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Ruiz Sarrias O, Gónzalez Deza C, Rodríguez Rodríguez J, Arrizibita Iriarte O, Vizcay Atienza A, Zumárraga Lizundia T, Sayar Beristain O, Aldaz Pastor A. Predicting Severe Haematological Toxicity in Gastrointestinal Cancer Patients Undergoing 5-FU-Based Chemotherapy: A Bayesian Network Approach. Cancers (Basel) 2023; 15:4206. [PMID: 37686482 PMCID: PMC10486471 DOI: 10.3390/cancers15174206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/28/2023] [Accepted: 08/16/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE Severe toxicity is reported in about 30% of gastrointestinal cancer patients receiving 5-Fluorouracil (5-FU)-based chemotherapy. To date, limited tools exist to identify at risk patients in this setting. The objective of this study was to address this need by designing a predictive model using a Bayesian network, a probabilistic graphical model offering robust, explainable predictions. METHODS We utilized a dataset of 267 gastrointestinal cancer patients, conducting preprocessing, and splitting it into TRAIN and TEST sets (80%:20% ratio). The RandomForest algorithm assessed variable importance based on MeanDecreaseGini coefficient. The bnlearn R library helped design a Bayesian network model using a 10-fold cross-validation on the TRAIN set and the aic-cg method for network structure optimization. The model's performance was gauged based on accuracy, sensitivity, and specificity, using cross-validation on the TRAIN set and independent validation on the TEST set. RESULTS The model demonstrated satisfactory performance with an average accuracy of 0.85 (±0.05) and 0.80 on TRAIN and TEST datasets, respectively. The sensitivity and specificity were 0.82 (±0.14) and 0.87 (±0.07) for the TRAIN dataset, and 0.71 and 0.83 for the TEST dataset, respectively. A user-friendly tool was developed for clinical implementation. CONCLUSIONS Despite several limitations, our Bayesian network model demonstrated a high level of accuracy in predicting the risk of developing severe haematological toxicity in gastrointestinal cancer patients receiving 5-FU-based chemotherapy. Future research should aim at model validation in larger cohorts of patients and different clinical settings.
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Affiliation(s)
- Oskitz Ruiz Sarrias
- Department of Mathematics and Statistic, NNBi, 31191 Esquiroz, Navarra, Spain; (O.R.S.)
| | - Cristina Gónzalez Deza
- Department of Medical Oncology, Clínica Universidad De Navarra, 31008 Pamplona, Navarra, Spain; (C.G.D.); (J.R.R.); (T.Z.L.)
| | - Javier Rodríguez Rodríguez
- Department of Medical Oncology, Clínica Universidad De Navarra, 31008 Pamplona, Navarra, Spain; (C.G.D.); (J.R.R.); (T.Z.L.)
| | | | - Angel Vizcay Atienza
- Department of Medical Oncology, Clínica Universidad De Navarra, 31008 Pamplona, Navarra, Spain; (C.G.D.); (J.R.R.); (T.Z.L.)
| | - Teresa Zumárraga Lizundia
- Department of Medical Oncology, Clínica Universidad De Navarra, 31008 Pamplona, Navarra, Spain; (C.G.D.); (J.R.R.); (T.Z.L.)
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Vilalta-Lacarra A, Aldaz A, Sala-Elarre P, Urrizola A, Chopitea A, Arbea L, Rotellar F, Pardo F, Martí-Cruchaga P, Zozaya G, Subtil JC, Rodríguez-Rodríguez J, Ponz-Sarvise M. Therapeutic drug monitoring of neoadjuvant mFOLFIRINOX in resected pancreatic ductal adenocarcinoma. Pancreatology 2023:S1424-3903(23)00065-0. [PMID: 37169668 DOI: 10.1016/j.pan.2023.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 02/20/2023] [Accepted: 03/06/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Despite a potentially curative treatment, the prognosis after upfront surgery and adjuvant chemotherapy for patients with resectable pancreatic ductal adenocarcinoma (PDAC) is poor. Modified FOLFIRINOX (mFOLFIRINOX) is a cornerstone in the systemic treatment of PDAC, including the neoadjuvant setting. Pharmacokinetic-guided (PKG) dosing has demonstrated beneficial effects in other tumors, but scarce data is available in pancreatic cancer. METHODS Forty-six patients with resected PDAC after mFOLFIRINOX neoadjuvant approach and included in an institutional protocol for anticancer drug monitoring were retrospectively analyzed. 5-Fluorouracil (5-FU) dosage was adjusted throughout neoadjuvant treatment according to pharmacokinetic parameters and Irinotecan (CPT-11) pharmacokinetic variables were retrospectively estimated. RESULTS By exploratory univariate analyses, a significantly longer progression-free survival was observed for patients with either 5-FU area under the curve (AUC) above 28 mcg·h/mL or CPT-11 AUC values below 10 mcg·h/mL. In the multivariate analyses adjusted by age, gender, performance status and resectability after stratification according to both pharmacokinetic parameters, the risk of progression was significantly reduced in patients with 5-FU AUC ≥28 mcg·h/mL [HR = 0.251, 95% CI 0.096-0.656; p = 0.005] and CPT-11 AUC <10 mcg·h/mL [HR = 0.189, 95% CI 0.073-0.486, p = 0.001]. CONCLUSIONS Pharmacokinetically-guided dose adjustment of standard chemotherapy treatments might improve survival outcomes in patients with pancreatic ductal adenocarcinoma.
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Affiliation(s)
| | - Azucena Aldaz
- Pharmacy Service, Clinica Universidad de Navarra, Pamplona, Spain
| | - Pablo Sala-Elarre
- Department of Medical Oncology, Clinica Universidad de Navarra, Pamplona, Spain
| | - Amaia Urrizola
- Department of Medical Oncology, Clinica Universidad de Navarra, Pamplona, Spain
| | - Ana Chopitea
- Department of Medical Oncology, Clinica Universidad de Navarra, Pamplona, Spain
| | - Leire Arbea
- Department of Radiation Oncology, Clinica Universidad de Navarra, Pamplona, Spain
| | - Fernando Rotellar
- Hepatobiliary Surgery, Clinica Universidad de Navarra, Pamplona, Spain
| | - Fernando Pardo
- Hepatobiliary Surgery, Clinica Universidad de Navarra, Pamplona, Spain
| | | | - Gabriel Zozaya
- Hepatobiliary Surgery, Clinica Universidad de Navarra, Pamplona, Spain
| | - Jose Carlos Subtil
- Department of Gastroenterology, Clinica Universidad de Navarra, Pamplona, Spain
| | | | - Mariano Ponz-Sarvise
- Department of Medical Oncology, Clinica Universidad de Navarra, Pamplona, Spain.
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3
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Schneider JJ, Galettis P, Martin JH. Overcoming barriers to implementing precision dosing with 5-fluorouracil and capecitabine. Br J Clin Pharmacol 2021; 87:317-325. [PMID: 33386659 DOI: 10.1111/bcp.14723] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 12/01/2020] [Accepted: 12/17/2020] [Indexed: 12/27/2022] Open
Abstract
Despite advances in targeted cancer therapy, the fluoropyrimidines 5-fluorouracil (5FU) and capecitabine continue to play an important role in oncology. Historically, dosing of these drugs has been based on body surface area. This approach has been demonstrated to be an imprecise way to determine the optimal dose for a patient. Evidence in the literature has demonstrated that precision dosing approaches, such as DPD enzyme activity testing and, in the case of intravenous 5FU, pharmacokinetic-guided dosing, can reduce toxicity and yield better patient outcomes. However, despite the evidence, there has not been uniform adoption of these approaches in the clinical setting. When a drug such as 5FU has been used clinically for many decades, it may be difficult to change clinical practice. With the aim of facilitating change of practice, issues and barriers to implementing precision dosing approaches for 5FU and capecitabine are identified and discussed with possible solutions proposed.
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Affiliation(s)
- Jennifer J Schneider
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Centre for Drug Repurposing and Medicines Research, Level 3 Hunter Medical Research Institute, Kookaburra Circuit, Newcastle, New South Wales, Australia
| | - Peter Galettis
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Centre for Drug Repurposing and Medicines Research, Level 3 Hunter Medical Research Institute, Kookaburra Circuit, Newcastle, New South Wales, Australia
| | - Jennifer H Martin
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Centre for Drug Repurposing and Medicines Research, Level 3 Hunter Medical Research Institute, Kookaburra Circuit, Newcastle, New South Wales, Australia
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4
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Jacob J, Mathew SK, Chacko RT, Aruldhas BW, Singh A, Prabha R, Mathew BS. Systemic exposure to 5-fluorouracil and its metabolite, 5,6-dihydrofluorouracil, and development of a limited sampling strategy for therapeutic drug management of 5-fluorouracil in patients with gastrointestinal malignancy. Br J Clin Pharmacol 2020; 87:937-945. [PMID: 32592630 DOI: 10.1111/bcp.14444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/27/2020] [Accepted: 06/05/2020] [Indexed: 11/28/2022] Open
Abstract
AIMS 5-Fluorouracil (5-FU) is widely used in combination chemotherapy, and literature suggests pharmacokinetic-guided dosing to improve clinical efficacy and reduce toxicity. This study aimed to determine the pharmacokinetic exposure of both 5-FU and its metabolite, 5,6-dihydrofluorouracil (DHFU), in patients with gastrointestinal malignancy and to establish a simplified strategy to assist in therapeutic drug management for dose optimization. METHODS This was a prospective, observational study, performed in 27 patients diagnosed with gastrointestinal malignancy who were prescribed 5-FU. Multiple samples were collected per patient over the slow bolus (15-20 min) and continuous infusion period (over 44 h) in doses 1 and 3, and the concentrations of 5-FU and DHFU were measured. RESULTS A higher proportion of patients had exposures within the therapeutic range in dose 3 (50%) as compared to dose 1 (37.5%) with 5-FU. There was an association between delayed time to maximum concentration of DHFU and a high maximum concentration of 5-FU. A limited sampling strategy was developed with 4 samples, 2 during the bolus period and 2 during the continuous period (at 18 h and the end of infusion), which accurately predicted the total area under the curve of 5-FU. CONCLUSION Using body surface area-based dosing with 5-FU, 50-60% of patients were outside of the therapeutic range. In the absence of genotype testing, measurement of the metabolite DHFU could be a phenotypical measure of dihydropyrimidine dehydrogenase enzyme activity. A limited sampling strategy was developed in patients who were prescribed a combination regimen of slow bolus, followed by a 44-hour continuous infusion of 5-FU to assist in the therapeutic drug management of patients.
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Affiliation(s)
- Jeana Jacob
- Department of Pharmacology and Clinical Pharmacology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Sumith K Mathew
- Department of Pharmacology and Clinical Pharmacology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Raju Titus Chacko
- Department of Medical Oncology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Blessed Winston Aruldhas
- Department of Pharmacology and Clinical Pharmacology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Ashish Singh
- Department of Medical Oncology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Ratna Prabha
- Department of Pharmacology and Clinical Pharmacology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Binu Susan Mathew
- Department of Pharmacology and Clinical Pharmacology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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5
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Arshad U, Ploylearmsaeng SA, Karlsson MO, Doroshyenko O, Langer D, Schömig E, Kunze S, Güner SA, Skripnichenko R, Ullah S, Jaehde U, Fuhr U, Jetter A, Taubert M. Prediction of exposure-driven myelotoxicity of continuous infusion 5-fluorouracil by a semi-physiological pharmacokinetic-pharmacodynamic model in gastrointestinal cancer patients. Cancer Chemother Pharmacol 2020; 85:711-722. [PMID: 32152679 PMCID: PMC7125253 DOI: 10.1007/s00280-019-04028-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/31/2019] [Indexed: 01/07/2023]
Abstract
Purpose To describe 5-fluorouracil (5FU) pharmacokinetics, myelotoxicity and respective covariates using a simultaneous nonlinear mixed effect modelling approach. Methods Thirty patients with gastrointestinal cancer received 5FU 650 or 1000 mg/m2/day as 5-day continuous venous infusion (14 of whom also received cisplatin 20 mg/m2/day). 5FU and 5-fluoro-5,6-dihydrouracil (5FUH2) plasma concentrations were described by a pharmacokinetic model using NONMEM. Absolute leukocyte counts were described by a semi-mechanistic myelosuppression model. Covariate relationships were evaluated to explain the possible sources of variability in 5FU pharmacokinetics and pharmacodynamics. Results Total clearance of 5FU correlated with body surface area (BSA). Population estimate for total clearance was 249 L/h. Clearances of 5FU and 5FUH2 fractionally changed by 77%/m2 difference from the median BSA. 5FU central and peripheral volumes of distribution were 5.56 L and 28.5 L, respectively. Estimated 5FUH2 clearance and volume of distribution were 121 L/h and 96.7 L, respectively. Baseline leukocyte count of 6.86 × 109/L, as well as mean leukocyte transit time of 281 h accounting for time delay between proliferating and circulating cells, was estimated. The relationship between 5FU plasma concentrations and absolute leukocyte count was found to be linear. A higher degree of myelosuppression was attributed to combination therapy (slope = 2.82 L/mg) with cisplatin as compared to 5FU monotherapy (slope = 1.17 L/mg). Conclusions BSA should be taken into account for predicting 5FU exposure. Myelosuppression was influenced by 5FU exposure and concomitant administration of cisplatin. Electronic supplementary material The online version of this article (10.1007/s00280-019-04028-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Usman Arshad
- Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, Department I of Pharmacology, University of Cologne, Cologne, Germany.
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden.
- Institute of Pharmacy, Clinical Pharmacy, University of Bonn, Bonn, Germany.
| | - Su-Arpa Ploylearmsaeng
- Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, Department I of Pharmacology, University of Cologne, Cologne, Germany
| | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Oxana Doroshyenko
- Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, Department I of Pharmacology, University of Cologne, Cologne, Germany
| | - Dorothee Langer
- Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, Department I of Pharmacology, University of Cologne, Cologne, Germany
| | - Edgar Schömig
- Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, Department I of Pharmacology, University of Cologne, Cologne, Germany
| | - Sabine Kunze
- Department of Radiotherapy, University Hospital Cologne, Cologne, Germany
| | - Semih A Güner
- Department of Radiotherapy, University Hospital Cologne, Cologne, Germany
| | | | - Sami Ullah
- Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, Department I of Pharmacology, University of Cologne, Cologne, Germany
- Institute of Pharmacy, Clinical Pharmacy, University of Bonn, Bonn, Germany
| | - Ulrich Jaehde
- Institute of Pharmacy, Clinical Pharmacy, University of Bonn, Bonn, Germany
| | - Uwe Fuhr
- Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, Department I of Pharmacology, University of Cologne, Cologne, Germany
| | - Alexander Jetter
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Max Taubert
- Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, Department I of Pharmacology, University of Cologne, Cologne, Germany
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van Kuilenburg AB, Maring JG. Evaluation of 5-fluorouracil pharmacokinetic models and therapeutic drug monitoring in cancer patients. Pharmacogenomics 2014; 14:799-811. [PMID: 23651027 DOI: 10.2217/pgs.13.54] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
5-fluorouracil (5-FU) remains the cornerstone of all currently applied regimens for the treatment of patients with cancers of the gastrointestinal tract, breast, and head and neck. Unfortunately, a large variation in the clearance of 5-FU has been observed between patients, suggesting that some patients might receive nonoptimal 5-FU doses. However, therapeutic drug monitoring of 5-FU has been shown to result in reduced intra- and inter-individual variability in 5-FU plasma levels and pharmacokinetically guided dose adjustments of 5-FU-containing therapy results in a significantly improved efficacy and tolerability. To date, compartmental Michaelis-Menten elimination-based modeling has proven to be a sensitive and accurate tool for analyzing the pharmacokinetics of 5-FU and to identify patients with a dihydropyrimidine dehydrogenase deficiency. These Michaelis-Menten models also allow the use of a limited sampling strategy and offer the opportunity to predict a priori the 5-FU plasma concentrations in patients receiving adapted doses of 5-FU.
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Affiliation(s)
- André Bp van Kuilenburg
- Academic Medical Center, University of Amsterdam, Emma Children's Hospital & Department of Clinical Chemistry, Laboratory Genetic Metabolic Diseases, F0-220, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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7
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Evaluation of 5-Fluorouracil Pharmacokinetics in Cancer Patients with a C.1905+1G>A Mutation in DPYD by Means of a Bayesian Limited Sampling Strategy. Clin Pharmacokinet 2012; 51:163-74. [DOI: 10.1007/bf03257473] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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8
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Predictors of survival and toxicity in patients on adjuvant therapy with 5-fluorouracil for colorectal cancer. Br J Cancer 2009; 100:1549-57. [PMID: 19384296 PMCID: PMC2696766 DOI: 10.1038/sj.bjc.6605052] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The present study aimed at investigating whether the simultaneous evaluation of pharmacokinetic, pharmacogenetic and demographic factors could improve prediction on toxicity and survival in colorectal cancer patients treated with adjuvant 5-fluorouracil (5FU)/leucovorin therapy. One hundred and thirty consecutive, B2 and C Duke's stage colorectal cancer patients were prospectively enrolled. 5FU pharmacokinetics was evaluated at the first cycle. Thymidylate synthase (TYMS) 5′UTR and 3′UTR polymorphisms and methylenetetrahydrofolate reductase (MTHFR) C677T and A1298C polymorphisms were assessed in peripheral leukocytes. Univariate and multivariate analyses were applied to evaluate which variables could predict chemotherapy-induced toxicity, disease-free survival (DFS) and overall survival (OS). Multivariate analysis showed that: (a) low 5FU clearance was an independent predictive factor for severe toxicity (OR=7.32; P<0.0001); (b) high-5FU clearance predicted poorer DFS (HR=1.96; P=0.041) and OS (HR=3.37; P=0.011); (c) advanced age was associated with shorter DFS (HR=3.34; P=0.0008) and OS (HR=2.66; P=0.024); (d) the C/C genotype of the MTHFR C677T polymorphism was protective against grade 3–4 toxicity (P=0.040); (e) none of the TYMS polymorphisms could explain 5FU toxicity or clinical outcome.
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Kaestner SA, Sewell GJ. Chemotherapy Dosing Part II: Alternative Approaches and Future Prospects. Clin Oncol (R Coll Radiol) 2007; 19:99-107. [PMID: 17355104 DOI: 10.1016/j.clon.2006.10.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This overview follows on from part I, which described the current practices used in chemotherapy dosing and the paucity of scientific evidence to support them. In part II, alternative approaches are discussed, both in terms of scientific rationale and practical application. These include therapeutic drug monitoring, the use of pharmacokinetic-pharmacodynamic relationships, flat-fixed dosing, Bayesian modelling and dose banding.
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Affiliation(s)
- S A Kaestner
- Department of Pharmacy and Pharmacology, 5W, University of Bath, Claverton Down, Bath BA2 7AY, UK
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Ploylearmsaeng SA, Fuhr U, Jetter A. How may anticancer chemotherapy with fluorouracil be individualised? Clin Pharmacokinet 2006; 45:567-92. [PMID: 16719540 DOI: 10.2165/00003088-200645060-00002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Fluorouracil is used clinically against various solid tumours. Both fluorouracil toxicity and pharmacokinetics vary highly within and between individuals. The reasons why doses are not individualised routinely are difficulties in defining, predicting and achieving an optimal fluorouracil exposure or dose because of a narrow therapeutic index, nonlinear pharmacokinetics, variabilities in administration rates and metabolism, and in targets like thymidylate synthase. To individualise fluorouracil administration before the first dose, assessment of the individual dihydropyrimidine dehydrogenase (DPD) activity may be useful, because this genetically highly polymorphic enzyme controls approximately 80% of fluorouracil elimination. A complete or partial loss of DPD activity in 0.1 and 3-5% of Caucasians, respectively, leads to increased fluorouracil exposure and toxicity. Several methods to assess DPD activity in patients have been proposed (genotyping, various phenotyping methods), but each of them has limitations, as has the fluorouracil test dose approach. To adapt exposure towards fluorouracil a priori, a combination of genotyping and phenotyping may yield better prediction of toxicity than one method alone. A prerequisite for dose adaptation is the definition of fluorouracil exposure ranges with sufficient therapeutic activity, but without serious toxicity. While an increased risk of leukopenia, diarrhoea, stomatitis, and hand-foot syndrome during continuous 5-day infusions was related to fluorouracil exposures above an area under the plasma concentration-time curve (AUC) threshold of 25-30 mg.h/L, tumour response was higher when an AUC of approximately 30 mg.h/L was achieved, illustrating the extremely narrow therapeutic window of fluorouracil. Pharmacokinetic target values are less clear for other regimens, including chronomodulated regimens, which yielded a superior clinically efficacy and tolerability in several trials. However, the monitoring of fluorouracil plasma concentrations seems principally useful for individual a posteriori dose adjustment. Whether an adaptation of the fluorouracil starting dose to the results of two DPD activity tests before fluorouracil administration a priori, and the adaptation of doses to fluorouracil exposure a posteriori is a reasonable approach to better prevent toxicity and increase efficacy, remains to be evaluated in randomised clinical studies comparing these strategies to routine clinical safety monitoring.
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Affiliation(s)
- Su-arpa Ploylearmsaeng
- Department of Pharmacology, Clinical Pharmacology, University Hospital of Cologne, Cologne, Germany
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Gusella M, Crepaldi G, Barile C, Bononi A, Menon D, Toso S, Scapoli D, Stievano L, Ferrazzi E, Grigoletto F, Ferrari M, Padrini R. Pharmacokinetic and demographic markers of 5-fluorouracil toxicity in 181 patients on adjuvant therapy for colorectal cancer. Ann Oncol 2006; 17:1656-60. [PMID: 16968871 DOI: 10.1093/annonc/mdl284] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The relationship between 5-fluorouracil (5-FU) pharmacokinetics and toxicity following i.v. bolus administration has not been extensively studied. PATIENTS AND METHODS One hundred and eighty-one patients on adjuvant therapy with 5-FU plus leucovorin for colorectal cancer were the study population. 5-FU pharmacokinetics was determined on day 2 of the first, third, and fifth cycles; type and the grade of adverse reactions were recorded on the next cycle. RESULTS The 5-FU area under the curve (AUC) measured at the first cycle ranged between 146 and 1236 mg x min/l and was significantly correlated with drug dose, patients' body weight (BW) and gender, females having higher AUCs. These covariates explained only 23% of AUC variability. AUC and age were the only covariates which discriminated between toxic (grade > or =2) and nontoxic cycles (grade <2), with an optimal AUC cut-off value of 596 mg x min/l. Such a correlation was lost during the next cycles following dose reduction because of toxicity in 80 patients. CONCLUSIONS A method for calculating the initial 5-FU dose is proposed which takes into account patient BW, gender and a target AUC of 596 mg x min/l. Nevertheless, it appears that a substantial part of 5-FU toxicity is not linked to pharmacokinetic factors and dose adjustments must still be on the basis of careful clinical surveillance.
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Affiliation(s)
- M Gusella
- Oncology Division, Rovigo General Hospital, Rovigo, Italy.
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Gusella M, Rebeschini M, Cartei G, Ferrazzi E, Ferrari M, Padrini R. Effect of Hemodialysis on the Metabolic Clearance of 5-Fluorouracil in a Patient With End-Stage Renal Failure. Ther Drug Monit 2005; 27:816-8. [PMID: 16306860 DOI: 10.1097/01.ftd.0000183384.89275.f4] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 64-year-old man on chronic hemodialysis for end-stage renal disease developed peritoneal carcinomatosis, and palliative chemotherapy with fluorouracil was started. The drug was administered (325 mg/m as IV bolus, at 2 PM) on 2 separate occasions, ie, 1 hour after dialysis and 2 days later, 49 hours after dialysis. The time course of the fluorouracil plasma concentration was determined, and the main pharmacokinetic parameters were calculated. The slope of the monoexponential decay of plasma concentration was significantly greater 1 hour (0.161 minutes) than 49 hours after dialysis (0.127 minutes), and plasma clearance was correspondingly higher (1.78 L/min versus 1.46 L/min). The volume of distribution did not change (11.1 L versus 11.5 L). Because fluorouracil is minimally excreted by the renal route (about 10% of the dose) and is almost entirely metabolized by dihydropyrimidine dehydrogenase (DPD), it is suggested that plasma factors that accumulate during the interdialytic period and are removed by dialysis may inhibit DPD activity and, consequently, fluorouracil metabolic clearance.
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Affiliation(s)
- Milena Gusella
- Nephrology and Dialysis Unit and Oncology Unit, Azienda-ULSS16 of Padova, Padova, Italy
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