1
|
Aquilani R, Brugnatelli S, Maestri R, Iadarola P, Corallo S, Pagani A, Serra F, Bellini A, Buonocore D, Dossena M, Boschi F, Verri M. Chemotherapy-Induced Changes in Plasma Amino Acids and Lipid Oxidation of Resected Patients with Colorectal Cancer: A Background for Future Studies. Int J Mol Sci 2024; 25:5300. [PMID: 38791339 PMCID: PMC11121634 DOI: 10.3390/ijms25105300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 05/07/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
Previous studies have documented that FOLFOX and XELOX therapies negatively impact the metabolism of skeletal muscle and extra-muscle districts. This pilot study tested whether three-month FOLFOX or XELOX therapy produced changes in plasma amino acid levels (PAAL) (an estimation of whole-body amino acid metabolism) and in plasma levels of malondialdehyde (MDA), a marker of lipid hyper oxidation. Fourteen ambulatory, resected patients with colorectal cancer scheduled to receive FOLFOX (n = 9) or XELOX (n = 5) therapy, after overnight fasting, underwent peripheral venous blood sampling, to determine PAAL and MDA before, during, and at the end of three-month therapy. Fifteen healthy matched subjects (controls) only underwent measures of PAAL at baseline. The results showed changes in 87.5% of plasma essential amino acids (EAAs) and 38.4% of non-EAAs in patients treated with FOLFOX or XELOX. These changes in EAAs occurred in two opposite directions: EAAs decreased with FOLFOX and increased or did not decrease with XELOX (interactions: from p = 0.034 to p = 0.003). Baseline plasma MDA levels in both FOLFOX and XELOX patients were above the normal range of values, and increased, albeit not significantly, during therapy. In conclusion, three-month FOLFOX or XELOX therapy affected plasma EAAs differently but not the baseline MDA levels, which were already high.
Collapse
Affiliation(s)
- Roberto Aquilani
- Department of Biology and Biotechnology “Lazzaro Spallanzani”, University of Pavia, 27100 Pavia, Italy; (R.A.); (P.I.); (A.B.); (D.B.); (M.D.)
| | - Silvia Brugnatelli
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (S.B.); (S.C.); (A.P.); (F.S.)
| | - Roberto Maestri
- Department of Biomedical Engineering of the Montescano Institute, Istituti Clinici Scientifici Maugeri IRCCS, 27040 Montescano, Italy;
| | - Paolo Iadarola
- Department of Biology and Biotechnology “Lazzaro Spallanzani”, University of Pavia, 27100 Pavia, Italy; (R.A.); (P.I.); (A.B.); (D.B.); (M.D.)
| | - Salvatore Corallo
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (S.B.); (S.C.); (A.P.); (F.S.)
| | - Anna Pagani
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (S.B.); (S.C.); (A.P.); (F.S.)
| | - Francesco Serra
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (S.B.); (S.C.); (A.P.); (F.S.)
| | - Anna Bellini
- Department of Biology and Biotechnology “Lazzaro Spallanzani”, University of Pavia, 27100 Pavia, Italy; (R.A.); (P.I.); (A.B.); (D.B.); (M.D.)
| | - Daniela Buonocore
- Department of Biology and Biotechnology “Lazzaro Spallanzani”, University of Pavia, 27100 Pavia, Italy; (R.A.); (P.I.); (A.B.); (D.B.); (M.D.)
| | - Maurizia Dossena
- Department of Biology and Biotechnology “Lazzaro Spallanzani”, University of Pavia, 27100 Pavia, Italy; (R.A.); (P.I.); (A.B.); (D.B.); (M.D.)
| | - Federica Boschi
- Department of Drug Sciences, University of Pavia, 27100 Pavia, Italy;
| | - Manuela Verri
- Department of Biology and Biotechnology “Lazzaro Spallanzani”, University of Pavia, 27100 Pavia, Italy; (R.A.); (P.I.); (A.B.); (D.B.); (M.D.)
| |
Collapse
|
2
|
Oura M, Oguro F, Agatsuma N, Imamaki H, Nishikawa Y. Fluoropyrimidine usage in cases with hyperammonemia: real-world data study using the Japanese Adverse Drug Event Report (JADER) database. Cancer Chemother Pharmacol 2023; 92:7-14. [PMID: 37204512 DOI: 10.1007/s00280-023-04542-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/09/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE Fluoropyrimidines are anticancer drugs and can cause hyperammonemia both intravenously and orally. Renal dysfunction may interact with fluoropyrimidine to cause hyperammonemia. We performed quantitative analyses of hyperammonemia using a spontaneous report database to examine the frequency of intravenously and orally administered fluoropyrimidine, the reported frequency of fluoropyrimidine-related regimens, and fluoropyrimidine's interactions with chronic kidney disease (CKD). METHODS This study used data collected between April 2004 and March 2020 from the Japanese Adverse Drug Event Report database. The reporting odds ratio (ROR) of hyperammonemia was calculated for each fluoropyrimidine drug and was adjusted for age and sex. Heatmaps depicting the use of anticancer agents in patients with hyperammonemia were drawn. The interactions between CKD and the fluoropyrimidines were also calculated. These analyses were performed using multiple logistic regression. RESULTS Hyperammonemia was observed in 861 of the 641,736 adverse events reports. Fluorouracil was the most frequent drug associated with hyperammonemia (389 cases). The ROR of hyperammonemia was 32.5 (95% CI 28.3-37.2) for intravenously administered fluorouracil, 4.7 (95% CI 3.3-6.6) for orally administered capecitabine, 1.9 (95% CI 0.87-4.3) for tegafur/uracil, and 2.2 (95% CI 1.5-3.2) for orally administered tegafur/gimeracil/oteracil. Calcium levofolinate, oxaliplatin, bevacizumab, and irinotecan were the most frequently reported agents in cases of hyperammonemia with intravenously administered fluorouracil. The coefficient of the interaction term between CKD and fluoropyrimidines was 1.12 (95% CI 1.09-1.16). CONCLUSION Hyperammonemia cases were more likely to be reported with intravenous fluorouracil than orally administered fluoropyrimidines. Fluoropyrimidines might interact with CKD in hyperammonemia cases.
Collapse
Affiliation(s)
- Mitsuaki Oura
- Department of Internal Medicine, Takeda General Hospital, Fukushima, Japan
| | - Fumiya Oguro
- Department of Internal Medicine, Hirata Central Hospital, Fukushima, Japan
| | - Nobukazu Agatsuma
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hirotaka Imamaki
- Department of Nephrology, Hirakata Kohsai Hospital, Osaka, Japan
| | - Yoshitaka Nishikawa
- Department of Health Informatics, Kyoto University School of Public Health, Yoshidakonoecho, Sakyo-ku, Kyoto, 606-8501, Japan.
| |
Collapse
|
3
|
Zupancic M, Farrajota Neves da Silva P, Kas Elyas K, Friesland S, Ellingsen Cederö T, Gerling M. Transient Coma and Signs of Encephalopathy Related to 5-Fluorouracil and Carboplatin: A Case Report. Case Rep Oncol 2023; 16:525-531. [PMID: 37485017 PMCID: PMC10359680 DOI: 10.1159/000531472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 05/26/2023] [Indexed: 07/25/2023] Open
Abstract
Chemotherapy-related encephalopathy is a rare but severe side effect of cancer therapy. Few reports exist on the course of encephalopathy due to 5-fluorouracil (5FU)/carboplatin treatment. Here, we report on a patient in his 70s, who received first-line palliative treatment with carboplatin followed by continuous infusion of 5FU against a metastasized cancer of the base of the tongue. During the first 5FU infusion, the patient developed a coma with sudden onset. In contrast to earlier reports of 5FU-induced encephalopathy, serum ammonium levels were near-normal, despite a slightly increased bilirubin. The electroencephalogram showed signs of general encephalopathy, for which no other probable cause than chemotherapy could be identified. Based on historical reports, the patient's encephalopathy was likely due to 5FU treatment rather than carboplatin. While initially in a coma with a Glasgow Coma Scale score of three, the patient regained consciousness within 3 days of supportive therapy. This case highlights the potentially benign clinical course of 5FU-induced encephalopathy, characterized by fulminant clinical deterioration and quick recovery. Such a rapid deterioration in a palliative setting can pose a clinical dilemma, where invasive treatments such as intubation must be weighed against a limited prognosis, for which this case may provide guidance.
Collapse
Affiliation(s)
- Mark Zupancic
- Medical Unit Head, Neck, Lung, and Skin Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Solna, Sweden
| | - Pedro Farrajota Neves da Silva
- Department of Oncology-Pathology, Karolinska Institutet, Solna, Sweden
- Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, Sweden
| | - Karam Kas Elyas
- Medical Unit Head, Neck, Lung, and Skin Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Signe Friesland
- Medical Unit Head, Neck, Lung, and Skin Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Solna, Sweden
| | - Thomasine Ellingsen Cederö
- Medical Unit Head, Neck, Lung, and Skin Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Gerling
- Medical Unit Head, Neck, Lung, and Skin Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, Sweden
| |
Collapse
|
4
|
Gupta P, Makkar TK, Goel L, Pahuja M. Role of inflammation and oxidative stress in chemotherapy-induced neurotoxicity. Immunol Res 2022; 70:725-741. [PMID: 35859244 DOI: 10.1007/s12026-022-09307-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/08/2022] [Indexed: 11/28/2022]
Abstract
Chemotherapeutic agents may adversely affect the nervous system, including the neural precursor cells as well as the white matter. Although the mechanisms are not completely understood, several hypotheses connecting inflammation and oxidative stress with neurotoxicity are now emerging. The proposed mechanisms differ depending on the class of drug. For example, toxicity due to cisplatin occurs due to activation of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), which alters hippocampal long-term potentiation. Free radical injury is also involved in the cisplatin-mediated neurotoxicity as dysregulation of nuclear factor erythroid 2-related factor 2 (Nrf2) has been seen which protects against the free radical injury by regulating glutathione S-transferases and hemeoxygenase-1 (HO-1). Thus, correcting the imbalance between NF-κB and Nrf2/HO-1 pathways may alleviate cisplatin-induced neurotoxicity. With newer agents like bortezomib, peripheral neuropathy occurs due to up-regulation of TNF-α and IL-6 in the sensory neurons. Superoxide dismutase dysregulation is also involved in bortezomib-induced neuropathy. This article reviews the available literature on inflammation and oxidative stress in neurotoxicity caused by various classes of chemotherapeutic agents. It covers the conventional medicines like platinum compounds, vinca alkaloids, and methotrexate, as well as the newer therapeutic agents like immunomodulators and immune checkpoint inhibitors. A better understanding of the pathophysiology will lead to further advancement in strategies for management of chemotherapy-induced neurotoxicity.
Collapse
Affiliation(s)
- Pooja Gupta
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, 110029, India. .,Coordinator, AIIMS Adverse Drug Reaction Monitoring Centre, Pharmacovigilance Program of India, New Delhi, India.
| | - Tavneet Kaur Makkar
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Lavisha Goel
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Monika Pahuja
- Division of Basic Medical Sciences, Indian Council of Medical Research, New Delhi, India
| |
Collapse
|
5
|
Perrain V, Bihan K, Bompaire F, Houillier C, Jomier F, Leclercq D, Combret S, Mahé J, Ricard D, Berzero G, Psimaras D. Leukoencephalopathy with transient splenial lesions related to 5-fluorouracil or capecitabine. Eur J Neurol 2021; 28:2396-2402. [PMID: 33817933 DOI: 10.1111/ene.14857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND 5-Fluorouracil (5-FU) and its oral prodrug capecitabine have been rarely but consistently associated with acute central nervous system toxicity, including transient leukoencephalopathies involving the splenium of the corpus callosum. METHODS We performed a retrospective search in the French Pharmacovigilance database (FPDB) (January 1985-July 2020) for adult patients affected by solid cancers who developed acute toxic leukoencephalopathies with splenial lesions following treatment with 5-FU or capecitabine. A comprehensive review of the literature helped to circumstantiate our findings. RESULTS Our research in the FPDB identified six patients who, within 3 days from their first cycle of 5-FU or capecitabine, developed acute neurological symptoms, including gait ataxia (n = 4), dysarthria (n = 3), dysmetria (n = 2), headache (n = 2), and confusion (n = 2). Brain magnetic resonance imaging (MRI) showed T2/FLAIR (fluid-attenuated inversion recovery) hyperintensities in the corpus callosum, with diffusion restriction and no contrast enhancement, generally accompanied by additional alterations in the bilateral supratentorial white matter (n = 5). All patients discontinued the agent supposedly responsible for the toxicity and experienced full recovery after a median of 8.5 days from symptom onset. Control MRI showed a progressive normalization of acute MRI abnormalities. Literature review identified 26 cases with similar clinical and paraclinical characteristics. A single patient from the literature resumed 5-FU at a lower dose, with no recurrent toxicity. CONCLUSIONS 5-FU and capecitabine might be responsible for acute leukoencephalopathies with transient splenial lesions that are generally reversible upon drug discontinuation. Resuming the agent responsible for toxicity might be feasible in selected cases, after having excluded dihydropyrimidine dehydrogenase deficiency, if expected benefits outweigh the risks.
Collapse
Affiliation(s)
- Valentine Perrain
- AP-HP Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, Service de Neurologie 2-Mazarin, Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - Kevin Bihan
- Regional Pharmacovigilance Center, Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France.,OncoNeuroTox Group, Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix et Hôpital Percy, Paris, France
| | - Flavie Bompaire
- OncoNeuroTox Group, Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix et Hôpital Percy, Paris, France.,Department of Neurology, Service de Santé des Armées, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Caroline Houillier
- AP-HP Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, Service de Neurologie 2-Mazarin, Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - Fanny Jomier
- Service de Neurologie, Hôpital Saint Joseph, Paris, France
| | - Delphine Leclercq
- Service de Neuroradiologie, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Sandrine Combret
- Department of Pharmacology, Regional Pharmacovigilance Center, Dijon, France
| | - Julien Mahé
- Department of Pharmacology, Regional Pharmacovigilance Center, Nantes, France
| | - Damien Ricard
- OncoNeuroTox Group, Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix et Hôpital Percy, Paris, France.,Department of Neurology, Service de Santé des Armées, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Giulia Berzero
- AP-HP Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, Service de Neurologie 2-Mazarin, Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dimitri Psimaras
- AP-HP Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, Service de Neurologie 2-Mazarin, Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France.,OncoNeuroTox Group, Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix et Hôpital Percy, Paris, France
| |
Collapse
|
6
|
Porta C, Bamias A, Danesh FR, Dębska-Ślizień A, Gallieni M, Gertz MA, Kielstein JT, Tesarova P, Wong G, Cheung M, Wheeler DC, Winkelmayer WC, Małyszko J. KDIGO Controversies Conference on onco-nephrology: understanding kidney impairment and solid-organ malignancies, and managing kidney cancer. Kidney Int 2020; 98:1108-1119. [PMID: 33126977 DOI: 10.1016/j.kint.2020.06.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 05/28/2020] [Accepted: 06/10/2020] [Indexed: 12/12/2022]
Abstract
The association between kidney disease and cancer is multifaceted and complex. Persons with chronic kidney disease (CKD) have an increased incidence of cancer, and both cancer and cancer treatments can cause impaired kidney function. Renal issues in the setting of malignancy can worsen patient outcomes and diminish the adequacy of anticancer treatments. In addition, the oncology treatment landscape is changing rapidly, and data on tolerability of novel therapies in patients with CKD are often lacking. Caring for oncology patients has become more specialized and interdisciplinary, currently requiring collaboration among specialists in nephrology, medical oncology, critical care, clinical pharmacology/pharmacy, and palliative care, in addition to surgeons and urologists. To identify key management issues in nephrology relevant to patients with malignancy, KDIGO (Kidney Disease: Improving Global Outcomes) assembled a global panel of multidisciplinary clinical and scientific expertise for a controversies conference on onco-nephrology in December 2018. This report covers issues related to kidney impairment and solid organ malignancies as well as management and treatment of kidney cancer. Knowledge gaps, areas of controversy, and research priorities are described.
Collapse
Affiliation(s)
- Camillo Porta
- Department of Internal Medicine and Therapeutics, University of Pavia and Division of Translational Oncology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy.
| | - Aristotelis Bamias
- Second Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Greece
| | - Farhad R Danesh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alicja Dębska-Ślizień
- Clinical Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, Luigi Sacco Department of Biomedical and Clinical Sciences, Università di Milano, Milan, Italy
| | - Morie A Gertz
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jan T Kielstein
- Medical Clinic V, Nephrology, Rheumatology, Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany
| | - Petra Tesarova
- Department of Oncology, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Germaine Wong
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia; Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | | | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK; George Institute for Global Health, Sydney, Australia
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis, and Internal Medicine, Medical University of Warsaw, Poland.
| |
Collapse
|
7
|
Ozaki Y, Imamaki H, Ikeda A, Oura M, Nakagawa S, Funakoshi T, Kataoka S, Nishikawa Y, Horimatsu T, Yonezawa A, Matsubara T, Yanagita M, Muto M, Watanabe N. Successful management of hyperammonemia with hemodialysis on day 2 during 5-fluorouracil treatment in a patient with gastric cancer: a case report with 5-fluorouracil metabolite analyses. Cancer Chemother Pharmacol 2020; 86:693-699. [PMID: 33011861 PMCID: PMC7595983 DOI: 10.1007/s00280-020-04158-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/24/2020] [Indexed: 12/01/2022]
Abstract
Purpose Hyperammonemia is an important adverse event associated with
5-fluorouracil (5FU) from 5FU metabolite accumulation. We present a case of an
advanced gastric cancer patient with chronic renal failure, who was treated with
5FU/leucovorin (LV) infusion chemotherapy (2-h infusion of LV and 5FU bolus followed
by 46-h 5FU continuous infusion on day 1; repeated every 2 weeks) and developed
hyperammonemia, with the aim of exploring an appropriate hemodialysis (HD) schedule
to resolve its symptoms. Methods The blood concentrations of 5FU and its metabolites, α-fluoro-β-alanine
(FBAL), and monofluoroacetate (FA) of a patient who had hyperammonemia from seven
courses of palliative 5FU/LV therapy for gastric cancer were measured by liquid
chromatography–mass spectrometry. Results On the third day of the first cycle, the patient presented with
symptomatic hyperammonemia relieved by emergency HD. Thereafter, the 5FU dose was
reduced; however, in cycles 2–4, the patient developed symptomatic hyperammonemia and
underwent HD on day 3 for hyperammonemia management. In cycles 5–7, the timing of
scheduled HD administration was changed from day 3 to day 2, preventing symptomatic
hyperammonemia. The maximum ammonia and 5FU metabolite levels were significantly
lower in cycles 5–7 than in cycles 2–4 (NH3 75 ± 38 vs 303 ± 119 μg/dL, FBAL
13.7 ± 2.5 vs 19.7 ± 2.0 μg/mL, FA 204.0 ± 91.6 vs 395.9 ± 12.6 ng/mL,
mean ± standard deviation, all p < 0.05). After
seven cycles, partial response was confirmed. Conclusion HD on day 2 instead of 3 may prevent hyperammonemia in 5FU/LV
therapy. Electronic supplementary material The online version of this article (10.1007/s00280-020-04158-1) contains supplementary material, which is available to authorized
users.
Collapse
Affiliation(s)
- Yoshinao Ozaki
- Department of Gastroenterology, Hirakata Kohsai Hospital, Osaka, Japan.
| | - Hirotaka Imamaki
- Department of Nephrology, Hirakata Kohsai Hospital, Osaka, Japan
| | - Aki Ikeda
- Department of Gastroenterology, Hirakata Kohsai Hospital, Osaka, Japan
| | - Mitsuaki Oura
- Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shunsaku Nakagawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Taro Funakoshi
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shigeki Kataoka
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshitaka Nishikawa
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Takahiro Horimatsu
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Takeshi Matsubara
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Motoko Yanagita
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Manabu Muto
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Norihiko Watanabe
- Department of Gastroenterology, Hirakata Kohsai Hospital, Osaka, Japan
| |
Collapse
|
8
|
Fukuda M, Nabeta M, Muta T, Cho T, Shimamatsu Y, Shimotsuura Y, Fukami K, Takasu O. Disturbance of consciousness due to hyperammonemia and lactic acidosis during mFOLFOX6 regimen: Case report. Medicine (Baltimore) 2020; 99:e21743. [PMID: 32872062 PMCID: PMC7437776 DOI: 10.1097/md.0000000000021743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION FOLFOX therapy is the main chemotherapy regimen for colorectal cancer. Peripheral neuropathy, hematotoxicity, and digestive symptoms are known to be the most frequent adverse events. Hyperammonemia and lactic acidosis rarely occur simultaneously during treatment with FOLFOX therapy; the number of case reports is limited worldwide. We report a case of disturbance of consciousness, considered to be caused by hyperammonemia and lactic acidosis that occurred during treatment with mFOLFOX6 therapy that was administered as postoperative adjuvant treatment for rectal cancer. PATIENT CONCERNS This case was of a 71-year-old man who had been receiving oral treatment for chronic kidney disease and diabetes mellitus. Laparoscopic low anterior resection and artificial anal construction surgery were performed for stage III rectal cancer. As adjuvant postoperative therapy, mFOLFOX6 therapy was started but was followed by a disturbance of consciousness. DIAGNOSES Results of the blood tests revealed notable hyperammonemia (ammonia level, 1,163 μg/dl) and lactic acidosis (pH 7.207; lactate, 17.56 mmol/L); however, imaging diagnosis did not reveal intracranial lesions that could cause disturbance of consciousness. INTERVENTIONS For hyperammonemia, branched-chain amino acid agents and Ringers solution supplementation were administered. For acidosis, 7% sodium hydrogen carbonate was administered as treatment. OUTCOMES The disturbance of consciousness improved within 12 hours of initiating the treatment, and the patient was discharged with no sequelae on 7th day after hospitalization. CONCLUSION In patients with chronic kidney disease, FOLFOX regimen may confer risks of hyperammonemia and lactic acidosis.
Collapse
Affiliation(s)
- Masafumi Fukuda
- Advanced Emergency and Critical Care Center, Kurume University Hospital
| | | | - Takanori Muta
- Department of Emergency and Acute Intensive Care Medicine
| | | | | | | | - Kei Fukami
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Osamu Takasu
- Department of Emergency and Acute Intensive Care Medicine
| |
Collapse
|
9
|
A 5-Fluorouracil-Induced Hyperammonemic Encephalopathy Challenged with Capecitabine. Case Rep Oncol Med 2020; 2020:4216752. [PMID: 32082663 PMCID: PMC7013286 DOI: 10.1155/2020/4216752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 01/09/2020] [Indexed: 12/20/2022] Open
Abstract
Cancer patients presenting with altered mental status demand a broad differential with early recognition of the etiology. Failure to do so is associated with increased morbidity and mortality. Causes that must be considered include organ involvement of the cancer, electrolytes abnormalities, and even chemotherapeutic agents. A 32-year-old female patient had been recently started on FOLFOX for metastatic colon cancer. Her initial treatments were uneventful, but she later developed encephalopathy during day three of cycle five. During her evaluation, she was found to have hyperammonemia (84 mcmol/L), without hepatic failure, that resolved with stopping chemotherapy and supportive care. After a trial of home infusion fluorouracil, she developed hyperammonemic encephalopathy again. During both admissions, her symptoms resolved with IV hydration and cessation of chemotherapy. She was then successfully challenged with capecitabine (1000 mg/m2 daily), and additional hydration, and continued chemotherapy without recurrence of symptoms. Hyperammonemia is associated with fluorouracil though the mechanism is unclear. Suspected etiologies include either elevated levels of the drug due to slower metabolism or accumulation of certain metabolites. Additionally, risk factors such urease-producing bacterial infections, dehydration, and increased catabolism are thought to increase the risk for hyperammonemia. This case demonstrates the need for greater awareness of fluorouracil as a cause of hyperammonemic encephalopathy. Knowledge of this may allow for earlier recognition and reduced unnecessary testing.
Collapse
|
10
|
5-Fluorouracil rechallenge after 5-fluorouracil-induced hyperammonemic encephalopathy. Anticancer Drugs 2019; 30:313-317. [DOI: 10.1097/cad.0000000000000730] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
11
|
Ly KNI, Arrillaga-Romany IC. Neurologic Complications of Systemic Anticancer Therapy. Neurol Clin 2018; 36:627-651. [DOI: 10.1016/j.ncl.2018.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
12
|
Ihoriya H, Yamamoto H, Yamada T, Tsukahara K, Inoue K, Yumoto T, Naito H, Nakao A. Hyperammonemic encephalopathy in a patient receiving fluorouracil/oxaliplatin chemotherapy. Clin Case Rep 2018; 6:603-605. [PMID: 29636922 PMCID: PMC5889268 DOI: 10.1002/ccr3.1422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 11/28/2017] [Accepted: 01/20/2018] [Indexed: 11/30/2022] Open
Abstract
Hyperammonemia is a rare adverse effect of 5‐fluorouracil (5‐FU) therapy, but can be very serious, even fatal. Physicians must be aware that hyperammonemic encephalopathy sometimes develops as an adverse event after 5‐FU therapy.
Collapse
Affiliation(s)
- Hiromi Ihoriya
- Department of Emergency and Critical Care Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences 2-5-1 Shikata-cho, Kita-ku Okayama-shi Okayama 700-8558 Japan
| | - Hirotsugu Yamamoto
- Department of Emergency and Critical Care Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences 2-5-1 Shikata-cho, Kita-ku Okayama-shi Okayama 700-8558 Japan
| | - Taihei Yamada
- Department of Emergency and Critical Care Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences 2-5-1 Shikata-cho, Kita-ku Okayama-shi Okayama 700-8558 Japan
| | - Kohei Tsukahara
- Department of Emergency and Critical Care Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences 2-5-1 Shikata-cho, Kita-ku Okayama-shi Okayama 700-8558 Japan
| | - Kanae Inoue
- Department of Emergency and Critical Care Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences 2-5-1 Shikata-cho, Kita-ku Okayama-shi Okayama 700-8558 Japan
| | - Tetsuya Yumoto
- Department of Emergency and Critical Care Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences 2-5-1 Shikata-cho, Kita-ku Okayama-shi Okayama 700-8558 Japan
| | - Hiromichi Naito
- Department of Emergency and Critical Care Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences 2-5-1 Shikata-cho, Kita-ku Okayama-shi Okayama 700-8558 Japan
| | - Atsunori Nakao
- Department of Emergency and Critical Care Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences 2-5-1 Shikata-cho, Kita-ku Okayama-shi Okayama 700-8558 Japan
| |
Collapse
|
13
|
Mitani S, Kadowaki S, Komori A, Sugiyama K, Narita Y, Taniguchi H, Ura T, Ando M, Sato Y, Yamaura H, Inaba Y, Ishihara M, Tanaka T, Tajika M, Muro K. Acute hyperammonemic encephalopathy after fluoropyrimidine-based chemotherapy: A case series and review of the literature. Medicine (Baltimore) 2017; 96:e6874. [PMID: 28562536 PMCID: PMC5459701 DOI: 10.1097/md.0000000000006874] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Acute hyperammonemic encephalopathy induced by fluoropyrimidines (FPs) is a rare complication. Its pathophysiology remains unclear, especially given the currently used regimens, including intermediate-doses of 5-fluorouracil (5-FU) or oral FP agents. We aimed to characterize the clinical manifestations in cancer patients who developed hyperammonemic encephalopathy after receiving FP-based chemotherapy.We retrospectively reviewed 1786 patients with gastrointestinal or primary-unknown cancer who received FP-based regimens between 2007 and 2012. Eleven patients (0.6%) developed acute hyperammonemic encephalopathy. The incidence according to the administered anticancer drugs were as follows: 5-FU (8 of 1176, 0.7%), S-1 (1 of 679, 0.1%), capecitabine (2 of 225, 0.9%), and tegafur-uracil (UFT) (0 of 39, 0%). Ten patients (90.9%) had at least 1 aggravating factor, including infection, dehydration, constipation, renal dysfunction, and muscle loss. All the 10 patients met the definition of sarcopenia. Median time to the onset of hyperammonemic encephalopathy in the cycle was 3 days (range: 2-21). Three patients (27.3%) developed encephalopathy during the first cycle of the regimen and the remaining 8 patients during the second or more cycles. Seven patients (63.6%) had received at least 1 other FP-containing regimen before without episodes of encephalopathy.All patients recovered soon after immediate discontinuation of chemotherapy and supportive therapies, such as hydration, infusion of branched-chain amino acids, and oral lactulose intake, with a median time to recovery of 2 days (range: <1-7). Four patients (36.4%) received FP-based regimens after improvement of symptoms; 3 patients were successfully managed with dose reduction, and 1 patient, who had developed encephalopathy due to S-1 monotherapy, received modified FOLFOX-6 therapy without encephalopathy later.FP-associated acute hyperammonemic encephalopathy is extremely rare, but a possible event at any time and even during the administration of oral FP agents. Particular attention is warranted when giving FP-based therapy for patients with aggravating factors, such as sarcopenia. This complication can be properly managed with early detection.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Yozo Sato
- Department of Diagnostic and Interventional Radiology
| | | | | | - Makoto Ishihara
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tsutomu Tanaka
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Masahiro Tajika
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | | |
Collapse
|
14
|
Accumulation of alpha-fluoro-beta-alanine and fluoro mono acetate in a patient with 5-fluorouracil-associated hyperammonemia. Cancer Chemother Pharmacol 2017; 79:629-633. [PMID: 28204913 DOI: 10.1007/s00280-017-3249-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 01/27/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE High-dose 5-fluorouracil (5-FU) containing chemotherapy occasionally causes hyperammonemia and can be lethal. However, the mechanism of 5FU-associated hyperammonemia has not been known. The aim of this study was to reveal the pharmacokinetics of 5-FU-associated hyperammonemia in a recurrent colorectal cancer patient with end-stage renal disease (ESRD). METHODS We experienced a case of hyperammonemia during mFOLFOX6 plus bevacizumab therapy for recurrent colorectal cancer. He was a dialyzed patient due to diabetic nephropathy and was registered to prospective blood sampling for pharmacokinetics analysis during chemotherapy. Blood concentrations of 5-FU and its catabolites were determined by inductively coupled plasma-mass spectrometry. RESULTS The patient developed hyperammonemia encephalopathy 41 h after the initiation of continuous 5-FU infusion (on the third day). Before onset of hyperammonemia encephalopathy, serum alpha-fluoro-beta-alanine (FBAL, 59.2 µg/ml) and fluoro mono acetate (FMA, 905.8 ng/ml) were gradually increased. After hemodialysis for hyperammonemia, FBAL and FMA were collaterally decreased and his symptom was improved. Other intermediate catabolites of 5-FU, dihydrofluorouracil, and alpha-fluoro-beta-ureidopropionic acid were not changed. CONCLUSION We found increases of serum FBAL and FMA under the condition of hyperammonemia in the patient with ESRD during mFOLFOX6 plus bevacizumab therapy. This research supported the hypothesis that impairment of tricarboxylic acid (TCA) cycle by FMA would cause 5-FU-associated hyperammonemia.
Collapse
|
15
|
Lischke J, Lang C, Sawodny O, Feuer R. Impairment of energy metabolism in cardiomyocytes caused by 5-FU catabolites can be compensated by administration of amino acids. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2015:5363-6. [PMID: 26737503 DOI: 10.1109/embc.2015.7319603] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Identification of patients with increased risk of 5-fluorouracil (5-FU)-related toxicity is an important challenge for cancer treatment. Research often focus on dihydropyrimidine dehydrogenase (DPYD) deficiency in this context. However, patients with normal DPYD activity may also develop life-threatening 5-FU adverse effects. DPYD initiates the catabolic route of 5-FU generating metabolites such as fluoroacetate (FAC). The catabolite FAC is known to inhibit the TCA cycle enzyme aconitase, which is supposed to impair mitochondrial energy metabolism. Therefore, we aim for a systems understanding of the association of 5-FU-related cardiac side effects with aconitase inhibition caused by FAC. Using a mitochondrial model of cardiomyocytes we found strong depletion of ATP production and citrate accumulation as main effects of aconitase inhibition. Shadow price analysis revealed that the uptakes of valine, arginine, proline and glutamate are most effective in compensating the impairment of energy metabolism. Our findings suggest that 5-FU catabolism contributes to the occurrence of cardiac adverse effects and are the basis for further biomarker identifications and development of side effect treatment.
Collapse
|
16
|
Yi HJ, Hong KS, Moon N, Chung SS, Lee RA, Kim KH. Acute hyperammonemic encephalopathy after 5-fluorouracil based chemotherapy. Ann Surg Treat Res 2016; 90:179-82. [PMID: 26942162 PMCID: PMC4773463 DOI: 10.4174/astr.2016.90.3.179] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/23/2015] [Accepted: 12/04/2015] [Indexed: 11/30/2022] Open
Abstract
5-Fluorouracil (5-FU) based chemotherapy has been commonly used to treat metastatic or advanced colon cancer as an adjuvant chemotherapy. Although the side effects of 5-FU such as gastrointestinal problems and neutropenia and thrombocytopenia are common, not many cases of 5-FU related encephalopathy are reported. Hyperammonemic encephalopathy is a rare central nervous system toxicity following 5-FU chemotherapy manifesting as altered mental status with elevated ammonia levels with no radiologic abnormality. We report one case of 5-FU induced hyperammonemic encephalopathy occurring after Folfox4 (oxaliplatin, folinic acid and 5-fluorouracil) chemotherapy in a colon cancer patient who presented with confused mental status soon after the chemotherapy and review the 5-FU related encephalopathy.
Collapse
Affiliation(s)
- Hee Jung Yi
- Department of Surgery, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kyung Sook Hong
- Department of Surgery, Ewha Womans University School of Medicine, Seoul, Korea
| | - Nara Moon
- Department of Surgery, Ewha Womans University School of Medicine, Seoul, Korea
| | - Soon Sup Chung
- Department of Surgery, Ewha Womans University School of Medicine, Seoul, Korea
| | - Ryung-Ah Lee
- Department of Surgery, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kwang Ho Kim
- Department of Surgery, Ewha Womans University School of Medicine, Seoul, Korea
| |
Collapse
|
17
|
Lazier J, Lupichuk SM, Sosova I, Khan AA. Hyperammonemic encephalopathy in an adenocarcinoma patient managed with carglumic acid. ACTA ACUST UNITED AC 2014; 21:e736-9. [PMID: 25302046 DOI: 10.3747/co.21.2076] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Hyperammonemic encephalopathy (he) is a rare complication of malignancy and chemotherapy. Although the cause of he is unclear, a functional arginine deficiency secondary to increased catabolism has been suggested as a possible mechanism. Either that deficiency or an undetermined metabolite could lead to inhibition of N-acetylglutamate synthase (nags), a urea cycle enzyme, resulting in hyperammonemia. We present a case of chemotherapy-induced he in a patient with no underlying primary urea cycle disorder. The patient had a successful trial of carglumic acid (a synthetic analog of the product of nags), which suggests that, at least in some cases, he can be treated by overcoming proximal inhibition of the urea cycle. Further, our case is the first in the literature to exclude genetic defects and disorders of the proximal urea cycle, suggesting that hyperammonemia in these patients is probably secondary to chemotherapy.
Collapse
Affiliation(s)
- J Lazier
- Department of Medical Genetics, Alberta Children's Hospital, University of Calgary, Calgary, AB
| | - S M Lupichuk
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB
| | - I Sosova
- Biochemical Genetics Laboratory, Alberta Children's Hospital, University of Calgary, Calgary, AB
| | - A A Khan
- Department of Medical Genetics, Alberta Children's Hospital, University of Calgary, Calgary, AB. ; Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, AB
| |
Collapse
|