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Villanueva G, Guscott M, Schaiquevich P, Sampor C, Combs R, Tentoni N, Hwang M, Lowe J, Howard S. A Systematic Review of High-Dose Methotrexate for Adults with Primary Central Nervous System Lymphoma. Cancers (Basel) 2023; 15:cancers15051459. [PMID: 36900250 PMCID: PMC10000886 DOI: 10.3390/cancers15051459] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 03/03/2023] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a highly aggressive non-Hodgkin lymphoma that is confined within the CNS. Due to its ability to cross the blood-brain barrier, high-dose methotrexate (HDMTX) is the backbone for induction chemotherapy. This systematic review was conducted to observe outcomes among different HDMTX doses (low, <3 g/m2; intermediate, 3-4.9 g/m2; high, ≥5 g/m2) and regimens used in the treatment of PCNSL. A PubMed search resulted in 26 articles reporting clinical trials using HDMTX for PCNSL, from which 35 treatment cohorts were identified for analysis. The median dose of HDMTX used for induction was 3.5 g/m2 (interquartile range IQR, 3-3.5); the intermediate dose was most frequently used in the studies examined (24 cohorts, 69%). Five cohorts used HDMTX monotherapy, 19 cohorts used HDMTX + polychemotherapy, and 11 cohorts used HDMTX + rituximab ± polychemotherapy. Pooled overall response rate (ORR) estimates for low, intermediate, and high dose HDMTX cohorts were 71%, 76%, and 76%, respectively. Pooled 2-year progression-free survival (PFS) estimates for low, intermediate, and high HDMTX dose cohorts were 50%, 51%, and 55%, respectively. Regimens that included rituximab showed a tendency to have higher ORR and 2-year PFS than those that did not include rituximab. These findings indicate that current protocols utilizing 3-4 g/m2 of HDMTX in combination with rituximab provide therapeutic efficacy in PCNSL.
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Affiliation(s)
| | - Martin Guscott
- Resonance, Inc., 5239 Jeffrey Keith Drive, Arlington, TN 38002, USA
- Correspondence:
| | | | - Claudia Sampor
- Resonance, Inc., 5239 Jeffrey Keith Drive, Arlington, TN 38002, USA
| | - Ryan Combs
- Resonance, Inc., 5239 Jeffrey Keith Drive, Arlington, TN 38002, USA
| | - Nicolás Tentoni
- Resonance, Inc., 5239 Jeffrey Keith Drive, Arlington, TN 38002, USA
- Laboratory of Applied Statistics in the Health Sciences, Faculty of Medicine, University of Buenos Aires, Paraguay 2155, Buenos Aires C1121 ABG, Argentina
| | - Miriam Hwang
- Resonance, Inc., 5239 Jeffrey Keith Drive, Arlington, TN 38002, USA
| | - Jennifer Lowe
- Resonance, Inc., 5239 Jeffrey Keith Drive, Arlington, TN 38002, USA
| | - Scott Howard
- Resonance, Inc., 5239 Jeffrey Keith Drive, Arlington, TN 38002, USA
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Barreto JN, Reid JM, Thompson CA, Mara KC, Rule AD, Kashani KB, Leung N, Larson T, McGovern RM, Witzig TE, Barreto EF. Prospective evaluation of high-dose methotrexate pharmacokinetics in adult patients with lymphoma using novel determinants of kidney function. Clin Transl Sci 2022; 15:105-117. [PMID: 34378331 PMCID: PMC8742646 DOI: 10.1111/cts.13125] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/06/2021] [Accepted: 07/10/2021] [Indexed: 12/14/2022] Open
Abstract
High-dose methotrexate (HDMTX) pharmacokinetics (PKs), including the best estimated glomerular filtration rate (eGFR) equation that reflects methotrexate (MTX) clearance, requires investigation. This prospective, observational, single-center study evaluated adult patients with lymphoma treated with HDMTX. Samples were collected at predefined time points up to 96 h postinfusion. MTX and 7-hydroxy-MTX PKs were estimated by standard noncompartmental analysis. Linear regression determined which serum creatinine- or cystatin C-based eGFR equation best predicted MTX clearance. The 80 included patients had a median (interquartile range [IQR]) age of 68.6 years (IQR 59.2-75.6), 54 (67.5%) were men, and 74 (92.5%) were White. The median (IQR) dose of MTX was 7.6 (IQR 4.8-11.3) grams. Median clearance was similar across three dosing levels at 4.5-5.6 L/h and was consistent with linear PKs. Liver function, weight, age, sex, concomitant chemotherapy, and number of previous MTX doses did not impact clearance. MTX area under the curve (AUC) values varied over a fourfold range and appeared to increase in proportion to the dose. The eGFRcys (ml/min) equation most closely correlated with MTX clearance in both the entire cohort and after excluding outlier MTX clearance values (r = 0.31 and 0.51, respectively). HDMTX as a 4-h infusion displays high interpatient pharmacokinetic variability. Population PK modeling to optimize MTX AUC attainment requires further evaluation. The cystatin C-based eGFR equation most closely estimated MTX clearance and should be investigated for dosing and monitoring in adults requiring MTX as part of lymphoma management.
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Affiliation(s)
| | - Joel M. Reid
- Department of Molecular Pharmacology and Experimental TherapeuticsMayo ClinicRochesterMinnesotaUSA,Department of OncologyMayo ClinicRochesterMinnesotaUSA
| | - Carrie A. Thompson
- Division of HematologyDepartment of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Kristin C. Mara
- Division of Biomedical Statistics and InformaticsDepartment of Health Sciences ResearchMayo ClinicRochesterMinnesotaUSA
| | - Andrew D. Rule
- Division of Nephrology and HypertensionDepartment of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Kianoush B. Kashani
- Division of Nephrology and HypertensionDepartment of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Nelson Leung
- Division of Nephrology and HypertensionDepartment of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Thomas R. Larson
- Department of Molecular Pharmacology and Experimental TherapeuticsMayo ClinicRochesterMinnesotaUSA
| | | | - Thomas E. Witzig
- Division of HematologyDepartment of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Erin F. Barreto
- Department of PharmacyMayo ClinicRochesterMinnesotaUSA,Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMinnesotaUSA
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Barreto JN, Peterson KT, Barreto EF, Mara KC, Dierkhising RA, Leung N, Witzig TE, Thompson CA. Early, empiric high-dose leucovorin rescue in lymphoma patients treated with sequential doses of high-dose methotrexate. Support Care Cancer 2021; 29:5293-5301. [PMID: 33661366 DOI: 10.1007/s00520-021-06106-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 02/24/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND In patients exposed to high-dose methotrexate (HDMTX; >1g/m2) with a history of elevated methotrexate (MTX) concentrations during previous doses, it is unclear whether prescribing high-dose leucovorin (HDLV) rescue limits future high levels or reduces the likelihood of acute kidney injury (AKI). METHODS This retrospective, single-center study longitudinally followed adult lymphoma patients treated with HDMTX between 1/1/2011 and 10/31/2017 from diagnosis until 30 days after the last HDMTX dose. Endpoints included elevated MTX concentrations at 48 h (>1.0 μmol/L) and incident AKI after each HDMTX dose. RESULTS The 321 included patients had a median (IQR) age of 65 (57, 72) years, 190 (59%) were male, and 293 (91%) were Caucasian. There were 1558 HDMTX doses [median (IQR) 3 (2, 6) doses per patient] prescribed with 265 (83%) patients receiving more than one MTX dose. Those receiving HDLV rescue were more likely to have an elevated MTX concentration after that dose (OR = 2.69, 95% CI: 1.75-4.11, p < 0.001). Receiving HDLV rescue was associated with a greater likelihood of AKI after MTX (OR = 2.18, 95% CI: 1.38-3.43, p < 0.001). Hospital LOS was longer in those prescribed empiric HDLV rescue after MTX than those prescribed standard leucovorin with an estimated difference of 1.1 days, (95% CI: 0.5-1.7, p < 0.001). CONCLUSION Sequential HDMTX doses are associated with a significant incidence of elevated MTX levels and AKI during lymphoma management. HDLV rescue prescribed during subsequent MTX doses in patients with a previously elevated level was not associated with improved safety outcomes. The optimal supportive care strategy following HDMTX administration requires further investigation.
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Affiliation(s)
- Jason N Barreto
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Kristen T Peterson
- Department of Pharmacy, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Erin F Barreto
- Department of Pharmacy, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ross A Dierkhising
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Nelson Leung
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Thomas E Witzig
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Carrie A Thompson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Incorporating Cystatin C to Predict Methotrexate Elimination in Patients with CNS Lymphoma and Suspicious Renal Function. Case Rep Hematol 2018; 2018:7169897. [PMID: 29780646 PMCID: PMC5892267 DOI: 10.1155/2018/7169897] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 02/18/2018] [Indexed: 01/26/2023] Open
Abstract
High-dose methotrexate (MTX; ≥1 g/m2) is a renally eliminated and nephrotoxic first-line therapy for central nervous system (CNS) lymphoma. Creatinine-based estimation of renal function is the recommended approach to dosing MTX in these cases, but nonrenal determinants of creatinine production and elimination in cancer patients such as malnutrition and cachexia lead to overestimation of glomerular filtration rate (GFR) by this method and a heightened risk for drug toxicity. Serum cystatin C is one of the first readily available, relatively inexpensive, endogenous biomarkers to emerge as a practical adjunct to creatinine for estimation of renal function for drug dosing. In this report, we describe two cases where cystatin C was used in conjunction with creatinine to inform MTX dosing for CNS lymphoma. In both cases, the estimated GFR was nearly 40% lower with the combination of the two biomarkers compared to creatinine-only estimates. Empiric MTX dose reductions as a product of these results likely spared the patients sustained exposure to toxic drug concentrations and facilitated earlier administration of supportive care interventions. Further prospective investigations with validated dosing regimens including cystatin C are warranted for high-dose MTX.
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Howard SC, McCormick J, Pui CH, Buddington RK, Harvey RD. Preventing and Managing Toxicities of High-Dose Methotrexate. Oncologist 2016; 21:1471-1482. [PMID: 27496039 PMCID: PMC5153332 DOI: 10.1634/theoncologist.2015-0164] [Citation(s) in RCA: 463] [Impact Index Per Article: 57.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 06/20/2016] [Indexed: 12/29/2022] Open
Abstract
: High-dose methotrexate (HDMTX), defined as a dose higher than 500 mg/m2, is used to treat a range of adult and childhood cancers. Although HDMTX is safely administered to most patients, it can cause significant toxicity, including acute kidney injury (AKI) in 2%-12% of patients. Nephrotoxicity results from crystallization of methotrexate in the renal tubular lumen, leading to tubular toxicity. AKI and other toxicities of high-dose methotrexate can lead to significant morbidity, treatment delays, and diminished renal function. Risk factors for methotrexate-associated toxicity include a history of renal dysfunction, volume depletion, acidic urine, and drug interactions. Renal toxicity leads to impaired methotrexate clearance and prolonged exposure to toxic concentrations, which further worsen renal function and exacerbate nonrenal adverse events, including myelosuppression, mucositis, dermatologic toxicity, and hepatotoxicity. Serum creatinine, urine output, and serum methotrexate concentration are monitored to assess renal clearance, with concurrent hydration, urinary alkalinization, and leucovorin rescue to prevent and mitigate AKI and subsequent toxicity. When delayed methotrexate excretion or AKI occurs despite preventive strategies, increased hydration, high-dose leucovorin, and glucarpidase are usually sufficient to allow renal recovery without the need for dialysis. Prompt recognition and effective treatment of AKI and associated toxicities mitigate further toxicity, facilitate renal recovery, and permit patients to receive other chemotherapy or resume HDMTX therapy when additional courses are indicated. IMPLICATIONS FOR PRACTICE High-dose methotrexate (HDMTX), defined as a dose higher than 500 mg/m2, is used for a range of cancers. Although HDMTX is safely administered to most patients, it can cause significant toxicity, including acute kidney injury (AKI), attributable to crystallization of methotrexate in the renal tubular lumen, leading to tubular toxicity. When AKI occurs despite preventive strategies, increased hydration, high-dose leucovorin, and glucarpidase allow renal recovery without the need for dialysis. This article, based on a review of the current associated literature, provides comprehensive recommendations for prevention of toxicity and, when necessary, detailed treatment guidance to mitigate AKI and subsequent toxicity.
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Affiliation(s)
- Scott C Howard
- School of Health Studies, University of Memphis, Memphis, Tennessee, USA
| | - John McCormick
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, New York, New York, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, New York, New York, USA
| | | | - R Donald Harvey
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
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