jamalpoor
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University , 3584 CG Utrecht, The Netherlands
| | - Janneke Ham
- Department of Oncology, Radboud University Medical Center , 6525 GA Nijmegen, The Netherlands
| | - Anastasia Goumenou
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University , 3584 CG Utrecht, The Netherlands
| | | | | | | | - Natalia Sanchez-Romero
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University , 3584 CG Utrecht, The Netherlands.,Centro Investigación Biomédica de Aragón (CIBA), 50009 Zaragoza, Spain
| | - Bertrand van Zelst
- Department of Clinical Chemistry, ErasmusMC , 3015 CE Rotterdam, The Netherlands
| | - Sandra G Heil
- Department of Clinical Chemistry, ErasmusMC , 3015 CE Rotterdam, The Netherlands
| | - Jitske Jansen
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University , 3584 CG Utrecht, The Netherlands
| | - Martijn J Wilmer
- Department of Pharmacology and Toxicology, Radboud Institute of Molecular Life Sciences, Radboudumc , 6500 HB Nijmegen, The Netherlands
| | - Carla M L van Herpen
- Department of Oncology, Radboud University Medical Center , 6525 GA Nijmegen, The Netherlands
| | - Rosalinde Masereeuw
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University , 3584 CG Utrecht, The Netherlands
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33
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Qu Y, Brady K, Apilado R, O'Malley T, Reddy S, Chitkara P, Ibarra C, Alexander RV, Dervieux T. Capillary blood collected on volumetric absorptive microsampling (VAMS) device for monitoring hydroxychloroquine in rheumatoid arthritis patients. J Pharm Biomed Anal 2017; 140:334-341. [PMID: 28391006 DOI: 10.1016/j.jpba.2017.03.047] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/22/2017] [Accepted: 03/23/2017] [Indexed: 01/18/2023]
Abstract
A novel technique for collection of capillary blood, termed volumetric absorptive microsampling (VAMS), has been recently cleared by the FDA for collection of human blood. VAMS absorbs a fixed volume of blood (10μl) and overcomes area bias and homogeneity issues associated with dried blood spot (DBS). This study is the application of VAMS for therapeutic drug monitoring (TDM) in human capillary blood. A liquid chromatography-tandem mass spectrometry (LC-MS/MS) workflow for analysis of VAMS sample was developed and validated. Concentration of hydroxychloroquine (HCQ) and its metabolites, desethylhydroxychloroquine (DHCQ), desethylchloroquine (DCQ), and bisdesethylchloroquine (BDCQ), in capillary blood on VAMS sampler were compared to those in venous blood in rheumatoid arthritis patients. Feasibility of capillary blood collected on both VAMS and DBS card were evaluated on patients. Stability of dried capillary blood on VAMS was also examined. Our results established that VAMS is a simple and accurate sampling technique that delivers the benefits of DBS sampling while overcoming the issues associated with hematocrit and homogeneity. It requires a small blood volume, simplifies sample logistics management, and may allow sample collection in the patient's home setting.
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Affiliation(s)
- Ying Qu
- Research and Development, Exagen Diagnostics Inc., Vista, CA, USA.
| | - Kelley Brady
- Research and Development, Exagen Diagnostics Inc., Vista, CA, USA
| | - Robert Apilado
- Research and Development, Exagen Diagnostics Inc., Vista, CA, USA
| | - Tyler O'Malley
- Research and Development, Exagen Diagnostics Inc., Vista, CA, USA
| | - Smitha Reddy
- Arthritis Care and Research Center, Poway, CA, USA
| | - Puja Chitkara
- Center for Arthritis and Rheumatologic Excellence, Chula Vista, CA, USA
| | - Claudia Ibarra
- Research and Development, Exagen Diagnostics Inc., Vista, CA, USA
| | | | - Thierry Dervieux
- Research and Development, Exagen Diagnostics Inc., Vista, CA, USA
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34
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DNA-thioguanine nucleotide concentration and relapse-free survival during maintenance therapy of childhood acute lymphoblastic leukaemia (NOPHO ALL2008): a prospective substudy of a phase 3 trial. Lancet Oncol 2017; 18:515-524. [PMID: 28258828 DOI: 10.1016/s1470-2045(17)30154-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 01/09/2017] [Accepted: 01/17/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Adjustment of mercaptopurine and methotrexate maintenance therapy of acute lymphoblastic leukaemia by leucocyte count is confounded by natural variations. Cytotoxicity is primarily mediated by DNA-incorporated thioguanine nucleotides (DNA-TGN). The aim of this study was to establish whether DNA-TGN concentrations in blood leucocytes during maintenance therapy are associated with relapse-free survival. METHODS In this substudy of the NOPHO ALL2008 phase 3 trial done in 23 hospitals in seven European countries (Denmark, Estonia, Finland, Iceland, Lithuania, Norway, and Sweden), we analysed data from centralised and blinded analyses of 6-mercaptopurine and methotrexate metabolites in blood samples from patients with non-high-risk childhood acute lymphoblastic leukaemia. Eligible patients were aged 1·0-17·9 years; had been diagnosed with non-high-risk precursor B-cell or T-cell leukaemia; had been treated according to the Nordic Society of Pediatric Hematology and Oncology ALL2008 protocol; and had reached maintenance therapy in first remission. Maintenance therapy was (mercaptopurine 75 mg/m2 once per day and methotrexate 20 mg/m2 once per week, targeted to a leucocyte count of 1·5-3·0 × 109 cells per L). We measured DNA-TGN and erythrocyte concentrations of TGN nucleotides, methylated mercaptopurine metabolites, and methotrexate polyglutamates. The primary objective was the association of DNA-TGN concentrations and 6-mercaptopurine and methotrexate metabolites with relapse-free survival. The secondary endpoint was the assessment of DNA-TGN concentration and 6-mercaptopurine and methotrexate metabolites during maintenance therapy phase 2. FINDINGS Between Nov 26, 2008 and June 14, 2016, 1509 patients from the NOPHO ALL2008 study were assessed for eligibility in the DNA-TGN substudy, of which 918 (89%) of 1026 eligible patients had at least one DNA-TGN measurement and were included in the analyses. Median follow-up was 4·6 years (IQR 3·1-6·1). Relapse-free survival was significantly associated with DNA-TGN concentration (adjusted hazard ratio 0·81 per 100 fmol/μg DNA increase, 95% CI 0·67-0·98; p=0·029). In patients with at least five blood samples, erythrocyte concentrations of TGN, methylated mercaptopurine metabolites, and methotrexate polyglutamates were associated with DNA-TGN concentration (all p<0·0001). INTERPRETATION Our results suggest the need for intervention trials to identify clinically applicable strategies for individualised drug dosing to increase DNA-TGN concentration, and randomised studies to investigate whether such strategies improve cure rates compared with current dose adjustments based on white blood cell counts. FUNDING Danish Cancer Society, Childhood Cancer Foundation (Denmark), Childhood Cancer Foundation (Sweden), Nordic Cancer Union, Otto Christensen Foundation, University Hospital Rigshospitalet, and Novo Nordic Foundation.
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35
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Wassenaar S, den Boer E, Westerman EM, Hazes JM, de Jonge R. Letter to the editor in response to the article "Clinical characteristics and risk factors for low dose methotrexate toxicity: a cohort of 28 patients" by Kivity S, Zafrir Y, Loebstein R, Pauzner R, Mouallem M, Mayan H, Autoimmun Rev. 2014 Nov.;13(11):1109-13: Height of MTX-PG levels in low-dose MTX-toxicity differs according to the time of onset. Autoimmun Rev 2016; 15:1109-1110. [PMID: 27095131 DOI: 10.1016/j.autrev.2016.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 04/05/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Sophie Wassenaar
- Department of Hospital Pharmacy, Erasmus MC, Postbus 2040, 3000 CA Rotterdam, The Netherlands; Department of Hospital Pharmacy, Sint Franciscus Gasthuis, Postbus 10900, 3004 BA Rotterdam, The Netherlands
| | - Ethan den Boer
- Department of Clinical Chemistry, Erasmus MC, Postbus 2040, 3000 CA Rotterdam, The Netherlands
| | - Elsbeth M Westerman
- Department of Hospital Pharmacy, Sint Franciscus Gasthuis, Postbus 10900, 3004 BA Rotterdam, The Netherlands
| | - Johanna M Hazes
- Department of Rheumatology, Erasmus MC, Postbus 2040, 3000 CA Rotterdam, The Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry, Erasmus MC, Postbus 2040, 3000 CA Rotterdam, The Netherlands.
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36
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Folylpolyglutamate synthase is a major determinant of intracellular methotrexate polyglutamates in patients with rheumatoid arthritis. Sci Rep 2016; 6:35615. [PMID: 27752107 PMCID: PMC5067511 DOI: 10.1038/srep35615] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 09/29/2016] [Indexed: 11/08/2022] Open
Abstract
We investigated major determinants of the intracellular concentrations of methotrexate polyglutamates (MTXPGs) in patients with rheumatoid arthritis (RA). In 271 RA patients on stable oral low dose weekly pulse MTX therapy, the concentrations of MTXPGs in red blood cells (RBCs) were measured by liquid chromatography-electrospray ionization-tandem mass spectrometry. Polymerase chain reaction-restriction fragment length polymorphism analysis was performed to determine the genotypes of solute carrier family 19 member 1 (SLC19A1), folylpolyglutamate synthase (FPGS), and gamma-glutamyl hydrolase (GGH). The mean total MTXPG concentration and the concentrations of individual MTXPGs increased dose-dependently, but reached a plateau at MTX doses >10 mg weekly. The MTXPG3-5/1-2 ratio was lower in patients with adverse events related to MTX than in patients without adverse events. Three polymorphisms of FPGS significantly influenced the MTXPG3-5/1-2 ratio in RBCs, while polymorphisms of SLC19A1 and GGH had no impact. The minor allele frequencies of 2 FPGS genotypes were significantly increased in our patients compared with a Caucasian population. FPGS may have a major role in regulating intracellular polyglutamation of MTX in RA patients receiving low-dose weekly MTX therapy.
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37
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Patel H, Giri P, Ghoghari A, Delvadia P, Syed M, Srinivas NR. Review of the bioanalytical methods for the determination of methotrexate and its metabolites inin vitro, preclinical and clinical studies: Case studies and perspectives. Biomed Chromatogr 2016; 31. [DOI: 10.1002/bmc.3849] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/31/2016] [Accepted: 09/06/2016] [Indexed: 12/18/2022]
Affiliation(s)
| | | | | | | | - Muzeeb Syed
- Department of Pharmacy, Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
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38
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Measures of 6-mercaptopurine and methotrexate maintenance therapy intensity in childhood acute lymphoblastic leukemia. Cancer Chemother Pharmacol 2016; 78:983-994. [PMID: 27600880 DOI: 10.1007/s00280-016-3151-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 08/26/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE Normal white blood cell counts (WBC) are unknown in children with acute lymphoblastic leukemia (ALL). Accordingly, 6-mercaptopurine (6MP) and methotrexate (MTX) maintenance therapy is adjusted by a common WBC target of 1.5-3.0 × 109/L. Consequently, the absolute degree of myelosuppression is unknown for the individual child and we wanted to evaluate this. METHODS A median of 22 (range 8-27) 6MP/MTX metabolite samples and 100 (range 25-130) blood counts during therapy and 10 (range 2-15) off therapy were collected in 50 children with ALL. Differences between off-therapy and on-therapy WBCs [including absolute neutrophil (ANC) and lymphocyte counts (ALC)] were used to retrospectively approximate the absolute myelosuppression (="delta-") and association with age, sex and 6MP/MTX doses explored. We applied linear mixed models to estimate on-therapy counts by 6MP/MTX metabolites: DNA-incorporated thioguanine nucleotides (DNA-TGN), erythrocyte thioguanine nucleotides (ery-TGN), erythrocyte-methylated 6MP metabolites (ery-MeMP) and erythrocyte MTX polyglutamates with 2-6 glutamate residues (ery-MTXpg2-6). RESULTS On-therapy WBC was correlated with ANC and ALC (r s = 0.84 and r s = 0.33, p values <0.001), whereas ANC was weakly correlated with ALC (r s = -0.11, p < 0.001), and neither significantly correlated with age. Off-therapy ALC, but not ANC, was strongly correlated with age (r s = -0.68 and -0.18, p < 0.001 and p = 0.22). Delta-ALC decreased with increasing age (r s = -0.69, p < 0.001). Incorporation of DNA-TGN was positively associated with ery-TGN (p < 0.001), ery-MeMP (p < 0.001) and ery-MTXpg2-6 (p = 0.047). On-therapy ALC decreased with increasing DNA-TGN level (p < 0.001, model adjusted for off-therapy ALC), whereas on-therapy ANC could not be modeled reliably. CONCLUSION Measurements of 6MP/MTX metabolites could supplement blood counts in assessing therapy intensity, but require prospective validation.
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Stoop MP, Visser S, van Dijk E, Aerts JGJV, Stricker BH, Luider TM. A new quantification method for assessing plasma concentrations of pemetrexed and its polyglutamate metabolites. J Pharm Biomed Anal 2016; 128:1-8. [PMID: 27209449 DOI: 10.1016/j.jpba.2016.04.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/19/2016] [Accepted: 04/22/2016] [Indexed: 12/01/2022]
Abstract
Currently no quantification method exists for potentially therapeutically relevant polyglutamate metabolites of the drug pemetrexed which is used for the treatment of lung carcinoma patients. We developed and tested an LC-MS/MS-based analytical assay that uses isotope-labeled internal standards to quantify pemetrexed and its (poly)glutamate metabolites in clinical human plasma samples of lung carcinoma patients. UHPLC chromatography and triple quadrupole mass spectrometry showed an LLOQ of 0.2nmol/L for pemetrexed and an LLOQ of 0.5nmol/L for the two metabolites (one glutamate and two glutamate moieties covalently bound to the pemetrexed molecule, for which no other quantification methods have previously been published). The recoveries for PMTX and its metabolites ranged between 30% and 67%. Precision and accuracy at a concentration of 20nmol/L for all four analytes was well below 15% CV. The precision (RSD) in the biological replicates of the separate days (within-run precision) as well as the reproducibility over several days (between-run precision), tested in the range of 5-250nmol/L, were all below 15%. Autosampler, benchtop and freeze-thaw cycle stability of the analytes was also demonstrated. To illustrate the new assay in a relevant biological context, concentrations of pemetrexed and the two metabolites were quantified in plasma samples of lung carcinoma patients treated with pemetrexed. The assay is straightforward, relatively easy to perform, and has potential for use in therapeutic drug monitoring in non-small cell lung carcinoma patients.
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Affiliation(s)
- Marcel P Stoop
- Department of Neurology, ErasmusMC, Rotterdam, The Netherlands
| | - Sabine Visser
- Department of Pulmonary Diseases, ErasmusMC, Rotterdam, The Netherlands
| | | | | | - Bruno H Stricker
- Department of Epidemiology, ErasmusMC, Rotterdam, The Netherlands
| | - Theo M Luider
- Department of Neurology, ErasmusMC, Rotterdam, The Netherlands.
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Fischer M, Siva S, Cook GK, Jones DR, Fadda HM. Methotrexate Polyglutamate Monitoring in Patients With Crohn's Disease. Clin Pharmacol Drug Dev 2016; 6:240-245. [PMID: 27274011 DOI: 10.1002/cpdd.279] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 05/09/2016] [Accepted: 05/24/2016] [Indexed: 12/18/2022]
Abstract
Methotrexate is an efficacious immunosuppressant for induction and maintenance of remission in Crohn's disease. The goal of this pilot study was to determine whether total or individual methotrexate glutamate levels (MTXGlun ) in red blood cells correlate with disease activity and adverse events in Crohn's disease. A cross-sectional study was undertaken with 12 patients on a stable dose of 25 mg weekly methotrexate (oral or subcutaneous). Clinical disease activity was assessed by the Harvey-Bradshaw Index (HBI), and biologic disease activity was measured by inflammatory markers. Concentrations of individual MTXGlun levels were measured in red blood cells (RBCs) using high-performance liquid chromatography-mass spectrometry. No association was observed between RBC individual (MTXGlun ) or total methotrexate glutamate concentrations and clinical disease activity (HBI score) or inflammatory markers or adverse events. Although Crohn's disease patients in remission appeared to generally have higher RBC total longer-chain methotrexate polyglutamate (MTXGlu3+4+5 ) concentrations compared with those with active disease, a definitive association between RBC MTXGlu3+4+5 levels and clinical disease activity could not be established. Larger longitudinal studies in patients with diverse disease activity are needed to establish the value of MTXGlun levels as indicators of treatment efficacy and clinical outcome.
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Affiliation(s)
- Monika Fischer
- Indiana University Division of Gastroenterology and Hepatology, Indianapolis, IN, USA
| | - Shivi Siva
- Indiana University Division of Gastroenterology and Hepatology, Indianapolis, IN, USA
| | - Gwendolyn K Cook
- Indiana University Division of Gastroenterology and Hepatology, Indianapolis, IN, USA
| | - David R Jones
- Indiana University Department of Medicine, Indianapolis, IN, USA
| | - Hala M Fadda
- College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN, USA
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Pasma A, den Boer E, van 't Spijker A, Timman R, van den Bemt B, Busschbach JJV, Hazes JMW. Nonadherence to disease modifying antirheumatic drugs in the first year after diagnosis: comparing three adherence measures in early arthritis patients. Rheumatology (Oxford) 2016; 55:1812-9. [PMID: 27354686 DOI: 10.1093/rheumatology/kew247] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to compare three measurement methods for non-adherence to DMARDs in early arthritis patients: the Compliance Questionnaire Rheumatology (CQR), the intracellular uptake of MTX in the form of MTX-polyglutamates (MTX-PGs) and electronic measurement with Medication Event Monitoring Systems (MEMS). METHODS DMARD naïve early arthritis patients were included in an ongoing cohort study. MEMS were used to measure adherence continuously, while every 3 months MTX-PGs were collected together with the CQR. The associations between the measures were estimated with Spearman rank correlations. Sensitivity and specificity of the CQR against a MEMS cut-off was compared at 3, 6, 9 and 12 months. The same applied to MTX-PGs against a MEMS cut-off and MTX-PGs against a CQR cut-off. For the association between MEMS, the CQR and MTX-PGs, a multilevel linear regression model was performed with age, gender, weeks of treatment and MTX dosage as covariates. RESULTS We included 206 patients. Non-adherence measured with MEMS varied over time and between DMARDs. The CQR score was not associated with MEMS non-adherence at 3, 9 and 12 months. At 9 months, MTX-PGs was associated with MEMS non-adherence, as well as with the CQR. All correlations were below 0.30. CONCLUSION Associations between the three measures are weak. Explanations are individual differences in the uptake of MTX, and little variance in adherence between patients. Moreover, the measurement domains differ: perceptions (CQR), behaviour (MEMS) and pharmacokinetics (MTX).
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Affiliation(s)
| | | | - Adriaan van 't Spijker
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus Medical Center, University Medical Center Rotterdam
| | - Reininer Timman
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus Medical Center, University Medical Center Rotterdam
| | - Bart van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Jan J V Busschbach
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus Medical Center, University Medical Center Rotterdam
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Becker ML. Using Methotrexate Metabolites to Make Clinical Decisions in JIA. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2015. [DOI: 10.1007/s40674-015-0028-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Using Fluorescence Polarization Immunoassay for Determination of Erythrocyte Methotrexate Polyglutamates, a Quick and Easy Test? Ther Drug Monit 2014; 36:819-23. [DOI: 10.1097/ftd.0000000000000085] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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de Rotte MCFJ, de Jong PHP, den Boer E, Pluijm SMF, Özcan B, Weel AEAM, Lindemans J, Hazes JMW, de Jonge R. Effect of methotrexate use and erythrocyte methotrexate polyglutamate on glycosylated hemoglobin in rheumatoid arthritis. Arthritis Rheumatol 2014; 66:2026-36. [PMID: 24692301 DOI: 10.1002/art.38652] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Accepted: 03/27/2014] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To investigate whether methotrexate (MTX) use, as compared to other therapies, and erythrocyte methotrexate polyglutamate (MTXGlu) concentrations are associated with changes in glycosylated hemoglobin (HbA1c ) levels in rheumatoid arthritis (RA) patients. METHODS The derivation cohort consisted of patients selected from the Treatment in the Rotterdam Early Arthritis Cohort who fulfilled the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for RA. Patients were randomized to 6 treatment arms: triple disease-modifying antirheumatic drug (DMARD) therapy (consisting of MTX, sulfasalazine, and hydroxychloroquine [HCQ]) + intramuscular (IM) glucocorticoids, triple DMARD therapy + oral glucocorticoids, MTX + oral glucocorticoid therapy, MTX therapy, oral glucocorticoid therapy, and HCQ therapy. HbA1c levels were determined at baseline and at 3 months. Concentrations of erythrocyte MTXGlu1-5 were measured after 3 months of treatment. Within treatment arms, changes in the level of HbA1c were compared by paired t-test. Associations of MTXGlu concentrations with changes in the level of HbA1c were tested using multiple linear regression analysis, adjusted for age, sex, body mass index, and comedication. Significant associations were validated using data on RA patients taking MTX who were enrolled in the Methotrexate in Rotterdam cohort. RESULTS In the derivation cohort, the mean change in HbA1c level after 3 months of treatment was -1.9 mmoles/mole (-0.18%) (P = 0.001). Levels of HbA1c decreased in 4 of the individual treatment groups, as follows: for the triple DMARD therapy + IM glucocorticoids treatment arm, -5.5 mmoles/mole (-0.50%) (P < 0.001), for the triple DMARD therapy + oral glucocorticoids treatment arm, -3.7 mmoles/mole (-0.34%) (P < 0.001), for the MTX treatment arm, -0.8 mmoles/mole (-0.08%) (P = 0.018), and for the HCQ treatment arm, -2.0 mmoles/mole (-0.19%) (P = 0.175). Increased levels of MTXGlu2 (β = -0.20, P = 0.005), MTXGlu3 (β = -0.31, P < 0.001), MTXGlu4 (β = -0.33, P < 0.001) after treatment, MTXGlu5 (β = -0.39, P < 0.001), and total MTXGlu (β = -0.29, P < 0.001) were associated with decreased levels of HBA1c . In the validation cohort, levels of HbA1c were decreased by 2.6 mmoles/mole (0.23%) (P < 0.001) after treatment, and MTXGlu3 was associated with decreased levels of HbA1c (β = -0.26, P = 0.018). CONCLUSION MTX use and higher concentrations of erythrocyte MTXGlu are associated with decreased levels of HbA1c in RA patients. Triple DMARD therapy and HCQ treatment resulted in reduced HbA1c levels, and glucocorticoid treatment resulted in increased levels of HbA1c .
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den Boer E, de Rotte MC, Pluijm SM, Heil SG, Hazes JM, de Jonge R. Determinants of Erythrocyte Methotrexate Polyglutamate Levels in Rheumatoid Arthritis. J Rheumatol 2014; 41:2167-78. [DOI: 10.3899/jrheum.131290] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objective.Low-dose methotrexate (MTX) is the anchor drug in the treatment for rheumatoid arthritis (RA). Response to MTX is related to the intracellular MTX-polyglutamate (MTX-PG) levels and little is known about its determinants. We aimed to define the determinants of erythrocyte MTX-PG concentrations in 2 prospective cohorts of patients with RA.Methods.Patients with RA treated with MTX from 2 longitudinal cohorts were included: 93 from the MTX-R study (Rotterdam, the Netherlands derivation cohort), and 247 from the treatment in Rotterdam Early Arthritis Cohort study (validation cohort). MTX-PG concentrations were measured at 3 months of treatment using liquid chromatography/mass spectrometry. The MTX-PG were used as outcome measure. Various sociodemographic, clinical, biochemical, and genetic factors were assessed at baseline. Associations with MTX-PG levels were analyzed using multivariate regression analysis.Results.Age was positively associated with MTX-PG1 (stβ 0.23, p = 0.033) and total MTX-PG (stβ 0.23, p = 0.018) in the derivation cohort, and with all MTX-PG in the validation cohort (MTX-PG1: stβ 0.13, p = 0.04; MTX-PG2: stβ 0.21, p = 0.001; MTX-PG3: stβ 0.22, p < 0.001; MTX-PG4+5: stβ 0.25, p < 0.001; and total MTX-PG: stβ 0.32, p < 0.001). Erythrocyte folate levels were positively associated with MTX-PG3 (stβ 0.3, p = 0.021) and total MTX-PG levels (stβ 0.32, p = 0.022) in the derivation cohort, which was replicated for MTX-PG3 (stβ 0.15, p = 0.04) in the validation cohort. Patients with the folylpolyglutamate synthase (FPGS) rs4451422 wild-type genotype had higher concentrations of MTX-PG3 (p < 0.05), MTX-PG4+5 (p < 0.05), and total MTX-PG (p < 0.05) in both cohorts. In the combined cohort, MTX dose was positively associated with levels of MTX-PG3 (stβ 0.23, p < 0.001), MTX-PG4+5 (stβ 0.30, p < 0.001), and total MTX-PG (stβ 0.20, p = 0.002), but negatively associated with MTX-PG2 levels (stβ −0.22, p < 0.001).Conclusion.Our prospective study shows that higher age, higher MTX dose, higher erythrocyte folate status, and the FPGS rs4451422 wild-type genotype are associated with higher MTX-PG concentrations. While only up to 21% of interpatient variability can be explained by these determinants, this knowledge may aid in the development of personalized treatment in RA.
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de Rotte MCFJ, den Boer E, de Jong PHP, Pluijm SMF, Bulatović Ćalasan M, Weel AE, Huisman AM, Gerards AH, van Schaeybroeck B, Wulffraat NM, Lindemans J, Hazes JMW, de Jonge R. Methotrexate polyglutamates in erythrocytes are associated with lower disease activity in patients with rheumatoid arthritis. Ann Rheum Dis 2013; 74:408-14. [DOI: 10.1136/annrheumdis-2013-203725] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ćalasan MB, den Boer E, de Rotte MCFJ, Vastert SJ, Kamphuis S, de Jonge R, Wulffraat NM. Methotrexate polyglutamates in erythrocytes are associated with lower disease activity in juvenile idiopathic arthritis patients. Ann Rheum Dis 2013; 74:402-7. [PMID: 24288013 DOI: 10.1136/annrheumdis-2013-203723] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To determine association of erythrocyte methotrexate polyglutamates (MTX-PG) with disease activity and adverse effects in a prospective juvenile idiopathic arthritis (JIA) cohort. METHODS One hundred and thirteen JIA patients were followed from MTX start until 12 months. Erythrocyte MTX-PGs with 1-5 glutamate residues were measured at 3 months with tandem mass spectrometry. The outcomes were Juvenile Arthritis Disease Activity Score (JADAS)-27 and adverse effects. To determine associations of MTX-PGs with JADAS-27 at 3 months and during 1 year of MTX treatment, linear regression and linear mixed-model analyses were used. To determine associations of MTX-PGs with adverse effects during 1 year of MTX treatment, logistic regression was used. Analyses were corrected for JADAS-27 at baseline and co-medication. RESULTS Median JADAS-27 decreased from 12.7 (IQR: 7.8-18.2) at baseline to 2.9 (IQR: 0.1-6.5) at 12 months. Higher concentrations of MTX-PG3 (β: -0.006, p=0.005), MTX-PG4 (β: -0.015, p=0.004), MTX-PG5 (β: -0.051, p=0.011) and MTX-PG3-5 (β: -0.004, p=0.003) were associated with lower disease activity at 3 months. Higher concentrations of MTX-PG3 (β: -0.005, p=0.028), MTX-PG4 (β: -0.014, p=0.014), MTX-PG5 (β: -0.049, p=0.023) and MTX-PG3-5 (β: -0.004, p=0.018) were associated with lower disease activity over 1 year. None of the MTX-PGs was associated with adverse effects. CONCLUSIONS In the first prospective study in JIA, long-chain MTX-PGs were associated with lower JADAS-27 at 3 months and during 1 year of MTX treatment. Erythrocyte MTX-PG could be a plausible candidate for therapeutic drug monitoring of MTX in JIA.
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Affiliation(s)
- Maja Bulatović Ćalasan
- Department of Paediatric Immunology, University Medical Centre Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Ethan den Boer
- Department of Clinical Chemistry, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Maurits C F J de Rotte
- Department of Clinical Chemistry, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sebastiaan J Vastert
- Department of Paediatric Immunology, University Medical Centre Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Sylvia Kamphuis
- Department of Paediatric Rheumatology, Erasmus University Medical Centre Rotterdam, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nico M Wulffraat
- Department of Paediatric Immunology, University Medical Centre Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
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de Rotte MCFJ, de Jong PHP, Pluijm SMF, Bulatović Ćalasan M, Barendregt PJ, van Zeben D, van der Lubbe PA, de Sonnaville PB, Lindemans J, Hazes JMW, de Jonge R. Association of Low Baseline Levels of Erythrocyte Folate With Treatment Nonresponse at Three Months in Rheumatoid Arthritis Patients Receiving Methotrexate. ACTA ACUST UNITED AC 2013; 65:2803-13. [DOI: 10.1002/art.38113] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Accepted: 07/25/2013] [Indexed: 11/10/2022]
Affiliation(s)
| | | | - S. M. F. Pluijm
- Erasmus University Medical Center; Rotterdam The Netherlands
| | - M. Bulatović Ćalasan
- University Medical Center Utrecht and Wilhelmina Children's Hospital; Utrecht The Netherlands
| | | | - D. van Zeben
- Sint Franciscus Gasthuis Hospital; Rotterdam The Netherlands
| | | | | | - J. Lindemans
- Erasmus University Medical Center; Rotterdam The Netherlands
| | - J. M. W. Hazes
- Erasmus University Medical Center; Rotterdam The Netherlands
| | - R. de Jonge
- Erasmus University Medical Center; Rotterdam The Netherlands
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Ćalasan MB, Thurlings RM, Wulffraat NM, Prakken BJ. Translational medicine from bedside to bench and back again: methotrexate revisited. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/ijr.13.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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