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Shi C, Li Z, Sun Z, Pan L. Maternal Administration of Busulfan before in Utero Hematopoietic Cell Transplantation Improves Congenic Bone Marrow Cell Engraftment in a Murine Model. Transplant Cell Ther 2024; 30:398.e1-398.e10. [PMID: 38331194 DOI: 10.1016/j.jtct.2024.01.081] [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] [Received: 07/14/2023] [Revised: 01/10/2024] [Accepted: 01/29/2024] [Indexed: 02/10/2024]
Abstract
In utero hematopoietic cell transplantation (IUHCT) is a nonmyeloablative procedure that leads to donor cell chimerism and donor-specific tolerance. However, most clinical applications of IUHCT have failed because of low levels or even no engraftment of donor cells in immunologically normal fetuses. It is likely that the competition from the host hematopoietic compartment is the primary barrier to successful IUHCT, suggesting that conditioning methods that provide a competitive advantage to donor cells may lead to higher-level engraftment following IUHCT. This study aimed to research whether maternal administration of low-dose total body irradiation (TBI) or busulfan (BU) before IUHCT may result in increased donor cell chimerism in postnatal bone marrow transplantation in a congenic murine model. We first determined the birth and mortality rates after maternal administration of low-dose TBI (0, 2 or 4 Gy) or BU (5, 10, 15, or 20 mg/kg) before IUHCT in B6 mice. The mice that received 2 Gy TBI plus IUHCT showed significantly lower birth rate (23.3%) and a 100% 3-day mortality rate. The mice that received 10 mg/kg BU plus IUHCT had similar birth and 3-day mortality rates (58.6% and 0%) compared to mice that received IUHCT alone (61.1% and 4.55%). We then performed maternal administration of BU at 1 of 3 dosages (5, 10, or 15 mg/kg) at 24 hours before intrauterine transplantation of 2.5 × 105 B6GFP Sca-1+ bone marrow cells (BMCs) or 2.5 × 106 B6GFP BMCs on gestational day 14 (E14). Green fluorescent protein (GFP) chimerism in peripheral blood mononuclear cells (PBMCs), RBCs, and platelets of mice at 4 weeks of age was enhanced significantly with an increase in BU dose. Moreover, GFP chimerism of PBMCs from the B6GFP BMC group was significantly higher than that of the B6GFP Sca-1+ BMC group (22.56% versus 7.20%; P = .018). Finally, the pregnant mice were treated with 10 mg/kg of BU at E13, E14, or E15, followed by intrauterine transplantation of 2.5 × 106 B6GFP BMCs 24 hours later. Except for the short-term level of chimerism in PBMCs, which showed no significant difference among the 3 study groups, the results indicate that both short-term (age 4 weeks) and long-term (age 14 weeks) engraftment in PBMCs, RBCs, and platelets was higher in group E16 compared with groups E14 and E15. We also discovered that the engraftment was stable, multilineage, and increased with time. In conclusion, maternal administration of BU, but not of TBI, along with IUHCT could significantly enhance engraftment in a congenic murine model.
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Affiliation(s)
- Chunyu Shi
- Department of Gastrointestinal Colorectal and Anal Surgery, The Third Bethune Hospital of Jilin University, Changchun, China
| | - Zhongmin Li
- Department of Gastrointestinal Colorectal and Anal Surgery, The Third Bethune Hospital of Jilin University, Changchun, China
| | - Zhanwei Sun
- National-Local Joint Engineering Laboratory of Animal Models for Human Diseases, Changchun, China; International Center of Future Science, Jilin University, Changchun, China
| | - Lu Pan
- Department of Pediatric Immunology, Allergy and Rheumatology, The First Bethune Hospital of Jilin University, Changchun, China.
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2
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McCune JS, Navarro SL, Risler LJ, Phillips BR, Ren S, Schoch HG, Baker KS. The presence of busulfan metabolites and pharmacometabolomics in plasma drawn immediately before allograft infusion in hematopoietic cell transplant recipients. Clin Transl Sci 2023; 16:2577-2590. [PMID: 37749994 PMCID: PMC10719475 DOI: 10.1111/cts.13651] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/07/2023] [Accepted: 09/10/2023] [Indexed: 09/27/2023] Open
Abstract
Busulfan is hepatically metabolized through glutathione (GSH) conjugation; in vitro, this process depletes hepatocyte GSH stores and generates the cytotoxic metabolite γ-glutamyldehydroalanylglycine, which is too unstable to be quantitated in vivo. We sought to evaluate if pre-graft (i.e., immediately before allograft infusion) concentrations of busulfan metabolites' and of endogenous metabolomic compounds (EMCs) representing the glutathione pathway were associated with clinical outcomes in hematopoietic cell transplant (HCT) recipients receiving busulfan. The clinical outcomes evaluated were relapse, acute graft versus host disease (GVHD), chronic GVHD, non-relapse mortality, and neutrophil nadir. In pre-graft samples obtained from patients immediately before allograft infusion, our objectives were to evaluate for: (1) the presence of busulfan and its metabolites tetrahydrothiophenium ion (THT+), tetrahydrothiophene 1-oxide, sulfolane, and 3-hydroxysulfolane (N = 124); (2) EMCs using a global metabolomics assay (N = 77); and (3) the association of the busulfan metabolites and the EMCs with clinical outcomes. In the pre-graft samples, busulfan and THT+ could not be detected. THT 1-oxide, sulfolane, and 3-hydroxysulfolane were quantitated in 9.6%, 26%, and 58% of pre-graft samples; their concentrations were not associated with clinical outcomes. Four pre-graft EMCs were statistically significantly associated with the neutrophil nadir. The pre-graft EMCs were not associated with the other clinical outcomes. In conclusion, busulfan's metabolites are present in patients' plasma immediately before allograft infusion; the neutrophil nadir is associated with pre-graft EMCs. Future research should investigate the association of clinical outcomes with the concentrations of busulfan's metabolites and EMCs in the pre-graft plasma from allogeneic HCT recipients.
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Affiliation(s)
- Jeannine S. McCune
- Department of Hematologic Malignancies Translational SciencesCity of HopeDuarteCaliforniaUSA
| | - Sandi L. Navarro
- Division of Public Health SciencesFred Hutchinson Cancer CenterSeattleWashingtonUSA
| | - Linda J. Risler
- Department of PharmaceuticsUniversity of WashingtonSeattleWashingtonUSA
| | - Brian R. Phillips
- Department of PharmaceuticsUniversity of WashingtonSeattleWashingtonUSA
| | - Suping Ren
- Department of Hematologic Malignancies Translational SciencesCity of HopeDuarteCaliforniaUSA
| | - H. Gary Schoch
- Clinical Research DivisionFred Hutchinson Cancer CenterSeattleWashingtonUSA
| | - K. Scott Baker
- Clinical Research DivisionFred Hutchinson Cancer CenterSeattleWashingtonUSA
- Department of PediatricsUniversity of WashingtonSeattleWashingtonUSA
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3
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Combarel D, Tran J, Delahousse J, Vassal G, Paci A. Individualizing busulfan dose in specific populations and evaluating the risk of pharmacokinetic drug-drug interactions. Expert Opin Drug Metab Toxicol 2023; 19:75-90. [PMID: 36939456 DOI: 10.1080/17425255.2023.2192924] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
INTRODUCTION Busulfan is an alkylating agent widely used in the conditioning of hematopoietic stem cell transplantation possessing a complex metabolism and a large interindividual and intra-individual variability, especially in children. Combined with the strong rationale of busulfan PK/PD relationships, factors altering its clearance (e.g., weight, age, and GST-A genetic polymorphism mainly) can also affect clinical outcomes. AREAS COVERED This review aims to provide an overview of the current knowledge on busulfan pharmacokinetics, its pharmacokinetics variabilities in pediatric populations, drug-drug interactions (DDI), and their consequences regarding dose individualization. This review was based on medical literature up until October 2021. EXPERT OPINION To ensure effective busulfan exposure in pediatrics, different weight-based nomograms have been established to determine busulfan dosage and provided improved results (65 - 80% of patients correctly exposed). In addition to nomograms, therapeutic drug monitoring (TDM) of busulfan measuring plasmatic concentrations to estimate busulfan pharmacokinetic parameters can be used. TDM is now widely carried out in routine practices and aims to ensure the targeting of the reported therapeutic windows by individualizing busulfan dosing based on the clearance estimations from a previous dose.
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Affiliation(s)
- David Combarel
- Service de Pharmacologie, Département de biologie et pathologie médicale, Gustave Roussy, Université Paris-Saclay, Villejuif, France.,Université Paris-Saclay, Faculté de Pharmacie, Université Paris-Saclay, Chatenay-Malabry, France
| | - Julie Tran
- Service de Pharmacologie, Département de biologie et pathologie médicale, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Julia Delahousse
- Service de Pharmacologie, Département de biologie et pathologie médicale, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Gilles Vassal
- Gustave Roussy Comprehensive Cancer Center, & University Paris-Saclay, Villejuif, France
| | - Angelo Paci
- Service de Pharmacologie, Département de biologie et pathologie médicale, Gustave Roussy, Université Paris-Saclay, Villejuif, France.,Université Paris-Saclay, Faculté de Pharmacie, Université Paris-Saclay, Chatenay-Malabry, France
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4
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Evolution of enzyme functionality in the flavin-containing monooxygenases. Nat Commun 2023; 14:1042. [PMID: 36823138 PMCID: PMC9950137 DOI: 10.1038/s41467-023-36756-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 02/15/2023] [Indexed: 02/25/2023] Open
Abstract
Among the molecular mechanisms of adaptation in biology, enzyme functional diversification is indispensable. By allowing organisms to expand their catalytic repertoires and adopt fundamentally different chemistries, animals can harness or eliminate new-found substances and xenobiotics that they are exposed to in new environments. Here, we explore the flavin-containing monooxygenases (FMOs) that are essential for xenobiotic detoxification. Employing a paleobiochemistry approach in combination with enzymology techniques we disclose the set of historical substitutions responsible for the family's functional diversification in tetrapods. Remarkably, a few amino acid replacements differentiate an ancestral multi-tasking FMO into a more specialized monooxygenase by modulating the oxygenating flavin intermediate. Our findings substantiate an ongoing premise that enzymatic function hinges on a subset of residues that is not limited to the active site core.
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Al-Enezi BF, Al-Hasawi N, Matar KM. Impact of valproic acid on busulfan pharmacokinetics: In vitro assessment of potential drug-drug interaction. PLoS One 2023; 18:e0280574. [PMID: 36696427 PMCID: PMC9876357 DOI: 10.1371/journal.pone.0280574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 01/03/2023] [Indexed: 01/26/2023] Open
Abstract
Busulfan (Bu) is an alkylating agent commonly used at high doses in the preparative regimens of hematopoietic stem cell transplantation (HSCT). It has been shown that such high doses of Bu are associated with generalized seizures which are usually managed by prophylactic antiepileptic drugs (AEDs) such as valproic acid (VPA). Being a strong enzyme inhibitor, VPA may inhibit Bu metabolism and thus increase its potential toxicity. Despite its clinical relevance, the potential interaction between Bu and VPA has not yet been evaluated. The aim of the present study was to assess and evaluate the potential drug-drug interaction (DDI) between Bu and VPA. This study was carried out by incubating Bu in laboratory-prepared rat liver-subcellular fractions including S9, microsomes, and cytosol, alone or in combination with VPA. The liver fractions were prepared by differential centrifugation of the liver homogenate. Analysis of Bu was employed using a fully validated LC-MS/MS method. The validation parameters were within the proposed limits of the international standards guidelines. Bu metabolic stability was assessed by incubating Bu at a concentration of 8 μg/ml in liver fractions at 37°C. There were significant reductions in Bu levels in S9 and cytosolic fractions, whereas these levels were not significantly (P ˃ 0.05) changed in microsomes. However, in presence of VPA, Bu levels in S9 fraction remained unchanged. These results indicated, for the first time, the potential metabolic interaction of Bu and VPA being in S9 only. This could be explained by inhibiting Bu cytosolic metabolism by the interaction with VPA either by sharing the same metabolic enzyme or the required co-factor. In conclusion, the present findings suggest, for the first time, a potential DDI between Bu and VPA in vitro using rat liver fractions. Further investigations are warranted in human-derived liver fractions to confirm such an interaction.
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Affiliation(s)
- Bashayer F. Al-Enezi
- Department of Pharmacology & Therapeutics, Faculty of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Nada Al-Hasawi
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Kamal M. Matar
- Department of Pharmacology & Therapeutics, Faculty of Pharmacy, Kuwait University, Kuwait City, Kuwait
- * E-mail: ,
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Lawson R, Staatz CE, Fraser CJ, Ramachandran S, Teague L, Mitchell R, O'Brien T, Hennig S. Population pharmacokinetic model for once‐daily intravenous busulfan in pediatric subjects describing
time‐associated
clearance. CPT Pharmacometrics Syst Pharmacol 2022; 11:1002-1017. [PMID: 35611997 PMCID: PMC9381908 DOI: 10.1002/psp4.12809] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/25/2022] Open
Abstract
This study aimed to characterize the population pharmacokinetics (PK) of busulfan focusing on how busulfan clearance (CL) changes over time during once‐daily administration and assess different methods for measuring busulfan exposure and the ability to achieve target cumulative exposure under different dosing adjustment scenarios in pediatric stem cell transplantation recipients. Daily serial blood sampling was performed and concentration‐time data were analyzed using a nonlinear mixed‐effects approach. The developed PK model was used to assess achievement of target exposure under six dose‐adjustment scenarios based on simulations performed in RStudio (RxODE package)®. A total of 2491 busulfan plasma concentration–time measurements were collected from 95 patients characterizing 379 dosing days. A two‐compartment model with time‐associated CL best described the data with a typical CL of 14.5 L/h for an adult male with 62 kg normal fat mass (NFM; equivalent to 70 kg total body weight), typical volume of distribution central compartment (V1) of 40.6 L/59 kg NFM (equivalent to 70 kg total body weight), and typical volume of distribution peripheral compartment of 3.57 L/62 kg NFM. Model interindividual variability in CL and V1 was 14.7% and 34.9%, respectively, and interoccasional variability in CL was 6.6%. Patient size described by NFM, a maturation component, and time since start of treatment significantly influenced CL. Simulations demonstrated that using model‐based exposure estimates with each dose, and either a proportional dose‐adjustment calculation or model‐based calculated individual CL estimates to support dose adjustments, increased proportion of subjects attaining cumulative exposure within 5% of target compared with using noncompartmental analysis (100% vs. 0%). A time‐associated reduction in CL during once‐daily busulfan treatment was described.
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Affiliation(s)
- Rachael Lawson
- School of PharmacyUniversity of QueenslandBrisbaneQueenslandAustralia
- Pharmacy DepartmentQueensland Children's HospitalBrisbaneQueenslandAustralia
| | | | - Christopher J. Fraser
- Blood and Marrow Transplant ServiceQueensland Children's HospitalBrisbaneQueenslandAustralia
| | | | - Lochie Teague
- Pediatric Blood and Cancer CentreStarship HospitalAucklandNew Zealand
| | - Richard Mitchell
- Kids Cancer CentreSydney Children's HospitalRandwickNew South WalesAustralia
- School of Women & Children's HealthUniversity of New South WalesSydneyNew South WalesAustralia
| | - Tracey O'Brien
- Kids Cancer CentreSydney Children's HospitalRandwickNew South WalesAustralia
- School of Women & Children's HealthUniversity of New South WalesSydneyNew South WalesAustralia
| | - Stefanie Hennig
- Certara, Inc.PrincetonNew JerseyUSA
- School of Clinical Sciences, Faculty of HealthQueensland University of TechnologyBrisbaneAustralia
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7
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Artul T, Henig I, Nassar L, Yehudai-Ofir D, Scherb I, Lurie Y, Efrati E, Zuckerman T, Kurnik D. Decreased Systemic Busulfan Exposure After Oral Dosing With Concomitant Levetiracetam Compared With Phenytoin. Ther Drug Monit 2022; 44:414-418. [PMID: 34739424 DOI: 10.1097/ftd.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/11/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Busulfan (Bu) conditioning used in hematopoietic stem cell transplantation may induce seizures, and prophylactic antiepileptic treatment is recommended. Following updated guidelines, in August 2019, the adult hematopoietic stem cell transplantation department of the Rambam Health Care Campus (Haifa, Israel) switched the antiepileptic prophylaxis protocol from phenytoin to oral levetiracetam during oral Bu conditioning. The aim of this study was to compare the pharmacokinetic parameters of Bu after oral dosing between patients receiving phenytoin and those receiving levetiracetam prophylaxis. METHODS This study was a retrospective cohort study in adults undergoing myoablative conditioning with oral Bu between August 2018 and August 2020. Bu pharmacokinetic parameters (AUC0-6, C0, Cmax, and Tmax) were compared in patients treated with phenytoin comedication (during the year before the change in policy) and levetiracetam comedication (during the year after the change). Potential confounders were accounted for including age, azole comedication, and body weight. RESULTS There were no significant differences in demographic and clinical parameters or weight-corrected Bu dose between the phenytoin group (n = 28) and the levetiracetam group (n = 25). There was no difference in the rate of voriconazole comedication, but fluconazole was more common in the phenytoin group (P = 0.026). The median AUC0-6 was significantly lower in the levetiracetam group (949 μM*min; IQR = 806 to 1101 μM*min) than in the phenytoin group (1208 μM*min; IQR = 1087 to 1389 μM*min; P < 0.001). This is a clinically significant difference of 258 μM*min (21%). Azole use was not associated with Bu exposure. CONCLUSIONS The findings suggest that, after treatment with oral Bu, oral levetiracetam comedication is associated with reduced systemic exposure compared with phenytoin comedication, possibly because of decreased bioavailability.
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Affiliation(s)
- Tareq Artul
- Section of Clinical Pharmacology and Toxicology, Hematology Department, Rambam Health Care Campus, Haifa, Israel
| | - Israel Henig
- Adult Bone Marrow Transplantation Unit, Hematology Department, Rambam Health Care Campus, Haifa, Israel; and
| | - Laila Nassar
- Section of Clinical Pharmacology and Toxicology, Hematology Department, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israeli Institute of Technology, Haifa, Israel
| | - Dana Yehudai-Ofir
- Adult Bone Marrow Transplantation Unit, Hematology Department, Rambam Health Care Campus, Haifa, Israel; and
| | - Inna Scherb
- Section of Clinical Pharmacology and Toxicology, Hematology Department, Rambam Health Care Campus, Haifa, Israel
| | - Yael Lurie
- Section of Clinical Pharmacology and Toxicology, Hematology Department, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israeli Institute of Technology, Haifa, Israel
| | - Edna Efrati
- Section of Clinical Pharmacology and Toxicology, Hematology Department, Rambam Health Care Campus, Haifa, Israel
| | - Tsila Zuckerman
- Adult Bone Marrow Transplantation Unit, Hematology Department, Rambam Health Care Campus, Haifa, Israel; and
- Rappaport Faculty of Medicine, Technion-Israeli Institute of Technology, Haifa, Israel
| | - Daniel Kurnik
- Section of Clinical Pharmacology and Toxicology, Hematology Department, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israeli Institute of Technology, Haifa, Israel
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8
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GSTM1 and GSTT1 double null genotypes determining cell fate and proliferation as potential risk factors of relapse in children with hematological malignancies after hematopoietic stem cell transplantation. J Cancer Res Clin Oncol 2021; 148:71-86. [PMID: 34499222 PMCID: PMC8752561 DOI: 10.1007/s00432-021-03769-2] [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: 07/06/2021] [Accepted: 08/14/2021] [Indexed: 10/29/2022]
Abstract
PURPOSE This study aimed to retrospectively evaluate the genetic association of null variants of glutathione S-transferases GSTM1 and GSTT1 with relapse incidence in children with hematological malignancies (HMs) undergoing busulfan (BU)- containing allogeneic hematopoietic stem cell transplantation (HSCT) and to assess the impact of these variants on BU-induced cytotoxicity on the immortalized lymphoblastoid cell lines (LCLs) and tumor THP1 GST gene-edited cell models. METHODS GSTM1- and GSTT1-null alleles were genotyped using germline DNA from whole blood prior to a conditioning BU-based regimen. Association of GSTM1- and GSTT1-null variants with relapse incidence was analyzed using multivariable competing risk analysis. BU-induced cell death studies were conducted in GSTs- null and non-null LCLs and CRISPR-Cas9 gene-edited THP1 leukemia cell lines. RESULTS Carrying GSTM1/GSTT1 double null genotype was found to be an independent risk factor for post-HSCT relapse in 86 children (adjusted HR: 6.52 [95% Cl, 2.76-15.42; p = 1.9 × 10-5]). BU-induced cell death preferentially in THP1GSTM1(non-null) and LCLsGSTM1(non-null) as shown by decreased viability, increased necrosis and levels of the oxidized form of glutathione compared to null cells, while GSTT1 non-null cells showed increased baseline proliferation. CONCLUSION The clinical association suggests that GSTM1/GSTT1 double null genotype could serve as genetic stratification biomarker for the high risk of post-HSCT relapse. Functional studies have indicated that GSTM1 status modulates BU-induced cell death. On the other hand, GSTT1 is proposed to be involved in baseline cell proliferation.
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9
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Review of the Pharmacokinetics and Pharmacodynamics of Intravenous Busulfan in Paediatric Patients. Clin Pharmacokinet 2020; 60:17-51. [PMID: 33128207 DOI: 10.1007/s40262-020-00947-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2020] [Indexed: 12/13/2022]
Abstract
We aimed to review the pharmacokinetics (PK) of intravenous busulfan in paediatric patients, identify covariate factors influencing exposure, investigate evidence of changes in PK behaviour over time, and correlate exposure with efficacy and toxicity outcomes. A literature review was undertaken of original research published between 2007 and 2019, investigating the PK and pharmacodynamics (PD) of intravenous busulfan in patients ≤ 18 years of age. The review identified 41 publications characterising the PK, and 45 publications describing the PD, of busulfan. Median typical clearance (CL) was 0.22 L/h/kg and median typical volume of distribution was 0.69 L/kg. Patient weight, age, glutathione-S-transferase A1 (GSTA1) genotype and busulfan dosing day/time were the most commonly identified factors affecting CL. Of nine studies investigating changes in CL, seven reported reduced CL over the 4-day course of treatment. Exposure monitoring methods and therapeutic targets were heterogeneous across studies. Relationships between busulfan exposure and patient outcomes were observed in five studies. One study observed a cumulative area under the concentration-time curve over all days of treatment of between 78 and 101 mg/L·h, and two studies observed an average concentration at first dose of < 600 ng/mL improved overall survival, transplant-related mortality, or relapse. One study observed increased sinusoidal obstructive syndrome with maximum busulfan concentration > 1.88 ng/mL. Patient weight, age and GSTA1 genotype are important covariates to consider when individualising busulfan therapy. Reduced busulfan CL over time may need to be accounted for, particularly in patients not receiving phenytoin co-therapy. Standardised monitoring of busulfan exposure over the entire course of treatment and further investigation of the role of busulfan metabolites and pharmacogenomics is warranted.
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10
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El-Serafi A, He R, Zheng W, Benkossou F, Oerther S, Zhao Y, Mellgren K, Gustafsson B, Heilmann C, Kanerva J, Lotfi K, Toporski J, Sundin M, Höglund M, Mattsson J, El-Serafi I, Hassan M. Vitamin D levels and busulphan kinetics in patients undergoing hematopoietic stem cell transplantation, a multicenter study. Bone Marrow Transplant 2020; 56:807-817. [PMID: 33087877 DOI: 10.1038/s41409-020-01091-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/24/2020] [Accepted: 10/08/2020] [Indexed: 11/09/2022]
Abstract
Vitamin D (Vit-D), an essential nutrient, interacts with different drugs including chemotherapeutic agents like busulphan, an alkylating agent used for conditioning prior to stem cell transplantation. The correlation between Vit-D plasma levels and busulphan clearance was investigated in an uncontrolled prospective study in patients and mice. Plasma 25(OH)D levels were measured and busulphan pharmacokinetics calculated in 81 patients. Adults received oral busulphan (n = 34) while children received busulphan orally (n = 19) or intravenously (n = 28). Patients received no Vit-D supplementation. To confirm our findings, pharmacokinetics after a single dose of busulphan (oral or intravenous) were evaluated in two groups of mice (n = 60) receiving high or standard-level Vit-D supplementation. Both busulphan clearance (P < 0.0001) and 25(OH)D levels (P = 0.0004) were significantly higher in adults compared to children. A significant negative correlation (P = 0.041) was found between busulphan clearance and 25(OH)D levels in children treated orally. No such correlation was observed in adults or in children receiving intravenous busulphan. In addition, no significant effect of Vit-D levels on busulphan pharmacokinetics in mice regardless of the administration route. In conclusion, 25(OH)D can affect oral busulphan pharmacokinetics in children and its level should be considered when personalizing oral busulphan treatment. Further studies are warranted to confirm the underlying mechanisms.
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Affiliation(s)
- Ahmed El-Serafi
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Rui He
- Experimental Cancer Medicine, Division of Clinical Research Center, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Clinical Research Center and Center of Allogeneic Stem Cell Transplantation (CAST), Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Wenyi Zheng
- Experimental Cancer Medicine, Division of Clinical Research Center, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Clinical Research Center and Center of Allogeneic Stem Cell Transplantation (CAST), Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Fadwa Benkossou
- Experimental Cancer Medicine, Division of Clinical Research Center, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Clinical Research Center and Center of Allogeneic Stem Cell Transplantation (CAST), Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Sandra Oerther
- Experimental Cancer Medicine, Division of Clinical Research Center, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Pre-clinical Laboratory, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Ying Zhao
- Experimental Cancer Medicine, Division of Clinical Research Center, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Clinical Research Center and Center of Allogeneic Stem Cell Transplantation (CAST), Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Karin Mellgren
- Department of Pediatric Oncology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Britt Gustafsson
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Carsten Heilmann
- Pediatric Clinic, Rigshospitalet, National University Hospital, Copenhagen, Denmark
| | - Jukka Kanerva
- HUS Helsinki University Hospital and University of Helsinki, New Children's Hospital, Division of Hematology-Oncology and Stem Cell Transplantation, Helsinki, Finland
| | - Kourosh Lotfi
- Clinical Pharmacology, Division of Drug Research, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.,Department of Hematology, Linköping University Hospital, Linköping, Sweden
| | - Jacek Toporski
- Department of Pediatrics, Skåne University Hospital, Lund, Sweden
| | - Mikael Sundin
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Section of Pediatric Hematology, Immunology and HCT, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Martin Höglund
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Jonas Mattsson
- Gloria and Seymour Epstein Chair in Cell Therapy and Transplantation, University of Toronto, Toronto, Canada.,Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Ibrahim El-Serafi
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Department of Biochemistry, Faculty of Medicine, Port-Said University, Port-Said, Egypt
| | - Moustapha Hassan
- Experimental Cancer Medicine, Division of Clinical Research Center, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden. .,Clinical Research Center and Center of Allogeneic Stem Cell Transplantation (CAST), Karolinska University Hospital Huddinge, Stockholm, Sweden.
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11
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Bradford KL, Liu S, Krajinovic M, Ansari M, Garabedian E, Tse J, Wang X, Shaw KL, Gaspar HB, Candotti F, Kohn DB. Busulfan Pharmacokinetics in Adenosine Deaminase-Deficient Severe Combined Immunodeficiency Gene Therapy. Biol Blood Marrow Transplant 2020; 26:1819-1827. [PMID: 32653625 PMCID: PMC7529956 DOI: 10.1016/j.bbmt.2020.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/28/2020] [Accepted: 07/01/2020] [Indexed: 12/15/2022]
Abstract
The pharmacokinetics of low-dose busulfan (BU) were investigated as a nonmyeloablative conditioning regimen for autologous gene therapy (GT) in pediatric subjects with adenosine deaminase-deficient severe combined immunodeficiency disease (ADA SCID). In 3 successive clinical trials, which included either γ-retroviral (γ-RV) or lentiviral (LV) vectors, subjects were conditioned with BU using different dosing nomograms. The first cohort received BU doses based on body surface area (BSA), the second cohort received doses based on actual body weight (ABW), and in the third cohort, therapeutic drug monitoring (TDM) was used to target a specific area under the concentration-time curve (AUC). Neither BSA-based nor ABW-based dosing achieved a consistent cumulative BU AUC; in contrast, TDM-based dosing led to more consistent AUC. BU clearance increased as subject age increased from birth to 18 months. However, weight and age alone were insufficient to accurately predict the dose that would consistently achieve a target AUC. Furthermore, various clinical, laboratory, and genetic factors (eg, genotypes for glutathione-S-transferase isozymes known to participate in BU metabolism) were analyzed, but no single finding predicted subjects with rapid versus slow clearance. Analysis of BU AUC and the postengraftment vector copy number (VCN) in granulocytes, a surrogate marker of the level of engrafted gene-modified hematopoietic stem and progenitor cells (HSPCs), demonstrated gene marking at levels sufficient for therapeutic benefit in the subjects who had achieved the target BU AUC. Although many factors determine the ultimate engraftment following GT, this work demonstrates that the BU AUC correlated with the eventual level of engrafted gene-modified HSPCs within a vector group (γ-RV versus LV), with significantly higher levels of granulocyte VCN in the recipients of LV-modified grafts compared to recipients of γ-RV-transduced grafts. Taken together, these findings provide insight into low-dose BU pharmacokinetics in the unique setting of autologous GT for ADA SCID, and these dosing principles may be applied to future GT trials using low-dose BU to open the bone marrow niche.
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Affiliation(s)
- Kathryn L Bradford
- Department of Pediatric Hematology/Oncology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Siyu Liu
- Department of Population Sciences, City of Hope/Beckman Research Institute, Duarte, California; Department of Hematology and Hematopoietic Cell Transplantation, City of Hope/Beckman Research Institute, Duarte, California
| | - Maja Krajinovic
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada; Department of Pharmacology and Physiology, University of Montreal, Montreal, Quebec, Canada
| | - Marc Ansari
- Hematology-Oncology Unit, Department of Pediatrics, Geneva University Hospital & CANSEARCH Research Laboratory, University of Geneva, Geneva, Switzerland
| | - Elizabeth Garabedian
- Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - John Tse
- Department of Pharmaceutical Services, Ronald Reagan Medical Center, UCLA, Los Angeles, California
| | - Xiaoyan Wang
- Department of General Internal Medicine and Health Services Research, UCLA Health, Los Angeles, California
| | - Kit L Shaw
- Department of Microbiology, Immunology and Molecular Genetics, University of California, Los Angeles, California
| | - H Bobby Gaspar
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Orchard Therapeutics, London, United Kingdom
| | - Fabio Candotti
- Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland; Division of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland
| | - Donald B Kohn
- Department of Pediatric Hematology/Oncology, David Geffen School of Medicine at UCLA, Los Angeles, California; Department of Microbiology, Immunology and Molecular Genetics, University of California, Los Angeles, California; Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California; The Broad Stem Cell Research Center, University of California, Los Angeles, California.
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12
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El-Serafi I, Remberger M, Ringdèn O, Törlén J, Sundin M, Björklund A, Winiarski J, Mattsson J. Reduced Risk of Sinusoidal Obstruction Syndrome of the Liver after Busulfan-Cyclophosphamide Conditioning Prior to Allogeneic Hematopoietic Stem Cell Transplantation. Clin Transl Sci 2019; 13:293-300. [PMID: 31675173 PMCID: PMC7070785 DOI: 10.1111/cts.12709] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 09/22/2019] [Indexed: 12/30/2022] Open
Abstract
The aim of this study is to evaluate the incidence of sinusoidal obstruction syndrome (SOS) of the liver and the clinical outcome after hematopoietic stem cell transplantation (HSCT) based on several modifications in our protocols. We retrospectively investigated 372 patients undergoing myeloablative conditioning with oral busulfan (Bu) and cyclophosphamide before allogeneic HSCT during 1990–2015. Patients' supportive care was changed in order to reduce the regimen‐related toxicities. Norethisterone use was terminated in 1998, therapeutic drug monitoring of Bu was initiated in 2000, and the use of liver supportive drugs, such as ursodeoxycholic acid and N‐acetyl‐L‐cysteine, were started in 2002 and 2009, respectively. In total, 26 patients (7.0%) developed SOS at a median of 19 days after transplantation. Of these 26 patients, 20 died at a median of 119 days after HSCT and 102 days after the diagnosis of SOS. The incidence of SOS decreased over time in accordance with the improvements in supportive care. The highest incidence of SOS was during 1995–1999 (16.2%) compared with 2.3% during 2010–2015. Overall survival for patients with SOS was 62%, 46%, and 27% at 100 days, 1 year, and 5 years after HSCT, respectively, compared with 92%, 77%, and 66% for those who did not develop SOS (P < 0.001). In conclusion, the incidence of SOS and related deaths were significantly decreased over the last years. Our institution pursues massive preventative and personalized measures for SOS. This strategy may also be applicable in other conditioning protocols in order to reduce the incidence of SOS and, hence, improve the clinical outcome.
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Affiliation(s)
- Ibrahim El-Serafi
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Biochemistry, Faculty of Medicine, Port-Said University, Port-Said, Egypt
| | - Mats Remberger
- Department of Medical Sciences, Uppsala University and KFUE, Uppsala University Hospital, Uppsala, Sweden
| | - Olle Ringdèn
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Johan Törlén
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Cell Therapies and Allogeneic Stem Cell Transplantation (CAST), Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Sundin
- Division of Pediatrics, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Hematology/Immunology Section, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Andreas Björklund
- Cell Therapies and Allogeneic Stem Cell Transplantation (CAST), Karolinska University Hospital, Stockholm, Sweden
| | - Jacek Winiarski
- Division of Pediatrics, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Hematology/Immunology Section, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Jonas Mattsson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Gloria and Seymour Epstein Chair in Cell Therapy and Transplantation and Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
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13
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Waidyanatha S, Black SR, Blystone CR, Patel PR, Watson SL, Snyder RW, Fennell TR. Disposition and metabolism of sulfolane in Harlan Sprague Dawley rats and B6C3F1/N mice and in vitro in hepatocytes from rats, mice, and humans. Xenobiotica 2019; 50:442-453. [PMID: 31184953 DOI: 10.1080/00498254.2019.1630786] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Sulfolane has been found as a ground water contaminant near refining sites. These studies investigated the in vitro hepatic clearance and in vivo disposition of [14C]sulfolane in rats and mice following a single oral administration (30, 100, or 300 mg/kg) and dermal application (100 mg/kg).[14C]Sulfolane was well-absorbed in male rats following oral administration and excreted extensively in urine (≥93%). Total radioactivity in tissues at 24 and 48 h was ∼7% and <2%. Disposition pattern was similar in female rats and male and female mice at 100 mg/kg oral dose.Dermally applied [14C]Sulfolane (covered dose site, 100 mg/kg) was poorly absorbed in male (∼16%) and female (∼19%) rats; absorption increased to 59% when the dose site was uncovered in male rats suggesting ingestion of dose via grooming of the dose site. Dermally applied [14C]sulfolane (100 mg/kg, covered dose site) was well absorbed in male (∼70%) and female (∼80%) mice.Urinary radiochemical profiles were similar between routes, species, and sexes; the main analytes present in urine were sulfolane and 3-hydroxysulfolane.Sulfolane was not cleared in hepatocytes from rodents or human suggesting sites other than liver might be involved in metabolism of sulfolane in vivo.
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Affiliation(s)
- Suramya Waidyanatha
- Division of the National Toxicology Program, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Sherry R Black
- Discovery Sciences, RTI International, Research Triangle Park, NC, USA
| | - Chad R Blystone
- Division of the National Toxicology Program, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Purvi R Patel
- Discovery Sciences, RTI International, Research Triangle Park, NC, USA
| | - Scott L Watson
- Discovery Sciences, RTI International, Research Triangle Park, NC, USA
| | - Rodney W Snyder
- Discovery Sciences, RTI International, Research Triangle Park, NC, USA
| | - Timothy R Fennell
- Discovery Sciences, RTI International, Research Triangle Park, NC, USA
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14
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Pejčić A, Janković SM, Opančina V, Babić G, Milosavljević M. Drug-drug interactions in patients receiving hematopoietic stem cell transplantation. Expert Opin Drug Metab Toxicol 2018; 15:49-59. [PMID: 30479183 DOI: 10.1080/17425255.2019.1552256] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Recipients of hematopoietic stem cell transplantation (HSCT) are exposed to numerous drugs in both pre- and post-transplantation period, which creates an opportunity for drug-drug interactions (DDIs); if clinically relevant DDIs happen, the risk of adverse treatment outcomes is increased. Areas covered: This review is focused on DDIs in recipients of HSCT that were observed and published as clinical trials, case series or case reports. Relevant publications were found by the systematic search of the following online databases: MEDLINE, SCOPUS, EBSCO, and SCINDEX. Expert opinion: The most important DDIs involve cytostatic or immunosuppressant drug on one side, and antimicrobial drugs on the other. The majority of clinically relevant interactions have pharmacokinetic character, involving drug metabolizing enzymes in the liver. Antifungal azoles inhibit metabolism of many cytostatic and immunosuppressant drugs at cytochromes and increase their plasma concentrations. Macrolide antibiotics and fluoroqunolones should be avoided in HSCT recipients, as they have much larger potential for DDIs than other antibiotic groups. HSCT recipients increasingly receive new immunomodulating drugs, and further observational studies are needed to reveal unsuspected DDIs with clinical relevance.
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Affiliation(s)
- Ana Pejčić
- a Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Slobodan M Janković
- a Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Valentina Opančina
- a Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Goran Babić
- a Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Miloš Milosavljević
- a Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
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15
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Li Y, Fan Y, Su H, Wang Q, Li GF, Hu Y, Jiang J, Tan B, Qiu F. Metabolic characteristics of Tanshinone I in human liver microsomes and S9 subcellular fractions. Xenobiotica 2018; 49:152-160. [PMID: 29357726 DOI: 10.1080/00498254.2018.1432087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tanshinone I (TSI) is a lipophilic diterpene in Salvia miltiorrhiza with versatile pharmacological activities. However, metabolic pathway of TSI in human is unknown. In this study, we determined major metabolites of TSI using a preparation of human liver microsomes (HLMs) by HPLC-UV and Q-Trap mass spectrometer. A total of 6 metabolites were detected, which indicated the presence of hydroxylation, reduction as well as glucuronidation. Selective chemical inhibition and purified cytochrome P450 (CYP450) isoform screening experiments revealed that CYP2A6 was primarily responsible for TSI Phase I metabolism. Part of generated hydroxylated TSI was glucuronidated via several glucuronosyltransferase (UGT) isoforms including UGT1A1, UGT1A3, UGT1A7, UGT1A9, as well as extrahepatic expressed isoforms UGT1A8 and UGT1A10. TSI could be reduced to a relatively unstable hydroquinone intermediate by NAD(P)H: quinone oxidoreductase 1 (NQO1), and then immediately conjugated with glucuronic acid by a panel of UGTs, especially UGT1A9, UGT1A1 and UGT1A8. Additionally, NQO1 could also reduce hydroxylated TSI to a hydroquinone intermediate, which was immediately glucuronidated by UGT1A1. The study demonstrated that hydroxylation, reduction as well as glucuronidation were the major pathways for TSI biotransformation, and six metabolites generated by CYPs, NQO1 and UGTs were found in HLMs and S9 subcellular fractions.
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Affiliation(s)
- Yue Li
- a Laboratory of Clinical Pharmacokinetics , Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine , Shanghai , China
| | - Yujuan Fan
- a Laboratory of Clinical Pharmacokinetics , Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine , Shanghai , China
| | - Huizong Su
- a Laboratory of Clinical Pharmacokinetics , Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine , Shanghai , China
| | - Qian Wang
- a Laboratory of Clinical Pharmacokinetics , Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine , Shanghai , China
| | - Guo-Fu Li
- b Center for Drug Clinical Research , Shanghai University of Traditional Chinese Medicine , Shanghai , China.,c Subei People's Hospital, Yangzhou University , Yangzhou , China
| | - Yiyang Hu
- a Laboratory of Clinical Pharmacokinetics , Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine , Shanghai , China
| | - Jian Jiang
- a Laboratory of Clinical Pharmacokinetics , Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine , Shanghai , China
| | - Bo Tan
- a Laboratory of Clinical Pharmacokinetics , Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine , Shanghai , China
| | - Furong Qiu
- a Laboratory of Clinical Pharmacokinetics , Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine , Shanghai , China
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16
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Correction: Flavin-containing monooxygenase 3 (FMO3) role in busulphan metabolic pathway. PLoS One 2017; 12:e0190181. [PMID: 29261803 PMCID: PMC5736229 DOI: 10.1371/journal.pone.0190181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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