Pharmacokinetics of carboplatin and etoposide in a haemodialysis patient with Merkel-cell carcinoma

IgA nephropathy: an overview of drug treatments in clinical trials

INTRODUCTION

IgA nephropathy (IgAN) is the commonest primary glomerulonephritis worldwide and may progress to end-stage kidney disease (ESKD) within a 10-20 year period. Its slowly progressive course has made clinical trials challenging to perform, however the acceptance of proteinuria reduction as a surrogate end point has significantly improved the feasibility of conducting clinical trials in IgAN, with several novel and repurposed therapies currently undergoing assessment. Already, interim results are demonstrating value to some of these, offering great hope to those with IgAN.

AREAS COVERED

This review explores the rationale, candidates, clinical precedents, and trial status of therapies that are currently or have recently been evaluated for efficacy in IgAN. All IgAN trials registered with the U.S. National Library of Medicine; ClinicalTrials.gov were reviewed.

EXPERT OPINION

For the first time, effective treatment options beyond supportive care are becoming available for those with IgAN. This is the culmination of commendable international efforts and signifies a new era for those with IgAN. As more therapies become available, future challenges will revolve around deciding which treatments are most appropriate for individual patients, which is likely to push IgAN into the realm of precision medicine.

Decreased Disposition of Anticancer Drugs Predominantly Eliminated via the Liver in Patients with Renal Failure

Background:

Evidence has revealed that renal impairment can affect the systemic exposure of drugs which are predominantly eliminated via the liver. The modulation of drug-metabolizing enzymes and transporters expressed in the liver and/or small intestine by diverse entities, including uremic toxins, in systemic circulation of patients with severe renal failure is considered as the cause of atypical pharmacokinetics, which sometimes induce undesirable adverse events that are especially critical for drugs with narrow therapeutic window such as anticancer drugs. A dosing strategy for anticancer drugs in these patients needs to be established.

Methods:

The effects of renal impairment on the systemic exposure and safety of anticancer drugs were summarized. The proposed mechanisms for the alterations in the pharmacokinetics of these anticancer drugs were also discussed.

Results:

Changes in pharmacokinetics and clinical response were reported in 9 out of 10 cytotoxic anticancer drugs investigated, although available information was limited and sometimes controversial. Systemic exposure of 3 out of 16 tyrosine kinase inhibitors was higher in patients with severe renal failure than that in patients with normal kidney function. An increase in systemic exposure of anticancer drugs in patients with renal impairment is likely to be observed for substrates of OATP1B1, despite the limited evidence.

Conclusion:

The molecular basis for the effect of uremia on non-renal drug elimination still needed to be clarified with further studies to generate generalizable concepts, which may provide insights into establishing better clinical usage of anticancer drugs, i.e. identifying patients at risk and dose adjustment.

Investigation of tolerability and quality of life for carboplatin-based chemotherapy in an elderly urothelial carcinoma patient undergoing hemodialysis: a case report

BACKGROUND

To our knowledge, no studies have evaluated the safety of carboplatin (CBDCA)-based chemotherapy in hemodialysis patients > 80 years-old. In addition, the impact of CBDCA-based chemotherapy on such elderly patients' quality of life (QOL) is unknown. We report a case of gemcitabine plus CBDCA chemotherapy treatment in an 81-year-old man with metastatic urothelial carcinoma undergoing hemodialysis.

CASE PRESENTATION

The optimal CBDCA dose and hemodialysis timing were determined by monitoring the measured area under the concentration-time curve (AUC) of CBDCA. This was used because the AUC of CBDCA is correlated with hematologic toxicities, especially nadir thrombocytopenia, and CBDCA is easily dialyzed during hemodialysis. In the first cycle, a 160 mg CBDCA dose, calculated using Calvert's formula (target-AUC: 5), was administered on day 1. Hemodialysis was performed for 3 h, starting 2 h after the end of the CBDCA infusion. The measured-AUC was 5.96 mg/mL min in the first cycle, after which the patient developed grade 3/4 hematologic toxicities. Thus, in the second cycle, the CBDCA dose was reduced to 135 mg and the time interval between CBDCA infusion and hemodialysis was shortened to 1 h, according to the results of a pharmacokinetic study performed using parameters from the first cycle. The measured-AUC in the second cycle was 4.97 mg/mL min, and hematologic toxic effects decreased to grade 2. Stable disease according to the Response Evaluation Criteria in Solid Tumors was demonstrated after the second and third cycles. QOL scores determined using a short-form questionnaire (SF-36) after 2 cycles were not significantly lower than pretreatment values.

CONCLUSIONS

CBDCA-based chemotherapy is clinically acceptable in hemodialysis patients aged > 80 years, and this systemic chemotherapy can be a treatment option in such elderly patients undergoing hemodialysis. However, the measured-AUC should be monitored, as the actual AUC is unpredictable in hemodialysis patients. This is due to the influence of various factors that may be different for each patient, such as the patient's residual renal function and hemodialysis duration and conditions, especially in elderly patients, who have a higher risk of chemotherapy-induced neutropenia.

Pharmacokinetic analyses of carboplatin in a patient with cancer of the fallopian tubes undergoing hemodialysis: A case report

Opportunities for patients undergoing hemodialysis to receive chemotherapy are increasing. A combination of paclitaxel and carboplatin (TC) is first-line chemotherapy in patients with Müllerian cancer. However, the optimal dose and time interval between the end of carboplatin administration and initiation of hemodialysis remains to be elucidated. TC was administered to a patient with fallopian tube cancer undergoing hemodialysis. The paclitaxel regimen was determined to be 135 mg/m² (total of 210 mg) over 3 h. After paclitaxel administration, 125 mg of carboplatin was administered over 1 h to achieve a target area under the concentration-time curve (AUC) of 5.0 mg•min/ml using the Calvert formula. The time interval between the end of carboplatin administration and hemodialysis initiation was 1 h at the first cycle, 16 h at the second cycle and 20 h at the third cycle, and the AUC obtained was 2.86, 4.16 and 6.0 mg•min/ml, respectively. The desired AUC of free platinum was demonstrated and only mild side effects were observed at the third cycle. Therefore, hemodialysis was initiated 20 h after completion of carboplatin infusion at cycles 4-6. The total chemotherapy planned was completed without severe adverse events. Measurement of the concentration of free platinum subsequent to administration is useful for determination of the optimal dose of carboplatin and time interval following administration to obtain an adequate AUC. The present study suggests that carboplatin can be administered to a patient undergoing hemodialysis, and that an adequate interval between the end of carboplatin administration and hemodialysis initiation may be ~20 h.

Carboplatin pharmacokinetics in a patient receiving hemodialysis

With refinements and advances in hemodialysis techniques, survival for patients with end-stage renal disease has improved significantly. To our knowledge, however, no prospective trials have been performed in patients receiving hemodialysis who are also diagnosed with cancer and are candidates for chemotherapy. We describe a 73-year-old man who was diagnosed with high-grade neuroendocrine carcinoma, metastatic to the bone and lymph nodes, and was undergoing hemodialysis. Although cisplatin is more commonly used in the treatment of metastatic neuroendocrine cancers, it may not be the best option in patients who suffer from renal insufficiency. Carboplatin is a second-generation, nonnephrotoxic platinum analog that can be hemodialyzed, although no formal guidelines are available regarding the dosing for patients receiving hemodialysis. This case describes a patient who was treated with five cycles of combination carboplatin 115 mg/m(2) on day 1 and etoposide 50 mg/m(2) on day 1 and day 3 of a 28-day cycle. Dialysis was performed for 3.5 hours starting 90 minutes after completion of carboplatin on day 1. Pharmacokinetic assessments were performed at 1, 2, 4, and 12 hours after chemotherapy infusion on day 1 of cycle 1. Total carboplatin concentrations in plasma and platinum ultrafiltrate were measured. The plasma concentration of free platinum at the end of the infusion was 31,000 ng/ml, and the area under the plasma concentration-time curve was 2.9 minute·mg/ml. No significant carboplatin-related toxicities were reported. This case report indicates that carboplatin can be safely administered in patients receiving hemodialysis.

Successful treatment of mediastinal seminoma in a hemodialysis patient

BACKGROUND

Extragonadal germ cell tumors (GCTs) are relatively uncommon neoplasms, affecting primarily men during the third and fourth decades of life.

CASE REPORT

We describe an unusual case of mediastinal seminoma in a 21-year-old male on chronic peritoneal dialysis for renal failure of uncertain etiology. The patient was treated with chemotherapy consisting of etoposide and cisplatin (EP) combined with hemodialysis. Cisplatin (20 mg/m(2)), and etoposide (50 mg/m(2)) were given on days 1, 3, and 5 for induction. Hemodialysis was started 1 h after completion of etoposide infusion. Following this course of treatment, another 4 cycles of cisplatin (20 mg/m(2)), and etoposide (50 mg/m(2)) were given on successive days from day 1 to 5. Hemodialysis was carried out daily, prior to the start of chemotherapy. Subcutaneous PEG-filgrastim was given on day 6 in all cycles. The patient's status after the first post-induction treatment was complicated by a pseudomonas infection. Tumor response to chemotherapy was prompt with remission lasting to date, 17 months after diagnosis.

CONCLUSION

This case report is the second description of chemotherapy given to a hemodialysis patient with extragonadal GCT. We suggest that treatment with EP combined with hemodialysis according to the presented protocol is feasible, and may result in a favorable outcome.

Tumor lysis syndrome in a patient with merkel cell carcinoma and provoked pathologic sequence of acute kidney injury, reduced clearance of carboplatin and fatal pancytopenia

BACKGROUND

Merkel cell carcinoma (MCC) is a rare, highly malignant cancer of the skin primarily affecting the elderly, with a tendency for local recurrence and regional lymph node metastasis. It is very unusual for this kind of tumor to induce clinically apparent tumor lysis syndrome (TLS) which is a consequence of spontaneous cytolysis or massive tumor cell lysis, beginning a few hours after the initiation of treatment.

CASE REPORT

We report here on a patient with metastatic MCC, who developed TLS following combination chemotherapy with carboplatin and etoposide.

CONCLUSION

The evolving acute kidney injury (AKI) provoked a pathologic sequence of reduced renal clearance leading to protracted clearance of carboplatin and subsequent fatal pancytopenia. When AKI occurs in close association with the administration of carboplatin, the institution of rescue hemodialysis is recommended to decrease plasma carboplatin levels and avoid this lethal complication.

Proposal for dosage adjustment and timing of chemotherapy in hemodialyzed patients

BACKGROUND

The increased incidence of malignancies in patients with chronic renal failure has been discussed since the mid-70s. On the other hand, the high frequency of chronic renal insufficiency among cancer patients has been recently assessed in the Insuffisance Rénale et Médicaments Anticancéreux Study which demonstrated a prevalence as high as 50%-60% of the patients for all stages of kidney disease. Furthermore, the incidence of end-stage renal disease is growing worldwide and so is the number of patients on chronic dialysis, hemodialysis (HD) for the large majority of them. As a result, the question of cytotoxic drug handling in those patients in terms of dosage adjustment and time of administration regarding the dialysis sessions needs to be addressed to optimize cytotoxic drug therapy in those patients.

METHODS

We reviewed the international literature on the pharmacokinetics, efficacy, tolerance and dosage adjustment of cytotoxic drugs used to treat solid tumor patients and when available, specific literature on HD cancer patients.

RESULTS

From these data, dosing recommendations are given for the most prescribed cytotoxic drugs in clinical practice.

CONCLUSIONS

Dosage adjustments are often necessary in HD cancer patients. These adaptations have to be carefully carried out to optimize drug exposure, ensure efficacy and reduce the risk of side-effects.

Continuous ambulatory peritoneal dialysis: pharmacokinetics and clinical outcome of paclitaxel and carboplatin treatment

Purpose

Administration of chemotherapy in patients with renal failure, treated with hemodialysis or continuous ambulatory peritoneal dialysis (CAPD) is still a challenge and literature data is scarce. Here we present a case study of a patient on CAPD, treated with weekly and three-weekly paclitaxel/carboplatin for recurrent ovarian cancer.

Experimental

During the first, second and ninth cycle of treatment, blood, urine and CAPD samples were collected for pharmacokinetic analysis of paclitaxel and total and unbound carboplatin-derived platinum.

Results

Treatment was well tolerated by the patient. No excessive toxicity was observed and at the end of treatment she was in a complete remission. The plasma pharmacokinetics of paclitaxel were unaltered compared to historical data, with neglectable urinary and CAPD clearance. In contrast, the pharmacokinetics of carboplatin were altered, with doubled half-lives compared to patients with normal renal function. Of the administered carboplatin dose, up to 20% was cleared via the dialysate, while only up to 8% was cleared via the urine.

Conclusion

Paclitaxel and carboplatin can be safely administered to patients with chronic renal failure on CAPD. For paclitaxel the generally applied dose can be administered, and although for carboplatin dose-adjustment is required due to the diminished renal function, the dose can be calculated using Calvert’s formula.

Systemic anticancer therapy in gynecological cancer patients with renal dysfunction

Chronic kidney disease is a common occurrence in patients with gynecological cancer. Systemic anticancer treatment in such patients is a challenge for clinicians because of altered drug pharmacokinetics. For those drugs that are excreted mainly by the kidneys, decreased renal function may lead to increased systemic exposure and increased toxicity. Dose adjustment based on pharmacokinetic changes is required in this situation to avoid life-threatening toxicity. In this review, we summarize the nephrotoxicity and pharmacokinetic data of agents commonly used in systemic anticancer treatment of gynecological cancers and dose adjustment guidelines in the presence of impaired renal function. We review 17 medications that need dose adjustment (cisplatin, carboplatin, doxorubicin, epirubicin, cyclophosphamide, ifosfamide, topotecan, irinotecan, etoposide, capecitabine, bleomycin, methotrexate, actinomycin D, granulocyte-macrophage colony-stimulating factor, metoclopramide, cimetidine, and diphenhydramine) as well as 27 drugs that do not (paclitaxel, docetaxel, pegylated liposomal doxorubicin, gemcitabine, oxaliplatin, fluorouracil, vincristine, letrozole, anastrozole, tamoxifen, leuprorelin, megestrol, gefitinib, erlotinib, trastuzumab, leucovorin, granulocyte colony-stimulating factor, erythropoietin, ondansetron, granisetron, palonosetron, tropisetron, dolasetron, aprepitant, dexamethasone, lorazepam, and diazepam). We also review the formulae commonly used to estimate creatinine clearance, including Cockcroft-Gault, Chatelut, Jelliffe, Wright, and the Modification of Diet in Renal Disease study formulae.

International Society of Geriatric Oncology (SIOG) recommendations for the adjustment of dosing in elderly cancer patients with renal insufficiency

A SIOG taskforce was formed to discuss best clinical practice for elderly cancer patients with renal insufficiency. This manuscript outlines recommended dosing adjustments for cancer drugs in this population according to renal function. Dosing adjustments have been made for drugs in current use which have recommendations in renal insufficiency and the elderly, focusing on drugs which are renally eliminated or are known to be nephrotoxic. Recommendations are based on pharmacokinetic and/or pharmacodynamic data where available. The taskforce recommend that before initiating therapy, some form of geriatric assessment should be conducted that includes evaluation of comorbidities and polypharmacy, hydration status and renal function (using available formulae). Within each drug class, it is sensible to use agents which are less likely to be influenced by renal clearance. Pharmacokinetic and pharmacodynamic data of anticancer agents in the elderly are needed in order to maximise efficacy whilst avoiding unacceptable toxicity.

Drug dosing in chronic kidney disease

Patients with chronic kidney disease (CKD) are at high risk for adverse drug reactions and drug-drug interactions. Drug dosing in these patients often proves to be a difficult task. Renal dysfunction-induced changes in human pathophysiology regularly results may alter medication pharmacodynamics and handling. Several pharmacokinetic parameters are adversely affected by CKD, secondary to a reduced oral absorption and glomerular filtration; altered tubular secretion; and reabsorption and changes in intestinal, hepatic, and renal metabolism. In general, drug dosing can be accomplished by multiple methods; however, the most common recommendations are often to reduce the dose or expand the dosing interval, or use both methods simultaneously. Some medications need to be avoided all together in CKD either because of lack of efficacy or increased risk of toxicity. Nevertheless, specific recommendations are available for dosing of certain medications and are an important resource, because most are based on clinical or pharmacokinetic trials.

Effect of haemodialysis on the pharmacokinetics of antineoplastic drugs

Since renal failure itself creates an immunocompromised situation, malignant tumours in haemodialysis patients are increasing due to the prolonged lifespan of these patients. In treating these patients with anticancer agents, dosage reduction is often recommended to avoid adverse drug reactions, particularly for drugs with extensive renal excretion. On the other hand, if an anticancer drug is removed significantly by haemodialysis, dosage increase would be required to ensure adequate therapeutic efficacy. We address in this review the clinical pharmacokinetic aspects of antineoplastic therapy, and the application of pharmacokinetic principles to the adjustment of dosage of anticancer agents in haemodialysis patients.

Pharmacokinetic analysis of combination chemotherapy with carboplatin and etoposide in small-cell lung cancer patients undergoing hemodialysis

BACKGROUND

The aim of this study was to use pharmacokinetic analysis to investigate the efficacy and toxicity of combined chemotherapy with carboplatin (CBDCA) and etoposide (ETP) in small-cell lung cancer (SCLC) patients with chronic renal failure undergoing hemodialysis (HD).

PATIENTS AND METHODS

Three SCLC patients with chronic renal failure undergoing HD were treated with CBDCA (300 mg/m(2)) on day 1 and ETP (50 mg/m(2)) on days 1 and 3, followed by HD 1 h after completing the administration of anticancer agents on each day. The pharmacokinetic analysis of CBDCA and ETP was planned for at least the first two courses of the chemotherapy in each patient.

RESULTS

Two complete responses and one partial response were achieved in the three patients. Two patients experienced grade 3/4 neutropenia and required blood transfusion due to thrombocytopenia and anemia. Non-hematological toxicities were moderate. The pharmacokinetic analysis revealed that the platinum and the ETP concentrations in the plasma were similar to those in patients with normal renal function during the first 24 h, while the platinum still remained in the plasma for over 90 h.

CONCLUSIONS

Chemotherapy with CBDCA (300 mg/m(2) on day 1) and ETP (50 mg/m(2) on day 1, 3) as used in the present study may be a suitable regimen for SCLC patients undergoing HD, although careful attention should be given to hematological toxicities.

Paclitaxel and carboplatin combination chemotherapy in a hemodialysis patient with advanced ovarian cancer

BACKGROUND

There are few reports on the pharmacokinetics of paclitaxel combined with carboplatin or on the dose schedule of carboplatin in combination use during hemodialysis in patients with ovarian cancer.

CASE

A 40-year-old woman with chronic renal failure on hemodialysis who had FIGO stage III ovarian cancer was treated with debulking surgery and carboplatin/paclitaxel combination chemotherapy. Paclitaxal was administered at 150 mg/m(2) as a 3-h intravenous infusion followed by a 30-min infusion of carboplatin on a nondialysis day. The carboplatin dose was chosen to produce a target area under the concentration/time curve (AUC) of 5.0 microg-min/ml according to the Calvert formula. The pharmacokinetic study showed that the AUCs of free platinum and paclitaxel were 4.43 microg-min/ml and 15.9 microg-h/ml, respectively. Dosing of carboplatin based on the AUC produced an acceptable degree of thrombocytopenia and neutropenia. After the completion of five cycles of the combination chemotherapy, the tumor showed complete response, and the patient remained disease free for 8 months.

CONCLUSION

Paclitaxel and carboplatin combination chemotherapy can be given to patients undergoing hemodialysis, with dialysis performed 16 h after the administration and with a dose adjustment of carboplatin to reach a target AUC. In these conditions, tumor response can be obtained.