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Tamraz B, Venook AP. DPYD Pharmacogenetics: To Opt-in or to Opt-out. JCO Oncol Pract 2024:OP2400255. [PMID: 38743915 DOI: 10.1200/op.24.00255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 03/29/2024] [Accepted: 04/05/2024] [Indexed: 05/16/2024] Open
Affiliation(s)
- Bani Tamraz
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA
| | - Alan P Venook
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
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2
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De Metz C, Hennart B, Aymes E, Cren P, Martignène N, Penel N, Barthoulot M, Carnot A. Complete DPYD genotyping combined with dihydropyrimidine dehydrogenase phenotyping to prevent fluoropyrimidine toxicity: A retrospective study. Cancer Med 2024; 13:e7066. [PMID: 38523525 PMCID: PMC10961597 DOI: 10.1002/cam4.7066] [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: 05/19/2023] [Revised: 01/19/2024] [Accepted: 02/18/2024] [Indexed: 03/26/2024] Open
Abstract
INTRODUCTION In April 2019, French authorities mandated dihydropyrimidine dehydrogenase (DPD) screening, specifically testing uracilemia, to mitigate the risk of toxicity associated with fluoropyrimidine-based chemotherapy. However, this subject is still of debate as there is no consensus on a standardized DPD deficiency screening test. We conducted a real-life retrospective study with the aim of assessing the impact of DPD screening on the occurrence of severe toxicity and exploring the potential benefits of complete genotyping using next-generation sequencing. METHODS All adult patients consecutively treated with 5-fluorouracil (5-FU) or its oral prodrug at six cancer centers between March 2018 and February 2019 were considered for inclusion. Dihydropyrimidine dehydrogenase deficiency screening included gene encoding DPD (DPYD) genotyping using complete genome sequencing and DPD phenotyping (uracilemia or dihydrouracilemia/uracilemia ratio) or both tests. Associations between each DPD screening method and (i) severe (grade ≥3) early toxicity and (ii) fluoropyrimidine dose reduction in the second chemotherapy cycle were evaluated using multivariable logistic regression analysis. Furthermore, we assessed the concordance between DPD genotype and phenotype using Cohen's kappa. RESULTS A total of 551 patients were included. Most patients were tested for DPD deficiency (86%) including DPYD genotyping only (6%), DPD phenotyping only (8%), or both (72%). Complete DPD deficiency was not detected in the study population. Severe early toxicity events were observed in 73 patients (13%), with two patients (0.30%) presenting grade 5 toxicity. Despite the numerically higher toxicity rate in untested patients, the occurrence of severe toxicity was not significantly associated with the DPD screening method (p = 0.69). Concordance between the DPD genotype and phenotype was weak (Cohen's kappa of 0.14). CONCLUSION Due to insufficient numbers, our study was not able to demonstrate any added value of DPYD genotyping using complete genome sequencing to prevent 5-FU toxicity. The optimal strategy for DPD screening before fluoropyrimidine-based chemotherapy requires further clinical evaluation.
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Affiliation(s)
- Côme De Metz
- Department of Medical OncologyCentre Oscar LambretLilleFrance
| | - Benjamin Hennart
- Toxicology Unit, Biology and Pathology CentreLille University Medical CentreLilleFrance
| | - Estelle Aymes
- Department of BiostatisticsCentre Oscar LambretLilleFrance
| | - Pierre‐Yves Cren
- Department of Medical OncologyCentre Oscar LambretLilleFrance
- Department of BiostatisticsCentre Oscar LambretLilleFrance
| | | | - Nicolas Penel
- Department of Medical OncologyCentre Oscar LambretLilleFrance
- Univ. Lille, CHU Lille, ULR 2694 ‐ Metrics: Evaluation des technologies de santé et des pratiques médicalesLilleFrance
| | | | - Aurélien Carnot
- Department of Medical OncologyCentre Oscar LambretLilleFrance
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Knikman JE, Lopez-Yurda M, Meulendijks D, Deenen MJ, Schellens JHM, Beijnen J, Cats A, Guchelaar HJ. A Nomogram to Predict Severe Toxicity in DPYD Wild-Type Patients Treated With Capecitabine-Based Anticancer Regimens. Clin Pharmacol Ther 2024; 115:269-277. [PMID: 37957132 DOI: 10.1002/cpt.3100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023]
Abstract
DPYD-guided dosing has improved the safety of fluoropyrimidine-based chemotherapy in recent years. However, severe toxicity remains in ~ 23% of patients not carrying DPYD variant alleles treated with capecitabine. Therefore, we developed a predictive model based on patient-related and treatment-related factors aimed at estimating the risk of developing severe capecitabine-related toxicity. The nomogram was developed using data from two large clinical trials (NCT00838370 and NCT02324452). Patients with cancer carrying a DPYD variant allele (DPYD*2A, c.1236G>A, c.2846A>T, and c.1679T>G) were excluded. Univariable and multivariable logistic regression using predetermined predictors based on previous findings, including age, sex, body surface area, type of treatment regimen, and creatinine levels were used to develop the nomogram. The developed model was internally validated using bootstrap resampling and cross-validation. This model was not externally or clinically validated. A total of 2,147 DPYD wild-type patients with cancer treated with capecitabine-based chemotherapy regimens were included of which complete data of 1,745 patients were available and used for the development of the nomogram. Univariable and multivariable logistic regression showed that age, sex, and type of treatment regimen were strong predictors of severe capecitabine-related toxicity in DPYD wild-type patients. Internal validation demonstrated a concordance index of 0.68 which indicates a good discriminative ability for prediction of severe capecitabine-related toxicity. The developed nomogram includes readily available parameters and may be a helpful tool for clinicians to assess the risk of developing severe capecitabine-related toxicity in patients without known risk DPYD variant alleles treated with capecitabine-based anticancer regimens.
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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
| | - Marta Lopez-Yurda
- Biometrics Department, The Netherlands Cancer Institute, Amsterdam, 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
| | - Maarten J Deenen
- Department of Clinical Pharmacy, Catharina Hospital, Eindhoven, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jan H M Schellens
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Jos 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
| | - 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 Centre, Leiden, The Netherlands
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4
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Larrue R, Fellah S, Hennart B, Sabaouni N, Boukrout N, Van der Hauwaert C, Delage C, Cheok M, Perrais M, Cauffiez C, Allorge D, Pottier N. Integrating rare genetic variants into DPYD pharmacogenetic testing may help preventing fluoropyrimidine-induced toxicity. THE PHARMACOGENOMICS JOURNAL 2024; 24:1. [PMID: 38216550 PMCID: PMC10786722 DOI: 10.1038/s41397-023-00322-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/23/2023] [Accepted: 12/05/2023] [Indexed: 01/14/2024]
Abstract
Variability in genes involved in drug pharmacokinetics or drug response can be responsible for suboptimal treatment efficacy or predispose to adverse drug reactions. In addition to common genetic variations, large-scale sequencing studies have uncovered multiple rare genetic variants predicted to cause functional alterations in genes encoding proteins implicated in drug metabolism, transport and response. To understand the functional importance of rare genetic variants in DPYD, a pharmacogene whose alterations can cause severe toxicity in patients exposed to fluoropyrimidine-based regimens, massively parallel sequencing of the exonic regions and flanking splice junctions of the DPYD gene was performed in a series of nearly 3000 patients categorized according to pre-emptive DPD enzyme activity using the dihydrouracil/uracil ([UH2]/[U]) plasma ratio as a surrogate marker of DPD activity. Our results underscore the importance of integrating next-generation sequencing-based pharmacogenomic interpretation into clinical decision making to minimize fluoropyrimidine-based chemotherapy toxicity without altering treatment efficacy.
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Affiliation(s)
- Romain Larrue
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France.
- Service de Toxicologie et Génopathies, CHU Lille, F-59000, Lille, France.
| | - Sandy Fellah
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Benjamin Hennart
- Service de Toxicologie et Génopathies, CHU Lille, F-59000, Lille, France
| | - Naoual Sabaouni
- Service de Toxicologie et Génopathies, CHU Lille, F-59000, Lille, France
| | - Nihad Boukrout
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Cynthia Van der Hauwaert
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Clément Delage
- Service de Toxicologie et Génopathies, CHU Lille, F-59000, Lille, France
| | - Meyling Cheok
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Michaël Perrais
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Christelle Cauffiez
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Delphine Allorge
- Service de Toxicologie et Génopathies, CHU Lille, F-59000, Lille, France
| | - Nicolas Pottier
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
- Service de Toxicologie et Génopathies, CHU Lille, F-59000, Lille, France
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Yang L, Yang J, Kleppe A, Danielsen HE, Kerr DJ. Personalizing adjuvant therapy for patients with colorectal cancer. Nat Rev Clin Oncol 2024; 21:67-79. [PMID: 38001356 DOI: 10.1038/s41571-023-00834-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 11/26/2023]
Abstract
The current standard-of-care adjuvant treatment for patients with colorectal cancer (CRC) comprises a fluoropyrimidine (5-fluorouracil or capecitabine) as a single agent or in combination with oxaliplatin, for either 3 or 6 months. Selection of therapy depends on conventional histopathological staging procedures, which constitute a blunt tool for patient stratification. Given the relatively marginal survival benefits that patients can derive from adjuvant treatment, improving the safety of chemotherapy regimens and identifying patients most likely to benefit from them is an area of unmet need. Patient stratification should enable distinguishing those at low risk of recurrence and a high chance of cure by surgery from those at higher risk of recurrence who would derive greater absolute benefits from chemotherapy. To this end, genetic analyses have led to the discovery of germline determinants of toxicity from fluoropyrimidines, the identification of patients at high risk of life-threatening toxicity, and enabling dose modulation to improve safety. Thus far, results from analyses of resected tissue to identify mutational or transcriptomic signatures with value as prognostic biomarkers have been rather disappointing. In the past few years, the application of artificial intelligence-driven models to digital images of resected tissue has identified potentially useful algorithms that stratify patients into distinct prognostic groups. Similarly, liquid biopsy approaches involving measurements of circulating tumour DNA after surgery are additionally useful tools to identify patients at high and low risk of tumour recurrence. In this Perspective, we provide an overview of the current landscape of adjuvant therapy for patients with CRC and discuss how new technologies will enable better personalization of therapy in this setting.
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Affiliation(s)
- Li Yang
- Department of Gastroenterology, Sichuan University, Chengdu, China
| | - Jinlin Yang
- Department of Gastroenterology, Sichuan University, Chengdu, China
| | - Andreas Kleppe
- Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
- Centre for Research-based Innovation Visual Intelligence, UiT The Arctic University of Norway, Tromsø, Norway
| | - Håvard E Danielsen
- Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
- Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - David J Kerr
- Radcliffe Department of Medicine, Oxford University, Oxford, UK.
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Fragoulakis V, Roncato R, Bignucolo A, Patrinos GP, Toffoli G, Cecchin E, Mitropoulou C. Cost-utility analysis and cross-country comparison of pharmacogenomics-guided treatment in colorectal cancer patients participating in the U-PGx PREPARE study. Pharmacol Res 2023; 197:106949. [PMID: 37802427 DOI: 10.1016/j.phrs.2023.106949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/10/2023] [Accepted: 10/03/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVES A cost-utility analysis was conducted to evaluate pharmacogenomic (PGx)-guided treatment compared to the standard-of-care intervention among patients diagnosed with colorectal cancer (CRC) in Italy. METHODS Data derived from a prospective, open-label, block randomized clinical trial, as a part of the largest PGx study worldwide (355 patients in both arms) were used. Mortality was used as the primary health outcome to estimate life years (LYs) gained in treatment arms within a survival analysis context. PGx-guided treatment was based on established drug-gene interactions between capecitabine, 5-fluorouracil and irinotecan with DPYD and/or UGT1A1 genomic variants. Utility values for the calculation of Quality Adjusted Life Year (QALY) was based on Visual Analog Scale (VAS) score. Missing data were imputed via the Multiple Imputation method and linear interpolation, when possible, while censored cost data were corrected via the Replace-From-The-Right algorithm. The Incremental Cost-Effectiveness Ratio (ICER) was calculated for QALYs. Raw data were bootstrapped 5000 times in order to produce 95% Confidence Intervals based on non-parametric percentile method and to construct a cost-effectiveness acceptability curve. Cost differences for study groups were investigated via a generalized linear regression model analysis. Total therapy cost per patient reflected all resources expended in the management of any adverse events, including medications, diagnostics tests, devices, surgeries, the utilization of intensive care units, and wards. RESULTS The total cost of the study arm was estimated at €380 (∼ US$416; 95%CI: 195-596) compared to €565 (∼ US$655; 95%CI: 340-724) of control arm while the mean survival in study arm was estimated at 1.58 (+0.25) LYs vs 1.50 (+0.26) (Log Rank test, X2 = 4.219, df=1, p-value=0.04). No statistically significant difference was found in QALYs. ICER was estimated at €13418 (∼ US$14695) per QALY, while the acceptability curve indicated that when the willingness-to-pay was under €5000 (∼ US$5476), the probability of PGx being cost-effective overcame 70%. The most frequent adverse drug event in both groups was neutropenia of severity grade 3 and 4, accounting for 82.6% of total events in the study arm and 65.0% in the control arm. Apart from study arm, smoking status, Body-Mass-Index and Cumulative Actionability were also significant predictors of total cost. Subgroup analysis conducted in actionable patients (7.9% of total patients) indicated that PGx-guided treatment was a dominant option over its comparator with a probability greater than 92%. In addition, a critical literature review was conducted, and these findings are in line with those reported in other European countries. CONCLUSION PGx-guided treatment strategy may represent a cost-saving option compared to the existing conventional therapeutic approach for colorectal cancer patient management in the National Health Service of Italy.
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Affiliation(s)
| | | | | | - George P Patrinos
- Laboratory of Pharmacogenomics and Individualized Therapy, Department of Pharmacy, University of Patras School of Health Sciences, Patras, Greece; Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, Abu Dhabi, United Arab Emirates; Zayed Center for Health Sciences, United Arab Emirates University, Al‑Ain, Abu Dhabi, United Arab Emirates
| | | | - Erika Cecchin
- Centro di Riferimento Oncologico (CRO), Aviano, Italy
| | - Christina Mitropoulou
- The Golden Helix Foundation, London, UK; Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, Abu Dhabi, United Arab Emirates.
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7
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Ruiz Sarrias O, Gónzalez Deza C, Rodríguez Rodríguez J, Arrizibita Iriarte O, Vizcay Atienza A, Zumárraga Lizundia T, Sayar Beristain O, Aldaz Pastor A. Predicting Severe Haematological Toxicity in Gastrointestinal Cancer Patients Undergoing 5-FU-Based Chemotherapy: A Bayesian Network Approach. Cancers (Basel) 2023; 15:4206. [PMID: 37686482 PMCID: PMC10486471 DOI: 10.3390/cancers15174206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/28/2023] [Accepted: 08/16/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE Severe toxicity is reported in about 30% of gastrointestinal cancer patients receiving 5-Fluorouracil (5-FU)-based chemotherapy. To date, limited tools exist to identify at risk patients in this setting. The objective of this study was to address this need by designing a predictive model using a Bayesian network, a probabilistic graphical model offering robust, explainable predictions. METHODS We utilized a dataset of 267 gastrointestinal cancer patients, conducting preprocessing, and splitting it into TRAIN and TEST sets (80%:20% ratio). The RandomForest algorithm assessed variable importance based on MeanDecreaseGini coefficient. The bnlearn R library helped design a Bayesian network model using a 10-fold cross-validation on the TRAIN set and the aic-cg method for network structure optimization. The model's performance was gauged based on accuracy, sensitivity, and specificity, using cross-validation on the TRAIN set and independent validation on the TEST set. RESULTS The model demonstrated satisfactory performance with an average accuracy of 0.85 (±0.05) and 0.80 on TRAIN and TEST datasets, respectively. The sensitivity and specificity were 0.82 (±0.14) and 0.87 (±0.07) for the TRAIN dataset, and 0.71 and 0.83 for the TEST dataset, respectively. A user-friendly tool was developed for clinical implementation. CONCLUSIONS Despite several limitations, our Bayesian network model demonstrated a high level of accuracy in predicting the risk of developing severe haematological toxicity in gastrointestinal cancer patients receiving 5-FU-based chemotherapy. Future research should aim at model validation in larger cohorts of patients and different clinical settings.
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Affiliation(s)
- Oskitz Ruiz Sarrias
- Department of Mathematics and Statistic, NNBi, 31191 Esquiroz, Navarra, Spain; (O.R.S.)
| | - Cristina Gónzalez Deza
- Department of Medical Oncology, Clínica Universidad De Navarra, 31008 Pamplona, Navarra, Spain; (C.G.D.); (J.R.R.); (T.Z.L.)
| | - Javier Rodríguez Rodríguez
- Department of Medical Oncology, Clínica Universidad De Navarra, 31008 Pamplona, Navarra, Spain; (C.G.D.); (J.R.R.); (T.Z.L.)
| | | | - Angel Vizcay Atienza
- Department of Medical Oncology, Clínica Universidad De Navarra, 31008 Pamplona, Navarra, Spain; (C.G.D.); (J.R.R.); (T.Z.L.)
| | - Teresa Zumárraga Lizundia
- Department of Medical Oncology, Clínica Universidad De Navarra, 31008 Pamplona, Navarra, Spain; (C.G.D.); (J.R.R.); (T.Z.L.)
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Schmitt A, Royer B, Boidot R, Berthier J, Ghiringhelli F. Case report: 5-Fluorouracil treatment in patient with an important partial DPD deficiency. Front Oncol 2023; 13:1187052. [PMID: 37409256 PMCID: PMC10319454 DOI: 10.3389/fonc.2023.1187052] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/30/2023] [Indexed: 07/07/2023] Open
Abstract
Esophageal cancer is a cancer with poor prognosis and the standard 1st line treatment for metastatic or recurrent EC is systemic chemotherapy with doublet chemotherapy based on platinum and 5-fluorouracil (5-FU). However, 5-FU could be a source of severe treatment-related toxicities due to deficiency of dihydropyrimidine dehydrogenase (DPD). In this case report, a 74-year-old man with metastatic esophageal cancer was found to have partial DPD deficiency based on uracilemia measurements (about 90 ng/mL). Despite this, 5-FU was safely administered thanks to therapeutic drug monitoring (TDM). The case report highlights the importance of TDM in administering 5-FU to patients with partial DPD deficiency, as it allows individualized dosing and prevents severe toxicity.
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Affiliation(s)
- Antonin Schmitt
- Pharmacy Department, Centre Georges-François Leclerc, Dijon, France
- Institut National de la Santé et de la Recherche Médicale (INSERM) U1231, University of Burgundy Franche-Comté, Dijon, France
| | - Bernard Royer
- Pharmacology and Toxicology Laboratory, Besançon University Hospital, Dijon, France
| | - Romain Boidot
- Unit of Molecular Biology, Centre Georges-François Leclerc, Institut de Chimie Moléculaire de l'Université de Bourgogne (ICMUB) Unité Mixte de Recherche (UMR) Centre National de la Recherche Scientifique (CNRS) 6302, Dijon, France
| | - Joseph Berthier
- Pharmacology and Toxicology Laboratory, Dijon University Hospital, Dijon, France
| | - François Ghiringhelli
- Institut National de la Santé et de la Recherche Médicale (INSERM) U1231, University of Burgundy Franche-Comté, Dijon, France
- Medical Oncology Department, Centre Georges-François Leclerc, Dijon, France
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9
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Basso J, Schwartsmann G, Ibaldi MR, Schaefer VD, Pavei CC, Hahn RZ, Antunes MV, Linden R. Evaluation of UGT1A1 and CYP3A Genotyping and Single-Point Irinotecan and Metabolite Concentrations as Predictors of the Occurrence of Adverse Events in Cancer Treatment. J Gastrointest Cancer 2023; 54:589-599. [PMID: 35710870 DOI: 10.1007/s12029-022-00840-0] [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] [Accepted: 06/05/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The variability on irinotecan (IRI) pharmacokinetics and toxicity has been attributed mostly to genetic variations in the UGT1A1 gene, responsible for conjugation of the active metabolite SN-38. Also, CYP3A mediates the formation of inactive oxidative metabolites of IRI. The association between the occurrence of severe adverse events, pharmacokinetics parameters, and UGT1A1 and CYP3A4 predicted phenotypes was evaluated, as the evaluation of [SN-38]/IRI dose ratio as predictor of severe adverse events. METHODS Forty-one patients undergoing IRI therapy were enrolled in the study. Blood samples were collected 15 min after the end of drug the infusion, for IRI, SN-38, SN-38G, bilirubin concentrations measurements, and UGT1A1 and CYP3A genotype estimation. Data on adverse event was reported. RESULTS Fifteen patients (36.5%) developed grade 3/4 adverse events. A total of 9.8% (n = 4) of the patients had UGT1A1 reduced activity phenotype, and 48.7% (n = 20) had UGT1A1 and 63.4% (n = 26) CYP3A intermediary phenotypes. Severe neutropenia and diarrhea were more prevalent in patients with reduced UGT1A1 in comparison with functional metabolism (50% and 75% versus 0% and 13%, respectively). SN-38 levels and its concentrations adjusted by IRI dose were significantly correlated to toxicity (rs = 0.31 (p = 0.05) and rs = 0.425 (p < 0.01)). The [SN-38]/IRI dose ratio had a ROC curve of 0.823 (95% CI 0.69-0.956) to detect any severe adverse event and 0.833 (95% CI 0.694-0.973) to detect severe diarrhea. The cut-off of 0.075 ng mL-1 mg-1 had 100% sensitivity and 65.7% specificity to predict severe diarrhea. CONCLUSION Our data confirmed the relevance of the pre-emptive genotypic information of UGT1A1. The [SN-38]/IRI ratio, measured 15 min after the end of the IRI infusion, was a strong predictor of severe toxicity and could be applied to minimize the burden of patients after IRI administration.
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Affiliation(s)
- Jeziel Basso
- Universidade Federal Do Rio Grande Do Sul, UFRGS, Postgraduate program, Porto Alegre, Brazil
| | - Gilberto Schwartsmann
- Universidade Federal Do Rio Grande Do Sul, UFRGS, Postgraduate program, Porto Alegre, Brazil
| | | | - Vitoria Daniela Schaefer
- Analytical Toxicology Laboratory, Universidade Feevale, Novo Hamburgo, RS, Brazil
- Graduate Program On Toxicology and Analytical Toxicology, Universidade Feevale, Novo Hamburgo, RS, Brazil
| | - Carla Casagrande Pavei
- Medical Residency in Oncology of Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Roberta Zilles Hahn
- Analytical Toxicology Laboratory, Universidade Feevale, Novo Hamburgo, RS, Brazil
| | - Marina Venzon Antunes
- Analytical Toxicology Laboratory, Universidade Feevale, Novo Hamburgo, RS, Brazil
- Graduate Program On Toxicology and Analytical Toxicology, Universidade Feevale, Novo Hamburgo, RS, Brazil
| | - Rafael Linden
- Analytical Toxicology Laboratory, Universidade Feevale, Novo Hamburgo, RS, Brazil.
- Graduate Program On Toxicology and Analytical Toxicology, Universidade Feevale, Novo Hamburgo, RS, Brazil.
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10
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Royer B, Launay M, Ciccolini J, Derain L, Parant F, Thomas F, Guitton J. Impact of renal impairment on dihydropyrimidine dehydrogenase (DPD) phenotyping. ESMO Open 2023; 8:101577. [PMID: 37267808 DOI: 10.1016/j.esmoop.2023.101577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/25/2023] [Accepted: 05/02/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND The chemotherapeutic agent 5-fluorouracil (5-FU) is catabolized by dihydropyrimidine dehydrogenase (DPD), the deficiency of which may lead to severe toxicity or death. Since 2019, DPD deficiency testing, based on uracilemia, is mandatory in France and recommended in Europe before initiating fluoropyrimidine-based regimens. However, it has been recently shown that renal impairment may impact uracil concentration and thus DPD phenotyping. PATIENTS AND METHODS The impact of renal function on uracilemia and DPD phenotype was studied on 3039 samples obtained from three French centers. We also explored the influence of dialysis and measured glomerular filtration rate (mGFR) on both parameters. Finally, using patients as their own controls, we assessed as to what extent modifications in renal function impacted uracilemia and DPD phenotyping. RESULTS We observed that uracilemia and DPD-deficient phenotypes increased concomitantly to the severity of renal impairment based on the estimated GFR, independently and more critically than hepatic function. This observation was confirmed with the mGFR. The risk of being classified 'DPD deficient' based on uracilemia was statistically higher in patients with renal impairment or dialyzed if uracilemia was measured before dialysis but not after. Indeed, the rate of DPD deficiency decreased from 86.4% before dialysis to 13.7% after. Moreover, for patients with transient renal impairment, the rate of DPD deficiency dropped dramatically from 83.3% to 16.7% when patients restored their renal function, especially in patients with an uracilemia close to 16 ng/ml. CONCLUSIONS DPD deficiency testing using uracilemia could be misleading in patients with renal impairment. When possible, uracilemia should be reassessed in case of transient renal impairment. For patients under dialysis, testing of DPD deficiency should be carried out on samples taken after dialysis. Hence, 5-FU therapeutic drug monitoring would be particularly helpful to guide dose adjustments in patients with elevated uracil and renal impairment.
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Affiliation(s)
- B Royer
- Laboratoire de Pharmacologie Clinique et Toxicologie, CHU Besançon, Besançon; Univ. Franche-Comté, INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon.
| | - M Launay
- Pôle de Biologie-Pathologie, Hôpital Nord-CHU Saint Etienne, Saint Etienne
| | - J Ciccolini
- SMARTc Unit, Centre de Recherche en Cancérologie de Marseille Inserm U1068 Aix Marseille Université and Assistance Publique Hôpitaux de Marseille, Marseille
| | - L Derain
- Service de Néphrologie, Dialyse, Hypertension et Exploration Fonctionnelle Rénale, Hospices Civils de Lyon, Hôpital E. Herriot, Lyon F-69003; University of Lyon 1; CNRS UMR 5305, Lyon
| | - F Parant
- Laboratoire de Biochimie et Toxicologie, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite
| | - F Thomas
- Laboratoire de Pharmacologie, Institut Claudius Regaud, Inserm CRCT, Université de Toulouse, Toulouse Cedex 9
| | - J Guitton
- Laboratoire de Biochimie et Toxicologie, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite; Laboratoire de Toxicologie, ISPB, Faculté de Pharmacie, Université Lyon 1, Université de Lyon, Lyon; Inserm U1052, CNRS UMR5286 Centre de Recherche en Cancérologie de Lyon, Lyon, France
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11
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Lau DK, Fong C, Arouri F, Cortez L, Katifi H, Gonzalez-Exposito R, Razzaq MB, Li S, Macklin-Doherty A, Hernandez MA, Hubank M, Fribbens C, Watkins D, Rao S, Chau I, Cunningham D, Starling N. Impact of pharmacogenomic DPYD variant guided dosing on toxicity in patients receiving fluoropyrimidines for gastrointestinal cancers in a high-volume tertiary centre. BMC Cancer 2023; 23:380. [PMID: 37101114 PMCID: PMC10131438 DOI: 10.1186/s12885-023-10857-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 04/17/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Dihydropyrimidine dehydrogenase (DPD) is a key enzyme in the metabolism of fluoropyrimidines. Variations in the encoding DPYD gene are associated with severe fluoropyrimidine toxicity and up-front dose reductions are recommended. We conducted a retrospective study to evaluate the impact of implementing DPYD variant testing for patients with gastrointestinal cancers in routine clinical practice in a high volume cancer centre in London, United Kingdom. METHODS Patients receiving fluoropyrimidine chemotherapy for gastrointestinal cancer prior to, and following the implementation of DPYD testing were identified retrospectively. After November 2018, patients were tested for DPYD variants c.1905+1G>A (DPYD*2A), c.2846A>T (DPYD rs67376798), c.1679T>G (DPYD*13), c.1236G>A (DPYD rs56038477), c.1601G>A (DPYD*4) prior to commencing fluoropyrimidines alone or in combination with other cytotoxics and/or radiotherapy. Patients with a DPYD heterozygous variant received an initial dose reduction of 25-50%. Toxicity by CTCAE v4.03 criteria was compared between DPYD heterozygous variant and wild type carriers. RESULTS Between 1st December 2018 and 31st July 2019, 370 patients who were fluoropyrimidine naïve underwent a DPYD genotyping test prior to receiving a capecitabine (n = 236, 63.8%) or 5FU (n = 134, 36.2%) containing chemotherapy regimen. 33 patients (8.8%) were heterozygous DPYD variant carriers and 337 (91.2%) were wild type. The most prevalent variants were c.1601G > A (n = 16) and c.1236G > A (n = 9). Mean relative dose intensity for the first dose was 54.2% (range 37.5-75%) for DPYD heterozygous carriers and 93.2% (42.9-100%) for DPYD wild type carriers. Overall grade 3 or worse toxicity was similar in DPYD variant carriers (4/33, 12.1%) as compared to wild-type carriers (89/337, 25.7%; P = 0.0924). CONCLUSIONS Our study demonstrates successful routine DPYD mutation testing prior to the initiation of fluoropyrimidine chemotherapy with high uptake. In patients with DPYD heterozygous variants with pre-emptive dose reductions, high incidence of severe toxicity was not observed. Our data supports routine DPYD genotype testing prior to commencement of fluoropyrimidine chemotherapy.
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Affiliation(s)
- David K Lau
- Gastrointestinal and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Caroline Fong
- Gastrointestinal and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Faten Arouri
- Gastrointestinal and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Lillian Cortez
- Department of Pharmacy, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Hannah Katifi
- Gastrointestinal and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Reyes Gonzalez-Exposito
- Gastrointestinal and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Muhammad Bilal Razzaq
- Gastrointestinal and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Su Li
- Gastrointestinal and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Aislinn Macklin-Doherty
- Gastrointestinal and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | | | - Michael Hubank
- Centre for Molecular Pathology, Royal Marsden Hospital and Institute of Cancer Research, Sutton, UK
| | - Charlotte Fribbens
- Gastrointestinal and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - David Watkins
- Gastrointestinal and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Sheela Rao
- Gastrointestinal and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Ian Chau
- Gastrointestinal and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - David Cunningham
- Gastrointestinal and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Naureen Starling
- Gastrointestinal and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London and Sutton, UK.
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12
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Narjoz C, Nadour Z, Zaanan A, Taieb J, Loriot MA, Pallet N. Screening for dihydropyrimidine dehydrogenase deficiency by measuring uracilemia in chronic kidney disease patients is associated with a high rate of false positives. Clin Chim Acta 2023; 543:117326. [PMID: 37011867 DOI: 10.1016/j.cca.2023.117326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Pretherapeutic screening for dihydropyrimidine dehydrogenase (DPD) deficiency based on the measurement of plasma uracil ([U]) is recommended prior to the administration of fluoropyrimidine-based chemotherapy. Cancer patients frequently have impaired kidney function, but the extent to which kidney function decline impacts [U] levels has not been comprehensively investigated. METHODS We assessed the relationship between DPD phenotypes and estimated glomerular filtration rate (eGFR) in 1751 patients who benefited on the same day from a screening for DPD deficiency by measuring [U] and [UH2]:[U], and an evaluation of eGFR. The impact of a kidney function decline on [U] levels and [UH2]:[U] ratio was evaluated. RESULTS We observed that [U] was negatively correlated with eGFR, indicating that [U] levels increase as eGFR declines. For each ml/min of eGFR decrease, [U] value increased in average by 0.035 ng/ml. Using the KDIGO classification of chronic kidney disease (CKD), we observed that [U] values >16 ng/ml (DPD deficiency) were measured in 3.6 % and 4.4 % of stage 1 and 2 CKD (normal-high eGFR, >60 ml/min/1.73m2) patients, but in 6.7 % of stage 3A CKD patients (45 to 59 ml/min/1.73m2), 25% of stage 3B CKD patients (30 to 44 ml/min/1.73m2), 22.7% of stage 4 CKD patients (15 to 29 ml/min/1.73m2 and 26.7% of stage 5 CKD patients (<15 ml/min/1.73m2). [UH2]:[U] ratios were not impacted by kidney function. CONCLUSION DPD phenotyping based on the measurement of plasma [U] in patients with decreased eGFR is associated with an exceedingly high rate of false positives when kidney function decline reaches 45 ml/minute/1.73m2 of eGFR or lower. In this population, an alternative strategy that remain to be evaluated would be to measure the [UH2]:[U] ratio in addition to [U].
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Affiliation(s)
- Céline Narjoz
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Zahia Nadour
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Aziz Zaanan
- Department of Gastroenterology and Digestive Oncology, Hôpital Européen Georges Pompidou, Paris University, France
| | - Julien Taieb
- Department of Gastroenterology and Digestive Oncology, Hôpital Européen Georges Pompidou, Paris University, France
| | - Marie-Anne Loriot
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Nicolas Pallet
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France.
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13
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de With M, Sadlon A, Cecchin E, Haufroid V, Thomas F, Joerger M, van Schaik RHN, Mathijssen RHJ, Largiadèr CR. Implementation of dihydropyrimidine dehydrogenase deficiency testing in Europe. ESMO Open 2023; 8:101197. [PMID: 36989883 PMCID: PMC10163157 DOI: 10.1016/j.esmoop.2023.101197] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/16/2023] [Accepted: 02/18/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND The main cause for fluoropyrimidine-related toxicity is deficiency of the metabolizing enzyme dihydropyrimidine dehydrogenase (DPD). In 2020, the European Medicines Agency (EMA) recommended two methods for pre-treatment DPD deficiency testing in clinical practice: phenotyping using endogenous uracil concentration or genotyping for DPYD risk variant alleles. This study assessed the DPD testing implementation status in Europe before (2019) and after (2021) the release of the EMA recommendations. METHODS The survey was conducted from 16 March 2022 to 31 July 2022. An electronic form with seven closed and three open questions was e-mailed to 251 professionals with DPD testing expertise of 34 European countries. A descriptive analysis was conducted. RESULTS We received 79 responses (31%) from 23 countries. Following publication of the EMA recommendations, 87% and 75% of the countries reported an increase in the amount of genotype and phenotype testing, respectively. Implementation of novel local guidelines was reported by 21 responders (27%). Countries reporting reimbursement of both tests increased in 2021, and only four (18%) countries reported no coverage for any testing type. In 2019, major implementation drivers were 'retrospective assessment of fluoropyrimidine-related toxicity' (39%), and in 2021, testing was driven by 'publication of guidelines' (40%). Although the major hurdles remained the same after EMA recommendations-'lack of reimbursement' (26%; 2019 versus 15%; 2021) and 'lack of recognizing the clinical relevance by medical oncologists' (25%; 2019 versus 8%; 2021)-the percentage of specialists citing these decreased. Following EMA recommendations, 25% of responders reported no hurdles at all in the adoption of the new testing practice in the clinics. CONCLUSIONS The EMA recommendations have supported the implementation of DPD deficiency testing in Europe. Key factors for successful implementation were test reimbursement and clear clinical guidelines. Further efforts to improve the oncologists' awareness of the clinical relevance of DPD testing in clinical practice are needed.
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Affiliation(s)
- M de With
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - A Sadlon
- Department of Clinical Chemistry, Inselspital, Bern University Hospital & University of Bern, INO F, Bern, Switzerland
| | - E Cecchin
- Department Experimental and Clinical Pharmacology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - V Haufroid
- Louvain Center for Toxicology and Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium; Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - F Thomas
- Institut Claudius Regaud, IUCT-Oncopole and CRCT, University of Toulouse, Inserm, Toulouse, France
| | - M Joerger
- Department of Internal Medicine, Klinik für Medizinische Onkologie & Hämatologie, Kantonsspital, St.Gallen, Switzerland
| | - R H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - R H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - C R Largiadèr
- Department of Clinical Chemistry, Inselspital, Bern University Hospital & University of Bern, INO F, Bern, Switzerland.
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14
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Etienne-Grimaldi MC, Pallet N, Boige V, Ciccolini J, Chouchana L, Barin-Le Guellec C, Zaanan A, Narjoz C, Taieb J, Thomas F, Loriot MA. Current diagnostic and clinical issues of screening for dihydropyrimidine dehydrogenase deficiency. Eur J Cancer 2023; 181:3-17. [PMID: 36621118 DOI: 10.1016/j.ejca.2022.11.028] [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: 06/13/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
Fluoropyrimidine drugs (FP) are the backbone of many chemotherapy protocols for treating solid tumours. The rate-limiting step of fluoropyrimidine catabolism is dihydropyrimidine dehydrogenase (DPD), and deficiency in DPD activity can result in severe and even fatal toxicity. In this review, we survey the evidence-based pharmacogenetics and therapeutic recommendations regarding DPYD (the gene encoding DPD) genotyping and DPD phenotyping to prevent toxicity and optimize dosing adaptation before FP administration. The French experience of mandatory DPD-deficiency screening prior to initiating FP is discussed.
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Affiliation(s)
| | - Nicolas Pallet
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Valérie Boige
- Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France; Department of Cancer Medicine, Institut Gustave Roussy, Villejuif, France
| | - Joseph Ciccolini
- SMARTc, CRCM INSERM U1068, Université Aix-Marseille, Marseille, France; Laboratory of Pharmacokinetics and Toxicology, Hôpital Universitaire La Timone, F-13385 Marseille, France; COMPO, CRCM INSERM U1068-Inria, Université Aix-Marseille, Marseille, France
| | - Laurent Chouchana
- Regional Center of Pharmacovigilance, Department of Pharmacology, Hôpital Cochin, Assistance Publique-Hopitaux de Paris, Université de Paris, Paris, France; French Pharmacovigilance Network, France
| | - Chantal Barin-Le Guellec
- Laboratory of Biochemistry and Molecular Biology, Centre Hospitalo-uinversitaire de Tours, Tours, France; INSERM U1248, IPPRITT, University of Limoges, Limoges, France
| | - Aziz Zaanan
- Department of Gastroenterology and Digestive Oncology, Hôpital Européen Georges Pompidou, Paris University; Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Céline Narjoz
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Julien Taieb
- SIRIC CARPEM, Université de Paris; Fédération Francophone de Cancérologie Digestive (FFCD), Assistance Publique-Hôpitaux de Paris, Department of Gastroenterology and Digestive Oncology, Hôpital Européen Georges Pompidou, Paris, France
| | - Fabienne Thomas
- Laboratory of Pharmacology, Institut Claudius Regaud, IUCT-Oncopole and CRCT, INSERM UMR1037, Université Paul Sabatier, Toulouse, France
| | - Marie-Anne Loriot
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMRS1138, Centre de Recherche des Cordeliers, F-75006 Paris, France.
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15
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Knikman JE, Rosing H, Guchelaar HJ, Cats A, Beijnen JH. Assay performance and stability of uracil and dihydrouracil in clinical practice. Cancer Chemother Pharmacol 2023; 91:257-266. [PMID: 36905444 DOI: 10.1007/s00280-023-04518-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/25/2023] [Indexed: 03/12/2023]
Abstract
PURPOSE Measurement of endogenous uracil (U) is increasingly being used as a dose-individualization method in the treatment of cancer patients with fluoropyrimidines. However, instability at room temperature (RT) and improper sample handling may cause falsely increased U levels. Therefore we aimed to study the stability of U and dihydrouracil (DHU) to ensure proper handling conditions. METHODS Stability of U and DHU in whole blood, serum, and plasma at RT (up to 24 h) and long-term stability (≥ 7 days) at - 20 °C were studied in samples from 6 healthy individuals. U and DHU levels of patients were compared using standard serum tubes (SSTs) and rapid serum tubes (RSTs). The performance of our validated UPLC-MS/MS assay was assessed over a period of 7 months. RESULTS U and DHU levels significantly increased at RT in whole blood and serum after blood sampling with increases of 12.7 and 47.6% after 2 h, respectively. A significant difference (p = 0.0036) in U and DHU levels in serum was found between SSTs and RSTs. U and DHU were stable at - 20 °C at least 2 months in serum and 3 weeks in plasma. Assay performance assessment fulfilled the acceptance criteria for system suitability, calibration standards, and quality controls. CONCLUSION A maximum of 1 h at RT between sampling and processing is recommended to ensure reliable U and DHU results. Assay performance tests showed that our UPLC-MS/MS method was robust and reliable. Additionally, we provided a guideline for proper sample handling, processing and reliable quantification of U and DHU.
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Affiliation(s)
- Jonathan E Knikman
- Division of Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Hilde Rosing
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Annemieke Cats
- Department of Gastroenterology and Hepatology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jos H Beijnen
- Division of Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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Poumeaud F, Dalenc F, Mathevet Q, Brice A, Eche-Gass A, De Maio D'Esposito E, Brac-de-la-Perriere C, Thomas F. Phenotype/Genotype Discrepancy of DPD Deficiency Screening in a Patient With Severe Capecitabine Toxicity: A Case Report. JCO Precis Oncol 2023; 7:e2200508. [PMID: 36926988 DOI: 10.1200/po.22.00508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Affiliation(s)
- François Poumeaud
- Department of Medical Oncology, Institut Claudius Regaud, IUCT-Oncopole, Toulouse, France
| | - Florence Dalenc
- Department of Medical Oncology, Institut Claudius Regaud, IUCT-Oncopole, Toulouse, France.,Centre de Recherches en Cancérologie de Toulouse, Inserm UMR1037, Université Toulouse III-Paul Sabatier, Toulouse, France
| | - Quentin Mathevet
- Department of Pharmacology, Institut Claudius Regaud, IUCT-Oncopole, Toulouse, France
| | - Aurélie Brice
- Department of Pharmacology, Institut Claudius Regaud, IUCT-Oncopole, Toulouse, France
| | - Audrey Eche-Gass
- Department of Medical Oncology, Institut Claudius Regaud, IUCT-Oncopole, Toulouse, France
| | | | | | - Fabienne Thomas
- Department of Medical Oncology, Institut Claudius Regaud, IUCT-Oncopole, Toulouse, France.,Centre de Recherches en Cancérologie de Toulouse, Inserm UMR1037, Université Toulouse III-Paul Sabatier, Toulouse, France
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17
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Maillard M, Launay M, Royer B, Guitton J, Gautier-Veyret E, Broutin S, Tron C, Le Louedec F, Ciccolini J, Richard D, Alarcan H, Haufroid V, Tafzi N, Schmitt A, Etienne-Grimaldi MC, Narjoz C, Thomas F. Quantitative impact of pre-analytical process on plasma uracil when testing for dihydropyrimidine dehydrogenase deficiency. Br J Clin Pharmacol 2023; 89:762-772. [PMID: 36104927 PMCID: PMC10092089 DOI: 10.1111/bcp.15536] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/29/2022] [Accepted: 08/15/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS Determining dihydropyrimidine dehydrogenase (DPD) activity by measuring patient's uracil (U) plasma concentration is mandatory before fluoropyrimidine (FP) administration in France. In this study, we aimed to refine the pre-analytical recommendations for determining U and dihydrouracil (UH2 ) concentrations, as they are essential in reliable DPD-deficiency testing. METHODS U and UH2 concentrations were collected from 14 hospital laboratories. Stability in whole blood and plasma after centrifugation, the type of anticoagulant and long-term plasma storage were evaluated. The variation induced by time and temperature was calculated and compared to an acceptability range of ±20%. Inter-occasion variability (IOV) of U and UH2 was assessed in 573 patients double sampled for DPD-deficiency testing. RESULTS Storage of blood samples before centrifugation at room temperature (RT) should not exceed 1 h, whereas cold (+4°C) storage maintains the stability of uracil after 5 hours. For patients correctly double sampled, IOV of U reached 22.4% for U (SD = 17.9%, range = 0-99%). Notably, 17% of them were assigned with a different phenotype (normal or DPD-deficient) based on the analysis of their two samples. For those having at least one non-compliant sample, this percentage increased up to 33.8%. The moment of blood collection did not affect the DPD phenotyping result. CONCLUSION Caution should be taken when interpreting U concentrations if the time before centrifugation exceeds 1 hour at RT, since it rises significantly afterwards. Not respecting the pre-analytical conditions for DPD phenotyping increases the risk of DPD status misclassification.
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Affiliation(s)
- Maud Maillard
- Laboratoire de Pharmacologie, Institut Claudius Regaud, IUCT-Oncopole et Centre de Recherches en Cancérologie de Toulouse, Inserm UMR1037, Université Paul Sabatier, Toulouse, France
| | - Manon Launay
- Laboratoire de Pharmacologie et Toxicologie, CHU de Saint-Etienne, Saint-Etienne, France
| | - Bernard Royer
- Laboratoire de Pharmacologie Clinique et Toxicologie, CHU Besançon and Univ. Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France
| | - Jérôme Guitton
- Laboratoire de Pharmacologie Toxicologie, CHU de Lyon, Lyon, France
| | - Elodie Gautier-Veyret
- Laboratoire de Pharmacologie, Pharmacogénétique et Toxicologie, CHU Grenoble-Alpes et Université Grenoble-Alpes, laboratoire HP2, INSERM U1300, Grenoble, France
| | - Sophie Broutin
- Département de Biologie et Pathologie Médicale, Service de Pharmacologie, Gustave Roussy, Villejuif, France
| | - Camille Tron
- Laboratoire de pharmacologie CHU de Rennes, Université de Rennes, CHU de Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail), UMR_S 1085, Rennes, France
| | - Félicien Le Louedec
- Laboratoire de Pharmacologie, Institut Claudius Regaud, IUCT-Oncopole et Centre de Recherches en Cancérologie de Toulouse, Inserm UMR1037, Université Paul Sabatier, Toulouse, France
| | - Joseph Ciccolini
- SMARTc Unit, CRCM Inserm U1068 et Laboratoire de Pharmacocinétique, CHU La Timone, Marseille, France
| | - Damien Richard
- Laboratoire de Pharmacologie et Toxicologie, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Hugo Alarcan
- Service de Biochimie et Biologie Moléculaire, CHRU de Tours, Tours, France
| | - Vincent Haufroid
- Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Clinical and Experimental Research Institute (IREC), Université catholique de Louvain, Brussels, Belgium.,Clinical Chemistry Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Naïma Tafzi
- INSERM, Université de Limoge, Service de Pharmacologie et Toxicologie, CHU de Limogess, U1248 IPPRITT, Limoges, France
| | - Antonin Schmitt
- Service Pharmacie, Centre Georges-François Leclerc et INSERM U1231, Université de Bourgogne, Dijon, France
| | | | - Céline Narjoz
- Assistance Publique des Hôpitaux de Paris, Hôpital européen Georges-Pompidou, Service de biochimie, Paris, France
| | - Fabienne Thomas
- Laboratoire de Pharmacologie, Institut Claudius Regaud, IUCT-Oncopole et Centre de Recherches en Cancérologie de Toulouse, Inserm UMR1037, Université Paul Sabatier, Toulouse, France
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18
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Sadowska A, Sawicka D, Godlewska K, Guzińska-Ustymowicz K, Zapora E, Sokołowska E, Car H. Beneficial Proapoptotic Effect of Heterobasidion Annosum Extract in Colorectal Cancer Xenograft Mouse Model. Molecules 2023; 28:molecules28031352. [PMID: 36771018 PMCID: PMC9919637 DOI: 10.3390/molecules28031352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/20/2023] [Accepted: 01/25/2023] [Indexed: 02/04/2023] Open
Abstract
Fungal extracts possess potential anticancer activity against many malignant neoplastic diseases. In this research, we focused on the evaluation of Heterobasidion annosum (HA) extract in colorectal cancer in an in vivo model. The mice with implanted DLD-1 human cancer cells were given HA extract, the referential drug-5-fluorouracil (5FU), or were treated with its combination. Thereafter, tumor volume was measured and apoptotic proteins such as caspase-8, caspase-3, p53, Bcl-2, and survivin were analyzed in mice serum with an ELISA assay. The Ki-67 protein was assessed in tumor cells by immunohistochemical examination. The biggest volumes of tumors were confirmed in the DLD-1 group, while the lowest were observed in the population treated with 5FU and/or HA extract. The assessment of apoptosis showed increased concentrations of caspase 8 and p53 protein after the combined administration of 5FU and HA extract. The levels of survivin and Bcl-2 were decreased in all tested groups compared to the DLD-1 group. Moreover, we observed a positive reaction for Ki-67 protein in all tested groups. Our findings confirm the apoptotic effect of extract given alone or with 5FU. The obtained results are innovative and provide a basis for further research concerning the antitumor activity of the HA extract, especially in the range of its interaction with an anticancer chemotherapeutic agent.
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Affiliation(s)
- Anna Sadowska
- Department of Experimental Pharmacology, Medical University of Bialystok, Szpitalna 37, 15-295 Bialystok, Poland
- Correspondence: ; Tel.: +48-85-748-5554
| | - Diana Sawicka
- Department of Experimental Pharmacology, Medical University of Bialystok, Szpitalna 37, 15-295 Bialystok, Poland
| | - Katarzyna Godlewska
- Department of Experimental Pharmacology, Medical University of Bialystok, Szpitalna 37, 15-295 Bialystok, Poland
- Department of Haematology, Medical University of Bialystok, M. Skłodowskiej-Curie 24A, 15-276 Bialystok, Poland
| | | | - Ewa Zapora
- Department of Silviculture and Forest Use, Institute of Forest Sciences, Bialystok University of Technology, Wiejska 45E, 15-351 Bialystok, Poland
| | - Emilia Sokołowska
- Department of Experimental Pharmacology, Medical University of Bialystok, Szpitalna 37, 15-295 Bialystok, Poland
| | - Halina Car
- Department of Experimental Pharmacology, Medical University of Bialystok, Szpitalna 37, 15-295 Bialystok, Poland
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19
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Callon S, Brugel M, Botsen D, Royer B, Slimano F, Feliu C, Gozalo C, Konecki C, Devie B, Carlier C, Daire V, Laurés N, Perrier M, Djerada Z, Bouché O. Renal impairment and abnormal liver function tests in pre-therapeutic phenotype-based DPD deficiency screening using uracilemia: a comprehensive population-based study in 1138 patients. Ther Adv Med Oncol 2023; 15:17588359221148536. [PMID: 36643657 PMCID: PMC9837271 DOI: 10.1177/17588359221148536] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 12/13/2022] [Indexed: 01/13/2023] Open
Abstract
Background Dihydropyrimidine dehydrogenase (DPD) deficiency screening is a pre-therapeutic standard to prevent severe fluoropyrimidine-related toxicity. Although several screening methods exist, the accuracy of their results remains debatable. In France, the uracilemia measurement is considered the standard in DPD deficiency screening. The objective of this study was to describe the hyperuracilemia (⩾16 ng/mL) rate and investigate the influence of hepatic and renal impairment in uracilemia measurements since the guidelines were implemented. Patients and methods Using a cohort of 1138 patients screened between 18 October 2018 and 18 October 2021, basic demographic characteristics, date of blood sampling, and potential biological confounders including liver function tests [aspartate aminotransaminase (AST), alanine aminotransaminase (ALT), gamma-glutamyl transferase (γGT), alkaline phosphatase (ALP), and bilirubin] and estimated glomerular filtration rate (eGFR) were collected. The second same-patient uracilemia analysis was also performed. Temporal change was graphically represented while potential confounders were stratified to show linearity when suspected. Results Hyperuracilemia was diagnosed in 12.7% (n = 150) samples with 6.7%, 5.4%, 0.5%, and 0.08% between 16 and 20 ng/mL, 20 and 50 ng/mL, 50 and 150 ng/mL, and >150 ng/mL, respectively. The median uracilemia concentration was 9.4 ng/mL (range: 1.2 and 172.3 ng/mL) and the monthly hyperuracilemia rate decreased steadily from >30% to around 9%. Older age, normalized AST, γGT, ALP results, bilirubin levels, and decreased eGFR were linearly associated with higher plasma uracil concentrations (all p < 0.001). In the adjusted multivariate linear model, AST, eGFR, and ALP remained associated with uracilemia (p < 0.05). When measured twice in 39 patients, the median uracilemia rate of change was -2.5%, which subsequently changed the diagnosis in nine patients (23.1%). Conclusions Better respect of pre-analytical conditions may explain the steady decrease in monthly hyperuracilemia rates over the 3 years. Elevated AST, ALP levels, and reduced eGFR could induce a false increase in uracilemia and second uracilemia measurements modified the first DPD deficiency diagnosis in almost 25% of the patients.
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Affiliation(s)
| | | | - Damien Botsen
- Department of Medical Oncology, Godinot Cancer Institute, Reims, France,Department of Digestive Oncology and Gastroenterology, University of Reims Champagne-Ardenne (URCA), CHU Reims, Reims, France
| | - Bernard Royer
- Clinical Pharmacology and Toxicology Laboratory, CHU Besançon, Besançon, France
| | | | - Catherine Feliu
- Pharmacology and Toxicology Department, CHU Reims, Reims, France
| | - Claire Gozalo
- Pharmacology and Toxicology Department, CHU Reims, Reims, France
| | - Céline Konecki
- Pharmacology and Toxicology Department, CHU Reims, Reims, France
| | - Bruno Devie
- Clairmarais Bioxa Medical Biology Laboratory, Reims, France
| | - Claire Carlier
- Department of Medical Oncology, Godinot Cancer Institute, Reims, France,Department of Digestive Oncology and Gastroenterology, University of Reims Champagne-Ardenne (URCA), CHU Reims, Reims, France
| | - Viktor Daire
- Department of Digestive Oncology and Gastroenterology, University of Reims Champagne-Ardenne (URCA), CHU Reims, Reims, France
| | - Nicolas Laurés
- Department of Digestive Oncology and Gastroenterology, University of Reims Champagne-Ardenne (URCA), CHU Reims, Reims, France
| | - Marine Perrier
- Department of Digestive Oncology and Gastroenterology, University of Reims Champagne-Ardenne (URCA), CHU Reims, Reims, France
| | - Zoubir Djerada
- Pharmacology and Toxicology Department, CHU Reims, Reims, France
| | - Olivier Bouché
- Department of Digestive Oncology and Gastroenterology, University of Reims Champagne-Ardenne (URCA), CHU Reims, Reims, France
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20
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Sivamani P, Eriyat V, Mathew SK, Singh A, Aaron R, Chacko RT, Joel A, Prabha R, Mathew BS. Identification of DPYD variants and estimation of uracil and dihydrouracil in a healthy Indian population. Per Med 2022; 20:39-53. [DOI: 10.2217/pme-2022-0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Aim: This study aimed to identify DPYD variants and the related but previously unexplored phenotype (plasma uracil, dihydrouracil [DHU], and the DHU-to-uracil ratio) in a healthy adult Indian population. Methods: Healthy adult volunteers (n = 100) had their uracil and DHU levels measured and were genotyped for selected variants. Results: Among the nine variants studied, c.1906-14763G>A and c.85T>C were the most prevalent. Participants with any of the variants except for c.85T>C and c.1627A>G had a significantly lower DHU-to-uracil ratio and those with c.1905+1G>A variant had significantly increased uracil concentration compared with wild type. Conclusion: Participants with five variants were identified as having altered phenotypic measures, and 40% of the intermediate metabolizers had their phenotype in the terminal population percentiles.
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Affiliation(s)
- Poornima Sivamani
- Department of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vishnu Eriyat
- Department of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sumith K Mathew
- Department of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ashish Singh
- Department of Medical Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Rekha Aaron
- Department of Clinical Genetics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Raju Titus Chacko
- Department of Medical Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anjana Joel
- Department of Medical Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ratna Prabha
- Department of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Binu Susan Mathew
- Department of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, Tamil Nadu, India
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21
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Paulsen NH, Qvortrup C, Vojdeman FJ, Plomgaard P, Andersen SE, Ramlov A, Bertelsen B, Rossing M, Nielsen CG, Hoffmann-Lücke E, Greibe E, Spangsberg Holm H, Nielsen HH, Lolas IBY, Madsen JS, Bergmann ML, Mørk M, Fruekilde PBN, Bøttger P, Petersen PC, Nissen PH, Feddersen S, Bergmann TK, Pfeiffer P, Damkier P. Dihydropyrimidine dehydrogenase (DPD) genotype and phenotype among Danish cancer patients: prevalence and correlation between DPYD-genotype variants and P-uracil concentrations. Acta Oncol 2022; 61:1400-1405. [PMID: 36256873 DOI: 10.1080/0284186x.2022.2132117] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Niels Herluf Paulsen
- Department of Clinical Pharmacology, Odense University Hospital, Odense, Denmark.,Clinical Pharmacology, Pharmacy and Environmental Medicine Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Camilla Qvortrup
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Fie Juhl Vojdeman
- Department of Clinical Biochemistry, Holbaek Hospital, Holbaek, Denmark
| | - Peter Plomgaard
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Anne Ramlov
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Birgitte Bertelsen
- Center for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Maria Rossing
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Center for Genomic Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Claus Gyrup Nielsen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
| | - Elke Hoffmann-Lücke
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus N, Denmark.,Institute for Clinical Medicine, Aarhus University of Health, Aarhus, Denmark
| | - Eva Greibe
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus N, Denmark.,Institute for Clinical Medicine, Aarhus University of Health, Aarhus, Denmark
| | | | - Heidi Hvid Nielsen
- Department of Clinical Biochemistry, Zealand University Hospital, Køge, Denmark
| | | | - Jonna Skov Madsen
- Department of Biochemistry and Immunology, Lillebaelt Hospital - University Hospital of Southern Denmark, Vejle, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Marianne Lerbaek Bergmann
- Department of Biochemistry and Immunology, Lillebaelt Hospital - University Hospital of Southern Denmark, Vejle, Denmark
| | - Morten Mørk
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark.,Department of Molecular Diagnostics, Aalborg University Hospital, Aalborg, Denmark
| | | | - Pernille Bøttger
- Department of Biochemistry and Immunology, Lillebaelt Hospital - University Hospital of Southern Denmark, Vejle, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | - Peter Henrik Nissen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus N, Denmark.,Denmark and Institute for Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Søren Feddersen
- Department of Clinical Biochemistry, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Troels K Bergmann
- Department of Clinical Pharmacology, Odense University Hospital, Odense, Denmark.,Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Per Damkier
- Department of Clinical Pharmacology, Odense University Hospital, Odense, Denmark.,Clinical Pharmacology, Pharmacy and Environmental Medicine Department of Public Health, University of Southern Denmark, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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22
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Paulsen NH, Vojdeman F, Andersen SE, Bergmann TK, Ewertz M, Plomgaard P, Hansen MR, Esbech PS, Pfeiffer P, Qvortrup C, Damkier P. DPYD genotyping and dihydropyrimidine dehydrogenase (DPD) phenotyping in clinical oncology. A clinically focused minireview. Basic Clin Pharmacol Toxicol 2022; 131:325-346. [PMID: 35997509 PMCID: PMC9826411 DOI: 10.1111/bcpt.13782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND In clinical oncology, systemic 5-fluorouracil (5-FU) and its oral pro-drugs are used to treat a broad group of solid tumours. Patients with dihydropyrimidine dehydrogenase (DPD) enzyme deficiency are at elevated risk of toxicity if treated with standard doses of 5-FU. DPYD genotyping and measurements of plasma uracil concentration (DPD phenotyping) can be applied as tests for DPD deficiency. In April 2020, the European Medicines Agency recommended pre-treatment DPD testing to reduce the risk of 5-FU-related toxicity. OBJECTIVES The objective of this study is to present the current evidence for DPD testing in routine oncological practice. METHODS Two systematic literature searches were performed following the PRISMA guidelines. We identified studies examining the possible benefit of DPYD genotyping or DPD phenotyping on the toxicity risk. FINDINGS Nine and 12 studies met the criteria for using DPYD genotyping and DPD phenotyping, respectively. CONCLUSIONS The evidence supporting either DPYD genotyping or DPD phenotyping as pre-treatment tests to reduce 5-FU toxicity is poor. Further evidence is still needed to fully understand and guide clinicians to dose by DPD activity.
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Affiliation(s)
- Niels Herluf Paulsen
- Department of Clinical PharmacologyOdense University HospitalOdenseDenmark,Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark
| | - Fie Vojdeman
- Department of Clinical BiochemistryHolbaek HospitalHolbaekDenmark
| | | | - Troels K. Bergmann
- Department of Clinical PharmacologyOdense University HospitalOdenseDenmark,Department of Regional Health ResearchUniversity of Southern DenmarkEsbjergDenmark
| | - Marianne Ewertz
- Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Peter Plomgaard
- Department of Clinical Biochemistry, Rigshospitalet, Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Morten Rix Hansen
- Department of Clinical PharmacologyOdense University HospitalOdenseDenmark,Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark,Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark,Novo NordiskSøborgDenmark
| | - Peter Skov Esbech
- Department of Clinical PharmacologyOdense University HospitalOdenseDenmark
| | - Per Pfeiffer
- Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark,Department of OncologyOdense University HospitalOdenseDenmark
| | - Camilla Qvortrup
- Department of Oncology, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
| | - Per Damkier
- Department of Clinical PharmacologyOdense University HospitalOdenseDenmark,Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark,Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
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23
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Laures N, Konecki C, Brugel M, Giffard AL, Abdelli N, Botsen D, Carlier C, Gozalo C, Feliu C, Slimano F, Djerada Z, Bouché O. Impact of Guidelines Regarding Dihydropyrimidine Dehydrogenase (DPD) Deficiency Screening Using Uracil-Based Phenotyping on the Reduction of Severe Side Effect of 5-Fluorouracil-Based Chemotherapy: A Propension Score Analysis. Pharmaceutics 2022; 14:pharmaceutics14102119. [PMID: 36297556 PMCID: PMC9610761 DOI: 10.3390/pharmaceutics14102119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/07/2022] Open
Abstract
Dihydropyrimidine dehydrogenase (DPD) deficiency is associated with severe fluoropyrimidines-induced toxicity. As of September 2018, French recommendations call for screening for DPD deficiency by plasma uracil quantification prior to all fluoropyrimidine-based chemotherapy. A dose reduction of fluoropyrimidine is recommended when uracil concentration is equal to or greater than 16 ng/mL. This matched retrospective study assessed the impact of DPD screening on the reduction of severe side effects and on the management of DPD-deficient patients. Using a propensity score, we balanced the factors influencing 5-Fluorouracil (5-FU) toxicity. Then, the severity scores (G3 and G4 severity as well as their frequency) of patients who did not benefit from DPD screening were compared with those of patients who benefited from DPD screening for each treatment cycle (from 1 to 4). Among 349 screened patients, 198 treated patients were included. Among them, 31 (15.7%) had DPD deficiency (median uracilemia 19.8 ng/mL (range: 16.1−172.3)). The median toxicity severity score was higher in the unscreened group for each treatment cycle (0 vs. 1, p < 0.001 at each cycle from 1 to 4) as well as the cumulative score during all courses of treatment (p = 0.028). DPD-deficient patients received a significantly lower dose of 5-FU (p < 0.001). This study suggests that pretherapeutic plasmatic uracil assessment, along with 5-FU dosage adjustment, may be beneficial in reducing 5-FU toxicity in real-life patients.
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Affiliation(s)
- Nicolas Laures
- Department of Gastroenterology and Digestive Oncology, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
| | - Céline Konecki
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA3801, 51097 Reims, France
- Department of Pharmacology and Toxicology, CHU Reims, 51100 Reims, France
| | - Mathias Brugel
- Department of Gastroenterology and Digestive Oncology, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
- Department of Hepato-Gastroenterology and Digestive Oncology, Centre Hospitalier Auban-Moët, 51200 Epernay, France
| | - Anne-Lise Giffard
- Department of Gastroenterology and Digestive Oncology, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
| | - Naceur Abdelli
- Department of Hepato-Gastroenterology and Digestive Oncology, Centre Hospitalier de Chalons en Champagne, 51000 Chalons en Champagne, France
| | - Damien Botsen
- Department of Gastroenterology and Digestive Oncology, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
| | - Claire Carlier
- Department of Gastroenterology and Digestive Oncology, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
| | - Claire Gozalo
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA3801, 51097 Reims, France
- Department of Pharmacology and Toxicology, CHU Reims, 51100 Reims, France
| | - Catherine Feliu
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA3801, 51097 Reims, France
- Department of Pharmacology and Toxicology, CHU Reims, 51100 Reims, France
| | - Florian Slimano
- Department of Pharmacy, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
| | - Zoubir Djerada
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA3801, 51097 Reims, France
- Department of Pharmacology and Toxicology, CHU Reims, 51100 Reims, France
- Correspondence:
| | - Olivier Bouché
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA3801, 51097 Reims, France
- Department of Pharmacology and Toxicology, CHU Reims, 51100 Reims, France
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24
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Salmani M, Ghaderi B, Fotoohi A, Omid-Shafa'at R, Vahabzadeh Z, Fotouhi O, Abdi M. Introducing a simple and cost-effective RT-PCR protocol for detection of DPYD*2A polymorphism: the first study in Kurdish population. Cancer Chemother Pharmacol 2022; 90:389-397. [PMID: 36083300 DOI: 10.1007/s00280-022-04472-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/29/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Fluoropyrimidines, the major chemotherapeutic agents in various malignancies treatment, are metabolized by dihydropyrimidine dehydrogenase (DPD). DPD deficiency can lead to severe and sometimes fatal toxicity. In the present study, we developed a simple protocol to detect the DPYD*2A variant. Common side effects in patients treated with these drugs were also evaluated in a Kurdish population. METHOD We established a reverse-transcriptase polymerase chain reaction (RT-PCR) technique for detection of DPYD*2A. Sanger sequencing was used to confirm the results. 121 Kurdish patients receiving fluoropyrimidine derivatives were enrolled, and clinical information regarding the dosage and toxicity was analyzed. RESULTS Our RT-PCR method was able to detect one patient with heterozygous state for DPYD*2A (0.8%). The most observed adverse drug reactions were tingling, nausea, and hair loss. The frequency of patients with the toxicity of grade 3 or worse was 6.6%. CONCLUSION This was the first study that detect DPYD*2A polymorphism in the Kurdish population. Our method was successfully able to detect the DPYD*2A variant and, due to its simplicity and cost-effectiveness, it may be considered as an alternative to the current methods, especially in developing countries. Our detected polymorphism rate at 0.8% is comparable with other studies. Despite the low rate of DPYD*2A polymorphism, pharmacogenetics assessment before beginning the treatment process is highly recommended due to its association with a high risk of severe toxicity.
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Affiliation(s)
- Mohammad Salmani
- Student Research Committee, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Bayazid Ghaderi
- Cancer and Immunology Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Alan Fotoohi
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ramtin Omid-Shafa'at
- Cellular and Molecular Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Zakaria Vahabzadeh
- Department of Clinical Biochemistry, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Omid Fotouhi
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Mohammad Abdi
- Cellular and Molecular Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran. .,Department of Clinical Biochemistry, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran.
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25
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Brooks GA, Tapp S, Daly AT, Busam JA, Tosteson ANA. Cost-effectiveness of DPYD Genotyping Prior to Fluoropyrimidine-based Adjuvant Chemotherapy for Colon Cancer. Clin Colorectal Cancer 2022; 21:e189-e195. [PMID: 35668003 PMCID: PMC10496767 DOI: 10.1016/j.clcc.2022.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/29/2022] [Accepted: 05/06/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Adjuvant fluoropyrimidine-based chemotherapy substantially reduces recurrence and mortality after resection of stage 3 colon cancer. While standard doses of 5-fluorouracil and capecitabine are safe for most patients, the risk of severe toxicity is increased for the approximately 6% of patients with dihydropyimidine dehydrogenase (DPD) deficiency caused by pathogenic DPYD gene variants. Pre-treatment screening for pathogenic DPYD gene variants reduces severe toxicity but has not been widely adopted in the United States. METHODS We conducted a cost-effectiveness analysis of DPYD genotyping prior to fluoropyrimidine-based adjuvant chemotherapy for stage 3 colon cancer, covering the c.1129-5923C>G (HapB3), c.1679T>G (*13), c.1905+1G>A (*2A), and c.2846A>T gene variants. We used a Markov model with a 5-year horizon, taking a United States healthcare perspective. Simulated patients with pathogenic DPYD gene variants received reduced-dose fluoropyrimidine chemotherapy. The primary outcome was the incremental cost-effectiveness ratio (ICER) for DPYD genotyping. RESULTS Compared with no screening for DPD deficiency, DPYD genotyping increased per-patient costs by $78 and improved survival by 0.0038 quality-adjusted life years (QALYs), leading to an ICER of $20,506/QALY. In 1-way sensitivity analyses, The ICER exceeded $50,000 per QALY when the cost of the DPYD genotyping assay was greater than $286. In probabilistic sensitivity analysis using a willingness-to-pay threshold of $50,000/QALY DPYD genotyping was preferred to no screening in 96.2% of iterations. CONCLUSION Among patients receiving adjuvant chemotherapy for stage 3 colon cancer, screening for DPD deficiency with DPYD genotyping is a cost-effective strategy for preventing infrequent but severe and sometimes fatal toxicities of fluoropyrimidine chemotherapy.
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Affiliation(s)
- Gabriel A Brooks
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center/Geisel School of Medicine, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH.
| | - Stephanie Tapp
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH
| | - Allan T Daly
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | | | - Anna N A Tosteson
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center/Geisel School of Medicine, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH
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26
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Verdez S, Albuisson J, Duffourd Y, Boidot R, Reda M, Thauvin-Robinet C, Fumet JD, Ladoire S, Nambot S, Callier P, Faivre L, Ghiringhelli F, Picard N. Detection of relevant pharmacogenetic information through exome sequencing in oncology. Pharmacogenomics 2022; 23:759-770. [PMID: 36043386 DOI: 10.2217/pgs-2022-0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Germline sequencing of individual genomes can detect alleles responsible for adverse drug reactions (ADRs) in relation to chemotherapy, targeted agents, antiemetics or pain treatment. Materials & methods: To evaluate the interest of such pharmacogenetic information, the authors retrospectively analyzed genes known to have an impact on cancer therapy in a cohort of 445 solid cancers patients. Results: Six patients treated with 5-fluorouracil carrying one DPYD variant classified as 1A showed decreased drug mean clearance (p = 0.01). Regarding CYP2D6, all patients (n = 5) with predicted CYP2D6 poor or ultra-rapid metabolizer status experienced adverse drug reactions related to opioid therapy. Conclusion: Genomic germline sequencing performed for theragnostic issues in patients with a solid tumor, can provide relevant information about common pharmacogenetic alleles.
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Affiliation(s)
- Simon Verdez
- UMR1231 GAD, Inserm - Université Bourgogne-Franche Comté, Dijon, France.,Unité Fonctionnelle Innovation en Diagnostic génomique des maladies rares, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France
| | - Juliette Albuisson
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center - UNICANCER, Dijon, 21000, France.,Genomic & Immunotherapy Medical Institute, Dijon, 21000, France
| | - Yannis Duffourd
- UMR1231 GAD, Inserm - Université Bourgogne-Franche Comté, Dijon, France.,Unité Fonctionnelle Innovation en Diagnostic génomique des maladies rares, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France
| | - Romain Boidot
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center - UNICANCER, Dijon, 21000, France.,Genomic & Immunotherapy Medical Institute, Dijon, 21000, France.,Department of Tumour Biology & Pathology, Georges François Leclerc Cancer Center - UNICANCER, Dijon, 21000, France
| | - Manon Reda
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center - UNICANCER, Dijon, 21000, France.,Department of Tumour Biology & Pathology, Georges François Leclerc Cancer Center - UNICANCER, Dijon, 21000, France.,Department of Medical Oncology, Georges François Leclerc Cancer Center - UNICANCER, 1 rue Professeur Marion, Dijon, 21000, France
| | - Christel Thauvin-Robinet
- Unité Fonctionnelle Innovation en Diagnostic génomique des maladies rares, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France.,Genomic & Immunotherapy Medical Institute, Dijon, 21000, France.,Centre de Référence Maladies Rares "Anomalies du Développement et Syndromes Malformatifs", Centre de Génétique, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France
| | - Jean-David Fumet
- Department of Medical Oncology, Georges François Leclerc Cancer Center - UNICANCER, 1 rue Professeur Marion, Dijon, 21000, France
| | - Sylvain Ladoire
- Department of Medical Oncology, Georges François Leclerc Cancer Center - UNICANCER, 1 rue Professeur Marion, Dijon, 21000, France
| | - Sophie Nambot
- Unité Fonctionnelle Innovation en Diagnostic génomique des maladies rares, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France.,Centre de Référence Maladies Rares "Anomalies du Développement et Syndromes Malformatifs", Centre de Génétique, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France
| | - Patrick Callier
- UMR1231 GAD, Inserm - Université Bourgogne-Franche Comté, Dijon, France.,Unité Fonctionnelle Innovation en Diagnostic génomique des maladies rares, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France
| | - Laurence Faivre
- Unité Fonctionnelle Innovation en Diagnostic génomique des maladies rares, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France.,Genomic & Immunotherapy Medical Institute, Dijon, 21000, France.,Centre de Référence Maladies Rares "Anomalies du Développement et Syndromes Malformatifs", Centre de Génétique, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France
| | - François Ghiringhelli
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center - UNICANCER, Dijon, 21000, France.,Genomic & Immunotherapy Medical Institute, Dijon, 21000, France.,Department of Tumour Biology & Pathology, Georges François Leclerc Cancer Center - UNICANCER, Dijon, 21000, France.,Department of Medical Oncology, Georges François Leclerc Cancer Center - UNICANCER, 1 rue Professeur Marion, Dijon, 21000, France
| | - Nicolas Picard
- Inserm U1248, Service de Pharmacologie et Toxicologie, Université de Limoges, CHU de Limoges, Limoges, 87000, France
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27
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Carriat L, Quaranta S, Solas C, Rony M, Ciccolini J. Renal impairment and DPD testing: watch out for false-positive results! Br J Clin Pharmacol 2022; 88:4928-4932. [PMID: 35939355 DOI: 10.1111/bcp.15482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/21/2022] [Accepted: 07/29/2022] [Indexed: 11/30/2022] Open
Abstract
Measuring uracil (U) levels in plasma is a convenient surrogate to establish DPD status in patients scheduled with 5-fluorouracil (5-FU) or capecitabine. To what extent renal impairment could impact on U levels and thus be a confounding factor is a rising concern. Here, we report the case of a cancer patient with severe renal impairment scheduled for 5-FU-based regimen. Determination of his DPD status was complicated because of his condition and the influence of intermittent hemodialysis when monitoring U levels. The patient was initially identified as markedly DPD-deficient upon U measurement (i.e., U = 40 ng/ml), but further monitoring between and immediately after dialysis showed mild deficiency only (i.e., U = 34 and U = 19 ng/ml, respectively). Despite this discrepancy, starting dose of 5-FU was cut by 50% upon treatment initiation. Tolerance was good and 5-FU dosing was next shifted to 25% reduction, then further shifted to normal dosing at the 5th course, with still no sign for drug-related toxicities. Further DPYD genotyping showed none of the 4 allelic variants usually associated with loss of DPD activity. Of note, the excellent tolerance upon standard dosing strongly suggests that this patient was actually not DPD-deficient, despite U values always above normal concentrations. This case report highlights how critical is the information regarding the renal function of patients with cancer when phenotyping DPD using U plasma as a surrogate, and that U accumulation in patients with such condition is likely to yield false-positive results.
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Affiliation(s)
- Laure Carriat
- Laboratoire de Pharmacocinétique et Toxicologie, CHU Timone, APHM, Marseille, France.,SMARTc unit, Centre de Recherche en Cancérologie de Marseille, Inserm, Marseille, France
| | - Sylvie Quaranta
- Laboratoire de Pharmacocinétique et Toxicologie, CHU Timone, APHM, Marseille, France
| | - Caroline Solas
- Laboratoire de Pharmacocinétique et Toxicologie, CHU Timone, APHM, Marseille, France
| | - Maelle Rony
- Oncologie Digestive, CHU Timone, APHM, Marseille, France
| | - Joseph Ciccolini
- Laboratoire de Pharmacocinétique et Toxicologie, CHU Timone, APHM, Marseille, France.,SMARTc unit, Centre de Recherche en Cancérologie de Marseille, Inserm, Marseille, France
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28
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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] [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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29
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Testing for Dihydropyrimidine Dehydrogenase Deficiency to Individualize 5-Fluorouracil Therapy. Cancers (Basel) 2022; 14:cancers14133207. [PMID: 35804978 PMCID: PMC9264755 DOI: 10.3390/cancers14133207] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 12/24/2022] Open
Abstract
Simple Summary 5-Fluorouracil (5-FU) is a chemotherapy drug that is commonly used to treat multiple cancers. Many people who are treated with 5-FU experience severe toxicity to the drug, and in severe cases, patients can die. This review discusses current methods for identifying people who are at high risk for severe side effects to 5-FU therapy. Abstract Severe adverse events (toxicity) related to the use of the commonly used chemotherapeutic drug 5-fluorouracil (5-FU) affect one in three patients and are the primary reason cited for premature discontinuation of therapy. Deficiency of the 5-FU catabolic enzyme dihydropyrimidine dehydrogenase (DPD, encoded by DPYD) has been recognized for the past 3 decades as a pharmacogenetic syndrome associated with high risk of 5-FU toxicity. An appreciable fraction of patients with DPD deficiency that receive 5-FU-based chemotherapy die as a result of toxicity. In this manuscript, we review recent progress in identifying actionable markers of DPD deficiency and the current status of integrating those markers into the clinical decision-making process. The limitations of currently available tests, as well as the regulatory status of pre-therapeutic DPYD testing, are also discussed.
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30
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Menestrina Dewes M, Cé da Silva L, Fazenda Meireles Y, Viana de Freitas M, Frank Bastiani M, Feltraco Lizot L, Zilles Hahn R, Venzon Antunes M, Linden R. Evaluation of the Tasso-SST® capillary blood microsampling device for the measurement of endogenous uracil levels. Clin Biochem 2022; 107:1-6. [PMID: 35709975 DOI: 10.1016/j.clinbiochem.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/24/2022] [Accepted: 06/12/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Uracil (U) plasma or serum levels can be used as surrogates of dihydropyrimidine dehydrogenase (DPD) activity, which is strongly related to the occurrence of severe or fatal toxicity after administration of fluoropyrimidines (FP) chemotherapy. Obtaining blood plasma or serum for U measurement usually requires a phlebotomy procedure by a qualified professional. An alternative to conventional blood drawn is the use of the Tasso-SST® device, which allows the collection of a small blood volume from skin capillaries. This study aimed to implement a sensitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) assay for the determination of U in small serum samples and to compare U concentrations measured in venous plasma, obtained after phlebotomy, and serum obtained with the Tasso-SST® device. METHODS Fifty microliter samples were prepared through simple protein precipitation with trichloroacetic acid. Chromatographic separation was performed with a porous graphitic carbon stationary phase and mass spectrometric detection used positive electrospray ionization. The assay was validated according to international guidelines. RESULTS The linear range of the assay was 5-250 ng/mL. Measurement accuracy was in the range of 98.8-108.2%, inter-assay precision was 4.3-7.3%, and intra-assay precision was 3.4-6.1%. The average matrix effect was -6.42%. The extraction yield was 95-103.3%. U concentrations measured in serum obtained with the Tasso-SST® device and venous blood plasma were highly correlated (rs = 0.910, P < 0.0001), and no systematic or proportional bias between U levels measured in both matrices was found. CONCLUSIONS The use of blood microsampling with the Tasso-SST® device is a useful alternative for the measurement of U and the identification of patients with DPD deficiency.
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Affiliation(s)
- Milene Menestrina Dewes
- Analytical Toxicology Laboratory, Universidade Feevale, Novo Hamburgo, RS, Brazil; Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Novo Hamburgo, RS, Brazil
| | - Laura Cé da Silva
- Analytical Toxicology Laboratory, Universidade Feevale, Novo Hamburgo, RS, Brazil; Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Novo Hamburgo, RS, Brazil
| | | | | | | | | | - Roberta Zilles Hahn
- Analytical Toxicology Laboratory, Universidade Feevale, Novo Hamburgo, RS, Brazil
| | - Marina Venzon Antunes
- Analytical Toxicology Laboratory, Universidade Feevale, Novo Hamburgo, RS, Brazil; Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Novo Hamburgo, RS, Brazil
| | - Rafael Linden
- Analytical Toxicology Laboratory, Universidade Feevale, Novo Hamburgo, RS, Brazil; Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Novo Hamburgo, RS, Brazil.
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31
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Farinango C, Gallardo-Cóndor J, Freire-Paspuel B, Flores-Espinoza R, Jaramillo-Koupermann G, López-Cortés A, Burgos G, Tejera E, Cabrera-Andrade A. Genetic Variations of the DPYD Gene and Its Relationship with Ancestry Proportions in Different Ecuadorian Trihybrid Populations. J Pers Med 2022; 12:jpm12060950. [PMID: 35743735 PMCID: PMC9225136 DOI: 10.3390/jpm12060950] [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: 05/04/2022] [Revised: 05/26/2022] [Accepted: 06/01/2022] [Indexed: 11/16/2022] Open
Abstract
Dihydropyrimidine dehydrogenase is one of the main pharmacological metabolizers of fluoropyrimidines, a group of drugs widely used in clinical oncology. Around 20 to 30% of patients treated with fluoropyrimidines experience severe toxicity caused by a partial or total decrease in enzymatic activity. This decrease is due to molecular variants in the DPYD gene. Their prevalence and allelic frequencies vary considerably worldwide, so their description in heterogeneous groups such as the Ecuadorian population will allow for the description of pharmacogenetic variants and proper characterization of this population. Thus, we genotyped all the molecular variants with a predictive value for DPYD in a total of 410 Ecuadorian individuals belonging to Mestizo, Afro-Ecuadorian, and Indigenous ethnic groups. Moreover, we developed a genetic ancestry analysis using 46 autosomal ancestry informative markers. We determined 20 genetic variations in 5 amplified regions, including 3 novel single nucleotide variants. The allele frequencies for DPYD variants c.1627G>A (*5, rs1801159), c.1129-15T>C (rs56293913), c.1218G>A (rs61622928), rs1337752, rs141050810, rs2786783, rs2811178, and g.97450142G>A (chr1, GRCh38.p13) are significantly related to Native American and African ancestry proportions. In addition, the FST calculated from these variants demonstrates the closeness between Indigenous and Mestizo populations, and evidences genetic divergence between Afro-Ecuadorian groups when compared with Mestizo and Indigenous ethnic groups. In conclusion, the genetic variability in the DPYD gene is related to the genetic component of ancestral populations in different Ecuadorian ethnic groups. The absence and low frequency of variants with predictive value for fluoropyrimidine toxicity such as DPYD *2A, HapB3, and c.2846A>T (prevalent in populations with European ancestry) is consistent with the genetic background found.
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Affiliation(s)
- Camila Farinango
- Facultad de Ingeniería y Ciencias Aplicadas, Universidad de Las Américas, Quito 170125, Ecuador; (C.F.); (J.G.-C.); (E.T.)
| | - Jennifer Gallardo-Cóndor
- Facultad de Ingeniería y Ciencias Aplicadas, Universidad de Las Américas, Quito 170125, Ecuador; (C.F.); (J.G.-C.); (E.T.)
| | - Byron Freire-Paspuel
- Laboratorios de Investigación, Universidad de Las Américas, Quito 170125, Ecuador; (B.F.-P.); (R.F.-E.)
- Vall d’Hebron Research Institute, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
| | - Rodrigo Flores-Espinoza
- Laboratorios de Investigación, Universidad de Las Américas, Quito 170125, Ecuador; (B.F.-P.); (R.F.-E.)
- Laboratório de Diagnóstico por DNA (LDD), Universidade do Estado do Rio de Janeiro, Rio de Janeiro 20550-013, Brazil
| | - Gabriela Jaramillo-Koupermann
- Laboratorio de Biología Molecular, Subproceso de Anatomía Patológica, Hospital de Especialidades Eugenio Espejo, Quito 170403, Ecuador;
| | - Andrés López-Cortés
- Escuela de Medicina, Facultad de Ciencias de la Salud, Universidad de Las Américas, Quito 170125, Ecuador; (A.L.-C.); (G.B.)
- Programa de Investigación en Salud Global, Facultad de Ciencias de la Salud, Universidad Internacional SEK, Quito 170302, Ecuador
- Latin American Network for the Implementation and Validation of Clinical Pharmacogenomics Guidelines (RELIVAF-CYTED), 28001 Madrid, Spain
| | - Germán Burgos
- Escuela de Medicina, Facultad de Ciencias de la Salud, Universidad de Las Américas, Quito 170125, Ecuador; (A.L.-C.); (G.B.)
| | - Eduardo Tejera
- Facultad de Ingeniería y Ciencias Aplicadas, Universidad de Las Américas, Quito 170125, Ecuador; (C.F.); (J.G.-C.); (E.T.)
- Grupo de Bio-Quimioinformática, Universidad de Las Américas, Quito 170125, Ecuador
| | - Alejandro Cabrera-Andrade
- Grupo de Bio-Quimioinformática, Universidad de Las Américas, Quito 170125, Ecuador
- Carrera de Enfermería, Facultad de Ciencias de la Salud, Universidad de Las Américas, Quito 170125, Ecuador
- Correspondence:
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32
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Araki H, Takenaka T, Takahashi K, Yamashita F, Matsuoka K, Yoshisue K, Ieiri I. A semimechanistic population pharmacokinetic and pharmacodynamic model incorporating autoinduction for the dose justification of TAS-114. CPT Pharmacometrics Syst Pharmacol 2022; 11:604-615. [PMID: 34951129 PMCID: PMC9124359 DOI: 10.1002/psp4.12747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 10/17/2021] [Accepted: 11/09/2021] [Indexed: 12/20/2022] Open
Abstract
TAS-114 is a dual deoxyuridine triphosphatase (dUTPase) and dihydropyrimidine dehydrogenase (DPD) inhibitor expected to widen the therapeutic index of capecitabine. Its maximum tolerated dose (MTD) was determined from a safety perspective in a combination study with capecitabine; however, its inhibitory effects on DPD activity were not assessed in the study. The dose justification to select its MTD as the recommended dose in terms of DPD inhibition has been required, but the autoinduction profile of TAS-114 made it difficult. To this end, an approach using a population pharmacokinetic (PPK)/pharmacodynamic (PD) model incorporating autoinduction was planned; however, the utility of this approach in the dose justification has not been reported. Thus, the aim of this study was to demonstrate the utility of a PPK/PD model incorporating autoinduction in the dose justification via a case study of TAS-114. Plasma concentrations of TAS-114 from 185 subjects and those of the endogenous DPD substrate uracil from 24 subjects were used. A two-compartment model with first-order absorption with lag time and an enzyme turnover model were selected for the pharmacokinetic (PK) model. Moreover, an indirect response model was selected for the PD model to capture the changes in plasma uracil concentrations. Model-based simulations provided the dose justification that DPD inhibition by TAS-114 reached a plateau level at the MTD, whereas exposures of TAS-114 increased dose dependently. Thus, the utility of a PPK/PD model incorporating autoinduction in the dose justification was demonstrated via this case study of TAS-114.
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Affiliation(s)
- Hikari Araki
- Pharmacokinetics Research LaboratoriesTaiho Pharmaceutical Co. Ltd.TsukubaIbarakiJapan
| | - Toru Takenaka
- Pharmacokinetics Research LaboratoriesTaiho Pharmaceutical Co. Ltd.TsukubaIbarakiJapan
| | - Koichi Takahashi
- Pharmacokinetics Research LaboratoriesTaiho Pharmaceutical Co. Ltd.TsukubaIbarakiJapan
| | - Fumiaki Yamashita
- Pharmacokinetics Research LaboratoriesTaiho Pharmaceutical Co. Ltd.TsukubaIbarakiJapan
| | - Kazuaki Matsuoka
- Pharmacokinetics Research LaboratoriesTaiho Pharmaceutical Co. Ltd.TsukubaIbarakiJapan
| | - Kunihiro Yoshisue
- Pharmacokinetics Research LaboratoriesTaiho Pharmaceutical Co. Ltd.TsukubaIbarakiJapan
| | - Ichiro Ieiri
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical SciencesKyushu UniversityFukuokaJapan
- Department of PharmacyKyushu University HospitalFukuokaJapan
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33
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La pharmacogénétique en oncologie, ce qu’il faut savoir à l’officine. ACTUALITES PHARMACEUTIQUES 2022. [DOI: 10.1016/j.actpha.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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34
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Capiau S, Van Landschoot A, Reyns T, Stepman H. Pre-analytical considerations for the analysis of uracil and 5,6-dihydrouracil in heparin plasma. Clin Chem Lab Med 2022; 60:e112-e115. [PMID: 35073467 DOI: 10.1515/cclm-2021-0921] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/10/2022] [Indexed: 01/04/2024]
Affiliation(s)
- Sara Capiau
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Tim Reyns
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Hedwig Stepman
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
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35
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Casneuf V, Borbath I, Van den Eynde M, Verheezen Y, Demey W, Verstraete AG, Bm Claes K, Haufroid V, Geboes KP. Joint Belgian recommendation on screening for DPD-deficiency in patients treated with 5-FU, capecitabine (and tegafur). Acta Clin Belg 2022; 77:346-352. [PMID: 33423619 DOI: 10.1080/17843286.2020.1870855] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Fluoropyrimidines such as 5-Fluorouracil (5-FU), capecitabine and tegafur are drugs that are often used in the treatment of maliginancies. The enzyme dihydropyrimidine dehydrogenase (DPD) is the first and rate limiting enzyme of 5-FU catabolism. Genetic variations within the DPYD gene (encoding for DPD protein) can lead to reduced or absent DPD activity. Treatment of DPD deficient patients with fluoropyrimidines can result in severe and, rarely, fatal toxicity. Screening for DPD deficiency should be implemented in practice. METHODS The available methods in routine to screen for DPD deficiency were analyzed and discussed in several group meetings involving members of the oncological, genetic and toxicological societies in Belgium: targeted genotyping based on the detection of 4 DPYD variants and phenotyping, through the measurement of uracil and dihydrouracil/uracil ratio in plasma samples. RESULTS The main advantage of targeted genotyping is the existence of prospectively validated genotype-based dosing guidelines. The main limitations of this approach are the relatively low sensitivity to detect total and partial DPD deficiency and the fact that this approach has only been validated in Caucasians so far. Phenotyping has a better sensitivity to detect total and partial DPD deficiency when performed in the correct analytical conditions and is not dependent on the ethnic origin of the patient. CONCLUSION In Belgium, we recommend phenotype or targeted genotype testing for DPD deficiency before starting 5-FU, capecitabine or tegafur. We strongly suggest a stepwise approach using phenotype testing upfront because of the higher sensitivity and the lower cost to society.
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Affiliation(s)
- Veerle Casneuf
- Department of Gastroenterology, OLV Aalst, Aalst, Belgium
| | - Ivan Borbath
- Department of Hepatology and Gastroenterology, University Hospital St Luc/UCLouvain, Woluwe
| | | | | | - Wim Demey
- Department of Oncology, AZ Klina, Brasschaat Belgium
| | | | | | - Vincent Haufroid
- Department of Toxicology and Applied Pharmacology, University Hospital St Luc/UCLouvain, Woluwe
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Kataria SP, Nagar M, Verma S, Purohit V. Oral Tegafur-Uracil Combination plus Leucovorin versus Other Fluoropyrimidine Agents in Colorectal Cancer: A Systematic Review and Meta-Analysis. South Asian J Cancer 2022; 11:84-94. [PMID: 35833043 PMCID: PMC9273330 DOI: 10.1055/s-0041-1735650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background
Systemic fluoropyrimidines, both oral and intravenous, are an integral part of colorectal cancer (CRC) management. They can be administered either with curative or palliative intent.
Objectives
This article examines the literature to analyze the efficacy and safety of the oral fixed-dose combination of uracil and tegafur (UFT)/leucovorin (LV) compared with other fluoropyrimidine agents, with an intention to implement the findings into the current treatment algorithms for CRC.
Methods
An exhaustive systematic literature search was performed for prospective studies using PUBMED, Cochrane Library, and EMBASE database. Studies which met eligibility criteria were shortlisted and grouped into chemotherapy given for curative or palliative intent.
Results
Eight trials were shortlisted involving 4,486 patients for the analysis. There was no difference between UFT/LV and other fluoropyrimidines in the primary endpoints—disease-free survival (hazard ratio [HR] 1.01; 95% confidence interval [CI] 0.90–.15;
p
= 0.81) and progression-free survival (HR 0.87; 95% CI 0.66–.66;
p
= 0.35) for curative and palliative intent CRC patients, respectively. In secondary analyses, there was no significant difference observed between UFT and other fluoropyrimidines in overall survival in CRC patients with curative intent (HR 1.04; 95% CI 0.88–1.23;
p
= 0.63) and palliative intent (HR 1.02; 95% CI 0.97–1.06;
p
= 0.42) . In the safety analysis, we found significantly lesser patients on UFT/LV had stomatitis/mucositis (odds ratio [OR] 0.20; 95% CI 0.05–0.85;
p
= 0.03), fever (OR 0.46; 95% CI 0.29–0.71;
p
< 0.001), infection (OR 0.42; 95% CI 0.24–0.74;
p
< 0.01), leukopenia (OR 0.04; 95% CI 0.00–0.95;
p
= 0.05), febrile neutropenia (OR 0.03; 95% CI 0.00–0.24;
p
= 0.001), and thrombocytopenia (OR 0.14; 95% CI 0.02–0.79;
p
= 0.03) compared with other fluoropyrimidines.
Conclusion
Oral UFT/LV is equally efficacious to other fluoropyrimidines, especially intravenous 5-fluorouracil, in the management of early as well as advanced CRC patients. Importantly, UFT/LV has a superior safety profile compared with other fluoropyrimidines in terms of both hematological and nonhematological adverse events.
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Affiliation(s)
- Satya Pal Kataria
- Department of Medical Oncology, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
| | - Mukesh Nagar
- Department of Medical Oncology, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
| | - Shikha Verma
- Department of Oncology, Lupin Ltd., Mumbai, Maharashtra, India
| | - Vinay Purohit
- Department of Oncology, Lupin Ltd., Mumbai, Maharashtra, India
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Schmulenson E, Zimmermann N, Mikus G, Joerger M, Jaehde U. Current status and future outlooks on therapeutic drug monitoring of fluorouracil. Expert Opin Drug Metab Toxicol 2022; 17:1407-1422. [PMID: 35029518 DOI: 10.1080/17425255.2021.2029403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION : Therapeutic drug monitoring (TDM) of the anticancer drug fluorouracil (5FU) as a method to support dose adjustments has been researched and discussed extensively. Despite manifold evidence of the advantages of 5FU-TDM, traditional body surface area (BSA)-guided dosing is still widely applied. AREAS COVERED : This review covers the latest evidence on 5FU-TDM based on a literature search in PubMed between June and September 2021. It particularly highlights new approaches of implementing 5FU-TDM into precision medicine by combining TDM with pharmacogenetic testing and/or pharmacometric models. This review further discusses remaining obstacles in order to incorporate 5FU-TDM into clinical routine. EXPERT OPINION : New data on 5FU-TDM further strengthen the advantages compared to BSA-guided dosing as it is able to reduce pharmacokinetic variability and thereby improve treatment efficacy and safety. Interprofessional collaboration has the potential to overcome the remaining barriers for its implementation. Pre-emptive pharmacogenetic testing followed by 5FU-TDM can further improve 5FU exposure in a substantial proportion of patients. Developing a model framework integrating pharmacokinetics and pharmacodynamics of 5FU will be crucial to fully advance into the precision medicine era. Model applications can potentially support clinicians in dose finding before starting chemotherapy. Additionally, TDM provides further assistance in continuously improving model predictions.
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Affiliation(s)
- Eduard Schmulenson
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany
| | - Nigina Zimmermann
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany.,Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany.,Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Joerger
- Department of Medical Oncology and Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Ulrich Jaehde
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany
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Gmeiner WH. A narrative review of genetic factors affecting fluoropyrimidine toxicity. PRECISION CANCER MEDICINE 2021; 4:38. [PMID: 34901834 PMCID: PMC8664072 DOI: 10.21037/pcm-21-17] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Our objective is to document progress in developing personalized therapy with fluoropyrimidine drugs (FPs) to improve outcomes for cancer patients and to identify areas requiring further investigation. BACKGROUND FPs including 5-fluorouracil (5-FU), are among the most widely used drugs for treating colorectal cancer (CRC) and other gastrointestinal (GI) malignancies. While FPs confer a survival benefit for CRC patients, serious systemic toxicities, including neutropenia, occur in ~30% of patients with lethality in 0.5-1% of patients. While serious systemic toxicities may occur in any patient, patients with polymorphisms in DPYD, which encodes the rate-limiting enzyme for pyrimidine degradation are at very high risk. Other genetic factors affecting risk for 5-FU toxicity, including miR-27a, are under investigation. METHODS Literature used to inform the text of this article was selected from PubMed.gov from the National Library of Medicine while regulatory documents were identified via Google search. CONCLUSIONS Clinical studies to date have validated four DPYD polymorphisms (DPYD*2A, DPYD*13, c.2846A>T, HapB3) associated with serious toxicities in patients treated with 5-FU. Genetic screening for these is being implemented in the Netherlands and the UK and has been shown to be a cost-effective way to improve outcomes. Factors other than DPYD polymorphisms (e.g., miR-27a, TYMS, ENOSF1, p53) also affect 5-FU toxicity. Functional testing for deficient pyrimidine catabolism {defined as [U] >16 ng/mL or [UH2]:[U] <10} is being implemented in France and has demonstrated utility in identifying patients with elevated risk for 5-FU toxicity. Therapeutic drug monitoring (TDM) from plasma levels of 5-FU during first cycle treatment also is being used to improve outcomes and pharmacokinetic-based dosing is being used to increase the percent of patients within optimal area under the curve (AUC) (18-28 mg*h/L) values. Patients maintained in the optimal AUC range experienced significantly reduced systemic toxicities. As understanding the genetic basis for increased risk of 5-FU toxicity becomes more refined, the development of functional-based methods to optimize treatment is likely to become more widespread.
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Affiliation(s)
- William H Gmeiner
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Chakwop Ngassa H, Elmenawi KA, Anil V, Gosal H, Kaur H, Mohammed L. Abnormal Dihydropyrimidine Dehydrogenase Activity as an Indicator of Potential 5-Fluorouracil Linked Cardiotoxicity in Colorectal Cancer Patients: Are Toxic Events Inevitable? Cureus 2021; 13:e17712. [PMID: 34650886 PMCID: PMC8489794 DOI: 10.7759/cureus.17712] [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: 06/02/2021] [Accepted: 09/04/2021] [Indexed: 11/05/2022] Open
Abstract
Colorectal cancer (CRC) treatment can be limited to surgical resection for low stages of the disease while subsequent chemotherapy is the preferred treatment for the higher-stage disease. This chemotherapy relies heavily on fluoropyrimidine: 5-fluorouracil (5-FU) and capecitabine, a role played for decades. Fluoropyrimidine-linked treatment can present important and even lethal toxic events at the cardiac level like acute coronary syndrome, arrhythmias, and death. The production of these toxic events depends on the capacity of a subject to metabolize the fluoropyrimidines adequately, and this depends on the activity of the enzyme dihydropyrimidine dehydrogenase (DPD). Any change that affects the quantity or quality of this enzyme will compromise its capacity to metabolize the fluoropyrimidines. The resultant abnormal enzyme activity exposes the patient to continuously high levels of the chemotherapeutic agent or its catabolites. Consequently, the patient becomes more susceptible to pyrimidine-linked toxic adverse events. Genetic testing of patients for potential decreased DPD activity before subjecting them to fluoropyrimidine-based chemotherapy will help identify subjects at greater risk of increased cardiotoxicities, the possibility of prompt intervention, should these appear, and a multidisciplinary strategy aimed at managing these cases. Potential cases of cardiotoxicity in CRC patients, candidates to fluoropyrimidine toxicities, can be anticipated by pretreatment screening of DPD activity. Pretreatment screening will reduce many hospitalizations with a consequent decrease in costs both to the patients and the healthcare system. This review article will examine the 5-FU linked cardiotoxicity, known correlated risk factors, clinical manifestations, management strategy, and the role of genetic testing in identifying high-risk patients.
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Affiliation(s)
- Hyginus Chakwop Ngassa
- Surgery, Università degli Studi di Brescia Facoltà di Medicina e Chirurgia, Brescia, ITA.,Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Khaled A Elmenawi
- Surgery, Cairo University, Cairo, EGY.,Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Vishwanath Anil
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Harpreet Gosal
- Internal Medicine/Emergency Medicine, Government Medical College Amritsar, Amritsar, IND.,Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Harsimran Kaur
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Lubna Mohammed
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Severe 5-Fluorouracil-Associated Gastrointestinal Toxicity Unexplained by Dihydropyrimidine Dehydrogenase Deficiency and Renal Impairment: Should We Be Investigating Other Elimination Pathways to Assess the Risk of 5-Fluorouracil Toxicity? Eur J Drug Metab Pharmacokinet 2021; 46:817-820. [PMID: 34570362 DOI: 10.1007/s13318-021-00721-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 10/20/2022]
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41
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Pretherapeutic screening for Dihydropyrimidine deshydrogenase deficiency in measuring uracilemia in dialysis patients leads to a high rate of falsely positive results. Cancer Chemother Pharmacol 2021; 88:1049-1053. [PMID: 34515833 DOI: 10.1007/s00280-021-04354-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/05/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Pretherapeutic screening for dihydropyrimidine dehydrogenase (DPD) deficiency is recommended prior to the administration of fluoropyrimidine-based chemotherapy. However, the best strategy to identify DPD deficiency in End Stage Renal Disease (ESRD) patients is unknown. METHODS We assessed the characteristics of both DPD phenotypes and DPYD genotypes in 20 dialyzed patients before and after dialysis session. The extent to which the concentrations of uracil [U] and dihydrouracil [UH2] were affected by dialysis was evaluated. RESULTS Mean [U] was 14 ± 3.3 ng/ml before the dialysis session, and 7.9 ± 2.7 ng/ml after. Notably, mean [U] in 119 non-ESRD patients during the same timeline was 8.7 ± 3.9 ng/ml, which is similar to [U] values after dialysis session (p = 0.38). [U] values > 16 ng/ml were measured in 4 ESRD patients (20%), whereas the rate was 3.3% in the non-ESRD cohort. Whole gene sequencing did not reveal DPYD deleterious allelic variants in the 4 ESRD patients with [U] values > 16 ng/ml. The profile of [UH2] values during dialysis was similar to that of [U]: 385 ± 86 ng/ml before, and 185 ± 62 ng/ml after (mean reduction rate 42.5%). Thus, [UH2]:[U] ratio remained unaffected by dialysis, and was similar to the values in non-ESRD patients (22.4 ± 7.1). CONCLUSION Phenotyping based on measuring plasma [U] before a dialysis sessions in ESRD patients is associated with an unacceptable high rate of false positives. The optimal strategy for the identification of patients with DPD deficiency in this population would be the monitor the [UH2]:[U] ratio, which remains unaffected.
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DPYD Genotyping in Patients Who Have Planned Cancer Treatment With Fluoropyrimidines: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2021; 21:1-186. [PMID: 34484488 PMCID: PMC8382304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Fluoropyrimidine drugs (such as 5-fluorouracil and capecitabine) are used to treat different types of cancer. However, these drugs may cause severe toxicity in about 10% to 40% of patients. A deficiency in the dihydropyrimidine dehydrogenase (DPD) enzyme, encoded by the DPYD gene, increases the risk of severe toxicity. DPYD genotyping aims to identify variants that lead to DPD deficiency and may help to identify people who are at higher risk of developing severe toxicity, allowing their treatment to be modified before it begins. Recommendations for fluoropyrimidine treatment modification are available for four DPYD variants, which are the focus of this review: DPYD∗2A, DPYD∗13, c.2846A>T, and c.1236G>A. We conducted a health technology assessment of DPYD genotyping for patients who have planned cancer treatment with fluoropyrimidines, which included an evaluation of clinical validity, clinical utility, the effectiveness of treatment with a reduced fluoropyrimidine dose, cost-effectiveness, the budget impact of publicly funding DPYD genotyping, and patient preferences and values. METHODS We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included systematic review and primary study using the Risk of Bias in Systematic Reviews (ROBIS) tool and the Newcastle-Ottawa Scale, respectively, and we assessed the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature review and conducted cost-effectiveness and cost-utility analyses with a half-year time horizon from a public payer perspective. We also analyzed the budget impact of publicly funding pre-treatment DPYD genotyping in patients with planned fluoropyrimidine treatment in Ontario. To contextualize the potential value of DPYD testing, we spoke with people who had planned cancer treatment with fluoropyrimidines. RESULTS We included 29 observational studies in the clinical evidence review, 25 of which compared the risk of severe toxicity in carriers of a DPYD variant treated with a standard fluoropyrimidine dose with the risk in wild-type patients (i.e., non-carriers of the variants under assessment). Heterozygous carriers of a DPYD variant treated with a standard fluoropyrimidine dose may have a higher risk of severe toxicity, dose reduction, treatment discontinuation, and hospitalization compared to wild-type patients (GRADE: Low). Six studies evaluated the risk of severe toxicity in DPYD carriers treated with a genotype-guided reduced fluoropyrimidine dose versus the risk in wild-type patients; one study also included a second comparator group of DPYD carriers treated with a standard dose. The evidence was uncertain, because the results of most of these studies were imprecise (GRADE: Very low). The length of hospital stay was shorter in DPYD carriers treated with a reduced dose than in DPYD carriers treated with a standard dose, but the evidence was uncertain (GRADE: Very low). One study assessed the effectiveness of a genotype-guided reduced fluoropyrimidine dose in DPYD∗2A carriers versus wild-type patients, but the results were imprecise (GRADE: Very low).We found two cost-minimization analyses that compared the costs of the DPYD genotyping strategy with usual care (no testing) in the economic literature review. Both studies found that DPYD genotyping was cost-saving compared to usual care. Our primary economic evaluation, a cost-utility analysis, found that DPYD genotyping might be slightly more effective (incremental quality-adjusted life years of 0.0011) and less costly than usual care (a savings of $144.88 per patient), with some uncertainty. The probability of DPYD genotyping being cost-effective compared to usual care was 91% and 96% at the commonly used willingness-to-pay values of $50,000 and $100,000 per quality-adjusted life-year gained, respectively. Assuming a slow uptake, we estimated that publicly funding pre-treatment DPYD genotyping in Ontario would lead to a savings of $714,963 over the next 5 years.The participants we spoke to had been diagnosed with cancer and treated with fluoropyrimidines. They reported on the negative side effects of their treatment, which affected their day-to-day activities, employment, and mental health. Participants viewed DPYD testing as a beneficial addition to their treatment journey; they noted the importance of having all available information possible so they could make informed decisions to avoid adverse reactions. Barriers to DPYD testing include lack of awareness of the test and the fact that the test is being offered in only one hospital in Ontario. CONCLUSIONS Studies found that carriers of a DPYD variant who were treated with a standard fluoropyrimidine dose may have a higher risk of severe toxicity than wild-type patients treated with a standard dose. DPYD genotyping led to fluoropyrimidine treatment modifications. It is uncertain whether genotype-guided dose reduction in heterozygous DPYD carriers resulted in a risk of severe toxicity comparable to that of wild-type patients. It is also uncertain if the reduced dose resulted in a lower risk of severe toxicity compared to DPYD carriers treated with a standard dose. It is also uncertain whether the treatment effectiveness of a reduced dose in carriers was comparable to the effectiveness of a standard dose in wild-type patients.For patients with planned cancer treatment with fluoropyrimidines, DPYD genotyping is likely cost-effective compared to usual care. We estimate that publicly funding DPYD genotyping in Ontario may be cost-saving, with an estimated total of $714,963 over the next 5 years, provided that the implementation, service delivery, and program coordination costs do not exceed this amount.For people treated with fluoropyrimidines, cancer and treatment side effects had a substantial negative effect on their quality of life and mental health. Most saw the value of DPYD testing as a way of reducing the risk of serious adverse events. Barriers to receipt of DPYD genotyping included lack of awareness and limited access to DPYD testing.
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Bukhari N, Alshangiti A, Tashkandi E, Algarni M, Al-Shamsi HO, Al-Khallaf H. Fluoropyrimidine-Induced Severe Toxicities Associated with Rare DPYD Polymorphisms: Case Series from Saudi Arabia and a Review of the Literature. Clin Pract 2021; 11:467-471. [PMID: 34449540 PMCID: PMC8395516 DOI: 10.3390/clinpract11030062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/13/2021] [Accepted: 06/24/2021] [Indexed: 11/16/2022] Open
Abstract
Dihydropyrimidine dehydrogenase (DPD) is the major enzyme in the catabolism of 5-Fluorouracil (5-FU) and its prodrug capecitabine. We report cases from our institute with colorectal cancer who experienced severe toxicities to standard dose 5-FU based chemotherapy. DPYD gene sequencing revealed rare different polymorphisms that prompted dose adjustments of administered 5-FU and capecitabine. To our knowledge, this is the first case series looking at DPYD polymorphisms in the Saudi Arabian population.
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Affiliation(s)
- Nedal Bukhari
- Department of Medical Oncology, King Fahad Specialist Hospital, Dammam 31444, Saudi Arabia;
- Department of Internal Medicine, Imam Abdulrahman Bin Faisal University, Dammam 34212, Saudi Arabia
| | - Abdulraheem Alshangiti
- Department of Medical Oncology, King Fahad Specialist Hospital, Dammam 31444, Saudi Arabia;
| | - Emad Tashkandi
- Oncology Centre, King Abdullah Medical City, Makkah 24246, Saudi Arabia;
- College of Medicine, Umm Al-Qura University, Makkah 24211, Saudi Arabia
| | - Mohammed Algarni
- Oncology Department, King Abdulaziz Medical City, Riyadh 11426, Saudi Arabia;
- King Saud bin Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia
| | - Humaid O. Al-Shamsi
- Department of Oncology, Burjeel Cancer Institute, Burjeel Medical City, Abu Dhabi 999041, United Arab Emirates;
- Emirates Oncology Society, Dubai 22107, United Arab Emirates
- College of Medicine, University of Sharjah, Sharjah 999041, United Arab Emirates
| | - Hamoud Al-Khallaf
- Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital, Dammam 31444, Saudi Arabia;
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44
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Hodroj K, Barthelemy D, Lega JC, Grenet G, Gagnieu MC, Walter T, Guitton J, Payen-Gay L. Issues and limitations of available biomarkers for fluoropyrimidine-based chemotherapy toxicity, a narrative review of the literature. ESMO Open 2021; 6:100125. [PMID: 33895696 PMCID: PMC8095125 DOI: 10.1016/j.esmoop.2021.100125] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/17/2021] [Accepted: 03/27/2021] [Indexed: 12/03/2022] Open
Abstract
Fluoropyrimidine-based chemotherapies are widely used to treat gastrointestinal tract, head and neck, and breast carcinomas. Severe toxicities mostly impact rapidly dividing cell lines and can occur due to the partial or complete deficiency in dihydropyrimidine dehydrogenase (DPD) catabolism. Since April 2020, the European Medicines Agency (EMA) recommends DPD testing before any fluoropyrimidine-based treatment. Currently, different assays are used to predict DPD deficiency; the two main approaches consist of either phenotyping the enzyme activity (directly or indirectly) or genotyping the four main deficiency-related polymorphisms associated with 5-fluorouracil (5-FU) toxicity. In this review, we focused on the advantages and limitations of these diagnostic methods: direct phenotyping by evaluation of peripheral mononuclear cell DPD activity (PBMC-DPD activity), indirect phenotyping assessed by uracil levels or UH2/U ratio, and genotyping DPD of four variants directly associated with 5-FU toxicity. The risk of 5-FU toxicity increases with uracil concentration. Having a pyrimidine-related structure, 5-FU is catabolised by the same physiological pathway. By assessing uracil concentration in plasma, indirect phenotyping of DPD is then measured. With this approach, in France, a decreased 5-FU dose is systematically recommended at a uracil concentration of 16 ng/ml, which may lead to chemotherapy under-exposure as uracil concentration is a continuous variable and the association between uracil levels and DPD activity is not clear. We aim herein to describe the different available strategies developed to improve fluoropyrimidine-based chemotherapy safety, how they are implemented in routine clinical practice, and the possible relationship with inefficacy mechanisms.
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Affiliation(s)
- K Hodroj
- Laboratoire de Biochimie et Biologie Moléculaire, Groupe Hospitalier Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - D Barthelemy
- Laboratoire de Biochimie et Biologie Moléculaire, Groupe Hospitalier Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Hospices Civils de Lyon Cancer institute, CIRculating CANcer (CIRCAN) Programme, Pierre-Bénite, France
| | - J-C Lega
- Hospices Civils de Lyon, Service de Médecine Interne et Vasculaire, Hôpital Lyon Sud, Pierre-Bénite, France
| | - G Grenet
- Hospices Civils de Lyon, Pole Santé Publique, Service Hospitalo-Universitaire de Pharmacotoxicologie, Lyon, France
| | - M-C Gagnieu
- Laboratoire de Biochimie et Biologie Moléculaire, Groupe Hospitalier Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - T Walter
- Hospices Civils de Lyon Cancer institute, CIRculating CANcer (CIRCAN) Programme, Pierre-Bénite, France; Hospices Civils de Lyon, Service d'Oncologie Médicale, Hôpital Edouard Herriot, Lyon, France
| | - J Guitton
- Laboratoire de Biochimie et Biologie Moléculaire, Groupe Hospitalier Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Centre de Recherche en Cancerologie de Lyon-Ribosome, Traduction et Cancer, UMR INSERM 1052 CNRS 5286, Lyon, France
| | - L Payen-Gay
- Laboratoire de Biochimie et Biologie Moléculaire, Groupe Hospitalier Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Hospices Civils de Lyon Cancer institute, CIRculating CANcer (CIRCAN) Programme, Pierre-Bénite, France; EMR 3738 Ciblage Therapeutique en Oncologie, Faculté de Médecine Lyon Sud, Université Lyon 1, Université de Lyon, Oullins, France.
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Hamzic S, Schärer D, Offer SM, Meulendijks D, Nakas C, Diasio RB, Fontana S, Wehrli M, Schürch S, Amstutz U, Largiadèr CR. Haplotype structure defines effects of common DPYD variants c.85T > C (rs1801265) and c.496A > G (rs2297595) on dihydropyrimidine dehydrogenase activity: Implication for 5-fluorouracil toxicity. Br J Clin Pharmacol 2021; 87:3234-3243. [PMID: 33491253 PMCID: PMC8359980 DOI: 10.1111/bcp.14742] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 01/09/2021] [Accepted: 01/12/2021] [Indexed: 12/18/2022] Open
Abstract
Aims The aim of this study was to identify risk variants and haplotypes that impair dihydropyrimidine dehydrogenase (DPD) activity and are, therefore, candidate risk variants for severe toxicity to 5‐fluorouracil (5‐FU) chemotherapy. Methods Plasma dihydrouracil/uracil (UH2/U) ratios were measured as a population marker for DPD activity in a total of 1382 subjects from 4 independent studies. Genotype and haplotype correlations with UH2/U ratios were assessed. Results Significantly lower UH2/U ratios (panova < 2 × 10−16) were observed in carriers of the 4 well‐studied 5‐FU toxicity risk variants with mean differences (MD) of −43.7% for DPYD c.1905 + 1G > A (rs3918290), −46.0% for DPYD c.1679T > G (rs55886062), −37.1%, for DPYD c.2846A > T (rs67376798), and −13.2% for DPYD c.1129‐5923C > G (rs75017182). An additional variant, DPYD c.496A > G (rs2297595), was also associated with lower UH2/U ratios (P < .0001, MD: −12.6%). A haplotype analysis was performed for variants in linkage disequilibrium with c.496A > G, which consisted of the common variant c.85T > C (rs1801265) and the risk variant c.1129‐5923C > G. Both haplotypes carrying c.496A > G were associated with decreased UH2/U ratios (H3, P = .003, MD: −9.6%; H5, P = .002, MD: −16.9%). A haplotype carrying only the variant c.85T > C (H2) was associated with elevated ratios (P = .004, MD: +8.6%). Conclusions Based on our data, DPYD‐c.496A > G is a strong candidate risk allele for 5‐FU toxicity. Our data suggest that DPYD‐c.85T > C might be protective; however, the deleterious impacts of the linked alleles c.496A > G and c.1129‐5923C > G likely limit this effect in patients. The possible protective effect of c.85T > C and linkage disequilibrium with c.496A > G and c.1129‐5923C > G may have hampered prior association studies and should be considered in future clinical studies.
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Affiliation(s)
- Seid Hamzic
- Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, INO-F, Bern, Switzerland.,Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Dominic Schärer
- Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, INO-F, Bern, Switzerland.,Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Steven M Offer
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Didier Meulendijks
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Christos Nakas
- Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, INO-F, Bern, Switzerland.,Laboratory of Biometry, University of Thessaly, Volos, Greece
| | - Robert B Diasio
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Stefano Fontana
- Regional Blood Transfusion Service of the Swiss RedCross, Bern, Switzerland
| | - Marc Wehrli
- Department of Medical Oncology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Stefan Schürch
- Department of Chemistry and Biochemistry, University of Bern, Bern, Switzerland
| | - Ursula Amstutz
- Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, INO-F, Bern, Switzerland
| | - Carlo R Largiadèr
- Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, INO-F, Bern, Switzerland
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46
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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] [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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47
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Maillard M, Eche-Gass A, Ung M, Brice A, Marsili S, Montastruc M, Puisset F, Thomas F. Severe toxicity of capecitabine in a patient with DPD deficiency after a safe FEC-100 experience: why we should test DPD deficiency in all patients before high-dose fluoropyrimidines. Cancer Chemother Pharmacol 2021; 87:579-583. [PMID: 33587160 DOI: 10.1007/s00280-021-04233-1] [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: 12/18/2020] [Accepted: 01/12/2021] [Indexed: 10/22/2022]
Abstract
We report the case of a 44-year-old patient who experienced severe toxicity while being treated with capecitabine at standard dose for metastatic breast cancer. As the patient had already received 5-FU within the FEC protocol (5-FU 500 mg/m2, epirubicin 100 mg/m2, and cyclophosphamide 500 mg/m2) 10 years ago without experiencing any severe adverse event, no DPD deficiency testing was performed before capecitabine treatment. Nevertheless, she experienced severe diarrhea and grade 2 hand-foot syndrome from the first cycle, forcing her to stop the treatment. Phenotypic and genotypic investigation of DPD activity revealed that the patient had a partial deficiency and had therefore been exposed to a higher risk of developing severe toxicities on fluoropyrimidines. This case proves that tolerance to low-dose fluoropyrimidines does not preclude DPD deficiency and the occurrence of severe toxicities if higher doses of fluoropyrimidines are used as a second-line treatment. It emphasizes the role of DPD phenotyping testing based on uracilemia in patients scheduled for fluoropyrimidine drugs, even if previous courses with low-dose 5-FU were safely administered.
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Affiliation(s)
- Maud Maillard
- Laboratoire de Biologie Médicale Oncologique, Secteur Pharmacologie, Institut Claudius-Regaud, Institut Universitaire du Cancer (IUCT), Oncopole, 1 Avenue Irène Joliot-Curie, 31059, Toulouse Cedex 9, France
- Centre de Recherches en Cancérologie de Toulouse (CRCT), Université de Toulouse, Inserm, U1037, Toulouse, France
| | - Audrey Eche-Gass
- Laboratoire de Biologie Médicale Oncologique, Secteur Pharmacologie, Institut Claudius-Regaud, Institut Universitaire du Cancer (IUCT), Oncopole, 1 Avenue Irène Joliot-Curie, 31059, Toulouse Cedex 9, France
| | - Mony Ung
- Laboratoire de Biologie Médicale Oncologique, Secteur Pharmacologie, Institut Claudius-Regaud, Institut Universitaire du Cancer (IUCT), Oncopole, 1 Avenue Irène Joliot-Curie, 31059, Toulouse Cedex 9, France
| | - Aurélie Brice
- Laboratoire de Biologie Médicale Oncologique, Secteur Pharmacologie, Institut Claudius-Regaud, Institut Universitaire du Cancer (IUCT), Oncopole, 1 Avenue Irène Joliot-Curie, 31059, Toulouse Cedex 9, France
- Centre de Recherches en Cancérologie de Toulouse (CRCT), Université de Toulouse, Inserm, U1037, Toulouse, France
| | - Sabrina Marsili
- Laboratoire de Biologie Médicale Oncologique, Secteur Pharmacologie, Institut Claudius-Regaud, Institut Universitaire du Cancer (IUCT), Oncopole, 1 Avenue Irène Joliot-Curie, 31059, Toulouse Cedex 9, France
- Centre de Recherches en Cancérologie de Toulouse (CRCT), Université de Toulouse, Inserm, U1037, Toulouse, France
| | - Marion Montastruc
- Laboratoire de Biologie Médicale Oncologique, Secteur Pharmacologie, Institut Claudius-Regaud, Institut Universitaire du Cancer (IUCT), Oncopole, 1 Avenue Irène Joliot-Curie, 31059, Toulouse Cedex 9, France
| | - Florent Puisset
- Laboratoire de Biologie Médicale Oncologique, Secteur Pharmacologie, Institut Claudius-Regaud, Institut Universitaire du Cancer (IUCT), Oncopole, 1 Avenue Irène Joliot-Curie, 31059, Toulouse Cedex 9, France
- Centre de Recherches en Cancérologie de Toulouse (CRCT), Université de Toulouse, Inserm, U1037, Toulouse, France
| | - Fabienne Thomas
- Laboratoire de Biologie Médicale Oncologique, Secteur Pharmacologie, Institut Claudius-Regaud, Institut Universitaire du Cancer (IUCT), Oncopole, 1 Avenue Irène Joliot-Curie, 31059, Toulouse Cedex 9, France.
- Centre de Recherches en Cancérologie de Toulouse (CRCT), Université de Toulouse, Inserm, U1037, Toulouse, France.
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48
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Lunar N, Etienne-Grimaldi MC, Macaire P, Thomas F, Dalenc F, Ferrero JM, Pivot X, Milano G, Royer B, Schmitt A. Population pharmacokinetic and pharmacodynamic modeling of capecitabine and its metabolites in breast cancer patients. Cancer Chemother Pharmacol 2021; 87:229-239. [PMID: 33386926 DOI: 10.1007/s00280-020-04208-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/19/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE The present study was performed to examine relationships between systemic exposure of capecitabine metabolites (5-FU, 5'-DFCR and 5'-DFUR) and toxicity or clinical response in patients with metastatic breast cancer. METHODS A population pharmacokinetic model for capecitabine and its three metabolites was built. Typical parameter values, characteristics of random distributions, associated with parameters, and covariates impact were estimated. Area under the curve (AUC) were computed for 5-FU and compared with grades of toxicity. Pharmacokinetic modeling was based on data collected on the first treatment cycle. Toxicity was assessed on the two first treatment cycles. RESULTS The study was conducted in 43 patients. The population pharmacokinetic model (a one-compartment model per compound) was able to capture the very complex absorption process of capecitabine. Statistically significant covariates were cytidine deaminase, alkaline phosphatase and dihydrouracilemia (UH2)/uracilemia (U) ratio. UH2/U ratio was the most significant covariate on 5-FU elimination and CDA on the transformation of 5'-DFCR in 5'-DFUR. A trend was observed between 5-FU AUC and thrombopenia toxicity grades, but not with other toxicities. Best clinical response was not linked to systemic exposure of capecitabine metabolites. CONCLUSION In our study, we propose a model able to describe, meanwhile, and its main metabolites, with a complex absorption process and inclusion of enzyme activity covariates such as CDA and UH2/U ratio. Trial registration Eudract 2008-004136-20, 2008/11/26.
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Affiliation(s)
- Nastja Lunar
- Pharmacy Department, Centre Georges-François Leclerc, 1 rue Pr Marion, 21079, Dijon Cedex, France
- INSERM U1231, University of Burgundy Franche-Comté, Dijon, France
| | - Marie-Christine Etienne-Grimaldi
- Centre Antoine-Lacassagne, 33, avenue de Valombrose, 06189, Nice cedex 2, France
- Groupe de Pharmacologie Clinique & Oncologique (GPCO)-Unicancer, 101 rue de Tolbiac, 75013, Paris, France
| | - Pauline Macaire
- Pharmacy Department, Centre Georges-François Leclerc, 1 rue Pr Marion, 21079, Dijon Cedex, France
- INSERM U1231, University of Burgundy Franche-Comté, Dijon, France
| | - Fabienne Thomas
- Groupe de Pharmacologie Clinique & Oncologique (GPCO)-Unicancer, 101 rue de Tolbiac, 75013, Paris, France
- ICR, IUCT-Oncopole, Toulouse, France
- Université de Toulouse, CRCT, Inserm UMR1037, 31000, Toulouse, France
| | - Florence Dalenc
- ICR, IUCT-Oncopole, Toulouse, France
- Université de Toulouse, CRCT, Inserm UMR1037, 31000, Toulouse, France
| | - Jean-Marc Ferrero
- Centre Antoine-Lacassagne, 33, avenue de Valombrose, 06189, Nice cedex 2, France
| | - Xavier Pivot
- Service Oncologie Médicale, CHU Jean-Minjoz, 3, boulevard Alexandre-Fleming, 25030, Besançon, France
| | - Gérard Milano
- Centre Antoine-Lacassagne, 33, avenue de Valombrose, 06189, Nice cedex 2, France
- Groupe de Pharmacologie Clinique & Oncologique (GPCO)-Unicancer, 101 rue de Tolbiac, 75013, Paris, France
| | - Bernard Royer
- Groupe de Pharmacologie Clinique & Oncologique (GPCO)-Unicancer, 101 rue de Tolbiac, 75013, Paris, France
- Laboratoire de Pharmacologie Clinique, CHU Jean-Minjoz, 3, boulevard Alexandre-Fleming, 25030, Besançon, France
- INSERM, EFS BFC, UMR1098, Interactions Greffon-Hôte-Tumeur/Ingénierie Cellulaire Et Génique, Université Bourgogne Franche-Comté, 25000, Besançon, France
| | - Antonin Schmitt
- Pharmacy Department, Centre Georges-François Leclerc, 1 rue Pr Marion, 21079, Dijon Cedex, France.
- INSERM U1231, University of Burgundy Franche-Comté, Dijon, France.
- Groupe de Pharmacologie Clinique & Oncologique (GPCO)-Unicancer, 101 rue de Tolbiac, 75013, Paris, France.
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49
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Schneider JJ, Galettis P, Martin JH. Overcoming barriers to implementing precision dosing with 5-fluorouracil and capecitabine. Br J Clin Pharmacol 2021; 87:317-325. [PMID: 33386659 DOI: 10.1111/bcp.14723] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 12/01/2020] [Accepted: 12/17/2020] [Indexed: 12/27/2022] Open
Abstract
Despite advances in targeted cancer therapy, the fluoropyrimidines 5-fluorouracil (5FU) and capecitabine continue to play an important role in oncology. Historically, dosing of these drugs has been based on body surface area. This approach has been demonstrated to be an imprecise way to determine the optimal dose for a patient. Evidence in the literature has demonstrated that precision dosing approaches, such as DPD enzyme activity testing and, in the case of intravenous 5FU, pharmacokinetic-guided dosing, can reduce toxicity and yield better patient outcomes. However, despite the evidence, there has not been uniform adoption of these approaches in the clinical setting. When a drug such as 5FU has been used clinically for many decades, it may be difficult to change clinical practice. With the aim of facilitating change of practice, issues and barriers to implementing precision dosing approaches for 5FU and capecitabine are identified and discussed with possible solutions proposed.
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Affiliation(s)
- Jennifer J Schneider
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Centre for Drug Repurposing and Medicines Research, Level 3 Hunter Medical Research Institute, Kookaburra Circuit, Newcastle, New South Wales, Australia
| | - Peter Galettis
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Centre for Drug Repurposing and Medicines Research, Level 3 Hunter Medical Research Institute, Kookaburra Circuit, Newcastle, New South Wales, Australia
| | - Jennifer H Martin
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Centre for Drug Repurposing and Medicines Research, Level 3 Hunter Medical Research Institute, Kookaburra Circuit, Newcastle, New South Wales, Australia
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50
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Jolivet C, Nassabein R, Soulières D, Weng X, Amireault C, Ayoub JP, Beauregard P, Blais N, Carrier C, Cloutier AS, Desnoyers A, Lemay AS, Lemay F, Loungnarath R, Jolivet J, Letendre F, Tehfé M, Vadnais C, Viens D, Aubin F. Implementing DPYD*2A Genotyping in Clinical Practice: The Quebec, Canada, Experience. Oncologist 2020; 26:e597-e602. [PMID: 33274825 DOI: 10.1002/onco.13626] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 11/20/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Fluoropyrimidines are used in chemotherapy combinations for multiple cancers. Deficient dihydropyrimidine dehydrogenase activity can lead to severe life-threatening toxicities. DPYD*2A polymorphism is one of the most studied variants. The study objective was to document the impact of implementing this test in routine clinical practice. METHODS We retrospectively performed chart reviews of all patients who tested positive for a heterozygous or homozygous DPYD*2A mutation in samples obtained from patients throughout the province of Quebec, Canada. RESULTS During a period of 17 months, 2,617 patients were tested: 25 patients tested positive. All were White. Twenty-four of the 25 patients were heterozygous (0.92%), and one was homozygous (0.038%). Data were available for 20 patients: 15 were tested upfront, whereas five were identified after severe toxicities. Of the five patients confirmed after toxicities, all had grade 4 cytopenias, 80% grade ≥3 mucositis, 20% grade 3 rash, and 20% grade 3 diarrhea. Eight patients identified with DPYD*2A mutation prior to treatment received fluoropyrimidine-based chemotherapy at reduced initial doses. The average fluoropyrimidine dose intensity during chemotherapy was 50%. No grade ≥3 toxicities were observed. DPYD*2A test results were available in an average of 6 days, causing no significant delays in treatment initiation. CONCLUSION Upfront genotyping before fluoropyrimidine-based treatment is feasible in clinical practice and can prevent severe toxicities and hospitalizations without delaying treatment initiation. The administration of chemotherapy at reduced doses appears to be safe in patients heterozygous for DPYD*2A. IMPLICATIONS FOR PRACTICE Fluoropyrimidines are part of chemotherapy combinations for multiple cancers. Deficient dihydropyrimidine dehydrogenase activity can lead to severe life-threatening toxicities. This retrospective analysis demonstrates that upfront genotyping of DPYD before fluoropyrimidine-based treatment is feasible in clinical practice and can prevent severe toxicities and hospitalizations without delaying treatment initiation. This approach was reported previously, but insufficient data concerning its application in real practice are available. This is likely the first reported experience of systematic DPYD genotyping all over Canada and North America as well.
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Affiliation(s)
- Catherine Jolivet
- Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Rami Nassabein
- Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Denis Soulières
- Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Xiaoduan Weng
- Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | | | - Jean-Pierre Ayoub
- Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Patrice Beauregard
- Centre Hospitalier de l'Université Sherbrooke, Sherbrooke, Quebec, Canada
| | - Normand Blais
- Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Christian Carrier
- Centre Hospitalier Régional Trois-Rivières, Trois-Rivières, Quebec, Canada
| | | | | | - Anne-Sophie Lemay
- Centre Hospitalier Régional Trois-Rivières, Trois-Rivières, Quebec, Canada
| | - Frédéric Lemay
- Centre Hospitalier de l'Université Sherbrooke, Sherbrooke, Quebec, Canada
| | - Rasmy Loungnarath
- Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Jacques Jolivet
- Centre Intégré de Santé et de Services Sociaux (CISSS) des Laurentides, Saint-Jérôme, Quebec, Canada
| | | | - Mustapha Tehfé
- Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Charles Vadnais
- Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Daniel Viens
- Hôpital Sainte-Croix, Drummondville, Quebec, Canada
| | - Francine Aubin
- Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
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