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Granados J, Pasternak AL, Henry NL, Sahai V, Hertz DL. Risk of Toxicity From Topical 5-Fluorouracil Treatment in Patients Carrying DPYD Variant Alleles. Clin Pharmacol Ther 2024; 115:452-456. [PMID: 38060335 PMCID: PMC10947784 DOI: 10.1002/cpt.3131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/03/2023] [Indexed: 12/19/2023]
Abstract
Patients carrying DPYD variant alleles have increased risk of severe toxicity from systemic fluoropyrimidine chemotherapy. There is a paucity of data regarding risk of toxicity from topical 5-fluorouracil (5-FU) treatment in these patients, leading to inconsistent guideline recommendations for pretreatment testing and topical 5-FU dosing. The objective of this retrospective cohort study was to investigate whether DPYD variant allele carriers have increased risk of toxicity from topical 5-FU. Treatment and toxicity data were retrospectively abstracted from the electronic medical records. Genotypes for the five DPYD variants that are associated with increased toxicity from systemic fluoropyrimidine chemotherapy (DPYD*2A, DPYD*13, DPYD p.D949V, DPYD HapB3, and DPYD p.Y186C) were collected from a genetic data repository. Incidence of grade 3+ (primary end point) and 1+ (secondary end point) toxicity was compared between DPYD variant carriers vs. wild-type patients using Fisher's exact tests. The analysis included 201 patients, 7% (14/201) of whom carried a single DPYD variant allele. No patients carried two variant alleles or experienced grade 3+ toxicity. DPYD variant allele carriers did not have a significantly higher risk of grade 1+ toxicity (21.4% vs. 10.2%, odds ratio = 2.40, 95% confidence interval: 0.10-2.53, P = 0.19). Given the low toxicity risk in patients carrying a single DPYD variant allele, there is limited potential clinical benefit of DPYD genetic testing prior to topical 5-FU. However, the risk of severe toxicity in patients with complete DPD deficiency remains unknown and topical 5-FU treatment should be avoided in these patients.
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Affiliation(s)
- Javier Granados
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI
- University of Texas at Austin College of Pharmacy, Austin, TX
| | - Amy L Pasternak
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI
| | - N Lynn Henry
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Vaibhav Sahai
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI
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2
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Hertz DL, Smith DM, Scott SA, Patel JN, Hicks JK. Response to the FDA Decision Regarding DPYD Testing Prior to Fluoropyrimidine Chemotherapy. Clin Pharmacol Ther 2023; 114:768-779. [PMID: 37350752 DOI: 10.1002/cpt.2978] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/31/2023] [Indexed: 06/24/2023]
Abstract
Fluoropyrimidine (FP) chemotherapy is associated with severe, life-threatening toxicities, particularly among patients who carry deleterious germline variants in the DPYD gene. Pretreatment DPYD testing is standard of care throughout most of Europe; however, it has not been recommended in clinical practice guidelines in the United States. Due to increased risk of severe toxicity, a Citizen's Petition asked the US Food and Drug Administration (FDA) to update language in FP drug labels to recommend DPYD testing as part of a boxed warning and recommend FP dose reduction in patients carrying deleterious germline variants. In response, the FDA updated the capecitabine package insert to inform patients about the toxicity risk and test availability and consider DPYD testing. However, the FDA did not include a testing recommendation or requirement, or a boxed warning. Additionally, the FDA did not recommend FP dose adjustment in DPYD variant carriers. This review provides a critical assessment of the DPYD-FP pharmacogenetic association using the FDA's previously published Pharmacogenetic Pyramid, demonstrating that the evidence is compelling for recommending DPYD testing prior to FP treatment. Additionally, the FDA's stated concerns about recommending DPYD testing and DPYD-guided FP dose adjustment are addressed and discussed in the context of the FDA's other genetic testing and dose adjustment recommendations. We call on the FDA to follow our European counterparts in recommending DPYD testing and genotype-based dose adjustment to ensure patients with cancer receive safe and effective FP chemotherapy.
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Affiliation(s)
- Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - D Max Smith
- Department of Oncology, Georgetown University Medical Center, Washington, DC, USA
- MedStar Health, Columbia, Maryland, USA
| | - Stuart A Scott
- Department of Pathology, Stanford University, Stanford, California, USA
- Clinical Genomics Laboratory, Stanford Medicine, Palo Alto, California, USA
| | - Jai N Patel
- Department of Cancer Pharmacology and Pharmacogenomics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - J Kevin Hicks
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, Florida, USA
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3
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Baker SD, Bates SE, Brooks GA, Dahut WL, Diasio RB, El-Deiry WS, Evans WE, Figg WD, Hertz DL, Hicks JK, Kamath S, Kasi PM, Knepper TC, McLeod HL, O'Donnell PH, Relling MV, Rudek MA, Sissung TM, Smith DM, Sparreboom A, Swain SM, Walko CM. DPYD Testing: Time to Put Patient Safety First. J Clin Oncol 2023; 41:2701-2705. [PMID: 36821823 PMCID: PMC10414691 DOI: 10.1200/jco.22.02364] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/02/2022] [Accepted: 01/17/2023] [Indexed: 02/25/2023] Open
Affiliation(s)
- Sharyn D. Baker
- College of Pharmacy, The Ohio State University, Columbus, OH
| | - Susan E. Bates
- Herbert Irving Comprehensive Cancer Center, Columbia University, Irving Medical Center, New York, NY
| | | | | | | | | | | | - William D. Figg
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, MD
| | - Dan L. Hertz
- College of Pharmacy, University of Michigan, Ann Arbor, MI
| | - J. Kevin Hicks
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL
| | - Suneel Kamath
- Cleveland Clinic, Lerner College of Medicine, Cleveland, OH
| | | | - Todd C. Knepper
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL
| | | | | | | | | | | | - D. Max Smith
- Georgetown Lombardi Comprehensive Cancer Center and MedStar Health, Georgetown University, Washington, DC
| | - Alex Sparreboom
- College of Pharmacy, The Ohio State University, Columbus, OH
| | - Sandra M. Swain
- Georgetown Lombardi Comprehensive Cancer Center and MedStar Health, Georgetown University, Washington, DC
| | - Christine M. Walko
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL
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Zawistowski M, Fritsche LG, Pandit A, Vanderwerff B, Patil S, Schmidt EM, VandeHaar P, Willer CJ, Brummett CM, Kheterpal S, Zhou X, Boehnke M, Abecasis GR, Zöllner S. The Michigan Genomics Initiative: A biobank linking genotypes and electronic clinical records in Michigan Medicine patients. CELL GENOMICS 2023; 3:100257. [PMID: 36819667 PMCID: PMC9932985 DOI: 10.1016/j.xgen.2023.100257] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 06/07/2022] [Accepted: 01/05/2023] [Indexed: 02/04/2023]
Abstract
Biobanks of linked clinical patient histories and biological samples are an efficient strategy to generate large cohorts for modern genetics research. Biobank recruitment varies by factors such as geographic catchment and sampling strategy, which affect biobank demographics and research utility. Here, we describe the Michigan Genomics Initiative (MGI), a single-health-system biobank currently consisting of >91,000 participants recruited primarily during surgical encounters at Michigan Medicine. The surgical enrollment results in a biobank enriched for many diseases and ideally suited for a disease genetics cohort. Compared with the much larger population-based UK Biobank, MGI has higher prevalence for nearly all diagnosis-code-based phenotypes and larger absolute case counts for many phenotypes. Genome-wide association study (GWAS) results replicate known findings, thereby validating the genetic and clinical data. Our results illustrate that opportunistic biobank sampling within single health systems provides a unique and complementary resource for exploring the genetics of complex diseases.
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Affiliation(s)
- Matthew Zawistowski
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan, Ann Arbor, MI 48103, USA
| | - Lars G. Fritsche
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan, Ann Arbor, MI 48103, USA
| | - Anita Pandit
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan, Ann Arbor, MI 48103, USA
| | - Brett Vanderwerff
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan, Ann Arbor, MI 48103, USA
| | - Snehal Patil
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan, Ann Arbor, MI 48103, USA
| | - Ellen M. Schmidt
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan, Ann Arbor, MI 48103, USA
| | - Peter VandeHaar
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan, Ann Arbor, MI 48103, USA
| | - Cristen J. Willer
- Department of Internal Medicine, Division of Cardiovascular Medicine, Department of Human Genetics, University of Michigan, Ann Arbor, MI 48103, USA
| | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48103, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48103, USA
| | - Xiang Zhou
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan, Ann Arbor, MI 48103, USA
| | - Michael Boehnke
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan, Ann Arbor, MI 48103, USA
| | - Gonçalo R. Abecasis
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan, Ann Arbor, MI 48103, USA
- Regeneron Genetics Center, Tarrytown, NY 10591, USA
| | - Sebastian Zöllner
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan, Ann Arbor, MI 48103, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, MI 48103, USA
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Hwang M, Medley S, Shakeel F, Vanderwerff B, Zawistowski M, Kidwell KM, Hertz DL. Lack of association of CYP2B6 pharmacogenetics with cyclophosphamide toxicity in patients with cancer. Support Care Cancer 2022; 30:7355-7363. [PMID: 35606478 DOI: 10.1007/s00520-022-07118-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/29/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Cyclophosphamide is a commonly used cancer agent that is metabolically activated by polymorphic enzymes. This study aims to investigate the association between predicted activity of candidate pharmacogenes with severe toxicity during cyclophosphamide treatment. METHODS Genome-wide genetic data was collected from an institutional genetic data repository for CYP2B6, CYP3A4, CYP2C9, CYP2C19, GSTA1, GSTP1, ALDH1A1, ALDH3A1, ABCC1, ABCB1, and ERCC1. Treatment and toxicity data were retrospectively collected from the patient's medical record. The a priori selected primary hypothesis was that patients who have CYP2B6 reduced metabolizer activity (poor or intermediate (PM/IM) vs. normal (NM) metabolizer) have lower risk of severe toxicity or cyclophosphamide treatment modification due to toxicity. RESULTS In the primary analysis of 510 cyclophosphamide-treated patients with available genetic data, there was no difference in the odds of severe toxicity or treatment modification due to toxicity in CYP2B6 PM/IM vs. NM (odds ratio = 0.97, 95% Confidence Interval: 0.62-1.50, p = 0.88). In an exploratory, statistically uncorrected secondary analysis, carriers of the ALDH1A1 rs8187996 variant had a lower risk of the primary toxicity endpoint compared with wild-type homozygous patients (odds ratio = 0.31, 95% Confidence Interval: 0.09-0.78, p = 0.028). None of the other tested phenotypes or genotypes was associated with the primary or secondary endpoints in unadjusted analysis (all p > 0.05). CONCLUSION The finding that patients who carry ALDH1A1 rs8187996 may have a lower risk of cyclophosphamide toxicity than wild-type patients contradicts a prior finding for this variant and should be viewed with skepticism. We found weak evidence that any of these candidate pharmacogenetic predictors of cyclophosphamide toxicity may be useful to personalize cyclophosphamide dosing to optimize therapeutic outcomes in patients with cancer.
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Affiliation(s)
- Mary Hwang
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Room 2560C, 428 Church St., Ann Arbor, MI, 48109-1065, USA
| | - Sarah Medley
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, 48109-2029, USA
| | - Faisal Shakeel
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Room 2560C, 428 Church St., Ann Arbor, MI, 48109-1065, USA
| | - Brett Vanderwerff
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan, Ann Arbor, MI, 48109-2029, USA
| | - Matthew Zawistowski
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan, Ann Arbor, MI, 48109-2029, USA
| | - Kelley M Kidwell
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, 48109-2029, USA
| | - Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Room 2560C, 428 Church St., Ann Arbor, MI, 48109-1065, USA.
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Koo K, Pasternak AL, Henry NL, Sahai V, Hertz DL. Survey of US Medical Oncologists' Practices and Beliefs Regarding DPYD Testing Before Fluoropyrimidine Chemotherapy. JCO Oncol Pract 2022; 18:e958-e965. [PMID: 35239419 DOI: 10.1200/op.21.00874] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Patients who carry reduced-activity DPYD polymorphisms have increased fluoropyrimidine (FP) toxicity risk. Although pretreatment DPYD testing is recommended throughout most of Europe, it is not recommended in the United States, and adoption has been limited. The objective of this survey was to describe the current practice in the United States regarding pretreatment DPYD testing and understand the factors deterring oncologists from ordering testing. METHODS Survey invitations were e-mailed to 325 medical oncologists practicing in the United States who are members of the SWOG Cancer Research Network Gastrointestinal Cancer, Breast Cancer, or Early Therapeutics Committees. Descriptive statistics were used to evaluate survey responses. RESULTS Responses were collected from 59 (18.2%) US medical oncologists, of whom 98% strongly or somewhat agree that patients with dihydropyrimidine dehydrogenase (DPD) deficiency have increased toxicity risk and 96% would modify FP dosing for a patient with known DPD deficiency. However, only 32% strongly or somewhat agree that pretreatment DPYD testing is useful to inform FP treatment, 20% have ever ordered pretreatment testing, and 3% order testing for at least 10% of their FP-treated patients. The most important factors that deter oncologists from ordering testing were low prevalence of DPD deficiency (54%) and lack of clinical practice guideline recommendations (48%). CONCLUSION Clinical adoption of pretreatment DPYD testing is extremely limited in the United States. Utilization may be substantially increased by inclusion in the oncology clinical practice guideline recommendations, coverage through health insurance, and potentially education of medical oncologists regarding available treatment modification guidelines.
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Affiliation(s)
- Kyoin Koo
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI
| | - Amy L Pasternak
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI
| | - N Lynn Henry
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI.,Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Vaibhav Sahai
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI.,Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI
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DPYD Exome, mRNA Expression and Uracil Levels in Early Severe Toxicity to Fluoropyrimidines: An Extreme Phenotype Approach. J Pers Med 2021; 11:jpm11080792. [PMID: 34442436 PMCID: PMC8401253 DOI: 10.3390/jpm11080792] [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: 06/28/2021] [Revised: 08/03/2021] [Accepted: 08/12/2021] [Indexed: 11/17/2022] Open
Abstract
Dihydropyrimidine dehydrogenase deficiency is a major cause of severe fluoropyrimidine-induced toxicity and could lead to interruption of chemotherapy or life-threatening adverse reactions. This study aimed to characterize the DPYD exon sequence, mRNA expression and in vivo DPD activity by plasma uracil concentration. It was carried out in two groups of patients with extreme phenotypes (toxicity versus control) newly treated with a fluoropyrimidine, during the first three cycles of treatment. A novel nonsense gene variant (c.2197insA) was most likely responsible for fluoropyrimidine-induced toxicity in one patient, while neither DPYD mRNA expression nor plasma uracil concentration was globally associated with early toxicity. Our present work may help improve pharmacogenetic testing to avoid severe and undesirable adverse reactions to fluoropyrimidine treatment and it also supports the idea of looking beyond DPYD.
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