Are 5-7 Days of Folic Acid Supplementation Necessary prior to Pemetrexed? Observations from a Case Series

Safety of Same-Day Vitamin B12 Supplementation in Patients Receiving Pemetrexed for the Treatment of Non-Small-Cell Lung Cancer or Pleural Mesothelioma: A Retrospective Analysis

BACKGROUND

Pemetrexed is a folate analog inhibitor for the treatment of non-small-cell lung cancer (NSCLC) and malignant pleural mesothelioma. Folic acid and vitamin B12 supplementation before initiating pemetrexed is necessary because of high rates of cytopenias without supplementation. However, the timing of supplementation has not been thoroughly investigated.

PATIENTS AND METHODS

This was a single-center, retrospective study investigating patients receiving pemetrexed from January 1, 2012, to June 30, 2015, who received same-day vitamin B12 supplementation versus ≥ 1 day before pemetrexed. The objective was to evaluate safety outcomes in patients who received vitamin B12 on the same day as pemetrexed (group A) versus vitamin B12 ≥ 1 day (group B) before pemetrexed.

RESULTS

Two hundred eighty-one patients met the inclusion criteria: 137 patients in group A (same-day administration of vitamin B12) and 144 patients in group B (median time of vitamin B12 administration before pemetrexed, 7 days; range, 1-42 days). Mean changes in hematologic indices from cycle (C) 1 to C2 or C2 to C3 did not differ significantly between groups. There were no significant differences in clinical events between C1 and C2 or C2 and C3 requiring supportive care. There was a significant difference noted in treatment delay in C3 [28/114 (24.6%) group A vs. 14/118 (11.9%) group B, P = .0164]. In group A, significant predictors of delay in C3 were baseline hemoglobin (mean 13.3 g/dL vs. 12.4 g/dL, P = .0137) and ANC (mean 6 × 10⁹/L vs. 5 × 10⁹/L, P = .0003).

CONCLUSION

Same-day vitamin B12 and pemetrexed administration is a safe practice in NSCLC and malignant pleural mesothelioma patients.

Association of Graded Folic Acid Supplementation and Total Plasma Homocysteine Levels With Hematological Toxicity During First-line Treatment of Nonsquamous NSCLC Patients With Pemetrexed-based Chemotherapy

BACKGROUND

Pemetrexed is the preferred treatment of nonsquamous non-small cell lung cancer (ns-NSCLC). Folic acid supplementation (FAS) (350 to 1000 μg daily PO) is recommended to minimize hematological toxicity (HTox). Elevated total plasma homocysteine (tpHcy) predicts increased risk of HTox with pemetrexed in absence of FAS. The current study aimed to assess prevalence of elevated tpHcy levels at baseline and after pemetrexed treatment. Association of graded tpHcy levels/FAS with toxicity was also assessed.

MATERIALS AND METHODS

Retrospective analysis of all ns-NSCLC patients undergoing first-line treatment with pemetrexed-containing platinum doublet over 3½ years was carried out. All eligible patients received pemetrexed (500 mg/m) and cisplatin (65 mg/m) each on D1 of a 3-week cycle. FAS was 400 μg for tpHcy< upper limit of normal (ULN), 700 μg for tpHcy 1 to 2 ULN, and 1000 μg for tpHcy>2 ULN. All patients also received oral ferrous sulphate and injectable vitamin B12. Exact 95% confidence intervals (CI) were calculated for comparison with previously published studies.

RESULTS

75.7% of 111 patients had stage IV disease. Prevalence of tpHcy levels <ULN, 1 to 2 ULN and >2 ULN were 47.8%, 41.4%, and 10.8% pretreatment and 78.9%, 21.1%, and 0% posttreatment, respectively (P<0.0001). Incidence of any grade and grade 3/4 HTox was 87.4% and 17.1% (anemia), 53.2% and 7.2% (leukopenia), 36.9% and 10.8% (neutropenia), and 39.6% and 7.2% (thrombocytopenia), respectively. HTox, non-HTox, and radiologic responses did not differ among patient groups based upon baseline tpHcy levels or upon graded baseline FAS. Incidence of grade 3/4 anemia was higher in current (17.1%; 95% CI, 11.3%-25.2%) as compared with previous studies.

CONCLUSIONS

Prevalence of elevated tpHcy levels posttreatment as compared with baseline was reduced significantly with FAS. Among ns-NSCLC patients treated with pemetrexed and with FAS of 400 to 1000 μg daily, HTox was not associated with either baseline tpHcy levels or with graded baseline FAS.

Efficacies and adverse reactions of modified vitamin supplement programs before pemetrexed chemotherapy as a second-line treatment against epidermal growth factor receptor (EGFR) mutant wild-type lung adenocarcinoma

OBJECTIVE

This study aims to observe the efficacies and adverse reactions of modified vitamin programs before pemetrexed chemotherapy (second-line treatment) against epidermal growth factor receptor (EGFR) mutant wild-type lung adenocarcinoma.

METHODS

477 patients with IIIB, phase IV glomerular filtration rate (GFR) mutant-negative lung adenocarcinomas and performed pemetrexed chemotherapy were collected and divided into group A (167 cases, with modified program) and group B (310 cases, with traditional program). The modified program was: orally administrated 400 μg folic acid once per day and 1 day before the first-round pemetrexed chemotherapy, until the 21st day of the final administration of pemetrexed, and intramuscularly injected 500 μg vitamin B12 1 day before the first-round pemetrexed chemotherapy, and injected once 1 day before every round pemetrexed treatment.

RESULTS

Comparison between group A and group B: mean chemotherapy cycles (4.08 vs 3.98); effectiveness rate (22.16% vs 22.90%); disease control rate (56.51% vs 55.00%); without significant difference (P > 0.05). Two groups currently all reached the median overall survival (OS). The median progression-free survival (PFS): 4.2 vs 4.1 months; OS: 12.9 vs 13.2 months, without statistical difference (P > 0.05). Such side effects between the two groups as leukopenia, neutropenia, thrombocytopenia, anemia, nausea, vomiting, diarrhea, fatigue, creatinine increasing, alanine transaminase (ALT) increasing, stomatitis, peripheral neuropathy, alopecia and rash had no significant difference (P > 0.05).

CONCLUSIONS

The modified vitamin supportive treatment could ensure the efficacy, significantly simplify, facilitate the clinical application, and increase the associated toxicities, indicating that the pemetrexed-based chemotherapy did not need to be delayed because applying the vitamin supportive treatment.