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Doornhof KR, van der Linden PD, Boeke GM, Willemsen AECAB, Daskapan A. Dihydropyrimidine dehydrogenase phenotype in peripheral blood mononuclear cells is related to adverse events of fluoropyrimidine-therapy. Eur J Clin Pharmacol 2023; 79:493-501. [PMID: 36757428 DOI: 10.1007/s00228-023-03466-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 02/02/2023] [Indexed: 02/10/2023]
Abstract
PURPOSE The primary objective of this study was to determine if dihydropyrimidine dehydrogenase (DPD) activity measured in peripheral blood mononuclear cells (PBMCs) is related to adverse events during fluoropyrimidine therapy. METHODS A retrospective cohort study was conducted. The study population included 481 patients who received fluoropyrimidine treatment and for whom relevant patient characteristics were known and adverse events were noted in the electronic health records. Factors besides DPD phenotype that could affect the incidence of adverse events were corrected for using log regression. These log regression models were used to identify an association between the DPD phenotype measured in PBMCs and adverse events. RESULTS Patients with a decreased DPD activity measured in PBMCs suffered more adverse events. Results from log regression data show that this effect remains significant after correcting for dosage, chemotherapy regimen and relevant patient characteristics. CONCLUSION A significant correlation was found between reduced DPD enzyme activity in PBMCs and adverse events. The findings in this paper support further exploring DPD phenotyping as a method for preventing fluoropyrimidine-related adverse events. Further assessment of DPD phenotyping will require clinical validation in a prospective study.
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Affiliation(s)
- K R Doornhof
- Department of Clinical Pharmacy, Tergooi Medical Center, Hilversum, The Netherlands
| | - P D van der Linden
- Department of Clinical Pharmacy, Tergooi Medical Center, Hilversum, The Netherlands
| | - G M Boeke
- Department of Clinical Pharmacy, Tergooi Medical Center, Hilversum, The Netherlands
| | - A E C A B Willemsen
- Department of Internal Medicine, Tergooi Medical Center, Hilversum, The Netherlands
| | - A Daskapan
- Department of Clinical Pharmacy, Tergooi Medical Center, Hilversum, The Netherlands.
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2
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Qin W, Wang X, Chen W, Du W, Zhang D, Zhang X, Li P. An in vitro approach to simulate the process of 5-fluorouracil degradation with dihydropyrimidine dehydrogenase: the process in accordance to the first-order kinetic reaction. Xenobiotica 2020; 51:24-30. [PMID: 32686977 DOI: 10.1080/00498254.2020.1799451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Partial or complete deficiency in the dihydropyrimidine dehydrogenase (DPD) has been observed in 3%-5% and 0.1% of the general population, respectively. It causes severe toxicity in the context of 5-fluorouracil (5-FU) therapy. However, the current tests for determination of DPD deficiency have limitations in routine clinical usage. Therefore, an in vitro approach for simulating 5-FU degradation was established by mixing 5-FU with blank whole blood matrix in this study. The effects of initial 5-FU concentrations and temperatures on DPD activities were investigated as well. The degradation process followed the first-order kinetic reaction (r2 > 0.98). The degradation rates were determined by temperature and individually different. The DPD inhibitor, gimeracil, could block this degradation, which indicated that DPD was the main factor. The degradation process of 5-FU in patients' whole blood in vitro was consistent with it after mixing 5-FU with blank whole blood matrix. In conclusion, mixing 5-FU with blank matrix can simulate the process of 5-FU degradation with DPD.
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Affiliation(s)
- Wei Qin
- Department of pharmacy, China-Japan Friendship Hospital, Beijing, PR China
| | - Xiaoxue Wang
- Department of pharmacy, China-Japan Friendship Hospital, Beijing, PR China
| | - Wenqian Chen
- Department of pharmacy, China-Japan Friendship Hospital, Beijing, PR China
| | - Wenwen Du
- Department of pharmacy, China-Japan Friendship Hospital, Beijing, PR China
| | - Dan Zhang
- Department of pharmacy, China-Japan Friendship Hospital, Beijing, PR China
| | - Xianglin Zhang
- Department of pharmacy, China-Japan Friendship Hospital, Beijing, PR China
| | - Pengmei Li
- Department of pharmacy, China-Japan Friendship Hospital, Beijing, PR China
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Roosendaal J, Jacobs BAW, Pluim D, Rosing H, de Vries N, van Werkhoven E, Nuijen B, Beijnen JH, Huitema ADR, Schellens JHM, Marchetti S. Phase I pharmacological study of continuous chronomodulated capecitabine treatment. Pharm Res 2020; 37:89. [PMID: 32382808 PMCID: PMC7205843 DOI: 10.1007/s11095-020-02828-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 04/21/2020] [Indexed: 11/30/2022]
Abstract
Purpose Capecitabine is an oral pre-pro-drug of the anti-cancer drug 5-fluorouracil (5-FU). The biological activity of the 5-FU degrading enzyme, dihydropyrimidine dehydrogenase (DPD), and the target enzyme thymidylate synthase (TS), are subject to circadian rhythmicity in healthy volunteers. The aim of this study was to determine the maximum tolerated dose (MTD), dose-limiting toxicity (DLT), safety, pharmacokinetics (PK) and pharmacodynamics (PD) of capecitabine therapy adapted to this circadian rhythm (chronomodulated therapy). Methods Patients aged ≥18 years with advanced solid tumours potentially benefitting from capecitabine therapy were enrolled. A classical dose escalation 3 + 3 design was applied. Capecitabine was administered daily without interruptions. The daily dose was divided in morning and evening doses that were administered at 9:00 h and 24:00 h, respectively. The ratio of the morning to the evening dose was 3:5 (morning: evening). PK and PD were examined on treatment days 7 and 8. Results A total of 25 patients were enrolled. The MTD of continuous chronomodulated capecitabine therapy was established at 750/1250 mg/m2/day, and was generally well tolerated. Circadian rhythmicity in the plasma PK of capecitabine, dFCR, dFUR and 5-FU was not demonstrated. TS activity was induced and DPD activity demonstrated circadian rhythmicity during capecitabine treatment. Conclusion The MTD of continuous chronomodulated capecitabine treatment allows for a 20% higher dose intensity compared to the approved regimen (1250 mg/m2 bi-daily on day 1–14 of every 21-day cycle). Chronomodulated treatment with capecitabine is promising and could lead to improved tolerability and efficacy of capecitabine. Electronic supplementary material The online version of this article (10.1007/s11095-020-02828-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jeroen Roosendaal
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Louwesweg 6, 1066, EC, Amsterdam, The Netherlands.
| | - Bart A W Jacobs
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Louwesweg 6, 1066, EC, Amsterdam, The Netherlands.,Department of Clinical Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066, CX, Amsterdam, The Netherlands
| | - Dick Pluim
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066, CX, Amsterdam, The Netherlands
| | - Hilde Rosing
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Louwesweg 6, 1066, EC, Amsterdam, The Netherlands
| | - Niels de Vries
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Louwesweg 6, 1066, EC, Amsterdam, The Netherlands
| | - Erik van Werkhoven
- Department of Biometrics, The Netherlands Cancer Institute, Plesmanlaan 121, 1066, CX, Amsterdam, The Netherlands
| | - Bastiaan Nuijen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Louwesweg 6, 1066, EC, Amsterdam, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Louwesweg 6, 1066, EC, Amsterdam, The Netherlands.,Science Faculty, Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, P.O. Box 80082, 3508, TB, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Louwesweg 6, 1066, EC, Amsterdam, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - Jan H M Schellens
- Science Faculty, Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, P.O. Box 80082, 3508, TB, Utrecht, The Netherlands
| | - Serena Marchetti
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066, CX, Amsterdam, The Netherlands
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4
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Henricks LM, Jacobs BAW, Meulendijks D, Pluim D, van den Broek D, de Vries N, Rosing H, Beijnen JH, Huitema ADR, Guchelaar H, Cats A, Schellens JHM. Food-effect study on uracil and dihydrouracil plasma levels as marker for dihydropyrimidine dehydrogenase activity in human volunteers. Br J Clin Pharmacol 2018; 84:2761-2769. [PMID: 30047584 PMCID: PMC6256055 DOI: 10.1111/bcp.13719] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/05/2018] [Accepted: 07/14/2018] [Indexed: 12/31/2022] Open
Abstract
AIMS This study aimed to determine the effect of food intake on uracil and dihydrouracil plasma levels. These levels are a promising marker for dihydropyrimidine dehydrogenase activity and for individualizing fluoropyrimidine anticancer therapy. METHODS A randomized, cross-over study in 16 healthy volunteers was performed, in which subjects were examined in fasted and fed state on two separate days. In fed condition, a high-fat, high-caloric breakfast was consumed between 8:00 h and 8:30 h. Whole blood for determination of uracil, dihydrouracil and uridine plasma levels was drawn on both test days at predefined time points between 8:00 h and 13:00 h. RESULTS Uracil levels were statistically significantly different between fasting and fed state. At 13:00 h, the mean uracil level in fasting state was 12.6 ± 3.7 ng ml-1 and after a test meal 9.4 ± 2.6 ng ml-1 (P < 0.001). Dihydrouracil levels were influenced by food intake as well (mean dihydrouracil level at 13:00 h in fasting state 147.0 ± 36.4 ng ml-1 and in fed state 85.7 ± 22.1 ng ml-1 , P < 0.001). Uridine plasma levels showed curves with similar patterns as for uracil. CONCLUSIONS It was shown that both uracil and dihydrouracil levels were higher in fasting state than in fed state. This is hypothesized to be an direct effect of uridine plasma levels, which were previously shown to be elevated in fasting state and reduced after intake of food. These findings show that, when assessing plasma uracil and dihydrouracil levels for adaptive fluoropyrimidine dosing in clinical practice, sampling should be done between 8:00 h and 9:00 h after overnight fasting to avoid bias caused by circadian rhythm and food effects.
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Affiliation(s)
- Linda M. Henricks
- Division of PharmacologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
- Department of Clinical Pharmacology, Division of Medical OncologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
| | - Bart A. W. Jacobs
- Department of Pharmacy & PharmacologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
| | - Didier Meulendijks
- Division of PharmacologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
- Department of Clinical Pharmacology, Division of Medical OncologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
- Dutch Medicines Evaluation Board (CBG‐MEB)UtrechtThe Netherlands
| | - Dick Pluim
- Division of PharmacologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
- Department of Clinical Pharmacology, Division of Medical OncologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
| | - Daan van den Broek
- Department of Clinical ChemistryThe Netherlands Cancer InstituteAmsterdamThe Netherlands
| | - Niels de Vries
- Department of Pharmacy & PharmacologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
| | - Hilde Rosing
- Department of Pharmacy & PharmacologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
| | - Jos H. Beijnen
- Department of Pharmacy & PharmacologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
- Utrecht Institute for Pharmaceutical SciencesUtrecht UniversityUtrechtThe Netherlands
| | - Alwin D. R. Huitema
- Department of Pharmacy & PharmacologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
- Department of Clinical PharmacyUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
| | - Henk‐Jan Guchelaar
- Department of Clinical Pharmacy and ToxicologyLeiden University Medical CenterLeidenThe Netherlands
| | - Annemieke Cats
- Department of Gastrointestinal Oncology, Division of Medical OncologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
| | - Jan H. M. Schellens
- Division of PharmacologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
- Department of Clinical Pharmacology, Division of Medical OncologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
- Utrecht Institute for Pharmaceutical SciencesUtrecht UniversityUtrechtThe Netherlands
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5
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Jacobs BAW, Pluim D, van der Laan P, Tzani A, Beijnen JH, Schellens JHM. Development and validation of a quantitative method for thymidine phosphorylase activity in peripheral blood mononuclear cells. NUCLEOSIDES NUCLEOTIDES & NUCLEIC ACIDS 2018; 37:436-454. [PMID: 30285552 DOI: 10.1080/15257770.2018.1498270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The enzyme thymidine phosphorylase (TP) is important for activation of capecitabine and 5-fluorouracil. Assessment of TP phenotype might be suitable for identification of patients at risk of fluoropyrimidine-induced toxicity. In this paper, we describe the development and validation an assay for TP activity in peripheral blood mononuclear cells (PBMCs). The assay was based on ex vivo conversion of the TP substrate thymidine to thymine. The amount of thymine formed was determined by high-performance liquid chromatography - ultraviolet detection (HPLC-UV) with 5-bromouracil as internal standard. Lymphocytes and monocytes were purified from isolated PBMCs to examine cell-specific TP activity. TP activity in PBMCs demonstrated Michaelis-Menten kinetics. The lower limit of quantification was 2.3 µg PBMC protein and assay linearity was demonstrated up to 22.7 µg PBMC protein. Within-day and between-day precisions were ≤9.2% and ≤6.0%, respectively. Adequate stability TP activity was demonstrated after long-term storage of PBMC dry pellets and lysates at -80 °C. In monocytes, TP activity was approximately 3 times higher than in lymphocytes. Clinical applicability was demonstrated in samples that were collected from five cancer patients. A simple, precise and sensitive HPLC-UV assay for quantification of TP activity in PBMCs was developed that can be applied for clinical research.
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Affiliation(s)
- Bart A W Jacobs
- a Department of Clinical Pharmacology , The Netherlands Cancer Institute , Amsterdam , The Netherlands.,b Department of Pharmacy & Pharmacology , The Netherlands Cancer Institute and MC Slotervaart , Amsterdam , The Netherlands
| | - Dick Pluim
- a Department of Clinical Pharmacology , The Netherlands Cancer Institute , Amsterdam , The Netherlands
| | - Pia van der Laan
- a Department of Clinical Pharmacology , The Netherlands Cancer Institute , Amsterdam , The Netherlands
| | - Anna Tzani
- a Department of Clinical Pharmacology , The Netherlands Cancer Institute , Amsterdam , The Netherlands
| | - Jos H Beijnen
- a Department of Clinical Pharmacology , The Netherlands Cancer Institute , Amsterdam , The Netherlands.,b Department of Pharmacy & Pharmacology , The Netherlands Cancer Institute and MC Slotervaart , Amsterdam , The Netherlands.,c Science Faculty, Utrecht Institute for Pharmaceutical Sciences (UIPS) , Division of Pharmaco-epidemiology & Clinical Pharmacology, Utrecht University , Utrecht , The Netherlands
| | - Jan H M Schellens
- a Department of Clinical Pharmacology , The Netherlands Cancer Institute , Amsterdam , The Netherlands.,c Science Faculty, Utrecht Institute for Pharmaceutical Sciences (UIPS) , Division of Pharmaco-epidemiology & Clinical Pharmacology, Utrecht University , Utrecht , The Netherlands
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The impact of liver resection on the dihydrouracil:uracil plasma ratio in patients with colorectal liver metastases. Eur J Clin Pharmacol 2018; 74:737-744. [PMID: 29430582 DOI: 10.1007/s00228-018-2426-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 02/01/2018] [Indexed: 12/30/2022]
Abstract
PURPOSE The dihydrouracil (DHU):uracil (U) plasma ratio is a promising marker for identification of dihydropyrimidine dehydrogenase (DPD)-deficient patients. The objective of this study was to determine the effect of liver resection on the DHU:U plasma ratio in patients with colorectal liver metastases (CRLM). METHODS An observational study was performed in which DHU:U plasma ratios in patients with CRLM were analyzed prior to and 1 day after liver resection. In addition, the DHU:U plasma ratio was quantified in six additional patients 4-8 weeks after liver resection to explore long-term effects on the DHU:U plasma ratio. Quantification of U and DHU plasma levels was performed using a validated ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) assay. RESULTS The median (range) DHU:U plasma ratio in 15 patients prior to liver resection was 10.7 (2.6-14.4) and was significantly reduced to 5.5 (< quantification limit (LLOQ-10.5) 1 day after resection (p = 0.0026). This reduction was caused by a decrease in DHU plasma levels from 112.0 (79.8-153) ng/mL to 41.2 (< LLOQ-160) ng/mL 1 day after resection (p = 0.0004). Recovery of the DHU:U plasma ratio occurred 4-8 weeks after liver resection, which was shown by a median (range) DHU:U plasma ratio in six patients of 9.1 (6.9-14.5). CONCLUSION Liver resection leads to very low DHU:U plasma ratios 1 day after liver resection, which is possibly caused by a reduction in DPD activity. Quantification of the DHU:U plasma ratios directly after liver resection could lead to false-positive identification of DPD deficiency and is therefore not advised.
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Henricks LM, Kienhuis E, de Man FM, van der Veldt AA, Hamberg P, van Kuilenburg AB, van Schaik RH, Lunenburg CA, Guchelaar HJ, Schellens JH, Mathijssen RH. Treatment Algorithm for Homozygous or Compound Heterozygous DPYD Variant Allele Carriers With Low-Dose Capecitabine. JCO Precis Oncol 2017; 1:1-10. [DOI: 10.1200/po.17.00118] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Linda M. Henricks
- Linda M. Henricks, Astrid A.M. van der Veldt, and Jan H.M. Schellens, the Netherlands Cancer Institute; André B.P. van Kuilenburg, Academic Medical Center, Amsterdam; Emma Kienhuis, Femke M. de Man, Astrid A.M. van der Veldt, Ron H.N. van Schaik, and Ron H.J. Mathijssen, Erasmus Medical Center; Paul Hamberg, Franciscus Gasthuis & Vlietland, Rotterdam; Carin A.T.C. Lunenburg and Henk-Jan Guchelaar, Leiden University Medical Center, Leiden; and Jan H.M. Schellens, Utrecht University, Utrecht, the Netherlands
| | - Emma Kienhuis
- Linda M. Henricks, Astrid A.M. van der Veldt, and Jan H.M. Schellens, the Netherlands Cancer Institute; André B.P. van Kuilenburg, Academic Medical Center, Amsterdam; Emma Kienhuis, Femke M. de Man, Astrid A.M. van der Veldt, Ron H.N. van Schaik, and Ron H.J. Mathijssen, Erasmus Medical Center; Paul Hamberg, Franciscus Gasthuis & Vlietland, Rotterdam; Carin A.T.C. Lunenburg and Henk-Jan Guchelaar, Leiden University Medical Center, Leiden; and Jan H.M. Schellens, Utrecht University, Utrecht, the Netherlands
| | - Femke M. de Man
- Linda M. Henricks, Astrid A.M. van der Veldt, and Jan H.M. Schellens, the Netherlands Cancer Institute; André B.P. van Kuilenburg, Academic Medical Center, Amsterdam; Emma Kienhuis, Femke M. de Man, Astrid A.M. van der Veldt, Ron H.N. van Schaik, and Ron H.J. Mathijssen, Erasmus Medical Center; Paul Hamberg, Franciscus Gasthuis & Vlietland, Rotterdam; Carin A.T.C. Lunenburg and Henk-Jan Guchelaar, Leiden University Medical Center, Leiden; and Jan H.M. Schellens, Utrecht University, Utrecht, the Netherlands
| | - Astrid A.M. van der Veldt
- Linda M. Henricks, Astrid A.M. van der Veldt, and Jan H.M. Schellens, the Netherlands Cancer Institute; André B.P. van Kuilenburg, Academic Medical Center, Amsterdam; Emma Kienhuis, Femke M. de Man, Astrid A.M. van der Veldt, Ron H.N. van Schaik, and Ron H.J. Mathijssen, Erasmus Medical Center; Paul Hamberg, Franciscus Gasthuis & Vlietland, Rotterdam; Carin A.T.C. Lunenburg and Henk-Jan Guchelaar, Leiden University Medical Center, Leiden; and Jan H.M. Schellens, Utrecht University, Utrecht, the Netherlands
| | - Paul Hamberg
- Linda M. Henricks, Astrid A.M. van der Veldt, and Jan H.M. Schellens, the Netherlands Cancer Institute; André B.P. van Kuilenburg, Academic Medical Center, Amsterdam; Emma Kienhuis, Femke M. de Man, Astrid A.M. van der Veldt, Ron H.N. van Schaik, and Ron H.J. Mathijssen, Erasmus Medical Center; Paul Hamberg, Franciscus Gasthuis & Vlietland, Rotterdam; Carin A.T.C. Lunenburg and Henk-Jan Guchelaar, Leiden University Medical Center, Leiden; and Jan H.M. Schellens, Utrecht University, Utrecht, the Netherlands
| | - André B.P. van Kuilenburg
- Linda M. Henricks, Astrid A.M. van der Veldt, and Jan H.M. Schellens, the Netherlands Cancer Institute; André B.P. van Kuilenburg, Academic Medical Center, Amsterdam; Emma Kienhuis, Femke M. de Man, Astrid A.M. van der Veldt, Ron H.N. van Schaik, and Ron H.J. Mathijssen, Erasmus Medical Center; Paul Hamberg, Franciscus Gasthuis & Vlietland, Rotterdam; Carin A.T.C. Lunenburg and Henk-Jan Guchelaar, Leiden University Medical Center, Leiden; and Jan H.M. Schellens, Utrecht University, Utrecht, the Netherlands
| | - Ron H.N. van Schaik
- Linda M. Henricks, Astrid A.M. van der Veldt, and Jan H.M. Schellens, the Netherlands Cancer Institute; André B.P. van Kuilenburg, Academic Medical Center, Amsterdam; Emma Kienhuis, Femke M. de Man, Astrid A.M. van der Veldt, Ron H.N. van Schaik, and Ron H.J. Mathijssen, Erasmus Medical Center; Paul Hamberg, Franciscus Gasthuis & Vlietland, Rotterdam; Carin A.T.C. Lunenburg and Henk-Jan Guchelaar, Leiden University Medical Center, Leiden; and Jan H.M. Schellens, Utrecht University, Utrecht, the Netherlands
| | - Carin A.T.C. Lunenburg
- Linda M. Henricks, Astrid A.M. van der Veldt, and Jan H.M. Schellens, the Netherlands Cancer Institute; André B.P. van Kuilenburg, Academic Medical Center, Amsterdam; Emma Kienhuis, Femke M. de Man, Astrid A.M. van der Veldt, Ron H.N. van Schaik, and Ron H.J. Mathijssen, Erasmus Medical Center; Paul Hamberg, Franciscus Gasthuis & Vlietland, Rotterdam; Carin A.T.C. Lunenburg and Henk-Jan Guchelaar, Leiden University Medical Center, Leiden; and Jan H.M. Schellens, Utrecht University, Utrecht, the Netherlands
| | - Henk-Jan Guchelaar
- Linda M. Henricks, Astrid A.M. van der Veldt, and Jan H.M. Schellens, the Netherlands Cancer Institute; André B.P. van Kuilenburg, Academic Medical Center, Amsterdam; Emma Kienhuis, Femke M. de Man, Astrid A.M. van der Veldt, Ron H.N. van Schaik, and Ron H.J. Mathijssen, Erasmus Medical Center; Paul Hamberg, Franciscus Gasthuis & Vlietland, Rotterdam; Carin A.T.C. Lunenburg and Henk-Jan Guchelaar, Leiden University Medical Center, Leiden; and Jan H.M. Schellens, Utrecht University, Utrecht, the Netherlands
| | - Jan H.M. Schellens
- Linda M. Henricks, Astrid A.M. van der Veldt, and Jan H.M. Schellens, the Netherlands Cancer Institute; André B.P. van Kuilenburg, Academic Medical Center, Amsterdam; Emma Kienhuis, Femke M. de Man, Astrid A.M. van der Veldt, Ron H.N. van Schaik, and Ron H.J. Mathijssen, Erasmus Medical Center; Paul Hamberg, Franciscus Gasthuis & Vlietland, Rotterdam; Carin A.T.C. Lunenburg and Henk-Jan Guchelaar, Leiden University Medical Center, Leiden; and Jan H.M. Schellens, Utrecht University, Utrecht, the Netherlands
| | - Ron H.J. Mathijssen
- Linda M. Henricks, Astrid A.M. van der Veldt, and Jan H.M. Schellens, the Netherlands Cancer Institute; André B.P. van Kuilenburg, Academic Medical Center, Amsterdam; Emma Kienhuis, Femke M. de Man, Astrid A.M. van der Veldt, Ron H.N. van Schaik, and Ron H.J. Mathijssen, Erasmus Medical Center; Paul Hamberg, Franciscus Gasthuis & Vlietland, Rotterdam; Carin A.T.C. Lunenburg and Henk-Jan Guchelaar, Leiden University Medical Center, Leiden; and Jan H.M. Schellens, Utrecht University, Utrecht, the Netherlands
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Meulendijks D, Cats A, Beijnen JH, Schellens JHM. Improving safety of fluoropyrimidine chemotherapy by individualizing treatment based on dihydropyrimidine dehydrogenase activity - Ready for clinical practice? Cancer Treat Rev 2016; 50:23-34. [PMID: 27589829 DOI: 10.1016/j.ctrv.2016.08.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 08/04/2016] [Accepted: 08/08/2016] [Indexed: 01/05/2023]
Abstract
Fluoropyrimidines remain the cornerstone of treatment for different types of cancer, and are used by an estimated two million patients annually. The toxicity associated with fluoropyrimidine therapy is substantial, however, and affects around 30% of the patients, with 0.5-1% suffering fatal toxicity. Activity of the main 5-fluorouracil (5-FU) metabolic enzyme, dihydropyrimidine dehydrogenase (DPD), is the key determinant of 5-FU pharmacology, and accounts for around 80% of 5-FU catabolism. There is a consistent relationship between DPD activity and 5-FU exposure on the one hand, and risk of severe and potentially lethal fluoropyrimidine-associated toxicity on the other hand. Therefore, there is a sound rationale for individualizing treatment with fluoropyrimidines based on DPD status in order to improve patient safety. The field of individualized treatment with fluoropyrimidines is now rapidly developing. The main strategies that are available, are based on genotyping of the gene encoding DPD (DPYD) and measuring of pretreatment DPD phenotype. Clinical validity of additional approaches, including genotyping of MIR27A has also recently been demonstrated. Here, we critically review the evidence on clinical validity and utility of strategies available to clinicians to identify patients at risk of developing severe and potentially fatal toxicity as a result of DPD deficiency. We evaluate the advantages and limitations of these methods when used in clinical practice, and discuss for which strategies clinical implementation is currently justified based on the available evidence and, in addition, which additional data will be required before implementing other, as yet less developed strategies.
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Affiliation(s)
- Didier Meulendijks
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Dutch Medicines Evaluation Board (CBG-MEB), Utrecht, The Netherlands.
| | - Annemieke Cats
- Department of Gastroenterology & Hepatology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Faculty of Science, Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Jan H M Schellens
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Faculty of Science, Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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Jacobs BAW, Deenen MJ, Pluim D, van Hasselt JGC, Krähenbühl MD, van Geel RMJM, de Vries N, Rosing H, Meulendijks D, Burylo AM, Cats A, Beijnen JH, Huitema ADR, Schellens JHM. Pronounced between-subject and circadian variability in thymidylate synthase and dihydropyrimidine dehydrogenase enzyme activity in human volunteers. Br J Clin Pharmacol 2016; 82:706-16. [PMID: 27161955 DOI: 10.1111/bcp.13007] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 04/25/2016] [Accepted: 05/08/2016] [Indexed: 01/04/2023] Open
Abstract
AIMS The enzymatic activity of dihydropyrimidine dehydrogenase (DPD) and thymidylate synthase (TS) are important for the tolerability and efficacy of the fluoropyrimidine drugs. In the present study, we explored between-subject variability (BSV) and circadian rhythmicity in DPD and TS activity in human volunteers. METHODS The BSVs in DPD activity (n = 20) in peripheral blood mononuclear cells (PBMCs) and in plasma, measured by means of the dihydrouracil (DHU) and uracil (U) plasma levels and DHU : U ratio (n = 40), and TS activity in PBMCs (n = 19), were examined. Samples were collected every 4 h throughout 1 day for assessment of circadian rhythmicity in DPD and TS activity in PBMCs (n = 12) and DHU : U plasma ratios (n = 23). In addition, the effects of genetic polymorphisms and gene expression on DPD and TS activity were explored. RESULTS Population mean (± standard deviation) DPD activity in PBMCs and DHU : U plasma ratio were 9.2 (±2.1) nmol mg(-1) h(-1) and 10.6 (±2.4), respectively. Individual TS activity in PBMCs ranged from 0.024 nmol mg(-1) h(-1) to 0.596 nmol mg(-1) h(-1) . Circadian rhythmicity was demonstrated for all phenotype markers. Between 00:30 h and 02:00 h, DPD activity in PBMCs peaked, while the DHU : U plasma ratio and TS activity in PBMCs showed trough activity. Peak-to-trough ratios for DPD and TS activity in PBMCs were 1.69 and 1.62, respectively. For the DHU : U plasma ratio, the peak-to-trough ratio was 1.43. CONCLUSIONS BSV and circadian variability in DPD and TS activity were demonstrated. Circadian rhythmicity in DPD might be tissue dependent. The results suggested an influence of circadian rhythms on phenotype-guided fluoropyrimidine dosing and supported implications for chronotherapy with high-dose fluoropyrimidine administration during the night.
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Affiliation(s)
- Bart A W Jacobs
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Maarten J Deenen
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Dick Pluim
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - J G Coen van Hasselt
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Martin D Krähenbühl
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Robin M J M van Geel
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Niels de Vries
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hilde Rosing
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Didier Meulendijks
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Artur M Burylo
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Annemieke Cats
- Department of Gastroenterology & Hepatology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jos H Beijnen
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan H M Schellens
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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10
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Jacobs BAW, Rosing H, de Vries N, Meulendijks D, Henricks LM, Schellens JHM, Beijnen JH. Development and validation of a rapid and sensitive UPLC-MS/MS method for determination of uracil and dihydrouracil in human plasma. J Pharm Biomed Anal 2016; 126:75-82. [PMID: 27179185 DOI: 10.1016/j.jpba.2016.04.039] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 04/24/2016] [Accepted: 04/26/2016] [Indexed: 12/27/2022]
Abstract
Quantification of the endogenous dihydropyrimidine dehydrogenase (DPD) substrate uracil (U) and the reaction product dihydrouracil (UH2) in plasma might be suitable for identification of patients at risk of fluoropyrimidine-induced toxicity as a result of DPD deficiency. In this paper, we describe the development and validation of a rapid and sensitive ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) assay for quantification of U and UH2 in human plasma. Analytes were extracted by protein precipitation, chromatographically separated on an Acquity UPLC(®) HSS T3 column with gradient elution and analyzed with a tandem mass spectrometer equipped with an electrospray ionization source. U was quantified in the negative ion mode and UH2 in the positive ion mode. Stable isotopes for U and UH2 were used as internal standards. Total chromatographic run time was 5min. Validated concentration ranges for U and UH2 were from 1 to 100ng/mL and 10 to 1000ng/mL, respectively. Inter-assay bias and inter-assay precision for U were within ±2.8% and ≤12.4%. For UH2, inter-assay bias and inter-assay precision were within ±2.9% and ≤7.2%. Adequate stability of U and UH2 in dry extract, final extract, stock solution and plasma was demonstrated. Stability of U and UH2 in whole blood was only satisfactory when stored up to 4hours at 2-8°C, but not at ambient temperatures. An accurate, precise and sensitive UPLC-MS/MS assay for quantification of U and UH2 in plasma was developed. This assay is now applied to support clinical studies with fluoropyrimidine drugs.
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Affiliation(s)
- Bart A W Jacobs
- The Netherlands Cancer Institute, Department of Clinical Pharmacology, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands; The Netherlands Cancer Institute, Department of Pharmacy and Pharmacology, Louwesweg 6, 1066 EC, Amsterdam, The Netherlands.
| | - Hilde Rosing
- The Netherlands Cancer Institute, Department of Pharmacy and Pharmacology, Louwesweg 6, 1066 EC, Amsterdam, The Netherlands
| | - Niels de Vries
- The Netherlands Cancer Institute, Department of Pharmacy and Pharmacology, Louwesweg 6, 1066 EC, Amsterdam, The Netherlands
| | - Didier Meulendijks
- The Netherlands Cancer Institute, Department of Clinical Pharmacology, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Linda M Henricks
- The Netherlands Cancer Institute, Department of Clinical Pharmacology, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Jan H M Schellens
- The Netherlands Cancer Institute, Department of Clinical Pharmacology, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands; Utrecht University, Department of Pharmaceutical Sciences, Universiteitsweg 99, 3584CG, Utrecht, The Netherlands
| | - Jos H Beijnen
- The Netherlands Cancer Institute, Department of Clinical Pharmacology, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands; The Netherlands Cancer Institute, Department of Pharmacy and Pharmacology, Louwesweg 6, 1066 EC, Amsterdam, The Netherlands; Utrecht University, Department of Pharmaceutical Sciences, Universiteitsweg 99, 3584CG, Utrecht, The Netherlands
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11
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Kuilenburg ABPV, Meijer J, Tanck MWT, Dobritzsch D, Zoetekouw L, Dekkers LL, Roelofsen J, Meinsma R, Wymenga M, Kulik W, Büchel B, Hennekam RCM, Largiadèr CR. Phenotypic and clinical implications of variants in the dihydropyrimidine dehydrogenase gene. Biochim Biophys Acta Mol Basis Dis 2016; 1862:754-762. [PMID: 26804652 DOI: 10.1016/j.bbadis.2016.01.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/21/2015] [Accepted: 01/08/2016] [Indexed: 12/22/2022]
Abstract
Dihydropyrimidine dehydrogenase (DPD) is the initial and rate-limiting enzyme in the catabolism of the pyrimidine bases uracil, thymine and the antineoplastic agent 5-fluorouracil. Genetic variations in the gene encoding DPD (DPYD) have emerged as predictive risk alleles for 5FU-associated toxicity. Here we report an in-depth analysis of genetic variants in DPYD and their consequences for DPD activity and pyrimidine metabolites in 100 Dutch healthy volunteers. 34 SNPs were detected in DPYD and 15 SNPs were associated with altered plasma concentrations of pyrimidine metabolites. DPD activity was significantly associated with the plasma concentrations of uracil, the presence of a specific DPYD mutation (c.1905+1G>A) and the combined presence of three risk variants in DPYD (c.1905+1G>A, c.1129-5923C>G, c.2846A>T), but not with an altered uracil/dihydrouracil (U/UH2) ratio. Various haplotypes were associated with different DPD activities (haplotype D3, a decreased DPD activity; haplotype F2, an increased DPD activity). Functional analysis of eight recombinant mutant DPD enzymes showed a reduced DPD activity, ranging from 35% to 84% of the wild-type enzyme. Analysis of a DPD homology model indicated that the structural effect of the novel p.G401R mutation is most likely minor. The clinical relevance of the p.D949V mutation was demonstrated in a cancer patient heterozygous for the c.2846A>T mutation and a novel nonsense mutation c.1681C>T (p.R561X), experiencing severe grade IV toxicity. Our studies showed that the endogenous levels of uracil and the U/UH2 ratio are poor predictors of an impaired DPD activity. Loading studies with uracil to identify patients with a DPD deficiency warrants further investigation.
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Affiliation(s)
- André B P van Kuilenburg
- Departments of Clinical Chemistry, Pediatrics, Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands.
| | - Judith Meijer
- Departments of Clinical Chemistry, Pediatrics, Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
| | - Michael W T Tanck
- Departments of Clinical Chemistry, Pediatrics, Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
| | - Doreen Dobritzsch
- Department of Chemistry, Biomedical Center, Uppsala University, S-751 24 Uppsala, Sweden
| | - Lida Zoetekouw
- Departments of Clinical Chemistry, Pediatrics, Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Jeroen Roelofsen
- Departments of Clinical Chemistry, Pediatrics, Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
| | - Rutger Meinsma
- Departments of Clinical Chemistry, Pediatrics, Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
| | - Machteld Wymenga
- Department of Oncology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Wim Kulik
- Departments of Clinical Chemistry, Pediatrics, Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
| | - Barbara Büchel
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raoul C M Hennekam
- Departments of Clinical Chemistry, Pediatrics, Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
| | - Carlo R Largiadèr
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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12
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13
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Meulendijks D, Henricks LM, Sonke GS, Deenen MJ, Froehlich TK, Amstutz U, Largiadèr CR, Jennings BA, Marinaki AM, Sanderson JD, Kleibl Z, Kleiblova P, Schwab M, Zanger UM, Palles C, Tomlinson I, Gross E, van Kuilenburg ABP, Punt CJA, Koopman M, Beijnen JH, Cats A, Schellens JHM. Clinical relevance of DPYD variants c.1679T>G, c.1236G>A/HapB3, and c.1601G>A as predictors of severe fluoropyrimidine-associated toxicity: a systematic review and meta-analysis of individual patient data. Lancet Oncol 2015; 16:1639-50. [PMID: 26603945 DOI: 10.1016/s1470-2045(15)00286-7] [Citation(s) in RCA: 238] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 08/26/2015] [Accepted: 08/28/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND The best-known cause of intolerance to fluoropyrimidines is dihydropyrimidine dehydrogenase (DPD) deficiency, which can result from deleterious polymorphisms in the gene encoding DPD (DPYD), including DPYD*2A and c.2846A>T. Three other variants-DPYD c.1679T>G, c.1236G>A/HapB3, and c.1601G>A-have been associated with DPD deficiency, but no definitive evidence for the clinical validity of these variants is available. The primary objective of this systematic review and meta-analysis was to assess the clinical validity of c.1679T>G, c.1236G>A/HapB3, and c.1601G>A as predictors of severe fluoropyrimidine-associated toxicity. METHODS We did a systematic review of the literature published before Dec 17, 2014, to identify cohort studies investigating associations between DPYD c.1679T>G, c.1236G>A/HapB3, and c.1601G>A and severe (grade ≥3) fluoropyrimidine-associated toxicity in patients treated with fluoropyrimidines (fluorouracil, capecitabine, or tegafur-uracil as single agents, in combination with other anticancer drugs, or with radiotherapy). Individual patient data were retrieved and analysed in a multivariable analysis to obtain an adjusted relative risk (RR). Effect estimates were pooled by use of a random-effects meta-analysis. The threshold for significance was set at a p value of less than 0·0167 (Bonferroni correction). FINDINGS 7365 patients from eight studies were included in the meta-analysis. DPYD c.1679T>G was significantly associated with fluoropyrimidine-associated toxicity (adjusted RR 4·40, 95% CI 2·08-9·30, p<0·0001), as was c.1236G>A/HapB3 (1·59, 1·29-1·97, p<0·0001). The association between c.1601G>A and fluoropyrimidine-associated toxicity was not significant (adjusted RR 1·52, 95% CI 0·86-2·70, p=0·15). Analysis of individual types of toxicity showed consistent associations of c.1679T>G and c.1236G>A/HapB3 with gastrointestinal toxicity (adjusted RR 5·72, 95% CI 1·40-23·33, p=0·015; and 2·04, 1·49-2·78, p<0·0001, respectively) and haematological toxicity (adjusted RR 9·76, 95% CI 3·03-31·48, p=0·00014; and 2·07, 1·17-3·68, p=0·013, respectively), but not with hand-foot syndrome. DPYD*2A and c.2846A>T were also significantly associated with severe fluoropyrimidine-associated toxicity (adjusted RR 2·85, 95% CI 1·75-4·62, p<0·0001; and 3·02, 2·22-4·10, p<0·0001, respectively). INTERPRETATION DPYD variants c.1679T>G and c.1236G>A/HapB3 are clinically relevant predictors of fluoropyrimidine-associated toxicity. Upfront screening for these variants, in addition to the established variants DPYD*2A and c.2846A>T, is recommended to improve the safety of patients with cancer treated with fluoropyrimidines. FUNDING None.
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Affiliation(s)
- Didier Meulendijks
- Department of Clinical Pharmacology, Netherlands Cancer Institute, Amsterdam, Netherlands; Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Linda M Henricks
- Department of Clinical Pharmacology, Netherlands Cancer Institute, Amsterdam, Netherlands; Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Gabe S Sonke
- Division of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Maarten J Deenen
- Department of Clinical Pharmacology, Netherlands Cancer Institute, Amsterdam, Netherlands; Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Tanja K Froehlich
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Ursula Amstutz
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Carlo R Largiadèr
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | | | | | | | - Zdenek Kleibl
- Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Petra Kleiblova
- Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Matthias Schwab
- Dr Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany; Department of Clinical Pharmacology, University Hospital Tuebingen, Tuebingen, Germany
| | - Ulrich M Zanger
- Dr Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany; University of Tuebingen, Tuebingen, Germany
| | - Claire Palles
- Molecular and Population Genetics Laboratory and Oxford NIHR Biomedical Research Centre, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Ian Tomlinson
- Molecular and Population Genetics Laboratory and Oxford NIHR Biomedical Research Centre, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Eva Gross
- Department of Gynecology and Obstetrics, Technische Universität München, Munich, Germany
| | - André B P van Kuilenburg
- Department of Clinical Chemistry, Laboratory Genetic Metabolic Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Cornelis J A Punt
- Department of Medical Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Miriam Koopman
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jos H Beijnen
- Department of Pharmacy and Pharmacology, Netherlands Cancer Institute, Amsterdam, Netherlands; Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, Netherlands
| | - Annemieke Cats
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Jan H M Schellens
- Department of Clinical Pharmacology, Netherlands Cancer Institute, Amsterdam, Netherlands; Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands; Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, Netherlands.
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14
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Meulendijks D, Jacobs BAW, Aliev A, Pluim D, van Werkhoven E, Deenen MJ, Beijnen JH, Cats A, Schellens JHM. Increased risk of severe fluoropyrimidine-associated toxicity in patients carrying a G to C substitution in the first 28-bp tandem repeat of the thymidylate synthase 2R allele. Int J Cancer 2015; 138:245-53. [PMID: 26189437 DOI: 10.1002/ijc.29694] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 06/02/2015] [Accepted: 07/02/2015] [Indexed: 01/16/2023]
Abstract
The fluoropyrimidines act by inhibiting thymidylate synthase (TS). Recent studies have shown that patients' risk of severe fluoropyrimidine-associated toxicity is affected by polymorphisms in the 5'-untranslated region of TYMS, the gene encoding TS. A G>C substitution in the promoter enhancer region of TYMS, rs183205964 (known as the 2RC allele), markedly reduces TS activity in vitro, but its clinical relevance is unknown. We determined rs183205964 in 1605 patients previously enrolled in a prospective multicenter study. Associations between putative low TS expression genotypes (3RC/2RC, 2RG/2RC, and 2RC/2RC) and severe toxicity were investigated using univariable and multivariable logistic regression. Activity of TS and TYMS gene expression were determined in peripheral blood mononuclear cells (PBMCs) of a patient carrying genotype 2RC/2RC and of a control group of healthy individuals. Among 1,605 patients, 28 patients (1.7%) carried the 2RC allele. Twenty patients (1.2%) carried a risk-associated genotype (2RG/2RC, n=13; 3RC/2RC, n=6; and 2RC/2RC, n=1), the eight remaining patients had genotype 3RG/2RC. Early severe toxicity and toxicity-related hospitalization were significantly more frequent in risk-associated genotype carriers (OR 3.0, 95%CI 1.04-8.93, p=0.043 and OR 3.8, 95%CI 1.19-11.9, p=0.024, respectively, in multivariable analysis). The patient with genotype 2RC/2RC was hospitalized twice and had severe febrile neutropenia, diarrhea, and hand-foot syndrome. Baseline TS activity and gene expression in PBMCs of this patient, and a healthy individual with the 2RC allele, were found to be within the normal range. Our study suggests that patients carrying rs183205964 are at strongly increased risk of severe, potentially life-threatening, toxicity when treated with fluoropyrimidines.
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Affiliation(s)
- Didier Meulendijks
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Bart A W Jacobs
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Abidin Aliev
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Dick Pluim
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Erik van Werkhoven
- Department of Biometrics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Maarten J Deenen
- Department of Clinical Pharmacy, Catharina Hospital, Eindhoven, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Annemieke Cats
- Division of Gastroenterology and Hepatology, Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan H M Schellens
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
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