1
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Turcott JG, Miyagui SM, Gutiérrez Torres S, Cárdenas-Fernández D, Caballé-Perez E, Rios-Garcia E, Cardona AF, Rolfo C, Arrieta O. Sarcopenia as a Predictive Factor for Carboplatin Toxicity in Patients with Advanced Non-Small Cell Lung Cancer. Nutr Cancer 2024:1-9. [PMID: 39066469 DOI: 10.1080/01635581.2024.2382390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 07/10/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024]
Abstract
Sarcopenia in cancer patients often negatively impacts various outcomes. Carboplatin, a first-line chemotherapy for non-small cell lung cancer (NSCLC), is dosed based on body weight, which doesn't account for sarcopenia. This study evaluated the association between sarcopenia and carboplatin-related toxicity in NSCLC patients. Patients with locally advanced or metastatic NSCLC treated with carboplatin were included. Toxicity events during the first two cycles of treatment were recorded. Sarcopenia was assessed using pretreatment computed tomography scans analyzed with Slice-O-Matic V4.2 software, defining sarcopenia as a skeletal muscle index (SMI) of <52.4 cm2/m2 for men and <38.5 cm2/m2 for women. Among 146 patients, 52% had sarcopenia. Hematological toxicity occurred in 71.2% of all patients and 77.6% of those with sarcopenia. The fat-free mass index (FFMI) was independently associated with hematological toxicity and dose-limiting toxicity (DLT), which was observed in 55.5% of patients. Sarcopenia significantly correlates with hematological toxicity and DLT during carboplatin treatment in NSCLC patients. Given its prevalence and noninvasive detection, further research is needed to understand its impact on treatment outcomes.
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Affiliation(s)
- Jenny G Turcott
- Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), Mexico City, Mexico
| | - Sayako M Miyagui
- Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), Mexico City, Mexico
| | | | | | - Enrique Caballé-Perez
- Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), Mexico City, Mexico
| | - Eduardo Rios-Garcia
- Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), Mexico City, Mexico
| | - Andrés F Cardona
- Thoracic Oncology Unit and Direction of Research, Science, and Education, Luis Carlos Sarmiento, Bogotá, Colombia
| | - Christian Rolfo
- Thoracic Oncology Center, Tisch Cancer Center, Mount Sinai Hospital System & Icahn School of Medicine, New York, New York, USA
| | - Oscar Arrieta
- Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), Mexico City, Mexico
- Personalized Medicine Laboratory, Instituto Nacional de Cancerología (INCan), Mexico City, Mexico
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2
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de Rouw N, Boosman RJ, Burgers JA, Huitema ADR, Dingemans AMC, Derijks HJ, Burger DM, Piet B, Hendriks LEL, Biesma B, Pruis MA, Dumoulin DW, Croes S, Mathijssen RHJ, van den Heuvel MM, ter Heine R. Renal function-based versus standard dosing of pemetrexed: a randomized controlled trial. Cancer Chemother Pharmacol 2023; 91:33-42. [PMID: 36413252 PMCID: PMC9685043 DOI: 10.1007/s00280-022-04489-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 10/30/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE Pemetrexed is a chemotherapeutic drug in the treatment of non-small cell lung cancer and mesothelioma. Optimized dosing of pemetrexed based on renal function instead of body surface area (BSA) is hypothesized to reduce pharmacokinetic variability in systemic exposure and could therefore improve treatment outcomes. The aim of this study is to compare optimized dosing to standard BSA-based dosing. METHODS A multicenter randomized (1:1) controlled trial was performed to assess superiority of optimized dosing versus BSA-based dosing in patients who were eligible for pemetrexed-based chemotherapy. The individual exposure to pemetrexed in terms of area under the concentration-time curve (AUC) was determined. The fraction of patients attaining to a predefined typical target AUC (164 mg × h/L ± 25%) was calculated. RESULTS A total of 81 patients were included. Target attainment was not statistically significant different between both arms (89% vs. 84% (p = 0.505)). The AUC of pemetrexed was similar between the optimized dosing arm (n = 37) and the standard of care arm (n = 44) (155 mg × h/L vs 160 mg × h/L (p = 0.436). CONCLUSION We could not show superiority of optimized dosing of pemetrexed in patients with an adequate renal function does not show added value on the attainment of a pharmacokinetic endpoint, safety, nor QoL compared to standard of care dosing. CLINICAL TRIAL NUMBER Clinicaltrials.gov identifier: NCT03655821.
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Affiliation(s)
- Nikki de Rouw
- grid.10417.330000 0004 0444 9382Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands ,grid.413508.b0000 0004 0501 9798Department of Pharmacy, Jeroen Bosch Hospital, ‘S-Hertogenbosch, The Netherlands
| | - René J. Boosman
- grid.430814.a0000 0001 0674 1393Department of Pharmacy & Pharmacology, Antoni Van Leeuwenhoek—The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Jacobus A. Burgers
- grid.430814.a0000 0001 0674 1393Department of Thoracic Oncology, Antoni Van Leeuwenhoek—The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Alwin D. R. Huitema
- grid.430814.a0000 0001 0674 1393Department of Pharmacy & Pharmacology, Antoni Van Leeuwenhoek—The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands ,grid.7692.a0000000090126352Department of Clinical Pharmacy, Utrecht University Medical Center, Utrecht University, Utrecht, The Netherlands ,grid.487647.eDepartment of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Anne-Marie C. Dingemans
- grid.412966.e0000 0004 0480 1382Department of Pulmonary Diseases, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands ,grid.508717.c0000 0004 0637 3764Department of Pulmonary Medicine, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Hieronymus. J. Derijks
- grid.10417.330000 0004 0444 9382Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands ,grid.413508.b0000 0004 0501 9798Department of Pharmacy, Jeroen Bosch Hospital, ‘S-Hertogenbosch, The Netherlands
| | - David M. Burger
- grid.10417.330000 0004 0444 9382Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Berber Piet
- grid.10417.330000 0004 0444 9382Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lizza E. L. Hendriks
- grid.412966.e0000 0004 0480 1382Department of Pulmonary Diseases, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bonne Biesma
- grid.413508.b0000 0004 0501 9798Department of Pulmonary Diseases, Jeroen Bosch Hospital, ‘s Hertogenbosch, The Netherlands
| | - Melinda A. Pruis
- grid.508717.c0000 0004 0637 3764Department of Pulmonary Medicine, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands ,grid.508717.c0000 0004 0637 3764Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Daphne W. Dumoulin
- grid.508717.c0000 0004 0637 3764Department of Pulmonary Medicine, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Sander Croes
- grid.412966.e0000 0004 0480 1382Department of Clinical Pharmacy & Toxicology, CARIM-School for Cardiovascular Disease, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ron H. J. Mathijssen
- grid.508717.c0000 0004 0637 3764Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Michel M. van den Heuvel
- grid.10417.330000 0004 0444 9382Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob ter Heine
- grid.10417.330000 0004 0444 9382Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
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3
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Cao P, Guo W, Wang J, Wu S, Huang Y, Wang Y, Liu Y, Zhang Y. Population pharmacokinetic study of pemetrexed in chinese primary advanced non-small cell lung carcinoma patients. Front Pharmacol 2022; 13:954242. [PMID: 36105185 PMCID: PMC9466465 DOI: 10.3389/fphar.2022.954242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
The purposes of this study were to identify physiological and genetic factors that contributed to variability of pemetrexed (PEM) exposure and to optimize the dosing regimens for Chinese non-small cell lung carcinoma patients. A prospective population pharmacokinetics (PPK) research was performed in this population. The PEM concentrations of 192 plasma samples from 116 in-hospital patients were detected. All patients were genotyped for polymorphisms. The PPK model of PEM was developed. The pharmacokinetic behavior of PEM was described by a two-compartment model with first-order elimination. The population typical values were as follows: clearance (CL) 8.29 L/h, intercompartmental clearance (Q) 0.10 L/h, central volume of distribution (V1) 18.94 L and peripheral volume of distribution (V2) 5.12 L. Creatinine clearance (CrCl) was identified as a covariate to CL, and ERCC1 (rs3212986) and CYP3A5 (rs776746) gene polymorphisms as covariates to Q. By using empirical body surface area (BSA)-based dosing strategy, PEM exposure decreased with the elevation of CrCl. Contrarily, CrCl-based dosing strategy exhibited a satisfactory efficacy of achieving the target PEM exposure. BSA-based dosing regimen in current clinic practice is not suitable to achieve the target exposure in PEM chemotherapy of Chinese NSCLC patients. Alternatively, renal function-based dosing strategy is suggested.
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Affiliation(s)
- Peng Cao
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Wei Guo
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Jun Wang
- Department of Clinical Pharmacy, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sanlan Wu
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Yifei Huang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Yang Wang
- Department of Clinical Pharmacy, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Yang Wang, ; Yani Liu, ; Yu Zhang,
| | - Yani Liu
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
- *Correspondence: Yang Wang, ; Yani Liu, ; Yu Zhang,
| | - Yu Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
- *Correspondence: Yang Wang, ; Yani Liu, ; Yu Zhang,
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4
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de Rouw N, de Boer M, Boosman RJ, van den Heuvel MM, Burger DM, Lieverse JE, Derijks HJ, Frederix GWJ, Ter Heine R. The pharmacoeconomic benefits of pemetrexed dose individualization in lung cancer patients. Clin Pharmacol Ther 2022; 111:1103-1110. [PMID: 35048355 PMCID: PMC9304220 DOI: 10.1002/cpt.2529] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/05/2022] [Indexed: 11/06/2022]
Abstract
Neutropenia is a dose-related treatment-limiting and costly adverse event of pemetrexed. We postulate that individualized dosing reduces the incidence of neutropenia. The aims of this study were to 1) investigate the costs of pemetrexed-related neutropenia and 2) to determine the pharmacoeconomic benefits of individualized dosing of pemetrexed in terms of budget impact, yearly cost savings and reduction in severe neutropenia. Retrospective data on the treatment of ≥grade 3 neutropenia during pemetrexed-based chemotherapy were collected from three Dutch hospitals to determine the mean health care consumption during a neutropenic episode. Subsequently, Monte Carlo simulations were performed using a validated pharmacokinetic/pharmacodynamic (PK/PD) model to predict the neutropenia incidence during four cycles for standard dosing of pemetrexed and individualized dosing. The mean costs per neutropenia and the expected neutropenia incidence were combined to calculate the budget impact and cost savings. We found that the average costs per pemetrexed-associated neutropenic episode to be € 1,490. The neutropenia incidence for the standard and individualized pemetrexed dosing strategies were 12.7 and 9.9%, respectively. This resulted in total expected neutropenia-related costs of approximately € 3.0 million and €2.4 million, respectively. Taking the number of patients eligible for pemetrexed treatment into account, individualized dosing could result in saving €686,000 on a yearly basis in the Netherlands alone. Individualized dosing of pemetrexed can decrease the incidence of neutropenia and thus result in a significant decrease in neutropenia-related costs and decreased risk of hospitalization or even death while maintaining therapeutic exposure.
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Affiliation(s)
- Nikki de Rouw
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Department of Pharmacy, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Merel de Boer
- Utrecht University, School of Pharmacy, Utrecht, The Netherlands
| | - René J Boosman
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michel M van den Heuvel
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pulmonary Diseases, Nijmegen, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Joris E Lieverse
- Department of Hospital Pharmacy, Haga Teaching Hospital, The Hague, the Netherlands
| | - Hieronymus J Derijks
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Department of Pharmacy, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Geert W J Frederix
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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5
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Optimized Dosing: The Next Step in Precision Medicine in Non-Small-Cell Lung Cancer. Drugs 2021; 82:15-32. [PMID: 34894338 DOI: 10.1007/s40265-021-01654-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 12/20/2022]
Abstract
In oncology, and especially in the treatment of non-small-cell lung cancer (NSCLC), dose optimization is often a neglected part of precision medicine. Many drugs are still being administered in "one dose fits all" regimens or based on parameters that are often only minor determinants for systemic exposure. These dosing approaches often introduce additional pharmacokinetic variability and do not add to treatment outcomes. Fortunately, pharmacological knowledge is increasing, providing valuable information regarding the potential of, for example, therapeutic drug monitoring. This article focuses on the evidence for the most promising and easily implemented optimized dosing approaches for the small-molecule inhibitors, chemotherapeutic agents, and monoclonal antibodies as treatment options currently approved for NSCLC. Despite limitations such as investigations having been conducted in oncological diseases other than NSCLC or the retrospective origin of many analyses, an alternative dosing regimen could be beneficial for treatment outcomes, prescriber convenience, or financial burden on healthcare systems. This review of the literature provides recommendations on the implementation of dose optimization and advice regarding promising strategies that deserve further research in NSCLC.
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6
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Mechanisms, Management and Prevention of Pemetrexed-Related Toxicity. Drug Saf 2021; 44:1271-1281. [PMID: 34741752 DOI: 10.1007/s40264-021-01135-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 12/17/2022]
Abstract
Pemetrexed is a cytostatic antifolate drug and a cornerstone in the treatment of lung cancer. Although generally well tolerated, a substantial part of the patient population experiences dose-limiting or even treatment-limiting toxicities. These include mucositis, skin problems, fatigue, renal toxicity, and neutropenia. Several studies confirmed that pemetrexed pharmacokinetics can serve as a prognostic factor for the development of toxicity, especially for neutropenia. Preventing and managing toxicity of pemetrexed can help to ensure durable treatment. Several evidence-based strategies are already implemented in clinical care. With the introduction of standard vitamin supplementation and dexamethasone, the incidence of hematological toxicity and skin reactions substantially decreased. In the case of high risk for toxicity, granulocyte colony-stimulating factor can be used to prevent severe hematological toxicity. Moreover, high-dose folinic acid can resolve severe pemetrexed-induced toxicity. There are several experimental options to prevent or manage pemetrexed-related toxicity, such as the use of standard folinic acid, hemodialysis, antidotes such as thymidine, hypoxanthine, and glucarpidase, and the use of therapeutic drug monitoring. These strategies still need clinical evaluation before implementation, but could enable treatment with pemetrexed for patients who are at risk for toxicity, such as in renal impairment.
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7
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de Rouw N, Derijks HJ, Hilbrands LB, Boosman RJ, Piet B, Koolen SLW, Burgers JA, Dingemans AMC, van den Heuvel MM, Hendriks LEL, Aerts JGJV, Croes S, Mathijssen RHJ, Huitema ADR, Burger DM, Biesma B, Ter Heine R. Hyperhydration with cisplatin does not influence pemetrexed exposure. Br J Clin Pharmacol 2021; 88:871-876. [PMID: 34374116 PMCID: PMC9290918 DOI: 10.1111/bcp.15031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/28/2021] [Accepted: 07/26/2021] [Indexed: 11/30/2022] Open
Abstract
Pemetrexed is a cytotoxic drug for first‐line treatment of lung cancer. It is often combined with other anticancer drugs such as cisplatin or carboplatin. In clinical practice, hyperhydration regimens are applied to overcome cisplatin‐related nephrotoxicity. As pemetrexed is almost completely eliminated from the body by the kidneys, hyperhydration can result in augmented clearance. Furthermore, administration of large quantities of fluid may increase the volume of distribution of pemetrexed. Pharmacokinetics and, thus, efficacy and toxicity may be influenced by hyperhydration. This has not yet been properly studied. We performed a population pharmacokinetic analysis to assess hyperhydration as a covariate for pemetrexed clearance and for volume of distribution A relevant change was defined as >25% increase in clearance or volume of distribution. In our extensive dataset of 133 individuals, we found that hyperhydration did not significantly or relevantly explain variability in pemetrexed clearance (unchanged, P = .196) or volume of distribution (+7% change, P = .002), despite a power of >99% to detect a relevant change. Therefore, dose adjustments of pemetrexed are not required during hyperhydration with cisplatin.
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Affiliation(s)
- Nikki de Rouw
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Pharmacy, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Hieronymus J Derijks
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Pharmacy, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Luuk B Hilbrands
- Department of Nephrology, Radboud university medical center, Nijmegen, the Netherlands
| | - René J Boosman
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek - The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Berber Piet
- Department of Pulmonology, Radboud university medical center, Nijmegen, the Netherlands
| | - Stijn L W Koolen
- Department of Pharmacy, Erasmus MC, Rotterdam, The Netherlands.,Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Jacobus A Burgers
- Department of Thoracic Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | | | - Lizza E L Hendriks
- Department of Pulmonary Diseases, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Sander Croes
- Department of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek - The Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Clinical Pharmacy, Utrecht University Medical Center, Utrecht University, Utrecht, the Netherlands.,Department of Pharmacology, Princes Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bonne Biesma
- Department of Pulmonary Diseases, Jeroen Bosch Hospital, 's Hertogenbosch, the Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
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8
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Boosman RJ, Dorlo TPC, de Rouw N, Burgers JA, Dingemans AMC, van den Heuvel MM, Hendriks LEL, Biesma B, Aerts JGJV, Croes S, Mathijssen RHJ, Huitema ADR, Ter Heine R. Toxicity of pemetrexed during renal impairment explained-Implications for safe treatment. Int J Cancer 2021; 149:1576-1584. [PMID: 34181276 DOI: 10.1002/ijc.33721] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/10/2021] [Accepted: 05/27/2021] [Indexed: 11/06/2022]
Abstract
Pemetrexed is an important component of first line treatment in patients with non-squamous non-small cell lung cancer. However, a limitation is the contraindication in patients with renal impairment due to hematological toxicity. Currently, it is unknown how to safely dose pemetrexed in these patients. The aim of our study was to elucidate the relationship between pemetrexed exposure and toxicity to support the development of a safe dosing regimen in patients with renal impairment. A population pharmacokinetic/pharmacodynamic analysis was performed based on phase II study results in three patients with renal dysfunction, supplemented with data from 106 patients in early clinical studies. Findings were externally validated with data of different pemetrexed dosing regimens. Alternative dosing regimens were evaluated using the developed model. We found that pemetrexed toxicity was driven by the time above a toxicity threshold concentration. The threshold for vitamin-supplemented patients was 0.110 mg/mL (95% CI: 0.092-0.146 mg/mL). It was observed that in patients with renal impairment (estimated glomerular filtration rate [eGFR]: <45 mL/min) the approved dose of 500 mg/m2 would yield a high probability of severe neutropenia in the range of 51.0% to 92.6%. A pemetrexed dose of 20 mg for patients (eGFR: 20 mL/min) is shown to be neutropenic-equivalent to the approved dose in patients with adequate renal function (eGFR: 90 mL/min), but would result in an approximately 13-fold lower area under the concentration-time curve. The pemetrexed exposure-toxicity relationship is explained by a toxicity threshold and substantially different from previously thought. Without prophylaxis for toxicity, it is unlikely that a therapeutic dose can be safely administered to patients with renal impairment.
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Affiliation(s)
- René J Boosman
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek-The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas P C Dorlo
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek-The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Nikki de Rouw
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmacy, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Jacobus A Burgers
- Department of Thoracic Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Anne-Marie C Dingemans
- Department of Pulmonary Diseases, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Pulmonology, Erasmus MC, Rotterdam, The Netherlands
| | | | - Lizza E L Hendriks
- Department of Pulmonary Diseases, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bonne Biesma
- Department of Pulmonary Diseases, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | | | - Sander Croes
- Department of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek-The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Clinical Pharmacy, Utrecht University Medical Center, Utrecht University, Utrecht, The Netherlands.,Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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