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Li M, Mindt S, Lück A, Hutzschenreuter U, Kollendt M, Lathan B, Zöller T, Frank-Gleich S, Lorentz C, Lamberti C, Sick C, Zingerle M, Tesch H, Stein W, Hebart H, Stosiek C, Sandner R, Fries S, Burkholder I, Hofheinz RD. Drug monitoring detects under- and overdosing in patients receiving 5-fluorouracil-containing chemotherapy-results of a prospective, multicenter German observational study. ESMO Open 2023; 8:101201. [PMID: 36965262 PMCID: PMC10073640 DOI: 10.1016/j.esmoop.2023.101201] [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: 01/23/2023] [Revised: 02/22/2023] [Accepted: 02/26/2023] [Indexed: 03/27/2023] Open
Abstract
INTRODUCTION Body surface area (BSA)-based dosing of 5-fluorouracil (5-FU) results in marked inter-individual variability in drug levels, whereas determination of plasma 5-FU concentration and area under the curve (AUC) is a more precise dosing method but has not been integrated into clinical routine. We conducted a multicenter, prospective study to study 5-FU AUC distributions and assess clinical factors predicting therapeutic dosing in patients receiving BSA-dosed 5-FU. METHODS Between June 2017 and January 2018, a total of 434 patients receiving continuous, infusional BSA-dosed 5-FU from 37 sites in Germany were included. Plasma 5-FU concentration and AUC were measured in venous blood samples at steady state. The primary objective was to determine 5-FU AUC distributions in relation to the target range, which is defined as 20-30 mg × h/l. The second objective was to explore clinical parameters that correlate with achievement of 5-FU AUC target range. RESULTS The primary tumor was mainly located in the gastrointestinal tract (96.3%), with colorectal cancer being the most common (71.2%) tumor entity. 5-FU was administered as monotherapy (8.1%) or as part of FOLFOX (33.2%), FOLFIRI (26.3%), or other regimens (12.4%). Treatment setting was adjuvant (31.3%) or metastatic (64.5%). The median AUC was 16 mg × h/l. Only 20.3% of patients received 5-FU treatment within the target range, whereas the majority of patients (60.6%) were underdosed and 19.1% of patients were overdosed. In the univariate logistic regression, treatment setting was the only clinical parameter that significantly correlated with achievement of the target range. Patients treated in the metastatic setting had a 2.1 (95% confidence interval 1.186-3.776, P = 0.011) higher odds to reach the target range compared with patients treated in the adjuvant setting. CONCLUSIONS The majority of patients received suboptimal doses of 5-FU using BSA dosing. Therapeutic drug monitoring of 5-FU is an option for optimized individualized cancer therapy and should be integrated into the clinical practice.
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Affiliation(s)
- M Li
- Department of Medicine II, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - S Mindt
- Institut für Labor- und Transfusionsmedizin, Klinikum Passau, Passau, Germany
| | - A Lück
- Facharztpraxis für Hämatologie, Onkologie und Innere Medizin, Rostock, Germany
| | - U Hutzschenreuter
- Hämatologisch-Onkologische Gemeinschaftspraxis Nordhorn, Nordhorn, Germany
| | - M Kollendt
- Praxis am Volkspark, Schwerpunktpraxis für Hämatologie und Onkologie, Berlin, Germany
| | - B Lathan
- Gemeinschaftspraxis für Hämatologie und Onkologie, Dortmund, Germany
| | - T Zöller
- Schwerpunktpraxis für Hämatologie und Internistische Onkologie, Coburg, Germany
| | - S Frank-Gleich
- Gemeinschaftspraxis und Tagesklinik Innere Medizin, Hämatologie, Onkologie, Gastroenterologie, Halle, Germany
| | - C Lorentz
- Onkologische Schwerpunkt-Praxis Worms, Worms, Germany
| | - C Lamberti
- Klinik für Hämatologie und Onkologie, Klinikum Coburg, Coburg, Germany
| | - C Sick
- Gemeinschaftspraxis Onkologie und Infektiologie, Bremen, Germany
| | - M Zingerle
- Hämato-Onkologische überörtliche Gemeinschaftspraxis Pasing und Fürstenfeldbruck, Munich, Germany
| | - H Tesch
- CHOP GmbH Comprehensive Haematology and Oncology Practice, Hämatologisch-Onkologische Gemeinschaftspraxis, Wiesbaden, Germany
| | - W Stein
- Medizinische Klinik, Klinikum Frankfurt (Oder), Frankfurt (Oder), Germany
| | - H Hebart
- Zentrum für Innere Medizin, Kliniken Ostalb, Stauferklinikum, Mutlangen, Germany
| | - C Stosiek
- Gemeinschaftspraxis Dr. med. Alexander Kröber und Dr. med. Catarina Stosiek, Regensburg, Germany
| | - R Sandner
- Passauer onkolologische Praxis Dres, Siegfried D. Prenninger und Reiner Sandner, Passau, Germany
| | - S Fries
- Onkologische Schwerpunktpraxis Bamberg, Bamberg, Germany
| | - I Burkholder
- Department of Nursing and Health, University of Applied Sciences of the Saarland, Saarbrücken, Germany
| | - R-D Hofheinz
- Mannheim Cancer Center, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
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Etienne-Grimaldi MC, Pallet N, Boige V, Ciccolini J, Chouchana L, Barin-Le Guellec C, Zaanan A, Narjoz C, Taieb J, Thomas F, Loriot MA. Current diagnostic and clinical issues of screening for dihydropyrimidine dehydrogenase deficiency. Eur J Cancer 2023; 181:3-17. [PMID: 36621118 DOI: 10.1016/j.ejca.2022.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
Fluoropyrimidine drugs (FP) are the backbone of many chemotherapy protocols for treating solid tumours. The rate-limiting step of fluoropyrimidine catabolism is dihydropyrimidine dehydrogenase (DPD), and deficiency in DPD activity can result in severe and even fatal toxicity. In this review, we survey the evidence-based pharmacogenetics and therapeutic recommendations regarding DPYD (the gene encoding DPD) genotyping and DPD phenotyping to prevent toxicity and optimize dosing adaptation before FP administration. The French experience of mandatory DPD-deficiency screening prior to initiating FP is discussed.
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Affiliation(s)
| | - Nicolas Pallet
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Valérie Boige
- Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France; Department of Cancer Medicine, Institut Gustave Roussy, Villejuif, France
| | - Joseph Ciccolini
- SMARTc, CRCM INSERM U1068, Université Aix-Marseille, Marseille, France; Laboratory of Pharmacokinetics and Toxicology, Hôpital Universitaire La Timone, F-13385 Marseille, France; COMPO, CRCM INSERM U1068-Inria, Université Aix-Marseille, Marseille, France
| | - Laurent Chouchana
- Regional Center of Pharmacovigilance, Department of Pharmacology, Hôpital Cochin, Assistance Publique-Hopitaux de Paris, Université de Paris, Paris, France; French Pharmacovigilance Network, France
| | - Chantal Barin-Le Guellec
- Laboratory of Biochemistry and Molecular Biology, Centre Hospitalo-uinversitaire de Tours, Tours, France; INSERM U1248, IPPRITT, University of Limoges, Limoges, France
| | - Aziz Zaanan
- Department of Gastroenterology and Digestive Oncology, Hôpital Européen Georges Pompidou, Paris University; Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Céline Narjoz
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Julien Taieb
- SIRIC CARPEM, Université de Paris; Fédération Francophone de Cancérologie Digestive (FFCD), Assistance Publique-Hôpitaux de Paris, Department of Gastroenterology and Digestive Oncology, Hôpital Européen Georges Pompidou, Paris, France
| | - Fabienne Thomas
- Laboratory of Pharmacology, Institut Claudius Regaud, IUCT-Oncopole and CRCT, INSERM UMR1037, Université Paul Sabatier, Toulouse, France
| | - Marie-Anne Loriot
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France.
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Schmulenson E, Zimmermann N, Mikus G, Joerger M, Jaehde U. Current status and future outlooks on therapeutic drug monitoring of fluorouracil. Expert Opin Drug Metab Toxicol 2022; 17:1407-1422. [PMID: 35029518 DOI: 10.1080/17425255.2021.2029403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION : Therapeutic drug monitoring (TDM) of the anticancer drug fluorouracil (5FU) as a method to support dose adjustments has been researched and discussed extensively. Despite manifold evidence of the advantages of 5FU-TDM, traditional body surface area (BSA)-guided dosing is still widely applied. AREAS COVERED : This review covers the latest evidence on 5FU-TDM based on a literature search in PubMed between June and September 2021. It particularly highlights new approaches of implementing 5FU-TDM into precision medicine by combining TDM with pharmacogenetic testing and/or pharmacometric models. This review further discusses remaining obstacles in order to incorporate 5FU-TDM into clinical routine. EXPERT OPINION : New data on 5FU-TDM further strengthen the advantages compared to BSA-guided dosing as it is able to reduce pharmacokinetic variability and thereby improve treatment efficacy and safety. Interprofessional collaboration has the potential to overcome the remaining barriers for its implementation. Pre-emptive pharmacogenetic testing followed by 5FU-TDM can further improve 5FU exposure in a substantial proportion of patients. Developing a model framework integrating pharmacokinetics and pharmacodynamics of 5FU will be crucial to fully advance into the precision medicine era. Model applications can potentially support clinicians in dose finding before starting chemotherapy. Additionally, TDM provides further assistance in continuously improving model predictions.
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Affiliation(s)
- Eduard Schmulenson
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany
| | - Nigina Zimmermann
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany.,Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany.,Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Joerger
- Department of Medical Oncology and Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Ulrich Jaehde
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany
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