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Subash S, Singh DK, Ahire D, Khojasteh SC, Murray BP, Zientek MA, Jones RS, Kulkarni P, Zubair F, Smith BJ, Heyward S, Leeder JS, Prasad B. Ontogeny of Human Liver Aldehyde Oxidase: Developmental Changes and Implications for Drug Metabolism. Mol Pharm 2024; 21:2740-2750. [PMID: 38717252 DOI: 10.1021/acs.molpharmaceut.3c01147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Despite the increasing importance of aldehyde oxidase (AO) in the drug metabolism of clinical candidates, ontogeny data for AO are limited. The objective of our study was to characterize the age-dependent AO content and activity in the human liver cytosolic fraction (HLC) and human hepatocytes (HH). HLC (n = 121 donors) and HH (n = 50 donors) were analyzed for (1) AO protein content by quantitative proteomics and (2) enzyme activity using carbazeran as a probe substrate. AO activity showed high technical variability and poor correlation with the content in HLC samples, whereas hepatocyte samples showed a strong correlation between the content and activity. Similarly, AO content and activity showed no significant age-dependent differences in HLC samples, whereas the average AO content and activity in hepatocytes increased significantly (∼20-40-fold) from the neonatal levels (0-28 days). Based on the hepatocyte data, the age at which 50% of the adult AO content is reached (age50) was 3.15 years (0.32-13.97 years, 95% CI). Metabolite profiling of carbazeran revealed age-dependent metabolic switching and the role of non-AO mechanisms (glucuronidation and desmethylation) in carbazeran elimination. The content-activity correlation in hepatocytes improved significantly (R2 = 0.95; p < 0.0001) in samples showing <10% contribution of glucuronidation toward the overall metabolism, confirming that AO-mediated oxidation and glucuronidation are the key routes of carbazeran metabolism. Considering the confounding effect of glucuronidation on AO activity, AO content-based ontogeny data are a more direct reflection of developmental changes in protein expression. The comprehensive ontogeny data of AO in HH samples are more reliable than HLC data, which are important for developing robust physiologically based pharmacokinetic models for predicting AO-mediated metabolism in children.
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Affiliation(s)
- Sandhya Subash
- College of Pharmacy and Pharmaceutical Sciences, Washington State University (WSU), Spokane, Washington 99202, United States
| | - Dilip K Singh
- College of Pharmacy and Pharmaceutical Sciences, Washington State University (WSU), Spokane, Washington 99202, United States
| | - Deepak Ahire
- College of Pharmacy and Pharmaceutical Sciences, Washington State University (WSU), Spokane, Washington 99202, United States
| | - S Cyrus Khojasteh
- Drug Metabolism and Pharmacokinetics, Genentech, Inc., South San Francisco, California 94080, United States
| | - Bernard P Murray
- Drug Metabolism, Gilead Sciences, Inc., Foster City, California 94404, United States
| | - Michael A Zientek
- Drug Metabolism and Pharmacokinetics, Takeda Development Center Americas, Inc., San Diego, California 92121, United States
| | - Robert S Jones
- Drug Metabolism and Pharmacokinetics, Genentech, Inc., South San Francisco, California 94080, United States
| | - Priyanka Kulkarni
- Drug Metabolism and Pharmacokinetics, Takeda Pharmaceuticals, Inc., Cambridge, Massachusetts 02139, United States
| | - Faizan Zubair
- Drug Metabolism and Pharmacokinetics, Takeda Development Center Americas, Inc., San Diego, California 92121, United States
| | - Bill J Smith
- Terminal Phase Consulting LLC, Colorado Springs, Colorado 94404, United States
| | - Scott Heyward
- BioIVT, Inc., Baltimore, Maryland 21227, United States
| | - J Steven Leeder
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri 64108, United States
| | - Bhagwat Prasad
- College of Pharmacy and Pharmaceutical Sciences, Washington State University (WSU), Spokane, Washington 99202, United States
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Möhlmann JE, de Roock S, Egas AC, Weijden ET, Doeleman MJH, Huitema ADR, van Luin M, Swart JF. Adherence to low-dose methotrexate in children with juvenile idiopathic arthritis using a sensitive methotrexate assay. Pediatr Rheumatol Online J 2024; 22:52. [PMID: 38715014 PMCID: PMC11075236 DOI: 10.1186/s12969-024-00988-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/29/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Low-dose weekly methotrexate (MTX) is the mainstay of treatment in juvenile idiopathic arthritis. Unfortunately, a substantial part of patients has insufficient efficacy of MTX. A potential cause of this inadequate response is suboptimal drug adherence. The aim of this study was to assess MTX adherence in juvenile idiopathic arthritis patients by quantification of MTX concentrations in plasma. Secondly, the association between MTX concentrations and either self-reported adherence issues, or concomitant use of biologics was examined. METHODS This was a retrospective, observational study using plasma samples from juvenile idiopathic arthritis patients. An ultrasensitive liquid chromatography-tandem mass spectrometry method was developed for quantification of MTX and its metabolite 7-hydroxy-MTX in plasma. The determined MTX plasma concentrations in juvenile idiopathic arthritis patients were compared with corresponding adherence limits, categorising them as either adherent or possibly non-adherent to MTX therapy. RESULTS Plasma samples of 43 patients with juvenile idiopathic arthritis were analysed. Adherence to MTX in this population was 88% shortly after initiation of MTX therapy and decreased to 77% after one year of treatment. Teenagers were more at risk for non-adherence (p = 0.002). We could not find an association between MTX adherence with either self-reported adherence issues, nor with the use of concomitant biological treatment (p = 1.00 and p = 0.27, respectively; Fisher's Exact). CONCLUSIONS Quantification of MTX in plasma is a feasible and objective method to assess adherence in patients using low-dose weekly MTX. In clinical practice, the use of this method could be a helpful tool for physicians to refute or support suspicion of non-adherence to MTX therapy.
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Affiliation(s)
- Julia E Möhlmann
- Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Sytze de Roock
- Department of Pediatric Rheumatology and Immunology, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - Annelies C Egas
- Department of Clinical Diagnostics, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Evelien Ter Weijden
- Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Martijn J H Doeleman
- Department of Pediatric Rheumatology and Immunology, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek hospital, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Pharmacology, Princess Máxima Centre for Pediatric Oncology, Utrecht, The Netherlands
| | - Matthijs van Luin
- Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Joost F Swart
- Department of Pediatric Rheumatology and Immunology, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
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Arun B, Joshi M, Kakkar AK, Madki S, Ivaturi V, Chinnaswamy G, Banavali S, Gota V. Bioequivalence study followed by model-informed dose optimization of a powder for oral suspension of 6-mercaptopurine. Pediatr Blood Cancer 2024; 71:e30813. [PMID: 38110844 DOI: 10.1002/pbc.30813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/15/2023] [Accepted: 11/23/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND 6-Mercaptopurine (6MP) is the mainstay chemotherapy for acute lymphoblastic leukemia (ALL) and is conventionally available as 50 mg tablets. A new 6MP powder for oral suspension (PFOS 10 mg/mL) was developed recently by IDRS Labs, India, intended for pediatric use. A comparative pharmacokinetics of PFOS with T. mercaptopurine was conducted to determine the dose equivalence. METHODS An open-label, randomized, two-treatment, two-period, two-sequence, single oral dose, crossover, bioequivalence study was conducted on 51 healthy adult subjects. Post hoc, a population pharmacokinetic (PopPK) model was developed using the healthy volunteer data to perform simulations with various PFOS doses and select a bioequivalent dose. Further, to confirm the safety of PFOS in pediatrics, a simulation of 6MP and 6-thioguanine exposures was performed by incorporating the formulation-specific parameters derived from the healthy volunteer study into the PopPK model in childhood ALL available in literature. RESULTS The 6MP PFOS had 47% higher oral bioavailability compared to the reference product. Simulations using a two-compartmental PopPK model with dissolution and transit compartments showed that 40 mg of PFOS was found to be equivalent to 50 mg tablets. The simulated 6-thioguanine nucleotide concentrations in children using the dose adjusted for PFOS were between 114 and 703.6 pmol/8 × 108 RBC, which was within the range reported in pediatric ALL studies. CONCLUSION 6MP PFOS 10 mg/mL should be administered at a 20% lower dose than the tablet to achieve comparable exposure. 6MP PFOS addresses an unmet medical need for a liquid formulation of 6MP in the Indian subcontinent.
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Affiliation(s)
- Bhavatharini Arun
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Navi Mumbai, Maharashtra, India
| | | | | | | | | | - Girish Chinnaswamy
- Department of Paediatric Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
- Homi Bhabha National Institute, Anushakthinagar, Mumbai, Maharashtra, India
| | - Shripad Banavali
- Department of Paediatric Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
- Homi Bhabha National Institute, Anushakthinagar, Mumbai, Maharashtra, India
| | - Vikram Gota
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Navi Mumbai, Maharashtra, India
- Homi Bhabha National Institute, Anushakthinagar, Mumbai, Maharashtra, India
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Nguyen TTT, Tanaka Y, Sanada M, Hosaka M, Tamai M, Kagami K, Komatsu C, Somazu S, Harama D, Kasai S, Watanabe A, Akahane K, Goi K, Inukai T. CRISPR/Cas9-Mediated Induction of Relapse-Specific NT5C2 and PRPS1 Mutations Confers Thiopurine Resistance as a Relapsed Lymphoid Leukemia Model. Mol Pharmacol 2023; 103:199-210. [PMID: 36669880 DOI: 10.1124/molpharm.122.000546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 12/13/2022] [Accepted: 01/04/2023] [Indexed: 01/21/2023] Open
Abstract
6-Mercaptopurine (6-MP) is a key component in maintenance therapy for childhood acute lymphoblastic leukemia (ALL). Recent next-generation sequencing analysis of childhood ALL clarified the emergence of the relapse-specific mutations of the NT5C2 and PRPS1 genes, which are involved in thiopurine metabolism. In this scenario, minor clones of leukemia cells could acquire the 6-MP-resistant phenotype as a result of the NT5C2 or PRPS1 mutation during chemotherapy (including 6-MP treatment) and confer disease relapse after selective expansion. Thus, to establish new therapeutic modalities overcoming 6-MP resistance in relapsed ALL, human leukemia models with NT5C2 and PRPS1 mutations in the intrinsic genes are urgently required. Here, mimicking the initiation process of the above clinical course, we sought to induce two relapse-specific hotspot mutations (R39Q mutation of the NT5C2 gene and S103N mutation of the PRPS1 gene) into a human lymphoid leukemia cell line by homologous recombination (HR) using the CRISPR/Cas9 system. After 6-MP selection of the cells transfected with Cas9 combined with single-guide RNA and donor DNA templates specific for either of those two mutations, we obtained the sublines with the intended NT5C2-R39Q and PRPS1-S103N mutation as a result of HR. Moreover, diverse in-frame small insertion/deletions were also confirmed in the 6-MP-resistant sublines at the target sites of the NT5C2 and PRPS1 genes as a result of nonhomologous end joining. These sublines are useful for molecular pharmacological evaluation of the NT5C2 and PRPS1 gene mutations in the 6-MP sensitivity and development of therapy overcoming the thiopurine resistance of leukemia cells. SIGNIFICANCE STATEMENT: Mimicking the initiation process of relapse-specific mutations of the NT5C2 and PRPS1 genes in childhood acute lymphoblastic leukemia treated with 6-mercaptopurine (6-MP), this study sought to introduce NT5C2-R39Q and PRPS1-S103N mutations into a human lymphoid leukemia cell line by homologous recombination using the CRISPR/Cas9 system. In the resultant 6-MP-resistant sublines, the intended mutations and diverse in-frame small insertions/deletions were confirmed, indicating that the obtained sublines are useful for molecular pharmacological evaluation of the NT5C2 and PRPS1 gene mutations.
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Affiliation(s)
- Thao Thu Thi Nguyen
- Department of Pediatrics, University of Yamanashi, Yamanashi, Japan (T.T.T.N., M.T., K.K., C.K., S.S., D.H., S.K., A.W., K.A., K.G., T.I.); Division of Medicinal Safety Science, National Institutes of Health Sciences, Kanagawa, Japan (Y.T.); and Advanced Diagnostic Research Department, Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Japan (M.S., M.H.)
| | - Yoichi Tanaka
- Department of Pediatrics, University of Yamanashi, Yamanashi, Japan (T.T.T.N., M.T., K.K., C.K., S.S., D.H., S.K., A.W., K.A., K.G., T.I.); Division of Medicinal Safety Science, National Institutes of Health Sciences, Kanagawa, Japan (Y.T.); and Advanced Diagnostic Research Department, Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Japan (M.S., M.H.)
| | - Masashi Sanada
- Department of Pediatrics, University of Yamanashi, Yamanashi, Japan (T.T.T.N., M.T., K.K., C.K., S.S., D.H., S.K., A.W., K.A., K.G., T.I.); Division of Medicinal Safety Science, National Institutes of Health Sciences, Kanagawa, Japan (Y.T.); and Advanced Diagnostic Research Department, Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Japan (M.S., M.H.)
| | - Masumi Hosaka
- Department of Pediatrics, University of Yamanashi, Yamanashi, Japan (T.T.T.N., M.T., K.K., C.K., S.S., D.H., S.K., A.W., K.A., K.G., T.I.); Division of Medicinal Safety Science, National Institutes of Health Sciences, Kanagawa, Japan (Y.T.); and Advanced Diagnostic Research Department, Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Japan (M.S., M.H.)
| | - Minori Tamai
- Department of Pediatrics, University of Yamanashi, Yamanashi, Japan (T.T.T.N., M.T., K.K., C.K., S.S., D.H., S.K., A.W., K.A., K.G., T.I.); Division of Medicinal Safety Science, National Institutes of Health Sciences, Kanagawa, Japan (Y.T.); and Advanced Diagnostic Research Department, Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Japan (M.S., M.H.)
| | - Keiko Kagami
- Department of Pediatrics, University of Yamanashi, Yamanashi, Japan (T.T.T.N., M.T., K.K., C.K., S.S., D.H., S.K., A.W., K.A., K.G., T.I.); Division of Medicinal Safety Science, National Institutes of Health Sciences, Kanagawa, Japan (Y.T.); and Advanced Diagnostic Research Department, Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Japan (M.S., M.H.)
| | - Chiaki Komatsu
- Department of Pediatrics, University of Yamanashi, Yamanashi, Japan (T.T.T.N., M.T., K.K., C.K., S.S., D.H., S.K., A.W., K.A., K.G., T.I.); Division of Medicinal Safety Science, National Institutes of Health Sciences, Kanagawa, Japan (Y.T.); and Advanced Diagnostic Research Department, Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Japan (M.S., M.H.)
| | - Shinpei Somazu
- Department of Pediatrics, University of Yamanashi, Yamanashi, Japan (T.T.T.N., M.T., K.K., C.K., S.S., D.H., S.K., A.W., K.A., K.G., T.I.); Division of Medicinal Safety Science, National Institutes of Health Sciences, Kanagawa, Japan (Y.T.); and Advanced Diagnostic Research Department, Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Japan (M.S., M.H.)
| | - Daisuke Harama
- Department of Pediatrics, University of Yamanashi, Yamanashi, Japan (T.T.T.N., M.T., K.K., C.K., S.S., D.H., S.K., A.W., K.A., K.G., T.I.); Division of Medicinal Safety Science, National Institutes of Health Sciences, Kanagawa, Japan (Y.T.); and Advanced Diagnostic Research Department, Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Japan (M.S., M.H.)
| | - Shin Kasai
- Department of Pediatrics, University of Yamanashi, Yamanashi, Japan (T.T.T.N., M.T., K.K., C.K., S.S., D.H., S.K., A.W., K.A., K.G., T.I.); Division of Medicinal Safety Science, National Institutes of Health Sciences, Kanagawa, Japan (Y.T.); and Advanced Diagnostic Research Department, Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Japan (M.S., M.H.)
| | - Atsushi Watanabe
- Department of Pediatrics, University of Yamanashi, Yamanashi, Japan (T.T.T.N., M.T., K.K., C.K., S.S., D.H., S.K., A.W., K.A., K.G., T.I.); Division of Medicinal Safety Science, National Institutes of Health Sciences, Kanagawa, Japan (Y.T.); and Advanced Diagnostic Research Department, Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Japan (M.S., M.H.)
| | - Koushi Akahane
- Department of Pediatrics, University of Yamanashi, Yamanashi, Japan (T.T.T.N., M.T., K.K., C.K., S.S., D.H., S.K., A.W., K.A., K.G., T.I.); Division of Medicinal Safety Science, National Institutes of Health Sciences, Kanagawa, Japan (Y.T.); and Advanced Diagnostic Research Department, Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Japan (M.S., M.H.)
| | - Kumiko Goi
- Department of Pediatrics, University of Yamanashi, Yamanashi, Japan (T.T.T.N., M.T., K.K., C.K., S.S., D.H., S.K., A.W., K.A., K.G., T.I.); Division of Medicinal Safety Science, National Institutes of Health Sciences, Kanagawa, Japan (Y.T.); and Advanced Diagnostic Research Department, Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Japan (M.S., M.H.)
| | - Takeshi Inukai
- Department of Pediatrics, University of Yamanashi, Yamanashi, Japan (T.T.T.N., M.T., K.K., C.K., S.S., D.H., S.K., A.W., K.A., K.G., T.I.); Division of Medicinal Safety Science, National Institutes of Health Sciences, Kanagawa, Japan (Y.T.); and Advanced Diagnostic Research Department, Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Japan (M.S., M.H.)
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Bajaj AO, Kushnir MM, Kish-Trier E, Law RN, Zuromski LM, Molinelli AR, McMillin GA, Johnson-Davis KL. LC-MS/MS Method for Measurement of Thiopurine Nucleotides (TN) in Erythrocytes and Association of TN Concentrations With TPMT Enzyme Activity. Front Pharmacol 2022; 13:836812. [PMID: 35387339 PMCID: PMC8978547 DOI: 10.3389/fphar.2022.836812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Monitoring concentrations of thiopurine metabolites is used clinically to prevent adverse effects in patients on thiopurine drug therapy. We developed a LC-MS/MS method for the quantification of 6-thioguanine (6-TG) and 6-methylmercaptopurine (6-MMP) in red blood cells (RBCs). This method utilizes an automated cell washer for RBC separation from whole blood samples and washing of the separated RBCs. The lower limit of quantification of the method was 0.2 μmol/L for 6-TG (∼50 pmol/8 × 108 RBC) and 4 μmol/L for 6-MMP (∼1,000 pmol/8 × 108 RBC). The total imprecision of the assay was <3.0%. The upper limit of linearity for 6-TG and 6-MMP was 7.5 μmol/L and 150 μmol/L, respectively. The stability of the thiopurine metabolites under pre- and post-analytically relevant conditions was also evaluated. A good agreement was observed between this method and validated LC-MS/MS methods from three laboratories, except for ∼40% low bias for 6-MMP observed in one of the methods. The assessment of the association between 6-TG and 6-MMP concentrations with thiopurine S-methyltransferase (TPMT) phenotype and genotype demonstrated a statistically significant difference in the thiopurine metabolite concentrations between the TPMT groups with normal and intermediate activity of 6-MMP (p < 0.0001), while the difference in 6-TG concentrations was statistically not significant (p = 0.096). Among the samples with normal TPMT activity, higher concentrations of 6-MMP (p = 0.015) were observed in pediatric samples than in the samples of adults. No statistically significant differences were observed in the distributions of 6-TG and 6-MMP concentrations among the evaluated genotypes.
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Affiliation(s)
- Amol O Bajaj
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, United States
| | - Mark M Kushnir
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, United States.,University of Utah Health Sciences Center, Department of Pathology, Salt Lake City, UT, United States
| | - Erik Kish-Trier
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, United States
| | - Rachel N Law
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, United States
| | - Lauren M Zuromski
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, United States
| | - Alejandro R Molinelli
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Gwendolyn A McMillin
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, United States.,University of Utah Health Sciences Center, Department of Pathology, Salt Lake City, UT, United States
| | - Kamisha L Johnson-Davis
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, United States.,University of Utah Health Sciences Center, Department of Pathology, Salt Lake City, UT, United States
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Nijstad AL, Barnett S, Lalmohamed A, Bérénos IM, Parke E, Carruthers V, Tweddle DA, Kong J, Zwaan CM, Huitema ADR, Veal GJ. Clinical pharmacology of cytotoxic drugs in neonates and infants: Providing evidence-based dosing guidance. Eur J Cancer 2022; 164:137-154. [PMID: 34865945 PMCID: PMC8914347 DOI: 10.1016/j.ejca.2021.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/11/2021] [Accepted: 11/01/2021] [Indexed: 01/29/2023]
Abstract
Cancer in neonates and infants is a rare but challenging entity. Treatment is complicated by marked physiological changes during the first year of life, excess rates of toxicity, mortality, and late effects. Dose optimisation of chemotherapeutics may be an important step to improving outcomes. Body size-based dosing is used for most anticancer drugs used in infants. However, dose regimens are generally not evidence based, and dosing strategies are frequently inconsistent between tumour types and treatment protocols. In this review, we collate available pharmacological evidence supporting dosing regimens in infants for a wide range of cytotoxic drugs. A systematic review was conducted, and available data ranked by a level of evidence (1-5) and a grade of recommendation (A-D) provided on a consensus basis, with recommended dosing approaches indicated as appropriate. For 9 of 29 drugs (busulfan, carboplatin, cyclophosphamide, daunorubicin, etoposide, fludarabine, isotretinoin, melphalan and vincristine), grade A was scored, indicating sufficient pharmacological evidence to recommend a dosing algorithm for infants. For busulfan and carboplatin, sufficient data were available to recommend therapeutic drug monitoring in infants. For eight drugs (actinomycin D, blinatumomab, dinutuximab, doxorubicin, mercaptopurine, pegaspargase, thioguanine and topotecan), some pharmacological evidence was available to guide dosing (graded as B). For the remaining drugs, including commonly used agents such as cisplatin, cytarabine, ifosfamide, and methotrexate, pharmacological evidence for dosing in infants was limited or non-existent: grades C and D were scored for 10 and 2 drugs, respectively. The review provides clinically relevant evidence-based dosing guidance for cytotoxic drugs in neonates and infants.
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Affiliation(s)
- A Laura Nijstad
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands.
| | - Shelby Barnett
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK
| | - Arief Lalmohamed
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, the Netherlands
| | - Inez M Bérénos
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, the Netherlands
| | - Elizabeth Parke
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK
| | - Vickyanne Carruthers
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK
| | - Deborah A Tweddle
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK; Great North Children's Hospital, NE1 4LP Newcastle Upon Tyne, UK
| | - Jordon Kong
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - C Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Department of Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Gareth J Veal
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK.
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Dreisig K, Brünner ED, Marquart HV, Helt LR, Nersting J, Frandsen TL, Jonsson OG, Taskinen M, Vaitkeviciene G, Lund B, Abrahamsson J, Lepik K, Schmiegelow K. TPMT polymorphisms and minimal residual disease after 6-mercaptopurine post-remission consolidation therapy of childhood acute lymphoblastic leukaemia. Pediatr Hematol Oncol 2021; 38:227-238. [PMID: 33205673 DOI: 10.1080/08880018.2020.1842570] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Bone marrow minimal residual disease (MRD) is the strongest predictor of relapse in children with acute lymphoblastic leukemia (ALL). 6-mercaptopurine (6MP) in ALL therapy has wide inter-individual variation in disposition and is strongly influenced by polymorphisms in the thiopurine methyltransferase (TPMT) gene. In 952 patients treated according to the NOPHO ALL2008 protocol, we explored the association between thiopurine disposition, TPMT genotypes and MRD levels after consolidation therapy with 6MP, high-dose methotrexate (HD-MTX), asparaginase, and vincristine. The levels of the cytotoxic DNA-incorporated thioguanine were significantly higher on day 70-79 in G460A/A719G TPMT heterozygous (TPMTHZ) compared to TPMT wild type (TPMTWT) patients (mean: 230.7 vs. 149.7 fmol/µg DNA, p = 0.002). In contrast, TPMT genotype did not associate with the end of consolidation MRD levels irrespective of randomization of the patients to fixed dose (25 mg/m2/day) or 6MP escalation (up to 50 or 75 mg/m2/day) during consolidation therapy.
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Affiliation(s)
- Karin Dreisig
- Pediatric Oncology research laboratory, The University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Emilie Damgaard Brünner
- Pediatric Oncology research laboratory, The University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Hanne V Marquart
- The Tissue Typing Laboratory, Department of Clinical Immunology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Louise Rold Helt
- Pediatric Oncology research laboratory, The University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jacob Nersting
- Pediatric Oncology research laboratory, The University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Thomas Leth Frandsen
- Department of Pediatrics and adolescent medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Mervi Taskinen
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Children and Adolescents, Helsinki University Hospital, Helsinki, Finland
| | - Goda Vaitkeviciene
- Children's Hospital, Vilnius University Hospital Santaros Klinikos and Vilnius University, Vilnius, Lithuania
| | - Bendik Lund
- Department of Pediatrics, St. Olavs Hospital, Trondheim; Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jonas Abrahamsson
- Department of Pediatrics, Institution for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Kjeld Schmiegelow
- Pediatric Oncology research laboratory, The University Hospital Rigshospitalet, Copenhagen, Denmark.,Department of Pediatrics and adolescent medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Denmark
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8
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Dynamics of leucocyte DNA thioguanine nucleotide levels during maintenance therapy of childhood acute lymphoblastic leukemia. Cancer Chemother Pharmacol 2021; 88:53-60. [PMID: 33754188 DOI: 10.1007/s00280-020-04219-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/20/2020] [Indexed: 10/21/2022]
Abstract
PURPOSE Methotrexate (MTX)/6-Mercaptopurine (6MP)-based maintenance therapy is crucial to cure childhood acute lymphoblastic leukemia (ALL). Cytotoxicity is mediated by incorporation of thioguanine nucleotides (TGN) into DNA (DNA-TG) with higher levels in leucocytes being associated with reduced relapse risk. To further understand the dynamics of DNA-TG formation, we measured DNA-TG levels in leucocyte subsets during maintenance therapy and in the months following its discontinuation. METHODS DNA-TG levels were measured in leucocytes (DNA-TGTotal), polymorph nucleated granulocytes (neutrophils, eosinophils, basophils [DNA-TGPMN]) and mononucleated cells (lymphocytes, monocytes [DNA-TGMNC]) in 1013 samples from 52 patients on ALL maintenance therapy (951 samples during therapy and 62 samples after therapy discontinuation, respectively). RESULTS Median DNA-TGTotal, DNA-TGPMN and DNA-TGMNC during maintenance therapy were 539, 563 and 384 fmol/µg DNA, respectively. DNA-TGPMN displayed more pronounced fluctuation than DNA-TGMNC (range 0-3084 [interquartile range IQR 271-881] versus 30-1411 [IQR 270-509] fmol/µg DNA). DNA-TGTotal was more strongly correlated with DNA-TGPMN (rS = 0.95, p < 0.0001) than DNA-TGMNC (rS = 0.73, p < 0.0001). DNA-TGPMN correlated less with DNA-TGMNC (rS = 0.64, p < 0.0001) and to a much lesser extent with absolute neutrophil count (rS = 0.35, p < 0.0001). Following discontinuation of therapy, DNA-TGPMN was rapidly eliminated, and not measurable beyond day 22 after discontinuation, whereas DNA-TGMNC was slowly eliminated, and five patients demonstrated a measurable DNA-TGMNC more than 365 days after therapy discontinuation. CONCLUSION Fluctuations in DNA-TGTotal are predominantly caused by corresponding fluctuations in DNA-TGPMN, thus DNA-TGTotal measures recent TGN incorporation in these short-lived cells. Measurement of DNA-TGTotal at 2-4 weeks intervals provides a reliable profile of DNA-TG levels.
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9
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Angiolillo AL, Schore RJ, Kairalla JA, Devidas M, Rabin KR, Zweidler-McKay P, Borowitz MJ, Wood B, Carroll AJ, Heerema NA, Relling MV, Hitzler J, Lane AR, Maloney KW, Wang C, Bassal M, Carroll WL, Winick NJ, Raetz EA, Loh ML, Hunger SP. Excellent Outcomes With Reduced Frequency of Vincristine and Dexamethasone Pulses in Standard-Risk B-Lymphoblastic Leukemia: Results From Children's Oncology Group AALL0932. J Clin Oncol 2021; 39:1437-1447. [PMID: 33411585 DOI: 10.1200/jco.20.00494] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE AALL0932 evaluated two randomized maintenance interventions to optimize disease-free survival (DFS) while reducing the burden of therapy in children with newly diagnosed NCI standard-risk (SR) B-acute lymphoblastic leukemia (B-ALL). METHODS AALL0932 enrolled 9,229 patients with B-ALL; 2,364 average-risk (AR) patients were randomly assigned (2 × 2 factorial design) at the start of maintenance therapy to vincristine/dexamethasone pulses every 4 (VCR/DEX4) or every 12 (VCR/DEX12) weeks, and a starting dose of weekly oral methotrexate of 20 mg/m2 (MTX20) or 40 mg/m2 (MTX40). RESULTS Five-year event-free survival and overall survival (OS) from enrollment (with 95% CIs), for all eligible and evaluable SR B-ALL patients (n = 9,226), were 92.0% (91.1% and 92.8%) and 96.8% (96.2% and 97.3%), respectively. The 5-year DFS and OS from the start of maintenance for randomly assigned AR patients were 94.6% (93.3% and 95.9%) and 98.5% (97.7% and 99.2%), respectively. The 5-year DFS and OS for patients randomly assigned to receive VCR/DEX4 (n = 1,186) versus VCR/DEX12 (n = 1,178) were 94.1% (92.2% and 96.0%) and 98.3% (97.2% and 99.4%) v 95.1% (93.3% and 96.9%) and 98.6% (97.7% and 99.6%), respectively (P = .86 and .69). The 5-year DFS and OS for AR patients randomly assigned to receive MTX20 versus MTX40 were 95.1% (93.3% and 96.8%) and 98.8% (97.9% and 99.7%) v 94.2% (92.2% and 96.1%) and 98.1% (97.0% and 99.2%), respectively (P = .92 and .89). CONCLUSIONS The 0NCI-SR AR B-ALL who received VCR/DEX12 had outstanding outcomes despite receiving one third of the vincristine/dexamethasone pulses previously used as standard of care on Children's Oncology Group (COG) trials. The higher starting dose of MTX of 40 mg/m2/week did not improve outcomes when compared with 20 mg/m2/week. The decreased frequency of vincristine/dexamethasone pulses has been incorporated into frontline COG B-ALL trials to decrease the burden of therapy for patients and their families.
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Affiliation(s)
- Anne L Angiolillo
- Children's National Medical Center, Washington, DC.,George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Reuven J Schore
- Children's National Medical Center, Washington, DC.,George Washington University School of Medicine and Health Sciences, Washington, DC
| | - John A Kairalla
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Karen R Rabin
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX
| | | | - Michael J Borowitz
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Brent Wood
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | | | - Nyla A Heerema
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | | | | | - Kelly W Maloney
- Children's Hospital Colorado and the Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Cindy Wang
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Mylène Bassal
- Division of Pediatric Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, ON
| | - William L Carroll
- Department of Pediatrics and Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY
| | - Naomi J Winick
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Elizabeth A Raetz
- Department of Pediatrics and Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY
| | - Mignon L Loh
- Department of Pediatrics, Benioff Children's Hospital, and the Helen Diller Family Comprehensive Cancer Institute, University of California, San Francisco, San Francisco, CA
| | - Stephen P Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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10
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Le TTT, Jost F, Raupach T, Zierk J, Rauh M, Suttorp M, Stanulla M, Metzler M, Sager S. A mathematical model of white blood cell dynamics during maintenance therapy of childhood acute lymphoblastic leukemia. MATHEMATICAL MEDICINE AND BIOLOGY-A JOURNAL OF THE IMA 2020; 36:471-488. [PMID: 30357334 DOI: 10.1093/imammb/dqy017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 08/30/2018] [Accepted: 10/02/2018] [Indexed: 11/12/2022]
Abstract
Acute lymphoblastic leukemia is the most common malignancy in childhood and requires prolonged oral maintenance chemotherapy to prevent disease relapse after remission induction with intensive intravenous chemotherapy. In maintenance therapy, drug doses of 6-mercaptopurine (6-MP) and methotrexate (MTX) are adjusted to achieve sustained antileukemic activity without excessive myelosuppression. However, uncertainty exists regarding timing and extent of drug dose responses and optimal dose adaptation strategies. We propose a novel comprehensive mathematical model for 6-MP and MTX pharmacokinetics, pharmacodynamics and myelosuppression in acute lymphoblastic maintenance therapy. We personalize and cross-validate the mathematical model using clinical data and propose a real-time algorithm to predict chemotherapy responses with a clinical decision support system as a potential future application.
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Affiliation(s)
- Thuy T T Le
- Institute of Mathematical Optimization, Faculty of Mathematics, Otto-von-Guericke University Magdeburg, Germany
| | - Felix Jost
- Institute of Mathematical Optimization, Faculty of Mathematics, Otto-von-Guericke University Magdeburg, Germany
| | - Thomas Raupach
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Jakob Zierk
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Manfred Rauh
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Meinolf Suttorp
- Pediatric Hematology and Oncology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Martin Stanulla
- Department of Pediatric Hemato-Oncology, Hannover Medical School, Hannover, Germany
| | - Markus Metzler
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Sebastian Sager
- Institute of Mathematical Optimization, Faculty of Mathematics, Otto-von-Guericke University Magdeburg, Germany
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11
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Larsen RH, Hjalgrim LL, Grell K, Kristensen K, Pedersen LG, Brünner ED, Als-Nielsen B, Schmiegelow K, Nersting J. Pharmacokinetics of tablet and liquid formulations of oral 6-mercaptopurine in children with acute lymphoblastic leukemia. Cancer Chemother Pharmacol 2020; 86:25-32. [PMID: 32519032 DOI: 10.1007/s00280-020-04097-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 06/04/2020] [Indexed: 01/15/2023]
Abstract
PURPOSE Mercaptopurine (6MP) is essential to cure childhood acute lymphoblastic leukemia (ALL). A liquid 6MP formulation was recently introduced to facilitate oral 6MP administration, especially to children. Its approval and bioequivalence with 6MP tablet were based on comparative pharmacokinetics in 60 healthy adults. Due to potential pharmacokinetic differences between healthy adults and children with ALL, we compared pharmacokinetics of tablet and liquid 6MP formulations in children with ALL. METHODS Pharmacokinetics of 50 mg 6MP tablet (Puri-Nethol®) and 20 mg/ml 6MP liquid suspension (Xaluprine®) were compared in a non-blinded, random order, single-dose, cross-over study in 16 children with ALL (eight males). 6MP was administered after a 12 h fast, and 6MP plasma concentrations measured consecutively over seven hours post-dose. Pharmacokinetic outcomes were as follows: Area under the curve (AUC), maximum plasma concentration (Cmax), time to maximum plasma concentration (Tmax), and terminal half-life (T½). RESULTS Liquid 6MP formulation resulted in a 26% lower AUC (p = 0.02) compared with tablet (median 1215 vs. 1805 h × nmol/l). No significant differences were observed for Cmax,Tmax and T½ (p = 0.28, p = 0.09, p = 0.41, respectively). Based on criteria declared by the World Health Organization the results did not establish non-inferiority of liquid 6MP formulation compared with 6MP tablet. CONCLUSION Non-inferiority of liquid 6MP formulation compared with 6MP tablet was not demonstrated. Yet, maintenance therapy doses are adjusted by degree of myelosuppression and not by 6MP dose. Thus, in spite of a lower bioavailability, a liquid 6MP formulation is still desirable in a clinical setting, especially for children. However, if shifting between 6MP formulation is indicated, dose adjustments should be anticipated to maintain equivalent treatment intensity in children with ALL. The study is registered on clinicaltrials.gov (NCT01906671). Date of registration: 24.07.13.
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Affiliation(s)
- Rikke Hebo Larsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lisa Lyngsie Hjalgrim
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kathrine Grell
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Kim Kristensen
- Discovery and Development PKPD, Novo Nordisk, Copenhagen, Denmark
| | - Line Gerner Pedersen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Emilie Damgaard Brünner
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Bodil Als-Nielsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Nersting
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.
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12
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Dragojević J, Marić P, Lončar J, Popović M, Mihaljević I, Smital T. Environmental contaminants modulate transport activity of zebrafish organic anion transporters Oat1 and Oat3. Comp Biochem Physiol C Toxicol Pharmacol 2020; 231:108742. [PMID: 32165351 DOI: 10.1016/j.cbpc.2020.108742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/28/2020] [Accepted: 03/06/2020] [Indexed: 10/24/2022]
Abstract
Organic anion transporters (OATs) are transmembrane proteins which belong to SLC22 subfamily. They are responsible for the uptake of various endo- and xenobiotics into the cells of different organs and tissues. Following our previous work on characterization of zebrafish Oat1 and Oat3, in this study we analyzed interaction of various classes of environmental contaminants with these membrane transporters using the transport activity assay with HEK293 Flp-In cell line stably overexpressing zebrafish Oat1 and Oat3, respectively. Based on the initial screening of a series of 36 environmental contaminants on their ability to interact with zebrafish Oat1 and Oat3, the most potent interactors were selected, their IC50 values calculated and type of interaction determined. Finally, to further confirm the type of interaction and initially evaluate their toxic potential, the cytotoxicity assays were performed. Broad ligand selectivity and similarity of zebrafish Oat1 and Oat3 with mammalian orthologs was confirmed and potent interactors among environmental contaminants identified.
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Affiliation(s)
- Jelena Dragojević
- Laboratory for Molecular Ecotoxicology, Division for Marine and Environmental Research, Ruđer Bošković Institute, Bijenička cesta 54, 10000 Zagreb, Croatia
| | - Petra Marić
- Laboratory for Molecular Ecotoxicology, Division for Marine and Environmental Research, Ruđer Bošković Institute, Bijenička cesta 54, 10000 Zagreb, Croatia
| | - Jovica Lončar
- Laboratory for Molecular Ecotoxicology, Division for Marine and Environmental Research, Ruđer Bošković Institute, Bijenička cesta 54, 10000 Zagreb, Croatia
| | - Marta Popović
- Laboratory for Molecular Ecotoxicology, Division for Marine and Environmental Research, Ruđer Bošković Institute, Bijenička cesta 54, 10000 Zagreb, Croatia
| | - Ivan Mihaljević
- Laboratory for Molecular Ecotoxicology, Division for Marine and Environmental Research, Ruđer Bošković Institute, Bijenička cesta 54, 10000 Zagreb, Croatia
| | - Tvrtko Smital
- Laboratory for Molecular Ecotoxicology, Division for Marine and Environmental Research, Ruđer Bošković Institute, Bijenička cesta 54, 10000 Zagreb, Croatia.
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13
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Quantification of Thiopurine Nucleotides in Erythrocytes and Clinical Application to Pediatric Acute Lymphoblastic Leukemia. Ther Drug Monit 2019; 41:75-85. [PMID: 30507626 PMCID: PMC6358190 DOI: 10.1097/ftd.0000000000000575] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: Concentrations of 6-thioguanine (6TG) nucleotides and 6-methylmercaptopurine (6MMP) nucleotides in RBCs were measured using liquid chromatography-tandem mass spectrometry (LC-MS/MS). This assay was validated for clinical use and was applied to blood samples from patients taking mercaptopurine (6MP). Methods: RBCs were hemolyzed and deproteinized using perchloric acid, followed by heating for the hydrolysis of nucleotides, and the resultant base was measured using LC-MS/MS. Precision, recovery, linearity, matrix effect, and limit of quantification was validated for clinical application. Our results were compared with another institution's established LC-MS/MS assay. We measured the concentrations of 6TG and 6MMP in RBCs of pediatric patients with acute lymphoblastic leukemia (ALL), and the clinical impact of those metabolites was investigated. Results: The imprecision coefficient of variations of 6TG and 6MMP were 5.7%–8.1%, and the bias was within 5%. Lower limits of quantification were set at 54 ng/mL for 6TG and 1036 ng/mL for 6MMP. Correlation coefficients for 6TG and 6MMP were 0.997 and 1.0 in a comparison study. For clinical proof-of-concept, 74 blood samples were collected from 37 pediatric ALL patients receiving maintenance therapy. Concentration of 6TG ranged from 16.1 to 880 pmol/8 × 108 RBCs and that of 6MMP from 55 to 20,937 pmol/8 × 108 RBCs. The 6MP metabolites were not correlated with WBC or absolute neutrophil count. On the other hand, the higher 6MMP level was associated with elevated alanine aminotransferase and aspartate aminotransferase. Conclusions: In this study, an assay for the quantification of 6TG and 6MMP in RBCs was established and applied to pediatric ALL patients. Interindividual variability in 6MP metabolite concentrations was considerable and associated with elevation of liver enzymes, which may be useful in the clinical monitoring of 6MP maintenance therapy in pediatric ALL patients.
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14
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Abedalthagafi M. Constitutional mismatch repair-deficiency: current problems and emerging therapeutic strategies. Oncotarget 2018; 9:35458-35469. [PMID: 30459937 PMCID: PMC6226037 DOI: 10.18632/oncotarget.26249] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/08/2018] [Indexed: 12/21/2022] Open
Abstract
Mismatch repair (MMR) proteins remove errors from newly synthesized DNA, improving the fidelity of DNA replication. A loss of MMR causes a mutated phenotype leading to a predisposition to cancer. In the last 20 years, an increasing number of patients have been described with biallelic MMR gene mutations in which MMR defects are inherited from both parents. This leads to a syndrome with recessive inheritance, referred to as constitutional mismatch repair-deficiency (CMMRD). CMMRD is a rare childhood cancer predisposition syndrome. The spectrum of CMMRD tumours is broad and CMMRD-patients possess a high risk of multiple cancers including hematological, brain and intestinal tumors. The severity of CMMRD is highlighted by the fact that patients do not survive until later life, emphasising the requirement for new therapeutic interventions. Many tumors in CMMRD-patients are hypermutated leading to the production of truncated protein products termed neoantigens. Neoantigens are recognized as foreign by the immune system and induce antitumor immune responses. There is growing evidence to support the clinical efficacy of neoantigen based vaccines and immune checkpoint inhibitors (collectively referred to as immunotherapy) for the treatment of CMMRD cancers. In this review, we discuss the current knowledge of CMMRD, the advances in its diagnosis, and the emerging therapeutic strategies for CMMRD-cancers.
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Affiliation(s)
- Malak Abedalthagafi
- Genomics Research Department, Saudi Human Genome Project, King Fahad Medical City, King Abdulaziz City for Science and Technology, Riyadh, Saudi Arabia
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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15
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Tulstrup M, Grosjean M, Nielsen SN, Grell K, Wolthers BO, Wegener PS, Jonsson OG, Lund B, Harila-Saari A, Abrahamsson J, Vaitkeviciene G, Pruunsild K, Toft N, Holm M, Hulegårdh E, Liestøl S, Griskevicius L, Punab M, Wang J, Carroll WL, Zhang Z, Dalgaard MD, Gupta R, Nersting J, Schmiegelow K. NT5C2 germline variants alter thiopurine metabolism and are associated with acquired NT5C2 relapse mutations in childhood acute lymphoblastic leukaemia. Leukemia 2018; 32:2527-2535. [PMID: 30201983 DOI: 10.1038/s41375-018-0245-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/12/2018] [Accepted: 07/19/2018] [Indexed: 12/18/2022]
Abstract
The antileukaemic drug 6-mercaptopurine is converted into thioguanine nucleotides (TGN) and incorporated into DNA (DNA-TG), the active end metabolite. In a series of genome-wide association studies, we analysed time-weighted means (wm) of erythrocyte concentrations of TGN (Ery-TGN) and DNA-TG in 1009 patients undergoing maintenance therapy for acute lymphoblastic leukaemia (ALL). In discovery analyses (454 patients), the propensity for DNA-TG incorporation (wmDNA-TG/wmEry-TGN ratio) was significantly associated with three intronic SNPs in NT5C2 (top hit: rs72846714; P = 2.09 × 10-10, minor allele frequency 15%). In validation analyses (555 patients), this association remained significant during both early and late maintenance therapy (P = 8.4 × 10-6 and 1.3 × 10-3, respectively). The association was mostly driven by differences in wmEry-TGN, but in regression analyses adjusted for wmEry-TGN (P < 0.0001), rs72846714-A genotype was also associated with a higher wmDNA-TG (P = 0.029). Targeted sequencing of NT5C2 did not identify any missense variants associated with rs72846714 or wmEry-TGN/wmDNA-TG. rs72846714 was not associated with relapse risk, but in a separate cohort of 180 children with relapsed ALL, rs72846714-A genotype was associated with increased occurrence of relapse-specific NT5C2 gain-of-function mutations that reduce cytosol TGN levels (P = 0.03). These observations highlight the impact of both germline and acquired mutations in drug metabolism and disease trajectory.
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Affiliation(s)
- Morten Tulstrup
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Marie Grosjean
- Department of Bio and Health Informatics, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Stine Nygaard Nielsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kathrine Grell
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Section of Biostatistics, Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Benjamin Ole Wolthers
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peder Skov Wegener
- Department of Pediatric Hematology and Oncology, H. C. Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | | | - Bendik Lund
- Department of Pediatrics, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Laboratory Medicine, Faculty of Medicine and Health sciences, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Arja Harila-Saari
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Jonas Abrahamsson
- Department of Pediatrics, Institution for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Goda Vaitkeviciene
- Clinic of Children's Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kaie Pruunsild
- Department of Onco-haematology, Talinn Children's Hospital, Talinn, Estonia
| | - Nina Toft
- Department of Hematology, University Hospital Rishospitalet, Copenhagen, Denmark
| | - Mette Holm
- Department of Haematology, Aarhus University Hospital, Aarhus, Denmark
| | - Erik Hulegårdh
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Sigurd Liestøl
- Department of Hematology, Ullevål University Hospital, Faculty Division Ullevål University Hospital, University of Oslo, Oslo, Norway
| | - Laimonas Griskevicius
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Hematology, Oncology and Transfusion Medicine Center, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Mari Punab
- Clinic of Hematology and Oncology, Tartu University Clinic, Tartu, Estonia
| | - Jinhua Wang
- Masonic Cancer Center, Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
| | - William L Carroll
- Department of Pediatrics, New York University Medical Center, Perlmutter Cancer Center, New York, NY, USA
| | - Zeyu Zhang
- Department of Bio and Health Informatics, Technical University of Denmark, Kongens Lyngby, Denmark.,Sino-Danish Center for Education and Research, University of Chinese Academy of Sciences, Beijing, China
| | - Marlene D Dalgaard
- Department of Bio and Health Informatics, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Ramneek Gupta
- Department of Bio and Health Informatics, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Jacob Nersting
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark. .,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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16
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Genomics and pharmacogenomics of pediatric acute lymphoblastic leukemia. Crit Rev Oncol Hematol 2018; 126:100-111. [PMID: 29759551 DOI: 10.1016/j.critrevonc.2018.04.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/21/2018] [Accepted: 04/03/2018] [Indexed: 12/14/2022] Open
Abstract
Acute lymphoblastic leukaemia (ALL) is a prevalent form of pediatric cancer that accounts for 70-80% of all leukemias. Genome-based analysis, exome sequencing, transcriptomics and proteomics have provided insight into genetic classification of ALL and helped identify novel subtypes of the disease. B and T cell-based ALL are two well-characterized genomic subtypes, significantly marked by bone marrow disorders, along with mutations in trisomy 21 and T53. The other ALLs include Early T-cell precursor ALL, Philadelphia chromosome-like ALL, Down syndrome-associated ALL and Relapsed ALL. Chromosomal number forms a basis of classification, such as, hypodiploid ALL, near-haploid, low-hypodiploid, high-hypodiploid and hypodiploid-ALL. Advances in therapies targeting ALL have been noteworthy, with significant pre-clinical and clinical studies on drug pharmacokinetics and pharmacodynamics. Methotrexate and 6-mercaptopurine are leading drugs with best demonstrated efficacies against childhood ALL. The drugs in combination, following dose titration, have also been used for maintenance therapy. Methotrexate-polyglutamate is a key metabolite that specifically targets the disease pathogenesis, and 6-thioguanine nucleotides, derived from 6-mercaptopurine, impede replication and transcription processes, inducing cytotoxicity. Additionally, glucocorticoids, asparaginase, anthracycline, vincristine and cytarabine that trans-repress gene expression, deprives cells of asparagine, triggers cell cycle arrest, influences cytochrome-P450 polymorphism and inhibits DNA polymerase, respectively, have been used in chemotherapy in ALL patients. Overall, this review covers the progress in genome technology related to different sub-types of ALL and pharmacokinetics and pharmacodynamics of its medications. It also enlightens adverse effects of current drugs, and emphasizes the necessity of genome-wide association studies for restricting childhood ALL.
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White-Koning M, Osborne C, Paci A, Boddy AV, Chatelut E, Veal GJ. Investigating the potential impact of dose banding for systemic anti-cancer therapy in the paediatric setting based on pharmacokinetic evidence. Eur J Cancer 2018; 91:56-67. [PMID: 29335155 PMCID: PMC5811050 DOI: 10.1016/j.ejca.2017.11.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/04/2017] [Accepted: 11/27/2017] [Indexed: 01/09/2023]
Abstract
Background To make systemic anti-cancer therapy (SACT) preparation more practicable, dose-banding approaches are currently being introduced in many clinical centres. The present study aimed to determine the potential impact of using recently developed National Health Service in England (NHSE) dose-banding tables in a paediatric setting. Methods Using pharmacokinetic parameters obtained from 385 drug administrations in 352 children aged from 1 month to 18 years, treated with five drugs (dactinomycin, busulfan, carboplatin, cyclophosphamide and etoposide), individual exposures (area under the plasma drug concentration versus time curve; AUC) obtained using doses rounded according to the published NHSE tables were calculated and compared with those obtained by standard dose calculation methods. Results For all five drugs, the relative variation between the NHSE dose and the recommended dose (RecDose) (standard individually calculated dose) was between −6% and +5% as expected. In terms of AUC, there was no statistically significant difference in precision between exposures obtained by the RecDose and those obtained with dose banding (absolute value of relative difference 15–34%). Conclusion Based on pharmacokinetic data for these five drugs, the results generated support the implementation of NHSE dose-banding tables. Indeed, inter-patient variability in drug clearance and exposure far outweighs the impact of relatively small drug dose changes associated with dose banding. The potential impact of using dose-banding tables in the setting of childhood cancer has been investigated. In 352 children receiving five anticancer drugs no difference was found in exposures using dose banding or recommended doses. Results generated support the implementation of National Health Service in England dose-banding tables.
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Affiliation(s)
- Melanie White-Koning
- CRCT (Cancer Research Centre of Toulouse), Université de Toulouse, Inserm UMR 1037, Université Paul Sabatier, 31059 Toulouse Cedex 9, France.
| | - Caroline Osborne
- Pharmacy Department, Alder Hey Children's NHS Foundation Trust, Liverpool L12 2AP, UK
| | - Angelo Paci
- UMR CNRS 8203, Institut Gustave Roussy, 94805 Villejuif Cedex, France
| | - Alan V Boddy
- Faculty of Pharmacy, University of Sydney, Sydney, NSW 2006, Australia
| | - Etienne Chatelut
- CRCT (Cancer Research Centre of Toulouse), Université de Toulouse, Inserm UMR 1037, Université Paul Sabatier, 31059 Toulouse Cedex 9, France; Institut Claudius Regaud, Institut Universitaire Du Cancer Toulouse-Oncopole, 31059 Toulouse Cedex 9, France
| | - Gareth J Veal
- Northern Institute for Cancer Research, Newcastle University, Newcastle Upon Tyne NE2 4HH, UK
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DNA-thioguanine nucleotide concentration and relapse-free survival during maintenance therapy of childhood acute lymphoblastic leukaemia (NOPHO ALL2008): a prospective substudy of a phase 3 trial. Lancet Oncol 2017; 18:515-524. [PMID: 28258828 DOI: 10.1016/s1470-2045(17)30154-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 01/09/2017] [Accepted: 01/17/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Adjustment of mercaptopurine and methotrexate maintenance therapy of acute lymphoblastic leukaemia by leucocyte count is confounded by natural variations. Cytotoxicity is primarily mediated by DNA-incorporated thioguanine nucleotides (DNA-TGN). The aim of this study was to establish whether DNA-TGN concentrations in blood leucocytes during maintenance therapy are associated with relapse-free survival. METHODS In this substudy of the NOPHO ALL2008 phase 3 trial done in 23 hospitals in seven European countries (Denmark, Estonia, Finland, Iceland, Lithuania, Norway, and Sweden), we analysed data from centralised and blinded analyses of 6-mercaptopurine and methotrexate metabolites in blood samples from patients with non-high-risk childhood acute lymphoblastic leukaemia. Eligible patients were aged 1·0-17·9 years; had been diagnosed with non-high-risk precursor B-cell or T-cell leukaemia; had been treated according to the Nordic Society of Pediatric Hematology and Oncology ALL2008 protocol; and had reached maintenance therapy in first remission. Maintenance therapy was (mercaptopurine 75 mg/m2 once per day and methotrexate 20 mg/m2 once per week, targeted to a leucocyte count of 1·5-3·0 × 109 cells per L). We measured DNA-TGN and erythrocyte concentrations of TGN nucleotides, methylated mercaptopurine metabolites, and methotrexate polyglutamates. The primary objective was the association of DNA-TGN concentrations and 6-mercaptopurine and methotrexate metabolites with relapse-free survival. The secondary endpoint was the assessment of DNA-TGN concentration and 6-mercaptopurine and methotrexate metabolites during maintenance therapy phase 2. FINDINGS Between Nov 26, 2008 and June 14, 2016, 1509 patients from the NOPHO ALL2008 study were assessed for eligibility in the DNA-TGN substudy, of which 918 (89%) of 1026 eligible patients had at least one DNA-TGN measurement and were included in the analyses. Median follow-up was 4·6 years (IQR 3·1-6·1). Relapse-free survival was significantly associated with DNA-TGN concentration (adjusted hazard ratio 0·81 per 100 fmol/μg DNA increase, 95% CI 0·67-0·98; p=0·029). In patients with at least five blood samples, erythrocyte concentrations of TGN, methylated mercaptopurine metabolites, and methotrexate polyglutamates were associated with DNA-TGN concentration (all p<0·0001). INTERPRETATION Our results suggest the need for intervention trials to identify clinically applicable strategies for individualised drug dosing to increase DNA-TGN concentration, and randomised studies to investigate whether such strategies improve cure rates compared with current dose adjustments based on white blood cell counts. FUNDING Danish Cancer Society, Childhood Cancer Foundation (Denmark), Childhood Cancer Foundation (Sweden), Nordic Cancer Union, Otto Christensen Foundation, University Hospital Rigshospitalet, and Novo Nordic Foundation.
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Sawicki E, Schellens JHM, Beijnen JH, Nuijen B. Inventory of oral anticancer agents: Pharmaceutical formulation aspects with focus on the solid dispersion technique. Cancer Treat Rev 2016; 50:247-263. [PMID: 27776286 DOI: 10.1016/j.ctrv.2016.09.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 09/13/2016] [Indexed: 11/16/2022]
Abstract
Dissolution from the pharmaceutical formulation is a prerequisite for complete and consistent absorption of any orally administered drug, including anticancer agents (oncolytics). Poor dissolution of an oncolytic can result in low oral bioavailability, high variability in blood concentrations and with that suboptimal or even failing therapy. This review discusses pharmaceutical formulation aspects and absorption pharmacokinetics of currently licensed orally administered oncolytics. In nearly half of orally dosed oncolytics poor dissolution is likely to play a major role in low and unpredictable absorption. Dissolution-limited drug absorption can be improved with a solid dispersion which is a formulation method that induces super-saturated drug dissolution and with that it enhances in vivo absorption. This review discusses formulation principles with focus on the solid dispersion technology and how it works to enhance drug absorption. There are currently three licensed orally dosed oncolytics formulated as a solid dispersion (everolimus, vemurafenib and regorafenib) and these formulations result in remarkably improved dissolution and absorption compared to what can be achieved with conventional formulations of the respective oncolytics. Because of the successful implementation of these three solid dispersion formulations, we encourage the application of this formulation method for poorly soluble oral oncolytics.
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Affiliation(s)
- E Sawicki
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute/MC Slotervaart, Louwesweg 6, 1066 EC Amsterdam, The Netherlands.
| | - J H M Schellens
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; Science Faculty, Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmaco-epidemiology & Clinical Pharmacology, Utrecht University, P.O. Box 80082, 3508 TB Utrecht, The Netherlands
| | - J H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute/MC Slotervaart, Louwesweg 6, 1066 EC Amsterdam, The Netherlands; Department of Clinical Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; Science Faculty, Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmaco-epidemiology & Clinical Pharmacology, Utrecht University, P.O. Box 80082, 3508 TB Utrecht, The Netherlands
| | - B Nuijen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute/MC Slotervaart, Louwesweg 6, 1066 EC Amsterdam, The Netherlands
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Tiphaine ADB, Hjalgrim LL, Nersting J, Breitkreutz J, Nelken B, Schrappe M, Stanulla M, Thomas C, Bertrand Y, Leverger G, Baruchel A, Schmiegelow K, Jacqz-Aigrain E. Evaluation of a pediatric liquid formulation to improve 6-mercaptopurine therapy in children. Eur J Pharm Sci 2016; 83:1-7. [PMID: 26657824 DOI: 10.1016/j.ejps.2015.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 08/21/2015] [Accepted: 12/01/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND 6-mercaptopurine (6-MP), a key drug for treatment of acute lymphoblastic leukemia (ALL), has until recently had no adequate formulation for pediatric patients. Several approaches have been taken but the only oral paraben-free 6-MP liquid formulation named Loulla was developed and evaluated in the target population. Preclinical and clinical evaluations were performed according to a Pediatric Investigation Plan, in order to apply for a Pediatric Use Marketing Authorization. METHODS The pre-clinical study assessed the maximum tolerated dosage-volume and evaluated local mucosal toxicity of 28 daily administrations in treated compared to controls gold hamsters. The multi-centre clinical study was single-dose, open-label, crossover trial, conducted in 15 ALL children during maintenance therapy. The bioavailability and palatability of a single 50mg fixed dose of Loulla compared to 50mg registered tablets were evaluated in a random order on two consecutive days. Seven blood samples over 9h were obtained each day to determine 6-MP pharmacokinetic parameters, including Tmax, Cmax, AUC0-9 and AUC0-∞. A questionnaire adapted to children testing Loulla palatability and preference for either Loulla or the usual 6-MP tablet was completed. Occurrence of adverse events was determined at study visits by vital sign measurements, patient's spontaneous reporting, investigator's questioning and clinical examination. RESULTS The preclinical study in gold hamsters showed that dosage-volume of 75 mg/kg/day was well tolerated. The relative bioavailability of liquid Loulla formulation compared to the reference presentation is 76% for AUC0-9 and AUC0-∞ and 80% for Cmax. The taste of Loulla and the mouth feeling after ingestion compare favorably to the tablet. No adverse event occurred. CONCLUSION Pharmacokinetic, palatability and safety data support the use of Loulla in children.
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Affiliation(s)
- Adam de Beaumais Tiphaine
- Department of Pediatric Pharmacology and Pharmacogenetics and Clinical Investigations Center CIC1426 INSERM, Robert Debre Hospital, Assistance Publique Hopitaux de Paris, Paris, France.
| | - Lisa Lynqsie Hjalgrim
- Department of Pediatrics and Adolescent Medicine, University Hospital, Copenhagen, Denmark
| | - Jacob Nersting
- Department of Pediatrics and Adolescent Medicine, University Hospital, Copenhagen, Denmark
| | - Joerg Breitkreutz
- Institute of Pharmaceutics and Biopharmaceutics, Heinrich-Heine-University, Universitätsstrasse 1, Düsseldorf, Germany
| | - Brigitte Nelken
- Department of Paediatric Haematology/Oncology, University Hospital of Jeanne de Flandre, Lille, France
| | - Martin Schrappe
- University Medical Center Schleswig-Holstein, Campus Kiel Schwanenweg, Kiel, Germany
| | - Martin Stanulla
- Medical Scholl Hannover, Department of Pediatric Hematology and Oncology, Hannover, Germany
| | - Caroline Thomas
- Immunohematology and Pediatric Oncology Department, Mother Child Hospital, Nantes, France
| | - Yves Bertrand
- Institute of Haematology and Paediatric Oncology, Hospices Civils de Lyon, Lyon, France
| | - Guy Leverger
- UPMC University Paris 06, Paediatric Haematology Oncology Unit, Armand Trousseau Hospital, Assistance Publique Hopitaux de Paris, Paris, France
| | - André Baruchel
- Paediatric Immunology and Haematology Department, Robert Debre Hospital, Assistance Publique Hopitaux de Paris, Paris, France; University Paris VII Diderot, Paris, France
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital, Copenhagen, Denmark; Institute of Clinical Medicine, University of Copenhagen, Denmark
| | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics and Clinical Investigations Center CIC1426 INSERM, Robert Debre Hospital, Assistance Publique Hopitaux de Paris, Paris, France; University Paris VII Diderot, Paris, France
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Lennard L, Cartwright CS, Wade R, Vora A. Thiopurine methyltransferase and treatment outcome in the UK acute lymphoblastic leukaemia trial ALL2003. Br J Haematol 2015; 170:550-8. [PMID: 25940902 PMCID: PMC4687427 DOI: 10.1111/bjh.13469] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 03/15/2015] [Indexed: 11/29/2022]
Abstract
The influence of thiopurine methyltransferase (TPMT) genotype on treatment outcome was investigated in the United Kingdom childhood acute lymphoblastic leukaemia trial ALL2003, a trial in which treatment intensity was adjusted based on minimal residual disease (MRD). TPMT genotype was measured in 2387 patients (76% of trial entrants): 2190 were homozygous wild-type, 189 were heterozygous for low activity TPMT alleles (166 TPMT*1/*3A, 19 TPMT*1/*3C, 3 TPMT*1/*2 and 1 TPMT*1/*9) and 8 were TPMT deficient. In contrast to the preceding trial ALL97, there was no difference in event-free survival (EFS) between the TPMT genotypes. The 5-year EFS for heterozygous TPMT*1/*3A patients was the same in both trials (88%), but for the homozygous wild-type TPMT*1/*1 patients, EFS improved from 80% in ALL97% to 88% in ALL2003. Importantly, the unexplained worse outcome for heterozygous TPMT*1/*3C patients observed in ALL97 (5-year EFS 53%) was not seen in ALL2003 (5-year EFS 94%). In a multivariate Cox regression analysis the only significant factor affecting EFS was MRD status (hazard ratio for high-risk MRD patients 4·22, 95% confidence interval 2·97–5·99, P < 0·0001). In conclusion, refinements in risk stratification and treatment have reduced the influence of TPMT genotype on treatment outcome in a contemporary protocol.
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Affiliation(s)
- Lynne Lennard
- Department of Human Metabolism, University of Sheffield, Sheffield, UK
| | - Cher S Cartwright
- Department of Human Metabolism, University of Sheffield, Sheffield, UK
| | | | - Ajay Vora
- Department of Paediatric Haematology, Children's Hospital, Sheffield, UK
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Lennard L. Implementation of TPMT testing. Br J Clin Pharmacol 2014; 77:704-14. [PMID: 23962279 DOI: 10.1111/bcp.12226] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 07/23/2013] [Indexed: 12/21/2022] Open
Abstract
The activity of the enzyme thiopurine methyltransferase (TPMT) is regulated by a common genetic polymorphism. One in 300 individuals lack enzyme activity and 11% are heterozygous for a variant low activity allele and have an intermediate activity. The thiopurine drugs azathioprine, mercaptopurine and thioguanine are substrates for TPMT; these drugs exhibit well documented myelosuppressive effects on haematopoietic cells and have a track record of idiosyncratic drug reactions. The development of severe bone marrow toxicity, in patients taking standard doses of thiopurine drugs, is associated with TPMT deficiency whilst the TPMT heterozygote is at an increased risk of developing myelosuppression. Factors influencing TPMT enzyme activity, as measured in the surrogate red blood cell, are discussed in this review to enable an appreciation of why concordance between TPMT genotype and phenotype is not 100%. This is particularly important for lower/intermediate TPMT activities to avoid misclassification of TPMT status. TPMT testing is now widely available in routine service laboratories. The British National Formulary suggests TPMT testing before starting thiopurine drugs. Dermatologists were quick to adopt routine TPMT testing whilst gastroenterologists do not specifically recommend TPMT screening. TPMT testing is mandatory prior to the use of mercaptopurine in childhood leukaemia. Thiopurine drug dose and other treatment related influences on cell counts explain some of the differing recommendations between clinical specialities. TPMT testing is cost-effective and the major role is in the identification of the TPMT deficient individual prior to the start of thiopurine drugs.
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Affiliation(s)
- Lynne Lennard
- Clinical Pharmacology Unit, Department of Human Metabolism, University of Sheffield, Sheffield, UK
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Jayachandran D, Rundell AE, Hannemann RE, Vik TA, Ramkrishna D. Optimal chemotherapy for leukemia: a model-based strategy for individualized treatment. PLoS One 2014; 9:e109623. [PMID: 25310465 PMCID: PMC4195683 DOI: 10.1371/journal.pone.0109623] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 09/12/2014] [Indexed: 12/11/2022] Open
Abstract
Acute Lymphoblastic Leukemia, commonly known as ALL, is a predominant form of cancer during childhood. With the advent of modern healthcare support, the 5-year survival rate has been impressive in the recent past. However, long-term ALL survivors embattle several treatment-related medical and socio-economic complications due to excessive and inordinate chemotherapy doses received during treatment. In this work, we present a model-based approach to personalize 6-Mercaptopurine (6-MP) treatment for childhood ALL with a provision for incorporating the pharmacogenomic variations among patients. Semi-mechanistic mathematical models were developed and validated for i) 6-MP metabolism, ii) red blood cell mean corpuscular volume (MCV) dynamics, a surrogate marker for treatment efficacy, and iii) leukopenia, a major side-effect. With the constraint of getting limited data from clinics, a global sensitivity analysis based model reduction technique was employed to reduce the parameter space arising from semi-mechanistic models. The reduced, sensitive parameters were used to individualize the average patient model to a specific patient so as to minimize the model uncertainty. Models fit the data well and mimic diverse behavior observed among patients with minimum parameters. The model was validated with real patient data obtained from literature and Riley Hospital for Children in Indianapolis. Patient models were used to optimize the dose for an individual patient through nonlinear model predictive control. The implementation of our approach in clinical practice is realizable with routinely measured complete blood counts (CBC) and a few additional metabolite measurements. The proposed approach promises to achieve model-based individualized treatment to a specific patient, as opposed to a standard-dose-for-all, and to prescribe an optimal dose for a desired outcome with minimum side-effects.
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Affiliation(s)
- Devaraj Jayachandran
- School of Chemical Engineering, Purdue University, West Lafayette, Indiana, United States of America
| | - Ann E. Rundell
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, United States of America
| | - Robert E. Hannemann
- School of Chemical Engineering, Purdue University, West Lafayette, Indiana, United States of America
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, United States of America
| | - Terry A. Vik
- Riley Hospital for Children, Indianapolis, Indiana, United States of America
| | - Doraiswami Ramkrishna
- School of Chemical Engineering, Purdue University, West Lafayette, Indiana, United States of America
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Abstract
The antileukemic mechanisms of 6-mercaptopurine (6MP) and methotrexate (MTX) maintenance therapy are poorly understood, but the benefits of several years of myelosuppressive maintenance therapy for acute lymphoblastic leukemia are well proven. Currently, there is no international consensus on drug dosing. Because of significant interindividual and intraindividual variations in drug disposition and pharmacodynamics, vigorous dose adjustments are needed to obtain a target degree of myelosuppression. As the normal white blood cell counts vary by patients' ages and ethnicity, and also within age groups, identical white blood cell levels for 2 patients may not reflect the same treatment intensity. Measurements of intracellular levels of cytotoxic metabolites of 6MP and MTX can identify nonadherent patients, but therapeutic target levels remains to be established. A rise in serum aminotransferase levels during maintenance therapy is common and often related to high levels of methylated 6MP metabolites. However, except for episodes of hypoglycemia, serious liver dysfunction is rare, the risk of permanent liver damage is low, and aminotransferase levels usually normalize within a few weeks after discontinuation of therapy. 6MP and MTX dose increments should lead to either leukopenia or a rise in aminotransferases, and if neither is experienced, poor treatment adherence should be considered. The many genetic polymorphisms that determine 6MP and MTX disposition, efficacy, and toxicity have precluded implementation of pharmacogenomics into treatment, the sole exception being dramatic 6MP dose reductions in patients who are homozygous deficient for thiopurine methyltransferase, the enzyme that methylates 6MP and several of its metabolites. In conclusion, maintenance therapy is as important as the more intensive and toxic earlier treatment phases, and often more challenging. Ongoing research address the applicability of drug metabolite measurements for dose adjustments, extensive host genome profiling to understand diversity in treatment efficacy and toxicity, and alternative thiopurine dosing regimens to improve therapy for the individual patient.
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Physiologically based pharmacokinetic modelling of methotrexate and 6-mercaptopurine in adults and children. Part 2: 6-mercaptopurine and its interaction with methotrexate. J Pharmacokinet Pharmacodyn 2014; 41:173-85. [DOI: 10.1007/s10928-014-9355-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 03/06/2014] [Indexed: 10/25/2022]
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Physiologically based pharmacokinetic modelling of methotrexate and 6-mercaptopurine in adults and children. Part 1: methotrexate. J Pharmacokinet Pharmacodyn 2014; 41:159-71. [DOI: 10.1007/s10928-014-9354-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 03/06/2014] [Indexed: 10/25/2022]
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Lennard L, Cartwright CS, Wade R, Richards SM, Vora A. Thiopurine methyltransferase genotype-phenotype discordance and thiopurine active metabolite formation in childhood acute lymphoblastic leukaemia. Br J Clin Pharmacol 2014; 76:125-36. [PMID: 23252716 DOI: 10.1111/bcp.12066] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 12/09/2012] [Indexed: 12/14/2022] Open
Abstract
AIMS In children with acute lymphoblastic leukaemia (ALL) bone marrow activity can influence red blood cell (RBC) kinetics, the surrogate tissue for thiopurine methyltransferase (TPMT) measurements. The aim of this study was to investigate TPMT phenotype-genotype concordance in ALL, and the influence of TPMT on thiopurine metabolite formation. METHODS We measured TPMT (activity, as units ml(-1) packed RBCs and genotype) at diagnosis (n = 1150) and TPMT and thioguanine nucleotide (TGN) and methylmercaptopurine nucleotide (MeMPN) metabolites (pmol/8 × 10(8) RBCs) during chemotherapy (n = 1131) in children randomized to thioguanine or mercaptopurine on the United Kingdom trial ALL97. RESULTS Median TPMT activity at diagnosis (8.5 units) was significantly lower than during chemotherapy (13.8 units, median difference 5.1 units, 95% confidence interval (CI) 4.8, 5.4, P < 0.0001). At diagnosis genotype-phenotype was discordant. During chemotherapy the overall concordance was 92%, but this fell to 55% in the intermediate activity cohort (45% had wild-type genotypes). For both thiopurines TGN concentrations differed by TPMT status. For mercaptopurine, median TGNs were higher in TPMT heterozygous genotype (754 pmol) than wild-type (360 pmol) patients (median difference 406 pmol, 95% CI 332, 478, P < 0.0001), whilst median MeMPNs, products of the TPMT reaction, were higher in wild-type (10 650 pmol) than heterozygous patients (3868 pmol) (P < 0.0001). In TPMT intermediate activity patients with a wild-type genotype, TGN (median 366 pmol) and MeMPN (median 8590 pmol) concentrations were similar to those in wild-type, high activity patients. CONCLUSIONS In childhood ALL, TPMT activity should not be used to predict heterozygosity particularly in blood samples obtained at disease diagnosis. Genotype is a better predictor of TGN accumulation during chemotherapy.
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Affiliation(s)
- Lynne Lennard
- Clinical Pharmacology Unit, Department of Human Metabolism, University of Sheffield, Sheffield, UK.
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Kaur G, Behrsing H, Parchment RE, Millin MD, Teicher BA. Analyses of the combination of 6-MP and dasatinib in cell culture. Int J Oncol 2013; 43:13-22. [PMID: 23652925 PMCID: PMC3742163 DOI: 10.3892/ijo.2013.1930] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 04/04/2013] [Indexed: 11/16/2022] Open
Abstract
A major tenet of cancer therapeutics is that combinations of anticancer agents with different mechanisms of action and different toxicities may be effective treatment regimens. Evaluation of additivity/synergy in cell culture may be used to identify drug combination opportunities and to assess risk of additive/synergistic toxicity. The combination of 6-mercaptopurine and dasatinib was assessed for additivity/synergy using the combination index (CI) method and a response surface method in six human tumor cell lines including MCF-7 and MDA-MB‑468 breast cancer, NCI-H23 and NCI-H460 non‑small cell lung cancer, and A498 and 786-O renal cell cancer, based on two experimental end‑points: ATP content and colony formation. Clonal colony formation by human bone marrow CFU-GM was used to assess risk of enhanced toxicity. The concentration ranges tested for each drug were selected to encompass the clinical Cmax concentrations. The combination regimens were found to be additive to sub‑additive by both methods of data analysis, but synergy was not detected. The non-small cell lung cancer cell lines were the most responsive among the tumor lines tested and the renal cell carcinoma lines were the least responsive. The bone marrows CFU-GM were more sensitive to the combination regimens than were the tumor cell lines. Based upon these data, it appears that the possibility of enhanced efficacy from combining 6-mercaptopurine (6-MP) and dasatinib would be associated with increased risk of severe bone marrow toxicity, so the combination is unlikely to provide a therapeutic advantage for treating solid tumor patients where adequate bone marrow function must be preserved.
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Affiliation(s)
- Gurmeet Kaur
- Molecular Pharmacology Branch, Developmental Therapeutics Program, Division of Cancer Treatment and Diagnosis, Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA.
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Beesley AH, Firth MJ, Anderson D, Samuels AL, Ford J, Kees UR. Drug–Gene Modeling in Pediatric T-Cell Acute Lymphoblastic Leukemia Highlights Importance of 6-Mercaptopurine for Outcome. Cancer Res 2013; 73:2749-59. [DOI: 10.1158/0008-5472.can-12-3852] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Advances made in the treatment of childhood malignancies over the past four decades have resulted in overall 5-year survival rates of approximately 80%. However, despite these advances, several childhood cancers still have unacceptably low cure rates, and, even when treatment is successful, the acute and long-term morbidity of current therapy can be substantial. The development of molecularly targeted anticancer drugs offers the prospect of more effective therapy with fewer side effects, but will require increasing partnership between governments, and the academic and private sectors.
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Affiliation(s)
- Robin E Norris
- The Rainbow Babies and Children's Hospital, Pediatric Hematology/Oncology, Cleveland, Ohio 44106, USA.
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Blaker PA, Arenas-Hernandez M, Marinaki AM, Sanderson JD. The pharmacogenetic basis of individual variation in thiopurine metabolism. Per Med 2012; 9:707-725. [DOI: 10.2217/pme.12.85] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Thiopurines are an important class of immunosuppressive therapy, which have been used in clinical practice for over 50 years. Despite this extensive experience many of the pharmacodynamic and pharmacokinetic properties of these drugs remain unknown. As a consequence there is often no clear explanation for the individual variation in response to treatment, both in terms of efficacy or adverse drug reactions. This review, which emphasizes practice in gastroenterology, summarizes the current understanding of thiopurine drug metabolism and highlights the role of nongenetic and genetic factors other than TPMT, which should be a focus for future research. Correlation of polymorphic variations in these genes with clinical outcomes is expected to clarify the basis for interindividual differences in thiopurine metabolism and enable a more personalized approach to therapy.
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Affiliation(s)
- Paul Andrew Blaker
- Department of Gastroenterology, 1st Floor College House, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH, London, UK
| | - Monica Arenas-Hernandez
- The Purine Research Laboratory, Guy’s & St Thomas’ Hospitals NHS Foundation Trust , London, UK
| | - Anthony Marin Marinaki
- The Purine Research Laboratory, Guy’s & St Thomas’ Hospitals NHS Foundation Trust , London, UK
| | - Jeremy David Sanderson
- Department of Gastroenterology, 1st Floor College House, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH, London, UK
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Involvement of Multiple Transporters-mediated Transports in Mizoribine and Methotrexate Pharmacokinetics. Pharmaceuticals (Basel) 2012; 5:802-36. [PMID: 24280676 PMCID: PMC3763673 DOI: 10.3390/ph5080802] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Revised: 07/25/2012] [Accepted: 08/07/2012] [Indexed: 12/19/2022] Open
Abstract
Mizoribine is administered orally and excreted into urine without being metabolized. Many research groups have reported a linear relationship between the dose and peak serum concentration, between the dose and AUC, and between AUC and cumulative urinary excretion of mizoribine. In contrast, a significant interindividual variability, with a small intraindividual variability, in oral bioavailability of mizoribine is also reported. The interindividual variability is mostly considered to be due to the polymophisms of transporter genes. Methotrexate (MTX) is administered orally and/or by parenteral routes, depending on the dose. Metabolic enzymes and multiple transporters are involved in the pharmacokinetics of MTX. The oral bioavailability of MTX exhibits a marked interindividual variability and saturation with increase in the dose of MTX, with a small intraindividual variability, where the contribution of gene polymophisms of transporters and enzymes is suggested. Therapeutic drug monitoring of both mizoribine and MTX is expected to improve their clinical efficacy in the treatment of rheumatoid arthritis.
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Emami Riedmaier A, Nies AT, Schaeffeler E, Schwab M. Organic Anion Transporters and Their Implications in Pharmacotherapy. Pharmacol Rev 2012; 64:421-49. [DOI: 10.1124/pr.111.004614] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Cytostatic drugs in infants: A review on pharmacokinetic data in infants. Cancer Treat Rev 2012; 38:3-26. [DOI: 10.1016/j.ctrv.2011.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 03/21/2011] [Accepted: 03/24/2011] [Indexed: 01/11/2023]
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Plasma methotrexate, red blood cell methotrexate, and red blood cell folate values and outcome in children with precursor B-acute lymphoblastic leukemia: a report from the Children's Oncology Group. J Pediatr Hematol Oncol 2012; 34:e1-7. [PMID: 21364468 PMCID: PMC3771527 DOI: 10.1097/mph.0b013e31820ee239] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Plasma steady state methotrexate (MTX) level and red blood cell (RBC) MTX and folate concentrations were evaluated in 1124 children with newly diagnosed acute lymphoblastic leukemia enrolled in the Pediatric Oncology Group studies 9005 (lower risk; Regimens A and C) and 9006 (higher risk; Regimen A). These regimens included intermediate-dose MTX (1 g/m) given as a 24 hours infusion every other week for 12 doses during intensification. Plasma MTX level was evaluated at the end of MTX infusions. RBC MTX and folate concentrations were measured at the end of intensification. The 5 year continuous complete remission was 76±1.4% versus 85±3.0% for those patients with steady state MTX levels less than or equal to and greater than 14 μM, respectively (P=0.0125). Hispanic children had significantly reduced median steady state MTX levels, 8.7 μM, compared with non-Hispanic children, 9.95 μM (P=0.0015), but this did not correlate with a difference in outcome. Neither RBC MTX, RBC folate, nor the RBC MTX:folate ratio identified children at increased risk of failure.
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Mehrotra S, Florian J, Gobburu J. Don't get boxed in: commentary on the visual inspection practices to assess exposure-response relationships from binary clinical variables. J Clin Pharmacol 2011; 52:1912-7. [PMID: 22174427 DOI: 10.1177/0091270011429568] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Mulla H, Leary A, White P, Pandya HC. A step toward more accurate dosing for mercaptopurine in childhood acute lymphoblastic leukemia. J Clin Pharmacol 2011; 52:1610-3. [PMID: 22174432 DOI: 10.1177/0091270011423663] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hussain Mulla
- Centre for Therapeutic Evaluation of Drugs in Children, Department of Pharmacy, University Hospitals of Leicester, England.
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Stanczyk M, Sliwinski T, Trelinska J, Cuchra M, Markiewicz L, Dziki L, Bieniek A, Bielecka-Kowalska A, Kowalski M, Pastorczak A, Szemraj J, Mlynarski W, Majsterek I. Role of base-excision repair in the treatment of childhood acute lymphoblastic leukaemia with 6-mercaptopurine and high doses of methotrexate. Mutat Res 2011; 741:13-21. [PMID: 22064329 DOI: 10.1016/j.mrgentox.2011.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Revised: 09/05/2011] [Accepted: 10/04/2011] [Indexed: 12/20/2022]
Abstract
Methotrexate (MTX) and 6-mercaptopurine (6MP) are the most commonly used drugs in the therapy of childhood acute lymphoblastic leukaemia (ALL). The main genotoxic effect of MTX resulting from inhibition of thymidylate synthase is mis-incorporation of uracil into DNA, which is considered essential for the effectiveness of the Protocol M in ALL IC BFM 2002/EURO LB 2002 regimens. In this study, we investigated the level of basal and induced DNA damage as well as the effectiveness of DNA repair in lymphocytes of children with ALL at four time-points during therapy with MTX and 6MP. To assess DNA damage and the efficacy of DNA repair we used the modified alkaline comet assay with uracil DNA glycosylase (Udg) and endonuclease III (EndoIII). In addition, we examined the induction of apoptosis in the lymphocytes of the patients during treatment. Finally, we compared the activity of base-excision repair (BER), involved in removal of both uracil and oxidized bases from DNA in lymphocytes of children with ALL and lymphocytes of healthy children. BER efficiency was estimated in an in vitro assay with cellular extracts and plasmid substrates of heteroduplex DNA with an AP-site. Our results indicate that there is a significant decrease in the efficacy of DNA repair associated with an increased level of uracil in DNA and induction of apoptosis during therapy. Moreover, it was found that the BER capacity was decreased in the lymphocytes of ALL patients in contrast to that in lymphocytes of healthy children. Thus, we suggest that an impairment of the BER pathway may play a role in the pathogenesis and therapy of childhood ALL.
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Affiliation(s)
- M Stanczyk
- Department of Clinical Chemistry and Biochemistry, Medical University of Lodz, Poland
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Brandalise SR, Pinheiro VR, Aguiar SS, Matsuda EI, Otubo R, Yunes JA, Pereira WV, Carvalho EG, Cristofani LM, Souza MS, Lee ML, Dobbin JA, Pombo-de-Oliveira MS, Lopes LF, Melnikoff KN, Brunetto AL, Tone LG, Scrideli CA, Morais VL, Viana MB. Benefits of the Intermittent Use of 6-Mercaptopurine and Methotrexate in Maintenance Treatment for Low-Risk Acute Lymphoblastic Leukemia in Children: Randomized Trial From the Brazilian Childhood Cooperative Group—Protocol ALL-99. J Clin Oncol 2010; 28:1911-8. [DOI: 10.1200/jco.2009.25.6115] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PurposeTo describe event-free survival (EFS) and toxicities in children with low-risk acute lymphoblastic leukemia (ALL) assigned to receive either continuous 6-mercaptopurine (6-MP) and weekly methotrexate (MTX) or intermittent 6-MP with intermediate-dose MTX, as maintenance treatment.Patients and MethodsBetween October 1, 2000, and December 31, 2007, 635 patients with low-risk ALL were enrolled onto Brazilian Childhood Cooperative Group for ALL Treatment (GBTLI) ALL-99 protocol. Eligible children (n = 544) were randomly allocated to receive either continuous 6-MP/MTX (group 1, n = 272) or intermittent 6-MP (100 mg/m2/d for 10 days, with 11 days resting) and MTX (200 mg/m2every 3 weeks; group 2, n = 272).ResultsThe 5-year overall survival (OS) and EFS were 92.5% ± 1.5% SE and 83.6% ± 2.1% SE, respectively. According to maintenance regimen, the OS was 91.4% ± 2.2% SE (group 1) and 93.6% ± 2.1% SE (group 2; P = .28) and EFS 80.9% ± 3.2% SE (group 1) and 86.5% ± 2.8% SE (group 2; P = .089). Remarkably, the intermittent regimen led to significantly higher EFS among boys (85.7% v 74.9% SE; P = .027), while no difference was seen for girls (87.0% v 88.8% SE; P = .78). Toxic episodes were recorded in 226 and 237 children, respectively. Grade 3 to 4 toxic events for groups 1 and 2 were, respectively, 273 and 166 for hepatic dysfunction (P = .002), and 772 and 636 for hematologic episodes (P = .005). Deaths on maintenance were: seven (group 1) and one (group 2).ConclusionThe intermittent use of 6-MP and MTX in maintenance is a less toxic regimen, with a trend toward better long-term EFS. Boys treated with the intermittent schedule had significantly better EFS.
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Affiliation(s)
- Silvia R. Brandalise
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Vitória R. Pinheiro
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Simone S. Aguiar
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Eduardo I. Matsuda
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Rosemary Otubo
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - José A. Yunes
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Waldir V. Pereira
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Eny G. Carvalho
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Lilian M. Cristofani
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Marcelo S. Souza
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Maria L. Lee
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Jane A. Dobbin
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Maria S. Pombo-de-Oliveira
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Luiz F. Lopes
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Katharina N.T. Melnikoff
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Algemir L. Brunetto
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Luiz G. Tone
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Carlos A. Scrideli
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Vera L.L. Morais
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
| | - Marcos B. Viana
- From the Serviço de Hematologia/Oncologia Pediátrica, Universidade Estadual de Campinas; Centro Infantil Boldrini, Campinas; Instituto da Criança, Universidade de São Paulo; Grupo de Apoio à Criança com Câncer; Hospital A.C. Camargo; Hospital Brigadeiro; Hospital das Clinicas, Ribeirão Preto, São Paulo; Hospital Universitário, Santa Maria; Instituto de Oncologia, Salvador; Hospital Regional, Campo Grande; Instituto Nacional do Câncer, Rio de Janeiro; Hospital das Clinicas, Porto Alegre; Hospital Oswaldo
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Schmiegelow K, Heyman M, Gustafsson G, Lausen B, Wesenberg F, Kristinsson J, Vettenranta K, Schroeder H, Forestier E, Rosthoej S. The degree of myelosuppression during maintenance therapy of adolescents with B-lineage intermediate risk acute lymphoblastic leukemia predicts risk of relapse. Leukemia 2010; 24:715-20. [PMID: 20130603 DOI: 10.1038/leu.2009.303] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Drug doses, blood levels of drug metabolites and myelotoxicity during 6-mercaptopurine/methotrexate (MTX) maintenance therapy were registered for 59 adolescents (>or=10 years) and 176 non-adolescents (<10 years) with B-cell precursor acute lymphoblastic leukemia (ALL) and a white blood cell count (WBC) <50 x 10(9)/l at diagnosis. Event-free survival was lower for adolescents than non-adolescents (pEFS(12y):0.71 vs 0.83, P=0.04). For adolescents staying in remission, the mean WBC during maintenance therapy (mWBC) was related to age (r(S)=0.36, P=0.02), which became nonsignificant for those who relapsed (r(S)=0.05, P=0.9). The best-fit multivariate Cox regression model to predict risk of relapse included mWBC and thiopurine methyltransferase activity, which methylates mercaptopurine and reduces the intracellular availability of cytotoxic 6-thioguanine nucleotides (coefficient: 0.11, P=0.02). The correlation of mWBC to the risk of relapse was more pronounced for adolescents (coefficient=0.65, P=0.003) than for non-adolescents (coefficient=0.42, P=0.04). Adolescents had higher mean neutrophil counts (P=0.002) than non-adolescents, but received nonsignificantly lower mercaptopurine and MTX doses during maintenance therapy. Red blood cell MTX levels were significantly related to the dose of MTX among adolescents who stayed in remission (r(S)=0.38, P=0.02), which was not the case for those who developed a relapse (r(S)=0.15, P=0.60). Thus, compliance to maintenance therapy may influence the risk of relapse for adolescents with ALL.
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Affiliation(s)
- K Schmiegelow
- Department of Pediatric Oncology, The University Hospital Rigshospitalet, Copenhagen, Denmark.
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Carlos Jaime-Pérez J, Gómez-Almaguer D, Sandoval-González A, Chapa-Rodríguez A, Gonzàlez-Llano O. Random serum methotrexate determinations for assessing compliance with maintenance therapy for childhood acute lymphoblastic leukemia. Leuk Lymphoma 2009; 50:1843-7. [DOI: 10.3109/10428190903216812] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Thioguanine pharmacokinetics in induction therapy of children with acute myeloid leukemia. Anticancer Drugs 2009; 20:7-14. [PMID: 19342996 DOI: 10.1097/cad.0b013e32831bc086] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We studied the pharmacokinetics of 6-thioguanine (6TG) in 50 children treated for newly diagnosed acute myeloid leukemia, four of them with Down syndrome (DS). They received oral 6TG 100 mg/m2 body surface area twice daily for 4 days. Etoposide, 100 mg/m2/24 h, and cytarabine, 200 mg/m2/24 h, were administered concomitantly by intravenous infusion. On day 5, doxorubicin 75 mg/m2 was given as an 8-h infusion. The concentration of thioguanine nucleotides (TGN) in erythrocytes, the active metabolites of 6TG, was determined by high-performance liquid chromatography. The mean TGN concentration from 72, 95, and 106-h samples was used as a measure of drug exposure for each individual. The median TGN concentration in non-DS children above 2 years of age was 2.30 micromol/mmol Hb (range 0.57-25.3). The TGN concentrations varied widely (30-fold) also after dose normalization. We found no correlation with demographic, clinical, or biochemical parameters, and differences in bioavailability might be the most important explanation to interpatient variability. Children with high TGN concentration tended to have longer treatment interval to the next course, but we found no correlation with our predefined parameters for clinical response, that is, remission and relapse rate. Therefore, 6TG does not seem to be a candidate for therapeutic drug monitoring by TGN measurement, at least not in the setting of short multidrug treatment courses. Children with DS had significantly higher TGN concentrations, indicating that dose reduction might be considered to reach the same drug exposure as in non-DS children.
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Actis GC, Pellicano R, Rizzetto M, Ayoubi M, Leone N, Tappero G, Pazienza P, Rosina F. Individually administered or co-prescribed thiopurines and mesalamines for inflammatory bowel disease. World J Gastroenterol 2009; 15:1420-6. [PMID: 19322913 PMCID: PMC2665135 DOI: 10.3748/wjg.15.1420] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Data from both basic research and clinical experience continue to suggest that mesalamines and thiopurines are effective and efficient for the maintenance of remission of inflammatory bowel diseases. Several decades following the formalization of their indications, attention on these two drugs has been fostered by recent achievements. Demonstration of the ability of mesalamine to activate a colonocyte differentiation factor has shed light on its chemopreventive effects on colorectal cancer; in addition to their anti-proliferative efficacy, thiopurines have been shown to be specific regulators of apoptosis. The two drugs are often co-administered in clinical practice. Recent advancements have shown that mesalamines exert a positive synergism in this context, insofar as they can inhibit side-methylation of thiopurines and hasten the function of the main immunosuppressive pathways. Considering that up to 40% of patients cannot tolerate thiopurines, such renovated targets have stimulated efforts to improve compliance by research on the toxicity mechanisms. The definition of genetic polymorphisms in the enzymes of thiopurine metabolism, and the uncovering of synergistic drug interactions, such as that with allopurinol, are just two of the results of such efforts. Interaction between basic research and clinical practice has continued to inform indications and refine the prescriptions of mesalamines and thiopurines; these have not been restrained (they have been implemented in some cases) by the advent of the novel biological molecules with anti-cytokine activity.
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Kang MH, Harutyunyan N, Hall CP, Papa RA, Lock RB. Methotrexate and aminopterin exhibit similar in vitro and in vivo preclinical activity against acute lymphoblastic leukaemia and lymphoma. Br J Haematol 2009; 145:389-93. [PMID: 19298590 DOI: 10.1111/j.1365-2141.2009.07631.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Due to the development of neurological toxicity and resistance to methotrexate (MTX), other antifolates have been evaluated for its potential replacement in the treatment of childhood acute lymphoblastic leukaemia (ALL). Aminopterin (AMT) has been suggested to provide clinical advantages over MTX and other antifolates. AMT activity, compared with MTX, was evaluated in ALL and lymphoma preclinical models. The minimum survival fraction at the range of concentrations tested was lower with AMT than with MTX in 3 out of 15 cell lines. Both AMT and MTX significantly extended the event-free survival of mice bearing 3 out of 4 xenografts with equivalent activity.
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Affiliation(s)
- Min H Kang
- Cancer Center, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
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Garcia-Ac A, Segura PA, Gagnon C, Sauvé S. Determination of bezafibrate, methotrexate, cyclophosphamide, orlistat and enalapril in waste and surface waters using on-line solid-phase extraction liquid chromatography coupled to polarity-switching electrospray tandem mass spectrometry. ACTA ACUST UNITED AC 2009; 11:830-8. [DOI: 10.1039/b817570e] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Pharmacogenetics covers the genetic variation affecting pharmacokinetics and pharmacodynamics, and their influence on drug-response phenotypes. The genetic variation includes an estimated 15 million single nucleotide polymorphisms (SNPs) and is a key determinator for the interindividual differences in treatment resistance and toxic side effects. As most childhood acute lymphoblastic leukemia treatment protocols include up to 13 different chemotherapeutic agents, the impact of individual SNPs has been difficult to evaluate. So far focus has mainly been on the widely used glucocorticosteroids, methotrexate, and thiopurines, or on metabolic pathways and transport mechanisms that are common to several drugs, such as the glutathione S-transferases. However, beyond the thiopurine methyltransferase polymorphisms, the candidate-gene approach has not established clear associations between polymorphisms and treatment response. In the future, high-throughput, low-cost, genetic platforms will allow screening of hundreds or thousands of targeted SNPs to give a combined gene-dosage effect (=individual SNP risk profile), which may allow pharmacogenetic-based individualization of treatment.
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Dumez H, Reinhart WH, Guetens G, de Bruijn EA. Human Red Blood Cells: Rheological Aspects, Uptake, and Release of Cytotoxic Drugs. Crit Rev Clin Lab Sci 2008; 41:159-88. [PMID: 15270553 DOI: 10.1080/10408360490452031] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The shape of a normal human red blood cell (RBC) is well known: under resting conditions it is that of a biconcave discocyte. However, RBCs can easily undergo transformation to other shapes with stomatocytes and echinocytes as extremes. Various anticancer agents, generally reactive and labile substances, e.g., oxazaphosphorines and fluoropyrimidines, can induce severe deformation of shape. Shape changes in erythrocytes can induce rheological disturbances, which occasionally have pathophysiological consequences. It is difficult to estimate the impact of shape changes on the in vivo behavior of agents of biological interest. However, it has been demonstrated for various anticancer agents that erythrocytes fulfill an important role in their uptake, transport, and release. Moreover, some anticancer agents are capable of influencing important transporters such as MRP and GLUT-1. Monitoring of erythrocyte concentrations of certain cytotoxic agents is therefore of interest as the data generated can have a predictive outcome for therapeutic efficacy. This is true for cyclophosphamide, ifosfamide, lometrexol, and 6-mercaptopurine, as well as MRP and GLUT-1 mediated agents.
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Affiliation(s)
- Herlinde Dumez
- Laboratory of Experimental Oncology, KuLeuven, Leuven, Belgium
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The effect of thiopurine drugs on DNA methylation in relation to TPMT expression. Biochem Pharmacol 2008; 76:1024-35. [PMID: 18708030 DOI: 10.1016/j.bcp.2008.07.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Revised: 07/21/2008] [Accepted: 07/21/2008] [Indexed: 11/30/2022]
Abstract
The thiopurine drugs 6-mercaptopurine (6-MP) and 6-thioguanine (6-TG) are well-established agents for the treatment of leukaemia but their main modes of action are controversial. Thiopurine methyltransferase (TPMT) metabolises thiopurine drugs and influences their cytotoxic activity. TPMT, like DNA methyltransferases (DNMTs), transfers methyl groups from S-adenosylmethionine (SAM) and generates S-adenosylhomocysteine (SAH). Since SAM levels are dependent on de novo purine synthesis (DNPS) and the metabolic products of 6-TG and 6-MP differ in their ability to inhibit DNPS, we postulated that 6-TG compared to 6-MP would have differential effects on changes in SAM and SAH levels and global DNA methylation, depending on TPMT status. To test this hypothesis, we used a human embryonic kidney cell line with inducible TPMT. Although changes in SAM and SAH levels occurred with each drug, decrease in global DNA methylation more closely reflected a decrease in DNMT activity. Inhibition was influenced by TPMT for 6-TG, but not 6-MP. The decrease in global methylation and DNMT activity with 6-MP, or with 6-TG when TPMT expression was low, were comparable to 5-aza-2'-deoxycytidine. However, this was not reflected in changes in methylation at the level of an individual marker gene (MAGE1A). The results suggest that a non-TPMT metabolised metabolite of 6-MP and 6-TG and the TPMT-metabolised 6-MP metabolite 6-methylthioguanosine 5'-monophosphate, contribute to a decrease in DNMT levels and global DNA methylation. As demethylating agents have shown promise in leukaemia treatment, inhibition of DNA methylation by the thiopurine drugs may contribute to their cytotoxic affects.
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Grossman AB, Noble AJ, Mamula P, Baldassano RN. Increased dosing requirements for 6-mercaptopurine and azathioprine in inflammatory bowel disease patients six years and younger. Inflamm Bowel Dis 2008; 14:750-5. [PMID: 18266236 DOI: 10.1002/ibd.20387] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND 6-Mercaptopurine (6-MP) and its prodrug azathioprine (AZA) are effective for the induction and maintenance of remission and reduction of corticosteroid exposure for pediatric inflammatory bowel disease (IBD). The standard dose of 6-MP is 1.0-1.5 mg/kg/day and for AZA is 2.0-2.5 mg/kg/day. The aim of this study was to determine whether IBD patients 6 years of age and younger require higher than standard doses of 6-MP/AZA to achieve clinical remission. METHODS Clinical data was collected retrospectively for all IBD patients 6 years of age or younger treated with 6-MP/AZA at The Children's Hospital of Philadelphia. RESULTS Thirty patients met the inclusion criteria. IBD was diagnosed at a median age of 3.3 years (25-75th %ile 2.3-4.6 years) and 6-MP/AZA was initiated at a median age of 3.9 years (range 0.8-6.8 years). After dose escalation, the median AZA-equivalent dose was 3.1 mg/kg/day (25-75th %ile 2.5-3.5, max. dose 5.1 mg/kg/day). At the final recorded dose, 8/13 (62%) patients receiving AZA >3.0 mg/kg/day achieved clinical remission, compared to 2/12 (17%) receiving 2-3 mg/kg/day (P = 0.02). The risk of having active disease was on average 85% lower if the AZA-equivalent dose was >3.0 mg/kg/day (95% confidence interval [CI] 72%-93%). Adverse events were experienced by 4/30 patients (hepatitis, n = 2; leukopenia, n = 2). No patients had to discontinue 6-MP/AZA, and all laboratory abnormalities improved spontaneously or with dose reduction. CONCLUSIONS The standard dose of 6-MP/AZA may not be adequate for IBD patients 6 years of age and younger. Closely monitored dose escalation beyond the standard dosing range is effective and well-tolerated.
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Affiliation(s)
- Andrew B Grossman
- Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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Lin TL, Vala MS, Barber JP, Karp JE, Smith BD, Matsui W, Jones RJ. Induction of acute lymphocytic leukemia differentiation by maintenance therapy. Leukemia 2007; 21:1915-20. [PMID: 17611566 PMCID: PMC2643128 DOI: 10.1038/sj.leu.2404823] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Despite extensive study in many malignancies, maintenance therapy has clinically benefited only two diseases: acute lymphocytic leukemia (ALL) and acute promyelocytic leukemia (APL). ALL maintenance therapy utilizes low-dose 6-mercaptopurine (6MP) and methotrexate (MTX), while maintenance in APL primarily consists of all-trans-retinoic acid (ATRA). 6MP and MTX as used in ALL are also now usually added to maintenance ATRA for APL, based on data suggesting an improved disease-free survival. Although the mechanism of action of MTX and 6MP as maintenance is unknown, low-dose cytotoxic agents are potent inducers of differentiation in vitro. Thus, we studied whether maintenance therapy in ALL, like ATRA in APL, may be inducing terminal differentiation of ALL progenitors. The APL cell line NB4, the ALL cell lines REH and RS4;11, and patients' ALL blasts were incubated with ATRA, 6MP, and MTX in vitro. All three drugs inhibited the clonogenic growth of the APL and ALL cell lines without inducing immediate apoptosis, but associated with induction of phenotypic differentiation. The three drugs similarly upregulated lymphoid antigen expression, while decreasing CD34 expression, on patients' ALL blasts. These data suggest that induction of leukemia progenitor differentiation plays an important role in the mechanism of action of maintenance therapy in ALL.
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Affiliation(s)
- T L Lin
- The Sidney Kimmel Comprehensive Cancer Center and Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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