Pharmacokinetics of methotrexate administered via the hepatic artery

Intrahepatic arterial administration of low-dose methotrexate in patients with severe hepatic graft-versus-host disease: An open-label, uncontrolled trial

BACKGROUND

Hepatic grafr-versus-host disease (GVHD) is associated with significant morbidity and mortality. Standard therapy includes systemically administered immunosuppressive drugs. More recent reports have described catheter-directed intrahepatic arterial (IHA) delivery of low-dose methotrexate (MTX) and methylprednisolone in the treatment of corticosteroid-resistant severe hepatic GVHD.

OBJECTIVE

This article reports on MTX toxicity and the variability in plasma drug concentrations after IHA administration of low-dose MTX in patients with severe hepatic GVHD.

METHODS

In this open-label, uncontrolled pilot study, MTX and methylprednisolone were administered via the hepatic artery in patients with corticosteroid-resistant grade III or IV GVHD of the liver. Patients also received standard therapy. MTX concentrations were measured in the hepatic artery 5 and 10 minutes after injection and in peripheral venous blood at 1, 2, and 24 hours.

RESULTS

Six patients (5 males [83.3%], I female [16.7%]; median age, 32 years; range, 8-42 years) were enrolled in the study. No hepatotoxicity was observed after IHA administration of MTX. In 5 patients with normal renal function, plasma drug concentrations 24 hours after administration of MTX ranged from 0.01 to 0.12 micromol/L (mean [SD], 0.043 [0.042] micromol/L). In 1 patient with renal failure, plasma MTX concentrations were 1.0 micromol/L 24 hours after administration and 0.07 micromol/L 5 days after administration. The severe hematologic and renal toxicity observed in this patient may have contributed to his death. Adverse events in patients with GVHD and normal renal function, who had normal plasma MTX concentrations, were comparable to those that have been reported after administration of an intravenous infusion.

CONCLUSIONS

In patients with GVHD and normal renal function, IHA administration of low-dose MTX was not associated with liver or bone marrow toxicity. Further study is needed to determine the optimal protocols for treating corticosteroid-resistant hepatic GVHD.

A pharmacokinetic study of adriamycin and 4'epi-adriamycin after simultaneous intra-arterial liver administration

The plasma pharmacokinetics of adriamycin and 4'epi-adriamycin were studied in patients with malignant tumors of the liver after simultaneous regional administration of equal amounts of the two anthracyclines by the arterial route. The use of a highly selective liquid chromatographic analytical method permitted quantification of plasma concentrations of the two drugs as well as their corresponding 13-hydroxy metabolites. The plasma concentrations of each drug followed a three-compartment open model. On average the area under the plasma concentration time curve (AUC) and the maximum plasma concentration (Cmax) were 2.1 and 1.7 times larger for adriamycin than for 4'epi-adriamycin, respectively. 4'Epi-adriamycin was eliminated faster than adriamycin, the terminal half-life time being on the average 1.5 times higher for adriamycin. These findings are in agreement with what has previously been observed after intravenous administration. The plasma concentrations of the 13-hydroxy metabolites did not exceed 30 ng ml-1. The AUC values of these metabolites were on average 20% of the AUC values of the intact drugs.

Intrahepatic and intravenous administration of adriamycin--a comparative pharmacokinetic study in patients with malignant liver tumours

The pharmacokinetics of adriamycin in patients with malignant tumours of the liver were studied after peripheral intravenous treatment and after regional administration of the drug either by the arterial route or by the portal vein, with or without hepatic artery ligation. The plasma concentration of adriamycin after intravenous as well as after intrahepatic administration followed a three-compartment open model. The results in the present study confirm previous reports of a large inter-individual variation of the pharmacokinetics of adriamycin. After intravenous administration the individual variations in AUC/mg/m2 and Cp,max/mg/m2 (dose normalized area under plasma concentration time curve and dose normalized maximum plasma concentration, respectively) were more than 5-fold. The area under the plasma concentration time curve (AUC) was on the average 1.5 times higher after the peripheral intravenous administration than after intrahepatic administration. The reduction of maximum plasma concentration (Cp,max) of adriamycin after intrahepatic administration was even more pronounced than the reduction in AUC (mean value Cp,max iv/Cp,max ihep = 1.7). The plasma concentration of adriamycinol did not exceed 20 ng/ml. The AUC values of adriamycinol were 20% (median value) of the AUC values of adriamycin, indicating the importance of adriamycinol in the adriamycin therapy.

Cancer chemotherapy: alternative routes of drug administration. A review

This review covers recent developments in regional cancer chemotherapy, including the pharmacological background, technical progress, and clinical experience. Intrathecal chemotherapy is an approach that has acquired an established place, although its ultimate potentials are not known yet. The therapeutic value of hepatic intraarterial drug infusion is still unclear, although this route has been used for more than 20 years. Furthermore, the evaluation of alternative routes via the pleural and peritoneal cavities and other arteries is still in an experimental phase. Interest in these treatment modalities has been stimulated by a number of recent developments in separate fields. Major technical advances have been made, including surgically placed and totally implantable elastic catheters and subcutaneous portals and pumps. In addition, a pharmacokinetic model describing the fate of drugs administered via an artery or cavity has been developed. These developments have made it possible not only to design randomized studies and treat a larger number of patients in a relatively short time with reduced morbidity, but also to improve greatly the selection of drugs, target organs, and administration schedules. Ongoing clinical studies can be expected to lead to improved treatment results as well as provide data on dose-response relationships and drug schedule dependency for specific tumor types.

Therapy of liver tumors metastatic from colorectal cancer with whole-liver radiation combined with 5-FU, adriamycin, and methotrexate

Twenty-seven patients with liver metastasis from colorectal cancer were treated with intrahepatic arterial chemotherapy and external radiotherapy consisting of 5-fluorouracil (5-FU) (10 mg/kg/day for 8 days), adriamycin (5 mg/m2/day for 7 days) and methotrexate (MTX) (240 mg/m2/X1), combined with 2,100 rads of whole liver irradiation. Twenty of these patients (74%) had previously received systemic chemotherapy. Of the 21 patients who could be fully evaluated, seven (33%) had an objective partial response and another 10 (48%) had stable disease following treatment. The median duration of survival for all patients after initiation of treatment was 6.5 months. Those patients responding to therapy survived longer (12.7 months) than those who had stable disease (5.5 months) or disease progression (2.5 months). The response rate was not affected by previous chemotherapy. Additionally, of the 14 patients with symptoms related to the disease, nine (64%) experienced substantial relief of these symptoms. Toxicity with the therapy used in this study was generally moderate. The median nadiR WBC was 3,500 cells/mm3; the median nadir platelet count, 121,000 cells/mm3. There was, however, one treatment-associated fatality from sepsis in a patient whose WBC was 900 cells/mm3.