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Perera J, Süsstrunk J, Thurneysen C, Steinemann D. Capecitabine-induced severe adverse events-therapeutic drug monitoring and DPYD-gene analysis are recommended. BMJ Case Rep 2024; 17:e256980. [PMID: 38684357 PMCID: PMC11146389 DOI: 10.1136/bcr-2023-256980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/02/2024] Open
Abstract
In this report, two cases of patients with severe adverse events after an adjuvant treatment with capecitabine are described in detail. The first patient suffered from a severe ileocolitis, where ultimately intensive care treatment, total colectomy and ileum resection was necessary. The second patient experienced a toxic enteritis, which could be managed conservatively. Post-therapeutic DPYD genotyping was negative in the former and positive in the latter case. Patients can be categorised in normal, moderate and poor DPYD metabolisers to predict the risk of adverse events of capecitabine treatment. Guidelines in various European countries recommend pretherapeutic DPYD genotyping, whereas it is not recommended by the National Comprehensive Cancer Network in the USA. Irrespective of DPYD genotyping, strict therapeutic drug monitoring is highly recommended to reduce the incidence and severity of adverse events.
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Affiliation(s)
- Johan Perera
- Faculty of Medicine, University of Basel, Basel-Stadt, Switzerland
| | - Julian Süsstrunk
- Department of Visceral Surgery, Clarunis University Digestive Health Care Center Basel, Basel, Switzerland
| | - Claudio Thurneysen
- Department of Oncology, Saint Clara Hospital Cancer Centre, Basel, Switzerland
| | - Daniel Steinemann
- Department of Visceral Surgery, Clarunis University Digestive Health Care Center Basel, Basel, Switzerland
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2
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Glewis S, Lingaratnam S, Krishnasamy M, H Martin J, Tie J, Alexander M, Michael M. Pharmacogenetics testing (DPYD and UGT1A1) for fluoropyrimidine and irinotecan in routine clinical care: Perspectives of medical oncologists and oncology pharmacists. J Oncol Pharm Pract 2024; 30:30-37. [PMID: 37021580 DOI: 10.1177/10781552231167554] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
BACKGROUND Despite robust evidence and international guidelines, to support routine pharmacogenetic (PGx) testing, integration in practice has been limited. This study explored clinicians' views and experiences of pre-treatment DPYD and UGT1A1 gene testing and barriers to and enablers of routine clinical implementation. METHODS A study-specific 17-question survey was emailed (01 February-12 April 2022) to clinicians from the Medical Oncology Group of Australia (MOGA), the Clinical Oncology Society of Australia (COSA) and International Society of Oncology Pharmacy Practitioners (ISOPP). Data were analysed and reported using descriptive statistics. RESULTS Responses were collected from 156 clinicians (78% medical oncologists, 22% pharmacists). Median response rate of 8% (ranged from 6% to 24%) across all organisations. Only 21% routinely test for DPYD and 1% for UGT1A1. For patients undergoing curative/palliative intent treatments, clinicians reported intent to implement genotype-guided dosing by reducing FP dose for DPYD intermediate metabolisers (79%/94%), avoiding FP for DPYD poor metabolisers (68%/90%), and reducing irinotecan dose for UGT1A1 poor metabolisers (84%, palliative setting only). Barriers to implementation included: lack of financial reimbursements (82%) and perceived lengthy test turnaround time (76%). Most Clinicians identified a dedicated program coordinator, i.e., PGx pharmacist (74%) and availability of resources for education/training (74%) as enablers to implementation. CONCLUSION PGx testing is not routinely practised despite robust evidence for its impact on clinical decision making in curative and palliative settings. Research data, education and implementation studies may overcome clinicians' hesitancy to follow guidelines, especially for curative intent treatments, and may overcome other identified barriers to routine clinical implementation.
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Affiliation(s)
- Sarah Glewis
- Department of Pharmacy, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | | | - Mei Krishnasamy
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Academic Nursing Unit, Peter MacCallum Cancer Centre, Melbourne, Australia
- VCCC Alliance, Parkville, Australia
| | - Jennifer H Martin
- School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
| | - Jeanne Tie
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
- Personalised Oncology Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Marliese Alexander
- Department of Pharmacy, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Michael Michael
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
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Glewis S, Krishnasamy M, Lingaratnam S, Harris S, Underhill C, Georgiou C, Warren M, Campbell R, IJzerman M, Fagery M, Campbell I, Martin JH, Tie J, Alexander M, Michael M. Patient and healthcare professional acceptability of pharmacogenetic screening for DPYD and UGT1A1: A cross sectional survey. Clin Transl Sci 2023; 16:2700-2708. [PMID: 37877594 PMCID: PMC10719470 DOI: 10.1111/cts.13664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/21/2023] [Accepted: 10/04/2023] [Indexed: 10/26/2023] Open
Abstract
This study explored the acceptability of a novel pharmacist-led pharmacogenetics (PGx) screening program among patients with cancer and healthcare professionals (HCPs) taking part in a multicenter clinical trial of PGx testing (PACIFIC-PGx ANZCTR:12621000251820). Medical oncologists, oncology pharmacists, and patients with cancer from across four sites (metropolitan/regional), took part in an observational, cross-sectional survey. Participants were recruited from the multicenter trial. Two study-specific surveys were developed to inform implementation strategies for scaled and sustainable translation into routine clinical care: one consisting of 21 questions targeting HCPs and one consisting of 17 questions targeting patients. Responses were collected from 24 HCPs and 288 patients. The 5-to-7-day PGx results turnaround time was acceptable to HCP (100%) and patients (69%). Most HCPs (92%) indicated that it was appropriate for the PGx clinical pharmacist to provide results to patients. Patients reported equal preference for receiving PGx results from a doctor/pharmacist. Patients and HCPs highly rated the pharmacist-led PGx service. HCPs were overall accepting of the program, with the majority (96%) willing to offer PGx testing to their patients beyond the trial. HCPs identified that lack of financial reimbursements (62%) and lack of infrastructure (38%) were the main reasons likely to prevent/slow the implementation of PGx screening program into routine clinical care. Survey data have shown overall acceptability from patients and HCPs participating in the PGx Program. Barriers to implementation of PGx testing in routine care have been identified, providing opportunity to develop targeted implementation strategies for scaled translation into routine practice.
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Affiliation(s)
- Sarah Glewis
- Department of PharmacyPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
| | - Mei Krishnasamy
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
- Academic Nursing UnitPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
- VCCC AllianceMelbourneVictoriaAustralia
| | - Senthil Lingaratnam
- Department of PharmacyPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
| | - Sam Harris
- Department of Medical OncologyBendigo HealthBendigoVictoriaAustralia
| | - Craig Underhill
- VCCC AllianceMelbourneVictoriaAustralia
- Border Medical Oncology Research UnitAlbury Wodonga Regional Cancer CentreEast AlburyNew South WalesAustralia
- UNSW Rural Medical SchoolAlbury CampusAlburyNew South WalesAustralia
| | - Chloe Georgiou
- Department of Medical OncologyBendigo HealthBendigoVictoriaAustralia
| | - Mark Warren
- Department of Medical OncologyBendigo HealthBendigoVictoriaAustralia
| | - Robert Campbell
- Department of Medical OncologyBendigo HealthBendigoVictoriaAustralia
| | - Maarten IJzerman
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
- Cancer ResearchUniversity of MelbourneParkvilleVictoriaAustralia
- Melbourne School of Population and Global Health, Centre for Health PolicyUniversity of MelbourneParkvilleVictoriaAustralia
| | - Mussab Fagery
- Cancer ResearchUniversity of MelbourneParkvilleVictoriaAustralia
| | - Ian Campbell
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
- Cancer Genetics LaboratoryPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
| | - Jennifer H. Martin
- School of Medicine and Public HealthUniversity of NewcastleCallaghanNew South WalesAustralia
| | - Jeanne Tie
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
- Department of Medical OncologyPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Personalised Oncology DivisionWalter and Eliza Hall Institute of Medical ResearchParkvilleVictoriaAustralia
| | - Marliese Alexander
- Department of PharmacyPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
| | - Michael Michael
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneParkvilleVictoriaAustralia
- Department of Medical OncologyPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
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4
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Lim CX, Bozkurt A, Chen ZY, Hird A, Wickens J, Lazarakis S, Hussainy SY, Alexander M. Healthcare professionals' and consumers' knowledge, attitudes, perspectives, and education needs in oncology pharmacogenomics: A systematic review. Clin Transl Sci 2023; 16:2467-2482. [PMID: 37991131 PMCID: PMC10719462 DOI: 10.1111/cts.13672] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 09/19/2023] [Accepted: 10/04/2023] [Indexed: 11/23/2023] Open
Abstract
Clinical implementation of pharmacogenomic (PGx)-guided prescribing in oncology lags behind research evidence generation. We aimed to identify healthcare professionals' (HCPs) and consumers' knowledge, attitudes, perspectives, and education needs to inform strategies for implementation of scalable and sustainable oncology PGx programs. Systematic review of original articles indexed in EMBASE, EMCARE, MEDLINE, and PsycInfo from January 2012 until June 2022, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and using the Mixed Methods Appraisal Tool. PROSPERO registration number CRD42022352348. Of 1442 identified studies; 23 met inclusion criteria with 87% assessed high quality. Of these, 52% reported on HCPs, 35% on consumers, and 13% on both HCPs and consumers. Most were conducted in the United States (70%) and included multiple cancer types (74%). Across studies, HCPs and consumers mostly perceived value in PGx, however, both groups reported barriers to utilization, including cost, lack of consistent recommendations across guidelines, and limited knowledge among HCPs; test accuracy, clear testing benefits, and genomic information confidentiality among consumers. HCPs and consumers value and want to engage in PGx strategies in oncology care, however, are inhibited by unmet needs and practice and knowledge gaps. Implementation strategies aimed at addressing these issues may best support increased PGx uptake in oncology practice.
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Affiliation(s)
- Chiao Xin Lim
- Pharmacy, School of Health and Biomedical SciencesRMIT UniversityBundooraVictoriaAustralia
| | - Alistair Bozkurt
- Pharmacy, School of Health and Biomedical SciencesRMIT UniversityBundooraVictoriaAustralia
| | - Zi Yue Chen
- Pharmacy, School of Health and Biomedical SciencesRMIT UniversityBundooraVictoriaAustralia
| | - Abbey Hird
- Pharmacy, School of Health and Biomedical SciencesRMIT UniversityBundooraVictoriaAustralia
| | - Joanne Wickens
- Pharmacy, School of Health and Biomedical SciencesRMIT UniversityBundooraVictoriaAustralia
| | - Smaro Lazarakis
- Health Sciences Library, Royal Melbourne HospitalParkvilleVictoriaAustralia
| | - Safeera Y. Hussainy
- Pharmacy Department, Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyThe University of MelbourneMelbourneVictoriaAustralia
- Department of General Practice, School of Public Health and Preventive MedicineMonash UniversityClaytonVictoriaAustralia
| | - Marliese Alexander
- Pharmacy Department, Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyThe University of MelbourneMelbourneVictoriaAustralia
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5
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Peruzzi E, Roncato R, De Mattia E, Bignucolo A, Swen JJ, Guchelaar HJ, Toffoli G, Cecchin E. Implementation of pre-emptive testing of a pharmacogenomic panel in clinical practice: Where do we stand? Br J Clin Pharmacol 2023. [PMID: 37926674 DOI: 10.1111/bcp.15956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 11/07/2023] Open
Abstract
Adverse drug reactions (ADRs) account for a large proportion of hospitalizations among adults and are more common in multimorbid patients, worsening clinical outcomes and burdening healthcare resources. Over the past decade, pharmacogenomics has been developed as a practical tool for optimizing treatment outcomes by mitigating the risk of ADRs. Some single-gene reactive tests are already used in clinical practice, including the DPYD test for fluoropyrimidines, which demonstrates how integrating pharmacogenomic data into routine care can improve patient safety in a cost-effective manner. The evolution from reactive single-gene testing to comprehensive pre-emptive genotyping panels holds great potential for refining drug prescribing practices. Several implementation projects have been conducted to test the feasibility of applying different genetic panels in clinical practice. Recently, the results of a large prospective randomized trial in Europe (the PREPARE study by Ubiquitous Pharmacogenomics consortium) have provided the first evidence that prospective application of a pre-emptive pharmacogenomic test panel in clinical practice, in seven European healthcare systems, is feasible and yielded a 30% reduction in the risk of developing clinically relevant toxicities. Nevertheless, some important questions remain unanswered and will hopefully be addressed by future dedicated studies. These issues include the cost-effectiveness of applying a pre-emptive genotyping panel, the role of multiple co-medications, the transferability of currently tested pharmacogenetic guidelines among patients of non-European origin and the impact of rare pharmacogenetic variants that are not detected by currently used genotyping approaches.
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Affiliation(s)
- Elena Peruzzi
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano, Istituti di Ricovero e Cura a Carattere Scientifico, Aviano, Italy
| | - Rossana Roncato
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano, Istituti di Ricovero e Cura a Carattere Scientifico, Aviano, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Elena De Mattia
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano, Istituti di Ricovero e Cura a Carattere Scientifico, Aviano, Italy
| | - Alessia Bignucolo
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano, Istituti di Ricovero e Cura a Carattere Scientifico, Aviano, Italy
| | - Jesse J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Giuseppe Toffoli
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano, Istituti di Ricovero e Cura a Carattere Scientifico, Aviano, Italy
| | - Erika Cecchin
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico di Aviano, Istituti di Ricovero e Cura a Carattere Scientifico, Aviano, Italy
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6
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Shue SA, Rowe E, Bell LA, Damush T, DeLong A, Gowan T, Skaar T, Haggstrom D. Pharmacogenomics implementation across multiple clinic settings: a qualitative evaluation. Pharmacogenomics 2023; 24:881-893. [PMID: 37975236 DOI: 10.2217/pgs-2023-0179] [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] [Indexed: 11/19/2023] Open
Abstract
Aim: To advance clinical adoption and implementation of pharmacogenomics (PGx) testing, barriers and facilitators to these efforts must be understood. This study identified and examined barriers and facilitators to active implementation of a PGx program across multiple clinic settings in an academic healthcare system. Materials & methods: 28 contributors to the PGx implementation (e.g., clinical providers, informatics specialists) completed an interview to elicit their perceptions of the implementation. Results: Qualitative analysis identified several barriers and facilitators that spanned different stages of the implementation process. Specifically, unclear test payment mechanisms, decision support tool development, rigid workflows and provider education were noted as barriers to the PGx implementation. A multidisciplinary implementation team and leadership support emerged as key facilitators. Furthermore, participants also suggested strategies to overcome or maintain these factors. Conclusion: Assessing real-world implementation perceptions and suggested strategies from a range of implementation contributors facilitates a more comprehensive framework and best-practice guidelines for PGx implementation.
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Affiliation(s)
- Sarah A Shue
- VA HSR&D Center for Health Information & Communication, Roudebush VA Medical Center, Indianapolis, IN 46202, USA
| | - Elizabeth Rowe
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Lauren A Bell
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Teresa Damush
- VA HSR&D Center for Health Information & Communication, Roudebush VA Medical Center, Indianapolis, IN 46202, USA
- Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN 46202, USA
| | - Alexis DeLong
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN 46202, USA
| | - Tayler Gowan
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN 46202, USA
| | - Todd Skaar
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - David Haggstrom
- VA HSR&D Center for Health Information & Communication, Roudebush VA Medical Center, Indianapolis, IN 46202, USA
- Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN 46202, USA
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7
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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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8
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Ragia G, Maslarinou A, Atzemian N, Biziota E, Koukaki T, Ioannou C, Balgkouranidou I, Kolios G, Kakolyris S, Xenidis N, Amarantidis K, Manolopoulos VG. Implementing pharmacogenetic testing in fluoropyrimidine-treated cancer patients: DPYD genotyping to guide chemotherapy dosing in Greece. Front Pharmacol 2023; 14:1248898. [PMID: 37781702 PMCID: PMC10536177 DOI: 10.3389/fphar.2023.1248898] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/30/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction: Dihydropyrimidine dehydrogenase (DPD), encoded by DPYD gene, is the rate-limiting enzyme responsible for fluoropyrimidine (FP) catabolism. DPYD gene variants seriously affect DPD activity and are well validated predictors of FP-associated toxicity. DPYD variants rs3918290, rs55886062, rs67376798, and rs75017182 are currently included in FP genetic-based dosing guidelines and are recommended for genotyping by the European Medicines Agency (EMA) before treatment initiation. In Greece, however, no data exist on DPYD genotyping. The aim of the present study was to analyze prevalence of DPYD rs3918290, rs55886062, rs67376798, rs75017182, and, additionally, rs1801160 variants, and assess their association with FP-induced toxicity in Greek cancer patients. Methods: Study group consisted of 313 FP-treated cancer patients. DPYD genotyping was conducted on QuantStudio ™ 12K Flex Real-Time PCR System (ThermoFisher Scientific) using the TaqMan® assays C__30633851_20 (rs3918290), C__11985548_10 (rs55886062), C__27530948_10 (rs67376798), C_104846637_10 (rs75017182) and C__11372171_10 (rs1801160). Results: Any grade toxicity (1-4) was recorded in 208 patients (66.5%). Out of them, 25 patients (12%) experienced grade 3-4 toxicity. DPYD EMA recommended variants were detected in 9 patients (2.9%), all experiencing toxicity (p = 0.031, 100% specificity). This frequency was found increased in grade 3-4 toxicity cases (12%, p = 0.004, 97.9% specificity). DPYD deficiency increased the odds of grade 3-4 toxicity (OR: 6.493, p = 0.014) and of grade 1-4 gastrointestinal (OR: 13.990, p = 0.014), neurological (OR: 4.134, p = 0.040) and nutrition/metabolism (OR: 4.821, p = 0.035) toxicities. FP dose intensity was significantly reduced in DPYD deficient patients (β = -0.060, p <0.001). DPYD rs1801160 variant was not associated with FP-induced toxicity or dose intensity. Triple interaction of DPYD*TYMS*MTHFR was associated with grade 3-4 toxicity (OR: 3.725, p = 0.007). Conclusion: Our findings confirm the clinical validity of DPYD reduced function alleles as risk factors for development of FP-associated toxicity in the Greek population. Pre-treatment DPYD genotyping should be implemented in clinical practice and guide FP dosing. DPYD*gene interactions merit further investigation as to their potential to increase the prognostic value of DPYD genotyping and improve safety of FP-based chemotherapy.
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Affiliation(s)
- Georgia Ragia
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Individualised Medicine and Pharmacological Research Solutions Center (IMPReS), Alexandroupolis, Greece
| | - Anthi Maslarinou
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Individualised Medicine and Pharmacological Research Solutions Center (IMPReS), Alexandroupolis, Greece
| | - Natalia Atzemian
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Individualised Medicine and Pharmacological Research Solutions Center (IMPReS), Alexandroupolis, Greece
| | - Eirini Biziota
- Department of Medical Oncology, University General Hospital of Alexandroupolis, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Triantafyllia Koukaki
- Department of Medical Oncology, University General Hospital of Alexandroupolis, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Charalampia Ioannou
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Ioanna Balgkouranidou
- Department of Medical Oncology, University General Hospital of Alexandroupolis, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - George Kolios
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Individualised Medicine and Pharmacological Research Solutions Center (IMPReS), Alexandroupolis, Greece
| | - Stylianos Kakolyris
- Department of Medical Oncology, University General Hospital of Alexandroupolis, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Nikolaos Xenidis
- Department of Medical Oncology, University General Hospital of Alexandroupolis, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Kyriakos Amarantidis
- Department of Medical Oncology, University General Hospital of Alexandroupolis, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Vangelis G. Manolopoulos
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Individualised Medicine and Pharmacological Research Solutions Center (IMPReS), Alexandroupolis, Greece
- Clinical Pharmacology Unit, Academic General Hospital of Alexandroupolis, Alexandroupolis, Greece
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9
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Fahim SM, Alexander CSW, Qian J, Ngorsuraches S, Hohmann NS, Lloyd KB, Reagan A, Hart L, McCormick N, Westrick SC. Current published evidence on barriers and proposed strategies for genetic testing implementation in health care settings: A scoping review. J Am Pharm Assoc (2003) 2023; 63:998-1016. [PMID: 37119989 DOI: 10.1016/j.japh.2023.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 04/20/2023] [Accepted: 04/22/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND The slow uptake of genetic testing in routine clinical practice warrants the attention of researchers and practitioners to find effective strategies to facilitate implementation. OBJECTIVES This study aimed to identify the barriers to and strategies for pharmacogenetic testing implementation in a health care setting from published literature. METHODS A scoping review was conducted in August 2021 with an expanded literature search using Ovid MEDLINE, Web of Science, International Pharmaceutical Abstract, and Google Scholar to identify studies reporting implementation of pharmacogenetic testing in a health care setting, from a health care system's perspective. Articles were screened using DistillerSR and findings were organized using the 5 major domains of Consolidated Framework for Implementation Research (CFIR). RESULTS A total of 3536 unique articles were retrieved from the above sources, with only 253 articles retained after title and abstract screening. Upon screening the full texts, 57 articles (representing 46 unique practice sites) were found matching the inclusion criteria. We found that most reported barriers and their associated strategies to the implementation of pharmacogenetic testing surrounded 2 CFIR domains: intervention characteristics and inner settings. Factors relating to cost and reimbursement were described as major barriers in the intervention characteristics. In the same domain, another major barrier was the lack of utility studies to provide evidence for genetic testing uptake. Technical hurdles, such as integrating genetic information to medical records, were identified as an inner settings barrier. Collaborations and lessons from early implementers could be useful strategies to overcome majority of the barriers across different health care settings. Strategies proposed by the included implementation studies to overcome these barriers are summarized and can be used as guidance in future. CONCLUSION Barriers and strategies identified in this scoping review can provide implementation guidance for practice sites that are interested in implementing genetic testing.
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10
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Maslarinou A, Manolopoulos VG, Ragia G. Pharmacogenomic-guided dosing of fluoropyrimidines beyond DPYD: time for a polygenic algorithm? Front Pharmacol 2023; 14:1184523. [PMID: 37256234 PMCID: PMC10226670 DOI: 10.3389/fphar.2023.1184523] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 04/19/2023] [Indexed: 06/01/2023] Open
Abstract
Fluoropyrimidines are chemotherapeutic agents widely used for the treatment of various solid tumors. Commonly prescribed FPs include 5-fluorouracil (5-FU) and its oral prodrugs capecitabine (CAP) and tegafur. Bioconversion of 5-FU prodrugs to 5-FU and subsequent metabolic activation of 5-FU are required for the formation of fluorodeoxyuridine triphosphate (FdUTP) and fluorouridine triphosphate, the active nucleotides through which 5-FU exerts its antimetabolite actions. A significant proportion of FP-treated patients develop severe or life-threatening, even fatal, toxicity. It is well known that FP-induced toxicity is governed by genetic factors, with dihydropyrimidine dehydrogenase (DPYD), the rate limiting enzyme in 5-FU catabolism, being currently the cornerstone of FP pharmacogenomics. DPYD-based dosing guidelines exist to guide FP chemotherapy suggesting significant dose reductions in DPYD defective patients. Accumulated evidence shows that additional variations in other genes implicated in FP pharmacokinetics and pharmacodynamics increase risk for FP toxicity, therefore taking into account more gene variations in FP dosing guidelines holds promise to improve FP pharmacotherapy. In this review we describe the current knowledge on pharmacogenomics of FP-related genes, beyond DPYD, focusing on FP toxicity risk and genetic effects on FP dose reductions. We propose that in the future, FP dosing guidelines may be expanded to include a broader ethnicity-based genetic panel as well as gene*gene and gender*gene interactions towards safer FP prescription.
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Affiliation(s)
- Anthi Maslarinou
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Individualised Medicine and Pharmacological Research Solutions Center, Alexandroupolis, Greece
| | - Vangelis G. Manolopoulos
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Individualised Medicine and Pharmacological Research Solutions Center, Alexandroupolis, Greece
- Clinical Pharmacology Unit, Academic General Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Georgia Ragia
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Individualised Medicine and Pharmacological Research Solutions Center, Alexandroupolis, Greece
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11
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Bignucolo A, De Mattia E, Roncato R, Peruzzi E, Scarabel L, D’Andrea M, Sartor F, Toffoli G, Cecchin E. Ten-year experience with pharmacogenetic testing for DPYD in a national cancer center in Italy: Lessons learned on the path to implementation. Front Pharmacol 2023; 14:1199462. [PMID: 37256229 PMCID: PMC10225682 DOI: 10.3389/fphar.2023.1199462] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/05/2023] [Indexed: 06/01/2023] Open
Abstract
Background: Awareness about the importance of implementing DPYD pharmacogenetics in clinical practice to prevent severe side effects related to the use of fluoropyrimidines has been raised over the years. Since 2012 at the National Cancer Institute, CRO-Aviano (Italy), a diagnostic DPYD genotyping service was set up. Purpose: This study aims to describe the evolution of DPYD diagnostic activity at our center over the last 10 years as a case example of a successful introduction of pharmacogenetic testing in clinical practice. Methods: Data related to the diagnostic activity of in-and out-patients referred to our service between January 2012 and December 2022 were retrieved from the hospital database. Results: DPYD diagnostic activity at our center has greatly evolved over the years, shifting gradually from a post-toxicity to a pre-treatment approach. Development of pharmacogenetic guidelines by national and international consortia, genotyping, and IT technology evolution have impacted DPYD testing uptake in the clinics. Our participation in a large prospective implementation study (Ubiquitous Pharmacogenomics) increased health practitioners' and patients' awareness of pharmacogenetic matters and provided additional standardized infrastructures for genotyping and reporting. Nationwide test reimbursement together with recommendations by regulatory agencies in Europe and Italy in 2020 definitely changed the clinical practice guidelines of fluoropyrimidines prescription. A dramatic increase in the number of pre-treatment DPYD genotyping and in the coverage of new fluoropyrimidine prescriptions was noticed by the last year of observation (2022). Conclusion: The long path to a successful DPYD testing implementation in the clinical practice of a National Cancer Center in Italy demonstrated that the development of pharmacogenetic guidelines and genotyping infrastructure standardization as well as capillary training and education activity for all the potential stakeholders are fundamental. However, only national health politics of test reimbursement and clear recommendations by drug regulatory agencies will definitely move the field forward.
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12
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Sukkarieh HH, AlSagoor T, Alnuhait M, Bustami R, Bryson S, Adem FMK, Abdalla H, Karbani G. Awareness and attitudes of oncology specialists toward dihydropyrimidine dehydrogenase testing in Saudi Arabia. Cancer Rep (Hoboken) 2023; 6:e1704. [PMID: 36806724 PMCID: PMC9939998 DOI: 10.1002/cnr2.1704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 06/28/2022] [Accepted: 07/21/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Fluoropyrimidines (FP) are among the most common class of prescribed anti-neoplastic drugs. This class has severe to moderate toxicity in around 10%-40% of those who take 5-fluorouracil (5-FU) or capecitabine for the treatment of cancer. In practice many patients with severe toxicities from FP use had dihydropyrimidine dehydrogenase (DPD) enzyme deficiency. Several studies have proposed DPD screening before treatment with 5-fluorouracil (5-FU) and capecitabine or other drugs belonging to the FP group. This study aims to assess the level of awareness and attitudes of oncology specialists in Saudi Arabia toward genetic screening for DPD prior to giving FP. This highlights the importance of health guidelines required for implementation in our health care system, as a framework to adopt testing as a regular practice in clinical care. Based on the findings in this study, guidelines have been suggested for the Middle East North Africa region. METHODS A cross-sectional survey study was conducted during 2021 targeting oncologists and clinical pharmacists working in the oncology departments across Saudi Arabia. RESULTS A total of 130 oncologists and pharmacists completed the questionnaire representing a response rate of 87%. Most of the respondents indicated that they prescribe FP in clinical practice, but 41% of respondents reported that they have never ordered a specific molecular test during their practice. Only 20% of respondents reported that they often screen for DPD deficiency prior to prescribing FP. Significantly higher rates of awareness of potential dihydropyrimidine dehydrogenase gene (DPYD) mutation were observed among respondents in governmental hospitals (81.1% vs. 47.4% in private hospitals), and among those with more years of practice (80.6% if 5 or more years of practice vs. 59.3% if less than 5 years of practice). Also, higher rates of observing the impact of DPD testing were present among respondents with a PharmD (35% vs. 11% for oncologists and 18% for other professions) and among those with 5 or more years of practice (24.6% vs. 7.7% among those with less than 5 years). CONCLUSION While in some institutions there is a high level of awareness among oncology specialists in Saudi Arabia regarding the effect of the potentially serious DPD enzyme deficiency as a result of gene mutations, screening for these mutations prior to prescribing FP is not a routine practice in hospitals across the country. The findings of this study should promote personalized medicine with recognition of interpatient variability via DPD testing to manage the risks of FP prescribing more effectively in the Kingdom of Saudi Arabia.
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Affiliation(s)
- Hatouf H. Sukkarieh
- College of MedicineAlfaisal UniversityRiyadhSaudi Arabia
- College of BusinessAlfaisal UniversityRiyadhSaudi Arabia
| | - Turki AlSagoor
- College of MedicineAlfaisal UniversityRiyadhSaudi Arabia
- Saudi Food and Drug Authority (SFDA)RiyadhSaudi Arabia
| | - Mohammed Alnuhait
- College of Pharmacy, Department of Clinical PharmacyUmm Al Qura UniversityMakkahSaudi Arabia
| | - Rami Bustami
- College of BusinessAlfaisal UniversityRiyadhSaudi Arabia
| | - Scott Bryson
- Institute of Pharmacy & Biomedical SciencesUniversity of StrathclydeGlasgowScotland
| | | | - Hana Abdalla
- College of MedicineAlfaisal UniversityRiyadhSaudi Arabia
| | - Gulsan Karbani
- College of MedicineAlfaisal UniversityRiyadhSaudi Arabia
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13
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Hertz DL. Assessment of the Clinical Utility of Pretreatment DPYD Testing for Patients Receiving Fluoropyrimidine Chemotherapy. J Clin Oncol 2022; 40:3882-3892. [PMID: 36108264 DOI: 10.1200/jco.22.00037] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Patients who carry pathogenic variants in DPYD have higher systemic fluoropyrimidine (FP) concentrations and greater risk of severe and fatal FP toxicity. Pretreatment DPYD testing and DPYD-guided FP dosing to reduce toxicity and health care costs is recommended by European clinical oncology guidelines and has been adopted across Europe, but has not been recommended or adopted in the United States. The cochairs of the National Comprehensive Cancer Network Guidelines for colon cancer treatment explained their concerns with recommending pretreatment DPYD testing, particularly the risk that reduced FP doses in DPYD carriers may reduce treatment efficacy. METHODS This special article uses previously published frameworks for assessing the clinical utility of cancer biomarker tests, including for germline indicators of toxicity risk, to assess the clinical utility of pretreatment DPYD testing, with a particular focus on the risk of reducing treatment efficacy. RESULTS There is no direct evidence of efficacy reduction, and the available indirect evidence demonstrates that DPYD-guided FP dosing results in similar systemic FP exposure and toxicity compared with standard dosing in noncarriers, and is well calibrated to the maximum tolerated dose, strongly suggesting there is minimal risk of efficacy reduction. CONCLUSION This article should serve as a call to action for clinicians and clinical guidelines committees in the United States to re-evaluate the clinical utility of pretreatment DPYD testing. If clinical utility has not been demonstrated, further dialogue is needed to clarify what additional evidence is needed and which of the available study designs, also described within this article, would be appropriate. Clinical guideline recommendations for pretreatment DPYD testing would increase clinical adoption and ensure that all patients receive maximally safe and effective FP treatment.
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Affiliation(s)
- Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI
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14
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White C, Scott R, Paul CL, Ackland SP. Pharmacogenomics in the era of personalised medicine. Med J Aust 2022; 217:510-513. [PMID: 36259142 PMCID: PMC9827847 DOI: 10.5694/mja2.51759] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/14/2022] [Accepted: 08/05/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Cassandra White
- Maitland HospitalMaitlandNSW,University of NewcastleNewcastleNSW
| | - Rodney Scott
- University of NewcastleNewcastleNSW,Pathology NorthNewcastleNSW
| | - Christine L Paul
- University of NewcastleNewcastleNSW,Priority Research Centre for Health BehaviourUniversity of NewcastleNewcastleNSW
| | - Stephen P Ackland
- Lake Macquarie Private HospitalGatesheadNSW,Hunter Cancer Research AllianceNewcastleNSW
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15
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van den Wildenberg SA, Streng AS, van den Broek R, Broeren MA, Deenen MJ, van Dongen JL, Hanrath MA, Lapré C, Brunsveld L, Scharnhorst V, van de Kerkhof D. Quantification of uracil, dihydrouracil, thymine and dihydrothymine for reliable dihydropyrimidine dehydrogenase (DPD) phenotyping critically depend on blood and plasma storage conditions. J Pharm Biomed Anal 2022; 221:115027. [DOI: 10.1016/j.jpba.2022.115027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/12/2022] [Accepted: 08/30/2022] [Indexed: 12/01/2022]
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16
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Albalwy F, McDermott JH, Newman WG, Brass A, Davies A. A blockchain-based framework to support pharmacogenetic data sharing. THE PHARMACOGENOMICS JOURNAL 2022; 22:264-275. [PMID: 35869255 DOI: 10.1038/s41397-022-00285-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 06/22/2022] [Accepted: 07/01/2022] [Indexed: 12/11/2022]
Abstract
The successful implementation of pharmacogenetics (PGx) into clinical practice requires patient genomic data to be shared between stakeholders in multiple settings. This creates a number of barriers to widespread adoption of PGx, including privacy concerns related to the storage and movement of identifiable genomic data. Informatic solutions that support secure and equitable data access for genomic data are therefore important to PGx. Here we propose a methodology that uses smart contracts implemented on a blockchain-based framework, PGxChain, to address this issue. The design requirements for PGxChain were identified through a systematic literature review, identifying technical challenges and barriers impeding the clinical implementation of pharmacogenomics. These requirements included security and privacy, accessibility, interoperability, traceability and legal compliance. A proof-of-concept implementation based on Ethereum was then developed that met the design requirements. PGxChain's performance was examined using Hyperledger Caliper for latency, throughput, and transaction success rate. The findings clearly indicate that blockchain technology offers considerable potential to advance pharmacogenetic data sharing, particularly with regard to PGx data security and privacy, large-scale accessibility of PGx data, PGx data interoperability between multiple health care providers and compliance with data-sharing laws and regulations.
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Affiliation(s)
- F Albalwy
- Department of Computer Science, Kilburn Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK. .,Department of Computer Science, College of Computer Science and Engineering, Taibah University, Madinah, Saudi Arabia. .,Division of Informatics, Imaging and Data Sciences, Stopford Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK.
| | - J H McDermott
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, M13 9WL, UK.,Division of Evolution Infection and Genomics, School of Biological Sciences, University of Manchester, Manchester, UK
| | - W G Newman
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, M13 9WL, UK.,Division of Evolution Infection and Genomics, School of Biological Sciences, University of Manchester, Manchester, UK
| | - A Brass
- Department of Computer Science, Kilburn Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK.,Division of Informatics, Imaging and Data Sciences, Stopford Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - A Davies
- Division of Informatics, Imaging and Data Sciences, Stopford Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
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17
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Testing for Dihydropyrimidine Dehydrogenase Deficiency to Individualize 5-Fluorouracil Therapy. Cancers (Basel) 2022; 14:cancers14133207. [PMID: 35804978 PMCID: PMC9264755 DOI: 10.3390/cancers14133207] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 12/24/2022] Open
Abstract
Simple Summary 5-Fluorouracil (5-FU) is a chemotherapy drug that is commonly used to treat multiple cancers. Many people who are treated with 5-FU experience severe toxicity to the drug, and in severe cases, patients can die. This review discusses current methods for identifying people who are at high risk for severe side effects to 5-FU therapy. Abstract Severe adverse events (toxicity) related to the use of the commonly used chemotherapeutic drug 5-fluorouracil (5-FU) affect one in three patients and are the primary reason cited for premature discontinuation of therapy. Deficiency of the 5-FU catabolic enzyme dihydropyrimidine dehydrogenase (DPD, encoded by DPYD) has been recognized for the past 3 decades as a pharmacogenetic syndrome associated with high risk of 5-FU toxicity. An appreciable fraction of patients with DPD deficiency that receive 5-FU-based chemotherapy die as a result of toxicity. In this manuscript, we review recent progress in identifying actionable markers of DPD deficiency and the current status of integrating those markers into the clinical decision-making process. The limitations of currently available tests, as well as the regulatory status of pre-therapeutic DPYD testing, are also discussed.
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18
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White C, Scott RJ, Paul C, Ziolkowski A, Mossman D, Fox SB, Michael M, Ackland S. Dihydropyrimidine Dehydrogenase Deficiency and Implementation of Upfront DPYD Genotyping. Clin Pharmacol Ther 2022; 112:791-802. [PMID: 35607723 DOI: 10.1002/cpt.2667] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/13/2022] [Indexed: 12/27/2022]
Abstract
Fluoropyrimidines (FP; 5-fluorouracil, capecitabine, and tegafur) are a commonly prescribed class of antimetabolite chemotherapies, used for various solid organ malignancies in over 2 million patients globally per annum. Dihydropyrimidine dehydrogenase (DPD), encoded by the DPYD gene, is the critical enzyme implicated in FP metabolism. DPYD variant genotypes can result in decreased DPD production, leading to the development of severe toxicities resulting in hospitalization, intensive care admission, and even death. Management of toxicity incurs financial burden on both patients and healthcare systems alike. Upfront DPYD genotyping to identify variant carriers allows an opportunity to identify patients who are at high risk to suffer from serious toxicities and allow prospective dose adjustment of FP treatment. This approach has been shown to reduce patient morbidity, as well as improve the cost-effectiveness of managing FP treatment. Upfront DPYD genotyping has been recently endorsed by several countries in Europe and the United Kingdom. This review summarizes current knowledge about DPD deficiency and upfront DPYD genotyping, including clinical and cost-effectiveness outcomes, with the intent of supporting implementation of an upfront DPYD genotyping service with individualized dose-personalization.
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Affiliation(s)
- Cassandra White
- School of Medicine and Public Health, University of Newcastle, College of Health, Medicine and Wellbeing, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Rodney J Scott
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia.,School of Biomedical Science and Pharmacy, University of Newcastle, College of Health, Medicine and Wellbeing, Callaghan, New South Wales, Australia.,Department of Molecular Genetics, Pathology North John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Christine Paul
- School of Medicine and Public Health, University of Newcastle, College of Health, Medicine and Wellbeing, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Andrew Ziolkowski
- Department of Molecular Genetics, Pathology North John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - David Mossman
- Department of Molecular Genetics, Pathology North John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Stephen B Fox
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael Michael
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen Ackland
- School of Medicine and Public Health, University of Newcastle, College of Health, Medicine and Wellbeing, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia.,Hunter Cancer Centre, Lake Macquarie Private Hospital, Gateshead, New South Wales, Australia
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19
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Begré UBM, Jörger M, Aebi S, Amstutz U, Largiadèr CR. Clinical Implementation of DPYD Pharmacogenetic Testing to Prevent Early-Onset Fluoropyrimidine-Related Toxicity in Cancer Patients in Switzerland. Front Pharmacol 2022; 13:885259. [PMID: 35662713 PMCID: PMC9159275 DOI: 10.3389/fphar.2022.885259] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/25/2022] [Indexed: 01/19/2023] Open
Abstract
The implementation of pharmacogenetic testing into clinical practice has been a slow process so far. Here, we review the implementation of pre-treatment testing of dihydropyrimidine dehydrogenase gene (DPYD) risk variants to prevent early-onset fluoropyrimidine (FP)-related toxicity in cancer patients in Switzerland based on data of a large Swiss diagnostic center. In January 2017, the Swiss Federal Office of Public Health introduced the reimbursement of DPYD testing by the compulsory health insurance in Switzerland based on evidence for the clinical relevance of DPYD-risk variants and the cost-effectiveness of pre-treatment testing, and on the availability of international guidelines. However, we did not observe a strong increase in DPYD testing at our diagnostic center from 2017 to 2019. Only a low number of DPYD-testing requests (28-42 per year), concerning mostly retrospective investigations of suspected FP-toxicity, were received. In contrast, we observed a 14-fold increase in DPYD testing together with a strong shift from retrospective to pre-treatment test requests upon the release of recommendations for DPYD testing prior to FP-treatment in April 2020 by the European Medicines Agency. This increase was mainly driven by three geographic regions of Switzerland, where partner institutions of previous research collaborations regarding FP-related toxicity are located and who acted as early-adopting institutions of DPYD testing. Our data suggest the important role of early adopters as accelerators of clinical implementation of pharmacogenetic testing by introducing these policies to their working environment and educating health workers from their own and nearby institutions.
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Affiliation(s)
- Ursina B. M. Begré
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus Jörger
- Department of Medical Oncology and Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Stefan Aebi
- Division of Medical Oncology, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Ursula Amstutz
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carlo R. Largiadèr
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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20
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Campanella B, Lomonaco T, Benedetti E, Onor M, Nieri R, Marmorino F, Cremolini C, Bramanti E. Fast, Direct Dihydrouracil Quantitation in Human Saliva: Method Development, Validation, and Application. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19106033. [PMID: 35627569 PMCID: PMC9140617 DOI: 10.3390/ijerph19106033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/11/2022] [Accepted: 05/14/2022] [Indexed: 12/04/2022]
Abstract
Background. Salivary metabolomics is garnering increasing attention in the health field because of easy, minimally invasive saliva sampling. Dihydrouracil (DHU) is a metabolite of pyrimidine metabolism present in urine, plasma, and saliva and of fluoropyrimidines-based chemotherapeutics. Its fast quantification would help in the identification of patients with higher risk of fluoropyrimidine-induced toxicity and inborn errors of pyrimidine metabolism. Few studies consider DHU as the main salivary metabolite, but reports of its concentration levels in saliva are scarce. We propose the direct determination of DHU in saliva by reversed-phase high-performance liquid chromatography (RP-HPLC-UV detector) as a simple, rapid procedure for non-invasive screening. Methods. The method used was validated and applied to 176 saliva samples collected from 21 nominally healthy volunteers and 4 saliva samples from metastatic colorectal cancer patients before and after receiving 5-fluorouracil chemotherapy. Results. DHU levels in all samples analyzed were in the μmol L−1 range or below proving that DHU is not the main metabolite in saliva and confirming the results found in the literature with LC-MS/MS instrumentation. Any increase of DHU due to metabolism dysfunctions can be suggestive of disease and easily monitored in saliva using common, low-cost instrumentation available also for population screening.
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Affiliation(s)
- Beatrice Campanella
- National Research Council of Italy, C.N.R., Institute of Chemistry of Organometallic Compounds—ICCOM, Via G. Moruzzi 1, 56124 Pisa, Italy; (B.C.); (M.O.); (R.N.)
| | - Tommaso Lomonaco
- Department of Chemistry and Industrial Chemistry, University of Pisa, Via G. Moruzzi 15, 56124 Pisa, Italy;
| | - Edoardo Benedetti
- Hematology Unit, Department of Oncology, Azienda Ospedaliero Universitaria Pisana, Via Roma 67, 56127 Pisa, Italy;
| | - Massimo Onor
- National Research Council of Italy, C.N.R., Institute of Chemistry of Organometallic Compounds—ICCOM, Via G. Moruzzi 1, 56124 Pisa, Italy; (B.C.); (M.O.); (R.N.)
| | - Riccardo Nieri
- National Research Council of Italy, C.N.R., Institute of Chemistry of Organometallic Compounds—ICCOM, Via G. Moruzzi 1, 56124 Pisa, Italy; (B.C.); (M.O.); (R.N.)
| | - Federica Marmorino
- Unity of Oncology, Department of Translational Research and New Technologies in Medicine, University of Pisa, Via Roma 67, 56127 Pisa, Italy; (F.M.); (C.C.)
| | - Chiara Cremolini
- Unity of Oncology, Department of Translational Research and New Technologies in Medicine, University of Pisa, Via Roma 67, 56127 Pisa, Italy; (F.M.); (C.C.)
| | - Emilia Bramanti
- National Research Council of Italy, C.N.R., Institute of Chemistry of Organometallic Compounds—ICCOM, Via G. Moruzzi 1, 56124 Pisa, Italy; (B.C.); (M.O.); (R.N.)
- Correspondence:
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21
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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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22
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The Value of Pharmacogenetics to Reduce Drug-Related Toxicity in Cancer Patients. Mol Diagn Ther 2022; 26:137-151. [PMID: 35113367 PMCID: PMC8975257 DOI: 10.1007/s40291-021-00575-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2021] [Indexed: 10/19/2022]
Abstract
Many anticancer drugs cause adverse drug reactions (ADRs) that negatively impact safety and reduce quality of life. The typical narrow therapeutic range and exposure-response relationships described for anticancer drugs make precision dosing critical to ensure safe and effective drug exposure. Germline mutations in pharmacogenes contribute to inter-patient variability in pharmacokinetics and pharmacodynamics of anticancer drugs. Patients carrying reduced-activity or loss-of-function alleles are at increased risk for ADRs. Pretreatment genotyping offers a proactive approach to identify these high-risk patients, administer an individualized dose, and minimize the risk of ADRs. In the field of oncology, the most well-studied gene-drug pairs for which pharmacogenetic dosing recommendations have been published to improve safety are DPYD-fluoropyrimidines, TPMT/NUDT15-thiopurines, and UGT1A1-irinotecan. Despite the presence of these guidelines, the scientific evidence showing the benefits of pharmacogenetic testing (e.g., improved safety and cost-effectiveness) and the development of efficient multi-gene genotyping panels, routine pretreatment testing for these gene-drug pairs has not been implemented widely in the clinic. Important considerations required for widespread clinical implementation include pharmacogenetic education of physicians, availability or allocation of institutional resources to build an efficient clinical infrastructure, international standardization of guidelines, uniform adoption of guidelines by regulatory agencies leading to genotyping requirements in drug labels, and development of cohesive reimbursement policies for pretreatment genotyping. Without clinical implementation, the potential of pharmacogenetics to improve patient safety remains unfulfilled.
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Schmulenson E, Zimmermann N, Mikus G, Joerger M, Jaehde U. Current status and future outlooks on therapeutic drug monitoring of fluorouracil. Expert Opin Drug Metab Toxicol 2022; 17:1407-1422. [PMID: 35029518 DOI: 10.1080/17425255.2021.2029403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION : Therapeutic drug monitoring (TDM) of the anticancer drug fluorouracil (5FU) as a method to support dose adjustments has been researched and discussed extensively. Despite manifold evidence of the advantages of 5FU-TDM, traditional body surface area (BSA)-guided dosing is still widely applied. AREAS COVERED : This review covers the latest evidence on 5FU-TDM based on a literature search in PubMed between June and September 2021. It particularly highlights new approaches of implementing 5FU-TDM into precision medicine by combining TDM with pharmacogenetic testing and/or pharmacometric models. This review further discusses remaining obstacles in order to incorporate 5FU-TDM into clinical routine. EXPERT OPINION : New data on 5FU-TDM further strengthen the advantages compared to BSA-guided dosing as it is able to reduce pharmacokinetic variability and thereby improve treatment efficacy and safety. Interprofessional collaboration has the potential to overcome the remaining barriers for its implementation. Pre-emptive pharmacogenetic testing followed by 5FU-TDM can further improve 5FU exposure in a substantial proportion of patients. Developing a model framework integrating pharmacokinetics and pharmacodynamics of 5FU will be crucial to fully advance into the precision medicine era. Model applications can potentially support clinicians in dose finding before starting chemotherapy. Additionally, TDM provides further assistance in continuously improving model predictions.
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Affiliation(s)
- Eduard Schmulenson
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany
| | - Nigina Zimmermann
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany.,Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany.,Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Joerger
- Department of Medical Oncology and Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Ulrich Jaehde
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany
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Lau-Min KS, Varughese LA, Nelson MN, Cambareri C, Reddy NJ, Oyer RA, Teitelbaum UR, Tuteja S. Preemptive pharmacogenetic testing to guide chemotherapy dosing in patients with gastrointestinal malignancies: a qualitative study of barriers to implementation. BMC Cancer 2022; 22:47. [PMID: 34996412 PMCID: PMC8742388 DOI: 10.1186/s12885-022-09171-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 12/28/2021] [Indexed: 12/12/2022] Open
Abstract
Background Pharmacogenetic (PGx) testing for germline variants in the DPYD and UGT1A1 genes can be used to guide fluoropyrimidine and irinotecan dosing, respectively. Despite the known association between PGx variants and chemotherapy toxicity, preemptive testing prior to chemotherapy initiation is rarely performed in routine practice. Methods We conducted a qualitative study of oncology clinicians to identify barriers to using preemptive PGx testing to guide chemotherapy dosing in patients with gastrointestinal malignancies. Each participant completed a semi-structured interview informed by the Consolidated Framework for Implementation Research (CFIR). Interviews were analyzed using an inductive content analysis approach. Results Participants included sixteen medical oncologists and nine oncology pharmacists from one academic medical center and two community hospitals in Pennsylvania. Barriers to the use of preemptive PGx testing to guide chemotherapy dosing mapped to four CFIR domains: intervention characteristics, outer setting, inner setting, and characteristics of individuals. The most prominent themes included 1) a limited evidence base, 2) a cumbersome and lengthy testing process, and 3) a lack of insurance coverage for preemptive PGx testing. Additional barriers included clinician lack of knowledge, difficulty remembering to order PGx testing for eligible patients, challenges with PGx test interpretation, a questionable impact of preemptive PGx testing on clinical care, and a lack of alternative therapeutic options for some patients found to have actionable PGx variants. Conclusions Successful adoption of preemptive PGx-guided chemotherapy dosing in patients with gastrointestinal malignancies will require a multifaceted effort to demonstrate clinical effectiveness while addressing the contextual factors identified in this study. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09171-6.
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Affiliation(s)
- Kelsey S Lau-Min
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa A Varughese
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, Smilow Center for Translational Research, University of Pennsylvania, 3400 Civic Center Boulevard, Bldg. 421 11th Floor, Room 143, Philadelphia, PA, 19104-5158, USA
| | | | - Christine Cambareri
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nandi J Reddy
- Ann B. Barshinger Cancer Institute, Penn Medicine at Lancaster General Health, Lancaster, PA, USA
| | - Randall A Oyer
- Ann B. Barshinger Cancer Institute, Penn Medicine at Lancaster General Health, Lancaster, PA, USA
| | - Ursina R Teitelbaum
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sony Tuteja
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, Smilow Center for Translational Research, University of Pennsylvania, 3400 Civic Center Boulevard, Bldg. 421 11th Floor, Room 143, Philadelphia, PA, 19104-5158, USA.
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25
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White C, Scott RJ, Paul C, Ziolkowski A, Mossman D, Ackland S. Ethnic Diversity of DPD Activity and the DPYD Gene: Review of the Literature. Pharmgenomics Pers Med 2021; 14:1603-1617. [PMID: 34916829 PMCID: PMC8668257 DOI: 10.2147/pgpm.s337147] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/10/2021] [Indexed: 12/31/2022] Open
Abstract
Pharmacogenomic screening can identify patients with gene variants that predispose them to the development of severe toxicity from fluoropyrimidine (FP) chemotherapy. Deficiency of the critical metabolic enzyme dihydropyrimidine dehydrogenase (DPD) leads to excessive toxicity on exposure to fluoropyrimidine chemotherapy. This can result in hospitalisation, intensive care admissions and even death. Upfront screening of the gene that encodes for DPD (DPYD) has recently been implemented in regions throughout Europe and the United Kingdom. Current screening evaluates DPYD variants that are well described within Caucasian patient populations and provides genotyped-guided dose adjustment recommendations based upon the presence of these variants. This article reviews the differences in DPYD gene variants within non-Caucasian populations compared to Caucasian populations, with regard to the implications for clinical tolerance of fluoropyrimidine chemotherapies and genotype guided dose adjustment guidelines.
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Affiliation(s)
- Cassandra White
- University of Newcastle, Newcastle, NSW, Australia.,Hunter Cancer Research Alliance, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Rodney J Scott
- University of Newcastle, Newcastle, NSW, Australia.,Hunter Cancer Research Alliance, Hunter Medical Research Institute, Newcastle, NSW, Australia.,Division of Molecular Medicine, Pathology North John Hunter Hospital, Newcastle, NSW, Australia
| | - Christine Paul
- University of Newcastle, Newcastle, NSW, Australia.,Hunter Cancer Research Alliance, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Andrew Ziolkowski
- Division of Molecular Medicine, Pathology North John Hunter Hospital, Newcastle, NSW, Australia
| | - David Mossman
- Division of Molecular Medicine, Pathology North John Hunter Hospital, Newcastle, NSW, Australia
| | - Stephen Ackland
- University of Newcastle, Newcastle, NSW, Australia.,Hunter Cancer Research Alliance, Hunter Medical Research Institute, Newcastle, NSW, Australia.,Hunter Cancer Centre, Lake Macquarie Private Hospital, Gateshead, NSW, Australia
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26
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Gmeiner WH. A narrative review of genetic factors affecting fluoropyrimidine toxicity. PRECISION CANCER MEDICINE 2021; 4:38. [PMID: 34901834 PMCID: PMC8664072 DOI: 10.21037/pcm-21-17] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Our objective is to document progress in developing personalized therapy with fluoropyrimidine drugs (FPs) to improve outcomes for cancer patients and to identify areas requiring further investigation. BACKGROUND FPs including 5-fluorouracil (5-FU), are among the most widely used drugs for treating colorectal cancer (CRC) and other gastrointestinal (GI) malignancies. While FPs confer a survival benefit for CRC patients, serious systemic toxicities, including neutropenia, occur in ~30% of patients with lethality in 0.5-1% of patients. While serious systemic toxicities may occur in any patient, patients with polymorphisms in DPYD, which encodes the rate-limiting enzyme for pyrimidine degradation are at very high risk. Other genetic factors affecting risk for 5-FU toxicity, including miR-27a, are under investigation. METHODS Literature used to inform the text of this article was selected from PubMed.gov from the National Library of Medicine while regulatory documents were identified via Google search. CONCLUSIONS Clinical studies to date have validated four DPYD polymorphisms (DPYD*2A, DPYD*13, c.2846A>T, HapB3) associated with serious toxicities in patients treated with 5-FU. Genetic screening for these is being implemented in the Netherlands and the UK and has been shown to be a cost-effective way to improve outcomes. Factors other than DPYD polymorphisms (e.g., miR-27a, TYMS, ENOSF1, p53) also affect 5-FU toxicity. Functional testing for deficient pyrimidine catabolism {defined as [U] >16 ng/mL or [UH2]:[U] <10} is being implemented in France and has demonstrated utility in identifying patients with elevated risk for 5-FU toxicity. Therapeutic drug monitoring (TDM) from plasma levels of 5-FU during first cycle treatment also is being used to improve outcomes and pharmacokinetic-based dosing is being used to increase the percent of patients within optimal area under the curve (AUC) (18-28 mg*h/L) values. Patients maintained in the optimal AUC range experienced significantly reduced systemic toxicities. As understanding the genetic basis for increased risk of 5-FU toxicity becomes more refined, the development of functional-based methods to optimize treatment is likely to become more widespread.
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Affiliation(s)
- William H Gmeiner
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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27
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Hodroj K, Barthelemy D, Lega JC, Grenet G, Gagnieu MC, Walter T, Guitton J, Payen-Gay L. Issues and limitations of available biomarkers for fluoropyrimidine-based chemotherapy toxicity, a narrative review of the literature. ESMO Open 2021; 6:100125. [PMID: 33895696 PMCID: PMC8095125 DOI: 10.1016/j.esmoop.2021.100125] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/17/2021] [Accepted: 03/27/2021] [Indexed: 12/03/2022] Open
Abstract
Fluoropyrimidine-based chemotherapies are widely used to treat gastrointestinal tract, head and neck, and breast carcinomas. Severe toxicities mostly impact rapidly dividing cell lines and can occur due to the partial or complete deficiency in dihydropyrimidine dehydrogenase (DPD) catabolism. Since April 2020, the European Medicines Agency (EMA) recommends DPD testing before any fluoropyrimidine-based treatment. Currently, different assays are used to predict DPD deficiency; the two main approaches consist of either phenotyping the enzyme activity (directly or indirectly) or genotyping the four main deficiency-related polymorphisms associated with 5-fluorouracil (5-FU) toxicity. In this review, we focused on the advantages and limitations of these diagnostic methods: direct phenotyping by evaluation of peripheral mononuclear cell DPD activity (PBMC-DPD activity), indirect phenotyping assessed by uracil levels or UH2/U ratio, and genotyping DPD of four variants directly associated with 5-FU toxicity. The risk of 5-FU toxicity increases with uracil concentration. Having a pyrimidine-related structure, 5-FU is catabolised by the same physiological pathway. By assessing uracil concentration in plasma, indirect phenotyping of DPD is then measured. With this approach, in France, a decreased 5-FU dose is systematically recommended at a uracil concentration of 16 ng/ml, which may lead to chemotherapy under-exposure as uracil concentration is a continuous variable and the association between uracil levels and DPD activity is not clear. We aim herein to describe the different available strategies developed to improve fluoropyrimidine-based chemotherapy safety, how they are implemented in routine clinical practice, and the possible relationship with inefficacy mechanisms.
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Affiliation(s)
- K Hodroj
- Laboratoire de Biochimie et Biologie Moléculaire, Groupe Hospitalier Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - D Barthelemy
- Laboratoire de Biochimie et Biologie Moléculaire, Groupe Hospitalier Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Hospices Civils de Lyon Cancer institute, CIRculating CANcer (CIRCAN) Programme, Pierre-Bénite, France
| | - J-C Lega
- Hospices Civils de Lyon, Service de Médecine Interne et Vasculaire, Hôpital Lyon Sud, Pierre-Bénite, France
| | - G Grenet
- Hospices Civils de Lyon, Pole Santé Publique, Service Hospitalo-Universitaire de Pharmacotoxicologie, Lyon, France
| | - M-C Gagnieu
- Laboratoire de Biochimie et Biologie Moléculaire, Groupe Hospitalier Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - T Walter
- Hospices Civils de Lyon Cancer institute, CIRculating CANcer (CIRCAN) Programme, Pierre-Bénite, France; Hospices Civils de Lyon, Service d'Oncologie Médicale, Hôpital Edouard Herriot, Lyon, France
| | - J Guitton
- Laboratoire de Biochimie et Biologie Moléculaire, Groupe Hospitalier Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Centre de Recherche en Cancerologie de Lyon-Ribosome, Traduction et Cancer, UMR INSERM 1052 CNRS 5286, Lyon, France
| | - L Payen-Gay
- Laboratoire de Biochimie et Biologie Moléculaire, Groupe Hospitalier Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Hospices Civils de Lyon Cancer institute, CIRculating CANcer (CIRCAN) Programme, Pierre-Bénite, France; EMR 3738 Ciblage Therapeutique en Oncologie, Faculté de Médecine Lyon Sud, Université Lyon 1, Université de Lyon, Oullins, France.
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28
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Schneider JJ, Galettis P, Martin JH. Overcoming barriers to implementing precision dosing with 5-fluorouracil and capecitabine. Br J Clin Pharmacol 2021; 87:317-325. [PMID: 33386659 DOI: 10.1111/bcp.14723] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 12/01/2020] [Accepted: 12/17/2020] [Indexed: 12/27/2022] Open
Abstract
Despite advances in targeted cancer therapy, the fluoropyrimidines 5-fluorouracil (5FU) and capecitabine continue to play an important role in oncology. Historically, dosing of these drugs has been based on body surface area. This approach has been demonstrated to be an imprecise way to determine the optimal dose for a patient. Evidence in the literature has demonstrated that precision dosing approaches, such as DPD enzyme activity testing and, in the case of intravenous 5FU, pharmacokinetic-guided dosing, can reduce toxicity and yield better patient outcomes. However, despite the evidence, there has not been uniform adoption of these approaches in the clinical setting. When a drug such as 5FU has been used clinically for many decades, it may be difficult to change clinical practice. With the aim of facilitating change of practice, issues and barriers to implementing precision dosing approaches for 5FU and capecitabine are identified and discussed with possible solutions proposed.
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Affiliation(s)
- Jennifer J Schneider
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Centre for Drug Repurposing and Medicines Research, Level 3 Hunter Medical Research Institute, Kookaburra Circuit, Newcastle, New South Wales, Australia
| | - Peter Galettis
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Centre for Drug Repurposing and Medicines Research, Level 3 Hunter Medical Research Institute, Kookaburra Circuit, Newcastle, New South Wales, Australia
| | - Jennifer H Martin
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Centre for Drug Repurposing and Medicines Research, Level 3 Hunter Medical Research Institute, Kookaburra Circuit, Newcastle, New South Wales, Australia
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