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Esposito A, Bossi P. How can we prevent diarrhea induced by systemic treatments in oncological patients? An evaluation of phase II trials. Expert Opin Emerg Drugs 2023; 28:213-216. [PMID: 37750491 DOI: 10.1080/14728214.2023.2264182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/25/2023] [Indexed: 09/27/2023]
Affiliation(s)
- Andrea Esposito
- Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, ASST-Spedali Civili Brescia, University of Brescia, Oncology Unit, Piazzale Spedali Civili, Brescia, Italy
| | - Paolo Bossi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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de Man FM, Goey AKL, van Schaik RHN, Mathijssen RHJ, Bins S. Individualization of Irinotecan Treatment: A Review of Pharmacokinetics, Pharmacodynamics, and Pharmacogenetics. Clin Pharmacokinet 2019. [PMID: 29520731 PMCID: PMC6132501 DOI: 10.1007/s40262-018-0644-7] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Since its clinical introduction in 1998, the topoisomerase I inhibitor irinotecan has been widely used in the treatment of solid tumors, including colorectal, pancreatic, and lung cancer. Irinotecan therapy is characterized by several dose-limiting toxicities and large interindividual pharmacokinetic variability. Irinotecan has a highly complex metabolism, including hydrolyzation by carboxylesterases to its active metabolite SN-38, which is 100- to 1000-fold more active compared with irinotecan itself. Several phase I and II enzymes, including cytochrome P450 (CYP) 3A4 and uridine diphosphate glucuronosyltransferase (UGT) 1A, are involved in the formation of inactive metabolites, making its metabolism prone to environmental and genetic influences. Genetic variants in the DNA of these enzymes and transporters could predict a part of the drug-related toxicity and efficacy of treatment, which has been shown in retrospective and prospective trials and meta-analyses. Patient characteristics, lifestyle and comedication also influence irinotecan pharmacokinetics. Other factors, including dietary restriction, are currently being studied. Meanwhile, a more tailored approach to prevent excessive toxicity and optimize efficacy is warranted. This review provides an updated overview on today’s literature on irinotecan pharmacokinetics, pharmacodynamics, and pharmacogenetics.
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Affiliation(s)
- Femke M de Man
- Department of Medical Oncology, Erasmus MC Cancer Institute, 's-Gravendijkwal 230, 3015, Rotterdam, The Netherlands
| | - Andrew K L Goey
- Department of Hospital Pharmacy, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, 's-Gravendijkwal 230, 3015, Rotterdam, The Netherlands
| | - Sander Bins
- Department of Medical Oncology, Erasmus MC Cancer Institute, 's-Gravendijkwal 230, 3015, Rotterdam, The Netherlands.
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Fischbach W, Andresen V, Eberlin M, Mueck T, Layer P. A Comprehensive Comparison of the Efficacy and Tolerability of Racecadotril with Other Treatments of Acute Diarrhea in Adults. Front Med (Lausanne) 2016; 3:44. [PMID: 27790616 PMCID: PMC5064048 DOI: 10.3389/fmed.2016.00044] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 09/20/2016] [Indexed: 12/27/2022] Open
Abstract
Racecadotril is a guideline-recommended treatment to alleviate symptoms of acute diarrhea. A systematic review of randomized studies was performed comparing efficacy and safety of treatment with racecadotril to that with placebo or active treatments in adults. In five double-blind studies, racecadotril and placebo had comparable tolerability, but racecadotril was more effective. This was consistent across multiple efficacy parameters including duration of diarrhea, number of diarrheic stools, abdominal pain, and meteorism; it was also consistent across countries in Africa, Asia, and Europe. In six randomized studies in outpatients comparing racecadotril to loperamide, resolution of symptoms occurred with similar speed and efficacy; however, racecadotril treatment was associated with less rebound constipation and less abdominal discomfort. The seventh comparative study performed in geriatric nursing home residents reported a superior efficacy of racecadotril. In direct comparison with Saccharomyces boulardii treatment, racecadotril exhibited similar tolerability but was more efficacious. One study compared racecadotril to octreotide in patients with acute diarrhea requiring hospitalization, rehydration, and antibiotic treatment; in this cohort, octreotide was more efficacious than racecadotril. In conclusion, in adults with acute diarrhea, racecadotril is more efficacious than placebo or S. boulardii, similarly efficacious as loperamide and, in patients with moderate to severe disease as add-on to antibiotics, less than octreotide. The tolerability of racecadotril is similar to that of placebo or S. boulardii and better than that of loperamide, particularly with regard to risk of rebound constipation. Taken together, these data demonstrate that racecadotril is a suitable treatment to alleviate symptoms of acute diarrhea in adults.
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Affiliation(s)
- Wolfgang Fischbach
- Medizinische Klinik II, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Viola Andresen
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Germany
| | - Marion Eberlin
- Department of Medical Affairs CHC Germany, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | - Tobias Mueck
- Department of Medical Affairs CHC Germany, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | - Peter Layer
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Germany
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Irinotecan- and 5-fluorouracil-induced intestinal mucositis: insights into pathogenesis and therapeutic perspectives. Cancer Chemother Pharmacol 2016; 78:881-893. [PMID: 27590709 DOI: 10.1007/s00280-016-3139-y] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 08/23/2016] [Indexed: 12/20/2022]
Abstract
PURPOSE Intestinal mucositis and diarrhea are common manifestations of anticancer regimens that include irinotecan, 5-fluorouracil (5-FU), and other cytotoxic drugs. These side effects negatively impact therapeutic outcomes and delay subsequent cycles of chemotherapy, resulting in dose reductions and treatment discontinuation. Here, we aimed to review the experimental evidence regarding possible new targets for the management of irinotecan- and 5-FU-related intestinal mucositis. METHODS A literature search was performed using the PubMed and MEDLINE databases. No publication time limit was set for article inclusion. RESULTS Here, we found that clinical management of intestinal mucositis and diarrhea is somewhat ineffective at reducing symptoms, possibly due to a lack of specific targets for modulation. We observed that IL-1β contributes to the apoptosis of enterocytes in mucositis induced by 5-FU. However, 5-FU-related mucositis is far less thoroughly investigated with regard to specific molecular targets when compared to irinotecan-related disease. Several studies have proposed that a correlation exists between the intestinal microbiota, the enterohepatic recirculation of active metabolites of irinotecan, and the establishment of mucositis. However, as reviewed here, this association seems to be controversial. In addition, the pathogenesis of irinotecan-induced mucositis appears to be orchestrated by interleukin-1/Toll-like receptor family members, leading to epithelial cell apoptosis. CONCLUSIONS IL-1β, IL-18, and IL-33 and the receptors IL-1R, IL-18R, ST2, and TLR-2 are potential therapeutic targets that can be modulated to minimize anticancer agent-associated toxicity, optimize cancer treatment dosing, and improve clinical outcomes. In this context, the pathogenesis of mucositis caused by other anticancer agents should be further investigated.
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Lam W, Jiang Z, Guan F, Hu R, Liu SH, Chu E, Cheng YC. The number of intestinal bacteria is not critical for the enhancement of antitumor activity and reduction of intestinal toxicity of irinotecan by the Chinese herbal medicine PHY906 (KD018). Altern Ther Health Med 2014; 14:490. [PMID: 25510341 PMCID: PMC4302098 DOI: 10.1186/1472-6882-14-490] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Accepted: 12/11/2014] [Indexed: 12/19/2022]
Abstract
Background The four-herb Chinese medicine PHY906(KD018) has been shown to both enhance the in vivo antitumor activity of irinotecan (CPT-11) against colon cancer tumor allografts and alleviate intestinal toxicity caused by CPT-11. Methods Since intestinal bacteria can metabolize CPT-11 and PHY906, we investigated whether intestinal bacteria play a critical role in the in vivo activity of PHY906 in murine Colon-38 tumor-bearing mice. Intestinal bacteria were depleted using streptomycin/neomycin for 10 days before and during treatment with PHY906 and/or CPT-11. qPCR using 16S DNA group-specific primers was used to quantify the levels of the major intestinal bacteria. Results Both PHY906 and antibiotic treatment changed the profile of intestinal bacteria species: Lactobacillus/Enterococcus, Bacteroides, Clostridium leptum, and E. rectale/C. coccoides. Antibiotic treatment did not alter the ability of PHY906 to enhance the antitumor activity of CPT-11. Antibiotic treatment alone partially reduced animal body weight loss in CPT-11-treated mice. However, PHY906 treatment was able to protect against the body weight loss in the CPT-11/antibiotic treatment group. H&E and PCNA staining of intestine showed that antibiotic treatment partially reduced the intestinal damage caused by CPT-11 but not as effectively as PHY906 treatment. Antibiotic treatment plus PHY906 conferred the most effective protection of intestine histological structure against damage by CPT-11. Both PHY906 and antibiotic treatment inhibited CPT-11-associated inflammatory processes, including infiltration of the intestine by neutrophils, MCP1 and TNF-alpha mRNA expression in the intestine, and expression of pro-inflammatory cytokines G-CSF and MCP1 proteins in the plasma. However, whereas antibiotic treatment suppressed the mRNA expression of two important intestinal progenitor/stem cell markers, Olfm4 and Lgr5, PHY906 treatment resulted in enhanced expression of these two stem cell markers. Conclusions Alterations in the population of intestinal bacteria did not affect the abilities of PHY906 to enhance CPT-11 antitumor activity or reduce the intestinal toxicity associated with CPT-11 treatment. The major species of intestinal bacteria do not appear to play a role in PHY906’s enhancement of the therapeutic index of CPT-11 in tumor-bearing mice. Thus, patients with different intestinal bacterial profiles may still benefit from PHY906 treatment alongside CPT-11.
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A phase II, randomized, double blind trial of calcium aluminosilicate clay versus placebo for the prevention of diarrhea in patients with metastatic colorectal cancer treated with irinotecan. Support Care Cancer 2014; 23:661-70. [PMID: 25160493 DOI: 10.1007/s00520-014-2402-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 08/11/2014] [Indexed: 12/22/2022]
Abstract
PURPOSE Calcium aluminosilicate clay (CASAD) is a naturally occurring clay that serves as a cation exchange absorbent. We hypothesized that oral administration of CASAD would reduce the rate of grade 3/4 diarrhea associated with irinotecan use for metastatic colorectal cancer (CRC) by adsorbing the SN-38 metabolite. METHODS Patients receiving irinotecan-based chemotherapy were randomized equally between CASAD and placebo arms in this multicenter trial in order to assess differences in the proportions of patients with grade 3/4 diarrhea within 6 weeks. Additionally, we compared symptom severity between the two arms using the M.D. Anderson Symptom Inventory. RESULTS Between May 2009 and May 2012, 100 patients were enrolled. In evaluable patients, 7 of 43 (16 %) on the CASAD arm compared to 3 of 32 (9 %) on the placebo arm experienced grade 3/4 diarrhea (P = 0.70). The rate of any diarrhea among all patients was similar (CASAD arm, 64 % vs. placebo arm, 70 %). The rate of study dropout was 14 % in the CASAD arm and 38 % in the placebo arm (P = 0.01). No differences were found in symptom severity, individual symptom items, and in serious adverse events between the two arms. CONCLUSION Compared to placebo, CASAD use was safe but ineffective in preventing diarrhea in metastatic CRC patients treated with irinotecan-containing chemotherapy regimens. There were no distinct signals in terms of patient symptoms between arms, but there was significantly more patient dropout in the placebo arm. Future CASAD trials will focus on the active treatment of diarrhea.
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Vetel JM, Hamza H, Coffin B, Lehert P. Racecadotril Efficacy in the Symptomatic Treatment of Adult Acute Diarrhoea: A Systematic Review and Meta-Analysis. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ijcm.2014.57052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Swami U, Goel S, Mani S. Therapeutic targeting of CPT-11 induced diarrhea: a case for prophylaxis. Curr Drug Targets 2013; 14:777-97. [PMID: 23597015 DOI: 10.2174/1389450111314070007] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 03/23/2013] [Accepted: 04/04/2013] [Indexed: 12/14/2022]
Abstract
CPT-11 (irinotecan), a DNA topoisomerase I inhibitor is one of the main treatments for colorectal cancer. The main dose limiting toxicities are neutropenia and late onset diarrhea. Though neutropenia is manageable, CPT-11 induced diarrhea is frequently severe, resulting in hospitalizations, dose reductions or omissions leading to ineffective treatment administration. Many potential agents have been tested in preclinical and clinical studies to prevent or ameliorate CPT-11 induced late onset diarrhea. It is predicted that prophylaxis of CPT-11 induced diarrhea will reduce sub-therapeutic dosing as well as hospitalizations and will eventually lead to dose escalations resulting in better response rates. This article reviews various experimental agents and strategies employed to prevent this debilitating toxicity. Covered topics include schedule/dose modification, intestinal alkalization, structural/chemical modification, genetic testing, anti-diarrheal therapies, transporter (ABCB1, ABCC2, BCRP2) inhibitors, enzyme (β-glucuronidase, UGT1A1, CYP3A4, carboxylesterase, COX-2) inducers and inhibitors, probiotics, antibiotics, adsorbing agents, cytokine and growth factor activators and inhibitors and other miscellaneous agents.
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Affiliation(s)
- Umang Swami
- Internal Medicine, St. Barnabas Hospital, Bronx, NY 10457, USA
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A randomised double-blind placebo-controlled phase II study of AGI004 for control of chemotherapy-induced diarrhoea. Br J Cancer 2013; 108:1027-33. [PMID: 23462724 PMCID: PMC3619064 DOI: 10.1038/bjc.2013.35] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: AGI004 is a controlled-release transdermal patch preparation of mecamylamine. We conducted a randomised placebo-controlled phase II study of two dose levels of AGI004 in chemotherapy-induced diarrhoea (CID). Methods: Adult patients receiving chemotherapy who had experienced diarrhoea (NCI grade 1–2) during previous cycles of chemotherapy were eligible. In all, 64 patients were randomised to receive AGI004 4 mg then 8 mg per 24 h transdermal patch or placebo for two sequential cycles of chemotherapy. Patients' severity of diarrhoea was physician-assessed using NCI grade of diarrhoea and patient-assessed using information recorded in daily diaries of bowel movements. Results: Overall AGI004 doubled the odds of a response to treatment on the first day of chemotherapy based on physician assessment of NCI grade of diarrhoea compared with placebo (odds ratio=2.0, 90% confidence interval: 0.9–4.5) and there was a trend to improved response rates for AGI004 for the full treatment cycle although these results were not statistically significant. There was also evidence of significantly improved response rates based on patient assessment of diarrhoea both overall (P=0.05) and at the 8-mg dose level (P=0.02) compared with placebo. Conclusion: AGI004 demonstrated effectiveness in reducing chemotherapy-associated diarrhoea, with results suggesting response across multiple measurements of diarrhoea. Treatment was well tolerated with no drug-related adverse events. Further evaluation of this agent in the management of CID is warranted.
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Eberlin M, Mück T, Michel MC. A comprehensive review of the pharmacodynamics, pharmacokinetics, and clinical effects of the neutral endopeptidase inhibitor racecadotril. Front Pharmacol 2012; 3:93. [PMID: 22661949 PMCID: PMC3362754 DOI: 10.3389/fphar.2012.00093] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 04/27/2012] [Indexed: 11/15/2022] Open
Abstract
Racecadotril, via its active metabolite thiorphan, is an inhibitor of the enzyme neutral endopeptidase (NEP, EC 3.4.24.11), thereby increasing exposure to NEP substrates including enkephalins and atrial natriuretic peptide (ANP). Upon oral administration racecadotril is rapidly and effectively converted into the active metabolite thiorphan, which does not cross the blood–brain-barrier. Racecadotril has mainly been tested in animal models and patients of three therapeutic areas. As an analgesic the effects of racecadotril across animal models were inconsistent. In cardiovascular diseases such as hypertension or congestive heart failure results from animal studies were promising, probably related to increased exposure to ANP, but clinical results have not shown substantial therapeutic benefit over existing treatment options in cardiovascular disease. In contrast, racecadotril was consistently effective in animal models and patients with various forms of acute diarrhea by inhibiting pathologic (but not basal) secretion from the gut without changing gastro-intestinal transit time or motility. This included studies in both adults and children. In direct comparative studies with loperamide in adults and children, racecadotril was at least as effective but exhibited fewer adverse events in most studies, particularly less rebound constipation. Several guidelines recommend the use of racecadotril as addition to oral rehydration treatment in children with acute diarrhea.
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Affiliation(s)
- Marion Eberlin
- Department of Medical Affairs Germany, Boehringer Ingelheim Pharma GmbH & Co KG Ingelheim, Germany
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Abstract
AIM Advances in molecular technology have resulted in the discovery of many putative biomarkers relevant to colorectal cancer (CRC). METHOD Literature searches were performed on PubMed and EMBASE using the words 'colorectal cancer', AND 'biomarkers OR markers'. Biomarkers that are either currently in clinical use or have potential clinical use were identified. RESULTS Most potential markers are in the discovery phase waiting to undergo clinical validation. Hypermethylation of the plasma septin-9 gene shows promise as a nonstool-based screening tool. Hypermethylation of the DYPD gene (encodes the enzyme dihydropyrimidine dehydrogenase) and variation of the uridine diphosphate-glucuronosyltransferase 1A (UGT1A1) gene have predictive value for side effects and the efficacy of 5-fluoruracil and irinotecan, respectively. Mismatch repair protein immunohistochemistry is able to predict response to 5-fluorouracil, and the KRAS (Kirsten rat sarcoma viral oncogene) and B-RAF (v-RAF murine sarcoma viral oncogene homolog B1) somatic gene mutation status can predict the response to anti-epidermal growth factor receptor therapy. CONCLUSION Recent advances indicate that the widespread use of biomarkers may herald the next major advance in the diagnosis and management of CRC.
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Affiliation(s)
- K F Newton
- Department of General Surgery, Manchester Royal Infirmary Department of Genetic Medicine, Manchester Academic Health Science Centre, Central Manchester University Hospitals Trust, Manchester, UK
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Takakura A, Kurita A, Asahara T, Yokoba M, Yamamoto M, Ryuge S, Igawa S, Yasuzawa Y, Sasaki J, Kobayashi H, Masuda N. Rapid deconjugation of SN-38 glucuronide and adsorption of released free SN-38 by intestinal microorganisms in rat. Oncol Lett 2011; 3:520-524. [PMID: 22740943 DOI: 10.3892/ol.2011.519] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Accepted: 11/24/2011] [Indexed: 11/06/2022] Open
Abstract
One of the dose-limiting toxicities of irinotecan hydrochloride (CPT-11) is delayed-onset diarrhea. CPT-11 is converted to its active metabolite, SN-38, which is conjugated to SN-38 glucuronide (SN-38G). SN-38G excreted in the intestinal lumen is extensively deconjugated by bacterial β-glucuronidase, resulting in the regeneration of SN-38, which causes diarrhea. However, the deconjugation of SN-38G by the intestinal microflora remains to be clarified. This study aimed to investigate the microbial transformation of SN-38G by an anaerobic mixed culture of rat cecal microorganisms. Concentrations of SN-38G and SN-38 were then determined using high-performance liquid chromatography. Complete deconjugation of SN-38G to SN-38 in the mixed cultures was observed within 1 h of incubation, with 62.7% of the added SN-38G being found in the supernatant. Approximately 80.4% of the SN-38 in the supernatant was bound to protein, and the remaining 19.6% was detected as active free SN-38. In total, only 12.3% (19.6 × 62.7%) of the SN-38G added to the test tube was found in the supernatant in the ultrafiltrable free form, indicating that approximately 90% of the SN-38G added to the growth medium either remained adsorbed onto the pelleted fraction or occurred in a protein-bound form in the supernatant. The remaining 10% of the SN-38G added to the growth medium existed in the unbound form, the form capable of causing damage to the intestinal membrane. In conclusion, these results indicated that the greater part of the SN-38 produced from SN-38G by the action of bacterial β-glucuronidase is rapidly adsorbed onto intestinal bacterial cell walls or dietary fibers in pelleted fraction, and only 10% remains in the ultrafiltrable unbound form in the intestinal luminal fluid.
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Affiliation(s)
- Akira Takakura
- Department of Respiratory Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa 252-0374
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Wagner LM, Crews KR, Stewart CF, Rodriguez-Galindo C, McNall-Knapp RY, Albritton K, Pappo AS, Furman WL. Reducing irinotecan-associated diarrhea in children. Pediatr Blood Cancer 2008; 50:201-7. [PMID: 17570704 DOI: 10.1002/pbc.21280] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Irinotecan is increasingly being used in pediatric oncology. Amelioration of diarrhea associated with protracted irinotecan administration may reduce morbidity and improve dose intensity. In this review, we discuss what is known about the pathogenesis of this toxicity as well as potential predisposing genetic factors. We comprehensively summarize the literature regarding available prevention and treatment strategies, and report data on the use of cephalosporin prophylaxis in 51 patients treated on various pediatric trials. This approach is feasible in children and allows for tolerance of higher doses of protracted irinotecan.
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Affiliation(s)
- Lars M Wagner
- Division of Pediatric Hematology/Oncology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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Flieger D, Klassert C, Hainke S, Keller R, Kleinschmidt R, Fischbach W. Phase II Clinical Trial for Prevention of Delayed Diarrhea with Cholestyramine/Levofloxacin in the Second-Line Treatment with Irinotecan Biweekly in Patients with Metastatic Colorectal Carcinoma. Oncology 2007; 72:10-6. [DOI: 10.1159/000111083] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2007] [Accepted: 06/21/2007] [Indexed: 11/19/2022]
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Topkan E, Karaoglu A. Octreotide in the management of chemoradiotherapy-induced diarrhea refractory to loperamide in patients with rectal carcinoma. Oncology 2007; 71:354-60. [PMID: 17873499 DOI: 10.1159/000108593] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Accepted: 05/30/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the efficacy of octreotide in the treatment of chemoradiotherapy (CRT)-induced diarrhea (CRTID) refractory to conventional loperamide treatment in this pilot study. METHODS Forty-two rectal carcinoma (T(3-4)N(0-2)M(0)) patients with grade 2 or 3 diarrhea refractory to loperamide were enrolled to receive octreotide. Eligible patients were treated with pelvic radiotherapy combined with bolus 5- fluorouracil CRT. Octreotide was administered subcutaneously, 150 microg three times daily, for 5 consecutive days. Only complete resolution of diarrhea was considered as therapeutic success. RESULTS Diarrhea mainly occurred in the first 4 weeks of CRT (83.3%) and completely resolved in 34 patients (80.9%) following octreotide administration. Mean time to response was 2.7 days: 27 patients (64%) responded during the first 3 days, and the remaining 7 (17%) on days 4 and 5. No significant side effect was reported. Eight patients (19.1%) with refractory diarrhea were hospitalized for additional treatment. No treatment delay was reported in complete responders, whereas an average 7.7-day delay was observed in refractory patients. Antidiarrheal treatment was administered on an outpatient basis in the response group, whereas refractory patients were hospitalized for an average of 8.8 days. CONCLUSION Daily subcutaneous octreotide administration (150 microg t.i.d.) for 5 days is apparently an effective, tolerable treatment modality for concurrent CRTID refractory to loperamide.
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Affiliation(s)
- Erkan Topkan
- Department of Radiation Oncology, Inonu University Turgut Ozal Medical Center, Malatya, Turkey.
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Abstract
This article aims to provide the reader with a broad overview of the current chemotherapeutic options available for the treatment of patients with metastatic colorectal cancer. The review includes discussion of both well established and experimental therapies.
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Affiliation(s)
- Claire Kelly
- Department of Medical Oncology, Beatson Oncology Centre, Dumbarton Road, Glasgow G11 6NT, UK.
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de Jong FA, Kehrer DFS, Mathijssen RHJ, Creemers GJ, de Bruijn P, van Schaik RHN, Planting AST, van der Gaast A, Eskens FALM, Janssen JTP, Ruit JB, Verweij J, Sparreboom A, de Jonge MJA. Prophylaxis of irinotecan-induced diarrhea with neomycin and potential role for UGT1A1*28 genotype screening: a double-blind, randomized, placebo-controlled study. Oncologist 2006; 11:944-54. [PMID: 16951398 DOI: 10.1634/theoncologist.11-8-944] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Delayed-type diarrhea is a common side effect of irinotecan and is associated with a bacterial-mediated formation of the active irinotecan metabolite SN-38 from its glucuronide conjugate in the intestine. Based on a pilot study, we hypothesized that concomitant administration of the antibiotic neomycin would diminish exposure of the gut to SN-38 and ameliorate the incidence and severity of diarrhea. PATIENTS AND METHODS Patients were treated with irinotecan in a multicenter, double-blind, randomized, placebo-controlled trial. Eligible patients received irinotecan (350 mg/m(2) once every 3 weeks) combined with neomycin (660 mg three times daily for three consecutive days, starting 2 days before chemotherapy) or combined with placebo. Blood samples were obtained for additional pharmacokinetic and pharmacogenetic analyses. RESULTS Sixty-two patients were evaluable for the toxicity analysis. Baseline patient characteristics, systemic SN-38 exposure, and UGT1A1*28 genotype status (i.e., an additional TA repeat in the promoter region of uridine diphosphate-glucuronosyltransferase isoform 1A1) were similar in both arms. Although distribution, severity, and duration of delayed-type diarrhea did not differ significantly between arms, grade 3 diarrhea tended to be less frequent in the neomycin arm. The presence of at least one UGT1A1*28 allele was strongly related to the incidence of grade 2-3 diarrhea. In the neomycin arm, grade 2 nausea was significantly more common. CONCLUSION Our results do not suggest a major role for neomycin as prophylaxis for irinotecan-induced delayed-type diarrhea. It is suggested that the UGT1A1*28 genotype status could be used as a screening tool for a priori prevention of irinotecan-induced delayed-type diarrhea.
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Affiliation(s)
- Floris A de Jong
- Erasmus University Medical Center Rotterdam-Daniel den Hoed Cancer Center, Department of Medical Oncology, Room AS-15, Groene Hilledijk 301, NL-3075 EA Rotterdam, The Netherlands.
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Michael M, Brittain M, Nagai J, Feld R, Hedley D, Oza A, Siu L, Moore MJ. Phase II Study of Activated Charcoal to Prevent Irinotecan-Induced Diarrhea. J Clin Oncol 2004; 22:4410-7. [PMID: 15514383 DOI: 10.1200/jco.2004.11.125] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PurposeThe dose-limiting toxicity of irinotecan (CPT-11; Camptosar) is delayed-onset diarrhea, with an incidence at the grade 3 to 4 level of 20% to 35%. SN38, its active moiety, is responsible by a direct effect on mucosal topoisomerase-I. The aim of this study was to assess whether activated charcoal (AC), possibly by adsorbing free lumenal SN38, can reduce irinotecan-induced diarrhea (CID) and optimize its dose-intensity.Patients and MethodsPatients with advanced colorectal cancer receiving irinotecan 125 mg/m2intravenously once a week for 4 weeks every 6 weeks were studied. In cycle 1, patients received irinotecan plus AC (5 mL aqueous Charcodote [1,000 mg AC] plus 25 mL water) given the evening before the irinotecan dose and then tid for 48 hours after the dose. In cycle 2, no AC was given. National Cancer Institute Common Toxicity Criteria diarrhea grade, irinotecan dose-intensity, and loperamide consumption were recorded prospectively in both cycles.ResultsTwenty-eight patients had completed cycle 1 with AC; 24 subsequently completed cycle 2 without AC. Grade 3 to 4 diarrhea was 7.1% v 25%, and grade 0 diarrhea was 46.4% v 20.8% in cycles 1 and 2, respectively. Median percent planned dose delivered was 98% v 70% in cycles 1 and 2, respectively. In cycles 1 and 2, respectively, 25% v 54% patients took more than 10 loperamide tablets. AC was well tolerated with excellent compliance.ConclusionThe administration of AC with irinotecan reduced the incidence of grade 3 to 4 diarrhea and antidiarrheal medication consumption and increased irinotecan dose-intensity. Prophylactic AC may have a role in reducing dose-limiting CID and optimizing irinotecan therapy.
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Affiliation(s)
- Michael Michael
- Department of Medical Oncology and Hematology, Princess Margaret Hospital, University of Toronto, Ontario, Canada.
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Benson AB, Ajani JA, Catalano RB, Engelking C, Kornblau SM, Martenson JA, McCallum R, Mitchell EP, O'Dorisio TM, Vokes EE, Wadler S. Recommended guidelines for the treatment of cancer treatment-induced diarrhea. J Clin Oncol 2004; 22:2918-26. [PMID: 15254061 DOI: 10.1200/jco.2004.04.132] [Citation(s) in RCA: 392] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To update and expand on previously published clinical practice guidelines for the treatment of cancer treatment-induced diarrhea. METHODS An expert multidisciplinary panel was convened to review the recent literature and discuss recommendations for updating the practice guidelines previously published by this group in the Journal of Clinical Oncology in 1998. MEDLINE searches were performed and the relevant literature published since 1998 was reviewed by all panel members. The treatment recommendations and algorithm were revised by panel consensus. RESULTS A recent review of early toxic deaths occurring in two National Cancer Institute-sponsored cooperative group trials of irinotecan plus high-dose fluorouracil and leucovorin for advanced colorectal cancer has led to the recognition of a life-threatening gastrointestinal syndrome and highlighted the need for vigilant monitoring and aggressive therapy for this serious complication. Loperamide remains the standard therapy for uncomplicated cases. However, the revised guidelines reflect the need for recognition of the early warning signs of complicated cases of diarrhea and the need for early and aggressive management, including the addition of antibiotics. Management of radiation-induced diarrhea is similar but may not require hospitalization, and chronic low- to intermediate-grade symptoms can be managed with continued loperamide. CONCLUSION With vigilant monitoring and aggressive therapy for cancer treatment-induced diarrhea, particularly in patients with early warning signs of severe complications, morbidity and mortality may be reduced.
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Affiliation(s)
- Al B Benson
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, 676 N St Clair, Suite 850, Chicago, IL 60611, USA.
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Méndez M, Salut A, García-Girón C, Navalon M, Diz P, García López MJ, España P, de la Torre A, Martínez del Prado P, Duarte I, Pujol E, Arizcun A, Cruz JJ. A Multicenter Phase II Study of Irinotecan in Patients with Advanced Colorectal Cancer Previously Treated with 5-Fluorouracil. Clin Colorectal Cancer 2003; 3:174-9. [PMID: 14706177 DOI: 10.3816/ccc.2003.n.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This multicenter, open-label, phase II study was performed to assess the efficacy and toxicity of irinotecan 350 mg/m2 intravenously every 3 weeks in patients with advanced colorectal cancer (CRC) previously treated with 5-fluorouracil (5-FU). The study enrolled 115 patients and a total of 558 cycles (median, 6 per patient) were administered. The overall objective response rate on an intent-to-treat basis was 18% (with 1 complete response and 20 partial responses), whereas 42 patients (37%) showed stable disease. Median time to progression was 4.8 months and median survival was 13.6 months. Grade 3/4 toxicities included delayed diarrhea (19.1%), nausea/vomiting (10.4%), and neutropenia (8.7%). There were 2 toxic deaths, 1 from delayed diarrhea and 1 from hemorrhage and grade 4 mucositis. In conclusion, the present study confirms the antitumor efficacy of irinotecan monotherapy in patients with CRC pretreated with 5-FU.
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Kehrer DF, Soepenberg O, Loos WJ, Verweij J, Sparreboom A. Modulation of camptothecin analogs in the treatment of cancer: a review. Anticancer Drugs 2001; 12:89-105. [PMID: 11261892 DOI: 10.1097/00001813-200102000-00002] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The topoisomerase I inhibitors reviewed in this paper are all semisynthetic analogs of camptothecin (CPT). Modulation of this intranuclear enzyme translates clinically in to antitumor activity against a broad spectrum of tumors and is therefore the subject of numerous investigations. We present preclinical and clinical data on CPT analogs that are already being used in clinical practice [i.e. topotecan and irinotecan (CPT-11)] or are currently in clinical development (e.g. 9-aminocamptothecin, 9-nitrocamptotecin, lurtotecan, DX 8951f and BN 80915), as well as drugs that are still only developed in a preclinical setting (silatecans, polymer-bound derivates). A variety of different strategies is being used to modulate the systemic delivery of this class of agents, frequently in order to increase antitumor activity and/or reduce experienced side effects. Three principal approaches are discussed, including: (i) pharmaceutical modulation of formulation vehicles, structural alterations and the search for more water-soluble prodrugs, (ii) modulation of routes of administration and considerations on infusion duration, and (iii) both pharmacodynamic and pharmacokinetic biomodulation.
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Affiliation(s)
- D F Kehrer
- Department of Medical Oncology, Rotterdam Cancer Institute (Daniel den Hoed Kliniek) and University Hospital, The Netherlands.
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