1
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Knikman JE, Wilting TA, Lopez-Yurda M, Henricks LM, Lunenburg CATC, de Man FM, Meulendijks D, Nieboer P, Droogendijk HJ, Creemers GJ, Mandigers CMPW, Imholz ALT, Mathijssen RHJ, Portielje JEA, Valkenburg-van Iersel L, Vulink A, van der Poel MHW, Baars A, Swen JJ, Gelderblom H, Schellens JHM, Beijnen JH, Guchelaar HJ, Cats A. Survival of Patients With Cancer With DPYD Variant Alleles and Dose-Individualized Fluoropyrimidine Therapy-A Matched-Pair Analysis. J Clin Oncol 2023; 41:5411-5421. [PMID: 37639651 DOI: 10.1200/jco.22.02780] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 04/24/2023] [Accepted: 07/11/2023] [Indexed: 08/31/2023] Open
Abstract
PURPOSE DPYD-guided fluoropyrimidine dosing improves patient safety in carriers of DPYD variant alleles. However, the impact on treatment outcome in these patients is largely unknown. Therefore, progression-free survival (PFS) and overall survival (OS) were compared between DPYD variant carriers treated with a reduced dose and DPYD wild-type controls receiving a full fluoropyrimidine dose in a retrospective matched-pair survival analysis. METHODS Data from a prospective multicenter study (ClinicalTrials.gov identifier: NCT02324452) in which DPYD variant carriers received a 25% (c.1236G>A and c.2846A>T) or 50% (DPYD*2A and c.1679T>G) reduced dose and data from DPYD variant carriers treated with a similarly reduced dose of fluoropyrimidines identified during routine clinical care were obtained. Each DPYD variant carrier was matched to three DPYD wild-type controls treated with a standard dose. Survival analyses were performed using Kaplan-Meier estimates and Cox regression. RESULTS In total, 156 DPYD variant carriers and 775 DPYD wild-type controls were available for analysis. Sixty-one c.1236G>A, 25 DPYD*2A, 13 c.2846A>T, and-when pooled-93 DPYD variant carriers could each be matched to three unique DPYD wild-type controls. For pooled DPYD variant carriers, PFS (hazard ratio [HR], 1.23; 95% CI, 1.00 to 1.51; P = .053) and OS (HR, 0.95; 95% CI, 0.75 to 1.51; P = .698) were not negatively affected by DPYD-guided dose individualization. In the subgroup analyses, a shorter PFS (HR, 1.43; 95% CI, 1.10 to 1.86; P = .007) was found in c.1236G>A variant carriers, whereas no differences were found for DPYD*2A and c.2846A>T carriers. CONCLUSION In this exploratory analysis, DPYD-guided fluoropyrimidine dosing does not negatively affect PFS and OS in pooled DPYD variant carriers. Close monitoring with early dose modifications based on toxicity is recommended, especially for c.1236G>A carriers receiving a reduced starting dose.
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Affiliation(s)
- Jonathan E Knikman
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Tycho A Wilting
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Marta Lopez-Yurda
- Biometrics Department, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Linda M Henricks
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Carin A T C Lunenburg
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Femke M de Man
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Didier Meulendijks
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
- Late Development Oncology, AstraZeneca, Cambridge, UK
| | - Peter Nieboer
- Department of Internal Medicine, Wilhelmina Hospital Assen, Assen, the Netherlands
| | - Helga J Droogendijk
- Department of Internal Medicine, Bravis Hospital, Roosendaal, the Netherlands
| | - Geert-Jan Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | | | | | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Johanneke E A Portielje
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Medical Oncology, Haga Hospital, The Hague, the Netherlands
| | | | - Annelie Vulink
- Department of Medical Oncology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | | | - Arnold Baars
- Department of Internal Medicine, Hospital Gelderse Vallei, Ede, the Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jan H M Schellens
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Annemieke Cats
- Department of Gastrointestinal Oncology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
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2
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van Schaik RH, Manolopoulos VG, Daly AK, Niemi M, Zukic B, Patrinos GP, Primorac D, Swen JJ, Ingelman-Sundberg M, Morris T, Molden E, Müller D, Pavlovic S, Russmann S, Ansari M, Henricks LM, den Broek WV, Florindi F, Bozina N, Akin D, Christrup L, Llerena A, Sipeky C, Stankovic S. The Sixth European Society of Pharmacogenomics and Personalised Therapy Congress (Belgrade, 8-9 November 2022). Pharmacogenomics 2023; 24:243-246. [PMID: 37014361 DOI: 10.2217/pgs-2023-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
On 8-9 November 2022, the European Society of Pharmacogenomics and Personalised Therapy organized its sixth biennial congress, in Belgrade, Serbia (congress website: www.sspt.rs). The congress aimed to address the current status and future perspectives of pharmacogenomics, share latest knowledge in the field of precision medicine and showcase the implementation of clinical applications in pharmacogenomics/pharmacogenetics. The 2 day congress consisted of 17 lectures given by key-opinion leaders and included a poster session plus discussions. The meeting was a great success by generating an informal environment and enabling the exchange of information between 162 participants from 16 different countries.
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Affiliation(s)
- Ron Hn van Schaik
- Department of Clinical Chemistry, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | | | - Ann K Daly
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Mikko Niemi
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
| | - Branka Zukic
- Institute of Molecular Genetics & Genetic Engineering, University of Belgrade, Belgrade, Serbia
| | - George P Patrinos
- Laboratory of Pharmacogenomics & Individualised Therapy, University of Patras, Department of Pharmacy, Patras, Greece
- Department of Genetics & Genomics, United Arab Emirates University, College of Medicine & Health Sciences, Al Ain, Abu Dhabi, UAE
- Zayed Center for Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, UAE
| | | | - Jesse J Swen
- Department of Clinical Pharmacology & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Tiffany Morris
- Precision Health & Pharmacogenomics, Illumina, Cambridge, UK
| | - Espen Molden
- Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Daniel Müller
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Sonja Pavlovic
- Institute of Molecular Genetics & Genetic Engineering, University of Belgrade, Belgrade, Serbia
| | - Stefan Russmann
- ETH Zürich, Hirslanden Hospitals & drugsafety.ch, Switzerland
| | - Marc Ansari
- Cansearch Research Platform for Pediatric Oncology & Hematology, Faculty of Medicine, Department of Pediatrics, Gynecology & Obstetrics, University of Geneva, Switzerland
| | - Linda M Henricks
- Division of Pediatric Oncology & Hematology, Department of Women, Child & Adolescent, University Geneva Hospitals, Geneva, Switzerland
| | - Wout van den Broek
- Department of Clinical Chemistry, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Nada Bozina
- Department of Pharmacology, University of Zagreb, Zagreb, Croatia
| | - Demet Akin
- Department of Pharmacology, Bahcesehir University, Istanbul, Türkiye
| | - Lona Christrup
- Department of Drug Design & Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Adrian Llerena
- INUBE Biosanitary University Research Institute, University of Extramedura, Spain
| | - Cilla Sipeky
- Department of Translational Medicine, UCB Biopharma, Waterloo, Belgium
| | - Sanja Stankovic
- Department of Medical Biochemistry, University Clinical Center of Serbia, Belgrade, Serbia
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3
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Henricks LM, Huisman EJ, Lopriore E, Luken JS, de Haas M, Ootjers CS, Albersen A. Acute haemolytic transfusion reaction after transfusion of fresh frozen plasma in a neonate-Preventable by using solvent/detergent-treated pooled plasma? Transfus Med 2022; 33:174-178. [PMID: 36257670 DOI: 10.1111/tme.12926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/26/2022] [Accepted: 09/29/2022] [Indexed: 10/24/2022]
Abstract
BACKGROUND Plasma is a commonly used blood product and is available in the form of fresh frozen plasma (FFP) or pooled solvent/detergent-treated plasma. In the Netherlands, solvent/detergent-treated plasma has become the standard product in the adult population since several years, but for neonatal use, FFP remains the product of preference. DESCRIPTION A preterm neonate developed lung bleeding at day 8 postpartum, for which intubation and mechanical ventilation was required and transfusions with packed red blood cells and plasma, in the form of FFP, were given. Five hours after transfusion, a red discoloration of the urine occurred. An acute haemolytic transfusion was suspected, confirmed by laboratory investigations (fast decrease in haemoglobin, increased free haemoglobin, decreased haptoglobin, increased lactate dehydrogenase and a positive direct antiglobulin test [IgG 2+]). Additional research showed that the FFP product contained nonspecific auto-antibodies that reacted with the transfused erythrocytes, most test erythrocytes and the donor's own erythrocytes. CONCLUSION A neonate experienced an acute haemolytic reaction, most probably caused by administrating a FFP product containing auto-antibodies. If transfused with solvent/detergent-treated plasma, such antibodies would have been diluted or captured. This case adds a new argument to the discussion on expanding the use of solvent/detergent-treated plasma to the paediatric population.
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Affiliation(s)
- Linda M Henricks
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Elise J Huisman
- Department of Paediatric Haematology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, the Netherlands.,Department of Transfusion Medicine, Sanquin, Amsterdam, the Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jessie S Luken
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, the Netherlands
| | - Masja de Haas
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, the Netherlands.,Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Claudia S Ootjers
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Arjan Albersen
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, the Netherlands
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4
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van Andel E, Henricks LM, Giliams APM, Noordervliet RM, Mensink WJ, Filippo D, van Rossum HH, Cobbaert CM, Gillis JMEP, Schenk PW, den Elzen WPJ. Moving average quality control of routine chemistry and hematology parameters - a toolbox for implementation. Clin Chem Lab Med 2022; 60:1719-1728. [PMID: 36044749 DOI: 10.1515/cclm-2022-0655] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Moving average quality control (MA QC) is a patient-based real-time quality control system. Advantages compared to conventional periodic internal quality control (IQC) include absence of commutability problems and continuous monitoring of performance. We implemented MA QC for multiple routine hematology and chemistry parameters. We describe the evaluation process and provide practical tools to aid MA QC implementation. METHODS Nine parameters (serum sodium, calcium, bicarbonate and free thyroxine, hemoglobin [Hb], mean corpuscular volume, mean corpuscular hemoglobin concentration [MCHC], reticulocyte count and erythrocyte sedimentation rate [ESR]) were chosen for initial consideration. Using data extractions from the laboratory information system (LIS; General Laboratory Information Management System), evaluation of usefulness and optimization of MA QC settings was performed using bias detection curves. After this, MA QC settings were incorporated in our LIS for further evaluation and implementation in routine care. RESULTS Three out of nine parameters (Hb, ESR, and sodium) were excluded from MA QC implementation due to high variation and technical issues in the LIS. For the six remaining parameters, MA QC showed added value to IQC and was therefore implemented in the LIS. For three parameters a direct MA alarm work-up method was set up, including newly developed built-in features in the LIS. For the other parameters, we identified MA utilization beyond real-time monitoring. CONCLUSIONS Implementation of MA QC has added value for our laboratory setting. Additional utilization beyond real-time QC monitoring was identified. We find MA QC especially useful for trend monitoring, detection of small shifts after maintenance and inter-analyzer comparisons.
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Affiliation(s)
- Esther van Andel
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Linda M Henricks
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Alex P M Giliams
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Richard M Noordervliet
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Willemina J Mensink
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Dionne Filippo
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Huub H van Rossum
- Department of Clinical Chemistry, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Huvaros, Bloemendaal, The Netherlands
| | - Christa M Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Judith M E P Gillis
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Paul W Schenk
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Wendy P J den Elzen
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
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5
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de With M, Knikman J, de Man FM, Lunenburg CATC, Henricks LM, van Kuilenburg ABP, Maring JG, van Staveren MC, de Vries N, Rosing H, Beijnen JH, Pluim D, Modak A, Imholz ALT, van Schaik RHN, Schellens JHM, Gelderblom H, Cats A, Guchelaar HJ, Mathijssen RHJ, Swen JJ, Meulendijks D. Dihydropyrimidine Dehydrogenase Phenotyping Using Pretreatment Uracil: A Note of Caution Based on a Large Prospective Clinical Study. Clin Pharmacol Ther 2022; 112:62-68. [PMID: 35397172 PMCID: PMC9322339 DOI: 10.1002/cpt.2608] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/01/2022] [Indexed: 11/12/2022]
Abstract
In clinical practice, 25-30% of the patients treated with fluoropyrimidines experience severe fluoropyrimidine-related toxicity. Extensively clinically validated DPYD genotyping tests are available to identify patients at risk of severe toxicity due to decreased activity of dihydropyrimidine dehydrogenase (DPD), the rate limiting enzyme in fluoropyrimidine metabolism. In April 2020, the European Medicines Agency recommended that, as an alternative for DPYD genotype-based testing for DPD deficiency, also phenotype testing based on pretreatment plasma uracil levels is a suitable method to identify patients with DPD deficiency. Although the evidence for genotype-directed dosing of fluoropyrimidines is substantial, the level of evidence supporting plasma uracil levels to predict DPD activity in clinical practice is limited. Notwithstanding this, uracil-based phenotyping is now used in clinical practice in various countries in Europe. We aimed to determine the value of pretreatment uracil levels in predicting DPD deficiency and severe treatment-related toxicity. To this end, we determined pretreatment uracil levels in 955 patients with cancer, and assessed the correlation with DPD activity in peripheral blood mononuclear cells (PBMCs) and fluoropyrimidine-related severe toxicity. We identified substantial issues concerning the use of pretreatment uracil in clinical practice, including large between-center study differences in measured pretreatment uracil levels, most likely as a result of pre-analytical factors. Importantly, we were not able to correlate pretreatment uracil levels with DPD activity nor were uracil levels predictive of severe treatment-related toxicity. We urge that robust clinical validation should first be performed before pretreatment plasma uracil levels are used in clinical practice as part of a dosing strategy for fluoropyrimidines.
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Affiliation(s)
- Mirjam de With
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands.,Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jonathan Knikman
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Femke M de Man
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Carin A T C Lunenburg
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Linda M Henricks
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Division of Medical Oncology, Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - André B P van Kuilenburg
- Laboratory Genetic Metabolic Diseases, Department of Clinical Chemistry, Amsterdam UMC, Cancer Center Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan G Maring
- Department of Pharmacy, Isala Hospital, Zwolle, The Netherlands.,Isala Diaconessen Hospital, Meppel, The Netherlands
| | - Maurice C van Staveren
- Department of Clinical Pharmacy and Toxicology, Treant Healthgroup, Scheper Hospital, Emmen, 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
| | - Jos H Beijnen
- Department of Pharmacy & 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
| | - Dick Pluim
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Anil Modak
- Cambridge Isotope Laboratories, Tewksbury, Massachusetts, USA
| | - Alex L T Imholz
- Department of Internal Medicine, Deventer Hospital, Deventer, The Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jan H M Schellens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Annemieke Cats
- Division of Medical Oncology, Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands.,Leiden Network for Personalised Therapeutics (LNPT), Leiden, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands.,Leiden Network for Personalised Therapeutics (LNPT), Leiden, The Netherlands
| | - Didier Meulendijks
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Division of Medical Oncology, Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Late Development Oncology, AstraZeneca, Cambridge, UK
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6
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Knikman JE, Gelderblom H, Beijnen JH, Cats A, Guchelaar H, Henricks LM. Individualized Dosing of Fluoropyrimidine-Based Chemotherapy to Prevent Severe Fluoropyrimidine-Related Toxicity: What Are the Options? Clin Pharmacol Ther 2021; 109:591-604. [PMID: 33020924 PMCID: PMC7983939 DOI: 10.1002/cpt.2069] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/18/2020] [Indexed: 12/19/2022]
Abstract
Fluoropyrimidines are widely used in the treatment of several types of solid tumors. Although most often well tolerated, severe toxicity is encountered in ~ 20-30% of the patients. Individualized dosing for these patients can reduce the incidence of severe fluoropyrimidine-related toxicity. However, no consensus has been achieved on which dosing strategy is preferred. The most established strategy for individualized dosing of fluoropyrimidines is upfront genotyping of the DPYD gene. Prospective research has shown that DPYD-guided dose-individualization significantly reduces the incidence of severe toxicity and can be easily applied in routine daily practice. Furthermore, the measurement of the dihydropyrimidine dehydrogenase (DPD) enzyme activity has shown to accurately detect patients with a DPD deficiency. Yet, because this assay is time-consuming and expensive, it is not widely implemented in routine clinical care. Other methods include the measurement of pretreatment endogenous serum uracil concentrations, the uracil/dihydrouracil-ratio, and the 5-fluorouracil (5-FU) degradation rate. These methods have shown mixed results. Next to these methods to detect DPD deficiency, pharmacokinetically guided follow-up of 5-FU could potentially be used as an addition to dosing strategies to further improve the safety of fluoropyrimidines. Furthermore, baseline characteristics, such as sex, age, body composition, and renal function have shown to have a relationship with the development of severe toxicity. Therefore, these baseline characteristics should be considered as a dose-individualization strategy. We present an overview of the current dose-individualization strategies and provide perspectives for a future multiparametric approach.
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Affiliation(s)
- Jonathan E. Knikman
- Division of PharmacologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
| | - Hans Gelderblom
- Department of Clinical OncologyLeiden University Medical CenterLeidenThe Netherlands
| | - Jos H. Beijnen
- Division of PharmacologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
- Department of Pharmaceutical SciencesUtrecht UniversityUtrechtThe Netherlands
| | - Annemieke Cats
- Department of Gastroenterology and HepatologyDivision of Medical OncologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
| | - Henk‐Jan Guchelaar
- Department of Clinical Pharmacy and ToxicologyLeiden University Medical CenterLeidenThe Netherlands
| | - Linda M. Henricks
- Department of Clinical Chemistry and Laboratory MedicineLeiden University Medical CenterLeidenThe Netherlands
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7
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Henricks LM, van Merendonk LN, Meulendijks D, Deenen MJ, Beijnen JH, de Boer A, Cats A, Schellens JHM. Effectiveness and safety of reduced-dose fluoropyrimidine therapy in patients carrying the DPYD*2A variant: A matched pair analysis. Int J Cancer 2019; 144:2347-2354. [PMID: 30485432 DOI: 10.1002/ijc.32022] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 11/06/2018] [Indexed: 12/27/2022]
Abstract
Carriers of the genetic DPYD*2A variant, resulting in dihydropyrimidine dehydrogenase deficiency, are at significantly increased risk of developing severe fluoropyrimidine-associated toxicity. Upfront DPYD*2A genotype-based dose reductions improve patient safety, but uncertainty exists whether this has a negative impact on treatment effectiveness. Therefore, our study investigated effectiveness and safety of DPYD*2A genotype-guided dosing. A cohort of 40 prospectively identified heterozygous DPYD*2A carriers, treated with a ~50% reduced fluoropyrimidine dose, was identified. For effectiveness analysis, a matched pair-analysis was performed in which for each DPYD*2A carrier a matched DPYD*2A wild-type patient was identified. Overall survival and progression-free survival were compared between the matched groups. The frequency of severe (grade ≥ 3) treatment-related toxicity was compared to 1] a cohort of 1606 wild-type patients treated with full dose and 2] a cohort of historical controls derived from literature, i.e. 86 DPYD*2A variant carriers who received a full fluoropyrimidine dose. For 37 out of 40 DPYD*2A carriers, a matched control could be identified. Compared to matched controls, reduced doses did not negatively affect overall survival (median 27 months versus 24 months, p = 0.47) nor progression-free survival (median 14 months versus 10 months, p = 0.54). Risk of severe fluoropyrimidine-related toxicity in DPYD*2A carriers treated with reduced dose was 18%, comparable to wild-type patients (23%, p = 0.57) and significantly lower than the risk of 77% in DPYD*2A carriers treated with full dose (p < 0.001). Our study is the first to show that DPYD*2A genotype-guided dosing appears to have no negative effect on effectiveness of fluoropyrimidine-based chemotherapy, while resulting in significantly improved patient safety.
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Affiliation(s)
- Linda M Henricks
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Lisanne N van Merendonk
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Didier Meulendijks
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.,Dutch Medicines Evaluation Board (CBG-MEB), Utrecht, The Netherlands
| | - Maarten J Deenen
- Department of Clinical Pharmacy, Catharina Hospital, Eindhoven, The Netherlands.,Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & 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
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Annemieke Cats
- Department of Gastrointestinal Oncology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Jan H M Schellens
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Clinical Pharmacology, Division of Medical Oncology, 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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Henricks LM, Lunenburg CATC, de Man FM, Meulendijks D, Frederix GWJ, Kienhuis E, Creemers GJ, Baars A, Dezentjé VO, Imholz ALT, Jeurissen FJF, Portielje JEA, Jansen RLH, Hamberg P, Ten Tije AJ, Droogendijk HJ, Koopman M, Nieboer P, van de Poel MHW, Mandigers CMPW, Rosing H, Beijnen JH, van Werkhoven E, van Kuilenburg ABP, van Schaik RHN, Mathijssen RHJ, Swen JJ, Gelderblom H, Cats A, Guchelaar HJ, Schellens JHM. A cost analysis of upfront DPYD genotype-guided dose individualisation in fluoropyrimidine-based anticancer therapy. Eur J Cancer 2018; 107:60-67. [PMID: 30544060 DOI: 10.1016/j.ejca.2018.11.010] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 11/01/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Fluoropyrimidine therapy including capecitabine or 5-fluorouracil can result in severe treatment-related toxicity in up to 30% of patients. Toxicity is often related to reduced activity of dihydropyrimidine dehydrogenase, the main metabolic fluoropyrimidine enzyme, primarily caused by genetic DPYD polymorphisms. In a large prospective study, it was concluded that upfront DPYD-guided dose individualisation is able to improve safety of fluoropyrimidine-based therapy. In our current analysis, we evaluated whether this strategy is cost saving. METHODS A cost-minimisation analysis from a health-care payer perspective was performed as part of the prospective clinical trial (NCT02324452) in which patients prior to start of fluoropyrimidine-based therapy were screened for the DPYD variants DPYD*2A, c.2846A>T, c.1679T>G and c.1236G>A and received an initial dose reduction of 25% (c.2846A>T, c.1236G>A) or 50% (DPYD*2A, c.1679T>G). Data on treatment, toxicity, hospitalisation and other toxicity-related interventions were collected. The model compared prospective screening for these DPYD variants with no DPYD screening. One-way and probabilistic sensitivity analyses were also performed. RESULTS Expected total costs of the screening strategy were €2599 per patient compared with €2650 for non-screening, resulting in a net cost saving of €51 per patient. Results of the probabilistic sensitivity and one-way sensitivity analysis demonstrated that the screening strategy was very likely to be cost saving or worst case cost-neutral. CONCLUSIONS Upfront DPYD-guided dose individualisation, improving patient safety, is cost saving or cost-neutral but is not expected to yield additional costs. These results endorse implementing DPYD screening before start of fluoropyrimidine treatment as standard of care.
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Affiliation(s)
- Linda M Henricks
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.
| | - Carin A T C Lunenburg
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Femke M de Man
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Didier Meulendijks
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Dutch Medicines Evaluation Board (CBG-MEB), Utrecht, the Netherlands
| | - Geert W J Frederix
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Emma Kienhuis
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Geert-Jan Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Arnold Baars
- Department of Internal Medicine, Hospital Gelderse Vallei, Ede, the Netherlands
| | - Vincent O Dezentjé
- Department of Internal Medicine, Reinier de Graaf Hospital, Delft, the Netherlands; Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Frank J F Jeurissen
- Department of Internal Medicine, Haaglanden Medical Center, The Hague, the Netherlands
| | - Johanna E A Portielje
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands; Department of Internal Medicine, Haga Hospital, The Hague, the Netherlands
| | - Rob L H Jansen
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Paul Hamberg
- Department of Internal Medicine, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands
| | - Albert J Ten Tije
- Department of Internal Medicine, Amphia Hospital, Breda, the Netherlands
| | - Helga J Droogendijk
- Department of Internal Medicine, Bravis Hospital, Roosendaal, the Netherlands
| | - Miriam Koopman
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Peter Nieboer
- Department of Internal Medicine, Wilhelmina Hospital Assen, Assen, the Netherlands
| | | | | | - Hilde Rosing
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & 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
| | - Erik van Werkhoven
- Department of Biometrics, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - André B P van Kuilenburg
- Laboratory Genetic Metabolic Diseases, Department of Clinical Chemistry, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology & Metabolism, Amsterdam, the Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Annemieke Cats
- Department of Gastrointestinal Oncology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jan H M Schellens
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Clinical Pharmacology, Division of Medical Oncology, 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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Lunenburg CATC, Henricks LM, van Kuilenburg ABP, Mathijssen RHJ, Schellens JHM, Gelderblom H, Guchelaar HJ, Swen JJ. Diagnostic and Therapeutic Strategies for Fluoropyrimidine Treatment of Patients Carrying Multiple DPYD Variants. Genes (Basel) 2018; 9:E585. [PMID: 30487465 PMCID: PMC6316498 DOI: 10.3390/genes9120585] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 11/26/2018] [Accepted: 11/26/2018] [Indexed: 01/16/2023] Open
Abstract
DPYD genotyping prior to fluoropyrimidine treatment is increasingly implemented in clinical care. Without phasing information (i.e., allelic location of variants), current genotype-based dosing guidelines cannot be applied to patients carrying multiple DPYD variants. The primary aim of this study is to examine diagnostic and therapeutic strategies for fluoropyrimidine treatment of patients carrying multiple DPYD variants. A case series of patients carrying multiple DPYD variants is presented. Different genotyping techniques were used to determine phasing information. Phenotyping was performed by dihydropyrimidine dehydrogenase (DPD) enzyme activity measurements. Publicly available databases were queried to explore the frequency and phasing of variants of patients carrying multiple DPYD variants. Four out of seven patients carrying multiple DPYD variants received a full dose of fluoropyrimidines and experienced severe toxicity. Phasing information could be retrieved for four patients. In three patients, variants were located on two different alleles, i.e., in trans. Recommended dose reductions based on the phased genotype differed from the phenotype-derived dose reductions in three out of four cases. Data from publicly available databases show that the frequency of patients carrying multiple DPYD variants is low (< 0.2%), but higher than the frequency of the commonly tested DPYD*13 variant (0.1%). Patients carrying multiple DPYD variants are at high risk of developing severe toxicity. Additional analyses are required to determine the correct dose of fluoropyrimidine treatment. In patients carrying multiple DPYD variants, we recommend that a DPD phenotyping assay be carried out to determine a safe starting dose.
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Affiliation(s)
- Carin A T C Lunenburg
- Department of Medical Oncology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands.
| | - Linda M Henricks
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands.
- Division of Pharmacology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands.
| | - André B P van Kuilenburg
- Department of Clinical Chemistry, Amsterdam University Medical Centre, 1105 AZ Amsterdam, The Netherlands.
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands.
| | - Jan H M Schellens
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands.
- Division of Pharmacology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands.
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands.
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands.
| | - Jesse J Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands.
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Henricks LM, Lunenburg CATC, de Man FM, Meulendijks D, Frederix GWJ, Kienhuis E, Creemers GJ, Baars A, Dezentjé VO, Imholz ALT, Jeurissen FJF, Portielje JEA, Jansen RLH, Hamberg P, Ten Tije AJ, Droogendijk HJ, Koopman M, Nieboer P, van de Poel MHW, Mandigers CMPW, Rosing H, Beijnen JH, Werkhoven EV, van Kuilenburg ABP, van Schaik RHN, Mathijssen RHJ, Swen JJ, Gelderblom H, Cats A, Guchelaar HJ, Schellens JHM. DPYD genotype-guided dose individualisation of fluoropyrimidine therapy in patients with cancer: a prospective safety analysis. Lancet Oncol 2018; 19:1459-1467. [PMID: 30348537 DOI: 10.1016/s1470-2045(18)30686-7] [Citation(s) in RCA: 210] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/05/2018] [Accepted: 09/06/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Fluoropyrimidine treatment can result in severe toxicity in up to 30% of patients and is often the result of reduced activity of the key metabolic enzyme dihydropyrimidine dehydrogenase (DPD), mostly caused by genetic variants in the gene encoding DPD (DPYD). We assessed the effect of prospective screening for the four most relevant DPYD variants (DPYD*2A [rs3918290, c.1905+1G>A, IVS14+1G>A], c.2846A>T [rs67376798, D949V], c.1679T>G [rs55886062, DPYD*13, I560S], and c.1236G>A [rs56038477, E412E, in haplotype B3]) on patient safety and subsequent DPYD genotype-guided dose individualisation in daily clinical care. METHODS In this prospective, multicentre, safety analysis in 17 hospitals in the Netherlands, the study population consisted of adult patients (≥18 years) with cancer who were intended to start on a fluoropyrimidine-based anticancer therapy (capecitabine or fluorouracil as single agent or in combination with other chemotherapeutic agents or radiotherapy). Patients with all tumour types for which fluoropyrimidine-based therapy was considered in their best interest were eligible. We did prospective genotyping for DPYD*2A, c.2846A>T, c.1679T>G, and c.1236G>A. Heterozygous DPYD variant allele carriers received an initial dose reduction of 25% (c.2846A>T and c.1236G>A) or 50% (DPYD*2A and c.1679T>G), and DPYD wild-type patients were treated according to the current standard of care. The primary endpoint of the study was the frequency of severe (National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03 grade ≥3) overall fluoropyrimidine-related toxicity across the entire treatment duration. We compared toxicity incidence between DPYD variant allele carriers and DPYD wild-type patients on an intention-to-treat basis, and relative risks (RRs) for severe toxicity were compared between the current study and a historical cohort of DPYD variant allele carriers treated with full dose fluoropyrimidine-based therapy (derived from a previously published meta-analysis). This trial is registered with ClinicalTrials.gov, number NCT02324452, and is complete. FINDINGS Between April 30, 2015, and Dec 21, 2017, we enrolled 1181 patients. 78 patients were considered non-evaluable, because they were retrospectively identified as not meeting inclusion criteria, did not start fluoropyrimidine-based treatment, or were homozygous or compound heterozygous DPYD variant allele carriers. Of 1103 evaluable patients, 85 (8%) were heterozygous DPYD variant allele carriers, and 1018 (92%) were DPYD wild-type patients. Overall, fluoropyrimidine-related severe toxicity was higher in DPYD variant carriers (33 [39%] of 85 patients) than in wild-type patients (231 [23%] of 1018 patients; p=0·0013). The RR for severe fluoropyrimidine-related toxicity was 1·31 (95% CI 0·63-2·73) for genotype-guided dosing compared with 2·87 (2·14-3·86) in the historical cohort for DPYD*2A carriers, no toxicity compared with 4·30 (2·10-8·80) in c.1679T>G carriers, 2·00 (1·19-3·34) compared with 3·11 (2·25-4·28) for c.2846A>T carriers, and 1·69 (1·18-2·42) compared with 1·72 (1·22-2·42) for c.1236G>A carriers. INTERPRETATION Prospective DPYD genotyping was feasible in routine clinical practice, and DPYD genotype-based dose reductions improved patient safety of fluoropyrimidine treatment. For DPYD*2A and c.1679T>G carriers, a 50% initial dose reduction was adequate. For c.1236G>A and c.2846A>T carriers, a larger dose reduction of 50% (instead of 25%) requires investigation. Since fluoropyrimidines are among the most commonly used anticancer agents, these findings suggest that implementation of DPYD genotype-guided individualised dosing should be a new standard of care. FUNDING Dutch Cancer Society.
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Affiliation(s)
- Linda M Henricks
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Carin A T C Lunenburg
- Department of Medical Oncology, Leiden University Medical Center, Leiden, Netherlands
| | - Femke M de Man
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Didier Meulendijks
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands; Dutch Medicines Evaluation Board (CBG-MEB), Utrecht, Netherlands
| | - Geert W J Frederix
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Emma Kienhuis
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Geert-Jan Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, Netherlands
| | - Arnold Baars
- Department of Internal Medicine, Hospital Gelderse Vallei, Ede, Netherlands
| | - Vincent O Dezentjé
- Department of Internal Medicine, Reinier de Graaf Hospital, Delft, Netherlands; Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Frank J F Jeurissen
- Department of Internal Medicine, Haaglanden Medical Center, The Hague, Netherlands
| | - Johanna E A Portielje
- Department of Medical Oncology, Leiden University Medical Center, Leiden, Netherlands; Department of Internal Medicine, Haga Hospital, The Hague, Netherlands
| | - Rob L H Jansen
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Paul Hamberg
- Department of Internal Medicine, Franciscus Gasthuis and Vlietland, Rotterdam, Netherlands
| | - Albert J Ten Tije
- Department of Internal Medicine, Amphia Hospital, Breda, Netherlands
| | | | - Miriam Koopman
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Peter Nieboer
- Department of Internal Medicine, Wilhelmina Hospital Assen, Assen, Netherlands
| | | | | | - Hilde Rosing
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Jos H Beijnen
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, Netherlands; Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, Netherlands
| | - Erik van Werkhoven
- Department of Biometrics, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - André B P van Kuilenburg
- Laboratory of Genetic Metabolic Diseases, Department of Clinical Chemistry, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology and Metabolism, Amsterdam, Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, Netherlands
| | - Annemieke Cats
- Department of Gastrointestinal Oncology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Jan H M Schellens
- Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Clinical Pharmacology, Division of Medical Oncology, The 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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12
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Henricks LM, Opdam FL, Beijnen JH, Cats A, Schellens JHM. DPYD genotype-guided dose individualization to improve patient safety of fluoropyrimidine therapy: call for a drug label update. Ann Oncol 2017; 28:2915-2922. [PMID: 29045513 DOI: 10.1093/annonc/mdx411] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The fluoropyrimidine anticancer drugs, especially 5-fluorouracil (5-FU) and capecitabine, are frequently prescribed for several types of cancer, including breast, colorectal, head and neck and gastric cancer. In the current drug labels of 5-FU and capecitabine in the European Union and the United States, no adaptive dosing strategies are incorporated for polymorphic metabolism of 5-FU. Although treatment with fluoropyrimidines is generally well tolerated, a major clinical limitation is that a proportion of the treated population experiences severe, sometimes life-threatening, fluoropyrimidine-related toxicity. This toxicity is strongly affected by interindividual variability in activity of dihydropyrimidine dehydrogenase (DPD), the main metabolic enzyme for inactivation of fluoropyrimidines, with an estimated 3%-8% of the population being partially DPD deficient. A reduced functional or abrogated DPD enzyme is often caused by genetic polymorphisms in DPYD, the gene encoding for DPD, and heterozygous carriers of such DPYD polymorphisms have a partial DPD deficiency. When these partially DPD deficient patients are treated with a full dose of fluoropyrimidines, they are generally exposed to toxic levels of 5-FU and its metabolites, and the risk of developing severe treatment-related toxicity is therefore significantly increased.Currently, functional and clinical validity is well established for four DPYD variants (DPYD*2A, c.2846A>T, c.1679T>G and c.1236G>A), as those variants have retrospectively and in a large population study prospectively been shown to be associated with increased risk of fluoropyrimidine-associated toxicity. Patient safety of fluoropyrimidine treatment can be significantly improved by pre-emptive screening for DPYD genotype variants and dose reductions in heterozygous DPYD variant allele carriers, thereby normalizing 5-FU exposure. Based on the critical appraisal of currently available data, adjusting the labels of capecitabine and 5-FU by including recommendations on pre-emptive screening for DPYD variants and DPYD genotype-guided dose adjustments should be the new standard of care.
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Affiliation(s)
- L M Henricks
- Division of Pharmacology.,Department of Clinical Pharmacology, Division of Medical Oncology
| | - F L Opdam
- Division of Pharmacology.,Department of Clinical Pharmacology, Division of Medical Oncology
| | - J H Beijnen
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam.,Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht
| | - A Cats
- Department of Gastroenterology and Hepatology, Division of Medical Oncology
| | - J H M Schellens
- Division of Pharmacology.,Department of Clinical Pharmacology, Division of Medical Oncology.,Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht
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13
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Amstutz U, Henricks LM, Offer SM, Barbarino J, Schellens JHM, Swen JJ, Klein TE, McLeod HL, Caudle KE, Diasio RB, Schwab M. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for Dihydropyrimidine Dehydrogenase Genotype and Fluoropyrimidine Dosing: 2017 Update. Clin Pharmacol Ther 2017; 103:210-216. [PMID: 29152729 DOI: 10.1002/cpt.911] [Citation(s) in RCA: 345] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/19/2017] [Accepted: 10/11/2017] [Indexed: 12/13/2022]
Abstract
The purpose of this guideline is to provide information for the interpretation of clinical dihydropyrimidine dehydrogenase (DPYD) genotype tests so that the results can be used to guide dosing of fluoropyrimidines (5-fluorouracil and capecitabine). Detailed guidelines for the use of fluoropyrimidines, their clinical pharmacology, as well as analyses of cost-effectiveness are beyond the scope of this document. The Clinical Pharmacogenetics Implementation Consortium (CPIC® ) guidelines consider the situation of patients for which genotype data are already available (updates available at https://cpicpgx.org/guidelines/guideline-for-fluoropyrimidines-and-dpyd/).
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Affiliation(s)
- Ursula Amstutz
- University Institute of Clinical Chemistry, Inselspital Bern University Hospital, University of Bern, Bern, Switzerland
| | - Linda M Henricks
- Department of Clinical Pharmacology, Division of Medical Oncology and Division of Pharmacology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Steven M Offer
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Julia Barbarino
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Jan H M Schellens
- Department of Clinical Pharmacology, Division of Medical Oncology and Division of Pharmacology, the Netherlands Cancer Institute, Amsterdam, the Netherlands.,Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Howard L McLeod
- DeBartolo Family Personalized Medicine Institute and the Department of Population Sciences, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Kelly E Caudle
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Robert B Diasio
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA.,Mayo Clinic Cancer Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthias Schwab
- Dr Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany.,Department of Clinical Pharmacology, University Hospital, Tuebingen, Germany.,Department of Pharmacy and Biochemistry, University of Tuebingen, Tuebingen, Germany
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Henricks LM, Siemerink EJ, Rosing H, Meijer J, Goorden SM, Polstra AM, Zoetekouw L, Cats A, Schellens JH, van Kuilenburg AB. Capecitabine-based treatment of a patient with a novelDPYDgenotype and complete dihydropyrimidine dehydrogenase deficiency. Int J Cancer 2017; 142:424-430. [DOI: 10.1002/ijc.31065] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/16/2017] [Accepted: 09/08/2017] [Indexed: 01/30/2023]
Affiliation(s)
- Linda M. Henricks
- Division of Pharmacology and Division of Clinical Pharmacology, Department of Medical Oncology; The Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Ester J.M. Siemerink
- Department of Internal Medicine; Ziekenhuis Groep Twente (ZGT); Hengelo The Netherlands
| | - Hilde Rosing
- Department of Pharmacy and Pharmacology; The Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Judith Meijer
- Laboratory Genetic Metabolic Diseases, Departments of Clinical Chemistry and Clinical Genetics; Academic Medical Center, University of Amsterdam; Amsterdam The Netherlands
| | - Susan M.I. Goorden
- Laboratory Genetic Metabolic Diseases, Departments of Clinical Chemistry and Clinical Genetics; Academic Medical Center, University of Amsterdam; Amsterdam The Netherlands
| | - Abeltje M. Polstra
- Laboratory Genetic Metabolic Diseases, Departments of Clinical Chemistry and Clinical Genetics; Academic Medical Center, University of Amsterdam; Amsterdam The Netherlands
- Department of Clinical Genetics; VU University Medical Center; Amsterdam The Netherlands
| | - Lida Zoetekouw
- Laboratory Genetic Metabolic Diseases, Departments of Clinical Chemistry and Clinical Genetics; Academic Medical Center, University of Amsterdam; Amsterdam The Netherlands
| | - Annemieke Cats
- Department of Gastrointestinal Oncology; The Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Jan H.M. Schellens
- Division of Pharmacology and Division of Clinical Pharmacology, Department of Medical Oncology; The Netherlands Cancer Institute; Amsterdam The Netherlands
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University; Utrecht The Netherlands
| | - André B.P. van Kuilenburg
- Laboratory Genetic Metabolic Diseases, Departments of Clinical Chemistry and Clinical Genetics; Academic Medical Center, University of Amsterdam; Amsterdam The Netherlands
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16
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Deenen MJ, Henricks LM, Sonke GS, Schellens JH, Meulendijks D. Letter regarding Zhao et al. entitled " DPYD gene polymorphisms are associated with risk and chemotherapy prognosis in pediatric patients with acute lymphoblastic leukemia". Tumour Biol 2017; 39:1010428317701629. [PMID: 28618970 DOI: 10.1177/1010428317701629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Zhao et al. investigated the association between germline genetic polymorphisms in DPYD, the gene encoding dihydropyrimidine dehydrogenase, and (1) the risk of developing pediatric acute lymphoblastic leukemia and (2) outcome of acute lymphoblastic leukemia following the treatment with 5-fluorouracil plus oxaliplatin (FOLFOX). The authors found that the common DPYD variant c.85T>C (rs1801265, DPYD*9A) was significantly associated with (1) risk of developing pediatric acute lymphoblastic leukemia, (2) complete response rate, (3) event-free survival, and (4) treatment-related toxicity. The authors conclude that patients carrying the c.85T>C C allele have an increased risk of developing acute lymphoblastic leukemia and have inferior outcome, and that DPYD c.85T>C can be used as a guide for individualized treatment and the decision to utilize 5-fluorouracil in acute lymphoblastic leukemia patients. In our view, the published article gives rise to multiple critical issues regarding the study's rationale and the methodology used, which strongly question the validity of the authors' conclusions.
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Affiliation(s)
- Maarten J Deenen
- 1 Department of Clinical Pharmacy, Catharina Hospital, Eindhoven, The Netherlands.,2 Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Linda M Henricks
- 3 Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Gabe S Sonke
- 4 Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan Hm Schellens
- 3 Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,5 Faculty of Science, Utrecht Institute of Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
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17
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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18
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Meulendijks D, Henricks LM, Amstutz U, Froehlich TK, Largiadèr CR, Beijnen JH, de Boer A, Deenen MJ, Cats A, Schellens JH. Rs895819 inMIR27Aimproves the predictive value ofDPYDvariants to identify patients at risk of severe fluoropyrimidine-associated toxicity. Int J Cancer 2016; 138:2752-61. [DOI: 10.1002/ijc.30014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 12/07/2015] [Accepted: 12/18/2015] [Indexed: 01/07/2023]
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
| | - Linda M. Henricks
- 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
| | - Ursula Amstutz
- Institute of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern; Bern Switzerland
| | - Tanja K. Froehlich
- Institute of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern; Bern Switzerland
| | - Carlo R. Largiadèr
- Institute of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern; Bern Switzerland
| | - Jos H. Beijnen
- Department of Clinical Pharmacology, Division of Medical Oncology; The Netherlands Cancer Institute; Amsterdam The Netherlands
- Department of Pharmacy & Pharmacology; The Netherlands Cancer Institute; Amsterdam The Netherlands
- Faculty of Science, Division of Pharmacoepidemiology and Clinical Pharmacology; Utrecht Institute for Pharmaceutical Sciences, Utrecht University; Utrecht The Netherlands
| | - Anthonius de Boer
- Faculty of Science, Division of Pharmacoepidemiology and Clinical Pharmacology; Utrecht Institute for Pharmaceutical Sciences, Utrecht University; Utrecht The Netherlands
| | - Maarten J. Deenen
- 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
| | - Annemieke Cats
- Department of Gastroenterology & Hepatology; 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
- Faculty of Science, Division of Pharmacoepidemiology and Clinical Pharmacology; Utrecht Institute for Pharmaceutical Sciences, Utrecht University; Utrecht The Netherlands
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19
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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20
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Henricks LM, Lunenburg CATC, Meulendijks D, Gelderblom H, Cats A, Swen JJ, Schellens JHM, Guchelaar HJ. Translating DPYD genotype into DPD phenotype: using the DPYD gene activity score. Pharmacogenomics 2015; 16:1277-86. [PMID: 26265346 DOI: 10.2217/pgs.15.70] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The dihydropyrimidine dehydrogenase enzyme (DPD, encoded by the gene DPYD) plays a key role in the metabolism of fluoropyrimidines. DPD deficiency occurs in 4-5% of the population and is associated with severe fluoropyrimidine-related toxicity. Several SNPs in DPYD have been described that lead to absent or reduced enzyme activity, including DPYD*2A, DPYD*13, c.2846A>T and c.1236G>A/haplotype B3. Since these SNPs differ in their effect on DPD enzyme activity, a differentiated dose adaption is recommended. We propose the gene activity score for translating DPYD genotype into phenotype, accounting for differences in functionality of SNPs. This method can be used to standardize individualized fluoropyrimidine dose adjustments, resulting in optimal safety and effectiveness.
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Affiliation(s)
- Linda M Henricks
- Division of Clinical Pharmacology, Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Carin A T C Lunenburg
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Didier Meulendijks
- Division of Clinical Pharmacology, Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Annemieke Cats
- Department of Gastroenterology & Hepatology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Jan H M Schellens
- Division of Clinical Pharmacology, Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Division of Pharmacoepidemiology & Clinical Pharmacology, Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
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Depeille P, Henricks LM, Ven RVD, Lemmens E, Matli M, Haigis KM, Donner D, Warren R, Roose JP. Abstract LB-306: The Ras exchange factor RasGRP1 opposes proliferative EGFR-SOS1 Ras signals and restricts intestinal epithelial cell growth. Cancer Res 2014. [DOI: 10.1158/1538-7445.am2014-lb-306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
The character of EGFR signals can influence cell fate. Anti-EGFR treatment has been successful as cancer therapy but not in colorectal cancer (CRC) where activating somatic KRAS mutations (KRASMUT) are prevalent. While relevant to CRC, intestinal EGFR signaling is poorly understood, particularly in the context of KRASMUT. Here we show that two distinct Ras nucleotide exchange factors, RasGRP1 and SOS1, lie downstream of the EGFR but act in functional opposition to one another in the context of KRASMUT. RasGRP1 creates a negative feedback loop that limits EGFR-SOS1-Ras signals and restricts CRC growth. Genetic Rasgrp1 depletion from KRasMUT mice exacerbates intestinal epithelial cell growth and dysplasia, leading to a highly serrated colonic epithelium. Furthermore, low RasGRP1 expression in CRC patient specimens correlates with poor clinical outcome. The unexpected inhibitory role of EGFR-RasGRP1 signals in KRASMUT gastrointestinal malignancies reveals an intricacy of EGFR signaling that should be considered for future molecular therapeutics.
Citation Format: Philippe Depeille, Linda M. Henricks, Robert van de Ven, Ed Lemmens, Mary Matli, Kevin M. Haigis, David Donner, Robert Warren, Jeroen P. Roose. The Ras exchange factor RasGRP1 opposes proliferative EGFR-SOS1 Ras signals and restricts intestinal epithelial cell growth. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr LB-306. doi:10.1158/1538-7445.AM2014-LB-306
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Affiliation(s)
| | | | | | | | | | - Kevin M. Haigis
- 2Molecular Pathology Unit, Massachusetts General Hospital, Charlestown, MA
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