Severe vascular adverse effects with thrombocytopenia and renal failure following emetogenic chemotherapy and ondansetron

In Vitro Inhibition of Renal OCT2 and MATE1 Secretion by Antiemetic Drugs

The organic cation transporter 2 (OCT2) and multidrug and toxin extrusion protein 1 (MATE1) mediate the renal secretion of drugs. Recent studies suggest that ondansetron, a 5-HT₃ antagonist drug used to prevent nausea and vomiting, can inhibit OCT2- and MATE1-mediated transport. The purpose of this study was to test the ability of five 5-HT₃ antagonist drugs to inhibit the OCT2 and MATE1 transporters. The transport of the OCT2/MATE1 probe substrate ASP⁺ was assessed using two models: (1) HEK293 kidney cells overexpressing human OCT2 or MATE1, and (2) MDCK cells transfected with human OCT2 and MATE1. In HEK293 cells, the inhibition of ASP⁺ uptake by OCT2 listed in order of potency was palonosetron (IC₅₀: 2.6 μM) > ondansetron > granisetron > tropisetron > dolasetron (IC₅₀: 85.4 μM) and the inhibition of ASP⁺ uptake by MATE1 in order of potency was ondansetron (IC₅₀: 0.1 μM) > palonosetron = tropisetron > granisetron > dolasetron (IC₅₀: 27.4 μM). Ondansetron (0.5–20 μM) inhibited the basolateral-to-apical transcellular transport of ASP⁺ up to 64%. Higher concentrations (10 and 20 μM) of palonosetron, tropisetron, and dolasetron similarly reduced the transcellular transport of ASP⁺. In double-transfected OCT2-MATE1 MDCK cells, ondansetron at concentrations of 0.5 and 2.5 μM caused significant intracellular accumulation of ASP⁺. Taken together, these data suggest that 5-HT₃ antagonist drugs may inhibit the renal secretion of cationic drugs by interfering with OCT2 and/or MATE1 function.

The Role of Transporters in the Toxicity of Chemotherapeutic Drugs: Focus on Transporters for Organic Cations

The introduction of chemotherapy in the treatment of cancer is one of the most important achievements of modern medicine, even allowing the cure of some lethal diseases such as testicular cancer and other malignant neoplasms. The number and type of chemotherapeutic agents available have steadily increased and have developed until the introduction of targeted tumor therapy. It is now evident that transporters play an important role for determining toxicity of chemotherapeutic drugs not only against target but also against nontarget cells. This is of special importance for intracellularly active hydrophilic drugs, which cannot freely penetrate the plasma membrane. Because many important chemotherapeutic agents are substrates of transporters for organic cations, this review discusses the known interaction of these substances with these transporters. A particular focus is given to the role of transporters for organic cations in the development of side effects of chemotherapy with platinum derivatives and in the efficacy of recently developed tyrosine kinase inhibitors to specifically target cancer cells. It is evident that specific inhibition of uptake transporters may be a possible strategy to protect against undesired side effects of platinum derivatives without compromising their antitumor efficacy. These transporters are also important for efficient targeting of tyrosine kinase inhibitors to cancer cells. However, in order to achieve the aims of protecting from undesired toxicities and improving the specificity of uptake by tumor cells, an exact knowledge of transporter expression, function, regulation under normal and pathologic conditions, and of genetically and epigenetically regulation is mandatory.

Vascular Toxicity of Antineoplastic Agents

Among the various deleterious effects of cancer chemotherapy, vascular toxicity is the least well recognized. This lack of recognition may be because the vasculotoxic phenomena are not unique to antineoplastic agents, can occur in patients without exposure to these agents, and the fact cancer itself may produce a hypercoagulable state. As a result, many vascular events either go unnoticed, are ignored, and/or are attributed to the underlying malignancy. Many antineoplastic therapies are associated with various vascular phenomena that range from simple phelibitis to lethal microangiopathy. Recognition of these events is important to minimize the morbidity and even prevent unnecessary deaths. Herein we review the vascular syndromes that have been reported in association with antineoplastic agents.

Thromboembolic events during chemotherapy for germ cell cancer: a cohort study and review of the literature

PURPOSE

To evaluate the risk of major thromboembolic complications in male germ cell cancer patients receiving cisplatin-based chemotherapy and to review the literature on this subject.

PATIENTS AND METHODS

One hundred seventy-nine germ cell cancer patients treated between January 1979 and May 1997 in our hospital were analyzed with respect to risk factors for developing thromboembolic events, such as baseline tumor characteristics, prior tumor therapy, administration of cytostatic agents, and the use of antiemetic drugs. The patients were treated with a variety of combination chemotherapy regimens, primarily cisplatin-containing combination regimens.

RESULTS

Of the 179 patients, 15 patients (8.4%) were identified who developed a total of 18 major thromboembolic complications in the time period between the start of chemotherapy and 6 weeks after administration of the last cytostatic drug in first-line treatment. Of these 18 events, three (16.7%) were arterial events, including two cerebral ischemic strokes, and 15 (83. 3%) were venous thromboembolic events, including 11 pulmonary embolisms. One (5.6%) of the 18 events was fatal. Liver metastases (odds ratio, 4.9; 95% confidence interval, 1.1 to 20.8) and the administration of high doses of corticosteroids (>/= 80 mg dexamethasone per cycle; odds ratio, 3.5; 95% confidence interval, 1. 2 to 10.3) as antiemetic therapy were identified as risk factors for the development of major thromboembolic complications.

CONCLUSION

Germ cell cancer patients who receive chemotherapy, in particular those who have liver metastases or receive high doses of corticosteroids, are at considerable risk of developing thromboembolic complications.

Protection from toxicant-mediated renal injury in the rat with anti-CD54 antibody

BACKGROUND

The benefit of the potent chemotherapeutic agent cisplatin in treating neoplasms is limited by nephrotoxicity. We tested the hypothesis that CD54 [intercellular adhesion molecule-1 (ICAM-1)] is an important mediator in cisplatin-mediated renal failure.

METHODS

The effect of a monoclonal anti-CD54 antibody was evaluated in a rat model of cisplatin toxicity. Renal function, histopathology, renal myeloperoxidase activity, and mortality were determined in the anti-CD54 and placebo groups.

RESULTS

Renal CD54 mRNA expression was markedly increased by 24 hours after exposure to cisplatin in mice. An improvement in renal function, mortality, and histological abnormalities was evident in animals exposed to cisplatin and treated with anti-CD54 antibody (mAb). Seven days after the administration of cisplatin, the mean creatinine was 0.65+/-0.05 mg/dl in the rats that received anti-CD54 mAb and 4.76+/-1.42 in control animals (P<0.02). Mortality was lower in experimental animals (0 vs. 29% in control rats seven days following cisplatin, P<0.04). Histological evidence of cell injury was markedly attenuated (P<0.04) in the treated compared with the control rats.

CONCLUSION

CD54 may be critical in the pathophysiology of renal injury following cisplatin, perhaps by its effects on leukocyte-endothelial interactions.

Antiemetics in cancer chemotherapy: historical perspective and current state of the art

Chemotherapy-related nausea and vomiting can today be controlled with available antiemetics in a high percentage of patients but emesis remains a problem for some patients, with certain drugs and with repeated cycles of chemotherapy. The fundamental steps of clinical research in antiemetics towards the improvement of the control of nausea and vomiting with new drugs or combinations are presented. Special emphasis is given to cisplatin-induced nausea and vomiting because of the frequency and relevance of this phenomenon. The use of high-dose metoclopramide, its combination with steroids, and later the addition of lorazepam or diphenhydramine represented the evolving standard of the 1980s, with the level of complete protection from vomiting improving from 30%-40% to 60%-70% with the three-drug combination. The introduction of new agents such as the 5-hydroxytryptamine 3 (5-HT3) receptor antagonists has recently offered new possibilities because of their activity and lack of toxicity. In particular, the combination of ondansetron plus dexamethasone is today the most efficacious and least toxic antiemetic treatment for prevention of emesis in patients treated with a single high dose or low repeated doses of cisplatin. A comparison of different 5-HT3 antagonists, always in combination with steroids, is now considered necessary. For patients treated with moderately emetogenic chemotherapy the use of steroids can still be considered the standard treatment. In this setting, the role of 5-HT3 receptor antagonists, alone or in combination with steroids, has to be better defined through large, well-planned clinical trials, which should have a cost-effectiveness analysis as one of their goals.

Repeated use of granisetron in patients receiving cytostatic agents

BACKGROUND

Granisetron was shown to be a safe and effective antiemetic agent when given with initial cytostatic therapy. This study was undertaken to investigate the efficacy and safety of the continued use of granisetron.

METHODS

Ninety-one patients were given 438 cycles of granisetron during subsequent courses of cytostatic treatment. In 56 patients, 40 micrograms/kg i.v. was given in 159 cycles, and in 42 patients, 3 mg i.v. was given in 279 cycles. In patients having breakthrough symptoms, as many as two rescue doses were given to re-establish control.

RESULTS

Overall objective control of nausea and vomiting was observed in 88.6% of the 40 micrograms/kg-cycles and in 90.32% of the 3-mg cycles. In the 438 cycles given, complete control was achieved in 105 of 159 (66%) of the 40-micrograms/kg cycles and in 217 of 279 (77.78%) of the 3-mg cycles. Thirty-three patients received 97 cycles of cisplatin-based regimens. The objective control rate was 82.47% (80 of 97 cycles) in these patients. The control rate in patients receiving regimens not containing cisplatin was 94.4% (322 of 341 cycles). Rescue doses improved or resolved symptoms in 53 of 61 (86.9%) cycles. No statistically significant difference in nausea and vomiting control was seen between men and women or between the different age groups. The only toxicities encountered were headache in 14 of 438 (3.2%) cycles and mild constipation in 8 of 438 (1.8%) cycles.

CONCLUSION

Granisetron is safe and well tolerated, maintains its antiemetic efficacy after repeated cycles of therapy, and is effective as an interventional treatment for nausea and vomiting.