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Pratt VM, Cavallari LH, Fulmer ML, Gaedigk A, Hachad H, Ji Y, Kalman LV, Ly RC, Moyer AM, Scott SA, Turner AJ, van Schaik RHN, Whirl-Carrillo M, Weck KE. DPYD Genotyping Recommendations: A Joint Consensus Recommendation of the Association for Molecular Pathology, American College of Medical Genetics and Genomics, Clinical Pharmacogenetics Implementation Consortium, College of American Pathologists, Dutch Pharmacogenetics Working Group of the Royal Dutch Pharmacists Association, European Society for Pharmacogenomics and Personalized Therapy, Pharmacogenomics Knowledgebase, and Pharmacogene Variation Consortium. J Mol Diagn 2024:S1525-1578(24)00154-5. [PMID: 39032821 DOI: 10.1016/j.jmoldx.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/09/2024] [Accepted: 05/21/2024] [Indexed: 07/23/2024] Open
Abstract
The goals of the Association for Molecular Pathology (AMP) Clinical Practice Committee's Pharmacogenomics (PGx) Working Group are to define the key attributes of pharmacogenetic alleles recommended for clinical testing and a minimum set of variants that should be included in clinical PGx genotyping assays. This document series provides recommendations for a minimum set of variant alleles (Tier 1) and an extended list of variant alleles (Tier 2) that will aid clinical laboratories when designing assays for PGx testing. The AMP PGx Working Group considered the functional impact of the variant alleles, allele frequencies in multiethnic populations, the availability of reference materials, and other technical considerations for PGx testing when developing these recommendations. The goal of this Working Group is to promote standardization of PGx testing across clinical laboratories. This document will focus on clinical DPYD PGx testing that may be applied to all DPD-related medications. These recommendations are not to be interpreted as prescriptive but to provide a reference guide.
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Affiliation(s)
- Victoria M Pratt
- Pharmacogenomics (PGx) Working Group of the Clinical Practice Committee*, Association for Molecular Pathology (AMP), Rockville, MD; Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN; Agena Bioscience, San Diego, CA.
| | - Larisa H Cavallari
- Pharmacogenomics (PGx) Working Group of the Clinical Practice Committee*, Association for Molecular Pathology (AMP), Rockville, MD; Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL
| | - Makenzie L Fulmer
- Pharmacogenomics (PGx) Working Group of the Clinical Practice Committee*, Association for Molecular Pathology (AMP), Rockville, MD; Department of Pathology and ARUP Laboratories, University of Utah School of Medicine, Salt Lake City, UT
| | - Andrea Gaedigk
- Pharmacogenomics (PGx) Working Group of the Clinical Practice Committee*, Association for Molecular Pathology (AMP), Rockville, MD; Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Research Institute, Kansas City, and School of Medicine, University of Missouri-Kansas City, Kansas City, MO
| | - Houda Hachad
- Pharmacogenomics (PGx) Working Group of the Clinical Practice Committee*, Association for Molecular Pathology (AMP), Rockville, MD; Department of Clinical Operations, AccessDx, Houston, TX
| | - Yuan Ji
- Pharmacogenomics (PGx) Working Group of the Clinical Practice Committee*, Association for Molecular Pathology (AMP), Rockville, MD; Department of Pathology and ARUP Laboratories, University of Utah School of Medicine, Salt Lake City, UT
| | - Lisa V Kalman
- Pharmacogenomics (PGx) Working Group of the Clinical Practice Committee*, Association for Molecular Pathology (AMP), Rockville, MD; Division of Laboratory Systems, Centers for Disease Control and Prevention, Atlanta, GA
| | - Reynold C Ly
- Pharmacogenomics (PGx) Working Group of the Clinical Practice Committee*, Association for Molecular Pathology (AMP), Rockville, MD; Indiana University School of Medicine, Department of Medical and Molecular Genetics, Indianapolis, IN
| | - Ann M Moyer
- Pharmacogenomics (PGx) Working Group of the Clinical Practice Committee*, Association for Molecular Pathology (AMP), Rockville, MD; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Stuart A Scott
- Pharmacogenomics (PGx) Working Group of the Clinical Practice Committee*, Association for Molecular Pathology (AMP), Rockville, MD; Department of Pathology, Stanford University, Stanford, CA; Clinical Genomics Laboratory, Stanford Medicine, Palo Alto, CA
| | - Amy J Turner
- Pharmacogenomics (PGx) Working Group of the Clinical Practice Committee*, Association for Molecular Pathology (AMP), Rockville, MD; Department of Pediatrics, Children's Research Institute, The Medical College of Wisconsin, Milwaukee, WI; RPRD Diagnostics LLC, Wauwatosa, WI
| | - Ron H N van Schaik
- Pharmacogenomics (PGx) Working Group of the Clinical Practice Committee*, Association for Molecular Pathology (AMP), Rockville, MD; Department of Clinical Chemistry/International Federation of Clinical Chemistry and Laboratory Medicine Expert Center Pharmacogenetics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Michelle Whirl-Carrillo
- Pharmacogenomics (PGx) Working Group of the Clinical Practice Committee*, Association for Molecular Pathology (AMP), Rockville, MD; Department of Biomedical Data Science, Stanford University, Stanford, CA
| | - Karen E Weck
- Pharmacogenomics (PGx) Working Group of the Clinical Practice Committee*, Association for Molecular Pathology (AMP), Rockville, MD; Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC; Department of Genetics, University of North Carolina, Chapel Hill, NC
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Montella A, Cantalupo S, D’Alterio G, Damiano V, Iolascon A, Capasso M. Improving single nucleotide polymorphisms genotyping accuracy for dihydropyrimidine dehydrogenase testing in pharmacogenetics. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2024; 5:374-383. [PMID: 38745766 PMCID: PMC11090686 DOI: 10.37349/etat.2024.00223] [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: 11/09/2023] [Accepted: 01/01/2024] [Indexed: 05/16/2024] Open
Abstract
Fluoropyrimidines, crucial in cancer treatment, often cause toxicity concerns even at standard doses. Toxic accumulation of fluoropyrimidine metabolites, culminating in adverse effects, can stem from impaired dihydropyrimidine dehydrogenase (DPYD) enzymatic function. Emerging evidence underscores the role of single nucleotide polymorphisms (SNPs) in DPYD gene, capable of inducing DPYD activity deficiency. Consequently, DPYD genotyping's importance is on the rise in clinical practice before initiating fluoropyrimidine treatment. Although polymerase chain reaction (PCR) followed by Sanger sequencing (SS; PCR-SS) is a prevalent method for DPYD genotyping, it may encounter limitations. In this context, there is reported a case in which a routine PCR-SS approach for genotyping DPYD SNP rs55886062 failed in a proband of African descent. The Clinical Pharmacogenetics Implementation Consortium (CPIC) categorizes the guanine (G) allele of this SNP as non-functional. The enforcement of whole genome sequencing (WGS) approach led to the identification of two adenine (A) insertions near the PCR primers annealing regions in the proband, responsible for a sequence frameshift and a genotyping error for rs55886062. These SNPs (rs145228578, 1-97981199-T-TA and rs141050810, 1-97981622-G-GA) were extremely rare in non-Finnish Europeans (0.05%) but prevalent in African populations (16%). Although limited evidence was available for these SNPs, they were catalogued as benign variants in public databases. Notably, these two SNPs exhibited a high linkage disequilibrium [LD; squared correlation coefficient (R2) = 0.98]. These findings highlighted the importance to consider the prevalence of genetic variants within diverse ethnic populations when designing primers and probes for SNP genotyping in pharmacogenetic testing. This preventive measure is essential to avoid sequence frameshifts or primer misalignments arising from SNP occurrences in the genome, which can compromise PCR-SS and lead to genotyping failures. Furthermore, this case highlights the significance of exploring alternative genotyping approaches, like WGS, when confronted with challenges associated with conventional techniques.
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Affiliation(s)
- Annalaura Montella
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80131 Naples, Italy
- CEINGE Biotecnologie Avanzate Franco Salvatore, 80145 Naples, Italy
| | - Sueva Cantalupo
- CEINGE Biotecnologie Avanzate Franco Salvatore, 80145 Naples, Italy
| | - Giuseppe D’Alterio
- CEINGE Biotecnologie Avanzate Franco Salvatore, 80145 Naples, Italy
- European School of Molecular Medicine, Università Degli Studi di Milano, 20122 Milan, Italy
| | - Vincenzo Damiano
- Medical Oncology, Integrated Activity Department of Onco-Hematological Diseases, Pathological Anatomy and Rheumatic Diseases, AOU Federico II, 80131 Naples, Italy
| | - Achille Iolascon
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80131 Naples, Italy
- CEINGE Biotecnologie Avanzate Franco Salvatore, 80145 Naples, Italy
| | - Mario Capasso
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80131 Naples, Italy
- CEINGE Biotecnologie Avanzate Franco Salvatore, 80145 Naples, Italy
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Le Teuff G, Cozic N, Boyer JC, Boige V, Diasio RB, Taieb J, Meulendijks D, Palles C, Schwab M, Deenen M, Largiadèr CR, Marinaki A, Jennings BA, Wettergren Y, Di Paolo A, Gross E, Budai B, Ackland SP, van Kuilenburg ABP, McLeod HL, Milano G, Thomas F, Loriot MA, Kerr D, Schellens JHM, Laurent-Puig P, Shi Q, Pignon JP, Etienne-Grimaldi MC. Dihydropyrimidine dehydrogenase gene variants for predicting grade 4-5 fluoropyrimidine-induced toxicity: FUSAFE individual patient data meta-analysis. Br J Cancer 2024; 130:808-818. [PMID: 38225422 PMCID: PMC10912560 DOI: 10.1038/s41416-023-02517-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/30/2023] [Accepted: 11/23/2023] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Dihydropyrimidine dehydrogenase (DPD) deficiency is the main known cause of life-threatening fluoropyrimidine (FP)-induced toxicities. We conducted a meta-analysis on individual patient data to assess the contribution of deleterious DPYD variants *2A/D949V/*13/HapB3 (recommended by EMA) and clinical factors, for predicting G4-5 toxicity. METHODS Study eligibility criteria included recruitment of Caucasian patients without DPD-based FP-dose adjustment. Main endpoint was 12-week haematological or digestive G4-5 toxicity. The value of DPYD variants *2A/p.D949V/*13 merged, HapB3, and MIR27A rs895819 was evaluated using multivariable logistic models (AUC). RESULTS Among 25 eligible studies, complete clinical variables and primary endpoint were available in 15 studies (8733 patients). Twelve-week G4-5 toxicity prevalence was 7.3% (641 events). The clinical model included age, sex, body mass index, schedule of FP-administration, concomitant anticancer drugs. Adding *2A/p.D949V/*13 variants (at least one allele, prevalence 2.2%, OR 9.5 [95%CI 6.7-13.5]) significantly improved the model (p < 0.0001). The addition of HapB3 (prevalence 4.0%, 98.6% heterozygous), in spite of significant association with toxicity (OR 1.8 [95%CI 1.2-2.7]), did not improve the model. MIR27A rs895819 was not associated with toxicity, irrespective of DPYD variants. CONCLUSIONS FUSAFE meta-analysis highlights the major relevance of DPYD *2A/p.D949V/*13 combined with clinical variables to identify patients at risk of very severe FP-related toxicity.
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Affiliation(s)
- Gwénaël Le Teuff
- Service de Biostatistique et d'Epidémiologie, Gustave Roussy, Oncostat U1018 INSERM, labeled Ligue Contre le Cancer, Université Paris-Saclay, Villejuif, France.
| | - Nathalie Cozic
- Service de Biostatistique et d'Epidémiologie, Gustave Roussy, Oncostat U1018 INSERM, labeled Ligue Contre le Cancer, Université Paris-Saclay, Villejuif, France
| | | | - Valérie Boige
- Department of cancer medicine, Gustave-Roussy Cancer Campus, Paris-Saclay and Paris-Sud Universities, Villejuif, France
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Equipe Labellisée Ligue Nationale Contre le Cancer, CNRS SNC, 5096, Paris, France
| | - Robert B Diasio
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Cancer Center, Rochester, MN, USA
| | - Julien Taieb
- Université Paris-Cité, SIRIC CARPEM, Department of Gastroenterology and Digestive Oncology, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - Didier Meulendijks
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Claire Palles
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany
- Departments of Clinical Pharmacology, and of Biochemistry and Pharmacy, University of Tuebingen, Tuebingen, Germany
- Cluster of Excellence IFIT (EXC 2180) "Image-Guided and Functionally Instructed Tumor Therapies", University of Tübingen, 72074, Tübingen, Germany
| | - Maarten Deenen
- Department of Clinical Pharmacy, Catharina Hospital, Eindhoven, the Netherlands
| | - Carlo R Largiadèr
- Department of Clinical Chemistry, Bern University Hospital, University of Bern, Inselspital, Bern, Switzerland
| | | | | | | | - Antonello Di Paolo
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Eva Gross
- LMU Munich, University Hospital, Campus Grosshadern, Munich, Germany
| | - Barna Budai
- National Institute of Oncology, Budapest, Hungary
| | - Stephen P Ackland
- College of Heath, Medicine and Wellbeing, University of Newcastle, Newcastle, NSW, Australia
| | - André B P van Kuilenburg
- Amsterdam UMC, location University of Amsterdam, Laboratory Genetic Metabolic Diseases, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Imaging and biomarkers, Amsterdam, The Netherlands
| | - Howard L McLeod
- Intermountain Precision Genomics, Intermountain Healthcare, St George, UT, USA
| | - Gérard Milano
- Oncopharmacology Laboratory, Centre Antoine Lacassagne, Nice, France
| | - Fabienne Thomas
- Institut Claudius Regaud, IUCT-Oncopôle and CRCT, University of Toulouse, Inserm, Toulouse, France
| | - Marie-Anne Loriot
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Equipe Labellisée Ligue Nationale Contre le Cancer, CNRS SNC, 5096, Paris, France
- Hôpital Européen Georges Pompidou, Hôpitaux Universitaires Paris Ouest, Paris, France
| | - David Kerr
- Nuffield Division of Clinical and Laboratory Sciences and University of Oxford, Oxford, UK
| | - Jan H M Schellens
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Pierre Laurent-Puig
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Equipe Labellisée Ligue Nationale Contre le Cancer, CNRS SNC, 5096, Paris, France
- Hôpital Européen Georges Pompidou, Hôpitaux Universitaires Paris Ouest, Paris, France
| | - Qian Shi
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Jean-Pierre Pignon
- Service de Biostatistique et d'Epidémiologie, Gustave Roussy, Oncostat U1018 INSERM, labeled Ligue Contre le Cancer, Université Paris-Saclay, Villejuif, France
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Pinheiro M, Peixoto A, Rocha P, Santos C, Escudeiro C, Veiga I, Porto M, Guerra J, Barbosa A, Pinto C, Arinto P, Resende A, Teixeira MR. Implementation of upfront DPYD genotyping with a low-cost and high-throughput assay to guide fluoropyrimidine treatment in cancer patients. Pharmacogenet Genomics 2023; 33:165-171. [PMID: 37611150 DOI: 10.1097/fpc.0000000000000505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
OBJECTIVES Genetic variants in the dihydropyrimidine dehydrogenase (DPYD ) gene are associated with reduced dihydropyrimidine dehydrogenase enzyme activity and can cause severe fluoropyrimidine-related toxicity. We assessed the frequency of the four most common and well-established DPYD variants associated with fluoropyrimidine toxicity and implemented a relatively low-cost and high-throughput genotyping assay for their detection. METHODS This study includes 457 patients that were genotyped for the DPYD c.1129-5923C>G, c.1679T>G, c.1905 + 1G>A and c.2846A>T variants, either by Sanger sequencing or kompetitive allele specific PCR (KASP) technology. Of these, 172 patients presented toxicity during treatment with fluoropyrimidines (post-treatment group), and 285 were tested before treatment (pretreatment group). RESULTS Heterozygous DPYD variants were identified in 7.4% of the entire series of 457 patients, being the c.2846A>T the most frequent variant. In the post-treatment group, 15.7% of the patients presented DPYD variants, whereas only 2.5% of the patients in the pretreatment group presented a variant. The KASP assays designed in this study presented 100% genotype concordance with the results obtained by Sanger sequencing. CONCLUSIONS The combined assessment of the four DPYD variants in our population increases the identification of patients at high risk for developing fluoropyrimidine toxicity, supporting the upfront routine implementation of DPYD variant genotyping. Furthermore, the KASP genotyping assay described in this study presents a rapid turnaround time and relatively low cost, making upfront DPYD screening feasible in clinical practice.
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Affiliation(s)
- Manuela Pinheiro
- Cancer Genetics Group, Research Center of IPO Porto (CI-IPOP)/RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center
| | - Ana Peixoto
- Cancer Genetics Group, Research Center of IPO Porto (CI-IPOP)/RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center
- Department of Laboratory Genetics, Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center, Porto, Portugal
| | - Patrícia Rocha
- Cancer Genetics Group, Research Center of IPO Porto (CI-IPOP)/RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center
- Department of Laboratory Genetics, Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center, Porto, Portugal
| | - Catarina Santos
- Cancer Genetics Group, Research Center of IPO Porto (CI-IPOP)/RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center
- Department of Laboratory Genetics, Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center, Porto, Portugal
| | - Carla Escudeiro
- Cancer Genetics Group, Research Center of IPO Porto (CI-IPOP)/RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center
- Department of Laboratory Genetics, Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center, Porto, Portugal
| | - Isabel Veiga
- Cancer Genetics Group, Research Center of IPO Porto (CI-IPOP)/RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center
- Department of Laboratory Genetics, Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center, Porto, Portugal
| | - Miguel Porto
- Cancer Genetics Group, Research Center of IPO Porto (CI-IPOP)/RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center
| | - Joana Guerra
- Cancer Genetics Group, Research Center of IPO Porto (CI-IPOP)/RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center
| | - Ana Barbosa
- Cancer Genetics Group, Research Center of IPO Porto (CI-IPOP)/RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center
- Department of Laboratory Genetics, Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center, Porto, Portugal
| | - Carla Pinto
- Cancer Genetics Group, Research Center of IPO Porto (CI-IPOP)/RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center
- Department of Laboratory Genetics, Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center, Porto, Portugal
| | - Patrícia Arinto
- Cancer Genetics Group, Research Center of IPO Porto (CI-IPOP)/RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center
| | - Adriana Resende
- Cancer Genetics Group, Research Center of IPO Porto (CI-IPOP)/RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center
| | - Manuel R Teixeira
- Cancer Genetics Group, Research Center of IPO Porto (CI-IPOP)/RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center
- Department of Laboratory Genetics, Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center, Porto, Portugal
- School of Medicine and Biomedical Sciences (ICBAS), University of Porto, Porto, Portugal
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Ockeloen CW, Raaijmakers A, Hijmans-van der Vegt M, Bierau J, de Vos-Geelen J, Willemsen AE, van den Bosch BJ, Coenen MJ. Potential added value of combined DPYD/DPD genotyping and phenotyping to prevent severe toxicity in patients with a DPYD variant and decreased dihydropyrimidine dehydrogenase enzyme activity. J Oncol Pharm Pract 2023; 29:5-13. [PMID: 34797200 DOI: 10.1177/10781552211049144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate if dihydropyrimidine dehydrogenase phenotyping has added value when combined with DPYD genotyping in predicting fluoropyrimidine-related toxicity. METHODS Retrospective cohort study in which treatment and toxicity data were collected of 228 patients genotyped for four DPYD variants and phenotyped using an ex vivo peripheral blood mononuclear cell assay. RESULTS Severe toxicity occurred in 25% of patients with a variant and normal dihydropyrimidine dehydrogenase activity, in 21% of patients without a variant and with decreased dihydropyrimidine dehydrogenase activity, and in 29% of patients without a variant and with normal dihydropyrimidine dehydrogenase activity (controls). The majority of patients with a variant or a decreased dihydropyrimidine dehydrogenase activity received an initial dose reduction (68% and 53% vs 19% in controls) and had a lower mean dose intensity (75% and 81% vs 91% in controls). Fifty percent of patients with a variant and decreased enzyme activity experienced severe toxicity, despite the lowest initial dose and whole treatment dose intensity. They also experienced more grade 4/5 toxicities. CONCLUSIONS Our results indicate that a combined genotype-phenotype approach could be useful to identify patients at increased risk for fluoropyrimidine-associated toxicity (e.g. patients with a variant and decreased dihydropyrimidine dehydrogenase activity). Because the group sizes are too small to demonstrate statistically significant differences, this warrants further research in a prospective study in a larger cohort.
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Affiliation(s)
- Charlotte W Ockeloen
- Department of Human Genetics, 6034Radboud University Medical Center, The Netherlands
| | | | | | - Jörgen Bierau
- Department of Clinical Genetics, Erasmus Medical Centre, Rotterdam, The Netherlands.,Department of Clinical Genetics, 199236Maastricht University Medical Center+, The Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, 199236Maastricht University Medical Center+, The Netherlands
| | | | | | - Marieke Jh Coenen
- Department of Human Genetics, 6034Radboud University Medical Center, Radboud Institute for Health Sciences, The Netherlands
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6
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Casneuf V, Borbath I, Van den Eynde M, Verheezen Y, Demey W, Verstraete AG, Bm Claes K, Haufroid V, Geboes KP. Joint Belgian recommendation on screening for DPD-deficiency in patients treated with 5-FU, capecitabine (and tegafur). Acta Clin Belg 2022; 77:346-352. [PMID: 33423619 DOI: 10.1080/17843286.2020.1870855] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Fluoropyrimidines such as 5-Fluorouracil (5-FU), capecitabine and tegafur are drugs that are often used in the treatment of maliginancies. The enzyme dihydropyrimidine dehydrogenase (DPD) is the first and rate limiting enzyme of 5-FU catabolism. Genetic variations within the DPYD gene (encoding for DPD protein) can lead to reduced or absent DPD activity. Treatment of DPD deficient patients with fluoropyrimidines can result in severe and, rarely, fatal toxicity. Screening for DPD deficiency should be implemented in practice. METHODS The available methods in routine to screen for DPD deficiency were analyzed and discussed in several group meetings involving members of the oncological, genetic and toxicological societies in Belgium: targeted genotyping based on the detection of 4 DPYD variants and phenotyping, through the measurement of uracil and dihydrouracil/uracil ratio in plasma samples. RESULTS The main advantage of targeted genotyping is the existence of prospectively validated genotype-based dosing guidelines. The main limitations of this approach are the relatively low sensitivity to detect total and partial DPD deficiency and the fact that this approach has only been validated in Caucasians so far. Phenotyping has a better sensitivity to detect total and partial DPD deficiency when performed in the correct analytical conditions and is not dependent on the ethnic origin of the patient. CONCLUSION In Belgium, we recommend phenotype or targeted genotype testing for DPD deficiency before starting 5-FU, capecitabine or tegafur. We strongly suggest a stepwise approach using phenotype testing upfront because of the higher sensitivity and the lower cost to society.
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Affiliation(s)
- Veerle Casneuf
- Department of Gastroenterology, OLV Aalst, Aalst, Belgium
| | - Ivan Borbath
- Department of Hepatology and Gastroenterology, University Hospital St Luc/UCLouvain, Woluwe
| | | | | | - Wim Demey
- Department of Oncology, AZ Klina, Brasschaat Belgium
| | | | | | - Vincent Haufroid
- Department of Toxicology and Applied Pharmacology, University Hospital St Luc/UCLouvain, Woluwe
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White C, Scott RJ, Paul C, Ziolkowski A, Mossman D, Ackland S. Ethnic Diversity of DPD Activity and the DPYD Gene: Review of the Literature. Pharmgenomics Pers Med 2021; 14:1603-1617. [PMID: 34916829 PMCID: PMC8668257 DOI: 10.2147/pgpm.s337147] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/10/2021] [Indexed: 12/31/2022] Open
Abstract
Pharmacogenomic screening can identify patients with gene variants that predispose them to the development of severe toxicity from fluoropyrimidine (FP) chemotherapy. Deficiency of the critical metabolic enzyme dihydropyrimidine dehydrogenase (DPD) leads to excessive toxicity on exposure to fluoropyrimidine chemotherapy. This can result in hospitalisation, intensive care admissions and even death. Upfront screening of the gene that encodes for DPD (DPYD) has recently been implemented in regions throughout Europe and the United Kingdom. Current screening evaluates DPYD variants that are well described within Caucasian patient populations and provides genotyped-guided dose adjustment recommendations based upon the presence of these variants. This article reviews the differences in DPYD gene variants within non-Caucasian populations compared to Caucasian populations, with regard to the implications for clinical tolerance of fluoropyrimidine chemotherapies and genotype guided dose adjustment guidelines.
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Affiliation(s)
- Cassandra White
- University of Newcastle, Newcastle, NSW, Australia.,Hunter Cancer Research Alliance, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Rodney J Scott
- University of Newcastle, Newcastle, NSW, Australia.,Hunter Cancer Research Alliance, Hunter Medical Research Institute, Newcastle, NSW, Australia.,Division of Molecular Medicine, Pathology North John Hunter Hospital, Newcastle, NSW, Australia
| | - Christine Paul
- University of Newcastle, Newcastle, NSW, Australia.,Hunter Cancer Research Alliance, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Andrew Ziolkowski
- Division of Molecular Medicine, Pathology North John Hunter Hospital, Newcastle, NSW, Australia
| | - David Mossman
- Division of Molecular Medicine, Pathology North John Hunter Hospital, Newcastle, NSW, Australia
| | - Stephen Ackland
- University of Newcastle, Newcastle, NSW, Australia.,Hunter Cancer Research Alliance, Hunter Medical Research Institute, Newcastle, NSW, Australia.,Hunter Cancer Centre, Lake Macquarie Private Hospital, Gateshead, NSW, Australia
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Kang J, Kim AH, Jeon I, Oh J, Jang IJ, Lee S, Cho JY. Endogenous metabolic markers for predicting the activity of dihydropyrimidine dehydrogenase. Clin Transl Sci 2021; 15:1104-1111. [PMID: 34863048 PMCID: PMC9099117 DOI: 10.1111/cts.13203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/09/2021] [Accepted: 11/02/2021] [Indexed: 12/01/2022] Open
Abstract
Five‐fluorouracil (5‐FU) is a chemotherapeutic agent that is mainly metabolized by the rate‐limiting enzyme dihydropyrimidine dehydrogenase (DPD). The DPD enzyme activity deficiency involves a wide range of severities. Previous studies have demonstrated the effect of a DPYD single nucleotide polymorphism on 5‐FU efficacy and highlighted the importance of studying such genes for cancer treatment. Common polymorphisms of DPYD in European ancestry populations are less frequently present in Koreans. DPD is also responsible for the conversion of endogenous uracil (U) into dihydrouracil (DHU). We quantified U and DHU in plasma samples of healthy male Korean subjects, and samples were classified into two groups based on DHU/U ratio. The calculated DHU/U ratios ranged from 0.52 to 7.12, and the two groups were classified into the 10th percentile and 90th percentile for untargeted metabolomics analysis using liquid chromatography‐quantitative time‐of‐flight‐mass spectrometry. A total of 4440 compounds were detected and filtered out based on a coefficient of variation below 30%. Our results revealed that six metabolites differed significantly between the high activity group and low activity group (false discovery rate q‐value < 0.05). Uridine was significantly higher in the low DPD activity group and is a precursor of U involved in pyrimidine metabolism; therefore, we speculated that DPD deficiency can influence uridine levels in plasma. Furthermore, the cutoff values for detecting DPD deficient patients from previous studies were unsuitable for Koreans. Our metabolomics approach is the first study that reported the DHU/U ratio distribution in healthy Korean subjects and identified a new biomarker of DPD deficiency.
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Affiliation(s)
- Jihyun Kang
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea.,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea
| | - Andrew HyoungJin Kim
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Inseung Jeon
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Jaeseong Oh
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - In-Jin Jang
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - SeungHwan Lee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Joo-Youn Cho
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea.,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea
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Conti V, De Bellis E, Manzo V, Sabbatino F, Iannello F, Dal Piaz F, Izzo V, Charlier B, Stefanelli B, Torsiello M, Iannaccone T, Coglianese A, Colucci F, Pepe S, Filippelli A. A Genotyping/Phenotyping Approach with Careful Clinical Monitoring to Manage the Fluoropyrimidines-Based Therapy: Clinical Cases and Systematic Review of the Literature. J Pers Med 2020; 10:jpm10030113. [PMID: 32899374 PMCID: PMC7564232 DOI: 10.3390/jpm10030113] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 12/27/2022] Open
Abstract
Fluoropyrimidines (FP) are mainly metabolised by dihydropyrimidine dehydrogenase (DPD), encoded by the DPYD gene. FP pharmacogenetics, including four DPYD polymorphisms (DPYD-PGx), is recommended to tailor the FP-based chemotherapy. These polymorphisms increase the risk of severe toxicity; thus, the DPYD-PGx should be performed prior to starting FP. Other factors influence FP safety, therefore phenotyping methods, such as the measurement of 5-fluorouracil (5-FU) clearance and DPD activity, could complement the DPYD-PGx. We describe a case series of patients in whom we performed DPYD-PGx (by real-time PCR), 5-FU clearance and a dihydrouracil/uracil ratio (as the phenotyping analysis) and a continuous clinical monitoring. Patients who had already experienced severe toxicity were then identified as carriers of DPYD variants. The plasmatic dihydrouracil/uracil ratio (by high-performance liquid chromatography (HPLC)) ranged between 1.77 and 7.38. 5-FU clearance (by ultra-HPLC with tandem mass spectrometry) was measured in 3/11 patients. In one of them, it reduced after the 5-FU dosage was halved; in the other case, it remained high despite a drastic dosage reduction. Moreover, we performed a systematic review on genotyping/phenotyping combinations used as predictive factors of FP safety. Measuring the plasmatic 5-FU clearance and/or dihydrouracil/uracil (UH2/U) ratio could improve the predictive potential of DPYD-PGx. The upfront DPYD-PGx combined with clinical monitoring and feasible phenotyping method is essential to optimising FP-based chemotherapy.
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Affiliation(s)
- Valeria Conti
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (V.C.); (F.S.); (F.D.P.); (V.I.); (B.C.); (T.I.); (A.C.); (S.P.); (A.F.)
- Clinical Pharmacology and Pharmacogenetics Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
| | - Emanuela De Bellis
- Postgraduate School in Clinical Pharmacology and Toxicology, University of Salerno, 84081 Baronissi, Italy; (E.D.B.); (B.S.); (M.T.); (F.C.)
| | - Valentina Manzo
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (V.C.); (F.S.); (F.D.P.); (V.I.); (B.C.); (T.I.); (A.C.); (S.P.); (A.F.)
- Clinical Pharmacology and Pharmacogenetics Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
- Postgraduate School in Clinical Pharmacology and Toxicology, University of Salerno, 84081 Baronissi, Italy; (E.D.B.); (B.S.); (M.T.); (F.C.)
- Correspondence: ; Tel.: +39-089-672-424
| | - Francesco Sabbatino
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (V.C.); (F.S.); (F.D.P.); (V.I.); (B.C.); (T.I.); (A.C.); (S.P.); (A.F.)
- Oncology Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
| | - Francesco Iannello
- Postgraduate School in Clinical Pharmacology and Toxicology, University of Campania “L. Vanvitelli”, 80138 Naples, Italy;
| | - Fabrizio Dal Piaz
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (V.C.); (F.S.); (F.D.P.); (V.I.); (B.C.); (T.I.); (A.C.); (S.P.); (A.F.)
- Clinical Pharmacology and Pharmacogenetics Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
| | - Viviana Izzo
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (V.C.); (F.S.); (F.D.P.); (V.I.); (B.C.); (T.I.); (A.C.); (S.P.); (A.F.)
- Clinical Pharmacology and Pharmacogenetics Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
| | - Bruno Charlier
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (V.C.); (F.S.); (F.D.P.); (V.I.); (B.C.); (T.I.); (A.C.); (S.P.); (A.F.)
- Clinical Pharmacology and Pharmacogenetics Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
| | - Berenice Stefanelli
- Postgraduate School in Clinical Pharmacology and Toxicology, University of Salerno, 84081 Baronissi, Italy; (E.D.B.); (B.S.); (M.T.); (F.C.)
| | - Martina Torsiello
- Postgraduate School in Clinical Pharmacology and Toxicology, University of Salerno, 84081 Baronissi, Italy; (E.D.B.); (B.S.); (M.T.); (F.C.)
| | - Teresa Iannaccone
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (V.C.); (F.S.); (F.D.P.); (V.I.); (B.C.); (T.I.); (A.C.); (S.P.); (A.F.)
| | - Albino Coglianese
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (V.C.); (F.S.); (F.D.P.); (V.I.); (B.C.); (T.I.); (A.C.); (S.P.); (A.F.)
| | - Francesca Colucci
- Postgraduate School in Clinical Pharmacology and Toxicology, University of Salerno, 84081 Baronissi, Italy; (E.D.B.); (B.S.); (M.T.); (F.C.)
| | - Stefano Pepe
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (V.C.); (F.S.); (F.D.P.); (V.I.); (B.C.); (T.I.); (A.C.); (S.P.); (A.F.)
- Oncology Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (V.C.); (F.S.); (F.D.P.); (V.I.); (B.C.); (T.I.); (A.C.); (S.P.); (A.F.)
- Clinical Pharmacology and Pharmacogenetics Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
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DPYD and Fluorouracil-Based Chemotherapy: Mini Review and Case Report. Pharmaceutics 2019; 11:pharmaceutics11050199. [PMID: 31052357 PMCID: PMC6572291 DOI: 10.3390/pharmaceutics11050199] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 12/13/2022] Open
Abstract
5-Fluorouracil remains a foundational component of chemotherapy for solid tumour malignancies. While considered a generally safe and effective chemotherapeutic, 5-fluorouracil has demonstrated severe adverse event rates of up to 30%. Understanding the pharmacokinetics of 5-fluorouracil can improve the precision medicine approaches to this therapy. A single enzyme, dihydropyrimidine dehydrogenase (DPD), mediates 80% of 5-fluorouracil elimination, through hepatic metabolism. Importantly, it has been known for over 30-years that adverse events during 5-fluorouracil therapy are linked to high systemic exposure, and to those patients who exhibit DPD deficiency. To date, pre-treatment screening for DPD deficiency in patients with planned 5-fluorouracil-based therapy is not a standard of care. Here we provide a focused review of 5-fluorouracil metabolism, and the efforts to improve predictive dosing through screening for DPD deficiency. We also outline the history of key discoveries relating to DPD deficiency and include relevant information on the potential benefit of therapeutic drug monitoring of 5-fluorouracil. Finally, we present a brief case report that highlights a limitation of pharmacogenetics, where we carried out therapeutic drug monitoring of 5-fluorouracil in an orthotopic liver transplant recipient. This case supports the development of robust multimodality precision medicine services, capable of accommodating complex clinical dilemmas.
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