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Hafez SMNA, Elbassuoni E, Abdelzaher WY, Welson NN, Batiha GES, Alzahrani KJ, Abdelbaky FAF. Efficacy of vitamin E in protection against methotrexate induced placental injury in albino rats. Biomed Pharmacother 2021; 139:111637. [PMID: 33965732 DOI: 10.1016/j.biopha.2021.111637] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/13/2021] [Accepted: 04/19/2021] [Indexed: 12/15/2022] Open
Abstract
Methotrexate (MXT) is a chemotherapeutic drug that has been used in a wide range of clinical practices. Unfortunately, the administration of MXT during pregnancy may induce abortion, fetal deformities, and intrauterine growth retardation. Vitamin E is an antioxidant agent that can ameliorate free radical damage. The current work aimed to shed more light on the possible protective effect of vitamin E against MXT induced placental toxicity and to determine the possible mechanisms; biochemically, histologically, and immunohistochemically. Four groups were used: control pregnant, Vitamin E (VIT E) pregnant, Methotrexate (MXT) pregnant, and Vitamin E Methotrexate (VIT E-MXT) pregnant. The placental tissues were processed for light, immunohistochemical, and electron microscopic study. Other samples were obtained for biochemical study; the placental oxidant/antioxidant status was evaluated. The results showed that MXT caused various placental morphological changes in the form of distorted chorionic projection with an accumulation of hemosiderin granules in the trophoblastic cells. Maternal blood vessels showed a homogenous acidophilic material Edema of the extra-embryonic fetal membranes was noticed. A significant decreased in placental weight as well as increase in the oxidative and inflammatory markers were detected. Increased COX2 and decreased eNOS expressions were observed in the MXT group if compared to the control group. VIT E significantly restored the normal histological and immunohistochemical appearance, placental weight, and oxidant/antioxidant balance. It could be concluded the biochemical, morphological, and morphometric findings suggested that vitamin E coadministration is promising in attenuating the placental toxic effect of methotrexate. In this study, VIT E decreased the inflammatory and oxidative stress effect of methotrexate on the placental tissue by enhancing the level of eNOS.
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Affiliation(s)
| | - Eman Elbassuoni
- Physiology Department, Minia University, Faculty of Medicine, Minia, Egypt.
| | | | - Nermeen N Welson
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Beni-Suef University, Egypt.
| | - Gaber El-Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Egypt.
| | - Khalid J Alzahrani
- Department of Clinical Laboratories Sciences, College of Applied Medical Sciences, Taif University, P.O. Box 11099, Taif 21944, Saudi Arabia.
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Škorić B, Jovanović M, Miljković B, Kuzmanović M, Vučićević K. Clinical pharmacokinetics of methotrexate in the treatment of acute lymphoblastic leukemia and non-Hodgkin lymphoma in pediatric patients. ARHIV ZA FARMACIJU 2020. [DOI: 10.5937/arhfarm2001020x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Levêque D, Becker G. The role of therapeutic drug monitoring in the management of safety of anticancer agents: a focus on 3 cytotoxics. Expert Opin Drug Saf 2019; 18:1009-1015. [PMID: 31478396 DOI: 10.1080/14740338.2019.1662395] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: Therapeutic drug monitoring in oncology is used to prevent major toxicities of selected anticancer agents due to overexposure by individualizing the dose based on a pharmacokinetic target. Areas covered: Numerous studies relating a relation between pharmacokinetic variability and toxicity have been reported since the eighties but very few have been implemented in clinical practice due to a lack of validation and harmonization, logistical constraints and reluctance from oncologists. Following recent recommendations, this paper highlights the current-validated applications of pharmacokinetic monitoring in oncology focusing on the safety of anticancer therapies. Expert opinion: Paradoxically given the oldness of the agents, guidelines of dose adjustment have been recently available for intravenous busulfan, 5-fluorouracil, and high-dose methotrexate. Interestingly, besides the enhancement of tolerability, it applies to potential curative clinical situations. In an era of personalized oncology that integrates complex molecular factors in the treatment of cancer, education is needed for oncologists to show the benefits of this valuable (even old) resource for the safety of patients. Therapeutic drug monitoring for busulfan, 5-fluorouracil and methotrexate will still hold in the future unless more active agents are available in the concerned indications.
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Li X, Sui Z, Jing F, Xu W, Li X, Guo Q, Sun S, Bi X. Identifying risk factors for high-dose methotrexate-induced toxicities in children with acute lymphoblastic leukemia. Cancer Manag Res 2019; 11:6265-6274. [PMID: 31308758 PMCID: PMC6615715 DOI: 10.2147/cmar.s207959] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 06/06/2019] [Indexed: 11/23/2022] Open
Abstract
Background Whether monitoring of the methotrexate (MTX) concentrations after high-dose MTX (HD-MTX) infusion can predict toxicities is still controversial, especially when HD-MTX therapy is used in the treatment of children with acute lymphoblastic leukemia (ALL), which is different than the previous schedules. The relationship between patient characteristics and severe adverse events (AEs) has yet to be determined. Objective To analyze the relationship between the MTX concentration and toxicities and to identify the risk predictors from patient characteristics for severe AEs during HD-MTX therapy in children with ALL. Methods We conducted a retrospective study on children with ALL who were treated with 388 HD-MTX infusions. The chi-square test and univariate and logistic regression analyses were used to analyze the relationship between the MTX concentrations and toxicities and to identify predictors for severe AEs. Results Febrile neutropenia (P=0.000) and vomiting (P=0.034) were more likely to occur if the infusion had an MTX level ≥1 μmol/L at 44 h, but other toxicities had no correlations with MTX concentration. Predictive factors for toxicities were as follows: higher risk stratification and higher values of albumin (ALB) for leucopenia, higher values of white blood cell count (WBC) for anemia, higher values of ALB and creatinine (Cr) for neutropenia, higher risk stratification and higher 44-h MTX concentration for febrile neutropenia, higher values of alanine transferase (ALT) for elevated ALT, higher values of ALT for elevated aspartate transferase (AST), and higher values of total bilirubin (TBil) for vomiting. Conclusion Routine monitoring of 44-h MTX concentrations is essential to identify patients at high risk of developing febrile neutropenia and vomiting. This study may provide a reference for clinicians to distinguish patients with a relatively high risk of severe AEs based on certain characteristics before HD-MTX infusion.
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Affiliation(s)
- Xiao Li
- Department of Clinical Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, People's Republic of China
| | - Zhongguo Sui
- Department of Clinical Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, People's Republic of China
| | - Fanbo Jing
- Department of Clinical Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, People's Republic of China
| | - Wen Xu
- Department of Clinical Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, People's Republic of China
| | - Xiangpeng Li
- Department of Clinical Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, People's Republic of China
| | - Qie Guo
- Department of Clinical Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, People's Republic of China
| | - Shuhong Sun
- Department of Clinical Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, People's Republic of China
| | - Xiaolin Bi
- Department of Nutrition, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266003, People's Republic of China
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Liang J, Zhang Z, Zhao H, Wan S, Zhai X, Zhou J, Liang R, Deng Q, Wu Y, Lin G. Simple and rapid monitoring of doxorubicin using streptavidin-modified microparticle-based time-resolved fluorescence immunoassay. RSC Adv 2018; 8:15621-15631. [PMID: 35539486 PMCID: PMC9080157 DOI: 10.1039/c8ra01807c] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/13/2018] [Indexed: 12/16/2022] Open
Abstract
Developing a simple analytical method suitable for therapeutic drug monitoring in a clinical setting is key to establishing guidelines on accurate dose administration and the advancement of precision medicine. We devised a simple rapid analytical method through the combination of streptavidin-modified microparticles and a time-resolved fluorescence immunoassay for therapeutic drug monitoring. The analytical performance of this method was investigated and validated using clinical samples. By determination of doxorubicin concentration, the proposed assay has shown a satisfactory linear range of detection (3.8-3000 ng mL-1) with a limit of detection of 3.8 ng mL-1 and an IC50 of 903.9 ng mL-1. The intra and inter-assay coefficients of variation were 4.12-5.72% and 5.48-6.91%, respectively, and the recovery was acceptable. The applicability of the proposed assay was assessed by comparing the determined results with those measured by LC-MS/MS, presenting a satisfactory correlation (R 2 = 0.9868). The proposed assay, which shows satisfactory analytical performance, has great potential for application in the field of TDM in the future.
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Affiliation(s)
- Junyu Liang
- Institute of Antibody Engineering, School of Laboratory Medicine and Biotechnology, Southern Medical University Guangzhou China +86-20-37247604 +86-20-62789355
| | - Zhigao Zhang
- Institute of Antibody Engineering, School of Laboratory Medicine and Biotechnology, Southern Medical University Guangzhou China +86-20-37247604 +86-20-62789355
| | - Hui Zhao
- Department of Plastic and Aesthetic Surgery, Third Affiliated Hospital, Sun Yat-Sen University Guangzhou China
| | - Shanhe Wan
- Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Science, Southern Medical University Guangzhou China
| | - Xiangming Zhai
- Institute of Antibody Engineering, School of Laboratory Medicine and Biotechnology, Southern Medical University Guangzhou China +86-20-37247604 +86-20-62789355
| | - Jianwei Zhou
- Guangzhou Darui Biotechnology Co. LTD Guangzhou China
| | - Rongliang Liang
- Institute of Antibody Engineering, School of Laboratory Medicine and Biotechnology, Southern Medical University Guangzhou China +86-20-37247604 +86-20-62789355
| | - Qiaoting Deng
- Institute of Antibody Engineering, School of Laboratory Medicine and Biotechnology, Southern Medical University Guangzhou China +86-20-37247604 +86-20-62789355
| | - Yingsong Wu
- Institute of Antibody Engineering, School of Laboratory Medicine and Biotechnology, Southern Medical University Guangzhou China +86-20-37247604 +86-20-62789355
| | - Guanfeng Lin
- Experimental Center of Teaching and Scientific Research, School of Laboratory Medicine and Biotechnology, Southern Medical University Guangzhou China +86-20-37247604 +86-20-62789356
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6
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Silva MF, Ribeiro C, Gonçalves VMF, Tiritan ME, Lima Á. Liquid chromatographic methods for the therapeutic drug monitoring of methotrexate as clinical decision support for personalized medicine: A brief review. Biomed Chromatogr 2018; 32:e4159. [PMID: 29226354 DOI: 10.1002/bmc.4159] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 11/22/2017] [Accepted: 11/29/2017] [Indexed: 01/24/2023]
Abstract
Methotrexate (MTX) is an antifolate drug used for several diseases. Depending on the disease, MTX can be administered at low dose (LDMTX) in some autoimmune diseases, like rheumatoid arthritis, or at high dose (HDMTX) in some cancers, such as acute lymphoblastic leukemia. After absorption, MTX is metabolized in the liver to 7-hydroxymethotrexate and in the intestine to 2,4-diamino-N10-methylpteroic acid (DAMPA). Moreover, inside red blood cells, MTX is converted to active metabolites, MTX polyglutamates (MTXPGs), contributing to its pharmacodynamics. Owing to its narrow therapeutic range, and inter- and intra-patient variability, either noneffectiveness and/or toxicity may occur. Because of the existence of a relationship between drug therapeutic outcome and its systemic concentration, therapeutic drug monitoring (TDM) may ensure the effectiveness and safety of MTX use. In order to monitor the optimization of patient clinical response profile, several analytical methods have been described for TDM in biological samples. These include liquid chromatography (LC) coupled with ultraviolet detection, fluorescence detection or mass spectrometry, each one presenting advantages and drawbacks. This paper reviews the most commonly used techniques for sample preparation and critically discusses the current LC methods applied for the TDM of MTX in biological samples, at LDMTX and HDMTX.
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Affiliation(s)
- Mónica Francisco Silva
- CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Rua Central de Gandra, Gandra, PRD, Portugal.,Faculdade de Medicina da Universidade de Coimbra, R. Larga, Coimbra, Portugal
| | - Cláudia Ribeiro
- CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Rua Central de Gandra, Gandra, PRD, Portugal.,Centro Interdisciplinar de Investigação Marinha e Ambiental, Universidade do Porto, Rua dos Bragas, Porto, Portugal
| | - Virgínia M F Gonçalves
- CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Rua Central de Gandra, Gandra, PRD, Portugal
| | - Maria Elizabeth Tiritan
- CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Rua Central de Gandra, Gandra, PRD, Portugal.,Centro Interdisciplinar de Investigação Marinha e Ambiental, Universidade do Porto, Rua dos Bragas, Porto, Portugal.,Laboratório de Química Orgânica e Farmacêutica, Departamento de Ciências Químicas, Faculdade de Farmácia, Universidade do Porto, Rua de Jorge Viterbo Ferreira, Porto, Portugal
| | - Áurea Lima
- CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Rua Central de Gandra, Gandra, PRD, Portugal.,Grupo de Oncologia Molecular e Patologia Viral, Centro de Investigação, Instituto Português de Oncologia do Porto, Rua Dr. António Bernardino de Almeida, Porto, Portugal.,Hospital de Santo António, Centro Hospitalar do Porto, E.P.E. Largo do Prof. Abel Salazar, Porto, Portugal
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Lucas CJ, Martin JH. Pharmacokinetic-Guided Dosing of New Oral Cancer Agents. J Clin Pharmacol 2017; 57 Suppl 10:S78-S98. [DOI: 10.1002/jcph.937] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 04/10/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Catherine J. Lucas
- Discipline of Clinical Pharmacology, School of Medicine and Public Health; University of Newcastle; New South Wales Australia
| | - Jennifer H. Martin
- Discipline of Clinical Pharmacology, School of Medicine and Public Health; University of Newcastle; New South Wales Australia
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Abstract
Therapeutic drug monitoring is not routinely used for chemotherapy agents. There are Several reasons, but one major drawback is the lack of established therapeutic Concentration ranges. Combination chemotherapy makes the establishment of Therapeutic ranges for individual drugs difficult, the concentration-effect relationship for a single drug may not be the same as when that drug is used in a drug combination. Pharmacokinetic optimization protocols for many classes of cytotoxic compounds exist in specialized centers, and some of these protocols are now part of large multicentre trials. Nonetheless, TDM clearly has the potential to improve the clinical use of chemotherapy gents, most of which have very narrow therapeutic indices and highly variable pharmacokinetics. A substantial body of literature accumulating during the past 15 years demonstrates relationships between systemic exposure to various chemotherapy agents and their toxic or therapeutic effects. This article reviews TDM concepts in addition to tools based on pharmacokinetic modeling of chemotherapy agents. The administered dose of chemotherapy agents is sometimes adjusted individually using either a priori or a posteriori methods. These models can only be applied by using the same dose and schedule as the original study. Bayesian estimation offers more flexibility in blood sampling times and, owing to its precision and to the amount of information provided is the method of choice for ensuring that a given patient benefits from the desired systemic exposure. Moreover, the role and application of Pharmacogenetics as a tool for individualizing chemotherapy is discussed highlighting the agents and mechanisms that have been well studied and defined and their relevance to clinical practice. Finally, this paper address issues critical to the optimal use of TDM in a clinical setting, and the role of clinical pharmacist in this regard. In addition, it discusses future developments in this field that can contribute to improving cancer chemotherapy In terms of patient outcome and survival. J Oncol Pharm Practice (2007) 13: 207—221.
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Affiliation(s)
- Lamya Alnaim
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, P.O. Box 22452, Riyadh, KSA 11495, Saudia Arabia,
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Salvati E, Stellacci F, Krol S. Nanosensors for early cancer detection and for therapeutic drug monitoring. Nanomedicine (Lond) 2015; 10:3495-512. [DOI: 10.2217/nnm.15.180] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The use of nanotechnology for drug delivery in cancer therapy has raised high expectations. Additionally, the use of nanomaterials in sensors to extract and detect tumor specific biomarkers, circulating tumor cells, or extracellular vesicles shed by the tumor holds the promise to detect cancer much earlier and hence improve long-term survival of the patients. Moreover, the monitoring of the anticancer drug concentration, which has a narrow therapeutic window, will allow for a personalized dosing of the drug and will lead to improved therapeutic outcome and life quality of the patient. This review will provide an overview on the use of nanosensors for the early diagnosis of cancer and for the therapeutic drug monitoring, giving some examples. We envision nanosensors to make significant improvements in the cancer management as easy-to-use point-of-care devices for a broad population of users.
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Affiliation(s)
- Elisa Salvati
- IFOM, The FIRC Institute for Molecular Oncology Foundation, IFOM-IEO Campus, Via Adamello 16, 20139 Milan, Italy
| | - Francesco Stellacci
- Institute of Materials, École Polytechnique Fédérale de Lausanne, Station 12, CH–1015 Lausanne, Switzerland
- Fondazione IRCCS Institute of Neurology Carlo Besta, Via Amadeo 42, 20133 Milan, Italy
| | - Silke Krol
- Fondazione IRCCS Institute of Neurology Carlo Besta, Via Amadeo 42, 20133 Milan, Italy
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Achanta S, Sewell A, Ritchey JW, Broaddus K, Bourne DWA, Clarke CR, Maxwell LK. Anatomical and physiological basis for the allometric scaling of cisplatin clearance in dogs. J Vet Pharmacol Ther 2015; 39:224-36. [PMID: 26440900 DOI: 10.1111/jvp.12266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 07/30/2015] [Indexed: 11/26/2022]
Abstract
Cisplatin is a platinum-containing cytotoxic drug indicated for the treatment of solid tumors in veterinary and human patients. Several of the algorithms used to standardize the doses of cytotoxic drugs utilize allometry, or the nonproportional relationships between anatomical and physiological variables, but the underlying basis for these relationships is poorly understood. The objective of this proof of concept study was to determine whether allometric equations explain the relationships between body weight, kidney weight, renal physiology, and clearance of a model, renally cleared anticancer agent in dogs. Postmortem body, kidney, and heart weights were collected from 364 dogs (127 juveniles and 237 adults, including 51 dogs ≥ 8 years of age). Renal physiological and cisplatin pharmacokinetic studies were conducted in ten intact male dogs including two juvenile and eight adult dogs (4-55 kg). Glomerular filtration rate (GFR), effective renal plasma flow, effective renal blood flow, renal cisplatin clearance, and total cisplatin clearance were allometrically related to body weight with powers of 0.75, 0.59, 0.61, 0.71, and 0.70, respectively. The similar values of these diverse mass exponents suggest a common underlying basis for the allometry of kidney size, renal physiology, and renal drug handling.
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Affiliation(s)
- S Achanta
- Departments of Physiological Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, OK, 74078, USA
| | - A Sewell
- Departments of Physiological Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, OK, 74078, USA
| | - J W Ritchey
- Department of Veterinary Pathobiology, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, OK, 74078, USA
| | - K Broaddus
- Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, OK, 74078, USA
| | - D W A Bourne
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73117, USA
| | - C R Clarke
- Departments of Physiological Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, OK, 74078, USA
| | - L K Maxwell
- Departments of Physiological Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, OK, 74078, USA
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Soeny K, Bogacka B, Jones B, Bouillon T. Optimizing dose regimens and fixed dose combination ratios in clinical trials. J Biopharm Stat 2015; 26:432-51. [DOI: 10.1080/10543406.2015.1052478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Gao B, Yeap S, Clements A, Balakrishnar B, Wong M, Gurney H. Evidence for Therapeutic Drug Monitoring of Targeted Anticancer Therapies. J Clin Oncol 2012; 30:4017-25. [DOI: 10.1200/jco.2012.43.5362] [Citation(s) in RCA: 158] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Therapeutic drug monitoring (TDM) provides valuable guidance for dose adjustment of antibiotics, immunosuppressives, antiepileptics, and other drugs, but its use for traditional anticancer therapies has been limited. Perhaps the most important obstacle is the impractical requirement of multiple blood samples to adequately define systemic exposure of drugs that have a short elimination half-life and are given by intermittent intravenous injections. However, the newer targeted anticancer therapies have different pharmacokinetic (PK) and dosing characteristics compared with traditional cytotoxic drugs, making it possible to estimate the steady-state drug exposure with a single trough-level measurement. Recent evidence indicates that certain PK parameters, including trough levels, are correlated with clinical outcomes for many of these agents, including imatinib, sunitinib, rituximab, and cetuximab. Although the current evidence is insufficient to mandate TDM in routine practice, a concerted investigation should be encouraged to determine whether the steady-state trough measurements of targeted agents will have a practical place in the clinical care of patients with cancer.
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Affiliation(s)
- Bo Gao
- Bo Gao, Arthur Clements, Bavanthi Balakrishnar, Mark Wong, and Howard Gurney, Westmead Hospital, Westmead; Bo Gao and Howard Gurney, University of Sydney, Sydney, New South Wales, Australia; and Shang Yeap, Johns Hopkins Hospital,Singapore
| | - Shang Yeap
- Bo Gao, Arthur Clements, Bavanthi Balakrishnar, Mark Wong, and Howard Gurney, Westmead Hospital, Westmead; Bo Gao and Howard Gurney, University of Sydney, Sydney, New South Wales, Australia; and Shang Yeap, Johns Hopkins Hospital,Singapore
| | - Arthur Clements
- Bo Gao, Arthur Clements, Bavanthi Balakrishnar, Mark Wong, and Howard Gurney, Westmead Hospital, Westmead; Bo Gao and Howard Gurney, University of Sydney, Sydney, New South Wales, Australia; and Shang Yeap, Johns Hopkins Hospital,Singapore
| | - Bavanthi Balakrishnar
- Bo Gao, Arthur Clements, Bavanthi Balakrishnar, Mark Wong, and Howard Gurney, Westmead Hospital, Westmead; Bo Gao and Howard Gurney, University of Sydney, Sydney, New South Wales, Australia; and Shang Yeap, Johns Hopkins Hospital,Singapore
| | - Mark Wong
- Bo Gao, Arthur Clements, Bavanthi Balakrishnar, Mark Wong, and Howard Gurney, Westmead Hospital, Westmead; Bo Gao and Howard Gurney, University of Sydney, Sydney, New South Wales, Australia; and Shang Yeap, Johns Hopkins Hospital,Singapore
| | - Howard Gurney
- Bo Gao, Arthur Clements, Bavanthi Balakrishnar, Mark Wong, and Howard Gurney, Westmead Hospital, Westmead; Bo Gao and Howard Gurney, University of Sydney, Sydney, New South Wales, Australia; and Shang Yeap, Johns Hopkins Hospital,Singapore
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Development and Validation of Limited-Sampling Models for the Antiretroviral Agent Zidovudine. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/bf03259243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Kapoor G, Sinha R, Abedin S. Experience with high dose methotrexate therapy in childhood acute lymphoblastic leukemia in a tertiary care cancer centre of a developing country. Pediatr Blood Cancer 2012; 59:448-53. [PMID: 22271707 DOI: 10.1002/pbc.24081] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 12/27/2011] [Indexed: 11/07/2022]
Abstract
BACKGROUND Intensification of systemic chemotherapy with inclusion of high dose methotrexate (HDMTX) has helped omit cranial irradiation from standard risk acute lymphoblastic leukemia (ALL) protocols, thereby eliminating the adverse side effects associated with its use. Administration of HDMTX needs meticulous monitoring. Limitations in the availability of trained staff and adequate infrastructure often pose problems in the developing world. The aim of this study was (1) to treat childhood ALL with a protocol that would have reduced use of cranial irradiation and containing infusions of high-dose methotrexate HDMTX (5 g/m(2)) without compromising on survival, and (2) evaluate the experience with HDMTX in a tertiary care cancer centre in a developing country. METHODS A retrospective chart review was done of 41 consecutive children with a confirmed diagnosis of ALL who had received at least one cycle of HDMTX as part of their consolidation treatment with regard to the patient demographic profile, details of HDMTX infusion and leucovorin rescue, toxicity, additional hospitalization, delay in next cycle of chemotherapy and survival. RESULTS The clinically most significant toxicities observed were mucositis 39% (58/149) and fever 28% (42/149) together leading to additional hospital stay in 7% (11/149) cycles and neutropenia grade 3 or more in 24.8% (34/137) contributing to delay in next cycle of chemotherapy in 15% (23/149) cycles. CONCLUSION With this strategy, it was possible to omit or reduce the dose of cranial irradiation while maintaining survival outcomes. The administration of HDMTX therapy was found to be feasible and safe with the precautions described.
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Affiliation(s)
- Gauri Kapoor
- Department of Pediatric Hematology and Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India.
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16
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Abstract
BACKGROUND Anticancer drugs are characterized by a narrow therapeutic window and significant inter-patient variability in therapeutic and toxic effects. Current body surface area (BSA)-based dosing fails to standardize systemic anticancer drug exposure and other alternative dosing strategies also have their limitations. Just as important as the initial dose selection is the subsequent dose revision to ensure the dose is correct. OBJECTIVE To provide an insight into the different dose individualization and dose adjustment methods, their feasibility and applicability in daily oncology practice and to suggest a practical framework for dose calculation and a basis for future research. METHODS Review of relevant literature related to dose calculation of anticancer drugs. RESULTS Strategies using clinical parameters, genotype and phenotype markers, and therapeutic drug monitoring all have potential and each has a role for specific drugs. However, no one method is a practical dose calculation strategy for many or all drugs. CONCLUSION Given that BSA-dosing leads to significant underdosing it is not reasonable to use this as the sole method of dose calculation. Because of wide disparity in individual patient characteristics and elimination mechanisms, we are unlikely to find the 'Holy Grail' of a single individualized dosing strategy for every patient and anticancer drug in the near future. We propose a pragmatic, although invalidated system for initial dose calculation using dose clusters and structured subsequent dose revision based on treatment-related toxicities and therapeutic drug monitoring. These models need to be tested in clinical trials.
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Affiliation(s)
- Bo Gao
- Westmead Hospital Sydney West Area Health Service, Department of Medical Oncology, Westmead, NSW 2145, Australia
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Zhang J, Tian Q, Yung Chan S, Chuen Li S, Zhou S, Duan W, Zhu YZ. Metabolism and transport of oxazaphosphorines and the clinical implications. Drug Metab Rev 2006; 37:611-703. [PMID: 16393888 DOI: 10.1080/03602530500364023] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The oxazaphosphorines including cyclophosphamide (CPA), ifosfamide (IFO), and trofosfamide represent an important group of therapeutic agents due to their substantial antitumor and immuno-modulating activity. CPA is widely used as an anticancer drug, an immunosuppressant, and for the mobilization of hematopoetic progenitor cells from the bone marrow into peripheral blood prior to bone marrow transplantation for aplastic anemia, leukemia, and other malignancies. New oxazaphosphorines derivatives have been developed in an attempt to improve selectivity and response with reduced toxicity. These derivatives include mafosfamide (NSC 345842), glufosfamide (D19575, beta-D-glucosylisophosphoramide mustard), NSC 612567 (aldophosphamide perhydrothiazine), and NSC 613060 (aldophosphamide thiazolidine). This review highlights the metabolism and transport of these oxazaphosphorines (mainly CPA and IFO, as these two oxazaphosphorine drugs are the most widely used alkylating agents) and the clinical implications. Both CPA and IFO are prodrugs that require activation by hepatic cytochrome P450 (CYP)-catalyzed 4-hydroxylation, yielding cytotoxic nitrogen mustards capable of reacting with DNA molecules to form crosslinks and lead to cell apoptosis and/or necrosis. Such prodrug activation can be enhanced within tumor cells by the CYP-based gene directed-enzyme prodrug therapy (GDEPT) approach. However, those newly synthesized oxazaphosphorine derivatives such as glufosfamide, NSC 612567 and NSC 613060, do not need hepatic activation. They are activated through other enzymatic and/or non-enzymatic pathways. For example, both NSC 612567 and NSC 613060 can be activated by plain phosphodiesterase (PDEs) in plasma and other tissues or by the high-affinity nuclear 3'-5' exonucleases associated with DNA polymerases, such as DNA polymerases and epsilon. The alternative CYP-catalyzed inactivation pathway by N-dechloroethylation generates the neurotoxic and nephrotoxic byproduct chloroacetaldehyde (CAA). Various aldehyde dehydrogenases (ALDHs) and glutathione S-transferases (GSTs) are involved in the detoxification of oxazaphosphorine metabolites. The metabolism of oxazaphosphorines is auto-inducible, with the activation of the orphan nuclear receptor pregnane X receptor (PXR) being the major mechanism. Oxazaphosphorine metabolism is affected by a number of factors associated with the drugs (e.g., dosage, route of administration, chirality, and drug combination) and patients (e.g., age, gender, renal and hepatic function). Several drug transporters, such as breast cancer resistance protein (BCRP), multidrug resistance associated proteins (MRP1, MRP2, and MRP4) are involved in the active uptake and efflux of parental oxazaphosphorines, their cytotoxic mustards and conjugates in hepatocytes and tumor cells. Oxazaphosphorine metabolism and transport have a major impact on pharmacokinetic variability, pharmacokinetic-pharmacodynamic relationship, toxicity, resistance, and drug interactions since the drug-metabolizing enzymes and drug transporters involved are key determinants of the pharmacokinetics and pharmacodynamics of oxazaphosphorines. A better understanding of the factors that affect the metabolism and transport of oxazaphosphorines is important for their optional use in cancer chemotherapy.
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Affiliation(s)
- Jing Zhang
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
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de Jonge ME, Huitema ADR, Schellens JHM, Rodenhuis S, Beijnen JH. Individualised Cancer Chemotherapy: Strategies and Performance of Prospective Studies on Therapeutic Drug Monitoring with Dose Adaptation. Clin Pharmacokinet 2005; 44:147-73. [PMID: 15656695 DOI: 10.2165/00003088-200544020-00002] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Therapeutic drug monitoring (TDM) is increasingly used in clinical practice for the optimisation of drug treatment. Although pharmacokinetic variability is an established factor involved in the variation of therapeutic outcome of many chemotherapeutic agents, the use of TDM in the field of oncology has been limited thus far. An important reason for this is that a therapeutic index for most anticancer agents has not been established; however, in the last 20 years, relationships between plasma drug concentrations and clinical outcome have been defined for various chemotherapeutic agents. Several attempts have been made to use these relationships for optimising the administration of chemotherapeutics by applying pharmacokinetically guided dosage. These prospective studies, individualising chemotherapy dose during therapy based on measured drug concentrations, are discussed in this review. We focus on the way a target value is defined, the methodologies used for dose adaptation and the way the performance of the dose-adaptation approach is evaluated. Furthermore, attention is paid to the results of the studies and the applicability of the strategies in clinical practice. It can be concluded that TDM may contribute to improving cancer chemotherapy in terms of patient outcome and survival and should therefore be further investigated.
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Affiliation(s)
- Milly E de Jonge
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute/Slotervaart Hospital, Amsterdam, The Netherlands.
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19
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Bos AME, Boom K, Vinks AA, Boezen HM, Wanders J, Dombernovsky P, Aamdal S, de Vries EGE, Uges DRA. Development of an optimal sampling strategy for clinical pharmacokinetic studies of the novel anthracycline disaccharide analogue MEN-10755. Cancer Chemother Pharmacol 2004; 54:64-70. [PMID: 15069581 DOI: 10.1007/s00280-004-0772-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2003] [Accepted: 01/19/2004] [Indexed: 10/26/2022]
Abstract
AIM MEN-10755 is a novel anthracycline analogue that has shown an improved therapeutic efficacy over doxorubicin in animal models, especially in gynaecological and lung cancers and is currently under clinical development for the treatment of solid tumours. The aim of the project was to develop an optimal sampling strategy for MEN-10755 to provide an efficient basis for future pharmacokinetic/pharmacodynamic investigations. METHODS Data from 24 patients who participated in a phase I clinical pharmacokinetic study of MEN-10755 administered as a short i.v. infusion were included. Individual pharmacokinetic values were calculated by fitting the plasma concentration data to a two-compartment model using nonlinear least-squared regression (KINFIT, Ed 3.5). Population pharmacokinetic analysis was carried out using (a) the traditional standard two-stage method (STS) based on all data (KINFIT-ALL), (b) the iterative two-stage Bayesian (IT(2)B) population modelling algorithm (KINPOP), and (c) the STS method using KINFIT and using four optimally timed plasma concentrations (KINFIT-OSS4). Determinant (D) optimal sampling strategy (OSS) was used to evaluate the four most information-rich sampling times. The pharmacokinetic parameters V(c) (l), k(el) (h(-1)), k(12) (h(-1)) and k(21) (h(-1)) calculated using KINPOP served as a model for calculation of four D-optimal sampling times. D-optimal sampling data sets were analysed using KINFIT-OSS4 and compared with the population model obtained by the traditional standard two-stage approach for all data sets (KINFIT-ALL). RESULTS The optimal sampling times were: the end of the infusion, and 1.5 h, 3.8 h and 24 h after the start of the infusion. The four-point D-optimal sampling design determined in this study gave individual parameter estimates close to the basic standard estimates using the full data set. CONCLUSION Because accurate estimates of pharmacokinetic parameters were achieved, the four-point D-optimal sampling design may be very useful in future studies with MEN-10755.
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Affiliation(s)
- A M E Bos
- Department of Medical Oncology, University Hospital Groningen, P.O. box 30.001, 9700 RB, Groningen, The Netherlands
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Dumez H, Guetens G, De Boeck G, Highley MS, Maes RAA, van Oosterom AT, de Bruijn EA. The relevance of therapeutic drug monitoring in plasma and erythrocytes in anti-cancer drug treatment. ACTA ACUST UNITED AC 2004; 42:1219-27. [PMID: 15576286 DOI: 10.1515/cclm.2004.244] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractTherapeutic drug monitoring generally focuses on the plasma compartment only. Differentiation between the total plasma concentration and the free fraction (plasma water) has been described for a number of limited drugs. Besides the plasma compartment, blood has also a cellular fraction which has by far the largest theoretical surface and volume for drug transport. It is with anti-cancer drugs that major progress has been made in the study of partition between the largest cellular blood compartment, i.e., erythrocytes, and the plasma compartment. The aim of the present review is to detail the progress made in predicting what a drug does in the body, i.e., pharmacodynamics including toxicity and plasma and/or red blood cell concentration monitoring. Furthermore, techniques generally used in anti-cancer drug monitoring are highlighted. Data for complex Bayesian statistical approaches and population kinetics studies are beyond the scope of this review, since this is generally limited to the plasma compartment only.
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Aquerreta I, Aldaz A, Giráldez J, Sierrasesúmaga L. Methotrexate pharmacokinetics and survival in osteosarcoma. Pediatr Blood Cancer 2004; 42:52-8. [PMID: 14752795 DOI: 10.1002/pbc.10443] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this study was to analyze the relationship between exposure to high-dose methotrexate (HDMTX) and tumor response in terms of survival in children with osteosarcoma. PROCEDURE This study included 44 patients (479 courses) who received a median dose of 5.92 g/m2 of MTX (interquartile range (IQR) 2.37 g/m2) in a 4-hr infusion. The mean area under the concentration-time curve (AUC) estimated by parametric methods (non-parametric expectation maximization, NPEM), and the mean concentration at the end of the infusion were considered to be the exposure parameters. Tumor response was recorded as disease-free survival (DFS), overall survival (OS), and histologic tumor response. The relationship between MTX exposure and survival parameters was analyzed by Cox regression. RESULTS The group of 11 patients who were the least exposed to MTX (AUC <2,400 micromol/L hr) presented a high DFS, probably due to the shorter interval of time between MTX courses that led to a higher dose density. In patients with AUC >2,400 micromol/L hr, an increase in the AUC was related to an increase in the DFS. Significant differences were observed in the DFS between patients whose mean AUC was below or above 4,000 micromol/L hr (P=0.024), such that 4,000 micromol/L hr was considered as the minimum AUC to be aimed at for future patients. CONCLUSIONS Dose density seems to be an important factor in osteosarcoma response, but this must be confirmed in further studies. In order to improve the response to osteosarcoma in children, it is recommended that the dose of MTX to be increased such as to obtain an AUC higher than 4,000 micromol/L hr.
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Affiliation(s)
- Irene Aquerreta
- Department of Pharmacy, University Hospital of Navarra, Pamplona, Spain.
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Limelette N, Ferry M, Branger S, Thuillier A, Fernandez C. In vitro stability study of methotrexate in blood and plasma samples for routine monitoring. Ther Drug Monit 2003; 25:81-7. [PMID: 12548149 DOI: 10.1097/00007691-200302000-00012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A study was conducted to assess the stability of methotrexate (MTX) in pooled plasma and whole blood samples during an 11-day period. The concentrations were determined by liquid chromatography with UV detection over time, in the dark or in light, at different temperatures (4 degrees C or room temperature), and for a low and a high concentration level (0.6 and 2.5 microg/mL, 1.32 and 5.5 micromol/L, respectively). The accuracy, linearity, and variability of the method were assessed. This work demonstrates that blood samples are stable for 2 days at room temperature and for 6 days at 4 degrees C. Furthermore, there is no significant loss (<17%) in plasma at any of the investigated temperatures for at least 6 days. This study shows that whole blood samples can be stored for 3 days before centrifugation and that plasma samples can be reanalyzed after 6 days without any loss.
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Affiliation(s)
- Nadège Limelette
- Department of Pharmacy, Pharmacokinetics and Therapeutic Drug Monitoring, Pitié-Salpêtrière Hospital (AP-HP), Paris, France
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Aquerreta I, Aldaz A, Giráldez J, Sierrasesúmaga L. Pharmacodynamics of high-dose methotrexate in pediatric patients. Ann Pharmacother 2002; 36:1344-50. [PMID: 12196049 DOI: 10.1345/aph.1a446] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To establish a relationship between the pharmacokinetics of high-dose methotrexate (MTX) and toxicity in children of a pediatric oncology department and to reassess MTX concentrations at which the patients would be at high risk for toxic effects. METHODS This study included 37 patients (227 treatment courses) who received a median dose of 4.87 g/m(2) of MTX in a 4-hour infusion. The population pharmacokinetic parameters of MTX were estimated by parametric (IT2B) and nonparametric methods (NPEM). Gastrointestinal, renal, and hematologic toxicity were evaluated. The relationship between pharmacokinetic parameters and toxicity was analyzed by logistic regression and multiple linear regression. RESULTS Equations to predict hematologic and nonhematologic toxicity were obtained. An increase of 100 micro mol/L in the MTX peak concentration meant a 12% (p = 0.03) higher risk of vomiting; a significant delay in MTX elimination implied a 5.76-fold higher risk of mucositis (p < 0.001). An increase of 1 micro mol/L in the MTX concentration 24 hours after the end of the infusion (Cp(24h)) led to a 43% increase in the risk of renal toxicity (p < 0.001). Hematologic toxicity was significantly conditioned by the baseline leukocyte count and Cp(24h) (p < 0.001). CONCLUSIONS The analysis of high-dose MTX pharmacokinetic/pharmacodynamic relationship to toxicity has led to equations able to predict toxicity that are easily applicable to daily practice. Cp(24h) >3.5 micro mol/L was confirmed as an indicator of high risk of toxicity.
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Affiliation(s)
- Irene Aquerreta
- Pharmacy Department, University Hospital of Navarra, Pamplona, Spain.
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Zufía L, Aldaz A, Giráldez J. Separation methods for camptothecin and related compounds. JOURNAL OF CHROMATOGRAPHY. B, BIOMEDICAL SCIENCES AND APPLICATIONS 2001; 764:141-59. [PMID: 11817025 DOI: 10.1016/s0378-4347(01)00319-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This paper reviews working procedures for the analytical determination of camptothecin and analogues. We give an overview of aspects such as the chemistry, structure-activity relationships, stability and mechanism of action of these antitumor compounds. The main body of the review describes separation techniques. Sample treatment and factors influencing high-performance liquid chromatography development are delineated. Published high-performance liquid chromatographic methods are summarized to demonstrate the variability and versatility of separation techniques and a critical evaluation of separation efficiency, detection sensitivity and specificity of these methods is reported.
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Affiliation(s)
- L Zufía
- Pharmacy Department, University Hospital of Navarra, Pamplona, Spain
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25
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Teutenberg T, Lerch O, Götze HJ, Zinn P. Separation of selected anticancer drugs using superheated water as the mobile phase. Anal Chem 2001; 73:3896-9. [PMID: 11534713 DOI: 10.1021/ac0101860] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Six anticancer drugs have been eluted on a polystyrene-divinylbenzene (PS-DVB) column with buffered superheated water as the mobile phase. The temperature range studied was from ambient temperature up to 160 degrees C, and the pH of the water was adjusted to 11.5 and 3.5 with phosphate buffer. It was possible to separate the substances 5-fluorouracil (5-FU), methotrexate (MTX), 7-hydroxymethotrexate (7-OH-MTX), and etoposide (VP-16) in one chromatographic run. The separation of these substances was optimized when adjusting the pH from 11.5 to 3.5, resulting in a total elution time of less than 13 min. Furthermore, retention factors of all of the investigated substances were measured at different temperatures and pH values.
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Affiliation(s)
- T Teutenberg
- Department of Analytical Chemistry, Ruhr-University Bochum, Germany.
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26
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Uluoğlu C, Oğuz A, Timlioğlu O, Biberoğlu G, Hasanoğlu A. Intermediate dose of methotrexate toxicity in non-Hodgkin lymphoma. GENERAL PHARMACOLOGY 1999; 32:215-8. [PMID: 10188622 DOI: 10.1016/s0306-3623(98)00181-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Methotrexate (MTX) is the chemotherapeutic for which the serum levels can be detected. If the MTX level is detected in time, high toxicity risk can be decreased. In this study, intermediate doses of MTX (1 g/m2) infusions are administered to B-cell non-Hodgkin lymphoma patients between 3 and 13 years old. The toxicity of MTX in accordance with serum levels and the toxicity of other combined drugs are investigated. Blood samples were collected consecutively, and MTX levels were detected by high-performance liquid chromatography. When hematological, gastrointestinal, and renal toxicity scores were compared with the 24-h serum levels of MTX, they showed a significant positive correlation. Hematological toxicity scores increased by Ifosfamide, Etoposide, and Cytarabine combined with MTX without altering the serum levels. Antibiotic combination with MTX has no effect on the toxicity scores. In conclusion, if MTX is combined with other myelosuppressive, hepatotoxic, and nephrotoxic drugs, the measurement of MTX serum levels alone is not a sufficient parameter to show the toxicity.
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Affiliation(s)
- C Uluoğlu
- Department of Pharmacology, Medical Faculty, Gazi University, Bahcelievler, Ankara, Turkey.
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Kivistö KT, Kroemer HK, Eichelbaum M. The role of human cytochrome P450 enzymes in the metabolism of anticancer agents: implications for drug interactions. Br J Clin Pharmacol 1995; 40:523-30. [PMID: 8703657 PMCID: PMC1365206 DOI: 10.1111/j.1365-2125.1995.tb05796.x] [Citation(s) in RCA: 236] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
1. Little information is available about the pharmacokinetic interactions of anticancer drugs in man. However, clinically significant drug interactions do occur in cancer chemotherapy, and it is likely that important interactions have not been recognized. 2. Specific cytochrome P450 (CYP) enzymes have been recently shown to be involved in the metabolism of several essential anticancer agents. In particular, enzymes of the CYP3A subfamily play a role in the metabolism of many anticancer drugs, including epipodophyllotoxins, ifosphamide, tamoxifen, taxol and vinca alkaloids. CYP3A4 has been shown to catalyse the activation of the prodrug ifosphamide, raising the possibility that ifosphamide could be activated in tumour tissues containing this enzyme. 3. As examples of recently found, clinically significant interactions, cyclosporin considerably increases plasma doxorubicin and etoposide concentrations. Although cyclosporin and calcium channel blockers may influence the pharmacokinetics of certain anticancer agents by inhibiting their CYP3A mediated metabolism, it is more likely that these P-glycoprotein inhibitors inhibit P-glycoprotein mediated drug elimination. 4. Appropriate caution should be exercised when combining P-glycoprotein inhibitors and potential CYP3A inhibitors with cancer chemotherapy.
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Affiliation(s)
- K T Kivistö
- Dr Margarete Fischer-Bosch-Institut für Klinische Pharmakologie, Stuttgart, Germany
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28
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Donelli MG, Zucchetti M, Robatto A, Perlangeli V, D'Incalci M, Masera G, Rossi MR. Pharmacokinetics of HD-MTX in infants, children, and adolescents with non-B acute lymphoblastic leukemia. MEDICAL AND PEDIATRIC ONCOLOGY 1995; 24:154-9. [PMID: 7838036 DOI: 10.1002/mpo.2950240303] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
A retrospective pharmacokinetic analysis was done of methotrexate serum levels after high-dose treatment (HD-MTX, four cycles at two-week intervals of 5 g/sq.1m. over 24 h i.v.) in children with non-B acute lymphoblastic leukemia (ALL) with the specific aim of seeking differences in patients of different ages, including infants under one year. A total of 122 children (seven infants aged 3 months-1 year, 26 children aged 1-3 years, 68 children aged 3-10 years and 21 adolescents aged 10-15 years) with normal liver and renal function, receiving consolidation therapy at the Pediatric Clinic of Monza between May 1988 and April 1992, were enrolled in this study. MTX was given as an intravenous infusion in 24 h and serum concentrations were measured up to at least 72 h after the start of infusion by an enzyme immunoassay (TDX Abbot, Dallas, TX) in order to modulate folinic acid rescue. Pharmacokinetic analysis of MTX levels according to a two-compartment open model indicated that, compared to all children up to 10 years old, in adolescents older than 10 years the drug reached higher concentrations in serum and was cleared at a lower rate. Steady-state levels and AUC were from 60% higher to more than double and the total clearance of the compound, expressed either per square meter surface area or per kg body weight, in each cycle was significantly lower in adolescents > 10 years of age, sometimes being only one-third of the clearance in infants (0.2 vs. 0.6 1/h/kg and 6.6 vs. 10.7 1/h/sq.m). The relationship between each age and systemic clearance was highly significant as measured by regression analysis. Methotrexate systemic clearance progressively decreased as a function of age. Subsequent treatments did not induce changes in MTX pharmacokinetics. These data suggest that the better tolerance of HD-MTX in children may have a pharmacokinetic basis. The faster elimination of MTX in infants, who usually show the worst prognosis, suggests that full doses could be safely used in order to maximize the antileukemic effect without a high risk of toxicity.
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Affiliation(s)
- M G Donelli
- Istituto di Richerche Farmacologiche Mario Negri, Dipartimento di Biologia e Genetica per le Scienze Mediche, Università degli Studi, Milan, Italy
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van Warmerdam LJ, ten Bokkel Huinink WW, Maes RA, Beijnen JH. Limited-sampling models for anticancer agents. J Cancer Res Clin Oncol 1994; 120:427-33. [PMID: 8188737 DOI: 10.1007/bf01240143] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Pharmacokinetic parameters of antineoplastic drugs are usually generated from concentration/time profiles obtained after multiple venipunctures. With limited-sampling models (LSM) this number can be reduced to between one and three timed plasma samples. LSMs may facilitate population pharmacokinetic/pharmacodynamic studies, which eventually may lead to a dosing strategy based on the characteristics of the individual patient. In this article, the development, validation and application of several LSMs reported in the literature are reviewed.
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Affiliation(s)
- L J van Warmerdam
- Department of Pharmacy, Slotervaart Hospital, Amsterdam, The Netherlands
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van Warmerdam LJ, Verweij J, Rosing H, Schellens JH, Maes RA, Beijnen JH. Limited sampling models for topotecan pharmacokinetics. Ann Oncol 1994; 5:259-64. [PMID: 8186175 DOI: 10.1093/oxfordjournals.annonc.a058804] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Limited sampling models for the estimation of the topotecan Area Under the concentration versus time Curve (AUC) and its lactone ring opened form (AUC Tm), from one or more plasma concentration determinations, are desired for further population-kinetic studies. PATIENTS AND METHODS The models were developed and validated using 34 pharmacokinetic curves in 19 patients who participated in a phase I study. RESULTS A single point model was selected as optimal: AUC (mumol/L.min) = 499 (min).C2h (mumol/L) +0.85 (m2/mg.mumol/L.min).dose(mg/m2), and for topotecan-metabolite (Tm), AUC Tm (mumol/L.min) = 55.1 (min).CTm2h (mumol/L) -0.011 (m2/mg.mg.mumol/L.min).dose (mg/m2), where C2h is the plasma concentration (mumol/L) of topotecan at 2 h after the end of a 30-min infusion, and CTm2h the concentration of the opened form at the same time point. The models are valid for dosages ranging from 0.5 to 1.5 mg/m2/day and proved to be unbiased (MPE% = -1.8% and -9.3%, respectively) and precise (RMSE% = 17.9% and 22.7%, respectively). From the predicted AUCs, the clearance (Cl = dose (mumol)/AUC(mumol/L.min)) could also reliably be predicted, as well as the total AUC (AUC+AUC Tm) RMSE% = 17.1% and MPE% = -0.02%). Half-life values could not be predicted with acceptable precision and accuracy. CONCLUSION The limited sampling models presented may useful for future studies focused on pharmacokinetic/pharmacodynamic relationships of topotecan in large populations.
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Affiliation(s)
- L J van Warmerdam
- Dept of Clinical Pharmacy, Slotervaart Hospital, Amsterdam, The Netherlands
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Abstract
The dose of anticancer drugs is currently adjusted to the patient body surface area, although patients have different abilities to clear anticancer drugs. The dose adjustment to physiological functions permits major toxic accidents to be avoided. The adjustment to tumour drug content is considered, but for ethical or technical reasons, it cannot be used routinely The best criterion for the dose adjustment seems to be drug plasma concentration. The relationship between plasma concentration and efficacy may not be excellent, since it depends on the presence of resistant cells and on the blood flow through the tumour. A relationship between plasma concentration and/or the area under the curve (AUC) with toxicity has been reported with all major anticancer drugs. Different methods of dose adjustment to the drug plasma concentration are reported. In conclusion, dose adjustment to the drug plasma concentration or to the AUC can improve the chemotherapy efficacy, while reducing toxicity.
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Affiliation(s)
- B Desoize
- GIBSA, Faculté de Pharmacie, Laboratoire de Pharmacologie, Institut Jean Godinot, Reims, France
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32
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Moore MJ, Erlichman C, Thiessen JJ, Bunting PS, Hardy R, Kerr I, Soldin S. Variability in the pharmacokinetics of cyclophosphamide, methotrexate and 5-fluorouracil in women receiving adjuvant treatment for breast cancer. Cancer Chemother Pharmacol 1994; 33:472-6. [PMID: 8137456 DOI: 10.1007/bf00686503] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A total of 23 women with stage II breast cancer receiving adjuvant cyclophosphamide, methotrexate and 5-fluorouracil had detailed pharmacokinetic monitoring performed on the first and third courses of therapy. The area under the concentration time curve (AUC) of each of these three drugs varied by a factor of 3-4 among patients. No systematic change in pharmacokinetics between the first and third courses was seen for cyclophosphamide, methotrexate or 5-fluorouracil, and the mean AUC for each of the three drugs did not change. However, significant intrapatient variability in drug pharmacokinetics was observed for all three drugs such that the AUC, clearance and half-life in an individual on the third course could not be reliably predicted from data generated on the first course. On the basis of these results, cyclophosphamide, methotrexate, and 5-fluorouracil pharmacokinetic data from one treatment would not be useful information from which the doses of subsequent courses could be determined.
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Affiliation(s)
- M J Moore
- Department of Medicine, Princess Margaret Hospital, University of Toronto, Ontario, Canada
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Gurney H, Dodwell D, Thatcher N, Tattersall MH. Escalating drug delivery in cancer chemotherapy: a review of concepts and practice--Part 2. Ann Oncol 1993; 4:103-15. [PMID: 8448079 DOI: 10.1093/oxfordjournals.annonc.a058411] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Affiliation(s)
- H Gurney
- Department of Medical Oncology, Westmead Hospital, Sydney, Australia
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34
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Panici PB, Greggi S, Scambia G, Ragusa G, Baiocchi G, Battaglia F, Coronetta F, Mancuso S. High-dose cisplatin and bleomycin neoadjuvant chemotherapy plus radical surgery in locally advanced cervical carcinoma: a preliminary report. Gynecol Oncol 1991; 41:212-6. [PMID: 1714417 DOI: 10.1016/0090-8258(91)90310-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
One course of chemotherapy containing cisplatin and bleomycin as a neoadjuvant treatment was given to 26 consecutive patients with previously untreated stage IB (bulky disease)-III cervical carcinoma and followed by radical surgery. After chemotherapy responses were detected in 23 patients (5 complete and 18 partial; overall, 88%) and permitted radical surgery in 21 cases (81%). Surgery consisted of type III-IV radical hysterectomy plus systematic para-aortic and pelvic lymphadenectomy. At histologic examination, complete responses were found in 5 (19%) and partial responses in 16 (62%) cases. The average number of lymph nodes removed was 61 (range, 38-118). A lower than expected incidence of lymph node metastases was detected (2/21, 9.5%). The chemotherapy-induced toxicity was mainly represented by nausea and vomiting. Chemotherapy did not seem to complicate surgery in these circumstances, even though moderate-degree postoperative complications occurred in 48% of cases. Eighteen months median follow-up time (range, 11-23) from hystological diagnosis has been reached in the operated patients, and no recurrences have been detected so far.
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Affiliation(s)
- P B Panici
- Department of Gynecology and Obstetrics, Università Cattolica del S. Cuore, Rome, Italy
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35
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Abstract
Great strides have been made in the treatment of pediatric solid tumors over the last three decades. A multimodality approach involving a combination of surgery, radiation therapy, and chemotherapy is now used in the treatment of these diseases. This article reviews the principles that guide the use of these modalities and the multidisciplinary approach used to integrate them into a coordinated treatment plan. The role of each modality in the control of local and systemic disease is described. Radiation treatment planning, dose fractionation, and toxicity are also discussed.
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Affiliation(s)
- S L Berg
- Pediatric Branch, National Cancer Institute, Bethesda, Maryland
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36
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Evans WE, Rodman JH, Relling MV, Crom WR, Rivera GK, Pratt CB, Crist WM. Concept of maximum tolerated systemic exposure and its application to phase I-II studies of anticancer drugs. MEDICAL AND PEDIATRIC ONCOLOGY 1991; 19:153-9. [PMID: 2023562 DOI: 10.1002/mpo.2950190302] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The traditional approach to conducting Phase I studies of anticancer drugs is to select a starting dosage for humans based on preclinical data (e.g., mg equivalent of 1/10 LD10 in mice), then empirically escalate dosages in cohorts of patients until the maximum tolerated dosage (MTD) is established. More recently, NCl and EORTC investigators have advocated the use of pharmacokinetic data from preclinical studies to facilitate more rapid dose escalation (e.g., double the dose until the area under the concentration-time curve [AUC] in humans equals the AUC in mice at the LD10). The present paper describes a strategy which builds on the above approach, by extending the application of pharmacokinetic principles to systematically escalate systemic exposure (AUC) instead of dosage in Phase I trials. Human trials are initiated at whatever patient-specific dosage is required to achieve an AUC equal to 1/10 the AUC in mice at the LD10, such that three patients at the first treatment level might receive three different dosages. If no dose-limiting toxicity is observed, the next cohort of patients receives whatever dosage is required to achieve 2 x AUC of the first dosage level, with AUC escalation continuing until the maximum tolerate systemic exposure (MTSE) is reached. By escalating systemic exposure instead of dosage, one adjusts for interpatient pharmacokinetic variability. This strategy will permit more rapid and precise dosage escalations and, more importantly, it should more precisely establish the maximum level of treatment intensity for future Phase II trials.
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Affiliation(s)
- W E Evans
- Pharmaceutical Division, St. Jude Children's Research Hospital, Memphis, TN 38101-0318
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37
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Abstract
The present review on the methods for the analysis of anticancer drugs should be seen as an addition to the excellent work of Eksborg and Ehrsson published half a decade ago in this journal (Vol. 340, p.31). The style and format have been followed closely, with the focus again on chromatographic techniques. We felt it important to add a list of compound (group) structures as a service to the reader. Methods have been reviewed for alkylating agents, platinum compounds, antitumour antibiotics, antimetabolites, alkaloids, suramin, 1-hydroxy-3-amino-propylidene-1,1-bisphosphonate and tamoxifen.
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Affiliation(s)
- U R Tjaden
- Division of Analytical Chemistry, University of Leiden, The Netherlands
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38
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Li X, Lu J, Zhou K, Chen Q, Chen X, Zhang G. Determination of serum harringtonine in patients with anll and its clinical implication. Chin J Cancer Res 1990. [DOI: 10.1007/bf02997235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Aarbakke J. Therapeutic drug monitoring in oncology. Pediatr Hematol Oncol 1990; 7:1-2. [PMID: 2397168 DOI: 10.3109/08880019009034315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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40
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Affiliation(s)
- W E Evans
- Pharmaceutical Division, St Jude Children's Research Hospital, Memphis, Tennessee
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41
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Sezaki H, Takakura Y, Hashida M. Soluble macromolecular carriers for the delivery of antitumour drugs. Adv Drug Deliv Rev 1989. [DOI: 10.1016/0169-409x(89)90013-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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42
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Abstract
Doxorubicin (adriamycin) has a very wide antitumour spectrum, compared with other anticancer drugs; however, except for Hodgkin's disease, it is not associated with curative chemotherapy. Doxorubicin has been in clinical use for more than 2 decades, and only recently has it been recognised that the cytotoxic effect is produced at the cellular level by multiple mechanisms which have not yet been conclusively identified. Key factors are a combination of doxorubicin-induced free radical formation due to metabolic activation, deleterious actions at the level of the membrane, and drug-intercalation into DNA. Multiple aspects of the clinical pharmacokinetics of this drug have been described. Wide interpatient variations in plasma pharmacokinetics have been noted, but without firm relation to clinical outcome. An apparent volume of distribution of approximately 25 L/kg points to extensive uptake by tissues. Up to several weeks after administration, significant concentrations of doxorubicin have been found in haematopoietic cells and in several other tissues. The maximum cellular doxorubicin concentrations reached in vivo remain significantly below those at which all clonogenic leukaemic cells are killed in vitro. Doxorubicin has been administered as frequent (weekly) low doses, single high doses, and as a continuous infusion. The optimal schedule with respect to tumour cytotoxicity and dose-limiting side effects such as myelosuppression or cardiotoxicity, has never been investigated in a prospective, randomised manner. Clinical trials large enough to study optimal, and possibly individualised, doxorubicin chemotherapy need to be performed. This review summarises pharmacological and pharmacodynamic data of doxorubicin, and discusses these in relation to possible improvement of its therapeutic index. Furthermore, drug interactions, dose-response relationships, mechanisms of action, multidrug resistance, and treatment scheduling are discussed in the perspective of the development of novel treatment strategies.
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Affiliation(s)
- P A Speth
- Department of Medical Oncology, University Hospital, Nijmegen, The Netherlands
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43
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Evans WE. Clinical pharmacodynamics of anticancer drugs: a basis for extending the concept of dose-intensity. BLUT 1988; 56:241-8. [PMID: 3289632 DOI: 10.1007/bf00320282] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The studies reviewed herein support the precept that "systemic dose-intensity" (i.e., systemic exposure) may be more informative than "administered dose-intensity" for certain anticancer drugs. This does not mean that the administered dose-intensity should be ignored; in fact these data indicate the importance of documenting and assessing administered dose-intensity as an initial step toward identifying those situations where systemic dose-intensity may be most important. The studies described in this review were selected as representative examples of successful clinical pharmacodynamic studies; other published examples include vincristine AUC versus severity of neurotoxicity, etoposide systemic exposure versus leukopenia, red cell concentration of mercaptopurine metabolites versus neutropenia in children with ALL, and ARA-CTP retention in leukemic blasts versus clinical response in acute non-lymphocytic leukemia. As is the case with other types of clinical trials in cancer patients, there are also examples of negative pharmacodynamic studies (i.e., no relationship found between concentration and effects). There are several possible reasons for such negative findings, including the lack of such a relationship for some drugs, measuring the inappropriate drug moiety (e.g., failure to measure all active metabolites), measuring drug concentrations in the wrong biological fluid, evaluating systemic exposure over too narrow a range (i.e., all patients have either sub- or supra-therapeutic systemic exposure), selecting inappropriate sampling times or pharmacokinetic parameters, inadequately assessing drug toxicity or response, or simply studying an inadequate number of patients or patients with drug-resistant cancers. Therefore, negative findings in some pharmacodynamic studies should not deter the investigation of other drugs and/or other malignant diseases, just as negative therapeutic trials do not preclude subsequent clinical trials in oncology. Also, finding a relation between systemic exposure and drug toxicity, in the absence of a clear relation to antitumor effects, is potentially of great clinical utility. Such data should allow more objective escalation of drug dosages in individual patients, to ensure maximum dose-intensity while avoiding host toxicity. Obviously, if such dose escalation could be guided by more easily measured patient characteristics (e.g., age, weight, CrCl, shoe size, etc.), then using drug concentrations in individual patients might be obviated.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- W E Evans
- Pharmaceutical Division, St. Jude Children's Research Hospital, Memphis, TN
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