Pemetrexed as a possible cause of severe rhabdomyolysis in the treatment of lung cancer

Correlation of toxicities and efficacies of pemetrexed with clinical factors and single-nucleotide polymorphisms: a prospective observational study

BACKGROUND

Pemetrexed is an efficacious multi-targeted antifolate with acceptable toxicity for non-squamous non-small cell lung cancer (non-Sq NSCLC) and malignant pleural mesothelioma. Vitamin B12 and folic acid as premedication can reduce the frequency of severe toxicities of pemetrexed chemotherapy. However, adverse effects are frequent in clinical settings. In this study, we aimed to identify the clinical factors and single-nucleotide polymorphisms (SNPs) associated with the toxicity and efficacy of pemetrexed chemotherapy.

METHODS

This observational study was conducted from October 2012 to December 2019; we evaluated the toxicities and efficacies of pemetrexed chemotherapy using multivariate logistic or Cox regression analysis. In total, 106 patients received pemetrexed chemotherapy. SNPs were analyzed for four patients with malignant pleural mesothelioma and 67 with non-Sq NSCLC.

RESULTS

The median progression-free survival (PFS) and overall survival of 63 patients with non-Sq NSCLC, excluding four in the adjuvant setting, were 6.8 and 33.3 months, respectively. Per propensity-score-adjusted multivariate Cox analyses, favorable factors for PFS were folic acid level ≥ 9.3 ng/mL before premedication, platinum combination, bevacizumab combination, vitamin B12 level < 1136 pg/mL before chemotherapy, A/A + A/G of BHMT (742 G > A), and A/A + A/C of DHFR (680 C > A). Favorable prognostic factors included good performance status, low smoking index, body mass index ≥ 20.66 kg/m2, folic acid level ≥ 5.55 ng/mL before premedication, higher retinol-binding protein before chemotherapy, and A/G of MTRR (66 A > G). Among the 71 patients who were analyzed for SNPs, the frequencies of hematologic toxicities and non-hematologic toxicities in Grades 3-4 were 38% and 36.6%, respectively. Per propensity-score-adjusted multivariate logistic analyses, risk factors for Grades 3-4 hematologic toxicities were vitamin B12 level < 486 pg/mL before premedication, leucocyte count < 6120 /µL before chemotherapy, folic acid level < 15.8 ng/mL before chemotherapy, status with a reduced dose of chemotherapy, and C/T + T/T of MTHFR (677 C > T). Risk factors for Grades 2-4 non-hematologic toxicities were homocysteine levels ≥ 11.8 nmol/mL before premedication, transthyretin level < 21.5 mg/dL before chemotherapy, C/C + T/T of MTHFR (677 C > T), and A/A + G/G of SLC19A1 [IVS2 (4935) G > A].

CONCLUSION

The information on metabolites and SNPs of the folate and methionine cycle will help predict the toxicities and efficacies of pemetrexed.

TRIAL REGISTRATION

This trial was retrospectively registered with the University hospital Medical Information Network (UMIN000009366) on November 20, 2012.

Lower starting dose of afatinib for the treatment of metastatic lung adenocarcinoma harboring exon 21 and exon 19 mutations

Background

Afatinib has shown favorable response rates (RRs) and longer progression free survival (PFS) in lung cancer patients harboring EGFR mutations compared with standard platinum-based chemotherapy. However, serious adverse drug reactions (ADRs) limit the clinical application of afatinib.

Methods

We designed a retrospective study, enrolling all patients with metastatic lung adenocarcinoma who were diagnosed and treated with 30 or 40 mg daily afatinib as their initial treatment in three Kaohsiung Medical University-affiliated hospitals in Taiwan.

Results

A total of 179 patients were enrolled in the study, of which 102 (57%) and 77 (43%) received 30 mg and 40 mg afatinib daily as their initial treatment, respectively. The patients initially using 30 mg afatinib daily had a similar RR (75% vs. 83%, p = 0.1672), median PFS (14.5 vs. 14.8 months, log-rank p = 0.4649), and median OS (34.0 vs. 25.2 months, log-rank p = 0.5982) compared with those initially using 40 mg afatinib daily. Patients initially receiving 30 mg afatinib daily had fewer ADRs compared with those using 40 mg daily. The overall incidence of moderate and severe ADRs was significantly lower in patients receiving 30 mg afatinib daily compared with those using 40 mg daily (49% vs. 77%, p = 0.002); similar findings was observed in terms of severe ADRs (7% vs. 24%, p < 0.0001).

Conclusion

Patients receiving 30 mg afatinib daily as their initial treatment had similar RR, PFS, OS, but significantly fewer serious ADRs, as compared with those using 40 mg as their starting dose.

Rehabilitation for Rhabdomyolysis Associated With Breast Cancer Treatment

Rhabdomyolysis can result in pain, physical limitations and may require hospitalization for medical management; however, little evidence has been reported on the efficacy of physical therapy (PT) interventions for this condition. Additionally, a review of literature on occurrences of rhabdomyolysis associated with cancer treatments yielded limited results. The purpose of this case report was to describe the acute and inpatient rehabilitation (IPR) examination, interventions, and outcomes for a patient with breast cancer and rhabdomyolysis. The patient was a 57-year-old female with a history of recurrent breast cancer who presented to the hospital with a chief complaint of bilateral thigh pain and weakness after the second cycle of chemotherapy and was diagnosed with rhabdomyolysis. After initially declining PT treatment during her first hospitalization, the patient was readmitted after a fall at home. She was hospitalized for 14 days with a transfer to IPR. The patient received a total of 12 days of PT (two acute care visits and 10 IPR visits) that included patient education, neuromuscular re-education, therapeutic exercise, and gait training. The patient was discharged home at a modified independent level with improvements in pain from 8/10 to 0/10 on the Numeric Pain Rating Scale. Functionally, she improved from ambulating 20 feet (6.1 m) to 600 feet (183 m); her Timed Up and Go score improved from 62 seconds to 10 seconds. Finally, her Berg Balance Scale improved from 31/56 to 55/56. Data from this case study suggest that PT management appears to improve functional outcomes for individuals diagnosed with rhabdomyolysis while undergoing chemotherapy, however, a holistic approach was necessary for progress to educate her on the importance of participation in PT with this condition. Further research is required to explore factors that influence rhabdomyolysis in the presence of chemotherapy as well as the recommended rehabilitation program for rhabdomyolysis.

Pemetrexed-induced severe rhabdomyolysis in lung cancer: A case report

Pemetrexed is an antifolate metabolite used to treat non-small cell lung cancer in the adjuvant and advanced setting. It is commonly known to cause rash, diarrhea, fatigue, mucositis, and myelosuppression. We report a case of a patient receiving adjuvant cisplatin and pemetrexed for non-small cell lung adenocarcinoma and experienced severe rhabdomyolysis.

Muscle spasms: an unexpected adverse drug reaction of pemetrexed?

In this report we describe a 53-year-old woman with advanced non-small cell lung cancer, treated with pemetrexed and cisplatin combination therapy, followed by pemetrexed monotherapy. The patient developed severe muscle spasms at least twice, shortly after administration of pemetrexed monotherapy. A possible explanation for this observation is that in combination with cisplatin therapy, the patient was hyperhydrated before administration to promote renal excretion and reduce toxicity. Pemetrexed is also renally excreted, which supports the finding that toxicity did not occur when the patient was hyperhydrated. After discontinuation of pemetrexed the symptoms did not reoccur. All aspects of this case point to a possible relationship between pemetrexed and an adverse drug reaction (ADR). We conclude that muscle spasms are a rare, but possibly dose-related ADR of pemetrexed-based therapy.