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Panetta JC, Roberts JK, Huang J, Lin T, Daryani VM, Harstead KE, Patel YT, Onar-Thomas A, Campagne O, Ward DA, Broniscer A, Robinson G, Gajjar A, Stewart CF. Pharmacokinetic basis for dosing high-dose methotrexate in infants and young children with malignant brain tumours. Br J Clin Pharmacol 2020; 86:362-371. [PMID: 31657864 DOI: 10.1111/bcp.14160] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/03/2019] [Accepted: 10/15/2019] [Indexed: 01/17/2023] Open
Abstract
AIMS No population pharmacokinetic studies of high-dose methotrexate (HDMTX) have been conducted in infants with brain tumours, which are a vulnerable population. The aim of this study was to evaluate HDMTX disposition in these children to provide a rational basis for MTX dosing. METHODS Patients received 4 monthly courses of HDMTX (5 g/m2 or 2.5 g/m2 for infants aged ≤31 days) as a 24-h infusion. Serial samples were analysed for MTX by an enzyme immunoassay method. Pharmacokinetic parameters were estimated using nonlinear mixed effects population modelling. Demographics, concomitant medications and genetic polymorphisms were considered as pharmacokinetic covariates while MTX exposure and patient age were considered as covariates for Grade 3 and 4 toxicities. RESULTS The population pharmacokinetics of HDMTX were estimated in 178 patients (age range 0.02-4.7 years) in 648 courses. The population clearance and volume were 90 mL/min/m2 and 14.4 L/m2 , respectively. Significant covariates on body surface area adjusted MTX clearance included estimated glomerular filtration rate and co-treatment with dexamethasone or vancomycin. No significant association was observed between MTX toxicity and MTX exposure, patient age, leucovorin dosage or duration. MTX clearance in infants ≤31 days at enrolment was 44% lower than in older infants, but their incidence of toxicity was not higher since they also received a lower MTX dosage. CONCLUSIONS By aggressively following institutional clinical guidelines, HDMTX-related toxicities were low, and using covariates from the population pharmacokinetic model enabled the calculation of a rational dosage for this patient population for future clinical trials.
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Affiliation(s)
- John C Panetta
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jessica K Roberts
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jie Huang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Tong Lin
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Vinay M Daryani
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - K Elaine Harstead
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yogesh T Patel
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Arzu Onar-Thomas
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Olivia Campagne
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Deborah A Ward
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Alberto Broniscer
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Giles Robinson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Amar Gajjar
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Clinton F Stewart
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
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Coadministration of vindesine with high-dose methotrexate therapy increases acute kidney injury via BCRP, MRP2, and OAT1/OAT3. Cancer Chemother Pharmacol 2019; 85:433-441. [DOI: 10.1007/s00280-019-03972-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 10/03/2019] [Indexed: 12/19/2022]
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3
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Couture M, Ray KK, Poirier-Richard HP, Crofton A, Masson JF. 96-Well Plasmonic Sensing with Nanohole Arrays. ACS Sens 2016. [DOI: 10.1021/acssensors.5b00280] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Maxime Couture
- Département
de Chimie and ‡Centre for Self-Assembled Chemical Structures
(CSACS), Université de Montréal, CP. 6128 Succ. Centre-Ville, Montréal, Quebec, Canada H3C 3J7
| | - Korak Kumar Ray
- Département
de Chimie and ‡Centre for Self-Assembled Chemical Structures
(CSACS), Université de Montréal, CP. 6128 Succ. Centre-Ville, Montréal, Quebec, Canada H3C 3J7
| | - Hugo-Pierre Poirier-Richard
- Département
de Chimie and ‡Centre for Self-Assembled Chemical Structures
(CSACS), Université de Montréal, CP. 6128 Succ. Centre-Ville, Montréal, Quebec, Canada H3C 3J7
| | - Anthony Crofton
- Département
de Chimie and ‡Centre for Self-Assembled Chemical Structures
(CSACS), Université de Montréal, CP. 6128 Succ. Centre-Ville, Montréal, Quebec, Canada H3C 3J7
| | - Jean-Francois Masson
- Département
de Chimie and ‡Centre for Self-Assembled Chemical Structures
(CSACS), Université de Montréal, CP. 6128 Succ. Centre-Ville, Montréal, Quebec, Canada H3C 3J7
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4
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Zhao SS, Bukar N, Toulouse JL, Pelechacz D, Robitaille R, Pelletier JN, Masson JF. Miniature multi-channel SPR instrument for methotrexate monitoring in clinical samples. Biosens Bioelectron 2015; 64:664-70. [DOI: 10.1016/j.bios.2014.09.082] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 08/11/2014] [Accepted: 09/29/2014] [Indexed: 01/02/2023]
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5
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Misra R, Mohanty S. Sustained release of methotrexate through liquid-crystalline folate nanoparticles. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2014; 25:2095-2109. [PMID: 24952639 DOI: 10.1007/s10856-014-5257-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 06/09/2014] [Indexed: 06/03/2023]
Abstract
To make chemotherapy more effective, sustained release of the drug is desirable. By controlling the release rates, constant therapeutic levels can be achieved which can avoid re-administration of drug. This helps to combat tumors more effectively with minimal side effects. The present study reports the control release of methotrexate through liquid-crystalline folate nanoparticles. These nanoparticles are composed of highly ordered folate self-assembly which encapsulate methotrexate molecules. These drug molecules can be released in a controlled manner by disrupting this assembly in the environment of monovalent cations. The ordered structure of folate nanoparticles offers low drug losses of about 4-5%, which is significant in itself. This study reports the size-control method of forming methotrexate encapsulated folate nanoparticles as well as the release of methotrexate through these nanoparticles. It has been demonstrated that methotrexate release rates can be controlled by controlling the size of the nanoparticles, cross-linking cation and cross-linking concentration. The effect of different factors like drug loading, release medium, and pH of the medium on methotrexate release rates was also studied.
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Affiliation(s)
- Rahul Misra
- Advance Materials & Nanoscience Laboratory, Department of Chemical Engineering, Indian Institute of Technology Delhi, Hauz Khas, New Delhi, 110016, India,
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Kumar N, Shirali AC. What is the Best Therapy for Toxicity in the Setting of Methotrexate-Associated Acute Kidney Injury: High-Flux Hemodialysis or Carboxypeptidase G2? Semin Dial 2014; 27:226-8. [DOI: 10.1111/sdi.12220] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Neelja Kumar
- Section of Nephrology; Yale University School of Medicine; New Haven Connecticut
| | - Anushree C. Shirali
- Section of Nephrology; Yale University School of Medicine; New Haven Connecticut
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Levêque D, Santucci R, Gourieux B, Herbrecht R. Pharmacokinetic drug–drug interactions with methotrexate in oncology. Expert Rev Clin Pharmacol 2014; 4:743-50. [DOI: 10.1586/ecp.11.57] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Choi SH, Kim KS, Kim KE, Kim JW. Comparison of High Dose Methotrexate Administration Between the Inpatient and Outpatient Setting in Children with Acute Lymphoblastic Leukemia. ASIAN ONCOLOGY NURSING 2014. [DOI: 10.5388/aon.2014.14.2.93] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Sun Hee Choi
- BMT Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Kwang Sung Kim
- BMT Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Kyung Eon Kim
- BMT Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jae Won Kim
- BMT Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
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May J, Carson KR, Butler S, Liu W, Bartlett NL, Wagner-Johnston ND. High incidence of methotrexate associated renal toxicity in patients with lymphoma: a retrospective analysis. Leuk Lymphoma 2013; 55:1345-9. [PMID: 24004183 DOI: 10.3109/10428194.2013.840780] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
High-dose methotrexate (HDMTX), defined by doses of methotrexate (MTX) ≥ 1 g/m(2), is a widely used regimen known to cause renal toxicity. The reported incidence of renal toxicity in patients with osteosarcoma is 1.8%, but the incidence in hematologic malignancies is not well characterized. In this retrospective study of 649 cycles of HDMTX in 194 patients, renal toxicity occurred in 9.1% of cycles in patients with lymphoma compared to 1.5% in patients with sarcoma. Older age, male sex, decreased baseline creatinine clearance (CrCl) and increased proton pump inhibitor use among the lymphoma population likely contributed to the observed difference. The incidence of renal toxicity was independent of the incidence of delayed MTX elimination, suggesting that kidney function is only one factor involved in MTX clearance. Renal toxicity prolonged the duration of hospitalization but severe renal insufficiency was uncommon. No significant impact on progression-free or overall survival was observed.
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Affiliation(s)
- Jori May
- Division of Medical Oncology, Internal Medicine, Washington University School of Medicine , St. Louis, MO , USA
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Cheah CY, Seymour JF. Is there still a need for specific central nervous system directed prophylaxis for diffuse large B-cell lymphoma in the rituximab era? Leuk Lymphoma 2013; 55:471-3. [PMID: 23906017 DOI: 10.3109/10428194.2013.830306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Chan Y Cheah
- Department of Haematology, Peter MacCallum Cancer Centre , East Melbourne, Victoria , Australia and University of Melbourne , Parkville, Victoria , Australia
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11
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Chan AJ, Rajakumar I. High-dose methotrexate in adult oncology patients: A case-control study assessing the risk association between drug interactions and methotrexate toxicity. J Oncol Pharm Pract 2013; 20:93-9. [DOI: 10.1177/1078155213482602] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction High-dose methotrexate, defined as dose ≥1 g/m2, is commonly used in chemotherapy protocols. Certain drugs such as acyclovir, allopurinol, proton pump inhibitors and some antibiotics have been associated with delayed renal clearance of methotrexate and may predispose patients to toxicities. Currently, no specific recommendations exist on adjusting the high-dose methotrexate regimen in the presence of potential interacting drugs. This study aims to determine whether presence of interacting drugs is associated with delayed methotrexate clearance. Methods This was a case-control study of adult oncology patients who received their first cycle of high-dose methotrexate. Cases were defined as patients who experienced delayed methotrexate clearance, as indicated by serum methotrexate level ≥ 0.1 umol/L at 72 h. The primary endpoint was the frequency of presence of interacting drugs between cases and controls. These were compared using Fisher's exact test. Where possible, adjustment for significant baseline differences that can affect methotrexate clearance was made using logistic regression. The secondary endpoint was frequency of methotrexate-related clinical toxicities between groups and included myelosuppression, nephrotoxicity, hepatotoxicity and mucositis. Results From January 2004 to March 2011, 73 patients met study criteria, of which 23 were defined as cases. Significant baseline differences were methotrexate dose received (9116 mg ± 4339 versus 6054 mg ± 2874, p=0.012) and renal impairment (5 versus 0, p = 0.002). The presence of interacting drugs was not associated with delayed methotrexate clearance (OR 0.91, 95% CI 0.24–3.38, p > 0.999). After adjusting for methotrexate dose, drugs observed more frequently (allopurinol, proton pump inhibitors and sulfamethoxazole/trimethoprim) were not associated with delayed methotrexate clearance ( p = 0.95, 0.59 and 0.20, respectively). Cases experienced more severe anemia (grade 2.52 versus 1.68, p = 0.007) and higher rates of mucositis (65.2% versus 20.0%, p < 0.001). Conclusion This study showed no significant association between presence of interacting drugs and delayed methotrexate clearance. Patients who experienced delayed methotrexate clearance had higher incidence of severe anemia and mucositis.
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Affiliation(s)
- April J Chan
- Department of Pharmacy, London Health Sciences Centre, London, Ontario, Canada
| | - Irina Rajakumar
- Department of Pharmacy, London Health Sciences Centre, London, Ontario, Canada
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12
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Aouinti I, Gaïes E, Trabelsi S, Salouage I, Jebabli N, Charfi R, Lakhal M, Klouz A. Delayed Elimination of Methotrexate in a Patient Receiving Ciprofloxacin. Therapie 2013; 68:175-7. [DOI: 10.2515/therapie/2013031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 03/14/2013] [Indexed: 11/20/2022]
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13
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Joerger M, Huitema ADR, Illerhaus G, Ferreri AJM. Rational administration schedule for high-dose methotrexate in patients with primary central nervous system lymphoma. Leuk Lymphoma 2012; 53:1867-75. [PMID: 22530664 DOI: 10.3109/10428194.2012.676177] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Methotrexate (MTX) at a dose of ≥1 g/m(2) remains the most efficient treatment against primary central nervous system lymphoma (PCNSL), and is the most widely used drug in prospective clinical trials. MTX is a folate analog that inhibits dihydrofolate reductase, thereby blocking de novo purine synthesis. MTX as well as 7-hydroxy-MTX, its main metabolite in serum, are both eliminated by the kidneys. The elimination of MTX is prolonged in patients with renal impairment and third-space fluid collections, and in patients receiving concurrent non-steroidal antirheumatic drugs, benzimidazoles and sulfonamides, among others. Main adverse events with high-dose MTX include severe myelosuppression, renal dysfunction and stomatitis. Supportive measures such as rigorous hydration, urine alkalinization and careful drug monitoring with supplemental leucovorin rescue are crucial to avoid significant toxicity. Strategies to optimize clinical efficacy of high-dose MTX in patients with PCNSL include administration of 3 h instead of longer infusions, potentially supplemented with an additional intravenous MTX bolus, and maintaining MTX dose intensity over the course of four treatment cycles. Some pharmacological studies suggest that achieving an MTX area under the plasma concentration-time curve (AUC(MTX)) of between 1000 and 1100 μmol.h/L may improve clinical outcome, but clinical data are not conclusive at present. In this review, we analyze the impact of patient, lymphoma and pharmacokinetic variables on the antitumor activity of high-dose MTX in patients with PCNSL, summarize recommendations for daily clinical practice and give some suggestions for future trials.
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Affiliation(s)
- M Joerger
- Department of Oncology and Hematology, Cantonal Hospital, St. Gallen, Switzerland.
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McBride A, Antonia SJ, Haura EB, Goetz D. Suspected methotrexate toxicity from omeprazole: a case review of carboxypeptidase G2 use in a methotrexate-experienced patient with methotrexate toxicity and a review of the literature. J Pharm Pract 2012; 25:477-85. [PMID: 22550162 DOI: 10.1177/0897190012442717] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We report a case of methotrexate toxicity potentially induced by a drug interaction between methotrexate and omeprazole in a 25-year-old man with osteosarcoma. The patient was placed on omeprazole after his first cycle of high-dose methotrexate for stress ulcer prophylaxis, and it was discontinued before the start of the first day of the patient's second round of high-dose methotrexate. The 24-hour methotrexate level was elevated and he continued to have sustained levels for 18 days. Side effects due to elevated serum methotrexate included seizures, mucositis, acute renal failure, and thrombocytopenia. Aggressive hydration, urinary alkalinization, and leucovorin were continued during the period of elevated methotrexate levels, with the patient receiving a course of hemodialysis and a dose of carboxypeptidase G2. The patient's symptoms resolved, and his renal function returned to baseline within 2 months. The patient was able to receive future courses of chemotherapy without methotrexate. Although use of the Naranjo adverse reaction probability scale indicated a probable relationship (score of 6) between the patient's development of methotrexate toxicity and omeprazole use, we believe this was a drug-drug interaction case consistent with previous reports in the literature.
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Affiliation(s)
- Ali McBride
- Department of Pharmacy, The Ohio State University, Columbus, OH 43210, USA.
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15
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Apostolovic B, Deacon SPE, Duncan R, Klok HA. Cell uptake and trafficking behavior of non-covalent, coiled-coil based polymer-drug conjugates. Macromol Rapid Commun 2010; 32:11-8. [PMID: 21432965 DOI: 10.1002/marc.201000434] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Indexed: 01/14/2023]
Abstract
This paper reports on the cell uptake and trafficking properties of a series of non-covalent polymer-drug conjugates. These nanomedicines are composed of a poly(N-(2-hydroxypropyl)methacrylamide) backbone functionalized with multiple copies of a drug. The drug moieties are attached to the polymer via a non-covalent, so called coiled coil motif, which is formed by heterodimerization of two complementary peptide strands, one of which is attached to the polymer carrier and the other to the drug. Cytotoxicity and FACS experiments, which were carried out with model anticancer drug or fluorophore conjugates, provided insight into the cell uptake and trafficking behavior of these conjugates.
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Affiliation(s)
- Bojana Apostolovic
- École Polytechnique Fédérale de Lausanne, Institut des Matériaux and Institut des Sciences et Ingénierie Chimiques, Laboratoire des Polymères, Bâtiment MXD, Station 12, CH-1015 Lausanne, Switzerland
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Modification de la pharmacocinétique du méthotrexate suite à l’administration d’amphotéricine B: à propos d’un cas. ACTA ACUST UNITED AC 2010. [DOI: 10.1007/s12558-010-0114-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Suzuki K, Doki K, Homma M, Tamaki H, Hori S, Ohtani H, Sawada Y, Kohda Y. Co-administration of proton pump inhibitors delays elimination of plasma methotrexate in high-dose methotrexate therapy. Br J Clin Pharmacol 2008; 67:44-9. [PMID: 19076159 DOI: 10.1111/j.1365-2125.2008.03303.x] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
AIM To assess whether or not co-administration of proton pump inhibitors (PPIs) is a risk factor for delayed elimination of plasma methotrexate (MTX) in high-dose MTX (HDMTX) therapy for malignant diseases. METHODS To assess the effects of PPI co-administration on elimination of plasma MTX, we examined plasma MTX concentration data on 171 cycles of HDMTX therapy performed in 74 patients. We performed multiple logistic regression analysis to evaluate PPI co-administration as a risk factor. Inhibitory potencies of omeprazole, lansoprazole, rabeprazole and pantoprazole on MTX transport via breast cancer resistance protein (BCRP, ABCG2) were also investigated in an in vitro study using membrane vesicles expressing human BCRP. RESULTS We identified co-administration of PPIs as a risk factor for delayed elimination (odds ratio 2.65, 95% confidence interval 1.03, 6.82) as well as renal and liver dysfunction. All four PPIs inhibited BCRP-mediated transport of MTX, with half-maximal inhibitory concentrations of 5.5-17.6 microM--considerably higher than the unbound plasma concentrations of the PPIs. CONCLUSIONS Our results support previous findings suggesting that PPI co-administration is associated with delayed elimination of plasma MTX in patients with HDMTX therapy. This drug interaction, however, cannot be explained solely by the inhibitory effects of PPIs on BCRP-mediated MTX transport.
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Affiliation(s)
- Kunihiro Suzuki
- Department of Pharmaceutical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan
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High-dose methotrexate in adults with osteosarcoma: a population pharmacokinetics study and validation of a new limited sampling strategy. Anticancer Drugs 2008; 19:267-73. [PMID: 18510172 DOI: 10.1097/cad.0b013e3282f21376] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Preoperative high-dose methotrexate (HD-MTX) with folinic acid (leucovorin) rescue is still a mainstay in the treatment of osteosarcoma. This anticancer agent is characterized by a narrow therapeutic index and wide interpatients variability. To ensure effective and safe administration of HD-MTX, we had earlier developed an adaptive-dosing schedule with a feedback strategy. In our institute, the MTX dosage was tailored according to individual pharmacokinetics parameters, determined in real time both from two blood samples (3.5 and 4.5 h) and from Bayesian population parameters. Up to 20 g of MTX was safely administered as 8-h infusions. Low MTX elimination rate has, however, been reported in 15-20% of the patients, and forecasting the MTX elimination phase and the management of leucovorin rescue is still a challenging issue in clinical oncology. This study aims at identifying the clinical or biological covariates related to impaired MTX clearance, and at validating a new limited sampling strategy (LSS), allowing for the accurate prediction of the MTX terminal elimination phase. This retrospective study was carried out on 49 patients (30 men, 19 women; mean age, 26.7 years) treated for osteosarcoma with HD-MTX. The population and individual pharmacokinetics parameters were computed, before the identification of the relevant covariates. Different LSSs were then tested, to predict accurately when the MTX plasma concentrations would drop below 0.2 micromol/l, the threshold associated with the end of the rescue of leucovorin with alkaline hydration. Two main covariates (creatinemia clearance and alanine aminotransferase) were correlated with MTX clearance. Conversely, the impact of body surface area on MTX pharmacokinetics was weak, suggesting that dosing schedules based on body surface area were inadequate and potentially hazardous. A new LSS predicting accurately when the MTX concentration would reach 0.2 micromol/l has been validated; blood samples are stopped as soon as the MTX concentration drops to 1 micromol/l. With this LSS, our retrospective study suggests that 60% of the patients would have left the hospital earlier than they actually did owing to a better forecasting of the MTX decrease, thus improving their quality of life while improving the cost-effectiveness for the institute. HD-MTX can be administered safely using an adaptive-dosing strategy with drug monitoring. Moreover, pharmacokinetic modeling permits the accurate forecasting of the MTX elimination profile, thus allowing for a better management of the postinfusion care of cancer patients treated with particularly high doses of this drug.
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Shamash J, Joel S, Lundholm L, Millard L, Oliver T. High-dose methotrexate clearance following prior vancomycin administration: no significant interaction in the absence of overt renal impairment. Ann Oncol 2003; 14:169-70. [PMID: 12488310 DOI: 10.1093/annonc/mdg021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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